The Hospital Emergency Incident Command System (Hospital Emergency Incident Command System), nowin its third edition, has emerged asa popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the Hospital Emergency Incident Command System in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (Severe Acute Respiratory Syndrome) outbreaks in eastern Asia and Toronto, Canada.Several modifications of the Hospital Emergency Incident Command System are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the Hospital Emergency Incident Command System to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in chemical, biological, radiological, nuclear emergencies; (3) new unit leaders in theOperations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, anddependents in terrorismrelated emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types ofpatients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems.New uses of the Hospital Emergency Incident Command System in hospital emergency management also are recommended, including: (1) the adoption of the Hospital Emergency Incident Command System as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the Hospital Emergency Incident Command System not only to healthcare facilities, but also to healthcare systems.Finally, three levels of healthcare worker competencies in the Hospital Emergency Incident Command Systemare suggested: (1) basic understanding of the Hospital Emergency Incident Command System for all hospital healthcare workers; (2) advanced understanding and proficiency in the Hospital Emergency Incident Command Systemfor hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the Hospital Emergency Incident Command System ad hoc from existing healthcare workers in resource-deficient settings. The Hospital Emergency Incident Command System should be viewed asa work in progress that will mature as additional challenges arise and ashospitals gain further experience with its use.

Background:This paper describes the two mass-casualty, terrorist attacks that occurred in Istanbul, Turkey in November 2003, and the resulting prehospital emergency response.Methods:A complex, retrospective, descriptive study was performed, using open source reports, interviews, direct measurements of street distances, and hospital records from the American Hospital (AH) and Taksim Education and Research State Hospital (TERSH) in Istanbul.Results:On 15 November, improvised explosive devices (IEDs) in trucks were detonated outside the Neve Shalom and Beth Israel Synagogues, killing 30 persons and injuring an estimated additional 300. Victims were maldistributed to 16 medical facilities. For example, AH, a private hospital located six km from both synagogues, received 69 injured survivors, of which 86% had secondary blast injuries and 13% were admitted to the hospital. The TERSH, a government hospital located 1 km from both synagogues, received 48 injured survivors. On 20 November, IEDs in trucks were detonated outside the Hong Kong Shanghai Banking Corporation (HSBC) headquarters and the British Consulate (BC), killing 33 and injuring an estimated additional 450. Victims were maldistributed to 16 medical facilities. For example, TERSH, located 18 km from the HSBC site and 2 km from the the BC received 184 injured survivors, of which 93% had secondary blast injuries and 15% were hospitalized. The AH, located 9 km from the HSBC site and 6 km from the BC, received 16 victims.Conclusion:The twin suicide truck bombings on 15 and 20 November 2003 were the two largest terrorist attacks in modern Turkish history, collectively killing 63 persons and injuring an estimated 750 others. The vast majority of victims had secondary blast injuries, which did not require hospitalization. Factors associated with the maldistribution of casualties to medical facilities appeared to include the distance from each bombing site, the type of medical facility, and the personal preference of injured survivors.

Emergency medical care, both prehospital and hospital-based, is currently provided by general practitioners in over 90% of the emergency departments in Turkey. In the early 1990s, government and university leaders recognized that Turkey needed to improve its emergency medical care system, and they chose to adapt the mature and tested Anglo-American model of emergency medicine (EM). EM was declared to be an independent specialty by the Ministry of Health in 1993. The first paramedic school and the first EM residency programme (36 months in length) were opened at the Dokuz Eylul University in 1993 and 1994, respectively. In 1995, the Emergency Medicine Association of Turkey (EMAT) was established. Today, there are 14 EM residency programmes around the country, and these are trying to design a common curriculum. The connection between departments is improving with annual meetings organized by EMAT. In addition, EMAT is developing international collaboration in the Middle East region. The Turkish government is trying to promote EM specialist physicians and paramedics in the national emergency care system.

The lack of a universally applicable definition of terrorism has confounded the understanding of terrorism since the term was first coined in 18th Century France. Although a myriad of definitions of terrorism have been advanced over the years, virtually all of these definitions have been crisis-centered, frequently reflecting the political perspectives of those who seek to define it.In this article, we deconstruct these previously used definitions of terrorism in order to reconstruct a definition of terrorism that is consequence-centered, medically relevant, and universally harmonized. A universal medical and public health definition of terrorism will facilitate clinical and scientific research, education, and communication about terrorism-related events or disasters.We propose the following universal medical and public definition of terrorism: The intentional use of violence — real or threatened — against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.

of the world. Methods: A dual phase evaluation process is proposed. In the first phase (precurriculum), prospective students will identify patients with an acute illness or injury most likely to benefit from field interventions with a standardized, validated case severity scale (CSS). The CSS categorizes patients on their initial level of severity and their interval status change upon arrival at the emergency department. The second phase (postcurriculum) would combine the CSS with a structured patient encounter data collection (quality assessment) tool, which would document clinical data and serve as a prompt for critical interventions. A cohort will be followed prospectively for 12 months to evaluate changes in CSS based on clinical interventions. Observed interventions will be controlled for a given locale's resources and prehospital infrastructure. The curriculum and quality assessment tool will be implemented in staggered intervals throughout the each center's jurisdiction allowing for comparisons between pre-and postcurriculum cohorts. Conclusion: A combination severity scale and quality assessment instrument may be useful in measuring patient outcomes, and in addition, have universal applications for improving and reinforcing the performance of prehospital providers.