Methodological Verification via Scientific Literature

To validate and substantiate the report’s data, studies related to the 6 February Kahramanmaraş Earthquakes were systematically reviewed across scientific research databases. This examination was conducted to ensure the accuracy of the report’s data and to situate the discussion on a global footing. The analyses encompass scientific evidence regarding the health impacts of the earthquakes and the health problems observed in the affected regions. This approach was employed to reinforce the scientific basis of the report and to enhance the credibility of its conclusions. In addition, second-year reports prepared by specialty societies, professional chambers, and international associations conducting disaster analyses on the 6 February Kahramanmaraş Earthquakes were also examined in detail. ^{7 – 10}

External Reports and Comparative Perspectives

The reviewed reports contain important information on the health impacts of the disaster, the status of health services in the affected regions, and the recovery processes. Reports issued by specialty societies and professional chambers are supported by the observations and assessments of subject-matter experts. Reports produced by international organizations that analyze disasters offer a broader, comparative perspective. These sources were examined and appraised to enhance the accuracy and reliability of the report’s data and to elucidate salient themes.

Thematic Framework (Analytic Approach)

The report was structured a priori around 6 themes, derived from the literature, EMAT field experience, and workshop outputs: (1) physicians’ family and social circumstances; (2) psychological impacts; (3) effects on hospital and ED operations (management, staffing, equipment, infrastructure); (4) effects on day-to-day ED functioning (physical space, workflow, motivation, care quality); (5) impacts on EMRs training; and (6) roles and responsibilities of specialty societies. Survey items were aligned to these themes; open-ended responses were classified via content analysis using a shared thematic codebook (Supp. 1). For each theme, quantitative results are reported with descriptive statistics (counts/percentages, mean/median, and 95% CIs), while qualitative findings are synthesized to highlight patterns and subdomains within themes. This framework guided both the presentation and interpretation of findings, ensuring comparability and reproducibility of the analysis.

Measurement of Earthquake-Related Psychological Symptoms

Traumatic-stress symptoms. We assessed post-earthquake symptoms using the 22 items of the Traumatic Stress Symptom Checklist (TSSC) from the Screening Instrument for Traumatic Stress in Earthquake Survivors (SITSES) (Supp. 2).Reference Başoğlu, Salcioğlu and Livanou ¹¹ Items were administered in Turkish with a four-option Likert response (0 = Not at all, 1 = A little, 2 = Quite a bit, 3 = Very much). In line with the study’s surveillance/description aim, we did not compute total or subscale scores, and we did not apply diagnostic cut-offs. Instead, each item was analyzed at the response-category level and reported as frequencies/percentages across the four options. Higher response categories indicate greater symptom severity for that item. Missing responses, if any, were treated as missing at random and excluded from the item-specific denominator. Accordingly, item-level prevalence is presented without deriving composite scores or making diagnostic inferences.

Psychological Impacts of Earthquakes

During the 6 February Kahramanmaraş Earthquakes, health care workers across 11 provinces both endured the physical and psychological trauma of the disaster—becoming disaster-affected themselves—while simultaneously striving to deliver care to the influx of patients presenting to hospitals in the early phase. In many affected areas, some health care workers lost their lives, and many others lost family members or loved ones.

Data from physicians still residing in the disaster zone indicate that post-traumatic stress symptoms persist even 2 years after the event (see Table 2). These findings underscore the widespread nature of post-disaster mental health problems and the need for comprehensive interventions. In the early post-earthquake period, the EMAT initiated a psychological support program targeting all ED personnel—primarily EPs and EMRs, as well as nurses, paramedics, EMTs, and technicians. It should be borne in mind that the traumatic bereavement process will be prolonged; while psychosocial impacts affect society at large, they also continue to affect health care workers who remain on duty in the region. Providing health care to others without the opportunity to process one’s own grief can compound and perpetuate trauma.

Table 2.

Post-traumatic stress symptoms among physicians in the affected region

Table 2. Long description

The table consists of 22 symptom rows and 4 columns representing severity levels: Not at all, A little, Quite a bit, and Very much. All values are percentages.

* I can’t get certain memories/images of the earthquake out of my mind: Not at all 8.1, A little 51.4, Quite a bit 32.4, Very much 8.1.

* At times, what I lived through suddenly flashes before my eyes like a film: Not at all 18.9, A little 40.5, Quite a bit 32.4, Very much 8.1.

* Fear of another earthquake makes it hard to do ordinary things: Not at all 37.8, A little 35.1, Quite a bit 18.9, Very much 8.1.

* My interest in life has decreased: Not at all 27.0, A little 40.5, Quite a bit 24.3, Very much 8.1.

* I feel distant from people; I feel alienated from them: Not at all 32.4, A little 32.4, Quite a bit 29.7, Very much 5.4.

* It feels as though my emotions are dead: Not at all 40.5, A little 27.0, Quite a bit 27.0, Very much 5.4.

* I have difficulty sleeping: Not at all 35.1, A little 45.9, Quite a bit 16.2, Very much 2.7.

* I become irritated or angry more easily: Not at all 18.9, A little 40.5, Quite a bit 32.4, Very much 8.1.

* I’m forgetful or have difficulty concentrating on tasks: Not at all 24.3, A little 32.4, Quite a bit 29.7, Very much 13.5.

* I stay on alert with constant anxiety that an earthquake will occur: Not at all 37.8, A little 35.1, Quite a bit 21.6, Very much 5.4.

* I startle at sudden sounds or movements: Not at all 24.3, A little 51.4, Quite a bit 13.5, Very much 10.8.

* I feel distress when something reminds me of my earthquake experience: Not at all 16.2, A little 48.6, Quite a bit 21.6, Very much 13.5.

* I try to push thoughts and feelings about the earthquake out of my mind: Not at all 18.9, A little 45.9, Quite a bit 27.0, Very much 8.1.

* I have difficulty recalling some parts of what I experienced: Not at all 24.3, A little 45.9, Quite a bit 24.3, Very much 5.4.

* Making long-term plans feels meaningless: Not at all 13.5, A little 45.9, Quite a bit 27.0, Very much 13.5.

* Physical symptoms when reminded of the earthquake: Not at all 45.9, A little 27.0, Quite a bit 18.9, Very much 8.1.

* I feel guilty: Not at all 56.8, A little 27.0, Quite a bit 13.5, Very much 2.7.

* I feel sad and grief-stricken: Not at all 24.3, A little 45.9, Quite a bit 24.3, Very much 5.4.

* I can’t enjoy life as I used to: Not at all 29.7, A little 35.1, Quite a bit 18.9, Very much 16.2.

* I feel hopeless about the future: Not at all 35.1, A little 27.0, Quite a bit 27.0, Very much 10.8.

* Thoughts of killing myself cross my mind: Not at all 70.3, A little 21.6, Quite a bit 2.7, Very much 5.4.

* I have less energy to carry out my daily activities: Not at all 51.4, A little 21.6, Quite a bit 16.2, Very much 10.8.

In mass traumas that affect large segments of the population, the psychological sequelae of physically injured individuals are frequently overlooked by health care providers.Reference Matamela, Wyatt and Johnson ¹² The same applies to health care workers themselves. Following traumatic events, survivors often cannot return to routine daily life for extended periods due to physical and mental health conditions, and in addition to trauma, they face numerous economic, social, and legal challenges.Reference Drury and Reicher ¹³

Effects of the Earthquake on Hospital and Emergency Department Operations

In our survey, the most prominent management-related problem reported was staffing shortages (89.2%) and the resultant increase in workload. Shortfalls in supplies and medical equipment (70.3%) and communication problems between management and staff (67.6%) were other major issues, indicating that managerial challenges remain substantial across health facilities. Regarding non-physician personnel, the leading problem was again staff shortages (86.5%). Reassignment of personnel to other units (67.6%) and disruptions in onboarding/training (64.9%) were also notable. The post-earthquake psychological burden on staff appears to be translating into reduced job performance. Health facilities in the disaster area were also affected in terms of patient-care equipment. The most salient issue was delayed in maintenance and repair of existing devices (64.9%). There were significant gaps in user training as well. Although procurement has partially improved, persistent problems in maintenance and utilization continue to impede service delivery (Table 3).

Table 3.

Hospital administration, health care staff, and equipment management issues in the earthquake-affected region

Table 3. Long description

The table consists of four columns: Domain, Issue, n (frequency), and % (percentage). It is divided into three sections:

Section A: Hospital administration

* Increased workload due to staffing shortages: 33, 89.2 percent.

* Insufficient supply of materials and medical equipment: 26, 70.3 percent.

* Communication problems between management and staff: 25, 67.6 percent.

* Delays or uncertainties in decision-making processes: 24, 64.9 percent.

* Inadequate physical infrastructure: 22, 59.5 percent.

* Lack of post-earthquake psychological support mechanisms: 20, 54.1 percent.

* Lack of or inadequate implementation of emergency response protocols: 19, 51.4 percent.

Section B: Non-physician health care staff

* Staffing shortages in clinical units: 32, 86.5 percent.

* Redeployment of staff to other departments or areas: 25, 67.6 percent.

* Disruptions in onboarding or ongoing training of new or existing staff: 24, 64.9 percent.

* Decreased job performance due to earthquake-related psychological distress: 20, 54.1 percent.

* Irregular shift scheduling: 17, 45.9 percent.

* Workload distribution issues due to unclear role descriptions: 17, 45.9 percent.

* Teamwork problems due to communication and coordination gaps: 16, 43.2 percent.

Section C: Medical equipment management

* Delays in maintenance and repair of existing equipment: 24, 64.9 percent.

* Insufficient training on routine or use protocols for equipment: 15, 40.5 percent.

* Problems in inventory management and equipment distribution: 11, 29.7 percent.

* Inadequate suitability of newly supplied post-earthquake equipment: 10, 27.0 percent.

* Failure to replace equipment that became nonfunctional: 9, 24.3 percent.

Large-scale disasters require unified coordination led by experienced teams capable of rapid reaction.Reference Aldrich ^{14 ,} Reference Yilmaz, Tatliparmak and Karakayali ¹⁵ By the second year, this joint coordination in the affected regions was weaker than in the early phase. Regarding the resolution of management-related issues, only 5.4% of respondents reported that problems had been fully resolved, while 64.9% indicated that some issues had been addressed but major gaps remained, 24.3% believed most problems were still unresolved, and 5.4% reported that the situation was worsening. In terms of staff morale, 27.0% reported a significant drop in motivation and 54.1% a partial loss—collectively indicating that 81.1% experienced varying degrees of motivation loss, an important risk factor that may adversely affect care quality in the long term. Only 10.8% reported no change, while 8.1% noted an increase attributable to post-disaster solidarity.

Effects of the Earthquake on Emergency Department Operations

In the second year after the disaster, when examining physicians’ working conditions and professional issues, no pronounced concern was reported specifically about ED structural safety. As detailed in Table 4, however, 59.4% of respondents remain concerned about their hospital’s overall structural safety, whereas only 29.7% feel safe. Regarding refurbishment of ED physical spaces, 62.2% report partial renovations with persisting gaps, and 24.3% report no renovation or wholly inadequate upgrades.

Table 4.

Effects of the earthquake on hospital and emergency department operations

Table 4. Long description

The table contains four columns: Question, Response option, n, and Percent (%).

* Question 1: Two years after 6th February, do you have concerns about the structural safety of your hospital and E D?

- Yes—serious concerns: n=15, 40.5%.

- Yes, but safety issues have been partially improved: n=7, 18.9%.

- No—I feel safe: n=11, 29.7%.

- Undecided/insufficient information: n=4, 10.8%.

* Question 2: Two years after 6th February, how would you rate the renewal of E D physical spaces (building, rooms, equipment)?

- Fully renewed and adequate: n=5, 13.5%.

- Partially renewed, but gaps remain: n=23, 62.2%.

- Not renewed or wholly inadequate: n=9, 24.3%.

* Question 3: Two years after 6th February, how would you rate the layout and usability of the E D physical spaces?

- Organized and fit for our needs: n=3, 8.1%.

- Partly organized, needs improvement: n=24, 64.9%.

- Inadequate; the workspace is not suitable: n=10, 27.0%.

* Question 4: Two years after 6th February, how suitable are E D physical spaces for emergencies (earthquake, fire, evacuation plans)?

- Fully suitable: n=2, 5.4%.

- Partly suitable, but gaps exist: n=24, 64.9%.

- Not suitable: n=11, 29.7%.

* Question 5: If non-physician staff issues remain unresolved, what will be the impact on clinical services and patient care?

- Services will be adversely affected and quality will decline: n=31, 83.8%.

- Services will be harder to manage, but without major quality loss: n=4, 10.8%.

- I do not think there will be an impact: n=2, 5.4%.

* Question 6: Two years after 6th February, how do you assess the resolution of management-related problems you experienced?

- Problems fully resolved: n=2, 5.4%.

- Some problems resolved, but significant gaps persist: n=24, 64.9%.

- Most problems remain unresolved: n=9, 24.3%.

- Problems are worsening: n=2, 5.4%.

* Question 7: Two years after 6th February, what has been the impact of hospital operations problems on your (and colleagues’) work motivation?

- Major decrease: n=10, 27.0%.

- Partial decrease: n=20, 54.1%.

- No change: n=4, 10.8%.

- Increase in motivation: n=3, 8.1%.

ED: Emergency department.

With respect to layout and usability of work areas, the majority (91.9%) find the environment only partially organized or inadequate. Preparedness for emergencies shows a similar pattern: 94.6% state that physical spaces are only partially suitable—or not suitable—for emergency scenarios.

A notable finding is that 83.8% believe that, unless problems affecting non-physician staff are resolved, clinical services will deteriorate, and care quality will decline. Regarding the resolution of management-related issues, 64.9% perceive some progress but with significant deficiencies remaining, while 29.7% think most problems are unresolved or worsening. In terms of work motivation, 81.1% report severe or partial loss of motivation, and only 8.1% report increased motivation. Collectively, these results indicate that even after 2 years post-earthquake, hospitals and EDs still require substantial improvements and that staff morale remains adversely affected.

Within ED units, the most critical issue was structural safety problems, including building integrity concerns (83.8%), followed by equipment shortages and out-of-service equipment (67.6%) and the lack of appropriate staff break and social areas (67.6%). Insufficient patient room capacity was reported by nearly half of respondents (48.6%), and inadequate fire or earthquake evacuation plans were identified by more than one third (35.1%). Overall, marked deficits in the physical improvement of EDs persisted 2 years after the earthquake.

Effects of the Earthquakes on Residency Training in Emergency Medicine

The most prominent academic challenges identified in the disaster zone included disruptions to education and scholarly activities (51.4%), psychological strain among academic staff, and lack of suitable working environments (both 48.6%). Regarding teaching facilities, only 21.6% of respondents reported rooms fully adequate for didactic sessions, and although 56.8% indicated that theoretical teaching had returned to pre-earthquake levels, 37.8% still observed persistent gaps. A perceived decline in academic standards compared with non-affected provinces (40.5%) and disruptions in curriculum continuity (48.6%) further suggest that the quality of education in the affected region has not fully recovered.

In clinical emergency medicine practice, the most impacted domains were patient volume surges and crowding (70.3%), increased workload due to staffing shortages (67.6%), and inadequate physical space (56.8%). A decline in professional performance attributable to psychological trauma was also notable (48.6%). The most frequently proposed remedy was expansion of ED physical capacity (48.6%), followed by enhancement of education and professional development opportunities (24.3%) (Table 5).

Table 5.

Impact of the earthquake on residency training and emergency department practice in the affected region

Table 5. Long description

The table is organized into four columns: Domain, Issue/status, n, and percent.

Domain A: Academic enterprise challenges.

- Disruptions to education: 19, 51.4 percent.

- Psychological strain among staff: 18, 48.6 percent.

- Lack of suitable working environments: 18, 48.6 percent.

- Shortage of academic staff: 15, 40.5 percent.

- Ambiguity in role definitions: 14, 37.8 percent.

- Communication problems: 13, 35.1 percent.

- Suspension of research: 12, 32.4 percent.

Domain B: Training facilities.

- Rooms fully adequate: 8, 21.6 percent.

- Rooms partially adequate: 25, 67.6 percent.

- Rooms inadequate: 4, 10.8 percent.

Domain C: Current state of didactic teaching.

- Returned to pre-earthquake level: 21, 56.8 percent.

- Partially recovered: 14, 37.8 percent.

- Not yet recovered: 2, 5.4 percent.

Domain D: Deficiencies in theoretical teaching.

- Disruptions in curriculum: 18, 48.6 percent.

- Decline in academic standards: 15, 40.5 percent.

- Limitations in methodologies: 11, 29.7 percent.

- Shortages in materials: 8, 21.6 percent.

- Insufficiencies in content: 7, 18.9 percent.

- Decrease in instructors: 5, 13.5 percent.

Domain E: Impact on E D practice.

- Surge in patient volume: 26, 70.3 percent.

- Increased workload: 25, 67.6 percent.

- Inadequate physical space: 21, 56.8 percent.

- Decline in performance due to trauma: 18, 48.6 percent.

- Procurement problems: 15, 40.5 percent.

- Logistical challenges: 13, 35.1 percent.

- Managing trauma conditions: 10, 27.0 percent.

- Communication issues: 10, 27.0 percent.

- Reduced development opportunities: 9, 24.3 percent.

Domain F: Proposed solutions for E D practice.

- Expand physical capacity: 18, 48.6 percent.

- Enhance development opportunities: 9, 24.3 percent.

- Effective coordination system: 5, 13.5 percent.

- Increase equipment supply: 3, 8.1 percent.

- Strengthen psychosocial support: 2, 5.4 percent.

Overall, these findings demonstrate substantial shortcomings in both clinical and educational processes 2 years after the disaster, indicating that recovery in the affected region remains incomplete.

Roles and Responsibilities for Professional Associations

The most prominent expectations for professional associations were supporting training programs (54.1%) and establishing psychosocial support mechanisms (48.6%). Providing resources and forming volunteer health care teams were also highlighted as important duties (both 40.5%). EMAT’s post-earthquake activities were rated as “very effective and successful” by 29.7% of respondents, while 54.1% found them partly effective but with gaps. Regarding communication, the leading recommendation was to issue more frequent updates and maintain active engagement with members (78.4%) (Table 6).

Table 6.

Roles, evaluation, and communication expectations for professional associations in disaster-affected regions

Table 6. Long description

The table consists of four columns: Domain, Item, n, and percent. It is divided into three sections.

Section A: Expected tasks for specialty associations.

- Support training and education programs: n equals 20, 54.1 percent.

- Establish psychological support mechanisms: n equals 18, 48.6 percent.

- Provide resources (equipment/medications/financial support): n equals 15, 40.5 percent.

- Form volunteer health care teams: n equals 15, 40.5 percent.

- Develop policy and national/international recommendations: n equals 14, 37.8 percent.

- Organize awareness campaigns: n equals 14, 37.8 percent.

- Conduct research and share data on post-earthquake health impacts: n equals 14, 37.8 percent.

Section B: Evaluation of E M A T’s post-earthquake activities.

- Very effective and successful: n equals 11, 29.7 percent.

- Partly effective, but with gaps: n equals 20, 54.1 percent.

- Not sufficiently effective; major shortcomings: n equals 5, 13.5 percent.

- Not effective at all; failed to fulfill its role: n equals 1, 2.7 percent.

Section C: Communication recommendations.

- Provide more frequent updates; maintain active communication: n equals 29, 78.4 percent.

- Current efforts are sufficient: n equals 8, 21.6 percent.

Discussion and Recommendations

The initial impact of earthquakes on societies typically arises from the destruction of structural environments, and the safety of physical infrastructure is one of the most critical determinants of vulnerability in disasters. Earthquakes frequently result in loss of life and extensive damage to buildings, critical facilities, lifelines, transportation networks, and the environment.Reference Yilmaz ¹⁶ High-impact seismic events over the past few decades—including those in San Francisco (1989), Wenchuan (2008), Haiti (2010), and Japan (2011)—have underscored the persistent need for robust risk reduction and resilience methodologies.Reference Liu, Gu and Zhang ^{17 ,} Reference Park, Seager and Rao ¹⁸ An additional issue is that health care workers are often required to provide medical care in environments that have themselves been compromised by structural damage and where safety remains uncertain.Reference Yilmaz, Tatliparmak and Ak ^{19 ,} Reference Şenol Balaban, Doğulu and Akdede ²⁰ According to Legal Aid at Work guidelines, every employer is legally obligated to ensure that employees work within a healthy and safe environment. ²¹

From an ED perspective, our findings indicate that both EPs and EMRs expressed concerns regarding residential security and the structural safety of health care facilities. Accordingly, we recommend that:

• • Permanent housing solutions are developed to address the accommodation needs of health care workers in earthquake-affected regions,

• • Secure and high-quality residential projects be established specifically for EPs and EMRs,

• • The structural safety standards of EDs are regularly assessed and strengthened, when necessary,

• • Physical workspaces be redesigned to improve functionality, and modernization initiatives be supported and accelerated,

• • The structural integrity of hospitals in affected regions is subject to periodic inspections by expert teams, and the resulting reports are shared transparently with EPs and EMRs. Such inspections should be conducted not only in disaster zones but also in unaffected regions to ensure preparedness and resilience. Lessons from the February 6 earthquakes emphasize that structurally safe health care facilities are essential to disaster resilience.

Disaster management is a comprehensive and integrated process encompassing the planning and execution of both proactive and reactive measures.Reference Civaner, Vatansever and Pala ²² Although preparedness forms the foundation of disaster management, the scale of destruction that follows major disasters often leads to a shift toward crisis management, which in many countries remains under the authority of the same leadership that experienced the disaster firsthand. These leaders are often disaster victims themselves. Therefore, based on the findings of this report, we recommend for health care system management in disaster zones that:

• • Hospital administrations are restructured post-disaster, and rehabilitation processes are implemented for disaster-affected leaders,

• • Regular coordination meetings and communication channels are established to strengthen alignment between the Ministry of Health and university administrations,

• • A crisis management protocol is developed to enhance inter-stakeholder collaboration in the post-disaster delivery of health care services.

Any event that disrupts the established balance of life may result in psychological trauma. A traumatic event is defined as exposure to actual or threatened death, serious injury, or a threat to one’s physical integrity or that of others, accompanied by emotional responses such as fear, horror, or helplessness.Reference Farooqui, Quadri and Suriya ²³ Earthquakes, characterized by sudden and severe experiences of death, injury, and drastic deterioration of living conditions, constitute disasters where multiple forms of trauma emerge simultaneously and at high intensity. This generates a unique field of vulnerability at both individual and societal levels. To address this psychological burden, we recommend:

• • Regular psychosocial support services are provided to EPs and EMRs, given the high prevalence of post-disaster mental health problems,

• • Specialized programs are established to support EPs and EMRs in processing their grief and accessing psychosocial care.

Earthquakes not only disrupt daily life but also significantly interfere with academic activities, including medical education. Postgraduate training in medical specialties, including EMRs residency programs, is similarly affected. This report, supported by the Coordination Council of the Turkish Medical Association Specialty Societies, highlights the impact on residents in affected regions. Based on our findings, we recommend the following for emergency medicine specialty training:

• Theoretical curricula in EMRs residency programs are updated, and deficiencies in post-disaster educational materials are addressed,

• Academic workforce shortages be resolved, and efforts be made to recruit and retain qualified academic staff in disaster-affected regions,

• Continuous professional development be supported through online training platforms and webinar-based educational programs to maintain educational quality.

Limitations

This study was conducted as a cross-sectional survey approximately 2 years after the earthquakes. The sample was selected using a non-probabilistic approach and consisted largely of EPs and EMRs from 3 severely affected provinces (Kahramanmaraş, Adıyaman, and Malatya). Due to the limited number of EPs and EMRs working in these regions, only a small number of participants could be included. Although the sample size was relatively restricted, 70.3% of respondents were residents, which may have led to underrepresentation of the perspectives of attending physicians and academic faculty. TSSC was analyzed only at the item level, without calculating total or subscale scores or applying diagnostic cut-off values. This approach limits comparability with existing literature and prevents diagnostic interpretations. Moreover, missing responses were assumed to be missing at random; however, this assumption may not hold true in all cases. Participant responses were clustered within specific hospitals and provinces, but clustering effects were not statistically modeled. This may have resulted in narrower confidence intervals or biased estimates. The survey covered multiple domains—such as family life, psychosocial effects, operational issues, and education—through brief items. Constructs such as burnout, workload, or medical device functionality should be evaluated in future studies using more in-depth and psychometrically validated scales.