Background: The tsunami of 26 December 2004 was responsible for the infliction of widespread death and injury across many countries bordering the Indian Ocean. In Krabi province, southern Thailand, the main provincial hospital ultimately received the bulk of the province's injured survivors including many tourists from outlying islands and beaches. This study aimed to observe the natural history of injuries and evolution of pathology following the effects of the Asian tsunami in Krabi province, with a view to gaining better understanding of the types of medical challenges that may follow in the wake of such events. Methods: A retrospective audit of patients' case notes from tsunami-related presentations and subsequent follow-up was gathered. Demographics and nature of injuries were collected and simple descriptive statistics were employed. Results: The majority of injuries at the time consisted of deep lacerations, fractures and aspiration syndromes and, over the first week, 1357 trauma victims were treated. Over the following weeks, public health issues were of great concern and psychiatric conditions were becoming increasingly evident, particularly depressive illnesses and post-traumatic stress disorder. Unusual pathogens were causing complicated, polymicrobial wound infections and pneumonic conditions. The non-Thai injured were continuing to return home to their own countries - 44 nations had people affected in this small geographical area. As the 1-year anniversary drew close, it was evident that mental health issues were the lasting testament to the waves, not physical injury. Conclusions: As time progresses from the tsunami, the anatomical, physiological and microbial pathology has healed but the remaining social and mental pathology will be the longest lasting effect from the tsunami, the ripples of which will be felt for many years.