On April 8, 2026, a series of large-scale airstrikes struck Lebanon, killing at least 254 people and injuring 1,165 others. The Lebanese American University Medical Center-Rizk Hospital, located in central Beirut, received 2 distinct waves of casualties totaling 42 patients: 28 red, 9 green, and 5 deceased. This report describes the hospital's emergency preparedness plan (EPP) response and examines challenges encountered across 3 sequential mass casualty incidents at the same institution: the Beirut Port Explosion (2020), the Pager Explosion (2024), and the April 2026 airstrikes. Each prior activation was formally debriefed, and its lessons incorporated into successive EPP revisions. The April 8 response exposed persistent and newly identified vulnerabilities: unassigned trainees accumulating in the red zone, premature code deactivation prior to a second casualty wave, surgical resident resource constraints, and the absence of a regional interfacility transfer network. Iterative debriefing and plan revision can produce an evolving EPP.

INTRODUCTION:Actors in conflict, those in asymmetric warfare, conducting criminal activity or participating in paramilitary training activities may possess explosive ordnance. For various reasons this ordnance can misfire resulting in failure to detonate and become impaled or embedded in those near an intended target. The management of the patient with an impaled or embedded unexploded ordnance (eUXO) is a high impact event with the potential to cause death of those in proximity and destruction of the health care facility. The probability of this event is low with less than 50 cases reported in the literature. The objective of this study is to use a modified Delphi approach to produce statements to develop treatment guidelines of the eUXO patient in low-resource settings without explosive ordnance disposal team (EOD) assets. MATERIALS AND METHODS:Fifty-three statements were derived from authoritative texts and a PRISMA-Scoping review through an iterative process by the authors. Included experts rated their agreement with each statement on a 7-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤1. Statements attaining consensus after the first and subsequent rounds moved to the final report. Statements that did not attain consensus moved to the next round and this process repeated for 3 rounds. The remaining statements did not attain consensus. The University of South Florida Institutional Review Board determined that this study met the criteria for exemption. RESULTS:After the 37 experts first, 35 experts second, and 33 experts third round, 29 statements attained consensus, and 24 statements did not attain consensus. CONCLUSIONS:Although agreement was reached on key safety, transport, and training principles, uncertainties remain on how best to weigh clinical priorities to manage an eUXO patient to reduce the risk of detonation without available EOD assets in low-resource settings.

There is a lack of ethical triage and treatment guidelines for the entrapped and mangled extremity (E&ME) in resource scarce environments: mass casualty incidents, low- to middle- income countries, complex humanitarian emergencies including conflict, and prolonged transport times (RSE). The aim of this study is to use a modified Delphi (mD) approach to produce statements to develop treatment guidelines of the E&ME in RSE to advance the 2021 WHO EMT Minimum Standards (EMT) treating the E&ME. Experts rated their agreement with each statement on a 7- point linear numeric scale. Consensus amongst experts was defined as a standard deviation <= 1. Statements attaining consensus after the first round moved to the final report. Those not attaining consensus moved to the second round in which experts were shown the mean response of the expert panel and their own response for the opportunity to reconsider their rating for that round. Statements attaining consensus after the second round moved to the final report. This process repeated in the third round. Statements attaining consensus moved to the final report. The remaining statements did not attain consensus. Seventy-seven experts participated in the first, 75 in the second, and 74 in the third round. Twenty-three statements attained consensus. Twenty-one statements did not attain consensus. A Delphi technique was used to establish consensus regarding the numerous complex factors influencing treatment of the E&ME in RSEs. Twenty-three statements attained consensus and can be incorporated into guidelines to advance the EMT treating the E&ME.

Objective The scoping review aims to provide an overview of the existing literature to inform an understanding of pharmacists' roles, skills, and knowledge requirements for Emergency Medical Teams responding to disasters or humanitarian crises.Methods The methodology utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines, with methodology adapted by the Joanna Briggs Institute. Six databases were searched for sources published after 2000: PubMed, Mednar, Scopus, Defense Technical Information Centre, LILACS, and CINAHL. A manual search of grey literature was conducted to discover additional sources of information outside of the electronic databases.Results Of the 427 initial studies and reports, 36 were selected for inclusion. Five key themes on role requirements were identified: supply chain management; establishment and operationalization of pharmacies; stakeholder communication, collaboration, and liaison; direct patient care; and response management and coordination. Each theme was delineated into subthemes linked with requisite skills and knowledge.Conclusions This scoping review identifies key roles, skills, and knowledge requirements of pharmacist contributions to Emergency Medical Teams responding to disasters or emergencies.

Objective To quantitatively assess key performance indicator changes between selected pre-pandemic and pandemic periods at the Sant’Anna Hospital emergency department (ED) in Como, Italy through the retrospective use of Hospital Surge Preparedness and Response index (HSPRI). Methods This study collected the average length of stay (LOS), time-to-physician initial assessment (TPIA), and left-without-being seen (LWBS) rates for 2 pre-pandemic (control group) and 3 pandemic periods (study group) in the COVID ED (C-ED) dedicated to treat COVID-19 patients and the non-COVID ED (NC-ED) dedicated to non-COVID cases. Quantitative analysis was based on hypothesis testing. A retrospective qualitative theme and subtheme analysis based on the HSPRI was conducted on baseline strategies before each pandemic period and on the actions implemented thereafter. Results LOS increased across all pandemic periods. TPIA decreased in the first 2 pandemic periods in comparison to pre-pandemic. LWBS decreased between pre-pandemic and pandemic periods. Of the 22 action items listed in the HSPRI, 8 were implemented in the first pandemic period, 8 in the second and 1 in the third, for a total of 17 items. Conclusions The HSPRI demonstrated value as a tool for a hospital staff to actively utilize during a pandemic to identify KPI triggers to formulate actions to maintain pre-pandemic care or ameliorate the deterioration of care during the pandemic.

BackgroundThere is a lack of ethical triage and treatment guidelines for the entrapped and mangled extremity (E&ME) in resource-scarce environments (RSE): mass casualty incidents, low- to middle-income countries, complex humanitarian emergencies including conflict, and prolonged transport times (RSE). The aim of this study is to use a modified Delphi (mD) approach to produce statements to develop treatment guidelines of the E&ME in RSE.MethodExperts rated their agreement with each statement on a 7-point linear numeric scale. Consensus amongst experts was defined as a standard deviation <= 1. Statements attaining consensus after the first round moved to the final report. Those not attaining consensus moved to the second round in which experts were shown the mean response of the expert panel and their own response for the opportunity to reconsider their rating for that round. Statements attaining consensus after the second round moved to the final report. This process was repeated in the third round. Statements attaining consensus were moved to the final report. The remaining statements did not attain consensus.ResultsSeventy-seven experts participated in the first, 75 in the second, and 74 in the third round. Twenty-three statements attained consensus. Twenty-one statements did not attain consensus.ConclusionA modified Delphi technique was used to establish consensus regarding the numerous complex factors influencing treatment of the E&ME in RSEs. Twenty-three statements attained consensus and can be incorporated into guidelines to advance the ethical treatment of the E&ME in RSEs.

In sudden-onset industrial disaster, responding effectively to a mass casualty incident (MCI) requires more than clinical readiness; it demands the integration of multiple regulatory frameworks and standards. In the context of an industrial disaster, the International Organization for Standardization 45001 will provide parameters for the creation of the response plan. In addition, the utilization of the Major Incident Medical Management and Support operational framework will expand the complex industrial interagency response. These should be components of the local MCI response plan, which has proven successful worldwide to enhance the capacity and capabilities in responding to complex emergencies.From a policy analysis perspective, the complexity and far-reaching consequences of industrial sudden onset disasters underscore the importance of implementing coordination mechanisms that bring together management systems and operational benchmarks. To build essential competencies among first responders, first receivers, and industrial workers, modular simulation exercises focusing on specific risk management and MCI response components are essential.

OBJECTIVE:Hospitals are under constant threat from internal and external hazards. A fire can cause substantial structural damage that necessitates evacuations which can compromise care. The objective of this study is to assess the lived experiences of the Wexford General Hospital Staff who responded to the fire to learn how to improve an Irish Hospital Fire Protection System. METHOD:This Hermeneutic Phenomenological research study was conducted through focus group discussions and structured interviews. Hospital staff who volunteered to participate in the study must have worked on the day or night shift of the incident. RESULTS:Discussion contents review yielded codes and themes, drawn into positive and negative lived experiences. Two main themes emerged: Positive Themes = Luck, Leadership, Level-headed, Liaison, Look-back and Learn (L5); Problem Themes = Alarms, Begrudge, Communication, Directive, Emergency Plan, Flow (ABCDEF). CONCLUSIONS:The Hermeneutic Phenomenology methodology utilized in this study specifically learning from the lived experiences of those who were on duty during the WGH fire can improve the fire protection system at hospitals based on the knowledge gained encompassed in the L5 and ABCDEF findings.

Public education in effective interventions for external hemorrhage control for gunshot wounds has become a priority focus. There remains a gap in training programs of populations of non-medical bystanders who would be the first to stop this bleeding in a mass shooting. To create a WHO EMT initiative community training program designed to close this gap in low-middle income countries, complex humanitarian events and in conflict zones. This study is a factorial randomized control study, utilizing four cohort groups. Two comprised of bystanders with no previous medical training, and the remaining two comprised of first responders previously trained to control external hemorrhage. Each group was put through the same hemorrhage control simulation; one cohort of each bystander/first responder groups acted as a respective control group receiving only a tourniquet, whereas other cohorts of each group received Stop-the-Bleed® handouts to serve as the point-of-care instructional method of Just-in-Time training alongside the tourniquets. Within the bystander’s cohort, 26.3% of the group who received JiT training applied the tourniquet correctly vs 6.3% of the control group. Of the first responder’s cohort, 75% of those who received JiT training applied the tourniquet correctly vs 66.7% of the control group. There was no statistically significant difference in the ability to correctly apply the tourniquet in the intervention vs control groups of either cohort. The WHO EMT initiative has the opportunity to train non-medical bystanders to receive Just-in-Time training to effectively place a tourniquet to stop the bleeding after a mass shooting.

Terrorist attacks involving children raised concern regarding the preparedness to treat pediatric trauma patients during mass casualty incidents (MCIs). The purpose of this project was to assess the resources available in Milan to respond to MCIs as the 2016 Bastille Day attack in Nice. Literature and guidelines were reviewed and minimal standard requirements of care of pediatric trauma patients in MCIs were identified. The hospitals that took part in the study were asked to answer a survey regarding their resource availability. An overall surge capability of 40-44 pediatric trauma patients was identified, distributed based on age and severity, hospital resources, and expertise. The findings showed that adult and pediatric hospitals should work in synergy with pediatric trauma centers, or offer an alternative if there is none, and should be included in disaster plans for MCIs. Simulations exercises need to be carried out to evaluate and validate the results.

In recent years, public authorities and rescue services have been discussing how Medical First Responders (MFRs) should behave in an Active Violent Incident (AVI) where it is necessary to weigh up self-protection and the rescuing of others. The aim of this exploratory study is to generate a preliminary picture of how European MFRs position themselves on this and related questions. With the help of a network of experts, an AVI scenario and accompanying questionnaire were developed and pretested. A refined version was then distributed among MFRs in eight European countries and Israel. We performed descriptive statistics and tested for significant differences among the participating countries. 1164 MFRs completed the survey. In the absence of police protection, a majority of respondents opted against providing immediate casualty care (56.6 %). Under certain circumstances, however, the rest decided in favour. More than 65.5 % did not fear disciplinary or legal consequences for not providing assistance immediately. Even with police protection, one in ten respondents would still not enter a "yellow zone", one in four would leave this to Emergency Medical Services (EMS) units specifically trained for such operations. While there are very few strong contrasts between MFRs with different work experience, roles (supervisor/instructor) or additional qualifications (e.g., firefighting, military service), there are significant differences between MFRs from participating countries. Most notably, (1) only Norwegian participants identified, on average, a clear paradigm shift from "safety first" to "controlled risk taking"; (2) while 69.8 % of the Austrian cohort were unwilling to enter without being escorted by the police, among Norwegians MFRs the figure was 42.7 %; (3) the question whether "weapons" are "useful" equipment in such a scenario is particularly divisive (ranging from 14.3 % of German to 58.9 % of Israeli respondents). Although most of the questions were answered in the same way by a large majority, significant differences can be observed, especially between countries. We offer various explanations for these and discuss whether MFRs can actually remain passive given the situational normative forces inherent to an AVI.

On September 17, 2024, at 15:30 local time, thousands of pagers used by members of a specific party group detonated across Lebanon. As a result of the explosions, 2800 were wounded and 12 lost their lives. Almost two-thirds of the injuries were in the face, eyes, or hands. The Lebanese American University Medical Center received 38 injured and admitted 36 patients, 13 of them to the Intensive care unit. A total of 33 patients needed surgeries. All medical and nursing staff were deployed. The health care workers faced major challenges that night: the severity of the injuries and the unprecedented types of injuries with the same pattern, and the urgent need for ophthalmology and orthopedics within the hospital and across the country. Learning from the Pager Explosion, each hospital should perform assessments of their disaster response plan, develop trainings, and conduct regular exercises in preparation for future disasters.

Objective: Mass casualty incidents (MCIs) come unannounced, mandating the immediate shift from the daily routine to crisis mode through the implementation of an MCI response plan (plan). On August 4, 2020, a massive explosion devastated the Lebanese capital, Beirut, causing 8643 injuries and 200 deaths.1 The private Lebanese American University Medical Center in Beirut has an an estimated 10,000 emergency department (ED) visits per year. The purpose of this study is to analyse the plan of this private hospital in a low resource country in response to a blast MCI. Methods: A retrospective analysis of the expected outcome of the pre-existing plan was performed. Results: Major flaws were noted. Triage was impossible using the START method and will be done outside the ED dividing patients into walking and non-walking. Identification and registration of patients was impossible. Patients will be assigned a number and be registered later. Colored jackets were created to recognize response team members for better organization.t Radiologic imaging will be ordered only when they change the patients' disposition. Conclusion: This analysis showed failure of the plan at different levels and adjustments were made to advance the plan. Periodic exercises and annual review are needed for continuous improvement.

Earthquakes cause the majority of deaths related to natural disasters. Explosions, floods, and other causes of building collapse are responsible for the majority of fatalities. The age of the patient, comorbid conditions, concomitant injuries, and the time from injury to initial care and subsequent delay between disaster and admission to health care facilities with hemodialysis capacity and capability can affect the outcome. The earlier that intravenous therapy by first responders and first receivers to alkalinize the urine is initiated, the better the chance of preventing acute renal failure. The ethical triage and treatment of the entrapped and mangled extremity require a collaborative approach from extrication through transportation to definitive care to include engineers and medical personnel specifically familiar with crush injury in the setting of multiple trauma. There are no guidelines for field amputation of the entrapped extremity, though scene safety is paramount for the injured and first responders. Rescue teams are advised to develop parameters with inclusion of the patient/family/patient advocate in treatment decisions. Damage control surgery in resource-scarce environments with temporary vascular shunts have been shown to improve clinical outcome. Careful documentation from the scene through transport to alternate medical posts or definitive care is recommended to include response to treatment, warm ischemia time, change in pain, onset of paresthesia, among other subjective and objective findings of a crush injury and mangled extremity.

Objectives: The SDMPH 10-year anniversary conference created an opportunity for a researcher to present at a professional association conference to advance their research by seeking consensus of statements using Delphi methodology. Methods: Conference attendees and SDMPH members who did not attend the conference were identified as Delphi experts. Experts rated their agreement of each statement on a 7- point linear numeric scale. Consensus amongst experts was defined as a standard deviation < = 1. Presenters submitted statements relevant to advancing their research to the authors to edit to fit Delphi statement formatting. Statements attaining consensus were included in the final report after the first round. Those not attaining consensus moved to the second round in which experts were shown the mean response of the expert panel and their own response for opportunity to reconsider their rating for that round. If reconsideration attained consensus, these statements were included in the final report. This process repeated in a third and final round. Results: 37 Experts agreed to participate in the first round; 35 completed the second round, and 34 completed the third round; 35 statements attained consensus; 3 statements did not attain consensus. Conclusions: A Delphi technique was used to establish expert consensus of statements submitted by the SDMPH conference presenters to guide their future education, research, and training.

OBJECTIVE:While many medical practitioners value the interactive nature of in-person conferences, results of these interactions are often poorly documented. The objective of this study was to pilot the Delphi method for developing consensus following a national conference and to compare the results between experts who did and did not attend. METHODS:A 3-round Delphi included experts attending the 2023 Society of Disaster Medicine and Health Preparedness Annual Meeting and experts who were members of the society but did not attend. Conference speakers provided statements related to their presentations. Experts rated the statements on a 1-7 scale for agreement using STAT59 software (STAT59 Services Ltd, Edmonton, Alberta, Canada). Consensus was defined as a standard deviation of ≤ 1.0. RESULTS:Seventy-five statements were rated by 27 experts who attended and 10 who did not: 2634 ratings in total. There was no difference in the number of statements reaching consensus in the attending group (26/75) versus that of the nonattending group (27/75) (P = 0.89). However, which statements reached consensus differed between the groups. CONCLUSION:The Delphi method is a viable method to document consensus from a conference. Advantages include the ability to involve large groups of experts, statistical measurement of the degree of consensus, and prioritization of the results.

On September 17, 2024, an unforeseen attack due to the Pagers Explosion targeting a military party in Lebanon left more than 2750 casualties. A total of 38 injured patients presented to the Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), a private university hospital. Most injuries were amputated fingers and eye injuries. Intensive training and regular drills are conducted at the hospital level to ensure readiness. This report highlights major challenges that were encountered during this explosion and provides possible strategies to overcome them.