Discussion

The Lebanese people have ample experience with explosions and dealing with injuries. After the Port of Beirut Blast on August 4^th, 2020, the hospital administrators and medical personnel lived a terrible experience which prepared them for future disasters.Reference Helou, El-Hussein and Aciksari⁴ After this experience, all Lebanese hospitals revised and updated their disaster response plan. A mass casualty management training was conducted by the Ministry of Health and the World Health Organization to reinforce the adequate response to mass casualty incidents.⁵ These three-day hands-on trainings were conducted in Lebanese hospitals all over the country. An assigned team representative from each hospital was sent to attend the training; afterwards, the representatives trained the rest of the hospital staff at their respective hospitals.

Bystanders and the Lebanese Red Cross played a major role in the initial response and in the transport of the injured to hospitals across the country. The Red Cross is a humanitarian organization, and they are the main providers of ambulances in the country.⁶ They are volunteers whoreceive regular trainings to be able to respond to emergencies and disasters.⁶ Services are managed through a radio communication system from four central operation rooms.

The health care workers faced major challenges the night of the Pager Explosion. The disaster response plan is designed for “all-hazards,” or the most common disasters. The Pager Explosion was an unprecedented event, with a high number of casualties that had the same pattern of injuries. Triage is a crucial part of a sudden onset disaster mass casualty incident response; with a high number of casualties arriving in a short period to a small space, the only means to adapt is with a rapid and effective sorting process. More than 99% of the injured were triaged (sorted) into the red category, indicating the need for immediate dedication of resources, which is not commonly seen in explosions. All these patients were admitted inside the 17 bed LAUMC Emergency Department, which is the red zone. There were five patients in the Emergency Department when the first patient injured in the Pager Explosion arrived. These patients were immediately evacuated to the wards, specifically to the sixth floor of the hospital, to be discharged later on. The case manager played a major role in transferring the injured to the wards as fast possible. At the same time, all patients in the ICU deemed transferrable by the ICU team were transferred to a regular ward to allow more room for the receiving of injured patients. After initial stabilization and primary survey, most patients in the emergency department required urgent brain imaging due to the nature of injuries. Radiologists and trainees were available on site for immediate reading. The Computed Tomography (CT) scan machine available in the Emergency Department was used for high acuity unstable patients while the Radiology Department CT scan was used for lesser acuity cases. For some patients, imaging occurred after transfer to ward.

Another challenge was the high number of casualties that needed ophthalmologic and orthopedic surgeries. Most of the ophthalmology and orthopedic surgeons at LAUMC worked on a full-time basis at the hospital and were immediately called in to the operation room. The part time surgeons were called to nearby medical centers where they performed surgeries all night long. On that night, the orthopedics and ophthalmology team sent a physician to join an anesthesiologist inside the LAUMC Emergency Department red zone and the intensive care unit to assess the priority for surgeries, determine whether a patient’s eye or the fingers/hands could be saved, and then prioritize transfer to the Operating Room (OR) accordingly. With eight operating rooms, all surgeries could not have been performed on the same day. By the third day, all surgeries were done. In addition to the manpower limitation, surgical instruments for ophthalmological surgeries were available for only three rooms, limiting the number of simultaneous ophthalmological surgeries. Another characteristic limitation was the inability to provide patients and their families with immediate answers regarding expected long-term disability in sight and function. The salvageability of the eyes and limbs were the main factor for transfer to OR.

Learning from the Pager Explosion, each hospital should perform an assessment of their disaster response plan. Every disaster provides an opportunity to improve the process of increasing resources and meeting the demands presented. Specific staff and equipment may be needed to meet the unique nature of the disaster. Systems, physical space, and other structures may be required to satisfy the challenges presented by a disaster that could not have been expected. Then, hospitals can develop education, trainings, and conduct regular exercises incorporating these lessons in preparation for future disasters.