The pager explosions: lessons learnt from a hybrid-warfare mass casualty incident

Hospitals responding to mass casualty incidents (MCIs) must rapidly scale up operations to accommodate high casualty counts, with little lead time. On 17 September 2024, 4000 pager devices were detonated across Lebanon, injuring 2323 individuals. This paper reports on a single-centre MCI response to this unprecedented hybrid warfare tactic, describing success features and identifying areas for improvement.

A qualitative analysis of 10 debrief meeting minutes held within 2 weeks of the incident, as part of the standard quality improvement process post-MCI response that included an after-action review conducted in accordance with the 2019 WHO guidelines. Group-based debriefs, facilitated by the emergency department (ED) chairperson, addressed different response elements and engaged relevant stakeholders. Conclusions were derived from the qualitative analysis of the meeting minutes.

Our hospital received 182 casualties, 66% of whom were triaged to urgent-level care (yellow), 21% to delayed-level care (green) and 13% to immediate-level care (red), with 35 requiring emergent surgery within the first 12 hours. The MCI response was activated 34 min postincident, initiating security lockdown protocols, expedited patient registration, MCI triage protocol implementation, opening of surge areas and command centre activation. Key success features included: shifting from ED-based response to a whole-hospital mobilisation to accommodate the influx; early secondary triage of urgent-level (yellow) patients for immediate transfer to inpatient wards, resulting in 22.5% being managed in the inpatient setting; and optimised information system workflows for admission and order entry. Recommended improvements include simplifying operating theatre transfer workflows, shifting to paper-based documentation of assessments/interventions, optimising surgical and diagnostic prioritisation processes and developing minimal diagnostic imaging standards of care.

This study highlights key successes and challenges of a hospital response to a large hybrid-warfare MCI. Future research on reliability of key success features, specifically use of ED secondary triage protocols, is needed to support wider adoption. In addition, developing minimal imaging standards in MCIs is needed to reduce bottlenecks in this area.