Discussion
This study describes Beirut blast patients’ injury characteristics and clinical outcomes across 16 major hospitals in Lebanon. It further assessed hospitals’ preparedness and response plans during an MCI. Synthesized findings from this study are critical to understanding AN-related injury characteristics and patterns, particularly in urban settings, with the aim to inform protocols for hospitals to improve their response strategies, especially in low-income and middle-income countries.
Throughout history, more than 30 AN-related explosions occurred globally, with varying strengths and outcomes, namely in Oppau (Germany, 1921), Texas (USA, 1947), and Tianjin (China, 2015).3 16 Contrary to the Beirut blast epicenter, the majority of these blasts happened in industrial settings and transportation sites.3 The central location of Beirut port and its proximity to the residential neighborhood resulted in the elevated number of casualties, with over 50% of the victims included in the first stage.
Consistent with the injury patterns reported in other open-air and urban MCIs, non-critical injuries were prevalent among Beirut blast victims.17 18 Collectively, the blast location, surge, and hospital management explain the relatively high rate of outpatients and immediate deaths. Yet, several studies suggested that the explosion’s timing amidst COVID-19 restrictions and after working hours (ie, 18:08), and the open-air setting limited the damages. Moreover, the massive grain silos bordering the stored AN, and the widespread concrete structures and residential homes across the Beirut metropolis absorbed the propagation of the blast shock wave and limited its impact on casualties’ severity.19 20
Mildly injured victims were able to reach the hospitals first and unassisted (spontaneous evacuations), explaining outpatients’ immediate surge. One study suggested that the first wave of mild casualties delayed the care for later-arriving severe injuries, plausibly explaining the high toll of death on arrival and within the first 24 hours.3 Nevertheless, as in other MCIs like 9/11 and the Oklahoma City bombing, most deaths occurred near ground zero and thus were excluded due to delayed extrication.18 21 The gradual drop in the death rate and the ≈3% postoperative death rate, which is comparable to USA’s ratio (0.57% to 2.1%), corroborates the proficiency of the medical staff.22 Besides the sparse critical patients, the latter justifies the relatively low hospital LOS compared with that of the Madrid bombings.18
Consistent with existing literature, secondary injuries are the leading cause of injuries in the Beirut blast17 21 23 24 due to the open-air blast nature, where secondary injuries constituted 84% of the Tianjin explosion’s injuries. Urban explosions, like the Oklahoma City bombing and the Beirut blast, notably reported secondary injuries due to propelled shrapnel fragments from windows and damaged building structures, particularly from unlaminated glass, causing lacerations and penetrating injuries.3 25 As reported in the current study, secondary injury settings commonly impacted the head, face, and extremities, and occasionally required hospitalization and operations, notably neuro-operations and extremity operations.3 24 The chaos and attention-grabbing initial explosion at the Beirut port few minutes before the massive blast, ignited individuals’ curiosity to move closer to residential windows and balconies instead of seeking protection before the onset of the second massive explosion, worsening victims’ injuries.26 In addition, victims’ exposure contributed to a number of secondary concussions as a result of flying objects from the overpressurized wave.27 Although the CDC claims that secondary blast injuries are the primary cause of death during a blast, this study did not show such an association.28 A plausible explanation is that the medical staff might have overlooked the process of identifying and documenting secondary blast injuries of patients suffering from additional severe injuries, such as blast lungs and fractures.
Similar to other AN explosions like in Tianjin and West Texas, this study revealed that tertiary blast injuries were common among Beirut blast victims.11 17 The blast wind, especially in open-air crowded residential areas, inflicts serious polytrauma on the victim’s body.17 21 The structural collapse that occurred near the blast epicenter is further linked to tertiary blast injuries, particularly crush injuries and concussions.5 29 A recent study reported that almost half of the patients sustaining crush injuries and reaching the hospital alive suffered from crush syndrome, a common cause of delayed post-injury mortality with the absence of immediate detection and treatment.30 This justifies the association between death and crush syndrome, as immediate detection and multidepartmental intervention were unlikely.
Primary blast injuries are thought to be underreported as the blast overpressure mostly affects victims near ground zero.24 This explains the insignificant association between primary blast injuries and mortality as the CDC confirms that primary blast injuries, particularly blast lung, increase the risk of death.31 The absence of classification of outpatient injuries, the incomplete inpatient data, and the delayed onset of many symptoms (ie, intoxication), hindered the classification of all injuries, particularly quaternary blast injuries.
Similar to earlier AN blasts, this study showed that the inpatient deaths and disabilities were affected by the collective blast forces, inflicting polytrauma on multiple body regions.3 16 Although this study revealed that spine injuries are associated with death and disability, proper short-term and long-term treatment helped reverse spine injury-induced disabilities, mostly attained in younger patients.32–34
Hospital management and preparedness
Several urban hospitals were partially or fully destroyed, limiting their functionality and capacity for care provision.3 17 The layered burdens of treating blast victims, non-blast patients, and COVID-19 patients restricted many hospitals.3 Notably, various protocols, including psychological evaluation, follow-ups, formal triaging tools, and precaution practices, like COVID-19 screening and personal protective equipment, were mostly disregarded.11 24
Despite the implementation of emergency response plans by most hospitals, one study claimed that hospitals were unprepared for this overwhelming surge.11 Although triage helped alleviate these challenges, this study showed that the time taken to start the triage was greater than the ideal time.35 This may have increased death on arrival and in the ED. The surge and delayed triage further hindered the documentation and tracking of the patients’ records and thus the emergency care.3 Although most hospitals successfully performed COVID-19 screening to control the virus spread, this may have delayed and reduced staff performance. Even with the chaos, challenges, and limited resources, this study confirms that hospitals successfully controlled the mortality and disability rates.
Given the long-term mental and physical impacts of traumatic events, this study proved that hospitals failed to address the victims’ short-term and long-term mental effects. The mental impact of MCIs affects individuals who are physically injured as well as the witnesses, hence psychological assistance was deemed critical after the Madrid bombings.17 18 Accordingly, behavior change, anxiety, and PTSD, among other psychological illnesses, should be followed up and treated.
The study has some strengths and limitations. The nature of this multicenter study, which included 16 major acute care hospitals, enabled the establishment of a unique injury database and registry for the Beirut blast. The synthesized knowledge from this massive manmade explosion in urban sites is critical to emphasize the importance of safe chemical storage away from residential areas and the importance of educating people on their individual and social responsibilities during MCI. This is necessary especially in low- and middle- income countries (LMICs) with limited resources and access to EMS. By identifying the gaps in the hospital emergency plans, hospitals can enhance their disaster and emergency preparedness and responses, by training their staff, adopting more efficient triage systems, increasing their resources and improving their post-blast interventions. The most important post-blast interventions include long-term mental healthcare, rehabilitating and monitoring disabled victims, programming ambulatory wound care, and screening for wound infection. Social and economic support is also crucial to help the affected individuals return to life preblast.
This study’s retrospective nature limited the outcomes. Missing data due to the lack of proper documentation hindered this study. The sudden surge of casualties and hospitals’ destruction prevented patient reliable registration and proper documentation, which further affected the representation of the collected data. Additionally, due to the emergency nature of the blast, medical staff might have misreported many of the patients’ injuries, particularly the outpatient records. The absence of standardized disaster alert notices adopted by hospitals, as well as electronic documentation in some hospitals in Lebanon, further created a discrepancy in the data collection. Moreover, despite training the data collectors and following up with them, many centers had inconsistencies and incomplete data. Another limitation is related to the diagnosis and follow-up on mental illnesses, especially that many victims may have experienced a delayed onset of PTSD symptoms. Victims might also experience delayed onset of tympanic membrane rupture symptoms, explaining why only one patient was reported in our study. The lack of follow-up on physical injuries and disabilities further limited this study. Underreporting injuries, particularly primary blast injuries due to delayed extrication near the epicenter and not performing autopsies on the deceased, represents an additional limitation that might have affected the outcome of this study.
