A 2-wave attack occurred in Lebanon on September 17 and 18, 2024, resulting in the largest mass casualty incident (MCI) to date caused by weaponized information and communications technology.Reference Pytlak, Siebens and Lad1
Thousands of handheld devices, including pagers (on September 17, 2024) and 2-way radios, commonly known as walkie-talkies (on September 18, 2024), simultaneously exploded, leaving 2931 injured and 37 dead.2, 3 The devices containing explosives were carefully designed to maximize physical damage.Reference Pytlak, Siebens and Lad1 Media reports and official statements have detailed the responsibility and circumstances surrounding this attack.Reference Pytlak, Siebens and Lad1, 4 Affected casualties were treated at over 150 hospitals across Lebanon.2, 3 Patients primarily sustained severe injuries to the eyes, face, hands, and pelvis, necessitating specialized care and extensive surgical procedures. The attacks caused significant mortality and morbidity, with a high prevalence of long-term disabilities among the survivors. This article explores the unique challenges associated with such unprecedented events and highlights lessons learned.
Injury Patterns and Patient Disposition
The patterns of injuries were strikingly similar, reflecting the high kinetic energy released by the devices’ explosions. Most patients sustained combined injuries to their hands and eyes, including mangled fingers and penetrating eye injuries. Others experienced pelvic penetrating injuries caused by carrying pagers near the hip.5
Below is a breakdown of patient distribution reported by Lebanese Ministry of Public Health (MoPH) on September 19, 2024.2, 3
Pagers Explosions (September 17th)
The event resulted in 12 dead and 2323 injured. A total of 1817 patients were transported by emergency medical services to over 100 hospitals.2 Disposition was as follows:
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• 824 treated in emergency rooms and discharged.
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• 156 required hospital admission for observation and were discharged within 24 hours.
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• 1343 with moderate to severe injuries, including:
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○ 226 admitted to intensive care units
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○ 1117 admitted to regular beds either recovering after surgeries or awaiting additional necessary procedures.
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A total of 955 surgeries were performed by the time of the press conference,2, 3 with more scheduled to follow.
Two-way Radios Explosions (September 18th)
Larger wireless devices explosions caused more severe injuries with greater impact on the victims.3 Patients were transported to 64 hospitals. This event resulted in 25 dead and 608 patients injured. Disposition was as follows:
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• 360 treated in emergency rooms and discharged.
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• 187 admitted to hospitals in stable condition.
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• 61 admitted to intensive care units.
A total of 141 surgeries were performed by the time of the press conference.2, 3
Prehospital Care and ED Care
Explosions on both days occurred without warning, leading to an influx of injured victims to hospitals within just 30 minutes. Hospitals were quickly overwhelmed with casualties.
The national response framework for MCIs in Lebanon involves multiple stakeholders but lacks a unified command structure.Reference El Sayed6 Due to the nature of MCIs that cause an immediate initial surge of patients to nearby hospitals, Lebanon’s MCI response is often marked by a lack of early centralized coordination and patient distribution, followed by delayed coordination focused primarily on transferring patients to more distant hospitals.Reference El Sayed7 Emergency medical services (EMS) agencies in Lebanon are predominantly volunteer-based with providers skilled in first aid and trauma care due to the region’s history of armed conflicts and high frequency of mass casualty events.Reference El Sayed and Bayram8 Beginning late 2023 and in response to rising regional tensions, Lebanon’s MoPH with support from the World Health Organization (WHO) introduced major initiatives to upgrade the national emergency preparedness framework. This included launching a war-specific health emergency response plan, activating trauma care pathways and strengthening of supply chains. A Public Health Emergency Operations Center (PHEOC) was also relocated to MoPH headquarters and enhanced to operate as a 24/7 coordination hub with advanced communication and data capabilities.9 The PHEOC was reportedly rapidly activated to support coordination and response efforts during this event.
Patients were transported to closest hospitals by EMS and by private vehicles. Prehospital care provided by EMS focused mainly on controlling bleeding, dressing wounds, and transporting victims to hospitals. Care in emergency departments included triage, bleeding control, pain management, wound dressing, tetanus vaccinations, antibiotics administration, and surgical prioritization. Because most injuries were anatomically localized to the hands and eyes, specific surgical subspecialties, not typically considered part of the first line of response, were required mainly ophthalmology, plastic surgery, otolaryngology, and orthopedic surgery.
Hospital Care and Surge Capacity
Hospitals in Lebanon had pre-established disaster preparedness plans supported by extensive national initiatives that aimed at strengthening and improving response capabilities after the COVID19 pandemic in 2019 and the Beirut Port Blast in 2020.Reference El Sayed7, 9, Reference Al-Hajj, Ghamlouche and Nasser AlDeen10
A total of 1096 surgeries were performed within the first 48 hours after the initial event,3 with more surgeries conducted in the following days reaching a total of 2078 procedures on September 21, 2024.11 Expanding surgical surge capacity was essential particularly for specialized procedures focused on the eyes and hands. To manage the increased surgical volumes, hospitals prioritized lifesaving, organ and limb saving surgeries and maintained a dynamic log of patients awaiting procedures. According to reports from the Ministry of Public Health, 92% of patients received their initial surgical care at hospitals across Lebanon while the remaining patients were transported to neighboring countries.12 Transfers between Lebanese hospitals were coordinated by MoPH based on need for specialized and surgical care. Transfer priorities were determined based on factors such as the need for surgical care, intensive care unit admission, and other critical considerations.
Impact on Society
The use of weaponized communication devices, which exploded in civilian areas such as public places, homes, and hospitals without identifying or confirming target individuals, resulted in not only in physical harm to affected victims but also in significant psychological trauma within the society. Conflicting initial media reports regarding the types of devices, including cellphones, pagers, and 2-way radios, as well as the varied explosive triggers, contributed to widespread distrust in mobile devices, fear of supply chain vulnerabilities, and concern for increasing use of technology to inflict injury. Pagers and 2-way radios, which are routinely used by first responders, hospitals, public service agencies, and other entities as redundant communication tools, were implicated in this attack. Beyond the ethical and legal concerns of weaponizing everyday technology, this attack highlights the need for enhanced cybersecurity measures and policy regulation to prevent the exploitation of vulnerabilities in critical infrastructures and to ensure the protection of civilian lives while safeguarding technological advancements from malicious uses.
Discussion
Lessons Learned
Field triage criteria during MCIs
Existing field triage criteria for trauma patients, such as those outlined in the 2021 National Guideline for the Field Triage of Injured Patients,Reference Newgard, Fischer and Gestring13 list penetrating injuries to the head and crush, degloved, mangled, or pulseless extremity as criteria for transport to the highest-level trauma centers. While these criteria are highly effective under routine circumstances, they may quickly overwhelm high-level trauma centers during mass casualty incidents. In such cases, field triage to lower-level trauma centers where patient needs can be addressed more efficiently, may be more appropriate. In fact, mass casualty events, such as the pager attacks, often require modifications to field criteria to accommodate the patient load, taking into account hospital resource distribution, the available medical capacity, and the surge capacity of receiving hospitals. Coordination between emergency medical services and hospitals is necessary to ensure timely and appropriate care.
Emergency Department Triage and Capacity During MCIs
Emergency department (ED) preparedness plans often use color-coded systems to categorize patients by injury severity and to distribute patients to different areas based on need for acute care.Reference El Sayed, Chami and Hitti14 In this specific mass casualty incident, a significant number of patients presented with similar injury patterns that were severe but required minimal ED interventions, such as bleeding control, wound care, pain management, tetanus vaccinations, and antibiotics administration. Most cases, however, necessitated more extensive specialized surgical care typically performed in operating rooms. MCI triage tools that focus on clinical severity may become ineffective when multiple patients with similar injuries arrive simultaneously and the ED reaches full capacity. Continuing to admit patients into an already saturated ED limits care for new arrivals. Dynamic triage systems that account for surge capacity and utilize alternative treatment areas are essential. Patients awaiting surgery further strain ED space, worsening the bottleneck. In this incident, approximately 1747 patients (59.6%) required hospital admission, with the majority needing surgical procedures.2, 3 Implementing a more efficient surgical prioritization system could optimize patient flow, reduce ED congestion, and enhance overall surge capacity. Other strategies to mitigate flow bottlenecks include prioritizing resource utilization in the ED and expediting the admission process. Imaging studies can also be minimized by relying on clinical assessment for admitted patients and by reserving diagnostic workups for cases where results directly influence immediate management plans. Additionally, alternative treatment areas within the hospital, including inpatient floors, can be used to distribute patient loads, deliver presurgical care, and improve response efficiency during mass casualty events.
Hospital Surgical Surge Capacity
Hospitals preparedness plans typically account for a surgical surge during disasters involving substantial mobilization of surgical resources.Reference Kelley, Toscano and Gestring15 Tools such as the Disaster Available Supplies in Hospitals (DASH) tool, developed by the Administration for Strategic Preparedness and Response (ASPR), offer guidance on stockpiling surgical equipment and supplies specific to trauma-related disasters.16 Following the pager attacks, over 2078 surgical procedures were performed across hospitals in Lebanon within 3 days, primarily involving eye and hand surgeries. These procedures required subspecialists, such as ophthalmologists and hand surgeons, who are not typically part of the first-line surgical responders, and utilized supplies like orbital implants, which are not commonly stocked. Surgical surge plans should be designed to accommodate scenarios like the pager attacks where underutilized specialties and low frequency procedures unexpectedly become priorities. Ensuring access to a broader range of surgical expertise and supplies is needed in disaster preparedness strategies. Preparedness plans should include mechanisms to activate supply chain channels for rarely stocked supplies during MCIs. Additionally, mass casualty incidents such as the pager attacks can create significant surgical backlogs with a high number of patients awaiting similar surgeries. Developing tools for efficient surgical prioritization and operating room utilization are vital to address this challenge. These surgical triage tools can help determine which surgeries are most urgent while optimizing hospital workflows to manage the surge in demand for surgical and critical care services.
Space and Patient Flow Strategies
Hospital disaster preparedness plans often focus on expanding physical space and implementing efficient patient flow strategies.Reference Kelley, Toscano and Gestring15 Enhancing surgical capacity requires not only mobilizing resources but also expanding space through other measures, such as cancelling elective admissions and procedures, reassigning spaces flexibly, and expediting patient movement through the care continuum.
In this incident, the high number of patients requiring specialized, organ and limb saving procedures and multiple surgeries for complex injuries, can result in extended hospital stays. Effective discharge planning becomes critical to ensure efficient flow of patients from pre-surgical units to operating rooms, post-anesthesia units (PACUs), and finally to intensive care units and inpatient floors. Discharge planning can however be particularly challenging in cases of mass casualty events, such as the pager attacks, where injuries often lead to long-term disabilities requiring follow-up care, rehabilitation, and appropriate patient placement. Surge capacity planning should therefore include provisions for long term discharge, access to rehabilitation services, and coordination with chronic care facilities or in-home care resources to improve patient outcomes.
Broader Implications Related to These Types of MCIs on Communication
Disaster preparedness plans continually adapt to address the evolving challenges posed by different types of MCIs. For example, the COVID-19 pandemic prioritized the stockpiling of personal protective equipment (PPE), while responses to chemical attacks have emphasized rapid decontamination and chemical exposure management protocols.
In modern MCIs, the weaponization of communication devices poses unique challenges, as it can disrupt communication networks critical to first responders and public service agencies. Such disruptions underscore the importance of incorporating communication downtime protocols and ensuring redundancy in communication systems as integral components of disaster preparedness. These measures help maintain effective coordination and response efforts even when primary communication channels fail.
Limitations
This manuscript examined a unique type of MCI related to pager explosions in Lebanon. The outcomes of such incidents are heavily influenced by the MCI setting, including preparedness of the health care system and the available resources for immediate activation or dispatch. It is likely that settings with more robust disaster response mechanisms would manage more effectively a larger volume of victims with similar injury patterns and who require specialized surgical care. Nonetheless, the strategies outlined in this manuscript are broadly applicable across different health care systems.
Conclusion
In summary, this emerging type of MCI presents significant challenges to health care systems worldwide. Prevention efforts should focus on implementing robust cybersecurity measures and establishing rigorous policies and regulations to mitigate risks. Preparedness planning must address potential disruptions in routine communication channels, incorporating redundant and resilient communication systems to maintain operational effectiveness.
Field and hospital triage protocols should remain flexible, accounting for the surge capacity and resource availability of receiving facilities to optimize patient care during crises. Validated tools for surgical care prioritization and for resource utilization during MCIs are needed. Additionally, comprehensive long-term discharge planning is essential, especially when MCIs result in a high prevalence of disabilities requiring extended care and rehabilitation.
The lessons learned from such events can help strengthen existing disaster preparedness and response frameworks, enhance the resilience of health care systems, and improve their ability to adapt and respond effectively to future crises.
Funding statement
None.
Competing interests
None declared.
