**This article was originally published in Emergency Physicians International.**
“Even when you think you know what to do after a blast, there will always be another one to push your technical, logistic and emotional boundaries.”
It was Aug. 5, the day after an explosion rocked downtown Beirut. Amin Antoine Kazzi, a professor of Clinical Emergency Medicine and the founding former chair of the Department at the American University of Beirut (AUB), had finished his second shift caring for blast victims.
Kazzi is an internationally recognized expert in mass casualty management in the emergency department. He has published and lectured internationally on the topic and is the former president of the American Academy of Emergency Medicine. But none of this experience fully prepared him for this scene.
“In my experience, following air raids, car bombs and armed street battles and riots, we had never received more than 250 patients within three hours in any single emergency department in Lebanon,” Kazzi said. “For the last 40 years, we experienced blasts destroying neighborhoods or movie theaters and secondary car bombs killing those who come to rescue. We accordingly had planned for a maximum of 300 victims. Yesterday we received more than 500 victims. We almost ran out of space and ventilators.”
When Kazzi first popped onto the screen on a grainy Zoom call for this interview, he sat in a bed with his 9-year-old son Alexandre. Kazzi said Alexandre has wanted to stay physically close to him ever since the explosion.
Before the interview began, Alexandre jumped in, detailing how the explosion shook their house. He eagerly recalled how his father ran straight towards the blast, like a superhero.
Kazzi smiled broadly with a twinkle in his eyes. He is a veteran of four civil wars (Lebanon, Bosnia, Herzegovina and Rwanda). In his 15 years working in Beirut, he has seen 25 or more mass casualty incidents. These years in the trenches have given him a tough guy exterior, but he’s also a widower, a single parent and a doting father.
Around 6 p.m. Aug. 4, Kazzi felt the blast. He was in his house in Damour, a neighborhood on the edge of Beirut. Even 20 km from the blast site, the explosion – now considered the fourth largest non-nuclear blasts in history – knocked down walls and sent glass shrapnel through apartments and streets.
Moments later, Kazzi received the text: “Level One Activation.” He was all too familiar with what needed to happen next. He cleared his head with a five-minute shower and then jumped in his car to make the 20-minute drive into downtown Beirut. One thing he didn’t do? Call or text the team.
“The last thing you need is someone calling in and saying ‘What’s going on? Do you need me?’ You would be over-taxing an overwhelmed system.”
As he neared the hospital, the street was covered with debris, window frames and a thick layer of glass. Thankfully, the hospital still had its emergency power.
THE FOUR ZONES
The first thing Kazzi did when he arrived at the hospital was to identify the person in charge – the “disaster medical officer.” This was Dr. Eveline Hitti, the Department Chair. She stood close to the ED entrance separating two of the three geographical zones of the emergency department. She was working closely with the Chief Medical Officer Dr. Pierre Sfeir and the ED medical director, Dr. Mazen el-Sayed. They moved between the triage entrance and the different sections of the ED and hospital, identifying and addressing needs as they arose.
Hitti asked Kazzi to join Dr. Imad Majzoub assuming charge of the Yellow Zone (ED2). The Yellow Zone is where triage sent casualties with a high risk of crashing at any moment, people who needed careful assessment and re-assessment. Kazzi described going through the Yellow Zone as walking through a mine field. Every patient could have a serious injury that he couldn’t miss. Delay would cause avoidable death and injury.
“Everyone was soaked in blood from the glass,” Kazzi said. “Everyone had been struck by debris and there were many with large and numerous penetrating injuries. Others had head, torso or limb trauma.”
If you could walk and talk, and had no injuries to the torso, head or neck, you were assessed carefully and rapidly sent to the Green Zone (ED3). In the Green Zone they lined them up on chairs and cleaned out their glass wounds one by one. Eventually, a fourth and fifth zone were created for additional space to remove glass, manage wounds and suture patients with superficial lacerations.
The Red Zone (the trauma bay of ED1) is where they sent the most critical patients, those in need of immediate life-saving treatment. When patients left ED1, it was either to the operating suite, to the post-resuscitation zone, or to the morgue. In the Red Zone, where surgical trauma teams worked side by side with EM faculty, Dr. Bashar Hamadeh was running code after code.
When asked about that first crush of patients in the Red Zone, Bashar couldn’t recall the patient numbers, names or even genders, only that there were several dozen intubations, chest tubes, runs of CPR and invasive interventions. He also remembered when his colleague, Dr. Ralph Bou-Chebel, jumped in to take a share of these critical patients. Codes were going on outside the red zone as well, under the eye of Dr. Nour Jalbout.
In addition to the emergency physicians, surgical attendings and their teams descended on the Red Zone, running resuscitations, stabilizing, triaging those who needed immediate OR, ICU or admission. As Kazzi passed through the Red Zone at one point he caught sight of the Chair of Surgery, Dr. Hoballah, as well as Drs. Hallal, Jamali, Faraj and Khalifeh. The Chief of Surgical ICU, Dr. Abi-Saad, was squeezing saline with his hand on a critical patient receiving chest compressions.
THE FIRST WAVE
By the time Kazzi got to the emergency department, the first wave of patients from the blast had already arrived. “The first wave typically arrives within 15 minutes of the blast,” Kazzi said. “They arrive before any paramedics or police. They are the ones who can walk or drive or be driven to the ED by bystanders. This is followed by the second wave. These patients are sicker. They arrive around 40-minutes after the blast, driven by paramedics, police and family members. Many are unstable, unconscious, in obvious distress. They are unable to stand, walk or drive. Typically, this second wave can be predicted to be double the size of the first. It peaks and plateaus down for 1-1.5 hour, but will not drop significantly before the end of the third hour.”
Kazzi was the second attending emergency physician in the Yellow Zone and he and Dr. Majzoub initially had 80 injured patients in front of them, with 16 beds. They were then joined by an additional ED attending Dr. Afif Mufarrij. Because Beirut was still battling the coronavirus, Kazzi and his team wore double masks, making it painfully difficult to identify nurses from physicians, or residents from student.
“I remember screaming out loud for a nurse to get an IV and narcotics to administer to a blood-soaked elderly man with obviously unstable and broken bones, on stretcher with back pain and a possible spine injury. The ankle was going one way and the leg in another. He screamed in pain. Fully awake, he held my arm and pulled me close to his chest screaming “Be nice to me!” The 15 minutes it took to get an IV and morphine administered seemed like eternity!”
Just a few meters away laid a man on a wheelchair, with his wife screaming “Take care of him! He is a doctor!” It struck Kazzi suddenly that this man was one of their faculty, a former department chair.
“I began caring for him only to discover that he was on blood thinners, making a brain bleed much more dangerous.” A meter away, a distraught mother yelled “so you take care of him because he is one of your doctors? My son is one of your medical students!”
“This struck a dagger deep into my heart, but it would have taken too long for me to explain priorities to this mother,” Kazzi said. “I just quickly assessed the student, ordered a scan and reassured the mother.”
In his scan and re-scan of his section of the Yellow Zone Kazzi found five brain bleeds. They were all awake. Sometimes they seemed mild, sitting there with abrasions to the head. But they’d have a headache or mild amnesia. When they took the patients to the CT scanner, they found that there was a long line. At one point, even with two CT scanners operational, there were 20 people waiting to be scanned, each with a potentially life-threatening internal injury. The team had no choice but to assess and reprioritize them as they stood in line.
“Hours one, two and three are the worst,” Kazzi said. “That’s when you really can’t afford to miss brain bleeds and injuries to the abdomen. That’s when you have salvageable patients deteriorating. You need to over-scan sometimes.”
When additional hospital administrative personnel and volunteers arrived, Kazzi quickly put them to work as surrogate parents, staying with a patient and holding their clipboard. “If a clipboard gets moved to another patient, you can have a disaster!” he explained.
If a volunteer showed up and they had a medical background, then Kazzi put them to work suturing or stapling.
“Our pockets were full of staplers. In those early hours, we weren’t suturing. It was staple, staple, staple! Everything was getting stapled! Occasionally a face injury would get sutured quickly by a medical student.”
“The whole hospital responded,” Kazzi said. “Dermatologists, pediatricians, obstetricians, anesthesiologists, family physicians, psychiatrists and plastic surgeons. Plus, our exceptional emergency nursing team deployed into all the sections, guiding the reinforcements through our processes as they had done time and time again, one activation after the other, over the years.”
At its peak, there were more than 200 people in the Yellow Zone – patients, companions and medical providers. “We were moving shoulder to shoulder,” Kazzi said. “Patients with altered level of consciousness were slumped on chairs or on makeshift couches or simply on the floor. There was blood and blue everywhere.”
Kazzi began assessing patients one after the other and identifying delegates among students and residents to follow-up after him. He would then move to the next patient, based on who was physically closest, searching for the clearly unstable ones – distressed breathing, severe pain, confusion and altered neurologic exams.
The lack of physical space made it nearly impossible to find beds and space for a proper exam or to receive a new arrival. “Sometimes we were forced to move or staple patients without proper sedation or pain management,” he said.
There is a third wave that comes after the third hour, Kazzi explains. “These are the ones that have been extricated from the rubble. They’re often dead on arrival or have major crush injuries. Their severity is greater, but their numbers are less. And of course, there will be patients showing up the day after, and for one to two weeks after with minor injuries that were missed or that they chose to wait on.”
Towards midnight (hour 6), things slowed down enough to complete one more final re-assessment. Kazzi found two patients with what he saw as botched sutures on the face, so he mobilized a plastic surgeon to fix that mess.
“That’s when you take time,” Kazzi said. “Two hours to suture (or re-suture!) people nicely.”
AFTER THE SHIFT
Kazzi left the hospital at around 1:30 in the morning, seven exhausting hours after he arrived. They had almost run out of ventilators – down from 40 to 3 – but they had made it through the night!
“Fortunately, we managed to take care of them all and to make sure no one suffered preventable death or disability from their injuries in our institution,” he said. “Yes, we did our best, but people died… Blasts are unforgiving, and we lost a dozen or more between the resuscitation rooms and the surgical suite.”
As he drove home, he discovered that he had more than 200 messages on his phone, many of them from people wanting to know if their loved ones were safe.
He crawled into bed but couldn’t sleep. At 3 a.m., he got three more calls from friends asking if he’d seen their sons, daughters, relatives or friends. One begged him to go back to look for his son, a 20-year-old fireman who was at the scene of the blast and was still missing. But Kazzi was exhausted and needed to sleep. He had to be back at the hospital by 8 a.m. the next morning. He could make no promises, even to a dear friend in despair.
MASS CASUALTY RESPONSE
Less than 24 hours following the blast, Kazzi is already doing a philosophical post-mortem. He free associates five after-action thoughts.
First, understand that the idea of “mass casualty incident” is relative. “It is a disaster if it overwhelms your system capacity. If you’ve only got single coverage, then 5-10 patients can overwhelm the system. Mass casualty is when our ED and hospital surge capacity is unable to meet the demand and we must ask for and hopefully secure external help.”
Second, if you have additional volunteers who come in you don’t know how to utilize, use them as a human shield barrier to keep crowds from coming in the front doors or as surrogate companion to identify patients or as transport to the CT scanner.
Third, while you’re setting up your triage, make sure there’s one way in, one way out, and a secret door for the staff. The primary measure that Kazzi and his department had for controlling the crowd were the industrial steel bars they had installed at the emergency department entrance.
“I doubt any emergency department in the United States has bars like these,” he said. “You couldn’t drive a car through these steel gates.”
These gates were only opened a crack, to let one person in at a time. Otherwise, says Kazzi, they would have had 1,000 people flowing in along with the 500 patients.
Fourth and foremost, make sure all your hospital and ED staff know those rules. Mass casualty management plans must not lay in the drawers or minds of the leadership that reviewed and adopted them. They should be an integral part of the orientation received by every new recruit – regardless of the role they have in the institution. It should be included in the yearly online training requirements since it is at least as important as fire training and infection control courses we must periodically complete.
Finally, don’t talk to the media while you’re still in the middle of the crisis.
COPING WITH TRAUMA
While the incident is over, for Kazzi it will take some time to fully emotionally process what he experienced.
“We also must remember that what happened at the American University of Beirut only represented 10% of the patients and doesn’t capture the terrific magnitude of this national tragedy nor the experience and gigantic suffering across the rest of Beirut and its hospitals,” Kazzi said. “It fails to properly relay the deep human distress and suffering that struck a hundred thousand families across Beirut! We must therefore pay tribute to the victims and families. We must stop here, acknowledge and salute our colleagues at the other institutions and their emergency services in Beirut. They stepped into the fray bravely, heroically.”
Ultimately, more than 30 medical cared for 6,000 casualties, Kazzi said.
“Four facilities including two tertiary care centers were incapacitated: St George University Medical Center & Jitawi University Medical Center were evacuated. The smaller Karantina and Rosary Haddad Hospitals were totally destroyed. Four nurses were killed on the spot at St. George and one at the Rosary hospital.”
“I cannot fairly describe what they all must have gone through,” Kazzi said. “They were picking up their own dead, evacuating patients of all ages while diverting or caring for patient arrivals to their EDs! Our colleagues, in all disciplines, nurses, physicians, staff and rescuers, were true heroes and I must pause, kneel and thank them. I hope others will tell their story.”
- Eveline A. Hitti, Mazen J. El Sayed, Mohamad Ali Cheaito, Arthur L. Kellermann, Amin A. Kazzi – Mass Casualty Management in the Emergency Department – Lessons Learned in Beirut, Lebanon – Part I. The Mediterranean Journal of Emergency Medicine & Acute Care (MedJEM) MedJEM.me
- Mazen J. El Sayed, Eveline A. Hitti, Mohamad Ali Cheaito, Tim Davis, Amin A. Kazzi – Mass Casualty Management in the Emergency Department – Lessons Learned in Beirut, Lebanon – Part II. The Mediterranean Journal of Emergency Medicine & Acute Care (MedJEM) MedJEM.me