Eric S. Weinstein

Introduction: Actors in conflict, those in asymmetric warfare, conducting criminal activity or participating in paramilitary training activities may possess explosive ordnance. For various reasons this ordnance can misfire resulting in failure to detonate and become impaled or embedded in those near an intended target. The management of the patient with an impaled or embedded unexploded ordnance (eUXO) is a high impact event with the potential to cause death of those in proximity and destruction of the health care facility. The probability of this event is low with less than 50 cases reported in the literature. The objective of this study is to use a modified Delphi approach to produce statements to develop treatment guidelines of the eUXO patient in low-resource settings without explosive ordnance disposal team (EOD) assets. Materials and Methods: Fifty-three statements were derived from authoritative texts and a PRISMA-Scoping review through an iterative process by the authors. Included experts rated their agreement with each statement on a 7-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤1. Statements attaining consensus after the first and subsequent rounds moved to the final report. Statements that did not attain consensus moved to the next round and this process repeated for 3 rounds. The remaining statements did not attain consensus. The University of South Florida Institutional Review Board determined that this study met the criteria for exemption. Results: After the 37 experts first, 35 experts second, and 33 experts third round, 29 statements attained consensus, and 24 statements did not attain consensus. Conclusions: Although agreement was reached on key safety, transport, and training principles, uncertainties remain on how best to weigh clinical priorities to manage an eUXO patient to reduce the risk of detonation without available EOD assets in low-resource settings.

On April 8, 2026, a series of large-scale airstrikes struck Lebanon, killing at least 254 people and injuring 1,165 others. The Lebanese American University Medical Center–Rizk Hospital, located in central Beirut, received 2 distinct waves of casualties totaling 42 patients: 28 red, 9 green, and 5 deceased. This report describes the hospital’s emergency preparedness plan (EPP) response and examines challenges encountered across 3 sequential mass casualty incidents at the same institution: the Beirut Port Explosion (2020), the Pager Explosion (2024), and the April 2026 airstrikes. Each prior activation was formally debriefed, and its lessons incorporated into successive EPP revisions. The April 8 response exposed persistent and newly identified vulnerabilities: unassigned trainees accumulating in the red zone, premature code deactivation prior to a second casualty wave, surgical resident resource constraints, and the absence of a regional interfacility transfer network. Iterative debriefing and plan revision can produce an evolving EPP.

The deliberate targeting of healthcare infrastructure and healthcare workers (HCW) in contemporary conflicts represents a collapse of respect and adherence to International Humanitarian Law (IHL) and, through this, poses a crisis for humanitarian health care. The massacre at the Saudi Hospital in El-Fasher, North Darfur, by the Rapid Support Forces (RSF) in October 2025, serves as the latest, stark evidence of this deliberate tactic to destroy a population's health system. With attacks on facilities doubling and over 900 health workers killed globally in the preceding year, 1 existing protections, including United Nations (UN) Security Council Resolution 2286, are demonstrably failing to deter aggressors. 2 Immediate, international action, robust accountability, and security are needed to end impunity and reaffirm the fundamental inviolability of health care and medical services in conflict and humanitarian settings. 3,4 Reports corroborated by satellite imagery confirming mass killings near medical sites underscore that hospitals are no longer sanctuaries; they are strategic military objectives to be eliminated. 5 This crisis is global and accelerating. In Sudan alone, 244 attacks, including the killing of 66 health workers, were reported prior to the El-Fasher incident, illustrating a pattern of targeting and destruction. 6,7 This violence is not collateral damage; it is a deliberate tactic of warfare designed to strip civilian populations of their means of survival, facilitating forced displacement and population control. 3 International legal frameworks, though robust on paper, have failed to enforce the protection or security of healthcare. Resolution 2286 (2016) of the UN Security Council strongly condemned these attacks and mandated state action. 8 The intentional directing of violence against civilian infrastructure, including hospitals, constitutes a war crime under customary IHL. 8 Yet, the increase in attacks since shows broad inaction and widespread impunity. 2 The human impact and public health consequences are devastating and enduring. Beyond immediate trauma casualties, the destruction leads to medicine shortages, the collapse of chronic care (as seen in Khartoum), 9 and the systemic erosion of community trust required for future public health initiatives, such as vaccination campaigns. 7 To reverse this trajectory, the global community must act upon the purpose and intent of established IHL and the Geneva Conventions. UN Member States should establish transparent, mandatory sanction mechanisms tracing the funding of perpetrators of verifiable attacks on HCWs. Travel restrictions and other economic penalties are tools that can be deployed against individuals and responsible groups beyond the legal process to dissuade these attacks. Nongovernment organization benefactors, sponsors, or patrons are urged to join the UN, government health authorities, and health care administrators to seek meaningful deterrents. Technology can be developed and deployed to prevent "mistake" attacks from the air. Confidential communication processes can be established for health care workers to report to the UN or other humanitarian agencies when their facility is being used as a shield from combatants. Philanthropic efforts to protect healthcare workers should be held in the same regard as delivering healthcare to those in conflict and humanitarian settings. Standing idle is not an option because there are no easy solutions. Enough is enough, the time is now, a non-negotiable imperative for civilization.

In sudden-onset industrial disaster, responding effectively to a mass casualty incident (MCI) requires more than clinical readiness; it demands the integration of multiple regulatory frameworks and standards. In the context of an industrial disaster, the International Organization for Standardization 45001 will provide parameters for the creation of the response plan. In addition, the utilization of the Major Incident Medical Management and Support operational framework will expand the complex industrial interagency response. These should be components of the local MCI response plan, which has proven successful worldwide to enhance the capacity and capabilities in responding to complex emergencies. From a policy analysis perspective, the complexity and far-reaching consequences of industrial sudden onset disasters underscore the importance of implementing coordination mechanisms that bring together management systems and operational benchmarks. To build essential competencies among first responders, first receivers, and industrial workers, modular simulation exercises focusing on specific risk management and MCI response components are essential.

"Spontaneous and unplanned mass gathering events: A scoping review of health considerations for riots, civil unrest, and protest" by Ranse et al. 1 is to obtain data to improve planning for spontaneous mass gathering events (SGME) as "unplanned assemblies of a significant number of people, often arising in response to specific triggers or circumstances." They write that "Unlike organized mass gathering events (MGEs), SMGEs are characterized by their rapid formation and lack of formal pre-planning." Thus, the key difference between a planned or unplanned gathering is the availability of on-site medical assets that have coordinated with local pre-hospital emergency medical services (EMS). The acceptance of this definition would have enabled a broader search with expanded keywords and search terms. For instance, a music festival with hundreds of attendees with MGE on-site medical response capabilities will likely have improved post-incident clinical outcomes with coordinated prehospital and hospital care. A piazza with screens to watch a Union of European Football Associations (UEFA) Champions League final on June 3, 2017, in essence a sports festival, that did not include MGE on-site response capabilities, should be considered a SMGE due to the lack of these resources. At least 1,672 people were injured, including seven who were seriously injured and three died. 2,3 The medical subject headings (MeSH) terms "special events" and "mass gatherings," and keywords "sport" and "stampede" should have captured this SMGE, yet this was not included as one of the publications found by the study and therefore data was not obtained. The authors noted that a limitation of their study was due to the lack of review of gray literature, typically government agency after-action and investigation reports or credible media reports 4 that are not captured in the peer-review medical literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) methodology. 5 The validity of such sources can be questioned but due diligence by the authors that utilize gray literature can determine accuracy to improve the compendium of data to then undergo analysis in addition to the data obtained through the PRISMA-ScR search of peer-reviewed medical literature. The above UEFA watch-party disaster is available through a gray literature search of credible media reports limited by the criminal investigation.

Objective: Hospitals are under constant threat from internal and external hazards. A fire can cause substantial structural damage that necessitates evacuations which can compromise care. The objective of this study is to assess the lived experiences of the Wexford General Hospital Staff who responded to the fire to learn how to improve an Irish Hospital Fire Protection System. Method: This Hermeneutic Phenomenological research study was conducted through focus group discussions and structured interviews. Hospital staff who volunteered to participate in the study must have worked on the day or night shift of the incident. Results: Discussion contents review yielded codes and themes, drawn into positive and negative lived experiences. Two main themes emerged: Positive Themes = Luck, Leadership, Level-headed, Liaison, Look-back and Learn (L5); Problem Themes = Alarms, Begrudge, Communication, Directive, Emergency Plan, Flow (ABCDEF). Conclusions: The Hermeneutic Phenomenology methodology utilized in this study specifically learning from the lived experiences of those who were on duty during the WGH fire can improve the fire protection system at hospitals based on the knowledge gained encompassed in the L5 and ABCDEF findings.

Objectives: When unexploded ordnance (UXO) is embedded in the body, the effect of explosive weapons used in conflict is amplified. Though relatively rare, such events present potentially devastating consequences for the patient and medical providers as routine diagnostic and therapeutic procedures hold potential to initiate detonation of the embedded UXO (eUXO). The objective is to identify and synthesize available literature relating to the management of eUXO in low resource settings. Methods: A scoping review was conducted using PRISMA-ScR methodology to evaluate literature in all languages from all date ranges until January 31, 2024, discussing the management of casualties with eUXO, including types of ordnance, injury patterns, diagnostics, resource utilization, surgical interventions, and outcomes. Results: Search strings identified 3,425 records. After title and abstract screening 3,397 were excluded yielding 18 for full text screening of which 5 were excluded. Therefore 13 reports were included in analysis. Data variable reporting was heterogeneous but themes and subthemes regarding safety, planning and communication emerged. Conclusions: A scoping review was conducted to identify gaps in existing literature on the management of eUXO in low resource settings. Coordinated engagement from personnel representing a variety of clinical and non-clinical specialties is required to safely manage eUXO.

Background/Introduction: Since the start of the full-scale military invasion of Ukraine by the Russian Federation in 2022, Ukrainian hospitals have been operating under surge capacity - working relentlessly to manage the tidal wave of war-wounded patients. Retrospective analysis of war-wounded casualty surgical admissions in a reconstructive hospital along the Trauma Pathway shows that 90% of casualties present with severe tissue and bone infections, due to sub-optimal surgical interventions, IPC measures and antibiotic usage in the Trauma Stabilization Points and secondary hospitals. Life-saving strategies predominately center around re-amputation with long durations of antibiotics, resulting in long length of hospital stay, excess morbidity and mortality, and delayed progression to rehabilitation. Objectives: To support the implementation and evaluation of an infectious disease and antimicrobial stewardship program in a surgical department in a reconstructive hospital along the Ukrainian Trauma Pathway Method/Description: An INGO supported the Ukrainian tertiary hospital to implement “Antimicrobial stewardship programs in health-care facilities in low-and middle-income countries: a WHO practical toolkit” Results/Outcomes: The following results were evaluated from March 2023 to September 2023: The average duration of antibiotics reduced from 5.18 days to 3.92 days The average cost of antibiotics per patient reduced from $31.2 to $19.33 USD and cost of surgical prophylaxis antibiotics per patient reduced from $4.87 to $3.17 USD Conclusion: Implementing an Antimicrobial Stewardship and Infectious Disease Program in a surgical department of a tertiary hospital could support the quicker movement of patients to rehabilitation, reduce cost to the health facility and support clinicians to more effectively treat war-wounded patients in a conflict zone.

Background/Introduction: There is a lack of ethical triage and treatment guidelines for the entrapped and mangled extremity (E&ME) in resource scarce environments: mass casualty incidents, low- to middle- income countries, complex humanitarian emergencies including conflict, and prolonged transport times (RSE). Objectives: The aim of this study is to use a modified Delphi (mD) approach to produce statements to develop treatment guidelines of the E&ME in RSE to advance the 2021 WHO EMT Minimum Standards (EMT) treating the E&ME. Method/Description: Experts rated their agreement with each statement on a 7- point linear numeric scale. Consensus amongst experts was defined as a standard deviation <= 1. Statements attaining consensus after the first round moved to the final report. Those not attaining consensus moved to the second round in which experts were shown the mean response of the expert panel and their own response for the opportunity to reconsider their rating for that round. Statements attaining consensus after the second round moved to the final report. This process repeated in the third round. Statements attaining consensus moved to the final report. The remaining statements did not attain consensus. Results/Outcomes: Seventy-seven experts participated in the first, 75 in the second, and 74 in the third round. Twenty-three statements attained consensus. Twenty-one statements did not attain consensus. Conclusion: A Delphi technique was used to establish consensus regarding the numerous complex factors influencing treatment of the E&ME in RSEs. Twenty-three statements attained consensus and can be incorporated into guidelines to advance the EMT treating the E&ME.