Three Activations, One Plan: Evolving Emergency Preparedness Through Recurrent Sudden-Onset Disasters in Beirut, Lebanon

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.