On Sept. 17, just before 3:30 p.m., the small waiting room of Dr. Nour’s three-room pediatrics clinic in southern Beirut was packed. A mother was waiting to get preschool checkups for her three children. Two elderly patients were booked in for cataract treatments at the ophthalmologist office next door. Sitting next to them was a young couple whom Nour, whose name has been changed for security reasons, had not met before. The father bounced a 10-day-old baby on his lap. Clipped to his belt was a Gold Apollo Rugged Pager.
Nour brought the young couple into her examination room. She pulled out a blank file for the newborn and wrote his name: Aiman. She placed him on the scales: a little over 7 pounds. She lay Aiman on his back on an examination table and began to record his weight. As she did so, the man’s pager beeped twice.
“Excuse me,” he said, and reached down to silence it.
As he did so, about an ounce of explosives concealed within the pager detonated, sending shards of metal and fragments of its thick plastic casing out in all directions. The shrapnel tore deep wounds in the man’s abdomen, lodged in the ceiling of the clinic and lacerated the face of the baby as he lay on his back. Nour was thrown backward as the room filled with dust. She could not see through the smoke, but she could hear the woman’s voice shouting: “Aiman!”
Nour did not know that scenes like these were being repeated all over Lebanon. Simultaneously, some 4,000 booby-trapped pagers that had been handed out to members of Hezbollah began beeping and then exploded. In shops, in houses and on sidewalks across the country, pagers blasted their users as well as anyone in their vicinity with small clouds of shrapnel.
Nour told me her first thought was that her clinic of 12 years had been hit by an Israeli airstrike, amid the ongoing fighting between Hezbollah and the Israeli military. But as the smoke cleared, she realized that the explosion had come from inside her examination room. She saw the man, lying on the floor unconscious, his blood splattered on the wall and two of his severed fingers on the ground. Baby Aiman was nowhere to be seen. As she tried to stem the flow of blood and resuscitate the man, she called in vain for a municipal ambulance, then tried the Red Cross. All lines were engaged.
Hearing sirens outside, she ran out onto the street and tried to hail a passing ambulance. “Here!” she shouted. “Over here!” It sped past her. A second ambulance came by. “Here, I need help!” she shouted again as it drove past her clinic. Looking around, she saw half a dozen men, maybe more, bleeding from their hands and crouched on the sidewalk or lying semiconscious, attended to by passersby. Nour had to run more than a mile back to her house to get help from a neighbor who drove the collapsed man to the hospital. Baby Aiman was eventually found, having been whisked out of the examination room by waiting patients. He suffered deep cuts and abrasions to his face but survived.
Across town, the chairperson of the Department of Emergency Medicine at the American University of Beirut Medical Center (AUBMC), Eveline Hitti, was walking out of a training session when she spotted the first casualty of the day, a young man holding on to a mangled hand.
“All of the first casualties that came in were all just carrying their hands wrapped with bloody towels,” she said. “Those were the walk-ins.” Then came the first ambulances “carrying the people who had eviscerated eyes who couldn’t self-transport.”
The mechanism of the explosions appears to have been designed to cause maximum damage. Most of those who were injured were men, along with a number of women and children. They tended to pick up the beeping pager and hold it toward their eyes to read the message. When it exploded, it caused damage to both hands and their face.
Within minutes, Hitti realized that they were dealing with thousands of casualties. At 4:25 p.m., she activated an emergency preparedness plan that stayed in effect until 8 p.m. All available staff were called in, all nonemergency hospital procedures canceled. Nonessential traffic was told to stay off the roads. The swell of friends and relatives outside the hospital grew along with the casualties. Almost every minute, an ambulance arrived, unloaded injured patients and drove back into the city to collect more.
Since returning to Lebanon in 2009 after studying and working in Baltimore, Maryland, Hitti had led 12 mass casualty events, including the Port of Beirut explosion of Aug. 4, 2020, that killed at least 220 people and overwhelmed the country’s medical infrastructure. She said that the suddenness of last week’s attack, along with the severity of the patients’ conditions and the identical nature of injuries, presented an unprecedented challenge.
Almost at once, the hospital faced an influx of 160 patients, some 90% of whom suffered from hand or eye injuries or both and almost all of whom desperately needed medical intervention.
“Usually in mass casualties, you have a small percentage that are really high acuity,” Hitti said. “These are the ones that you need to resuscitate, intubate or send straight to the operating room; you have the majority that you see and send home, and then the rest are people who can be admitted and taken care of operatively the next day.”
In the attack aftermath, Hitti said, almost none fell into these last two categories.
“All inevitably needed some sort of surgery with hands and eyes involved,” she said.
And of these serious cases, many were “exactly replicated injuries,” she said. “It’s very unusual where your specialty needs are the exact same and are shouldered by one or two specialties.”
Of the 160 patients who came into the emergency room, 140 suffered serious eye injuries. For almost two hours, AUBMC’s head of ophthalmology, Bahaa Noureddine, conducted triage among the waiting patients to see “which were the eyes that can be salvaged,” deciding which could wait and which were beyond hope. At 7 p.m., the first case was wheeled into the operating room. Noureddine and his staff of nine surgeons did not stop operating until midnight three days later.
Almost all were severe cases. Noureddine and his team pulled shards of metal and plastic from their patients’ eyes. Most were men, he said, but six of them were young women and at least one was a small child.
Complicating the job were the patients’ other injuries, Noureddine said, among them “terrible burns” and lacerations across the face.
“There’s not a single case I have seen who was not injured in both hands,” he said. “Not a single one. The vast majority had amputated fingers on both.” Initially, Noureddine had plastic surgeons in the same theater, simultaneously trying to reconstruct the patients’ hands, but by the second day of surgeries they realized they needed to move faster and continued without them.
The department at AUBMC has better resources than most. Unlike some other large hospitals, which have just one ophthalmic surgical microscope per department, Noureddine has five. Whereas others were forced to bring in staff from elsewhere to deal with the influx of patients needing eye surgery, he benefited from a large team. At no point did they run out of supplies, he said, while others across Lebanon reported a shortage of everything down to prosthetic eyeballs.
Despite the team’s best efforts, most of those who came in were left partially blind. At least 10 lost their sight entirely. Across the country, local media reports that more than 300 were left blinded.
The week that followed the attack saw increased violence that engulfed the country and overshadowed previous attacks. A similar operation detonated Hezbollah walkie-talkies around Lebanon the day after the initial attack. The total deaths from both attacks reached at least 32, with more than 3,000 people injured.
The following days saw casualties skyrocket, as Israeli airstrikes spread across the country. On Monday, the number of recorded deaths was 558, making it the bloodiest day since the 1975-90 civil war. The Health Ministry, which issues the figures, does not differentiate between civilians and fighters. But the health minister, Firass Abiad, said in a press conference that “the vast majority were unarmed people in their homes.”
When the last of the urgent eye surgeries were completed at AUBMC, many of Noureddine’s staff requested time with a clinical psychiatrist to help process the past few days. Some couldn’t sleep, he said. Some would wake up in floods of tears.
“It affects you,” said Noureddine, who has worked at the hospital for 32 years. “Seeing a healthy young individual who has lost both his eyes, or one of his eyes, and you did your best, but what is the outcome?
“After all,” he said, “he is a citizen of this country.”
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