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a. Event type: Explosion
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b. Event Date: September 25, 2023, to February 02, 2024
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c. Location of event: Nagorno Karabakh Region; 39.87376285477832, 46.782140129982785
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d. Response type: Humanitarian, Emergency Medical Team
Introduction
Burn disasters, resulting from fires or explosions, involve the severe impact of thermal agents on individuals, leading to high numbers of people with critical burns, often resulting in significant mortality and disability.Reference Spronk, Legemate and Dokter1 Burn injuries can have profound short- and long-term biopsychosocial effects, impacting overall quality of life and the ability to participate fully in meaningful activities.Reference Jawad, Kadhum and Evans2 Long-term functional impairments are more common in older adults, those with burns covering greater than 30% total burn surface area, or those who experience complications such as respiratory failure, intensive care unit admission, thromboembolism, joint contractures, heterotropic ossification, and mental health challenges.Reference Radzikowska-Büchner, Łopuszyńska and Flieger3
The World Health Organization (WHO) recognizes rehabilitation as vital in burn care during emergencies, highlighting the role of Emergency Medical Teams (EMTs) and Burn Specialist Teams (BSTs) in providing early rehabilitation.4, 5 It affects survival rates and incidence of long-term disability and is crucial in preventing complications like respiratory issues, joint contractures, and scarring.Reference Radzikowska-Büchner, Łopuszyńska and Flieger3, Reference Hughes, Almeland and Leclerc6 Without early rehabilitation, individuals face higher risks of complications, poorer outcomes, and lack of follow-up care.Reference Radzikowska-Büchner, Łopuszyńska and Flieger3 Despite its importance, burn rehabilitation expertise is scarce in many low- and middle-income countries, and many EMTs and BSTs fail to include rehabilitation providers.Reference Abou-Abbas, Najmeddine, Bernhard, Jaoude, Benyaich and Yaacoub7 For example, after a tanker explosion in Sierra Leone in 2021, burn rehabilitation expertise had to be mobilized from a neighboring country.Reference Oyugi, Kamara, Nuwagira, Musoke, Lakoh and Jalloh8 WHO also recognizes capacity building and health system strengthening activities as an essential role of EMTs and BSTs.4, 5 Just-in-time learning, an approach that focuses on providing learners with clear, concise training during a health emergency, is recognized as foundational for building capacities for both robust emergency preparedness and an effective response, minimizing socioeconomic losses in affected communities and countries.9
On September 25, 2023, as thousands of refugees fled from Nagorno-Karabakh, an explosion at a fuel storage depot killed over 200 people and seriously injured more than 300.Reference Melkonyan, Oyugi, Conovali, Storozhenko, Gijs and Paronyan10 Survivors were transported to nine hospitals in Yerevan.Reference Melkonyan, Oyugi, Conovali, Storozhenko, Gijs and Paronyan10 The National Center for Burns and Dermatology, Armenia’s only specialized burn care facility, had just 80 beds, making it difficult to meet the survivors’ complex health needs.Reference Melkonyan, Oyugi, Conovali, Storozhenko, Gijs and Paronyan10 As a result, the Ministry of Health of Armenia (MOH) requested international assistance, prompting WHO Europe to activate the Emergency Medical Teams Coordination Cell (EMTCC).Reference Melkonyan, Oyugi, Conovali, Storozhenko, Gijs and Paronyan10, 11 From September 30 to October 28, 2023, 4 international EMTs, including Samaritan’s Purse (SP) and the United Kingdom’s Emergency Medical Team (UK EMT), deployed 32 healthcare providers to embed within four MOH facilities.Reference Melkonyan, Oyugi, Conovali, Storozhenko, Gijs and Paronyan10 SP, a WHO-verified Type 2 EMT with surgical capacity, and the UK EMT, a WHO-verified Type 1 and Rehabilitation Specialized Care Team, both included specialized rehabilitation professionals. Their strong clinical governance, effective human resources management, and self-sufficiency met WHO standards and, at the invitation of the MOH, enabled them to provide just-in-time training to strengthen the capacity of the Armenian healthcare workforce, ensuring continued delivery of acute and long-term rehabilitation services for burn survivors.
Methods
The objective of this field report is to provide an overview of the rehabilitation components of the 2023 Armenia EMT response, emphasizing a sharing of lessons observed to contribute to strengthening national and global capacities in burn rehabilitation in emergencies. It is based on a grey literature review of 16 documents—identified through targeted searches of WHO and UN databases, organizational websites, and expert recommendations—including technical guidelines, field reports, news articles, and government documents published between 2012 and 2025 in English (n = 13) and Armenian (n = 3). It is also based on lessons observed and secondary analysis of (a) publicly available data shared with EMTCC, (b) reports and guidelines published by regional authorities, and (c) observations and reflections of authors. The authors’ roles in the response range from health and operations in the deployed EMTs, national and international coordination, and technical support. MOH provided ethical approval for this report (Reference number LN/10.1/14434-24, dated May 16, 2024).
Results
The four deployed EMTs provided inpatient services for over 229 survivors across 4 national health facilities.11 MOH supported burn rehabilitation by recognizing the need for acute care in the intensive care unit and instructing EMTs to integrate rehabilitation specialists into hospitals treating burn survivors. UK EMT and SP were the only two EMTs that had the capabilities to deliver rehabilitation, delivering 386 rehabilitation interventions in close collaboration with 292 bedside wound care sessions, and 217 surgeries, across three national health facilities (Table 1).
Table 1. Summary of the multidisciplinary burn care and rehabilitation services
As part of the emergency response, MOH aimed to strengthen national burn rehabilitation capacity by requesting WHO Armenia, UK EMT, and SP to deliver just-in-time training aimed to enhance healthcare providers’ skills in evidence-based burn rehabilitation. This approach, underutilized in global EMT responses, involved designing and delivering the first course while EMTs provided direct services. The first 3-day course, designed as a Training of Trainers and held in the final week of the EMT response, trained 26 multidisciplinary national providers from 5 provinces and Yerevan, across 9 MOH facilities. The second 4-day course, held 3 months later, was led by EMT trainers and 3 national trainers from the first course, with 30 new multidisciplinary providers from 5 provinces and 9 MOH facilities.
The just-in-time training was enhanced with utilization of nationally available rehabilitation equipment and assistive products and diverse teaching methods, including lectures, skills practice, group discussions, role plays, simulations, and a provider-burn survivor panel. Key focuses alongside rehabilitation interventions included functional retraining, psychosocial skills, pain management, person-centered recovery (e.g. focused on ensuring care respects and responds to each person’s needs, preferences, and values), and education for survivors and caregivers. Unique aspects included an extensive simulation exercise with volunteer physiotherapy students acting out realistic case scenarios in an MOH hospital, coupled with participants providing supervised burn rehabilitation services to the survivors of the emergency. See Figure 1 for evidence of self-reported knowledge, skills, and confidence changes.
Figure 1. Composite self-reported overall change in knowledge, skills, and self-confidence of all participants before and after the first 3-day and the second 4-day courses on providing burn rehabilitation services and educating burn survivors, their families, and peer healthcare providers.
The workforce within the deployed EMTs and national healthcare facilities in Armenia had insufficient number of skilled rehabilitation providers to deliver specialized burn rehabilitation services. WHO Guidelines recommend that BSTs have a minimum of 2 rehabilitation specialists with 2 burn surgeons.5 Extrapolating from this, for every burn surgeon, there should be 1 rehabilitation specialist.5 Within the 4 EMTs, 12 burn surgeons required 12 rehabilitation specialists, but only 3 were deployed, which was insufficient. For the UK EMT and SP, the main challenges in deploying enough rehabilitation providers were financial limitations and limited available rehabilitation staff, respectively. During the acute phase of the emergency, the rehabilitation workforce gap was not filled nationally, with only one physiotherapist working with burn survivors due to a lack of trained workforce and policies supporting rehabilitation in acute care and emergencies.
Since neither SP nor UK EMT was a verified BST and WHO standards for BSTs were not yet released, clinical documentation and protocols had to be adapted in the field to meet the unique needs of a burn emergency. Both SP and UK EMT faced challenges with the complexity of burns, with burns often covering more than 20% of total body surface area, including burns to critical areas such as the hands, face, perineum, and feet. This required specialized rehabilitation equipment, which was not available due to logistical delays with customs clearance and EMTs having insufficient supplies in stock. Another challenge was ensuring continuity of care, with inadequate structures for clinical record sharing, transfers between facilities, and referral mechanisms for post-discharge rehabilitation, burn care, and livelihood and disability support services for survivors.
In Armenia, as in many other countries, burn care expertise is centralized in a single national center, contributing to challenges providing burn rehabilitation at the other MOH facilities during the emergency. National practices often prioritized bedrest over early rehabilitation, with limited recognition of its evidence-based benefits. Multiple burn survivors shared rooms, increasing infection risks and hindering rehabilitation. Challenges with pain management were experienced as this area of clinical practice was still in a developmental phase in Armenia, with incomplete implementation of legislation and limited awareness of rehabilitation’s role in pain management, further complicated by healthcare providers’ fear of legal consequences.
WHO’s standards recognize capacity building as a key role of EMTs, but limited rehabilitation capacity within EMTs and national providers, along with inadequate mobilization of national workers, delayed its implementation until the response’s final stages. These challenges were exacerbated by a lack of publications and EMT guidelines for practical, competency-based capacity building. Although just-in-time trainings were delivered, their impact was limited, as participants were not effectively mobilized to provide rehabilitation services during the acute phase of the emergency. Time and resource constraints also hindered competency-based learning, and gaps in national capacity for burn rehabilitation guidelines and clinical supervision further compounded the issues.
Despite challenges, the integration of rehabilitation in deployed EMTs and just-in-time training contributed to long-term health system strengthening efforts in Armenia. MOH, with key ministries and WHO, while developing a national strategy on rehabilitation and assistive technology, incorporated emergency preparedness and emphasized early and acute rehabilitation. With WHO Armenia’s support, clinical practice guidelines and standard operating procedures for burn rehabilitation were developed. MOH is also developing national standards for acute rehabilitation, including for burn injuries. Additionally, MOH is evaluating the rehabilitation workforce to inform policies that will strengthen healthcare professionals’ abilities to address population needs.
Limitations
This report’s limitation lies in its reliance on a grey literature review and secondary data, which may introduce biases due to data availability and quality. Publicly available data and regional reports may not fully capture the emergency response or reflect the latest information. Additionally, the authors’ subjective observations, influenced by their roles during the EMT response, may not represent all perspectives. Finally, the focus on a single emergency response in Armenia may limit the findings’ generalizability to other EMT responses, contexts, or health systems.
Discussion
Armenia’s response underscored the need to mobilize sufficient rehabilitation providers skilled in burn rehabilitation during emergencies. To strengthen national preparedness, rehabilitation professionals should be integrated into acute care facilities and national emergency plans. These plans should include surge mechanisms with thresholds for activating additional rehabilitation support. In alignment with the WHO EMT initiative, countries working toward national EMT classification—such as Armenia, which is progressing toward verification as a Type 1 Fixed EMT—are encouraged to strengthen their rehabilitation capacity to meet WHO standards. As part of this, WHO’s guidance on burn care in mass casualty incidents recommends that national emergency systems include a burn assessment team (BAT), with rehabilitation professionals as core members, or establish agreements to request such teams from neighboring countries.5
Effective burn emergency response requires EMTs to be equipped with burn-specific equipment, clinical documentation, standard operating procedures, and just-in-time training materials. When international EMTs are deployed, the MOH, EMTCC, and EMTs play a key role in enabling clinical information sharing, inter-facility collaboration, patient transfers, and continuity of care. In the absence of national emergency plans, health facilities may be forced to provide burn care beyond their usual scope. In such situations, the EMTCC and EMTs should collaborate with the MOH and facility leadership to adapt protocols—ensuring early rehabilitation, effective pain management, infection control, and appropriate support to enable staff to meet the complex needs of burn survivors. Emergency preparedness should prioritize capacity building from the outset, including just-in-time training focused on competencies and delivered through collaborative care, workshops, simulations, and clinical mentorship.
Conclusion
The 2023 EMT response in Armenia included rehabilitation providers playing a crucial role in delivering services and building national capacity. However, gaps were evident in skilled personnel, specialized equipment, and continuity of care mechanisms. Lessons observed emphasize the need for EMTs and national facilities to be equipped with burn-specific equipment, protocols, and systems for comprehensive care. Including rehabilitation specialists from the outset—in EMT deployments, acute care, and preparedness plans—is critical. Just-in-time training, as implemented in Armenia, supports immediate response and should be prioritized, with long-term impact strengthened through workforce planning and a competency-based approach.
Acknowledgements
The Ministry of Health of Armenia sincerely appreciates and acknowledges the WHO and all EMTs for their prompt and professional response to the burn mass casualty incident. Your efforts were crucial in providing critical treatment and care and ensuring an effective, coordinated response. We value our international partners’ support and look forward to continued collaboration in strengthening Armenia’s emergency preparedness.
The World Health Organization extends its deepest gratitude to the Ministry of Health of Armenia for its continued effective collaboration, as well as to all EMTs that took part in Armenia’s emergency response in 2023. Their unwavering dedication, professionalism, and swift action were instrumental in saving lives, providing critical care to those affected, and building national capacity on burn management, including rehabilitation.
UK EMT and UK-Med would like to thank the United Kingdom’s Foreign, Commonwealth and Development Office for funding the UK EMT Armenia Response. We would also like to thank Interburns for contributing training materials for the capacity building activities.
Samaritan’s Purse would like to thank its donor base, allowing for continued research and development of global innovations. Samaritan’s Purse would like to thank Pastor Garik Khachatryan and the Armenian Baptist Church congregation, along with the Operation Christmas Child Church network in Yerevan, who provided ongoing personal and spiritual care to recovering burn survivors and their families.
Author contribution
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• Zhanna Harutyunyan: formulating the research questions and developing the study design, including the methodology and experimental setup; collecting and analyzing data, and ensuring the accuracy of the results; interpreted the results, and developed the initial findings; wrote the initial draft of the manuscript, integrating contributions from all co-authors, and took the lead in revising and editing the final version; conducted the literature review, synthesizing relevant studies to provide context for the research and identify gaps in existing knowledge; reviewed and revised the manuscript critically, ensuring all aspects of the research were accurately reflected, and gave final approval for submission.
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• April Gamble: formulating the research questions and developing the study design, including the methodology and experimental setup; collecting and analyzing data, and ensuring the accuracy of the results; interpreted the results, and developed the initial findings; wrote the initial draft of the manuscript, integrating contributions from all co-authors, and took the lead in revising and editing the final version; conducted the literature review, synthesizing relevant studies to provide context for the research and identify gaps in existing knowledge; reviewed and revised the manuscript critically, ensuring all aspects of the research were accurately reflected, and gave final approval for submission.
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• Liana Barseghyan: collecting and analyzing data; wrote sections of results.
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• Jessica Burger: collecting data; wrote sections of results and discussion.
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• Michael L. Cheatham: collecting data; wrote sections of results.
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• Lala Gevorgyan: collecting and analyzing data.
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• Lizzi Marmont: collecting data.
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• Cathal Morgan: reviewed manuscript for accuracy.
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• Mohan Shanmugam: collecting and analyzing data, wrote sections of the observations.
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• Harvey Surial: collecting and analyzing data, wrote sections of the introduction and observations, and contributed to comprehensive review of existing literature to support the study’s background.
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• Lusine Paronyan: wrote sections of results and discussion.
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• Vahagn Petrosyan: collecting and analyzing data.
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• Peter Skelton: wrote sections of the introduction, results, and discussion; reviewed manuscript for accuracy.
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• Sasha Thew: collecting data; wrote sections of results and discussion.
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• Ram Vadi: collecting data; wrote sections of introduction and results; reviewed manuscript for accuracy.
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• Matilda Willow: collecting and analyzing data; wrote sections of the introduction, results, and discussion; contributed to comprehensive review of existing literature for the introduction.
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• Oleg Storozhenko: collecting and analyzing data; contributed to the plan for manuscript; reviewed manuscript for accuracy.
Competing interests
No conflicts of interest to disclose.
Open access
