The constant state of alert at Israel's hospitals undoubtedly saved lives on 7 October, says the author of newly-published study.
Regular drills for mass casualty events meant doctors, nurses and support staff instinctively understood their roles, and could focus on solving unexpected problems rather than getting to grips with basic procedures.
The investment of time and effort in advanced preparations over many years saved the lives of soldiers and civilians, said Maximilian Nerlander, lead author of the study, which was published online last week by Cambridge University Press.
“I think we can safely say that a strong culture of preparedness, which was well rehearsed with processes that everyone knew very well, certainly contributed to saving lives on October 7 when the crisis hit,” he told the JC.
The study, entitled Wartime Mass Casualty Incident Plan Operation: Staff Experiences from a Civilian Hospital in Southern Israel on October 7, 2023, investigates how a hospital in southern Israel managed to function effectively on 7 October, despite being under fire from Hamas.
It does, however, also expose areas of concern, such as a communications breakdown and staff who faced impossible choices on the day – between treating patients or to report for reserve duty with the IDF.
The findings offer practical lessons for other hospitals, particularly in war zones such as Ukraine, which are facing prolonged armed conflicts or other mass casualty events.
In the study, Nerlander, a Ph.D. candidate at Linköping University, in Sweden, and a visiting scholar at the Hebrew University of Jerusalem's School of Public Health, draws on interviews with staff who were on duty on 7 October at the Assuta Ashdod Hospital, about 16 miles from the Gaza border.
On the day, the 300-bed hospital treated 87 casualties for gunshot wounds, blast injuries, burns and other injuries, and ED (emergency department) staff believe they had the capacity to have safely treated more patients.
The hospital had been carrying out drills every three months for mass casualty events.
Its well-rehearsed and coordinated response involved a structured triaging of patients, who were then sent to dedicated care zones.
Many of the stabilised patients were then sent for a CT scan and subsequently to the operating room, intensive care unit, or an inpatient ward.
Nerlander said: “The strong culture of preparedness that we've seen in Assuta and in Israel as a whole can certainly serve as an inspiration for decision makers and caregivers in the UK and elsewhere to adopt a frame of mind and a culture of preparedness that can save lives in the future.”
In a moving open letter published the day after 7 October, Dr Debra West, ED Director at the hospital, said: "The teamwork was exemplary. A soldier who was present throughout the day told me that in her 18 years of experience in high casualty incidents, she had never seen such professional and calm work, and such sensitive conduct towards the wounded and their families."
The study notes that while many hospitals have dealt with mass casualty events – notably the 2005 London bombings, the 2015 Paris attacks, the 2016 Orlando nightclub shooting, and the 2017 Las Vegas shooting – none of these events directly threatened the hospitals themselves.
Assuta Ashdod and hospitals even closer to Gaza, such as Barzilai Medical Center, in Ashkelon, had some "safe" reinforced areas, but were still under constant threat of a missile hit on the day.
The research was conducted together with Prof. Adam Rose, from Hebrew University of Jerusalem's School of Public Health, and Dr. West.
Although it finds that a culture of preparedness counts for much, it does also identify critical systemic gaps across Israel in communication, staffing, logistics, and casualty distribution which need to be addressed.
The scale of the attack, in which 1,200 people were killed, was unlike conventional mass casualty events, it says.
Ambulances struggled to reach casualties, communications broke down, and hospital staff often had to piece together what was happening from patients, soldiers and social media.
"It had characteristics of an armed invasion with multiple communities temporarily overrun, disrupted lines of communication, and delayed restoration of government control," say the authors of the study,
"Israel’s Emergency Medical Services had not planned for a scenario in which they would be unable to safely access casualties and provide care within Israeli territory. This resulted in delayed evacuation and the presentation of many patients to hospital by informal means."
Operational conditions more closely resemble those of large-scale armed conflict than of a conventional terrorist attack, they said.
In contrast to single-site incidents, the October 7 attack was an ongoing, large-scale, multi-front assault, says the study, affecting numerous communities primarily, in the Gaza Envelope.
The study is based on in-depth interviews with 19 staff members, from the emergency department, as well as the head of trauma and disaster management.
“It is becoming increasingly evident that at some point in the future, other parts of the world will face the same type of high-intensity asymmetric warfare as Israel did on October 7," said Nerlander.
"My hope with this study is that the tragedy of that day can be converted into knowledge that can save lives and avert suffering in the future, wherever it occurs.”
Hospitals have traditionally planned for isolated mass casualty incidents such as terrorist attacks or natural disasters, but the experience of October 7 demonstrated that prolonged warfare presents a very different challenge.
“The lessons from October 7 extend well beyond Israel,” said Prof. Rose. “Our findings show that hospitals preparing for future conflicts need plans that account not only for treating casualties, but also for protecting staff, maintaining communication in rapidly changing situations, and adapting operational plans when reality departs from even the best rehearsed scenarios.”
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