A new study of an Israeli hospital’s response to the October 7 attacks shows that while years of disaster training made it possible for staff to continue treating patients under rocket fire, real wartime conditions exposed critical gaps in communication, logistics, staffing, and distribution of casualties.
The findings offer practical lessons that could help hospitals worldwide prepare for prolonged armed conflicts and other large-scale emergencies.
When the first rockets began falling over southern Israel on the morning of Oct. 7, 2023, staff at the Samson Assuta Ashdod University Medical Center activated a plan they had rehearsed for years.
Within hours, the emergency department was treating waves of patients suffering from gunshot wounds, blast injuries, and burns while the hospital itself was under rocket fire.
The new study was published in the journal Disaster Medicine and Public Health Preparedness under the title “Wartime mass casualty incident plan operation: Staff experiences from a civilian hospital in southern Israel on October 7, 2023.”
It was led by Maximilian Nerlander, a doctoral candidate at Linköping University in Sweden and a visiting scholar at the Hebrew University of Jerusalem’s Braun School of Public Health and Community Medicine.
It offers one of the most detailed accounts yet of how a modern civilian hospital functioned during an unprecedented wartime emergency.
He conducted it together with Prof. Adam Rose of the Braun School and Dr. Debra West of the emergency medicine department at the Ashdod hospital.
Based on in-depth interviews with 19 staff members from the emergency department and the head of trauma and disaster management who worked during the Hamas attacks, the study offers practical lessons for hospitals around the world as many countries strengthen their preparedness for large-scale armed conflict.
Unlike previous terrorist attacks in cities like London, Paris, or Boston, the Oct. 7 assault unfolded over many hours, across multiple communities, while large parts of the surrounding region remained under active attack.
Ambulances struggled to reach casualties, communications broke down, and hospital staff often had little awareness of the rapidly evolving situation beyond what they could piece together from patients, soldiers, and social media.
Yet despite the chaos, the hospital continued to function.
The research team found that one of the greatest strengths was not sophisticated technology but preparation. Years of frequent mass casualty drills meant doctors, nurses, and support staff instinctively understood their roles, allowing them to focus on solving unexpected problems.
The hospital’s reinforced, missile-protected emergency department also enabled teams to continue caring for patients without needing to seek shelter, preserving both workflow and morale.
The interviews also revealed weaknesses that became apparent only under real wartime conditions. Many staffers faced an impossible choice after being called by both the military reserve system and the hospital.
Others hesitated to leave home because their own families were in danger. Administrative personnel responsible for registering patients were unable to report to work, creating unexpected bottlenecks.
Plans to relocate less critical patients out of the emergency department proved impossible because other hospital areas were not protected against incoming rockets.
The researchers found that perhaps most striking was the lack of reliable information.
Emergency department staff often knew little about the broader situation outside the hospital, forcing them to rely on fragmented updates from military personnel, emergency responders, patients, and even social media videos to anticipate what might arrive next.
The study also uncovered an unexpected consequence of the day’s events. While some hospitals were overwhelmed with casualties, the emergency department staff thought they could have safely treated many more patients.
The finding suggests that future emergency planning should put more stress on apportioning patients efficiently among hospitals during large-scale crises rather than allowing some facilities to become overloaded while others retain available capacity.
What can be improved upon
Rose told The Jerusalem Post that he felt it was important to document the hospital staff’s experiences scientifically rather than simply as eyewitness accounts by using qualitative research to understand what went well, what went less well, and what could be improved in the future.
“While many of the world’s hospitals conduct disaster drills, our simulation revealed something that the others didn’t: Israeli planners hadn’t ever considered the possibility that our country would not control part of its own territory for a period of time,” he said.
If he could rewrite the hospital’s emergency plan today, the first changes Rose said he would make would be to “have an organized central body controlling which casualties are sent where and when, to reduce the likelihood of one hospital being overwhelmed while others are underutilized.
“And making sure that if there was a plan to move less-sick patients to a second area, that area would also be missile-proof; and for people who could be called to work in the hospital or to be in the army, there would have to be a way to decide where they would go and to call them to only one.”
Relying on social media to understand what was happening “was the best they could do, but there needs to be a more organized and proactive way to share information. Many communication strategies failed that day,” Rose noted.
“Hospitals, ambulance services, the military, and government agencies should be part of a dedicated mechanism for sharing such information and make it part of the emergency drills.”
Having a missile-protected emergency department at Assuta was very important, he continued.
“I think that’s one of the two central things that went so right, the other being the monthly emergency drills. This was largely an example of two big things that went extremely right accompanied by many medium-to-small things that went wrong.
“The overall effect was a big success, and this is one of the two reasons why. Any hospital without such a protected area must make it happen as soon as possible.”
So far, none of the team’s recommendations have been adopted by other Israeli hospitals or the Health Ministry, but “clearly they should be.”
The findings arrive at a time when governments across Europe and North America are reevaluating civilian preparedness amid rising geopolitical tensions.
Hospitals have traditionally planned for isolated mass casualty incidents such as terrorist attacks or natural disasters.
The experience of Oct. 7 proved that prolonged warfare presents a different challenge altogether – one in which hospitals must continue operating while transportation, communications, and emergency response systems are simultaneously under strain.
“The lessons from Oct. 7 extend well beyond Israel,” said 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.”
Looking back to look forward
West, who ran Assuta’s emergency department on that terrible day almost three years ago, said that “unlike a conventional mass casualty event, one under fire disrupts every aspect of hospital operations – from patient flow and emergency department evacuation to staffing and the ability of personnel to work while their families are under threat.
“These experiences offer lessons beyond clinical care for hospitals preparing for disasters in which the healthcare system itself becomes part of the crisis.”
Asked if there was one patient or moment from that day that has stayed with her, she recalled: “It was a woman in the final stages of labor, brought in by Magen David Adom paramedics wearing full body armor.
“As her stretcher came through the fortified entrance to the protected emergency department, one child, not yet three years old, was clinging to the side of the stretcher while her other young child was being carried by a paramedic.
“What I remember most was the overwhelming look of fear and despair on the mother’s face, and in the eyes of her two young children. That image has never left me. It captured the emotional trauma of that day in a way that no words can fully describe.”
What still keeps her awake at night “are the voices. I can still hear the casualties who arrived that day, almost like an echo in the background, pleading, ‘Let me go. My whole family has been killed. My whole team is dead. Just let me go back.’
“Those voices have never really left me.”
The first thing West remembered was “preparing the emergency department for what we believed would be a mass casualty event caused by missile attacks.
“During the handover, one of the physicians showed me videos and photographs that were already circulating on Telegram.
“There were images of three people lying dead at a bus stop, a young man in running clothes shot dead in the street, and then a short video that I will never forget – a soldier, his face covered in blood, being dragged by his feet from his car by armed Hamas terrorists.
“Until that moment, I thought we were dealing with another large-scale missile attack. Seeing that video in real time changed everything. That was the moment I realized this was not another escalation. This was an invasion. This was war.”
She didn’t have to keep the staff calm.
“They already were,” she said. “Everyone immediately went into professional mode and focused on their job. At the same time, there was a sense of shock that kept us all functioning almost automatically.
“My role was to give clear instructions, keep everyone updated, and remind the team that alongside treating physical injuries, we also needed to care for our patients emotionally.”
“The Russian full-scale invasion of Ukraine and Oct. 7 were historical inflection points,” noted Nerlander. “It’s 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 Oct. 7.
“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.”
Although born out of one of Israel’s darkest days, the study offers a practical blueprint for strengthening hospital preparedness in an increasingly uncertain world, the team concluded.
“As conflicts become more complex and civilian infrastructure is drawn into modern warfare, the experiences of front-line healthcare workers at our hospital could help hospitals elsewhere prepare for crises they hope never to face.”
Before Oct. 7, they had trained for war and for mass casualty events under fire, “but training is not the same as living through it.”
“The biggest lesson we learned was that there is a profound difference between responding to a mass casualty event when the hospital is functioning normally and responding while the entire healthcare system is under attack.
“We learned that you have to plan for the whole disrupted ecosystem. Staff may not be able to reach the hospital; they will be worried about their own families, communication may fail, and every part of the system is affected.
“Those lessons have fundamentally changed how we prepare, train, and build our emergency response plans today.”