Emergency Department Preparedness During a Major Asymmetric Attack: Lessons from a Hospital in Southern Israel During the October 7, 2023, Massacre

Introduction: The October 7, 2023, massacre in Israel was a large, multi-site asymmetric attack with characteristics of both a very large terrorist attack and a conventional armed invasion, where Israel temporarily lost territorial control. Thus, it is a unique event in a Western democracy. Assuta Ashdod is a Level 2 trauma center located 26km from the Gaza Strip, which received 114 patients on October 7th, during which it activated its Mass Casualty Protocol (MCP). This study aimed to explore the experiences of staff working in this environment to inform hospital preparedness efforts in Israel and globally. Methods: A purposeful sample of 18 key staff, including physicians, nurses, security, and orderlies, underwent semi-structured interviews. These were recorded, transcribed, and processed using thematic analysis methodology. Results: The participants felt well prepared for this event because of recurring, frequent, and immersive MCP drills that had preceded it. Participants mentioned entering a state of mind where they worked mechanically without reflecting on the event itself. The hospital being structurally protected from rocket attacks allowed participants to concentrate on the work without fear of injury. Assuta Ashdod is a relatively small hospital where staff know each other well, and this was recognized as allowing for flexibility and effective communication. Obstacles included a shortage of secretaries for the correct registration and tracing of patients. While paper-based patient files are used during MCP drills, the lack of familiarity with interacting with these during regular work resulted in suboptimal documentation. Some clinicians mentioned a lack of situational awareness as they worked in isolation in a single part of the system throughout MCP activation. Conclusion: This study has offered insights from staff with practical experience from MCP activation in a major asymmetric attack and has identified several organizational and resilience-related aspects that may inform preparedness efforts in the future.