Lessons Learned from the Management of a Mass Casualty Event While under Fire: An After-Action Report from a Frontline Hospital in Southern Israel

Summary: Samson Assuta Ashdod is a 300-bed hospital located in Southern Israel and is the equivalent of a Level 2 trauma center. During the October 7, 2023, massacre, Assuta received a total of 114 patients while under direct threat from the attack. Due to the ongoing threat, a mass casualty event was declared in the hospital, but staff were not called in from home out of concern for their safety. As a result, the response was limited to on-duty personnel and those who arrived voluntarily. Additionally, due to safety reasons, the emergency department could not be evacuated of routine patients, requiring the management of mass casualty patients alongside existing patients. This after-action report presents key findings and lessons learned, focusing on how preparedness influenced the response under these unique conditions. The analysis covers staffing, communication, documentation, command and control, training and preparedness, facilities and equipment, and staff discipline. The findings highlight both strengths and challenges. Staffing limitations emphasized the need to define critical personnel and develop strategies to rapidly adapt roles and responsibilities. Communication issues, especially during simultaneous threats, pointed to the need to adjust modes of communication, including internal and external channels of communication. Inadequacies in documentation significantly affected care continuity of care. The Command-and-Control structure set in place proved itself adaptable to evolving needs. Training was found to be crucial for the response, but revealed gaps in readiness for urgent and conflicting needs. Facility limitations, particularly the inability to clear the emergency department, impacted patient management. Discipline among staff and a common purpose proved vital for maintaining order in the chaotic conditions and MCE. This report provides insights into refining disaster response strategies for hospitals facing MCEs while under threat and underscores the importance of flexible and resilient emergency preparedness