From 7:30 a.m. to midnight Oct 7, Soroka received 676 wounded

Preventative medicine: After Oct. 7 mass casualty event, Israeli MDs share tough lessons

While dealing with the ongoing medical challenges of the war, physicians are already in touch with others over what they learned about honing lifesaving preparedness protocols

Renee Ghert-Zand is the health reporter and a feature writer for The Times of Israel.

Wounded Israelis arrive at the Soroka Medical center in Beersheba, southern Israel, October 7, 2023. (Dudu Greenspan/Flash90)
Wounded Israelis arrive at the Soroka Medical center in Beersheba, southern Israel, October 7, 2023. (Dudu Greenspan/Flash90)

As the only level-1 trauma and tertiary medical center in southern Israel, Soroka University Medical Center (SUMC) in Beersheba received the largest number of wounded from Hamas’s onslaught on October 7.

Soroka is located 40 kilometers (25 miles) from the Gaza Strip, and on October 7, terrorist activity took place as close as 10 kilometers (6 miles) from the hospital as Hamas invaded southern Israel in a surprise attack. In the worst single day in Israeli history and for the Jewish people since the Holocaust, 1,200 people were killed, 1,600 were wounded, and 253 were taken hostage to Gaza.

Between 7:30 a.m. and midnight that Saturday, Soroka received 676 wounded individuals brought in by ambulance, helicopter and private car.

The number of casualties treated while under a non-stop missile barrage was more than quadruple the largest number ever treated before in 24 hours at Soroka. Since October 7, the number of casualties treated at the medical center has risen to over 2,700, most of them soldiers wounded while fighting Hamas in Gaza since October 27.

“During [the initial 24-hour] period, 120 patients who were critically wounded were cared for in our trauma unit. Ninety-six surgeries were performed and 200 blood units were transfused as additional blood supplies were rushed to SUMC. Two-hundred and nine patients required hospital admission due to their injuries,” wrote a group of Soroka physicians in an article published recently in the Intensive Care Medicine peer-reviewed journal.

Almost immediately, doctors from Soroka Medical Center, like many physicians who treated Hamas victims on October 7, felt the need to quickly disseminate the lessons learned from this unprecedented mass casualty event. Recently, director-general of Rambam Medical Center Prof. Michael Halbertal delivered a presentation on the topic to the British House of Lords.

By examining what went to plan and what did not on October 7, medical staff, hospital administrators and the Health Ministry have sharpened protocols for individual institutions and the Israeli healthcare system as a whole.

“The philosophy is that the knowledge we gather is not ours. It’s for us to share,” said Halbertal.

Wounded Israelis arrive at the Soroka Medical Center in Beersheba, southern Israel, October 7, 2023. (Dudu Greenspan/Flash90)

The authors of the article titled, “October 7th, 2023 Attacks in Israel: Frontline Experience of a Single Tertiary Center,” are Soroka CEO Dr. Shlomi Codish, Soroka deputy director and director of internal medicine Dr. Dan Schwarzfuchs, critical care specialist Dr. Amit Frenkel, emergency department head Dr. Moti Klein, orthopedist Dr. Alex Geftler, and Soroka deputy director Dr. Jacob Dreiher.

In the paper, the doctors provided a detailed timeline of how events unfolded in the hospital on October 7 and several days following. Critically, they explained how Soroka followed a five-part approach that proved successful in handling such an unusual and intense event.

‘Early, independent mobilization’ is key

First, as early as 8:00 a.m. on October 7, Soroka declared a mass casualty incident in what the authors called an “early, independent mobilization.” All the hospital’s medical staff was immediately called in to treat the arriving wounded.

To boost staffing, Soroka also requested assistance from external personnel from other medical centers, resulting in help from 28 nurses and 18 physicians by the evening.

The third piece was to quickly reorganize hospital space, equipment and resources to accommodate so many severely wounded people requiring trauma care, surgery and imaging.

Illustrative: Wounded people arrive at Soroka Medical Center in Beersheba, August 24, 2023. (Flash90)

Fourth, Soroka began transferring injured patients to other hospitals as soon as the early hours of October 8. In total, 130 of the wounded were transferred out by ambulance or helicopter within a few days. This allowed Soroka to make room for potential additional waves of casualties as it quickly restocked supplies.

Finally, Soroka simultaneously continued to care for and protect patients already hospitalized. Those who had to stay in the hospital were quickly moved to fortified areas, and 190 were discharged to make room for the incoming casualties.

Caring for staff and families

The article also discussed how Soroka’s administration cared for families of the wounded, many of whom did not know if their loved ones were dead or alive, or where they might be.

“As the events of the day unfolded and the public became aware of the large number of victims and missing people, the medical center became inundated with families looking for their loved ones. An information center for the public was opened, providing for these needs both
in person and by phone, based on the staff of our social workers,” the authors wrote.

Medical staff and others at Hadassah Medical Center gather to mark 100 days since the beginning of the war with Hamas and to stand in solidarity with the 136 hostages who still remain in Gaza, January 14, 2024. (Hadassah Medical Center)

They also noted that it was their hospital’s responsibility to care for its staff during and after the mass casualty incident.

“Firstly, [this meant] caring for the many staff members and families who were directly affected by the deadly events of October 7th, including the death or kidnapping of staff members or close relatives. Daycare facilities were opened on day two of the war, caring for hundreds of staff’s children, a service without which the parents could not attend to their life-saving duties,” the doctors wrote.

“Supportive care is also provided to the caregivers and first responders who cared for the endless flow of casualties on October 7,” they added.

British lords learn from Rambam

Many of the points raised in the article were similar to ones included in Rambam director-general Halbertal’s January 24 keynote presentation in the British House of Lords, to which he was invited by Lord Bew, a long-time Israel supporter.

The next day, Halbertal and Rambam’s head of trauma Dr. Hani Bachus met with British colleagues at The Royal London Hospital, the busiest trauma center in the UK to discuss possible collaborations.

Rambam Medical Center director-general Prof. Michael Halbertal (center) with Rambam’s head of trauma Dr. Hani Bachus (right) and Dr. Anne Weaver, clinical director for trauma at Royal London Hospital stand in front of the Royal London’s helicopter, January 25, 2024. (Courtesy)

“One of the main topics they wanted me to speak about [in the Parliament] was Rambam’s preparedness and how this can help Britain’s National Health System think about improving its preparedness,” Halbertal told The Times of Israel.

“It is all about how you get your systems to cooperate and work together — inside the hospital, with pre-hospital [emergency services], and with government partners — how do you get them to work together in challenging times when you need to be the most efficient to save life,” he said.

Tailoring preparedness solutions to particular risks

Unlike Soroka, Rambam in Haifa was not on the front lines on October 7. Instead, it mainly received secondary triage patients. However, with ongoing constant IDF engagement with Hezbollah and other Iran-backed terror groups along Israel’s northern border, Rambam has been on high alert and is ready to immediately move all operations to its underground hospital — the largest in the world — should a full-scale war break out along Israel’s northern border.

“When you want to deal with emergency preparedness, the first thing you need to do is your own risk assessment. Every country has different risk assessments. Obviously, for us, military confrontation is a big issue, but it’s not the same all over the world. So you have to drill down to the risks faced by each facility in a country. Different facilities have different challenges,” Halbertal explained.

“Preparedness plans need to be tailor-made to each facility. It’s not cut and paste,” he said.

This time around, the reference scenario that Rambam is planning for is 60 days of war, with extremely powerful missiles falling around the hospital every four minutes.

The Sammy Ofer Fortified Underground Emergency Hospital at Rambam Medical Center in Haifa was prepared for receiving patients following the outbreak of war, October 11, 2023. (Courtesy of Rambam)

Being ready individually, and as an interlinked system

Similar to the Soroka doctors’ emphasis on “early, independent mobilization,” Halbertal said that it is up to each medical institution to be proactive in putting into place what it needs to be fully ready for any emergency.

Halbertal explained that the idea for an underground parking lot at Rambam that can be transformed into a fully functioning, self-contained 2,000-bed medical facility within 36 hours came from the hospital’s board after the 2006 Second Lebanon War.

“The home front was attacked and there was no fortification for the hospital. The staff, casualties and patients were not safe. So at the end of the war, the hospital management concluded that this could not happen again. This commitment for this was by the hospital, not the government or the Health Ministry,” he said.

Like the Soroka doctors, Halbertal highlighted the importance of maintaining the resilience of hospitals, so that they don’t get overwhelmed in mass casualty incidents.

“You have to look at it all as a system. You cannot work by yourself in big events. Israel is a small country, but this is important in larger countries, too. You have to cooperate with others, and those linkages need to be built ahead of time,” he said.

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