A new study of an Israeli hospital's response to the October 7 attacks shows that while years of disaster training enabled staff to continue treating patients under rocket fire, real wartime conditions exposed critical gaps in communication, staffing, logistics, and casualty distribution. 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 October 7, 2023, staff at Assuta Ashdod Hospital 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—all while the hospital itself remained under rocket fire.

A new study led by Maximilian 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, offers one of the most detailed accounts yet of how a modern civilian hospital functioned during an unprecedented wartime emergency. The research was conducted together with Prof. Adam Rose, from Hebrew University of Jerusalem's School of Public Health, and Dr. Debra West of the Department of Emergency Medicine at Assuta Ashdod Medical Center. Based on in-depth interviews with 19 staff members, from the emergency department, as well as the head of trauma and disaster management, who worked during the October 7 attacks, the study provides practical lessons for hospitals around the world as many countries strengthen their preparedness for large-scale armed conflict.

Unlike previous terrorist attacks in cities such as London, Paris or Boston, the October 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 understanding 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 operate.

Researchers 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 rather than basic procedures. 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 only became apparent under real wartime conditions.

Many employees faced an impossible choice after being called simultaneously 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 unworkable because other hospital areas were not protected against incoming rockets.

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 became overwhelmed with casualties, Assuta Ashdod's emergency department believed it could have safely treated many more patients. The finding suggests that future emergency planning should place greater emphasis on distributing casualties efficiently among hospitals during large-scale crises rather than allowing some facilities to become overloaded while others retain available capacity.

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 October 7 demonstrated 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 October 7 extend well beyond Israel” said Prof. Adam Rose from the School of Public Health at Hebrew University of Jerusalem. “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.”

Dr Debra West, who was ED Director at Assuta on October 7, added that “Unlike a conventional mass casualty event, a mass casualty event 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.”

“The Russian full-scale invasion of Ukraine and October 7 were historical inflection points,” notes Maximilian Nerlander, the lead author. “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. 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.”

The researchers conclude that future preparedness should include more realistic disaster drills that test complex logistical challenges, stronger coordination between civilian healthcare systems and military authorities, secure transportation options for healthcare workers during active conflict, and better mechanisms for sharing operational information among hospitals and emergency agencies.

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. As conflicts become more complex and civilian infrastructure is drawn into modern warfare, the experiences of frontline healthcare workers at Assuta Ashdod may help hospitals elsewhere prepare for crises they hope never to face.