The medical staff of Soroka-University Medical Center in Beersheba, which was hard hit by Iranian missiles in June, proved themselves by functioning exceptionally well in the aftermath of the October 7, 2023, attack on the South by Hamas terrorists.
“Prior mass casualty incident reports such as those following the Boston Marathon bombing and the 2011 Norway attacks taught us a lot about radiology under pressure,” said Dr. Gal Ben-Arie, senior radiologist and head of Innovation & Artificial Intelligence in Imaging at Soroka and vice-dean for innovation affairs at the Faculty of Health Sciences at Ben-Gurion University of the Negev (BGU) to which it’s affiliated.
Researchers in its Radiology Department studied the performance, providing recommendations for future crisis preparedness, which have been published in Radiology, the journal of the Radiological Society of North America, titled “Crisis-Responsive Imaging: Lessons from a High-Volume Mass Casualty Incident.” The journal is the “most prestigious” in the field of radiology, he told The Jerusalem Post.
The findings underscored the critical importance of in-hospital protocols of triage – the preliminary assessment of patients to determine the urgency of their need for treatment, and the nature of treatment required, protocols, rapid staff mobilization, and versatile imaging resources management.
“What’s different here is the combination of scale, duration, and the need to run imaging during active missile alerts, while dynamically redistributing patients across shielded scanners and conducting imaging triage at the scanner itself,” he explained. “Soroka, with 1,200 inpatient beds in 40 departments, has a catchment area of a million Israelis, including 400,000 children.”
Today, his department is functioning normally – which is at 150% capacity. Some other departments are not yet working as usual. “Renovations to correct the damage caused by the Iranian missile that landed on the old administration building – fortunately evacuated the day before – and caused collateral damage will take a long time.”
The Radiology Department employs 20 specialists and 10 doctors in training, along with 60 scanning technicians, said Ben-Arie, who lives in Moshav Kelahim near Netivot. When he heard the sirens and the missiles on October 7, he woke up immediately and got to the hospital, and within an hour after the incursion, he was treating the first wounded. “Over 700 were admitted to the hospital that day, and I stayed on duty for 24 hours, went home, and then was called to reserve duty as a physician in Gaza for half a year.”
He decided to specialize in radiology because “it integrates radiology, technology, treatment – the whole world of medicine. Nothing happens today without imaging.”
The department had three locations for scanning patients with X-rays and CT; there were many penetrating trauma cases that needed scanning to find out which organs were affected and what damage exactly was caused.
On regular weekends and holidays, Soroka’s emergency radiology team consists of one resident on 24-hour shifts, two attending physicians available from 1 p.m. to 9:30 pm, and five technologists in the radiography and CT stations. After the terrorist incursion unfolded on Simhat Torah that Shabbat at 6:29 a.m., staffing was increased immediately.
Mass-casualty events temporarily overwhelm medical systems. As the only level-one trauma center in the Negev, Soroka served as the primary destination for evacuating the wounded soldiers and civilians who far exceeded the threshold for such a major incident.
Unlike most such events, the attack triggered a prolonged and chaotic phase and an unprecedented admission of casualties. Due to the large number of casualties and the dispersed nature of the attack, victims were transported quickly with minimal or no triage carried out at the scene. The continuous arrival of severely wounded patients, many with penetrating injuries, caused immediate and extreme pressure on the imaging services. Speed and quality of imaging are vital for guiding clinical decisions in this type of high-stakes setting.
Casualties arrived by ambulances, helicopters, and private vehicles, with over 400 patients being admitted within the first eight hours of the attack. The sustained pressure was further complicated by ongoing rocket attacks, which hampered staff mobilization and resource adaptation.
Examining the attack
The research team looked at the first 24 hours after the attack, tracking which patients were imaged, clinical and imaging findings, imaging locations, and step-by-step time intervals –comparing these data with a 12-month baseline.
A total of 461 wounded patients underwent imaging; of these, 351 had X-rays, 164 had CTs, and 54 underwent both. Wounds ranged from blunt trauma caused by direct physical contact to penetrating trauma involving guns, grenades, and other explosive devices.
“Staffing escalated rapidly, with a radiologist positioned at each CT console and stable patients redirected to shielded non-emergency department scanners,” recalled Ben-Arie. “Artificial intelligence analyzed all CTs in real time and used natural language processing to flag image–report mismatches.”
Introduced in 2021, AI is used to analyze all CT examinations in real time to detect pathologic abnormalities, including intracranial hemorrhage, brain aneurysm, large vessel occlusion, cervical spine fractures, rib fractures, and pulmonary embolism. It also reviews radiology reports using a natural language-processing algorithm and issues an alert if there is a discrepancy between ts image interpretation and the report. AI performed best as a real-time safety net, flagging critical findings quickly and cross-checking reports, he noted.
“In contrast to earlier experience in the emergency department, our center had to repurpose our non-emergency department and shielded CT systems and perform on-site re-triage at distant scanners to prevent misses and bottlenecks,” he added. To handle misclassifications among patients initially categorized as stable and transported to distant CT scanners, the ad-hoc triage system was implemented, with a radiologist or clinician stationed at the distant CT sites to re-evaluate patients, identify unrecognized life-threatening conditions, and adjust scanning priorities. This reassessment proved to be a lifesaving measure: at one of the distant CT sites, a quarter of the patients were reclassified as having major trauma.
The team also had to provide emergency care not caused by the vicious terrorist incursion. They maintained a parallel pathway for non-mass casualty cases, with clinical assessment for all and urgent imaging when indicated, so routine emergency care could continue.
“That balancing act is a key part of the story of such large-scale mass casualty incidents and underscores disaster plans that prioritize life-threatening trauma without abandoning other acute patients,” Ben-Arie said.
“Staff worked under extreme physical and emotional strain, often caring for patients while simultaneously worrying about their own families during the attacks. That resilience is an inseparable part of this experience and underscores the need to build systems that safeguard both patients and providers during prolonged mass casualty incidents, whether precipitated by terror attacks, as in this case, natural disasters, or other crises,” said Ben-Arie.
“First, there’s chaos, and then emergency services usually stabilize, but we faced chaos for 24 hours. Other Israeli hospitals were very complimentary about the journal article, while some abroad voiced nasty, anti-Israel comments, including that ‘Israel should be boycotted.’ Yet, hospitals around the world could learn a lot from Soroka’s experience. An earthquake or major flooding can happen anywhere.”
Soroka can thus serve as a model for coping with such mass-catastrophe events. “Hospitals of all sizes can adapt these ideas,” he suggested. “They can also plan staffing on-site and remotely with pre-credentialed teleradiology partners and protect staff well-being by incorporating mandatory rest rotations and a protected respite area to sustain performance and morale during prolonged operations.
“Preparation must focus on flexibility. Train for the unexpected –not just for the last disaster – and build systems that can adapt quickly as conditions evolve.”