Across a Europe that had long been spared war, many countries are now planning and building up their preparedness following Russia’s invasion of Ukraine. In modern conflicts, hospitals and transports carrying injured people are increasingly being deliberately attacked, creating a major need to prepare emergency healthcare systems for potential armed conflict.
“We need to prepare our hospitals for the asymmetric warfare we see around the world, where the aggressor doesn’t care about the Geneva Conventions,” says Maximilian Nerlander, a specialist in emergency medicine and PhD student at the Center for Disaster Medicine and Traumatology at Linköping University and a visiting scholar at the Hebrew University of Jerusalem Braun School of Public Health and Community Medicine, Jerusalem, Israel.
Preparedness includes having mass casualty plans and training staff to function during crises and war. Israel’s healthcare system is similar to those in Western Europe, but unlike them, it has experience of real wartime situations. Together with two research colleagues, Maximilian Nerlander has studied how an Israeli hospital, Assuta Ashdod Public Hospital, met its needs and how its preparedness plan was affected by the war when Hamas launched a large-scale attack on Israel on the holiday of 7 October 2023.
Thor Balkhed
Culture of flexibility
One of the immediate effects of the war observed by the researchers was that the ongoing attacks prevented some staff from reaching the hospital safely, while others found it difficult to leave children and families without being able to ensure their safety. As a result, the incident command team decided not to require all the staff on the emergency call-up lists to report for duty, which caused problems when certain specific tasks could not be carried out. At the same time, other healthcare professionals without emergency medicine expertise volunteered to work. The study also shows that because hospital porters, who are responsible for moving patients within the hospital, are among the staff who take part in the hospital’s exercises, they helped maintain an effective flow of patients. Clearing patients from the emergency department, however, had not been included in the exercises, so when the need arose to empty the department, an improvised emergency solution had to be found.
“That was a problem they hadn’t anticipated. You need to have plans, but you also need a culture of flexibility so that you can adapt to new circumstances,” says Maximilian Nerlander.
War is an extreme situation involving many different stress factors that affect individuals beyond what they normally experience. In this qualitative study, based on interviews with 19 members of staff at the hospital’s emergency department, no one reported being unsure of what to do on the day in question. The researchers think the regular mass casualty drills, held four times a year, contributed to this.
“Drills mean that you function better under the extreme stress that arises during war and can carry out the work automatically. In a sudden attack, there is no time to familiarise yourself with protocols and procedures; they have to be second nature.”
Smaller hospitals needs to be prepared
It is also important that smaller hospitals without access to the full range of specialist trauma care form part of the preparedness planning. Attacks can occur anywhere geographically, and the number of wounded can be very large. The hospital studied is comparable in size to Växjö Hospital, for example, where Maximilian Nerlander works clinically as a lead physician in the emergency department.
“In case of total war, the frontline will be everywhere, and large volumes of casualties can therefore occur anywhere. Therefore you need to be able to manage these in rural areas too,” he says.
The study shows that staff safety is an important factor for success in mass casualty incidents. At Assuta Ashdod Public Hospital, the emergency department is housed in a building reinforced to withstand rocket attacks, which provides a safe working environment.
“It was remarkable, but really a no-brainer, how important it was for staff to feel safe in order to be able to do their jobs, and this also benefited clinical patient safety. Isn’t this something we should take into account when we build new hospitals in Europe?” asks Maximilian Nerlander.
Thor Balkhed
At the same time, the study identifies challenges relating to the evacuation of patients who were already in the hospital before the attacks. Because the relevant wards available for transfer at the time were not located in protected areas, patients could not be moved there. Instead, the emergency department was divided into two zones, allowing the internal medicine physicians to safely care for the patients who were not part of the mass casualty group. These are important findings for future planning.
“If we’re going to build new hospitals, it’s important that they have external protection and that we can move operations to safety,” says Maximilian Nerlander.
Communication is key
Thor Balkhed
One conclusion of the study is therefore that a function that coordinates incoming information and passes it on in a structured way can be an important component in a mass casualty situation under wartime conditions. Another conclusion is that it is important to develop a shared reporting system for civilian and military healthcare, as it was found that a great deal of pre-hospital information was lost during handovers between the organisations. Other areas of cooperation between civilian and military healthcare also need to be strengthened, for example to ensure that staff can be transported to hospitals.
The fact that the attacks took place on a public holiday when many people were off work was a vulnerability that has relevance to other healthcare systems. One of the study’s conclusions is therefore that preparedness planning must include anticipating when periods of increased vulnerability may arise, whether due to timing or structural factors – on Christmas Eve, the morning of New Year’s Day or the evening of Midsummer Eve in Sweden, for example.
The study was conducted together with Adam J Rose at the Hebrew University of Jerusalem Braun School of Public Health and Community Medicine, in Jerusalem, Israel, and Debra Gershov West former director of the Emergency Department at Assuta Ashdod Public Hospital, Israel. The study was approved by the Swedish Ethical Review Authority and funded in part by Region Kronoberg.
Article: Wartime Mass Casualty Incident Plan Operation: Staff Experiences from a Civilian Hospital in Southern Israel on October 7, 2023. Maximilian P Nerlander, Adam J Rose, Debra Gershov West, Disaster Medicine and Public Health Preparedness, published online 21 July 2026. DOI: 10.1017/dmp.2026.10407
Thor Balkhed
