Radiology lessons learned from the 2023 terror attacks in Israel
New research published in Radiology offers guidance on how imaging departments can collaborate during mass casualty events, as detailed by a team of providers who treated patients during the 2023 terrorist attack on southern Israel.
Soroka University Medical Center (SUMC), a Level 1 trauma center in Be'er Sheva, served as the primary evacuation destination after the attack. During that time, nearly 700 injured patients flooded the hospital, over 400 of whom were seen and treated within 8 hours of the attack.
Of the 673 patients who presented to SUMC, 461 underwent imaging—351 patients had X-rays, 164 underwent CT and 54 received both. Many of the injuries were grave, involving blunt force trauma, gunshot wounds and penetrating trauma caused by explosive projectiles. What was already an onerous challenge was further complicated by continuous rocket attacks, which hindered staff mobilization and resource replenishment.
Nearly two years after the attacks, a radiology team who helped care for the influx of patients is sharing insight into their experience and offering advice on navigating similar high-stakes scenarios.
"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," lead author, Gal Ben-Arie, MD, senior radiologist and head of Innovation & Artificial Intelligence in Imaging at SUMC, said in an announcement from the Radiological Society of North America (RSNA), which published the piece. "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."
The team highlighted four key factors that enabled staff to successfully serve patients in the hours following the attack:
Staffing protocols specific to mass casualty events: After the attacks, the hospital increased on-site staffing immediately, calling in all radiologists and radiology residents to assist with triage and reads. Radiologists who were unable to be physically present were instructed to log into the hospital’s PACS remotely to assist with reads, which freed up on-site docs to help with triage and patient care. On-call technologists were called in as well, giving the department ample staff to tend to patients and prevent bottlenecks.
Imaging triage at the CT site: Radiologists positioned themselves at the scanning consoles to quickly triage patients and determine their imaging needs. This allowed them to view imaging in real-time, enabling them to immediately steer severely wounded individuals toward treatment.
Utilization of nontraditional scanners: Under normal circumstances, the hospital operates three CT scanners, one of which is located in the ED and is shielded to ensure safety during missile attacks. The continuous strikes resulted in two of those scanner being shut down, leaving just one operational for hundreds of patients. During this time, leaders made the decision to use scanners typically deployed for PET/CT and radiation therapy simulation to address the growing patient load. These units were located in shielded areas a few minutes away from the ED, allowing staff to safely image patients.
AI backup: During the surge, an integrated AI system was used to flag critical imaging findings in 7.3 minutes. It also flagged discrepancies between reports and imaging, giving providers an added safety net.
"In contrast to earlier single-site emergency department experiences, our center had to repurpose our nonemergency department, shielded CT systems (radiotherapy simulation and PET-CT) and perform on-site re-triage at distant scanners to prevent misses and bottlenecks,” Ben-Arie said. "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 suggested these systems can be adapted by organizations of all sizes. He emphasized that flexibility is critical, as these events are unpredictable and put an incredible amount of strain on staff.
"Train for the unexpected—not just for the last disaster—and build systems that can adapt quickly as conditions evolve," he said.
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In addition to her background in journalism, Hannah also has patient-facing experience in clinical settings, having spent more than 12 years working as a registered rad tech. She began covering the medical imaging industry for Innovate Healthcare in 2021.