On October 7, 2023, somewhere around 1,500-3,000 terrorists invaded southern Israel killing 1,200 people, injuring 1,455, and taking 239 as hostages resulting in the largest mass-casualty event (MCE) in the country’s history. Most of the victims were civilians who suffered from complex injuries including high-velocity gunshot wounds, blast injuries from rocket-propelled grenades, and burns. Many would later require complex surgeries by all disciplines including general surgeons, vascular surgeons, orthopedists, neurosurgeons, cardiothoracic surgeons, otolaryngologists, oral maxillofacial surgeons, and plastic surgeons. Magen David Adom (MDA) is Israel’s National Emergency Prehospital Medical Organization and a member of the International Red Cross. While there are also private and non-profit ambulance services in Israel, the Ministry of Health has mandated MDA with the charge of managing an MCE. For this event, MDA incorporated a five-part strategy in this mega MCE: (1) extricating victims from areas under fire by bulletproof ambulances, (2) establishing casualty treatment stations in safe areas, (3) ambulance transport from the casualty treatment stations to hospitals, (4) ambulance transport of casualties from safe areas to hospitals, and (5) helicopter transport of victims to hospitals. This is the first time that MDA has responded to a mega MCE of this magnitude and lessons are continually being learned.

On October 7, 2023, Israel experienced the worst terror attack in its history – 1,200 people were killed, 239 people were taken hostage, and 1,455 people were wounded. This mass-casualty event (MCE) was more specifically a mega terrorist attack. Due to the overwhelming number of victims who arrived at the two closest hospitals, it became necessary to implement secondary transfers to centers in other areas of the country. Historically, secondary transfer has been implemented in MCEs but usually for the transfer of critical patients from a Level 2 or Level 3 Trauma Center to a Level 1 Center. Magen David Adom (MDA), Israel’s National Emergency Pre-Hospital Medical Organization, is designated by the Health Ministry as the incident command at any MCE. On October 7, in addition to the primary transport of victims by ambulance to hospitals throughout Israel, they secondarily transported patients from the two closest hospitals – the Soroka Medical Center (SMC; Level 1 Trauma Center) in Beersheba and the Barzilai Medical Center (BMC; Level 2 Trauma Center) in Ashkelon. Secondary transport began five hours after the event started and continued for approximately 12 hours. During this time, the terrorist infiltration was still on-going. Soroka received 650 victims and secondarily transferred 26, including five in Advanced Life Support (ALS) ambulances. Barzilai received 372 and secondarily transferred 38. These coordinated secondary transfers helped relieve the overwhelmed primary hospitals and are an essential component of any MCE strategy.

During July through August 2014, Operation Protective Edge, a military conflict between Israel and the Hamas regime in Gaza, dramatically affected both populations. Magen David Adom (MDA), the Israeli national Emergency Medical Service (EMS) and a member of the Red Cross, faced a unique challenge during the conflict: to continue providing crucial service to the entire civilian population of Israel, which was under constant missile threat. This challenge included not only providing immediate care for routine EMS calls under missile threat, but also preparing and delivering immediate care to civilians injured in attacks on major cities, as well as small communities, in Israel. This task is a challenge for a civilian EMS agency that normally operates in a non-military environment, yet, in an instant, must enhance its capability to respond to a considerable threat to its population. During Operation Protective Edge, MDA provided care for 842 wounded civilians and utilized a significant amount of its resources. Providing EMS services for a civilian population in a mixed civilian/military scenario is a challenging task on a national level for an EMS system, especially when the threat lasts for weeks. This report describes MDA’s preparedness and operations during Operation Protective Edge, and the unique EMS challenges and dilemmas the agency faced.

Jaffe E, Wacht O, Strugo R. Operation Protective Edge – A Unique Challenge for a Civilian EMS Agency. Prehosp Disaster Med. 2015;30(5):539–542.