Narrative

HUMC-EK is 1 of 29 hospitals in Israel, a tertiary care medical center with over 800 beds, and is 1 of 7 supra-regional trauma centers. Most of the patient rooms in the ED, including the trauma bays, acute care areas, and pediatrics, are “bombproof” to the highest technical standards. This includes outer concrete walls that are at least 25 cm thick, a blast door that opens out, and specially designed blast windows.¹ The ambulatory ED, designated for low acuity patients, is not a protected area.

Per Ministry of Health (MOH) regulations, all hospitals in Israel must have comprehensive disaster preparedness plans, including written protocols and regular training exercises.Reference Nitzan, Mendlovic and Ash² In 2022, the hospital conducted a 2-day drill simulating a mass casualty incident (MCI) resulting from a missile penetrating the hospital. The ED and trauma service also practiced at least one annual large-scale MCI drill. This threat was realized on April 14 and again on October 1, 2024, when multiple ballistic missiles were fired at Israel, increasing the need for preparedness. Israel was again subject to a missile barrage, which began on June 13, 2025, and continued for 10 days.

Data on missile alerts in Jerusalem was taken from the website of the Home Front Command (HFC).³ The data on the number of patients in the ED was taken from the hospital’s Business Intelligence (BI) database. IRB approval was obtained (Protocol 0012-25-HMO).

In the city of Jerusalem, there were a total of 11 separate events (including April 14, 2024, October 1, 2024, and June 13-22, 2025) warning of incoming ballistic missiles. On October 1, 2024, 3 separate alerts occurred within a span of less than 20 minutes, whereas all other sirens were single events.

At the time of an oncoming missile, an alert from the HFC was broadcast via news outlets and a dedicated phone app, indicating a 10-minute warning of an attack. In response, the hospital-wide public address system repeated the alert along with instructions to move to protected areas. Ninety seconds before a predicted missile impact, a siren was sounded as a final warning.

The primary objectives of hospital response for a ballistic missile attack were: (1) to move patients, staff, and visitors to previously identified protected areas, (2) to continue to treat routine patients while ensuring the safety of staff, patients, and visitors, and (3) to free beds for potential MCI victims. To free beds, the ED and other departments activated “reverse triage”—either by direct discharges from the ED or from wards.Reference Pollaris, De Bondt and Hoogmartens⁴ This process of early discharge was mandated by the MOH and drills were conducted to ensure appropriate functioning of the process. The process during the exercises and in real time was supervised by a charge nurse and an internist and was based primarily on provider judgment.

The designated protected areas in the ED are acute care, trauma, and pediatrics (Fig. 1a). All patients in the unprotected ambulatory ED during this time had to be able to walk as opposed to being in a wheelchair, which was common during routine times. Once hospital-wide protocols were implemented, Zoom meetings were held for all ED staff to ensure everyone knew the locations of the protected zones, with maps depicting these areas distributed electronically to staff. Anytime a warning of a potential incoming missile was received, ED staff, security personnel, and designated clerical staff wearing yellow vests guided patients from unprotected to protected areas. During each shift, the nurses instructed admitted patients and their families on where to relocate during a siren. They were also responsible for evacuating these patients when the siren went off.

Figure 1.

Emergency Department map by zones.

To mitigate the risk of blast injuries, the number of exits within the protected space was reduced, thereby restricting access. Other ED doors flanking the protective spaces had to be sealed (Fig. 1b). Typically, these doors are kept open with metal ramps to facilitate rolling beds through the doorways. However, these ramps prevented the closure of the doors. Without the ramps, the lip that remained around the doorway frame after they were removed created a tripping hazard. As a temporary measure, in-house engineers removed the metal ramp and replaced it with a lightweight wooden panel to facilitate easy removal and hermetic closure of the doors. During the alerts, the security and ED staff took responsibility for removing the wood panels and sealing the doors (Fig. 1b).

More than 200 people, including hospital workers and visitors near the ED, entered the protected areas during each alert. When the ED became aware of a missile threat for the first time in October 2024, ambulatory patients were briefly moved to the protected zones (Fig. 1a) and treatment was paused until after the all-clear was sounded, enabling a safe return to their designated areas.

In April of 2024, during a sustained missile attack lasting upward of 3 hours, it became clear that pausing operations was not reasonable, and to provide continuing care, an appropriately protected working space for ambulatory patients had to be created. Continuous missile threats were not included in previous drills. During this attack, a patient arrived with a suspected aortic dissection and was placed on a monitored bed in the protected acute care area. A physician escorted him between the sirens to the unprotected computed tomography (CT) suite located several meters outside the protected area. The patient was returned to the protected acute care area after the CT was completed, and there was a break in the alerts. When his results showed he needed immediate surgery, he was escorted between the sirens to the protected operating room.

During the April and October 2024 ballistic missile launches, the ambulatory area patients were relocated to the protected area between the pediatric ED and trauma room (Fig. 1a).

The hospital again faced waves of ballistic missile attacks during 10 days in June 2025. At this time, the protected area was reformatted to include the ambulatory ED. An approximately 230 m² corridor, located in the back hallway, ensured a safe space for continued patient treatment (Fig. 1a). Chairs and beds were set up. The adjacent staff lounge was converted into a triage area with the ability to perform phlebotomy and electrocardiograms (Fig. 1a). Orthopedic and suturing supplies were prearranged on carts for easy transport. Two medication rooms are within the protected area.

During the warning sirens, on average, 46 patients were in the ambulatory and 40 in the acute care areas of the ED. This did not include staff, visitors, and others who ran to the ED’s protected areas. During the recorded times of the ballistic missile attacks, the number of ED patients showed a 30-70% reduction from a comparison period during all but two of the sirens. The hospital suffered no direct hits.