A retrospective analysis of radiology operations during the October 7, 2023, mass casualty incident in southern Israel revealed how workflow adaptations and resource reallocation enabled imaging services for 673 injured patients.
The analysis of services at Soroka University Medical Center (SUMC), the sole tertiary and level 1 trauma center in southern Israel, found that enhanced staffing and flexible resource management reduced computed tomography turnaround times from 54 minutes to 28 minutes while maintaining diagnostic accuracy. Radiography turnaround times increased modestly from 43 to 49 minutes.
"Both enhanced staffing, achieving more than a fourfold increase compared with routine operations, and flexible resource reallocation, including the repurposing of nontraditional computed tomography scanners, were key in managing the patient surge and optimizing diagnostic workflows," reported researchers, led by Gal Ben-Arie, MD, of the Department of Medical Imaging at SUMC.
Of the 673 injured patients who arrived within the first 24 hours, 461 (69%) underwent imaging, with 431 patients (94%) having mass casualty-related injuries. Patients had a mean age of 30 years, with 77% being male. Gunshot wounds (43%) and shrapnel injuries (37%) were the most common, with a median Injury Severity Score of 4.
The radiology department implemented several adaptations. Staffing increased from the typical weekend complement of one resident and two attending physicians to two residents and seven attending physicians on-site, with five additional attending physicians providing remote support via the picture archiving and communication system. Technologist staffing expanded from 5 to 20 personnel.
Resource utilization required innovative solutions as ongoing missile attacks limited access to unshielded areas. "As patient load increased by midday, alternative scanners, typically used for radiation therapy simulation and positron emission tomography/computed tomography, were used," noted Dr. Ben-Arie and colleagues. These scanners, located in shielded areas 5 to 10 minutes from the emergency department, accommodated stable patients when the primary computed tomography scanner became overwhelmed.
The department's trauma computed tomography protocol was streamlined during the crisis. "During the mass casualty incident, most scans included contrast-unenhanced head computed tomography, computed tomography angiography from the skull base down to the groin, and portal venous phase imaging in the abdomen and pelvis," noted analysis authors.
"In cases where patients arrived at distant computed tomography sites unaccompanied by a clinical team, and injuries were identified (Injury Severity Score greater than 15), a handwritten report was created with the standard electronic report," they explained. This measure proved lifesaving, as approximately 25% of patients initially categorized as stable were reclassified as having major trauma.
The institution's artificial intelligence (AI) system provided additional safety measures, identifying pathologic abnormalities including intracranial hemorrhage, brain aneurysm, large vessel occlusion, cervical spine fracture, rib fractures, pulmonary embolism, and abdominal free air. The median time to AI alert was 7 minutes, with no discrepancies between AI interpretation and radiology reports.
Digital radiography was performed in 351 patients, with computed tomography performed in 164 patients. Fifty-four patients underwent both modalities. A total of 739 radiographic examinations were completed, most frequently involving the limbs (64%), while 179 computed tomography examinations were performed, with 51% being whole-body trauma computed tomography.
Among patients undergoing computed tomography, 33% were classified as having severe injuries (Injury Severity Score greater than 15), 29% had moderate injuries, and 38% had mild injuries. Notably, 22% were unresponsive or unable to provide personal details.
The study identified several operational weaknesses requiring future attention: the need for standardized handwritten report templates, automatic archiving of focused assessment with sonography in trauma examinations, formal triage training for remote site personnel, dynamic artificial intelligence-assisted worklist prioritization, and rotation protocols to prevent staff fatigue during prolonged operations.
"These findings underscored the importance of dynamic in-hospital triage protocols, rapid staff mobilization, and versatile management of imaging resources," the researchers concluded. "These strategies are essential components of radiology preparedness plans to improve patient outcomes during future high-casualty incidents."
Jacob Sosna, MD, serves as a consultant to the editor of Radiology; All other authors reported no relevant relationships.
Source: Radiology
