Challenges of a regional trauma center in treating combat and civilian casualties. The experience of Assuta Ashdod Hospital in the Iron Swords War

•Designating a hospital as an emergency landing zone for air evacuation can lead to a disproportionate load of severe injuries on a smaller hospital.•A well-organized regional trauma center can treat major trauma and mass casualty events.•Personal related limitations and absences should be taken into consideration in the management of major causalities events.•Routine challenges and limited resources will become more evident during emergency situations and the on-going implementation of novel changes or untrained personal will not be effective measures. Assuta Ashdod Hospital is a regional trauma center. The hospital received casualties on the first day of the civilian massacre of October 7th and thereafter. The Assuta Ashdod Hospital was designated as an emergency landing site only for unstable or deteriorating patients who would not survive longer flights to a central trauma center. The aim of this study is to share our experience and challenges as a new regional trauma center in a war zone. A descriptive cohort study consisting of all trauma patients admitted in the Emergency Department, between October 7, 2023, and December of the same year. The data is part of the Israel National Trauma Registry. A total of 397 heavily wounded patients were admitted, of which 3 were declared dead on arrival, 95 were hospitalized and 299 were discharged from the emergency department after initial care. Of the 95 wounded patients hospitalized, 60 (63.1 %) had a single mechanism of injury, of which, 35.7 % were penetrating injuries. The most frequent injury was to the extremities (60 %) followed by chest and abdomen, 35.7 % and 14.7 % respectively. Multi-trauma injuries were present in 40 % of the wounded patients. The average ISS was 15 (median=9). Of all patients, 10.5 % of patients were considered to have severe and 23.1 % to have profound (very-severe) injuries by the ISS classification. Twelve patients received whole blood transfusions, fourteen received the Massive Transfusion Protocol. Sixty-one of the 95 (64 %) patients underwent surgery, with a total of 137 surgeries performed. Sixty-seven percent of surgical procedures were orthopedic and 16.7 % were of general surgery. The average length of stay was 6.5 days (median=6). We transferred 14 patients to central trauma centers, 3 of which did not survive. The outcomes of patients admitted to the Assuta Ashdod Hospital were good in treating major trauma patients in a mass casualty event, reaffirming its capabilities