On October 7, 2023, southern Israel faced the largest terror attack in its history, with over 1,144 deaths and 1,600 injured. The Soroka University Medical Center (SUMC), located in Beer-Sheva, Israel, is the only tertiary medical center in southern Israel and the only level 1 trauma center in the region. SUMC serves approximately 1 million people and is located 40 km from the Gaza Strip, with terrorist activity as close as 10 km away. SUMC has extensive experience in managing mass casualty incidents (MCIs) and was prepared for the attack. The attack began at 6:30 am with rockets and simultaneous Hamas attacks. The emergency response team convened to prepare for the attack. The first casualty arrived at 7:37 am, and by 8 am, an MCI was declared. By 9 am, hundreds of medical staff were on hand, and 59 casualties had arrived. By 1 pm, 281 casualties were brought in, with 42 air raid sirens sounding, including 18 for rockets expected to hit SUMC. By 9 pm, 572 casualties had been treated, rising to 676 in the first 24 hours. During this time, 120 critically injured patients were treated, 96 surgeries were performed, and 200 blood units were transfused. To increase capacity, SUMC doubled its treatment bays, opened an 8-bed ICU, and converted a 40-bed ward into an acute surgical ward. External medical staff were also recruited. To address the need for CT scans, two additional scanners were used. The medical center also faced a surge in families seeking information about missing loved ones. By 9 pm, the flow of casualties slowed, and the focus shifted to patients admitted earlier. Over 80 casualties were transferred to other hospitals. SUMC replenished supplies, purchased medical equipment, and planned for future events. Care for staff and their families was also a priority, with day care facilities opened for staff children. SUMC treated 680 casualties within 24 hours, with a large percentage requiring emergency surgery. Key elements in managing the event included early mobilization, protecting other patients, increasing capacity, recruiting external staff, and transferring patients for definitive care. The experience provided valuable lessons for future preparedness.On October 7, 2023, southern Israel faced the largest terror attack in its history, with over 1,144 deaths and 1,600 injured. The Soroka University Medical Center (SUMC), located in Beer-Sheva, Israel, is the only tertiary medical center in southern Israel and the only level 1 trauma center in the region. SUMC serves approximately 1 million people and is located 40 km from the Gaza Strip, with terrorist activity as close as 10 km away. SUMC has extensive experience in managing mass casualty incidents (MCIs) and was prepared for the attack. The attack began at 6:30 am with rockets and simultaneous Hamas attacks. The emergency response team convened to prepare for the attack. The first casualty arrived at 7:37 am, and by 8 am, an MCI was declared. By 9 am, hundreds of medical staff were on hand, and 59 casualties had arrived. By 1 pm, 281 casualties were brought in, with 42 air raid sirens sounding, including 18 for rockets expected to hit SUMC. By 9 pm, 572 casualties had been treated, rising to 676 in the first 24 hours. During this time, 120 critically injured patients were treated, 96 surgeries were performed, and 200 blood units were transfused. To increase capacity, SUMC doubled its treatment bays, opened an 8-bed ICU, and converted a 40-bed ward into an acute surgical ward. External medical staff were also recruited. To address the need for CT scans, two additional scanners were used. The medical center also faced a surge in families seeking information about missing loved ones. By 9 pm, the flow of casualties slowed, and the focus shifted to patients admitted earlier. Over 80 casualties were transferred to other hospitals. SUMC replenished supplies, purchased medical equipment, and planned for future events. Care for staff and their families was also a priority, with day care facilities opened for staff children. SUMC treated 680 casualties within 24 hours, with a large percentage requiring emergency surgery. Key elements in managing the event included early mobilization, protecting other patients, increasing capacity, recruiting external staff, and transferring patients for definitive care. The experience provided valuable lessons for future preparedness.