Patterns of war related trauma in Gaza during armed conflict: survey study of international healthcare workers

Objective To systematically document the patterns of war related injuries in Gaza, Palestine.

Design Survey study of international healthcare workers, August 2024 to February 2025.

Participants 78 international healthcare workers deployed to Gaza.

Main outcome measures The main outcome was the type of injuries observed by international healthcare workers during the conflict in Gaza. A Delphi informed survey was distributed through non-governmental organisation rosters and secure WhatsApp and email groups. Respondents completed the survey using contemporaneous logbooks and shift records.

Results The survey collected data on 12 anatomical regions, mechanisms of trauma, and general medical conditions. 78 healthcare workers reported 23 726 trauma related injuries and 6960 injuries related to weapons. The most common traumatic injuries were burns (n=4348, 18.3%), lower limb injuries (n=4258, 17.9%), and upper limb injuries (n=3534, 14.9%). Explosive injuries accounted for most of the weapon related trauma (n=4635, 66.6%), predominantly affecting the head (n=1289, 27.8%), whereas firearm injuries disproportionately affected the lower limbs (n=526, 22.6%). Healthcare workers reported 4188 people with chronic disease across 11 domains requiring long term treatment.

Conclusion Healthcare workers deployed to Gaza reported an injury phenotype defined by extensive polytrauma (≥2 anatomical regions), complex blast injuries from high yield explosives, firearm related injuries to upper and lower limbs, and severe disruption to primary care and the treatment of chronic diseases. The results provide actionable insights to tailor humanitarian response and highlight the urgent need for structured, resilient clinical surveillance systems.

Editor’s note This paper is based on research from an active war zone, where conventional research methods may be impossible to apply.

Development of Delphi informed survey

A structured literature review and a Delphi informed panel of 13 international healthcare workers with experience of deployment for humanitarian reasons were used to generate a comprehensive list of medical conditions across 12 anatomical regions and medical specialities. We iteratively reviewed items over two rounds until consensus was reached on clinical relevance and ICD-10 mapping. Each final item was linked to its corresponding ICD-10 code comprising three or four characters. The initial draft questionnaire employed a 5 point Likert scale (from 0=never encountered to 4=very frequently encountered) to measure frequency. After pilot testing with 10 healthcare workers, the scale was revised into structured categorical ranges of patient counts for clarity and usability. Other revisions included reducing free text fields, clarifying instructions to emphasise the importance of logbook completion and role specific completion, and grouping items by anatomical region. No sample size was calculated; instead, sample size was dictated by feasibility and access. The final survey contained 12 anatomical regions and 161 items mapped to ICD-10 (see supplementary tables S1.01-1.05).

Survey content

Respondents provided information on their professional role (nurse, resident physician, attending physician), medical specialty, previous deployments to war zones, date of return, duration of deployment, and location.

For each ICD-10 mapped condition, respondents recorded the number of injuries they directly managed, and the anatomical site involved. By design, this survey reflects injuries among individuals who survived long enough to reach clinical evaluation and does not capture those who died before medical contact. Event counts were reported in structured categorical ranges rather than as precise counts (0, 1-5, 6-10, 11-15, 16-20, >20). Conditions were categorised into two domains: trauma (by anatomical region, including psychological trauma), and general medical and chronic disease presentations. Firearm and explosive injuries were documented through separate structured questions, each specifying the affected body regions and the reported frequency of injuries. Although coded anatomically, these data were collected in parallel to the overall injury dataset and are presented with their own denominators; they were not included in the anatomical totals shown for all traumatic injuries. A mass casualty was defined as an event involving ≥10 injured patients presenting simultaneously, consistent with operational thresholds in conflict settings.15

Open text fields—Each section of the survey concluded with an optional free text field where respondents could record reflections on clinical challenges, diagnostic uncertainty, or adaptations made under resource constraints. We collated and summarised these responses descriptively.

Survey distribution and participants

The final questionnaire was distributed between 1 August 2024 and 1 February 2025. Distribution channels included WhatsApp groups coordinated by non-governmental organisations (NGOs) involved in Gaza deployments, and direct email invitations from NGO team leaders to their clinical rosters.

Eligibility to be included in the study was strictly limited to healthcare workers (nurse, resident, or attending physician) who had worked in Gaza during the study period and completed the survey within three months of their deployment end date. This recall window, designed to optimise recall accuracy across varied deployment lengths, meant that most data reflected deployments that concluded between May 2024 and January 2025. Respondents were asked to complete the sections relevant to their clinical role and to do so with reference to contemporaneous logbooks, shift records, or case notes routinely maintained as standard practice by humanitarian healthcare workers during deployment.13 Completion of all mandatory quantitative and demographic items was required for inclusion.

Statistical analysis

We report demographic characteristics of respondents (specialty, country of practice, deployment governorate, and facility type) as counts and percentages. For each condition or injury, we report the number of injuries, the proportion of total responses, and the number of healthcare workers who completed that survey section. These figures represent clinician level case estimates and should be interpreted as a subset of the overall caseload. To mitigate recall error, event counts were captured in categorical ranges and, for analysis, conservatively coded to the lower bound (eg, 6-10 coded as 6).16 To further minimise the risk of overreporting or duplication, survey responses were collected independently, and reporting focused on injuries and conditions that were consistently observed across multiple respondents. To emphasise anatomical patterns, we present injury data as a body atlas of war related trauma. All analyses were performed in Python 3.10.

Patient and public involvement

Patients and members of the public were not directly involved in the design, conduct, reporting, or dissemination of the study. The questionnaire was developed through a Delphi informed process with experienced humanitarian clinicians to ensure clinical relevance and feasibility in this setting.

Anatomical distribution of trauma injuries

Overall, the 78 healthcare workers reported 23 726 traumatic injuries during deployment in Gaza, reflecting multisystem trauma (fig 1, fig 2). A median of 49 respondents (IQR 47.0-61.0) contributed data for each injury category. The most frequently affected regions were the lower limbs (n=4258, 17.9%) and upper limbs (n=3534, 14.9%), with 67 (86%) and 62 (79%) healthcare workers, respectively, reporting injuries (table 2). Common injuries included fractures of the tibia or fibula (29.7% of lower limb injuries), fractures of the radius or ulnar (19.6% of upper limb injuries), and crush injuries affecting both the upper and the lower limbs (see supplementary tables S2.09-2.10). Head trauma (n=2303, 9.7%) was reported by 57 healthcare workers (73%), including diffuse (17.4%) and penetrating (15.9%) brain injuries. Neck injuries (n=348, 1.5%) were reported by 50 healthcare workers (64.1%) and were mostly penetrating. Pulmonary injuries (n=2237, 9.4%) were reported by 48 healthcare workers (62%), with traumatic pneumothorax most common (41.8%); penetrating cardiac injuries accounted for 18.6% of all trauma related cardiac conditions. Abdominal trauma (n=785, 3.3%) was reported by 47 healthcare workers (60%), including bowel (53.1%), liver (19.2%), and splenic (14.1%) injuries. Vascular injuries (n=715, 3.0%) were reported by 61 healthcare workers (78%), predominantly affecting the legs (n=313, 43.8%). Urogenital injuries (n=145, 0.6%) were reported by 45 healthcare workers (58%), mainly kidney trauma. Overall, 742 (3.1%) obstetric related traumas were reported by 36 healthcare workers (46%), of which 269 (36.3%) involved mortality of the fetus or the mother, or both. Psychological trauma (n=1533, 6.5%) was reported by 47 healthcare workers (60%), with depression (40.8%), acute stress reactions (35.2%), and suicidal ideation (12.7%) being most common (see supplementary tables S2.01-2.13).

Fig 1

Body atlas of trauma injuries in Gaza, including distribution of trauma injuries across anatomical regions. Absolute counts are presented, and represented by circle sizes, using area based calculations. The top three injury subtypes per body region are presented. Burns are further subdivided by severity: first degree burns involve only the epidermis (superficial), second degree burns involve the epidermis and a portion of the dermis (partial thickness), third degree burns involve the entire epidermis and dermis (full thickness), and fourth degree burns are full thickness, extending into underlying muscle, tendon, ligament, or bone

Fig 2

Mechanisms of trauma by anatomical region. Total injury counts and distribution between firearm and explosive injuries are presented. The injury counts are also represented by circle sizes, using area based calculations

Healthcare workers often encountered patients with polytraumas (≥2 anatomical regions affected); more than 70% reported managing people with injuries across two or more anatomical regions. Additionally, experience of mass casualties was widespread, with 77% and 18% of healthcare workers reporting managing 5-10 and >10 patients with trauma simultaneously, respectively (fig 3).

Fig 3

Distribution of mass casualties reported by healthcare workers deployed to Gaza. Mass casualties defined as ≥10 patients with trauma presenting simultaneously

Burn injury characteristics and distribution

Burns were the most common trauma related injury, with 55 healthcare workers (71%) reporting 4348 cases (18.3%). These injuries mainly affected the head or neck (n=1004, 23.1%), upper limbs (n=1102, 25.3%), or lower limbs (n=1198, 27.6%) (fig 1; also see supplementary table S2.14). Burns affecting only the epidermis (n=1315, 30.2%) were frequently seen, whereas partial thickness burns affecting the dermis (n=1398, 32.2%) were the most common. Full thickness burns involving the entire dermis (n=1173, 27.0%) were also notable, with the most severe injuries extended into muscle or bone (n=462, 10.6%).

Weapon related injury patterns

Weapon related trauma mainly involved high energy explosives and firearms, with a total of 6960 documented injuries (fig 2). Explosive injuries made up two thirds (n=4635, 66.6%) of weapon related injuries, whereas firearms injuries accounted for 2325 (33.4%). Explosive injuries occurred across various anatomical regions: head (n=1289, 27.8%), chest (n=650, 14.0%), abdomen (n=675, 14.6%), upper limb (n=663, 14.3%), and lower limb (n=777, 16.8%), reported by 62-66 healthcare workers depending on the anatomical site. Although fewer in number, firearm injuries mainly affected critical areas: head (n=230, 9.9%), chest (n=237, 10.2%), abdomen (n=256, 11.0%), lower limb (n=526, 22.6%), and upper limb (n=363, 15.6%). Polytrauma constituted 12.5% of explosive related (n=581) and 9.8% of firearm related (n=227) injuries (see supplementary tables S2.15-2.16).

General medical, infectious, and chronic disease presentations

Healthcare workers reported a total of 5405 general medical and infectious disease presentations. The most common general medical conditions were malnutrition (n=1002, 18.5%) and dehydration (n=865, 16.0%), reported by 59 (76%) and 54 healthcare workers (69%), respectively. Fifty four healthcare workers (69%) recorded sepsis in 631 patients with injury (11.7%), and 47 (60%) recorded gastroenteritis in 986 (18.2%). Healthcare workers reported 4188 people presenting to hospitals with chronic disease requiring long term treatment (see supplementary tables S2.17 and 2.18).

Free text responses

Sixty four of the respondents (82%) provided free text responses that offered additional context to the quantitative findings. They frequently described injuries as unusually severe, including multi-limb trauma, degloving wounds, open skull fractures, and extensive visceral or vascular injuries. One surgeon recounted the blast injury of a “10-year-old with shattered pelvis and femur, ruptured bladder, avulsed ureter, rectal injury, and torn femoral and external iliac arteries, who died hours later in pain.” Severe burns were also emphasised, particularly in children. Respondents with previous experience of deployment in other conflict zones commented that the severity and scale of injuries encountered in Gaza were greater than those they had previously managed.

Malnutrition was repeatedly cited as worsening outcomes, with delayed wound healing and preventable deaths from otherwise treatable conditions. One respondent noted: “Hepatitis cases worsened due to malnutrition; several developed encephalopathy.” Other reflections described neonatal deaths owing to the absence of continuous positive airway pressure, and the breakdown in chronic disease management, with patients presenting in crisis from uncontrolled hypertension. As another respondent wrote: “Access to cancer treatment was unobtainable and regarded as a luxury.”

Respondents reported working with minimal laboratory support, imaging, or monitoring. Improvisation was constantly required, with accounts of “operating on emergency room floors without anaesthesia or sterile tools,” and of “care rationed to those most likely to survive.”

Many respondents described profound psychological trauma among patients, including children expressing suicidal intent after witnessing deaths of family members. As one physician recalled: “The worst part was mothers begging us to save their already-dead children.”

Comparison with other studies

The pattern of injuries in Gaza reflects an extreme form of high energy trauma rarely observed in civilian populations. Extensive burns, polytrauma, and severe injuries from both explosives and firearms were prevalent. The distribution of injuries aligns with the use of thermobaric, incendiary, and area effect munitions designed for maximum tissue destruction. Explosive injuries predominantly occurred in the head, neck, and limbs, where wounds are difficult to treat owing to complex anatomy and limited soft tissue coverage. These findings are supported by outpatient data from Médecins Sans Frontières, which reported that 83% of consultations for wounds due to violent trauma were related to bombs and shells, reinforcing the view that explosive weapons are the main cause of injury, as evidenced in our study.17 In contrast, firearm injuries disproportionately affected the limbs, often involving major vascular territories, where, in the absence of surgical resources, amputation was often the only viable solution.18

Compared to previous conflicts, explosive injuries made up 67% of the cases in our cohort, aligning with US military data from Iraq and Afghanistan, and more than double the 31% of explosive injuries reported among civilian populations in contemporary conflicts.192021 The resulting injury profiles resembled those reported in combat settings among trained military personnel, highlighting the burden of trauma among civilians in Gaza. Explosive weapons, designed for open battlefields, are increasingly being deployed in densely populated urban areas.22 Documenting these specific injury patterns contributes to the evidence base for humanitarian analysis of the health consequences of modern urban conflict.23 We found that 18.3% of trauma presentations were related to burns, higher than the ≤11% reported in previous other conflicts.5 Notably, more than 30% of burns involved the full thickness of the dermis and extended into muscle and bone, resulting in complex, high morbidity wounds with limited options for definitive care, consistent with the use of incendiary and fuel-air munitions. Firearm injuries accounted for about 30% of war related trauma in our study, similar to reports from the Syrian conflict.24

Beyond traumatic injuries, our findings highlight a critical and often underestimated public health crisis caused by widespread general medical, infectious, and chronic diseases. More than 5400 acute presentations, with malnutrition alone accounting for almost 20%, aligns with humanitarian reports and emphasises the lack of basic survival needs in Gaza.25 The large number of chronic disease presentations highlights the profound indirect morbidity and mortality resulting from the systemic collapse of healthcare due to the blockade, fractured pathways, and loss of facilities.26

Strengths and limitations of this study

This study’s free text reflections provide important qualitative context on the complex and interconnected challenges the healthcare system in Gaza faces. Respondents’ narratives describe severe resource intensive injuries and conditions that require long term rehabilitation, underscoring the lasting effects for all aspects of healthcare and population wellbeing for years, if not decades, to come.11 These reflections broaden our understanding of the human and systemic costs inherent to prolonged humanitarian crises.

Despite the strength of this international healthcare worker sample, several limitations must be acknowledged. Despite entry restrictions preventing many healthcare workers from deployment, responses were obtained from 78 clinicians, ensuring a robust and diverse dataset under challenging access conditions.27 Firstly, our data are prone to recall bias. Respondents were required to use contemporaneous logbooks, shift records, or case notes to complete the survey, but reliance on retrospective reporting inevitably introduces uncertainty. During periods of large influxes of injured people, recording may have been incomplete, contributing to possible underestimation or imprecision. This limitation was unavoidable given the destruction of Gaza’s electronic and paper medical records. To mitigate these risks, we restricted the recall period to three months, employed structured categorical ranges, and conservatively coded the lower bound of each reported range. As a result, our figures likely underestimate the true clinical burden. Notably, the frequency of injuries was broadly consistent in order of magnitude with WHO surveillance data, which reported 33 000 injuries over the same period.28 Secondly, duplicated reporting is a possible risk. To address this, we examined deployment periods and hospital locations. Fifty six respondents (72%) worked during non-overlapping time periods. Among the remaining 22 respondents, only four overlapping deployments occurred at the same hospital, contributing to 4.3% of all data. Although duplication cannot be entirely excluded, we highlight this as a clear limitation of the study. Nevertheless, the overlap was small, and our data indicate that its impact on overall estimates was minimal. Importantly, Palestinian healthcare workers were not included in this study. The perspectives of international responders were used as a feasible interim proxy given the operational, communication, and genuine safety concerns that local healthcare workers face.

The implications of these findings need urgent attention. Firstly, the extent of polytrauma observed across several anatomical regions in our cohort, reflecting the impact of indiscriminate aerial and heavy explosive bombardment in civilian areas, underscores the need for preparedness in managing complex, resource intensive injuries that exceed those typically reported in conflicts elsewhere. Secondly, humanitarian missions must be equipped not only for trauma care but also for reconstruction after burns, critical care, and rehabilitation, including long term psychological support.1729 Many UK surgeons deployed to Gaza, including several of the authors of this study, had undertaken hostile environment surgical training, which proved vital in preparing clinicians to practise in such areas.30 Thirdly, chronic disease management and antenatal care must be central to the humanitarian response. Finally, that this study required retrospective survey methods highlights critical gaps in clinical documentation. Although a global standard exists in the WHO Emergency Medical Team minimal dataset, its use in Gaza was partial and inconsistent, hampered by communication blackouts and destruction of facilities.1329 Strengthening the resilience of such systems and ensuring their pre-positioning in future crises would enable more accurate real time surveillance and better allocation of resources. The absence of systematic clinical data in Gaza hampers humanitarian responses and limits global understanding of the true scale and nature of suffering among civilians.

Conclusions

This international healthcare worker reported survey highlights the scale and complexity of traumatic injuries and medical conditions in Gaza during the ongoing conflict. The volume, distribution, and military grade severity of injuries, indicate patterns of harm that exceed those reported in previous modern-day conflicts. These findings highlight the urgent need for resilient, context specific surveillance systems, designed to function amid sustained hostilities, resource scarcity, and intermittent telecommunications, to inform tailored surgical, medical, psychological, and rehabilitation interventions.