BMC Emergency Medicine volume 25, Article number: 105 (2025) Cite this article

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Abstract

Background

As part of a hostage-prisoner exchange negotiation, 105 hostages were released to hospitals throughout Israel for treatment after being taken into captivity by Hamas to the Gaza Strip on October 7, 2023. The aim of this study is to describe the establishment of a clinical protocol for hostages returning from captivity.

Method

The process of the creation of procedures for implementation of and the clinical protocol itself is described.

Results

A total of 24 returning hostages arrived at Shamir Medical Center (SMC); all were foreign workers and all but one were from the same nationality. The majority group of 23 returning hostages from the same nationality received testing for Q-fever, Hepatitis B, and human immunodeficiency virus (HIV). Orthopedic, dermatological, and ear nose and throat (ENT) consultation, chest and limb X-rays, head and abdominal CT scans, and antibiotics were also utilized by the 23 returning hostages of the same nationality. The returning hostage from a different nationality of origin utilized consults with an ENT, underwent a hearing test, and tests for Q-fever, urine toxicology, Hepatitis B and HIV. Among the group of 23 hostages from the same nationality of origin, the mean percentage loss of body weight was 10%±10%. No correlation was found between age and change in weight (rho = -0.227; p = 0.350). In addition, 17.4% tested positive for Q fever, 30.4% tested positive for Hepatitis B and 13% tested positive for a sexually transmitted disease. They spent a mean of 5 ± 1 days hospitalized. The sole hostage of different nationality of origin lost 15% of his body weight, tested positive for Q fever and spent 3 days hospitalized. Consults with social workers and dietitians, translators and COVID-19 tests were used by all returning hostages.

Conclusion

In this study, no significant correlation was found between age and change in weight among returning hostages. This novel clinical protocol was successfully utilized in real-time and may serve as a framework for the complex and sensitive clinical management of returning hostages, in case of need.

Clinical trial number

Not Applicable.

Peer Review reports

Introduction

On October 7, 2023, thousands of terrorists invaded Israel from the Gaza Strip. The country was infiltrated by land, sea, and air at numerous locations, and severe war crimes were committed in what was the largest terror attack in its history [1]. 1697 people were killed during the terror attacks on Israel, 53 of them children, and hundreds were kidnapped [2]. In November 2023, a hostage exchange agreement was reached, which included the release of 105 hostages via the Red Cross. They were transported to six medical centers throughout the country, including the Shamir Medical Center (SMC), an academic medical facility with the 4^th largest governmental hospital in Israel, that provides care for over 1 million residents of the country’s central region. Twenty-four returning hostages arrived at SMC over the course of one week [3]. In anticipation of their return, the SMC management team created a clinical protocol based on scientific evidence, clinical experience, and official guidelines from the local Ministry of Health (MOH) to assess and treat the returning hostages. This paper describes the creation of procedures for the clinical protocol and its implementation.

Background

Few studies have reported on the clinical care of hostages released from captivity. Existing papers on the health and functioning of former prisoners of war (POWs), clearly depict the serious psychological consequences after release from captivity, where captives undergo extreme and inhumane conditions, as well as psychological and physical abuse [4]. In their study of POWs from the Second World War, Robson et al. reported on the physical health consequences of captivity, such as nutritional deficiencies, dysentery, malaria, tropical ulcers and cholera, and high rates of mortality due to tuberculosis, cirrhosis, and suicides [5].

Post-traumatic stress disorder (PTSD)-associated musculoskeletal, cardiovascular, and gastrointestinal diseases, as well as endocrine and metabolic diseases have also been discussed in the literature [6]. In a longitudinal study of ex-POWs from the Yom Kippur War, higher PTSD rates, as well as greater incidence of psychiatric symptoms and health problems were reported compared to controls. There were also more cases of inflammation and metabolic syndrome, as well as shorter telomeres and higher mortality rates [7]. Post-captivity PTSD has also been reflected in the biomarkers of released captives, such as elevations in plasma and salivary cortisol, urinary catecholamines, and salivary testosterone; salivary cortisol has specifically been found to be correlated with ratings of psychological disturbance in released hostages [8]. Despite the data on the severe health effects of captivity, both clinical and psychosocial, our literature search did not identify any published protocols detailing clinical protocols for the treatment of released hostages, which was urgently needed in real-time.

Methods

Study design

This study describes the establishment and implementation of a clinical protocol for hostages returning from captivity. Ethical approval was sought and approved by the Shamir Medical Center Helsinki committee, 0027 − 24. The Helsinki Committee waived the requirement for written informed consent.

Setting

Shamir Medical Center, a 904-bed academic medical facility with the fourth largest emergency medicine department in the country, which treats about 160,000 patients each year.

Clinical team selection

Initial steps taken by hospital management included the selection of clinical team members to receive and treat the returned hostages. The team included a site operational manager, who was a physician member of hospital management and integral to building the protocol. In addition, a floor manager physician who was a specialist in emergency medicine was selected to serve as the emergency department (ED) manager, oversee the clinical site, and assign case management teams, together with another emergency medicine (EM) physician for triage. In the case of hostage arrival, this specialist would wait on the helipad to meet the air ambulances, receive a brief summary from the care team, greet the hostages, and conduct an initial triage to assess if urgent care was required. In the case of those requiring urgent care, they would be transported and accompanied by medical staff to the urgent care ward.

In addition, case management teams were assigned for each patient, as per the official guidelines of the MOH for hospitals selected to receive hostages returning from captivity. The medical team was required to include an ED physician or an internist, and an ED nurse. As a result, a triad concept for case management teams was formulated; each patient would be provided their medical team, consisting of an ED physician/internist, an ED nurse, a social worker, and a translator, if required.

The medical teams included physicians with ample experience, exceptional bedside manner, and a capacity for extreme sensitivity and empathy; team members also had to be quick learners who were able to participate in the operational exercises and work seamlessly with the team as a whole. Due to the need for physician availability 24 h a day, seven days a week, medical residents (mostly female) were also included. They remained on standby to ensure that all shifts could be filled.

Since many women were known to have been kidnapped and existing evidence supported the use of sexual assault as a weapon of war, various experts in sexual assault recommended that a predominance of female staff might be less of a trigger for the returning hostages. It was also felt that a greater presence of women would assist in differentiating the experience between captivity and the hospital/inpatient experience. Ultimately, the gender of medical team members was left to the patients to choose.

Medical specialists

The medical team included nurses and physicians from every area of specialty, to ensure that returning hostages had access to comprehensive medical care. A general ED doctor, a pediatric ED doctor, an internal medicine doctor, a surgeon, an orthopedist, a pediatrician, an infectious disease specialist, a psychiatrist, and a gynecologist (specializing in sexual assault) were all included in the multi-disciplinary team. In addition, as it was known that foreign agricultural workers were among the kidnapped, it was arranged to have translators available to facilitate their communication with the staff.

Training of the clinical team

The clinical team training took between ten to twenty hours. The training included preparation on the operational level, in addition to several hours of in-person training, which served to support the knowledge base of the clinical team. Thereafter, complete simulations with actors were carried out, followed by a trial run-through in which the team experienced a simulated return of the hostages. Additional refresher training was added to maintain a high level of knowledge and readiness. These trainings lasted 1–2 h each session and began several days before the hostages’ arrival. No specific curriculum from which to build a protocol was used; the lack of such a curriculum was one of the motivations for the writing of this manuscript.

Establishing a medical workup/laboratory testing protocol

All returning hostages were to be provided a complete medical evaluation after checking in to the inpatient ward. The decision to perform blood work and the time frame in which it was to be performed were to be decided upon by the case and floor manager physicians. Final decisions to provide treatment or testing were to be made in collaboration by the medical, nursing and social worker staff, with the final approval of the case physician and the facility manager and with full consent of the patient.

Due to the lack of existing literature and to create homogeneity and standards of treatment among the patients, protocols were built to support the clinical team. Three protocols were developed for laboratory testing, including routine and mandatory testing, which were administered to all returning hostages, and a list of additional laboratory tests, for whom such testing was relevant (Appendix 1).

[Appendix 1: Medical workup/Laboratory testing protocol]

A protocol of additional medical tests was developed to be utilized as required, based on patient status:

• Chest X-ray
• Electrocardiography (EKG)
• Echocardiogram (ECG)
• Ophthalmological exam
• Audiometry
• Dental exam
• Physical therapy evaluation
• Nutritional evaluation

Assessment of nutritional status and prevention of refeeding syndrome

It was of the utmost priority to identify returning hostages who might be at risk of refeeding syndrome. Refeeding syndrome is a complex condition resulting from metabolic changes (namely in fluids and electrolytes) that may occur in malnourished patients who are re-fed. These shifts result from metabolic and hormonal changes and can cause severe clinical complications. Hypophosphatemia is a main feature of refeeding syndrome. In addition, hypokalemia, hypomagnesemia, abnormal sodium, and fluid balance, changes in the metabolism of glucose, protein, and fat, and thiamine deficiency, can also occur. The deficits of these nutrients in the serum as they undergo rapid influx into the cells accompanied by a swift change in basal metabolic rate, can lead to a range of clinical features associated with the syndrome. Decreases in serum phosphorus may lead to dysfunction of the cellular processes in almost every physiological system. In addition, hypokalemia can cause derangements in cell membrane potential, resulting in arrhythmias and cardiac arrest, and encephalopathy may result from a deficiency in thiamin [9].

Prior to assessment by a dietitian, three parameters were assessed: weight and height for calculation of body mass index (BMI); and weight loss (calculation of weight lost based on weight prior to the event and decrease in food intake). A patient was determined to be at high risk if he/she met one of the following criteria: BMI under 16.5, weight loss of over 15% body weight, or experienced a significant decrease in food intake in the last month. The assessment of risk of re-feeding syndrome is outlined in Appendix 2.

Protocol for victims of sexual assault

The focus of medical intervention for victims of sexual assault was on providing primary medical treatment and not the treatment of the trauma from the assault. Nevertheless, the medical team was trained in how to broach the patient experience of rape during wartime. They were taught to impart particular sensitivity, as the rape of captives is considered “a trauma within a trauma.” Their training emphasized the lost sense of humanity, elements of shame, and sense of complete helplessness. In addition, they were trained to recognize common victim reactions, including freezing up, self-blame (“I didn’t do enough to prevent it”), dissociation, avoidance of feelings about or talking about the trauma, depression, feelings of repulsion, shame, suicidal thoughts and impulses, and PTSD (which may all be worsened if the rape resulted in pregnancy). The team was also instructed not to sabotage any defense mechanisms that may have been built, such as dissociation, during the early stages of healing.

Confirmative questioning and evaluation regarding sexual assault were to be carried out only by experts in the treatment of victims of sexual assault (not by the clinical team), under the assumption that assault may have occurred. Other team members were instructed not to ask questions related to the subject and to speak of it only if it was brought up by the patient himself or herself.

In the framework of the initial patient interview, patients were to be asked whether they had experienced sexual assault during their time in captivity. Regardless of their response, a directed medical history was to be oriented towards genito-urinary and rectal symptoms (i.e. pain in the genitalia and anal area, burning during urination and vaginal discharge, etc.).

In the case of suspected or confirmed sexual assault, a gynecologist with a specialty in sexual assault was to be brought in to interview the patient more specifically. In all cases of an affirmative response, patients were to be asked whether they would prefer a female or a male physician to examine them. Patients were to undergo a thorough examination in the presence of a companion/escort (including an additional hospital staff member). As is the typical routine, physical exams could also be performed by a surgeon or urologist with a full explanation at each step of the exam to ensure receipt of complete consent. In addition, all staff were reminded to avoid expressing personal opinions about the event or situation and to avoid leaving the patient alone at any point during the exam.

Standard prophylactic treatment for sexually transmitted infections (STIs) was to be provided upon admission to those with any symptoms or positive test results.

Documentation of evidence of war crimes and sexual assault

The electronic medical record system (EMR) was classified. Evidence of physical forensic findings was recorded and documented by a designated professional team upon receiving patient consent.

Additional testing and therapies

The following protocols were written to address suspected exposure or infection with Hepatitis B, HIV and other infections:

Hepatitis B protocol:

• For patients who could confirm that they had been vaccinated fully as per MOH recommendations (3 doses of live vaccine), the decision to treat would be based upon levels of anti-hepatitis B antibodies.
• For vaccinated individuals, calibrate anti-hepatitis B antibodies to over 10 ml/mIU – no need for further intervention.
• For unvaccinated individuals, for anti-hepatitis B antibodies under 10 ml/mIU, give booster of live vaccine (Engerix B 20 mcg).
• Consider administering inactivated vaccine (if up to 14 days from exposure).
• Patients for whom vaccine status is unknown, or for the unvaccinated, administer booster of live vaccine and consider administering inactivated vaccine.

HIV protocol:

• Provide prophylaxis if under 72 h from exposure.
• Give for 8 days. Tab Emtricitabine 200 mg & Tenofovir disoproxil phosphate 245 mg (Truvada) *1/day + Tab Dolutegravir (Tivicay) 50 mg * 1 /day.

Tetanus: Administer booster if not vaccinated in the last 10 years.

Fresh bite marks: If no signs of infection, administer Augmentin 875 mg BID x 5 days. If signs of infection are present, treatment type and length to be determined by an infectious disease specialist.

Guidelines for follow-up and ambulatory treatment:

1. 1.Women up to age 45 and men up to age 26 not vaccinated against HPV – refer to HMO clinic for vaccination.
2. 2.If prophylaxis was not provided and the initial evaluation is negative for STI, repeat urine STI testing (gonorrhea, chlamydia trichomatis, and trichomonas, ) and testing for syphilis serology after 2 weeks.
3. 3.Blood test for HIV serology, syphilis, and HCV PCR – after 6 weeks.
4. 4.Blood test for HIV serology, syphilis – after 3 months.
5. 5.If relevant, complete HBV vaccine as needed via family doctor.
6. 6.If relevant, complete PEP for HIV for 28 days.
7. 7.Females: follow up with gynecologist after 1 month.

Statistical analysis

Data collected on participants was analyzed separately based on nationality to maintain group homogeneity and due to the different utilization of hospital resources between the individuals from the different nationalities, which impacted the length of stay. Frequencies for categorical variables were tested using SPSS 29.0 software. Descriptive statistics were calculated for continuous variables including the mean, standard deviation, median, interquartile range, and range. The correlations between independent continuous variables were assessed using Spearman correlation coefficient. Two-tailed P < 0.05 was considered statistically significant.

Results

Twenty-four returning hostages (mean age of 35 + 6.5 years) arrived at SMC, including one female and 23 males, all individuals were foreign workers (Table 1) throughout Nov 24-Dec 1. The returning hostage of a different nationality was 33 years of age (Table 1). Due to limitations outlined in our IRB approval, we were not able to identify, connect these individuals to their country of origin or provide more information regarding the identities of the returned hostages. From a demographic perspective, all of the individuals lacked advanced education and were agricultural workers. No details regarding their prior health status was available. None of the returning hostages were taking medications regularly prior to their abduction.Table 1 Demographic data

Full size table

Conditions in captivity

The group of hostages who came from the same nationality spent a total of 51 + 2.3 days in captivity. During this time, 26.1% saw daylight (defined as access to a window), and 4.3% had access to sanitary facilities (including sinks, toilet and showers). Violence was experienced by 95.7% and there were no reports of sexual assault. Among those who reported experiencing pain, the mean rating of intensity was 0.8 + 1.9 on the VAS scale (median 0; range 6–6) (Table 2).Table 2 Conditions in captivity

Full size table

The returning hostage of a different nationality was held for 49 days in captivity without access to daylight or sanitary facilities. He did not report any sexual assault, experienced one violent act and his pain intensity was ranked as 3 (VAS scale) (Table 2).

Clinical outcomes

Among the 23 returning hostages of the same nationality, the mean percentage loss of body weight was 10%±10% (median 11%) with a range from 3 to 32% loss. The returning hostage from a different nationality lost 15% of his body weight (Table 3). Ten returning hostages were determined to be at high risk of refeeding syndrome, 11 at moderate risk, and 3 at low/no risk. No correlation was found between age and change in weight (rho = -0.227; p = 0.350).Table 3 Clinical data

Full size table

The participants from the larger group spent a mean of 5 ± 1 days hospitalized. 17.4% (4) tested positive for Q fever, 30.4% (7) tested positive for Hepatitis B and 13% (3) tested positive for an STI (Table 3). The returning hostage of another origin spent three days hospitalized and tested positive only for Q fever (3).

A variety of different consultations were available and every returning hostage utilized at least two types of consultations, including social workers and dietitians. 16% of the group utilized some form of imaging and some form of lab testing (ex: urine toxicology and Covid-19) was used by all 24 returning hostages.

Discussion

This paper describes the medical and clinical protocol created and used by SMC during the first phase of hostage release in November 2023. In the current study, the mean weight loss was 10%+10%, thus the majority of patients were considered only at moderate risk of refeeding syndrome. The returning hostages utilized a broad range of consultations including consultations with social workers and dietitians which were utilized by 100% of the population. This use pattern was due to the food scarcity and high frequency of weight loss experienced by the hostages, as well as the need for emotional support after the trauma of captivity.

Due to both the extreme violence, as well as the shelling and explosions of an ongoing war, imaging, including head CT, as well as orthopedic, ophthalmological and ENT consultations, and audiometry tests were frequently utilized. There was also a need for dermatological consultations due to skin infections that were common occurrences due to the physical circumstances of captivity.

The sole returning hostage of a different nationality spent the shortest time hospitalized (3 days vs. 5 ± 1 days). This may have been due in part to the lack of language barrier (he did not require the assistance of a translator to communicate with hospital staff) and certain cultural aspects.

It is important to note that the laboratory testing protocol included an expansive serological panel which resulted in numerous instances of positives, including 14 total positives and 3 positive for sexually transmitted infections (3/23). Since no reports of sexual assault were made, the infections may have been present prior to captivity.

Finally, the results showed a lack of effect of age on clinical variables, which was likely due to the homogeneity of the patient population, who were predominantly male, in good physical condition prior to being kidnapped, and from the same ethnic background.

Limitations and lessons

One of the main limitations was the lack of existing literature on the clinical treatment of released hostages which may have affected the comprehensiveness of the protocol. In addition, even though the patient profiles were similar in terms of age and nationality, and although circumstances in captivity were similar, the cultural background of the population might have affected results. It is important to note that our results did not reflect the more extreme experiences of women or locals, many of whom were subject to more extreme treatment in captivity.

Another limitation related to our lack of ability to provide continuation of care for the returning hostages after their release. Since all of the returned hostages were foreign citizens, their clinical care ended with the preparation and distribution of release letters summarizing their medical needs (in English), in coordination with the foreign ministries of their governments, to the relevant body in their home country.

No details about dietary and social mores were provided in advance, and there were several non-clinical needs not anticipated prior to the arrival of the returning hostages. Although a variety of toiletries and personal care items, including perfumes and tobacco products not normally kept on-site were arranged for in advance, there were requests that arose for specific products that were not have on hand in real-time, but this was easily resolved. Future protocols should attempt to prepare for such requests. In addition, since the majority of the hostages that were received at SMC were Buddhists, we made last-minute arrangements to provide religious texts and symbols and to prepare a suitable place of worship in the ward. Future protocols should plan to address this essential aspect of psycho-spiritual support.

In addition, despite the special areas designated for media, photographers popped up in unexpected areas on the SMC campus, presenting an operational challenge to the maintenance of privacy. In the clinical setting, the preference of many returning hostages to engage in bathing and hygiene prolonged the time to medical examination, which also required flexibility in the operational protocol.

Finally, from an operational perspective, it is strongly suggested that a sufficient number of translators, ideally trained together with the clinical team, be present at the point of arrival of the returning hostages, which was not the case in the current protocol.

Conclusion

The real-time implementation of this original clinical protocol highlighted the unique and complex needs of newly released hostages, particularly when they are foreign citizens. The importance of multi-disciplinary teamwork and continued psychosocial and medical treatment in the community setting cannot be emphasized enough. It is recommended that medical facilities involved in such events prepare as far in advance as possible for the arrival of returning hostages. This protocol may serve as a foundation for other medical centers and institutions in case of future need.

Data availability

Raw Data were generated at Shamir Medical Center. Derived data supporting the findings of this study are available from the corresponding author DT on request.

References

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Acknowledgements

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Funding

This trial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

1. Medical Management, Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, 70300, IsraelIdit Segal, Orna Tal & Osnat Levtzion Korach
2. Medical Management, Tel Aviv Sourasky Medical Center, Tel Aviv, IsraelDaniel Trotzky
3. Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelDaniel Trotzky, Idit Segal, Ronit Koren, Orna Tal, Galina Goltzman, Karen Or, Margarita Alpro, Ronit Zaidenstein, Maayan Bachar, Baruch Berzon, Inbar Hartmann & Osnat Levtzion Korach
4. Department of Emergency Medicine, Shaare Zedek Medical Center, Jerusalem, IsraelGal Pachys
5. The School of Medicine, The Hebrew University, Jerusalem, IsraelGal Pachys
6. Department of Internal Medicine A, Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, IsraelRonit Koren, Ronit Zaidenstein, Maayan Bachar & Baruch Berzon
7. Department of Emergency Medicine, Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, IsraelMargarita Alpro
8. Department of Internal Medicine D, Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, IsraelGalina Goltzman & Karen Or
9. Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, IsraelRoni Enten Vissoker
10. Pediatric Neurology Unit, Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, IsraelInbar Hartmann
11. Nursing Administration, Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, IsraelMiri Avraham
12. Department of Social Work, Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, IsraelVered Shinar
13. Department of Nutrition, Shamir Medical Center (formerly Assaf-Harofeh), Zerifin, IsraelAda Azar

Contributions

DT was involved with conceptualization, visualization, methodology; data curation, formal analysis, project administration, drafting the manuscript, reviewing and editing the manuscript; IS was involved with reviewing and editing the manuscript; RK was involved with methodology, data curation reviewing and editing the manuscript; OT was involved with methodology, data curation reviewing and editing the manuscript; GP was involved with methodology, data curation reviewing and editing the manuscript; GG was involved with methodology, data curation reviewing and editing the manuscript; KO was involved with methodology, data curation reviewing and editing the manuscript; MA was involved with data curation reviewing and editing the manuscript; RZ was involved with methodology, data curation reviewing and editing the manuscript; MB was involved with data curation reviewing and editing the manuscript; BB was involved with data curation reviewing and editing the manuscript; REV was involved with drafting, reviewing and editing the manuscript; IH was involved with methodology, data curation reviewing and editing the manuscript; MA was involved with methodology, data curation reviewing and editing the manuscript; VS was involved with methodology, data curation reviewing and editing the manuscript; AA was involved with methodology, data curation reviewing and editing the manuscript; OLK was involved with supervision, methodology, data curation reviewing and editing the manuscript.

Corresponding author

Correspondence to Daniel Trotzky.

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Ethics approval and consent to participate

Ethical approval was sought and approved by the Shamir Medical Center Helsinki committee, reference 0027 − 24. The Helsinki committee waived the requirement for written informed consent.

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The authors declare no competing interests.

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Trotzky, D., Segal, I., Koren, R. et al. The establishment of a clinical protocol for hostages returning from captivity. BMC Emerg Med 25, 105 (2025). https://doi.org/10.1186/s12873-025-01257-1

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• Received27 October 2024
• Accepted30 May 2025
• Published01 July 2025