Recent acts of mass violence during active shooter events and other incidents in schools, churches and businesses continue to highlight the need for a multi-pronged strategy for both training and response.
This special EMS1/Lexipol guide outlines lessons identified from past incidents that can direct EMS involvement in pre-planning mass gatherings, improve multi-agency cooperation, and inform incident command and response strategies on the ground: Mass violence: How lessons identified inform training, response
On July 7, 2005, in the City of London, four terrorists, in a coordinated suicide attack, separately detonated three homemade bombs in quick succession aboard London Underground trains across the city and, later, a fourth on a London double-decker bus. A total of 52 citizens were killed on the trains and bus, and more than 700 were injured. For the UK, 7/7, very much like the U.S. 9/11, was one of those moments you remember what you were doing and where you were on that day.
At the time, I was the executive director of operations of the East Anglian Ambulance Service National Health Service (NHS) Trust, geographically placed to the northeast of London, covering 4,000 square miles and housing a population of 2.2 million people. While not a part of the London Ambulance Service, East Anglian, like all UK NHS services, was part of a mutual aid agreement. The UK has regrettably been home to and victim of domestic terrorism because of the Irish Troubles (the Northern Ireland conflict) for many years and response to terrorist incidents was sadly not a new experience for many in the higher echelons of EMS leadership.
For me, 7/7 started as any other day did, with a meeting with my Chief Executive, Dr. Chris Carney, and other colleagues. Our meeting was interrupted by our emergency manager, who informed us that there appeared to be a “fire on the tube” – essentially notification that the underground network in London was having an issue. We thanked him and carried on with our meeting. Just 10 minutes later, the next message caused us to spring into action. The fire was caused by a bomb, and it wasn’t one bomb, it was three – and a bus had also exploded on the surface. One nod from my boss and I headed to our HQ emergency medical control center to take up post in our incident management center to assume the role of gold commander (in the UK, the incident command structure, is described as gold [strategic], silver [tactical] and bronze [operational]).
Managing MCI staff recall
As with all major incidents, national news networks had responded as quickly as the emergency services, and no sooner than key personnel been summoned to the planning room, then we witnessed the live scenes on cable news channel, Sky, from London. Part of the mutual aid plan, as it would be here in the U.S., was to prepare ambulance units to deploy either to the scene itself or to backfill other ambulance services so they, in turn, could deploy into the incident. As on duty control staff prepared to enact a recall, the power of media had assisted, and staff were calling in to offer their services.
Delicate discussions took place as we had to be careful not to select people to come in immediately who were due to go on shift imminently, as we would then reduce our ability to respond in our first due areas. We also followed the plan to stand up crews that had recently booked on shift to be the part of the London response and backfill them in their home stations with personnel called in from home. A gentle discussion took place with some staff, keen to do their bit to assist London, who would only volunteer if they could head to the city, and wouldn’t step forward if they had to go to a local ambulance station and stand by. Not many of those conversations occurred and common sense mostly prevailed.
Giving and receiving mutual aid
After conversations with the main London Ambulance Service Control room, it was decided that we would form up packets of ambulances and supervisors, and prepare to mobilize to designated rally points outside the city. The considerable effort by our slick and well-drilled emergency managers made this happen with what appeared to be great ease. At the same time, as we sent units south, we too received support in terms of ambulance crews from the service to the north of us. The simple plan was to move assets from every service on pace to the south. Then we had to identify locations to send arriving units and ensure radio frequencies were correctly selected and local area mapping was appropriately issued as the mapping contained in one service’s mobile data terminals (MDTs) did not cover other jurisdictions.
Hospital capacity issues
Thereafter, interesting issues and incidents occurred that aren’t in any playbook and caused us to pause, think, then act. One of the immediate actions already full London hospitals took was to identify that they may have to create capacity. Hospitals began to arrange to discharge patients and move them out to facilities providing a step down level of care. This required the one thing that was heading into the emergency already – ambulances and personnel.
Suddenly, there seemed to be a ripple effect traveling up the country as hospitals attempted to empty and called for the urgent transport of non-critical patients This took a while to filter through. Some hospitals were truly receiving very critical patients into the EDs and theaters, others were just taking precautions. In my jurisdiction, we had several of the country’s leading specialist hospitals and they too were attempting to create capacity.
The aftermath
Because the underground had been targeted, the whole network was suspended, and all stations evacuated. At the same time, the national rail network also stopped services to and from the. Like in any major capital city, most of the London workforce commutes in from the suburbs and the primary method of travel is underground to a mainline station, then train home. On 7/7, millions of people were effectively stranded for hours in the city and it wasn’t until later in the evening that trains rolled again. This led to a second command decision. Knowing that over-filled trains were now bringing workers home – to our stations, I authorized the deployment of paramedics to our larger stations to be available on the platforms to help if required.
This was met with initial skepticism, but sometimes the command presence of the leader must insist that action be carried out – this was one of those times. Medics attended and we discovered patients who had been on the very underground trains that had been hit. In their shock, travelers had decided to head for home, which entailed leaving the scene, walking to the mainline station, and getting on a train.
Our medics made bull horn announcements offering assistance, and to our astonishment, people who had slipped the net in downtown London came forward.
Lessons identified
Here are three things I learned from the 7/7 London terrorist attack for incident commanders to consider:
- In a prolonged major incident, the amount of ambulances truly needed is probably double what you think. The need for the hospital to create space for you to take patients in, requires you to also take patients out.
- If you must evacuate from one hospital to another, first send a liaison officer in to control outflow and ensure patients aren’t simply wheeled to the curb. Also work out the loop time of a unit – the time it takes to go to the next hospital, discharge and return. This, when multiplied by the number of ambulances and the number of patients, informs how long it will take to conduct the transfer. The liaison officer is key in ensuring that key staff understand it could be hours before the last patient leaves. Finally, Newton’s law of patient evacuation will most probably apply – what goes out, must come back. In this case, as all I have described occurred under one National Health umbrella, U.S. based conundrums of who is paying and when, did not feature.
- Be prepared for the unusual or unexpected. We know that patients will be transported to the nearest hospital in many forms of transport – in fact we have come to expect that now. But think about those in shock and where they may go to and be prepared to help. We intercepted victims 100 miles from the scene of the bombs.
In the commander’s chair: EMS One-Stop With Rob Lawrence
In this edition of EMS One-Stop, Rob chats with Jason Killens, chief executive of the UK’s Welsh Ambulance Service. During the London Bombings, Jason was the deputy director of operations for the London Ambulance Service and played a major part in the command and control of the response to the UK’s first multi-site, simultaneous major incident. Jason describes training staff to deal with major incidents, the complexity of response to an 800 casualty incident across four separate locations. He also describes lessons identified and the inquiry that followed.
