Sollid et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:3 http://www.sjtrem.com/content/20/1/3 ORIGINAL RESEARCH Open Access Oslo government district bombing and Utøya island shooting July 22, 2011: The immediate prehospital emergency medical service response Stephen JM Sollid1,2,3*, Rune Rimstad4,5,6, Marius Rehn2, Anders R Nakstad1, Ann-Elin Tomlinson7, Terje Strand1, Hans Julius Heimdal1, Jan Erik Nilsen1,8 and Mårten Sandberg1,9, for Collaborating group Abstract Background: On July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents. Methods: A retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project. Results: We describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately. Conclusions: Many EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS. Keywords: Terrorism, Mass Casualty Incidents, Triage, Prehospital Emergency Care Background describe the immediate prehospital EMS response to the On July 22, 2011, Norway was struck by two terrorist July 22, 2011 attacks. attacks. In the first attack, a car bomb exploded in the Oslo government district. The bomb comprised an Methods ammonium nitrate/fuel oil (ANFO) mixture or “fertiliser The Norwegian EMS bomb”. Eight people were killed in the explosion. Two The backbone of the Norwegian EMS is provided by on- hours later, a lone gunman attacked a political youth call general practitioners (GPs) and ground ambulances camp on Utøya island, approximately 40 kilometres [1]. According to national regulations, all ambulance from Oslo, and killed 69 civilians. A single perpetrator units must be staffed by at least one certified emergency carried out both attacks. medical technician (EMT) [2]. However, most units are The scale of the July 22, 2011 attacks and the resulting staffed by two EMTs, and in most urban systems, at least emergency medical service (EMS) response was unpre- one EMT is a trained paramedic. The ambulance service cedented in Norway. The massive EMS response crossed is government-funded and organised under local health jurisdictional lines and involved responders from multi- enterprises. In Oslo, a physician-manned ambulance is ple agencies throughout the region. In this paper, we operational during the daytime on weekdays and is staffed by certified or in-training anaesthesiologists. Since 1988, a national government-funded air ambu- * Correspondence: [email protected] lance system has provided rapid access to advanced life 1Air Ambulance Department, Oslo University Hospital, Oslo, Norway support by specially trained anaesthesiologists [3,4]. This Full list of author information is available at the end of the article © 2012 Sollid et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Sollid et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:3 Page 2 of 12 http://www.sjtrem.com/content/20/1/3 service consists of 11 helicopter EMS (HEMS) bases and Scene descriptions and EMS resources; Oslo 7 fixed-wing EMS bases, all operating 24 hours a day Oslo is the capital of Norway and has a population of [5]. All HEMS units are staffed by an anaesthesiologist approximately 605,000 inhabitants. The immediate and a HEMS paramedic. Six search-and-rescue (SAR) urban area around Oslo, however, accounts for nearly helicopter bases operated by the Royal Norwegian Air one million people. The Oslo government district is Force under the jurisdiction of the Ministry of Justice located in the business district of Oslo and consists of and the Police are also an integral part of the national several buildings housing most of the ministries. Tradi- air ambulance system [1]. These helicopters are also tionally, the area has been open to the public, and all staffed by an anaesthesiologist and a rescue-man [5]. As nearby streets have been accessible to civilian vehicles. back-up during non-flying weather conditions or for The road transport time from the bomb site to Oslo incidents close to the helicopter base, all civilian and University Hospital (OUH) takes 5-10 minutes. OUH is some SAR helicopter bases use rapid response cars [6]. the major health institution in Oslo and consists of Twenty emergency medical communication centres three university hospital campuses: Rikshospitalet, Ulle- (EMCC) coordinate EMS resources and on-call GPs in vål and Aker (Table 1). OUH-Ullevål (OUH-U) is a their region. Nurses who answer public emergency calls combined primary and regional referral trauma centre through the national toll-free medical emergency num- that serves almost half the Norwegian population. A ber (113) staff the EMCCs together with EMT-trained combined casualty clinic and GP-staffed primary health operators who coordinate the EMS and HEMS resources care facility in the Oslo business district attends to in the region. walk-in patients and is located 2-3 minutes away from the government district by vehicle. The ambulance The Norwegian trauma care system department of OUH has 15 ambulance stations and 43 Norway has a three-tiered system of local, central and ambulance units (25 units on-call day and night) in university hospitals. The catchment areas for the local Oslo and the surrounding municipalities. In addition, an and central hospitals range from 13,000 to 400,000 peo- ambulance commander is on duty day and night in a ple. University hospitals serve as trauma referral centres separate vehicle and acts as the ASC in incidents invol- and provide definitive care for populations ranging from ving multiple units. The air ambulance base of OUH 460,000 to 2.5 million [7]. with two HEMS units is located in Lørenskog, which is just outside the city limits of Oslo. The EMCC of Oslo EMS major incident preparedness and Akershus coordinate the activity of all the EMS A standard for major incident triage does not exist in resources of OUH. Norway; most triage systems are confined to local sys- tems [8]. However, a framework for the management, Scene description and local EMS resources; Utøya organisation and coordination of major incident scenes Utøya island is 39 kilometres from central Oslo and lies has been established [9]. According to this framework, in the Tyrifjorden lake (Figure 1). The 0.12 square incident command is managed by a police officer. Other branches involved are represented by their respective Table 1 The distance by road from the scenes of July 22, branch scene commanders, and the most central are 2011 to the Oslo University Hospital campuses and the those from the fire and rescue and EMS. An ambulance hospitals of the Vestre Viken Health Enterprise scene commander (ASC) is responsible for coordinating Hospital Distance (km)* all on-scene EMS resources, and a medical scene com- Name Type Utøya island Oslo2 mander (MSC) is the leading medical person on scene, Oslo University Hospital who is responsible for triage and on-scene medical treat- Rikshospitalet University 34 5 ment. In addition, the scene is organised with parking Ullevål University1 38 4 and loading points for EMS vehicles and casualty-clearing Aker University 44 5.5 stations. Casualty clinic Local 40 1.5 A light emergency stretcher system (LESS), developed Vestre Viken Health Enterprise in the Optimal Patient Evacuation Norway (OPEN) con- Ringerike Local 16 n/a cept, is available in several EMS and SAR systems in Drammen Central 43 n/a Norway [10]. These stretchers are stored in transport- Asker-Bærum Local 20 n/a friendly bags of five and are insulating and radiolucent. Kongsberg Local 90 n/a Within the intended function for which they were devel- 1 2 oped [10], they are intended to follow the patient from Dedicated trauma hospital; Bomb incident site *Distances are approximate because there are several alternate routes first contact to hospital arrival, thus avoiding unneces- n/a = Not applicable because no patients were transported to this hospital sary patient manipulation. from the site Sollid et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:3 Page 3 of 12 http://www.sjtrem.com/content/20/1/3 Figure 1 Map of the greater Oslo area including Utøya depicting all (H)EMS bases in the area, the hospitals and main roads. kilometre island is owned by the youth organisation of depicted in Figure 1. The ambulance service in VVE has the Norwegian Labour Party and is known for its annual 17 ambulance stations with 24 ambulances operating summer camp. The island can only be reached by boat day and night and an additional 5 daytime ambulances. from the mainland. A small ferry that can accommodate The HEMS base at Ål covers the VVE region together one car is the only organised transport route to the with the HEMS units from OUH. The EMCC of Bus- island. The shortest distance from Utøya to the main- kerud coordinates the activity of all EMS resources of land is approximately 630 metres. VVE. The Vestre Viken Health Enterprise (VVE) is responsi- ble for the specialist health services and the EMS in the Environmental conditions region.