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Patient Care

Underground Attack

For Londoners, terrorist bombings are nothing new. Those of a certain age survived the World War II aerial blitz by Hitler. Later generations endured years of violence at the hands of the Irish Republican Army (IRA), including bombings in and around London in 1981, '82, '83, '90, '91, '92, '93 and '96. According to researchers with the University of Ulster's CAIN (Conflict Archive on the Internet) project, the IRA killed more than 1,700 people during a period generally known as "the Troubles" (roughly from 1969 through the mid or late 1990s), including 497 civilians.

So if you're wondering about the famed stoicism with which the Brits handled the events of July 7 (and the unsuccessful sequel of July 21), that's part of it. And if you're wondering how it was that the city's emergency services fared so well under such duress, it's important background to know.

"Second to None"

Terrorist incidents, as EMS providers know, require an efficient and coordinated response by a number of important entities. Foremost among these are the emergency services. Law enforcement must secure scenes, gather evidence and pursue those responsible. The fire service must eradicate life threats and ensure scene safety. And EMS must evaluate, treat and transport casualties. Accomplishing these discrete jobs requires working together, and that's much easier when you have compatible protocols, command structures and terminologies, and scopes of responsibility that dovetail neatly with each other.

In the U.S., real efforts toward achieving this have only recently-with the creation of NIMS (the National Incident Management System)-begun. In London, they're more than three decades old.

The mechanism by which it happened is the London Emergency Services Liaison Panel (LESLP). Since 1973, it has provided a forum for the city's major emergency-service providers-the London Ambulance Service (LAS), the London Fire Brigade, and city, metro and transit police, as well as others potentially involved in major-incident response (the military, port authorities, etc.)-to prepare jointly for the Next Big Thing. It meets quarterly.

The LESLP's Major Incident Procedure Manual is the emergency services' bible for such events. This publication (available at describes the responsibilities and agreed-upon procedures for each agency involved in a response like that of July 7: generally, who does what, when and how. "In this way," it states, "the overall response of the emergency services will be greater than the sum of their individual efforts."

"The whole idea behind having that kind of multiagency document," says LAS emergency planning manager Jonathan Edmondson, "is that everybody will have an understanding of each other's roles. That's important, because I think there can be a perception by other emergency services about what the ambulance service does during a major incident. They might think we'll turn up, grab a patient and take them to the hospital. But in a major incident, it doesn't work like that. The first couple of ambulances at the scene don't actually treat anybody. And that's why that document is important: to try to get that through to all of the agencies at all levels."

Notwithstanding the specific priorities of the first personnel on scene, the LAS has distinct duties at a major incident. These include:

  • establishing effective triage;
  • treatment, stabilization and care of the injured;
  • providing transport and other resources as appropriate;
  • providing communications and other resources for the National Health Service (NHS);
  • selecting and alerting hospitals to receive the injured.

The smooth operations of 7/7 resulted in no small part from adherence to the plan.

"As an emergency planning manager, I'm remarkably critical about how we respond to major incidents," Edmondson says. "But I have to say, how our staff, the Fire Brigade, the police, the London Underground and members of the public actually responded on July 7 was second to none."

Gold, Silver, Bronze

July 7 began like any other Thursday, with millions of Londoners heading to work. Many of them utilized the London Underground, the city's extensive rail-transit system, which accommodates 2.67 million passenger journeys a day. A day earlier, London had been awarded the 2012 Olympic Games, and the Group of 8 (G-8) Summit of world leaders kicked off in Gleneagles, Scotland.

At around 8:50 a.m. local time, explosions ripped almost concurrently through three trains. The first occurred between the Aldgate and Liverpool Street stations in the city's financial district; the second at the Edgware Road station in west London; the third between the Russell Square and King's Cross stations in north London. Between them, 35 people were killed immediately, and scores injured.

The first explosion prompted near-simultaneous calls to the city's Metropolitan Police and the Underground's Network Control Centre (NCC). NCC officials initially believed they were dealing with a power-supply issue, but the police had been told of a train derailing. At 8:53, acting on the basis of the power surge, the Underground activated its Gold Control level.

Per the manual, Gold is the strategic level of incident management, with command over subordinate Silver (tactical) and Bronze (operational) levels. Gold-level leaders have overall control of resources, but delegate tactical decisions to their Silvers. At the beginning of an incident, the Gold leader will determine a strategy, which is recorded for ongoing evaluation and modification. Each emergency-service participant follows this template.

Calls then started coming quickly, some reporting passengers fleeing through tunnels, some reporting injuries. The first request to NCC for an ambulance came at 9:10, and five minutes later, recognizing that multiple explosions had occurred throughout the Underground network, all trains were ordered held at stations.

The Edgware explosion wasn't reported to Metro Police until 9:17, by which time other responders were already activated and all Underground passengers were being taken off trains. Then, at 9:47, a fourth explosion ripped the top off a double-decker bus at Tavistock Place, killing another 13. By 10 a.m., Scotland Yard had stated what responders on the ground knew: They were dealing with a "major incident."

First on Scene

When a major incident is declared-any participant in the LESLP can do it-first-on-scene responders have certain duties. For EMS, it involves assuming the role of Ambulance Incident Officer (AIO) until a senior officer arrives to take over. The next-arriving crew begins triage and controls parking, ensuring access and egress for emergency vehicles and preventing the kind of gridlock that immobilized some apparatus in New York City on September 11, 2001. As more personnel arrive, a senior clinician serves as Medical Incident Officer (MIO), overseeing deployment of medical staff and working with the AIO to manage resources. The LAS has a standing pool of doctors from which an MIO is assigned.

By this time, with multiple calls coming in and the big picture as yet unclear, LAS personnel had been dispatched to six Underground stations, as well as Tavistock Place. At each incident scene, responders created mobile joint emergency-service control centers under the command of Silver officers, with communications links between all command/control vehicles.

Meanwhile, personnel set about triaging victims emerging from the tunnels. Triage is physiological, based on changes in vital signs, rather than anatomical, or based on visible injuries. It has two components: sieving and sorting. Sieving entails putting victims into priority groups in advance of substantive treatment; sorting, which occurs as more resources arrive, involves moving the injured to a safer place (aka a casualty clearing point) and retriaging them in a more thorough way.

EMS crews delivered basic stabilization on scene-things like oxygen, bleeding control, splinting, drugs and fluids-and transported those needing more definitive care. The worst-off went by ambulance, while those with minor injuries were taken by transport-service vehicles, volunteer agencies and buses, with medical accompaniment.

London's hospitals were involved in the incident response from the beginning. Staff at centrally located University College Hospital were alerted to a major incident happening by pager around 9:30 a.m.; soon all of the city's hospitals were on major incident alert.

Standard procedure for single major incidents is to spread out casualties to avoid overloading hospitals. "The difference you have with four incidents," says Edmondson, "is that the even distribution of casualties goes out the window. If you have four incidents in close proximity, it's actually better to appoint one hospital per incident."

The service eventually mobilized an estimated 100 ambulances and more than 250 paramedics and other staff for the day's events, as well as calling in mutual aid. It transported 45 patients with serious or critical injuries and treated around 300 for minor injuries. Around 350 more self-transported to hospitals. Nonemergency service was suspended to handle the large number of victims.

All victims were removed from all incident scenes in just over four hours.

Other Responders

Other medical resources throughout the city also sprang into quick action: St. John Ambulance and the British Red Cross typically offer support for major incidents; mutual aid reinforcements from Bedfordshire and Hertfordshire, Kent, Surrey and Essex were also called in.

"Basically, our role as defined by LESLP is support of the call services-we essentially do what LAS needs of us," says Andrew Houghton, operational planning and emergency services liaison officer with St. John's London branch. "We deployed 37 ambulances and 19 mobile treatment centers, and we also supplied call fleet support [answering calls elsewhere in the city] and health and safety cover at the bomb sites, with treatment centers and first aid for the emergency workers who were down in the tunnels."

Other clinicians turned out to assist as well. By coincidence, trauma docs and medics from the city's emergency aeromedical service had collected for their regular monthly meeting that morning at the Royal London Hospital, less than a mile from the Liverpool Street station. When the first bomb detonated, they rushed to assist, eventually fanning out to all four sites. Air resources based at Royal London were activated, as were five quick-response vehicles. As well, the bus explosion occurred outside the headquarters of the British Medical Association, drawing a number of doctors out to assist.

Lessons Learned

While the overall response to the bombings went extremely well, there were some problems that arose. One was quite familiar: Like New Yorkers on 9/11, London responders ran into communications difficulties amid the hubbub of the response. Theirs involved the public telephone network.

"We rely on the public telephone network, and that became congested very quickly," says Edmondson. "The hospitals' phones were constantly engaged, so we couldn't get through to say, ‘Can you accept these extra 10 casualties or not?' So we're now setting up priority lines that are not reliant on the public network."

Other challenges included the patient-distribution puzzle, a shortage of equipment support vehicles, and maintaining separate control of each of the incidents.

"In terms of resources, it's fairly straightforward," says Edmondson. "You pump in a number of ambulance resources, a number of officers, a number of support vehicles and a number of control room staff to manage each of those incidents. The issue is how a command center actually controls those incidents. For example, you can't have four or five incidents on one CAD system. You need to separate the incidents out, make sure they're on different channels. We actually put a number of incidents onto one radio channel, and it was very difficult from a controller's perspective: Was that ambulance crew talking about that incident, or were they talking about one of the others?"

There are spare major incident channels available to London responders, and the various responses were ultimately spread among them.

But perhaps the biggest lesson Americans can take from the London response is training. Man, do these guys train.

"We have a number of airports and transport systems, and a lot of our multiagency training is based around those," explains Edmondson. "The airports, for instance, will have live major incident drills every two years, and we'll ride on the backs of those, because it brings us all together. It's the same for the Underground and for the overground rail system. So we end up doing 5-6 large-scale major incident exercises in London every year.

"The second thing is that we do goodness knows how many tabletop exercises. All the agencies will get together and run out a scenario over a morning or an afternoon. That happens about 40 times a year. Then on top of that, we do specific major incident training that's generally headed up by the Metropolitan Police. The Public Order branch also does tabletops that we're part of, and there are a couple of others who do it as well. We have, probably, about 15 of those a year. And that's important, because it puts our tacticians and strategic players alongside the police and Fire Brigade tacticians and strategic players in a room for a weekend, and they run out a particular type of scenario.

"And then on top of that, we do all the CBRN stuff-goodness knows how many exercises we do with that."

Even for the biggest agency in the U.S., that would be a lot of training. But for an agency as vast as LAS, it just scratches the surface.

"We actually feel we don't train enough," says Edmondson. "Because we're such a large organization-we have around 4,000 employees-that number of live exercises a year really only touches a small group. But it does help. Two of the ambulance crews I saw during the incidents were actually people I'd trained about four weeks before. One of them came up to me and said, "Thank goodness you gave us that training session about what the first crews do at the scene of the incident,' because she was one of the first crews at the Aldgate bombing. And you know, to effectively do command and control and incident response, you need to refresh those skills every three months."

Working so often with police and fire counterparts also creates something even the most detailed major-incident manual can't teach: trust.

"Over here we work very well together, and we're quite used to hanging out with each other," says LAS paramedic Craig Cassidy, who was the first medical responder on the train at Aldgate (see sidebar). "It's the little things. At my station, the police will stop in for a cup of tea. When we're driving down the road, we wave at each other as we drive by. Those little examples of camaraderie help when you get a big scene. Regardless of how bad it is, we know we've worked so much with each other, there's no second-guessing. It gives you confidence."

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