The authors describe a number of potential lessons that emerged after early analysis of the incident. They describe some failure of communication. It is unclear whether this had any significant impact on patient outcome. It is important to note that no well reported major incident has ever been free of communication issues. Providing good care without perfect communication should be the aim of all EMS systems. This appears to have happened in these incidents and may have been due to the presence of senior physicians and paramedics at the scene. Analysis of multiple scenes after the London bombings suggested improved triage and low mortality associated with physician-paramedic teams on scene [5]. This was the model used at these incidents and the mortality after attendance by physician-paramedic teams is reported as very low. The fact that sixty flight movements were recorded during this incident does demonstrate the importance of air ambulances at this type of incident. It would be valuable to model the likely attendance times of advanced medical teams and evacuation times of casualties without the use of helicopters. The need to re-site the casualty clearing station is a good learning point but the initial site may well have appeared reasonable given the information available at the time. Security after identification of the threat appears to have been excellent. The authors suggest that a national triage guideline is required. It is difficult to know how many high level practitioners really rely on triage tools at major incidents but having one recognised system would seem good practice.
This paper provides a valuable insight into a complex and unpredictable incident. Other EMS systems may well benefit from the initial lessons learned. Similar incidents on a smaller scale are reported regularly and have been reportedly increasing in frequency [6]. This report also highlights the need for an international template to identify the medical lessons learned from major incidents which can be produced easily and quickly to propagate widely to the international EMS community. The pre-hospital response described in this article is impressive and it is difficult to see how the mortality in these incidents could have been improved. While the scale of this tragedy is immense for Norway, many aspects of the response to it will be viewed by international EMS systems as an example of good practice in major incident management.