The use of suicide attacks as a terrorist tactic is a relatively new phenomenon worldwide, with a general trend of increasing frequency since the 1980s. There is no universally accepted definition of terrorism, with some commentators including within the definition only acts against non-military targets. When examining the issue of safety at major incidents and the threat of suicide attacks the author has used a broad definition of a suicide attack, and have not sought to exclude attacks against certain targets, or attacks which would not fall within some definitions of terrorism. Thus, the author has included in the definition attacks by individuals or groups of individuals, whether organised or acting alone, in which part of the intended or accepted result is the death of the perpetrator. Suicide attacks could also be combined with a chemical, biological, radiological and nuclear (CBRN) element; however, issues related to this are excluded and will not be considered in this article.
Suicide attacks occur most frequently in the Middle East, (specifically Israel, Lebanon and Iraq), although other countries, including Sri Lanka, have, in recent history, undergone aggressive campaigns of suicide bombing. Since the attacks in the USA on 11 September 2001, the details of which are widely known, there has been a greater focus in the USA and countries allied to it, including the UK, on the threat of suicide attacks. The first suicide attack in the UK took place in London on the morning of 7 July 2005, in the form of four bombs, three of which were detonated on underground trains, the other being detonated on a bus. This type of attack was very different from the terrorist attacks that had previously taken place in the UK, many of which had been perpetrated by the IRA, where advance warnings were usually given, and where the focus was on causing maximum economic loss and property destructions rather than loss of life. This new threat clearly carries with it specific risks which must be managed in order to ensure safety and minimise injury and loss of life, both to emergency services personnel and bystanders.
Background
Major incidents include a range of events, including terrorist attacks, but also include outbreaks of infectious diseases, train and air crashes and fires in public buildings. The current operating principle of most NHS Ambulance Service major incident plans comes from the Major Incident Medical Management and Support (MIMMS) course (Hodgetts, 2003). The MIMMS concept is that major incident planning should follow an ‘all-hazards approach,’ designed to deal with all types of major incident (Hodgetts and Mackway-Jones, 2002), irrespective of their cause or nature (Sammut et al, 2001). This ‘all-hazards approach’ works on seven key principles:
There are two main types of suicide attack. The first and most obvious is the suicide bomb, which involves an individual or group of individuals carrying explosives, detonating them, and thereby causing their own death alongside the deaths of any bystanders. The other type of attack, sometimes referred to as a ‘Mumbai-style’ attack, so called because of an attack in Mumbai in 2008 in which more than 170 people died, combines suicide bombs preceded with a firearms attack in which an individual or group of individuals using guns and grenades to kill as many people as possible. Such attacks can be targeted at specific groups (the 2008 attackers appeared to target British and American citizens), but shooting can also be indiscriminate. This is included within the definition of a suicide attack because it is very unlikely that an attacker will escape alive, with the attack usually ending in the perpetrator detonating a suicide belt or bomb, or being shot by the police. The shooting of the individual by police following a confrontation is referred to as ‘suicide by police’, defined by Geberth (1993) as:
‘Incidents in which individuals, bent on self-destruction, engage in life-threatening and criminal behaviour in order to force the police to kill them.’
Suicide bombing and suicide by police intersect when armed police face a situation in which they believe they are challenging a suicide bomber. Following the terrorist attacks in the USA in September 2001, the Metropolitan Police Service developed Operation Kratos, the name given to a range of tactics used to defend against the threat from suicide bombers, the highest level of which is the deployment of armed officers. While not a ‘shoot to kill’ policy, using reasonable force in order to prevent detonation of a bomb can often result in the death of the suspect (Kennison and Loumansky, 2007).
The threat of suicide attacks in the UK is no longer a theoretical one, with the attacks on the London transport network in 2005 having brought what had previously been an international news story into the domestic arena. As observed by Almgody et al (2007), ‘suicide bombing has emerged as a lethal weapon in the hands of terrorist groups.’ Detonation through delayed timers or remote control has been replaced by precise timing by the attacker. The explosive device, which was once concealed under seats and inside litter bins, is now carried at chest height and detonated in the centre of a crowd. These changes have brought about a marked increase in the number of fatalities per attack and the severity of injuries incurred (Almogy and Rivkind, 2006). As per the definition, detonation results in the death of the bomber. Further, the damage to people and property in the immediate vicinity of the blast is often devastating, particularly where the explosion occurs in a confined space. Suicide bombers usually seek out locations where the damage can be maximised, and target mass gathering sites such as public buses and bus stations, wedding halls, hotel dining rooms, restaurants, open markets, supermarkets and discotheques. As counter terrorism security has increased worldwide, suicide bombings have become increasingly popular, particularly with Islamic groups, because the ability to control individual movement is limited by the balance of civil liberty and social practicality (Morley and Leslie, 2007).
Most literature on suicide attacks is based on the Israeli situation, because of the frequency of suicide attacks there. Overall, there is very little published literature looking at the pre-hospital management of the hostile environment, which has previously been noted by Caldicott et al (2002). The unpredictable nature of major incidents makes research and experimentation extremely difficult.
Issues facing the ambulance service when responding to terrorist incidents and suicide attacks
The only known suicide bomb attack in the UK occurred on 7 July 2005. Attacks by individuals with guns have included well-known incidents in Dunblane, Hungerford and Cumbria. These differed from the attack in Mumbai in that the UK incidents all involved individuals acting alone, while the attack in Mumbai was part of a series of coordinated attacks by a terrorist organisation and carried out by a group of gunmen. To date, there has been no attack in the UK of similar proportions to the 2008 shooting in Mumbai, although it has been reported in the media that such an attack is expected.
Despite this obvious difference however, many of the same risks face responders to any incident involving firearms, whether or not it is on the large scale of the Mumbai attacks. Thus it is worth examining the Ambulance Service approach to those incidents that took place in the UK. There is, however, no central reporting system for major incidents, meaning that, aside from those incidents which are subject to an official report or public inquiry, published information is difficult to find and of questionable accuracy (Carley et al, 1998).
The only reference to the Ambulance Service in relation to the Hungerford shooting (Bee et al, 1997) was wide reporting that a responding ambulance crew had come under fire, although Broome et al (1988) note that the crew was injured only by broken glass after the windscreen was shattered by a bullet. A current affairs story run in a daily newspaper at the time of the Cumbria shooting criticised the fact that ambulance crews and air ambulances were significantly delayed in reaching and treating casualties because of safety fears (Doyle, 2010). Operation Bridge, which was a peer review into the response of Cumbria Constabulary following the Cumbria incident, highlighted the significant interoperability issue between police and ambulance service in relation to differing risk threshold in that the ambulance service would not dispatch ambulances to the scene without armed police protection despite the fact that unarmed police officers and members of the public were at all scenes (Chesterman, 2011).
The reason for non-deployment of ambulance resources appeared to be due to safety of staff;however, this meant that police officers were left at scenes for significant periods of time with seriously injured casualties with police patrols diverted from their deployments to convey casualties to hospital. An example is given from one scene of an ambulance crew already in attendance and treating the casualty being instructed to leave by ambulance control. The review goes on to state that it is very unlikely that the police will be a position to guarantee that the scene is safe, but that it would be reasonable for the public to expect the ambulance service to attend scenes where these is residual risk.
In this situation armed police officers priority should always be to try and contain the attacker or attackers. Following on from this, Clews (2011) identifies that the West Cumbria Coroner, David Roberts, will be writing to health secretary Andrew Lansley and the home secretary under rule 43 regulations, which requires coroners to make recommendations where they believe future deaths could be avoided. The coroner in this case would be looking to make recommendations on how ambulance staff attend dangerous events, and on how communication between the police and ambulance services could be improved.
When developing plans to deal with major incidents, decision makers in the emergency services will need to consider a number of factors including the issue of scene safety and the risk arising from the possible presence of a secondary explosive device or armed terrorist, the intended target of which may be responders to the incident (Hodgetts and Mackway-Jones, 2002). Second, consideration will need to be given to whether to deploy ambulance crews, whether locking down is appropriate, and what level of risk is acceptable when operating in hazardous areas. Third, ambulance services need to ensure that staff are adequately trained to recognise different types of major incident, including a ‘Mumbai-style’ terror attack. Finally, decision makers should consider whether ambulance personnel should be trained in recognising characteristics and taking appropriate action where they suspect that someone is a suicide bomber.
‘…police officers were left at scenes for significant periods of time with seriously injured casualties’
The normal course of events, where it is suspected that a secondary device were present, is for the police to cordon off the area and search for the device. Ambulance personnel will then begin triage and treatment in the areas that have been declared safe. A scene layout using an ‘inner’ and ‘outer’ cordon or ‘hot’ and ‘cold’ zone is used in both Israel and the UK. Phelps (2006), however, argues that there is no such thing as a true hot or cold zone.
In the event of a ‘Mumbai-style’ incident, attackers may move quickly between locations by using public transport or stolen vehicles. In an attack involving several individuals, they may all travel in different directions, thus further complicating the situation and creating further challenges in ensuring scene safety. Movement of attackers means that the ‘hot zone’ is constantly moving and there ceases to be a safe rendezvous point, which would be used in a ‘normal’ firearms incident for ambulance service responders. Faced with this situation, decision makers may wish to consider whether it is appropriate to deploy any ambulance personnel to the incident, instead of waiting for confirmation from the police that the attacker or attackers are contained. This would essentially mean ‘locking down’ ambulance stations. NHS Protect has developed operational guidance for NHS ambulance trusts on how to lockdown premises. This would, however, be controversial and could only be justified in the most extreme circumstances, as the protection of Ambulance Service staff would be at the expense of injured civilians who would not receive treatment. Such action would be analogous to that discussed by May and Aulisio (2006), namely the proposed closure of hospital doors following a terror attack.
Almogy and Rivkind (2007) describe an attack in which terrorist organisations combine different methods (e.g. bombing and shooting), which is the approach that was used in the Mumbai attacks, noting that such incidents have a longer duration (possibly several days), thereby limiting the access of medical and paramedic crews to the scene.
During this type of attack, initial treatment and evacuation will only begin once the scene is secured by police and, in the case of Israel, paramilitary units. This could result in long delays before victims receive clinical care, and raises the question of whether those who are able to access the scene, namely police officers, should be trained in triage and clinical care. There are, of course, costs and benefits to this approach.
The most obvious benefit is that it prevents any delay in clinical care in a situation where ambulance crews are not allowed to enter a hazardous area. Set against this, however, is the cost of providing not only initial, but ongoing training to police officers, particularly when they would use the skills only in limited circumstances. Second, it does not reduce the number of people needed at the scene; it simply means that the staff at risk are police officers rather than ambulance personnel. It also means that police officers would be distracted from searching for further bombers, devices or attackers, and raises the question of whether it might in fact be more appropriate to allow paramedics into the inner cordon to carry out triage and deliver clinical care. This puts ambulance personnel at considerable risk, although the risk is no greater than that posed to other emergency services personnel who work within the inner cordon.
Evidence suggests that despite the risk to their own safety, ambulance personnel are willing to bear this risk and deploy in such situations, as they did in the 2005 attacks in London (Lockey et al, 2005; Redhead et al, 2005; Hallett, 2011) and as they do in Israel, where suicide attacks are far more frequent (Almogy and Rivkind, 2007). Whether or not crews and those making the decision to deploy them would be prepared to bear the risk may of course depend on the degree of certainty surrounding the presence of a secondary device and the nature thereof.
Eckstein (1999) refers to the new ‘rules of engagement’ for emergency responders when faced with the risks inherent in dealing with suicide attacks, other terrorist attacks or potential snipers (Sullivan, 1990), noting that we as a society must acknowledge that, although our public servants knowingly put their lives on the line every day, it is incumbent on their supervisors to not place them at undue risk. Entry into a particular area may sometimes pose an unacceptable risk, and in such situations we must acknowledge the possibility that victims may die as a result of this delayed evacuation and treatment. This is always an exercise in balancing the risks, and there is no scientific and foolproof solution to assessing these risks.
‘Evidence suggests that despite the risk to their own safety, ambulance personnel are willing to bear this risk and deploy in such situations’
In England, hazardous area response teams (HART) are trained ambulance personnel who respond to incidents involving hazardous materials, or which present hazardous environments. The formation of the HART programme represented a departure from previous operating practice, in which the ambulance service had only operated within the ‘cold zone.’ Various major incidents in recent years, alongside the increasing CBRN threat, has necessitated a change in tactics for the ambulance service, and resulted in the HART programme, which involves HART paramedics working within the ‘hot zone’ in certain incidents (e.g. CBRN, hazardous material, or building collapse). HART paramedics would currently not enter a hot zone in a terror attack, although consideration should be given to whether this practice now needs to change, in light of the issues discussed above.
Tactical medicine
As noted earlier in the article, there are various different operating models when responding to incidents. The model used in some areas in the USA is known as tactical medicine, in which specially trained paramedics and doctors attend high risk scenes with police and other law enforcement agencies, with the aim of providing clinical care to injured officers, suspected criminals and bystanders. This has been developed for use in operations where access to emergency care is limited. These operations are challenging, inherently unsafe activities with increased risk of morbidity and mortality for law enforcement officers, perpetrators, hostages, and bystanders. Conventional emergency medical services systems in the US and UK do not adequately prepare their personnel for these types of operations, but in the US strategies have evolved to meet this need in some areas. US Tactical EMS teams must be able to provide care with less medical equipment, limited space, light and sound restrictions, and without contact to medical control. These conditions are not dissimilar from those in which UK HART paramedics find themselves.
‘In Israel, medical teams enter the scene of an explosion before it is deemed safe by police or paramilitary personnel’
The additional skills required for operating in such environments are the ability to disarm and render safe weapons, evidence protection and forensics awareness. In all services where the tactical medicine approach is used paramedics and doctors are trained in these skills, and in some services they are armed. This brings the discussion to the question of whether to use the strategy of training and potentially arming ambulance personnel, or to train law enforcement officers in emergency medical care. Ciccone et al (2005) highlight the issues associated with arming civilian paramedics and doctors, noting that it increases the size of the operational team, can cause problems with security clearance, and exposes a greater number of individuals to potentially harmful situations. They conclude that providing law enforcement personnel with appropriate medical training may be a more desirable alternative than providing tactical law enforcement training to EMS personnel. Kilner and Hall (2005) highlight that in the UK there is no national agreement regarding the nature and degree of clinical skills required by frearms-trained police officers. Specialist medical training of police firearms officers is inconsistent and no training on operating in tactical situations is available for pre-hospital care providers. In order to address some of these issues, a number of educational models have been developed to provide frearms-trained police officers with essential patient assessment and treatment skills required to look after an injured colleague or civilian during the time before an ambulance is allowed to approach or the victim can be extracted from a hostile environment. With basic clinical skills and appropriate decision support materials, police firearms officers in their study were able to make accurate triage decisions in a multiple-casualty scenario, meaning that when ambulance service personnel are allowed onto the scene they are presented with casualties who are already triaged allowing them to know where to focus their immediate treatment priorities.
As mentioned briefy already, it is worth discussing whether there is any merit in ambulance personnel being trained in recognising characteristics of suicide attackers, especially since crews will often be on site at large scale public events or undertaking ‘stand-by’ duties near to iconic sites. Nixon and Stewart (2005) examine the results of studies on the profle and characteristics of suicide bombers, primarily in Israel. The characteristics they identify, however, are not sufficiently unambiguous or easily identifiable to make training UK paramedics a proportionate response to the threat.
Time on scene
Where an ambulance crew has been deployed, the possible presence of a secondary device will impact on decisions taken with regard to time on scene. In Israel, medical teams enter the scene of an explosion before it is deemed safe by police or paramilitary personnel even though there is the potential for a secondary bomb causing additional injuries to the emergency services personnel responding to the primary event. This is because time is critical in life-threatening conditions and clearing and securing the scene may take significant time and manpower. Because of this they remove the casualties from the immediate vicinity of the initial event rapidly. The only medical care given before this initial evacuation is external haemorrhage control.
Even cervical spine immobilisation is deferred until the injured are removed from the immediate danger zone (Almogy and Rivkind, 2007). These victims are moved to an area which is not in direct line of sight with the scene, and if possible behind some shielding like a wall, ideally this area being searched by police for a secondary device prior to moving casualties in. No personal belongings are taken in the ambulance with the casualty so as to prevent a secondary device inadvertently being taken to hospital.
In Israel, because of the increased threat of a secondary device, a ‘load and go’ operating practice is commonly used as this minimises the time spent in the hazardous area. It also, however, as noted by Aylwin et al (2006), has the effect of creating a surge at receiving hospitals. The volatile situation in Israel has resulted in the emergency services taking additional action to mitigate the risks to personnel, including the wearing of protective clothing and headwear. Singer et al (2007) report that all emergency medical teams at the scene wear bulletproof vests and helmets to minimize the risk of injury from secondary attacks, while Ellis and Sorene (2008) note that MDA, the Israeli Ambulance Service, uses custom made armoured ambulances in some locations following incidents of ambulances being stoned or fired upon.
Ways to mitigate risks to personnel
Given then, that ambulance personnel appear willing to accept certain risks to their own safety, in order to provide emergency care in the wake of a terrorist incident, the ambulance service should consider what measures are appropriate to manage and minimise the risks posed. The current approach to responding to major incidents is based on the approach set out in the MIMMS course, which only briefly discusses hazards and secondary devices.
If ambulance crews and those making decisions with regard to their deployment during terrorist incidents had a greater awareness of the possible approaches and options for action, it could serve both to facilitate informed decision making and to reduce real risks to ambulance personnel. Building on the outline that the course already provides, then, there are potential benefits in expanding on the current MIMMS material on the action to be taken where a secondary device or devices are a risk factor. A further way of reducing risk to staff would be the use of protective clothing and headwear, as is common practice in Israel. The issue of protective clothing for ambulance crews is one that has faced all ambulance services and arises not usually in the context of terrorist attacks, but rather in response to the question of violence from members of the public. The ambulance service's current position is that there is insufficient evidence to approve the purchase of personal issue ballistic or stab vests for all frontline staff, but trusts should be ensuring that actions arising from risk assessments are taken forward, and should keep the need for protective clothing under review.
Triage and screening for explosives and firearms
In the UK, triage in major incidents is based purely on physiological signs such as mental status, hemodynamic stability and respiratory distress, this system being advocated by MIMMS. Hodgetts and Mackway-Jones (2002) advocate the MIMMS approach of physiological triage by highlighting the limitation of anatomical triage stating that patients have to be undressed to see injuries which is time-consuming and impractical.
In these circumstances, however, undressing the patient to see injuries may be useful as it has the by product of potentially detecting any suicide bomb or gun on the victim.
‘It further poses the risk of the firearm being used or the bomb being detonated upon arrival at the casualty clearing station’
The scene following an attack is likely to be chaotic, involving large numbers of injured and distressed people. In any attack, whether it is a bombing or a firearms attack, there is the possibility that one or more of the perpetrators is injured and needs to be conveyed to hospital. This may put ambulance personnel at risk if the person is carrying a firearm or a bomb. It further poses the risk of the firearm being used or the bomb being detonated upon arrival at the casualty clearing station, in the ambulance or at the receiving hospital. While this has never happened in the UK, in Baquba, Iraq in March 2010, a suicide bomber detonated an explosive device in an ambulance outside the receiving hospital, having disguised himself as a policeman in order to travel with injured casualties (August, 2010). Although the perpetrator in this case was not himself a casualty, it demonstrates that terrorists may attempt to detonate explosives at hospitals, and thus suggests that precautionary measures should be considered. This raises the question, then, of whether ambulance personnel should screen casualties for firearms and explosives, either at the scene before conveyance to casualty clearing stations, or at the clearing station before conveyance to hospital. Detection of guns or explosives by ambulance crews may be very difficult, and is, arguably, the role of the police. Ambulance crews attempting to detect guns or explosives may also have legal ramifications which would be worsened if the person refuses to consent to a search and whether that would then allow the ambulance service to refuse treatment.
‘The primary risk is that if a suicide attacker anticipates a challenge, she or he will detonate the device or use the frearm immediately’
Current practice is for a primary survey to be carried out either at the scene, in the casualty clearing station or in the ambulance. This primary survey should identify life threatening injuries that are time critical. A secondary survey will then usually be carried out in hospital. This is a more thorough survey, and will incorporate a search for further potentially non-life threatening injuries. While the purpose of that search is not to find weapons or explosives any that are concealed on a person will be found in the course of the survey. However, carrying out a secondary survey at the scene or casualty clearing point would increase the time on scene, and would be at odds with the load and go approach. Another question is whether the ambulance service should introduce metal detectors to identify perpetrators of firearms attacks who are still carrying a weapon? There are risks associated with any form of search, whether it is as part of a medical survey, or through the use of detection devices. The primary risk is that if a suicide attacker anticipates a challenge, she or he will detonate the device or use the firearm immediately. The risk of this, however, should be considered in light of the risk of the secondary attack taking place in the receiving hospital.
The ambulance service as part of a terrorist plot
Miranda (2004) and Viskin (2003) both look at the issue of Palestinians exploiting freedom of passage given to ambulances as a means to transport explosives, weapons, and terrorists to evade the Israel Defense Force. Because of this, all ambulances, even those conveying critically injured victims have to pause for brief inspection at the perimeter of the hospital's grounds (Shapira and Cole, 2006). Alves and Bissell (2003) identify in their study that Emergency Medical Services (EMS) providers rightfully enjoy a relative immunity from many societal restraints due to the time-sensitive nature of their mission and as identified by uniform and vehicles are often escorted directly into the most secure environments. Further identifying that this privilege creates a tempting potential for abuse— namely that an ambulance might be hijacked for terrorism purposes (Leppard, 2008).
Their study looks at ambulance security with regards to leaving the engine running, locking the vehicle and leaving the vehicle unattended while outside the emergency department. While worrying, it does not infuence how the ambulance service should respond to a suicide attack major incident. Leaving the keys in the ignition of ambulances that are parked at the ambulance parking area to allow them to be easily moved to the ambulance loading point by any police or ambulance personnel makes practical sense. So in the absence of a preferred and safer working practice it should remain the same. It has been argued that the police should only let recognisable NHS ambulances through the outer cordon. However, this argument is flawed as most NHS ambulance services have the option of using private ambulance services or voluntary aid societies (such as British Red Cross or St John's Ambulance) written into their major incident plans and use them during peak demand to meet operational need.
Human rights and ethical issues
This is not intended to be a comprehensive study of the human rights arguments in such situations. It is, however, worth making a few observations in relation to this.
The Geneva Convention provides guidelines for the medical treatment of enemy wounded and sick, as well as prisoners of war. There are, however, no comparable provisions for the treatment of terrorists. It is therefore argued by Gesundheit et al (2009) that international guidelines should be established in order to define the rights of terrorists and the professional duties of medical personnel treating them. They identify that at present we act in accordance with the philosophy that all human beings in need—including terrorists, as long as they do not constitute an imminent threat to their surroundings (e.g. still have live arms or explosives on them when they are wounded)— deserve full medical care. In Israel this has meant that at times injured Palestinian terrorists have been treated ahead of Israeli nationals (Rivkind and Ellis, 2005). In practice this means that as long as a suspected terrorist does not pose a threat, they should be treated based on clinical need and conveyed to the nearest appropriate accident and emergency facility, even if this means they are treated in the same location as victims.
Conclusion
Most of the issues that the ambulance service needs to consider rely heavily on close cooperation with other emergency services, particularly the police. Careful consideration should be given to the available options around deployment, including training police in triage and clinical care, and allowing ambulance personnel into the inner cordon or hot-zone. However, these two options are not mutually exclusive and since no two situations will be the same, it is important for emergency responders to have a range of approaches at their disposal, depending on the risks factors involved.
When making a decision as to whether police should provide triage and care for victims, the primary consideration must be for them to focus on containing the attackers. Where containment can be achieved and maintained alongside providing medical care, then it is appropriate for them to provide that care. However, it should not be provided if doing so increases the risk of the attackers(s) escaping.
Furthermore, the decision as to whether to deploy ambulance crews is one that should be kept under review as the situation unfolds. It may be the case that the risk fuctuates throughout the course of an incident, particularly where it involves a prolonged attack, crews may need to deploy or withdraw at very short notice. Decision making on the approach to time on scene, namely whether to treat at the scene or ‘load and go’ will be a particular consideration that will apply in a prolonged ‘Mumbai-style’ attack where ‘load and go’ will certainly be the safest tactic, as the hot zone may be moving, so a previously safe area, may become unsafe.
It is vital that the emergency services work closely together to develop appropriate training programmes and reference material for such eventualities. Ambulance services should ensure that 999 ambulance control room staff are trained to recognise when a ‘Mumbai-style’ terror attack may be taking place. The ‘step 1-2-3’ approach used when dealing with a suspected CBRN incident could be used as the basis for developing operating practices in this area.
The MIMMS course and associated material may benefit from expansion in certain areas, including raising awareness of the risks associated with suicide attacks and potential further development of the ambulance safety officer role at a major incident, which currently focuses predominantly on checking that personnel are wearing protective equipment (Hodgetts and Mackway-Jones, 2002). This could assist with both pre-incident planning and on-scene operating practice. Aside from this, MIMMS should continue to be used, as there is no evidence to suggest that it is no longer relevant or effective (Hodgetts, 2000).
As regards the appropriateness of deploying ambulance personnel into hazardous areas, careful consideration should be given to using those staff that are already trained in working in hazardous environments, namely HART paramedics. As noted earlier the question of the provision of protective clothing to paramedics is one which arises outside the context of terror attacks. In an attack involving explosives, protective clothing will be of little use in the event of a suicide bomber detonating in close vicinity. Protective equipment may, however, be of use in a frearms attack. Currently, however, the issue of such equipment to all ambulance personnel is not deemed to be a proportionate response to the threat.
The deployment of HART paramedics in such situations may simplify this somewhat, as well as making it a more viable option financially, as only HART paramedics, and not all ambulance personnel, would need to be provided with equipment. In relation to screening for firearms and explosives, given that this is likely to increase time on scene, thus being at odds with some approaches to operating practice, and is, arguably, outside the remit of the ambulance service, this should be left to the police.
Because major incidents are unpredictable events, with research being difficult if not impossible, there is therefore very little in the way of an evidence base to suggest that changes are absolutely necessary.