Danish emergency medical services
The Danish national distress number 1–1-2 provides one point of entry for citizens requiring emergency assistance from police, fire brigade or emergency medical services (EMS). 1–1-2 calls are received by three national command centers: two operated by the police and one by the Copenhagen fire brigade, forwarding medical emergencies to the relevant health care regional Emergency Medical Dispatch Center (EMDC). Each EMDC is responsible for the EMS response from receiving the call until the patient is handed over to a hospital or patient contact either has been finalized on scene or during the call. Each health region has its own EMDC that operates prehospital units, using criteria-based dispatch [6]. The Danish EMS has been described in detail elsewhere [7].
The Danish EMS is a three-tiered system, comprising emergency medical technician ambulances, paramedic ambulances and anesthesiologist-staffed mobile emergency care units (MECU) [8]. A nationwide anesthesiologist-staffed helicopter EMS (HEMS) can be dispatched by all five health care regions. In total, approximately 300 ambulances, twenty-six MECU and four HEMS helicopters are available in Denmark. Military medical helicopter assistance can also be provided in MI or harsh, adverse weather conditions.
Danish crisis management principles
Crisis management in Denmark relies on seven principles that include sector responsibility principle, the cooperation principle and the action principle. The crisis management principles are summarized in Table 1. Danish National Crisis and MI Management System is outlined in Additional file 1.
Danish trauma system
In a two-tiered system, Danish trauma management includes both regional and university hospitals. Trauma referral centers are located in Copenhagen, Odense, Aarhus and Aalborg. They all provide definitive care for 500 000 to 2 800 000 people since catchment areas differ between the five regions. Some trauma centers have national competencies, such as a burns unit, hyperbaric oxygen treatment, limb saving surgery etc.
Major incident preparedness
In Denmark, a set of guidelines for joint services incident command, [9] constitutes a theoretical and practical framework for MI management. The concept accounts for every aspect of interdisciplinary MI management and incident commanders are trained during a three-week, joint service course offered by the Danish Emergency Management Agency. During the course, several table-top and full-scale exercises are conducted and comprehensive training in the use of communication devices is included. After completion of the course and passing a final examination, Police, Fire & Rescue, and Medical Incident Commanders share a common language and understanding of MI management.
Communication
In Denmark, authorities responsible for safety, health, and public order utilize a nationwide secure emergency radio network, a Terrestrial Trunked Radio [10] TETRA standard based system. According to the national guidelines for joint services incident command [9, 11], the police issue a temporary interdisciplinary communication channel within the TETRA-based system in the event of an incident involving multiple authorities. EMS units are expected to switch radios to the assigned Health sector channel, as forced steering or patching of communication channels in MI is not yet in use in Denmark [12]. Incident Commanders have a dedicated channel for internal, joint service command communication.
Copenhagen emergency medical services
EMS in the Copenhagen metropolitan area is operated by the Capital Region. The EMDC is located in Ballerup and features a 24/7 in-house coordinating senior prehospital physician with the overall medical responsibility for the EMS-response in the region. Up until 62 ambulances operate from 21 ambulance stations around the region. Five MECUs are on duty from four bases, three of these 24/7. The HEMS helicopters from Danish Air Ambulance are available for the Capital Region as well. Positioned strategically across Denmark, one of these helicopters is located on a base in Ringsted, 50 km south-west of Copenhagen. The Capital region also operates two mobile Emergency Room trailers/casualty clearing stations which may be mobilized in MI (See Additional file 2).
Tactical emergency casualty care
Tactical emergency casualty care, TECC®, is a concept for training EMS personnel on how to respond to and care for patients in a civilian tactical environment [13]. The TECC® concept focuses on situational awareness and treatment in the safe zone of a tactical environment and does not include personal protective equipment.
Tactical emergency medical service
TEMS is a concept to ensure that certified and specially equipped paramedics and prehospital physicians are able to enter an area that is not yet declared safe by police to perform triage and time critical lifesaving emergency procedures to stop patients dying from e.g., gunshot wounds, stabbing etc. The TEMS teams are educated and trained in working in a tactical setting on not yet secured scenes. They pass a demanding physical test every year and train tactically on a regular basis with the police. A TEMS team is on duty 24/7, staffing one of the five MECUs in the Capital Region, carrying their personal protective gear and equipment for MI.
TEMS has been operational in the Capital Region since 2018 [14]. The TEMS unit is dispatched to approximately 200 incidents per year, ranging from assistance to the police arresting known dangerous perpetrators or assessing potentially violent psychotic patients to actual or threatening terrorist incidents. TEMS is seconded to the police as needed and is under police command and protection when deployed. Between TEMS tasks, the team functions as a standard MECU at the disposal of the EMDC.
Copenhagen hospitals
There are five emergency university hospitals in the Copenhagen metropolitan area, located in Hvidovre, Herlev, Bispebjerg, Hillerød and Copenhagen City where Rigshospitalet, a Level 1 trauma centre with a catchment population of 2 800 000 people, is situated. In addition, four smaller hospitals are part of the MI preparedness plans with the capability to treat lightly injured patients (See Fig. 1).
Copenhagen metropolitan area hospitals
Scene description
Field’s is one of Denmark’s largest shopping malls. It comprises 135 stores, nine cinemas and twenty-two restaurants. Situated seven kilometers from the center of Copenhagen with a nearby metro station, the 115 000 square meters mall is popular among families and young people. An estimated 15–40 000 people visit the mall on a regular day. In the event of concerts in the nearby Royal Arena, a 16 000 capacity indoor sports and concert venue, it is customary that Field’s restaurants are used extensively prior to the event.
Study design
The present case report describes the prehospital EMS response on 3rd July, 2022 to the mass shooting at Field’s, Copenhagen, Denmark. The case report adheres to the CONFIDE (CONsensus guidelines on Reports of Field Observations in Disasters and Emergencies) [15] concept, used in the assessment of the quality of non-traditional studies, intended to acquire the optimal evidence approach to MI and disaster response. (See Additional file 3).
Data acquisition
Data sources included:
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Control room system LOGIS® (Nærum, Denmark), Copenhagen EMS, Ballerup, Denmark
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The electronic Prehospital patient medical record system (Judex®, Aalborg, Denmark)
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Center of Emergency Communication, Frederiksberg, Copenhagen, Denmark
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Public domain
Alarm and dispatch
The national distress number 1–1-2 received the first of over 550 calls from the incident site at 17.33. Copenhagen Police dispatched units to the incident at 17:35. Copenhagen EMS was alerted at 17:39. The call taker in the EMDC acknowledged that the incident was potentially serious and initiated dispatch of a MECU as the Medical Incident Commander (MIC) and the first ambulance at 17.42. Radio contact was established between MIC, Police, and Fire Brigade Incident Commanders en route and a contact point 200 m from the mall main entrance was agreed upon.
Upon arrival as the first medical unit on scene at 17:49, simultaneously with the Fire Incident Commander (FIC), immediate physical contact was made with the Police Incident Commander (PIC) and Joint Incident Command (JIC) was established. The exact incident location was verified, and the presence of active shooter(s) was confirmed. One shooter had just been apprehended, and one or two more gunmen were still believed to be at large in the mall. Four severely injured in need of immediate treatment were being evacuated from inside the mall by police. Based upon the size of the mall, the assumed number of assailants and number of visitors, a joint assessment of a potential double-digit number of casualties was agreed on. MIC reported immediately back to the EMDC, formally declaring MI at 17:50.
Site access and security
The mall has multiple entry points, including the main entrance on the eastern side of the complex, additional entrances and access points from in-house parking lots. MIC designated an ambulance staging area approximately 200 m north of the main entrance (See Fig. 2), with safe access/egress via a specific ambulance route from the north. The staging area was not in direct line of potential fire from within the mall.
A massive presence of armed police formed a secure corridor from the ambulance point to the main entrance. This protected passage was established within minutes after being requested by MIC and was in place before the second ambulance arrived on scene. The corridor enabled a coordinated and safe evacuation by ambulance of injured people from an interim Casualty Collection Point (CCP) established by tactical fire units at street level outside the main entrance. Close and ongoing liaison between incident commanders was maintained throughout the initial critical phase.
Arriving EMS units were, initially individually and later in groups, regularly briefed by MIC on the situation, including safety precautions.
Mall guests fleeing the incident via the main entrance were herded by police and directed away from the scene. The first sight that met MIC approaching the scene was a huge crowd of people running in panic toward the blue lights of the MECU. Having passed a city park immediately before arriving at the Incident Command contact point, MIC directed the crowd to continue running towards the park where they could assemble. The park itself was completely shielded from the mall by a tall housing complex and deemed to be safe. It was already noted at this point that some individuals were lightly injured, i.e., walking wounded.
The traffic on the Metro railway line opposite Field´s Mall was halted and the station, surrounding streets and junctions as well as the nearby Royal Arena were secured by armed police.
Site organization
The incident site was organized as per guidelines and dynamically adapted according to the rapidly developing scenario. The crew comprising physician and paramedic/physician’s assistant from the first MECU dispatched to the scene continued in the roles of MIC and Medical Communications Officer (MCO) for the duration.
Extensive inner and outer cordons were established by police according to the nature of the incident and the ensuing manhunt for multiple perpetrators presumed still at large. The danger zone consisted initially of the entire inside of the mall, gradually being reduced in size as police incrementally swept, cleared, and secured segments of the building.
A Joint Services Incident Command Post (IC-Post), physically consisting of a MECU and the Fire Incident Commander command vehicles parked next to each other, was set up at the road junction at the northeast corner of the mall (See Fig. 2). The location provided an excellent visual overview of the safe corridor established by armed police to the south, along the eastern façade towards the main entrance and CCP, as well as north towards the ambulance staging area and access/egress route. A spacious and well-staffed and equipped Police Incident Command module was set up on the west side of the mall to lead police operations. Normally serving as a Joint Incident Command post, the module was more than 600 m away from the focus of medical operations and its facilities were thus unavailable for MIC.
An interim CCP was designated at the foot of the stairs leading up to the main entrance of the mall. It was decided by the joint incident command that neither a Casualty Evacuation Point (CEP) nor a Casualty Clearing Station (CCS) for secondary triage could be established close to the mall in the chaos phase of the incident due to safety issues and lack of personnel. It was therefore decided that ambulances would be called forward as needed through the safe corridor to load patients at the CCP after primary triage. Treatment would be provided en route to the hospital according to the load-and-go principle. The second MECU on-scene was deployed to the CCP as Forward Medical Commander in order to supervise triage and report back to MIC. A manoeuvre plan for setting up a CCS indoors in a secure location on the ground floor of the mall close to the main entrance if needed, once safety had been assured, was agreed on by incident commanders.
Standard key roles such as Ambulance Commander, Ambulance Loading Officer, ambulance personnel for staffing CCS and Casualty Clearing Officer were intentionally not designated due to a critical lack of resources in the initial phase, where all ambulances were needed for immediate transport. See Fig. 2 for site organization.
Field’s incident site organization
TETRA communication
65.3% of the EMS units switched to the designated interdisciplinary talk group. Seventy TETRA radios were in use in the MI. There were 213 radio grid related shifts. The 34.7% that did not switch as intended primarily switched by mistake to the joint incident command channel instead of the designated HEALTH channel or had trouble shifting the radios. There were no reports of compromised TETRA network bands coverage difficulties.
Strict radio discipline was enforced from an early stage by MIC/MCO, keeping assigned and designated channels clear of unnecessary communication. All EMS units were issued a default listen only order on the common, designated HEALTH channel. In acknowledgement of the inherent different perspectives on the situation as it unfolded, MIC and EMDC communicated continuously on an assigned EMDC channel, with regular updates reported up the chain of command from the scene and operational lead and support provided from the EMDC. Other key roles could participate on the EMDC channel by invitation. An example of this was the Trauma Centre at Rigshospitalet, which provided invaluable information and regular updates regarding surge capacity status.
TEMS teams reported status and findings to MIC/MCO at intervals over a dedicated tactical channel on a do not answer basis, verifying or refuting rumors regarding the number and type of casualties and deceased. The Forward Medical Officer and the mobile medical teams, consisting of on-duty MECUs and mobilized off-duty MECU staff, were assigned a common, dedicated channel for medical coordination at the scene and reporting back to MIC. The Incident Commanders from the three sectors remained in contact by radio when not physically together.
Ambulance resources
Ten ambulances, four on-duty MECUs and a mobile emergency room trailer (MERT) were requested immediately by MIC as well as the mobilization of further ambulances as and when they became available. Of the first ten ambulances requested, five were intended as per MI protocol for command support roles and for preparing a Casualty Clearing Station (CCS)/MERT, while the other five ambulances were intended for transport of priority 1 casualties. Furthermore, assistance from the neighboring Region Zealand and mobilization of off-duty prehospital personnel from home were advocated. Safe access/egress along a specific route from the north with ambulance parking north and out of sight of the mall was ordered. The on-duty TEMS team was notified directly by Copenhagen police, arriving in a MECU on the west side of the mall at 17:57, and was immediately deployed under police command and protection.
The first ambulance arrived at the incident at 17:53, three minutes after MI was declared.
The next three ambulances arrived 14, 21 and 24 min after the first ambulance. A second MECU arrived at 18.17 together with the fourth ambulance.
In total, 48 EMS units were dispatched sequentially during the entire incident, including 31 ambulances, eight MECUs (five of these as TEMS teams), seven Non-Emergency Medical Transport (NEMT) vehicles, and social services mobile unit, and one mobile emergency room trailer (See Table 2 and Fig. 3). Off-duty personnel, including four TEMS teams using off-duty MECU vehicles for transportation, were called in from home, issued with uniforms and kit at the EMDC Major Incident Preparedness depot, teamed up and transported successively to the scene.
Graphic presentation of dispatched units and time expenditure
To avoid crowding of ambulances at the incident site and to ensure capacity for regular ambulance services, EMDC decided to position eleven ambulances at five ambulance bases and assembly points within a 5 km radius of Field’s for possible rapid dispatch to the incident site. Furthermore, in order to maintain regular ambulance services in Copenhagen, EMDC commissioned ambulances from the neighboring region for possible ordinary missions besides the MI. An overview of the available ambulances is provided in Table 3.
Patient treatment and characteristics
All ambulance transported patients were treated en route to the hospital. Treatment consisted primarily of lifesaving first aid measures, i.e., tourniquets/wound packing/hemorrhage control as warranted at the CCP, supplemented with oxygen, large bore intravenous cannula, intravenous fluid, and pain medication with opioids as needed during transport. All four critical patients had verified or assumed thoraco-abdominal gunshot wounds and were in varying degrees of circulatory shock.
Triage
Initial eyeballing triage was undertaken by police and firefighters at the CCP after evacuation of wounded from the danger zone. Three victims were pronounced dead by deployed tactical units during the initial sweep and left on scene in the mall. One severely wounded victim with time critical and immediately life-threatening injuries was evacuated and transported to the trauma center on the rear seat of a police patrol car as ambulances had not yet arrived. Three other evacuated, critically injured patients were triaged by the first ambulance arriving at the scene and reported to MIC over the radio. Triage was performed on the basis of wound location and the Triage Sieve, and all three victims were categorized Priority 1. Transport priority and destination was decided by MIC and a load-and-go order was issued. The remaining casualties were transported at intervals as and when the next two ambulances arrived.
Tactical emergency medical service
Five TEMS teams were dispatched to the incident site. The on-duty team arrived within minutes, whereas four off-duty teams were mobilized from home, arriving at intervals during the ensuing 90 min. Initially shortly briefed by MIC on arrival, mobilized TEMS teams were immediately seconded to the police and deployed. During this phase of the incident, a manhunt was still in progress, as it was uncertain whether the arrested perpetrator was acting alone, or if more gunmen were on the loose. Teamed up with armed police, TEMS’ primary task was to help search the mall sector by sector and floor by floor for casualties and guests hiding in cinemas, shops, storage rooms, washrooms, stairwells and elevators. TEMS pronounced life-extinct victims dead and left them as they were found for further police investigation.
Management of uninjured survivors
Local municipal authorities established a Survivor Reception Centre on request from the police at a nearby sports arena, approximately one km from the incident. Uninjured survivors and witnesses were registered and questioned by the police, and psychological support and counseling was provided by a dedicated team of psychologists and psychiatrists.
A major contributing event in an adjacent arena
In the nearby Royal Arena, a concert featuring British pop star Harry Styles was scheduled to commence at 19.00. The 16 000-capacity venue was about half full at the time of the mass shooting at 17.33. The promoters first postponed the concert to 20.00 but a final decision to cancel the concert was made at 21.37. As per police orders, the Copenhagen Metro was commissioned at 21.41 for transportation of approximately 6000 predominantly teenage concert guests away from the area to a metro station on the other side of the city for safety issues and to avoid inadvertent contamination of the crime scene.
Continued assessment
As the hours passed, repeated sweeps of the complex revealed no further gunmen or serious casualties in the mall. Several uninjured survivors were found hiding in restrooms, storage rooms, back offices and shuttered shops and were evacuated as and when they were found well into the night. In the meantime, a substantial force of EMS units and personnel had been accumulated. Following briefing, they were initially tasked with setting up a CCS and preparing for secondary triage, treatment and transport of any potential casualties found during the ongoing sweeping operation.
At approximately 20.30, Incident Command acknowledged that any untreated, critically wounded not yet found would already have died from their injuries. A massive presence of EMS was no longer justified, and a majority of units were released from the scene after defusing. A stand down of the mobilized off-duty staff and ambulance crews at the end of their shifts were declared. On-duty units were released for service as needed elsewhere in the region. A de-escalation recommendation was forwarded up the chain of command by MIC, and the hospitals started winding down from 21.30, returning to normal service at 23.00.
All TEMS teams, one MECU, and five ambulances were retained on site with MIC in order to receive and treat any unexpected civilian or tactical casualties until MI was declared closed for EMS around midnight.
Defusing and debriefing
Fit for the task, a brief on-scene defusing was performed by MIC immediately following the incident before units were released. The ambulance crews were also defused locally, i.e., each ambulance base conducted ad hoc debriefing as per request and guideline. Furthermore, all EMDC personnel and ambulance personnel were offered structured defusing a few hours after the incident or the following day.
Structured debriefings for involved personnel were conducted by Copenhagen EMS as per guidelines for joint services incident command. The debriefings were performed at two meetings, approximately three weeks after the incident took place.
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