Intended for healthcare professionals

Feature Medical Response to Terrorism

From the Christchurch mosque shootings to London Bridge: translating lessons for general healthcare

BMJ 2019; 364 doi: (Published 27 March 2019) Cite this as: BMJ 2019;364:l1366
  1. Rebecca Coombes, head of news and views
  1. The BMJ
  1. rcoombes{at}

Practices that develop in the heat of extreme situations have applications in day-to-day healthcare, finds Rebecca Coombes

“It was around 10 pm,” says Mike Christian, “and we had just dropped off a patient at the Royal London Hospital when the call came to respond to a road traffic collision—a car versus pedestrian—and we were dispatched to Tooley Street at London Bridge, less than 10 minutes away.”

Christian is a doctor with the Helicopter Emergency Medical Service (HEMS), which responds to serious trauma emergencies in and around London. On 3 June 2017 he was a first responder to the London Bridge terror attack.

Major incidents

Aside from the day job Christian works with the NHS and the police to learn lessons from major incidents and improve future responses to crises. At the Risky Business conference this June (see below for details) he will share insights into how the practices that develop in the heat of extreme situations can be applied to everyday healthcare.

He spoke to The BMJ on the day of the recent mosque shootings in Christchurch, New Zealand, commenting, “We know that these crisis situations will keep coming, as we unfortunately see today. From experiences at London Bridge, the Bataclan in Paris, and others, we know that some of the challenges are actually quite predictable, and it is important for us to plan in advance and come up with ways to learn to deal with them.”

A Canadian living in London, Christian is a critical care physician and former military doctor who was in his first month with HEMS at the time of the London Bridge attack. During a 30 year career he has cared for patients with severe acute respiratory syndrome in Toronto, and he joined a national team investigating the outbreak; he was part of the medical response in Haiti after the 2010 earthquake; and he has advised governments and hospitals on critical care in austere environments and emergency preparedness.

“So, when London Bridge happened it’s maybe fortuitous that I was working that day along with a paramedic who was with me,” he says. “She just happened to be one of the resilience leads for London Ambulance. We both had a fair amount of background knowledge and experience that night.”

En route to Tooley Street—by car because of the dangers of landing a helicopter at night—the HEMS team were told of multiple patients at the crash site. Within minutes came another update: a report of possible stabbings. “That’s when the penny dropped that this might be something more,” says Christian.

Three terrorists travelling south across London Bridge in a van had deliberately driven into pedestrians before crashing on Borough High Street. Armed with knives, they left the van and headed for Borough Market, entering pubs and restaurants, killing and maiming people as they went. Police shot the attackers dead within nine minutes. Eight people were killed and 48 injured in the attack.

Hearing the police shots over the radio, the HEMS team were forced to turn back to the north side of the river.

“We headed to the north side of London Bridge to set up a casualty clearing area: crowds of people were being directed from Borough Market,” says Christian. “Usually, where it’s one patient, the first thing we start doing is treating people. But in this situation the most important thing, particularly in a leadership role, is to start coordinating other people into action, because you need a larger response and you have to get that set up in order to help most patients.”

Therapeutic vacuum

Since the attack, an emerging issue for the police and the NHS has been how to stop doctors and other responders from being shut out of crisis areas during a fast moving security operation. The risk in such tense situations is that a “therapeutic vacuum” arises, says Christian.

“This is where a lot of resources coming into the scene get shut down because it’s unclear exactly which areas are safe and which areas are not,” he explains. “Once it’s a declared terrorist incident you get a higher level of control: this also came up with the Manchester bombing [in May 2017]. But it can create difficulty in getting additional resources to the scene.

“At London Bridge we were trying to pull resources in, but in the meantime it was a case of mobilising people who just happened to be there and were caught up in the incident—particularly off-duty junior doctors, nurses, and police officers. We put them to work and started to form ‘instant teams.’”

He explains, “It’s always amazing to me, how calm people can be. Lots of civilians were going above and beyond, carrying victims across the bridge, and doing first aid—some literally taking their shirts off their back for bandages. People were scared, but they were actually very effective, and they took instructions very well.”

The concept of instant teams, he says, is one that translates into everyday healthcare: “A crisis occurs, such as a cardiac arrest on the ward, and suddenly a somewhat random group of people who just happen to be on call come together. They may have never met each other before, and they have to work together in effective ways to provide lifesaving care.”

As well as therapeutic vacuums there is a threat of multiple attacks and the confusion this creates. The London Bridge attack occurred on an average weekend night in London—always very busy for the team, typically with dozens of calls about stabbings and other assaults coming into the operations centre. “The rest of London just doesn’t stop happening,” says Christian. “During the attack, when other calls are coming in, you wonder: is this just another regular incident, or is this another terrorist attack starting somewhere else?

“This happened at the Bataclan in Paris, and it’s one of the things that we’re very attuned to. You saw it with Christchurch, too—you need to expect the potential for multiple locations and multiple attacks.”

Limited and changing information

The challenge of making decisions when you have limited and changing information is not so different from other types of alerts in a hospital, such as a sick patient suddenly having a medical emergency.

“Some of these scenarios aren’t unpredictable, so these things don’t need to be unexpected and chaotic,” says Christian. “We know that there’ll be challenges of communication, and we know that information will rarely be as clear as it could be, but there’s still an imperative to act, to deliver care and make a difference for these patients.”

He left the scene around 2 am on the night of the London Bridge attack. There was an immediate debrief the next morning but then a call to respond to another unfortunate stabbing. Christian’s military background and the full support of the air ambulance service have helped him to build up a psychological resilience.

“The jobs keep coming in, and we have to keep responding,” he says. “The attack reinforced a lot of the work I was doing and has made me more passionate about the need to continue to improve our response.”


  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • Mike Christian will be speaking at the Risky Business conference in June along with a fellow HEMS doctor, Claire Parkes. To book and to see the rest of the programme go to

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