European perspectives on pre-hospital interagency collaboration during terrorist incidents: a focus group study

Abstract

Background

Recent international developments have led to increased terrorist activity and intentional violence across Europe. Interagency collaboration has repeatedly been identified as a key challenge in previous scenarios. This study explores the perspectives of European pre-hospital medical providers and law enforcement officers on collaboration during violent incidents, aiming to identify barriers, best practices, and opportunities for improvement.

Methods

Twelve modified focus group interviews (3–8 individuals per group) with embedded polls were conducted online. Deductive coding was performed for predefined topics, e.g., Command, Communication, Hot Zone Care, Provider Safety, and Interagency Understanding. Inductive coding was applied to additional content arising from the interview dynamics.

Results

64 participants from 20 European countries were interviewed. 41% (26/64) were non-physician pre-hospital providers, 38% (24/64) worked as pre-hospital emergency physicians, and 22% (14/64) served in law enforcement, including special forces. 49% (30/61) of participants denied feeling adequately trained to collaborate with other responding services in a tactical scenario. Training methods were criticised for neglecting situational awareness and interpersonal competencies. Overall, joint training opportunities are reportedly rare, leading to misconceptions of the capabilities and priorities of interagency counterparts on scene. 64% (39/61) of participants reported police as the primary care provider for casualties in the hot zone, with many regional protocols extending this reliance into the warm zone and specifically onto special forces. However, the interviews indicated that police are unlikely to deliver such care without significant delay. Thus, casualty evacuation emerged as a key bottleneck and priority for further debate.

Conclusions

This study revealed a significant paucity of joint education and training opportunities. Training concepts should place greater emphasis on behavioural competencies instead of rigid protocol compliance. Although promising response frameworks exist across Europe, various deployed strategies risk prolonging the therapeutic vacuum of casualties inside high-risk zones and impairing provider safety. Joint strategies and interprofessional exchange will be essential to decrease such systemic vulnerabilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-025-01482-4.

Background

Current Europol reports describe a noteworthy increase in terrorist activity across the European Union (EU) [1]. Jihadist terrorism accounted for the highest direct impact and was thus named a key security concern for the EU. Accentuated by growing socioeconomic tensions, politically motivated terrorism and non-terrorist intentional violence also persist as a relevant threat. Recent international developments, i.e. the rise of right-wing parties and the escalation of conflicts in the Middle East, have fostered a conducive environment for extremist narratives of the entire ideological spectrum to thrive. Concomitantly, the rise of “lone wolf” actors and the adoption of improvised methods of violence, i.e. intentional vehicular assaults (IVAs) and stabbings, have posed significant challenges to authorities’ prevention efforts.

Poor collaboration between responding agencies has repeatedly been named as a key obstacle to effective management of mass casualty incidents (MCIs) [2–4]. Scenarios involving intentional violence inherently exacerbate such systemic vulnerabilities.

Nevertheless, little research has been done to assess and enhance interagency collaboration. Despite rising security concerns, European providers face a void of opportunities to engage with their international and interagency counterparts.

This study thus sought to connect European pre-hospital medical providers and law enforcement officers to explore their perspectives. It was designed to identify challenges, best practices, and opportunities to strengthen pre-hospital interagency collaboration in response to acts of intentional violence.

Methods

Study setting

This was a qualitative interview study of European pre-hospital emergency medical staff and law enforcement officers. Modified focus group interviews were conducted online between August and October 2024.

This manuscript follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [5].

Inclusion criteria

Inclusion criteria encompassed:

• Adults (≥ 18 years).

• English language proficiency.

• ≥ 2 years of experience as pre-hospital emergency medical services (EMS) personnel including physicians, or law enforcement officer within Europe.

For details regarding recruitment, see Additional File 1, p.3.

Interview design

All interviews were conducted via video conference, following a structured protocol to ensure consistency across groups (see Additional File 1, p.4). Each group was assembled with a focus on diversity regarding participants’ national and professional backgrounds.

Participants were given a fictitious scenario outlining an IVA with subsequent stabbing of pedestrians in an unspecified city centre, selected in consultation with a security analyst monitoring international developments. Consequently, participants were asked to discuss a priori defined questions and respond to anonymous polls covering the topics Command, Communication, Hot Zone Care, Evacuation, Spatial Planning, Provider Safety, and Interagency Understanding.

Once data saturation was reached, indicating that further interview sessions were unlikely to yield novel insights, the interview process was discontinued.

Data handling and analysis

Audio recordings were immediately transcribed and anonymised, and transcripts underwent content analysis.

Analyses included deductive coding for an a priori selected set of codes and inductive coding for additional content emerging from the interview dynamics (see Additional File 1, pp.4–5).

Results

Study cohort

During twelve modified focus group interviews, 64 participants were interviewed in interdisciplinary groups of 3–8 (median 5.5), respectively (see Supplementary Figure S1, Additional File 1). The final cohort included interviewees from 20 European countries (median 3 nationalities per interview; Fig. 1).

Fig. 1.

Nationalities of interview participants. Nationalities of interview participants (orange), indicating the respective number of participants per country: Iceland (2), United Kingdom (5), Ireland (1), Netherlands (1), Belgium (4), Austria (1), Hungary (1), Romania (1), Germany (29), Switzerland (3), Italy (3), France (1), Spain (1), Greece (2), Poland (1), Lithuania (1), Finland (1), Sweden (2), Norway (1), Denmark (3)

Created with mapchart.net (free-to-use software)

92% (59/64) of participants were male. 41% (26/64) worked as non-physician EMS providers and 38% (24/64) as pre-hospital emergency physicians. 22% (14/64) served in law enforcement, including special forces. Of these, 43% (6/14) were physicians, and 14% (2/14) had additional EMS training (Fig. 2).

Fig. 2.

Professional backgrounds of interview participants. Professional backgrounds are highlighted according to participants’ self-disclosure during the recruitment process

Findings

The poll response rate was 95% (61/64), non-responses were due to technical difficulties.

Throughout the interviews, participants shared a multitude of issues and potential solutions. This manuscript will devote particular attention to the most prominent themes. For more details and quotations, see Additional File 1, pp.6–20.

State of preparedness

Polls demonstrated that 49% (30/61) of participants did not feel adequately prepared to collaborate with other responding services during a terrorist incident, one participant was unsure (Fig. 3).

Fig. 3.

Subjective preparedness for interagency collaboration among interview participants. This figure depicts participants’ responses to poll 1: “Do you feel adequately trained to collaborate with other responding agencies during a terrorist scenario?”, with the response options displayed in the figure. Poll response rate: 95% (61/64 participants)

In fact, scarcity of training opportunities for tactical incidents among regular providers was an overarching theme. Disparities in funding and political support as well as staff shortages were named among the main reasons. These disparities became evident not only between state entities (e.g., law enforcement, fire services) and non-state actors (typically EMS), but also between countries with and without recent terrorist activity. While participants from countries with recent large-scale attacks often reported state-mandated, national standards for education, training, and response, participants from countries without recent terrorist activity criticised the stagnation in developing such concepts, stating it was “very difficult to create preparedness in times of peace”.

Additionally, participants observed that regular responders often stayed fixated on individualised medical approaches even in MCIs. The necessity of MCI training was thus highlighted.

Casualty care in zones of higher risk

In this study, the terms “hot zone”, “warm zone”, and “cold zone” will be used to describe areas of direct threat, indirect threat, and no known threat, respectively [6]. 64% (39/61) of participants stated that their response protocols relied primarily on police for casualty care inside the hot zone, with 59% (23/39) in this subgroup specifically relying on special forces. 15% (9/61) reported that tactically trained (non-police) medical staff (e.g., tactical emergency medical services teams) were responsible, and 5% (3/61) relied primarily on bystanders (Fig. 4).

Fig. 4.

Responsibilities for casualty care within the hot zone according to local response protocols. This figure depicts participants’ responses to poll 2: “Do your local protocols for tactical/terrorist incidents focus on any of the following to take care of casualties inside the red (hot) zone?”, with the response options displayed in the figure. Poll response rate: 95% (61/64 participants)

Subsequent discussions disclosed notable discrepancies between reported realities of police officers and expectations conveyed through the polls: Due to resource constraints and delayed arrival of special forces, initial police resources were reported likely not to be sufficient to manage casualty care before threat elimination was achieved. Moreover, it became evident that police medics’ roles and capabilities were often misconceived among medical providers, with many being unaware that these providers typically fill other roles inside their units apart from their medic roles.

Strikingly, several participants explained that their protocols exclusively allowed for medical personnel in the cold zone, thus leaving casualty care in the warm zone, including evacuation to safer zones, largely to police as well. Participants working under such protocols mostly experienced them as unsatisfactory and inefficient, while few agreed with this approach. Reasons for the latter sentiment included provider safety and ethics, i.e., explicit distinction between police and medical personnel (see Additional File 1, pp.7–11).

There was clear unison regarding the prioritisation of threat elimination. Multiple factors were considered to reduce the risk of delayed casualty care whenever threat elimination wasn’t swiftly achievable: First, participants agreed that the declaration of a hot zone required careful consideration and was dependent on various aspects, i.e., number/movement of perpetrator(s) and type of weapon. It was noted that zoning decisions were decisively conditional on the police commander’s mindset and may thus vary substantially. Moreover, multiple participants experienced threat zones as a theoretical concept that not every police and medical provider was familiar with, leading to a lack of actual implementation of concepts in real incidents (see Additional File 1, pp.12–15). Operations within a true hot zone were agreed to fall under the sole jurisdiction of law enforcement, and the medical focus should be on casualty evacuation to a safer zone.

Accordingly, casualty evacuation was identified as a key bottleneck. Solutions proposed by participants included evacuation teams, i.e., tactically trained EMS or fire services personnel entering warm zones under police protection. Whenever resources allowed, participants favoured cohorting casualties inside insular, police-protected warm zones for stabilisation and evacuation by these teams through protected corridors. 45% (9/20) of represented countries supposedly provided such interagency teams in at least major metropolitan areas (Fig. 5).

Fig. 5.

Distribution of specialised interagency teams among countries represented in the interviews. Distribution of interagency teams for tactical incidents: Only countries represented in the interviews are taken into consideration. Definition of interagency teams: Pre-defined, specialised teams composed of EMS/fire personnel trained to enter the warm and/or hot zone (typically under police protection) for the purpose of casualty care and/or extraction, must exist at least in major metropolitan areas

Colour coding: Orange = interagency teams exist; anthracite = no interagency teams; light grey = country not represented in interviews

Created with mapchart.net (free-to-use software)

Regularity and level of tactical training varied considerably between these countries. However, participants agreed that training should focus on adequate situational awareness and that teams operating in zones of higher risk should not be formed ad hoc, i.e., without prior training.

Participants pronounced yet again the importance of prompt evacuation to adequate hospitals with emphasis on surgical needs. Transport priorities should be defined accordingly, only allowing for immediately necessary on-scene interventions. Several participants recommended “transport officers” for casualty prioritisation and triage algorithms with a focus on surgical urgency [7, 8].

The “human factor”

Beyond distinct operational factors, participants highlighted various “human factors” influencing collaboration and provider safety. Communication was named the most urgent issue.

The early creation of an information flow and synchronisation of efforts between responding services should be a main target. Due to its low risk of misinterpretation and information loss, direct communication was clearly preferred – particularly for on-scene commanders. For most participants, co-location of commanders was a standard procedure embedded in their national response protocols. However, German participants indicated that police command was typically located at an off-site command centre while medical command was on-site. Moreover, they reported difficulty identifying the on-scene police command representative. One German participant recounted a well-received regional solution involving an on-call police commander, enabling immediately available on-scene leadership. Participants without standardised co-location protocols largely relied on communication via dispatch centres. Although this facilitates information clustering, it inherently introduces information delays between entities. Particularly for dynamic scenarios, this approach was widely criticised for its potential to compromise provider safety and hinder effective on-site collaboration.

In fact, interagency communication was recommended to be initiated even before commanders arrived on scene, e.g. through function-linked phone numbers. Moreover, participants highlighted the urgency of joint and readily available communication channels between responding services, e.g. joint Terrestrial Trunked Radio (TETRA) call groups. Most participants stated to use TETRA for everyday operations, and joint call groups for major incidents reportedly exist in multiple European countries. However, some described delays in permission to use these call groups. Others emphasised the substantial unfamiliarity of personnel with radio communication revealed by previous incidents. In addition to routine radio communication training, suggested strategies to mitigate the impact of human factors implied utilising communication methods that were universally familiar to all responders, such as commonly used and monitored radio frequencies (e.g., between law enforcement and EMS dispatch to request EMS support in everyday operations), or encrypted messengers allowing for shared visual data. Albeit some recounted forced radio steering through dispatch centres to be highly effective, it was not standard practice for most participants.

Apart from technical issues, the interviews highlighted differences in terminology, priorities, mindset, and risk awareness between police and medical responders. Further, it was mentioned that capabilities and strategies of responding services were often unclear to their respective interagency counterparts, significantly impeding operational efficiency and provider safety.

Some represented regions addressed these issues by introducing joint education models, e.g., the Danish joint school compulsory for future incident commanders. Others created regular joint lessons for paramedics and police officers in training. Further ideas comprised a legal requirement to include other services when conducting an exercise. Moreover, interagency social events have been suggested to tighten relations and build personal trust.

Several participants felt unsupported by political leadership in establishing joint structures. Notably, pragmatic, locally driven initiatives, reliant on individual commitment and personal networks, attempt to address this issue and fill the gap.

Discussion

This modified focus group study of pre-hospital providers and police officers revealed vulnerabilities and key opportunities to enhance collaboration during violent incidents.

The interviews demonstrated that several represented regions not only relied on police forces for casualty care inside the hot zone but extended this reliance into the warm zone and on special forces specifically. Such concepts introduce the risk of an extended therapeutic vacuum for casualties, a major hindrance to preventing fatalities in past incidents [9, 10]. While an initial therapeutic vacuum seems nearly inevitable, any prolongation should be actively avoided. Interview statements aligned with previous appeals to synchronise police and medical efforts early on – specifically when threat elimination isn’t immediately possible [9–14]. Generally, a paradigm shift is needed from delaying care until full scene security towards a balanced approach, prioritising provider safety while allowing for timely evacuation (see Additional File 1, pp.7–11).

Evacuation was recognised both as a priority measure and crucial bottleneck. Given the availability of rapidly scalable resources and their non-involvement in direct threat elimination, EMS and fire personnel have been proposed to perform casualty extraction and stabilisation under police protection. Fire services traditionally handle chemical, biological, radiological, and nuclear (CBRN) hazards and technical rescue, rendering them the most experienced with zoning concepts and extraction techniques. Such specialised teams staffed by fire services operate in Belgium, France, and the Netherlands [15–17]. Others, e.g., Spain, Finland, and the United Kingdom, primarily deploy tactically trained EMS personnel, while Denmark deploys both [18–22]. Scientific literature from countries without such teams, most dominantly Germany, acknowledges the need for collaborative efforts in the warm zone [23, 24]. Thus far, however, specialised teams in Germany remain rare local initiatives [25]. Overall, there is a lack of data investigating the net benefit and personal risk of specialised interagency teams.

Aiming to “teach those who will be there”, participants emphasised the underutilised potential of regular police officers and bystanders. Both can be valuable assets to bridge the gap to advanced care, and training efforts should be made accordingly [11, 26]. Yet, recent injury patterns merit consideration: While injuries caused by explosives in the 2000s prompted widespread tourniquet provision among police and civilians, current attack types show injuries less amenable to tourniquet application. Bladed weapons reportedly lead to high numbers of vascular injury to the torso, neck, and abdomen [27]. Data from IVAs suggest a higher ratio of severe head injuries, alongside abdominal and pelvic injuries [28, 29]. Thus, greater focus is needed on prioritising evacuation to surgical care. In these circumstances, bystanders may play a limited role beyond assisting with evacuation. Additionally, evacuation may necessitate analgesia – underscoring the advantage of specialised medical teams.

Another noteworthy finding of this study was the discrepancy between the frequency of zoning references and the failure to implement and communicate zoning concepts in real incidents. Considering the implications of risk perimeters and their implicitness in response plans, their implementation requires training to avoid delays and compromised provider safety.

This study revealed a profound lack of training opportunities and inadequate state of preparedness in many European regions. In a time of growing threat, less than half of the cohort felt adequately trained to collaborate during violent incidents. Acknowledging participants’ backgrounds, this ratio is likely even lower in regular police and pre-hospital staff. Repeated exercises not only establish crucial trust between leaders and individual providers [30]. Preparedness has also been proven critical to strengthening operational efficiency and provider safety – both physical and psychological [3, 31, 32].

Apart from highlighting distinct technical factors, e.g., providing readily available and routinely utilised communication structures, the interviews exposed the need for a shift in training of responders: Emphasis should be placed on behavioural competencies like situational awareness and effective communication. For instance, frequent micro training in TETRA communication contributed to improved on-scene performance in Denmark [33].

Training and response concepts should allow for the prioritisation of principles over rigid protocol compliance. This need becomes particularly salient considering that responders are often trained using static concepts yet are expected to operate effectively in dynamic scenarios. European research aligns with this, urging to prepare responders to improvise beyond predefined guidelines [34–36].

Moreover, interagency understanding was considered one of the most critical factors for provider safety. Efforts should be made to create shared response concepts and terminology, and to understand each entity’s priorities and capabilities. Joint education and training programmes could bridge this gap [37, 38].

Interview participants frequently emphasised the value of engaging with colleagues across national backgrounds and professions. Notably, several participants contacted the authors after the interviews to share local initiatives inspired by the discussions. This highlights both the shortage and the potential of platforms for knowledge exchange among providers [39].

Recent developments indicate perpetrators’ growing exploitation of systemic weaknesses, such as interagency communication [40]. However, many of the vulnerabilities described in this study are not new. In fact, deficient interagency collaboration has been identified as a main challenge, and opportunities for enhanced concepts have been pronounced repeatedly after past incidents [13, 19, 41–43]. Greater emphasis needs to be put on the distinction between lessons identified and lessons learned [44].

Strengths and limitations

To the authors’ knowledge, this is the first international and interprofessional interview study on pre-hospital interagency collaboration during violent incidents, involving both police (including special forces) and medical providers from 20 European countries. Several participants also worked in fire services. Thus, a key strength is the diversity of perspectives, including first-hand accounts from participants who experienced terrorist incidents. Further, the study yielded both qualitative insights and quantitative trends.

Limitations may include the study cohort’s composition, with relative overrepresentation of German participants and potential underrepresentation of other countries. National-level observations should therefore be interpreted cautiously, as they may reflect regional experience. The high quantity of German participants may reflect both the authors’ nationality and widespread dissatisfaction with current concepts in this subgroup. Given their high regional variability in response frameworks, including multiple German regions in fact adds value.

This study may be influenced by selection bias, as several participants had tactical training. This likely underrepresents regular providers, who may feel even less prepared for tactical incidents.

Conclusions

Although promising concepts exist across Europe, various deployed strategies risk impairing provider safety and prolonging the therapeutic vacuum of casualties.

The rise in terrorist activity and intentional violence underscores the urgency of enhanced collaboration across professions and borders. During this study, multiple incidents, some closely resembling the interview scenario, tragically highlighted its pressing relevance.

The extraordinary level of individual providers’ personal commitment holds strong potential for meaningful change. However, political support will be crucial — to foster learning from international counterparts, develop joint education and response concepts, and ensure lessons identified finally become lessons learned.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CBRN

Chemical, Biological, Radiological, and Nuclear

EMS

Emergency Medical Services

EU

European Union

IVA

Intentional Vehicular Assault

MCI

Mass Casualty Incident

TETRA

Terrestrial Trunked Radio

Author contributions

DR served as the principal investigator and was responsible for study design, participant recruitment, data acquisition, analysis and interpretation of data, and drafting the manuscript and supplementary materials. MB provided crucial support with study design, participant recruitment, data acquisition, interpretation of data, and critically revised the manuscript and supplementary materials. YR supported this study during study design, participant recruitment, interpretation of data, and critically revised the manuscript and supplementary materials. Both MB and YR served as senior advisors to the principal investigator. All authors approved the final version of this manuscript and agree to be accountable for all aspects of the submitted work.

Funding

This study, i.e., the underlying MSc programme for which this study was initially designed, was partially funded by the B. Braun Foundation in a general scholarship granted to the principal investigator DR (grant no. BBST-D-23-00105). The sponsor had no role in this study. Additionally, the authors wish to express their gratitude to Michael Henrich, Head of the Centre for Anaesthesiology, Critical Care and Emergency Medicine at ViDia Hospitals Karlsruhe, for providing administrative and financial support in ensuring this research reaches a wider public.

Data availability

In accordance with the provisions outlined in the initial participant information sheet and the approved application to the respective ethics committee, participant data and interview transcripts cannot be made available to external parties.

Declarations

Ethics approval and consent to participate

Ethics approval was granted by the Ethics Committee at the University Hospital Bonn, Germany (IRB 2024-271-BO). Interview participants provided written informed consent.

Consent for publication

Not applicable (anonymised data).

Competing interests

The authors declare no competing interests.