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BACKGROUND: The optimal response to a major incident in a road tunnel involves efficient decision-making among the responding emergency services (fire and rescue services, police, and ambulances). The infrequent occurrence of road tunnel incidents may entail unfamiliarity with the tunnel environment and lead to uncertain and inefficient decision-making among emergency services commanders. Ambulance commanders have requested tunnel-specific learning materials to improve their preparedness.

OBJECTIVE: We aimed to assess decision-making among ambulance commanders in simulated road tunnel incidents after they had participated in a tunnel-specific e-learning course designed to support timely and correct decisions in this context.

METHODS: We conducted a web-based intervention study involving 20 participants from emergency medical services in Sweden who were randomly allocated to a test or control group. The control group (n=10, 50%) received a lecture on general incident management, while the intervention group (n=10, 50%) completed an e-learning course consisting of 5 modules focused on tunnel structure, safety, and collaboration in response. The participants took part in 2 simulation-based assessments for ambulance commander decision-making in major road tunnel incidents 1 month and 6 months after their allocated study intervention. In each simulation, the participants decided on the best course of action at 15 independent decision points, designed as multiple-choice questions. The primary outcome was the correct response to the question regarding how to appropriately enter the road tunnel. The secondary outcome measurements were correct or incorrect responses and the time taken to decide for each of the 15 decisions. Limited in-depth follow-up interviews were conducted with participants (n=5, 25%), and collected data were analyzed using qualitative content analysis.

RESULTS: All 20 participants completed the first simulation, and 16 (80%) completed the second. The main finding was that none (0/20, 0%) of the participants correctly answered the question on entering the tunnel system in the 1-month assessment. There were no significant differences between the groups (P=.59; 2-sample test of proportions) in the second assessment. The e-learning course was not associated with more correct answers at the first assessment, including accounting for participant factors (mean difference between groups: -0.58 points, 95% CI -1.88 to 0.73; P=.36). The e-learning course was also not associated with a shorter time to completion compared to the nonintervention group in either assessment. Interviews identified 3 categories linked to the main outcome: information (lack of), risk (limited knowledge and equipment), and mitigation (access to maps and aide-mémoire).

CONCLUSIONS: Participation in a tunnel-specific e-learning course did not result in a measurable change in ambulance commanders' decision-making behavior during simulated road tunnel incidents. The observed hesitation to enter the road tunnel system may have several plausible causes, such as the lack of actionable intelligence and tunnel-specific plans. This novel approach to assessing commander decision-making may be transferable to other educational settings.

Den 9 januari 2024 inträffade den dittills största vägtunnelbranden i Sverige. Störst i den bemärkelsen att många fick vård av sjukvårdspersonal (på skadeplats och på sjukhus). Då omfattande vägtunnelolyckor är ovanliga i Sverige ställs höga krav på inblandade organisationer såsom räddningstjänst, polis och ambulans som inte rutinmässigt hanterar stora skadehändelser i denna särskilda miljö. Medicinska och organisatoriska aspekter har analyserats genom granskning av händelserapporter, slagningar i aktuella databaser och djupintervjuer med insatspersonal i ledningsfunktion. 

Background: The complexity of modern road tunnel systems may delay an efficient rescue effort. Capable decision-making is needed to limit time to care. The Swedish ambulance commander, responsible for the on-scene ambulance personnel, may lack education and experience from managing road tunnel incidents. Their competence is sometimes questioned by fellow emergency services commanders. Such marginalization may obscure the medical focus and give the ambulance commander a subservient role. The ambulance commander’s role and lack of knowledge need to be explored and addressed to potentially improve their competence in managing road tunnel incidents.

Aim: The overall aim of this thesis was to explore the possibilities of strengthening the decision-making ability of ambulance commanders to create more efficient rescue efforts in road tunnel incidents.

Methods: In studies I and II, interviews were conducted with ambulance commanders (n=18) in Norway and Sweden concerning their experience in managing real and simulated road tunnel incidents. In study III, interviews were conducted with participants (n=19) from organizations that collaborates with the Swedish ambulance services in road tunnel incidents, about their opinions on how the ambulance commanders can improve their incident management. In study IV, an e- learning course was created based on the findings of studies I–III. The course influence on the ambulance commander’s ability to make decisions in road tunnel incidents was tested through an intervention study (n=20) which contained two simulations of major road tunnel incidents.

Results: In study I, the requirement of familiarity with the tunnel system and involved organizations tasks were highlighted as important for the Norwegian ambulance commanders in their leadership role. In study II, the Swedish ambulance commanders described their leadership role as greater than that at the incident site, e.g., caring for their colleagues and being proactive, although having limited time allocated for these tasks. Findings from study III highlighted the importance of risk management and a shared terminology when responding to road tunnel incidents to avoid time-consuming misunderstandings. In study IV, the main finding was that none of the participants entered the dual- tube road tunnel correctly at the early stage of an incident. Secondly, theiiie-learning course did not significantly impact the ambulance commanders decision-making capabilities.

Conclusion: The resilience of ambulance services to road tunnel incidents requires a knowledgeable and decisive ambulance commander. Inter- and intraorganizational obstacles limit the ambulance commander to become familiar with the tunnel environment, generating ambiguous decision-making. Tailored assessment methods and educational material may improve the ambulance commander situational awareness. Findings also indicate that the ambulance services command structure may be less than optimal in its current form. A senior ambulance commander, hierarchically equal to corresponding emergency services command structures, could possibly strengthen prehospital medical management in unfamiliar and complex settings such as the currently studied.

Bakgrund: Våra vägtunnlar blir alltmer komplexa vilket kan leda till fördröjning av räddningsinsatsen. Skickliga beslut behöver fattas för att minska tiden till vård. Sjukvårdsledaren, ansvarig för ambulanspersonalen på skadeplatsen, anses sakna utbildning och erfarenhet från att leda skadehändelser i vägtunnlar. Deras kompetens ifrågasätts ibland av befäl från samverkande blåljusorganisationer. Denna typ av marginalisering kan leda till att det medicinska fokuset hamnar i skymundan och att sjukvårdsledaren får en underställd roll. Sjukvårdsledarens roll och kunskapsbrist behöver utforskas och adresseras för att potentiellt stärka deras kompetens att leda skadehändelser i vägtunnlar.

Syfte: Det övergripande syftet med denna avhandling var att undersöka möjligheterna att stärka sjukvårdsledarnas förmåga att fatta beslut, för att skapa mer effektiva sjukvårdsinsatser vid skadehändelser i vägtunnlar.

Metod: I studie I och II genomfördes intervjuer med sjukvårdsledare (n=18) i Norge och Sverige avseende deras erfarenheter av att leda verkliga och simulerade skadehändelser i vägtunnlar. I studie III genomfördes intervjuer med deltagare (n=19) från organisationer som samverkar med den svenska ambulanssjukvården vid skadehändelser i vägtunnlar avseende deras uppfattning om vad sjukvårdsledaren behöver för att förbättra sitt sätt att leda. I studie IV utvecklades och testades en internetbaserad utbildning som baserats på fynden i studie I—III. Kursens påverkan på sjukvårdsledarens förmåga att fatta beslut vid skadehändelser i vägtunnlar testade genom en interventionsstudie (n=20) som innefattande två simuleringar av stora skadehändelser i vägtunnlar.

Resultat: I studie I framkom det att förtrogenhet med tunnelsystemet och samverkande organisationers uppgifter var viktigt för de norska sjukvårdsledarna i deras ledarroll. I studie II beskriver svenska sjukvårdsledare ledarrollen som något som är mer omfattande än att enbart leda arbetet på skadeplatsen, som exempelvis att bry sig om sina kollegor och arbeta förbyggande, trots att de fick begränsad tid avsatt för dessa uppgifter. Det huvudsakliga fyndet i studie IV var att ingen av deltagarna beslutade att gå in i tunnelsystemet (som har separata tunnelrör) på rätt sätt i det inledande skedet av en skadehändelse. Ett avvde sekundära fynden var att den internetbaserade utbildningen inte hade en signifikant påverkan på sjukvårdsledarens förmåga att fatta beslut.

Slutsats: Ambulanssjukvårdens motståndskraft mot skadehändelser i vägtunnlar kräver en kunnig och beslutskapabel sjukvårdsledare. Intra- och interorganisatoriska hinder begränsar sjukvårdsledarens möjlighet att bli förtrogen med tunnelmiljön vilket leder till ambivalens i beslutsfattandet. Utvärderingsmetoder och utbildningsmaterial som är skräddarsydda efter sjukvårdsledarens behov kan förbättra sjukvårdsledarens situationsförståelse. Fynden indikerar även att ambulanssjukvårdens ledningsstruktur kanske inte är helt optimal i dess nuvarande form. En mer senior sjukvårdsledare, hierarkiskt likställd med samverkande blåljusorganisationers ledningsstruktur kan möjligtvis stärka sjukvårdsledningen i den främmande och komplexa miljö som har studerats i denna avhandling.

Introduction: Leadership during major incidents has been described as challenging and dependent on the non-technical skills of leaders. The complex tunnel environment contributes to an even more challenging incident response. Hence, this study aims to identify elements of non-technical skills when leading collaborative road-tunnel incident responses.

Methods: The study was conducted using four focus group discussions with tactical leaders from the rescue services, emergency medical services, police, and collaborative organizations from the emergency dispatch center and road-traffic control center. The data was analyzed using a non-technical skills taxonomy.

Results: Twelve non-technical skill elements emerged. Abilities to gather, sort, and proactively share relevant information and dispatch the correct resources were described. Additionally, abilities to prioritize actions and cooperate to establish a shared operational picture were found. Abilities to adjust leadership to the tunnel environment and conditions and assess the severity of the incident to make decisions were also described.

Conclusion: When managing a road-tunnel incident response, tactical leaders utilizes a range of non-technical skills. The elements of these skills were found to be specific both to the tunnel environment and the collaborative nature of the response. Further studies into and development of these skills are needed to facilitate a timely response and minimize potential risks to personnel or evacuees in future tunnel incident responses.

Purpose: Major incidents in road tunnels remain a collaborative challenge for the emergency services (fire and rescue service, police and ambulance), emergency dispatch centres (EDCs) and infrastructure owners. The aim of this paper is to investigate how collaborative partners to the ambulance services perceive the rescue effort and to identify factors that may influence its efficiency.

Design/methodology/approach: Focus group and individual interviews were conducted with 19 participants who were infrastructure owners or had operational or tactical responsibilities with the emergency services or EDCs in two regions in Sweden with multiple road tunnels. The collected data were analysed using qualitative content analysis.

Findings: Three main categories described efficiency factors during and after an incident: (1) coordinating the initial information (using a shared terminology), (2) achieving situational awareness (identifying those persons in need) and (3) lessons (not) learnt (lack of joint tactical plans and exercises). The emerging theme was access, assess and evaluate.

Practical implications: The findings suggest that establishing national policies and collaborative forums might yield more efficiently managed rescue efforts in road tunnel incidents in Sweden and other countries with similar organisational structures.

Originality/value: This study offers new insights on interoperability during responses to complex underground incidents.

OBJECTIVES: Increased demands are placed on emergency services and their role and ability to act in incidents in challenging environments, for example, road tunnels. Collaboration between officers from emergency services (fire brigade, police and ambulance services) is important for an effective rescue effort. In Gothenburg, Sweden, a position as a senior ambulance officer (SAO) within the emergency medical services (EMS) has been introduced to support the regular force during major incidents. The aim of this paper was to explore the perceptions and experiences of the SAO's new management role in challenging incidents, such as those occurring in road tunnels.

DESIGN: A qualitative interview study.

SETTING: The study was carried out from February to June 2019 in Gothenburg, Sweden, which is a municipality with several road tunnels and a population of approximately 580 000 people. SAOs collaborate with the corresponding function within the police and fire brigade, both having senior officers at major incident sites.

PARTICIPANTS: Twelve SAOs.

METHODS: The study used semistructured interviews. The collected data were analysed using qualitative content analysis.

RESULTS: According to SAOs' experience, prehospital medical management included not only leadership, but also planning, training and indepth knowledge of, for example, tunnel environments. Furthermore, SAOs adopted an encouraging and teaching role for their colleagues. SAOs' responsibilities also included proactive planning together with the fire brigade and police, which was regarded as enhancing interorganisational collaboration. An overall theme emerged which the SAOs described as 'A new holistic approach to EMS leadership and management'.

CONCLUSIONS: The participants considered that the new SAO role not only seems to improve the prehospital medical management, but also makes the EMS command structure during challenging incidents symmetrical with the fire brigade and police command structure. The implementation of national guidelines is desirable and is requested by the SAOs.

Background: High demands are placed on the emergency medical services to handle rescue operations in challenging environments such as tunnels. In Oslo, Norway a specialised management function within the emergency medical services, the medical on-scene commander, in line with the command structure within the police and fire brigade, might support or take over command and control from the ambulance incident officer arriving as the first ambulance personnel on scene. The aim was to shed light on the emergency medical service experiences from real tunnel incidents described by the Oslo medical on-scene commanders.

Methods: Interviews were conducted with six of the seven medical on-scene commander in Oslo, Norway. Data were analysed using a qualitative content analysis.

Results: The overall theme was "A need for mutual understanding of a tunnel incident". The medical on-scene commander provided tactical support, using their special knowledge of risk objects and resources in the local area. They established operation plans with other emergency services (the police and fire brigade) in a structured and trustful way, thus creating a fluent and coordinated mission. Also, less time was spent arguing at the incident site. By socialising also outside ordinary working hours, a strong foundation of reliance was built between the different parties. A challenge in recent years has been the increasing ordinary workload, giving less opportunity for training and exchange of experiences between the three emergency services.

Conclusions: The enthusiastic pioneers within the three emergency services have created a sense of familiarity and trust. A specially trained medical on-scene commander at a tunnel incident is regarded to improve the medical management. To improve efficiency, this might be worth studying for other emergency medical services with similar conditions, i.e. tunnels in densely populated areas.