title: A retrospective observational study of medical incident command and decision-making in the 2011 Oslo bombing.
abstract: BACKGROUND
  A core task for commanders in charge of an emergency response operation is to make decisions. The purposes of the study were to describe what critical decisions the ambulance commander and the medical commander make in a mass casualty incident response and to explore what the underlying conditions affecting decision-making are. The study was conducted in the context of the 2011 government district terrorist bombing in Norway.
  
  
  METHODS
  The study was a retrospective, descriptive observational study collecting data through participating observation, semi-structured interviews, and recordings of emergency medical services' radio communications. Analysis was conducted using systematic text condensation. The ambulance commander was interviewed using the critical decision method.
  
  
  RESULTS
  The medical emergency response lasted 6.5 h, with little clinical activity after 2 h. Most critical decisions were made within the first 30 min, with the ambulance commander making the bulk of decisions. Situation assessment and underlying uncertainties strongly affected decision-making, but there was a mutual interaction between these three factors that developed throughout the different stages of the operation. Knowledge and experience were major determinants of how easily commanders picked up sensory cues and translated them into situation assessments. The number and magnitude of uncertainties were largest in the development stage, after most of the critical decisions had been made.
  
  
  CONCLUSIONS
  In the studied mass casualty incident, the commanders made most critical decisions in the early stages of the emergency response when resources did not meet demand. Decisions were made under significant uncertainty and time pressure. Ambulance and medical commanders should be prepared to make situation assessments and decisions early and be ready to adjust as uncertainties are reduced.
authors: Department of Research and Development, Norwegian Air Ambulance Foundation, Holterveien 24, 1448 Drøbak, Norway ; Medicine, Health and Development, Oslo University Hospital, Kirkeveien 166, 0424 Oslo, Nydalen Norway ; Department of Industrial Economics, Risk Management and Planning, University of Stavanger, Kjell Arholms gate 41, 4036 Stavanger, Norway.
authors: Rune
authors: R
authors: Rimstad
authors: Department of Research and Development, Norwegian Air Ambulance Foundation, Holterveien 24, 1448 Drøbak, Norway ; Faculty of Social Sciences, University of Stavanger, Kjell Arholms gate 41, 4036 Stavanger, Norway ; Air Ambulance Department, Oslo University Hospital, Kirkeveien 166, 0424 Oslo, Nydalen Norway.
authors: Stephen Jm
authors: SJ
authors: Sollid
keywords: Decision-making; Emergency medical services; Emergency medicine; Leadership; Mass casualty incidents; Observational study; Risk management