In this qualitative study, we interviewed 20 staff members of the road emergency and Red Crescent emergency stations. Of these, 14 (70%) had an associates’ degree, 5 (25%) had a bachelor's degree, and 1 (5%) had a master's degree. Nine of them (45%) had 10 to 14 years of road emergency experience. The same number had degrees in medical emergency or road crash rescue. The details of the level of education, work experience, and education of the study participants are given in Table 1.
Table 1: Interviewees’ characteristics by education, work experience and field of study
The analysis of 20 interviews resulted in the formation of 247 initial codes. Then, the same codes were merged and 167 final codes were obtained. From the juxtaposition of similar codes, 28 sub-categories were obtained, and the integration of the similar sub-categories resulted in nine main categories as follows:
2. Lack of preparedness of the emergency responders
3. Challenges of triage on the scene
4. Shortcomings, deficiencies and limitations
5. Management of special accidents and accidences caused by hazardous substances
6. Difficulties in dealing with victims
7. Lack of coordination
8. Lack of psychosocial support for the emergency responders
Cultural and social challenges
The details of the codes, subcategories, and themes are presented in Table 2.
1- Infrastructural problems
From the participants’ perspective, due to problems in infrastructure such as freeways, main and rural roads, telecommunication, as well as some unavoidable geographical and environmental constraints, traffic collision SM is problematic. Many of the roads are bi-directional, non-standard and narrow, that slowing down ambulances speed.
In freeway, there is no U turn, underpass or overpass. As a result, when crashes occur on opposite lanes, rescue teams have to travel a long distance. With the exception of some roads and freeways near the cities, other roads lack proper lighting, making it difficult to find the crash scene and rescue at night. The overcrowding and heavy traffic on the roads leading to the mega cities cause ambulances and emergency vehicles to get held up on their way.
On many roads, there are no signs indicating the distance to the cities. As a result, when accidents occur, those asking for rescue cannot provide the exact location of the accident to the emergency organization, causing them to be misled and delayed. Here are some examples of interviewees' statements in this regard:
"... There are points on the road that are blind spots, there is no phone service and the two-way radio doesn’t work". "... Our station is in an area that the two-way radio doesn't have much signaled..."."... In this ... there is nowhere to turn around. I have to go and ... turn around from… and come back ..." "... The road we took was two-way and very crowded, I could not overtake maybe for more than ten minutes ..." "... our roads, except the... road, none of them have lights ..."
2- Lack of preparedness of the emergency responders
Some emergency staff, especially in the Red Crescent, does not have relevant education. Knowledge and skills of these staff are also not continually evaluated, and naturally, the training programs that are designed are not based on their basic needs. In some cases, such courses are not generally held. The interviewed staff said:
"... We have not studied emergency. We are volunteers ..." "... our training is not practical at all, and it is just theoretical. For example, they do not simulate our training, for example what to do with such a situation you face ..." "... during the time I have been a paramedic, no one has taken a test from us ..."
3. Challenges of triage at the RTAs scene
One of the most important measures that must be taken on traffic collision scenes, especially when there are a large number of casualties, is triage. But according to the participants, many emergency staff lacks the skills and expertise to do so. On the other hand, the injured and those around them also do not allow prioritizing the injured and, on the contrary, the noisy ones get more attention. Comments from some participants include:
"... We have been taught triage in our courses, but they have not allowed us ..." "... Once I wanted to prioritize the injured, but it didn’t end well and I was about to get beat ..." "... I haven't done any triage so far ..."
4. Deficiencies, shortcomings and limitation
The emergency staff attributes that an important part of their daily challenges related to lack of supplies, equipment, and amenities. They stated that their medicines were limited or had no medications, ambulances were not equipped and had difficulty in transporting of the injured. Even in some cases there is a shortage of ambulances. Inside the ambulance, there are no fire and ventilation facilities and no emergency equipment.
Some ambulances are old and have repeatedly broken down during operations and are in need of assistance themselves. There are no fire stations on the roads, and if there is a fire, we should use city fire stations, which is also a problem. The stations are in short supply, and sometimes have to be on duty two days in a row. The interviewees had detailed discussions, some of which included:
"... The ambulance is not standard ..." "... These ambulances are such that the patients feel sick in them and their height is so much that their back is..." "... In this ambulance, we have no rescue equipment. There is a small capsule for ourselves ..." "Our ambulances are outdated and out of order ..." "... we don't even have the primary medicines ..." "... The ambulance doesn’t work every other day, and makes us look so bad…”
5. Management of special accidents and accidents caused by hazardous substances
Vehicles carrying smuggling loads are usually speeding and when they perceive they are being followed, they perform dangerous actions causing many accidents. They may cause problems for the emergency team while receiving help. Sometimes the loads of these cars are dangerous and require special management.
On the roads and freeways, hundreds tons of fuel and hazardous chemical materials are shipped daily, their accidents can be very dangerous. The management of such accidents is tremendously difficult and should be handled with extreme caution. Another problem with the SM of such accidents is the clearing of the scene from these substances. These are extremely dangerous and can cause secondary accidents due to slippery road condition in addition to irreparable damages to the environment. Some of the interviewees' statements in this regard are:
"... this is a smuggling route ..." "... the one who smuggles acid, for example, does not say that my load is acid or oil ..." "... he never gives the right information and our job is like is like someone who is driving in the dark with his eyes closed..." "... they tell the operator that it is like the previous one, but then we go and see the car has been smuggling hazardous substances and has had an accident, and the driver has lied that he has had a heart attack, we ask why did you lie, he says otherwise you wouldn’t have come ...”. “…the cargo is dangerous and when we burn and die it will be discovered…”
6. Difficulties in communicating with accident victims
People who are involved in a traffic collision or passersby seek help from an emergency organization as soon as they encounter the scene. Timely asking for help and with the right information can help emergency services in timely response. However, there is still no single number in the country for asking emergency services and every organization has its own number so the caller is confused as to what number to call. Some emergency organizations are focused on responding to their own calls that are centralized in the province.
Provincial operators are not fully familiar with the details of the addresses and cannot quickly locate and report to emergency services. Those asking for rescue often give incomplete information and quickly disconnect. Lack of information can delay arrival to the scene and even provision of rescue advice. Interviewees argue:
"... People who call to report an accident are often passersby and don't know the exact address or sometimes there is a similarity between the names of two places which are completely different in route ..." "... One of the most important reasons for delayed arrival of the force to the scene is giving incorrect, incomplete or even unreal addresses to the operator ..."
7- Lack of coordination
Traffic collision SM is a team work, and many organizations are involved in them. The greater the number of organizations and individuals involved, the harder they are to coordinate. Interviewees stated that they had many problems in this regard. In their view, the task of clearing the scene is not specified and as a result, the scenes are usually not cleared. There is no rule on how to manage the scene.
The organization in charge of fatalities is not specified, and sometimes it is observed that bodies remain on the scene for hours. No one is responsible for keeping their valuable belongings until the police arrive. There is no center to coordinate and guide the operation. Organizations enter the scene without coordination and take action. This will cause some actions to be repeated and some necessary activities not to be performed at all. Although the commander is the police, they do not arrive on time and cause many problems upon arrival, including that they insist to transfer the injured without triage and providing first aid. They also do not fulfill their primary task of securing the scene and establishing security. Electricity, fire and road departments operate very slowly and uncoordinated.
The hospital staff treats the Red Crescent staff very harshly and do not deliver their consumables. In some cases, the emergency department does not inform the hospital. In recent years, the use of air emergencies has also been made possible, but coordination between these two emergencies is usually difficult. Coordination is a problem when there is a need for more than one station or more than one city. In this regard, interviewees stated:
"... based on our principles, we don't take any dead bodies at all, but people ask us to take care of the person who does not have any vital signs and transfer him to the hospital more quickly… ". "….even once a police officer came to me and said if a riot occurs, you are the one responsible for it, so come on take him to the hospital quickly...". "...the police have repeatedly insulted us and our colleagues ..." "... A colleague of mine had transferred a body out of humanity and respect, and then his son came to claim that he has had a gold denture but it was stolen ..." "... in recent years, they make staged accidents to claim for car insurance money ...".
8. Lack of mental and physical security for paramedics
Traffic collision scenes are always hectic and dangerous for everyone present there and emergency staff are no exception. Numerous hazards always threaten them. The likelihood of transmission of contagious diseases, explosions, occurrence of secondary collisions, aggression and beatings by spectators and companions, exposure to the injured from hazardous substances, etc. are events that may affect paramedics at any time. Seeing injured children, severed limbs, crushed limbs, and so forth are not pleasant scenes for any human being and will certainly affect the minds and souls of anyone who has seen them for days and weeks. Emergency staff faces these scenes every day.
On the one hand, they see these scenes, on the other hand they have to act rationally, scientifically and professionally, and this is a contradiction that always bothers them. As a human being, they are always influenced by these scenes and in the long run, these things will definitely irritate them. Some of the interviewees' statements in this regard are as follows:
"... sometimes the injured is drunk and he is not feeling well. He may start a fight..." "... One of our own safety concerns is exposure to injuries and the likelihood of disease transmission..." "... Our work is very stressful such that most of our colleagues have hypertension due to stress ..." "... due to occupational stress and difficult working conditions we often have hypertension and problems with our lumbar spine..."."... Sometime after my corneal transplant, I was attacked by a relative of an injured in an operation and my eye was injured ..."
9- Cultural and social problems
The cultural and social characteristics of people involved in traffic collisions were among the challenges that were recurrently mentioned in the interviews. One of the challenges is the companions' insistence on the immediate transfer of the injured to hospital and the companions' entry into the ambulance. Many people are unaware of the rescue process, which can cause them both to lose time and to complain about not receiving timely service, and in some cases, they behave with aggression toward the employees for a variety of reasons. About the loads, especially if it is among the socially prohibited loads, usually the right information is not given and this can endanger the health of paramedics.
In the Iranian culture, many people are interested in stopping and watching the scene closely. This causes congestion at the scene and, while causing secondary accidents, also impedes rescue. Some of these spectators intervene in the process and, in some cases, assist with the movement of the injured and relocating the victims, which makes the situation worse and more severe. Some of these viewers, even though the situation is dangerous, do not follow the initial precautions. Some drivers do not give way to ambulances on the roads and delay the arrival of ambulances. There are also obstacles to the assessment of injuries by paramedics (all paramedics are male). Some of the interviewees’ statements are as follows:
"... Unfortunately, people do not have the necessary knowledge, but because they want to help, they sometimes cause more harm ..." "... that they will not give way ..." "... companions of the injured may even attack the station ..." "... they say just come on take him. They have often come and taken the stretcher from us and put it in the ambulance. Some of them provoking…" "... As we arrive at the scene, the insured's relatives insist on transferring him to the hospital as soon as possible, not allowing us to provide first aid and thinking these actions on the scene are a waste of time ..."