Four FGDs and five interviews were held with 26 participants. Eighteen of them were EMS paramedics and eight were officials. Seven of the participants were women and 19 were men. All of them had either participated directly in providing services to the injured people in the early hours after the earthquakes or had been involved in managing the response. Table 1 presents their profile.
Table 1
The demographic characteristics of the study participants
|
Title
|
Number
|
Percentage
|
Education
|
General physician
|
5
|
19.23
|
Master
|
4
|
15.38
|
Bachelor
|
11
|
42.31
|
Associate Degree
|
6
|
23.08
|
Total
|
26
|
100
|
Work Experience
|
More than 25 years
|
4
|
15.38
|
20−24 years
|
6
|
23.08
|
15−19 years
|
5
|
19.23
|
10−14 years
|
4
|
15.38
|
5−9 years
|
3
|
11.54
|
Less than 5 years
|
4
|
15.38
|
Total
|
26
|
100
|
Workplace
|
Emergency Department
|
11
|
42.31
|
City EMS headquarters
|
5
|
19.23
|
EMS headquarters of the province
|
10
|
38.48
|
Total
|
26
|
100
|
After the earthquakes, EMS started its response operation at two levels, including the district (local) and the provincial level. The paramedics who were present at the local EMS posts in the earthquake-affected area had gone to the nearest villages from the very first moments after the turmoil along with other people and began to gather the injured in certain points, prioritize them and provide basic medical services to them; then, using ambulances, they began transferring the injured to Ahar, Haris and Varzaghan hospitals. At the local level, since the earthquake occurred in the afternoon and the buildings were closed and since the cities themselves were not badly damaged, the paramedics first ensured the family's health and then deployed them locally (mostly to relatives' homes) and immediately went to their departments and started the response operation.
In the provincial department, almost all the officers had set up their families in a safe place after learning of the earthquake and had come back to their workplace within the first minutes. They had then begun getting information from places hit by the earthquakes. After getting the initial information, three rapid assessment teams were deployed to the affected areas. Afterwards, the officers began calling on other coworkers from the provincial towns, and after about two hours, ambulances deployed to the affected zones. As the earthquake-affected cities were in the neighboring province of Ardabil, ambulances were immediately sent from this province to the city of Ahar for relief. More ambulances were sent from West Azerbaijan Province. Despite these efforts, most of the injured had reached the hospitals by their own personal cars, which were mostly unsuitable for carrying an injured. Overall, more than 3000 earthquake victims were transferred to hospitals in the region. The initial response was almost completed around 2:00 AM (approximately eight hours after the first shakes).
After the analysis of the FGDs and interviews and their encoding, the codes were finally extracted by eliminating the repetitive codes and merging the similar items. The similar codes were placed into subcategories, yielding 32 subcategories. The similar subcategories were also merged to form the top ten categories, including:
The challenge of dead bodies management
Lack of psychosocial support for the EMS responders
Deficiencies and the lack of facilities, equipment, supplies and ambulances
Difficulty of access to damaged rural areas
Relief volunteer management
Lack of documentation of experiences
The challenges of communicating with the earthquake-affected areas and between teams
Recalling and deploying EMS responders
Table 2 presents the details of the codes, subcategories and categories.
Table 2
The categories and sub-categories extracted from the interviews and FGDs
Code
|
Subcategory
|
Category
|
Code
|
Subcategory
|
Category
|
Code
|
Subcategory
|
Category
|
Unable to identify the deceased people
|
Identification problems
|
The challenge of dead body management
|
Workers' concerns about their families
|
Lack of attention to the safety and security of the personnel’s family
|
Psychosocial support for the responders
|
Unfamiliarity of the paramedics with the basics of triage
|
Lack of EMS paramedics’ and officers’ individual preparedness
|
Lack of preparedness
|
Failure to effectively deal with the dead bodies
|
The importance of family status
|
Inadequate training of the paramedics and the lack of necessary skills
|
Failure to properly define the mission for the deceased
|
Not having a developed program
|
Authorities’ failure to support the responder' families
|
Lack of paramedics’ readiness to provide services in disaster situations
|
Carrying corpses instead of injured people with ambulances
|
Psychological disorders developing in the personnel
|
Lack of mental support
|
Personnel’s lack of familiarity with earthquake signs
|
Not properly equipping the responders
|
Lack of equipment
|
Lack of facilities, equipment, supplies and ambulances
|
Employees’ fatigue because of large volumes of work
|
Lack of familiarity about how to respond to an earthquake
|
Lack of equipment in the early hours
|
Failure to deal with personnel problems after the disasters
|
Lack of prior organization
|
Lack of organizational preparedness
|
Equipment disproportionate to geographic area
|
Lack of personal security
|
Low attention to the safety and security of the responders
|
Lack of accurate planning to cover the costs of the crisis
|
Lack of basic relief supplies
|
Fear of showing up on the field and its impact on decision-making
|
Lack of readiness to confront the disasters
|
Failure to supply appropriate medications
|
Lack of supplies
|
Failure to supply water and food to the responders
|
Lack of support
|
Lack of triage tags
|
The difficulty of making decisions in the early moments
|
The difficulty of decision-making in emergency situations
|
Failure to perform specialized exercises (between organizations and between relief agencies)
|
Shortage of first-aid means
|
Simultaneously treating several patients
|
Lack of a disaster management room in EMS
|
Small number of ambulances in the early hours
|
Lack or inappropriate ambulances
|
Lack of access due to the severe destruction of the villages
|
Closure of rural roads and alleys
|
Lack of access to villages and damaged areas
|
The ordinary people disrupting the first responders
|
Lack of community preparedness
|
The number of ambulances being disproportionate to the mission volume in the first hours
|
The entrance of villages being obstructed
|
Ambulances being disproportionate to the region
|
Lack of access to the areas in the early hours
|
Lack of familiarity of the residents with relief issues
|
Ambulances not appropriate for disaster situations
|
Poorly-constructed regional roads
|
Poorly-constructed rural roads
|
The local people’s inability to perform proper triage
|
Lack of advanced facilities and ambulances
|
Geographical conditions
|
The impossibility of landing helicopters
|
Damage to the roads and bridges
|
Destruction of communication routes
|
The people’s inability to perform medical first aids
|
Inviting people to help the responders
|
Community relief
|
Managing Volunteers and People's Aid
|
Road traffic
|
Misalignment in missions by ambulances
|
Lack of inter-sectional coordination
|
Lack of coordination
|
People transferring the patients to health centers
|
Road closure
|
Community members rescuing and prioritizing the injured
|
Failure to transfer experiences to other relief forces
|
No lessons learnt from the past
|
No lessons learnt from the past
|
Inconsistencies between pre-hospital and hospital emergencies
|
People dominating the management of the scene
|
No lessons learnt from the past
|
Uncoordinated forces’ decisions
|
The abundance of popular and organizational gifts
|
Community donations
|
Suspension of measures after the change of management
|
Uncoordinated management of ambulances
|
The existence of spontaneous help from the people
|
Failure to improve post-earthquake affairs
|
Not learning from this earthquake
|
Lack of full access to all the facilities available at the local level
|
People’s insistence on receiving services themselves
|
Challenges of people’s presence on the scene
|
Failure to act on the experiences of the Ahar-Haris incident
|
Non-therapeutic intervention in treatment
|
Lack of intra-sectional coordination
|
The influx of people and residents into health and service centers
|
Not taking advantage of past experiences
|
Lack of document actions
|
|
Unfamiliarity of the organizations involved in responding with each other’s tasks
|
Involvement of ordinary people in therapeutic measures and triage
|
Failure to record the response experience
|
Lack of coordination between the organizations
|
The gathering of people and residents in health centers
|
|
|
Lack of coordination in supplying staffing needs
|
Calling on all the ready forces
|
|
Recall and management of volunteers
|
Disconnection from all sources of communication in the early hours
|
Communication interruptions
|
The challenge of communicating with earthquake-affected areas and between teams
|
Relief turmoil in the affected villages
|
Lack of unity of commands
|
Quickly sending donations from other provinces
|
Satellite phones not operating
|
Lack of access to the authorities
|
Deployment of forces from different routes
|
Calling on and dispatch of forces
|
Unaccountability of the officials
|
Rapid deployment of responders from Tabriz center
|
Difficulty of communication with the rescue teams
|
Lack of communication equipment
|
Not offering a definition of responsibility to the forces
|
Cooperation and readiness of other provinces
|
Lack of communication equipment
|
Lack of time management for helping in the early hours
|
The arrival of auxiliary forces from neighboring cities
|
Lack of private communication systems
|
Poor allocation of paramedics to the areas
|
High sense of responsibility among the personnel
|
High motivation to provide services
|
Lack of communication equipment in ambulances
|
Collecting earthquake information by visiting the site
|
Failure to perform a quick assessment in the first hours
|
Rapid arrival of equipment and assistance from Tehran
|
Lack of physical facilities for communication
|
Dispersed information in the first minutes of the incident
|
Fast delivery of equipment
|
Lack of access to SMS
|
Results from communication problems
|
Failure to perform an early initial needs assessment
|
1- Lack Of Ems Preparedness
The lack of preparedness in the EMS paramedics and officers was one of the main issues discussed by most interviewees. The lack of preparedness was reported at different levels and has been divided into three sub-categories: The lack of paramedics’ and officer's preparedness, the lack of EMS organizations’ preparedness and the lack of community preparedness. Examples of participants' statements are given below:
... We did not know that there was an earthquake; we were afraid, but did not know what to do ...” “... We have been trained to provide services in the case of road accidents and emergency situations such as heart attacks. We did not know what to do there …” “… We never had a maneuver that covered such a situation …” “… People didn’t know what triage was. They didn’t know how to help us. They put a lot of pressure on us …
2- The Lack Of Coordination
The most frequently discussed issue by the interviewees was the lack of coordination, which entailed internal (EMS) and external (between the different relief organizations) levels. The lack of internal coordination refers to coordination in missions, dispatches and organizing of responders and equipment, and the lack of external or intersectional coordination mainly means the inconsistency of different organizations with each other in providing services.
There were numerous challenges in managing and organizing relief affairs in the affected areas. Rapid assessment was not carried out in the early hours of the incident, and more pressure was put on EMS organizations that revealed their managers’ weakness in the allocation of equipment and human resources.
... We became involved with the police and the police hit our colleagues. They insisted that we should take the corps with us …” “… We didn’t know where to go; the division was poor, and everyone gave a command. He said you were going to the village of Varzaghan, or you go to the villages around Tabriz, and so on” “… Another problem was protection…” “…The university had good facilities; we couldn’t serve them all though …” “The security forces contacted our colleagues; unfortunately, they think we are under their control and should listen to whatever they say …” “… The school watchman resisted opening the school …” “… In that village, there were a few injuries, but the number of ambulances was higher …
3- The Challenge Of Dead Bodies Management
Another challenge noted by the interviewees was the challenge of managing the dead bodies; that is, the inability to identify, organize and transport the deceased bodies.
“… Some of the corpses were not recognizable …” “I saw an ambulance bring a corpse ...” “... We didn’t know what to do with the bodies, and people also pressured us ...” “… Where should we put them? ...”.
4- Psychosocial Support For The Ems Responders
From the viewpoint of the interviewees, the lack of mental support for the EMS personnel, the lack of attention to the safety and security of them and their families, the lack of proper water and food supply and the presence of fear and unrest in emergency situations affect correct decision-making and deployment of responders and put the personnel in unfavorable conditions.
... I gave everything to my nephew and carried my car to Varzaghan ...” “... I was able to call my family, who said they were good and safe ...” “... We were worried about our own families ...” “They said all the troops have gone to their own families’ rescue ...” “... Everyone received tents and the basic necessities except our own families ...” “... After the earthquake, nobody came to us to see how we were finally doing …” “... We are always neglected by the staff…
5- Deficiencies and the lack of facilities, equipment, supplies and ambulances
The most common problems noted by the participants included the lack of equipment, especially in the early hours after the incident, the lack of supplies and treatment facilities, the failure to supply appropriate medications to the injured and inappropriate or lack of ambulances and the lack of proper and balanced allocation of equipment to the earthquake-affected areas.
“… There was an ambulance and we brought eight patients on it …” “… Our ambulances are Sprinter and not suitable for our area …” “… The equipment is very important. We have many shortcomings…” “… We are not equipped with clothes…” “… We didn’t have tags for the triage”.
6- The Challenge Of Access To Villages And Damaged Areas
Access to villages was very difficult, and the rural texture of the earthquake-affected areas (narrow streets and rural roads) also exacerbated this problem. Some road bridges were either destroyed or completely unreliable. Some roads could not be crossed due to the collapse of the mountains or because they were subsiding. In the first moments, heavy traffic was created on the roads that delayed the response.
... We went there and I saw that both the entrance and the exit were destroyed. We had to keep on the bridge ...” “... There was about 30 centimeters subsidence in the direction of the road ...” “... Our second problem was the traffic; after the announcement of the earthquake in these three areas, the road was actually blocked ...” “… On the Khaje-Haris path, the mountain had collapsed …
7- Relief Volunteer And Donation Management
The participants discussed the role of volunteers in the process of providing relief to the injured and public and organizational donations. They also discussed the problems and challenges of people’s presence in the regions, which mainly included people’s pressures to receive services, invasions of and gatherings in health centers and interferences in the provision of health care.
… Several trucks brought in patients …” “… I think about 10% of the injured were brought in by EMS personnel and the rest by the locals. People themselves took over the situation and did everything by themselves …” “… People insisted that we take their patients and did not let us do triage …” “… They disturbed our efforts for triage as soon as they saw us in our uniforms …” “People came and went to help the injured trapped beneath the rubble …
8- The Lack Of Documentation Of Experiences
Almost all the EMS responders had not recorded their experiences, including the actions taken, the existing problems and challenges, potential solutions and the strengths and weaknesses of each decision and action. This lack of documentation impedes the transfer of experience to other responders and is not conducive to the improvement of weaknesses, the promotion of preparedness, the enhancement of skills and the strengthening of management in similar future situations.
“... We did not record our experiences and everything remained only in our minds; after we’re gone, there’ll be no trace of our experiences …” “… Whenever there’s an earthquake, I believe these problems will be repeated ...” “... We constantly talk about problems at our meetings, but that’s only talk …” “… The experiences have not been transmitted even then, even if they move, they cannot solve the problem, they must work on the thoughts of managers…”.
9- The challenges of communicating with the earthquake-affected areas and between teams
The participants noted communication problems, including the disconnection of communication systems in the early hours and the lack of communication equipment. According to the participants, it later became clear that communication problems had led to a lack of communication with the health centers and relief organizations. Other problems in this domain included the lack of public awareness, not knowing about the center of the earthquake during the early hours, and the lack of coordination between the organizations. There was a disorder in the provision of services as a result of these shortcomings.
“... Landlines and cellphones were completely cut off ...” “... We were not connected anywhere; our sites were mostly wireless. We did not have any other connections with the ambulance ...” “The satellite phone does not help much …” “... We couldn’t communicate with the hospitals and we didn’t know which hospitals would take in the patients ...” “... They couldn’t call us from the villages”.
10- Recalling And Deploying Ems Responders
The interviewees discussed some positive points in their statements, such as the good recall and dispatch of EMS paramedics and the rapid receipt of donations from other provinces and neighboring cities. The high motivation and sense of responsibility in the relief forces to provide services and the spontaneous hastening of the pre-hospital personnel to help the earthquake victims were constantly discussed by the participants of this study.
… All our colleagues came, because everyone felt responsible …” “… Several surgeons, anesthesiologists, physicians and nurses came …” “… Our colleagues from Ardabil and Meshkin Shahr had reached Ahar even earlier than ourselves…