Post-crash management of road traffic injury victims in Iran. Stakeholders' views on current barriers and potential facilitators

Focus was placed on PCM for road traffic injuries that occurred in West Azarbaijan Province (WAP) and Tehran; both local and national stakeholders were interviewed. The province covers an area of 37,411 km², and the population density is 77 inhabitants/km². In 2005, the total number of fatal road traffic injuries reached 1,018, i.e., 34 per 100,000 of the population [19].

In Iran, Emergency Medical Services, the police and the fire brigades can all function as emergency services and take care of victim management when road traffic crashes occur. People can contact them by dialling the three-digit numbers 115, 110 and 125, respectively. Additional potential actors include different ambulance services and the Red Crescent, whose activities are primarily focused on rendering relief to the victims of natural and man-made disasters in general [36] but who can become involved in multiple crashes and road-victim management. Further, as mentioned earlier, members form public, who are usually present at crash scenes, can also help victims and transport them to hospital.

Stakeholders of varying experience and knowledge, representing different perspectives on PCM, were approached for interviews. A few victims were also interviewed because of the unique perspective they could add on what takes place at the crash scene. The number of participants was determined based on saturation principles [34]. From thirty-eight approached participants, thirty-six agreed to be interviewed, including seven members of the Emergency Medical Services (abbreviated as EMS) – physicians, nurses, and technicians -, six police officers (PO), two members of Red Crescent (RC), one firefighter (FF), five public health professionals (PH), two experts members from the Ministry of Road (RT), four experts from Road & Transportation Office (RT), two motorcyclists (MC), two car drivers (CD), and five road traffic injury victims (VI). EMS members and public health professionals had academic knowledge and experience of victim management with regard to training and re-training in their field. Red Crescent members, firefighters and police officers also had experience and training in the field of RTI victim management. Their age range was between 20 and 65, with education level ranging from nine-year intermediate school to professional education in the field of medicine.

Data were gathered through semi-structured interviews beginning with general questions, gradually progressing to more specific ones. Probing was performed according to the reflections of each participant, concerning prior experiences of the post-crash event; perception about barriers to PCM; opinions about facilitators of effective PCM; opinions relating to the role of laypeople at crash scenes; opinions about the organization and coordination of PCM. The interviews lasted between 45 and 80 minutes. They were conducted between March and December 2007.

Finding and contacting eligible participants was made easier by the fact that the principal investigator had experience in the domain, having worked with the management of road traffic injury victims. The interviews were conducted in Persian, transcribed verbatim and summarized in English, and two interviews had read by a researcher who was not a Persian speaker. The rest of the researchers were fluent in both Persian and English.

The interview transcriptions were compared with the recorded digital files for accuracy. The data gathered were analyzed following the principals put forward by Strauss and Corbin [34, 35], i.e., data collection and data analysis took place simultaneously in order to identify ideas, which then guided the next interview. For that purpose, the principal investigator carefully read the whole text to get an impression and obtain an overall understanding of each interview. During the open coding phase, all the interviews were read several times, and key words or phrases, incidents and facts in the text were noted. During this phase, primary codes were extracted. The codes and data were compared for similarities and differences, and then categories and sub-categories were developed. From the first interview, a preliminary set of codes, categories and sub-categories was created and approved by the co-authors and research group. For the first four interviews, the principal investigator came back to the participants and checked the transcription (member check) and the summary of understanding of the interview. Selection of the participants was guided by theoretical sampling method. This process was continued until saturation of each concept was reached and further data collection failed to contribute new information. Accordingly, during interviews, any identified concepts were discussed until saturation. Data saturation supported the sample size. After axial coding, and at the end of the selective coding phase, a core variable was identified.

The study was approved by the National Ethics Committee of Iran [37]. Interviewees were informed that their participation was confidential, anonymous, and voluntary. Information explaining the aim of the study was provided orally and in writing. The interviewees then signed an informed consent form or verbally consented to participate in the study, which included both being interviewed and recorded.

One of the most common issues raised in relation to PCM was the interaction of untrained laypeople and their lack of knowledge and skills in handling the situation in general; and the victims in particular. According to the World Health Organization (WHO) [39], the role of laypeople who are present at a crash scene should be: to contact the emergency services; help to put out fires; and take action to secure the crash scene (e.g. preventing further crashes, preventing harm to rescuers and bystanders, controlling the crowd of onlookers, and applying first aid). It seems that some – but not all – of these WHO recommendations are not fully followed in the study area. More specifically, laypeople extricate – or try to extricate – victims instead of taking action to secure the scene. This might be related in part to the sense of haste and urgency that they also have reported, but also to the late arrival of the emergency services at the scene, which has an adverse effect on the management of the crash scene.

This, in turn, calls for better public information concerning what should preferably be done by laypeople at the crash scene (including calling the emergency service, and not moving any victims unless trained in doing so). Such information should also point out the important role that trained laypeople can play when, among other things, applying first aid e.g., checking the victims' airways, bleeding and circulation [40], and being involved in the scene management. Public education should also emphasize the issue of the emotional behaviour of laypeople and how this can impede the work of ambulance team members, which would be important to address in a public education campaign.

An additional educational aspect to be dealt with is the training of target groups. Indeed, studies from low-and middle-income countries indicate that basic first-aid training for professional drivers (taxi, bus or truck drivers) could help improve PCM, as they can often provide care and transportation [12, 41, 42]. This could even apply to the combination of formal training of both paramedics, and basic training for laypeople, and the provision of some basic supplies and equipment which could decrease the mortality rate to an even greater extent [43].

According to Nathens et al. [44], the trauma system of a given region or country represents a local solution to a complex organizational problem involving the coordination of resources and services provided by many actors and is largely dependent on tradition rather than outcome-driven data. Pre-hospital services (i.e. extrication of trapped casualties in road traffic crashes and their transportation) require coordination of rescue activities by different organizations and groups. Without it, extrication becomes slow, frustrating, and may be dangerous for both victims and rescuers[6]. Lack of coordination as a major barrier to effective PCM has also been raised in earlier studies in case of disaster [45, 46]. Bazzoli [2] poses that the most important strategies to counteract this problem include broad-based participation of key stakeholders and changes in trauma delivery. Although various parameters can come into play [42], the study participants mainly referred to difficulties in coordination rather than in equipment, staffing and physical resources.

The vast majority of road traffic deaths in low-and middle-income countries [39, 47] and in Iran [17, 48] occur in the pre-hospital phase. It has been hypothesized that the reduction in the proportion killed of all those who are involved in road traffic injuries is, at least in part, attributable to an improved provision of emergency medical services[7]. As proposed elsewhere, comprehensive trauma systems [49] should be widely put into place and, according to Zargar et al. [50], they are a must in Iran.

Although rapid improvements in pre-hospital care services have occurred in the country [21], it seems that their administration needs further improvement. Moreover, a holistic approach to the trauma system as a whole might be required. It ought to be underlined that, in rural areas, most of pre-hospital service problems originate from a lack of ambulance dispatch sites and equipment which leads to late arrival of the ambulances, a result that is in line with findings from Mock et al. [42, 49].

This interview-based study gathers the opinions of various actors relating to the barriers to and possible facilitators of effective PCM in the Iranian context. As such, it is one of the few studies adopting a qualitative approach to highlight ways of improving the current situation. The results point to a number of crucial areas in need of improvement, and for which some strategies have been proposed.

As is the case in qualitative studies, the number of participants was relatively small, but all stakeholders were experienced and knowledgeable and saturation was reached. The data was even validated using constant comparison analysis, which means returning to the data in order to verify and develop the categories further. In this vein, the input from previous victims can be regarded as an important contribution – and an originality of the study.

Because of our design, the generalizability of these data is not self-evident. It would definitely be of interest, however, to see the extent to which future research in the same field, but from other parts of the country, yielded similar result.