The cost of health care services for injuries due to traffic accidents in some low- and middle-income countries has an economic volume corresponding to 5% of the gross domestic product. The “World Day of Remembrance for Road Traffic Victims”246 is commemorated on the third Sunday of November each year with the decision made in the meeting of the UN General Assembly in 2005 to draw attention to traffic accident victims.
All emergency, first-aid, and rescue-oriented interventions made during the process between the time the accident happened and the transfer to the hospital are evaluated within this scope. They vary by resource and methods as the humanitarian aid and interventions performed by citizens and the ones performed by police, fire department, AFAD staff, and medical first-aid staff.
According to the result of a research conducted by the World Health Organization the proper and appropriate health care services provided for injured persons in traffic accidents may reduce the deaths caused by traffic accidents by 25% in a low and middle income country. Again, according to research conducted by international organizations, less than half of the victims seriously injured in traffic accidents in around 40% of all countries around the world are transferred to the hospital and only 10% or less of the persons seriously injured in traffic accidents in one-fourth of the countries are transferred to the hospital by ambulance. No clear data is available on under what conditions the transfer of the remaining persons is performed to the hospital and which first-aid practice they are provided.247
According to a study published by the “Traffic Accident Victims European Federation” on the efforts to be made after a traffic accident, it is stated that it is necessary to perform legal studies on;248
after traffic accidents and it will not be possible to secure justice in case one of the four components is missing.
When examining as part of the safe system approach, it is set forth that the death of many people can be prevented with proper interventions to be performed within the period from the site of the accident to the transfer to the hospital.
Furthermore, first-aid intervention is of vital importance in terms of forming the first step of therapeutic health services. The post-accident health services are analysed in steps as;249
The work steps on the trauma treatment chain including the happening of the accident and the treatment process at the hospital determined by the World Health Organization
Figure: Trauma Treatment Chain
The effect of traffic accidents on society are;250 the social security expenses made for the injured, the rehabilitation and psychological support process across the process as well as the emergency care and trauma treatment, medications, prothesis, surgical instruments most of which are imported from abroad and used throughout the treatment process reaching exorbitant sums, and the traffic accidents causing additional costs along with the increase in the number of patients per doctors and health care professionals affecting performance.
The primary duty of the government is to ensure the public’s life and property safety Thus, governments provide or ensure the provision of emergency health services. The emergency response system is, in general, provided through 3 groups; the police, fire department, and ambulance. Each country structure this system in different forms and management levels. However, the common goal is to take quick action and reach the whole country.
In reports published by the World Health Organization, it is stated that most of the death caused by traffic accidents took place before the injured person reached to the hospital. The first aid and emergency response performed to the injured before the hospital, the care of the person until reaching the hospital and ensuring their timely transfer to a proper health care facility or trauma centre is important in terms of determining whether the person will stay alive or become permanently disabled.251
Traffic accident intervention processes:
The traffic accidents intervention processes consist of the following steps; obtaining all information on the accident through a proper communication after the accident, the performance of first response with proper methods by other victims or the persons witnessing the accident on site of the accident until the first aid units arrive, ensuring the fastest and proper arrival of the first aid units to the site of the accident, ensuring the arrival of these units with sufficient staff, tools, and equipment to the site of the accident, rescuing the injured stuck inside the vehicle, staying under other physical structures as a result of the accident, or be stuck under these structures and performing simultaneous emergency medical intervention by evaluating the conditions on site of the accident, ensuring the referral of the rescued victims to the closest health care organization with sufficient resources under medical support and intervention, performing necessary intervention in the emergency response department of the closest health care organization with sufficient resources, continuing the care and treatment of the injured made progress in terms of recovery after the emergency response in trauma units, and ensuring the participation of persons recovering, becoming disabled after the treatment, or losing their relatives in the accident in social life, economy, and society as part of the society by rehabilitating.
Chain of interventions in traffic accidents:
Loss of life in traffic accidents is a preventable outcome and it is a scientifically approved fact that a large part of the deaths happens in the process between the site of the accident the hospital.
It is considered that the health interventions to be performed on the victims consist of the following chain of interventions:252
The establishment of a traffic accident and injured monitoring system:
Analysing the traffic accidents and establishing systems of the monitoring of injured have several benefits. It is, therefore, considered suitable for the system to meet the following matters:253
and carrying out all of these in a coordinated and planned manner.
Traffic accidents don’t happen as a result of a sole factor, they occur as a result of the interaction between several factors. Thus, it is necessary to research the direct and indirect factors. Public health approach plays a key role in both the analysis and solution of traffic accidents.
The main risk factors affecting traffic accidents and their results can be discussed in four groups:
Strengthening the emergency response and first-aid services amongst the actions to be taken to reduce the fatal consequences of traffic accidents has great importance. The first-aid and emergency response system needs to be supported by the trauma, medical care, and treatment and rehabilitation states. The prehospital interventions performed on-site of the accident can be decisive in keeping the injured alive. It is possible to ensure that many injured get over traffic accidents with minor injuries in case the ambulatory rescue services are performed by a sufficient number of staff with proper training, tools, equipment, and medical supply.254
Advanced Life Support in Children (ÇİLYAD) courses are provided and the tools and equipment to be needed for children are kept available in ambulances. Amongst these materials are airway tubes, caps, blood pressure measurement equipment, etc. Besides, the staff assigned in ambulances are provided with training on how to intervene in children in coo emergency.
There are country examples on the effectiveness of providing information and training for the citizens residing in areas being away from accessing emergency service on the essentials of emergency medical intervention in saving lives. These trainings can be provided with the support from voluntary organizations such as Turkish Red Crescent.
It considered that the presence of emergency services with high capacity in road sections with high traffic density is effective in terms of saving lives in traffic accidents.
It is important to ensure that the ambulance vehicles are adapted for the equipment and have the quality to enable the transport the injured laid down and carry one of the relatives of the injured with them if any. The fast arrival of the ambulance on site of the accident and transferring the injured to the closes care unit as soon as possible is of vital importance to ensure the safety of life of the injured. However, the “Problem of Moving Fast” arises here and puts the life of ambulance workers on the line. The ambulance drivers must drive as fast as they can when receiving a report of an accident. The unit should remember that they should follow the speed limits and rules like red light under all circumstances and use the right of way only in case the other vehicles yield them so without risking anything.
Therefore, it is important to establish a traffic culture that is conducive for the ambulances to move in safety, arrange strip width pertinent to the movement of ambulances, equip the ambulance vehicles with sufficient safety measures, and make regulations that facilitate the passage of ambulances.
To keep someone or something out of harm’s way is called “Rescue”. The entire process of maintaining the health condition of the victim and transferring them to the hospital by ambulance to provide advanced medical support by providing treatment is called “Advanced Rescue”, and it is of vital importance to rescue the victims stuck between vehicle parts or other physical structure around road after the accidents, and the ones staying under the vehicle as a result of the vehicles in various position as a consequence of the accident without harm.
According to the Article 6 of the Municipal Fire Department Regulation put into practice being published in the Official Gazette dated 21.10.2006 and No. 26326, the duties to intervene in incidents requiring technical rescue in cases of “all kinds of accidents”, collapse, explosion, being stuck, etc. as well as fires and running the first-aid services such as conducting the search and rescue efforts in the field, above and underwater was allocated to the fire department.
Therefore, the presence of fire crew with proper tools and equipment to intervene in traffic accidents along with an ambulance and ensuring that they intervene in traffic accidents under optimal conditions is of vital importance in saving the injured in traffic accidents. The minimum number of vehicles was determined with the Article 42 of the regulation in line with the relevant TSI or EN standards and the presence of at least 1 emergency rescue vehicle was stipulated in areas with a population more than 10,000. The positioning of aforesaid rescue vehicles close to road sections with high accident prevalence and at the ready has vital importance in emergency response to traffic accidents.
All efforts made by the fire crews from the moment they leave the station to intervene in traffic accidents can be systematically grouped under seven titles:
The intervention of well-organized, well-trained staff with enough equipment in traffic accidents is crucial in saving lives. Therefore, all fire departments to perform the intervention with staff provided with the same standard and well-trained in traffic accidents is of great importance in terms of reducing the post-accident loss of lives.
the Disaster and Emergency Management Presidency (AFAD) is a versatile, multi-actor, work-oriented institution, observing the rational use of resources in this field, basing its activities on interdisciplinary effort in its activities, organized in a flexible and dynamic structure, ensuring coordination between all institutions and organizations in the country to plan, direct, support, coordinate, and effective implementation of activities to prevent disasters and minimize the damages, intervene in disasters, and rapidly complete the recovery efforts following the disasters.
Within this scope, a new disaster management model was adopted in Turkey and the priority was given to “Risk Management” from “Crisis Management” with this model introduced. This model, defined as the “Integrated Disaster Management System” today, projects the predetermination of threats and risks to prevent the harms caused by disasters and emergencies, taking the measures to prevent or minimize the damages to occur before the disaster, the provision of effective intervention and coordination, and conduct of recovery activities in integration after the disaster.
The AFAD carries out its activities through the Provincial Directorates of Disaster and Emergency directly affiliated to the Governorship and the Directorates of Disaster and Emergency Rescue Team in 11 provinces. According to the classification made by the Disaster and Emergency Management Presidency, the transport accidents are ranked amongst human-related disasters and transportation accidents amongst technological disasters,255 and it is of great importance to make efforts on traffic accidents in coordination.
According to Article 4 of the Emergency Health Services Regulation published in the Official Gazette dated 11.05.2000 and No. 24046, Emergency Service refers to the “emergency services existing within the structure of public institutions and organizations providing health care services and the inpatient treatment organizations built by private entities and natural entities”, and the Emergency Health Services to “all the health services provided in health care institutions and organizations in cases of emergency disease and injuries by units receiving special education on their field on the scene with medical tools and equipment, and during transfer”.
The transfer of victims injured as a result of a traffic accident to emergency care units with sufficient equipment and staff to receive treatment is extremely important. The emergency identification of the condition of injured on site of the accident, performing effective interventions in the ambulance and making necessary preparations in the emergency service to be transferred by informing them have priority to keep the victim of the traffic accident alive. The injured in traffic accidents are generally in a condition referred to as “Polytrauma” and better results are obtained in case the emergency response is performed in full-capacity emergency response centres specialized on such injuries.
The whole of services provided for persons in need of emergency medical treatment in hospitals and other health care institutions and organizations are defined as “Emergency Treatment”, and the units where emergency health services are provided within secondary and tertiary public and private health care institutions and organizations are defined as the hospital emergency services. These services and units must perform an emergency medical intervention on the patients and injured directly applying or brought by units affiliated to the head physician provincial ambulance service, keep records on the service provided, and provide feedback to the centre directly or through the institutions and organizations, they are affiliated to when necessary.
Traumatology is the discipline dealing with traumatic lesions such as injuries, fractures, burns, bruises, and dislocations and aims at restoring the old functions of the damaged and injured movement system elements (bones, joints) and saving the life of the injured person. On the other hand, traumatology involves issues such as upper extremity fractures, lower extremity fractures, pseudarthrosis and mals traumatology radiology, fractures requiring surgical treatment, vertebral fractures, pelvis fractures, acetabulum fractures, child fractures, and dislocations. Scientific studies express that around half of the cases transferred to emergency services due to injuries caused by head trauma are resulting from traffic accidents, and the most prevalent reason of an application for the patients hospitalized with head trauma is a traffic accident.
Trauma units are units where the treatment and interventions of children and adult patients having an accident or exposing to injuries are performed and are departments enabling the performance of small- and full-scale surgical interventions, and plaster and splinter practice of patients transferred by ambulance and walking the hospital by going through examination in the yellow zone. The trauma units are prepared in a way to meet all requirements such as oxygen, vacuum, aspiration to enable the performance of small-scale surgical interventions, equipped with developed medical devices, and including departments such as major trauma, resuscitation, decontamination, and plaster room.256 Health care professionals specialized in trauma work at trauma units.257
According to the Trauma and Resuscitation Course Book (TRC), it is considered to be appropriate to take measures in the following two fields for the post-accident stage:258
Figure: Important Factors in the Development of Policies on Protection Against Trauma
It is believed that increasing the number of Emergency and Traumatology Hospitals, if possible, to be able to intervene in patients applying the emergency services due to accidents and other reasons will reduce the loss of lives caused by traffic accidents.
It is incontrovertible that the traffic accidents have a serious impact on the individual and society based on the fact that they rank number eight amongst the causes of death across the world and number first amongst the causes of death of young population between the ages of 15-29. In this sense, when examining the effect of traffic accidents on the individual and society, one can see that they cause injuries, deaths, socio-economic losses affecting the national economy and welfare to a great extent, and several psychological and physiological disorders in the lives of victims and their relatives.
The organ damages the person is exposed to (fractures and traumatic brain damage-TBD as a result of head traumas, whiplash, spinal and rib cage injuries), the psychological damages the person is exposed to (Post-Traumatic Stress Disorder-PTSD), and the socio-economic losses are in the lead amongst the damages the traffic accidents bring to the person.
The traffic accidents that are listed amongst traumatic events cause the emergence of countless physical, psychological, and social effects. The person driving the vehicle shows indications of guilt, travel anxiety, and negative changes on themselves and their philosophy of life, especially in accidents resulting in death and serious injuries, and these changes may cause the detachment of the person from their social environment, occupation, and education.
Physical and mental disabilities can be observed depending on injuries after traffic accidents stated to be one of the traumatic events. Most of the persons surviving these injuries become physically disabled limiting their mobility and functioning. It is possible to prevent and minimize most of these outcomes through early and multi-disciplinary rehabilitation services. Many advice is given on performing first-aid and emergency response after the traffic accidents, the interventions to be performed on-site of the accident, during the transfer to hospital, in hospital emergency service or trauma units and polyclinic interventions, and the rehabilitation services to be provided during and after the treatment as part of the recommendations of the World Health Organizations and relevant institutions.
POST-CRASH RESPONSE, CARE AND REHABILITATION
STRATEGIC OBJECTIVE: Contributing to the Prevention of Deaths as a result of Traffic Accidents by Strengthening the Post-Crash Response, Care and Rehabilitation Methods
GUIDING STRATEGIES AND SUGGESTIONS