Intervention Areas / Post Accident
6.POST-ACCIDENT INTERVENTION, CARE, AND REHABILITATION
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
- Accident research,
- Forensic investigation
- Statutory damages,
- and victim rights
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 aids and intervention performed by the injured or the other persons around them,
- the transmission of accident information to the emergency response system,
- the health care service provided by the first-aid health care staff on-site of the accident and an ambulance,
- the health care service provided in the hospital emergency department,
- the therapeutic health care services provided in hospital outpatient clinics,
- and psychological rehabilitation service.
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.
1.FIRST AID AND EMERGENCY RESPONSE
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 first response performed by the victims themselves or the one provided bystanders
- The transfer of accident information to the first aid and emergency response information system,
- Medical interventions performed by the first aiders on the injured,
- Medical intervention performed in the ambulance,
- Trauma treatment at the hospital,
- Rehabilitative psychological support.
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
- Taking into consideration the opinions, suggestions, and demands of not only the stakeholders in the health sector but also all stakeholders being active related to traffic safety, especially the transportation and law enforcement,
- Defining the traffic accident injuries while establishing the monitoring system, ensuring that all stakeholders to use the same definitions,
- Defining traffic accident together, for the same situation may have been defined differently from each other by transportation, engineering, health, police, and other stakeholders due to professional expertise,
- Determining which dataset will be included in the system by identifying the information and data resources, updating the dataset periodically,
- Determining the information procedure by providing the best environment as part of within the bounds of possibility while obtaining information from injured and their relatives on the available staff before the establishment of the system, their educational background, and whether they need new software and hardware,
- Ensuring the involvement of all stakeholders in each stage of the implementation,
- Identifying needs, determining which information will be recorded into the system,
- Ensuring that each stakeholder records the information on their field into the system, for the proper input on the step related to the field of the relevant stakeholder and repeated data input will cause a loss of time during data gathering,
- Establishing the data processing system through an interinstitutional professional software,
- Distributing the reports prepared over data analysed to relevant stakeholders periodically four times a year,
- Training the staff on the system and ensuring that they can work on data input, analysis, and reporting without having a problem,
- Operating the system, monitoring and evaluating it,
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:
- Factors determining the risk of being exposed to traffic accidents such as demographic and economic factors, motorization level, and land planning,
- Factors affecting being involved in a traffic accident such as excessive and under speed, unsafe road structure, ineffective laws and controls,
- Factors increasing the severity of the accident and injury such as not using a seatbelt, child protection equipment, or helmet insufficient in-vehicle protections to protect the persons in the vehicle during an accident, lack of external option preventing the pedestrian from getting harmed in case being crashed into, and the presence of alcohol,
- Factors affecting the treatment of injuries such as getting delayed information on the accident, delayed provision of rescue interventions, and psychological support.
a. Ambulance
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.
b. Fire
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:
- Knowledge acquisition (Notice, Information, Information gathering),
- Safety efforts,
- The evaluation made on the way the accident happened,
- Evaluation of the condition of persons being stuck,
- Determining the option of getting them out of the vehicle,
- Getting them out of the vehicle,
- First-aid and triage.
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.
c. AFAD (Disaster and Emergency Management Presidency)
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.
2. EMERGENCY CARE UNITS
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.
3. TRAUMA SERVICES
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
- Challenging with the damage and injury arising (improving the national emergency response services and prehospital trauma care, organizing units, etc.)
- Treatment of the damage caused (trauma centres, rehabilitation institutions, etc.) The policy to be developed with the sector having a part in protection against trauma in this field is as follows:
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.
4. REHABILITATION AND SOCIAL INCLUSION
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
- Establishing good and fast functioning communication systems for receiving, evaluating and transmitting traffic accident notifications to the first response units,
- Developing effective coordination mechanisms in order to ensure that the relevant stakeholders are transferred to the accident scene, to work in cooperation and coordination, to response effectively, to ensure that the injured are transported safely from the accident scene to the health institution, to ensure that the road is opened to traffic in suitable conditions and as soon as possible after receiving the traffic accident notification,
- Among the basic requirements of the first and emergency response to the injured after a traffic accident; Accurate transmission of emergency and accident information and coordination between units, making necessary emergency response during transfer to the accident scene and hospital and keeping the injured alive,
- Evaluating the first and emergency response infrastructure within this framework by analyzing the severity of death and injury cases in traffic accidents,
- Since human resources, physical capabilities and organizational structure are the basic components of health institutions, increasing the necessary support in all of these areas,
- Dissemination of 112, which is called the emergency call system, in all provinces,
- Deployment of emergency response units in appropriate places, especially in the main route sections where traffic accidents occur intensively in order to respond to traffic accidents in rural areas in an urgent and qualified manner,
- Continuing to deploy health institutions in areas suitable for first and emergency health response, as in the case of city hospitals,
- Developing and implementing systems to monitor reaction times,
- Making and implementing the necessary arrangements to reduce the time between receiving the call and directing the ambulance to the scene to 30 seconds or less,
- Giving first and emergency aid trainings, including how to respond to traffic accidents and how to make a qualified notification,
- Training all healthcare professionals about the importance of first and emergency response to traffic accidents,
- Developing a program to train first aid teams on trauma care and to improve the quality of trauma care provided at the accident scene,
- Creating first and emergency response awareness regarding traffic accidents in all citizens,
- Informing and raising awareness of all institutions and organizations and private sector enterprises at all levels about the importance of first and emergency response in traffic accidents and their priority in saving lives,
- Ensuring that all search and rescue and emergency lifeguard teams receive standard training on traffic accident response methods, equip them with appropriate tools, equipment and materials, and conduct joint and coordinated exercises at certain times according to real scenarios,
- Providing first and emergency aid trainings to occupational groups that are constantly in the field such as road workers engaged in construction, maintenance and repair works on roads, drivers of buses, trucks and tow trucks, service vehicles, taxis, cargo vehicles, and postal delivery vehicles that are commercially engaged in freight and passenger transport and constantly use the route and to public personnel who need to go to the scene firstly due to their duties, such as AFAD staff, firefighters and police.
- Regarding the issues to be considered in traffic accidents occurring outside the residential area and the additional risks that arise; providing information to learner drivers in driving courses and continuing to provide this information to drivers through information campaigns within the lifelong learning methodology,
- Providing training to learner drivers and drivers about helping vehicles that have been involved in an accident or broken down,
- Evaluating the effectiveness of the management of the treatment processes of the injured and the recovery of the injuries, accepting the post-traumatic care and rehabilitation services as an integral part of the post-treatment health services and preparing an effective plan for this,
- Increasing group-oriented social work practices with individuals who have lost a limb after a traffic accident, adding social functionality, employment, entrepreneurship and practices facilitating the fulfillment of daily activities to the response plans,
- While the protection of the society from traffic accidents is the first priority, it is necessary to carry out studies in order to eliminate the individual and social negative effects that occur after the traffic accident.