Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents Living along Accident-Prone Highways in Ghana

*Enoch F. Sam, David K. Blay, Samuel Antwi, Constance Anaafi and Juliet A. Adoma*

#### **Abstract**

Road traffic accidents (RTAs) and associated injuries are a major public health problem in developing countries. The timely emergency pre-hospital care and subsequent transportation of accident victims to the health facility may help reduce the accident and injury outcomes. Available evidence suggests that RTA victims stand a greater chance of survival if attended to and cared for in a timely manner. This exploratory qualitative study set out to explore the experiences of residents of 12 communities along the Kasoa-Mankessim highway in Ghana (an accident-prone highway) in administering emergency pre-hospital care to RTA victims. We utilised data from a purposive sample of 80 respondents (i.e., people who have ever attended to RTA victims) from the communities through structured interview schedules. We found that the majority of the respondents had little knowledge and/or professional training in first-aid and emergency pre-hospital care to RTA victims. The skills and knowledge exhibited were gained through years of rescue services to RTA victims. The "scoop and run" method of first-aid care was predominant among the respondents. We recommend regular community member (layperson first responder) sensitisation and training on emergency pre-hospital care for RTA victims.

**Keywords:** road traffic accident victims, emergency pre-hospital care, layperson first responders, Kasoa-Mankessim highway, Ghana

#### **1. Introduction**

Road traffic accidents (RTAs) are associated with an estimated 1.25 million deaths globally each year with about 50 million others injured in the process [1]. The Ghanaian situation follows a similar trend. An estimated 1800 people are killed in road traffic accidents yearly with almost 14,500 others injured [2].

According to the WHO Global Burden of Disease project 2002, road traffic injuries (RTIs) are the 10th leading cause of death for all age groups globally, accounting for 1,183,492 deaths. More specifically, RTIs is the second and third leading cause of death for persons aged 5–29 years and 30–44 years, respectively [3, 4].

#### *Emergency Medicine and Trauma*

In low- and middle-income countries, RTIs constitute the ninth leading cause of death and the tenth leading cause of disability-adjusted life years (DALYs) [4, 5]. A number of factors account for the high RTIs in these countries including poorly maintained vehicles, inadequate traffic enforcement, inefficient pre-hospital emergency medical response and overburdened healthcare infrastructure [6]. As a result, about 80% of the injury deaths in these countries are said to occur in the pre-hospital setting [7].

Many of these injury deaths could be prevented with the timely arrival of competent emergency pre-hospital medical services at the accident scene [8, 9]. Timely emergency pre-hospital care to traffic accident victims at the accident scene and subsequent transportation to the health facility may reduce the probability of injury severity and deaths. Regarding injury severity and death, trauma experts consider the first 60 minutes (termed the "golden hour") after the injury occurred as the most important period to save lives. The risk of death or severe injury is believed to increase after this period [10].

Recently, the World Health Organisation has proposed training of layperson first responders as the first essential step in developing Emergency Medical Services systems in settings where the formal pre-hospital system is not available [6, 11]. This system has been found to be effective in reducing traffic accident-induced mortalities in most countries [5, 11–13]. A previous study revealed that about 51% of severely injured persons in Kumasi, Ghana died in a pre-hospital setting (cited in 7). This suggests that improving pre-hospital care to RTA victims is important to reduce "the mortality of critically injured roadway casualties" [7]. This stresses the urgency to establish layperson first responder care systems in Ghana (as proposed by the WHO) where formal pre-hospital care is inadequate. Pre-hospital care and post-crash intervention happen to be the focus of the fifth pillar of the UN Decade of Action of Road Safety 2011–2020 which aims to reduce the anticipated magnitude of RTAs and casualties [14].

#### **1.1 Study objective**

Given the important role of layperson first responders in the chances and quality of survival of RTA victims, this study explores the experiences of residents living along the Kasoa-Mankessim road network, an accident-prone road in Ghana, in administering emergency pre-hospital care to RTA victims. We explored their knowledge of pre-hospital first-aid and trauma care and the nature of the assistance they offer at accident scenes. The study results will expose the "pre-hospital trauma care knowledge and skill gaps" which can inform future training to facilitate safe handling and rescue of RTA victims in line with best practices. The remaining part of this paper proceeds as follows: Section 2 discusses the study methodology, while Sections 3–6 presents the study findings, discussion, study limitation and conclusion and implications for practice.

#### **2. Methodology**

We adopted a phenomenological research methodology [15] to explore and provide an in-depth description of participants' experiences/encounters with pre-hospital care for road traffic accident victims on the Kasoa-Mankessim highway (**Figure 1**) in the central region of Ghana. This highway is a segment of the Accra-Cape Coast road network. The entire road network is classified as a national route 1 (N1) road and also forms part of the Trans-West African Highway network.

**5**

the casualties.

accidents)1

**Figure 1.**

*Map of the study areas and road network.*

**2.1 Procedure**

*Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents…*

is between 50 and 100 kph with a weighted average annual daily traffic volume of 9661 vehicles per day. The road links many settlements in the region to Accra, the national capital [16]. There are 11 'police-identified blackspots' on the road network namely Brigade, Galilea, Amanfrom, Potsin Junction, Budumburam, Okyereko Junction, Adawuku, Bible College Area, Tipper Junction, Awutu Beraku and Gomoa Buduatta Junction. These black spots are characterised by dangerous curves, slippery steeps, narrow bridges and undulating surfaces. For the year 2014 alone, 631 RTAs (i.e., 90 fatal, 137 serious, 158 slight and 246 property-damage-only

with 696 casualties (119 killed, 241 serious and 336 slight injuries). These figures translate into 4.5 accidents per kilometre and 4.9 casualties per kilometre [17].

Prior to data collection (interviews), we carried out a reconnaissance visit to the selected communities. Our aim was to introduce the study to the community stakeholders, familiarise ourselves with the terrain, and pre-select and schedule interview appointments with potential respondents. At the data collection stage, we employed a mix of non-probability sampling techniques (i.e., purposive, convenient and snowball sampling techniques) in selecting the study participants and communities. Our study comprised of 80 purposive samples from 12 conveniently sampled communities/settlements (mostly blackspots) along the Kasoa-Mankessim road network (the communities are indicated in **Figure 1**). To be eligible to participate in the study, a person ought to have first-hand-on-the-spot experience assisting RTA victims on this road segment. At some stages of the data collection, we employed

<sup>1</sup> Fatal accident is here defined as an accident where at least one casualty dies of injuries sustained within 30 days of occurrence; serious injury accidents involve at least one casualty detained in hospital as an in-patient for more than 24 hours; slight injury accident is minor requiring at most first-aid attention for

were recorded on the entire Accra-Cape Coast road network associated

*DOI: http://dx.doi.org/10.5772/intechopen.86118*

The Kasoa-Mankessim section is a single two-lane carriageway (31.1 km in length; 7.3 m wide with 2.5 m shoulders on both sides). The road's posted speed *Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents… DOI: http://dx.doi.org/10.5772/intechopen.86118*

**Figure 1.** *Map of the study areas and road network.*

is between 50 and 100 kph with a weighted average annual daily traffic volume of 9661 vehicles per day. The road links many settlements in the region to Accra, the national capital [16]. There are 11 'police-identified blackspots' on the road network namely Brigade, Galilea, Amanfrom, Potsin Junction, Budumburam, Okyereko Junction, Adawuku, Bible College Area, Tipper Junction, Awutu Beraku and Gomoa Buduatta Junction. These black spots are characterised by dangerous curves, slippery steeps, narrow bridges and undulating surfaces. For the year 2014 alone, 631 RTAs (i.e., 90 fatal, 137 serious, 158 slight and 246 property-damage-only accidents)1 were recorded on the entire Accra-Cape Coast road network associated with 696 casualties (119 killed, 241 serious and 336 slight injuries). These figures translate into 4.5 accidents per kilometre and 4.9 casualties per kilometre [17].

#### **2.1 Procedure**

*Emergency Medicine and Trauma*

pre-hospital setting [7].

increase after this period [10].

**1.1 Study objective**

**2. Methodology**

sion and implications for practice.

In low- and middle-income countries, RTIs constitute the ninth leading cause of death and the tenth leading cause of disability-adjusted life years (DALYs) [4, 5]. A number of factors account for the high RTIs in these countries including poorly maintained vehicles, inadequate traffic enforcement, inefficient pre-hospital emergency medical response and overburdened healthcare infrastructure [6]. As a result, about 80% of the injury deaths in these countries are said to occur in the

Many of these injury deaths could be prevented with the timely arrival of competent emergency pre-hospital medical services at the accident scene [8, 9]. Timely emergency pre-hospital care to traffic accident victims at the accident scene and subsequent transportation to the health facility may reduce the probability of injury severity and deaths. Regarding injury severity and death, trauma experts consider the first 60 minutes (termed the "golden hour") after the injury occurred as the most important period to save lives. The risk of death or severe injury is believed to

Recently, the World Health Organisation has proposed training of layperson first responders as the first essential step in developing Emergency Medical Services systems in settings where the formal pre-hospital system is not available [6, 11]. This system has been found to be effective in reducing traffic accident-induced mortalities in most countries [5, 11–13]. A previous study revealed that about 51% of severely injured persons in Kumasi, Ghana died in a pre-hospital setting (cited in 7). This suggests that improving pre-hospital care to RTA victims is important to reduce "the mortality of critically injured roadway casualties" [7]. This stresses the urgency to establish layperson first responder care systems in Ghana (as proposed by the WHO) where formal pre-hospital care is inadequate. Pre-hospital care and post-crash intervention happen to be the focus of the fifth pillar of the UN Decade of Action of Road Safety 2011–2020

which aims to reduce the anticipated magnitude of RTAs and casualties [14].

Given the important role of layperson first responders in the chances and quality

of survival of RTA victims, this study explores the experiences of residents living along the Kasoa-Mankessim road network, an accident-prone road in Ghana, in administering emergency pre-hospital care to RTA victims. We explored their knowledge of pre-hospital first-aid and trauma care and the nature of the assistance they offer at accident scenes. The study results will expose the "pre-hospital trauma care knowledge and skill gaps" which can inform future training to facilitate safe handling and rescue of RTA victims in line with best practices. The remaining part of this paper proceeds as follows: Section 2 discusses the study methodology, while Sections 3–6 presents the study findings, discussion, study limitation and conclu-

We adopted a phenomenological research methodology [15] to explore and provide an in-depth description of participants' experiences/encounters with pre-hospital care for road traffic accident victims on the Kasoa-Mankessim highway (**Figure 1**) in the central region of Ghana. This highway is a segment of the Accra-Cape Coast road network. The entire road network is classified as a national route 1

(N1) road and also forms part of the Trans-West African Highway network. The Kasoa-Mankessim section is a single two-lane carriageway (31.1 km in length; 7.3 m wide with 2.5 m shoulders on both sides). The road's posted speed

**4**

Prior to data collection (interviews), we carried out a reconnaissance visit to the selected communities. Our aim was to introduce the study to the community stakeholders, familiarise ourselves with the terrain, and pre-select and schedule interview appointments with potential respondents. At the data collection stage, we employed a mix of non-probability sampling techniques (i.e., purposive, convenient and snowball sampling techniques) in selecting the study participants and communities. Our study comprised of 80 purposive samples from 12 conveniently sampled communities/settlements (mostly blackspots) along the Kasoa-Mankessim road network (the communities are indicated in **Figure 1**). To be eligible to participate in the study, a person ought to have first-hand-on-the-spot experience assisting RTA victims on this road segment. At some stages of the data collection, we employed

<sup>1</sup> Fatal accident is here defined as an accident where at least one casualty dies of injuries sustained within 30 days of occurrence; serious injury accidents involve at least one casualty detained in hospital as an in-patient for more than 24 hours; slight injury accident is minor requiring at most first-aid attention for the casualties.

the snowball sampling technique to sample other eligible participants from our initial contacts. On average, we interviewed six persons in each community lasting nearly 15 minutes from March to April 2017.

#### **2.2 Analysis**

Data coding and analysis were done in stages. At the first stage, we produced a transcript of each interview in English (participants gave consent to the audio recording of the interviews) and loaded into the Atlas.ti 7.0 software. At the second stage, we conducted inductive data coding and analysis using open and *In Vivo* coding (to 'honour' participant's voice and to ground the analysis from their unique experiences and perspectives) [18]. Lastly, we conducted a thematic analysis of the data, resulting in two main themes namely, knowledge of pre-hospital care for road traffic accident victims and the nature of assistance offered to the accident victims.

#### **3. Findings**

Our sample was mainly males (83.7%) over 30 years old (53.8%) and mostly Junior High school graduates (43.7%) **Table 1**. Study sample characteristics (*n* = 80).

From our interviews, we gathered that at least an accident occurs every month on this road as evidenced by the quotes below. Interestingly, 2 days to the interviews, an accident occurred around Okyereko (one of the selected communities) as recounted by this respondent:

*A sprinter bus had an accident just in front of our house 2 days ago (Male, 42 years, Okyereko).*

*Yes, I have witnessed a number of road accidents on this highway. I can count about six of them and the last one I witnessed, 14 people died. This happened 2 weeks ago (Male, 29 years, Apam junction).*

*On this road, almost every month we hear of road accidents. The last one I witnessed was about 3 weeks ago where everyone on board the vehicle died. I personally have witnessed more than seven accidents on this road and heard of uncountable others (Male, 33 years, Gomoa Mprumem).*

The accident-prone nature of this highway is depicted by the number of cautionary billboards planted close to previous accident spots. On each billboard, the number of people killed in a particular accident at a spot is indicated as shown in **Figure 2**.

Below, we present the study findings based on the themes and supported by relevant quotes from the transcript.

#### **3.1 Knowledge of pre-hospital care for RTA victims**

As it is customary for residents along the highway to attend to RTA victims in the event of accidents, we sought to explore their knowledge of some basic pre-hospital emergency care for RTA victims. Generally, we assessed respondents' knowledge of care for victims bleeding, recovery position for victims with fracture (broken bones) and basic airway control in unconscious persons.

Generally, we noted that the majority of the participants have no practical training in pre-hospital care for RTA victims. For those who have received some

**7**

RTA victims.

**Figure 2.**

**Table 1.**

*Study sample (n = 80).*

*(Male, 32 years, Apam-junction).*

*Billboard indicating previous accidents on some spots on the highway.*

nature of the injury sustained.

*Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents…*

**Variable N %** Sex Male 67 83.7

Age 18–25 years 17 21.2

Education (attained) Non-formal 7 8.7

Total 80 100

Female 13 16.3

26–30 years 20 25.0 Above 30 years 43 53.8

Junior High 35 43.7 Senior High 27 33.7 Tertiary 11 13.7

training (n = 16 or 20%), they claimed it was just talk-based with a little demonstration. The rest acquired appreciable knowledge through years of rescue care for

*Yes. I remember one day, a group of people came here to talk to us about how we should handle accident victims. They said whenever we hear of a road accident, we should rush to the accident scene to help and try our best to call the Ambulance service and the Police. But it was mainly a talk show with little demonstration* 

Regarding victim recovery position(s) in the event of suspected fracture (broken bone), 20% of the participants (those with some training) rightly revealed that victim recovery position(s) depends on the nature of the injury sustained. They emphasised placing the victim on the ground as it is difficult to determine the

*Not all victims who are involved in road accidents sustain serious or severe injuries. So those victims who are not hurt or injured, some of them could stand and others* 

*DOI: http://dx.doi.org/10.5772/intechopen.86118*

*Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents… DOI: http://dx.doi.org/10.5772/intechopen.86118*


#### **Table 1.**

*Emergency Medicine and Trauma*

**2.2 Analysis**

accident victims.

recounted by this respondent:

*42 years, Okyereko).*

*(Male, 29 years, Apam junction).*

relevant quotes from the transcript.

*others (Male, 33 years, Gomoa Mprumem).*

**3.1 Knowledge of pre-hospital care for RTA victims**

bones) and basic airway control in unconscious persons.

**3. Findings**

nearly 15 minutes from March to April 2017.

the snowball sampling technique to sample other eligible participants from our initial contacts. On average, we interviewed six persons in each community lasting

Data coding and analysis were done in stages. At the first stage, we produced a transcript of each interview in English (participants gave consent to the audio recording of the interviews) and loaded into the Atlas.ti 7.0 software. At the second stage, we conducted inductive data coding and analysis using open and *In Vivo* coding (to 'honour' participant's voice and to ground the analysis from their unique experiences and perspectives) [18]. Lastly, we conducted a thematic analysis of the data, resulting in two main themes namely, knowledge of pre-hospital care for road traffic accident victims and the nature of assistance offered to the

Our sample was mainly males (83.7%) over 30 years old (53.8%) and mostly Junior High school graduates (43.7%) **Table 1**. Study sample characteristics (*n* = 80). From our interviews, we gathered that at least an accident occurs every month on this road as evidenced by the quotes below. Interestingly, 2 days to the interviews, an accident occurred around Okyereko (one of the selected communities) as

*A sprinter bus had an accident just in front of our house 2 days ago (Male,* 

*Yes, I have witnessed a number of road accidents on this highway. I can count about six of them and the last one I witnessed, 14 people died. This happened 2 weeks ago* 

*On this road, almost every month we hear of road accidents. The last one I witnessed was about 3 weeks ago where everyone on board the vehicle died. I personally have witnessed more than seven accidents on this road and heard of uncountable* 

The accident-prone nature of this highway is depicted by the number of cautionary billboards planted close to previous accident spots. On each billboard, the number of people killed in a particular accident at a spot is indicated as shown in **Figure 2**. Below, we present the study findings based on the themes and supported by

As it is customary for residents along the highway to attend to RTA victims in the event of accidents, we sought to explore their knowledge of some basic pre-hospital emergency care for RTA victims. Generally, we assessed respondents' knowledge of care for victims bleeding, recovery position for victims with fracture (broken

Generally, we noted that the majority of the participants have no practical training in pre-hospital care for RTA victims. For those who have received some

**6**

*Study sample (n = 80).*

#### **Figure 2.**

*Billboard indicating previous accidents on some spots on the highway.*

training (n = 16 or 20%), they claimed it was just talk-based with a little demonstration. The rest acquired appreciable knowledge through years of rescue care for RTA victims.

*Yes. I remember one day, a group of people came here to talk to us about how we should handle accident victims. They said whenever we hear of a road accident, we should rush to the accident scene to help and try our best to call the Ambulance service and the Police. But it was mainly a talk show with little demonstration (Male, 32 years, Apam-junction).*

Regarding victim recovery position(s) in the event of suspected fracture (broken bone), 20% of the participants (those with some training) rightly revealed that victim recovery position(s) depends on the nature of the injury sustained. They emphasised placing the victim on the ground as it is difficult to determine the nature of the injury sustained.

*Not all victims who are involved in road accidents sustain serious or severe injuries. So those victims who are not hurt or injured, some of them could stand and others* 

*sit on the ground. But the severely injured victims should be placed on the floor with their backs to the ground (Male, 34 years, Apam-junction).*

*If the victim has a broken leg or hand, let the victim lie with the back to the ground. Usually, the position of the victim depends on the form of injury I suspect might have occurred (Male, 32 years, Apam-junction).*

*I think the casualty should be made to lie down at the back to get enough air because the casualty may be suffering from a spinal problem or a dislocated waist or leg and so allowing such a victim to sit or squat may result in other injuries (Male, 30 years, Potsin).*

Yet, others, like this respondent, revealed:

*I usually do not know the affected part of the victims, so my aim is to remove the victims from the car to be transported to the hospital (Male, 35 years, Gomoa Mprumem).*

In case the victim is bleeding, most respondents (86%) demonstrated adequate knowledge of pre-hospital care including applying pressure to the affected area by pressing hard with the hands and subsequently applying local herbs or leaves and bandage to the bleeding part in order to stop or reduce bleeding (external compression for haemorrhage control).

*I tear the victim's shirt and use it to bandage the affected part. This helps to reduce the bleeding to prevent loss of blood, even if there is a delay in transporting them to the hospital (Male, 34 years, Apam-junction).*

*I am a driver, so I usually use dusters from my car or the shirts of (male) victims to tie the bleeding part before I transport them to the hospital (Male, 37 years, Apam-junction).*

It is evident from the interviews that bandaging or tying the bleeding area (haemorrhage control) is the common first aid most residents know of. However, others revealed different indigenous methods to stop bleeding.

*For me, what I normally do is to look for leaves like "Acheampong" (a local herb) and I grind it on the road and apply it on the bleeding part to reduce the bleeding, or even at times I use plantain leaves, grind it and after that, I squeeze the water content on the bleeding part. Even though it hurts when the leaves are applied to injuries, but they help to reduce bleeding as soon as possible (Male, 35 years, Gomoa Mprumem).*

Lastly, we also quizzed respondents on their knowledge on how to assist unresponsive RTA victims. About 27% of the respondents rightly suggested checking the victim's pulse and body movements to determine the chances of survival and shouting into the victim's ear to determine if the victim responds or not. Other participants also think because most unresponsive victims become short of breath, the best way to assist them is by placing them on the ground with the head tilted backwards to open the airway in the throat to enable the victim to take in more air (basic airway control in unconscious persons).

*If the victim still breaths or the heart still beats, I put the victims in an open space to get more air. But if I cannot feel the heartbeat, I conclude that the victim is dead yet still we transport them to the hospital (Male, 35 years, Gomoa Mprumem).*

**9**

**Figure 3.**

*Residents trying to rescue victims stacked in a vehicle.*

*Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents…*

In sum, we realised that the study respondents were more adequate in their knowledge of pre-hospital care for bleeding accident victim(s) than in the case of the recovery position for the victim(s) who suffer fracture (broken bones) or are

Varied methods, mainly indigenous, are employed in saving RTA victims. **Figures 3**–**5** depict the kind of assistance community residents provide at accident scenes. We observed that the "*scoop and run*" method of pre-hospital care (which involves providing basic care at the trauma site and rushing the victim to a hospital) was the common practice among the respondents. Some respondents also call on the National Fire Service and the Ambulance Service to help. The quotes below

*We have not been trained on how to administer first aid and also do not have what it takes to treat the accident victims, and so we usually arrange with an oncoming vehicle to transport them to the nearest hospital (Female, 34 years,* 

*A taxi had an accident here 2 weeks ago and it caught fire. We all had to run to our homes to fetch water to quench the fire before we were able to remove the* 

However, the situation was different for those who had ever received some first-

Notwithstanding, we noted that the rescue efforts were often saddled with challenges. The major challenge we noted was the lack of proper tools to cut open vehicles in order to bring out trapped victims. There was also the difficulty of rescuing victims in burning vehicles. Some respondents revealed sustaining burns and deep cuts by the broken glasses of the crashed vehicles in the process of rescuing victims.

*I have received some training in first aid. As a taxi driver, I usually carry a first aid box in my car with the basic supplies. Anytime I witness an accident and the victims bleed, I wash the bleeding part with water and apply methylated spirit to the affected part(s) and subsequently put cotton wool and plaster to stop the bleeding. Shortly after, I transport the victims in my taxi to the hospital (Male, 38 years,* 

*DOI: http://dx.doi.org/10.5772/intechopen.86118*

**3.2 Nature of assistance offered to accident victims**

illustrate the kind of assistance provided at accident scenes.

*victims from the car (Male, 28 years, Kwabenata).*

unresponsive.

*Kwabenata).*

*Okyereko).*

aid training:

*Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents… DOI: http://dx.doi.org/10.5772/intechopen.86118*

In sum, we realised that the study respondents were more adequate in their knowledge of pre-hospital care for bleeding accident victim(s) than in the case of the recovery position for the victim(s) who suffer fracture (broken bones) or are unresponsive.

#### **3.2 Nature of assistance offered to accident victims**

*Emergency Medicine and Trauma*

*(Male, 30 years, Potsin).*

sion for haemorrhage control).

*Apam-junction).*

Yet, others, like this respondent, revealed:

*the hospital (Male, 34 years, Apam-junction).*

(basic airway control in unconscious persons).

others revealed different indigenous methods to stop bleeding.

*sit on the ground. But the severely injured victims should be placed on the floor with* 

*If the victim has a broken leg or hand, let the victim lie with the back to the ground. Usually, the position of the victim depends on the form of injury I suspect* 

*I think the casualty should be made to lie down at the back to get enough air because the casualty may be suffering from a spinal problem or a dislocated waist or leg and so allowing such a victim to sit or squat may result in other injuries* 

*I usually do not know the affected part of the victims, so my aim is to remove the victims from the car to be transported to the hospital (Male, 35 years, Gomoa Mprumem).*

In case the victim is bleeding, most respondents (86%) demonstrated adequate knowledge of pre-hospital care including applying pressure to the affected area by pressing hard with the hands and subsequently applying local herbs or leaves and bandage to the bleeding part in order to stop or reduce bleeding (external compres-

*I tear the victim's shirt and use it to bandage the affected part. This helps to reduce the bleeding to prevent loss of blood, even if there is a delay in transporting them to* 

*I am a driver, so I usually use dusters from my car or the shirts of (male) victims to tie the bleeding part before I transport them to the hospital (Male, 37 years,* 

It is evident from the interviews that bandaging or tying the bleeding area (haemorrhage control) is the common first aid most residents know of. However,

*For me, what I normally do is to look for leaves like "Acheampong" (a local herb) and I grind it on the road and apply it on the bleeding part to reduce the bleeding, or even at times I use plantain leaves, grind it and after that, I squeeze the water content on the bleeding part. Even though it hurts when the leaves are applied to injuries, but they help to reduce bleeding as soon as possible (Male, 35 years, Gomoa Mprumem).*

Lastly, we also quizzed respondents on their knowledge on how to assist unresponsive RTA victims. About 27% of the respondents rightly suggested checking the victim's pulse and body movements to determine the chances of survival and shouting into the victim's ear to determine if the victim responds or not. Other participants also think because most unresponsive victims become short of breath, the best way to assist them is by placing them on the ground with the head tilted backwards to open the airway in the throat to enable the victim to take in more air

*If the victim still breaths or the heart still beats, I put the victims in an open space to get more air. But if I cannot feel the heartbeat, I conclude that the victim is dead yet still we transport them to the hospital (Male, 35 years, Gomoa Mprumem).*

*their backs to the ground (Male, 34 years, Apam-junction).*

*might have occurred (Male, 32 years, Apam-junction).*

**8**

Varied methods, mainly indigenous, are employed in saving RTA victims. **Figures 3**–**5** depict the kind of assistance community residents provide at accident scenes. We observed that the "*scoop and run*" method of pre-hospital care (which involves providing basic care at the trauma site and rushing the victim to a hospital) was the common practice among the respondents. Some respondents also call on the National Fire Service and the Ambulance Service to help. The quotes below illustrate the kind of assistance provided at accident scenes.

*We have not been trained on how to administer first aid and also do not have what it takes to treat the accident victims, and so we usually arrange with an oncoming vehicle to transport them to the nearest hospital (Female, 34 years, Kwabenata).*

*A taxi had an accident here 2 weeks ago and it caught fire. We all had to run to our homes to fetch water to quench the fire before we were able to remove the victims from the car (Male, 28 years, Kwabenata).*

However, the situation was different for those who had ever received some firstaid training:

*I have received some training in first aid. As a taxi driver, I usually carry a first aid box in my car with the basic supplies. Anytime I witness an accident and the victims bleed, I wash the bleeding part with water and apply methylated spirit to the affected part(s) and subsequently put cotton wool and plaster to stop the bleeding. Shortly after, I transport the victims in my taxi to the hospital (Male, 38 years, Okyereko).*

Notwithstanding, we noted that the rescue efforts were often saddled with challenges. The major challenge we noted was the lack of proper tools to cut open vehicles in order to bring out trapped victims. There was also the difficulty of rescuing victims in burning vehicles. Some respondents revealed sustaining burns and deep cuts by the broken glasses of the crashed vehicles in the process of rescuing victims.

**Figure 3.** *Residents trying to rescue victims stacked in a vehicle.*

**Figure 4.** *RTA victims put at recovery position.*

#### **Figure 5.** *Some community residents assisting RTA victims.*

*Our ability to rescue victims from crashed vehicles depend on the extent of damage to the vehicle. We lack the necessary equipment to cut open accident vehicles. Mostly, we use cutlass, axes and any available tool to cut the vehicle in order to get the victims out. We end up injuring ourselves in the process (Male, 35 years, Gomoa Mprumem).*

*Whenever an accident occurs here and the vehicle catches fire, removing the victims becomes very difficult but because we want to help, we persist and end up sustaining injuries in the process (Male, 29 years, Kwabenata).*

#### **4. Discussion**

In this study, we sought to explore the experiences of residents of communities along the Kasoa-Mankessim highway in providing pre-hospital care to RTA victims. This knowledge is important to provide the basis for future training to ensure safe victim handling in line with international best practices. Recently, WHO has encouraged layperson first responder programmes as a basic step in the development of a functioning pre-hospital system [13]. Given that communities along accident-prone highways are normally the first people to come into contact with the RTA victims (first responders), the need to train them adequately cannot be overemphasised.

**11**

*Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents…*

likely to result in further injuries or even the death of victims.

The current study found that there is a natural inclination to help RTA victims among the study respondents, yet only a handful of them have received proper pre-hospital training to facilitate safe victim handling and pre-hospital care in line with best practices. Of the 80 participants, only 20% had received some form of pre-hospital first-aid training, howbeit inadequate. In view of this, most participants had little knowledge in first aid care processes. As a consequence of the lack of training, participants had devised various strategies to assist RTA victims, which is

It was also apparent that even though most of the respondents have not been trained in pre-hospital care to RTA victims, through continuous victim rescue efforts, they have gained some valuable experiences. However, respondents with some training exhibited appropriate knowledge of the pre-hospital procedures in the areas of our knowledge assessment consistent with previous findings [7, 12, 13]. Another important finding was that the scoop and run method of pre-hospital

care [19] was common among the study participants. This could be explained by their little or no clinical (pre-hospital) know-how and appropriate tools and supplies to cater for RTA victims. This notwithstanding, available evidence suggests that the scoop and run method is effective in increasing the chance of victim survival in the event of serious injuries [19, 20]. Any delay to transport victims for definitive care decrease the chance of victim survival (which is time-critical) [20]. The study results further support the establishment of layperson first responder systems in pre-hospital deficient settings. Generally, the natural inclination to help RTA victims and the success of the programme in other countries, mostly in Africa makes this workable in our study areas [5, 11–13]. These studies demonstrate that trained layperson first responders retain and appropriately use their newly acquired

It is noteworthy that similar studies were either quantitative in design or at best evaluation of the impact of a pre-hospital care or first-aid training course or a systematic review of the literature. Unlike these studies, our study was mainly qualitative and exploratory in nature and unique in its approach to exploring the knowledge of pre-hospital care for RTA victims. As a qualitative, exploratory study, it suffers from concerns with generalisability of the study findings to the population, a supposed problem associated with qualitative studies in general. However, the study findings are significant in their own right and provide a valuable first view of the processes residents of the named highway goes through to assist RTA victims

Based on the study findings, we conclude that there is a general enthusiasm to assist RTA victims among the respondents and the communities, yet there are gaps in their knowledge of, and skills in pre-hospital care for RTA victims. The study findings thus suggest several courses of action in line with best practices.

To take advantage of community members' eagerness to assist RTA victims, the relevant stakeholders and policy-makers (Ghana Red Cross Society, National Ambulance, Ghana National Fire Service, and Ministry of Health) could undertake a couple of policy and practical actions toward ensuring efficient pre-hospital care

which is important for further studies and intervention programmes.

*DOI: http://dx.doi.org/10.5772/intechopen.86118*

knowledge and skills for societal good [7, 12].

**5. Study limitation**

**6. Conclusion**

for RTA victims.

#### *Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents… DOI: http://dx.doi.org/10.5772/intechopen.86118*

The current study found that there is a natural inclination to help RTA victims among the study respondents, yet only a handful of them have received proper pre-hospital training to facilitate safe victim handling and pre-hospital care in line with best practices. Of the 80 participants, only 20% had received some form of pre-hospital first-aid training, howbeit inadequate. In view of this, most participants had little knowledge in first aid care processes. As a consequence of the lack of training, participants had devised various strategies to assist RTA victims, which is likely to result in further injuries or even the death of victims.

It was also apparent that even though most of the respondents have not been trained in pre-hospital care to RTA victims, through continuous victim rescue efforts, they have gained some valuable experiences. However, respondents with some training exhibited appropriate knowledge of the pre-hospital procedures in the areas of our knowledge assessment consistent with previous findings [7, 12, 13].

Another important finding was that the scoop and run method of pre-hospital care [19] was common among the study participants. This could be explained by their little or no clinical (pre-hospital) know-how and appropriate tools and supplies to cater for RTA victims. This notwithstanding, available evidence suggests that the scoop and run method is effective in increasing the chance of victim survival in the event of serious injuries [19, 20]. Any delay to transport victims for definitive care decrease the chance of victim survival (which is time-critical) [20].

The study results further support the establishment of layperson first responder systems in pre-hospital deficient settings. Generally, the natural inclination to help RTA victims and the success of the programme in other countries, mostly in Africa makes this workable in our study areas [5, 11–13]. These studies demonstrate that trained layperson first responders retain and appropriately use their newly acquired knowledge and skills for societal good [7, 12].

#### **5. Study limitation**

*Emergency Medicine and Trauma*

*RTA victims put at recovery position.*

**Figure 4.**

**Figure 5.**

*Our ability to rescue victims from crashed vehicles depend on the extent of damage to the vehicle. We lack the necessary equipment to cut open accident vehicles. Mostly, we use cutlass, axes and any available tool to cut the vehicle in order to get the victims out. We end up injuring ourselves in the process (Male, 35 years, Gomoa* 

*Whenever an accident occurs here and the vehicle catches fire, removing the victims becomes very difficult but because we want to help, we persist and end up sustain-*

In this study, we sought to explore the experiences of residents of communities along the Kasoa-Mankessim highway in providing pre-hospital care to RTA victims. This knowledge is important to provide the basis for future training to ensure safe victim handling in line with international best practices. Recently, WHO has encouraged layperson first responder programmes as a basic step in the development of a functioning pre-hospital system [13]. Given that communities along accident-prone highways are normally the first people to come into contact with the RTA victims (first responders), the need to train them adequately cannot be overemphasised.

*ing injuries in the process (Male, 29 years, Kwabenata).*

**10**

*Mprumem).*

*Some community residents assisting RTA victims.*

**4. Discussion**

It is noteworthy that similar studies were either quantitative in design or at best evaluation of the impact of a pre-hospital care or first-aid training course or a systematic review of the literature. Unlike these studies, our study was mainly qualitative and exploratory in nature and unique in its approach to exploring the knowledge of pre-hospital care for RTA victims. As a qualitative, exploratory study, it suffers from concerns with generalisability of the study findings to the population, a supposed problem associated with qualitative studies in general. However, the study findings are significant in their own right and provide a valuable first view of the processes residents of the named highway goes through to assist RTA victims which is important for further studies and intervention programmes.

#### **6. Conclusion**

Based on the study findings, we conclude that there is a general enthusiasm to assist RTA victims among the respondents and the communities, yet there are gaps in their knowledge of, and skills in pre-hospital care for RTA victims. The study findings thus suggest several courses of action in line with best practices.

To take advantage of community members' eagerness to assist RTA victims, the relevant stakeholders and policy-makers (Ghana Red Cross Society, National Ambulance, Ghana National Fire Service, and Ministry of Health) could undertake a couple of policy and practical actions toward ensuring efficient pre-hospital care for RTA victims.

The most obvious and immediate action involves implementing a functioning layperson first responder systems in the communities along the road network. As suggested in a previous study [7], persons (e.g., taxi drivers, community leaders) who are likely to chance upon and transport RTA victims could be the target of this layperson first responder training programmes. These persons should be equipped with the needed skills and first-aid kits/supplies to provide basic life support services pending definitive care as well as transport RTA victims to the nearest health facility. Periodic refresher training and incentives for the laypersons will ensure the sustainability of the system [6, 7]. As indicated earlier, this is an important and cost-effective step to developing formal emergency pre-hospital care systems [12]. Related to this is the urgent need to establish effective communication and transportation channels between the communities, the relevant stakeholders and health facilities.

It is also possible to utilise modern information and communication technology to send out messages to the relevant stakeholders in the event of RTAs. By the use of a global positioning system (GPS)-enabled devices, exact coordinates of accident locations could be sent to the national ambulance and other stakeholders for immediate deployment and assistance. For instance, the request for emergency service feature of the recently launched "*GhanaPost GPS App*" could be a useful system in this regard. This, however, implies that both community members and the relevant stakeholders should be trained to use it.

Last but not least, given that the driving population (motorists) are probably more likely to chance upon accident scenes, first-aid training/course could be made mandatory for motorists when obtaining a driving licence. This will ensure a wellequipped driving population who could promptly assist RTA victims should they chance upon an accident scene in the course of their journeys [20].

#### **Acknowledgements**

We are grateful to all persons who participated in the study. Without you, this study could not have come this far. We are also grateful to all stakeholders in the selected communities where we conducted interviews.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Enoch F. Sam\*, David K. Blay, Samuel Antwi, Constance Anaafi and Juliet A. Adoma Department of Geography Education, University of Education, Winneba, Ghana

\*Address all correspondence to: efsam@uew.edu.gh

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**13**

*Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents…*

pdf

Injury Prevention. Geneva: World Health Organisation; 2004. Available from: http://apps.who.int/iris/

[10] Carr BG, Caplan JM, Pryor JP, Branas CC. A meta-analysis of prehospital care times for trauma. Prehospital Emergency Care. 2006;**10**(2):198-206. DOI: 10.1080/10903120500541324

[11] Callese TE, Richards CT, Shaw P, Schuetz SJ, Issa N, Paladino L, et al. Layperson trauma training in low- and middle-income countries: A review. Journal of Surgical Research. 2014;**190**(1):104-110. Available from: http://www.ncbi.nlm.nih.gov/

[12] Jayaraman S, Mabweijano JR, Lipnick MS, Cadwell N, Miyamoto J, Wangoda R, et al. First things first: Effectiveness and scalability of a basic prehospital trauma care program for lay first-responders in Kampala, Uganda.

[13] Geduld H, Wallis L. Taxi driver training in Madagascar: The first step in developing a functioning prehospital emergency care system. Emergency Medicine Journal. 2011;**28**(9):794-796

[14] United Nations. Global Plan for the Decade of Action for Road Safety 2011-2020. Geneva: WHO; 2011. p. 25. Available from: http://scholar.google. com/scholar?hl=en&btnG=Search&q= intitle:Global+Plan+for+the+Decade+of+ Action+for+Road+Safety+2011-2020#0

[15] Gray DE. Doing Research in the Real World. UK: Sage Publications; 2004

[16] Sam EF, Akansor J, Agyemang W. Understanding road traffic risks from the street hawker's perspective. International Journal of Injury Control

PLoS ONE. 2009;**4**(9):1-7

pubmed/24746252

bitstream/10665/42871/1/9241562609.

*DOI: http://dx.doi.org/10.5772/intechopen.86118*

[1] World Health Organization. Global Status Report on Road Safety 2015. Geneva: World Health Organisation; 2015. Available from: http://www. who.int/violence\_injury\_prevention/

[2] National Road Safety Committee. National Road Safety Strategy III (2011- 2020). Accra: National Road Safety

[3] Anthony DR. Promoting emergency medical care systems in the developing world: Weighing the costs. Global Public

[4] Krug EG, Sharma GK, Lozano R. The global burden of injuries. American Journal of Public Health.

[5] Razzak JA, Kellermann AL.

Emergency medical care in developing countries: Is it worthwhile? Bulletin of the World Health Organization.

[6] Sasser S, Varghese M, Kellermann A, Lormand J-D. Prehospital Trauma Care Systems. Vol. 1. Geneva: World Health

[7] Tiska MA, Adu-Ampofo M, Boakye G, Tuuli L, Mock CN. A model of prehospital trauma training for

laypersons devised in Africa. Emergency Medicine Journal. 2004;**21**(2):237-239

[8] Bigdeli M, Khorasani-Zavareh D, Mohammadi R. Pre-hospital care time intervals among victims of road traffic injuries in Iran. A crosssectional study. BMC Public Health. 2010;**10**(1):406. Available from: http:// bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-10-406

[9] Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al. World Report on Road Traffic

road\_safety\_status/2015/en/

Health. 2011;**6**(8):906-913

2000;**90**(4):523-526

2002;**80**:900-905

Organisation; 2005

Commission; 2011

**References**

*Pre-Hospital and Trauma Care to Road Traffic Accident Victims: Experiences of Residents… DOI: http://dx.doi.org/10.5772/intechopen.86118*

#### **References**

*Emergency Medicine and Trauma*

stakeholders should be trained to use it.

**12**

**Author details**

and Juliet A. Adoma

**Acknowledgements**

**Conflict of interest**

Enoch F. Sam\*, David K. Blay, Samuel Antwi, Constance Anaafi

chance upon an accident scene in the course of their journeys [20].

\*Address all correspondence to: efsam@uew.edu.gh

provided the original work is properly cited.

selected communities where we conducted interviews.

The authors declare no conflict of interest.

Department of Geography Education, University of Education, Winneba, Ghana

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

The most obvious and immediate action involves implementing a functioning layperson first responder systems in the communities along the road network. As suggested in a previous study [7], persons (e.g., taxi drivers, community leaders) who are likely to chance upon and transport RTA victims could be the target of this layperson first responder training programmes. These persons should be equipped with the needed skills and first-aid kits/supplies to provide basic life support services pending definitive care as well as transport RTA victims to the nearest health facility. Periodic refresher training and incentives for the laypersons will ensure the sustainability of the system [6, 7]. As indicated earlier, this is an important and cost-effective step to developing formal emergency pre-hospital care systems [12]. Related to this is the urgent need to establish effective communication and transportation channels between the communities, the relevant stakeholders and health facilities. It is also possible to utilise modern information and communication technology to send out messages to the relevant stakeholders in the event of RTAs. By the use of a global positioning system (GPS)-enabled devices, exact coordinates of accident locations could be sent to the national ambulance and other stakeholders for immediate deployment and assistance. For instance, the request for emergency service feature of the recently launched "*GhanaPost GPS App*" could be a useful system in this regard. This, however, implies that both community members and the relevant

Last but not least, given that the driving population (motorists) are probably more likely to chance upon accident scenes, first-aid training/course could be made mandatory for motorists when obtaining a driving licence. This will ensure a wellequipped driving population who could promptly assist RTA victims should they

We are grateful to all persons who participated in the study. Without you, this study could not have come this far. We are also grateful to all stakeholders in the

[1] World Health Organization. Global Status Report on Road Safety 2015. Geneva: World Health Organisation; 2015. Available from: http://www. who.int/violence\_injury\_prevention/ road\_safety\_status/2015/en/

[2] National Road Safety Committee. National Road Safety Strategy III (2011- 2020). Accra: National Road Safety Commission; 2011

[3] Anthony DR. Promoting emergency medical care systems in the developing world: Weighing the costs. Global Public Health. 2011;**6**(8):906-913

[4] Krug EG, Sharma GK, Lozano R. The global burden of injuries. American Journal of Public Health. 2000;**90**(4):523-526

[5] Razzak JA, Kellermann AL. Emergency medical care in developing countries: Is it worthwhile? Bulletin of the World Health Organization. 2002;**80**:900-905

[6] Sasser S, Varghese M, Kellermann A, Lormand J-D. Prehospital Trauma Care Systems. Vol. 1. Geneva: World Health Organisation; 2005

[7] Tiska MA, Adu-Ampofo M, Boakye G, Tuuli L, Mock CN. A model of prehospital trauma training for laypersons devised in Africa. Emergency Medicine Journal. 2004;**21**(2):237-239

[8] Bigdeli M, Khorasani-Zavareh D, Mohammadi R. Pre-hospital care time intervals among victims of road traffic injuries in Iran. A crosssectional study. BMC Public Health. 2010;**10**(1):406. Available from: http:// bmcpublichealth.biomedcentral.com/ articles/10.1186/1471-2458-10-406

[9] Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al. World Report on Road Traffic Injury Prevention. Geneva: World Health Organisation; 2004. Available from: http://apps.who.int/iris/ bitstream/10665/42871/1/9241562609. pdf

[10] Carr BG, Caplan JM, Pryor JP, Branas CC. A meta-analysis of prehospital care times for trauma. Prehospital Emergency Care. 2006;**10**(2):198-206. DOI: 10.1080/10903120500541324

[11] Callese TE, Richards CT, Shaw P, Schuetz SJ, Issa N, Paladino L, et al. Layperson trauma training in low- and middle-income countries: A review. Journal of Surgical Research. 2014;**190**(1):104-110. Available from: http://www.ncbi.nlm.nih.gov/ pubmed/24746252

[12] Jayaraman S, Mabweijano JR, Lipnick MS, Cadwell N, Miyamoto J, Wangoda R, et al. First things first: Effectiveness and scalability of a basic prehospital trauma care program for lay first-responders in Kampala, Uganda. PLoS ONE. 2009;**4**(9):1-7

[13] Geduld H, Wallis L. Taxi driver training in Madagascar: The first step in developing a functioning prehospital emergency care system. Emergency Medicine Journal. 2011;**28**(9):794-796

[14] United Nations. Global Plan for the Decade of Action for Road Safety 2011-2020. Geneva: WHO; 2011. p. 25. Available from: http://scholar.google. com/scholar?hl=en&btnG=Search&q= intitle:Global+Plan+for+the+Decade+of+ Action+for+Road+Safety+2011-2020#0

[15] Gray DE. Doing Research in the Real World. UK: Sage Publications; 2004

[16] Sam EF, Akansor J, Agyemang W. Understanding road traffic risks from the street hawker's perspective. International Journal of Injury Control and Safety Promotion. 2019;**26**(1):92- 98. Available from: http://www. tandfonline.com/action/journalInforma tion?journalCode=nics20

Chapter 2

Abstract

understand its rations.

1. Introduction

2. Definition

2.1 Linguistic definition

2.2 In medical use

15

emergency department triage

prioritize patients who need urgent care.

a large number that require attention" [1].

Triage

Abdulnasir F.H. Aljazairi

During austere conditions when there is a large demand on healthcare services and the resources are limited for different reasons, there should be a special way of managing patients and victims in order to make the most benefit to the community. Trial of first come, first served will lead to losing most of the seriously injured patients because they will reach late if they reached a healthcare facility. In addition, day-to-day work protocols with full resources also are not the optimum to offer for the whole community during a major incident. Triage has been created and evolved in military medical services to face mass casualty with limited resources and then transferred to civilian life to deal with mass casualty incidents. Applying triage to patients created some interference with medical bioethics if those applied on individual bases, but if applied in the whole picture of state or country, we can

Keywords: military triage, major incident, disaster, bioethics, sorting,

God created human beings and honored them over other creatures; therefore, keeping life is one of utmost urges. This urge to save lives is challenged in time of major incidents when patients' needs are exceeding care resources. Moreover, with the increase in global population and escalation in the costs of healthcare, more patients are visiting emergency departments (EDs) all over the world to cut

expenses and bypass remote appointments. Most EDs today adopt a triage system to

"The process of determining the most important people or things from amongst

It is the sorting of victims by giving them grade to prioritize them for treatment and transportation in order to maximize the number of survivors in major incidents and war victims [2]. According to the assigned grade, patients will have their priority in attending by healthcare givers, investigations, and operation rooms.

[17] National Road Safety Commission. Road Traffic Crashes in Ghana. Accra: National Road Safety Commission; 2014

[18] Saldana J. The Coding Manual for Qualitative Researchers. London, UK: Sage Publications Ltd; 2009. xii, 410 p

[19] Taran S. The scoop and run method of pre-clinical care for trauma victims. McGill Journal of Medicine. 2009;**12**(2):73-75. Available from: http://www.pubmedcentral.nih.gov/ articlerender.fcgi?artid=2997263&tool= pmcentrez&rendertype=abstract

[20] Elvik R, Vaa T, Høye A, Sorensen M. The Handbook of Road Safety Measures. Bingley, UK: Emerald Group Publishing Limited; 2009. p. 1137

#### Chapter 2

*Emergency Medicine and Trauma*

tion?journalCode=nics20

and Safety Promotion. 2019;**26**(1):92- 98. Available from: http://www.

tandfonline.com/action/journalInforma

[17] National Road Safety Commission. Road Traffic Crashes in Ghana. Accra: National Road Safety Commission; 2014

[18] Saldana J. The Coding Manual for Qualitative Researchers. London, UK: Sage Publications Ltd; 2009. xii, 410 p

[20] Elvik R, Vaa T, Høye A, Sorensen M. The Handbook of Road Safety Measures. Bingley, UK: Emerald Group Publishing

[19] Taran S. The scoop and run method of pre-clinical care for trauma victims. McGill Journal of Medicine. 2009;**12**(2):73-75. Available from: http://www.pubmedcentral.nih.gov/ articlerender.fcgi?artid=2997263&tool= pmcentrez&rendertype=abstract

Limited; 2009. p. 1137

**14**

## Triage

Abdulnasir F.H. Aljazairi

#### Abstract

During austere conditions when there is a large demand on healthcare services and the resources are limited for different reasons, there should be a special way of managing patients and victims in order to make the most benefit to the community. Trial of first come, first served will lead to losing most of the seriously injured patients because they will reach late if they reached a healthcare facility. In addition, day-to-day work protocols with full resources also are not the optimum to offer for the whole community during a major incident. Triage has been created and evolved in military medical services to face mass casualty with limited resources and then transferred to civilian life to deal with mass casualty incidents. Applying triage to patients created some interference with medical bioethics if those applied on individual bases, but if applied in the whole picture of state or country, we can understand its rations.

Keywords: military triage, major incident, disaster, bioethics, sorting, emergency department triage

#### 1. Introduction

God created human beings and honored them over other creatures; therefore, keeping life is one of utmost urges. This urge to save lives is challenged in time of major incidents when patients' needs are exceeding care resources. Moreover, with the increase in global population and escalation in the costs of healthcare, more patients are visiting emergency departments (EDs) all over the world to cut expenses and bypass remote appointments. Most EDs today adopt a triage system to prioritize patients who need urgent care.

#### 2. Definition

#### 2.1 Linguistic definition

"The process of determining the most important people or things from amongst a large number that require attention" [1].

#### 2.2 In medical use

It is the sorting of victims by giving them grade to prioritize them for treatment and transportation in order to maximize the number of survivors in major incidents and war victims [2]. According to the assigned grade, patients will have their priority in attending by healthcare givers, investigations, and operation rooms.

The term triage is similar to "rationing" and "allocation" which is practiced on a daily basis in every field. For the term triage to be applied for a situation, there are three prerequisites that must be fulfilled:

treatment for the sake of others. The triage decision now is to which facility best

Health system ethics has been developing and improving since the eighteenth century by the First Geneva Conventions (1859) and Nuremberg Act [9]. In 1979, Beauchamp and Childress published their book Principles of Biomedical Ethics [10].

transfer the patient and what is the optimum method of transportation.

To have a triage system, there are three requirements to be fulfilled:

A. There should be shortage of resources in comparison to the need.

B. There should be a system set by health authority to be used in such

C. There are personnel trained on the system who will implement it.

health facility will do its best to treat the patient.

If there is no shortage, then no need to use triage, but for every patient, the

A triage system should be set by the health authority or facility administration to be followed by anyone doing this task. The aim of this step is to look for the benefit of the community and the population as a whole and not to

D.Trained personnel to practice the triage to ensure the justice and prevent

During major incidents, there are situations in which the triage officer should take some decisions that may be hard and not in the best interest of some patients. The decisions made by the planners in the First and Second World Wars and before are made not by patients' will or his best interest and benefit. Below is the discus-

1. Respect of autonomy: During a normal life, this is the first patient's right. No intervention should be done unless the patient understands the issue fully and accepts it. For this reason, the informed consent is needed to be signed by the patient. In time of major incidents with a large number of patients present, there should be prioritization of patients according to system agreed upon by the hospital or health authority. In time of major incidents, absolute knowledge of the whole community needs is predominant over individual liberty. It is sure

4. Moral and ethical issues in triage

DOI: http://dx.doi.org/10.5772/intechopen.86227

They put four main principles which are:

4.1 Requirements for a triage system

circumstances (point A).

just part of it.

personal preference.

sion of the principles one by one:

17

1. Respect of autonomy

2. Beneficence

4.Justice

Triage

3. Non-maleficence

1. There is shortage of resources in comparison to the needs.


#### 3. History of triage

Triage started as war time medical effort driven by the increased number of wounded and shortage of resources. In addition the need for manpower during wars affected the priorities in triage in some armies.

It is believed that the first time triage used in military medicine to prioritize treatment for the wounded was by Baron Dominque Jean Larry (8 July 1766–25 July 1842). He made rules that the wounded are treated by the severity of their clinical conditions regardless of the rank; even enemies were treated in the same way [4].

The next milestone in triage was attributed to British rear admiral John Crawford Wilson (1834–4 July 1885) [5]. He differentiated between the severity levels of the wounded; he wrote in his book Outlines of Naval Surgery: "If a case should be hopeless, or the man apparently dying, an operation then would be useless" [6]. He was sorting wounded soldiers into three categories: slight, serious, and fatal. This was the base for further division in triage system by creation of the expectant zone. In the triage system created by Dominique, all serious cases are treated in the same level.

Triage in the American civil war was depending on the first-come, first-served basis regardless of the severity, salvageability, or best use of limited resources [3].

The World War I with the development of more lethal weapons like machine guns and chemical gases with a large number of wounds that could be treated pushed the military surgeons to apply and refine triage protocols. This has led to the concept of "The greatest good of the greatest number." This is the rule for triage practiced in military and civilian life during major incidents now [7]. This rule means that at time of limited resources and facing huge demand, some patients can be saved if long time and large amount of resources devote to them, but this will not be done. The reason to not offering help to those patients is that we can save much more number of wounded patients (who are less critical) using the same resources during the same time. We may save 10 patients instead of one. The pressure of escalating numbers of wounded soldiers with limited fighters in the battles made some health strategic planners in the armies to give higher priorities to patients that can be treated and sent back to front war lines rapidly over seriously injured patients that need urgent intervention for long duration. Winslow listed the two objectives of triage as "1st, conservation of manpower; 2nd, the conservation of the interest of the sick and wounded" [8].

In the World War II, the weapons were more developed with the introduction of tanks and air forces. On the other hand, medications and health services improved. The health strategic planners still concentrate on supporting the troops. They direct resources for soldiers who are able to fight rather than injured or diseased ones.

With the improvement of transportation and less dependence on the manpower in modern wars, it is rarely nowadays needed to leave somebody without

treatment for the sake of others. The triage decision now is to which facility best transfer the patient and what is the optimum method of transportation.

### 4. Moral and ethical issues in triage

Health system ethics has been developing and improving since the eighteenth century by the First Geneva Conventions (1859) and Nuremberg Act [9]. In 1979, Beauchamp and Childress published their book Principles of Biomedical Ethics [10]. They put four main principles which are:


The term triage is similar to "rationing" and "allocation" which is practiced on a daily basis in every field. For the term triage to be applied for a situation, there are

1. There is shortage of resources in comparison to the needs.

3. Trained health personnel should do the triage [3].

affected the priorities in triage in some armies.

2. There should be a system set to triage by the health body or facility.

Triage started as war time medical effort driven by the increased number of wounded and shortage of resources. In addition the need for manpower during wars

It is believed that the first time triage used in military medicine to prioritize treatment for the wounded was by Baron Dominque Jean Larry (8 July 1766–25 July 1842). He made rules that the wounded are treated by the severity of their clinical conditions regardless of the rank; even enemies were treated in the same way [4]. The next milestone in triage was attributed to British rear admiral John Crawford Wilson (1834–4 July 1885) [5]. He differentiated between the severity levels of the wounded; he wrote in his book Outlines of Naval Surgery: "If a case should be hopeless, or the man apparently dying, an operation then would be useless" [6]. He was sorting wounded soldiers into three categories: slight, serious, and fatal. This was the base for further division in triage system by creation of the expectant zone. In the triage system created by Dominique, all serious cases are

Triage in the American civil war was depending on the first-come, first-served basis regardless of the severity, salvageability, or best use of limited resources [3]. The World War I with the development of more lethal weapons like machine guns and chemical gases with a large number of wounds that could be treated pushed the military surgeons to apply and refine triage protocols. This has led to the concept of "The greatest good of the greatest number." This is the rule for triage practiced in military and civilian life during major incidents now [7]. This rule means that at time of limited resources and facing huge demand, some patients can be saved if long time and large amount of resources devote to them, but this will not be done. The reason to not offering help to those patients is that we can save much more number of wounded patients (who are less critical) using the same resources during the same time. We may save 10 patients instead of one. The pressure of escalating numbers of wounded soldiers with limited fighters in the battles made some health strategic planners in the armies to give higher priorities to patients that can be treated and sent back to front war lines rapidly over seriously injured patients that need urgent intervention for long duration. Winslow listed the two objectives of triage as "1st, conservation of manpower; 2nd, the conservation of the

In the World War II, the weapons were more developed with the introduction

With the improvement of transportation and less dependence on the manpower

improved. The health strategic planners still concentrate on supporting the troops. They direct resources for soldiers who are able to fight rather than injured or

of tanks and air forces. On the other hand, medications and health services

in modern wars, it is rarely nowadays needed to leave somebody without

three prerequisites that must be fulfilled:

Emergency Medicine and Trauma

3. History of triage

treated in the same level.

interest of the sick and wounded" [8].

diseased ones.

16

#### 4.1 Requirements for a triage system

To have a triage system, there are three requirements to be fulfilled:

A. There should be shortage of resources in comparison to the need.


If there is no shortage, then no need to use triage, but for every patient, the health facility will do its best to treat the patient.

A triage system should be set by the health authority or facility administration to be followed by anyone doing this task. The aim of this step is to look for the benefit of the community and the population as a whole and not to just part of it.

D.Trained personnel to practice the triage to ensure the justice and prevent personal preference.

During major incidents, there are situations in which the triage officer should take some decisions that may be hard and not in the best interest of some patients. The decisions made by the planners in the First and Second World Wars and before are made not by patients' will or his best interest and benefit. Below is the discussion of the principles one by one:

1. Respect of autonomy: During a normal life, this is the first patient's right. No intervention should be done unless the patient understands the issue fully and accepts it. For this reason, the informed consent is needed to be signed by the patient. In time of major incidents with a large number of patients present, there should be prioritization of patients according to system agreed upon by the hospital or health authority. In time of major incidents, absolute knowledge of the whole community needs is predominant over individual liberty. It is sure that some people will not be happy with delaying them regardless of their presentation time or their degree of severity.

people, and in time of limited resources with the equality of other factors, priority should be given to children for the sake of the community.

B. Pregnant women: In dealing with pregnant women, we are dealing with two lives; therefore, they have double importance and should take priority.

C. Emergency services personnel: All those personnel should not be counted as one person; if we give them priority and save them, they will help in saving more lives. We give them the value of the expected number of lives they may save. In addition taking care of someone injured rapidly will encourage other to put all their efforts, knowing that their colleagues will treat them in high priority if they are injured, and this will improve the quality of care given to all

D.People with special skills or knowledge or with special importance: There are some people who possess some special knowledge and skills or have some special importance to the country. Those should also get special treatment and priority. This will need confirmation of their status and priority from local or

E. The surrounding circumstance: If there is a critical need to manpower like in war condition, for example, then the triage officer may make the highest priority to simple cases that can be treated with minimal resources and time and go back to combat area. Another example is facing floods and waiting for central help, until extra help reaches them, and there is a desperate need for all

hands even the slightly wounded; otherwise, the whole area and local

F. Combination of the abovementioned conditions needs the triaging officer to

3. Emergency department triage system which is used for managing patients

1. Military triage system: The military triage differs from civilian life because in many occasions there is chaos and many of the infrastructures are not present or destroyed by the combat. Another reason is that the troops are usually located outside the cities where there are no or small services and they need to build their own treatment and evacuation system. The healthcare in present time is provided to every wounded for two reasons. First, there is no dependence on manpower like previous battles, and, second, there is huge improvement in communication and transportation tools and equipment. Now every wounded soldier is treated, but the difference is in time and place.

national authority to recognize them during major incidents.

community will have grave outcomes.

put his priority at that single moment.

We can divide triage systems into several categories:

6. Common triage systems

1. Military triage system

on a daily basis

19

2. Major incidents in civilian life

patients.

Triage

DOI: http://dx.doi.org/10.5772/intechopen.86227

2. Beneficence: In 1964, the World Medical Association (WMA) developed the Declaration of Helsinki as a set of ethical principles for experimentation on human beings. The declaration strongly emphasizes (a) that the concern for the interests of the subject must always prevail over the interests of science and society and (b) that ethical considerations must always take precedence over laws and regulations. Those principles cannot be applied during disaster conditions. The overall benefit to the community should overrule the personal benefit, and the concept of "maximum benefit to maximum number" should be used to maximize community benefit and welfare.

Later in the chapter, there is a section regarding exceptions to the general rules.


#### 5. Special circumstances in triage

Although triage depends mainly on patients' injury severity, there are conditions which oblige the officer to modify his triage decision or in austere condition to decide to whom priority of care is given. The triage officer should look to the whole picture of the community, putting in his mind the aims at that particular time he is doing it and the full resources in addition to the type of patients he is dealing with. The following are examples of special conditions which need special care and by no means are they exhaustive:

A.Children: Dealing with children is sensitive not only from the emotional side but also the practical side. Children have more expected life span than old

that some people will not be happy with delaying them regardless of their

2. Beneficence: In 1964, the World Medical Association (WMA) developed the Declaration of Helsinki as a set of ethical principles for experimentation on human beings. The declaration strongly emphasizes (a) that the concern for the interests of the subject must always prevail over the interests of science and society and (b) that ethical considerations must always take precedence over laws and regulations. Those principles cannot be applied during disaster conditions. The overall benefit to the community should overrule the personal benefit, and the concept of "maximum benefit to maximum number" should

Later in the chapter, there is a section regarding exceptions to the general rules.

3. Non-maleficence: Non-maleficence means doing non-harming or inflicting the least harm possible to reach a beneficial outcome [11]. In this meaning trying to save as much as possible of the community can explain depriving some patients from treatment or delay them until suitable time and resources are available. In this issue we may not consider all people as the same, for example, if there is a healthcare giver and a fighter that are wounded, then we should not count each as one person, because when the healthcare giver is treated, he

4.Justice: In justice we mean that each patient should take what he needs and no one should be disadvantaged or deprived from treatment. People may misunderstand the meaning well and have high expectations to treat all patients as the highest-priority patient. To explain this we should differentiate between equality and justice. The first one means that everybody should receive the same amount. For example, a patient with fracture can wait for days, while the unconscious patient with multiple injuries needs rapid assessment and a full management plan rapidly implemented. This is justice; each patient will take time and resources according to the severity of the

5. Ownership of resources is challenged in time of major incidents, and the

hospital should accept and treat any patient involved in the incident (according

Although triage depends mainly on patients' injury severity, there are conditions

A.Children: Dealing with children is sensitive not only from the emotional side but also the practical side. Children have more expected life span than old

which oblige the officer to modify his triage decision or in austere condition to decide to whom priority of care is given. The triage officer should look to the whole picture of the community, putting in his mind the aims at that particular time he is doing it and the full resources in addition to the type of patients he is dealing with. The following are examples of special conditions which need special care and

presentation time or their degree of severity.

Emergency Medicine and Trauma

be used to maximize community benefit and welfare.

will help in saving the other.

condition.

to the plan) [3].

5. Special circumstances in triage

by no means are they exhaustive:

18

people, and in time of limited resources with the equality of other factors, priority should be given to children for the sake of the community.


#### 6. Common triage systems

We can divide triage systems into several categories:


2.Major incidents in civilian life: Civilian triage started around 200 years after the military one. The first triage system is simple triage and rapid treatment (START) which is a method used in the field to rapidly sort and prioritize patients during major incidents according to the severity of their injuries. It was developed in 1983 in California [12, 13]. Later there will be discussion of other systems that are developed later.

The physiological systems are easily learned and need simple training; any health personnel can be trained and perform it. Moreover it can be reproduced easily and is a reliable method of following up the patient's condition. On the other hand, it is time-consuming and not suitable for incidents with a huge number of victims. Anatomical systems of triage are fast and depend on visual recognition of injuries. These methods need a good amount of experience in injuries and when the patient needs surgery. It is difficult to reproduce the results as it is subjective and not objective. A very large number of victims is suitable for this type of triage. After knowledge of the anatomical and physiological condition of patients, the

triage officer needs to know the comorbidities to and other circumstances (discussed above in the section of special situations) to give the patient the final

injured. The reactions to be noticed are:

be interpreted in different combinations for the same score [17].

The most common triage systems used in major incidents are as follows:

A.Glasgow Coma Scale: It is a scoring system used to evaluate the patients with coma or disturbed consciousness (Table 2). It was first described by Graham Teasdale and Bryan Jennett in 1974 and was used as a practical method to evaluate patients with brain injury and a good method to communicate the patient's condition between different healthcare providers or facilities. The findings use the scale guide initial decision-making and monitor trends in responsiveness that are important in signaling the need for new actions [15]. Each point will be given a number: the maximum score is (15) and means the patient is fully conscious, and the lowest is (3) which is clearly seriously

There are studies comparing the full GCS to the motor reaction alone. It is believed that motor response is better predictive of patients' condition than full GCS [16]. Recently the use of GCS in triage is objected because it is time-consuming and can

B. Simple triage and rapid treatment (START): It is currently widely used in the United States and many other countries. People can be easily trained on it and used to sort victims rapidly into four categories: red, yellow, green, and white (or black). It depends on the ability of the victim to walk and then give the green category. If the patient cannot walk and has any alteration in his level of

consciousness or vital signs, then he is categorized as red. If there is no alteration, he will be yellow. If no breathing and unconscious, then he is considered dead

(white). Figure 1 shows the flowchart for START triage system [18].

C.JumpSTART: It is the pediatric version of the START system; the main difference is the trial with the child to do airway maneuver and short

Spontaneous 4 Orientated 5 Obey commands 6 To sound 3 Confused 4 Localizing 5 To pressure 2 Words 3 Normal flexion 4 None 1 Sounds 2 Abnormal flexion 3

None 1 Extension 2

None 1

Eyes Verbal Motor

Glasgow Coma Scale (GCS). (glasgowcomascale.org) [15].

triage level.

Triage

DOI: http://dx.doi.org/10.5772/intechopen.86227

Table 2.

21

The triage systems used in military and major incidents "that occur in civilian life" are the same, and it will be discussed in combination. They differ in the infrastructures supporting each one, with clear overlap between them.

Table 1 shows some of scoring systems used to evaluate the severity of the injuries which is the base for triage.

There are different categories for triage in major incidents. They are the physiological and the anatomical methods.


### Table 1.

#### Triage DOI: http://dx.doi.org/10.5772/intechopen.86227

2.Major incidents in civilian life: Civilian triage started around 200 years after the military one. The first triage system is simple triage and rapid treatment (START) which is a method used in the field to rapidly sort and prioritize patients during major incidents according to the severity of their injuries. It was developed in 1983 in California [12, 13]. Later there will be discussion of

The triage systems used in military and major incidents "that occur in civilian life"

Table 1 shows some of scoring systems used to evaluate the severity of the

There are different categories for triage in major incidents. They are the

are the same, and it will be discussed in combination. They differ in the infrastructures supporting each one, with clear overlap between them.

other systems that are developed later.

injuries which is the base for triage.

Emergency Medicine and Trauma

physiological and the anatomical methods.

Year introduced Abbreviation Name

 TI Trauma index GCS Glasgow Coma Scale TISS Therapeutic intervention ISS Injury severity score TI Triage index

1982 PGCS Pediatric GCS

1987 PT Pediatric trauma score 1987 OIS Organ injury scale (AAST) 1988 PRISM Pediatric risk of mortality score

1989 AP Anatomical profile 1989 RTS Revised trauma score 1989 T-RTS Triage version of RTS

1997 NISS New ISS

Table 1.

20

List of scoring systems [14].

1970 AIS Abbreviated injury scale

1980 TRISS Trauma injury and severity score

1990 ASCOT A severity characterization of trauma

1994 APSC Acute physiology score for children

1996 TOXALSTM Toxic advanced life support TM

 ASPTS Age-specific pediatric trauma score PAAT Pediatric age-adjusted TRISS START Simple triage and rapid treatment JUMP-START Pediatric version of START The year input is the first time the system was introduced. Some has been updated later.

1994 UST Uniform scoring system for trauma (Utstein style)

1996 ICD-9-CM ICD-9 clinical modification based on AIS and ISS

1981 APACHE Acute physiological and chronic health evaluation

The physiological systems are easily learned and need simple training; any health personnel can be trained and perform it. Moreover it can be reproduced easily and is a reliable method of following up the patient's condition. On the other hand, it is time-consuming and not suitable for incidents with a huge number of victims.

Anatomical systems of triage are fast and depend on visual recognition of injuries. These methods need a good amount of experience in injuries and when the patient needs surgery. It is difficult to reproduce the results as it is subjective and not objective. A very large number of victims is suitable for this type of triage.

After knowledge of the anatomical and physiological condition of patients, the triage officer needs to know the comorbidities to and other circumstances (discussed above in the section of special situations) to give the patient the final triage level.

The most common triage systems used in major incidents are as follows:

A.Glasgow Coma Scale: It is a scoring system used to evaluate the patients with coma or disturbed consciousness (Table 2). It was first described by Graham Teasdale and Bryan Jennett in 1974 and was used as a practical method to evaluate patients with brain injury and a good method to communicate the patient's condition between different healthcare providers or facilities. The findings use the scale guide initial decision-making and monitor trends in responsiveness that are important in signaling the need for new actions [15]. Each point will be given a number: the maximum score is (15) and means the patient is fully conscious, and the lowest is (3) which is clearly seriously injured. The reactions to be noticed are:

There are studies comparing the full GCS to the motor reaction alone. It is believed that motor response is better predictive of patients' condition than full GCS [16]. Recently the use of GCS in triage is objected because it is time-consuming and can be interpreted in different combinations for the same score [17].



Table 2. Glasgow Coma Scale (GCS). (glasgowcomascale.org) [15].

#### Emergency Medicine and Trauma

resuscitation trial in the field before declaring death of the child. In addition to considering the change of heart rate in different age groups, Figure 2 shows

D.Triage-revised trauma score (T-RTS): This system depends on physiological parameters of the patient at the time of evaluation. It is found to be a good indicator of the severity of the injury [19]. It depends on three physiological parameters which are (1) Glasgow Coma Score (GCS), (2) systolic blood pressure (BP), and (3) respiratory rate (RR). Each factor will be given a score, and then the scores of the three factors are summed: the more the score, the

the flowchart for JumpSTART triage system.

DOI: http://dx.doi.org/10.5772/intechopen.86227

Triage

Step 1: Different variables in TRTS. Step 2: Interpretation of the results.

Table 3.

23

Triage-revised trauma score [19].

Figure 1. Flowchart for START triage system [18].

Figure 2. Flow sheet for JumpSTART triage system [18].

resuscitation trial in the field before declaring death of the child. In addition to considering the change of heart rate in different age groups, Figure 2 shows the flowchart for JumpSTART triage system.

D.Triage-revised trauma score (T-RTS): This system depends on physiological parameters of the patient at the time of evaluation. It is found to be a good indicator of the severity of the injury [19]. It depends on three physiological parameters which are (1) Glasgow Coma Score (GCS), (2) systolic blood pressure (BP), and (3) respiratory rate (RR). Each factor will be given a score, and then the scores of the three factors are summed: the more the score, the



Step 1: Different variables in TRTS. Step 2: Interpretation of the results.

#### Table 3. Triage-revised trauma score [19].

Figure 2.

22

Figure 1.

Flowchart for START triage system [18].

Emergency Medicine and Trauma

Flow sheet for JumpSTART triage system [18].


If the validation depends on the injury severity score (ISS) and any patient with

acceptable level is 5% [24]. It is found that patients with under-triage have less mortality rate than patients with right triage to the trauma centers because they

prioritizing that person's management over that of a patient with more urgent needs [26]. This is a less risky medical mistake. Its effect is on the limited resources during a major incident in terms of human resources, stuff used, or space occupied, e.g., intensive care beds, CT scan, operating theater, etc.; due

Triage is a key step in managing major incidents properly. It is not contradicting

a score of >15 transferred to a hospital without trauma center, then the

2. Over-triage: A term of art referring to unintentionally overestimating the urgency of the condition of a person arriving in A&E (casualty) and

to its low risk to patients, it is agreed that 25–50% is accepted [25].

bioethics, but it is looking from a different focus to make the best to the whole community. It has no rigid rules, and the triage officer must look for different aspects of resources and patients'situation to make the best triage decision leading

8. Summary

Triage

to most benefits for all.

Author details

25

Abdulnasir F.H. Aljazairi

Emergency Department, Hamad Medical Corporation, Qatar

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

\*Address all correspondence to: ahuaidi@hamad.qa

provided the original work is properly cited.

have better GCS score, blood pressure, and base deficit [25].

DOI: http://dx.doi.org/10.5772/intechopen.86227

#### Table 4.

The five levels of triage in emergency department [21].

better the condition of the patient and vice versa. Table 3 shows the different items in T-RTS and their interpretation.

There are several other systems, but they are used to assess and predict prognosis in trauma patients and not used for prioritizing them during response to major incidents.

3.Emergency department triage systems: The emergency department shares with the military life the inability to control the number and time of patients presented. With timeliness of the care and relative scarce of resources, in addition to the increase in the demand on beds and blocked access to other services, more patients are seeking medical care in emergency departments [20]. To make risk assessment of patient introduced to the ED and make the best benefit of the resources, a five-level triage system was introduced in Ipswich, Australia. This system was validated and adopted in several states in Australia and formed the base for different national systems in several countries in the world. The triage is done by experienced nurses, will give patients one of the five levels depending on the urgency of the conditions. Table 4 shows the five levels in emergency department triage and the period allowed before attending the patient [21].

There are several triaging systems in different countries like the Manchester triage system which is widely used in the UK hospitals and the Canadian triage system (CTAS) and others, all using five levels and basically similar in sorting patients. There are minimal differences in the bench mark for the time frame each category should be seen within.

#### 7. Wrong triage

With the rush and chaos occurring during response to major incidents, there are mistakes that may be committed by the triaging officer. Under-triage and overtriage are the wrong decisions that may occur:

1. Under-triage: It is defined as "A term of art referring to underestimating the urgency of the condition of a person arriving in A&E and not prioritizing his or her management over that of a patient with less urgent needs" [22]. It is a medical problem and may result is serious bad outcomes because it deprives a patient from the resources he/she needs. What is the level of acceptable risk of under-triage? The CDC puts the threshold as 20%, but in practice it is 35% [23].

#### Triage DOI: http://dx.doi.org/10.5772/intechopen.86227

If the validation depends on the injury severity score (ISS) and any patient with a score of >15 transferred to a hospital without trauma center, then the acceptable level is 5% [24]. It is found that patients with under-triage have less mortality rate than patients with right triage to the trauma centers because they have better GCS score, blood pressure, and base deficit [25].

2. Over-triage: A term of art referring to unintentionally overestimating the urgency of the condition of a person arriving in A&E (casualty) and prioritizing that person's management over that of a patient with more urgent needs [26]. This is a less risky medical mistake. Its effect is on the limited resources during a major incident in terms of human resources, stuff used, or space occupied, e.g., intensive care beds, CT scan, operating theater, etc.; due to its low risk to patients, it is agreed that 25–50% is accepted [25].

#### 8. Summary

better the condition of the patient and vice versa. Table 3 shows the different

There are several other systems, but they are used to assess and predict prognosis in trauma patients and not used for prioritizing them during response to major

Two Patients will have priority and seen in the next doctor available. By passing que of patients

3.Emergency department triage systems: The emergency department shares with the military life the inability to control the number and time of patients presented. With timeliness of the care and relative scarce of resources, in addition to the increase in the demand on beds and blocked access to other services, more patients are seeking medical care in emergency departments [20]. To make risk assessment of patient introduced to the ED and make the best benefit of the resources, a five-level triage system was introduced in Ipswich, Australia. This system was validated and adopted in several states in Australia and formed the base for different national systems in several countries in the world. The triage is done by experienced nurses, will give patients one of the five levels depending on the urgency of the conditions. Table 4 shows the five levels in emergency department triage and the period

There are several triaging systems in different countries like the Manchester triage system which is widely used in the UK hospitals and the Canadian triage system (CTAS) and others, all using five levels and basically similar in sorting patients. There are minimal differences in the bench mark for the time frame each

With the rush and chaos occurring during response to major incidents, there are mistakes that may be committed by the triaging officer. Under-triage and over-

1. Under-triage: It is defined as "A term of art referring to underestimating the urgency of the condition of a person arriving in A&E and not prioritizing his or her management over that of a patient with less urgent needs" [22]. It is a medical problem and may result is serious bad outcomes because it deprives a patient from the resources he/she needs. What is the level of acceptable risk of under-triage? The CDC puts the threshold as 20%, but in practice it is 35% [23].

items in T-RTS and their interpretation.

The five levels of triage in emergency department [21].

Categories and urgencies in the emergency triage system

Three To place the patient's file at the front of the waiting list

One Patients in this category should be attended immediately when presented

Four Wait for their que or may be advised to go to a primary health facility

Five Discharged from emergency side and advised to visit the primary health facility

Category Urgency of the condition

present

Emergency Medicine and Trauma

allowed before attending the patient [21].

triage are the wrong decisions that may occur:

category should be seen within.

7. Wrong triage

24

incidents.

Table 4.

Triage is a key step in managing major incidents properly. It is not contradicting bioethics, but it is looking from a different focus to make the best to the whole community. It has no rigid rules, and the triage officer must look for different aspects of resources and patients'situation to make the best triage decision leading to most benefits for all.

#### Author details

Abdulnasir F.H. Aljazairi Emergency Department, Hamad Medical Corporation, Qatar

\*Address all correspondence to: ahuaidi@hamad.qa

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### References

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[17] Stratton SJ. Glasgow coma scale score in trauma triage: A measurement without meaning. Annals of Emergency Medicine. 2018;72(3):270-271. Available

from: https://insights.ovid.com/

[19] Lichtveld RA, Spijkers AT, Hoogendoorn JM, Panhuizen IF, Van der werken C. Triage revised trauma score change between first assessment and arrival at the hospital to predict mortality. International Journal of Emergency Medicine. 2008;1(1):21-26. Available from: https://www.ncbi.nlm. nih.gov/pmc/articles/PMC2536180/

[Accessed: 2 April 2019]

[20] Fitzgerald G, Jelinek GA, Scott D, Gerdtz MF. Emergency department triage revisited. Emergency Medicine Journal. 2010;27(2):86-92. Available

April 2019]

April 2019]

27

crossref/00000566–201809000-00008? isFromRelatedArticle=Y [Accessed: 1

[18] Bazyar J, Farrokhi M, Khankeh H. Triage Systems in Mass Casualty Incidents and Disasters: A review study with a worldwide approach. Open Access Macedonian Journal of Medical Sciences. 2019;7(3):482-494. DOI: 10.3889/oamjms.2019.119. Available from: https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC6390156/ [Accessed: 1

2019]

Triage

2019]

[10] Beauchamp TL. Childress JF: Principles of Biomedical Ethics. New York: Oxford University Press; 2009

[11] Sundean LJ, McGrath JM. Ethical considerations in the neonatal intensive care unit. Available from: https://www. medscape.com/viewarticle/811079\_5 [Accessed: 10 March 2019

[12] Ciottone GR, Biddinger PD, Darling RG, et al. Ciottone's Disaster Medicine. Elsevier Health Sciences; 2015. Available from: https://books.google.com.qa/ books?redir\_esc=y&hl=ar&id=9cUMog EACAAJ&q=START+TRIAGE +SYSTEM#v=snippet&q=START% 20TRIAGE%20SYSTEM&f=false [Accessed: 12 March 2019]

[13] Lee CH. Disaster and mass casualty triage. AMA Journal of Ethics. Virtual Mentor. 2010;12(6):466-470. DOI: 10.1001/virtualmentor.2010.12.6. cprl1-1006. Available from: https:// journalofethics.ama-assn.org/article/ disaster-and-mass-casualty-triage/ 2010-06 [Accessed: 4 April 2019]

[14] Wilson WC, Grande CM, Hoyt DB. Trauma, Emergency Resuscitation, Perioperative Anesthesia, Surgical Management. AMA Journal of Ethics. CRC Press; 2007. Available from: https://books.google.com.qa/books?id= 6FPvBQAAQBAJ&pg=PA60&lpg= PA60&dq=%22Acute+physiological +and+chronic+health+Evaluation%22 +triage&source=bl&ots= PO9hPZEU4x&sig=ACfU3U1bjru8o5\_ HzgmJI-mg9v-d2OZahg&hl=ar&sa= X&ved=2ahUKEwjC5IuapLLh AhXF8HMBHRkGAmQQ6

#### Triage DOI: http://dx.doi.org/10.5772/intechopen.86227

AEwA3oECAgQAQ#v=onepage&q=% 22Acute%20physiological%20and% 20chronic%20health%20Evaluation% 22%20triage&f=false [Accessed: 2 April 2019]

References

[1] Oxford dictionary. Available from: https://en.oxforddictionaries.com/def inition/triage [Accessed: 1 March 2019]

Emergency Medicine and Trauma

[9] Bernd D, Tobias K, Stefan G, Peter B, Tanja G. Ethical aspects of triage. 2 VOJENSKÉ ZDRAVOTNICKÉ LISTY ROČNÍK LXXIX, 2010, č. P 77–82. Available from: https://www.mmsl.cz/ pdfs/mms/2010/02/08.pdf [Accessed: 3

[10] Beauchamp TL. Childress JF: Principles of Biomedical Ethics. New York: Oxford University Press; 2009

[11] Sundean LJ, McGrath JM. Ethical considerations in the neonatal intensive care unit. Available from: https://www. medscape.com/viewarticle/811079\_5

[12] Ciottone GR, Biddinger PD, Darling RG, et al. Ciottone's Disaster Medicine. Elsevier Health Sciences; 2015. Available from: https://books.google.com.qa/ books?redir\_esc=y&hl=ar&id=9cUMog

[13] Lee CH. Disaster and mass casualty triage. AMA Journal of Ethics. Virtual Mentor. 2010;12(6):466-470. DOI: 10.1001/virtualmentor.2010.12.6. cprl1-1006. Available from: https:// journalofethics.ama-assn.org/article/ disaster-and-mass-casualty-triage/ 2010-06 [Accessed: 4 April 2019]

[14] Wilson WC, Grande CM, Hoyt DB. Trauma, Emergency Resuscitation, Perioperative Anesthesia, Surgical Management. AMA Journal of Ethics. CRC Press; 2007. Available from: https://books.google.com.qa/books?id= 6FPvBQAAQBAJ&pg=PA60&lpg= PA60&dq=%22Acute+physiological +and+chronic+health+Evaluation%22

PO9hPZEU4x&sig=ACfU3U1bjru8o5\_ HzgmJI-mg9v-d2OZahg&hl=ar&sa= X&ved=2ahUKEwjC5IuapLLh AhXF8HMBHRkGAmQQ6

+triage&source=bl&ots=

[Accessed: 10 March 2019

EACAAJ&q=START+TRIAGE +SYSTEM#v=snippet&q=START% 20TRIAGE%20SYSTEM&f=false [Accessed: 12 March 2019]

April 2019]

[2] Triage (n.) in Merriam Webester dictionary. Retrieved from: https:// www.merriam-webster.com/dictionary/ triage [Accessed: 1 February 2019]

[3] http://scholar.google.com/scholar\_ url?url=https://www.researchgate.net/ profile/Kenneth\_Iserson/publication/ 262637907\_Triage\_Ethics-Part\_1/links/ 0f3175384caa07fc8a000000.pdf&hl= ar&sa=X&scisig=AAGBfm1ChejVnHa 5pPw72hFGiaDK2zyl2Q&nossl=1&oi= scholarr [Accessed: 1 March 2019]

[4] Nakao H, Ukai I, Kotani J. A review of the history of the origin of triage from a disaster medicine

ams2.293

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perspective. Acute Medicine & Surgery. 2017;4(4):379-384. DOI: 10.1002/

[5] https://en.wikipedia.org/wiki/John\_

[6] John Wilson D. Outlines of Naval Surgery. Edinburgh: MACLACHLAN, STEWART & Co. p. 26. Available from: https://books.google.com.qa [Accessed:

[7] Keen WW. The Treatment of War Wounds (Classic Reprint). Forgotten Books; 2017. W. B. Saunders Company 1918. Available from: https://archive. org/details/treatmentofwarwo00keen/ page/13 [Accessed: 3 April 2019]

[8] Manring MM, Hawk A, Calhoun JH, Andersen RC. Treatment of war wounds: A historical review. Clinical Orthopaedics and Related Research. 2009;467(8):2168-2191. DOI: 10.1007/ s11999-009-0738-5. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC2706344/ [Accessed:

Wilson\_(Royal\_Navy\_officer) [Accessed: 8 March 2019]

[15] https://www.glasgowcomascale. org/what-is-gcs/ [Accessed: 15 March 2019]

[16] Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow coma scale score: Motor score alone is a better predictor. The Journal of Trauma. 2003; 54(4):671-678. Available from: https:// insights.ovid.com/pubmed?pmid= 12707528 [Accessed: 1 April 2019]

[17] Stratton SJ. Glasgow coma scale score in trauma triage: A measurement without meaning. Annals of Emergency Medicine. 2018;72(3):270-271. Available from: https://insights.ovid.com/ crossref/00000566–201809000-00008? isFromRelatedArticle=Y [Accessed: 1 April 2019]

[18] Bazyar J, Farrokhi M, Khankeh H. Triage Systems in Mass Casualty Incidents and Disasters: A review study with a worldwide approach. Open Access Macedonian Journal of Medical Sciences. 2019;7(3):482-494. DOI: 10.3889/oamjms.2019.119. Available from: https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC6390156/ [Accessed: 1 April 2019]

[19] Lichtveld RA, Spijkers AT, Hoogendoorn JM, Panhuizen IF, Van der werken C. Triage revised trauma score change between first assessment and arrival at the hospital to predict mortality. International Journal of Emergency Medicine. 2008;1(1):21-26. Available from: https://www.ncbi.nlm. nih.gov/pmc/articles/PMC2536180/ [Accessed: 2 April 2019]

[20] Fitzgerald G, Jelinek GA, Scott D, Gerdtz MF. Emergency department triage revisited. Emergency Medicine Journal. 2010;27(2):86-92. Available

from: https://www.ncbi.nlm.nih.gov/ pubmed/20156855 [Accessed: 2 April 2019]

[21] Hospital triage. NSW, Australia. Available from: https://www.health. nsw.gov.au/Hospitals/Going\_To\_ hospital/Pages/triage.aspx [Accessed: 3 April 2019]

[22] Available from: https://medicaldictionary.thefreedictionary.com/ undertriage [Accessed: 16 March 2019]

[23] Nishimoto T, Mukaigawa K, Tominaga S, et al. Serious injury prediction algorithm based on largescale data and under-triage control. Accident; Analysis and Prevention. 2017;98:266-276. Available from: https://www.sciencedirect.com/science/ article/pii/S000145751630358X [Accessed: 3 April 2019]

[24] Barsi C, Harris P, Menaik R, Reis NC, Munnangi S, Elfond M. Risk factors and mortality associated with undertriage at a level I safety-net trauma center: A retrospective study. Open Access Emergency Medicine. 2016;8:103-110. Available from: https:// www.ncbi.nlm.nih.gov/pmc/articles/ PMC5108619/ [Accessed: 3 April 2019]

[25] Davis JW, Dirks RC, Sue LP, Kaups KL. Attempting to validate the overtriage/undertriage matrix at a level I trauma center. Journal of Trauma and Acute Care Surgery. 2017;83(6): 1173-1178. Available from: https://www. ncbi.nlm.nih.gov/pmc/articles/ PMC5732627/ [Accessed: 16 March 2019]

[26] Retrieved from: https://medicaldictionary.thefreedictionary.com/ overtriage [Accessed: 3 April 2019]

**29**

them.

**Chapter 3**

**Abstract**

activations.

**1. Introduction**

ground ambulance transfer

Prehospital Emergency Care in

It is well known at this moment that a systems and systematic approach to trauma care cases is ideal. The prehospital controversies of in-the-field care in trauma cases, resuscitation, and transport, ground or air, are still debated. The most controversial is rapid transport to definitive care ("scoop and run") versus field stabilization in trauma, which remains a topic of debate and resulted in great variability of prehospital policy. Emergency medical services, including ground and air transportation, significantly extend the reach of tertiary care facilities, leading to rapid transport of critically ill patients. Emergency medical services (EMS) providers are the first link to a trauma care system, and trauma triage made by EMS personnel is also a very important factor in a good outcome of trauma patients. The assessment of patient and the treatment delivered by the first medical crew could have a large impact over the clinical evolution and output of trauma patient; that way, it is necessary to apply a systematic approach in this pathology, guided by clear and simple-to-follow recommendations applied on the scene. Recent review of the literature on helicopter emergency medical services (HEMS) showed an overall benefit of 2.7 additional lives saved per 100 HEMS

**Keywords:** trauma, primary assessment, trauma algorithm, prehospital care, HEMS,

Emergency management of a patient with multiple trauma is complex and takes place on several stages and successive levels, requiring a great deal of specialized forces and expertise, experience, and competence and carrying out a number of risks that crews have to know, consciously assume, and learn to control and avoid

Trauma is a consequence of an unexpected event, which appears sometime in plain health; that is why, one of the main goals is to return the patient to a level of function as close to preinjury as possible. The other goals of trauma patient management are to identify and treat first life-threatening injuries and to prevent exacerba-

tion of existing injuries or the appearance of additional injuries [1–3].

Acute Trauma Conditions

*Tudor Ovidiu Popa, Diana Carmen Cimpoesu* 

*and Paul Lucian Nedelea*

#### **Chapter 3**
