Perceptions of pre-hospital emergency personnel regarding trauma patient care

Abstract

Background

Providing care to trauma patients in pre-hospital emergencies is a vital and life-sustaining factor for individuals. This study was conducted to percept of pre-hospital emergency personnel regarding trauma patient care.

Methods

This qualitative study was done using a conventional content analysis method that employed purposive sampling technique. A total of 12 in-depth semi-structured interviews were conducted with 10 operational staff members of pre-hospital emergency services from May 2021 to September 2022. After recording and transcribing the data, qualitative content analysis, based on Graneheim and Lundman’s approach, was performed on the data.

Results

From the data analysis, a total of 478 initial codes were extracted, leading to the identification of two main categories, namely “Stress as an Unavoidable Factor” and “Emotional Impasse”. The first category included three sub-categories of work under stress, associating your family in the face of life-threatening conditions, and worrying about the patient’s fate. Three sub-categories of a long-term mental occupation of the technician with the encounter scene, the feeling of guilt despite trying as much as possible, and emotional distress in certain groups emerged from the second category.

Conclusions

“Stress as an Unavoidable Factor” and “Emotional Impasse” have been introduced as main categories of perceptions of pre-hospital emergency personnel regarding trauma patient care.

Introduction

Trauma is the most important cause of death from accidents in all ages [1]. Every year, more than 1 million people worldwide suffer from trauma [2]. Every year, about 5 million people die due to injuries. On the other hand, it is estimated that by 2030, injuries will be the seventh most important cause of death worldwide [3]. Falls and accidents caused by vehicles are the most important causes of trauma to Medical Services [4]. According to the statistics available in the world, an average of 1.35 million people are lost every hour due to accidents, so 50 million people are injured yearly. In Iran, every 19 min, 1 person dies due to accidents, so in terms of statistics, it ranks first in the Iranian region per 100,000 people [2]. Meanwhile, trauma is expected to increase daily [5]. Trauma is the second cause of death, in Iran [6].

In addition to death, trauma increases the cost of treatment and care provision, creating a financial burden for health organizations [7]. Trauma management and control is always one of the basic challenges of care systems in all countries [8]. If trauma is not managed, its consequences will affect all social levels and health organizations [9]. In any case, trauma is a controllable and preventable problem [10]. Providing care to trauma patients continues from the accident scene until their transfer and delivery to the hospital [11]. Medical Services care in emergencies is carried out to prevent or reduce deaths caused by injuries [12]. Based on the nature of trauma, the most important services and care should be provided to accident patients in the early hours of the accident to save their lives [13] and Systematic and structured management of patients at the scene and until the transfer of patients significantly reduces the possibility of death [14]. In this regard, Organizations in charge should always put serious emphasis on the field of trauma management of Medical Services [15]. This management includes the provision of infrastructure, human resources needed to provide quality and safe services, and caretakers [16].

In Iran, the issue of emergency medical technicians (EMTs) still has challenges. However, the condition of Medical Services is expected to be better than before. Improving the conditions for effective care in EMTs will improve health in society [17]. Preserving the survival of injured people and transferring them to the hospital to receive continued treatment is the most important point in the care of Medical Services for trauma patients [18]. The management of trauma patients in pre-hospital emergency settings is guided by the primary survey, which follows the ABCDE method: Airway, Breathing, Circulation, Disability, and Exposure. This structured approach prioritizes the identification and treatment of the most critical injuries, ensuring that life-threatening conditions are addressed promptly [19, 20]. The concept of the “golden hour” in management of trauma patients underscores the critical importance of swift transport to trauma centers capable of delivering definitive care. Pre-hospital emergency personnel must carefully balance the time spent on the scene with the necessity of providing immediate medical attention [19, 21]. Decision-making in trauma care frequentlyq involves recognition-primed decision-making, where providers draw on their experience to quickly interpret cues and make judgments. While this method facilitates rapid responses, it can also introduce biases or errors [22]. Additionally, the high-stress nature of the pre-hospital environment can impair cognitive functions, hindering the thorough evaluation of available information. As a result, decisions may often rely on initial impressions rather than on comprehensive assessments [20, 22].

Pre-hospital emergency personnel, due to the sensitive and unique nature of these situations, are influenced by specific conditions. These conditions include time urgencies, a high diversity of crises, and challenging life-threatening trauma conditions. They often face life-threatening situations, including severe injuries, fatalities, and violent incidents. This exposure can result in acute stress reactions and may contribute to long-term psychological issues such as post-traumatic stress disorder (PTSD) [23]. In addition, pre-hospital emergency personnel encounter emotional impasse denotes the inability to process emotions effectively, frequently resulting in emotional exhaustion and diminished empathy toward patients. For Pre-hospital emergency personnel, this can lead to impaired performance during critical incidents. Interviews with Iranian pre-hospital emergency personnel revealed that many experienced profound emotional reactions when faced with traumatic situations, which occasionally resulted in conflicts among team members due to stress overload [24]. The actions of these individuals in such circumstances not only require proficiency in medical techniques and emergency skills but also necessitate stress management and coping with the pressures arising from the situation.

This research addresses the perceptions of pre-hospital emergency personnel regarding the care of trauma patients. Knowing the experiences of emergency personnel in dealing with life-threatening trauma helps us to create a basis for developing optimal solutions. Refined care processes are then formulated and innovative ideas for special training to overcome existing challenges are presented. Therefore, in order to clarify and examine personnel’s perceptions, it is necessary to implement a process based on structuralist philosophy. Given the importance of the topic and the statistics on trauma and accidents, it appears necessary to understand the pre-hospital emergency personnel’s experiences of the challenges of caring for trauma patients. On the other hand, it is based on the fact that few studies have explained these perceptions. In this context, the current study was conducted to make emergency responders understand the challenges of caring for trauma patients. A qualitative study, particularly of the content analysis type, helps to describe and analyze the phenomenon clearly and in-depth. Given that our phenomenon is complex, multifaceted, and context-based, and that we do not have much information about this phenomenon, there is a need for an inductive method to accurately discover the various dimensions of the phenomenon in question.

Methods

Study design

A qualitative study using a conventional content analysis method was used from May 2021-September 2022 to explore the perceptions of EMTs towards the provision of care for trauma patients. Since qualitative research emphasizes trust, transparency, verifiability, and flexibility, it is considered a good method to develop insight and interpretation in the field of nursing education [25].

Settings

The research environment in this study included road and urban pre-hospital Medical Services emergency centers affiliated with Shiraz University of Medical Sciences in Iran.

Participants

Participants in current study included emergency operational personnel. Various groups based on age, education, and experience in working with trauma patients in pre-hospital settings were involved in order to gather extensive and in-depth data. The inclusion criteria an associate degree or higher, experience in the direct care of medical services for trauma patients, willingness to participate in expressing rich information from their experiences, and included more than one year of operational experience in emergency centers. These centers were chosen due to their conditions, focusing on areas that are prone to incidents, particularly in urban and interurban settings where encounters with trauma are more frequent. The participants of this study consisted of 10 pre-hospital emergency operational staff.

The selection of participants, along with interviews, continued until data saturation was achieved. This point was defined as the moment when no new data or categories emerged, and the existing data and categories attained sufficient depth and richness [26].

Data collection

The semi-structured in-depth interview method was used to data collection. The duration of the interviews varied between 30 and 90 min. To obtain deeper and richer data, 12 interviews were conducted with 10 participants. Opening, reflection, and immersion in the data have been done. The place and manner of conducting the interviews were chosen based on the participants’ preference for the college or a place close to their residence. With the participants’ permission, all the interviews were recorded with a voice recorder and then implemented verbatim by the researcher.

Interviews started using the interview guide featuring general questions (Table 1). Following the flow of the interview, memos, and the insights shared by participants, subsequent questions were posed. Probing questions such as “Please explain more” or “Give an example” were also used.

Table 1 Interview guide

Data analysis

Through the method of Graneheim and Lundman (2004), analysis was done concurrently with qualitative data gathering. In the current study, the researcher read the interviews multiple times and a general understanding of the interviews was made. Then, the text of the interviews was transcribed after each interview and the experiences of the participants regarding the operational staff in pre-hospital emergencies regarding the care of trauma patients were put together in a single text consisting of units of analysis. Using the participants’ statements and the proper conceptual labels, meaning units were coded. Subsequently, condensed meaning units were derived by extracting and synthesizing meaning units from the interview texts. These condensed meaning units were then abstracted and categorized using suitable codes. The created codes underwent constant comparison and revision. Reflexivity persisted until consensus was reached on the validation of the codes. Primary codes that were built on a single idea were given their own category. The sub-categories were evaluated based on similarities and differences after being reviewed numerous times. In this stage, the categories developed by four researchers were examined, and reflexivity was revisited and maintained until consensus was achieved on the categorization. Ultimately, a suitable title emerged, encapsulating the underlying meaning of the categories, which represents the latent content within them. In creating the categories and themes, the goal was to achieve the greatest degree of uniformity within each category and the greatest degree of variety between categories [27]. MAXQDA 10 software was used to manage text data and extracted codes.

Trustworthiness

Based on the procedures recommended by Lincoln and Guba, the accuracy and reliability of the data used in this investigation were evaluated. Confirmability was achieved through prolonged engagement with the data. Also, the interviews continued until no new data was obtained. Member checking was used to ensure validity, during which emergency operations staff were asked to confirm the correspondence between the generated codes and their own experiences. Peer checking was also used by two experts in qualitative studies for the accuracy of coding and data classification. Maintaining the documentation related to the different stages of the research added to the dependability of this research. To ensure transferability, the researcher made extensive explanations such as deep and rich descriptions, detailed descriptions of the participants, sampling method, time, and place of data collection so that other readers can understand the process and reach the data [28].

Results

A total of 12 interviews were conducted with 10 EMTs workers. The demographic characteristics are shown in Table 2.

Table 2 Demographic characteristics of the participants

The main findings of this study included 2 main categories and 6 sub-categories. The main categories obtained in this study and based on data analysis included “Stress as an Unavoidable Factor” and “Emotional Impasse” (Table 3). These findings somehow depict the experience of torment and desperation in EMTs.

Table 3 Categories, sub-categories derived from the study

Stress as an unavoidable factor

According to the participants, this main category had three sub-categories, work under stress, associating your family in the face of life-threatening conditions, and worrying about the patient’s fate. This category stemming from exposure to traumatic experiences, highlights that technicians frequently feel overwhelmed during patient care and subsequently encounter a range of pressures. This situation is associated with associating your family in the face of life-threatening conditions, work under stress, and worrying about the patient’s fate. In certain cases, such intense stress can hinder their ability to respond effectively, thereby compromising the quality of the interventions they provide.

Work under stress

The participants all emphasized the stress of dealing with trauma patients; they considered stress as an unavoidable factor in all their working conditions, whether before being on the scene, during the encounter with the patient, or transport to the hospital. Participant 4 says:

“… Even though rotating light causes stress, the sound of the siren also causes stress, and it even affects the sleep of our colleagues. The noise of your companions even disturbs you, and you become confused; for example, you know where your things are, but you forget, and you lose your things. Many times, you look after the mission and see that you threw all your things together and threw them all out; why? Because you are stressed …” (Male, 42 years old, Married, Associate’s degree).

Some stated that this stress may have led to forgetting a part of the patient care process. For example, participant 5 says:

“… But from the very first moment, stress overcomes us, and maybe in some places, it prevents us from doing what we are doing. I mean, it really happened. Sometimes, my colleague or I would talk to each other after the scene and say that we should have done such and such a thing, but we had forgotten due to stress …” (Male, 44 years old, Married, Bachelor’s degree).

According to the participants’ statements, stress was sometimes ambiguous and was experienced since encountering trauma patients in Medical Services.

Participant 2 says:

“… When we go on a mission, and they announce that the patient is in critical condition, no matter how much the technician controls himself, the first thing that starts is stress with worry. I know what I must do now and what should I do, but is the situation such that I can’t save my patient? There’s a stress with worrying whether I’m doing my job right or not …” (Male, 33 years old, Married, Associate’s degree).

Associating your family in the face of life-threatening conditions

The participants mentioned in their statements that they attributed the trauma patients’ condition at the accident scene to their own family; they thought that one of their family members was traumatized. The participants stated that these perceptions made them make more efforts to save the lives of trauma patients at the accident scene. Even based on their comments, one of the consequences of this situation was that they always thought that this incident might happen to one of their family members. Participant 1 described this situation as follows:

“… For example, when dispatch is giving an address, and I hear that it is near my house, it says accident! It doesn’t say who is this accident anymore?! It does not have a name for us to understand. For example, it says child, pedestrian, and car accidents. Well, for a moment, it comes to your mind that my wife or mother went to the store far away from my child, and a car hit him; I quickly called to say hello and tell him not to be one of my relatives …” (Male, 45 years old, Married, Bachelor’s degree).

Every announcement of an incident creates this spark in medical technicians’ minds, even if the injured person is one of their relatives. They are always waiting for this news, and they experience anxiety and stress after the emergence of these feelings, which can cause mental and emotional pain.

Worrying about the patient’s fate

In terms of worrying about the patient’s fate, the participants stated that they always and continuously followed up on the condition of the patients in the hospital and after the delivery of the patient. They mentioned that even after the delivery of the patient and long after, they were worried about the condition of the trauma patients. In fact, the staff needs to know the condition of the trauma patients they transferred. Participant 5 describes this situation:

“… You know, for example, when I come back from the stage, I always think this”. Whether my patient will be saved or not, whether my actions were effective or not. “Did my patient survive in the hospital or not?…” (Male, 44 years old, Married, Bachelor’s degree).

Emotional Impasse

The emotional impasse was another main category in this study. The emotional impasse is actually a psychological condition in which a person feels powerless and unable to deal with his situation properly. In EMTs, this situation may occur due to exposure to critical and dangerous accidents, diseases, and severe physical injuries. This feeling of lack of ability can cause EMTs to be in a situation where they cannot do their work properly and with concentration. Emotional deadlock in EMTs can negatively affect their efficiency and performance. Emotional impasse includes sub-categories, a long-term mental occupation of the technician with the encounter scene, the feeling of guilt despite trying as much as possible, and emotional distress in certain groups.

Long-term mental occupation of the technician with the encounter scene

According to the participants, the Medical Services staff constantly dealt with trauma patients. This mental preoccupation was due to reasons such as seeing a deadly scene, losing a patient for whom they tried, death of a child and youth; the reality of the accident scene had a deep impact on the mind and spirit of the employees. Their mental preoccupation was in the conditions outside the work environment and following the discomfort of facing heartbreaking scenes at the site of Medical Services incidents. For example, Participant 7 says:

“… Especially when a patient dies or, for example, especially when a family head dies, we are mentally involved for a prolonged engagement with what problems that family will have to deal with …” (Male, 44 years old, Married, Associate’s degree).

Participant 8 says:

“… For example, I want to go to the gym, but I remember the patient in the gym where I revived him. When I went to the hospital, I remembered the patient who was sick, and I handed him over, and he passed out during the handover. In most places, bad memories return to us and occupy our minds for a while …” (Male, 26 years old, Single, Associate’s degree).

The feeling of guilt despite trying as much as possible

The participants pointed out that despite the efforts of the Medical Services staff, they always felt a sense of guilt. According to people’s statements, the most common reasons for tormenting conscience after being alone in the back cabin of an ambulance are the feeling of the ineffectiveness of actions and the feeling of guilt after losing a life-threatening trauma patient. Participant 1 says:

“… There were scenes that were very painful for me; you are talking to the patient, taking a history from him, and the patient dies before the first word is finished! He dies in front of you; it is very difficult!” I say to myself, he was talking to me until now; what happened suddenly?! Did I do something wrong?! Should I have acted faster?! What happened?! Well, the law also says that you must follow the protocol, that if you want to give medicine or do something, do something right, but unfortunately, my mind is going crazy! Why! Wouldn’t it be better if I had transferred it faster? Well, these questions come to your mind (silence)…” (Male, 45 years old, Married, Bachelor’s degree).

The participants stated that they felt discomfort due to the loss of the patient and a sense of inadequacy. Also, they mentioned that for some time after the incident, they considered themselves the main culprits for the death of trauma patients. According to the participants, in situations where the patient was dying while causing worry and stress, they were always looking for the culprit for the death of the trauma patient. Participant 4 says:

“… You look for someone to blame, you blame yourself, and you say you wish I had arrived earlier, you say you would have arrived sooner if I had taken a certain route, or you say you wish I had done such a thing …” (Male, 42 years old, Married, Associate’s degree).

They pointed to creating states of restlessness in themselves after the accident and said that, In fact, they feel worried and anxious after the shift, and after the death of a trauma patient, they feel restlessness and anxiety, which leads to a reluctance to do the current activities of life. These cases are all signs of their stressful situation.

Emotional distress in certain groups

According to the participants in the study, emotional distress occurs in certain situations and certain groups of EMTs employees. They pointed out that injured children are technicians’ first priority and attention at the scene. They also stated that the importance of the method of trauma, gender, and age of the patient is a factors for the intensity of employees’ emotional involvement in trauma situations. For example, Participant 10 says:

“… For me, two of the worst and most difficult missions are one with a child and one with a pregnant woman, because I get emotionally involved in the scene …” (Male, 27 years old, Married, Bachelor’s degree).

In the cases of facing scenes where the child suffered trauma due to being helpless and oppressed, the emotional involvement of the staff was also higher.

Discussion

The findings of the present study revealed that emergency operational staff work under considerable work and life stress and experience difficult emotional conditions and exhaustion in patient care, According to the studies, care in Medical Services has always faced many challenges, and this field still needs basic effective management measures [29]. Based on the participants’ statements in this study, stress is one of the main challenges of caring for trauma patients in EMTs. Although stress is an integral part of human life [30], when stress exceeds its significant limit, it is considered a disorder [31]. According to studies, medical service employees are exposed to many daily stresses due to the nature of their work [32]. These stresses can seriously affect people’s performance and daily life and disrupt their normal work and life [33].

In our study, the source of the stress of the employees was the stress originating from the work, the association of their family in the face of life-threatening conditions, and worry about the patient’s fate. Studies show that following the stress caused by high work pressure in Medical Services technicians, they suffer burnout, which will affect their effective performance in critical situations [34]. In Fernández-Aedo et al.‘s study, many short-term and long-term effects manifested following an unsuccessful resuscitation. Positive responses include the conviction that everything in your power is being done to preserve the patient’s life, while negative ones include despair or uncertainty. The findings of the study show that dealing with the family of the deceased or dealing with a young and children patient puts the operational staff work under more emotional strain [35]. In our study, it was found that emergency operational staff experienced heightened stress when dealing with pediatric trauma, which was in line with the focus of our research. A study examining the stressors encountered by nurses in pediatric emergency care revealed that nurses with less clinical experience exhibited higher levels of anxiety. The results demonstrated a negative correlation between the length of time spent working in the pediatric department and anxiety levels, indicating that greater experience may be associated with a reduction in stress over time [36]. In the current study, 70% of the participants had 16.72 years of work experience, yet they reported experiencing high levels of stress while providing care for pediatric trauma.

Occupational stress is a kind of emotional, floating, behavioral and psychological reaction to traumatic factors in work and work environment [37]. In general, occupational stress results from stress caused by work-related factors, such as heavy workload, prolonged working hours, and lack of control over job responsibilities, lack of job security, lack of support from colleagues and managers, and inappropriate working conditions. These factors can lead to chronic stress, negatively affecting physical and mental health, job performance, and job satisfaction. Job stress can be especially high for first responders, such as firefighters, police, and emergency medical personnel. These people are often exposed to traumatic events and high levels of stress during rescue and recovery operations, which can significantly impact their ability to perform their job duties [38]. In the present study, concerns about patient outcomes, time constraints, and the stress of losing patients, along with mental preoccupation with fear of such events occurring for their families, placed additional pressure on operational staff to the extent that it even disrupted their sleep and nutrition patterns. In addition, high pressure during the need for quick decision-making can increase the risk of errors and accidents, which adds to the stress and pressure experienced by first responders [39].

Aminizadeh et al. emphasize in their study that the quality of life of Medical Services employees should always be emphasized due to multiple stressors [40]. Organizations can implement various strategies to manage occupational stress in the workplace, such as providing support programs for employees and training on stress management, promoting work-life balance, and improving working conditions [41]. First responders in crisis management must have access to appropriate support resources and services, such as peer support groups, counseling, and mental health services, to help them cope with work-related stress and trauma [42]. In the context of crisis management, first responders are especially exposed to high levels of stress that can affect their health and ability to perform their job duties. Consequently, job stress is a widespread issue in the workplace and can have a significant negative impact on individuals and organizations. Therefore, managers and organizations should implement appropriate strategies to manage occupational stress in the workplace and provide EMTs access to appropriate resources and support services.

Another finding in the current study was the creation of preoccupations after encountering the accident scene, feeling guilty despite trying to reach the limit and emotional distress in special groups for hospital emergency technicians in the care of trauma patients. According to studies, the personnel in Medical Services face many deaths, and sometimes they have to continue interventions until the patient reaches the hospital due to compelling reasons not to announce the patient’s death [43]. Studies show that there is always a sense of hopelessness in EMTs technicians; that’s why their unpredictable working conditions will cause states of stress and mental preoccupation [33]. Research shows that around 30% of EMTs are affected by PTSD, which is strongly linked to depression and occupational stress. This indicates that even in the absence of guilt, EMTs may still endure emotional distress stemming from their professional experiences [44, 45].

In one study, emergency operational staff described guilt, shame, and self-condemnation. They stated that the traumatic event was often associated with guilt, which caused them to react negatively. Participants reported feeling guilty when they thought they had failed to save a victim’s life, especially if a promise had been made to the patient or family that did not lead to a positive outcome. Many emergency technicians report experiencing moral distress rather than feelings of guilt or shame. This distress stems from ethical dilemmas and the challenging decisions they must make under pressure, such as prioritizing patients in critical situations or coping with limited resources. While these moral dilemmas can result in feelings of inadequacy and frustration, they do not necessarily lead to self-condemnation [46].

Also, in this study, after delivering the patient to the hospital, EMTs felt confused and were constantly mentally involved with the patient [47]. Similar to the results obtained in our study, medical technicians openly expressed that they were still mentally involved with the scene long after encountering the trauma scene. They also stated that in cases where they could not do anything for the patient, they felt extremely guilty. The results of the study which was conducted to investigate the factors influencing the decision-making of EMTs at the scene in emergencies, showed that their duties should be clear, community culture should be improved, people’s expectations should be corrected, monitoring and control should be done, and the decision-making process should also be examined to facilitate emergency team decision-making at the scene [48]. In the current study the experience of EMTs depicted torment and desperation in a way. This suffering and helplessness, as a part of the nature of the profession, was intertwined with their lives and needed serious attention.

Limitations

One limitation of this study is that, due to the peak of the Covid-19 pandemic, focus group interviews and the collection of interactive data were not feasible. Additionally, the heavy workload of some participants prevented their involvement in the interviews. Efforts were made to conduct the interviews by clarifying the study’s objectives, emphasizing the topic’s importance, and accommodating participants’ preferences for the timing and setting of the interviews. To explore the perceptions of pre-hospital emergency personnel regarding trauma patient care in various contexts more thoroughly, further studies should be conducted in other communities. This approach would help document the perceptions of pre-hospital emergency personnel regarding trauma patient care and enable a more comprehensive comparison of the results.

Conclusions

Based on the findings of this study, the main categories of “Stress as an Unavoidable Factor” and “Emotional Impasse” emerged as perceptions of pre-hospital emergency personnel regarding trauma patient care. The category of “Stress as an Unavoidable Factor,” arising from exposure to traumatic situations, indicates that technicians often feel overwhelmed during patient care and subsequently face a multitude of pressures. This phenomenon is linked to the distressing emotions that emerge when considering family connections in life-threatening scenarios, the demands of working under stress, and concerns about patient outcomes. In some instances, this intense stress may impede their capacity to respond effectively, ultimately affecting the quality of interventions they are able to provide. In an “Emotional Impasse”, individuals may experience a sense of powerlessness and an inability to effectively manage their circumstances. For EMTs, this state can arise from exposure to critical incidents, such as severe accidents, life-threatening illnesses, and significant physical trauma. This perception of helplessness can adversely impact their overall efficiency and performance in their professional roles. To manage this challenge, it is recommended that appropriate training techniques be implemented to mitigate the impact of witnessing distressing scenes on healthcare professionals. Additionally, the emergency response system should establish mechanisms that enable technicians to employ defense mechanisms and coping strategies in high-stress situations.