Pre-hospital Emergency and Legal Challenges in Iran: a Qualitative Study

doi:10.21203/rs.3.rs-4909282/v1

Background

As the first level of people's contact with the healthcare system, the Pre-hospital Emergency Staff )PHES) often encounter patient and companion complaints and legal challenges. Frequent court appearances consume the time of PHES and negatively impact their morale, leading to dissatisfaction and job burnout. This study aims to identify the factors contributing to legal challenges and complaints against PHES.

Method

A qualitative study was conducted, and the data were collected through a focus group session and semi-structured interviews with 21 Emergency Medical Technicians (EMTs) and 4 Emergency Medical Services (EMS) managers with at least two years of experience in Pre-hospital Emergency Medical Services (PEMS). The data were analyzed using thematic content analysis. MAXQDA/10 software was also used for data analysis and code extraction.

Results

The content analysis of the focus group and all interviews extracted four main areas: the nature of the EMS profession, mismanagement in PEMS, legal ambiguities, and other stakeholders' performance.

Conclusion

To mitigate legal challenges, training employees on legal matters, supporting them in fulfilling their duties, coordinating and collaborating with all stakeholders, and educating the public about pre-hospital emergency procedures are important.

Pre-hospital emergency medicine

Legal

Emergency medical services

As the first level of people's contact with the healthcare system, the pre-hospital emergency system provides timely and quick medical care at the scene of the crash and fast transfer of patients to medical centers to reduce patient mortality [1]. The PEMS often encounter critical and unpredictable situations that require clinical judgment, decision-making, and immediate treatment [2].

In some situations, communication with the dispatch physician for guidance and consultation may not be possible due to cut-off communication systems or time constraints. In these cases, PEMS must rely on their knowledge, judgment, and experience to provide the necessary treatment to the patient. However, the stress and tension of crash scenes, the presence of bystanders, and the additional pressure on PEMS can lead to lapses in memory or the wrong treatment measures, which could result in legal challenges [3, 4]. Also, failure to complete patient reports and medical files due to stressful conditions and lack of time can lead to professional responsibility and legal challenges for PEMS [5].

Medical professionals often lack knowledge about the law, legal rulings, and the legal challenges they face, which can significantly impact their professional lives. These challenges can reduce patient trust in the staff and erode the individuals' self-confidence due to the fear of making the same error again [6, 7]. Examining the statistics and quality of medical malpractice cases indicates that one contributing factor to the rise in complaints against medical personnel is the insufficient awareness among healthcare professionals regarding the legal considerations and regulations that govern the medical field and physicians' duties to their patients [6].

In a study in Pennsylvania, Brian examined the complaints against EMS retrospectively between 1999 and 2008, nine years, and divided them into four categories: operational, clinical, educational, and customer service [8]. Christopher also conducted a study analyzing 286 complaints against EMS over six years. The goal was to identify various sources of complaints against EMS to enhance the quality of emergency services. The most significant causes of complaints against EMS were rude behavior, technical skills, transportation problems, and lost items, respectively [9]. Because of the growing population, improving health indicators, and changing social structures, medical-legal cases are rising in Iran. Despite the efforts of the medical community and healthcare staff, advancements in treatment technology, and the special importance of this field, patient dissatisfaction and complaints about treatment and medical staff are unfortunately increasing. It's now more important than ever to understand the legal challenges against medical staff in the country [6].

The first solution to minimize complaints against PEMS is identifying the legal challenges they face while performing their duties. This is an important issue, especially considering that no study has been conducted on the legal challenges faced by PEMS. This qualitative study aims to identify the legal challenges EMS employees face while performing their duties by interviewing officials and workers in EMS.

Research design

This study used a qualitative approach to describe the experience of PEMS and pre-hospital emergency managers regarding legal challenges for on-duty staff. The data was collected through semi-structured interviews and a focus group to reflect specific situations they have undergone [10, 11]. The data was analyzed using a content analysis approach.

Participants

The participants of this study included 21 PEMS with at least two years of experience working in the pre-hospital emergency system and 4 EMS managers with at least two years of management experience in different levels of the pre-hospital emergency organization. Also, the participants in the focus group included nine pre-hospital emergency technicians with at least two years of work experience. The authors contacted PEMS and managers with at least two years of work experience and invited those willing to be interviewed for face-to-face interviews. In total, 25 persons, including 21 PEMS and 4 EMS managers, showed interest in participating. (Table 1)

Table 1

The demographic characteristics of the interview participants
Participant no	Level of education	Workplace	Operational experience (years)
P1	Associates’ degree	EMS^*	3
P2	Bachelor’s degree	EMS	10
P 3	Bachelor’s degree	EMS	18
P 4	Associates degree	EMS	20
P 5	Master’s Degree	EMS	5
P 6	associates’ degree	EMS	3
P 7	Bachelor’s degree	EMS	7
P 8	Bachelor’s degree	EMS	6
P 9	Associates’ degree	EMS	5
P 10	Associates’ degree	EMS	3
P 11	Bachelor’s degree	EMS	6
P 12	Bachelor’s degree	EMS	3
P 13	Bachelor’s degree	EMS	8
P 14	Bachelor’s degree	EMS	10
P 15	Master’s Degree	EMS	6
P 16	Bachelor’s degree	EMS	9
P 17	Bachelor’s degree	EMS	15
P 18	Bachelor’s degree	EMS	12
P19	Bachelor's degree	EMS	4
P 20	Bachelor’s degree	EMS	2
P 21	Associates’ degree	EMS	2
P 22	Ph.D.	Faculty member	16
P 23	Ph.D.	Faculty member	15
P 24	Master Degree	EMS manager	16
P 25	Master Degree	Inspector of EMS system	15

Table 1.

Data collection

Before the interview, the participants received sufficient information about the interview and the purpose of the study. They were assured about the confidentiality of the information and told that their participation in this study was completely voluntary. They were also told their interview would be recorded, and they could cancel it anytime.

Data were collected through a focus group session and semi-structured interviews with 21 PEMS and 4 EMS managers with experience of at least two years in prehospital EMS. Of the participants in the focus group meeting, 2 had a master's degree in nursing, 5 had a bachelor's degree in emergency medicine, 2 had an associate’s degree in emergency medicine, and a minimum of 3 and 12 years of work experience in a pre-hospital emergency. All participants in the focus group were men, and the focus group session lasted 120 minutes. The Interviews were conducted in a separate room at the workplace of PEMS and managers. An Interview guide and open-ended questions were used, and the interviews lasted 45 to 75 minutes. The interviews were recorded using a voice recorder and later transcribed by the authors. )Table 2)

Table 2

Interview guide
- Please introduce yourself and summarize your work history in pre-hospital emergency care - Please describe if you or your colleagues have experienced conflicts with patients, companions, or lay people during your mission. -Have you ever been criticized or reprimanded by emergency officials for issues during the mission? - Please explain if you were summoned to court due to the issues arising from the mission. - In your opinion, what issues cause legal challenges for pre-hospital emergency staff? - What solutions do you suggest to reduce legal challenges while performing duties? - Is there anything left you want to talk about?

Table 2.

Data analysis

The study used the content analysis approach to analyze the data. Instead of using predetermined categories, the authors looked for similar words and expressions with the same meaning in the participants' interview texts to form categories. They read the text multiple times in the initial analysis stage to find meaning units related to the study targets. These meaning units were then condensed and coded [10, 12, 13]. Granheim et al. suggest that categories can be created from meaning units and compared or grouped into broader categories or subgroups [10]. In this study, the codes were compared and categorized in two stages. Eventually, four main categories were identified, and each category was further divided into several sub-categories to capture the main content of the interviews. MAXQDA/10 software was used for data analysis.

Ethical considerations

The current study received approval from the Ethical Committee of the XXX (Ethics code: IR.SKUMS.REC.1402.063). Participants were provided with comprehensive information about the study and gave informed consent to participate. They were encouraged to ask questions if they had any uncertainties, which were addressed to the best of our ability. Participants were assured that their information would be kept confidential and used solely for research. Furthermore, the findings were published in a way that ensured the anonymity of all participants. Additionally, participants had the right to withdraw from the study at any time [14].

Following the data analysis, four main areas were identified from all interviews: the nature of the EMS profession, Mismanagement in PEMS, legal ambiguities, and other stakeholders' performance. These categories are described in the continuous text and participant quotes for clarification. (Fig. 1)

Figure 1.

A. The nature of the EMS profession

When the dispatcher sends a mission to the technician's phone, they must move to the mission location by ambulance within 60 seconds during the day and within 90 seconds at night. The EMS applications record various time points, including sending the mission, ambulance departure, arrival at the patient's location, departure to the hospital, arrival at the hospital, and delivering the patient to the hospital. The PEMS then should prepare for the next mission immediately. Almost all interview participants mentioned that this process causes stress, haste, and fatigue in the emergency profession. (Table 3)

Table 3

Distribution of subcategories, categories, and central areas related to the nature of the EMS profession
Sub-category	Category	Main area
Inaccurate information from Dispatch	Stress	The nature of the EMS profession
Forgetting medical procedures
Forgetting registration and documentation
Hastiness and errors in performing treatment procedures	Haste
Haste and forgetfulness of treatment measures
Haste and accident
Streets traffic
Driving haste in critically ill patients
The high volume of work	Fatigue
fatigue and reduced tolerance threshold
fatigue and lack of concentration in driving
fatigue and laziness
fatigue and reduced concentration on treatment measures
fatigue and forgetting to record actions taken

Table 3.

Stress

Every mission induces stress and anxiety due to the unknown. Often, the correct information isn't communicated through dispatch, leading to a lack of concentration needed to administer proper treatment and documentation. This problem can result in legal complications.

“Whenever the phone rings, we get stressed because we don't know what's going to happen” (P4)

”When we enter a scene, particularly a challenging one, we may become stressed and forget important treatment tips or fail to document everything." (P8)

Haste

In the EMS missions, there is often a rush to reach the patient's bed or transfer the patient to the hospital quickly. This rush can lead to overlooking appropriate treatment measures, neglecting to document the patient's condition accurately, or causing a crash, mainly when dealing with traffic and when instructed to hurry by the dispatcher due to the severity of the patient's condition.

"During orders code: 10–33 from the dispatcher (i.e., rushing to attend to sick patients), I had a crash with a car. The car owner sued me, and I encountered legal issues, leading to a prolonged court case" (P7).

Fatigue

The high number of emergency missions can lead to fatigue among PEMS, which may cause them to forget to perform appropriate treatment measures and register detailed reports. Fatigue can lower their tolerance threshold, leading to conflicts and aggression with patients or their companions. In some cases, fatigue may result in negligence and legal issues.

"It was a challenging night as both emergency stations had already completed 5–6 missions by morning. At 5:00 a.m., EMS received a call from a patient experiencing chest pain. The dispatcher assigned the mission to the nearest station, but the technicians tried to pass the mission to another station using a weak excuse. The second station also completed the mission but with a delay. Unfortunately, the patient went into cardiac arrest before EMS arrived, and despite their efforts, the patient could not be saved. Subsequently, legal issues arose involving the technicians from both stations." (P22)

Ambiguous regulations

A) Conditions created in the scene

Personal Consent Form

In many missions, PEMS encounter incidents where they are unsure how to manage the scene due to a lack of clear instructions or because the law conflicts with pre-hospital emergency protocols. One of the issues they face is obtaining consent from the patient or their companion to either refuse medical procedures or decline transfer to the hospital.

"During one mission, we encountered a patient with a heart problem who did not consent to be transferred. When we consulted with the dispatch doctor, he said that a personal consent form must be completed in the presence of the police. We find it confusing because this type of mission is not defined for police involvement. When we call, the police either don't come or come late. The patient's family also asked us why we brought the police to their house.”(P2)

The consent form for not performing Cardiopulmonary Resuscitation (CPR) is also one of the legal ambiguities. When the patient's family does not consent to CPR, time is so valuable that the golden time to perform CPR is lost until the police arrive. (Table 4)

Table 4

Distribution of subcategories, categories, and central areas related to the legal ambiguities
Sub-category	Category	Main area
Consent for non-transfer	Personal consent form	Ambiguous regulations
consent for non-treatment	Personal consent form
Place of transportation of deceased persons	Those who died at the scene
responsible for the transportation of deceased persons
Resuscitation of people who died due to the conditions of the scene
Suicide scenes
Forcing the ambulance to go faster in critical cases	Conflicting guidelines
The priority of staff lives in unsafe scenes
Transferring the patient to the private sector
Remaining at the scene in high-casualty incidents

Table 4

"We went on a mission where an 80-year-old woman with cancer went into cardiac arrest. Despite our intention to perform CPR, the patient's son refused. When we called the doctor at the emergency center, he advised us to obtain a consent form and not resuscitate. Two months later, another of her sons sued us for not performing CPR, and we had to go to court several times because of this.” (P9)

Those who died at the scene

Handling deceased individuals at a scene involves many legal complexities and challenges for PEMS. While pre-hospital emergency organizations are not typically responsible for moving deceased bodies from crash sites, changing instructions can lead to complaints from the police and the deceased's companions about why this was not done.

In some situations, PEMS may perform CPR, even if death is certain, due to unsafe scene conditions and bystander pressure. However, they may be sued later for performing CPR when death was certain and not taking the person to a hospital if there were signs of life. It is also possible that if the deceased person is transferred to the hospital, the hospital personnel will refuse to accept and complain against them because, according to the law, the deceased person must be transferred to the municipal morgue

"At the scene of the crash, one person had died. We had to wait for the police to file a report. Due to the insecurity and pressure from people at the scene, we had to perform some medical procedures. However, we were later accused of performing medical procedures without transferring the patient to the hospital sooner." (P1)

Suicide scenes

When dealing with suicide attempts, PEMS may face challenges and conflicting priorities. Administering medical treatment before the police arrive could compromise evidence at the scene and hamper potential crime investigations. However, failing to provide timely medical intervention to save a patient's life and pressure from bystanders to perform medical procedures quickly can also lead to legal challenges and complaints against PEMS.

“We were called to a mission where a person had committed suicide by hanging. The police were not present. Even though the person had already died before our arrival and the scene was suspicious, we were forced to perform CPR by his companions. After the mission, we used to go to court for 6 months to answer the judge's questions” (P11)

B) Conflicting guidelines

In many cases, implementing pre-hospital emergency operating instructions at the scene can cause legal challenges for PEMS.

The priority of staff lives in unsafe scenes

According to the guidelines, to ensure the safety of PEMS in aggressive situations, such as fights and conflicts, we must wait for the police to arrive. However, this waiting period results in a delay in providing emergency treatment, leading to complaints against PEMS due to the delayed treatment.

"Our mission was to help an amphetamine-poisoning patient. We waited for the police for 30 minutes; during this time, the person hurt himself and his family, and we could not enter. Later, they sued us because of the delay in starting the treatment.” (P17)

Forcing the ambulance to go faster in critical cases

The instructions allow the dispatcher to order “code: 10–33” (hurry up) to the ambulance in case of critically ill patients. However, the Prehospital Emergency Organization holds PEMS responsible if a crash occurs during a rush.

“I received the 10–33 (hurry up) order from Dispatch while dispatching to a patient with a heart problem. I had a crash while driving. The ambulance and another car were damaged. I was sued and found guilty and had to pay for the ambulance and the car I crashed into.” (P11)

Remaining at the scene in high-casualty incidents

In the event of mass casualties, the first ambulance to arrive at the scene must prioritize patients based on the severity of their injuries and should be the last to leave. If PEMS leave with only one or two patients due to aggressive, angry, or threatening bystanders, they have not followed the protocol. Conversely, bystanders may harm them if they remain at the scene and face possible legal action for delaying patient transport.

“One person with minor injuries and two dead bodies were left at the scene, and as we were the first ambulance, we were waiting for other ambulances to arrive. However, due to the insecurity of the scene and the possibility of conflict, we had to take the injured to the hospital. Later, a non-specialist individual, for entirely unscientific reasons, believed that one of the deceased individuals was still alive and caused a commotion at the scene. This led to our involvement in court and legal matters for several months.” (P9)

Transferring the patient to the private sector

According to pre-hospital emergency instructions, critical patients should be taken to the nearest hospital. If the closer hospital is a private hospital, the patient's companion may complain to you due to the high cost of treatment.

"We transferred a patient with a femur fracture and low blood pressure to the nearest hospital due to his acute condition. However, the patient's companion later complained against us about his inability to pay the hospital fees and questioned why we did not transfer the patient to a government hospital." (P12)

Mismanagement in Pre-hospital EMS

A) The province's EMS managers

The staff lacks support

The pre-hospital emergency organization fails to support personnel when facing legal challenges, leaving them independently accountable to the court and judge. (Table 5)

Table 5

Distribution of subcategories, categories, and central areas related to the pre-hospital EMS managers
Sub-category	Category	Main area
The staff lacks support	The province's pre-hospital EMS managers	Mismanagement in Pre-hospital EMS
Lacks independent and specialized legal counsel
Inadequate supervision
Compulsory overtime
Communication system
personnel shortage and forced to use inexperienced staff
Inadequate in-service training
Ignoring legal challenges
Failure to implement leveling of the staff	The country's pre-hospital EMS managers
Missions when changing shift
Issues with the report registration forms
The public is not being provided with sufficient information.

Table 5.

"The emergency organization did not have legal representation, so I pleaded with the legal affairs officer at the university (since the emergency organization is under the university) to accompany me to court and help convince the judge instead of him having to pursue our problems."(P23)

Lacks independent and specialized legal counsel

Usually, in the provinces' EMS, no lawyer or specialist in legal matters is specific to PEMS and follows up on the legal challenges created for them

"When the patient's companion sued me, the emergency organization provided no support. I knew I was not guilty, but the fact that I had to leave my work and go to court for several sessions and answer to the judge was bothering me.” (P16)

Inadequate supervision

The lack of proper supervision by officials can lead to employees leaving their shifts without informing the authorities or improperly handing over their duties to someone else. If a problem arises with a patient and they file a complaint, legal issues may arise for the person originally scheduled for the shift and the person who took over the shift illegally.

"I replaced one of my colleagues without informing the authorities and left the shift while my national code was in the registration system. Unfortunately, a crash occurred; The patient complained, and the authorities reprimanded me"

Compulsory overtime

Due to a permanent staff shortage in the pre-hospital emergency department, the employees are frequently required to work overtime. This leads to discomfort and fatigue among the PEMS, reducing their concentration and accuracy at work and potentially resulting in legal issues.

"I have twenty years of experience in pre-hospital emergency. We have always been short of manpower, and they force us to work overtime. They never pay attention to our protests and our tiredness” (P4)

Inadequate education and training

Many interview participants mentioned the weakness of education and training, both in the university and during the service, as one of the essential causes of getting stuck in legal challenges.

"During my time at university and in in-service training, I didn't receive any basic training in childbirth or caring for women in labor and babies. Suddenly, I found myself on a mission where I encountered a pregnant lady in labor, and I didn't know what to do. If I'm sued because of my inability to take care of the mother and baby, am I guilty?" (P1)

Ignoring legal challenges

The PHES do not receive education on legal challenges, leaving them vulnerable to legal issues.

"I have been working for eight years and have not received any education regarding legal challenges in the scene." (P13)

Staff shortage and forced to use inexperienced personnel

During crises like the coronavirus outbreak, the pre-hospital emergency system often experiences a staff shortage. This leads to an influx of inexperienced personnel, increasing the risk of legal challenges.

"I sometimes go on a mission with someone who doesn't have experience in patient care. If I'm driving and something goes wrong with the patient during care, I'm at fault because the senior technician has to care for the patient in the back cabin. If I want to care for the patient, the newly recruited person doesn't have a driver's license."(P20)

Communication systems

Iran's pre-hospital emergency system follows the Anglo-American model. In this model, a physician is present at the emergency center, and PEMS consults with him at the patient's bedside using communication systems to ensure the best possible treatment. Although the offline protocol is provided for times of communication disconnection, certain treatments and medications in the offline protocol require consultation with the dispatch physician. However, communication may be hindered by weak telecommunication coverage in certain remote or mountainous areas. Sometimes, when a patient is in critical condition, there might not be a chance to consult with the dispatch physician. In these situations, PEMS could be at risk of legal action from the patient's family or the emergency system based on giving or not giving certain drugs or treatments.

"Our base is located among the mountains. We often experience communication system problems, especially during power outages. There was a three-hour period without communication due to a power outage recently. Emergency officials later reprimanded us as to why we did not respond to a mission in time” )P3(

B) The country's Pre-hospital EMS managers"

Failure to implement leveling of the staff

In Iran, individuals with diverse backgrounds and educational levels, ranging from associate to master's degrees, are employed to handle pre-hospital emergencies. Although job descriptions exist for different levels of expertise, such as basic, intermediate, and paramedic, the PEMS are uncertain regarding their job classification and corresponding job description. This uncertainty arises from the absence of a transparent route for determining their level of expertise, causing confusion, challenges, and legal problems.

"According to the protocol, the senior person should take care of the patient in the back cabin, and the person with the lower education degree will drive. However, the newly hired person may not have a driver's license, so the senior person should drive. If something happens to the patient, the judge will condemn both, and both are equally guilty." (P8)

Issues with report registration forms

Patient report forms have several problems that may expose the technician to lawsuits because they do not include the various situations that may arise for the technician at the scene.

"I went to a mission where a worker had fallen from the top of a building under construction. Because the building under construction was not on the patient status registration forms, I ticked the fall from the top of the building. Later, I faced a legal problem and went to court for several sessions to answer the judge.”(P10)

Also, in some cases, the forms for registering the patient's condition are very specialized and higher than the expertise of the PEMS.

"When filling out the patient's condition registration form, there's a section about "Auscultation of extra heart sounds." This isn't within our expertise. If we don't check it, the form is considered incomplete. However, if we do check it, we are questioned about why we did so. The judge only deals with the patient's report registration form." (P7)

Furthermore, there is a significant lack of public awareness about pre-hospital emergencies. This lack of understanding can lead to misconceptions, complaints, and even legal challenges against EMS.

"According to the protocol, we must have stayed at the scene of the crash until the last casualty was transferred, but the patient's companions insisted on transferring the patient now and later complained against us that the patient was transferred late." (P9)

Other stakeholders' performance

The performance of other agencies involved in crash scenes can lead to legal challenges for PEMS. (Table 6)

Table 6

Distribution of subcategories, categories, and central areas related to the other stakeholders' performance
Sub-category	Category	Main area
Poor training	Red Crescent Organization	Other stakeholders' performance
Unspecified and parallel tasks.
Doing non-specialized work
Late arrival
Late arrival	Police
Lack of cooperation
Causing delays in the pre-hospital emergency work
Recording the patient's speech in a state of reduced consciousness
Lack of familiarity with the emergency system	Judges
Failure to pay attention to the stressful conditions of the scene in judgment	Judges
Non-acceptance of deceased persons	Hospitals
Recording the problems in the file regardless of the scene conditions
Inciting patients' companions to complain against EMS
Concerning the condition of their patients	General public
Lack of knowledge about pre-hospital emergency working protocols	General public

Table 6.

Iranian Red Crescent Society

Employees of the IRCS in Iran have particular responsibilities, including rescuing people from life-threatening crashes, evacuating the injured from remote areas like mountain peaks, and extracting the injured from crash vehicles. While they may not always have adequate expertise and experience in providing pre-hospital emergency treatment, they often carry out pre-hospital emergency tasks, sometimes conflicting with their job description. They usually arrive late at the scene of crashes, and PEMS have to wait for the injured person to be removed from the car to start treatment. Thus, the golden time of care is lost.

“My ambulance team was the first to arrive at the scene of a crash. We assisted the injured individuals and coordinated with the police before departing, leaving behind a deceased person. Later, dispatch informed us that another injured person had been left at the scene. Upon returning, we observed IRCS staff applying a cervical collar to the deceased person. Subsequently, the patient's companions complained against the PEMS” (P20).

Police

In mission scenes, the police closely relate to the PEMS. Still, sometimes, lack of coordination and poor cooperation, arriving late at the scene, delaying the ambulance departure to record the police report, or recording the patient's speech in a state of reduced consciousness can cause legal problems for PEMS.

“The government should have the same sensitivity towards the early arrival of police at the scenes as they have for EMS. Sometimes, when we arrive, the police have not yet shown up, and when they do, they take time to file their report, which delays our movement to the hospital. In some cases, they record the patient's speech while patients are at a low level of consciousness, which could interfere with our report and potentially cause legal issues." (P3)

Judges

Judges are often unfamiliar with EMS guidelines and protocols. They may not consider the stress and pressure faced by PEMS and laypeople at the scene, which can lead to mistakes or oversights in report recording. Instead, they rely solely on registered reports when forming their opinions and making judgments.

"The judge didn't let me speak at all. He just read the registered form. I think only the registered form can defend you, and the judge does not consider the pressure and stress of the scene when issuing a verdict." (P11)

Hospitals

Hospital staffs sometimes document the emergency department's mistakes in the patient's file, regardless of the situation and stress present at the scene. They also occasionally speak in a manner that encourages the patient's companion to complain about the PEMS.

"We were called to assist a 60-year-old patient on a mission. After consulting with the dispatch physician, he recommended that the patient go to the hospital himself. Two days later, the patient suffered a stroke. The hospital staff informed the patient's family that if EMS had transferred the patient sooner, the stroke may have been prevented. As a result, the patient's family members filed complaints against us". (P18)

General public

People sometimes complain about PEMS because they are concerned about their patient's condition and don't know about PEMS procedures. They are not given enough information in this regard. Some complaints people make against PEMS include delays in getting to the patient's bed, transfers to the hospital, lack of proper equipment, inappropriate behavior of emergency personnel, and inappropriate treatment.

"People are unaware that we were on another mission a few minutes ago, and they believe we arrived late due to negligence, leading to a confrontation with a patient companion. They are hostile, assaulting us and lodging complaints." (P4)

The participants in this study pointed out that PEMS often experience fatigue, stress, and urgency in their work. This, combined with pressure and aggression from patients' companions, can lead to a lack of concentration when choosing the appropriate treatment. As a result, they may forget necessary treatments or medications, leading to potential errors. These errors could result in legal challenges.

In this regard, Bahadori et al. states in his study about treatment decision-making in stressful situations that although offline protocols are helpful and a guide for the technician, decision-making in a very limited time and choosing treatment in stressful conditions can be with mistakes followed by numerous legal challenges. Also, the insistence and aggressiveness of the patient's companions and laypeople at the scene for a faster transfer may not allow the technician to contact the dispatch physicians. In contrast, the technician must contact the dispatch physicians for better guidance and treatment [3]. Moshtagh-Eshgh et al. mentioned that occupational stress is unavoidable among healthcare staff. They also pointed out that implementing measures to improve the working conditions of PEMS can enhance their professional health and help them play a more effective and accurate role in various incidents [15].

Fieldheim has also confirmed the presence of stress, anxiety, and other mental health issues among PEMS [4]. Motiei et al. also mentioned that brief rest periods, inadequate staff, and insufficient facilities stress PEMS, thereby reducing the accuracy of their work [16].

Rangraz et al. stated that the requirement to complete reports and medical files at the scene could potentially reduce the quality of PEMS. He believes that PEMS should focus on performing crucial clinical procedures in critical patient conditions instead of spending time writing reports. On the other hand, one of the most essential responsibilities is accurately reporting and recording information. Even the slightest error or oversight in this process can lead to professional liability and potentially result in legal claims [5].

Darvish et al. has stated that, according to professional rules, medical care and activities must be fully recorded. Any negligence and mistakes in reporting and recording them will result in legal punishment. There is no doubt that from a legal point of view, failure to register accurately indicates inadequate care [17]. In this study, participants noted that unclear guidelines and regulations may create legal challenges for PEMS. This is because emergency instructions may lack clarity or contradict situations at the crash scene. Examples include patients refusing to be transferred to the hospital or declining treatment, suicide cases, and instances requiring cardiopulmonary resuscitation. One of the contradictions highlighted is the requirement to obtain personal consent in the presence of the police without defining this duty for the police.

As there is no legislation for “Do Not Resuscitate” (DNR) orders in South Africa, emergency healthcare practitioners face uncertainty about medical treatment for a patient with a DNR order and cardiac arrest, says Viljoen Additionally, they feel uncertain about the legal consequences of following or ignoring the DNR order [18].

In their study, Rees et al. addressed the concerns of PHES who attend the bedsides of people who have attempted self-harm and suicide. He said these staff is worried about getting stuck in lawsuits and legal problems, losing their professional positions, and being fired by their employers. When alone, they have to decide on stress based on their clinical judgment, which may not be the right decision, especially when patients refuse to be transferred to the hospital [19].

Jordan writes that a decision to withhold out-of-hospital CPR or to initiate or terminate resuscitative efforts may be viewed by observers as a failure to provide emergency medical services and may seem to be the cause of death. This situation will likely raise questions for family members and bystanders and may lead to the mistreatment of emergency personnel at the scene and lawsuits against them in the courts. Therefore, it is understandable that prehospital emergency personnel are concerned about legal liability. Jordan also mentions that while court rules are meant to promote help in PEMS, a judge may not provide this assistance for reasons such as the educational qualifications or medical malpractice of the person involved in the resuscitation [20].

The study highlighted the lack of cooperation and mutual understanding between PEMS and other stakeholders involved in incident scenes, including the police, Iranian Red Crescent Society (IRCS) staff, judges, and the general public. This lack of cooperation can lead to legal challenges due to conflicting job descriptions, delayed police arrival at the scene of crash s, and misunderstandings between the different forces involved. Eftekhari et al. stated that while the police are responsible for ensuring the safety of the scene, conflicts between the people, rescue team, and police have sometimes disrupted the security of the scene and caused tension in crash situations. The delayed arrival of police at crash scenes, along with potential misunderstandings between police and PEMS, has led to tension and negatively impacted the performance of PEMS. This has hindered the immediate care at crash scenes. He also states that all the interveners in the scene require a checklist of tasks to prevent interference, but they currently lack a checklist and clear task description [21].

In their study, Van Scotter and Leonard emphasized the importance of cooperation and coordination among first responders in crashes to improve outcomes. They highlighted that a lack of cooperation and coordination among firefighters, police, and PEMS can result in loss of life or property. Understanding and addressing potential cultural differences can help these groups to work together more effectively [22].

Mahmoudi Maymand et al. also stated that the primary reason for the rise in people's dissatisfaction with the performance of PEMS, leading to an increase in complaints against the personnel, is the lack of public knowledge about the roles and responsibilities of PEMS [23]. Burrell et al. considered the cooperation of different professions in different scenes of pre-hospital emergencies necessary and emphasized the cooperation of the pre-hospital emergency, police, and fire departments [24].

The interview participants cited mismanagement in the country's and provinces' EMS as another cause of legal challenges for the PHES. Lack of support, lack of an independent legal affairs officer in the emergency department, non-implementation of leveling of PHES, insufficient training, inadequate supervision, forced overtime, and communication system problems were among the issues raised in this regard. In his study, Poornazari et al. stated that the failure to implement personnel leveling confuses personnel at the scene of incidents because the description of each person's duties is incorrectly specified. The pre-hospital emergency organization has failed to properly designate the driver and the caregiver for the patient in the back cabin of the ambulance. Researchers pointed out that the PEMS does not adequately support its PEMS when they encounter work-related issues. He also highlighted the high cost of ambulances and the potential risks of rushing with critical patients, such as crashes that pose dangers to PEMS, patients, and their companions and damage to the ambulance. In such situations, employees are often required to pay fines for ambulance damage, contribute to covering some costs, and face lawsuits for any harm caused to patients or their companions in crashes [25].

Andersonand Mangino emphasized that healthcare professionals must be well-versed in the legal aspects of their work. This includes pre-hospital emergency workers, who should be knowledgeable about legal challenges to prevent legal issues for themselves and their patients. All healthcare providers must avoid illegal work actions and be informed about the laws throughout their duties [26].

In his 2019 study, Ghassemi Toussi and Karimi Moonaghi emphasized the importance of students knowing criminal laws and legal medical provisions. Many people enter therapeutic fields outside of their expertise due to ignorance or incorrect information about their job description. When individuals take action outside of their functional fields because of insufficient knowledge and experience, it can lead to errors. These errors may cause physical and mental harm to the patient and also impact the professional life of the therapist [6]. Yadolahi said that the quality of documentation in the EMS report forms for PEMS missions did not meet the desired standards [27].

Pervez et al. mentioned that internet issues are causing incomplete reports. He pointed out that inadequate infrastructure, limited internet coverage, and poor mobile phone battery performance during critical times are causing problems for the PEMS and the patients [28].

In this study, forced overtime has been proposed as a factor for fatigue and reducing the accuracy of PHES, which can increase the number of complaints from PHES. Firozbakht et al. writes in the context of reducing the working hours of the PEMS: to reduce the stress of the personnel and their better performance, their working hours should be reduced, and laws should be established to support them [29]. Bahrami et al. assessed the effectiveness of the pre-hospital emergency department in Yazd. They found that the main challenge was the shortage of critical equipment and adequate staffing. A lack of manpower and poorly equipped ambulances can decrease the efficiency of pre-hospital emergency missions [30].

Limitation

This research examines and investigates cases that have led to complaints against PEMS and legal challenges from the perspectives of both emergency personnel and emergency officials. Their views may differ from those of other participants at the scene, such as the police. Also, the participants in this research were selected from 4 provinces and nine different cities in the country. Although the national emergency guidelines are the same for all cities and regions, it is possible that, compared to the people participating in the study, the level of support for personnel in lawsuits Judiciary may be higher in some provinces or less in others.

The PEMS often encounter distressing scenes such as crashes, suicides, falls, and cardiopulmonary arrests, which cause significant stress and pressure. The patient's companions are also worried about their patient's condition, and they convey this to the emergency personnel by complaining aggressively and fighting. In such a scenario, accurate clinical judgment, decision-making, treatment, and documentation will be compromised, leading to errors in action and omission of recording. In critical situations and during the initial moments, the priority is to provide clinical care, which may result in the inability to immediately document the details of the incident. This can lead to the risk of forgetting important information when later filing reports, potentially involving emergency personnel in legal disputes. Other contributing factors to legal challenges include conflicting regulations, communication issues, lack of cooperation and coordination among responders at the scene, and inadequate PEMS support from the emergency organization. Appropriate and continuous training regarding legal challenges, policy-making, and legislation necessary to support personnel, identify legal gaps and resolve them, and resolve conflicts between emergency internal regulations and the country's general laws can effectively reduce legal challenges. It is important to employ legal experts who understand the responsibilities of pre-hospital emergency personnel and their procedures to assist them in court. Joint meetings should be held with all stakeholders, including the police and the IRCS, to define the responsibilities of each organization at incident scenes. When making judgments, prosecutors and judges should consider the working conditions in the emergency room, the stress of the scene, the pressure faced by those present, and the instructions of the emergency room.

CPR: Cardiopulmonary Resuscitation

DNR: Do Not Resuscitate

IRCS: Iranian Red Crescent Society

PEMS: Pre-hospital Emergency Medical Services

PHES: Pre-hospital Emergency Staff

EMTs: Emergency Medical Technicians

EMS: Emergency Medical Services

Acknowledgment

This study is related to a research design ratified and Financial Support by the research and technology deputy of the Medical Sciences University of Shahrekord (Grant No. 6865). I now express my deep gratitude to the respectable Deputy of Researches and Technology of Shahrekord University of Medical Sciences and all the participants who assisted us in this research work, without whom the study could not have been possible.

Authors’ contributions

RAS framed the research design, conducted and analyzed the interviews, interpreted the findings, and drafted the manuscript. MH framed the research design, analyzed and interpreted the findings and contributed to the manuscript. RAS, MH framed the research design, analyzed, and interpreted the findings. RAS, MH framed the research design, analyzed, and interpreted the findings. All authors revised the manuscript critically. All authors have read and approved the manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The budget of this project was allocated by Shahrekord University of Medical Sciences, Shahrekord, Iran. (Grant No. 6865).

Data availability

The data that support the findings of this study are available by request to correspond author.

Availability of data and materials

The data sets analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The present study was approved by the Ethical Committee Medical Sciences University of Shahrekord (Ethics code: IR.SKUMS.REC.1402.063). The participants were given adequate information about the nature of the study, and informed consent was obtained. They had the right to ask questions about the ambiguities and tried to clarify them as much as possible. They were assured that the information they obtained would be confidential and used only for this research. Also, the findings were published so that none of the participants could be identified. Also, participants had the right to withdraw from the study at any time.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

Pre-hospital Emergency and Legal Challenges in Iran: a Qualitative Study

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Abstract

Background

Method

Results

Conclusion

Figures

Introduction

Methods

Data analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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Version 1