We have some areas in the city, where we have no coverage and then we have to call to the nearest dispatch center to send our message to the central dispatch center”. (Participant 2) “Sometimes the line is very busy and there is a lot of noise so we can’t contact the central dispatch center or report to the consultant physicians”. (Participant 1) Inefficient medical direction was another important issue, which was OTX015 mouse considered as being a consequence of communication system limitations, poorly experienced consultant physicians Inhibitors,research,lifescience,medical and staff with inadequate skills. Moreover,

even if taking medical advice from the consultant physicians is obligatory for all cases, the participants implied that for many cases it is not needed Inhibitors,research,lifescience,medical and this is more a waste of time which can be critical for the patient’s health outcome. “We have telephone consulting with physicians, but in practice it’s not efficient because of the technical problems with the communication system. We have a lot of ambulance dispatches every day and the radio lines and consultant physicians are very busy and there is not a special line for the consultant

physicians and we can’t wait long for that… sometimes the services that Inhibitors,research,lifescience,medical we provide for the victims are better than the consultant physicians’ advice”. (Participant 2) Moreover, the participants explained that the referral system has some limitations that may contribute to a delayed transportation of the victim to the hospital. One of the major limitations Inhibitors,research,lifescience,medical identified was using out of date maps in the referral system something that become even more important in the absence of Satellite Navigation (GPS). Furthermore, the difficulties in contacting hospitals due to the limitations of the communication system have a major effect on the referral system. “The referral system has a lot Inhibitors,research,lifescience,medical of problems. The streets have changed, and since we don’t have GPS, we can’t track our ambulances. The maps we are using are old and not updated. This system is ineffective, not only for traumas but also for other specialties”.

(Participant 1) Factors outside the EMS Involved organizations In addition to the EMS, there are three other organizations involved in the management of a crash and the rescue of crash victims in Iran: the Police, the Red Crescent and the Fire Department. The participants believed that poor coordination and cooperation between Calpain these organizations and the EMS and the insufficient knowledge and skills regarding the rescue of victims and managing the crash are important obstacles to providing prompt and effective pre-hospital trauma care at the crash scene and when transporting the victims to hospital. They explained that each organization arrives at the crash scene at different times and there is no communication or a common telephone line between these organizations that can be used for coordination and information exchange.