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Objective: Vehicle materials developments raise concerns about new patterns of vehicle fire toxic gas emissions. This study aimed to describe toxicologic components in a recent material of fatal car crashes on Swedish roads in which the vehicle caught fire and compare the results to a previous material. Methods: Retrospective registry study. All fatal car crashes with fire in Sweden 2009–2018 were extracted from the Swedish Transport Administration’s In-Depth Studies Database and compared with an earlier study of the time period 1998–2008. Results: A total of 79 crashes and 94 fatalities were included. Carbon monoxide (COHb) blood levels >10% were found in 13 cases. Hydrogen cyanide (HCN) blood levels 0.1–1.7 µg/g were found in 10 cases. In 31 of the cases the person had a blood alcohol level (BAC) >0.2‰, which is the legal driving limit in Sweden. A total of 15 people died due to burn injuries and 2 individuals died due to toxic gas emissions without any other fatal traumatic injury. Total number of deaths in fire-related crashes halved from 181 (1998–2008) to 94 (2009–2018) but the percentage of fatalities in burning vehicles was unaltered (5% vs. 6%). The proportion of fatalities with HCN in the blood increased from 2% between 1998–2008 to 10% during 2009–2018 (p = 0.006). The age of the car involved in a crash increased by 0.26 years per calendar year (p = 0.001). Conclusions: The proportion of fatalities with measured levels of HCN in the blood has increased. Eleven of the 15 burn injury fatalities had high levels of alcohol, HCN, or COHb, possibly contributing to an inability to leave a burning vehicle. Faster rescue brought by improved specific education and training of ambulance and rescue services personnel may be of future importance, as may on-scene antidote administration and revised regulations of vehicle flammability.

The crash of a coach with 58 occupants at 100 kmph revealed the danger of covering ditch areas with sharp stones 5–20 cm in size. Stones and dirt were sprayed into the coach compartment resulting in serious injuries and death. Road safety works need to address this factor in the future.

The loss of human lives and body injuries due to post-crash fires, either by smoke inhalation or due to burn injuries, are unfortunately not uncommon. The literature indicates that fire events related to crashes are still a significant problem. The increased combustible load in newer vehicles is an important factor to be taken into account for the fire safety, as well as their potential to release toxic fumes while burning. Trends indicate that the survivable collision energy will continue to increase, and, at the same time, the probability of post-crash fires rises with the collision energy. This means that the occupants of a vehicle may probably survive a high-energy collision but might sustain severe injuries or death due to a post-collision fire. This work reports a literature and interview study about post-crash fires including statistics on the causes and dynamics of post-crash fires in road vehicles based on the literature, crash and incident reports, as well as on interviews with medicine specialists. Results from this study indicate that fires in vehicles which originated by a collision event are a problem that remains to be solved.

OBJECTIVES: Increased demands are placed on emergency services and their role and ability to act in incidents in challenging environments, for example, road tunnels. Collaboration between officers from emergency services (fire brigade, police and ambulance services) is important for an effective rescue effort. In Gothenburg, Sweden, a position as a senior ambulance officer (SAO) within the emergency medical services (EMS) has been introduced to support the regular force during major incidents. The aim of this paper was to explore the perceptions and experiences of the SAO's new management role in challenging incidents, such as those occurring in road tunnels. DESIGN: A qualitative interview study. SETTING: The study was carried out from February to June 2019 in Gothenburg, Sweden, which is a municipality with several road tunnels and a population of approximately 580 000 people. SAOs collaborate with the corresponding function within the police and fire brigade, both having senior officers at major incident sites. PARTICIPANTS: Twelve SAOs. METHODS: The study used semistructured interviews. The collected data were analysed using qualitative content analysis. RESULTS: According to SAOs' experience, prehospital medical management included not only leadership, but also planning, training and indepth knowledge of, for example, tunnel environments. Furthermore, SAOs adopted an encouraging and teaching role for their colleagues. SAOs' responsibilities also included proactive planning together with the fire brigade and police, which was regarded as enhancing interorganisational collaboration. An overall theme emerged which the SAOs described as 'A new holistic approach to EMS leadership and management'. CONCLUSIONS: The participants considered that the new SAO role not only seems to improve the prehospital medical management, but also makes the EMS command structure during challenging incidents symmetrical with the fire brigade and police command structure. The implementat

Objective: Identify factors of preparedness for peer first response to underground mining emergencies with injured victims. Design: Cross-sectional questionnaire study of Swedish underground mineworkers. Setting: Seven out of nine Swedish underground mines. Participants: A total of 741 mineworkers out of 1022 (73%) participated in this study. Interventions: None. Outcome measures: Level of preparedness for emergencies with injuries in underground mines. Results: Three factors influenced the preparedness of mineworkers for a peer first response: (1) familiarity with rescue procedures during emergencies with injuries; (2) risk perception of emergencies with injuries and (3) experience of using self-protective and first aid equipment. Mineworkers who believed that they knew how to handle emergencies with injuries (OR 1.30, 95% CI 1.22 to 1.38) and those who were trained in the use of self-protective and first aid equipment (OR 1.19, 95% CI 1.07 to 1.32) considered themselves to be better prepared for a peer first response than those who were unfamiliar with the rescue procedures or who had not used self-protective and first aid equipment. However, mineworkers who rated the risk for emergencies with injuries as high considered themselves to be less prepared than those who rated the risk as low (OR 0.95, 95% CI 0.91 to 0.98). Conclusion: This study identified three factors that were important for the peer-support preparedness of underground mineworkers. More research is needed to adapt and contextualise first aid courses to the needs of underground peer responders.

Händelsen: Tågolyckan inträffade på morgonen den 22 februari 2012 när ett lokaltåg okontrollerat körde in i stoppanordningen i slutet av perrongen på Once station, i centrala Buenos Aires. Hastigheten var mellan 20 och 27 km i timmen, men stoppet var så kraftigt att vagn nummer två trängde sex meter in i vagn nummer ett. Sammanlagt skadades cirka 850 personer varav 51 avled, de flesta omkom i samband med att de två första vagnarna klämdes ihop. Bidragande faktorer till att så många skadades var, ett överfullt tåg av äldre modell, som var dåligt underhållet, och kördes av en organisation med låg säkerhetsmedvetenhet. Händelsen visar att en masskadesituation kan uppstå även vid låga hastigheter. Räddningsinsatsen var omfattande: ett hundratal ambulanser, tre helikoptrar och mer än 500 räddningsarbetare engagerades för att omhänderta skadade och fördela dem mellan huvudstadens 13 akutsjukhus. Beredskapen i Buenos Aires var god vid denna händelse, tack vare genomförda risk- och sårbarhetsanalyser, övningar och utbildningsinsatser. Den argentinska akutmedicinska responsorganisationen och sjukhusen arbetade i stor utsträckning enligt samma katastrofmedicinska principer som i Sverige. Händelsen kunde därför analyseras utifrån ett svenskt perspektiv. Erfarenheter: Sverige har varit relativt förskonat från tågolyckor med många svårt skadade. Däremot har tillbuden ökat kraftigt och järnvägssystemet är idag slitet och överbelastat. Det finns därför anledning att studera inträffade tågolyckor i världen för att dra lärdom av internationella erfarenheter av olika skadebegränsande faktorer som kan vara av betydelse för svensk katastrofmedicinsk beredskap. Det går att dra flera lärdomar ifrån tågolyckan på Once-stationen. Nedan redovisas ett antal sammanfattande slutsatser från händelsen med relevans för den svenska beredskapen: • Det finns en risk att händelser med många svårt skadade kan inträffa även vid låga hastigheter. • Tågens konstruktion, utformningen av koppel och deforma

Rationale: There is a lack of long-term follow-up studies focused on injured and uninjured survivors’ experiences of the recovery process after major traffic crashes. Aim/objective: To explore survivors’ experiences of long-term physical and psychological consequences and recovery five years after a major bus crash. Methodological design and justification: A qualitative design was used to explore experiences in a 5-year follow-up study. Research methods: Participants were 54 survivors of a bus crash with 56 survivors and six fatalities. Telephone interviews were analyzed with qualitative content analysis. Results: The theme overarching the categories is “visible and existential marks in everyday life” and it represents the range of the crash’s influence in the survivors’ lives. The first category, “health consequences in daily life,” has four subcategories covering quick recovery, suffering in daily life, distress in traffic situations, and long-term pain. Described reasons for quick recovery among survivors were previous crisis experiences, traveling alone, being uninjured, and not being exposed to traumatic impressions. For the other survivors, being reminded of the crash caused disturbing reactions, such as sweating, anxiety, and flashbacks. Survivors avoided going by bus if they could. A group of the injured survivors were still suffering from limiting and painful injuries. The second category, “oneself and social connection,” has three subcategories that include self-awareness, impact on relationships, and connectedness. Survivors developed a stronger bond to their significant other or separated from their partner within the first couple of years. Friendships and a sense of connectedness among survivors were sources of long-lasting comfort and support. Conclusion: There is a need for more information about disruptive long-lasting consequences, such as travel anxiety, and available treatments. Initially, health-promoting connectedness can be facilitated by treat

OBJECTIVE: Underground mining is associated with obvious risks that can lead to mass casualty incidents. Information about such incidents was analyzed in an integrated literature review. METHODS: A literature search (1980-2015) identified 564 modern-era underground mining reports from countries sharing similar occupational health legislation. These reports were condensed to 31 reports after consideration of quality grading and appropriateness to the aim. The Haddon matrix was used for structure, separating human factors from technical and environmental details, and timing. RESULTS: Most of the reports were descriptive regarding injury-creating technical and environmental factors. The influence of rock characteristics was an important pre-event environmental factor. The organic nature of coal adds risks not shared in hard-rock mines. A sequence of mechanisms is commonly described, often initiated by a human factor in interaction with technology and step-wise escalation to involve environmental circumstances. Socioeconomic factors introduce heterogeneity. In the Haddon matrix, emergency medical services are mainly a post-event environmental issue, which were not well described in the available literature. The US Quecreek Coal Mine incident of 2002 stands out as a well-planned rescue mission. CONCLUSION: Evaluation of the preparedness to handle underground mining incidents deserves further scientific attention. Preparedness must include the medical aspects of rescue operations.

Objective The aim of this study was to explore physical and mental consequences and injury mechanisms among bus crash survivors to identify aspects that influence recovery. Methods The study participants were the total population of survivors (N=56) from a bus crash in Sweden. The study had a mixed-methods design that provided quantitative and qualitative data on injuries, mental well-being, and experiences. Results from descriptive statistics and qualitative thematic analysis were interpreted and integrated in a mixed-methods analysis. Results Among the survivors, 11 passengers (20%) sustained moderate to severe injuries, and the remaining 45 (80%) had minor or no physical injuries. Two-thirds of the survivors screened for posttraumatic stress disorder (PTSD) risk were assessed, during the period of one to three months after the bus crash, as not being at-risk, and the remaining one-third were at-risk. The thematic analysis resulted in themes covering the consequences and varying aspects that affected the survivors' recoveries. The integrated findings are in the form of four core cases of survivors who represent a combination of characteristics: injury severity, mental well-being, social context, and other aspects hindering and facilitating recovery. Core case Avery represents a survivor who had minor or no injuries and who demonstrated a successful mental recovery. Core case Blair represents a survivor with moderate to severe injuries who experienced a successful mental recovery. Core case Casey represents a survivor who sustained minor injuries or no injuries in the crash but who was at-risk of developing PTSD. Core case Daryl represents a survivor who was at-risk of developing PTSD and who also sustained moderate to severe injuries in the crash. Conclusion The present study provides a multi-faceted understanding of mass-casualty incident (MCI) survivors (ie, having minor injuries does not always correspond to minimal risk for PTSD and moderate to severe injuries

Objectives. To explore the perceptions and experiences of mining-, rescue service- (RS), and emergency medical service (EMS) personnel regarding how to handle incidents in an underground mine. Methods. Six focus-group interviews and 10 individual interviews were carried out with groups of mining-, RS and EMS personnel, who served the underground mining industry located in small municipalities in a sparsely populated area of northern Sweden. The transcripts of the interviews were analysed using qualitative content analysis. Results. The three groups mostly described experiences of minor incidents and announced a limited preparedness for handling major mining incidents. Collaboration was described as being difficult because of limited knowledge about the others’ responsibilities and capacities. Few non-mining personnel were trained, or prepared to fulfil their tasks in an underground environment, and some expressed that they would even refuse to go underground because of concerns for their own safety. Conclusions. There is a need for more collaboration and joint practices between and among the groups involved in rescue operations. Collaboration between mine- and RS personnel exists, but the EMS personnel is largely excluded from this interaction. Therefore, the EMS personnel are insecure about how to handle underground mining incidents. A closer collaboration between all organizations in preparing for mining incidents is emphasized, and would have positive effects on the rescue operation. Some experiences may also be used under similar circumstances, such as incidents in railway and road tunnels.