TRANSPORT AND EMERGENCY MEDICAL RESPONSE SYSTEMS

PRE-HOSPITAL EMERGENCY CARE IN SWEDEN– with Special Emphasis on Care of Traffic Victims –Ulf BJÖRNSTIG
Professor of Surgery
The Institution for Surgery and Perioperative Sciences
Division of Surgery, Umeå University
Umeå, Sweden(Received June 30, 2004)
Traffic injuries cause a heavy burden on society in most motorized countries. Pre-hospital and hospital trauma care may have a potential toreduce these losses. By tradition the pre-hospital ambulance care has not until the last decades been integrated in the medical sector organization in
Sweden. Nowadays it is regarded as the extended arm of trauma care. Improved qualification level to Registered Nurse (R.N.) and structured educationand training has improved the competence of the pre-hospital personnel. However, few objective studies of the effect are available.
The National Board of Health and Welfare publish national guidelines for pre-hospital care and disaster management and support economically training in mass casualty and disaster command and control.
Systemized training of rescue and ambulance teams in co-operation at a crash site may reduce the extrication time of entrapped car/truck
crash victims by 40-50 per cent. This is a valuable time gain especially in a cold climate, which may add hypothermia problems to the injuries.
In Sweden (9 million inhabitants), a sparsely populated country with sometimes long transportation distances to the nearest trauma hospital,
800 ambulances, 7 ambulance helicopters and 3-5 fixed wing ambulance aircraft are the available transport resources. In case of a mass casualty or
disaster situation, inside or outside the country, a governmental project (Swedish National Medevac) aims to convert a passenger aircraft from Scandinavian Airlines System (SAS) to a qualified medical resource for long distance transport, with capacity to nurse six intensive care patients and an
additional 6-20 lieing or seated patients during transport.
Key Words: Pre-hospital, Ambulance, Traffic injuries, Ambulance helicopter, Fixed wing, Mass casualty, Disaster

1. BACKGROUND
In 1899, the Swedish Crown Prince, later King
Gustav V, bought one of the first automobiles in Sweden and by this act, he exposed a positive attitude to thisinnovation. During the first decade of the 1900’s the
speed limit was 10 km/h in urban areas and 15 km/h inrural areas so the losses in injuries and dead were few1.
The losses have since then increased tremendously andglobally 1.2 million people are estimated to loose theirlives every year in traffic incidents.
In Sweden, the number of traffic fatalities was highest, about 1300 per year, around 1970. Despite increasing traffic, the losses in dead have decreased to currently
less than half that number. The decrease has been mostpronounced for the “vulnerable” or “unprotected” road
users. In fact the number of fatalities is now the same(530) as 1939, before World War 2. Contributing to thispositive development is the traffic safety work done byauthorities, organisations and devoted people, a work,
which started in connection with the shift from left toright hand traffic in 1967.
In Sweden with today 9 million inhabitants, cur-24 • IATSS RESEARCH Vol.28 No.2, 2004

rently about 530 people are killed annually in traffic, i.e.
6 per 100,000 inhabitants or 7-8 per 10 billion motor vehicle kilometres. Four million passenger cars, 230,000
motorcycles, 200,000 mopeds, 75,000 trucks and14,000 buses/coaches are in traffic. Additionally at least
five million Swedes are bicycle owners.
According to statistics from the medical sector thenumber of traffic injured needing medical attention isabout 80,000 per year, i.e. nearly 1 per 100 inhabitants.
Bicyclists and passenger car occupants are the most frequently injured, but pedestrians and motorcyclists/
mopedists have the highest proportion of serious injuries.
During the last decades, the improvement of the pre-hospital and hospital medical care has been one post-crash
factor aiming to reduce these losses.
1.1

Development of pre-hospital care
Before the 1980’s the ambulance service was regarded as a pure transport service, with very limited capacity to treat the injured at the crash site and during thetransport. Gradually the insight of the importance of earlyand correct medical treatment came to characterise thedevelopment. Data from especially the U.S. pointed out
the importance of the correct and professional handlingPRE-HOSPITAL EMERGENCY CARE IN SWEDEN – with Special Emphasis on Care of Traffic Victims –of injuries during the first critical hour after an injury
event (the Golden hour)2. “If the critical trauma patient
is not given definitive surgical care within 60 minutes
from the time of injury the odds of his successful recovery diminish dramatically” 2.
In a sparsely populated country as Sweden, withoften-long transportation distances of traffic victims, thisconcept raises high expectations on the competence andorganisation of the pre-hospital care of the injured. During the 1980’s and 1990’s a gradual increase of the basic competence, training and organisation of the
pre-hospital care has been realised. The basic medical
training for ambulance personnel was before the 1980’s“rudimentary”, roughly equivalent with basic first responder training. During the1980’s and 1990’s an increasing number of ambulance personal received 20 weeks
training. During the 1990’s the Swedish National Boardof Health and Welfare increased the basic competence requirements to Registered Nurse (R.N.) in ambulanceswhere the crew is expected to perform more advanced
medical treatment. It has been a painful and somewhat
costly process with this change, but currently most ambulance organisations have at least one R.N. in each
emergency ambulance.
Luckily enough the medical sector in Sweden has
had a limited experience of handling severe injuries.
However, the down of this was that Sweden was not in
the front line to introduce improvements of the trauma
care. These improvements are, e.g., represented of programs and protocols as the Advanced Trauma Life Support (ATLS)3, Trauma Nurse Core Course (TNCC)4 andPrehospital Trauma Life Support (PHTLS)2 programs(Figure 1). Since the middle of the 1990’s these programs
have gradually been introduced and they have given acommon structure to, and improved the quality of, thetrauma care. In this context, the PHTLS is of special interest. The PHTLS-course is a 3-day course focused on
pre-hospital trauma care, with special emphasis on problems related to traffic crashes. Interestingly with this training course is the strong focus on the relation between
injury mechanisms and injuries, as this citation indicates;“A complete, accurate history and proper interpretationof this information can allow the EMT (Emergency Medical Technician) to predict more than 90% of the patient’s
injuries before he ever lays a hand on the patient” 2.
In the pre-hospital setting, the relation between
trauma energy, injury mechanisms, biomechanical factors
and injury factors forms the basis for a professional judgement of the consequences of a crash and how to handle
identified and expected injuries. Certain types of injuries,

U. BJÖRNSTIG

Fig. 1 Examples on different trauma and mass casualty training programs; ATLS for emergency
physicians, TNCC for emergency nurses, PHTLS
for pre-hospital personnel and MIMMS for command and control of mass casualty incidents inthe pre-hospital setting

as fractures and superficial injuries, are often obvious andeasy identifiable. Other, more hidden internal injuries tothe thorax, abdomen, brain and spinal cord, causes much
more trouble for pre-hospital personnel to identify andhandle. It is obvious that these latter injuries are especially
important to be handled correctly and quickly e.g. to compensate excessive internal blood loss, to treat a tension
pneumothorax (“punctured lung”), or to handle a spin lesion with the risk for para- or quadriplegi (paralysis).
It has been estimated that a high quality trauma carecan reduce fatalities by nearly 20% of those who are notkilled immediately in the incident. The proportion of“immediate deaths” used to be between 55-65% for
Swedish traffic victims.

2. ORGANIZATIONS INVOLVED
The three organisations involved in pre-hospitaltrauma care are the ambulance service, the rescue service(fire brigade) and the police. The personnel from thesethree organisations are working together at the crash site.
In Sweden, a national organisation, (SOS Alarm), is responsible for handling the alarms and the dispatch of
emergency resources.
2.1

The alarm centre
In Sweden (Figure 2) with 9 million inhabitants distributed over an area 500 × 1570 km or 450,000 km2,
IATSS RESEARCH Vol.28 No.2, 2004 •25

TRANSPORT AND EMERGENCY MEDICAL RESPONSE SYSTEMS

NorwaySwedenEuropeFig. 2 Map over Europe and Sweden(larger than e.g. Japan), 21 alarm centres are localisedaround the country, one in each county or region. It is
possible to dial 112 and reach the nearest alarm centre
in the whole of Sweden. The alarms in traffic crashes areraised by mobile phones in more than 95% of cases today, so the need for emergency phones along the roads
has disappeared.
On receiving an emergency call, the alarm centre
dispatches the necessary rescue-, ambulance-, and police
resources. The staff at the alarm centre have a broad
knowledge of medical emergencies, however not so deep.
By support of different decision protocols they can inmost cases follow standard procedures, and in this way
reduce the risk for errors.
2.2

The Rescue service
The Rescue service has been developed from theformer Fire brigade. The main duty of the Rescue service at a crash site is to secure the site against environmental hazards, to prevent further injuries to victims andrescuers, to uncover victims jammed in e.g. a car, and toclean up the site from spill of glass and oil.
By a recent governmental decision the Rescue service is also responsible for the injury preventive work in

26 • IATSS RESEARCH Vol.28 No.2, 2004

the local community in a broader sense. This is quite a
new task for the organisation and working methods is under development. This is, however, an interesting and serious attempt from the government to localise the injury
preventive work “near the people” in the local community.
The personnel of the Rescue service have special
training to handle car crashes in which one important task
is to uncover the injured. They have special cutting equipment to open up crashed cars. However, modern cars arebuilt with so hard and strong steel, especially in their sideprotection structure, that the tools used may have problems to cut these parts. For the Rescue service located insmaller communities, often staffed with voluntary personnel, it is an obvious problem to buy updated expensive
equipment and train the personnel. All rescue personnel
also have 40 hours training in first aid so they may act
as medical First Responders.
2.3

PoliceThe police are responsible for making the crash site
safe from other traffic. By redirecting other traffic andsealing off the area from curious people, the safety increases. The police are also responsible for identifying
the injured and dead and to investigate the circumstances

PRE-HOSPITAL EMERGENCY CARE IN SWEDEN – with Special Emphasis on Care of Traffic Victims –of the crash. The police also decide on the autopsy of thefatally injured. The autopsy rate in Sweden is nearly
100% for traffic victims and alcohol and drug analysis
is routinely done. About 30% of the traffic fatalities arealcohol related.
2.4

Emergency and ambulance service
During the last 15 years, the ambulance service has
moved closer to the medical sector institutions, from often being localized at fire stations or at private entrepreneurs. In rural areas, it is today quite common to havethe ambulance connected to the local medical centre fromwhich some, or all of the ambulance personnel, is recruited. This is convenient and economically beneficial,
especially in areas where the ambulances make only a few
missions per day.
The aim of the pre-hospital care is to give the injured or sick adequate care already at the incident site and“secure” him or her before the transport to hospital. Especially in modern trauma care, the “Golden hour” puts
high demands on the pre-hospital care.
Ambulance vehicles and equipment
In Sweden, two types of ambulance vehicles areused (Figure 3):• large ambulances based on van or minibus chassis• small ambulances based on passenger car chassis

Fig. 3 Examples of common large and small ambulance vehicles in Sweden

U. BJÖRNSTIG

The advantage of large ambulances is a spacious
care-cabin, which creates the necessary conditions foradvanced treatment of the injured. The disadvantage isbad comfort especially when driving on rough roads. The
ambulances based on passenger-car chassis are most commonly used in rural areas with long driving distances, because of their better driving comfort and handling. Totally
about 800 emergency ambulances are in use, i.e. nearly
one per 1000 inhabitants, most of them with 24-hour service. Nationally, although not too accurate estimates, indicate that a ground ambulance can reach about 90 per
cent of the population within 30 minutes. For some rural
areas, the average driving distance per mission (to the injured - to the hospital - and back) is around 150-200 km.
In densely built up areas of course these numbers are reduced; in the biggest cities to 5-10 minutes response timeand 10 km.
The medical equipment in an ambulance must fulfil a basic standard specification, valid for all Swedish
ambulances. The equipment permits advanced medicalcare with anti-shock treatment, assisted ventilation,
defibrillation etc. Equipment for fixation and stabilisationof fractures and special devises as fixation mattresses
and special stretchers, are necessary in tricky situations,e.g. during extrication of victims jammed in a car wreck.
Traffic congestion problems may interfere with thetraffic ability for ground ambulances. This may happen
in the two biggest cities in Sweden, Stockholm and
Gothenburg, with 1 and 0.4 million inhabitants respectively. In e.g. Gothenburg, certain lanes have been marked
with a sign indicating which lane should be cleared incase of emergency vehicles approaching. This is an attempt to facilitate the traffic ability for these vehicles.
Helicopters
Some areas, especially in the northern rural half ofSweden, ambulance helicopter service is available 24
hours a day. In most cases, an experienced
anaesthesiologist or emergency doctor staffs the helicopter. In a few cases, the basic competence is only R.N. withspecial training, but with possibility for reinforcement on
severe missions. The helicopters used are often midsize
helicopters as e.g. Aerospatiale Dauphin AS 365 andSikorsky S-76. The aim for the helicopter service is tobring the best medical competence to the injured as soon
as possible, to stabilize the victim’s vital functions, andto assure a safe and quick transport to hospital.
The ambulance helicopters are equipped with advanced medical equipment permitting a high degree of
emergency and intensive care. They can bring one or two
IATSS RESEARCH Vol.28 No.2, 2004 •27

TRANSPORT AND EMERGENCY MEDICAL RESPONSE SYSTEMS

injured. These helicopters are mostly used outside urban
areas because ground ambulances are often quicker to theincident site in urban areas. Only in the two biggest cities may traffic congestion problems sometimes justify useof helicopters in the city.
A helicopter does between 400 and 1200 missions
annually, depending on local circumstances. Nearly half
the Swedish population have access to helicopter service
provided by seven ambulance helicopters and these helicopters make a total of 6000-7000 missions annually i.e.
about 1.5 per 1000 inhabitants and year. Additionally,
at a few places around the long Swedish coast, heavy rescue helicopters (e.g. Super Puma and Vertol) are available for primarily sea rescue operations. They fly about
150 sea rescue missions annually. These helicopters usually do not have medical staff on call.
The helicopter in a big city as Gothenburg does
about 1000 missions a year, with a total time in the airof 660 hours, i.e. the helicopter is airborne on average
40 minutes per mission. This is equivalent with a flying
distance of 140 km. On average, the “total turn around”
time (from alarm to “ready for next mission”) is twohours per mission. The helicopter is on average airborne
within 4 minutes after an alarm during daytime and after
7 minutes at nighttime. On average, the helicopter arrives
to the injured 21 minutes after the alarm. In the northern, sparsely populated part of Sweden, a helicopter
makes about 400 missions annually, but the length of eachmission is at least double, sometimes much more, thanfor the helicopters in the two biggest cities. About 5-15%of the transported patients are traffic victims.
Fixed wing aircraft
In the northern part of Sweden, the flying distances
may be so long that refuelling may be necessary for ahelicopter. This makes transport with aircraft, or “fixedwing”, an attractive alternative for inter-hospital transports (Figure 4). The advantage is higher speed (2-2.5
times higher than with a helicopter), all weather capacity, and no refuelling. The disadvantage is the necessary
secondary transport with ground ambulances between
hospitals and airports. The University Hospital for
Northern Sweden (the only level 1 trauma hospital in
the northern half of Sweden) is situated within threekilometres driving distance from Umeå airport, which
is a great advantage when using fixed wing transport.
These aircrafts fly between 6,000 – 8,000 missions per
year, the majority planned secondary transport between
hospitals.

28 • IATSS RESEARCH Vol.28 No.2, 2004

Fig. 4 Fixed wing air ambulance transport is a convenient mode for long distance inter-hospitaltransports especially in the sparsely populated
northern part of Sweden.

3. MASS CASUALTY AND DISASTER
MANAGEMENT
3.1

Bus crashes
In a bus crash at high speed, as we have experienced
a number during recent years, the consequences will often be disastrous. (Figure 5). The available rescue-resources will be insufficient at least in rural areas. In thissituation, it is very important to have an accurate plan formass casualty incidents worked out in advance. In Sweden the governmental body, The National Board of Healthand Welfare (NBHW), has worked out recommendations
on “Emergency and Rescue service in the event of a major incident”. NBHW conduct and economically support
training courses within different areas of Disaster Medicine. With these guidelines and this support, the medical
personnel involved in the pre-hospital care will get a goodbasis and training in handling of mass casualty or disaster situations.
3.2

Disaster experiences
The NBHW have an organisation (KAMEDO) forcollecting data from mass casualty or disaster incidents
around the world. The aim is to learn from these incidents
and disseminate this information. Those responsible forPRE-HOSPITAL EMERGENCY CARE IN SWEDEN – with Special Emphasis on Care of Traffic Victims –U. BJÖRNSTIG

countries in Europe (Figure 1).
3.4

Fig. 5 A bus crash with 34 injured in a remote area ofnorthern Sweden. An example of a mass casualty
or disaster for a sparsely populated area withlimited resources. (Photo; Leif Danielsson)

Swedish National Medevac
This is a governmental project headed by the Section for Emergency Planning and Security in the Swedish Civil Aviation Administration in cooperation with the
National Board of Health and Welfare and the Scandinavian Airlines System (SAS). Within six hours, an SAS
aircraft can be converted to an ICU equipped transport
resource with capacity for six intensive care patients, plus
6-8 patients on stretchers and about 20 seated patients.
The aircraft may be a Boeing 737-600, Airbus 321-100
or MD-80-90 (Figure 6). All equipment is certified forflying and is compatible with that particular airplane inwhich it will be used. The stretchers are small intensive
care units and the patients are transported from hospital
to hospital on the same stretcher. This aircraft may be
used for long demanding transports inside or outside Sweden. Crews, trained also in aviation medicine, are readyto depart within 12 hours after an alarm.

disaster preparedness can, via these reports, gain experiences from “real incidents”, wherever they happen.
In this context, it could be mentioned that just transport incidents, (ground, air or sea), as in most developed
and motorized countries, are the cause of a majority ofmass casualty incidents in Sweden. Mass casualty bus
crashes have exposed many interesting rescue and emergency medical problems, which have not received muchattention earlier. For example, where is the most convenient emergency entrance and escape routes in an overturned bus wreck? How to make triage (classification of
injured) when many people are piled up unconscious ina bus? How to move in a bus/coach that has rolled 90
degrees, so it is impossible to use the aisle? How tohandle the injured when common rescue equipment may
be difficult or impossible to use etc.?
3.3

MIMMS-course
Recently the “Major Incident Medical Management
and Support” (MIMMS)5 course from the United Kingdom have been introduced in Sweden. This is a very wellestablished course accepted in several European countries, which gives a common structure for the action incase of a major incident. This is a well thought out andpedagogic model gaining acceptance in more and more

Fig. 6 Swedish National Medevac. Within six hours, a
regular SAS passenger aircraft can be converted
to transport six intensive care patients and afurther 20 more or less severely injured. (Photopublished with courtesy of MICUS AB and SAS)
IATSS RESEARCH Vol.28 No.2, 2004 •29

TRANSPORT AND EMERGENCY MEDICAL RESPONSE SYSTEMS

3.5

Hercules as carrier for an ambulance
In case of a mass casualty incident or in cases withspecial needs, victims may have a need for transportation to big referral centres with e.g. a burns unit, or to aunit with resources to perform ECMO-treatment of
ARDS-cases; (ECMO=Extra Corporeal Membrane Oxygenation, i.e. oxygenation via heart-lung machine;
ARDS=Acute Respiratory Distress Syndrome, a life
threatening lung complication to trauma). A Swedish Air
Force Hercules airplane has been converted for transportof an ambulance vehicle with a patient. The ambulancecan drive into the fuselage and disconnection of the patient from the ICU-equipment in the ambulance is
avoided. Three ambulances with intensive care equipment
have been tested and modified so the ambulances and theequipment do not interfere with the aircrafts’ electronics/
avionics. These three ambulances and the aircraft are located at different places in the middle of Sweden. Oneof the ambulances is developed for transport of patientswith severe contagious diseases e.g. hemorrhagic fevers.

tual understanding between the medical and rescue personnel for their different tasks in the extrication process.
The algorithm includes the following main factors6:• Safety/access; stabilize and secure the vehicle, establish necessary ABC-procedures on the trapped victims
in the car;• “Read the crash”. Estimate the trauma energy and which“hidden” injuries that may be expected;• Documentation by photo of the crash situation to present
to receiving hospital’s staff;• Triage of the patients in case of several victims, i.e.
classification of priority to treatment;• Primary survey and resuscitation according to the
PHTLS-principles2. Immobilization e.g. with cervicalcollar and ABC- control. Secondary survey, i.e. total
body examination.
Evaluation has shown that by a 3-day “team training” course, the extrication and on scène-time may be reduced by as much as 40-50%6.

4. EXTRICATION OF ENTRAPPED VICTIMSAn entrapped car occupant indicates a high-energy
crash with risk for severe injuries2. Uncontrolled internal bleeding and hypoxia are the main causes of earlymortality. The extrication process may impose a risk ofaggravation of spinal/neurological injuries6. Prolonged
extrication in a cold climate exposes the victims to therisk of being hypothermic (body core temperature below
35 degrees), which is an aggravating factor in a trauma
situation7. Hypothermia interferes with bleeding and coagulation factors in a negative way. It also affects manyother functions e.g. causing cold diuresis7, which meansthat the victims produce a lot of diluted urine that sometimes must be evacuated.
Consequently many factors point to the fact thatquick and safe extrication is important. To facilitate theextrication process a high degree of bilateral exchangeof “know how” between the medical and rescue service
personnel is needed. Courses have been developed putting emphasis on a “team or crew concept” with the aim
to reduce time spent at the site and time to treatment6(Figure 7). The basic factor is that the victims’ condition is steering for the work and that the medical personnel are in charge of the extrication process.
A standard algorithm and flow pattern facilitatesorganization and cooperation. The concept means a mu-

30 • IATSS RESEARCH Vol.28 No.2, 2004

Fig. 7 Extrication course with the aim to reduce theextrication and on scène time for entrapped
victims. The medical and rescue team train
structured cooperation, with the status of the
injured as the steering factor for the work.

5. QUALITY OF CARE - ANY
IMPROVEMENTS?
In the beginning of the 1990’s, the National Boardof Health and Welfare conducted a couple of quality as-PRE-HOSPITAL EMERGENCY CARE IN SWEDEN – with Special Emphasis on Care of Traffic Victims –U. BJÖRNSTIG

surance studies of pre-hospital care. The data indicatedinadequate measures in some cases e.g. only 1/3 of patientswith concussion got a cervical collar and half of those withthorax injuries were treated with oxygen. The proportionof people with femur fracture who got any type of pain
relieving treatment or fracture stabilization was also inadequate. An all-pervading characteristic of the study was
insufficient medical documentation, by crew memberswith a competence level below R.N. In Sweden, an ambulance crew has by law a responsibility to document vital parameters and treatment in the pre-hospital setting.
This has been improved to a very high documentation rate
today in those cases that are treated in some way during
the pre-hospital phase. However, more quality assurance
studies are needed to verify if the quality of the pre-hospital care has resulted in an improved outcome. A studyof trauma care at hospital indicates a reduced number of“avoidable” deaths during recent decades, the majority
related to better intensive care8.

tains and deep fjords/rivers. These facts, together with an
offensive attitude to handle the transportation and prehospital care problems, have resulted in a national strategy to cover most of the country by ambulance helicopter
service. Such a national strategy for air ambulance transport is lacking in Sweden. The extensive Norwegian offshore oil industry in the Nordic Sea uses many heavy helicopters usable also for sea rescue operations. This makes
Norway a country with very good resources for sea rescue. The comparable Swedish, and Finnish, resources are
scarce and may be insufficient in case of a major transport incident e.g. as when the passenger ship Estonia 1994
went down between Finland and Sweden and 860 persons died. By bilateral agreement, Norwegian ambulance
helicopters cover some remote areas of Sweden, where
the population has a bad coverage of ground ambulances.
This is a good example of how the organization of prehospital trauma care can be optimized, independent ofdifferent administrative boarders.

6. DISCUSSION

REFERENCES

The understanding of the importance of the “Goldenhour” has improved the competence and organization of
the pre-hospital care in Sweden. However, any time limit
within which an injured or sick person should be reachedby pre-hospital care, is not established. This is peculiar
in view of the strong regulation for the rescue/fire service.
The rescue service has from a maximum of 5-10 minutes response time in densely built up areas to 30 minutes in rural areas. Consequently, Sweden has more
rescue/fire stations than ambulance stations; in rural areas more than two times more. This has initiated a few
attempts to use rescue personnel as medical First Responders, but old tradition and organisation boarders
make these good attempts scarce. The extrication andteam training courses is another way to cut down the prehospital time to a minimum. The “platinum quarter” is aconcept introduced in this course i.e. the victim should
be taken out from a crashed car within less than 15 minutes. This is especially important in a country with longtransportation distances.
The ambulance helicopter and fixed wing service
is more developed and structured in our neighbour country Norway, where the whole country is covered by thisservice. Contributing to this positive Norwegian development is the problem for quick ground transports inmany areas, because the difficult terrain with high moun-

1. Englund A. Historik. In A.Englund, N.P.Gregersen, C.Hydén,
P.Lövsund, L.Åberg (Eds). Trafiksäkerhet-en kunskapsöversikt.
Studentlitteratur, Lund. pp. 9-39. (1998). (In Swedish).
2. Pre-Hospital Trauma Life Support Committee of The National Association of Emergency Medical Technicians in Cooperation with The
Committee on Trauma of The American College of Surgeons. C Merric,
R. Goldberg (Eds). Pre-Hospital Trauma Life Support, PHTLS-Basicand Advanced. Mosby Lifeline, London. p.53 and 11. (1994).
3. Committee on Trauma. Advanced Trauma Life Support (ATLS). Sixth
Edition. American College of Surgeons, Chicago. Il. (1997).
4. TNCC Revision Task Force. B.Bennet Jacobs , K S. Hoyt (Eds).Trauma
Nursing Core Course, 5th ed. Emergency Nurses Association, Des
Plaines. Il. (2000).
5. Advanced Life Support Group.T.J. Hodgetts, K Mackway-Jones (Eds).
Major Incident Medical Management and Support. BMJ PublishingGroup, London. (2000).
6. Ersson, A.; Lundberg, M.; Wramby, C-O. and Svensson, H. Extricationof entrapped victims from motor vehicle accidents: the crew concept.
“EUROPEAN JOURNAL OF EMERGENCY MEDICINE” 7:pp. 341347. (1999).
7. The National Board of Health and Welfare. H. Brandstrom, M.Hamlet,
B.Paton (Eds.). Hypothermia- Cold Injuries and Cold Water Drowning.,
Modin-Tryck, Stockholm. pp.29-31. (2002).
8. Boman, H.; Bjornstig, U.; Hedelin, A. and Eriksson, A. ”Avoidable”
Deaths in Two Areas of Sweden. “EUROPEAN JOURNAL OF SURGERY” 6:pp. 828-833. (1999).

IATSS RESEARCH Vol.28 No.2, 2004 •31