Introduction
Floods with the highest incidence of largely affected populations and economic losses are by far more important compared to other natural disasters. Reference Guha-Sapir, Hargitt and Hoyois1 Iran, with 90% of its population at risk of floods is a flood-prone country. Reference Khankeh, Khorasani-Zavareh, Johanson, Mohammadi, Ahmadi and Mohammadi2,Reference Babaie, Noori, Sarani and Sadeghi3 In the year 2019, devastating floods in Iran had 200 cities and 4300 villages affected, 80 dead and 1136 injured. 4 Golestan province, having repeatedly faced the consequences of floods such as death, injury and the spread of food-related illnesses, is 1 of the most flood-prone provinces of Iran. Reference Ardalan, Holakouie Naieni and Kabir5 Due to the morbidity and mortality following the flood, the pre-hospital emergency system as a gateway to health-system services is required to provide timely services to the injured and patients. 6 These services are usually provided by ground ambulances including cars, buses, motorbikes, boats, and sometimes air aid using helicopters and aircraft, Reference Stewart, Brennan and Krohmer7 which often face problems serving their duties due to disasters, exposure to casualties, and limited resources. Therefore, the efficient and effective use of the minimum available supplies and alternative resources play an important role in providing pre-hospital services, as well as reducing mortality and morbidity. Reference Wang and Yealy8 In many disasters, especially floods, the use of Heavy-duty and assisted vehicles is inevitable in the management of the scene. Reference Caporale, Cergneux, Freed and Matzal9 Therefore, this study was conducted to provide a report of tractor ambulance (Tractorlance) services in the Golestan province flood in March 2019.
Narrative
Heavy rains in March, 2019 led to severe floods in large parts of Iran, with severe financial and casualties’ consequences. Affected by the floods were 200 cities and 4304 villages, which resulted in 3285 injured, including 1411 people transferred to medical centers and 1874 treated on the scene.
In Golestan province, which is adjacent to the Caspian Sea (north of Iran), precipitation occurred over an area of 8500 square kilometers (about 40% of the total area of the Golestan province). Of the districts under the Golestan province, 11 were trapped in water. Affected areas were approximately 170 kilometers long and 50 kilometers wide with a population of over 695000 inhabitants. The cities of Gonbad-Kavous, Anbar Alum, Aq Qala and Simin-Shahr (Gomishan Basin) were within the direct impact of the flood. While the cities of Gomishan, Aq-Qala, Kordkoye, Turkmen, and Gonbad-Kavous were surrounded the most, the cities of Aq Qala and Gonbad received more damage and loss due to their terrain (soil slope) and their geographic location. Reference Beitollahi10 Since more than 40% of the Gomishan city was trapped in the flood and linking roads were damaged, it was difficult to provide Emergency Medical Services (EMS).
Discussion
An increase in EMS missions coupled with the pressure of serving a big portion of the needed population was a big problem for the health system during floods because in normal missions, they were served by 2 emergency medical technicians in an ambulance, but in disastrous conditions where a lack of linked safe-roads missions prevailed, serving capacity was increased to 8 ambulances with 16 technicians (in a small city, not in the whole province). In addition, these conditions were only available on land, and in the case of flooding, they would have to service the boat or the back of the tractor and deliver the injured and the patients 6 km away to a safe place by ambulance, helicopter or ambulance bus. Another challenge was that although more than 30% of the missions were carried out by tractors, these missions were registered only in the name of the ambulance, so there are no exact statistics on the number of missions performed by the vehicle (Table 1).
Table 1. The statistics of the missions carried out from 3/20/2019 to 4/3/2019
Therefore, a new solution was needed to overcome this problem. Using a farm tractor for transporting the patients and injured people was the first relief experience ever documented in the whole country and it was done in Gomishan city. Since the area was flooded to a height of 130cm, and normal ambulances were not able to operate in the mud, the tractor helped carry in people from the flooded site to the ambulance site. The tractor was equipped with a metal chamber on hydraulic arms on its back to transport the patients to a safe place and it was used for 24 hours in 3 shifts (Figure 1). The patients transported by the ambulance tractor were 34 in number (Table 2).
Figure 1. EMS personnel are transporting the patients with tractor ambulance in the flooded area.
Table 2. The total number of patients transported with tractor in the Golestan floods 2019
Conclusion
Due to sanctions and financial instability in developing countries such as Iran, there is a short supply of ambulances on roads and remote routes following disaster, the tractor can be used as a high-capacity relief device. In the present report, despite the limitations and challenges, the tractor has been shown to be a proper and effective disaster relief vehicle. Community-based initiatives and enhancing local capacity in countries like Iran are a rational way to enhance health system proficiency and service efficacy. Training and employing native workers to use the local vehicle like a tractor can improve the effectiveness of emergency medical services in disaster situations; it can partially reduce the limitations of pre-hospital emergency resources and provide a timely and effective response to disasters.
