INTRODUCTION

Paramedicine is a new profession in Thailand. The most important role of paramedics is to provide pre- hospital advanced life support for emergency patients.1 Paramedics often need to assist the injured at crime

scenes. However, paramedics have not received any official educational sessions or trainings to deal with crime scene management.2 Currently, the role of paramedics in forensic evidence and crime scene preservation (FECSP) is unclear in Thailand. In the past, the management of

Huabbangyang et al.

the evidence and the crime scene depended on individual knowledge and experience. Consequently, paramedics might damage the evidence and crime scene due to a lack of a recognized role and understanding of FECSP and may damage evidence at the crime scene while performing their duties due to not following appropriate handling processes, potentially causing a more complicated inquest, an inconclusive judgement or even a miscarriage of justice.3

The aim is to study the perceptions of roles and understanding about FECSP of Thai paramedics as well as factors affecting the perceptions of roles and understanding of FECSP in Thai paramedics.

MATERIALS AND METHODS

The study design was a cross-sectional survey. The sample was composed of Thai paramedics registered with National Institute for Emergency Medicine (NIEMS). The questionnaire data was collected during 1st March – 31st March 2021. Inclusion criteria were being registered with NIEMS and having the intention to renew their 5-year license. Exclusion criteria were incomplete data in NIEMS database, such missing as e-mail addresses, as well as declining participation. The questionnaire was examined using a validity index by three forensic experts. The validity index was 1 for all questionnaires.

The questionnaire was comprised of 4 parts. Part one was comprised of of 9 questions about participants’ personal information and included questions about participant sex, age, education level, income, position, employment period, hospital level, crime scene experience and additional forensic training experience. The second and third parts contained 30 questions in total: 15 questions referred to the perception of roles in FECSP of Thai paramedics and another 15 regarding their understanding of FECSP. The questionnaire employed closed questions, with responses structured using 5-point Likert rating scales - 5 being the highest, 4 being high, 3beingneutral,and2and1beinglowandlowestrespectively. Parts two and three were validated via a tryout, tested by 30 fourth-year paramedic students who had similar characteristics to the sample. Reliability indices were calculated using Cronbach’s alpha and were 0.868 and 0.875 for parts two and three respectively, indicating high reliability. The scoring criteria of the questionnaire parts two and three was divided into 5 levels, in accordance with the mean score (Best, 1986). Mean scores of 4.21-5.00, 3.41-4.20, 2.61-3.40, 1.81-2.60 and 1.00-1.80 mean highest, high, neutral, low, and lowest, respectively.4 Part four contained two questions relating to problems, obstacles, and solutions to improve FECSP. The questionnaires

were sent out as Google forms to the paramedics by e-mail. Participants were given 30 days to complete the survey. The definitions of factors were determined, firstly, hospital level regarding geographic information system (GIS), including tertiary, secondary and primary hospitals, as well as university hospital, separated from tertiary hospital. The university hospital was defined as a super tertiary hospital with the highest service capability and treatment readiness as well as provided medical personnel training and medical research. The tertiary hospital was an excellence center dedicated to sub- specialty care. Low, middle and high levels of secondary services were assembled in secondary hospital. The low secondary service level consisted of general practice to in-patient department (cared by general practitioner/ family medicine physician). While the middle level was composed of major sub-specialty care. Both major and minor sub-specialty cares were offered in the high level of secondary service. The primary hospital was a combination of initial and main levels of primary service. The initial primary service level included elementary health promotion, prevention, rehabilitation and treatment (serviced by non-physician personnel). Whereas the main level of primary service comprised preliminary promotion, prevention, rehabilitation and treatment to out-patient department (cared by general practitioner/ family medicine physician, etc.), besides paramedics under local administration were involved. Secondly, the perceptions of roles about FECSP were defined as paramedics’ behavior or duty regarding knowledge and profession in FESCP according to emergency medicine. Thirdly, the understanding about FECSP was defined as paramedics’ psychological process and evaluation in FECSP.

Statistical analyses

382 paramedics both registered with NIEMS in 2021 and determined to renew their 5-year license responded (NIEMS, 2021). The Taro Yamane formula was used for sample size calculation (Taro Yamane, 1973). The calculated sample size was 196, with an error margin of 0.05. After 20% of sample size was added to compensate for non-responses using the formula nnew = 196 / (1-0.2)5, final sample size was 245. However, the questionnaire was sent to every paramedic.

Descriptive statistics were used to analyze the personal data including sex, age, education level, income, position, employment period, hospital level, crime scene experience and additional forensic training experience. For the qualitative data, frequency distribution and percentage were reported. Mean with standard deviation (SD) or

median with interquartile range (IQR) were used for the quantitative data, as appropriate. For the data of perceptions of roles and understanding about FECSP of Thai paramedic, mean with SD were reported, while frequency distribution and percentage were reported for problems, obstacles, and solutions for improvement of FECSP in Thai paramedics. Inferential statistics, multiple linear regression, were utilized for analysis of factors affecting perceptions of roles and understanding about FECSP of Thai paramedics.

IBM SPSS Statistics for Windows, Version 26.0 (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY, USA: IBM Corp.) was used. All statistical tests were considered statistically significant at P-value ≤.05.

Ethical approval

This study was approved by the institutional review board of Suan Sunandha Rajabhat University, No. COA. 1-006/2021.

RESULTS

Of 382 questionnaires sent, 281 responded (74%). Most respondents were female (61.9%). The average age was 26.09 ± 4.44 years. The average employment period was 1 year (IQR 1-3 years) for most paramedics. The most common crime scenes experienced were traffic accidents (91.1%), physical assaults (56.6%), and suicide attempts (55.5%). Most Thai paramedics (73%) had never received additional training related to forensic science (Table 1).

Mean of overall perceptions of roles about FECSP of this cohort was at the highest level (𝑥̅= 4.27, SD = 0.51). (Table 2)

Mean of overall understanding about FECSP of the sample was at the highest level (𝑥̅= 4.28, SD = 0.63). (Table 3)

Most paramedics (99.6%) faced problems and obstacles in FECSP. The most reported problems were: no FECSP law (68.7%), no standard FECSP guideline (64.8%), and lack of forensic evidence preservation equipment and collection systems (61.2%). The most commonly reported solutions to improve the practice of FECSP were: standard FECSP guideline development (83.3%), FECSP training program development (82.9%) and the passing of FECSP related laws (Table 4).

Multiple linear regression analysis revealed hospital level was the key factor related to the perceptions of roles about FECSP of Thai paramedics. The average score of a cohort who worked at tertiary hospitals was less than the cohort working at university hospitals (B = -0.220, p-value = 0.018), after controlling for current position

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and crime scene experience (physical assault, falls from height, poisoning, occupational accident and suspicious death or suspected homicide) (Tables 5 and 6).

Hospital level was also the factor most related with the understanding about FECSP of Thai paramedics, as shown by multiple linear regression analysis. The average score of cohorts who worked at primary or secondary hospitals was less than that of university hospitals (B = -0.197, p-value = 0.022), after controlling for crime scene experience (falls from height and sexual assault) (Tables 7 and 8).

DISCUSSION

Overall, the perception of roles and understanding of FECSP reported in this study were at the highest level, reflecting a good quality of educational institutions providing training in paramedicine. Presently there are only four institutions, namely Navamindradhiraj University, Mahidol University, Mahasarakham University and University of Phayao that provide education and training about roles and understanding of FECSP, even though, most paramedics in this study did not have additional forensic training. Most paramedics in university hospitals were teachers and teacher assistants which had a higher level of perception of roles and understanding of FECSP than ones in tertiary, secondary and primary hospitals, respectively. Although they mainly didn’t have experience in the field, due to their skill and knowledge in forensic science and crime scene, their level of perception of roles and understanding of FECSP was higher. Further, consistent with Khamya’s study, emergency medical responders (EMRs) at the Poh Teck Tung Foundation in Bangkok mostly did not have additional forensic training, while overall knowledge and understanding, regard to emergency calls management aspect and crime scene preservation aspect were at the highest level, and forensic evidence understanding was at a high level.6 In addition, the most common problems and hindrances of FECSP the paramedics faced was a lack of an FECSP law and a lack of standard FECSP guidelines for EMRs, emergency medical technicians (EMTs), advanced emergency medical technicians (AEMTs), paramedics, emergency nurse practitioners (ENPs) and emergency physicians (EPs).7-8 At this moment, no FECSP guideline has been developed in Thailand, comparable to the study by Asci et al. in which there was no proper guideline relating to forensic patients for emergency medical staff and emergency stations in Turkey.3 EMRs did not clearly recognize the role as well as confronted problems and obstacles in handling the subject, while overall role perception was at a middle level for personnel, as

Sadudee reported.9 Regarding solutions for improving FECSP, the paramedics most wanted development of standard guidelines for FECSP and FECSP training programs, agreeing with the study by Saenkaew showing the best crime scene investigation improvement was annual training and guideline development.10 To improve emergency nurses’ practice, hospitals should focus on and support forensic tasks by providing training in forensic medicine and forensic science, as suggested in Suwanchasri’s study.11 This paper would encourage the National Institute for Emergency Medicine to develop Forensic Evidence and Crime Scene Preservation training course together with launching national standard FECSP law and guidelines. In Thailand, the multidisciplinary team involved with crime scene, including crime scene investigators, forensic medicine doctors, pathologists and forensic anthropologists.12 Paramedics were required only if there is injury necessary for emergency treatment and hospital admission. Sexual assault was common in Thailand and counted as a criminal case. Sperm detection in specimen collection after male sexual assault was essential in court.13-14 Therefore, knowledge of forensic evidence preservation in sexual assault case was crucial for paramedics to prevent forensic evidence damage and investigation compromise.

The most important limitation of this study was that of potential insufficient experience on the part of survey respondents, as their average employment period was only 1 year. Hence, information regarding problems, hindrances and solutions for FECSP improvement might not be representative, because they had less experience

about problems and hindrances of FECSP. Secondly, no e-mail addresses of the older generation of paramedics was in the database, hence they could not be included in this study. Thirdly, the second and third parts of the questionnaire regarding the perceptions of roles and understanding about FECSP of Thai paramedics were positive questions only because most paramedics might choose without consideration, possibly leading to bias. Hence, the highest levels of the perceptions of roles and understanding about FECSP of Thai paramedics were presented. In the future study, both positive and negative questions should be set to get rid of this limitation.

CONCLUSION

Thai paramedics had overall perceptions of the roles and understanding of FECSP at the highest level. Hospital level was the factor related to the perceptions of the roles of Thai paramedics, with the group working in tertiary hospitals scoring less than those at university hospitals. The factor related to the understanding of FECSP of Thai paramedics was hospital level, as the scores of those working in primary or secondary hospitals were lower than those at university hospitals. The professional council, NIEMS and educational or training institutes should focus on roles of paramedics in FECSP, by developing standard guidelines and FECSP training for paramedics.

ACKNOWLEDGEMENTS

The present study was supported by Assistant Professor Police Lieutenant General Narong Kulnides Ph.D, my thesis adviser, who suggested publication of the

study. The authors thank the experts of the Department of Forensic Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University for validating and improving our research tools; The National Institute for Emergency Medicine for their effort in obtaining the contact information of the certified paramedics used in the study; The Research Facilitation Division, Faculty of Medicine Vajira Hospital, Navamindradhiraj University for statistical analysis guidance as well as providing third and fourth-year paramedicine students who assisted in collecting the data and monitoring questionnaire responses. The authors were grateful to Institute for Research and Development and Suan Sunandha Rajabhat University for proofreading the manuscript regarding universally standard research methodology and ethics and also thanked Aniwat Berpan MD for correcting English for the present study.

Conflicts of interest: There are no conflicts of interest.

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