Blast injury is a dominant and increasing mode of battlefield injuries. The resulting complex injury pattern may include hypoxia due to primary blast lung injury and haemorrhage due to severe secondary and tertiary blast injuries. It has been previously shown that hypotensive resuscitation, as recommended by NICE for pre-hospital trauma resuscitation, is not compatible with survival over extended evacuation times following combined blast injury and haemorrhage, due to underlying inadequacy of systemic tissue oxygen delivery. This thesis investigates a hybrid resuscitation strategy, utilising a novel target blood pressure profile of hypotension (SBP 80 mmHg) for one hour followed by normotension (SBP 110 mmHg). This strategy, termed novel hybrid resuscitation (NH), was investigated with an in vivo model of terminally anesthetised pigs exposed to either a blast shock wave or sham blast, followed by severe controlled haemorrhage plus uncontrolled haemorrhage from a grade IV liver injury. In this model of survivable battlefield injury, NH resuscitation using 0.9% saline demonstrated superiority over hypotensive resuscitation for extended evacuation times (up to 8 hours), with significantly improved survival time after combined blast injury and haemorrhage (from 258 to 452 minutes, mean, p=0.0169) and a clinically significant improvement in physiological state after haemorrhage in the absence of blast. There was no evidence of increased re- bleeding associated with NH. The use of hypertonic saline dextran (HSD) as the initial resuscitation fluid in an NH strategy was also assessed. Although HSD did show some physiological benefit after haemorrhage in the absence of blast injury, survival time was Significantly shorter when animals were initially resuscitated with HSD after combined blast and haemorrhage (208 minutes, mean, p=0.04). The reason remains unclear. In conclusion, NH should be considered as an emergency measure when delayed casualty evacuation is enforced. However HSD should be contraindicated when significant primary blast injury complicates haemorrhage.

No description available.

This research seeks to identify the knowledge, skills, personal qualities and understanding underpinning expert practice in response to emergency calls, the core role of the paramedic, and to explore how paramedics believe their expertise was a role I developed. In-depth interviews grounded in recalled incidents (calls) were employed to generate data from which deductions were made about the underlying capabilities and guiding principles of the work of paramedics. This was supplemented by a questionnaire and the data analysed using a range of theoretical lenses. Responding to a call is described through a sequential series of key activities that, in practice, merge into each other, often in an iterative way: information gathering, managing situations and people and treating patients. Such a description leads to an identification of expertise used in the early stages of responding to a call, such as focusing on reducing and managing ambiguity through the utilisation of situated knowledge to generate tentative hypotheses about the nature of the call and the development of initial plans for action. Such hypotheses are left open and modifiable in the light of new information actively sought by the expert practitioner and are guided by capabilities such as: communication, planning and organising, decision making / problem solving and learning from experience. Additionally, expert paramedic practice is characterised by high levels of resilience and flexibility needed to leave plans incomplete for further development in the heat of practice. This thesis therefore characterises the expertise underpinning the work of experienced paramedics in a way that transcends attempts to describe paramedic practice through lists of skills, knowledge or competencies to be acquired. In so doing the thesis contributes to the evidence base about the knowledge and skill used by paramedics in practice, and how and where this is developed.

No description available.

Introduction: Existing literature on trauma and coping with traumatic events in paramedics has often concentrated on the concept of posttraumatic stress disorder (PTSD), using quantitative pre-defined self-report measures to investigate symptoms and coping strategies, thereby preventing elaboration of these concepts. The concept of positive adaption or posttraumatic growth (PTG) has also largely been ignored. Furthermore, research has often focussed on emergency workers (EWs) within disaster situations, ignoring the impact of their day-to-day experiences, e.g. cardiac arrests and road traffic accidents. Moreover, paramedics have been investigated alongside emergency medical technicians (EMTs) in some studies, and other EWs (e.g. fire-fighters and police) in other studies, despite different occupational roles. This means that focussed research on the experience of individual paramedics in their day-to-day roles is missing. Objectives: Therefore, this study aimed to carry out a qualitative, phenomenological exploration of the impact of multiple work-related potentially traumatic experiences on paramedics, alongside their ways of coping. Therefore, providing a deeper more individualised and nuanced account of their experiences than has been reported previously. Design: A semi-structured qualitative interview was used to conduct a retrospective study of seven full-time qualified paramedics, working for an ambulance service NHS Trust. Methods: Ethical and Research and Development approval was granted. Interpretative Phenomenological Analysis (IPA) was used to analyse the interview transcripts. Results: Four inter-related super-ordinate themes were generated: ‘The salience of memories,’ ‘the process of reflection and making sense,’ ‘the impact of context on coping’ and ‘emotional management and control.’ The first theme discusses the vivid memories experienced by the participants and the types of circumstances that make these memories more vivid and potentially distressing. The remaining themes focus on coping, including factors that impact on the individual’s ability to cope and their particular ways of coping with their job demands. All the themes consider the psychological impact of the job on the participants. Discussion: The results build upon the existing literature providing a more individualised and nuanced account of the lived experience of paramedics who are exposed to multiple work-related potentially traumatic events. A more detailed and exploratory account of the types of incidents paramedics find stressful or traumatic is provided, indicating the impact of such events on memories. In addition, an account of the ways in which these paramedics cope is provided, particularly the process of reflection and meaning making, which has been referred to in previous studies but not as extensively elaborated upon. The study will be of interest to professionals involved in training paramedics and/or providing occupational health support. Study limitations include the omission of objective assessments of PTSD and PTG and these should be included alongside qualitative data in future research, to gain a fuller understanding of responses following cumulative trauma. Using mixed research methods might help to ascertain the types of coping strategies associated with PTSD and/or PTG, something the current study has been unable to comment on, thereby indicating avenues for preventing PTSD and encouraging PTG within paramedics.

Orientadora: Profª. Drª. Lilian Daisy Gonçalves Wolff / Dissertação (mestrado) - Universidade Federal do Paraná, Setor de Ciências da Saúde, Programa de Pós-Graduação Mestrado Profissional em Enfermagem. Defesa: Curitiba, 06/12/2016 / Inclui referências : f.121-140 / Área de concentração: Prática Profissional / Resumo: Com a finalidade de melhor atender a grande demanda das urgências em saúde no Brasil, foi criada a Política Nacional de Atenção às Urgências (PNAU), que normatizou os serviços que prestam atendimento à população e criou o Serviço de Atendimento Móvel de Urgência - SAMU. É um serviço essencial à população acometida por um agravo de urgência e emergência e tem como objetivo reduzir a morbi-mortalidade, com atendimento de qualidade e com diminuição do tempo de chegada de usuários a um serviço de referência. A estrutura organizacional do SAMU inclui recursos humanos, materiais, tecnológicos, de informação e o modelo de gestão, que influenciam diretamente na qualidade da assistência. Trata-se de pesquisa avaliativa, sob a perspectiva gerencial, conduzida por uma abordagem qualitativa e quantitativa. O objetivo foi avaliar a estrutura organizacional do SAMU de um município da região sul do Brasil, com ênfase nos aspectos humanos, materiais, tecnológicos, de informação e normativos relacionados ao modelo de gestão. Como método de procedimento, utilizou-se o estudo de caso, em quatro etapas metodológicas. Ocorreram entrevistas em profundidade e preenchimento de questionário estruturado por dois informantes-chaves da gestão do SAMU no município. Foram realizados seis encontros nos meses de julho a agosto de 2016, os quais foram gravados e transcritos. A coleta de dados também ocorreu em diferentes documentos, como normativas institucionais e relativas à PNAU, escalas de trabalho, ofícios, informativos, check lists, livro-ponto, livros de registro de intercorrências e de troca de plantões. Outra etapa de pesquisa foi a observação sistemática não-participante nas viaturas, realizada pela pesquisadora e pelos membros das equipes do SAMU, em conjunto. Foram coletados dados para medir indicadores já validados em outras pesquisas. Os dados quantitativos foram submetidos à análise de frequência absoluta e relativa, e cálculo dos indicadores. Os dados qualitativos foram submetidos à análise temática. Os resultados relativos aos recursos humanos evidenciaram: equipes completas; jornada de trabalho adequada para a enfermagem e condutores, mas inadequada para os médicos contratados; taxa de rotatividade baixa, considerando que a maioria dos profissionais são funcionários estatutários; taxa de absenteísmo adequada, com afastamentos para tratamento de saúde; taxa de educação permanente adequada, sendo atividade essencial para a qualificação do atendimento. Os recursos materiais apresentaram-se adequados, atingindo 94,8% do previsto pela legislação. Evidenciou-se a necessidade de melhorias na comunicação entre as viaturas de atendimento e a Central de Regulação Médica de Urgências, elemento fundamental e ordenador da Rede de Atenção à Saúde; assim como a carência de meios de comunicação mais eficazes entre a base e as viaturas nos atendimentos em zona rural. Ressalta-se a análise e monitoramento de indicadores ligados ao SAMU como indispensáveis à gestão e ao planejamento. Propõe-se aos gestores a utilização periódica dos instrumentos de avaliação da estrutura do SAMU aplicados nesta pesquisa, como subsídios relevantes à tomada de decisão em prol do aprimoramento do atendimento às urgências pré-hospitalares. Palavras chave: Serviço Médico de Emergência. Ambulância. Avaliação em Saúde. Estrutura dos serviços. Qualidade da Assistência à Saúde. / Abstract: In order to better meet the high demand for health emergencies in Brazil, the National Emergency Care Policy (PNAU) was created, which standardized the services that provide care to the population and created the Mobile Emergency Care Service (SAMU). It is an essential service to the population affected by urgent and emergency illness and aims to reduce morbidity and mortality, with quality caring and decreasing in the arrival time of patients to a referral service. SAMU's organizational structure includes human, material, technological, information resources and the management model, that directly influence the quality of care. It is an evaluation research, from the managerial perspective, conducted by a qualitative and quantitative approach. The objective was to evaluate the organizational structure of the SAMU of a municipality in the southern region of Brazil, focusing on human, material, technological, information and normative aspects related to the management model. As method of procedure, the case study was used in four methodological stages. In-depth interviews were conducted with two key informants from SAMU management in the municipality. Six meetings were held in the months of July to August 2016, which were recorded and transcribed. Data collection also took place in different documents, such as institutional and PNAU regulations, work scales, offices, information sheets, check lists, point books, intercurrent registration books and shift shifts. Another research step was the systematic non-participant observation in the vehicles, carried out by the researcher and the team members of SAMU, together. Data were collected to measure indicators already validated in other surveys. The quantitative data were submitted to the analysis of absolute and relative frequency and calculation and analysis of the indicators. Qualitative data were submitted to thematic analysis. The results related to human resources showed: complete teams; adequate workday for nursing and drivers, but inadequate for contracted physicians; low turnover rate, considering that most of the professionals are employed under the statutory regime; adequate absenteeism rate, with leave for health treatment; adequate permanent education rate, being an essential activity to qualify the service. The material resources were adequate, reaching 94.8% of what is foreseen by the legislation. It was evidenced the need for improvements in the communication between the attendance vehicles and the Central Emergency Medical Regulation, fundamental element and that orders the Network of Attention to Health; as well as the lack of more effective means of communication between the base and the vehicles in the rural areas. It is important to analyze and monitor indicators linked to SAMU as indispensable for management and planning. It is proposed to the managers, the periodic use of the instruments of evaluation of the structure of the SAMU applied in the research, as relevant subsidies to the decision making in order to improve the attendance to the prehospital urgencies. Key words: Emergency Medical System. Ambulance. Health Evaluation. Structure of services. Quality of Health Care.

Rapid changes in the healthcare environment increase the need for nurse practitioners to be motivated, knowledgeable and skilled in order to ensure quality patient care. Accident and emergency units are challenging environments and by ensuring that nurse practitioners work in an enabling environment, they should be motivated, skilled and knowledgeable and be able to think critically to enhance their own professional growth and emancipated practice. This in turn may increase the nurse practitioners’ job satisfaction, which in turn encourage job retention and may influence patient outcomes positively. A journey towards a shared vision namely “emancipatory practice development” was undertaken in an accident and emergency unit of a Level III public hospital. Following the diagnosis of an emergency situation, action research was applied to change the perceived toxic environment to an enabling environment. The study was conducted within the critical social theory paradigm and descriptive, explorative and contextual in nature. Both qualitative and quantitative approaches were utilised. Throughout the action research for practitioners project, collaboration enhanced the emancipation of the nurse leaders, as key drivers of the process, as well as the nurse practitioners. Short and long-term actions were planned, implemented and amended based on observations and reflection following each cycle of the project. During this process a toxic environment was changed to an enabling environment, in which nurse practitioners were retained and additional spin-offs followed. Guidelines for the application and implementation of the process as utilised in this study were compiled to guide others who experience similar challenges. / Health Sciences / D.Litt. et Phil. (Health Studies)

Que se passe-t-il chez les sujets confrontés à une crise cardiaque ? L’irruption brutale de symptômes dans lecorps active des phénomènes mentaux pour faire face à une urgence biologique qui menace la survie. Le sujeten crise est un soi à préserver en tant que soi-même, et un soi à transformer en tant que soi souffrant,nécessitant des soins. Deux niveaux de délibérations sont investis par la conscience en prise avec la menace :soi comme corps en crise, et soi, comme sujet en crise. L'urgence de préservation est psychique et corporelle.En se représentant soi-même avec toutes ses capacités, le sujet en crise lutte contre l'angoisse provoquée parl’infarctus du myocarde. Mais pendant que le soi-même résiste, le corps en crise impose sa temporalité etmenace le vivant. L'acceptation en urgence d'un soi souffrant est facilitée par une pleine conscience de soicomme corps et comme sujet. L'écoute au présent par le sujet en crise de ses ressentis du corps et de savulnérabilité, favorise la demande de soins. / What happens to subjects confronted with a heart attack? The raid of symptoms in the body activates mentalphenomena in order to deal with a threat to the life. The subject living a crisis is a self to protect as oneself, anda self to transform into a suffering self, requiring care. Two levels of deliberations are invested: the self as abody in crisis, and the self, as a subject in crisis. The urgency of self-preservation is psychic and physical. Byrepresenting the self with full capacities, subject in crisis fight against the anxiety caused by the myocardialinfarction. But while the oneself resists, the body in crisis imposes its temporality and threatens life. Urgentacceptance as a suffering self is facilitated by mindfulness of the self as body and subject. By listening to bodysensations and vulnerability in the present, subjects are more inclined to ask for care.

Rapid changes in the healthcare environment increase the need for nurse practitioners to be motivated, knowledgeable and skilled in order to ensure quality patient care. Accident and emergency units are challenging environments and by ensuring that nurse practitioners work in an enabling environment, they should be motivated, skilled and knowledgeable and be able to think critically to enhance their own professional growth and emancipated practice. This in turn may increase the nurse practitioners’ job satisfaction, which in turn encourage job retention and may influence patient outcomes positively. A journey towards a shared vision namely “emancipatory practice development” was undertaken in an accident and emergency unit of a Level III public hospital. Following the diagnosis of an emergency situation, action research was applied to change the perceived toxic environment to an enabling environment. The study was conducted within the critical social theory paradigm and descriptive, explorative and contextual in nature. Both qualitative and quantitative approaches were utilised. Throughout the action research for practitioners project, collaboration enhanced the emancipation of the nurse leaders, as key drivers of the process, as well as the nurse practitioners. Short and long-term actions were planned, implemented and amended based on observations and reflection following each cycle of the project. During this process a toxic environment was changed to an enabling environment, in which nurse practitioners were retained and additional spin-offs followed. Guidelines for the application and implementation of the process as utilised in this study were compiled to guide others who experience similar challenges. / Health Sciences / D.Litt. et Phil. (Health Studies)

L'arrêt cardiaque est principalement d'étiologie cardio-vasculaire. Dans le contexte actuel des arrêts cardiaques extrahospitaliers, 20 à 25% des victimes présentent une fibrillation ventriculaire. Environ 3 à 5% des personnes sont sauvées sans séquelle neurologique. La survie à un arrêt cardiaque extrahospitalier dépend d'une prise en charge précoce et rapide de la victime. Les premiers témoins actifs réalisant la réanimation cardio-pulmonaire combinée à l'utilisation d'un défibrillateur sont ainsi un maillon important pour sauver la victime.Notre objectif principal est d'améliorer le taux de survie à un arrêt cardiaque extrahospitalier. Une première voie d'investigation est de proposer un fonctionnement de défibrillateur optimal combinant judicieusement les différents modules de détection embarqués (détection de fibrillation ventriculaire, détection de massage cardiaque, détection d'interférences électromagnétiques) afin de réduire les temps de pause péri-choc durant la procédure de réanimation. En effet, pendant ces temps, dits « hands-off » en anglais, aucun geste de secours n'est administré au patient qui, lui, voit d'une part sa pression de perfusion coronarienne chuter, d'autre part la probabilité de succès des tentatives de défibrillation décroître. C'est pourquoi une deuxième voie d'investigation porte sur la prédiction de l'efficacité de choc. Dans ce contexte, nous proposons de combiner des paramètres de l'électrocardiogramme dans les domaines temporel, fréquentiel et de la dynamique non-linéaire. Un classifieur bayésien utilisant le modèle de mélange de gaussiennes a été appliqué aux vecteurs de paramètres les plus prédicteurs de l'issue de la défibrillation et l'algorithme Espérance-Maximisation a permis de mener à bien la procédure d'apprentissage des paramètres du modèle probabiliste représentant les distributions conditionnelles de classe.L'ensemble des méthodes proposées a permis d'atteindre des résultats prometteurs pour à la fois réduire les temps de pause péri-choc et prédire l'efficacité de défibrillation et ainsi espérer améliorer le taux de survie à un arrêt cardiaque / The cardiac arrest is mainly of cardiovascular etiology. In the actual context of out-of-hospital cardiac arrests, 20 to 25% of the victims present a ventricular fibrillation. About 3 to 5% of the victims are saved without neurological damage. The chance of surviving a cardiac arrest outside an hospital depends on the early and fast support of the victim. The first active witnesses performing cardiopulmonary resuscitation combined with the use of a defibrillator are an important link to save the victim.Our main objective is to improve survival rate in out-of-hospital cardiac arrest cases. A first way of investigation is to propose an optimal functioning of defibrillator combining wisely the different processes of detection embedded (ventricular fibrillation detection, chest compressions detection, electromagnetic interferences detection), in order to reduce the peri-shock pauses during the resuscitation procedure. In fact, during these pauses, known as "hands-off" pauses, no emergency action is provided to the patient, what is correlated to a drop of the coronary pression, but also to a decrease of the chance of successful defibrillation. That is the reason why, a second way of investigation is based on the prediction of the efficiency of defibrillation. In this context, we propose to use a combination of parameters extracted from electrocardiogram in time, frequency and non-linear dynamics domains. A bayesian classifier using a gaussian mixture model was applied to the vectors of parameters, which are the most predictor of the defibrillation outcome and the algorithm Expectation-Maximization allowed to learn the parameters of the probabilistic model representing the class conditional distributions.All of the proposed methods allowed to reach promising results for both reducing the peri-shock pauses and predicting the efficiency of defibrillation in hope to improve the survival rate in cardiac arrest cases