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The modern concept of Emergency Medical Services (EMS) has grown from its humble volunteerism origins to a multidisciplinary enterprise, outstretched into the realms of both healthcare and public service. As the American EMS community continues to assume greater responsibilities and further develop its professional standards, the moral foundations of this field open themselves to more thorough scrutiny. Upon examination, the major deficit in the ethical structuring of EMS becomes glaringly obvious: it exists as a piecemeal collection of its medical and militaristic counterparts unified by theoretical generalizations that avoid its inherently unique structure. If EMS wishes to matriculate into complete professionalism, or even continue its assumption of critical responsibilities surrounding the health and safety of others, then it must also develop and maintain its own individual ethical framework from which it operates. In doing so, an urban bioethical approach rooted in context-driven analysis and pragmatic solutions may provide the best guidance and protections for all those who interact with the EMS system while respecting the values of this distinctively prideful service. / Urban Bioethics

Akutsjukvård är vård som finns tillgänglig för patienter dygnet runt för patienter som kräver omedelbar eller skyndsam tillsyn eller åtgärder. Inom svenska akutsjukvården används RETTS (Rapid Emergency Triage and Treatment System) i flera verksamheter för att prioritera patienterna. Prioriteringen av patienter utförs i flera fall av en sjuksköterska. Hälso- och sjukvårdslagen säger att vården i Sverige ska vara jämlik och på lika villkor, patienten med störst behov ska få vård först. Socialstyrelsen påvisar skillnader i väntetider mellan män och kvinnor på akutmottagningar där kvinnor väntar längre än män. Syftet var att belysa skillnader i omhändertagandet av manliga och kvinnliga patienter inom akutsjukvård. Litteraturöversikten är genomförd med en systematisk ansats. 15 artiklar har extraherats och utgör resultatet, samtliga är kvantitativa studier. Artiklarna är kvalitetsgranskade enligt Sophiahemmet högskolas modifierade granskningsverktyg. Resultatet syntetiserades till kategorier och underkategorier. Artiklarna till resultatet har ett etiskt övervägande beskrivet. Resultatet visar skillnader mellan hur män och kvinnor söker vård. Män och kvinnor kommer på olika sätt till sjukvården, män kommer i större utsträckning än kvinnor med ambulans, kvinnor beskriver oftare andra typer av symtom än män, Kvinnor får oftare en lägre prioritet än män, trots beskrivning av samma typ av symtom. Män får oftare en mer högspecialiserad vård än kvinnor. Slutsatsen är att brister i omhändertagandet att kvinnor gör att de får vänta längre än män och att kvinnor inte tas på allvar för sina symtom och då får en annan typ av behandling. / Emergency care is care available around the clock for patients who require immediate or urgent supervision or interventions. In Swedish emergency healthcare, RETTS (Rapid Emergency Triage and Treatment System) is used in several facilities to prioritize patients. Prioritization of patients is often performed by a nurse. The Swedish Health and Medical Services Act states that healthcare in Sweden should be on equal terms; the patient with the greatest need should receive care first. The National Board of Health and Welfare (Socialstyrelsen) indicates differences in waiting times between men and women in emergency departments, where women wait longer than men. The aim was to highlight differences in the care of male and female patients in emergency healthcare. The literature review was conducted with a systematic approach. 15 articles were extracted and constitute the results, all of which are quantitative studies. The articles were quality assessed according to a modified review tool from Sophiahemmet University. The results were synthesized into categories and subcategories. Ethical considerations for the articles included in the results were described in the articles. The results show differences in how men and women seek care. Men and women arrive at healthcare facilities in different ways, with men more likely to arrive by ambulance. Women more often describe other symptoms than men. More often women receive a lower priority than men, despite describing the same type of symptoms. Men more often receive more highly specialized care than women. The conclusion is that deficiencies in the care of women result in them waiting longer than men and not being taken seriously for their symptoms, leading to a different type of treatment.

This paper explains the increased use of hospital-based emergency facilities for primary care. The analysis identifies socio-demographic characteristics, individual resources and selected access variables which influence use of physician services or emergency rooms. The selection of variables is based on a model of facility use which has been derived from the literature on medical care. The results from the analysis concluded that socio-demographic characteristics are both directly and indirectly related to facility use, but there is no apparent association between health insurance as an individual resource and access variables, and use of health care services. Suggestions of further research ar:e proposed based upon a theoretical model of health care choice behavior. / Master of Urban Affairs

Emergency Medical Services (EMS) is provided in a variety of different ways in the United States. Methods of service delivery range from the purely private to the completely public and include mixtures that are not clearly one or the other. Based on a review of the literature, this variation is hypothesized to reflect, in part, variation in community characteristics. Using localities in the Commonwealth of Virginia, this hypothesis is tested by examining the characteristics of forty-seven communities in which emergency medical services are provided. Survey research was used to explore the association between public or private provision of EMS and five variable clusters: socioeconomic, medical resources, geographic, governmental, and unique local resources. Analysis of these variable clusters resulted in the conclusion that there is a statistically significant difference between the characteristics of communities with public service provision and the characteristics of communities with private provision. Thus, it seems highly likely that the public-private variation in EMS service delivery reflects to a certain extent differences in the communities themselves. Socioeconomically advantaged, urban communities with quick access to a large number of medical facilities are more likely to provide EMS through private means. On-the-other-hand, relatively socioeconomically disadvantaged, rural communities with fewer medical resources are more likely to publicly provide EMS service. The fact that this relationship between the characteristics or nature of the community and the method of service provision exists raises several issues. It indicates that rural communities are carrying the burden of public service provision while more urban areas have been able to recover some costs. It also raises the issue of service provision to the indigent in urban areas, since we are unsure as to whether or not a fee structure inhibits utilization by the poor. The relationship between access to the EMS system and the selection of a financing strategy of service provision deserves investigation. Perhaps most importantly, this effort points out how little we know about emergency medical services in the larger context of municipal services. / Master of Urban and Regional Planning

Titel: Våldet mot vårdaren i akutsjukvården. Effekter av preventiva åtgärder för våld riktat mot akutvårdspersonal – En kvantitativ litteraturstudie Bakgrund: Flertalet studier visar på att vårdpersonal är utsatta för våld på arbetsplatsen. Vilket kan leda till minskad livskvalitet, stress, sämre omvårdnad och sjukskrivningar. Syfte: Att beskriva åtgärder för att förebygga våld, riktat mot sjukvårdspersonal på akutvårdsavdelningar samt värdera dess effekt. Metod: En litteraturstudie som omfattar nio kvantitativa artiklar. Artiklarna granskades utifrån relevans och kvalitét och resultatet kategoriserades. Resultat: Sammantaget finns det lite forskning som stödjer att det är möjligt att minska hur sjukvårdspersonal är utsatta för våld. Varken lagstiftning, utbildning eller andra konkreta åtgärder har långsiktigt positiva effekter. Vissa kortsiktiga effekter samt effekter på verbalt våld kan skönjas. Konklusion: Resultatet tyder på att om utbildning repeteras kan långsiktiga resultat påvisas. Eftersom få studier har långsiktigt perspektiv med repetitiv design behövs mer forskning för att kunna hitta en fungerande strategi för att tackla problemet: Våldet mot vårdaren.

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A Thesis Submitted to the School of Social Sciences, in the Faculty of Humanities, in Fulfilment of the Requirement for the Degree of Doctor of Philosophy in Political Studies THE UNIVERSITY OF THE WITWATERSRAND JOHANNESBURG, SOUTH AFRICA NOVEMBER 2014 / This thesis is the culmination of medical aid work and 24 one-on-one interviews with undocumented Mexican women in the U.S.A. and Zimbabwean women in South Africa seeking lifesaving emergency healthcare access. The theoretical research combined with practitioner-based fieldwork, shows the direct and deplorable effects of xenophobic policies coupled with a demonstrable failure to enforce healthcare access rights.

Abstract Trauma patients are a significant patient group for emergency medical services (EMS). Not only are injuries a significant cause of death, they also have a significant long-term impact on functionality and quality of life. Previous studies have shown that the injury-related mortality rate is higher in sparsely populated areas and that the majority of patients die before the arrival of EMS. Intensive care mortality is significant, and half of seriously injured patients develop multiple organ dysfunction. Airway management is one of the most important procedures that EMS provide for a critically injured patient, but making high-quality care available in a sparsely populated area is challenging. Seriously injured patients also appear to benefit from being transported directly to a trauma centre. In recent years particular attention has been given to the level and availability of EMS. Hospitals’ readiness to provide acute surgery is also being reorganised. More information is needed about the frequency, circumstances, outcome and acute care of serious and fatal injuries so that health care resources can be allotted appropriately and requirements for prevention can be identified. The purpose of this research was to investigate the frequency and circumstances of injury-related deaths in Northern Finland and the prognosis of trauma patients encountered by the Finnish helicopter emergency services (FinnHEMS). A particular objective was to examine differences between rural and urban areas. The National Advisory Committee for Aeronautics (NACA) severity score’s ability to predict 30-day mortality was also examined. The fourth part of the study aimed to investigate the pre-hospital airway management performed by non-physicians in Northern Finland. The study material was comprised of trauma deaths that occurred in Northern Finland in 2007–2011, trauma patients encountered by FinnHEMS units in Northern Finland in 2012–2013, patients encountered by HEMS in Northern Norway in 1999–2009 and a questionnaire regarding pre-hospital airway management to non-physicians. The study concluded that the rate of trauma deaths is high in Northern Finland, and the influence of alcohol was found in nearly half of pre-hospital trauma death cases. A larger portion of pre-hospital deaths also took place in rural areas. Trauma patients encountered by FinnHEMS units in urban areas who survived to hospital, appeared to have higher 30-day mortality than patients injured in rural areas. The most probable explanation for this difference is that patients injured in urban areas survive to hospital, while trauma patients in rural areas die pre-hospital. The NACA score was found to reliably predict 30-day mortality. Due to its simplicity, the NACA score can be used to compare patient material from different HEMS bases. It was found that non-physicians seldom performed airway management. On average, the frequency of performing airway management was low, and there is a need to improve maintenance of skills. / Tiivistelmä Vammapotilaat ovat merkittävä ensi- ja tehohoidon potilasryhmä. Paisi, että vammautumiset ovat merkittävä kuolinsyy, aiheuttavat ne myös merkittäviä pitkäaikaisvaikutuksia toimintakykyyn ja elämänlaatuun. Aikaisemmissa tutkimuksissa on osoitettu, että vammakuolleisuus on yleisempää harvaanasutuilla seuduilla ja valtaosa potilaista kuolee jo ennen ensihoidon saapumista paikalle. Tehohoitokuolleisuus on merkittävää ja puolet vaikeasti loukkaantuneista potilaista kärsii monielinvauriosta. Ensihoidon tärkeimpiä tehtäviä kriittisesti vammautuneilla on hengitystien varmistaminen, mutta korkeatasoisen hoidon saatavuus harvaanasutulla seudulla on haasteellista. Vaikeasti vammautuneet potilaat näyttävät myös hyötyvän kuljetuksesta suoraan lopulliseen hoitopaikkaan. Viime vuosina ensihoidon tasoon ja saatavuuteen on kiinnitetty erityistä huomiota. Lisäksi sairaaloiden päivystysvalmiuden uudelleenorganisointi on käynnissä. Lisätietoa tarvitaan vakavien ja kuolemaan johtavien vammojen esiintyvyydestä ja olosuhteista, ennusteesta sekä akuuttihoidon toteutumisesta, jotta terveydenhuollon resursseja voitaisiin kohdentaa tarkoituksenmukaisesti ja ennaltaehkäisyn tarpeet voitaisiin tunnistaa. Tämän tutkimuksen tarkoituksena oli selvittää vammakuolemien esiintyvyyttä ja olosuhteita Pohjois-Suomessa sekä suomalaisten lääkintä- ja lääkärihelikopteriyksikköjen (FinnHEMS) kohtaamien vammapotilaiden ennustetta. Erityisenä tavoitteena oli tutkia maaseutu- ja kaupunkialueiden eroja. Lisäksi tutkittiin National Advisory Committee for Aeronautics (NACA)- vaikeusasteluokittelun kykyä ennustaa 30 päivän kuolleisuutta. Neljännen osatyön tavoitteena oli tutkia ensihoitajien suorittaman hengitystien varmistamisen käytäntöä Pohjois-Suomessa. Tutkimusaineisto koostui vuosina 2007‒2011 Pohjois-Suomessa tapahtuneista vammakuolemista, FinnHEMS:in yksiköiden kohtaamista vammapotilaista Pohjois-Suomessa vuosina 2012‒2013, Pohjois-Norjan pelastushelikopterin kohtaamista potilaista vuosina 1999‒2009 sekä ensihoitajille tehdystä kyselytutkimuksesta hengitystien hallintaan liittyen. Tutkimuksessa todettiin, että kuolemaan johtaneiden vammojen esiintyvyys on korkea Pohjois-Suomessa. Lisäksi havaittiin, että lähes puoleen sairaalan ulkopuolella tapahtuneisiin vammapotilaiden kuolintapauksiin liittyi alkoholi. Maaseudulla myös suurempi osa menehtyi sairaalan ulkopuolella. FinnHEMS:in yksiköiden kaupunkialueella kohtaamilla vammapotilailla, jotka selvisivät sairaalaan, havaittiin viitettä korkeampaan 30 päivän kuolleisuuteen verrattuna maaseudulla vammautuneihin. Ero johtuu todennäköisemmin siitä, että kaupunkialueella vammautuneet ehtivät sairaalaan kun taas maaseudulla vammapotilaat kuolevat jo ennen ensihoitopalvelun saapumista. NACA-vaikeusasteluokittelun todettiin ennustavan luotettavasti 30 päivän kuolleisuutta. Yksinkertaisuutensa vuoksi se soveltuu potilasmateriaalin vertailemiseen eri tukikohtien välillä. Ensihoitajan suorittama hengitystien varmistaminen havaittiin olevan harvinaista. Keskimääräisesti suoritteita tapahtui harvoin, ja taitojen ylläpitämisessä oli parantamisen varaa.

Dissertation submitted in fulfilment of the requirements for the Degree of Master in Technology: Emergency Medical Care, Durban University of Technology, 2010. / South Africa currently has 1631 registered Advanced Life Support (ALS) paramedics to tend to the pre-hospital advanced life support needs of just under 50 million people. Compared to the globally accepted ratio of 1:10 000, the number of ALS paramedics in South Africa is grossly inadequate. The current shortage of South African ALS paramedics may be ascribed to migration. However, although literature on health worker migration in general abounds, there is a marked lack of national or international statistics and information on migration of ALS paramedics and their migration. Current measures to manage migration appear to be ineffective. The success of future strategies is dependent on an understanding of the migration of South African ALS paramedics - an understanding that presently does not exist. Purpose The purpose of this study was to describe the migration of South African undergraduate Advanced Life Support paramedics who qualified between 2001 and 2006, and to then develop a framework of retention strategies. In particular, it determined the extent and nature of their migration, identified the factors that have contributed to their decision to work outside South Africa and identified strategies to retain or encourage the return of ALS paramedics to practice exclusively in South Africa. Methods The study consisted of a two-phase mixed method descriptive survey. Paramedics with ALS undergraduate diplomas who qualified in South Africa between 2001 and 2006 made up the study population. Quantitative data (Phase One) was obtained from a web-based survey distributed to the accessible population (N=97). Thereafter, qualitative data (Phase Two) was gathered through in-depth interviews with selected information rich participants (n=10) also from within the accessible population. Through methodological triangulation, data from Phase One and Phase Two were Page vi integrated to obtain an in-depth understanding of South African ALS paramedic migration. Results Significant differences existed in the distribution of age (p=0.035), and years of experience post-graduation (p=0.007) and the ALS paramedic deemed most likely to migrate were individuals between the ages of 21 – 30. 15 (55%) of the participants working outside the country were engaged in short term contracts while all 24 (100%) of participants working inside South Africa were permanently employed. 18 (75%) of respondents working inside South Africa intended migrating, 12 (67%) of which intended to do so within 0 to 2 years. Nine major factors or reasons for migration were identified by participants. Working conditions, physical security and economic considerations were ranked as the top three major factors most likely to contribute to the decision or intended decision to migrate. This study also found five primary decisions that likely emerge during the life of a South African ALS Paramedic. The outcome of each decision is a result of facilitators weighted against barriers. Facilitators are factors that supported each of the primary decisions while barriers weakened or rejected them. Findings indicated that many barriers existed which rejected or weakened the decision of ALS paramedics to work inside South Africa, return to South Africa or remain in South Africa. On the converse, a vast number of facilitators existed which spurred continued migration. Conclusions As the decision to migrate may be conceptualised as early on as when individuals decide to become ALS paramedics, the constructs of return and retention strategies have to extend as far as revising recruitment policies. Preference or places into training programmes should be given to individuals who are less inclined to migrate, these include: military personnel; those already employed in the EMS, older mature candidates; candidates with families that have already settled in SA; and recognition of prior learning (RPL) candidates who are predominately obligated by contract to remain in South African EMSs.