Trata-se de estudo descritivo quantitativo, cujo objetivo foi analisar a aplicabilidade de intervenções da NIC, para situações de Volume de líquidos deficiente no Atendimento Préhospitalar Móvel Avançado à vítima de trauma. Os sujeitos do estudo foram 11 enfermeiros que atuam em Unidades Avançadas Pré-hospitalares da região de Ribeirão Preto. O estudo foi realizado em três etapas, na primeira, foram descritas pelos enfermeiros quais atividades eram realizadas para vítimas de trauma com diagnósticos de Volume de líquidos deficiente e Risco de volume de líquidos deficiente e aplicado um instrumento para apontar a aplicabilidade das intervenções e atividades contidas na NIC para os dois diagnósticos. Na segunda etapa, foram realizados o mapeamento cruzado das atividades e das intervenções da NIC para cada diagnóstico. Na terceira etapa, foram realizados o refinamento do mapeamento comparativo por enfermeiros expertos e a análise da opinião dos enfermeiros quanto à aplicabilidade das atividades à vítima de trauma. A seguir, foi realizada a proposta de reestruturação da NIC para situação de Volume de líquidos deficiente, no APH Avançado Móvel. Nos resultados identificamos 10 enfermeiros do sexo feminino, um do sexo masculino; um com doutorado, cinco com mestrado, quatro especialistas e um somente com graduação; quatro enfermeiros possuem entre 20 e 30 anos, dois entre 31 a 40 anos e cinco entre 41 e 50 anos; com relação ao tempo de atividade no APH Avançado Móvel, identificamos três enfermeiros com três anos, quatro entre quatro e cinco anos e quatro com seis anos ou mais nesse campo de assistência. Na primeira etapa identificaram-se 55 atividades descritas pelos enfermeiros para Volume de líquidos deficiente e 54 para Risco de volume de líquidos deficiente. No mapeamento cruzado, foram listadas 12 intervenções e 59 atividades das 30 intervenções e 750 atividades contidas na NIC, para o diagnóstico Volume de líquidos deficiente e, para Risco de volume de líquidos, 8 intervenções e 34 atividades das 28 intervenções e 691 atividades da NIC. Após refinamento do mapeamento cruzado pelos expertos, foi sugerido agregar as intervenções Encaminhamento, Gerenciamento de protocolo de emergência e Cuidados de emergência para ambos os diagnósticos e Controle de suprimentos para o diagnóstico Volume de líquidos deficiente. Foram refinadas, para Volume de líquidos deficiente, as seguintes intervenções: Controle da hipovolemia, Controle do choque: hipovolêmico, Monitoração hídrica, Terapia endovenosa, Controle do choque, Monitoração dos sinais vitais, Precauções contrassangramento, Punção venosa, Prevenção do choque, Redução do sangramento, Monitoração neurológica, Supervisão, Cuidados de emergência, Gerenciamento do protocolo de emergência, Controle de suprimentos e Encaminhamento e, para Risco de volume de líquidos deficiente, Controle da hipovolemia, Monitoração hídrica, Controle hídrico, Precauções contrassangramento, Prevenção do choque, Redução do sangramento, Supervisão, Sondagem gastrintestinal, Cuidados de emergência, Gerenciamento do protocolo de emergência e Encaminhamento. Na análise da aplicabilidade, foi considerado que as intervenções prioritárias, para Volume de líquidos deficiente, são Punção venosa (0,88) e Terapia endovenosa (0,81) e, para Risco de volume de líquidos, a intervenção Prevenção do choque (0,84). Na proposta de reorganização dos níveis de intervenções da NIC, sugerimos como prioritárias, para Volume de líquidos deficiente, Controle do choque, Monitoração de sinais vitais, Controle da hipovolemia e Supervisão e, para Risco de volume de líquidos deficiente, as intervenções Prevenção do choque e Supervisão. Concluímos que as intervenções contidas na NIC possuem aplicabilidade no cotidiano do APH Avançado Móvel e que algumas alterações devem ser realizadas para melhor utilização neste contexto. / It is a quantitative descriptive study, which aim was to examine the applicability of NIC interventions in situations of inadequate volume of fluid in the pre-hospital Advanced Mobile on the victim of trauma. The group responsible for this study was composed by 11 nurses who work in Advanced Pre-hospital units in the region of Ribeirão Preto. The study was conducted in three stages. The first one was a description given by the nurses, explaining which activities were performed on victims of trauma with diagnoses of fluid volume deficit and risk of fluid volume deficit and then was applied an instrument to indicate the applicability of interventions and activities contained the NIC for both diagnoses. In the second step, was performed a cross-mapping of the interventions and activities of the NIC for each diagnosis. In the third step, were performed by expert nurses the refinement of the cross-mapping and the analysis of the applicability of the activities to victims of trauma. Next, the proposal was to restructure the NIC to the fluid volume deficit victims in APH Advanced Mobile. Results identified that 10 nurses were female, one male. One with a doctorate, five with master, four specialists and only one with graduation. Four nurses have between 20 and 30 years, two between 31 to 40 years and five between 41 and 50 years. About the time of activity in APH Advanced Mobile, we identified three nurses with 3 years, four between 4 and 5 years and four with 6 or more years in this field for assistance. The first stage identified, through the nurses description, 55 activities for the fluid volume deficit treatment and 54 risk fluid volume deficit treatments. In the mapping cross were listed 12 interventions and 59 activities from 30 interventions and 750 activities contained in the NCI for this diagnosis. The results obtained for Risk of fluid volume deficit were 8 interventions and 34 activities of the 28 interventions and 691 activities contained in the NIC. After the refinement of the mapping cross by experts, it was suggested adding interventions Routing, Emergency management protocol and Emergency care for both diagnosis and Control of supplies for the diagnosis of fluid volume deficit. Were refined for fluid volume deficit the following interventions: Hypovolemia management, Shock management: volume , Fluid monitoring, intravenous therapy, Shock management, Vital signs monitoring, Bleeding precautions, Intravenous (IV) insertion, Shock prevention, Bleeding reduction, Neurological monitoring, Surveillance, Emergency care, Emergency Management, Protocol and Routing Control Supplies, and Risk of fluid volume deficit, Hypovolemia management, Fluid Monitoring, Bleeding precautions, Shock prevention, Bleeding reduction, Supervision, Gastrointestinal tube care, Emergency Care, Emergency Management and Routing Protocol. Analyzing the applicability, it was considered that the priority interventions for the fluid volume deficit are Intravenous (IV) insertion (0.88) and Intravenous therapy (0.81), and risk of fluid volume deficit, the impact Shock prevention (0,84). In the proposed reorganization of the levels of the NIC interventions, was suggested as a priority intervention for volume of fluid volume deficit, control of shock, vital signs Monitoring, supervision, hypovolermia management, and Risk of inadequate volume of fluid, the impact of prevention interventions and Supervision. We conclude that the interventions in the NIC have applicability in the daily lives of APH Advanced Mobile and that some changes should be made to a better use in this context.

För att trivas på en arbetsplats där påfrestande händelser präglar vardagen, måste det finnas vissa delar som gör att personalen stannar kvar och trivs med sitt arbete. Som ambulanssjuksköterska kan man dagligen utsättas för påfrestande händelser som kan påverka den enskilde och vårdandet. Vilka är då de positiva aspekterna och hur beskrivs de positiva delarna av att arbeta inom ambulanssjukvård?Syftet med denna studie var att belysa positiva upplevelser i ambulanssjuksköterskors arbete.En kvalitativ intervjustudie utfördes på tre olika ambulansstationer i Södra Sverige. Åtta informanter deltog, samtliga ambulanssjuksköterskor.Resultatet visar olika teman som belyser de positiva aspekterna med arbetet som ambulanssjuksköterska. Samhörighet, tillfredsställelse, ständig utveckling, variation, utmaning och frihetskänsla upplevdes som viktiga faktorer som upplevdes som positiva delar, gentemot bakgrunden med de negativa skildringarna.I diskussionen förs av författarna resonemang kring studiens genomförande samt de positiva upplevelserna av arbetet inom ambulanssjukvård. Slutsatsen är att de positiva upplevelserna har stor betydelse för personalens arbetstrivsel. Det är viktigt att ha kännedom om glädjeämnena inom yrket för att främja en god arbetsmiljö och hålla sig motiverad i sitt yrkesutförande. Har man inte kunskap om vad som är positivt med arbetet kan detta påverka vårdandets kvalitet i negativ riktning / Program: Specialistsjuksköterskeutbildning med inriktning mot ambulanssjukvård

[Truncated abstract] Objective: To investigate the demographics, success rate of application, nature and frequency of complication and the survival outcome of patients receiving advanced airway management in the pre-hospital setting. Design: Prospective observational cohort study. Participants: Patients who were attended to by St. John Ambulance Paramedics in the Perth Metropolitan area and selected regional areas within Western Australia. The patients were unconscious, unresponsive with no gag reflex and where application of an advanced airway would improve ventilation. Methods: Ambulance Paramedics received mannequin training within the classroom environment on the techniques for the application of the Endo-Tracheal Tube and the Laryngeal Mask Airway. The indication for the application of an advanced airway was any patient whose ventilation may be improved by intubation. These patients would be either deeply unconscious and areflexic, long term transport, severely injured (especially head injured) or cardiac arrest patients. Results: ... Paramedic assessment demonstrated that 14 (7.4%) 3 patients had an improvement in outcome. Of the 14 patients, 5 (2.7%) cardiac arrest patients survived to discharge from hospital compared to a 2.1 % survival rate for all cardiac arrest cases attended by the WAAS in 2002. Conclusion: Ambulance Paramedics can successfully apply an advanced airway apparatus in the pre-hospital environment. There was no statistical significance to demonstrate whether the introduction of advanced airway skills was beneficial or detrimental to patient survival outcome.

Den akuta prehospitala vården börjar ofta med ett nödsamtal. Detta, mycket komplexa samtal, är vård som ska vara av god kvalitet, ges på lika villkor och den som har störst behov ska ges företräde. Syftet med förbättringsarbetet var att genom regelbunden återkommande, strukturerad återkoppling och reflektion öka säkerställandet av vitala parametrar och korrekt prioritering i nödsamtalen. Syftet med studien var identifiera framgångs- och riskfaktorer ur SOS-operatörens perspektiv på nödsamtalet med fokus på säkerställande av vitala parametrar, korrekt prioritering samt sammanhanget runt ett nödsamtal.   Genom att, under fyra månader, tillsammans med initialt 12 operatörer, individuellt reflektera över innehållet samtalet samt skriva ned reflektionerna medvetandegjordes operatören på innehållet i samtalet. Detta ledde till en ökning gällande säkerställande av vitala parametrar och korrekt prioritering. En innehållsanalys av reflektionerna visade att det var en framgångsfaktor att vara professionell och att brister i samtalsmetodiken var en stor riskfaktor. När fastställd process för samtalet följdes var det en framgångsfaktor likväl som det var en riskfaktor när den inte följdes.   Slutsatsen blev att regelbunden avlyssning och reflektion ökar säkerställandet av vitala parametrar och korrekt prioritering i nödsamtalen samt att det är en framgångsfaktor att följa fastställd process för samtalet men att tekniskt stöd för ändamålet saknas. / The purpose of the underlying improvement work was to increase the proportion of calls in which vital parameters are secured, and the case is given correct prioritization through regular interception and reflection. The purpose of the study was to identify success and risk factors from the perspective of the emergency call-taker on the emergency call with a focus on securing vital parameters, correct prioritization and the context of the emergency call.   In the improvement work, 12 emergency call-takers were asked, within a period of four months, to individually reflected on the contents in calls and write down reflections. This was contributing to an increase in secured vital parameters and correct prioritization. A content analysis of the reflections demonstrated that it was a success factor to be professional and limitations in the call methodology was a risk factor. When the set process for the call was followed it was a success factor and a risk factor when it was not followed.   The conclusion is that regular interception and reflection increase securing vital parameters and correct prioritization in emergency calls and that it is a success factor to follow the set process for the call, but that technical support for the purpose is missing.

Bakgrund: Centralisering av sjukvård har bidragit till färre antal akutmottagningar. Antalet ambulanstransporter har blivit fler och avstånden till sjukhus längre, vilket ställer höga krav på ambulanspersonalens kompetens. I glesbygd ställs ambulanspersonalen ofta inför utmaningar då för få resurser finns att tillgå. Syfte: att beskriva sjuksköterskors upplevelser av att prehospitalt vårda patienter med kritiska tillstånd i glesbygd. Metod: Nio legitimerade sjuksköterskor som arbetade på två olika ambulansstationer belägna i glesbygd i Norra Sverige intervjuades med semistrukturerade intervjuer. Den transkriberade texten analyserades med kvalitativ innehållsanalys. Resultat: Analysen av intervjuerna resulterade i fem kategorier: Att långa avstånd förlänger vårdtiden, Att bristande resurser försvårar omhändertagandet, Att känna sig ensam och otillräcklig, Att trygghet i teamet stärker omvårdnaden av patienten, Att utbildning och utveckling bidrar till ökad trygghet. Sjuksköterskorna i ambulans i glesbygdstudien upplevde att det var påfrestande att stå ensam med stora och för patienten livsavgörande beslut. De upplevde att arbetet krävde mycket av dem som sjuksköterskor då de fick vårda patienter med kritiska tillstånd under en lång tid på grund av långa avstånd och samtidigt hade för få resurser att tillgå. Vidare upplevdes arbetet som utmanande och deltagarna beskrev att de alltid försökte lösa situationerna efter de förutsättningar som fanns. Ett väl fungerande samarbete med kollegor beskrevs vara viktigt. Sjuksköterskorna beskrev även att det var viktigt att ha en bred kompetens inom akutsjukvård. Slutsats: Prehospital vård i glesbygd och omhändertagande av patienter med kritiska tillstånd är utmanande. Sjuksköterskor bör besitta bred kompetens och utbildning inom akutsjukvård kan främja omvårdnaden i komplexa situationer. Utvecklingsområden har identifierats under studiens process och ytterligare forskning inom området är önskvärt för vidare kliniska implikationer.

Trata-se de estudo descritivo quantitativo, cujo objetivo foi analisar a aplicabilidade de intervenções da NIC, para situações de Volume de líquidos deficiente no Atendimento Préhospitalar Móvel Avançado à vítima de trauma. Os sujeitos do estudo foram 11 enfermeiros que atuam em Unidades Avançadas Pré-hospitalares da região de Ribeirão Preto. O estudo foi realizado em três etapas, na primeira, foram descritas pelos enfermeiros quais atividades eram realizadas para vítimas de trauma com diagnósticos de Volume de líquidos deficiente e Risco de volume de líquidos deficiente e aplicado um instrumento para apontar a aplicabilidade das intervenções e atividades contidas na NIC para os dois diagnósticos. Na segunda etapa, foram realizados o mapeamento cruzado das atividades e das intervenções da NIC para cada diagnóstico. Na terceira etapa, foram realizados o refinamento do mapeamento comparativo por enfermeiros expertos e a análise da opinião dos enfermeiros quanto à aplicabilidade das atividades à vítima de trauma. A seguir, foi realizada a proposta de reestruturação da NIC para situação de Volume de líquidos deficiente, no APH Avançado Móvel. Nos resultados identificamos 10 enfermeiros do sexo feminino, um do sexo masculino; um com doutorado, cinco com mestrado, quatro especialistas e um somente com graduação; quatro enfermeiros possuem entre 20 e 30 anos, dois entre 31 a 40 anos e cinco entre 41 e 50 anos; com relação ao tempo de atividade no APH Avançado Móvel, identificamos três enfermeiros com três anos, quatro entre quatro e cinco anos e quatro com seis anos ou mais nesse campo de assistência. Na primeira etapa identificaram-se 55 atividades descritas pelos enfermeiros para Volume de líquidos deficiente e 54 para Risco de volume de líquidos deficiente. No mapeamento cruzado, foram listadas 12 intervenções e 59 atividades das 30 intervenções e 750 atividades contidas na NIC, para o diagnóstico Volume de líquidos deficiente e, para Risco de volume de líquidos, 8 intervenções e 34 atividades das 28 intervenções e 691 atividades da NIC. Após refinamento do mapeamento cruzado pelos expertos, foi sugerido agregar as intervenções Encaminhamento, Gerenciamento de protocolo de emergência e Cuidados de emergência para ambos os diagnósticos e Controle de suprimentos para o diagnóstico Volume de líquidos deficiente. Foram refinadas, para Volume de líquidos deficiente, as seguintes intervenções: Controle da hipovolemia, Controle do choque: hipovolêmico, Monitoração hídrica, Terapia endovenosa, Controle do choque, Monitoração dos sinais vitais, Precauções contrassangramento, Punção venosa, Prevenção do choque, Redução do sangramento, Monitoração neurológica, Supervisão, Cuidados de emergência, Gerenciamento do protocolo de emergência, Controle de suprimentos e Encaminhamento e, para Risco de volume de líquidos deficiente, Controle da hipovolemia, Monitoração hídrica, Controle hídrico, Precauções contrassangramento, Prevenção do choque, Redução do sangramento, Supervisão, Sondagem gastrintestinal, Cuidados de emergência, Gerenciamento do protocolo de emergência e Encaminhamento. Na análise da aplicabilidade, foi considerado que as intervenções prioritárias, para Volume de líquidos deficiente, são Punção venosa (0,88) e Terapia endovenosa (0,81) e, para Risco de volume de líquidos, a intervenção Prevenção do choque (0,84). Na proposta de reorganização dos níveis de intervenções da NIC, sugerimos como prioritárias, para Volume de líquidos deficiente, Controle do choque, Monitoração de sinais vitais, Controle da hipovolemia e Supervisão e, para Risco de volume de líquidos deficiente, as intervenções Prevenção do choque e Supervisão. Concluímos que as intervenções contidas na NIC possuem aplicabilidade no cotidiano do APH Avançado Móvel e que algumas alterações devem ser realizadas para melhor utilização neste contexto. / It is a quantitative descriptive study, which aim was to examine the applicability of NIC interventions in situations of inadequate volume of fluid in the pre-hospital Advanced Mobile on the victim of trauma. The group responsible for this study was composed by 11 nurses who work in Advanced Pre-hospital units in the region of Ribeirão Preto. The study was conducted in three stages. The first one was a description given by the nurses, explaining which activities were performed on victims of trauma with diagnoses of fluid volume deficit and risk of fluid volume deficit and then was applied an instrument to indicate the applicability of interventions and activities contained the NIC for both diagnoses. In the second step, was performed a cross-mapping of the interventions and activities of the NIC for each diagnosis. In the third step, were performed by expert nurses the refinement of the cross-mapping and the analysis of the applicability of the activities to victims of trauma. Next, the proposal was to restructure the NIC to the fluid volume deficit victims in APH Advanced Mobile. Results identified that 10 nurses were female, one male. One with a doctorate, five with master, four specialists and only one with graduation. Four nurses have between 20 and 30 years, two between 31 to 40 years and five between 41 and 50 years. About the time of activity in APH Advanced Mobile, we identified three nurses with 3 years, four between 4 and 5 years and four with 6 or more years in this field for assistance. The first stage identified, through the nurses description, 55 activities for the fluid volume deficit treatment and 54 risk fluid volume deficit treatments. In the mapping cross were listed 12 interventions and 59 activities from 30 interventions and 750 activities contained in the NCI for this diagnosis. The results obtained for Risk of fluid volume deficit were 8 interventions and 34 activities of the 28 interventions and 691 activities contained in the NIC. After the refinement of the mapping cross by experts, it was suggested adding interventions Routing, Emergency management protocol and Emergency care for both diagnosis and Control of supplies for the diagnosis of fluid volume deficit. Were refined for fluid volume deficit the following interventions: Hypovolemia management, Shock management: volume , Fluid monitoring, intravenous therapy, Shock management, Vital signs monitoring, Bleeding precautions, Intravenous (IV) insertion, Shock prevention, Bleeding reduction, Neurological monitoring, Surveillance, Emergency care, Emergency Management, Protocol and Routing Control Supplies, and Risk of fluid volume deficit, Hypovolemia management, Fluid Monitoring, Bleeding precautions, Shock prevention, Bleeding reduction, Supervision, Gastrointestinal tube care, Emergency Care, Emergency Management and Routing Protocol. Analyzing the applicability, it was considered that the priority interventions for the fluid volume deficit are Intravenous (IV) insertion (0.88) and Intravenous therapy (0.81), and risk of fluid volume deficit, the impact Shock prevention (0,84). In the proposed reorganization of the levels of the NIC interventions, was suggested as a priority intervention for volume of fluid volume deficit, control of shock, vital signs Monitoring, supervision, hypovolermia management, and Risk of inadequate volume of fluid, the impact of prevention interventions and Supervision. We conclude that the interventions in the NIC have applicability in the daily lives of APH Advanced Mobile and that some changes should be made to a better use in this context.

Introdução: Manaus dispõe de um Serviço de Atendimento Móvel de Urgência (SAMU) fluvial que atende a população que reside em comunidades ribeirinhas dos rios Negro e Amazonas. Tem-se observado várias iniciativas de atendimento pré-hospitalar (APH) com uso desse tipo de transporte; no entanto, não foram encontradas na literatura informações sobre esses serviços, perfil dos usuários e fatores associados a desfechos indesejáveis do atendimento. Objetivo: Caracterizar o perfil dos usuários, aspectos do atendimento do SAMU fluvial de Manaus e identificar fatores relacionados ao agravamento no APH fluvial. Método: Estudo descritivo correlacional realizado em duas etapas. Na primeira etapa, a coleta de informações foi retrospectiva e teve como fonte os registros dos atendimentos realizados pelo SAMU fluvial de Manaus de 2009 a 2015. Na segunda etapa, a coleta de dados foi prospectiva; indivíduos com 15 anos ou mais, atendidos pelo SAMU fluvial no período de seis meses (janeiro a junho de 2016), tiveram informações coletadas desde a chamada na Central de Regulação até a chegada à base fluvial. Pacientes encaminhados para hospitais tiveram a coleta de informações estendida até a saída hospitalar. Testes de associação foram aplicados considerando as características do atendimento e usuário perante o agravamento do paciente, identificado por meio das mudanças do Rapid Emergency Medicine Score (REMS) entre o atendimento inicial e final do SAMU fluvial. Resultados: Entre 2009 e 2015, o SAMU fluvial de Manaus realizou 2.002 atendimentos, a maior parte em comunidades do Rio Negro e próximas da base fluvial. A grande maioria dos atendidos pelo SAMU fluvial foi removida para Manaus (92%), variando o tipo de embarcação mais frequentemente utilizada no transporte ao longo dos anos e com ajustes na tripulação da modalidade Unidade de Suporte Avançado (USA) após 2015. Foi baixa a frequência de procedimentos nos atendimentos (média 1,5 procedimento), porém o acesso venoso foi realizado em quase todos os usuários (97,8%). Houve grande variabilidade dos tempos de APH. As médias do tempo de resposta (84 minutos) e total de APH fluvial (172 minutos) foram bastante elevadas. A maioria dos pacientes removidos foi encaminhada para hospital (44,9%) ou serviço de pronto atendimento (37,1%). A frequência de homens e mulheres atendidos foi semelhante e os usuários com menos de 35 anos predominaram. As causas mais frequentes dos atendimentos foram as relacionadas a sintomas, sinais e achados anormais e causas externas de morbidade e mortalidade. Os parâmetros fisiológicos e o valor médio do REMS inicial, 2,7 (dp = 3,6), indicaram baixo risco de morte dos pacientes. No entanto, a mortalidade hospitalar dos internados foi de 8,7%. Dos pacientes transportados pelo SAMU fluvial, 68,5% mantiveram o quadro clínico, 18,0% pioraram e 13,5% melhoraram durante o atendimento. Houve associação entre piora e local de destino dos usuários (p=0,037), também com as ocorrências relacionadas a contato com serpentes venenosas (p= 0,039) e dor aguda (p= 0,005). Conclusão: No geral, os resultados mostraram peculiaridades do SAMU fluvial de Manaus em relação a serviços terrestres que necessitam ser consideradas no planejamento, implementação e avaliação do APH fluvial. / Introduction: Manaus has a fluvial Mobile Emergency Care Service (SAMU) that serves the population who lives in riverside communities of Negro and Amazon rivers. Several prehospital care initiatives (APH) have been observed regarding this type of transportation. However, information on these services, users\' profiles and factors associated with undesirable outcomes were not found in the literature. Objective: To characterize the profile of the users and aspects of Manaus fluvial SAMU and to identify factors related to the worsening in fluvial APH. Method: Descriptive, correlational study carried out in two stages. In the first stage, the information collection was retrospective and was based on the records of the services performed by Manaus fluvial SAMU from 2009 to 2015. In the second stage, data collection was prospective. Individuals aged 15 years and older attended by fluvial SAMU in the six-month period (January to June 2016) had information collected from the call to the Regulation Center until arrival at the fluvial base. Patients referred to hospitals had information collection extended until hospital discharge. Association tests were applied considering the characteristics of care and user before the patient\'s worsening, identified through the changes of the Rapid Emergency Medicine Score (REMS) from the initial care until the final care by fluvial SAMU. Results: From 2009 to 2015, Manaus fluvial SAMU carried out 2,002 visits, mostly in communities of Rio Negro and near the fluvial base. The vast majority of people served by the fluvial SAMU were removed to Manaus (92%). The type of boat most frequently used has changed over the years. Additionally, there were adjustments to the Advanced Support Unit (USA) crew after 2015. The frequency of procedures occurred during management was low (mean 1.5 procedure), but venous access was performed in almost all patients (97.8%). There was great variability of APH times. The mean response time (84 minutes) and total fluvial APH (172 minutes) were quite high. The majority of patients removed were referred to hospital (44.9%) or emergency care (37.1%). The frequency of men and women attended was similar and users less than 35 years old predominated. The most frequent causes of the visits were related to \"symptoms, signs and abnormal findings\" and \"external causes of morbidity and mortality\". The physiological parameters and the mean value of the initial REMS, 2.7 (SD = 3.6), indicated a low risk of death related to the patients. However, in- hospital mortality was 8.7%. Considering the patients transported by fluvial SAMU, 68.5% maintained the clinical presentation, 18.0% worsened and 13.5% improved during the care. There was an association between worsening and destination of the users (p = 0.037), as well as occurrences related to contact with venomous snakes (p = 0.039) and acute pain (p = 0.005). Conclusion: In general, the results showed peculiarities of Manaus fluvial SAMU related to terrestrial services that need to be considered in the planning, implementation and evaluation of fluvial APH.

SAMMANFATTNING Prehospital sjukvård innebär akuta medicinska insatser som sker utanför sjukhus av hälso- och sjukvårdspersonal. I mötet med patienten ingår det i ambulanssjuksköterskans arbetsroll att värna om patientens integritet samt organisera omvårdnaden så att det främjar patientens välbefinnande och minskar lidande. Faktorer i miljön där vårdandet sker, i den prehospitala sjukvården, påverkar inte bara patienten och dennes anhöriga utan även ambulanssjuksköterskan. Arbetsmiljön inom prehospital sjukvård kan innebära hälsorisker för ambulanssjuksköterskan då arbetet kan vara både mentalt och fysiskt ansträngande eftersom det bland annat förekommer tunga lyft, omedelbar beredskap och ogynnsamma arbetsställningar. Det krävs en förmåga att arbeta under tidspress och att kunna hantera allvarliga situationer.   Syftet med studien var att belysa ambulanssjuksköterskans upplevelse av arbetsmiljörelaterade faktorers påverkan på omvårdnaden i den prehospitala miljön. Studien är en kvalitativ intervjustudie där författarna intervjuade åtta ambulanssjuksköterskor med stöd av en intervjuguide där informanterna fick belysa sina upplevelser och erfarenheter av arbetsmiljön i den prehospitala miljön. Intervjuerna analyserades sedan genom en kvalitativ innehållsanalys för att ge en djupare förståelse för det studerade fenomenet. Resultatet visade att det fanns ett flertal faktorer i arbetsmiljön som ambulanssjuksköterskan upplevde påverkade omvårdnaden av patienten i den prehospitala sjukvården. Innehållsanalysen av intervjuerna resulterade i fyra kategorier, kommunikation, erfarenhet och utbildning, ambulansfordonet samt egen säkerhet och hälsa. Kategorierna sammanfattar informanternas upplevelser kring faktorer i arbetsmiljön som kunde påverka omvårdanden samt önskemål om förbättring och utveckling som kan påverka detta. Studiens slutsats innebar att det fanns många faktorer i arbetsmiljön som påverkade ambulanssjuksköterskans utförande av omvårdnad i den prehospitala miljön. Det visade att god kommunikation med kollega, patienter och anhöriga var av stor vikt för att kunna ge organiserad och adekvat omvårdnad. Många upplevde att det fanns ett stort behov av vidareutbildning för kompetensutveckling och förbättring av kommunikation med andra samverkande grupper för att förtydliga syftet med uppdraget och förbättra omvårdnaden till patienten. Det fanns ett behov av att vidareutveckla utrustningen i ambulansen samt utformningen av ambulansen för att minska risken för skador på kroppen. Nyckelord: ambulanssjuksköterska, fysisk arbetsmiljö, psykosocial arbetsmiljö, prehospital sjukvård, omvårdnad. / ABSTRACT Emergency medical service is healthcare that takes place outside the hospital and is performed by specializes nurses. In the interaction between the specialized ambulance nurse and the patient, it is important to address the patients´ well-being and organize the care to prevent the patient from unnecessary suffering. Factors in the environment where prehospital care is taking place are not often studied and is not something that just affects the patient, but also presents risks to the ambulance personnel as working in the emergency medical services can be both mentally and physically exerting. Working in emergency medical service includes heavy lifting, immediate preparedness, unfavorable work environments, and requires the ability to work under time pressure as well as the ability to handle serious situations. The aim of the study was to highlight the ambulance nurses experience of the effects of work environment-related factors on nursing care in the prehospital setting. The study was a qualitative interview study in which the authors interviewed eight ambulance nurses using a questionnaire where informants were able to highlight their experiences in the prehospital setting as well as their experiences of the work environment in the ambulance care industry. The interviews were then analyzed to provide a deeper understanding of the studied phenomenon. The results showed several factors in the work environment that affect the care of the patient in the prehospital setting. The content analysis of the interviews resulted in four separate categories; communication, experience and education, the ambulance vehicle and the workers own safety and health. The categories summarized the informants´ experiences about factors in the work environment and how they can affect these, as well as the desire for improvement and development in order to provide adequate and safe care for the patients. The conclusion of the study implied that there are many factors in the work environment that influence the ambulance nurse in the prehospital setting. Direct communication between the college, patient and their relative was important to be able to organize the care and provide safe medical care. However, many of the ambulance nurses experienced a need for further education and improved communication with other collaborative groups to clarify the purpose of the assignment and to improve the care of the patient. There was also a need for development of the equipment used in the prehospital setting and in the vehicle to prevent damages on the ambulance nurse´s health. Keywords: ambulance nurse, physical work environment, psychosocial work environment, prehospital care, nursing.

Varje år sker omkring sextusen hjärtstopp utanför sjukhus i Sverige. Endast tio procent beräknas överleva. Ambulanssjuksköterskan har riktlinjer för hur hon ska påbörja, genomföra och eventuellt avsluta en hjärtlungräddning prehospitalt. Frågan om att avbryta en hjärtlungräddning är studerad i begränsad omfattning. Beslutet fattas under ansträngda förhållanden med etiska konflikter involverade, vilket kan påverka ambulanssjuksköterskan psykiska välbefinnande och hennes förmåga att vidare utföra sitt arbete. Syftet med studien är att beskriva upplevelsen av att avbryta hjärtlungräddning hos sjuksköterskor inom ambulanssjukvården och hur upplevelsen eventuellt påverkas av olika faktorer (förbättringspotentialer) kopplade såväl till ambulansorganisationen, vårdaren och omständigheterna kring hjärtstoppet. En kvalitativ intervjustudie har gjorts för att besvara studiens syfte. Tolv intervjuer genomfördes med ambulanssjuksköterskor från tre ambulansstationer i Västsverige. En öppen fråga med hänvisning till studiens syfte besvarades av informanterna. Resultatet indikerar att ambulanssjuksköterskan, vid den vanligaste varianten av hjärtstopp, inte upplever avbrytandet som särskilt problematiskt. Vidare visar studien på att omgivande faktorer i samband med avbrytandet har en påverkan på ambulanssjuksköterskan. Det som informanterna beskrev som viktigt i sammanhanget var samtalet med kollegan samt tid för återhämtning och reflektion efter en emotionellt påfrestande situation. Ambulanssjuksköterskan värnar om sin yrkesroll och för att bevara denna behöver de vissa förutsättningar i sin omgivning. Det är viktigt att organisationen kring ambulanssjuksköterskan tillser att dessa behov tillgodoses för att de på ett tillfredställande sätt ska kunna utföra sitt arbete och samtidigt inte påverkas allt för mycket på ett personligt plan. Ett nytt spår i utbildningen av hjärtlungräddning där ambulanssjuksköterskan får ökad kunskap i att hantera människor i sorg och kris samt att organisatoriskt beakta behovet av tid för samtal och reflektion, främst tillsammans med närmast kollegan, kan vara av värde i framtiden. / Every year, about six thousand cardiac arrests occur outside hospitals in Sweden. Only ten percent are estimated to survive. The ambulance nurse has guidelines for how she should start, carry out and possibly terminate a cardiopulmonary resuscitation in the prehospital setting. The problems surrounding termination of a cardiopulmonary resuscitation has been scarcely studied. The decision is made under strained conditions with ethical conflicts involved, which can affect the ambulance nurse's mental well-being and her ability to further carry out her work. The purpose of the study is to describe the experiences of interrupting cardiopulmonary resuscitation among nurses in ambulance care and how these experiences may be influenced by different factors (some of which may be amenable for improvement) and linked to the ambulance organization, the healthcare provider and circumstances at the event. A qualitative interview study has been performed to address the purpose of the study. Twelve interviews were conducted with ambulance nurses from three ambulance stations in western Sweden. An open-ended question with reference to the purpose of the study was answered by the informants. The result indicates that the ambulance nurse, during the most common type of cardiac arrest, does not experience the interruption as particularly problematic. Furthermore, the study shows that surrounding factors in connection with the interruption have an impact on the ambulance nurse. What the informants described as important in the context was the conversation with the colleague and time for recovery and reflection after an emotionally stressful situation. The ambulance nurse safeguards her professional role and in order to maintain this, they need certain conditions in the environment. It is important that the organization around the ambulance nurse ensures that these requirements are met so that she or he can carry out the work in a satisfactory manner and at the same time not be affected too much on a personal level. A new track in the training of cardiopulmonary resuscitation where the ambulance nurse gains increased knowledge in dealing with people in grief and crisis and to organizationally consider the need for time for conversation and reflection, mainly together with the closest colleague, may be of value in the future.

Introduktion: I dag är det många äldre som vårdas i hemmet med avancerad hemsjukvård. En ökning av antal äldre personer i samhället kommer sannolikt leda till ökat antal patienter med central venös infart i prehospital vård.Syfte: Syftet med studien var att studera sjuksköterskors upplevelser av befintliga centrala venösa infarter vid prehospital vård. Forskningsfrågorna var hur sjuksköterskorna upplevde användning av central venös infart och deras upplevelse av vad som påverkade valet av venös infart.Metod: Metoden som användes var deskriptiv kvalitativa design med semistrukturerade intervjuer av tjugo sjuksköterskor som arbetade inom Ambulanssjukvården i Region Dalarna. Samtliga sjuksköterskor hade arbetat mer än fem år inom ambulanssjukvård. Analysen av intervjuerna genomfördes genom innehållsanalys.Resultat: Resultatet visade att de intervjuade sjuksköterskorna upplevde osäkerhet, bristande erfarenhet och bristande stöd. Detta var avgörande för deras upplevelse av centrala venösa infarter. Det fanns skillnader i sjuksköterskornas kunskap avseende hantering av centrala venösa infarter. En annan faktor var en tydlig och stark vilja hos de intervjuade att inte göra fel och att inte skada.Slutsats: Slutsatsen av studien visade att Sjuksköterskorna önskade mer kunskap och ett kunskapsstöd i form av behandlingsriktlinjer samt möjligheter att öva. / Introduction: Today, numerous elderly people are cared for at home with advanced home health care. An increase in the number of elderly people in society is likely to lead to a rice in the number of patients with central venous access in prehospital care.Purpose: The purpose of the study was to investigate nurses' experiences of existing central intravenous inline in prehospital care. The research questions were how the nurses experienced the use of central venous access and their experience of what influenced the choice of venous access.Method: The method was based on descriptive qualitative semi-structured interviews with twenty nurses working in Ambulance Care in Region Dalarna. All nurses had more than five years work experience in ambulance care. The answers of the interviews have been compiled through a content analysis.Results: The result presented that almost all the nurses interviewed perceived their own insecurity or uncertainty with their colleagues when it comes to managing central intravenous catheters. There were differences in knowledge among the nurses to manage central intravenous catheters.Conclusion: The conclusion of the study showed that the Nurses wanted more knowledge and the results showed that the interviewed nurses experienced uncertainty, shortage of experience and of support. This was crucial for their experience of central venous entrances. There were differences in the nurses' knowledge regarding the management of central venous entrances. Another factor was a distinct and strong will of the interviewees not do mistakes and not to hurt knowledge support in the form of treatment guidelines and opportunities to practice.