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.

Critical Incident Stress has the potential to affect emergency services personnel to the degree that it can change the way the responder acts and reacts in all facets of his or her life, including the job and his or her family. Research into these potential effects has produced a greater understanding of the responders experiences within a short period of time after the perceived critical incident. This study investigates the long-term effects of critical incident stress among emergency responders from two cities in the three emergency services professions were interviewed to determine what their experiences were at least six months post critical incident. A structured incident had in three areas of teh emergency responders lives: impact on job, impact on the individual responder, and perceived impact on emergency responders families. For particpants, symptoms of Critical Incident Stress lasted between 6 months and 2 years after the perceived critical incident. Analysis of the data indicatees that single responder critical incidents have the potential to negatively affect emergency responders resulting in the loss of enthusiasm and passion for their work, debilitating psychological distress, and isolation from valued support systems. Long-term effects of Critical Incident Stress change the perceptions that responders have about the job, about themselves, and the relationships with their families. The culture of emergency services, changing identities, and the lack of support from both within the system and outside of the system were seen as variables that contribute to the long-term effects of Critical Incident Stress. / xi, 181 leaves ; 29 cm.

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.

This thesis engages in its theoretical part description of the process of pursuance and assurance of quality in emergency medical dispatch centre. There is also a comprehensive description of key quality parameters used in this environment in this part. The content of the empiric section is an organizational case study, which aim was to evaluate an extensive organizational change in emergency medical dispatch centre of the Emergency Medical Service of the Central Bohemian region and its impacts on the quality of care. The first phase of centralization of emergency medical dispatch centres in the Central Bohemian region went through during the first half of 2011. Four local emergency medical dispatch centres were gradually brought together into one entity. The aim of the research was to evaluate impacts of the organizational change on key quality parameters. The observational retrospective study consists of two groups of data, collected from identical area during two equivalent periods. Group A contains data from the period of six months before and group B contains data from the period of six months after the centralization. Key quality indicators were compared in both groups: response time; call processing times; safety of classification and indication of calls; use of dispatch life support and...

Out-of-hospital cardiac arrest (OHCA) is a significant public health problem in most westernized industrialized nations. In spite of national and international guidelines for cardiopulmonary resuscitation and emergency cardiac care, the overall survival of patients with OHCA was essentially unchanged for 30 years--from 1978 to 2008 at 7.6%. Perhaps a better indicator of Emergency Medical System (EMS) effectiveness in treating patients with OHCA is to focus on the subgroup that has a reasonable chance of survival, e.g., patients found to be in ventricular fibrillation (VF). But even in this subgroup, the average survival rate was 17.7% in the United States, unchanged between 1980 and 2003, and 21% in Europe, unchanged between 1980 and 2004. Prior to 2003, the survival of patients with OHCA, in VF in Tucson, Arizona was less than 9% in spite of incorporating previous guideline recommendations. An alternative (non-guidelines) approach to the therapy of patients with OHCA and a shockable rhythm, called Cardiocerebral Resuscitation, based on our extensive physiologic laboratory studies, was introduced in Tucson in 2003, in rural Wisconsin in 2004, and in selected EMS areas in the metropolitan Phoenix area in 2005. Survival of patients with OHCA due to VF treated with Cardiocerebral Resuscitation in rural Wisconsin increased to 38% and in 60 EMS systems in Arizona to 39%. In 2004, we began a statewide program to advocate chest compression-only CPR for bystanders of witnessed primary OHCA. Over the next five years, we found that survival of patients with a shockable rhythm was 17.7% in those treated with standard bystander CPR (mouth-to-mouth ventilations plus chest compression) compared to 33.7% for those who received bystander chest-compression-only CPR. This article on Cardiocerebral Resuscitation, by invitation following a presentation at the 2011 Danish Society Emergency Medical Conference, summarizes the results of therapy of patients with primary OHCA treated with Cardiocerebral Resuscitation, with requested emphasis on the EMS protocol.

Introduktion: Sjuksköterskor inom somatisk vård möter och vårdar vid ett antal tillfällen per år patienter med diagnosen anorexia nervosa. Anorexia nervosa är en allvarlig sjukdom med hög dödlighet. Diagnosen påverkar både patientens somatiska och psykiatriska status. Patienter med diagnosen anorexia nervosa beskriver ett omvårdnadsbehov ur både ett somatiskt- och psykiatriskt omvårdnadsperspektiv. En framgångsrik allians är viktig för att vård och behandling ska kunna uppnås och upprätthållas. Sjuksköterskor inom somatisk vård upplever flera utmaningar i mötet med patientgruppen, däribland fördjupad förståelse för sjukdomens komplexitet. Syfte: Att undersöka hur sjuksköterskor inom somatisk vård upplever omvårdnaden i förhållande till patienter med diagnosen anorexia nervosa. Metod: Intervjustudie med kvalitativ ansats samt ett induktivt förhållningssätt. Studien bygger på åtta semistrukturerade intervjuer med sjuksköterskor på en somatisk vårdavdelning. Tematisk analys användes för analys av intervjuerna. Resultat: Dataanalysen resulterade i tre övergripande teman: Sjuksköterskan och anorexi, Komplex somatisk omvårdnad samt Ropet efter psykiatrin. Sjuksköterskorna upplevde svårigheter som starka känslor, bristande vårdstruktur och otillräcklig kunskap om diagnosen anorexia nervosa i omvårdnadsarbetet med patientgruppen. Sjuksköterskorna önskade handledning och utbildning om sjukdomens komplexitet samt ett förbättrat samarbete mellan somatiken och psykiatrin. Slutsats: Sjuksköterskor inom somatisk vård upplevde flera svårigheter i mötet med patienter med diagnosen anorexia nervosa. Brist på tid, omvårdnadsstruktur och fördjupad kunskap om sjukdomen upplevdes försvåra möjligheterna till god kommunikation och allians med patientgruppen. Stöd, kunskap och ett välfungerande samarbete med psykiatrin ansågs kunna förbättra och utveckla omvårdnadsarbetet på den somatiska avdelningen för patienter med diagnosen anorexia nervosa. / Introduction: Nurses working in an acute medical care setting sometimes participate in the treatment of patients diagnosed with anorexia nervosa. Anorexia nervosa is a serious disease with a high mortality-rate. The disease affects the body as well as the mind. Patients diagnosed with anorexia nervosa describe nurses' lack of knowledge about the diagnosis. Nurses in medical care settings describe several challenges in the nursing process involving patients diagnosed with anorexia nervosa. Purpose: To examine the experiences of nurses working in an acute medical care setting when treating and nursing patients diagnosed with anorexia nervosa. Method: A qualitative interview study. Semi-structured interviews were conducted with eight nurses working in an acute medical care setting. The text material was analyzed with thematic analysis. Results: The nurses experienced strong feelings when nursing patients diagnosed with anorexia nervosa. The nurses described unclear treatment structures and insufficient knowledge about the diagnosis. A well-established cooperation with the psychiatric unit as well as improved knowledge about the diagnosis were described as requirements in order to offer the patients advanced nursing. Conclusion: Nurses in a medical care unit experienced several challenges when nursing patients with anorexia nervosa. The nurses described a constant lack of time, unclear treatment structures and insufficient knowledge about the diagnosis. Tutorials, education and cooperation with the psychiatric unit could support nurses in medical health units to improve in order to understand the complex needs of patients diagnosed with anorexia nervosa.

Bakgrund: Regionalt Läkarstöd (RLS) har utformats för att säkra prehospital involvering från läkare. Dagens ambulanssjukvård ställer höga krav på att bedöma och triagera patienter till rätt vårdnivå. Till sin hjälp i sitt dagliga arbete med detta behöver sjuksköterskan en läkare som är väl insatt i verksamheten. Syfte: Att beskriva läkares erfarenhet av att fungera som rådgivare till sjuksköterskor inom ambulanssjukvården Metod: Kvalitativ intervjustudie med tio läkare som tjänstgör som RLS. Analysen genomfördes med en kvalitativ innehållsanalys. Resultat: Resultatet beskrivs med de fyra kategorierna Teamsammanhållning, Frustration, Bristande ansvarskänsla och Lyhördhet, som speglade läkarnas erfarenheter av att vara telefonstöd till sjuksköterskor. Ett latent huvudbudskap identifierades som Skör tillit. Att som en del i teamet finnas som stöd och rådgivare till sjuksköterskor i ambulanssjukvården upplevdes som positivt och funktionen ses som relevant och viktig. Det krävs en god teamsamverkan mellan professionerna för en patientsäker vård och för att uppnå det utkristalliserades tillit som en nyckelfaktor. Konklusion: En telefonbaserad bakjourslinje dit sjuksköterskor kan vända sig för råd och stöd är en relevant funktion för läkarna, där de känner sig som en del i det prehospitala teamet. I arbetet med bättre teamsamverkan inkluderande god kommunikation för säker vård, är gemensamma möten och övningar en viktig del för att ge professionerna en chans att mötas som personer och främja ökad förståelse för varandras kunskap och utforma gemensamma mål. / Background: Regional Medical support has been designed to ensure an involvement of doctors in the prehospital field. The current system for ambulance care raise high demands to ensure a correct patient assessment and triage to the right level of care, and for their assistance in this daily work, the nurse needs a doctor who is very knowledgeable in the organization. Purpose: To describe doctors’ experience of functioning as advisors for nurses working in the ambulance. Method: A qualitative research design was conducted including interviews with nine doctors serving as Regional Medical support. The content analysis was conducted according to a qualitative content analysis method.  Result: The analysis resulted in the four categories team spirit, frustration, lack of sense of responsibility and responsiveness, which mirrored the doctors’ experiences of acting as a phone support for specialist nurses on the ambulance. An underlying main message was identified as delicate trust. To be part of the team and act as a support and advisor for nurses working on the ambulance was perceived as positive, relevant and important. Good teamwork between the professions is required to guarantee patient safe care, and to obtain that, trust came through as a key factor. Conclusion: For the nurses to have an on call doctor that they can reach on the phone for support and advice was seen as a relevant system for the doctors, where they feel as a part of the prehospital team. In the continuous work for better teamwork, including good communication for safe care, it's important with common gatherings and training sessions to give the professions a chance to meet in person and gain a better understanding for each other’s roles, and enunciate common goals.

Aim: To describe and interpret patients’, family members’ and ambulance personnel’s experiences with regard to survival, attendance, and caring at cardiac arrests and deaths, and to analyze ethical conflicts that arise in relation to families and how the personnel’s ethical competence can affect caring and the ability to handle ethical problems. Method: The three interview studies were guided by a reflective lifeworld approach grounded in phenomenology and analyzed by searching for the essence of the phenomenon in two studies and by attaining a main interpretation in one study. In the fourth study, the general approach was supplemented by “reflective equilibrium” that guided the ethical analysis. Results: The survivors are striving towards a good life by means of efforts to reach meaning and coherence, facing existential fear and insecurity as well as gratitude and the joy of life. Family members lose everyday control through feelings of unreality, inadequacy and overwhelming responsibility. Ambulance personnel’s care mediates hope and despair until the announcement of survival or death. After the event, family members risk involuntary loneliness and anxiety about the future. For the ambulance personnel, caring for families involves a need for mobility in decision making, forcing the personnel to balance their own perceptions, feelings and reactions against interpretative reasoning. To base decision making on emotional reactions creates the risk of erroneous conclusions and a care relationship with elements of dishonesty, misdirected benevolence and false hopes. Identification with family members can promote recognition of and response to their existential needs, but also frustrate meeting family members emotions’ and handling one’s own vulnerability and inadequacy. It was found that futile cardiopulmonary resuscitation, administered to patients for the benefit of family members, is not an acceptable moral practice, due both to norms of not deliberately treating persons as mere means and to norms of taking care of families. Conclusions: Ethical conflicts exist when it comes to conveying realistic hope, relief from guilt, participation, responsibility for decision making, and fairness in the professional role. Ambulance personnel need support to enhance ethical caring competence and to deal with personal discomfort, as well as clear guidelines on family support.

In this thesis, we propose novel optimization and spatial queueing models that expand the currently existing methods by allowing multiple servers to be located at the same station and multiple servers to be dispatched to a single call. In particular, a mixed integer linear programming (MILP) model is introduced that determines how to locate and dispatch ambulances such that the coverage level is maximized. The model allows multiple servers to be located at the same station and balances the workload among them while maintaining contiguous first priority response districts. We also propose an extension to the approximate Hypercube queueing model by allowing multi-server dispatches. Computational results suggest that both models are effective in optimizing and analyzing the emergency systems. We also introduce the M[G]/M/s/s queueing model as an extension to the M/M/s/s model which allows for multiple servers to be assigned to a single customer.

M. Tech. Business Administration / The city of Tshwane Emergency Services is the first in South Africa to be certified ISO 9001:2008 in 2013. This saw the department leading the course of quality management both in the city and throughout the country. As a service rendering undertaking their efficiency and effectiveness requires evaluation from a quality management perspective. The city seeks to roll-out certification throughout all city departments so as to enable a quality driven municipal entity. This study was conducted to identify the factors that affect adherence to ISO 9001:2008 within the city. The results of this study can be used by managers throughout the Emergency Services and related services around the world to evaluate the importance of the implementation of the management system. The study is descriptive and cross-sectional. A quantitative method was used to collect data and analyse it. A stratified random sampling techniques was used with sample size of n=121 on employees within the Emergency Services of the city of Tshwane. Frequency tables, pie-chart, histograms and tables were used to present and analyse the data collected. The study identified qualification, effective communication and proper record keeping (documentation) as key factors affecting adherence to ISO 9001:2008.