M.A. / This study looks into the types of stressors specific to the Emergency Medical Services. The study was undertaken over a period of two years with the following objectives: • A literature survey regarding stress, organisational stress in general and stress in the context of Emergency Medical Services in particular. • An investigation of the personnel of the Emergency Medical Services to ascertain the stressors perceived as stressful by them. • Recommendations on how to prevent or lower stress in the Emergency Medical Services. The first part of this study is devoted to a theoretical investigation which gives an overview of stress in its broadest sense as well as stress in organisations which includes cumulative stress/burnout. Critical Incident Stress and Post Traumatic Stress are also closely examined, as well as the personality characteristics of members of the Emergency Medical Services. The point of departure for the researcher is an ecosystemic perspective where objectivity itself is questionable. Therefore, qualitative research was called for and the transactional/interactional model of Richard Lazarus was used to categorise stressors. The research results suggest that what the Emergency Medical Service personnel perceive as stressful are mainly organisational stressors but they acknowledge that in the long term the continual dealing with death and trauma starts to take its toll. Criticisms that could be levelled against the study are that the results are only generalisable to the personnel of the Johannesburg Emergency Services, whose demographic characteristics and backgrounds differ, for instance, from those who work at Bryanston, or Pretoria. As the study relied solely on personal disclosure and observation the results can be seen as somewhat subjective in nature. What was communicated as stress-related events was what was perceived as stressful by the personnel as well as the researcher's subjective perception of whether certain events were perceived as stressful for the personnel. After working on the ambulance with these personnel for over three years, the researcher is an accepted part of their system, and became subject to the same blunting of affect and depersonalisation of victims as the Emergency workers. Over an extended period in time, it became harder to divorce the researcher from the "worker" while on duty, to maintain a scientific perspective and to write objectively. However, the findings of this study concur with those done by previous researchers on this subject such as Sparrius (1992) and Du Toit & Botes (1996).

Bakgrund: Självskadebeteende är ett symtom på psykisk ohälsa som sedan millennieskiftet uppmärksammats i allt högre utsträckning. Den första kontakten med vården personer med självskadebeteende tar sker ofta via den somatiska akutsjukvården. Patienter vittnar om negativa upplevelser i mötet med dessa vårdinstanser. Det är därför av värde att öka kunskapen om hur sjuksköterskor upplever mötet med patienter med självskadebeteende. Syfte: Syftet med litteraturöversikten var att beskriva sjuksköterskors upplevelser av att möta patienter med självskadebeteende inom somatisk akutsjukvård. Metod: Studien genomfördes som en litteraturöversikt där 15 vetenskapliga artiklar söktes via databaserna PubMed, CINAHL, PsycINFO och Web of Science. Artiklarna kvalitetsgranskades, analyserades och sammanställdes till ett resultat. Resultat: Av resultatet har framgått tre huvudkategorier vilka var: Sjuksköterskans tankar och känslor; Kompetens och kunskap; Faktorer som påverkar mötet och vården. Slutsats: Resultatet visade att sjuksköterskor inom somatisk akutsjukvård erfor både positiva och negativa upplevelser i mötet med patienter med självskadebeteende vilka frammanade olika känslor och tankar hos sjuksköterskor. Gemensamt för studierna var att sjuksköterskor uppgav att de hade bristande kompetens och kunskap i samband med omvårdnaden av dessa patienter. / Background: Deliberate self-harm is a symptom of mental illness that ever since the turn of the millennium has been increasingly highlighted. The first contact with healthcare a person with deliberate self-harm often takes place via the somatic emergency medical care. Patients testify to negative experiences in the meeting with these care instances. Therefore, it may be useful to investigate how nurses perceive the meeting with patients with deliberate self-harm. Aim: The aim of the literature review was to describe nurses’ experiences of meeting patients with deliberate self-harm in somatic emergency medical care. Method: The study was conducted as a literature review where 15 scientific articles were sought via the databases PubMed, CINAHL, PsycINFO and Web of Science. The articles were quality-reviewed, analyzed and compiled into a result. Results: In the process of describing nurses’ experiences, three main categories emerged which were: The nurse's thoughts and feelings; Competence and knowledge; Factors that affect the meeting and care. Conclusion: The result showed that nurses in somatic emergency medical care had both positive and negative experiences in the meeting with patients with deliberate self-harm which evoked different feelings and thoughts among nurses. Common to the studies was that nurses stated that they had a lack of competence and knowledge about this patient group.

Bakgrund: Den prehospitala vården bedrivs utanför sjukhusets trygga väggar när en patient är i akut behov av sjukvård. Av patienten kan den prehospitala vården upplevas skrämmande och kan leda till en känsla av maktlöshet. Ambulanssjuksköterskan ska i mötet med patienten kunna genomföra ett systematiskt, stödjande och reflekterat omhändertagande. För att kunna genomföra detta omhändertagande är det av stor vikt att kunna skapa tillit i den vårdande relationen. Tidigare forskning visar att patienten såg tillit som en betydelsefull faktor i samspelet med sjuksköterskan. Syfte: Syftet är att belysa hur patienten upplever att tillit skapas i mötet med ambulanssjuksköterskan i den prehospitala vården. Metod: Tre systematiska artikelsökningar genomfördes. Tolv stycken kvalitativa artiklar granskades och inkluderades i litteraturstudien. Analysen genomfördes i nio steg enligt en stegmodell framtagen för kvalitativa litteraturstudier. Meningsbärande enheter skapades och öppen kodning av materialet gjordes. Därefter skapades teman och subteman som utgjorde resultatet. Resultat: Tillit skapades enligt patienten genom verbal och icke verbal kommunikation. Relevant information samt en ambulanssjuksköterska som var närvarande och hade ett lugnt bemötande skapade tillit. Resultatet presenteras enligt följande teman: Dialog med subteman; verbal och icke verbal kommunikation skapade tillit samt informationsöverföring skapade tillit. Professionalism med subteman; kompetens och kliniska färdigheter skapade tillit, lugn skapade tillit, en helhetssyn skapade tillit, förmåga att generera delaktighet skapade tillit samt närvaro skapade tillit. Slutsats: Tillit är en avgörande faktor för att patienten ska lita på ambulanssjuksköterskans kunskap och kompetens. Litteraturstudien bidrar med kunskap om hur tillit skapas och vilka förutsättningar som skapar en tillitsfull relation i det korta prehospitala mötet. / Background: Prehospital care is performed outside the safe environment of the hospital when a patient needs emergency care. The patient can feel powerless and experience the prehospital care as frightening. In the meeting with the patient the prehospital emergency nurse should be able to perform care that is systematic, supportive and deliberate. To be able to accomplish this care it is important to create trust. Previous research has shown that trust is an essential factor in the meeting with the nurse. Aim:The aim is to illustrate how the patient experiences trust in the prehospital setting with the prehospital emergency nurse. Method: Three systematic article researches have been conducted. Twelve qualitative articles were rated based on quality and included in the literature review. The articles were analysed based on a step-by-step guide. The guide is made for qualitative systematic reviews. Sentences that applied to the aim of the study were selected and open coding was conducted. Themes and subthemes constituted the result. Result: Trust was created by verbal and nonverbal communication. It was also important that the prehospital nurse provided relevant information, was calm and present in order for the patient to feel trust. The result was presented as follows: dialogue with subthemes: verbal and nonverbal communication created trust and information created trust. Professionalism with subthemes: competence and clinical skills created trust, calm created trust, a lifeworld perspective created trust, ability to create participation created trust and presence created trust. Conclusion: Trust was a vital factor for the patient to be able to trust the knowledge and competence the prehospital emergency nurse possesses. The literature review gave immersed knowledge regarding how to create trust and which parts that create a trustful relationship in the short prehospital care relationship.

Abstract Patients with acute drug poisonings are common in emergency departments and hospitals. Patients typically ingest medical products, most commonly psychotropic drugs that lead to intoxication. The outcome is usually good and hospital stays are short, even among patients requiring intensive care. Complications such as aspiration pneumonia can prolong hospital stays. Acute mortality is low (usually less than 5%) but repetition of self-harm is common and long-term mortality is high. The aim of this study was to evaluate the outcome of drug poisoned patients and the factors associated with unfavourable outcome, including morbidity, length of intensive care unit (ICU) and hospital stays, repetition of drug poisonings, and mortality. The study population consisted of patients treated in Oulu University Hospital due to acute drug poisoning between 1985–2006 and drug poisoned patients in the data base of the Finnish Consortium intensive Care Data. In the first part of the study 276 hospitalised self-poisoned adolescents were examined retrospectively from the patient records for acute contributing risk factors before the intake. Patients with such risk factors had higher rates of depression, non-ethanol poisonings and repetition of self-poisoning within one year. The second part of the study included 257 acute drug-poisoned adult patients requiring intensive care. The factors associated to aspiration pneumonia were evaluated retrospectively. Of these, 28.4% had aspiration pneumonia. Pre-hospital intubation of the comatose patients was associated with lower number of aspiration pneumonias. The third study evaluated 2755 drug-poisoned patients requiring intensive care for risk factors for prolonged ICU length of stay (LOS) using national intensive care database. Factors associated with prolonged stay were respiratory failure, renal dysfunction and lowered platelet count on admission. The hospital mortality in these studies ranged from 0 to 1.6%. The fourth study evaluated the long-term mortality and causes of deaths of 3709 patients admitted to Oulu University Hospital due to acute drug poisoning between 1985 and 2000. The all-cause mortality was recorded at the end 2009 and patients were compared to age- and sex-matched controls. Mortality among the study population was 30.6% compared to 13.6% for the controls. In conclusion, patients admitted to hospital due to acute drug poisoning have good short-term outcomes. Factors associated with prolonged ICU LOS were aspiration pneumonia, respiratory failure on admission, lowered platelet count on admission and renal dysfunction on admission. Impulsive self-poisonings among adolescents are associated with psychopathology and repetitions. Patients with acute drug poisonings have high long-term mortality. / Tiivistelmä Myrkytyspotilaat ovat yleinen potilasryhmä päivystyksissä ja sairaaloissa. Sairaalahoitoisen, akuutin lääkeainemyrkytyksen ennuste on hyvä ja jopa tehohoitoa vaativat potilaat selviävät lyhyellä sairaalahoitojaksolla. Komplikaatiot, kuten mahan sisällön hengitysteihin joutumisesta aiheutuva keuhkokuume (aspiraatiokeuhkokuume) pitkittävät hoitoa. Kuolleisuus hoitojakson aikana on yleensä alle 5 %, mutta pitkäaikaiskuolleisuus näillä potilailla on merkittävä. Tutkimuksen tarkoituksena oli selvittää akuutin lääkeainemyrkytyspotilaan ennustetta ja ennusteeseen vaikuttavia tekijöitä. Ensimmäisessä osatyössä tutkittiin 276 nuoren myrkytyspotilaan myrkytystapahtumaan vaikuttaneita akuutteja riskitekijöitä. Potilaat, joilla oli riskitekijöitä, olivat useammin masentuneita ja heillä oli enemmän uusintakäyntejä myrkytysten vuoksi vuoden sisällä. Toisessa osatyössä selvitettiin aspiraatiokeuhkokuumeen yleisyyttä 257 tehohoitoa tarvinneella lääkemyrkytyspotilaalla. Potilaista 28,4 % sai aspiraatiokeuhkokuumeen. Ennen sairaalaan tuloa suoritettu hengitysteiden varmistaminen hengitysputkella (intubaatio) pienensi aspiraatiokeuhkokuumeen riskiä merkittävästi verrattuna niihin, jotka intuboitiin vasta sairaalassa. Kolmannessa osatyössä tutkittiin 2755 myrkytyspotilaan riskitekijöitä pitkittyneeseen tehohoitoon. Hengitysvajaus, munuaisten toiminnan vajaus ja matala veren verihiutalearvo sairaalaan tullessa olivat pitkittyneen hoidon riskitekijöitä. Kuolleisuus hoitojakson aikana oli näissä kolmessa tutkimuksessa 0–1.6 %. Neljännessä osatyössä tutkittiin 1985–2000 OYS:ssa hoidettujen myrkytyspotilaiden pitkäaikaisennustetta ja kuolinsyitä. Kuolleisuus vuoden 2009 loppuun mennessä oli 3709 potilaan joukossa 30,4 %, kun vastaava kuolleisuus ikä- ja sukupuolivakioitujen verrokkien keskuudessa oli 13,6 %. Kaikki kuolinsyyt olivat yleisempiä tutkimusjoukossa verrattuna verrokkeihin. Yhteenvetona voidaan todeta että akuuttien myrkytyspotilaiden ennuste on hyvä akuutissa vaiheessa. Aspiraatiokeuhkokuume on yleinen komplikaatio myrkytyspotilailla ja se on osittain vältettävissä hengitystien varhaisella varmistamisella. Impulsiivinen käytös nuorella myrkytyspotilaalla assosioituu psykopatologiaan ja uusintamyrkytyksiin. Myrkytyspotilaan pitkäaikaisennuste on huono. Kuolleisuus ennaltaehkäistäviin syihin, kuten itsemurhiin sekä sydän- ja verisuonitauteihin, on huomattava.

No description available.

Bag-valve mask (BVM) ventilation maintains a patient's oxygenation and ventilation until a more definitive artificial airway can be established. In the prehospital setting of a traffic collision or medical aid scene this is performed by an Emerency Medical Technician or medical first responder. Few studies have looked at the effectiveness of Bag-valve masks (BVM) or the complication rate of ventilating an unprotected airway. The purpose and goal of this study is to educate both medical first responders and basic emergency medical technicians.

Simulation is a powerful technique to study complex problems and systems. This thesis explores two different problems. Part 1 (Chapters 2 and 3) focuses on the theory and practice of the problem of simulating graphs with a prescribed degree sequence. Part 2 (Chapter 4) focuses on how simulation can be useful to assess policy changes in emergency medical services (EMS) systems. In particular, and partially motivated by the COVID-19 pandemic, we build a simulation model based on New York City’s EMS system and use it to assess a change in its hospital transport policy. In Chapter 2, we study the problem of sampling uniformly from discrete or continuous product sets subject to linear constraints. This family of problems includes sampling weighted bipartite, directed, and undirected graphs with given degree sequences. We analyze two candidate distributions for sampling from the target set. The first one maximizes entropy subject to satisfying the constraints in expectation. The second one is the distribution from an exponential family that maximizes the minimum probability over the target set. Our main result gives a condition under which the maximum entropy and the max-min distributions coincide. For the discrete case, we also develop a sequential procedure that updates the maximum entropy distribution after some components have been sampled. This procedure sacrifices the uniformity of the samples in exchange for always sampling a valid point in the target set. We show that all points in the target set are sampled with positive probability, and we find a lower bound for that probability. To address the loss of uniformity, we use importance sampling weights. The quality of these weights is affected by the order in which the components are simulated. We propose an adaptive rule for this order to reduce the skewness of the weights of the sequential algorithm. We also present a monotonicity property of the max-min probability. In Chapter 3, we leverage the general results obtained in the previous chapter and apply them to the particular case of simulating bipartite or directed graphs with given degree sequences. This problem is also equivalent to the one of sampling 0–1 matrices with fixed row and column sums. In particular, the structure of the graph problem allows for a simple iterative algorithm to find the maximum entropy distribution. The sequential algorithm described previously also simplifies in this setting, and we use it in an example of an inter-bank network. In additional numerical examples, we confirm that the adaptive rule, proposed in the previous chapter, does improve the importance sampling weights of the sequential algorithm. Finally, in Chapter 4, we build and test an emergency medical services (EMS) simulation model, tailored for New York City’s EMS system. In most EMS systems, patients are transported by ambulance to the closest most appropriate hospital. However, in extreme cases, such as the COVID-19 pandemic, this policy may lead to hospital overloading, which can have detrimental effects on patients. To address this concern, we propose an optimization-based, data-driven hospital load balancing approach. The approach finds a trade-off between short transport times for patients that are not high acuity while avoiding hospital overloading. To test the new rule, we run the simulation model and use historical EMS incident data from the worst weeks of the pandemic as a model input. Our simulation indicates that 911 patient load balancing is beneficial to hospital occupancy rates and is a reasonable rule for non-critical 911 patient transports. The load balancing rule has been recently implemented in New York City’s EMS system. This work is part of a broader collaboration between Columbia University and New York City’s Fire Department.

Bakgrund: Ett barn som drabbas av ett hjärtstopp är något av det mest traumatiska en barnsjuksköterska kan ställas inför på barnakutmottagningen. Brist på teamsamarbete är en starkt bidragande faktor till ökad stress hos akutpersonalen. Vid ett hjärtstopp krävs effektivt teamsamarbete mellan olika professioner och att teamets kompetenser kompletterar varandra. Det är barnsjuksköterskans ansvar att tillgodose omvårdnadsbehovet hos barnet och dess familj.   Syfte: var att utforska barnsjuksköterskans upplevelser av teamsamarbete vid hjärtstopp hos barn på barnakutmottagning.  Metodbeskrivning: En kvalitativ metod valdes för att utföra denna studie. Genom ett strategiskt urval intervjuades tio sjuksköterskor som arbetar på barnakutmottagning. Analysen genomfördes med hjälp av kvalitativ innehållsanalys med induktiv ansats.  Resultat: Barnsjuksköterskans upplevelse av teamsamarbete identifierades som att involvera föräldrarna, uppleva trygghet genom erfarenhet, hantera utmanande situationer, föra en dialog genom ord och handlingar samt att finnas där för varandra. För att uppnå en väl fungerande teamsamverkan menade barnsjuksköterskorna att övning, förberedelse, samarbete, tydligt ledarskap och rollfördelning var viktiga aspekter.  Slutsatser: För att få samskapande omvårdnad och genom interaktioner skapa teamsamarbete utmärkte sig två begrepp genom hela studien vilka var trygghet och kommunikation. / Background: A child suffering from a cardiac arrest is one of the most traumatic things a paediatric nurse can face at the paediatric emergency department. Lack of teamwork is a strong contributing factor to increased stress among emergency personnel. In the event of a cardiac arrest, effective team collaboration between different professions is required and the team´s competencies complement each other. It is the paediatric nurse´s responsibility to meet the child´s and their family´s need for care.  Aim: Was to explore paediatric nurse´s experiences of teamwork in cardiac arrest on children in paediatric emergency departments.  Method: A qualitative method was chosen for this study. Through a strategic selection, ten nurses working at the paediatric emergency department were interviewed. The analysis was made with the help of qualitative content analysis with an inductive approach.  Result: The paediatric nurse´s experience of teamwork was identified as involving the parents, feeling safety through experience, managing challenging situations, conducting a dialogue through words and actions and being there for each other. In order to achieve a well-functioning team collaboration, the paediatric nurses believed that training, preparation, cooperation, leadership, and division of roles were important aspects.  Conclusion: In order to receive co-creative nursing and through interactions create team collaboration, two concepts stood out throughout the study, which were safety and communication.

Covid-19 utbröt 2020, hälso- och sjukvården omorganiserar sina verksamheter, patienter insjuknar samt isoleras. Sjuksköterskan har en fundamental roll i akutsjukvård och förväntas kunna bedriva personcentrerad vård även i en hektisk situation. Sjuksköterskor har en klinisk erfarenhet i omhändertagandet av patienter med Covid-19, men saknar evidens riktad mot Covid-19 vilket hotar den personcentrerade vården. Syftet var att belysa sjuksköterskors erfarenheter och utmaningar av att vårda vuxna patienter med Covid-19 inom akutsjukvård under pandemin. En allmän litteraturöversikt utfördes med en systematisk design. I datainsamlingen användes två databaser, PubMed och CINAHL. Sammanlagt inkluderades 17 artiklar som analyserades i enlighet med en integrerad analys vilket utformade två huvudkategorier samt sju underkategorier. Resultatets utformade huvudkategorier belyste omvårdnadens utmaningar samt psykologiska och fysiska utmaningar under Covid-19. Flertal studier belyste vikten av teamarbetet i vårdandet och sjuksköterskor kände att given vård inte var adekvat. Dem isolerade patienterna med Covid-19 hade ett ökat behov av stöd och sjuksköterskor blev utmattade samt upplevde ångest. Skyddsutrustningen utgjorde ett hinder vid omvårdnadsåtgärder, kommunikationen försvåras till patienter och sjuksköterskorna fick skador av utrustningen. Sammanfattningsvis var vårdandet av patienter med Covid-19 psykiskt och fysiskt krävande för sjuksköterskor. Det var flertal faktorer som påverkade sjuksköterskors förmåga att utföra omvårdnad till patienterna som inte erhöll en värdig vård och teamarbete var en viktig del för patientens säkerhet samt personcentrerade vård. I framtida händelser som pandemier behövs specialistsjuksköterskor för att de har en högre omvårdnadsintention och utgör en viktig del i det tvärprofessionella vårdteamet. / Covid-19 erupted in 2020, the health services reorganized it’s operations, patients became ill and isolated. Nurses have a fundamental role in emergency care and are expected to provide person-centered care, even in a hectic situation. Nurses have a clinical experience in the care of patients with Covid-19, but the lack of evidence about Covid-19 threatens the personcentered care. The aim was to illuminate nurses´ experiences and challenges of caring for adult patients with Covid-19 in emergency care during the pandemic. A general literature review with a systematic design was performed. In the data collection two databases were used, PubMed and CINAHL. In total, 17 articles were included and analyzed in accordance with an integrated analysis that designed two main categories and seven subcategories. The main categories of the results highlighted the challenges of nursing as well as psychological and physical challenges during Covid-19. Many studies highlighted the importance of teamwork in care and nurses felt that the care provided was not sufficient. The isolated patients with Covid-19 had an increased need for support and nurses became exhausted and experienced anxiety. The protective equipment contributed an obstacle to nursing activities, the communication to patients became difficult and the nurses were physically affected by the protective equipment. In conclusion, caring for patients with Covid-19 was mentally and physically demanding for nurses. There were several factors that affected nurses´ ability to provide care to patients who did not receive valuable care and teamwork was an important part of patient safety and person-centered care. In future events such as pandemics, specialist nurses are needed because of their higher nursing intentions and their important role in the interprofessional team.

When patients develop new-onset infections after hospital admission, the origin of the infection is typically assumed to be nosocomial; however, ambulances are potentially unexplored reservoirs for emerging pathogens. This study seeks to identify the scope of bacterial contamination in rural East Tennessee ambulances. Though universal precautions and cleaning procedures aim to reduce the spread of infectious diseases to provider and patient, little is known about the bacterial microbiome of ambulances. To the best of our knowledge, this is the first study of its kind to be performed in the state of Tennessee and the first since the introduction of UVGI units as an ambulance-based COVID-19 infection control measure. Our dissemination of post-pandemic findings may impact ambulance sanitation measures and will add to the national and global knowledge pertaining to the microbiome of emergency medical patient transport systems. Ambulances in East Tennessee were sampled using environmental sampling contact plates. At least one active ambulance unit for each EMS service underwent sampling. Three samples were obtained from each of three areas: the floor of the ambulance transport area, the rear door panel inside the transport area and stretcher. The plates were then incubated at 30-35C for 48 hours. Colony counts were manually performed before the plates were shipped for species identification via MALDI-TOF DNA analysis by MIDI laboratories (Newark, DE). One plate from each ambulance door and stretcher was sent for bacterial identification. Only one sample returned free of growth. All floor samples, several stretcher samples, and three door samples presented vast growth with colonies too numerous to count. The results from bacterial identification showed all flora were human commensal flora or environmental flora. The flora found on ambulance doors with opportunistic capabilities are as follows: Staphylococcus hominis, Staphylococcus epidermidis, Enterobacter cloacae, Enterobacter xinagfangensis, Bacillus cereus, Klebsiella oxytoca, and Bacillus subtilis; and the flora found on the stretchers with opportunistic capabilities are as follows: Staphylococcus haemolyticus, Staphylococcus epidermidis, Staphylococcus cohnii ssp urealyticus, Bacillus cereus, Corynebaccterium mucifaciens, Staphylococcus pettenkoferi, Klebsiella oxytoca, Staphylococcus capitis, Bacillus subtillis, and Staphylococcus caprae. In this era of increasing antibiotic resistance, it is concerning that several microbes with pathogenicity were found, including species that often confer the spread of resistance such as Klebsiella oxytoca and Enterobacter cloacae. Overall, the finding of numerous diverse colonies does not support adequate sanitation of the ambulances. Further study is required to identify the most effective sanitation methods, and further metagenomic study is needed to explore the presence of genes that facilitate the spread of microbial resistance.