Background: Rapid sequence intubation (RSI) is an advanced airway skill commonly performed in the pre-hospital setting globally. In South Africa, pre-hospital RSI was first approved for non-physician providers by the Health Professions Council of South Africa in 2009 and introduced as part of the scope of practice of degree qualified Emergency Care Practitioners (ECPs) only. The aim of the research study was to investigate and describe, based on the components of the minimum standards of pre-hospital RSI in South Africa, specific areas of interest related to current pre-hospital RSI practice. Methods: A descriptive cross-sectional study design in the form of an online survey were conducted amongst operational ECPs in the pre-hospital setting of South Africa, using convenience and snowball sampling strategies. Results: A total of 87 participants agreed to participate. Eleven (12.6%) incomplete survey responses were excluded while 76 (87.4%) were included in the data analysis. The survey response rate could not be calculated. Most participants were operational in Gauteng (n=27, 35.5%) and the Western Cape (n=25, 32.9%). Overall participants reported that their education and training were perceived as being of good quality. An overwhelming number of participants (n=69, 90.8%) did not participate in an internship programme before commencing duties as an independent practitioner. Most RSI and post-intubation equipment were reported to be available, however, our results found that introducer stylets and/or bougies and EtCO2 devices are not available to some participants. Only 50 (65.8%) participants reported the existence of a clinical governance system within their organisation. Furthermore, our results indicate a lack of clinical feedback, deficiency of an RSI database, infrequent clinical review meetings and a shortage of formal consultation frameworks. Conclusion: The practice of safe and effective pre-hospital RSI, performed by non-physician providers or ECPs, rely on comprehensive implementation and adherence to all the 51 components of the minimum standards. Although there is largely an apparent alignment with the minimum standards, recurrent revision of practice needs to occur to ensure alignment with recommendations. Additionally, there are areas that may benefit from further research to improve current practice.

No description available.

Bakgrund: Den psykiska ohälsan ökar i Sverige. Det innebär förändringar inom den prehospitala sjukvården. Ambulanssjuksköterskans arbete riktas ofta initialt mot akuta somatiska problem, men att vårda patienter med psykosomatisk bröstsmärta till följd av ångest är också en viktig del av omvårdnadsarbetet. Detta medför stor potentiell patientnytta då obehandlad, svår ångest indirekt kan bli livshotande med hänseende till suicidrisken. För att öka kunskapen om psykosomatisk bröstsmärta finns det ett behov av att beforska området. Syfte: Att beskriva sjuksköterskors upplevelser av mötet med patienter med psykosomatisk bröstsmärta prehospitalt. Metod: Åtta sjuksköterskor varav sex vidareutbildade inom ambulanssjukvård rekryterades från tre olika ambulansstationer i Norrland. Datan insamlades genom individuella semistrukturerade intervjuer och analyserades genom en kvalitativ innehållsanalys med induktiv ansats. Resultat: Vald analysmetod resulterade i tre huvudkategorier: Samtalet har en viktig roll i mötet, Bedömningen av allvarlighetsgrad är utmanande i mötet, och Ett per- soncentrerat förhållningssätt är viktigt i mötet, med sex tillhörande underkategorier som svarar på syftet. Slutsats: Psykisk ohälsa ses vara ett fullvärdigt problem inom den prehospitala sjukvården. Sjuksköterskor inom prehospital sjukvård utesluter i första hand somatisk orsak, men ser samtalet som ett naturligt nästa steg i bemötandet och behandlingen av patienter som söker vård för psykosomatisk bröstsmärta. Samtalet i kombination med ett personcentrerat förhållningssätt anses vara de bästa verktygen i bemötandet.

Bakgrund: Prehospitala smärtbedömningar är en utmaning för ambulanssjuksköterskan. Korrekt smärtbedömning är viktig då akut smärta som inte lindras kan ge allvarliga konsekvenser för patienten. Smärta definieras som en obehaglig sensorisk och emotionell upplevelse som kan vara förknippad med vävnadsskada eller en upplevelse som liknas vid detta. Smärtbedömning prehospitalt består av flera olika metoder och tillvägagångssätt vilka sjuksköterskan anpassar efter patientens tillstånd och situation samt sin egna erfarenhet, förmåga och kompetens. Syfte: Syftet med denna studie är att belysa sjuksköterskors erfarenheter av smärtbedömning inom ambulanssjukvård. Metod: Genom kvalitativ intervju av 10 deltagare inhämtades datamaterial som analyserades induktivt genom manifest kvalitativ innehållsanalys. Resultat: Efter innehållsanalysen delades resultatet upp i 3 huvudkategorier: smärtans subjektiva karaktär, värdera patienters smärta och smärtskattning. Sjuksköterskans tidigare erfarenheter av att möta patienter med olika smärtbeteende och smärtuttryck påverkar förmågan att värdera och relatera till patientens smärtupplevelse. I smärtbedömningen vägs en värdering av patientens smärtskattning in och i de fall sjuksköterskans och patientens bild av situationen inte överensstämmer riskeras patienten att inte bli trodd. Förutfattade meningar beskrivs kunna påverka en smärtbedömning och vissa grupper riskeras att stigmatiseras. Kommunikationen påverkar vårdrelationen och i de fall patienten har en oförmåga att kommunicera verbalt finns risk för bristande smärtbedömning. Slutsats: Smärtans subjektivitet har stor inverkan vid prehospital smärtbedömning, vilket ställer krav på ambulanssjuksköterskan att skapa en professionell vårdrelation. Att kunna relatera till patientens smärttillstånd underlättar vid smärtbedömning, motsatt kan sjuksköterskans svårighet att relatera till patientens smärta öka risken för vårdlidande genom misstroende. / Background: Prehospital pain assessments is challenging for theambulance nurse. Correct pain assessment is important as unalleviatedacute pain can have serious consequences for patients. Pain is definedas an unpleasant sensory and emotional experience that may be associatedwith tissue damage or an experience similar to such damage. Prehospitalpain assessment consists of several different methods and approacheswhich the nurse adapts to the patient's condition and situation as wellas their own experience, ability and competence. Purpose: The purpose of this study is to highlight nurses' experiencesof pain assessment in prehospital healthcare. Method: Through a qualitative interview of 10 participants, datamaterial was obtained and analyzed inductively through manifestqualitative content analysis. Results: After the content analysis, 3 main categories emerged: The subjective nature of the pain, Evaluate patients' pain, and Pain Assessment. The nurse's previous experiences of meeting patients withdifferent pain behaviours and pain expressions affect the ability tovalue and relate to patients' pain experience. In the pain assessment, avaluation of patients' self-assessment is weighed in, and in cases wherethe nurse's and the patient's view of the situation do not match, thepatient risks not being trusted. Preconceived notions are described asbeing able to influence a pain assessment and certain groups are at riskof being stigmatized. Communication affects the care relationship and incases where patients have an inability to communicate verbally there isa risk of insufficient pain assessment. Conclusion: The subjectivity of pain has a major impact on prehospitalpain assessment, which places demands on the ambulance nurse to create aprofessional care relationship. Being able to relate to the patient'spain condition facilitates pain assessment. Conversely, the nurse'sdifficulty in relating to patients' pain can increase the risk of caresuffering through mistrust.

Musculoskeletal trauma including fractures, represents a significant burden of disease for Low- and Middle-Income Countries (LMICs). Within LMICs, women possess reduced agency to make health care decisions and represent a vulnerable population. In this thesis, I aimed to characterize priority fractures among women within LMICs, and investigated whether women were delayed in hospital admission following an orthopaedic trauma. In Chapter 1, I introduce and review the existing literature on injury burden, health care deficiencies, and gender inequities within LMICs. In Chapter 2, we analyzed regional distributions of fracture burdens across 9,934 female orthopaedic trauma patients across 17 LMICs. Half of our study patients were ≥ 60 years old. We determined that the major burden of orthopaedic trauma among women within LMICs were fractures among the elderly. Fracture burden in Africa was notably different. A majority of patients were between the ages 18-59, and common fractures included tibia/fibula and femur fractures. In Chapter 3, we analyzed 26,910 orthopaedic trauma patients across 17 LMICs to determine whether women were delayed in hospital admission by >24 hours. After controlling for confounds, sex was not a significant predictor of delay. We found that instead, the severity and type of fracture influenced the delay of patient’s hospital admission. Closed fractures, falling-related injuries, pelvic, spine and hip fractures were associated with increasing delay. Irrespective of sex and region, inter-hospital referrals accounted for nearly half of the reasons patients were delayed. These two chapters highlight regional trends in orthopaedic burden sustained by women, pointing to the high frequency of fragility fractures. In addition, this thesis identifies critical gaps within LMICs’ health care systems infrastructure, demonstrating the need for improved hospital referral systems and ambulatory services. This analysis will enable policymakers, and future researchers to target interventions to address the rising global burden of injuries especially among women. / Thesis / Master of Science (MSc) / Fractures represent life-threatening injuries within Low- and Middle-Income Countries (LMICs), and globally are a top-ten leading cause of death and disability. Within LMICs, due to gender inequalities, women may be restricted from receiving hospital care following an injury. We investigated the most common types of fractures in women within LMICs and determined that women most frequently experienced fractures due to old age. We further examined whether women were delayed in reaching a hospital after sustaining a fracture, and found that sex did not significantly play a role in determining delay. Instead, injury associated factors, such as the type and severity of the fracture influenced whether a patient was delayed. In addition, transferring patients between hospitals was the most common reason for delay. As a result, policymakers in LMICs should explore strategies to treat the high burden of fractures in the elderly and improve communication between hospitals to reduce delays.

India, the world’s largest democracy and second most populous country, is in the midst of an economic boom with gross domestic product growth averaging nearly 8% over the past several years despite a worldwide recession. The World Health Organization (WHO) has predicted that trauma case related deaths in India will move from ninth position up to the third position by 2020. The organization structure for an improved national trauma system in India will depend on a national inclusive strategy supported by resources and funding within a service quality framework to win public trust. This must include an integrated nationally coordinated approach to the organization of pre-hospital care facilities, hospital networking and communication systems, and the organization of in-hospital care.

This thesis explores the potential of visual information and communication technologies (ICTs) for collaboration in emergency care. The thesis consists of four studies exploring future technology, 3D telepresence technology for medical consultation (3DMC), from several different methodological and analytical perspectives. Together the studies provide a broad view of the potential benefits, risks and implications of using visual technologies for collaboration in emergency care. The results show that paramedic-physician collaboration via 3DMC might have some benefits for patient care, both in the immediate patient care situation and beyond, for example, when coordinating transport and resources; improving understanding between different actors; and in developing paramedic competence and confidence in their skills. However, collaboration is heavily impacted by physicians’ and paramedics’ respective work practices which are situated in very different physical, professional and organizational contexts. Adding a visual dimension to this collaboration presents unique challenges for the overall design, development, implementation, and appropriation process. Thus, the thesis emphasizes the importance of understanding both the individual users as well as the complex overall image which, although often neglected or ignored, is crucial to understand when developing and introducing new technology that is successful and justified in the overall context while also being useful and meaningful for the individual users. / <p>Academic dissertation for the Degree of Doctor of Philosophy in Library and Information Science at the University of Gothenburg and the University of Borås to be publicly defended on Thursday 19 September 2013 at 13:15 in the auditorium at Simonsland, University of Borås, Skaraborgsvägen 3, Borås.</p>

Some innovations are termed ‘disruptive’, a designation that is normally applied to technology; examples include computers, digital cameras, and mobile phones. The term can also be applied to groups of workers, particularly if they are able to offer specific technical capabilities within a market at lower cost, but broadly equal and effective to that offered by traditional products or services. Paramedics could be described in this way and are a newly professionalised group, with distinctive capabilities in terms of responding to the needs of not just the acutely ill and injured, but increasingly those patients with undifferentiated non-life- threatening conditions, which increasingly make up the bulk of 999 call demand. The key to their transition from an artisan, skilled worker to professional status is the acquisition of certain ‘hallmarks’. Perhaps the most important of these is the completion of more prolonged education that affords the opportunity to graduate with enhanced decision-making and other clinical skills in order to meet the needs of the full spectrum of patients in the pre-hospital setting. Paramedics were surveyed to determine how they rated their ‘traditional’ preparation and to establish what their attitudes were to a more educationally based approach. Paramedics themselves proved to be realistic regarding shortcomings in established training and education systems, while also being strongly motivated to learn more within a higher education setting, particularly if this additional effort would result in being able to offer a wider range of care to their patients. During the study, major changes in the health care environment and the role of the Ambulance Service took place, leading to a requirement to undertake a second phase of research. This took the form of ‘Horizon Scanning’ in an attempt to detect ‘signals’, themes and trends in relation to newly emerging ‘competitors’ to the paramedic role. These included nursing, new practitioners and most critically, the rapidly emerging medical sub-speciality of pre-hospital care, staffed by medical personnel on a pattern found specifically in some European countries, sometimes termed the ‘Franco-German’ model/System (FGM/S). Hitherto, the model of provision in the UK had followed the ‘Anglo-American’ model/System (AAM/S), approach, with paramedics providing direct patient care in the field and medical staff largely involved in medical oversight, teaching, clinical governance and other higher level roles. As part of this research, the evidence base for change was examined and consideration given to the factors that might help clarify what the likely situation could be in 2030 in respect of ambulance services, pre-hospital care and paramedics. This future is uncertain, but factors have been identified that would militate in favour of one or other model prevailing, with close links established between educational preparation, system design, career structure and the continuance of the professionalisation process favouring paramedic progression. However, other factors, most specifically professional power, the absence of a clear evidence base and an apparent reluctance to clearly acknowledge this in some respects, lead to the conclusion that the future of pre-hospital care remains uncertain and contested, but also potentially amenable to a well-directed influencing strategy.

A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfillment of the degree of Master of Science in Medicine, 2014 / The earliest possible initiation of reperfusion therapy is necessary to reduce morbidity and mortality from acute STEMI. Therefore improving the time to thrombolysis where percutaneous coronary interventional facilities are limited or do not exist is critical. The most effective system would integrate three key components to deliver continuous patient care, including: 1) from time of call for help through to emergency response; 2) transportation to and admission to hospital; 3) assessment and initiation of thrombolytic therapy. The purpose of this prospective study is: to develop a chest pain awareness education programme appropriate for the South African context; to assess safe initiation of thrombolytic therapy by emergency care practitioners for STEMI; and to compare the performance of emergency care practitioner thrombolysis with historical control data.

Introdução: O transporte médico de crianças gravemente enfermas envolve particularidades que aumentam o risco de complicações, que podem contribuir para o aumento no tempo de internação e mortalidade. Objetivos: Avaliar a frequência e os tipos de complicações observadas durante o transporte pré- hospitalar e inter-hospitalar de crianças gravemente enfermas, assim como o impacto dessas complicações na mortalidade, no tempo de internação hospitalar e nos custos hospitalares. Pacientes e Métodos: Estudo realizado em duas etapas: a primeira foi um estudo transversal, no qual, por meio de entrevista padronizada com o médico que admitiu as crianças gravemente enfermas que necessitaram de transporte pré-hospitalar ou inter-hospitalar, foram identificadas e caracterizadas possíveis complicações ocorridas durante esse transporte. Estes dados foram auditados por três médicos independentes que definiram a presença ou ausência de complicações durante o transporte. A segunda etapa constituiu-se de uma coorte prospectiva, na qual os pacientes, divididos em dois grupos distintos (com e sem complicações durante o transporte), foram seguidos, prospectivamente, por 60 dias, observando-se a ocorrência de morte ou alta hospitalar. Resultados: Foram incluídas 143 crianças no estudo. Pelo menos uma complicação durante o transporte foi observada em 74 pacientes (52%). As complicações mais frequentes foram relacionadas com as vias aéreas (69%), seguidas por distúrbios metabólicos (47%), alterações cardiovasculares (40%) e falhas relacionadas aos dispositivos e à monitorização (37%). Na análise univariada, os seguintes preditores para ocorrência de complicações durante o transporte foram observados: peso <10Kg (risco relativo - RR: 1,52; intervalo de confiança (IC 95%: 1,11-2,09); distância >100Km (RR: 1,67; IC 95%: 1,16-2,40); presença de doença respiratória (RR: 1,46; IC 95%: 1,06-1,95) e comorbidades (RR: 1,68; IC 95%: 1,23-2,30). Já na análise multivariada, não foram observados preditores independentes para ocorrência de complicações. A ocorrência de complicações durante o transporte foi associada com maior taxa de mortalidade hospitalar (hazard ratio - HR: 5,668; IC 95%: 1,26-26,65; p=0,0130) e menor taxa de alta hospitalar (HR: 0,48; IC 95%: 0,31-0,74; p=0,0007). Após a aplicação da regressão de Cox para ajuste de potenciais fatores de confusão, a presença de complicação durante o transporte permaneceu associada com o índice de mortalidade hospitalar (HR: 6,74; IC 95%: 1,40-32,34; p=0,017), contudo deixou de ser associada com o tempo para a alta hospitalar (HR: 0,76; IC 95%: 0,49- 1,16; p=0,213). Conclusões: As complicações foram frequentes durante o transporte pediátrico. A presença de doenças respiratórias, peso <10Kg, presença de comorbidades e a distância >100 Km foram preditores de risco para a ocorrência dessas complicações. As complicações ocorridas durante o transporte foram associadas com o aumento nas taxas de mortalidade hospitalar. / Introduction: The medical transport of critically ill children involves characteristics that increase the risk of complications, which can contribute to an increase in length of stay and mortality. Objectives: To evaluate the frequency and type of complications observed during the pre-hospital and inter-hospital transport of critically ill children, as well as the impact of these complications on mortality, length of hospital stay and hospital costs. Patients and Methods: A study carried out in two stages: the first was a cross-sectional study where through a standardized interview with the doctor who admitted the critically ill children requiring pre-hospital or inter-hospital transport identified and characterized possible complications during this transport. These data were audited by three independent doctors who defined the presence or absence of complications during transport. The second stage consists of a prospective cohort study, where patients divided into two groups (with and without complications during transportation) were followed prospectively for 60 days observing the occurrence of death or hospital discharge. Results: We included 143 children in the study. At least one complication during transportation was observed in 74 patients (52%). The most frequent complications have been associated with airway (69%), followed by metabolic disorders (47%), cardiovascular disorders (40%) and failure in the device and monitoring (37%). In the uni-variate analysis, the following predictors for the occurrence of complications during transport were observed: weight <10 kg (relative risk - RR: 1.52; 95% confidence interval - CI: 1.11-2.09); distance greater than 100 km (RR: 1.67; 95% CI: 1.16-2.40); presence of respiratory disease (RR: 1.46; 95% CI: 1.06-1.95) and associated comorbidity (RR: 1.68; 95% CI: 1.23- 2.30). In the multivariate analysis, no independent predictors were observed for the occurrence of complications. The occurrence of complications during transport was associated with higher hospital mortality (hazard ratio - HR: 5.668; 95% CI: 1.26-26.65; p=0.0130) and a lower hospital discharge rate (HR: 0.48; 95% CI: 0.31-0.74; p=0.0007). After Cox regression to adjust for potential confounding factors, the presence of complications during transport remained associated with hospital mortality (HR: 6.74; IC 95%: 1.40-32.34; p=0.017), however, was not associated with hospital discharge rates (HR: 0.76; 95% CI: 0.49-1.16; p=0.213). Conclusions: The complications were common during pediatric transport. Distance greater than 100 km, presence of respiratory disease, associated comorbidity and weight <10 kg were risk predictors for occurrence of complications. Complications during pediatric transport were associated with increased hospital mortality rates.