A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / The rate of technology expansion is rapidly covering even the most remote parts of the globe and in the lowest resource settings. With globalization however, low and middle income areas are facing emerging health issues such as injuries and chronic medical conditions. With these illnesses, there are inevitable demands on emergency services. It has been thought that technology be utilized to augment emergency medical care in such settings where formal Emergency Medical Services. To aggregate and analyze the existing literature on the topic a systematic literature review was conducted. This study analyzed the existing literature on prehospital emergency care in settings in which no formal EMS services were utilized. Four databases were searched with inclusion and exclusion criteria, yielding 1782 results. The initial screening excluded all but 21 articles. Of the 21 articles in full review, 15 were included in the final review. Studies included in the final review were grouped into those reporting outcomes from five categories: Feasibility, Quality of Care, Response Time, Patient Outcomes, and Cost Effectiveness. Only one study was identified to be of high quality. There was a lack of studies with adequate statistical analysis to conduct statistical aggregation. Most studies however reported prehospital telemedicine in settings without EMS to be feasible, provide quality care, are be cost effective. However, the lack of statistical analysis makes it difficult to make conclusions. Also, several studies did show response time of a trained basic life support volunteer to be faster than EMS in many of the settings. But no positive health outcomes were observed in patients treated with projects utilizing technology in the prehospital setting. The prehospital emergency medicine setting is a young field of study that may have significant hurdles in application. The studies conducted have shown promise in the use of technology in prehospital settings without formal EMS services, but are not robust enough to make strong conclusions or recommendations that could be put into practice. Thus, more robust, statistically oriented research is imperative in the field so that we can fully explore the potential of technology in the prehospital setting, especially in low resource and rural settings without formal EMS services. With more robust studies, we can hope to integrate new technologies into practice and better serve the populations without adequate EMS coverage to provide more timely emergency care.

O objetivo da presente investigação foi identificar os diagnósticos de enfermagem em vítimas de trauma no Atendimento Pré-hospitalar (APH) Móvel Avançado.Trata-se de um estudo qualitativo descritivo, em que se utilizou o método de estudo de caso.Como referencial teórico utilizamos o Modelo Conceitual de Horta e o método sistematizado do ATLS (Advanced Trauma Life Support). Os dados foram coletados pela pesquisadora na Unidade de Suporte Avançado (USA) do SAMU (Serviço de Atendimento Móvel de Urgência) da Secretaria da Saúde de Ribeirão Preto (São Paulo), no período de janeiro a junho de 2004, utilizando um instrumento previamente validado. A amostra se constituiu de 23 pessoas vítimas de trauma maiores de 18 anos atendidas pela pesquisadora na USA. Após a coleta de dados, procedemos à identificação dos diagnósticos de enfermagem, utilizando um processo raciocínio diagnóstico e a construção das categorias diagnósticas teve como referência as Taxonomias I e II da NANDA (North American Nursing Diagnosis). Os dados coletados e os diagnósticos de enfermagem estabelecidos pela pesquisadora foram analisados por cinco enfermeiras com experiência na assistência a vítima de trauma e com conhecimento específico em diagnóstico de enfermagem e, posteriormente, com a análise das sugestões foram revisados pela pesquisadora que acatou as opiniões. No Atendimento Pré-hospitalar (APH) Móvel Avançado foram identificados 24 diagnósticos de enfermagem sendo 15 do tipo real e nove de risco. Com percentual igual ou superior a 50% identificamos Risco para infecção, Risco para trauma, Dor aguda e Integridade tissular prejudicada. Os demais diagnósticos identificados foram: Desobstrução ineficaz de vias aéreas (17%), Padrão respiratório ineficaz (30%), Risco para aspiração (17%), Risco para disfunção neurovascular periférica (39%), Risco para função respiratória alterada (13%), Volume de líquidos deficiente (43%), Risco para volume de líquidos deficiente (43%), Perfusão ineficaz periférica (13%),cerebral (30%), gastrintestinal (8%),. Percepção sensorial perturbada visual (4%), cinestésica e tátil (22%), Confusão aguda (17%), Risco para temperatura corporal alterada (34%), Integridade da pele prejudicada (21%), Mobilidade física prejudicada (21%), Risco para queda (17%), Ansiedade (43%), Medo (4%) e Violência direcionada para si (4%).Verificamos que o grupo de diagnósticos representam a gravidade da vítima por identificarem alterações em sistemas orgânicos vitais. / The aim of this study was to identify the nursing diagnoses of adult trauma victims in the pre-hospital attendance. The research methodology used was a descriptive, qualitative, case study strategy. It was based on Horta’s Conceptual Model and the ATLS (Advanced Trauma Life Support) theoretical framework. The researcher collected data in the SAMU-192 pre-hospital intensive care ambulance, from the Advanced Vital Support Unit, in Ribeirão Preto (SP), Brazil during the period of January to June 2004, using a previously validated instrument for data collection. The sampling was made up of 23 adult trauma victims, of 18 years or older. After data collection the nursing diagnostics were identified through a rational thought process and forming of diagnostic categories based on the NANDA (North American Nursing Diagnosis) taxonomy II. Both the collected data and nursing diagnoses elaborated by the researcher were analyzed by five other nurses with experience in trauma care and specific Knowledge of nursing diagnosis and afterwards, the suggestions made were reviewed and accepted. During the advanced mobile prehospital assistance 24 nursing diagnoses were identified, 15 of which were actual problems and 9 were at risk of occurring. Of the latter, the factors with a 50% or higher at risk status were infection, trauma, acute pain and tissue integrity damage. The other diagnoses that were established included: ineffective airway clearance (17%), ineffective breathing pattern(30%), risk for aspiration (22%), risk for altered breath pattern (13%), fluid volume deficit (43%), risk for fluid volume deficit (43%), altered peripheral tissue perfusion (13%),. altered cerebral tissue perfusion (30%), altered gastrointestinal tissue perfusion (8%), risk for peripheral neurovascular dysfunction (39%), visual sensory/perceptual alterations (4%), tactile and kinesthetic sensory/perceptual alterations (22%), acute confusion (17%),risk for altered corporal temperature (34%), damaged skin integrity (22%), impaired physical mobility (22%),risk for falling, anxiety (43%), fear (4%) and risk for self directed violence (4%). We verify that the group of disgnostic represents the gravity of the victim for identifying alterations in vital organic systems.

O SAMU brasileiro utiliza o modelo francês e opera com uma Central Única de Regulação Médica regionalizada, hierarquizada e descentralizada na composição das equipes de socorro e unidades móveis como USBs (Unidade de Suporte Básico) e USAs (Unidade de Suporte Avançado) que variam de acordo com o tipo de gravidade do caso. Na cidade de Ribeirão Preto, o serviço do SAMU, implantado em 1996, era municipal até 2012, porém seguindo as resoluções e portarias do Ministério da Saúde houve a necessidade da transição do SAMU Municipal para o SAMU Regional, com um único número (192) para os 26 municípios do Departamento Regional de Saúde de Ribeirão Preto (DRS XIII) sendo composto/constituído por 38 (trinta e oito) USBs sendo 01 USB para cada base descentralizada, 13 USB para Ribeirão Preto, 01 (uma) equipe de motolância e mais 03 (três) USAs (unidades de suporte avançado de vida) para cada base nos municípios polos microrregionais (Ribeirão Preto, Sertãozinho e Batatais). Com base nessas informações, este estudo visou caracterizar a estrutura e funcionamento do SAMU Municipal e sua Central de Regulação de Urgência e a transição para a regionalização nos seus aspectos estruturais, recursos humanos, tecnológicos e principalmente a viabilidade financeira, considerando o repasse tripartite (estado - união e município) insuficientes. Para a viabilidade financeira foi instituído o Consórcio CIS-AVH (consórcio intermunicipal de saúde - Aquífero guarani, Vale das cachoeiras e Horizonte verde). Os Consórcios Intermunicipais de Saúde (CISs) são importantíssimos instrumentos de cooperação e gestão entre municípios integrados, com 9interesses comuns definidos através do Plano Anual de Trabalho descritos pelos gestores municipais, conselhos e entidades públicas que estabelecem as prioridades e necessidades de determinado local e região. O objetivo foi criar soluções para problemas comuns, racionalizando a ação governamental a partir da realização conjunta de atividades de promoção, proteção e recuperação da saúde. Observa-se o fortalecimento da co-gestão compartilhada em saúde, em especial para os municípios de menor porte, cujas capacidades de investimento no setor são reduzidas em razão do limitado orçamentos disponível, as crescentes necessidades dos cidadãos, o avanço do aparato tecnológico e seus custos e principalmente o ganho por meio de editais de aquisição, compras ou contratação em escala seja de serviços, exames ou insumos. / The Brazilian SAMU uses the French model and operates with a regionalized, hierarchical and decentralized Single Regulated Medical Regulation Center in the composition of rescue teams and mobile units such as USBs (Basic Support Unit) and USAs (Advanced Support Unit) that vary according to with the type of severity of the event. In the city of Ribeirão Preto, the SAMU service, implemented in 1996, was municipal until 2012, but following the resolutions and ordinances of the Ministry of Health, there was a need to transition from SAMU Municipal to SAMU Regional, with a single number (192) for the 26 municipalities of the Regional Health Department of Ribeirão Preto (DRS XIII) consisting of 38 (thirty-eight) USBs, with 1 USB for each decentralized base, 13 USB for Ribeirão Preto, 01 (one) motolance team and more 03 (three) USAs (advanced life support units) for each base in the microregional poles municipalities (Ribeirão Preto, Sertãozinho and Batatais). Based on this information, this study aimed to characterize the structure and functioning of the Municipal SAMU and its Central Emergency Regulation and the transition to regionalization in its structural aspects, human resources, technological and mainly financial viability, considering the tripartite pass-through insufficient. (2013 to 2016). For the financial viability, the CIS-AVH Consortium (inter-municipal health consortium - Aquifer, Guaraní, Vale das cachoeiras and Horizonte verde) was instituted. The Intermunicipal Health Consortiums (CISs) are very important instruments of cooperation and 11management among integrated municipalities, with common interests defined through the Annual Work Plan described by municipal managers, councils and public entities that establish the priorities and needs of a given place and region. With the objective of creating a solution to common problems, rationalizing government action through joint activities to promote, protect and recover health. The strengthening of shared co-management in health is observed, especially for smaller municipalities, whose investment capacities in the sector are reduced due to the limited budgets available, the growing needs of the citizens, the advancement of the technological apparatus and its costs, and especially the gain through purchase, purchase or scale calls for services, examinations or inputs.

O Atendimento pré-hospitalar (APH) móvel é uma modalidade de assistência recente no Brasil e, em especial, no município de Ribeirão Preto-SP, tendo sido criada em 1996, com a finalidade de atendimento a toda e qualquer solicitação de ajuda, fora do âmbito hospitalar, visando a manutenção da vida e/ou a minimização das seqüelas, podendo ser oriunda do próprio cidadão ou ainda de instituições de saúde. Tendo em vista a recente implantação deste serviço, os objetivos do presente estudo são descrever a epidemiologia do atendimento pré-hospitalar móvel primário e secundário de urgência e emergência, o fluxo de atendimento pré-hospitalar móvel secundário e o fluxo do atendimento pré-hospitalar móvel da unidade de suporte avançado no município de Ribeirão Preto. Nossa pesquisa trata-se de um estudo de natureza descritiva, em que utilizamos dados de fonte secundária com transcrição de informações específicas do Serviço de APH do Município em Ribeirão Preto-SP, quando da solicitação de atendimento em situações de agravos à saúde. Os dados referentes ao objeto de estudo, foram coletados junto ao Programa de Assistência Médica Emergencial da Secretaria Municipal da Saúde. A base de dados analisada permitiu delinear a caracterização da atenção pré-hospitalar móvel da Secretaria Municipal da Saúde. Os resultados da pesquisa revelam o perfil das solicitações de atendimento das urgências e emergências com análises importantes que poderão subsidiar futuras reorganizações do serviço de APH móvel primário e secundário. O estudo poderá subsidiar ainda decisões dos atores sociais envolvidos na promoção, prevenção, recuperação e reabilitação aos agravos à saúde, tais como: conselhos de saúde, gestores de saúde, prestadores de serviços, usuários, conselhos de classes, órgãos de educação, promoção social, segurança social, transporte e outros. / The pre-hospital mobile attendant is a recent modality of assistance in Brazil, in special, at the District of Ribeirão Preto – SP, created since 1996, with the intention of attending any help of solicitation of care outside the hospital environment, looking for a life maintenance and/or a sequel minimization, and still looking to be accepted for the health institutions or the own patient. Because of the this new system implementation of service, the goals for the recent studies are to describe the pre-hospital assistance mobile of Epidemology for the first and second degrees of emergency and urgent care, the overflowing of the system now settle at this district of Ribeirão Preto for this type of help/ work with patients. Our research is about a descriptive nature where we can use secondary sources of database with transcription of specified information of the APH Service in the District of Ribeirão Preto-SP, when in need of care the solicitation of worst problems for health at own. The database collected for the goals of this research were taken at the Emergency Medical Assistance Program of the Health Minister of Care. The base studied let us create a line of attention in characterization of the pre-hospital mobile assistance from the Health Municipal Secretary . The results of the research reveals the profile of each assistance solicitations of emergencies and urgent cases with very important analyses which can create future reorganizations of the first and secondary mobile APH service. This study will subside many important decisions of the social actors involved at this promotion, prevention, recover, rehabilitation of the worst problems in health care such as: health counseling, health managers, services, utilitarian, class counseling, education organism, social promotion, social security, transportation and others.

Självmord erkänns som ett stort folkhälsoproblem i många länder. Enligt världshälsoorganisationen är det årligen upp emot en miljon människor som tar sitt liv världen över. Årligen begår cirka 1100 människor i Sverige självmord. Det är ungefär tre självmord om dagen. I den prehospitala vården möter ambulanssjuksköterskor ofta patienter med psykisk ohälsa. Många av dessa människor ser tillslut ingen annan utväg än att försöka ta sitt liv. Ambulanssjuksköterskor kan i mötet med dessa patienter ställas inför etiska dilemman, som till exempel att vårda patienten mot hans/hennes egen vilja. Syftet med studien är att beskriva ambulanssjuksköterskors upplevelser av etiskt problematiska situationer i mötet med patienter som har försökt ta sitt liv. Metoden var kvalitativ intervju med sex ambulanssjuksköterskor. Metoden innebär att koncentrera sig på informantens livsvärld och ha en öppenhet för informantens upplevelse. Resultatet visade att ambulanssjuksköterskorna upplevde att de tog över patientens bestämmanderätt och gick emot patientens vilja att avsluta sitt liv. En känsla av maktlöshet kunde infinna sig när de kunde se att det stora behovet av stöd till närstående hade brustit. I mötet med den självmordsbenägna patienten var det inte helt ovanligt att ambulanssjuksköterskan upplevde ett hot från patienten och kände en rädsla för sitt eget liv. Resultatet påvisar också en frustration hos ambulanssjuksköterskorna då de upplevde att patienter som försökt ta sitt liv får en otillräcklig vård, de upplevde också att de får ett ignorant och nedvärderande bemötande av andra inom vården. Slutsatsen är att ambulanssjuksköterskor konfronteras med etiskt problematiska situationer i mötet med självmordsnära patienter, det handlar många gånger om hot, rädsla och känslan att ta över patientens bestämmanderätt. / Program: Specialistsjuksköterskeutbildning med inriktning mot ambulanssjukvård

<p>Within the ambulance care in Uppsala County a vacuum splint is used to immobilize fractures on extremities. The research available on which method of immobilizing to prefer during pre-hospital treatment is limited.</p><p> </p><p>The purpose of this pilot study was to examine the perceptions of the ambulance personal in Uppsala County on the issue of usability of SAM-splint and vacuum splint when immobilizing extremities. The project was also aimed at researching if SAM-splint could be seen as an alternative or a complement to vacuum splint, and to get an apprehension on any evident differences in patients’ perceived pain when treated with the two different approaches.</p><p> </p><p>A descriptive comparative study was carried out. All patients, regardless of age and sex, with the need of immobilizing supposed fractures, were included.  Patients with suspected femur fracture, collum fracture, or where pre-hospital care was not possible or in question, was excluded. The collection of data was done using a questionnaire designed by the students responsible for the project. The ambulance personal completed the questionnaire after having concluded the treatment.</p><p> </p><p>The result showed that all patients with fractures to their extremities were immobilized. There were no evident differences in how the personal experienced the application of the two methods of immobilizing, but rather they were generally both perceived as easy to use. In Uppsala, where the paramedics had access to both SAM-splint and vacuum splint, the SAM-splint was the predominant choice.</p><p> </p><p>Based on this pilot study it can be established that the ambulance personal experienced the methods for immobilizing as easy in the event of fractures to the extremities. The SAM-splint is to be seen as a complement to the vacuum splint. Any difference in perceived patient rated pain connected to the different methods of immobilizing was not to deduce.</p> / <p>Inom ambulanssjukvården i Uppsala län används vakuumsplint för immobilisering av extremitetsfrakturer. Forskning och kunskap om vilken immobiliseringsmetod som är att föredra vid prehospital handläggning av extremitetsfrakturer är begränsad.</p><p><strong> </strong></p><p>Syftet med detta pilotprojekt var att i Uppsala län undersöka ambulanspersonalens uppfattning om användarvänligheten av vakuumsplint och SAM-splint vid immobilisering. Målet med projektet var även att ta reda på om SAM-splint kunde ses som alternativ eller komplement till vakuumsplintar samt om det fanns några uppenbara skillnader i patientskattad smärta mellan de olika immobiliseringsmetoderna.<strong> </strong></p><p><strong> </strong></p><p>En deskriptiv komparativ studie genomfördes där alla patienter oavsett ålder och kön i behov av immobilisering av misstänkta extremitetsfrakturer inkluderas. Patienter med misstänkt femurfraktur, collumfraktur eller där prehospital immobilisering ej varit möjlig eller aktuell exkluderades. Insamling av data har skett med hjälp av ett frågeformulär utformat av projektansvariga studenter. Frågeformuläret besvarades av vårdansvarig ambulanspersonal efter avslutat vårdtillfälle.</p><p> </p><p>Resultatet visade att samtliga patienter med extremitetsfrakturer immobiliserades. Det fanns ingen uppenbar skillnad gällande personalupplevd applicering mellan de olika immobiliseringsmetoderna utan generellt uppfattades de enkla att använda. I Uppsala där ambulanspersonalen hade tillgång till både SAM-splint och vakuumsplint valdes övervägande SAM-splint.</p><p><strong> </strong></p><p>Med detta pilotprojekt som grund kan sägas att ambulanspersonalen ansåg att immobiliseringsmetoderna var enkla att använda vid extremitetsfrakturer. SAM-splint kan ses som komplement till vakuumsplinten. Någon skillnad i patientskattad smärta mellan de båda immobiliseringsmetoderna framkom ej.</p>

This thesis aims to describe the initial phase of an acute coronary syndrome (ACS) in overall terms from a national perspective and to evaluate the impact of an information campaign designed to inform the public about how to act when suspecting an ACS. A total of 1939 patients at 11 hospitals in Swedenwith diagnosed ACS and symptom onset outside hospital completed a questionnaire(I-IV).In Study V, a questionnaire was completed by 116 patients withACS before the campaign and 122 after it. Register data were followed every year to evaluate ambulance use and emergency department (ED) visits. With regard to symptoms, patients with ST-elevation ACS (STE-ACS) more frequently had associated symptoms and pain with an abrupt onset reaching maximum intensity within minutes. However, fewer than half the patients with STE-ACS had this type of symptom onset. There were more similarities than differences between genders and differences between age groups were minor (I). Three-quarters of the patients interpreted the symptoms as cardiac in origin. The majority contacted a family member after symptom onset, whereas few called directly for an ambulance. Approaching someone after symptom onset and the belief that the symptoms were cardiac in origin were factors associated with a shorter pre-hospital delay (II). Half the patients went to hospital by ambulance. Independent factors for ambulance use were knowledge of the importance of quickly seeking medical care and calling for an ambulance when experiencing chest pain, severe symptoms, abrupt onset of pain, STE-ACS, increasing age and distance to hospital of &gt; 5 km. Reasons for not calling for an ambulance were thinking self-transport would be faster or not being ill enough (III). Pain with abrupt onset, STE-ACS, symptoms such as vertigo or near syncope, experiencing the pain as frightening, interpreting the pain as cardiac in origin and knowledge were major factors associated with a short delay between symptom onset and decision to seek medical care, patient decision time (IV). The information campaign did not result in a reduction in patient decision time, but it appeared to increase ambulance use and the number of patients seeking the ED for acute chest pain (V).

Within the ambulance care in Uppsala County a vacuum splint is used to immobilize fractures on extremities. The research available on which method of immobilizing to prefer during pre-hospital treatment is limited.   The purpose of this pilot study was to examine the perceptions of the ambulance personal in Uppsala County on the issue of usability of SAM-splint and vacuum splint when immobilizing extremities. The project was also aimed at researching if SAM-splint could be seen as an alternative or a complement to vacuum splint, and to get an apprehension on any evident differences in patients’ perceived pain when treated with the two different approaches.   A descriptive comparative study was carried out. All patients, regardless of age and sex, with the need of immobilizing supposed fractures, were included.  Patients with suspected femur fracture, collum fracture, or where pre-hospital care was not possible or in question, was excluded. The collection of data was done using a questionnaire designed by the students responsible for the project. The ambulance personal completed the questionnaire after having concluded the treatment.   The result showed that all patients with fractures to their extremities were immobilized. There were no evident differences in how the personal experienced the application of the two methods of immobilizing, but rather they were generally both perceived as easy to use. In Uppsala, where the paramedics had access to both SAM-splint and vacuum splint, the SAM-splint was the predominant choice.   Based on this pilot study it can be established that the ambulance personal experienced the methods for immobilizing as easy in the event of fractures to the extremities. The SAM-splint is to be seen as a complement to the vacuum splint. Any difference in perceived patient rated pain connected to the different methods of immobilizing was not to deduce. / Inom ambulanssjukvården i Uppsala län används vakuumsplint för immobilisering av extremitetsfrakturer. Forskning och kunskap om vilken immobiliseringsmetod som är att föredra vid prehospital handläggning av extremitetsfrakturer är begränsad.   Syftet med detta pilotprojekt var att i Uppsala län undersöka ambulanspersonalens uppfattning om användarvänligheten av vakuumsplint och SAM-splint vid immobilisering. Målet med projektet var även att ta reda på om SAM-splint kunde ses som alternativ eller komplement till vakuumsplintar samt om det fanns några uppenbara skillnader i patientskattad smärta mellan de olika immobiliseringsmetoderna.   En deskriptiv komparativ studie genomfördes där alla patienter oavsett ålder och kön i behov av immobilisering av misstänkta extremitetsfrakturer inkluderas. Patienter med misstänkt femurfraktur, collumfraktur eller där prehospital immobilisering ej varit möjlig eller aktuell exkluderades. Insamling av data har skett med hjälp av ett frågeformulär utformat av projektansvariga studenter. Frågeformuläret besvarades av vårdansvarig ambulanspersonal efter avslutat vårdtillfälle.   Resultatet visade att samtliga patienter med extremitetsfrakturer immobiliserades. Det fanns ingen uppenbar skillnad gällande personalupplevd applicering mellan de olika immobiliseringsmetoderna utan generellt uppfattades de enkla att använda. I Uppsala där ambulanspersonalen hade tillgång till både SAM-splint och vakuumsplint valdes övervägande SAM-splint.   Med detta pilotprojekt som grund kan sägas att ambulanspersonalen ansåg att immobiliseringsmetoderna var enkla att använda vid extremitetsfrakturer. SAM-splint kan ses som komplement till vakuumsplinten. Någon skillnad i patientskattad smärta mellan de båda immobiliseringsmetoderna framkom ej.

Premature death due to cardiovascular disease, including myocardial infarction, is higher in Hispanics (23.5%) than non-Hispanic White (16.5%) adults. Delaying treatment over 60 minutes increases the risk of sudden death by 50%. The purpose of this study was to describe the perceived benefits and barriers to seeking cardiac emergency care including emergency medical services (EMS) activation during an acute myocardial infarction (MI) in Mexican American adults. A qualitative descriptive design was used wherein semi-structured interviews and sociodemographic questionnaire were conducted with 12 Mexican Americans who had experienced an MI in the last two years. Qualitative conventional content analysis was used to uncover unique perceptions of Mexican Americans seeking emergency care. The overall theme that arose was degree of perceived threat leads to action. This theme was comprised five categories: perceived susceptibility, perceived severity, perceived barriers, perceived benefits, and learned behavior. Perceived severity was closely intertwined with perceived susceptibility. Recent appointments with HCPs facilitated low perceived susceptibility to an MI and acted as a barrier leading to ix decreased initiation of emergency services for MI. Participants attempted self-treatment and evaluation which was a barrier to immediate emergency care. Perceived benefits to initiation of emergency care were using EMS to achieve rapid treatment of MI symptoms. Though several participants initially stated they would activate EMS, further inquiry revealed calling EMS was considered a last resort if the participant were alone. The findings suggest education of lay people and HCPs needs to emphasize that MIs can present in a variety of ways from slow-onset to fast-onset. A goal for nursing practice is to include regular screening on cardiac risk factors along with interventions and evaluation among patients and family. Future research should aim at finding the most successful format to provide public education to Mexican Americans on MI symptom and rapid initiation of EMS. / text

Wireklint Sundström, Birgitta, 2005. Prepared to be unprepared. A phenomeno-logical study of assessment with a caring approach and how it can be learned in the ambulance services.A focal point in this dissertation is that there is knowledge in the ambulance ser-vice that is experience-based, which has not always been made explicit, and that provides the foundation for the caregivers’ assessment of the patients and their needs for care. The first aim of the study was to describe and analyse the ambu-lance services with a focus on the phenomenon of assessment from the lifeworld perspective in the caring sciences. The second aim of the study was of an educa-tional nature where the object was to be able to draw conclusions about the learning process in the ambulance service in the light of the knowledge generat-ed by the empirical findings. Thus the aim was to create a synthesis consisting of didactic ideas that are based on the caring sciences and describing how assess-ment can be learnt and can support future caregivers in the ambulance services.Assessment in the ambulance service entails, on an overall level, having a natu-ral caring attitude that includes striving in two directions at the same time. These are that on the one hand the caregivers strive to bring order to that which is dis-ordered as soon as possible, to structure the unstructured, and in short define the indefinite in order to provide medical assistance. There is a need to quickly as-sess the patient’s condition and which measures are necessary. On the other hand the caregivers strive to let the indefinite wait a while in order to be able to meet the patient’s suffering. There is thus a desire to listen attentively to the individual patient.The essential meaning of assessment of patients in the ambulance services is that there are conflicting demands on assessment and care, which entails that the caregiver adapts him/herself to the prevailing care situation in a way that means being flexible and adaptable to the patient’s medical condition. The caregivers also have a flexibility and adaptability in relation to their colleague, which leads to a mutual interplay in the assessment. Assessment in the ambulance services also means that the caregivers are paradoxically prepared at the same time as be-ing unprepared, i.e. they are prepared for the unprepared. The assessment thus starts before the caregivers have reached the patient and the actual situation. Even if they “know” what awaits them, they do not really “know”. It becomes a dynamic struggle between on the one side the expectancy that feels certain and on the other the unknown in every new situation. The struggle contains a desire for control and effectiveness in a care practice full of surprises. / Kunskapscentrum PreHospen vid Högskolan i Borås, Institutionen för vårdvetenskap.