Organiza����o do trabalho, conflitos e agress��es em uma emerg��ncia hospitalar na cidade de S��o Paulo, Brasil

As condi����es e processos de trabalho penosos dos pronto-socorros somados a elevada demanda frente �� capacidade e gravidade dos casos, dificultam as decis��es, impactam no atendimento e favorecem conflitos. Trata-se de um estudo de caso, explorat��rio e qualitativo, utilizou-se dados documentais, entrevistas semiestruturadas e observa����o do trabalho, especificamente dos porteiros. Objetivou-se verificar como caracter��sticas da organiza����o do trabalho aumentam conflitos e agress��es em um pronto-socorro comprometendo os atendimentos. Constatou-se que os porteiros est��o na linha de frente e s��o expostos �� press��o dos usu��rios por atendimento. Para solucionar conflitos, extrapolam regras e procedimentos, realizam tarefas al��m da sua compet��ncia, podendo alterar o fluxo e a qualidade do atendimento. Os arranjos organizacionais desconsideram os porteiros como parte da equipe de cuidados expondo-os a conflitos e agress��es. Espera-se contribuir para mudan��as, melhorar as rela����es, a seguran��a e o fluxo de atendimento.

Caracter��sticas e fatores associados ��s quedas atendidas em servi��os de emerg��ncia

OBJETIVO: Analisar as caracter��sticas dos atendimentos decorrentes de quedas em servi��os de urg��ncia e emerg��ncia e identificar fatores associados. M��TODOS: Estudo transversal com 12.617 atendimentos decorrentes de quedas registrados no Sistema de Vigil��ncia de Viol��ncias e Acidentes, coletados em 23 capitais e Distrito Federal, de setembro a novembro de 2009, por meio de uma amostra por conglomerado. Foi utilizada a t��cnica de an��lise de correspond��ncia, por permitir a observa����o conjunta de um grande n��mero de vari��veis qualitativas. RESULTADOS: A maior parte das v��timas foi do sexo masculino (56,5%), faixa et��ria de 0 a 19 anos (45,7%) e declarados n��o brancos (62,2%). A maioria das quedas ocorreu na resid��ncia (54,6%) e via p��blica (17,4%); 14,3% foram relacionadas ao trabalho. Os tipos predominantes foram "queda no mesmo n��vel" (57,0%) e "queda de escada/degrau" (15,6%). A maioria das les��es foi classificada como entorse, luxa����o, contus��o, corte e lacera����o (68,3%). Quedas dentre as crian��as associaram-se �� ocorr��ncia na resid��ncia; com os adolescentes na escola; e jovens na pr��tica esportiva. Quedas em adultos estiveram associadas ao local de trabalho, queda de andaimes, telhados, escada/degrau e buracos e uso de ��lcool. As quedas no mesmo n��vel resultaram em les��es de menor gravidade, em membros inferiores e superiores, e as quedas de andaime e telhado se associaram com les��es de maior gravidade e interna����es. CONCLUS��ES: Os resultados mostram que estrat��gias para a preven����o das quedas devem ser implantadas particularmente em resid��ncias, escolas e ambientes de trabalho.

Prioriza����o de pacientes em emerg��ncias m��dicas: uma an��lise ��tica

Objetivo: Identificar e analisar, �� luz de referencial ��tico, as escolhas e justificativas de profissionais de sa��de p��blica em situa����es hipot��ticas de prioriza����o de pacientes em casos de limita����es de recursos no atendimento de emerg��ncias m��dicas. M��todos: Pesquisa qualiquantitativa, mediante entrevistas com 80 profissionais de sa��de p��blica, p��s-graduandos (mestrado e doutorado) em Sa��de P��blica, aos quais foram apresentadas situa����es hipot��ticas, envolvendo os crit��rios de sexo, idade e responsabilidade, sendo requeridos que escolhessem entre alternativas que se referiam �� exist��ncia de pessoas, correndo risco igual de vida, que necessitam de atendimento em um servi��o de emerg��ncia. Resultados: As escolhas priorizaram crian��as, jovens, mulheres e casadas, com a tomada de decis��o invocando os princ��pios ��ticos de vulnerabilidade, utilidade social e equidade. Conclus��o: A pesquisa mostra clara tend��ncia de justificativas das escolhas feitas, orientadas pela ��tica utilitarista.

Atendimentos decorrentes de queimaduras em servi��os p��blicos de emerg��ncia no Brasil, 2009

O objetivo foi analisar os atendimentos por queimaduras em servi��os de emerg��ncia, e fatores associados. Estudo transversal de 761 atendimentos coletados pelo Sistema de Vigil��ncia de Viol��ncias e Acidentes em 2009. A maioria foi do sexo masculino (58,6%); adultos de 30 a 49 anos (23,1%) e crian��as de 0 a 9 anos (23%). A resid��ncia foi o local de ocorr��ncia mais frequente (62,1%), especialmente para crian��as e mulheres; em seguida com��rcio, servi��os, ind��stria e constru����o (19,1%), especialmente entre homens de 20 a 49 anos. Queimaduras no trabalho foram 29,1% do total. Uso de ��lcool chegou a 5,1%. Agentes causadores em todas as idades: subst��ncia quente (43,6%) e fogo/chama (24,2%); na faixa produtiva: subst��ncias qu��micas. As queimaduras entre 0 e 14 anos foram associadas com resid��ncia, subst��ncia e objeto quente e interna����o hospitalar; entre os de 15 a 49 anos associaram-se com fogo/chama e choque el��trico, via p��blica e alta da emerg��ncia. Estrat��gias de preven����o para crian��as e trabalhadores devem ser implantadas.

The viewpoint of health professionals on the role of basic units in the healthcare network of the Brazilian Unified Health System

In the process of creation of the Unified Health System (SUS) as a universal policy seeking to ensure comprehensive care, unscheduled assistance in primary healthcare units (UBS) is an unresolved challenge. The scope of this paper is to analyze the viewpoint of health professionals on the role of primary healthcare units in meeting this demand. It is a transversal study of qualitative data obtained through questionnaires and interviews with 106 medical practitioners from 6 emergency medical services and 190 professionals from 30 units. They explained why people seek emergency care for occurrences pertaining to primary care. The content analysis technique with thematic categories was used for data analysis. Lack of resources and problems with primary health unit work processes (50.8%) were the reasons most frequently cited by emergency care physicians to explain this inadequate demand. Only 33.3% of the health unit professionals agreed that these occurrences should be attended in the primary healthcare services. The limited viewpoint of the role of health services on the unscheduled care, particularly among primary care professionals, possibly leads to restrictive practices for access by the population.

Diagn��sticos de enfermagem em v��timas de trauma nas primeiras seis horas ap��s o evento

OBJETIVO: Identificar a frequ��ncia dos diagn��sticos de enfermagem em v��timas de trauma nas primeiras 6 horas, ap��s o evento traum��tico e verificar a rela����o desses diagn��sticos com a mortalidade. M��TODOS: Estudo prospectivo transversal com an��lise quantitativa, realizado em hospital terci��rio, centro de refer��ncia ao trauma no Munic��pio de S��o Paulo. Durante seis meses, foram avaliados 407 pacientes maiores de 18 anos atendidos no Pronto -Socorro desse hospital. RESULTADOS: Os diagn��sticos de enfermagem mais frequentes foram: Risco de Infec����o (84,5%), Integridade da pele prejudicada (77,9%), Dor aguda (71,5%), Conforto prejudicado (68,3%) e Integridade tissular prejudicada (54,1%). A associa����o entre diagn��sticos de enfermagem e mortalidade foi observada em 28 (66,7%) dos diagn��sticos identificados. CONCLUS��O: Os dados acrescentaram informa����es que poder��o auxiliar na forma����o e atua����o do enfermeiro no cen��rio das emerg��ncias em trauma e evidenciaram o potencial dos diagn��sticos de enfermagem para avaliar os resultados e a qualidade da assist��ncia.

O processo comunicativo no servi��o de atendimento m��vel de urg��ncia (SAMU-192)

Este trabalho objetiva caracterizar o processo comunicativo entre os auxiliares de enfermagem das viaturas de Suporte B��sico de Vida do Servi��o de Atendimento M��vel de Urg��ncia, a coordena����o deste servi��o e a Central ��nica de Regula����o M��dica de um munic��pio do Estado de S��o Paulo. Trata-se de uma pesquisa descritivo-qualitativa que utilizou a an��lise tem��tica de conte��do para a an��lise dos dados. Usou-se entrevista semi-estruturada para a coleta de dados que foi realizada em janeiro de 2010. Os resultados obtidos mostram dificuldades de comunica����o tanto com a Central de Regula����o M��dica quanto com a coordena����o. Os aspectos que mais se destacaram foram as falhas durante a transmiss��o via r��dio, falta de capacita����o dos operadores de r��dio, acesso �� coordena����o dificultado e aus��ncia da supervis��o dos enfermeiros. No entanto, foi poss��vel detectar solu����es que visam �� melhoria da comunica����o e, consequentemente, do atendimento ofertado pelo Servi��o de Atendimento M��vel de Urg��ncia.

Inserimento eterofamigliare supportato di adulti sofferenti di disturbi psichici: Valutazione degli esiti

L���Inserimento Eterofamigliare Supportato di Adulti (IESA) sofferenti di disturbi psichici consiste nell���accogliere persone in cura presso i servizi psichiatrici territoriali, nel proprio domicilio, integrandole nelle proprie relazioni famigliari. Obiettivo �� migliorare la qualit�� di vita dell���utente e favorirne l���integrazione nella comunit��. Obiettivo. Valutare gli esiti dello IESA, con un disegno di ricerca longitudinale, considerando: psicopatologia, benessere psicologico, funzionamento sociale e familiare. Metodologia. 40 soggetti: 20 pazienti e 20 ospitanti. La valutazione clinica �� stata effettuata all���inizio della convivenza e al follow-up di 1, 3, 6 e 12 mesi. Strumenti utilizzati: BPRS, VGF, PWB, SQ, FAD. Analisi statistica: Modello Lineare Generale (GLM) con l���Analisi della Varianza per prove ripetute e calcolo dell���effect-size. Risultati. 15 pazienti maschi e 5 femmine, 17 italiani. 11 soddisfano i criteri diagnostici (DSM-IV-TR) per schizofrenia e disturbi psicotici, 5 per i disturbi dell���umore e 4 per i disturbi di personalit��. Dopo l���inserimento 3 sono stati i ricoveri e 4 le visite psichiatriche urgenti. 8 pazienti modificano/diminuiscono la terapia e 3 la sospendono. Aumenta il benessere psicologico (PWB); diminuiscono i sintomi psicopatologici (BPRS ed SQ) e migliora il funzionamento globale (VFG). Il gruppo dei famigliari composto da 11 uomini e 9 donne, 19 di nazionalit�� italiana; con et�� media di 55 anni. 8 sono coniugati, 6 celibi/nubili, 4 divorziati e 2 vedovi. 9 hanno figli, 11 lavorano e 8 sono pensionati. Nei famigliari aumenta il benessere psicologico (PWB), migliora il funzionamento famigliare (FAD) e la valutazione del funzionamento globale (VGF) rimane costante nel tempo. Discussioni e conclusioni. Il progetto IESA sembra migliorare la psicopatologia, con una diminuzione dei comportamenti maladattativi e un aumento delle capacit�� relazionali dell���ospite favorendone l���integrazione. Inoltre, lo IESA sembra diminuire i costi della cronicit�� psichiatrica: diminuzione degli accessi al Pronto Soccorso, delle visite psichiatriche urgenti e delle giornate di ricovero.

Night Vision Imaging System (NVIS) certification requirements analysis of an Airbus Helicopters H135

The safe operation of nighttime flight missions would be enhanced using Night Vision Imaging Systems (NVIS) equipment. This has been clear to the military since 1970s and to the civil helicopters since 1990s. In these last months, even Italian Emergency Medical Service (EMS) operators require Night Vision Goggles (NVG) devices that therefore amplify the ambient light. In order to fly with this technology, helicopters have to be NVIS-approved. The author have supported a company, to quantify the potentiality of undertaking the certification activity, through a feasibility study. Even before, NVG description and working principles have been done, then specifications analysis about the processes to make a helicopter NVIS-approved has been addressed. The noteworthy difference between military specifications and the civilian ones highlights non-irrevelant lacks in the latter. The activity of NVIS certification could be a good investment because the following targets have been achieved: Reductions of the certification cost, of the operating time and of the number of non-compliance.

[Oesophageal and fundic variceal bleeding]

Oesophageal and fundic varices belong to the most frequent complications of cirrhosis and portal hypertension. Due to their significant morbidity and mortality, bleedings from oesophageal or fundic varices represent a challenge for the emergency medical team as well as for the gastroenterologist. The patient with a variceal bleeding should be accurately monitored and his/her hemodynamic parameters should be maintained stable with the administration of plasma expanders and blood units when indicated. An antibiotic prophylaxis in this setting--norfloxacin or ceftriaxon--has been demonstrated to significantly reduce morbidity and mortality. Additionally, the early administration of vasoactive compounds, such as terlipressin, somatostatin or octreotide, is associated with beneficial effects in reducing the bleeding. An upper gastrointestinal endoscopy should be generally performed within the first twelve hours from the beginning of the bleeding in order to obtain an accurate diagnosis and to provide an adequate treatment. Endoscopic procedures to control the bleeding include the rubber band ligation, the treatment of the varix with a sclerosing agent or the injection of tissue glue into the varix. In case of recurrent bleeding, beyond the above methods, different techniques, such as the transjugular porto-caval shunt, surgical shunt procedures, as well as embolisation of splanchnic blood vessels, represent additional therapeutic options. However, they are associated with very high mortality rates and their indication has to be discussed case by case by an interdisciplinary team of experts. Future therapies include the optimisation and the improvement of the current medical and endoscopic armamentarium, as well as the application of treatments to novel targets, such as the coagulation cascade.

Time to admission in acute ischemic stroke and transient ischemic attack

BACKGROUND AND PURPOSE: The effect of thrombolysis depends on the time from stroke onset to treatment and therefore also on the time when patients come to the hospital. This study was designed to analyze the variables that influence the time from symptom onset to admission (TTA) to the stroke unit. METHODS: We evaluated the medical records of 615 consecutive stroke or transient ischemic attack (TIA) patients admitted to our neurological department within 48 hours after symptom onset. RESULTS: The median TTA was 180 minutes. Referral by emergency medical services (EMS; P<0.001), high National Institutes of Health Stroke Scale (NIHSS) scores (P<0.001), strokes in the carotid territory (P<0.001), and strokes not attributable to small vessel disease (P<0.001) were associated with shorter prehospital delays. The TTA was adjusted for travel times (adjTTA), and all these variables remained significantly associated with time to admission. In addition, patients with previous experience with stroke or TIA had longer adjTTA (P=0.028). Regression analysis confirmed the independent association between referral by EMS (P=0.010), high NIHSS scores (P<0.001), carotid territory stroke (P<0.001), and first-ever cerebrovascular event (P=0.022) with shorter adjTTA. CONCLUSIONS: Factors such as NIHSS scores and stroke location influence the time to admission but, unlike referral pathways, cannot be modified. Educational programs and stroke campaigns should therefore not only teach typical and less common stroke symptoms and signs but also that EMS provides the fastest means of transportation to a stroke unit and the best chances to get treatment early.

Dual dispatch early defibrillation in out-of-hospital cardiac arrest in a mixed urban���rural population

Aims The effects of a system based on minimally trained first responders (FR) dispatched simultaneously with the emergency medical services (EMS) of the local hospital in a mixed urban and rural area in Northwestern Switzerland were examined. Methods and results In this prospective study 500 voluntary fire fighters received a 4-h training in basic-life-support using automated-external-defibrillation (AED). FR and EMS were simultaneously dispatched in a two-tier rescue system. During the years 2001���2008, response times, resuscitation interventions and outcomes were monitored. 1334 emergencies were included. The FR reached the patients (mean age 60.4��������19 years; 65% male) within 6��������3���min after emergency calls compared to 12��������5���min by the EMS (p���<���0.0001). Seventy-six percent of the 297 OHCAs occurred at home. Only 3 emergencies with resuscitation attempts occurred at the main railway station equipped with an on-site AED. FR were on the scene before arrival of the EMS in 1166 (87.4%) cases. Of these, the FR used AED in 611 patients for monitoring or defibrillation. CPR was initiated by the FR in 164 (68.9% of 238 resuscitated patients). 124 patients were defibrillated, of whom 93 (75.0%) were defibrillated first by the FR. Eighteen patients (of whom 13 were defibrillated by the FR) were discharged from hospital in good neurological condition. Conclusions Minimally trained fire fighters integrated in an EMS as FR contributed substantially to an increase of the survival rate of OHCAs in a mixed urban and rural area.

Hypoglycemia despite hyperglycemia. Is a cerebral glucose deficiency possible even with raised blood sugar levels?

Hypoglycemia represents the most frequent endocrinologic emergency situation in prehospital patient care. As the patients are usually unconscious on arrival of emergency medical personnel, often the only way to establish a diagnosis is by determination of the blood glucose concentration. However, even normoglycemic or hyperglycemic levels cannot definitively exclude the diagnosis of a previous hypoglycemia as the cause of the acute cerebral deficiency. Therefore, and especially in the case of insulin-dependent diabetes mellitus, a differential diagnosis should be considered. We report a case of emergency treatment of a hypoglycemic episode in a female patient with prolonged neuroglycopenia together with cerebrovascular dementia and Alzheimer's disease.

Death after Sexual Intercourse

Sexuality is an essential aspect of quality of life. Nevertheless, sexual intercourse is physically challenging and leads to distinct changes in blood pressure, heart, and respiratory rate that may lead to vital complications. We present a case report of a 22-year-old female suffering from subarachnoid hemorrhage after sexual intercourse. The patient was immediately transported to hospital by emergency medical services and, after diagnosis, transferred to a tertiary hospital with neurosurgical expertise but died within 24���hours. After postcoital headaches, subarachnoid hemorrhage is the second most common cause of neurological complications of sexual intercourse and therefore patients admitted to an emergency department with headache after sexual intercourse should always be carefully evaluated by cerebral imaging.

Assessing the need and options available for trauma physician funding in Texas

Efforts have been made to provide supplemental funding to emergency departments to offset the costs of uncompensated medical care. But a problem exists within the trauma system in Texas that has largely been overlooked by the state. This project will focus on the lack of funding available to physicians and on-call specialists who contract with hospitals to provide emergency care. ^ A lack of funding and reimbursement for emergency care is directly influencing the number of medical specialists willing to provide emergency treatment in hospitals on a contractual basis. A shortage of emergency physicians has an impact on the public health of all Texans who may need trauma care in a hospital. Specifically, a shortage of emergency physicians can lead to a complete denial of specialty emergency health care, a delay in patient treatment, and increased ambulance diversions. Quality and access barriers to emergency services undoubtedly threaten the stability of the trauma care system in Texas and the health status of its citizens. ^ In 2003, Texas took a significant step towards addressing the issue of uncompensated care provided by the trauma system and passed House Bill 3588, creating the Trauma Facilities and Emergency Medical Services Fund (���the Trauma Fund���). However, the primary shortfall to this legislation is that the Trauma Fund is only available to emergency medical service providers and hospitals. The Trauma Fund does little to help offset the cost incurred by contracting physicians and on-call specialists who provide emergency services to the uninsured. ^ This paper addresses how funding shortages for emergency department physicians negatively impact the trauma care system in Texas and the policy options available to create physician funding to offset the cost of uncompensated trauma care. Ultimately this paper concludes that although creating a new funding stream similar to the actions taken in other states would be a dramatic step towards addressing the problem, the political process in Texas may slow implementation of this option. Consequently, modifying existing legislation, although the weaker of the options, may be more attractive to those looking for immediate action. ^