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PDF | Many of the people who die of trauma, heart attacks, or stroke die within the In an attempt to encourage research into prehospital emergency care and to. Article (PDF Available) in Journal of Emergency Medicine 32(4) · June Type of Training And Short Courses For Prehospital Care Personnel From Year. Prehospital emergency care. Injury: the British Journal of Accident Surgery ( ) Vol. 18/No. 5 Clinical Care and Pathop~ysiology. J. David Richardson.
The PEC may assess the patient to be in need of care and transport, but the patient refuses at least initially to co-operate with this or parts of this. An analysis of dilemmas posed by prehospital DNR orders. Conclusion Few of the conflicts identified are unique to the prehospital emergency field, even if some are found with greater frequency within it. The groups were selected to reflect variation in sociogeographical location, educational background, sex and work experience. A discussion around these centres is to be found only in Naess et al.
Factors said to support this are: Nevertheless, these factors have the potential to result in ethical situations in which the prehospital emergency team will have to face difficult priorities between conflicting values and norms that may have far-ranging consequences, and where members of the emergency team sometimes make decisions more usually made by more qualified carers or medical professionals.
However, before providing the tools it is essential to Address for correspondence: This article provides a survey of different types of ethical conflict faced by prehospital emergency carers PECs in the Swedish care context as a background to the further development of normative tools.
The term PEC will be used for both registered nurses and paramedics working in prehospital emergency care. Even though Swedish health authorities have required at least one registered nurse in every prehospital emergency team since October , this was not the case when the study was performed. Even in teams involving a registered nurse, ethical decision making was performed jointly with the paramedics.
Hence, PECs are required to handle the ethical situations arising in their field of work in a reflected and well-founded way. In line with the development of prehospital emergency care in Sweden from being more of a transport service to becoming prehospital emergency care, the need for well-founded and reflected ethical decisions has been emphasized.
At the same time, there is a lack of in-depth discussion around ethical issues in the prehospital emergency field. Discussion focuses mainly on ethical problems with cardiopulmonary resuscitation CPR, do not resuscitate orders etc. The values and norms that should guide prehospital emergency care are those of health care in general, in which ethical decisions are often made with limited time and space for reflection. This approach does not imply that ethical problems and conflicts can be solved before facing them in real life.
Rather, to solve these problems in the best possible way, PECs should consider possible arguments for and against different options and should be able to weigh these arguments against each other in real situations. We will discuss different types of conflict elsewhere. Even if all care could be characterized as ethical situations because it involves values and norms about issues such as health and a good life, not all care could be characterized as ethically problematic.
To consider a situation to be an ethical conflict, there needs to be conflict between legitimate values or norms. Aim The aim of the study was to analyse and describe ethical conflicts faced by PECs in the prehospital emergency setting. Three interviews were conducted with registered nurses with different educational backgrounds and three with paramedics who had undergone complementary education in ambulance nursing.
Table 1 details the distribution of educational background, sex and years working in prehospital emergency care of 29 participants. The groups were selected to reflect variation in sociogeographical location, educational background, sex and work experience. In order to avoid professional conflict and influences of authority structures on the material, registered nurses and paramedics were interviewed separately. Contact was made with the supervisors of the prehospital emergency services in the chosen areas to gain overall approval and to identify ambulance stations whose personnel would participate in the interviews.
The heads of the ambulance stations were then asked to recruit registered nurses and paramedics with a work experience of at least five years. In the sparsely populated area, the registered nurses shared their time between the prehospital emergency service, the intensive care unit ICU and primary care respectively. Two interviewers were present during the focus group interviews.
No pre-existing scheme was followed, but the informants received a short text about ethical conflicts together with information about the study. When necessary, the moderator told of an ethical conflict he had experienced in his own work, checking also that other fields of care situations were touched upon. Each interview lasted between 2. Both interviewers recorded their first-hand impressions of each interview straight after the event. The interviews were then transcribed verbatim.
Ethical considerations On recruitment, the participants were given information about the research project concerning how the material would be handled and emphasizing their right to withdraw at any time. All signed a consent form. The research project was piloted and approved on three different occasions owing to the locations being situated in areas covered by different ethics committees.
Analysis The data were analysed using content analysis, focusing on the explicit and implicit ethical conflicts found in the material. Individual Group no. First, the transcripts were read through to obtain an overall picture of the content; then each interview was read carefully, noting each new conflict or version of a conflict and the handling of the conflicts. Codes were then used for grouping into a number of clusters. Finally, the items in each cluster were regrouped in order to identify a number of nodes between which conflict could be said to arise.
Ten such nodes were found and grouped together in what might be called a conflict scheme Figure 1. Results When PECs care for a patient, the relationship is the centre around which, and in relation to which, the conflict arises.
At other times, the prehospital emergency care of patients also involves significant others or bystanders, other care professionals, and other professionals primarily police and firefighters. In many of these situations, there is no conflict between the different nodes involved. However, at other times, one or several of the nodes give rise to a conflict that can be characterized as ethical.
At times, when there are different care options and it is not obvious which one is in the best interest of the patient, a care conflict can arise. For example, in situations where initiating CPR or not is the option. The PEC may assess the patient to be in need of care and transport, but the patient refuses at least initially to co-operate with this or parts of this. Here, a complicating factor in some situations was to assess whether the patient was competent or not.
The PEC may assess the patient as not being in need of prehospital emergency care and transport, but the patient demands or wants care and transport. For example, the PEC meets a patient living in social misery and reports this. However, the patient does not want to agree with the characterization that he or she lives in such miserable conditions.
For example, a patient with influenza may demand transport to the emergency room, where he or she will not receive any help but is at risk of passing on the infection to other patients. For example, a patient wants to be transported to the university hospital which is actually closer , but resource management considerations and the organizational structure require that the patient is transported to the local hospital in the health care region where he or she has been taken ill.
Professional ideals. According to the professional self-identity of PECs, they should care for patients with prehospital care needs. At the same time, they face patients with more general care needs that go beyond or fall outside the prehospital care responsibility or what the PECs view as their care responsibility.
The professional ideals of caring for patients regardless of their need may give rise to conflict. The professional ideal also includes the ambition of providing fair care for all patients. At times, different patient interests will imply a conflict for PECs eg when facing a patient with a minor need that does not require prehospital emergency care. Other more needy patients may thus have to wait to receive prehospital care.
Similarly, the social situation of a drug user can be taken into account as a reason for not providing relevant care because of a lack of adherence on behalf of the drug user. The professional ideal of treating patients as unique beings at times conflicts with the actual care eg when the PEC needs to interpret general signs of a situation in order to make a decision. Professional role and self-identity.
Being in a professional role as a PEC also implies a distinction between the professional and the private role. At times this will conflict with the long- term best interest of the patient or the overall resource management of the care system.
This can be seen in situations when a colleague breaks these norms and the PEC does not intervene until afterwards. Organizational structure and resource management. The organization has certain guidelines or protocols to which PECs should adhere. Examples are situations when a decision about providing CPR must be made. The organizational structure is set up according to a formal authority structure. These patients are often not accepted anywhere.
The organizational protocols of an emergency medical dispatch centre may at times conflict with professional self-identity and the professional ideals of PECs eg in requiring PECs to be ready for a new call after the death of a patient when the PEC finds it essential that he or she should stay with the relatives and friends.
Lack of resources conflicts with the best interest of patients. Here, the PEC with his or her professional ideals and self-identity of caring for patients in need is caught between two needs. Sometimes the prehospital team will have to transport a patient from the hospital to his or her home, even if they judge the patient as still being in need of hospital care. The professional ideal of always informing the patient can conflict with the organi- zational demands of transporting a patient, without trouble, to a new care facility.
Societal ideals. Society demands that we should be true to our own personal values, opinions and judgements. Society demands equality between the sexes. This will at times conflict with the professional self-identity of some PECs of being able to transport a patient on a stretcher in all situations when it is required. The ideal of equality between the sexes will at other times conflict with the professional ideal of caring for patients according to their own perspective of their best interest as influenced by cultural and religious norms eg when a woman wants to be cared for by a female PEC.
In most cases when there is someone else present at the care scene besides the patient it is someone close to the patient. However, at times there are other bystanders not close to the patient present, but these are grouped together in this article as we found that the conflicts arising with bystanders are a subgroup of conflicts arising with significant others.
This can happen when significant others are so stressed by the situation that the PEC has no possibility of taking care of the patient. For example, significant others may claim that they can take care of the patient, but the PEC considers the significant other to be too stressed to manage this. Here, the PEC is caught between these different wants around the patient. Other care professionals. Here, professional PECs are caught in the middle. The patient has the right to be transported to a hospital of his or her own choice but the care professionals question having the patient transported to their care unit.
Different care professionals can be in conflict over what is in the best interest of the patient. The PEC may be caught in the middle when registered nurses and health care assistants at a nursing home are in conflict over whether a patient should be allowed to die at their care facility or be transported to the emergency room or ICU.
Other professionals mainly police and firefighters. The professional self-identity and ideal of caring for the best interest of the patient may come into conflict with the role and duty of other professionals, for example, when the police want to question a badly hurt patient before the PEC takes him or her away for care.
Discussion Method A problem with using focus group interviews is a certain lack of depth in the data material compared with individual interviews. However, since the aim of the study was to find as wide a variety of ethical conflicts as possible, this was not considered a serious problem. Another aspect of focus group interviews is the extent to which group dynamics influence the data material.
Some of the groups showed a great degree of unanimity about how to deal with ethical conflicts, while others demonstrated some disagree- ment. There was also some disagreement about whether a conflict was indeed a conflict or not. Therefore it could be that group dynamics hindered some of the informants from talking about conflicts that they expected the rest of the group not to see as conflicts. Hence, group dynamics could to some extent have restricted some of the informants from being open about more problematic conflicts or ways of handling the conflicts.
Compared with other studies in the field, we found a few examples of conflicts where group dynamics could have played a role in restricting the informants from talking about these types of conflict.
However, the aim of the study was not to assess how PECs deal with ethical conflicts, but rather to identify these ethical conflicts.
The dynamics of the focus groups gave us reason to believe that, given our aim, we found more types of ethical conflict than we would have done by using individual interviews.
In the sparsely populated area, the registered nurses shared their time between the prehospital service, the ICU and primary care respectively, which was to some extent shown in the material in terms of role conflict. However, this was considered too peripheral and is hence not included in the results. Results The ethical conflicts have been presented as arising between different nodes of conflict, where these different nodes represent values that could conflict in a specific situation.
Some of the nodes represent more or less basic values in prehospital care, for example, that self-determination is best for the patient. Some nodes are representative of a cluster of values, such as professional and societal ideals.
Others have a more instrumental relationship to relevant values: However, in the choice between analysing and presenting the conflict nodes exclusively in terms of more or less basic values and analysing and presenting the nodes in terms of factors that would be recognizable as conflict nodes by the prehospital carer, the latter approach was chosen.
Only one published study surveying the field of ethical conflict in a prehospital setting was found. Below, these studies will be related to the results of the present study. The fact that this situation constitutes a conflict for the carers is expressed in the material. Here, PECs try to balance the chance of further life against allowing the patient to die a dignified death. Prehospital and emergency trauma care in disaster medicine. Prehospital care knowledge base of non-emergency medicine resident physicians.
Use of checklists facilitates guideline adherence in prehospital emergency care. Prehospital emergency care: Prehospital emergency pharmacology. Telemetry in prehospital care.
Medical control of prehospital care. Year Book Medical Publishers Distr. Wolfe Medical. The Arterial Anatomy of Skin Flaps. Half anatomical Trauma: Three of references, at a level raises many questions and the clinical section on delay of flaps with copious references dealing free radicals and free radical scavengers.
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