[Carbon monoxide poisoning, treatment and orientation]. / Intoxication au monoxyde de carbone, prise en charge et orientation.

Colourless and odourless, each year carbon monoxide is responsible for several thousand cases of poisoning. Often collective, their symptoms are non specific and can result in serious neurological sequelae or even death, if they are not detected in time. The (pre-) hospital emergency nurse plays an important role in the management of these patients, in terms of assessment, treatment and monitoring as well as the organisation of the admittance of victims, categorisation and medical triage. As part of a team, the nurse ensures that the patient enters an adapted, regulated pathway, with the most serious cases being directed towards a hospital equipped with a hyperbaric medicine facility.

Teaching Guatemalan traditional birth attendants about obstetrical emergencies.

INTRODUCTION: Guatemala's Maternal Mortality Rate is 65th highest in the world at 120 deaths per 100,000 births. Contributing to the problem is traditional birth attendants (TBAs) attend most births yet lack knowledge about obstetrical emergencies. Government trainings in existence since 1955 have not changed TBA knowledge. Government trainings are culturally insensitive because they are taught in Spanish with written material, even though most TBAs are illiterate and speak Mayan dialects. The purpose of the observational study was to evaluate the effect of an oral training, that was designed to be culturally sensitive in TBAs' native language, on TBAs' knowledge of obstetrical emergencies. METHODS: one hundred ninety-one TBAs participated. The study employed a pretest-posttest design. A checklist was used to compare TBAs' knowledge of obstetrical emergencies before and after the training. FINDINGS: the mean pretest score was 5.006±SD 0.291 compared to the mean posttest score of 8.549±SD 0.201. Change in knowledge was a P value of 0.00. DISCUSSION: results suggest an oral training that was designed to be culturally sensitive in the native language improved TBAs' knowledge of obstetrical emergencies. Future trainings should follow a similar format to meet the needs of illiterate audiences in remote settings.

A cost-effective approach to simulation-based team training in obstetrics.

Many larger facilities regularly stage obstetric drills in modern simulation departments equipped with expensive simulators. Despite lacking these resources, we wanted to provide effective simulation training at our rural hospital. A team of clinicians and educators developed a cost-effective and time-efficient simulation drill for nurses, which included both a didactic review and a simulation day. The drill included obstetric providers and incorporated scenarios for shoulder dystocia, neonatal resuscitation and postpartum hemorrhage. This was a successful multidisciplinary learning experience that was high in creativity and teamwork, but low in cost.

Itinerários terapêuticos em urgências e emergências pediátricas em uma comunidade quilombola / Itinerarios terapéuticos en urgencias y emergencias pediátricas en una comunidad quilombola / Therapeutic itineraries in pediatric urgencies and emergencies in a quilombola community

O Itinerário Terapêutico (IT) compreende o conjunto de práticas e estratégias de cuidado adotadas por pessoas e famílias, englobando a motivação que direciona a busca por cuidados, que está associada ao contexto sociocultural e à disponibilidade de recursos. O objetivo foi conhecer os IT em situações de urgência e emergência pediátricas adotados por uma comunidade quilombola. Trata-se de um estudo descritivo, com abordagem qualitativa, que teve como suporte teórico a Teoria Transcultural do Cuidado de Madeleine Leininger. Para contextualizar o objeto de estudo, buscou-se aprofundamento nas temáticas: urgências e emergências pediátricas, condições de vida e saúde da população negra no Brasil e itinerários terapêuticos na busca por cuidados em saúde. O estudo foi desenvolvido na comunidade quilombola de Praia Grande, localizada na Ilha de Maré, em Salvador-BA, com doze mães de crianças para as quais já prestaram alguma assistência em situação de urgência/emergência. Os dados foram coletados de dezembro/2013 a junho/2014 por meio de entrevista semiestruturada, após aprovação da pesquisa pelo comitê de ética da Universidade Federal da Bahia, sob o protocolo nº 420.096. Para tratamento dos dados foi utilizada a técnica de análise temática de Bardin, que deu origem a três artigos: 1) Percepções de urgência e emergência pediátrica entre quilombolas: uma abordagem à luz de Leininger; 2) Itinerário terapêutico em situações de urgência e emergência pediátrica em uma comunidade quilombola; e 3) Funcionamento de ambulanchas em uma comunidade quilombola ilhéus: percepção da população. Os resultados demonstram que as percepções acerca das situações de urgência/emergência pediátrica são plurais e abarcam desde fatores biológicos até problemas e necessidades relacionadas ao contexto social e geográfico da comunidade, que também influenciam na construção do IT. As situações caracterizadas como urgência/emergência neste estudo foram crise convulsiva febril, febre alta, desidratação, crise asmática e queimadura. O IT teve início no subsistema popular, a partir dos cuidados prestados pela família e a rede de suporte social inerente a este subsistema, com recursos da vida diária, como chás, remédios caseiros, banhos, automedicação e massagens. A passagem pelo subsistema profissional ocorreu após tentativas de cuidado no subsistema popular e se revelou como uma peregrinação pelas instituições de saúde, caracterizando a dificuldade de acesso dos quilombolas aos serviços do sistema formal. Ficou evidenciado que a atenção primária não funciona como porta de entrada do SUS naquela comunidade no que se refere às situações de urgência/emergência e também que o serviço de ambulanchas não é efetivo, visto que as pessoas não obtêm resposta aos seus chamados, demonstrando desvirtuação do seu propósito e consequente descrédito da população. Com este estudo, permitimos que as mães compartilhassem suas experiências e expressassem as dificuldades enfrentadas no acesso aos serviços de saúde do subsistema formal, o que serviu de diagnóstico das fragilidades e insuficiência deste subsistema. Com isso, alertamos para a necessidade de elaboração de políticas públicas que garantam à comunidade quilombola de Praia Grande o acesso integral aos serviços ofertados pelo sistema formal, possibilitando o alcance do cuidado congruente referido por Leininger. (AU)

Involving traditional birth attendants in emergency obstetric care in Tanzania: policy implications of a study of their knowledge and practices in Kigoma Rural District.

INTRODUCTION: Access to quality maternal health services mainly depends on existing policies, regulations, skills, knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries. OBJECTIVES: This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services. METHODS: 157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required. FINDINGS: Among all 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents. CONCLUSION: TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs' inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about their competence to deliver the recommended maternal services. Thus, the authorities seeming to recognize and promote TBAs should provide support to TBAs in relation to necessary training and giving them essential working facilities, routine supportive supervision and rewarding those seeming to comply with the standard guidelines for delivering EmoC services.

Ground zero: holistic care for the first responders of 9/11.

Holistic nurses bring a dynamic tool box to the front lines of caring. We offer specialized clinical knowledge that embodies holistic values, principles and therapies. These skills and competencies prepare us to provide the best possible holistic care, even in the most unfavorable circumstances.

Emergencies during home births.

This article reflects on how community midwifery skills days have assisted community midwives to develop confidence in managing unexpected emergencies at home births, and how team work, communication and working in partnership have supported women in their choices for birth.

Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian.

Patient safety is enhanced when nursing staff recognize and respond to subtle changes in a patient's condition. In this quality improvement project, simulated clinical scenarios were conducted with staff nurses on a multi-specialty surgical unit. Scenarios were developed from actual patient situations as well as from calls to the rapid response team. Nurses were given the opportunity to practice assessment, critical thinking, and communication skills. Pre- and post-project surveys were used to assess nurses' perceived level of confidence and skill in handling emergency situations. Post-project survey data showed that nurses perceived that the scenario exercises improved their confidence and skill in managing critical patient situations. In addition, the findings supported the continued use of the scenarios as a teaching strategy. The scenarios have increased nurses' awareness of early signs of patients' conditions deteriorating and have the potential to decrease the number of patient situations that escalate to emergencies.

High-fidelity simulation and emergency preparedness.

Ongoing threats of bioterrorism and the consequences of natural disasters require nurses entering the workforce to be competent in emergency preparedness. Nurses need to collaborate with multidisciplinary teams and use their critical thinking skills to provide safe nursing care during potentially chaotic public health emergencies. Using Institute of Medicine recommendations and Quality and Safety Education for Nurses competencies, the authors describe a public health emergency simulation exercise with undergraduate senior nursing students enrolled in a public health clinical course. Students applied chronic disease, mental health, and pharmacology knowledge acquired in previous nursing courses to an unfolding infectious disease outbreak while practicing their assessment, treatment, delegation, organizational, and leadership skills. The students' quantitative evaluation of the experience indicated that 90.36% thought the purpose of the experience was clear, 91.5% thought the importance of delivering safe care during a public health emergency was stressed, and 79.5% thought the presimulation briefing and postsimulation debriefing helped them understand and participate in the drill. Qualitatively, the students' reflections of the exercise indicated that although they initially felt overwhelmed and anxious, they realized the importance of participating in emergency preparedness and recognized their ability to apply nursing skills learned in previous courses.

Using the human patient simulator to foster critical thinking in critical situations.

New registered nurses are expected to utilize critical thinking when providing care to their patients, especially in critical situations. Using mini-scenarios on the human patient simulator, faculty members can foster critical thinking and expose students to critical situations in a nonthreatening environment. An example of one such scenario, using an oncology patient with hypercalcemia and ventricular tachycardia, is outlined in the article.

Playing it safe: simulated team training in the OR.

Health care professionals are expected to make prompt, accurate decisions in life-threatening emergency situations in the OR. Perioperative leaders are faced with the challenge of ensuring that OR team members are prepared to respond to potentially lethal emergencies, including rare and infrequent events. This article describes the importance of team training for all members of the OR team. The use of simulation is discussed as a tool to accomplish this goal. Steps for developing a simulation scenario are presented.

Evoking the essence of caring: experiences from a Peruvian adventure relevant for leaders in healthcare today.

There are times when an experience is so powerful that it evokes caring in its purest form. This is what happened when a group of healthcare providers traveled together on a trip to Peru. This article recounts a harrowing experience that called each person to give caring and receive learning regarding his or her own journey. It is about how caring can simply happen with ease and purpose. Communication and collaboration occurred effortlessly. In this experience, there was a remembering of the passion and purpose that exists when we are called to serve in healthcare settings. The learning gained included 4 key elements of caring: intent, presence, action, and surrender. This learning offers insight, direction for healthcare environments today. Healthcare leaders must be responsive to creating cultures and providing opportunities to support those serving patients to intentionally think about their caring approaches. It is possible to evoke caring through providing opportunities that help healthcare providers transcend the daily barriers to being present and be more effective in their caring. It is imperative that they experience ways to examine their ability to care for themselves and others and to reconnect to the passion of choosing the healthcare profession.

The criteria nurses use in assessing acute trauma in military emergency care.

Emergency medical care for seriously injured patients in war or warlike situations is highly important when it comes to soldiers' survival and morale. The Swedish Armed Forces sends nurses, who have limited experience of caring for injured personnel in the field, on a variety of international missions. The aim of this investigation was to identify the kind of criteria nurses rely on when assessing acute trauma and what factors are affecting the emergency care of injured soldiers. A phenomenographic research approach based on interviews was used. The database for the study consists of twelve nurses who served in Bosnia in 1994-1996. The criteria nurses rely on, when assessing acute trauma in emergency care, could be described in terms of domain-specific criteria such as a physiological, an anatomical, a causal and a holistic approach as well as contextual criteria such as being able to communicate, having a sense of belonging, the military environment, the conscript medical orderly and familiarity with health-caring activity. The present study shows that the specific contextual factors affecting emergency care in the field must also be practised before the nurse faces military emergency care situations. This calls for realistic exercises and training programs, where experience from civilian emergency care is interwoven with the knowledge specific to military medical care.

Rapid response teams in hospitals: improving quality of care for patients and quality of the work environment for nursing staff.

As the healthcare delivery system continues to evolve in the new millennium, initiatives such as the Institute for HealthCare Improvement's 100,000 Lives Campaign include the development of rapid response teams in hospitals. Introduction of rapid response teams provides nurses assistance in difficult clinical situations and provides early clinical intervention to mitigate negative patient outcomes and save lives. Development, implementation strategies, and benefits of rapid response teams are described.

Modelling emergency decisions: recognition-primed decision making. The literature in relation to an ophthalmic critical incident.

AIMS: To review and reflect on the literature on recognition-primed decision (RPD) making and influences on emergency decisions with particular reference to an ophthalmic critical incident involving the sub-arachnoid spread of local anaesthesia following the peribulbar injection. BACKGROUND: This paper critics the literature on recognition-primed decision making, with particular reference to emergency situations. It illustrates the findings by focussing on an ophthalmic critical incident. DESIGN: Systematic literature review with critical incident reflection. METHODS: Medline, CINAHL and PsychINFO databases were searched for papers on recognition-primed decision making (1996-2004) followed by the 'snowball method'. Studies were selected in accordance with preset criteria. RESULTS: A total of 12 papers were included identifying the recognition-primed decision making as a good theoretical description of acute emergency decisions. In addition, cognitive resources, situational awareness, stress, team support and task complexity were identified as influences on the decision process. CONCLUSIONS: Recognition-primed decision-making theory describes the decision processes of experts in time-bound emergency situations and is the foundation for a model of emergency decision making (Fig. 2). RELEVANCE TO CLINICAL PRACTICE: Decision theory and models, in this case related to emergency situations, inform practice and enhance clinical effectiveness. The critical incident described highlights the need for nurses to have a comprehensive and in-depth understanding of anaesthetic techniques as well as an ability to manage and resuscitate patients autonomously. In addition, it illustrates how the critical incidents should influence the audit cycle with improvements in patient safety.

How safe is triage by an after-hours telephone call center?

OBJECTIVES: Our goals were to assess (1) compliance with nurse disposition recommendations, (2) frequency of death or potential underreferral associated with hospitalization within 24 hours after a call, and (3) factors associated with potential underreferral, for children receiving care within an integrated health care delivery organization who were triaged by a pediatric after-hours call center. METHODS: The study population included all pediatric patients enrolled in Kaiser Permanente Colorado whose families called the Children's Hospital after-hours call center in Denver, Colorado, during the period between October 1, 1999, and March 31, 2003. Postcall disposition recommendations were categorized as urgent (visit within 4 hours), next day (visit in > 4 hours but within 24 hours), later visit (visit in > 24 hours), or home care (care at home without a visit). Compliance with the nurses' triage disposition recommendations was calculated as the proportion of cases for which utilization data matched the disposition recommendations. RESULTS: Of the 32,968 eligible calls during the study period, 21% received urgent, 27% next day, 4% later visit, and 48% home care disposition recommendations. Rates of compliance with both urgent and home care disposition recommendations were 74%, and the rate of compliance with next day recommendations was 44%. No deaths occurred within < 1 week after the after-hours calls. The rate of potential underreferral with subsequent hospitalization was 0.2%, or 1 case per 599 triaged calls. In multivariate modeling, age of < 6 weeks or > 12 years and being triaged after 11 pm were associated with higher rates of potential under-referral. CONCLUSIONS: Approximately three fourths of families complied with recommendations for their child to be evaluated urgently or to be treated at home, with much lower rates of compliance with intermediate dispositions. The rate of potential underreferral with hospitalization was low, and age and time of call triage were associated with this outcome.

Training nurses and technologists for trauma surgery.

Getting assigned to a trauma for the first time is still stressful for perioperative staff members. However, viewing the video/DVD does seem to help overcome some of the inherent anxiety. In addition, encouraging new or inexperienced staff nurses and technologists to participate on trauma cases with more seasoned staff also seems to alleviate some of those fears. Saying "let's make believe it's an emergency" and setting up quickly for a scheduled case will keep those skills current. Having staff members utilize "what if" scenarios tends to keep them thinking and anticipating. Prioritizing and reviewing all the case actions will allow nurses and technologists to perform these actions/skills in an emergency without even thinking. Although specific internal injuries a trauma patient will have cannot always be predicted, the perioperative staff members must still use their basic training to be ready for anything that comes through the doors to surgery. Making a video seemed like an overwhelming task at first, but the team sought out guidance and support from appropriate resources (videographer, surgeons, etc) in order to collaborate effectively, and the result was a great educational product. The Staff Development team continues to present inservices that are specialty or case specific. The "trauma" aspect of these presentations is also always included to reinforce the topics that were brought out in the video.