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The bachelor thesis discusses the issue of states of dyspnoea, specifically pulmonary embolism from the perspective of a paramedic working in the area of pre-hospital emergency care. In the theoretical part, a brief characteristic of pre-hospital emergency care is given, the paramedic branch is briefly defined and further on, the basic anatomy and the physiology of the circulatory and respiratory systems is given. Dyspnoea is defined from a general perspective, its causes, diagnosis and risk factors are mentioned. Diagnostically and therapeutically, the thesis is focused on specific characteristics of dyspnoea within pulmonary embolism, including the main causes of their origin. The research part of the thesis was implemented based on semi-structured, anonymously processed interviews. The research file was made of randomly chosen paramedics of the Ambulance in South Bohemia and Central Bohemia. The analysis of the obtained data was focused on the awareness of the paramedics themselves concerning the given issue of dyspnoea, including the presentation of their perspective on the implementation of professional preparation in the dyspnoea issue from their employer´s side. Further on, the procedures of differential diagnosis and pulmonary embolism treatment in pre-hospital emergency care were evaluated. The implemented research has found out that the paramedics from South Bohemia are not sufficiently educated in the issue of dyspnoea, including pulmonary embolism. The paramedics from Central Bohemia are, compared to that, educated by the relevant educational and training centre, educated enough concerning states of dyspnoea. Based on the findings, the thesis results might be presented to the educational and training centre of the South-Bohemian and Central-Bohemian Ambulances to perhaps consider the future aiming of educational and training programmes concerning dyspnoea issues, including the specific aiming at the awareness about pulmonary embolism diagnosis and therapy.

This thesis deals with providing special care for motorcycle trauma in pre-hospital emergency care. The work has set three goals. The first goal is to map the processes of providing specialized care for trauma bikers both by paramedics and general nurses. The second goal is to map paramedics and nurses' knowledge about the nature of trauma in view of urgent transport to a higher catchment area. The third objective is to map the specifics of bikers from the perspective of paramedics and nurses. To those objectives were to answer three research questions. The research part of the thesis was carried out by a qualitative research. A combination of semi-standardized interview, which consisted of 13 questions, was used for a data collection. There was used the knowledge test, too, which consisted of 21 questions. Semi-structured interviews and knowledge tests were conducted with randomly selected paramedics and nurses working in Emergency Medical Services in Vysocina Region and South- Bohemia Region. The results of the knowledge tests were arranged into tables. Semi-structured interviews were transcribed and processed into tables. There is the list of semi-standardized interview questions and a knowledge test in the attachment. The research showed that knowledge of paramedics and nurses working in Emergency Medical Services in Vysocina region are more optimal than in the South Bohemia Region. However, the differences are minimal. Only one question, number 9, which is related to the knowledge of neurogenic shock, showed insufficient knowledge, when only 8 out of 40 respondents answered correctly. Other mapped knowledge is good, in some areas is excellent. In conclusion I would like to say that despite excellent knowledge of paramedics and nurses working in emergency medical services there is still some space left for further training, especially in specific injuries and complications of injuries, which may occur at motorcyclists. I think it is important to be knowledgeable and educated in this issue because a good training practice of pre-hospital emergency care is crucial for the further development of the patient's condition. This issue could be supported by this thesis, which tries to be a comprehensive overview of the problem of motorcyclists and procedures providing special care for motorcycle trauma in pre-hospital emergency care.

The thesis deals with the forms of provision of pre-hospital emergency care (PEC) by paramedics of the Army of the Czech Republic (ACR) and this means above all those forms of PEC which are provided by Combat Medic and Combat Lifesaver (a Combat Lifesaver trained soldier). With regard to the terminology and conception of the thesis comprising the areas of providing PEC, the thesis deals with the levels 1 3 outfeed chain, consequently with the care of the patient to the relevant Role 1 including. The aim of the thesis was to show the basic differences in providing PEC by the Army of the Czech Republic in comparison with the system of emergency medical services of the Czech Republic and then to find out what the specific qualifications for a paramedic´s profession are. I tried to demonstrate this knowledge both by the practical part of the thesis and by its theoretical part.The theoretical part deals with the problems of reaching the paramedic post of the ACR either the Combat Medic or Combat Lifesaver, by required education and necessary courses. Then the thesis deals with providing PEC in the battlefield, up to Role 1, when the wounded person is given the first aid by paramedics. The practical part meant the qualitative research in the form of semi-structured interview and research questions. There I managed to achieve particular aims of the thesis thanks to the interviews with the respondents of the medical personnel of the ACR and the respondents of emergency medical services. All the inverviewed medical personnel of the ACR had to participate in at least one foreign mission. Among the respondents were both the CLS trained soldiers, Combat Medics, and even one medical corps doctor. The thesis is a contribution to the paramedics of the ACR and paramedics in general who could learn more about the problems of providing PEC in extreme circumstances or possibly consolidate the knowledge they have. The research showed that the basic differences in providing PEC between the interviewed groups (it means the military paramedics and paramedics) are above all external factors, the terrain, and material or even the kind of wound or the hierarchy of the medical personnel of the foreign mission. The research also outlines the specifics necessary for exercising an ACR paramedic´s profession, and those are the courses they take before a foreign mission.

O município de Olinda, Pernambuco, criou instrumento para armazenamento de dados dos formulários das ocorrências do Serviço de Atendimento Móvel de Urgência (SAMU-192) e de forma pioneira georreferencia os atendimentos realizados. Objetiva-se descrever o perfil epidemiológico das ocorrências atendidas no município, de fevereiro (implantação do serviço) a junho de 2006, com ênfase na distribuição espacial das ocorrências mais relevantes. Foram utilizados dados secundários do banco de dados SAMU-192, considerando a freqüência das seguintes variáveis: sexo, faixa etária, tipo de ocorrências, dias da semana, tipo de causas clínicas, tipo de causas externas, tipo de acidentes de transportes e veículos envolvidos. Tendo por base as freqüências dos tipos de causas clínicas/externas, identificaram-se aquelas de maior magnitude para mapeamento e identificação dos aglomerados espaciais com o emprego de estimador de intensidade Kernel. Das 1956 ocorrências, 1114 foram por causas clínicas e 645 por causas externas; finais de semana acumularam 46,0% dos atendimentos; 55,1% das ocorrências por causas clínicas foram em mulheres, enquanto 72,1% das causas externas em homens. A média etária para as causas clínicas foi de 47 anos e 34 anos para causas externas. Destacaram-se as doenças do aparelho circulatório (23,1% das causas clínicas) e acidentes de transporte (52,7% das causas externas); desses 61,1% motivados por atropelamentos e 33,6% com motocicletas envolvidas. A análise espacial reforça a necessidade da integração entre a Secretaria de Saúde e órgãos afins para a implantação de medidas preventivas, e o perfil epidemiológico apresentou informações capazes de auxiliar na organização do serviço e na compreensão do perfil de morbidade. The city of Olinda (Pernambuco, Brazil) created a tool for storing data from the Emergency Mobile Healthcare Service forms (SAMU-192) which is a pioneer in providing georeferenced information on the treatment given. The aim of the present study was to describe the epidemiological profile of care in the city from February (implementation of the service) to June 2006, with an emphasis on the spatial distribution of the most relevant events. Secondary data from the SAMU-192 database was used, considering the frequency of the following variables: gender, age, type of event, day of the week, type of clinical cause, type of external cause, type of traffic accident and vehicles involved. Based on the frequency of the types of clinical/external causes, those of greater magnitude were used for mapping and identifying spatial clusters using the Kernel intensity estimator. Among the 1,956 events, 1,114 were due to clinical causes and 645 were due to external causes; weekends totaled 46.0% of the events; 55.1% of events due to clinical causes were in women, whereas 72.1% of external causes were in men. The average age for clinical causes was 47 years and for external causes was 34 years. Circulatory system diseases accounted for 23.1% of clinical causes. Traffic accidents accounted for 52.7% of external causes, 61.1% of which were run overs and 33.6% involved motorcycles. The spatial analysis emphasized the need for integration between the Health Department and other agencies in order to implement preventive measures. The epidemiological profile offers information that can assist in the organization of the service and in the understanding of the morbidity profile.

BACKGROUND: \ud \ud Health services research is expected to involve service users as active partners in the research process, but few examples report how this has been achieved in practice in trials. We implemented a model to involve service users in a multi-centre randomised controlled trial in pre-hospital emergency care. We used the generic Standard Operating Procedure (SOP) from our Clinical Trials Unit (CTU) as the basis for creating a model to fit the context and population of the SAFER 2 trial.\ud \ud METHODS: \ud \ud In our model, we planned to involve service users at all stages in the trial through decision-making forums at 3 levels: 1) strategic; 2) site (e.g. Wales; London; East Midlands); 3) local. We linked with charities and community groups to recruit people with experience of our study population. We collected notes of meetings alongside other documentary evidence such as attendance records and study documentation to track how we implemented our model.\ud \ud RESULTS: \ud \ud We involved service users at strategic, site and local level. We also added additional strategic level forums (Task and Finish Groups and Writing Days) where we included service users. Service user involvement varied in frequency and type across meetings, research stages and locations but stabilised and increased as the trial progressed.\ud \ud CONCLUSION: \ud \ud Involving service users in the SAFER 2 trial showed how it is feasible and achievable for patients, carers and potential patients sharing the demographic characteristics of our study population to collaborate in a multi-centre trial at the level which suited their health, location, skills and expertise. A standard model of involvement can be tailored by adopting a flexible approach to take account of the context and complexities of a multi-site trial.\ud \ud TRIAL REGISTRATION: \ud \ud Current Controlled Trials ISRCTN60481756 . Registered: 13 March 2009.

peer-reviewed The introduction of a Regulatory body in Ireland with responsibility for ensuring high standards of education and professionalism for ambulance, and other pre-hospital, practitioners was a welcomed initiative in 2001 due to a need for improvement in care delivered to patients before arrival at hospital. This Regulatory body, the Pre-Hospital Emergency Care Council (PHECC), was established under Statutory Instrument with an initial priority being to develop three levels of pre-hospital practitioner: Emergency Medical Technician (EMT); Paramedic; Advanced Paramedic (AP). The introduction of these three levels meant that only such registered practitioners could practice in the pre-hospital environment. However for practitioners to renew their registration, they had only to meet simple and minimal criteria with no requirement to demonstrate any level of competence. The Council’s 2011-2014 Strategic plan identified the need to introduce a system of continuous professional development/competence as a priority. The purpose of the studies in this thesis was to engage with the three levels of practitioner in Ireland and to seek their views and opinions so as to identify factors that would inform the implementation of a continuous professional competence (CPC) framework for all pre-hospital practitioners. The expectation in when initiating this work was that the results would assist in the introduction of a framework for one group of registrants in particular, EMTs. In reality the outcomes from these studies provided the evidence base when drafting the formal guidance document that was subsequently issued officially to all EMTs in Ireland by the Regulator. Following that introduction of CPC, a retrospective analysis was performed through engagement with those registrants so to allow for further refinement of the process before the framework would subsequently be introduced to the two remaining registrant groups, paramedics and APs. At a practical level, this thesis represents the first series of studies to engage with all levels of pre-hospital emergency care registrants on a national level in Ireland and is one of only very few to report nationwide pre-hospital research. Data were gathered using qualitative and quantitative methods, in the form of on-line surveys and focus groups. These data then formed the basis for the initial introduction of the CPC model. After a six-month period, further engagement with registrants provided the additional data to refine the process further. Therefore, this work represented a meaningful process of consultation with practicing pre-hospital care providers that would inform the information to be provided to them by their Regulator and the format in which that would be delivered. To my knowledge, there is no previously published example of such relationship between pre-hospital practitioners and Regulators internationally. Further, the design of this thesis allowed additional engagement with Irish pre-hospital practitioners following the introduction of CPC. Through publication of the outcomes, the thesis makes a contribution to both the international literature on continuous professional competence (CPC) for pre-hospital practitioners specifically and, in particular, the development of the profession in Ireland. The implementation of CPC aligns Irish pre-hospital practitioners with other well established international best practice models. This thesis, through substantial engagement with registrants, has identified the factors which they believe are important for the successful implementation of CPC and adds to the international literature on pre-hospital care and, in particular, practitioner competence in this regard. The model of CPC will have significant implications for all registrants; organisations who operate in the pre-hospital environment; the Regulator; and will positively impact on patient care by ensuring a national standard of competence exists for all relevant practitioners. While Ireland has been the focus of this thesis, the publication of its findings in peer-reviewed journals means that its relevance may extend beyond the Irish setting to those working more broadly in the fields of continuous professional development and professionalism internationally.

It is necessary to consider each patient to be a unique entity and respect his or her rights. This position requires an individual approach of paramedics. They should give the client a sense of security, certainty of assistance and take into account the fact that the patient is exposed to stress, which can change his behaviour. The paramedic must cope with these facts, he cannot be influenced, he must know how to prevent conflicts and behave according to the rules of medical ethics. The aims of this thesis was to map out the level of knowledge of patients in the area of their rights, and to find out their views on the attitude and behaviour of the paramedics during an intervention of a medical rescue service. The third part of this bachelor thesis deals with the knowledge of paramedics in the area of the patients' rights and their observance of these rights. Three research questions were set up. Whether the legal awareness among patients regarding the intervention of medical rescue services is sufficient and how patients evaluate the attitude and behaviour of paramedics during the intervention. A research question was also set up for the third aim of this thesis: what is the point of view of paramedics on respecting the patients' rights during pre-hospital emergency care. In the theoretical part I focused on explaining of the basic concepts of the medical ethics issues, its history and development. The most important part of the thesis is the ethic of emergency medicine and the issues of the rights of patients during prehospital emergency care. The thesis also discusses the ethical dilemmas that paramedics deals with during their responses and an equally important area is focused on different patients' rights, including legal standards that modify them. The research part consists of interviews with two groups of respondents: eight paramedics of the Ambulance Service of Pardubice Region and eight patients who used their services. The research showed that the legal awareness of patients is inadequate. At first glance, all patients were satisfied with the intervention of the medical rescue service and had no objections. After targeted questions targeted on the compliance of individual patient's rights, I concluded that in some cases the right to privacy and dignity of the patient was not respected. The patients were not sufficiently informed about their health and procedures that paramedics performed. None of the interviewed paramedics complied the patient's right to know the name of the medical staff member who treated him. The paramedics themselves commented on the issue of the rights of patients during the pre-hospital emergency care in the sense that they try to comply these rights, but they had problems with is not always possible. They are aware of the ethical code of the rights of patients, but they had problems with telling its content. The most frequent reason for non-compliance of the rights of patients was reported in connection with responses to people under the influence of alcohol, drugs or to patients with disorders of consciousness. The surprising result of the research was the finding that half of the responding paramedics have used violence against a patient during their practice. Among the groups of patients, to whom the responding paramedics do not like to drive, are mostly Romani people, homeless people and repeatedly calling patients. This bachelor thesis will contribute to a better awareness of paramedics and the general public about the respecting the rights of patients. Paramedics can use the observations of patients and by that remove the deficiencies they have been committing during their responses.

Intoxication through methanol is a relatively less frequent type of poisoning, which can lead even to a serious damage to the human body; can cause loss of vision as well as permanent infliction of the central nervous system. And also the death of the afflicted person is possible with late treated conditions. The methanol metabolites are quilted for the damage of the human body - mainly formic acid that is why the therapy of this health and life-threatening condition is mostly focused on the metabolism of methanol. The theoretical part deals with pre-medical that is pre-hospital emergency care of patients with a methanol intoxication. The first chapter deals with the pre-hospital emergency care, a medical rescuer and his competencies, and the ambulance crew is listed here as well. Furthermore, the theoretical part of the thesis deals with the acid-base balance, metabolic acidosis, but also involves the Toxicological Information Centre. The next chapter explore methanol and its characteristics and the history of methanol in the course of the human civilisation. It explains the metabolism of methanol and highlights the symptoms of acute and chronic methanol intoxications. The last chapter is directly focused on first aid in this state provided by a layman; and on the treat methanol intoxication in terms of pre-hospital emergency. Last but not least, it is also concerned with the effects of the methanol intoxication. The practical part of the thesis is focused on mapping the activities of a paramedic in a pre-medical care of a patient with a methanol intoxication and on determination the level of awareness of laity as well as the clients of the sobering-up station for this type of poisoning. As well as a laity with help of anonymous questionnaires. The research survey was conducted through the quantitative method among the paramedics. The amount of the data was collected during the March 2015. The research group were the randomly choired laymen and clients of the sobering-up station and the paramedics working in the Emergency Medical Services of South Bohemia Region at the regional centres of Strakonice, Písek, Prachatice, Český Krumlov and Jindřichův Hradec. The anonymous questionnaire was distributed to the above stated regional centres in the number of 100 pieces, for the laity in the same number and 10 pieces for the sobering-up station in České Budějovice. The questionnaire for the paramedics contained a total of 18 questions. The first four questions were the ones of stratification, the questions no 5 to 18 were closed and directly addressed the issues concerning the provision of pre-hospital emergency care in methanol intoxication, whereas the hypothesis no. 1 was confirmed. The questionnaire for the laity in itself contained a total of 14 questions. The first three questions were of socio demographic character. The fourth question was closed and crucial to the continued questionnaire. The question no. 5 was semi-open and remaining questions no. 6 to 14 related to determine the level of awareness among the laity methanol intoxication. The results are processed into clear graphs and the related hypothesis no. 2 was also confirmed. The first goal was to map the activity of a paramedic in a pre-medical care of a patient with a methanol intoxication. The second objective was to determine the level of awareness of the laity of this intoxication. Both the objectives have been met. The statistical method of processing a research survey showed that paramedics are knowledgeable in the procedures of pre-medical care for patients with a methanol intoxication and that lay people are informed of this intoxication, but would welcome more active involvement of experts in informing society about this issue. Based on the results of the work an information leaflet was produced for the lay and paramedics in the field of alcohol intoxication.

Many older people who fall require ambulance attendance, however around 25% are not subsequently transported to emergency departments (ED). This population is at high risk of future falls and unplanned health care use, and non-transported fallers have poorer health outcomes than their transported counterparts, potentially due to a lack of appropriate referral pathways and follow-up care. This randomised controlled trial investigated the effect of a multidisciplinary, individualised fall prevention program offered to older non-transported fallers. It aimed to reduce subsequent falls and health service use by addressing identified risk factors, linking participants into existing services and providing proactive assistance to implement physiotherapy, occupational therapy, geriatric assessment, optometry review and/ or medication management as appropriate. The control group received written fall prevention advice. Uptake and adherence, as well as benefits beyond fall prevention, were also assessed. Intention-to-treat analysis showed no significant difference between groups in regard to subsequent falls and health service use after 12 months’ follow-up. Within-group analysis revealed that control group participants had significantly worse depressive symptomatology, lower quality of life and increased fear of falling six months post index fall, while this deterioration was not evident within the intervention group. Adherence data revealed around half of intervention group participants did not complete the recommendations as intended. Analysis based on adherence to treatment protocol showed that there was a significant difference in fall rates and health service use, in favour of the “adherers” at 12 months compared to those who did not adhere to recommendations. Baseline attitudes towards falls-prevention interventions were predictive of adherence rates recorded during the reassessment. This study found that the multidisciplinary intervention did not prevent falls in older people who have received ambulance care. However, this model of care may have the potential to significantly reduce falls and fall-related health service use. When targeted at individuals intending to adhere to the tailored recommendations, there is significant benefit for participants, regardless of their medical history and fall risk factors.

The thesis deals with the management of difficult intubation in pre-hospital emergency care. In the context of a difficult intubation it tries to solve the issue of difficult airways management when dealing in such arduous situations. Within the interim legislation a paramedic is not qualified to perform the actual endotracheal intubation, by ordinance No. 55/2011 statue book which determines activities of medical staff and other professionals. Except in extreme emergency situations. (29) Despite of this, he is expected to know all the procedures and master these functions mainly in emergency situations when he must assist a doctor. The aim of this work was to set out the possibilities of solving difficult intubation in pre-hospital emergency care with a focus on competence of a paramedic. But during the research process I reached the view that, taking into consideration the interim legislation and the attitude of paramedics to this issue, it will be more suitable to map out the experience and knowledge of paramedics related to the management of a difficult intubation and airways management. In the theoretical part I tried to approach the issue of difficult intubation and with that, of course, airways management. The part of the procedure of solving difficult intubation, which it is not in the competence of paramedic, is also the use of alternative tools that every paramedic should manage. The research was carried using a qualitative method in the form of a structured interview. The interview was conducted with paramedics who were randomly selected in various regional centers of the Emergency Medical Services in South Region. The research group consisted of thirteen respondents of different gender, age and length of service. Respondents were asked 11 questions, which surveyed the attitudes of paramedics to the issue of difficult airways management. The questions concerned the experience of these states, their options and also verified general knowledge of whether paramedics are theoretically prepared to tackle difficult intubation and difficult airways management in pre-hospital emergency care. When processing data from the research I concluded that the approach to the issue of paramedics' difficult airways management is not as responsible as it should. Although paramedics met with difficulty in ensuring the airway, it was usually the doctors who solved these states. In the majority opinion, the paramedics agreed that for the time being using the laryngeal mask is sufficient or, if need be, they call the doctor. But if the doctor was not available, it is not certain whether they would be able to handle the situation themselves, because their theoretical knowledge is not always sufficient. As a positive outcome of my research was finding that most of the paramedics did not object to further practical and theoretical training in this direction and that there are some individuals who are privately educated in this area.The thesis can be beneficial for students in the paramedic field and also specialized healthcare professionals to bring together information on airway management. Part of the thesis is also a DVD-ROM complete with video attachments.

Die Telemedizin (TM) birgt auf dem Gebiet der Notfallmedizin eine Vielzahl von Potenzialen, um die Qualität der herkömmlichen präklinischen Notfallversorgung (pNV) zu verbessern, sowie die Zugänglichkeit einer notärztlichen Versorgung auszuweiten. Aktuell besteht eine Tendenz, Telemedizinzentren einzurichten, die zukünftig telemedizinische Dienste für die Akutversorgung ferner Notfallpatienten erbringen sollen. Der Einsatz telemedizinischer Verfahren geht mit Veränderungen im herkömmlichen medizinischen Versorgungsprozess einher. Im Rahmen der Dissertation bestand das Ziel, Anforderungen aus medizinischer Sicht an eine neue Notfallversorgungsstruktur abzuleiten, die es ermöglichen soll eine („tele“-) notärztliche Versorgung von Patienten in der Ferne zu realisieren. Zunächst wurde auf der Grundlage von internen Einsatzauswertungen fünf deutscher Rettungsdienstträger die Häufigkeitsverteilung von Notfalldiagnosen im Rettungsdienst ermittelt, um daraus Indikationen für eine telemedizinisch gestützte präklinische Notfallversorgung (tpNV) abzuleiten. Basierend auf der Auswertung von insgesamt 459.363 Notarzteinsätzen, wurde ein Gesamtdiagnosespektrum erstellt, welches die häufigsten 18 Notfälle der eingeschlossenen Rettungsdienstträger und ihre durchschnittliche Verteilung zeigt. Das SHT (5,7%), (sonstige) Verletzungen (22,6%), das ACS (12,1%) sowie TIA/Insult/Blutungen (7,0%) stellen die häufigsten Notfalldiagnosen dar und waren für durchschnittlich fast die Hälfte der Notarzteinsätze eines Jahres verantwortlich. Im zweiten Schritt wurde im Rahmen einer Literaturrecherche (Einschluss von Leitlinien anerkannter Fachgesellschaften) ein Maßnahmenkatalog erarbeitet, der 123 verschiedene Notfallmaßnahmen erfasst, die für eine Leitlinien-gerechte pNV der häufigsten Notfälle erforderlich sind und folglich auch im Rahmen einer tpNV realisierbar sein sollten. Abschließend wurde eine umfangreiche Literaturrecherche hinsichtlich angewandter Telemedizinverfahren in der Notfallmedizin durchgeführt und eine systematische Literaturübersicht bezüglich aktueller telemedizinischer Anwendungen zur pNV von Trauma-, ACS- und Schlaganfall-Patienten erstellt. Insgesamt wurden 36 Studien hinsichtlich bestimmter telemedizinischer Gestaltungskriterien (Qualifikation des Tele- Arztes und der Hilfsperson vor Ort, angewandte Kommunikationsverfahren & Telemedizinsysteme, Inhalt des Datentransfers) analysiert. Aus den Ergebnissen der drei aufeinander aufbauenden Arbeitsschritte wurden schließlich folgende Anforderungen an die Gestaltung einer tpNV abgeleitet: Eine tpNV sollte so gestaltet werden, dass auf ein möglichst breites Notfallspektrum reagiert werden kann. Insbesondere sollte eine Versorgung der häufigsten Notfälle gewährleistet werden können. Das erstellte Gesamtdiagnosespektrum kann orientierend zur Identifizierung von Indikationen einer tpNV herangezogen werden. Eine tpNV sollte sich am Anspruch einer Evidenz-basierten Medizin orientieren. Der erstellte Maßnahmenkatalog erfasst sämtliche Notfallmaßnahmen, die laut Leitlinien anerkannter Fachgesellschaften zur präklinischen Versorgung der abgeleiteten Indikationen empfohlen werden und folglich auch im Rahmen der tpNV mittels telemedizinischer Verfahren umsetzbar sein sollten. Er könnte eine Grundlage für weiterführende praktische Tests darstellen. Die tele-notärztliche Fachexpertise sollte von einem erfahrenen Notarzt und bedarfsweise erfahrenen Facharzt der notfallspezifischen Fachdisziplin geleistet werden. Hilfspersonen am Notfallort sollten den Tele- Arzt bei der Ausführung der Notfallmaßnahmen unterstützen. Eine synchrone Audio-Video-Kommunikation unter Nutzung entsprechender Videokonferenzsysteme, einer Breitbandinternetverbindung oder eines (Mobil-)Funknetzes ist anzustreben. Die Zuverlässigkeit und einfache Anwendbarkeit der Telemedizintechnik sowie eine maximale Datenqualität stellen essenzielle Voraussetzungen dar. Die Messung und Übertragung von Vitalparametern (EKG, NIBP, SpO2, Temperatur, BZ), eines 12-Kanal-EKGs, von Auskultationsbefunden und wenn möglich radiologischen Bildern sollte möglich sein. Die ermittelten Anforderungen sollen eine Grundlage darstellen, die notfallmedizinische Versorgung via TM im Rahmen von Testreihen und klinischen Studien weiter zu erproben und zu evaluieren. Weiterführende Studien, insbesondere randomisierte kontrollierte Studien, werden unbedingt benötigt. Nur durch eine strenge klinische Evaluierung im Sinne einer Evidenz-basierten Medizin kann die TM in die Regelversorgung integriert werden., The application of telemedicine in the field of emergency care has a lot of potential to improve the quality of traditional pre-hospital care and to expand the accessibility of care conducted through an emergency physician. Currently there is a tendency to set up telemedicine centers that are supposed to provide emergency services to remote patients. However, the use of telemedicine alters the traditional way of emergency care. Precise requirements for telemedicine in emergency care have not been identified yet. The objective of this paper was to determine requirements from the medical point of view for a new emergency service which is supposed to realize an emergency care of remote patients provided by a tele-physician. In order to identify medical indications for telemedicine emergency care, internal data from five different German emergency medical care services was analyzed regarding their most frequent emergency causes. On the basis of the data included (459.363 emergency cases) a spectrum of 18 different emergency diagnoses was generated. The most frequent emergency cases represent craniocerebral injury (5.7%), other type of trauma (22.6%), acute coronary syndrome (12.1%) and stroke (7.0%). Altogether they account for almost half of all emergency cases of the included emergency medical care services. Furthermore in the context of a conducted literature research a catalog of medical measures was generated which includes 123 different measures of preclinical diagnostics and treatment care which need to be conducted according to medical guidelines to provide emergency care of the diagnoses considered. This catalog means to represent all emergency measures which need to be implemented by telemedicine in order to establish remote emergency care according to medical guidelines. Finally, an extended literature research was conducted referring to telemedicine applications in emergency care of trauma patients, stroke and acute coronary syndrome patients. Overall 36 studies were included and analyzed regarding determined criteria of the telemedicine design (including qualification of the tele-physician, qualification of remote assistants, used communication and telemedicine technology as well as medical data transfer). Based on the results of the described steps above the following general requirements of pre-hospital telemedicine emergency care were determined: First it is a precondition to be able to treat a wide range of emergency cases by telemedicine. Especially one should be prepared to provide acute medical care by telemedicine to frequent emergency cases. The generated spectrum of pre-hospital emergency diagnoses can give an idea of what kind of emergency calls one has to be prepared. Telemedicine emergency care must be based upon evidence based medicine. The generated catalog of pre- hospital emergency measures includes all measures of acute care that are recommended by medical guidelines to provide first aid to most frequent emergency causes. It is supposed to represent the demand of measures which need to be implemented by telemedicine. It may be used for further practical tests or clinical trials. Tele-medical expertise needs to be provided by an experienced emergency physician or specialized physician in the specific field of emergency. Remote assistants are necessary to support the tele-physician realizing and conducting the emergency measures on the patient. Videoconference systems based on a broadband internet connection or mobile phone network are needed for telemedicine emergency services. In addition measuring, transferring and continuous monitoring of vital parameters (ECG, NIBP, SaO2, TEMP, BG) as well as a 12-lead-ECG, auscultation findings and radiological data should be possible. Technical reliability and easy application as well as maximum data quality are essential. The results of this paper are supposed to be a basis for practicing and evaluating telemedicine emergency care within further tests and clinical trials. Further clinical trials especially randomized controlled trials are absolutely needed. Only after strict clinical evaluation in terms of evidence based medicine telemedicine may be incorporated into regular health care.

Wprowadzenie: Urazy głowy towarzyszyły człowiekowi od zawsze. Urazy czaszkowo – mózgowe są jednymi z najczęściej spotykanych, często też prowadzić mogą do bezpośredniego zagrożenia życia. Cel pracy: Analiza retrospektywna wyjazdowości Zespołów Ratownictwa Medycznego pod kątem : płci i wiek pacjentów, pory dnia i roku obarczonych największą częstością tego typu urazów, przyczyny urazu , rodzaj zadysponowanego zespołu („S” lub „P”), czasu dotarcia na miejsce zdarzenia oraz dalszego postępowania z pacjentem na miejscu zdarzenia.. Materiał i metoda: Analizie poddano karty wyjazdowe pogotowia ratunkowego zabezpieczającego medycznie powiat otwocki w okresie 1.01-31.12 2009 roku. Spośród 6937 interwencji medycznych jakie wykonano w tym okresie, wyodrębniono grupę 502 chorych, którzy doznali urazu mózgowo-czaszkowego. Grupa ta stała się podstawą dalszej analizy. Wyniki i wnioski: W wyniku przeprowadzonych badań stwierdzono, że urazy mózgowo-czaszkowe dotyczą głównie mężczyzn w wie-ku 50-59 lat oraz w wieku 20-29 lat. Częstość urazów czaszkowo-mózgowych znamiennie statystycznie częściej kumuluje się w miesiącach letnich ( przede wszystkim w sierpniu i czerwcu), najczęściej dotyczy niedziel, poniedziałków i piątków, głównie występując w godzinach popołudniowych ( 17-18 godzina).U prawie co 2-giego chorego zespoły ratownictwa medycznego docierały do 6 minut od momentu wypadku, jednak niemal co 10-ty poszkodowany otrzymał pomoc ratowników dopiero po upływie co najmniej 15 minut od chwili wypadku. U co 10-tego chorego, który doznał urazu czaszko-wo-mózgowego ratownicy napotykali kategoryczną niechęć do korzy-stania z ich pomocy i kontynowania dalszego leczenia w szpitalu. Introduction: Head injuries have been experienced by humans from the time immemorial. Craniocerebral injuries appear to be one of the most frequent head injuries. Moreover, they can often pose a threat to a patient’s life. Objectives: The aim of the study was a retrospective analysis of the emergency medical rescue teams’ attendance at accidents or other medical emergencies. The criteria included: the sex and age of a pa-tient, the time of day and a season when craniocerebral injuries are most frequent, the cause of injury, the type of service provided (Basic Life Support or Advanced Life Support), the time it took to reach the destination and the method of treating the patient at the scene of the accident. Materials and methods: The reports on emergency medical service provided in the Otwock district in 2009 were analysed. 502 patients out of 6937 suffered from craniocerebral injuries. The cases of those 502 provided a basis for further analysis. Results and conclusions: According to the research carried out, men aged between 50 and 59, as well as between 20 and 29 experience craniocerebral injuries most frequently. Summertime (mainly June and August) turned out to be the season of the highest frequency of craniocerebral injuries. The days on which craniocerebral injuries were most common were Sundays, Mondays and Fridays, and the time of day with the highest frequency was late afternoon (5 to 6 p.m.). Almost every other patient was provided with emergency med-ical service within 6 minutes after the accident. However, in every tenth case, it took no less than 15 minutes for the rescue team to ar-rive. What is more, every tenth patient who suffered a craniocerebral injury refused to be treated and transported to hospital.

The issue of the Crush syndrome in pre-hospital care is not a topic into which new findings are often brought by science workers. All the currently known and available knowledge about the Crush syndrome has not changed for decades. In part this is caused by the difficulty in pre-hospital emergency care to determine whether the condition signifies the Crush syndrome or also a hypovolemic shock resulting in kidney damage. In the Czech Republic there are neither big earthquakes, fortunately nor major landslides, and yet from time to time such an event occurs. That is why today it is more and more desirable that paramedics should be theoretically well prepared for such interventions. The purpose of this study was to survey and compare theoretical knowledge of paramedics working at the Emergency Medical Service of the South Bohemian and the Central Bohemian regions, including the ability to utilize this knowledge in practice. In the study quantitative and qualitative research was used. The quantitative part of the research mapped, using anonymous structured questionnaires, the theoretical knowledge of paramedics working at the Emergency Medical Service of the South Bohemian and the Central Bohemian regions in terms of the Crush syndrome issue. The results of the quantitative research have proved very good knowledge of the Crush syndrome issue in both regions and thus the hypothesis has been verified. The qualitative part of the research identified, through structured interviews with three respondents from the Central Bohemian region and three respondents from the South Bohemian region, the practical connection of theoretical knowledge directly in the field in a client with developing Crush syndrome. The knowledge was assessed as sufficient to provide quality pre-hospital emergency care. The results of this study have shown that paramedics in the South Bohemian as well as the Central Bohemian regions are well familiar with the theory for providing high-quality pre-hospital care for clients with developing Crush syndrome.

This bachelor thesis deals with the perception of dying and death by emergency medical personnel. The theoretical part includes not only issues of dying and death, but also the ethics of pre-hospital emergency care. The activities of emergency medical services and some methods of psychological intervention are also described here in detail. The theoretical part is amended by a chapter about stress and the related post-traumatic stress disorder and burnout. The practical part of this thesis is a qualitative research carried out by semi-structured interview with 8 emergency medical workers. The respondents were selected from the South Bohemian, the Central Bohemian and the South Moravian Region; one respondent is employed by emergency medical services abroad (Austria). The research objective was to determine how the medical personnel of emergency services copes with critical situations such as dying and death of a patient, to what extent they are influenced by their profession and to determine the level of readiness of future emergency medical personnel for this occupation. The purpose of this bachelor thesis was to point out the need for psychological intervention for emergency medical services personnel, which is still insufficient in the Czech Republic.

At present, an absolute necessity for health workers is knowledge of the way how to access the bloodstream both in an area of the pre-hospital care and in an area of the health care. The bloodstream is an ideal choice in cases when times plays a major role in the onset of a drug. In my bachelor thesis I focused on issues regarding an assurance of the peripheral bloodstream by a medical rescue worker in the pre-hospital emergency care. I concentrated on the assurance of an intravenous access and at present more and more discussed intraosseous entry. Nowadays, when a lot of medical rescue workers yearn for raising their competences, it is necessary to think if they really know and apply these basic skills while assuring the peripheral bloodstream. An aim of the thesis was to determine if medical rescue workers have an appropriate theoretic preparation and if they know principles of the assurance of the peripheral bloodstream, if they follow these procedures in practice and if there are any differences in the issues of the assurance of the peripheral bloodstream at chosen regional centres of Medical Rescue Service of the South Bohemian Region given by a different driving distance to a hospital facility. A quantitative research was selected as a method applied. An anonymous questionnaire was used as a technique of the data collection. It was distributed to medical rescue workers operating at Medical Rescue Service of the South Bohemian Region. The results of the research showed that medical rescue workers did not have very deep knowledge in case of the intravenous entry but on the contrary they had good knowledge of the intraosseous access. It was also proved that medical rescue workers did not follow prescribed procedures during the intravenous cannulation and not all of them used safety devices. Another result of the research is a fact that medical rescue workers have theoretic knowledge of the intraosseous cannulation but they do not have enough practical experience with it. The last of the most important results of the research was the finding that medical rescue workers in České Budějovice cannulate with a lower frequency than medical rescue workers from other regional centres where there are not so noticeable differences. On the grounds of the data obtained I think that the results of the research included in the bachelor thesis could be used to deepen theoretical knowledge of medical rescue workers in the area of cannulation issues of the peripheral bloodstream.

Drowning, especially in children, is a relatively frequent cause of death. Statistics speak clearly. Children´s drowning is the second most frequent cause of death of children in industrialized countries. Good knowledge of the issue of drowning in children, therefore, seems to be the best way how to at least partially minimize the unfavorable statistics. But it is necessary to be aware of the child drowning specificity due to the child age. And the nursing care specifics are the subject of the thesis. The main objective was to survey the knowledge of prevention and first aid for children in the context or drowning and near-drowning on the part of adult and child public and also in the Emergency Medical Rescue Service workers. The quantitative research method through anonymous questionnaires was chosen. The research sample representing the general public was composed of staff members and pupils and students of several primary and secondary schools in České Budějovice. The research was conducted with the Emergency Medical Rescue Service workers in the regional centers of the Emergency Medical Rescue Service of the South Bohemia region. The questionnaire addressed to the general public contained a set of 25 questions, the questionnaire for the Emergency Medical Rescue Service workers comprised a set of 20 questions. The research has confirmed that the general public knows the first aid basics, but does not have enough knowledge about prevention and first aid for child drowning and near-drowning. The outcomes have mainly proved unfamiliarity with principles of resuscitation for children. The research has also shown that in children in general the knowledge of prevention and first-aid provision for near-drowning or drowning only minimally depends on their age. According to the research results the Emergency Medical Rescue Service workers have adequate knowledge about prevention and first aid for drowning or near-drowning children. The obtained results suggest the need to increase training and education in issues relating to the near-drowning of children in the general public of all ages. In a limited range it would be useful to organize training on issues related to pre-hospital emergency care also for the Emergency Medical Rescue Service workers. The need of the knowledge of prevention and first aid for drowning or near-drowning is confirmed by the fact that even among the public, with which the research was conducted, several persons who had already met this problem were found.

Injuries represent the greatest danger for children and the most frequent cause of their death. A certain dangerous situation precedes every injury and as such it can always be prevented. Emergency rescue teams provide professional urgent pre-hospital care. Based on theoretical knowledge and practical experience of a member of a rescue team providing pre-hospital urgent care, two research objectives were determined. Objective no. 1 was to map out the number of children{\crq}s injuries in the regional centre of České Budějovice between 2004-2008. Objective no. 2 was to analyze the situations in which children of various ages get injured. Three hypotheses were determined. Hypothesis no. 1 ``Children living in towns get injured more frequently than children in villages``, was not confirmed. Hypothesis no. 2 ``Children up to 6 years of age most frequently suffer injuries when they are at home and their parents are not cautious enough``, was confirmed. The last determined hypothesis ``Children between 6 {--} 18 years of age get injured during active sports and traffic accidents most frequently``, was confirmed. It is more efficient to invest in preventative activities that reduce the number and seriousness of injuries in children. If we take measures to prevent injuries, the number of fatalities will go down.

Esse estudo tem, por objetivo, descrever a organização do atendimento pré-hospitalar, prestado pelas equipes de suporte básico do Serviço de Atendimento Móvel de Urgência – SAMU 192 de Porto Alegre, em relação ao fluxo, encaminhamento e recepção nos serviços de saúde, identificando como se articulam as ações entre o médico regulador de urgência e as equipes de suporte básico. Trata-se de um estudo de caso, com abordagem qualitativa. A coleta de dados foi realizada por meio de observação e entrevistas semi-dirigidas. O foco da observação foi sobre o trabalho das equipes de suporte básico do SAMU em relação à comunicação com o médico regulador de urgência, referente à passagem dos casos, às orientações de condutas no atendimento e no encaminhamento, aos serviços de saúde, dos pacientes atendidos por essas equipes. Os entrevistados foram os profissionais, que compõem as equipes de suporte básico (auxiliares e técnicos de enfermagem e condutores de veículos de urgência), e médicos da central de regulação de urgência. Os dados obtidos foram classificados em estruturas de relevância e, posteriormente, agrupados em dois núcleos: a articulação do trabalho entre a regulação médica e as equipes de suporte básico do SAMU e o trabalho das equipes para além do APH móvel. No primeiro núcleo, aborda-se como a regulação se comunica com as equipes na passagem dos casos às quais estes são enviadas para atendimento, assim como em relação às orientações dadas às equipes na cena dos eventos e aos contatos com os serviços de urgência que recebem os pacientes encaminhados pelo SAMU. Constatou-se que as informações, dadas pelo médico regulador, carecem de detalhamento sobre as condições dos pacientes que serão atendidos pelas equipes de suporte básico, fazendo com que as equipes trabalhem com pouca preparação prévia ao evento. A recepção, nas portas de urgência, evidencia as dificuldades encontradas pela superlotação dos serviços. Nesse cenário, as equipes de suporte básico usam de suas relações interpessoais para garantir a acolhida dos pacientes. No segundo núcleo, abordam-se a articulação do trabalho em equipe e o desempenho dos profissionais do suporte básico em tratar situações que, a priori, fogem da classificação de risco iminente à vida. Os dados analisados revelam a importância do trabalho das equipes de suporte básico do SAMU, constituindo-se num dos pilares do serviço. Evidenciam, também, a estreita relação com a regulação médica, numa combinação de ações para o cuidado dos usuários que demandam o SAMU. Conclui-se pela necessidade de aprofundar as discussões sobre os processos de trabalho, tanto na relação interna do serviço quanto nas relações interinstitucionais com os serviços de saúde da cidade, na perspectiva de desenvolver um trabalho em rede, articulado e solidário. This study aims at describing the organization of the pre-hospital care delivered by the basic support crew of the Emergency Mobile Care Service (Serviço de Atendimento Móvel de Urgência – SAMU - 192) of Porto Alegre, in relation to the flow, delivery and reception within the healthcare services, by identifying how actions between the emergency coordinator physician and the basic support crews are articulated. This is a case study with qualitative approach. Data collection was performed by means of observation and semi-oriented interviews. The focus of observation was the work of the basic support crews of SAMU regarding communication with the emergency coordinator physician, concerning information about addressing the cases, guidelines about attendance management, and patient delivery to the health services rendered by these crews. Interviews were carried out with the professionals that compose the basic support crews (nursing assistants and technicians and drivers of emergency vehicles) and the coordinator physicians from the urgency regulation center. The obtained data were classified into structures of relevance and, afterwards, grouped in two nuclei: the articulation of the work between coordinator physicians and basic support crews of SAMU and, the work of the crews beyond the mobile Pre-Hospital Care (PHC). The first nucleus approaches communication ways between the medical regulation and the basic crews which the cases are addressed to as well as regarding the guidelines given to the crews in the site of events besides the contacts with the emergency services received by the patients delivered by SAMU. It was found out that the information given by the medical regulation lacks details about the condition of the patients that will be cared by the basic support crews resulting that the crews work without enough previous preparation when attending an event. The reception, at the emergency services, evidences the difficulties met due to overcrowded facilities. Within this scenario, the basic support crews use their interpersonal relations to guarantee the patient reception. The second nucleus approaches the articulation of crew work and the performance of the basic support professionals in managing situations that, a priori, are not classified as an eminent life threat. The analyzed data reveal the importance of the work by SAMU basic support crews who constitute one of the pillars of the service. They also evidence a close relation with the medical regulation in a combination of actions towards the care rendered to the users that call for SAMU. The conclusion drawn appoints to the need of further discussions about the work processes concerning to internal relations of the service and inter-institutional relations with other healthcare services from the city, in the perspective of developing an articulated and humanized healthcare network. Ese estudio tiene el objetivo de describir la organización del atendimiento pre-hospitalario prestado por los equipos de soporte básico del Servicio de Atendimiento Móvil de Urgencia – SAMU 192 de Porto Alegre, en relación al flujo, encaminamiento y recepción en los servicios de salud, identificando como se articulan las acciones entre el médico regulador de urgencia y los equipos de soporte básico. Se trata de un estudio de caso, con abordaje cualitativo. La recolección de datos fue realizada por medio de observación y entrevistas semi-dirigidas. El foco de la observación fue acerca del trabajo de los equipos de soporte básico del SAMU en relación a la comunicación con el médico regulador de urgencia, referente al pasaje de los casos, a las orientaciones de conductas en el atendimiento y en el encaminamiento a los servicios de salud de los pacientes atendidos por eses equipos. Los entrevistados fueron los profesionales, que componen los equipos de soporte básico (auxiliares y técnicos de enfermería y conductores de vehículos de urgencia), y los médicos de la central de regulación de urgencia. Los datos obtenidos fueron clasificados en estructuras de relevancia y, luego, agrupados en dos núcleos: la articulación del trabajo entre la regulación médica y los equipos de soporte básico del SAMU y el trabajo de los equipos más allá del APH – Atendimiento Pre-Hospitalario móvil. El primer núcleo aborda las formas de comunicación entre la regulación y los equipos en el pasaje de casos que les son encaminados para atendimiento así como en relación a las orientaciones dadas a los equipos en el sitio de los eventos además de los contactos con los servicios de emergencia que reciben los pacientes encaminados por el SAMU. Se constató que las informaciones dadas por el médico regulador carecen de detalles acerca de las condiciones de los pacientes, que serán atendidos por los equipos de soporte básico, de manera que los equipos trabajan con poca preparación previa al evento. La recepción, en las puertas de emergencia, evidencia las dificultades encontradas por la superpoblación de los servicios. En tal escenario, los equipos de soporte básico usan de sus relaciones interpersonales para garantizar la acojida de los pacientes. El segundo núcleo aborda la articulación del trabajo en equipo y el desempeño de los profesionales de soporte básico al tratar situaciones que, a priori, huyen de la clasificación de riesgo inminente a la vida. Los datos analizados revelan la importancia del trabajo de los equipos de soporte básico del SAMU, uno de los pilares del servicio. Evidencian, además, la estrecha relación con la regulación médica en una combinación de acciones para la atención a los usuarios que demandan el SAMU. Se concluye por la necesidad de profundizar las discusiones acerca de los procesos de trabajo tanto en la relación interna del servicio cuanto en las relaciones interinstitucionales con los servicios de salud de la ciudad, en la perspectiva de desarrollar un trabajo en red, articulado y solidario.

Trata o presente de uma reflexão acerca do surgimento do Atendimento Pré-Hospitalar no Brasil e os respectivos modelos assistenciais, nas últimas décadas. Ao traçarmos a trajetória histórica apontamos os caminhos e os descaminhos desta modalidade de assistência à saúde, em nosso país. São analisadas as tentativas mais recentes de normatização em nível nacional desse serviço, especialmente a Portaria do Ministério da Saúde nº 2048/02, a qual se constitui num ponto de partida, oferecendo subsídios para as instituições e àqueles envolvidos neste campo específico de conhecimento em saúde, a fim de refazer o caminho numa outra perspectiva. The present paper is about a reflection related to the emerging of Pre-Hospital Care in Brazil ant its respective models of care during the last few decades. By drawing out a basic historical trajectory we were able to point out the successful and dead end paths of this modality of health assistance in our country. The most recent attempts of standardization at a national level of this kind of service were analyzed, especially the Health Ministry Decree no. 2048/02, which constitutes itself as a starting point, offering subsidies to institutions and to those involved in this specific field of health knowledge, in order to remake the path within another perspective. Trata el presente de una reflexión acerca del surgimiento de la Atención prehospitalar en Brasil y los respectivos modelos asistenciales, en las últimas décadas. Al trazar la trayectoria histórica apuntamos los caminos y los descaminos de esta modalidad de asistencia a la salud en nuestro país. Se analizan los intentos más recientes de normatización en nivel nacional, especialmente, el Decreto del Ministerio de la Salud no. 2048/02, como punto de partida, ofreciendo subsidios para las instituciones y todos los involucrados en este campo de conocimiento en salud, con la finalidad de reconstituir el camino en una otra perspectiva.

ResumenSe describe la organización general de la atención urgente extrahospitalaria en las comunidades autónomas y se recogen datos de actividad correspondientes a 2010, a partir de la información disponible en el Sistema de Información de Atención Primaria del Ministerio de Sanidad, Política Social e Igualdad. La atención urgente se presta a través de dispositivos diversos que cubren las 24 horas. Medicina de familia atendió 17,8 millones de consultas urgentes y enfermería 10,2 millones (año 2010, 14 comunidades autónomas, 79,7% de la población del Sistema Nacional de Salud). La frecuentación a urgencias oscila entre 0,11 y 0,83 consultas urgentes por habitante y año a medicina de familia, y entre 0,05 y 0,57 consultas por habitante y año a enfermería. Toda reforma en la gestión de las urgencias prehospitalarias comporta cambios organizativos y pretende mejoras valorables en la coordinación asistencial. Respecto a los nuevos diseños organizativos, el mayor peso específico recae en la parcela de recursos humanos para poder conseguir los nuevos objetivos de futuro que se planteen en una estructura de trabajo en equipo en su significado más operativo. No cabe duda de que el reto principal que se plantea es una óptima coordinación con otros niveles asistenciales, sin olvidar otros colectivos de servicios al ciudadano, como cuerpos policiales, servicios sociales, residencias geriátricas, etc. Si la mejor atención al usuario tiene que centrar todos estos esfuerzos, su contrapartida, con su movilidad, variabilidad individual, nivel de exigencia y, sobre todo, según su uso de los servicios disponibles, es la que determinará el resultado final. La cuantificación de los logros puede medirse de diversas maneras, pero principalmente como los recursos empleados, el grado de satisfacción de todos los actores implicados y la óptima gestión de la demanda que contribuya a difundir la necesidad de un uso racional de los servicios sanitarios.AbstractThe present article describes the general organization of pre-hospital emergency care in the autonomous regions and provides data on activity corresponding to 2010, drawn from the information available in the Primary Care Information System of the Ministry of Health, Social Policy and Equality. Emergency care is provided through various organizational structures covering 24-hour periods. Family medicine attended 17.8 million emergency consultations and nursing attended 10.2 million (year 2010, 14 autonomous communities, 79.7% of the National Health System population). Emergency department utilization ranged between 0.11 and 0.83 urgent family physician consultations per inhabitant/year and between 0.05 and 0.57 nursing consultations per inhabitant/year. Any reform in the management of pre-hospital emergency care will involve organizational changes and aims to produce measurable improvements in healthcare coordination. In the new organizational designs, most of the responsibility lies with human resources in order to achieve the new goals for the future aims to be presented in an operational teamwork structure. Undoubtedly, the main challenge is to achieve optimal coordination with other welfare levels, including the police, social services, nursing homes, etc. If optimal care of the population needs to count on the efforts of all these groups, mobility, individual differences, consistent achievement of high standards, and –most of all– the use of these services by citizens will determine the final result. The results can be quantified in various ways, but evaluation should concentrate on the resources used, the degree of satisfaction among all the parties involved and optimal management of demand, which will help to disseminate the need for a rational resource use.

BACKGROUND: Pre-hospital emergency care requires proper categorization of emergency calls and assessment of emergency priority levels by the medical dispatchers. We investigated predictors for emergency call categorization as "unclear problem" in contrast to "symptom-specific" categories and the effect of categorization on mortality.METHODS: Register-based study in a 2-year period based on emergency call data from the emergency medical dispatch center in Copenhagen combined with nationwide register data. Logistic regression analysis (N = 78,040 individuals) was used for identification of predictors of emergency call categorization as "unclear problem". Poisson regression analysis (N = 97,293 calls) was used for examining the effect of categorization as "unclear problem" on mortality.RESULTS: "Unclear problem" was the registered category in 18% of calls. Significant predictors for "unclear problem" categorization were: age (odds ratio (OR) 1.34 for age group 76+ versus 18-30 years), ethnicity (OR 1.27 for non-Danish vs. Danish), day of week (OR 0.92 for weekend vs. weekday), and time of day (OR 0.79 for night vs. day). Emergency call categorization had no effect on mortality for emergency priority level A calls, incidence rate ratio (IRR) 0.99 (95% confidence interval (CI) 0.90-1.09). For emergency priority level B calls, an association was observed, IRR 1.26 (95% CI 1.18-1.36).DISCUSSIONS: The results shed light on the complexity of emergency call handling, but also implicate a need for further improvement. Educational interventions at the dispatch centers may improve the call handling, but also the underlying supportive tools are modifiable. The higher mortality rate for patients with emergency priority level B calls with "unclear problem categorization" could imply lowering the threshold for dispatching a high level ambulance response when the call is considered unclear. On the other hand a "benefit of the doubt" approach could hinder the adequate response to other patients in need for an ambulance as there is an increasing demand and limited resources for ambulance services.CONCLUSIONS: Age, ethnicity, day of week and time of day were significant predictors of emergency call categorization as "unclear problem". "Unclear problem" categorization was not associated with mortality for emergency priority level A calls, but a higher mortality was observed for emergency priority level B calls.