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array:23 [ "pii" => "S113086212030471X" "issn" => "11308621" "doi" => "10.1016/j.enfcli.2020.07.021" "estado" => "S300" "fechaPublicacion" => "2020-12-01" "aid" => "1677" "copyright" => "Elsevier España, S.L.U.. All rights reserved" "copyrightAnyo" => "2020" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Enferm Clin. 2020;30 Supl 7:102-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S1130862120304721" "issn" => "11308621" "doi" => "10.1016/j.enfcli.2020.07.022" "estado" => "S300" "fechaPublicacion" => "2020-12-01" "aid" => "1678" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Enferm Clin. 2020;30 Supl 7:106-10" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "titulo" => "Determinants of a sedentary lifestyle among school-aged children based on a family ecological model" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "106" "paginaFinal" => "110" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Eka Mishbahatul Marah Has, Herlyn Afifah Nurwitanti, Sylvia Dwi Wahyuni, Elida Ulfiana" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Eka Mishbahatul Marah" "apellidos" => "Has" ] 1 => array:2 [ "nombre" => "Herlyn Afifah" "apellidos" => "Nurwitanti" ] 2 => array:2 [ "nombre" => "Sylvia Dwi" "apellidos" => "Wahyuni" ] 3 => array:2 [ "nombre" => "Elida" "apellidos" => "Ulfiana" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130862120304721?idApp=UINPBA00004N" "url" => "/11308621/00000030000000S7/v1_202012250829/S1130862120304721/v1_202012250829/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S1130862120304708" "issn" => "11308621" "doi" => "10.1016/j.enfcli.2020.07.020" "estado" => "S300" "fechaPublicacion" => "2020-12-01" "aid" => "1676" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Enferm Clin. 2020;30 Supl 7:96-101" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "titulo" => "Antenatal depression and its associated factors among pregnant women in Jakarta, Indonesia" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "96" "paginaFinal" => "101" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => " Misrawati, Yati Afiyanti" "autores" => array:2 [ 0 => array:1 [ "apellidos" => "Misrawati" ] 1 => array:2 [ "nombre" => "Yati" "apellidos" => "Afiyanti" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130862120304708?idApp=UINPBA00004N" "url" => "/11308621/00000030000000S7/v1_202012250829/S1130862120304708/v1_202012250829/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "titulo" => "Autonomy of patients in emergency services in the border area: A phenomenology study" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "102" "paginaFinal" => "105" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Dewy Haryanti Parman, Hendy Lesmana, Maria Imaculata Ose, Ramdya Akbar Tukan" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Dewy Haryanti" "apellidos" => "Parman" "email" => array:1 [ 0 => "dewyanmarsya79@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Hendy" "apellidos" => "Lesmana" ] 2 => array:2 [ "nombre" => "Maria Imaculata" "apellidos" => "Ose" ] 3 => array:2 [ "nombre" => "Ramdya Akbar" "apellidos" => "Tukan" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Nursing, Faculty of Health, University of Borneo Tarakan, Indonesia" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The increasing number of emergency patient visits is a challenge for the health system in many developing countries. Cases of traumatic injury and bleeding and acute symptoms of coroner syndrome become a common condition that is treated by emergency doctors. Management of complex emergencies must be explained and handled well and remains with time management.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a> Critical considerations and appropriate treatment can prevent disability and death. An overview of emergency service is a short time service with large guidance in fast and efficient care.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Early emergency management includes early resuscitation, referral systems, and transfer of patients to more capable health units. Indicators of emergency service quality are waiting time, preventable death, time to take vital treatment, and time to emergency operation. The chance of survival rate for referral patients being directed and closer to health facilities is greater than those with distant facilities.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> However, in Indonesia, the referral system, the quality available at the place of reference, and transportation facilities and infrastructure at the emergency services have not been optimally available.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Health service problems in remote areas with no health service access are caused by factors like limited human resources and geographical conditions such as coastal areas and mountains. Some approaches used to overcome these problems are to improve coordination between primary care and emergency care.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> The first treatment and referral process is a series of processes that are always faced by health workers.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Sebatik is one of the border areas and islands in Indonesia which is adjacent to Malaysia. This area has several primary health care centers that provide primary care in health. However, due to the absence of hospitals on this island, to access and get further care must be referred outside the island. Some cases of emergencies can only be treated to the fulfilment of basic needs so that complete diagnostic and complete examination needs to be referred. Comprehensive health services in this area face challenges. This is the complexity of the problem experienced by the patients of the island. Residents of this border area have to access health services in primary health care centers both in conditions and cases of emergency and non-emergency. Therefore, this study aimed to reveal the situation and experience of patients in this border area in obtaining emergency treatment.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study explored the experience of patients who were treated with emergency cases and were referred to hospitals outside of Sebatik island. It was designed with a qualitative method and a descriptive phenomenology approach was used. It involved 10 participants who were taken using purposive sampling techniques with the following criteria: being Sebatik residents, had emergency case experience and referred to outside Sebatik island, and being willing to become participants. Before data collection was conducted the researcher explained the Inform Consent. After obtaining further approval, a contract for data collection was performed. Data was collected through interviews with semi-structured questions for 30–60<span class="elsevierStyleHsp" style=""></span>min and field notes were performed. Data collection took place from August to October 2018. Data were analyzed using a thematic analysis of Braun and Clarke (2006). This study obtained ethical conduct from the Poltekes of the Ministry of Health in Padang.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Participants’ criteria</span><p id="par0030" class="elsevierStylePara elsevierViewall">Participants were residents who lived on Sebatik Island that aged between 25 and 50 years. Their educational background was between high school and graduate. They had different professions, three participants were as employees, four as housewives, one as a student, and two did not work. Cases experienced by participants included moderate head injury, bleeding, chest pain, femoral fracture, and stroke. All participants were treated in the emergency room, six were referred to the hospital in Nunukan, two in Tarakan of North Kalimantan, and another two in Tawau of Malaysia. From the experiences of the participants in getting emergency treatment in the border area of North Kalimantan, this study found three themes namely emergency management that did not meet the standards, patients chose to use the right to be referred, and patients received assistance in dealing with obstacles to the place of referral.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Theme 1: Handling of emergencies that did not meet the standards</span><p id="par0035" class="elsevierStylePara elsevierViewall">The condition felt by the participants when experiencing an emergency was the handling of emergencies that did not meet the standards. This theme was built from the initial treatment in primary health care, the limitations of health workers and the facilities, and no progress in treatment felt by the patients.<span class="elsevierStyleDisplayedQuote" id="dsq0005"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">“After entering the emergency room I was handled by a nurse, then the nurse called the doctor because he was not there … (p1)</p></span><span class="elsevierStyleDisplayedQuote" id="dsq0010"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">“… nurses only put intravenous doses, and I was given medicine, after that, I was moved in the treatment room … and there were no other examinations … after some days there was no progress in the treatment … there should be a complete examination because there was no heart examination here …” (p2)</p></span><span class="elsevierStyleDisplayedQuote" id="dsq0015"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">“I was only given pain medication, and in primary health care there were no ultrasound devices … so there was no further examination … so the pain could recur again” (p4)</p></span><span class="elsevierStyleDisplayedQuote" id="dsq0020"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">“We can’t be taken anywhere if conditions are bad … well, it must be under primary health care … there is no hospital …” (p5)</p></span></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Theme 2: Patients chose to use the right to be referred</span><p id="par0040" class="elsevierStylePara elsevierViewall">This theme was built from the sub-themes that emerged: patients’ conditions and illness that needed further treatment, patients wanted better facilities, and patients doubted the ability of the health workers. This was expressed by the following participants:</p><p id="par0045" class="elsevierStylePara elsevierViewall">“My husband and son decided I should be referred at that time … because my left hand and foot were weak … the nurse said this was a symptom of a stroke … so I had to be referred to Tarakan hospital … that is a good hospital” (p2)</p><p id="par0050" class="elsevierStylePara elsevierViewall">“It can’t just be here … I was asked to be referred to as Tawau … there is a large, good and complete hospital there, so a more complete examination could be performed” (p7)</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Theme 3: Assistance in dealing with obstacles to the place of reference</span><p id="par0055" class="elsevierStylePara elsevierViewall">This theme was built from several issues in a reference such as comfort when accompanied and difficulties in access and transportation. To get the best health services to the place of reference, patients had to face obstacles caused by geographical conditions and difficulties of access and transportation. This was revealed by the following participants:</p><p id="par0060" class="elsevierStylePara elsevierViewall">“When I was taken to the hospital … at that time the sea waves were high … finally, it was delayed due to fear … could not cross …” (p3)</p><p id="par0065" class="elsevierStylePara elsevierViewall">“During the trip to the hospital, we were accompanied by a nurse. My infusion was always checked. The nurse always took care of me. I felt safer.” (p4)</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Emergency handling is not optimal</span><p id="par0070" class="elsevierStylePara elsevierViewall">Emergency management in primary health care centers should be the first aid treatment for emergency patients to reduce disability and pain before they were referred to. Every emergency unit should have a doctor on duty who was always ready for 24<span class="elsevierStyleHsp" style=""></span>h. Health workers in emergency services should be based on qualifications and have good competence and skills. In an emergency, patients who have an airway, respiratory, circulation, and disability disorders must get complex treatment or surgery. This condition must be considered and treated in the ICU. Some of the approaches taken by Australia, Denmark, Britain, France, Germany, and the Netherlands to improve the emergency care system are expanding the availability of basic care, focusing on providing primary care, increasing coordination between primary care and emergency care and focusing on providing focused emergency care when planning this nationally.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> The limited number of health workers will have an impact on the services provided to patients. This can cause dissatisfaction with the patient. Also, it will cause physical and psychological fatigue for nurses. Psychological pressure often occurs in officers in the emergency department.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">6–8</span></a> The impact of fatigue and pressure on work can reduce the attitude, attention, and empathy in patients. Lack of attention and sympathy can cause poor communication.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Patients’ choice of using the right to be referred</span><p id="par0075" class="elsevierStylePara elsevierViewall">Participants in the study realized that they had the right to choose better and more adequate facilities. The choice decided by the participants was due to the limited facilities and hospital facilities in the area. Every individual has basic human rights including autonomy, benefits, justice, non-maleficence, validity, loyalty, confidentiality, patient-centered accountability, and prioritizing patient needs.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> The principle of autonomy is based on the belief that individuals can think logically and decide. Adults are considered competent and have the power to make their own decisions, choices, and have a variety of decisions or choices that are valued. The principle of autonomy is a form of respect for someone, also seen as an agreement not to impose and act irrationally.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Autonomy is the right to independence and freedom of individuals who demand self-differentiation. Professional practice reflects autonomy when nurses respect the rights of patients in making decisions about their care. Autonomy has been described as a major part of participation because it is related to the ability of individuals to make decisions for themselves and to decide on their care.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Autonomy shows that patients with high expectations can adopt a positive attitude towards adjusting to changes in the patient's condition. Patient participation and involvement are strategies to achieve patient-centered care.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> Decision making for patient Autonomy involves the family, as well as other health workers who consider this to have an impact on the good condition of the patient.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> Respect for patient autonomy is a basic principle of health care ethics that is expected to be applied as long as the patient makes decisions.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Assistance in dealing with obstacles to the reference site</span><p id="par0090" class="elsevierStylePara elsevierViewall">Difficulties and challenges in getting access to emergency services in border areas and islands are mostly related to transportation. Ground transportation in primary health services includes primary health care ambulances, village ambulances, and community vehicles, and sea transportation such as boats and ships. Limited facilities and limited medical personnel are reasons for patients to request hospital referrals. The readiness of primary health care in this border area was not yet fully maximized. This was seen from the limited resources of both personnel and tools. Transportation in the reference site was available at any time but was not well organized for emergency referral cases. The transportation factor becomes an obstacle in the referral process in emergency cases, apparently a lack of ambulances.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> Communication with the referred hospitals is very important to facilitate access to the patients. This can reduce patient waiting time. Current reference communication models that can control the referral system have been developed through online-based media, for example, to see the maximum and a minimum number of beds available.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The role of the nurse was very important in accompanying the patient. This was conveyed by participants who felt there was calm and reduced anxiety during the referral trip. Also, the role of the nurse helps patients to engage in healthy behaviors that enhance and maintain healthy habits to prevent disease and reduce mortality and morbidity.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> The role of nurses is to establish good communication and provide attention and value to patients which can have an impact on the psychological calmness of the patients.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The emergency services in the border area did not meet the standards because of the limited health personnel and health service facilities. Patients chose to use the right to be referred to as an attempt to get better health services. Some problems in referral included the administrative process, accompanying health workers, and access and transportation in the referral. The role of the nurse was felt to be very important in accompanying the patient and establishing good communication and giving attention and values to the patient which can have an impact on the psychological calmness of the patient.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Suggestion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The government and stakeholders need to be involved to improve health services, especially emergency cases. Emergency management systems need to be improved by increasing the number of officers and increasing competence in treating patients as well as improvements in referrals managed by the government.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1441016" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1315160" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 4 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Participants’ criteria" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Theme 1: Handling of emergencies that did not meet the standards" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Theme 2: Patients chose to use the right to be referred" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Theme 3: Assistance in dealing with obstacles to the place of reference" ] ] ] 5 => array:3 [ "identificador" => "sec0040" "titulo" => "Discussion" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Emergency handling is not optimal" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Patients’ choice of using the right to be referred" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Assistance in dealing with obstacles to the reference site" ] ] ] 6 => array:2 [ "identificador" => "sec0060" "titulo" => "Conclusion" ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Suggestion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-12" "fechaAceptado" => "2020-07-15" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1315160" "palabras" => array:4 [ 0 => "Border area" 1 => "Emergency" 2 => "Patients" 3 => "Referral" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The absence of hospitals is one of the problems that arise in health services in remote areas. To get further medical care, patients must be referred outside the island. The purpose of this study was to reveal the situation and experience of patients in emergency treatment in border and coastal areas in North Kalimantan. This study was designed with a qualitative method and a descriptive phenomenological approach was used. It involved 10 participants who lived on Sebatik island with the criteria of having experience with emergency cases and being referred out of the island. Data analysis was performed using a thematic analysis of Braun and Clarke (2006). Three themes emerged from this study: inappropriate emergency actions, patients’ choice of using the right to be referred, and assistance in challenging referrals. It was revealed that emergency management was not maximal due to the limitations of health workers and service facilities. Patients chose the right to be referred to as an effort to get better health services.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Peer-review under responsibility of the scientific committee of the International Nursing Research Conference of Udayana University. Full-text and the content of it is under responsibility of authors of the article.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trauma-informed care for violently injured patients in the emergency department" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.R. Fischer" 1 => "K.M. Bakes" 2 => "T.J. Corbin" 3 => "J.A. Fein" 4 => "E.J. Harris" 5 => "T.L. James" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0196-0644(87)80467-5" "Revista" => array:3 [ "tituloSerie" => "Ann Emerg Med" "fecha" => "2019" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3662156" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0090" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "More than medical treatment: the patient's first encounter with prehospital emergency care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Elmqvist" 1 => "B. Fridlund" 2 => "M. 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