Clinical Conversations

A monthly summary of clinical information from the Ambulance Victoria Office of the Medical Director. Overview 1. Clinical Practice Updates • CPG App Update Details: o Secondary triage review o Changes to pediatric analgesia guidelines o Stacked shock CWI updates o Minor error corrections • Pediatric Cannulation: o ALS IV access is supported for: Major trauma and traumatic arrest (all ages), and Pain relief (12-15 years). o Avoid IV access in younger patients unless necessary; consider IN route for pain relief in children. • Joint Reduction Adverse Event: o Important that we share the outcomes of adverse events openly but without blame. o Recent adverse event involved shoulder reduction that was not indicated. o Our main focus is on the system issues: we’re looking at making the indications clearer. o In the meantime, we’d like to raising awareness of the indication for reduction at the start of the CPG • Amiodarone & Ondansetron: o VT following Ondansetron administration only contraindicated if the drug is suspected to be the cause. ___________________________ 2. Patient Safety Review • Scene Safety vs. Patient Care: o Both paramedic and patient safety are important. No easy answers. o We encourage reflection on the best way to optimize the balance of risks rather than to be overly simplistic. • Manual Handling of Bariatric Patients: o Risks and benefits of asking patients with high BMI to move themselves to minimize manual handling injuries. o Importance of recognizing strained physiology and the need for careful risk assessment in every case. • Ambulation Risk Assessment: o Shout out to this guideline, which highlights risk factors in patient extrication. ___________________________ 3. Research Update • Video Assisted Technology: o Study on EMS providers in New York using smart glasses for live-streaming cases to medical control. o Limited adoption so far, but promising developments for future use in 2025. Stay tuned for more in this space at AV. • Intraosseous Access: o New research indicates IO access has minimal long-term complications (e.g., osteomyelitis, osteonecrosis) and should remain a viable option when IV access isn't possible. • Cardiac Arrest Survival Rates: o Study shows a three-fold increase in survival to hospital discharge from 2003-2022 in Victoria. o Post-COVID recovery efforts and ongoing strategies for improving cardiac arrest survival rates. o Please consider attending a HPCPR refresher session if possible. ___________________________ 4. Equipment Updates • Ketone Strips: New bags for separating ketone strips from glucose strips in response to feedback. ___________________________ 5. Professional Development Opportunities • Institute for Healthcare Improvement & Australian Institute of Clinical Governance: o Courses, memberships, and qualifications focusing on clinical governance, leadership, and patient safety. • Australasian College of Paramedicine: o Upcoming Critical Care Summit in May 2024, focusing on clinical excellence. • Critical Care Reviews Conference: o Dissecting randomized control trials in medicine and pre-hospital care. o Also a great opportunity to learn how feedback can be delivered and received positively. ___________________________ Resources A Smart Glass Telemedicine Application for Prehospital Communication: User-Centered Design StudyAn assessment of long-term complications following prehospital intraosseous access: A nationwide study Out-of-hospital cardiac arrests in Victoria, 2003–2022: retrospective analysis of Victorian Ambulance Cardiac Arrest Registry data ⁠Cardiac arrest improvement strategy   External development opportunities Australasian Institute of Clinical Governance IHI Open School ACP Critical Care Summit   Get in touch X / Twitter James: ⁠⁠⁠⁠@JamesOz1⁠⁠⁠ Ben: ⁠⁠@ben_meadley⁠⁠ Linkedin ⁠James⁠ ⁠Ben Bluesky Social James: @jamesoz1.bsky.social

Pain is one of the most common reasons people seek help from paramedics and other healthcare professionals. Do we take it seriously? Could we be doing better? James sits down with paramedicine luminary and pain researcher A/Prof Bill Lord for a three-part series on pain. In Episode 2, we look at best practice in the management of pain. Further resources ⁠Acute Pain Management: Scientific Evidence: 5th Edition⁠   ⁠Ketamine for the treatment of prehospital acute pain: a systematic review of benefit and harm⁠ ⁠Pain relief that matters to patients: systematic review of empirical studies assessing the minimum clinically important difference in acute pain⁠   ⁠Ambulance call triage outcomes for patients reporting pain: a retrospective cross-sectional analysis of pain score versus triage level⁠   ⁠Chronic pain in the paramedic practice setting – a qualitative study of patients’ perspective⁠   ⁠Influence of patient race on administration of analgesia by student paramedics⁠    ⁠Report on Government Services 2024⁠    Get in touch ⁠⁠clinicalguidelines@ambulance.vic.gov.au⁠⁠   X / Twitter David: ⁠⁠@expensivecare⁠⁠ James: ⁠⁠@JamesOz1 Linkedin ⁠James David Bluesky Social James: @jamesoz1.bsky.social

A monthly summary of clinical information from the Ambulance Victoria Office of the Medical Director. Quick summary (0:30) Patient Safety (1:30) Discussing the lessons from specific adverse events is challenging due to patient privacy/consent, crew psychological safety, and investigation timelines. We need to find a way to collectively share these lessons in a safe way. Plans for quarterly clinical forums (2025) to foster psychologically safe discussions. Clinical Updates (4:52) IV Cannulation for STEMI:Avoid sites near the radial artery to support PCI access. Extrication Monitoring: Monitoring is sometimes removed during extrication, especially self-extrication. Associated with adverse events. We need to emphasise monitoring (especially ECG/pulse oximetry) during extrication. Ectopic Pregnancy: Patient safety Assume ectopic pregnancy for women of childbearing age with abdominal pain and shock. Cardiac Arrest: Always prioritize high-performance CPR over antiarrhythmics. Clarification on stacked shocks and their intended use. CWI out soon.   ALS paramedics encouraged to consult for post-ROSC hypotension management. Guideline Monitoring (12:36) Success of expanded croup guidelines: increased dexamethasone use and reduced hospital transports. Research Updates (14:20) PANDA Trial: Comparing noradrenaline and adrenaline in cardiogenic shock. IV vs IO Access: Preference for IV first in cardiac arrest; IO as backup. ROSC Blood Pressure: Minimum diastolic pressure of 35mmHg linked to better outcomes. Equipment Notices (19:20) Normal saline shortages persist; substitute with Hartmann’s or PlasmaLite. New ketone strips now available—use carefully. Professional Development (20:11) CPD resources from the Australasian College of Paramedicine and Victorian Ambulance Union. Links to registration standards and CPD tools in the show notes. Resources PARAMEDIC 3 Intraosseous or Intravenous Vascular Access for Out-of-Hospital Cardiac Arrest Prehospital endotracheal intubation for traumatic out-of-hospital cardiac arrest and improved neurological outcomes PANDA trial - If you want to learn more about the study or have any questions, search for PANDA on the AV intranet or contact the team at PANDA@ambulance.vic.gov.au.   Pain research with Monash - Get involved: Paramedic confidence & barriers to paediatric pain management   External development opportunities https://www.paramedicineboard.gov.au/professional-standards/faq/faq-cpd.aspx https://paramedics.org/education https://paraed.vau.org.au/events   Get in touch X / Twitter James: ⁠⁠⁠@JamesOz1⁠⁠ Ben: ⁠@ben_meadley⁠ Linkedin James Ben

Pain is one of the most common reasons people seek help from paramedics and other healthcare professionals. Do we take it seriously? Could we be doing better? James sits down with paramedicine luminary and pain researcher A/Prof Bill Lord for a three-part series on pain. In Episode 1, we look at assessment, bias, and disparities in pain care. In the coming months, we’ll bring you the rest of our discussion covering best practice pain relief, system issues, myths about opioids, and special circumstances in pain care. Further resources Acute Pain Management: Scientific Evidence: 5th Edition   Ketamine for the treatment of prehospital acute pain: a systematic review of benefit and harm Pain relief that matters to patients: systematic review of empirical studies assessing the minimum clinically important difference in acute pain   Ambulance call triage outcomes for patients reporting pain: a retrospective cross-sectional analysis of pain score versus triage level   Chronic pain in the paramedic practice setting – a qualitative study of patients’ perspective   Influence of patient race on administration of analgesia by student paramedics    Report on Government Services 2024    Get in touch ⁠clinicalguidelines@ambulance.vic.gov.au⁠   X / Twitter David: ⁠@expensivecare⁠ James: ⁠@JamesOz1

This is the first in a new series of monthly clinical updates for Ambulance Victoria clinical staff. Director of Paramedicine A/Prof Ben Meadley and Clinical Guideline Specialist James Oswald summarise the need-to-know clinical information, all in one spot. This month: New CPG updates, trends in our patient safety data, and new cardiac monitors.   Times stamps: 2:00 New CPG updates 4:40 Snakebite 6:30 Acute coronary syndrome and activating the cath lab 7:35 Patient safety trends 10:20  Dislocation reduction – how are we doing? 12:10 Ketone strips 13:50 Case report templates 15:05 Thunderstorm asthma 15:25 IV Fluid shortage 15:50 PANDA trial update 16:40 New cardiac monitors 17:25 Professional development opportunities   Resources Australasian College of Paramedicine Critical Care Summit April 2025 European EMS Congress Copenhagen June 2025 Safe airway society Get in touch X / Twitter James: ⁠⁠⁠@JamesOz1⁠⁠ Ben: ⁠@ben_meadley⁠ Linkedin James Ben

In this episode, James speaks with critical care paramedic, academic, and newly appointed Director of Paramedicine, Associate Professor Ben Meadley. We discuss strategic clinical leadership and the future of the profession.  X / Twitter David: ⁠⁠⁠@expensivecare⁠⁠⁠ James: ⁠⁠⁠@JamesOz1⁠⁠ Ben: ⁠@ben_meadley⁠

Part 2 of David's discussion with Associate Professor Andrew Udy on Sepsis Management. Get in touch ⁠clinicalguidelines@ambulance.vic.gov.au⁠   X / Twitter David: ⁠@expensivecare⁠ James: ⁠@JamesOz1 Resources mentioned [PHANTASI trial] Alam N, Oskam E, Stassen PM, Exter Pv, van de Ven PM, Haak HR, et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet Respiratory Medicine. 2018;6(1):40-50. Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006;34(6):1589-96. Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med. 2017;376(23):2235-44. ARISE Invetigators. Goal-Directed Resuscitation for Patients with Early Septic Shock. New England Journal of Medicine. 2014;371(16):1496-506. PRISM Investigators. Early, Goal-Directed Therapy for Septic Shock — A Patient-Level Meta-Analysis. New England Journal of Medicine. 2017;376(23):2223-34. Australian Commission on Safety and Quality in Health Care. Sepsis Clinical Care Standard 2022 [Available from: https://www.safetyandquality.gov.au/standards/clinical-care-standards/sepsis-clinical-care-standard#:~:text=The%20Sepsis%20Clinical%20Care%20Standard,Commission%20on%2030%20June%202022. Shapiro NI, Douglas IS, Brower RG, Brown SM, Exline MC, Ginde AA, et al. Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension. N Engl J Med. 2023;388(6):499-510. Other resources Poynter MJ, Farrugia A, Kelly E, Simpson PM. Prehospital administration of antibiotics in addition to usual care versus usual care alone for patients with suspected sepsis – a systematic review. Paramedicine. 2024;21(2):52-65. Varney J, Motawea KR, Kandil OA, Hashim HT, Murry K, Shah J, et al. Prehospital administration of broad-spectrum antibiotics for sepsis patients: A systematic review and meta-analysis. Health Sci Rep. 2022;5(3):e582.

Sepsis is arguably the most common time critical emergency we face as paramedics. This is the first of a two part series on sepsis with Professor Andrew Udy. Andrew is Head of Research at The Alfred ICU, and Deputy Director, Australian and New Zealand Intensive Care Research Centre. He was involved in the development of the recently released Ambulance Victoria Sepsis and Infection guideline. In this episode, Ambulance Victoria Medical Director A/Prof David Anderson and Andrew discuss the assessment and diagnosis of sepsis. Get in touch ⁠⁠clinicalguidelines@ambulance.vic.gov.au⁠⁠   X / Twitter David: ⁠⁠@expensivecare⁠⁠ James: ⁠⁠@JamesOz1⁠ Further resources NICE. Sepsis: recognition, diagnosis and early management 2017. Available from: https://www.nice.org.uk/guidance/ng51. Royal Children's Hospital. Sepsis – assessment and management 2020. Available from: https://www.rch.org.au/clinicalguide/guideline_index/SEPSIS_assessment_and_management/. Inada-Kim M. NEWS2 and improving outcomes from sepsis. Clin Med (Lond). 2022;22(6):514-7. Lisa S, Shammi R, Steve G. Comparison of qSOFA and Hospital Early Warning Scores for prognosis in suspected sepsis in emergency department patients: a systematic review. Emergency Medicine Journal. 2022;39(4):284. Mellhammar L, Linder A, Tverring J, Christensson B, Boyd JH, Sendi P, et al. NEWS2 is Superior to qSOFA in Detecting Sepsis with Organ Dysfunction in the Emergency Department. J Clin Med. 2019;8(8). Oduncu AF, Kıyan GS, Yalçınlı S. Comparison of qSOFA, SIRS, and NEWS scoring systems for diagnosis, mortality, and morbidity of sepsis in emergency department. Am J Emerg Med. 2021;48:54-9. Patel R, Nugawela MD, Edwards HB, Richards A, Le Roux H, Pullyblank A, et al. Can early warning scores identify deteriorating patients in pre-hospital settings? A systematic review. Resuscitation. 2018;132:101-11. Steve G, Laura S, Ben T, Olivia H, Khurram I, Susan C, et al. Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study. Emergency Medicine Journal. 2023;40(11):768. Verity Frances T, Melanie M, Graham H, Andy S, Aroha B, Tony S, et al. Predictive value of the New Zealand Early Warning Score for early mortality in low-acuity patients discharged at scene by paramedics: an observational study. BMJ Open. 2022;12(7):e058462. Wang C, Xu R, Zeng Y, Zhao Y, Hu X. A comparison of qSOFA, SIRS and NEWS in predicting the accuracy of mortality in patients with suspected sepsis: A meta-analysis. PLoS ONE. 2022;17:e0266755.

In Australia, penetrating truncal trauma is rare and the care of these patients involves a quite different mindset than we're used to. This is a cohort where our stay-and-play approach can do harm. James and David discuss the evidence relating to penetrating trauma and practical recommendations for your practice. Further resources Over view of major traumatic injury in Australia–Implications for trauma system design The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment Association of Police Transport With Survival Among Patients With Penetrating Trauma in Philadelphia, Pennsylvania - PubMed (nih.gov)  The effect of transport mode on mortality following isolated penetrating torso Trauma - PubMed Every minute counts: The impact of pre-hospital response time and scene time on mortality of penetrating trauma patients Get in touch clinicalguidelines@ambulance.vic.gov.au X / Twitter David: @expensivecare James: @JamesOz1

Clinical practice varies between the different state ambulance services in Australia. Yet we all claim to be evidence-based. So why is this, how big of a problem is it and what should we do about it? Are national guidelines the answer? James speaks with paramedic and PhD candidate Matt Wilkinson-Stokes to find out, while David shares his perspective on national guidelines. Further resources Matt's presentation on the differences between state ambulance service guidelines Comparisons of clinical guidelines between states Other papers mentioned: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2243-y Get in touch clinicalguidelines@ambulance.vic.gov.au X / Twitter David: @expensivecare James: @JamesOz1

For over a decade after a large study showed a mortality benefit, this drug remained controversial. David and James look at the TXA saga.

Clinical conversations is back. But where have we been, what have we been doing and what do we have planned for the future?

We’re all familiar with the concept of STEMI. But the definition is built around a single ECG sign – not the underlying problem itself. Is that the best way to do it? Should we be thinking about this in a totally different way? Is Occlusive Myocardial Infarction (OMI) the new STEMI? Notes OMI Manifesto Amal Mattu on YouTube Subtle STEMI iOS app The Ancient Scholar

Capnography plays a crucial role in the treatment of a range of life-threatening conditions. Its central role following intubation is undeniable and it's also an important part of our approach to cardiac arrest and sedated patients of all kinds. Yet it is not always as straightforward as it might seem. In this episode, David and James speak with Matt Humar (intensive care paramedic, acting patient safety review lead at Ambulance Victoria, and secretary of the safe airway society) about matters capnographic.  Further reading https://derangedphysiology.com/main/cicm-primary-exam/required-reading/respiratory-system/Chapter%20414/difference-between-end-tidal-and-arterial-pco2 https://www.capnography.com/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231274/

Shock is the quintessential critical illness. Bread and butter for everyone involved in prehospital and critical care. But do we really understand it? Could we be doing better for these patients? James is joined by Assoc. Prof. David Anderson, intensivist and Ambulance Victoria Medical Director, for a... shocking discussion. 

People experiencing acute behavioral disturbance are some of the most vulnerable patients we treat. It’s a deeply distressing situation for the patient and extremely confronting for clinicians and carers. In this episode, we speak with psychiatrist Dr Alison Taylor about important changes we're making to improve care for these patients.

Family violence is a deeply confronting and serious problem that occurs across all ages, genders, and socioeconomic groups. It has a profound impact on the health and well-being millions of people across the globe. How can we identify family violence? How should we respond to a disclosure of family violence? How can we help victim survivors? Ambulance Victoria Safe Guarding Care Lead Amber Smith joins James and David to discuss this important issue. MARAM Family violence practice guide

The decision to withhold or cease resuscitation is one of the most impactful and also one of the more confronting decisions that paramedics make in the field. AV Medical Director Associate Professor David Anderson discuss Dr Natalie Anderson, PhD discuss the decision making process and how to better approach these difficult cases.    MyGriefToolbox - Great Canadian resource for all paramedics, with helpful modules covering decision-making, patient death and grief. Breaking bad news in the ED - Notifying family members of a death in the emergency department.

Ambulance Victoria recently introduced intranasal ketamine for the treatment of moderate and severe pain. It has proven to be effective but we have identified opportunities to do better. Clinical Practice Development Specialist James Oswald and Medical Director David Anderson discuss the new Clinical Practice Guideline and some of the lessons we've learned along the way.