Your monthly clinical update from James Oswald (Clinical Practice Guideline Specialist) and A/Prof Ben Meadley (Director of Paramedicine):

Clinical Update

• Warm IV fluid (13:38): Stop warming IV fluids in overhead compartments or with hot water bottles. Risks scalding/superheating. Store in equipment towers only.
• Paediatric distraction (03:26): kits available now. Evidence-based, non-digital active tools work best. Order via iProc. Document use in VACIS.
• Paediatric NIV (9:20): pathways with RCH/Monash/PIPER. Use patient device if feasible; alternatives include Flow-Safe and Zoll Z-Vent. More guidance coming.

Patient safety

• Low acuity, high risk (12:32): Some high-risk patients sit in apparently low acuity cases. Advocate, self-upgrade when risk warrants. Lodge cases in RiskMan.
• Standing height falls (14:49): Standing-height falls in older adults: great feedback from the field, we discuss common themes.

Paper of the Month (19:26): measurable “hyperacute T-wave” definition predicts OMI even without STEMI criteria.

Equipment (21:40): new neonatal BVMs; syringe-holder prototypes to separate RSI meds.

CPD (24:21): short courses and LinkedIn Learning suggestions.

Further resources

• https://journals.sagepub.com/doi/full/10.1177/27536386251371078
• https://shortcourses.rmit.edu.au/collections/all
• https://mbs.edu/short-courses
• https://www.monash.edu/business/corporate-education/short-courses
• Linkedin.com/learning/

Get in touch

James: https://linktr.ee/ClinicalConversations

Ben: X/Twitter⁠ | Linkedin

clinicalguidelines@ambulance.vic.gov.au 

This month James and David look at cardiogenic shock: recognition and classification, oxygen targets, fluid resuscitation, vasopressors, inotropes, and the possibility of shock centres in the future. They're joined by Professor Dion Stub, an interventional cardiologist, prolific researcher, professor at Monash University, member of the Australian Resuscitation Council, and medical advisor to Ambulance Victoria.

Further resources

Avoid trial: https://www.ahajournals.org/doi/10.1161/circulationaha.114.014494

DETO2XAMI:  https://www.nejm.org/doi/full/10.1056/NEJMoa1706222#:~:text=The%20Determination%20of%20the%20Role,not%20have%20hypoxemia%20at%20baseline.

 EXACT pilot trial: Concerns regarding the safety of prehospital titrated oxygen in post-cardiac arrest patients  https://pubmed.ncbi.nlm.nih.gov/29684433/

PANDA Trial (AV Staff) https://ambulancevic.sharepoint.com/sites/OneAVQualityandClinicalInnovation/SitePages/PANDA-TRIAL-(.aspx

Get in touch

⁠clinicalguidelines@ambulance.vic.gov.au⁠

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David: ⁠@expensivecare⁠ | @expensivecare.bsky.social | LinkedIn

James: https://linktr.ee/ClinicalConversations

Your monthly clinical update covering:

• Cardiac arrest outcomes
• An update on the sedation safety guideline
• Lessons learned from the patient safety team: appropriate use of the CT-6 traction splint and having a high index of suspicion for spinal and head injuries in older adults followingstanding height falls
• BVM blow off valve reminder
• Paper of the month: Prehospital antibiotics in sepsis
• Miller blade use for ALS paramedics

Resources

ACP Critical Care Summit

Get in touch

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James: ⁠⁠⁠@JamesOz1⁠⁠ | @jamesoz1.bsky.social

Ben: ⁠@ben_meadley⁠

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Ben

In this episode of Clinical Conversations, hosts James Oswald (paramedic and clinical guidelines specialist) and Dr. David Anderson (Medical Director of Ambulance Victoria) dive into one of the most ethically and clinically complex areas of pre-hospital care—the questions of safety for during sedation for acute behavioural disturbance (ABD). They explore the ethical and legal considerations surrounding the use of sedation, the significant clinical risks, and real-world cases that highlight the gravity of these situations.

The episode features a discussion on the tragic case of Elijah McClain, whose death following pre-hospital sedation underscores the importance of safe practices, inter-agency communication, and decision-making in high-stress environments.

James and David also break down Ambulance Victoria’s current approach to sedation, including agent selection, risk assessment, and the importance of de-escalation. They stress the role of checklists, consultation, and a "prevention-first" approach to mitigate risks.

This is the first of a two-part discussion. In the next episode, they will cover preparation for sedation and how to recognize and respond to deterioration.

Further resources

 APIC Session: https://paramedics.org/recordings/acpic24-spotlight-on-sedation

 Clinical Conversations – AcuteBehavioural Disturbance https://open.spotify.com/episode/2ahoO2WWHc27zOLocqoQR8?si=u4Sr_RjeQj-_lzPUWkUelQ

 Safer Care Victoria ABD guideline: https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/emergency/acute-behavioural-disturbance

Get in touch

⁠clinicalguidelines@ambulance.vic.gov.au⁠

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David: ⁠@expensivecare⁠ | @expensivecare.bsky.social

James: ⁠⁠⁠@JamesOz1⁠⁠ | @jamesoz1.bsky.social

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James

David

James and Ben cover the latest clinical news from across Ambulance Victoria, including:

• Intranasal Fentanyl Update – Using IV preparation for intranasal use.
• Other guidelines updates: Extrication monitoring, shoulder reduction, wilderness pain relief.
• Blood Administration – New pre-hospital blood transfusion training coming.
• Rocuronium Storage – Heat-related potency issues; rotate every 30 days.
• Communication Book – New tool for patients with communication disabilities.
• MICA targeted Dispatch – 8-week trial, enter any patient safety concerns in Riskman or ROAM app
• Paper of the Month – ALS paramedics safely managing post-thrombolysis STEMI.
• Equipment Update – Check serial numbers when reporting medical device issues.
• Professional Development – Advanced mechanical ventilation workshop available.

Chapters

00:00 Introduction and Overview of ClinicalUpdates

01:21 Rapid summary

02:50 Updates on Intranasal Fentanyl

5:40 Other CPG updates: Extrication monitoring, shoulder reduction, wilderness pain relief.

07:50 Blood Product Administration andSafety

10:00 Rocuronium storage and efficacy concerns

11:18  Emergency Healthcare Communication Book

12:11 Medical Advisor on Call and PatientSafety

12:50 MICA targeted Dispatch and PatientSafety Reporting

14:12 Extrication related adverse events

15:30 Case reports

16:01 Paper of the Month: STEMI CareInsights

17:30 Equipment updates

18:31 External Professional DevelopmentOpportunities

19:25 Small Steps to Transform YourPractice

Further resources

Adverse events and paramedic interventionsduring extended ground transport in a rural pharmaco-invasive STEMI program https://onlinelibrary.wiley.com/doi/full/10.1111/1742-6723.70005?saml_referrer=

Ventilator workshop: https://www.alfredicu.org.au/files/general/Documents/2025_EVENT_FLYER_CURRENT.pdf

Medication stability in hot environments: https://www.sciencedirect.com/science/article/pii/S2211419X23000630

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Ben

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In this episode of Clinical Conversations, James Oswald (Paramedic and Clinical Practice Guidelines Specialist) and Dr. David Anderson (Ambulance Victoria Medical Director) tackle one of the most challenging aspects of paramedicine—delivering bad news. Joined by guest Liz Perry (MICA Paramedic), they explore the difficulties paramedics face when communicating death and critical updates to families in the pre-hospital setting.

We talk personal experiences, theoretical models like SPIKES, and practical strategies to navigate these conversations with confidence, clarity, and compassion. They also discuss the impact of breaking bad news on paramedics themselves and strategies to prevent burnout.

Get in touch

⁠clinicalguidelines@ambulance.vic.gov.au⁠

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David: ⁠@expensivecare⁠

James: ⁠@JamesOz1

James Oswald and Director of Paramedicine Dr Ben Meadley discuss the important clinical messages for January 2025:

• patient safety during sedation and the importance of planning for resuscitation;
• the exploration of low acuity pathways; and
• they review a significant research paper on physician-led teams in pre-hospital care.

The episode also covers equipment updates, professional development opportunities, and practical steps for paramedics to enhance their practice.

Time stamps:

0:45 Rapid summary

02:20 Patient Safety Update: If you sedate, plan to resuscitate.

06:13 Exploring Low Acuity Pathways

10:40 Strategic Planning for 2025

11:27 Case Reports and Community Engagement

12:21 Research Update: Physician-Led Teams – do they improve outcomes?

16:59 Equipment Update and Safety Protocols

19:22 Professional Development Opportunities

21:04 Small Steps to Transform Your Practice

Resources

Benefits of targeted deployment of physician-led interprofessional pre-hospital teams on the care of critically Ill and injured patients: a systematic review and meta-analysis

Get in touch

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James: ⁠⁠⁠@JamesOz1⁠⁠

Ben: ⁠@ben_meadley⁠

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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 3, we look at challenges in building a system that leads to good pain relief as well as some special circumstances including opioid dependence and chronic 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

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David: ⁠⁠⁠@expensivecare⁠⁠⁠

James: ⁠⁠⁠@JamesOz1⁠

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⁠David⁠

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A monthly summary of clinical information from the Ambulance Victoria Office of the Medical Director.

Overview

1. Clinical Practice Updates

•CPG App Update Details:

oSecondary triage review

oChanges to pediatric analgesia guidelines

oStacked shock CWI updates

oMinor error corrections

•Pediatric Cannulation:

oALS IV access is supported for:

Major trauma and traumatic arrest (all ages), and

Pain relief (12-15 years).

oAvoid IV access in younger patients unless necessary; consider IN route for pain relief in children.

•Joint Reduction Adverse Event:

oImportant that we share the outcomes of adverse events openly but without blame.

oRecent adverse event involved shoulder reduction that was not indicated.

oOur main focus is on the system issues: we’re looking at making the indications clearer.

oIn the meantime, we’d like to raising awareness of the indication for reduction at the start of the CPG

•Amiodarone & Ondansetron:

oVT following Ondansetron administration only contraindicated if the drug is suspected to be the cause.

___________________________

2. Patient Safety Review

•Scene Safety vs. Patient Care:

oBoth paramedic and patient safety are important. No easy answers.

oWe encourage reflection on the best way to optimize the balance of risks rather than to be overly simplistic.

•Manual Handling of Bariatric Patients:

oRisks and benefits of asking patients with high BMI to move themselves to minimize manual handling injuries.

oImportance of recognizing strained physiology and the need for careful risk assessment in every case.

•Ambulation Risk Assessment:

oShout out to this guideline, which highlights risk factors in patient extrication.

___________________________

3. Research Update

•Video Assisted Technology:

oStudy on EMS providers in New York using smart glasses for live-streaming cases to medical control.

oLimited adoption so far, but promising developments for future use in 2025. Stay tuned for more in this space at AV.

•Intraosseous Access:

oNew 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:

oStudy shows a three-fold increase in survival to hospital discharge from 2003-2022 in Victoria.

oPost-COVID recovery efforts and ongoing strategies for improving cardiac arrest survival rates.

oPlease 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:

oCourses, memberships, and qualifications focusing on clinical governance, leadership, and patient safety.

•Australasian College of Paramedicine:

oUpcoming Critical Care Summit in May 2

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 3Intraosseous 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/

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

Your monthly clinical update covering:

Mandatory VVED Consults for Infants <28 Days – trends, rationale for policy, clarifications, and case example demonstrating impact.

Stroke updates - performing ACT-FAST on all MASS positive patients, changes to VACIS and a plug for IV access.

Complex Paediatric Respiratory Patients – Managing patients on home non-invasive ventilation, maintaining continuity of care, and upcoming resources.

Trauma Updates –

• Blood component therapy expansion and compliance requirements.
• STAB-5 mnemonic and minimising scene time in major trauma.
• PANDA trial enrolment reminder.

Standing-Height Falls in Elderly – Missed spinal injury cases, cultural pendulum shift, guideline review, and call for feedback.

Manual Handling & Patient Safety in ED Cohorting – Safe movement of high-risk patients and preventing deterioration during cohorting.

Paper of the Month – Danish machine learning study outperforming NEWS2 for predicting deterioration from first-five-minute vitals, with explainable AI.

Equipment Committee Updates – New traction splints, medication safety devices via 3D printing, thermal blanket effectiveness, and syringe driver software updates.

Professional Development & Resources – Coroner’s Communiques, ACP International Conference, new paramedic podcasts.

Small Steps to Transform Practice –

1. Treat elderly standing-height falls as potential spinal injuries.
2. Minimise scene time for major trauma unless safety or critical intervention requires it.

Further resources

ACP Conference

Thermal blanket study

Machine learning study

STAB-5

Coroner's communique 

Get in touch

clinicalguidelines@ambulance.vic.gov.au

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James: ⁠⁠⁠@JamesOz1⁠⁠ | @jamesoz1.bsky.social

Ben: ⁠@ben_meadley⁠

Linkedin

James

Ben

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 ofParamedicine Critical Care Summit April 2025

EuropeanEMS Congress Copenhagen June 2025

Safe airwaysociety

Get in touch

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James: ⁠⁠⁠@JamesOz1⁠⁠

Ben: ⁠@ben_meadley⁠

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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

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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

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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

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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

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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/

In this special Q&A episode of Clinical Conversations, James Oswald and Dr. David Anderson respond to the most common — and most complex — questions we've received on sedation, CPG implementation, and the evolving role of paramedics. We also reflect on why clinical guidelines are becoming more detailed, how to balance complexity with emergency care, and what the future holds for paramedics. 

Get in touch

⁠clinicalguidelines@ambulance.vic.gov.au⁠

Socials

David: ⁠@expensivecare⁠ | @expensivecare.bsky.social| LinkedIn

James: https://linktr.ee/ClinicalConversations | LinkedIn

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.

Your monthly update on clinical issues including:

Clinical Practice

Care and Control Powers (02:38 – 07:10)

Overview of section 232 and 241 powers.

Documentation: VACIS + RiskMan entries are essential.

More info: See Mental Health Crisis Reform on OneAV.

Verification of Death (07:10 – 08:48)

Verifying death is voluntary for paramedics.

Review WinOps 025 for current processes.

AV is working with VicPol to improve processes.

Encourage local discussion with TM/CSO about your approach.

Resus Ready Campaign (08:48 –10:34)

Aims to boost preparedness for cardiac arrest.

Includes: equipment checks, airway readiness, skills rehearsal.

Backed by patient safety reviews and cardiac arrest strategy.

Goal: Ensure every paramedic is ready regardless of experience/frequency.

Case 1: Pediatric respiratory case attended with only adult equipment.

Reflect on the potential trajectory of cases with reference to the balance of between taking all equipment vs minimising manual handling risk

Case 2: Chest rise/fall insufficient alone to assess ventilation.

Use waveform capnography early and consistently.

Case 3: CO₂ of 6mmHg was the only clue of incorrect tube placement in intubated asthma patient.

Always consider full clinical picture and question if data doesn’t make sense.

Paper of the month (14:46 – 20:55)

Parental Concern in Pediatric Deterioration

Asking "Are you worried your child is getting worse?" adds predictive value.

Parents who said “yes” had children:

• 4x more likely to go to ICU/be ventilated.
• More likely to be admitted or have longer stays.

Concern was a stronger predictor than abnormal vital signs.

Recommendation: Make carer concern an active, routine part of pediatric assessment.

Equipment Update (20:55 – 22:55)

New absorbent transfer sheet ("large bluey") improves:

• Patient hygiene and comfort.
• Paramedic safety.

Part of AV's broader equipment strategy under new Clinical Technology & Equipment Committee.

Professional Development: Postgraduate Study (22:55 – 24:59)

Encouragement for paramedics to pursue study outside paramedicine:

• Public health, digital health, systems leadership, etc.

Builds capability to:

• Lead teams, influence policy, improve care.
• Resource guide in show notes; feedback encouraged.

Small Steps to Transform Practice (24:59 – 26:42)

Ben’s tip: Don’t rely on chest rise alone—use capnography toassess ventilation.

James’s tip: Proactively ask parents if they’re worried their child is deteriorating.

Resources

Association between caregiver concern for clinicaldeterioration and critical illness in children presenting to hospital: a prospective cohort study https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(25)00098-7/abstract

Clinical Technology andEquipment Committee

https://ambulancevic.sharepoint.com/sites/OneAV-resource-hub/_layouts/15/viewer.aspx?sourcedoc={1633f009-99d3-4d08-9805-d5fb409fec3b}

In this episode of Clinical Conversations, we explore the complexities of managing acute behavioural disturbance (ABD) in children and adolescents—a small but increasingly common and high-risk cohort. Host James Oswald and AV Medical Director Dr. David Anderson are joined by paediatric emergency physician Dr. Claire Wilkin, who brings deep expertise in paediatric critical care. Together, they discuss the causes of ABD in younger patients, differences from adult presentations, principles of de-escalation, the role of sedation, and how to assess and manage risk.

Get in touch

⁠clinicalguidelines@ambulance.vic.gov.au⁠

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David: ⁠@expensivecare⁠ | @expensivecare.bsky.social

James: ⁠⁠⁠@JamesOz1⁠⁠ |

Linkedin

James

David

Your monthly clinical update covering:Clinical Practice

03:10 – Respiratory CPG Update: Pulmonary edema, COVID, ILI, paediatric asthma changes coming soon.

04:00 – First Responder Analgesia: Supply challenges beingaddressed; updates coming.

 05:10 – Button Batteries: New blue dye marker—importantvisual sign but not universally present.

06:00 – Mushroom Season Warning: Watch for toxidromes; VPIC support emphasized.

06:40 – VVED changes: Easier access to emergency physicians.

Patient Safety 08:30

Case: Declined transport with adverse outcome.

Consent must be truly informed—document clearly, especially under cognitive load or red flags.

Guideline monitoring 11:15

Sedation Safety Update: Improved safety with guidelinechanges.

Case Reports & Engagement 13:10

Case reports welcome—CPG team happy to assist.

Paper of the month 13:40

Comparison of demand valve vs. standard BVM. No differencein oxygenation delivery in healthy volunteers. Nasal prongs speed time to oxygenation saturation. Continue using both tools in RSI prep.

New ACS Guidelines Summary (ft. Andrew Bishop) (18:30)

ACOMI terminology replaces STEMI/Non-STEMI binary. Key ECG findings added. Serial ECGs every 10 mins; prehospital thrombolysis within 30mins.

Equipment 23:50

Asset Numbers: Include in Riskman reports to aid faultresolution.

Professional Development 24:30

AICG Highlight: Leadership training relevant across paramedicine—CPD eligible and recommended.

Small Steps to Transform Practice 26:30

Get in touch

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James: ⁠⁠⁠@JamesOz1⁠⁠ | @jamesoz1.bsky.social

Ben: ⁠@ben_meadley⁠

Linkedin

James

Ben

James Oswald and Dr David Anderson explore how consultation has evolved from a perceived weakness to a hallmark of clinical maturity. They discuss the growing role of virtual emergency care, particularly the Victorian Virtual Emergency Department (VVED), in supporting paramedics with decision-making—especially when assessing young infants. Joined by pediatric emergency specialist Dr Harith Al-Rawi, the episode dives into the challenges of remote pediatric assessment, the value of collaboration between paramedics and virtual care clinicians, and the structured information required during remote consultation to safely support care at home. The conversation highlights that newborns are a uniquely high-risk group, and outlines why VVED consultation is now a must for infants aged 28 days or younger.

Get in touch

⁠clinicalguidelines@ambulance.vic.gov.au⁠

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David: ⁠@expensivecare⁠ | @expensivecare.bsky.social

James: ⁠⁠⁠@JamesOz1⁠⁠

Linkedin

James

David

Producer: Liam Hennebry

Your monthly clinical update covering:

VVED Consultations for small infants

• New requirement: VVEDconsultation for non-transport of infants ≤28 days
• Strong recommendation for 29days–3 months
• Driven by patient safety reviewand expert consensus
• Not about removing autonomy —it’s about adding clinical support

RSI Checklist Update

• Addition of a pop-off valve checkfollowing a critical safety event
• Prevents misdiagnosis of failedventilation
• Reinforces value of checklists,even for experienced clinicians

Advanced Paramedic PracticeProposal

• Public consultation open
• Framework for advanced practiceregistration in primary care and critical care
• Facilitates further advancementssuch as prescribing rights and scope self-determination
• Big implications for AVparamedics — see link in show notes to respond

STEMI Transfer Pilot

• ALS paramedics trialing regionalSTEMI transfers
• Target: stable patientspost-thrombolysis
• Reflects data showing most STEMIpatients are low risk

Patient Safety Focus

• Standing height falls in theelderly: don’t underestimate risk
• Rhythm misinterpretation:shockable rhythms missed or misidentified
• No link between junior staff anderror rates — we all share responsibility, we are all vulnerable

Guideline Monitoring:Palliative Care CPG

• 9.9% increase in patients dyingat home — great outcome
• No major change in meds given —possibly due to barriers in the current CPG
• Evidence supports simplifying CPG

Case Reports on Viva Engage

• Recent cases: paediatricrespiratory failure, polypharmacy overdose, snake bite
• Submit your own case via the Vivatemplate

Paper of the Month: PACKMaNTrial

• RCT comparing ketamine vsmorphine for trauma pain
• Found no difference ineffectiveness
• Points to multimodal analgesia asa next step in research, which is already AV’s approach

Equipment

• Check Pop-off Valve position atstart of shift
• “Resus Ready” campaign comingsoon
• Cardiac Monitor ReplacementProgram- New device coming
• Discussion underway: do we needto carry everything all the time?

Professional DevelopmentOpportunities

• Critical Care Summit – May 15–16,Essendon
• Grand Rounds (CPG + RMH collab) –May 27, Sunshine Hub or virtual
• Trauma Grand Rounds – June 18 atRoyal Children’s or online

Small steps to transform youpractice

• Deliberate practice = highperformance, visualisation and mental rehearsal make a difference
• Practice rhythm recognition
• Rehearse SITREPs

Resources
Paramedic analgesia comparing ketamine and morphine in trauma (PACKMaN): a randomised,double-blind, phase 3 trial

Palliative paramedicine: An interrupted time series analysis of pre-hospital guideline efficacy

Proposal to regulate advanced practice paramedics

Rhythm recognition

Get in touch

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In Part 2 of their sedation safety conversation, hosts James Oswald (paramedic and clinical guidelines specialist) and Dr. David Anderson (Medical Director of Ambulance Victoria) cover preparation for sedation and how to recognize and respond to deterioration.
They break the problem into three evidence‑backed pillars:

1. Prevent deterioration (have a listen to Part 1)
2. Prepare for side‑effects – if you plan to sedate, you must plan to resuscitate
3. Recognise & Respond when things go wrong

Further resources

APIC Session: https://paramedics.org/recordings/acpic24-spotlight-on-sedation

Clinical Conversations – Acute Behavioural Disturbance https://open.spotify.com/episode/2ahoO2WWHc27zOLocqoQR8?si=u4Sr_RjeQj-_lzPUWkUelQ

Safer Care Victoria ABD guideline: https://www.safercare.vic.gov.au/best-practice-improvement/clinical-guidance/emergency/acute-behavioural-disturbance

Get in touch

⁠clinicalguidelines@ambulance.vic.gov.au⁠

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David: ⁠@expensivecare⁠ | @expensivecare.bsky.social

James: ⁠⁠⁠@JamesOz1⁠⁠ |@jamesoz1.bsky.social

Linkedin

James

David