Clinical Conversations – Details, episodes & analysis

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

Socials

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

X / Twitter / Bluesky

James: ⁠⁠⁠@JamesOz1⁠⁠ | @jamesoz1.bsky.social

Ben: ⁠@ben_meadley⁠

Linkedin

James

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

X / Twitter / Blusky

David: ⁠@expensivecare⁠ | @expensivecare.bsky.social

James: ⁠⁠⁠@JamesOz1⁠⁠ | @jamesoz1.bsky.social

Linkedin

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

Get in touch

X / Twitter

James: ⁠⁠⁠@JamesOz1⁠⁠

Ben: ⁠@ben_meadley⁠

Linkedin

James

Ben

Bluesky Social

James: ⁠⁠@jamesoz1.bsky.social

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

X / Twitter

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

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 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

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.

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