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 ⁠⁠[email protected]⁠⁠   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 [email protected].   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 ⁠[email protected]⁠   X / Twitter David: ⁠@expensivecare⁠ James: ⁠@JamesOz1