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

[email protected] 

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

⁠[email protected]⁠

Socials

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

James: https://linktr.ee/ClinicalConversations

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

[email protected]

X / Twitter / Bluesky

James: ⁠⁠⁠@JamesOz1⁠⁠ | @jamesoz1.bsky.social

Ben: ⁠@ben_meadley⁠

Linkedin

James

Ben

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

⁠[email protected]⁠

Socials

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

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

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

⁠[email protected]⁠

X / Twitter / Blusky

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

X / Twitter / Bluesky

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

⁠[email protected]⁠

X / Twitter / Blusky

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

X /

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

⁠[email protected]⁠

X / Twitter / Blusky

David: ⁠@expensivecare⁠ | @expensivecare.bsky.social

James: ⁠⁠⁠@JamesOz1⁠⁠ |@jamesoz1.bsky.social

Linkedin

James

David