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Objective: Out‐of‐hospital seizures demand rapid management. Midazolam plays a key role in stopping seizures. At times the first dose of midazolam proves insufficient, necessitating additional doses. Within the New South Wales Ambulance (NSWA) service, the upper limit for midazolam administration is set at 15 mg. However, the outcomes and safety of using midazolam at this maximum dosage have not been thoroughly investigated. Methods: A retrospective analysis of out of hospital electronic health records from New South Wales, Australia, over the year 2022, was conducted. The study manually reviewed cases where adult patients received the maximum dose of midazolam for seizure management by paramedics. It focused on seizure cessation success rates and the incidence of adverse effects to evaluate the clinical implications of high‐dose midazolam administration. Results: Of 818 790 individual attendances by NSWA clinicians, a total of 11 392 (1.4%) adults had seizures noted, of which midazolam was administered in 2565 (22.5%). An algorithm shows that in 2352 (91.7%) instances the midazolam was associated with the apparent termination of seizures. Analysis revealed that 176 (1.5%) proportion of all adult's seizure patients required the maximum dose of midazolam for seizure control. These higher doses successfully terminate seizures in about half of the instances. AEs following the maximum dose of midazolam included hypoxia in 26.7% of patients and respiratory depression in 9.7%, indicating significant side effects at higher dosages. Conclusion: In New South Wales, Australia, administering the maximum dose of midazolam to seizure patients is rare but proves effective in approximately half of the refractory seizure cases. Therefore, assessing the potential for additional doses of midazolam or the use of a second‐line agent is advisable. [ABSTRACT FROM AUTHOR]

Objective: Emergency medical services (EMS) use of naloxone in the prehospital setting is indicated in patients who have significantly impaired breathing or level of consciousness when opioid intoxication is suspected. The present study characterised naloxone use in a nationwide sample of Aotearoa New Zealand road EMS patients to establish a baseline for surveillance of any changes in the future. Methods: A retrospective analysis of rates of patients with naloxone administrations was conducted using Hato Hone St John (2017–2021) and Wellington Free Ambulance (2018–2021) electronic patient report form datasets. Patient demographics, presenting complaints, naloxone dosing, and initial and last vital sign clinical observations were described. Results: There were 2018 patients with an equal proportion of males and females, and patient median age was 47 years. There were between 8.0 (in 2018) and 9.0 (in 2020) naloxone administrations per 100 000 population‐years, or approximately one administration per day for the whole country of 5 million people. Poisoning by unknown agent(s) was the most common presenting complaint (61%). The median dose of naloxone per patient was 0.4 mg; 85% was administered intravenously. The median observed change in Glasgow Coma Scale score was +1, and respiratory rate increased by +2 breaths/min. Conclusions: A national rate of EMS naloxone patients was established; measured clinical effects of naloxone were modest, suggesting many patients had reasons other than opioid toxicity contributing to their symptoms. Naloxone administration rates provide indirect surveillance information about suspected harmful opioid exposures but need to be interpreted with care. [ABSTRACT FROM AUTHOR]

Objectives: Video laryngoscopy (VL) is increasingly used as an alternative to direct laryngoscopy (DL) to improve airway visualisation and endotracheal intubation (ETI) success. Intensive Care Paramedics in New South Wales Ambulance, Australia started using VL in 2020, and recorded success in a new advanced airway registry. We used this registry to compare VL to DL. Methods: The present study was a retrospective analysis of out‐of‐hospital data for ETI by specialist paramedics using an airway registry. We calculated overall and first‐pass success for VL versus DL, and compared success using a Χ2 test. Results: The DL overall success was 61 out of 78 (78.2%) and VL was 233 out of 246 (94.7%); difference of 16.5% (P < 0.001). First‐pass for DL was successful for 49 out of 78 (62.8%) and for VL in 195 out of 246 (79.3%); difference of 16.5% (P = 0.003). There were five (1.6%) patients where both VL and DL were used and in all instances, DL was used first. Conclusions: This analysis of a new airway registry used by specialist paramedics in New South Wales shows a substantial increase in overall and first‐pass intubation success with the use of VL when compared to DL. [ABSTRACT FROM AUTHOR]

Femur shaft and neck of femur (NOF) fractures are often undertreated in the prehospital setting. These injuries can present unique clinical and logistical concerns in the prehospital setting. This systematic review aimed to investigate paramedic prehospital pain management of patients who had suffered NOF or femur fractures, and to investigate which interventions are effective. A systematic review was conducted in line with Preferred Reporting Item for Systematic Reviews and Meta‐Analyses guidelines. Four databases were searched from inception date 23 March 2020. Articles were independently reviewed by two authors and conflicts resolved by a third author, followed by a hand search of the included reference lists. References were included if they addressed paramedic interventions for NOF or femur shaft fractures. Outcomes of interest were the effectiveness and complications of different modalities administered by paramedics. The search yielded 6868 articles, of which 19 met the final inclusion criteria. Studies investigated a variety of interventions including traction splints, intravenous (IV) analgesia and alternative analgesic options. Traction splinting and IV analgesia were consistently reported as underutilised. Alternative analgesics such as auricular acupressure, transcutaneous electrical nerve stimulation (TENS) and fascia iliaca compartment block were found to be effective techniques that could be safely and competently employed by paramedics, reducing pain for patients with limited adverse events. NOF and femur shaft fractures are an undertreated injury in the prehospital setting. Traction splinting and IV analgesia remain the traditional methodologies of treatment for these injuries; however, there are alternatives such as TENS, auricular acupressure and fascia iliaca compartment block that appear to be emerging as safe and effective options for the prehospital setting. [ABSTRACT FROM AUTHOR]

Objective: To determine the adequacy of cool running water first aid provided by healthcare professionals in the early management of children with thermal burn injuries. Methods: A cross‐sectional study was undertaken using a prospectively collected registry of children who presented with a thermal burn to the only major paediatric burns centre in Queensland, Australia, from January 2013 to December 2018. Main outcome measures included the type and duration of first aid administered by paramedics, general practitioners and emergency providers at local general hospitals and a children's hospital. In accordance with current Australian guidelines, adequate cooling was defined as 20 min of cool running water within 3 h of the injury. Results: Of the 4537 children who presented to the paediatric burns centre, 3261 (71.9%) received adequate first aid, including 1502 (33.1%) at the scene of injury. Paramedics and general practitioners administered adequate cooling to 184 (25.0%) and 52 (24.2%) of their patients, respectively. ED clinicians adhered to guidelines in the treatment of 1019 (56.3%) children at general hospitals and 411 (76.0%) at the children's hospital. Among ED patients who presented with incomplete prior first aid, the risk of inadequate cooling was significantly greater for those transported via ambulance (P < 0.001). Conclusion: Deficiencies remain in the cooling of paediatric burns patients at all levels of initial management. There is a need in the healthcare community for improved education regarding the parameters and clinical benefits of cool running water first aid. [ABSTRACT FROM AUTHOR]

Objective: Rapid sequence intubation (RSI) is used to secure the airway of some patients with stroke. Recent observational studies suggest that RSI is associated with poorer survival, and that decreases in systolic blood pressure (BP) following RSI could be a cause of worse survival. The present study aims to find if decreased systolic BP after paramedic RSI is associated with poorer survival in stroke patients transported by ambulance. Methods: The present study was a retrospective analysis of all stroke patients who received paramedic RSI attended by Ambulance Victoria, Australia. Logistic regression predicted the survival for strokes that had received RSI. The change in systolic BP during paramedic care was the main predictor. Results: Of 43 831 patients with stroke, 882 (2%) received RSI. Almost 48% of RSI had a decline in systolic BP of more than 20% from baseline, and the decline in systolic BP after RSI was largest for intra‐cerebral haemorrhage (−22.7 mmHg) compared to ischaemic strokes (−10.1 mmHg) or subarachnoid haemorrhage (−15.6 mmHg) (P = 0.001). Sixteen percent of the RSI group had an episode of hypotension anytime during the out‐of‐hospital care. For each 10 mmHg decrease in systolic BP with RSI for intra‐cerebral haemorrhage an increase of 11% in the odds of survival is apparent (P = 0.04); for subarachnoid haemorrhage an increase of 17% (P = 0.02) and for ischaemic strokes a non‐significant decrease of 7% (P = 0.26). Conclusions: Paramedic RSI‐related decrease in systolic BP is associated with improved survival in those with intra‐cerebral or subarachnoid haemorrhage but not ischaemic stroke. [ABSTRACT FROM AUTHOR]

Pre‐hospital providers (PHPs) undertake initial patient assessment, often spending considerable time with patients prior to arrival at ED. However, continuity of this assessment with ongoing care of patients in the ED is limited, with repeated assessment in the ED, starting with the process of triage in hospital. A systematic review of the literature was conducted to assess the ability of PHPs to predict patient outcomes in the ED. Manuscripts were screened and were eligible for inclusion if they included patients transported by non‐physician PHPs to the ED and assessed ability of PHPs to predict triage scores, clinical course, treatment requirements or disposition from ED. The initial search returned 10 753 unique articles. After screening and full text review, 10 studies were included in data analysis. Of these, six assessed prediction of disposition (admission versus discharge) from ED, two compared triage score application, one assessed prediction of clinical requirements and one assessed prediction of mortality prior to discharge. Prediction of admission across five studies had a pooled sensitivity of 0.73 (95% confidence interval 0.67–0.79) and specificity of 0.78 (95% confidence interval 0.69–0.85). Triage score application had weighted kappa variables of 0.409 and 0.452 indicating moderate agreement on assessment priority between PHPs and triage nurses. The ability of PHPs to assign triage scores, predict clinical course and predict disposition from the ED have mild concordance with clinical assessment by ED staff. This is an area of potential expansion in PHPs' role; however, training would be required prior to implementation. [ABSTRACT FROM AUTHOR]

Research related to the paramedic workforce is increasing, particularly given the associations with physical and mental health outcomes. However, it is clear that the evidence base to support future paramedic workforce initiatives lacks longitudinal data in cohorts of paramedics. We identify gaps in the epidemiological evidence base for this workforce, and provide insight into the role that prospective cohorts can, and should, play in future research in the paramedic workforce in order to identify health and safety changes over time, and the associations with job requirements, particularly shift work. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to describe the in‐event, ambulance and ED impacts of patient presentations from an Australian mass gathering event (MGE) including patient demographics, provision of care, length of stay and discharge disposition. Methods: This research was set at one MGE in Australia. The MGE had one first aid post and one in‐event health team staffed by doctors, nurses and paramedics. A retrospective analysis of patient care records from providers of in‐event, ambulance and ED services was undertaken. Data analysis included descriptive and inferential statistics. Results: Of the 20 000 MGE participants, 197 (0.99% [95% CI 0.86–1.13], 9.85/1000) presented for in‐event first aid care, with 24/197 (12.2% [95% CI 8.33–17.49], 1.2/1000) referred to in‐event health professionals. Fifteen of the referred patients (62.5% [95% CI 42.71–78.84]) returned to the MGE following administration of intravenous fluids (n = 13) and/or anti‐emetics (n = 11). Seven (29.2% [95% CI 14.92–49.17], 0.35/1000) were referred to ambulance paramedic care, requiring endotracheal intubation (n = 1) and airway adjuncts (n = 3) prior to transportation to ED; these patients had an ED median length of stay of 7 h (5.5–12.5) receiving imaging and ventilator support. Five were discharged from ED, one required an operation and another required intensive care unit admission. Conclusions: There was an impact on in‐event, ambulance and ED services from this MGE but the in‐event model of care may have limited ambulance usage and ED visits. The ED length of stay was greater than the national median, perhaps reflecting the appropriateness of transport and nature of care requirements while in the ED. [ABSTRACT FROM AUTHOR]

Objective: Timor Leste has one of the highest maternal death rates in the world at 215 per 100 000 live births.1 Post‐partum haemorrhage (PPH) accounts for 27% of maternal deaths globally. Annually the Timor Leste National Ambulance Service (TLNAS) attends over 20 000 cases, of which 2% are diagnosed with PPH. The objective of this study was to evaluate prehospital care of PPH patients transported by the TLNAS. Methods: A retrospective audit of PPH patients transported between May 2015 and May 2017. The inclusion criteria were patients diagnosed with PPH and transported during the study period. Results: Data from the patient care records of 214 TLNAS PPH patients were abstracted using the PPH care evaluation tool. Paramedics diagnosed 211 (97%) PPH patients, took observations on 181 (85%) and obtained a patient history from 193 (90%) patients. TLNAS paramedics did not regularly provide other treatment including oxygen 36 (17%), intravenous isotonic crystalloid fluid 117 (55%), uterine massage 0 (0%), external aortic compression 0 (0%) and non‐pneumatic anti‐shock garments 9 (4%). Conclusions: This research has shown that paramedics are not consistently using available clinical interventions. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Amiodarone is commonly used in the treatment of stable ventricular tachycardia (VT), but its efficacy has not been empirically examined in the prehospital setting. The objective of this study was to examine the safety and efficacy of amiodarone administered by paramedics to patients with stable VT. Methods: Patient records from Victoria, Australia between 1 May 2007 and 30 June 2017 were examined retrospectively. Patients attended by Ambulance Victoria with stable sustained VT who were administered amiodarone by paramedics as the initial treatment were included. Data were used to determine the prevalence of treatment with amiodarone, the incidence of VT termination prior to transfer of care, and the incidence of progression to electrical cardioversion. Results: Sixty‐one patients were identified who met the inclusion criteria. The mean age was 72 years (standard deviation = 14) with 77% (n = 47) being male. Of the patients treated with amiodarone, 52% (n = 32) reverted successfully during paramedic care while 48% (n = 29) did not. Two patients required cardioversion for haemodynamic instability after amiodarone administration. One patient experienced cardiac arrest after receiving amiodarone and was successfully resuscitated by paramedics. Conclusions: Approximately half of the patients treated with amiodarone reverted from VT while under paramedic care. Patient deterioration was rare, with cardiac arrest or requirement for cardioversion occurring very infrequently. Amiodarone was relatively safe and moderately effective for the treatment of sustained stable VT. However, given recent evidence of increased efficacy of procainamide for stable VT, further studies are required in the prehospital setting to compare these two drugs. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To describe the incidence and outcomes from out‐of‐hospital cardiac arrest (OHCA) in the New Zealand population served by the St John Ambulance Service. Methods: A retrospective observational study was conducted using data from the St John New Zealand OHCA registry, which serves a population of around 4 million. The incidence and outcomes of adult patients who were treated for an OHCA between 1 October 2013 and 30 September 2015 are reported. Results: A total of 7996 adult OHCA cases were attended, resuscitation was attempted in 3862 cases (60 per 100 000 person‐years). The median response time was 9 min (interquartile range 7–12), the median age was 66 (interquartile range 53–77) and 69% were men. Most events occurred in the home (67%), bystanders witnessed 53%, EMS witnessed 16% and 31% were unwitnessed. Bystander CPR was administered in 62% of cases and 8% were defibrillated prior to EMS arrival. Most events had a presumed cardiac aetiology (77%) and 38% presented in a shockable rhythm. Of those who had attempted resuscitation, a return of spontaneous circulation sustained to hospital handover occurred in 30% of events and 15% survived to 30 days. Adjusted survival outcomes demonstrated differences according to ethnicity. Conclusion: This is the first study to describe the epidemiology and outcomes of OHCA in New Zealand. Our findings provide important baseline data to monitor temporal trends, investigate the impact of changes in the management of OHCA and demonstrate that there are opportunities for improvement across the system of care. [ABSTRACT FROM AUTHOR]

Objective The present study aimed to describe and examine similarities and differences in the current service provision and resuscitation protocols of the ambulance services participating in the Aus- ROC Australian and New Zealand out-of-hospital cardiac arrest ( OHCA) Epistry. Understanding these similarities and differences is important in identifying ambulance service factors that might explain regional variation in survival of OHCA in the Aus- ROC Epistry. Methods A structured questionnaire was completed by each of the ambulance services participating in the Aus- ROC Epistry. These ambulance services were SA Ambulance Service, Ambulance Victoria, St John Ambulance Western Australia, Queensland Ambulance Service, St John Ambulance NT, St John New Zealand and Wellington Free Ambulance. The survey aimed to describe ambulance service and dispatch characteristics, resuscitation protocols and details of cardiac arrest registries. Results We observed similarities between services with respect to the treatment of OHCA and dispatch systems. Differences between services were observed in the serviced population; the proportion of paramedics with basic life support, advanced life support or intensive care training skills; the number of OHCA cases attended; guidelines related to withholding or terminating resuscitation attempts; and the variables that might be used to define 'attempted resuscitation'. All seven participating ambulance services were noted to have existing OHCA registries. Conclusion There is marked variation between ambulance services currently participating in the Aus- ROC Australian and New Zealand OHCA Epistry with respect to workforce characteristics and key variable definitions. This variation between ambulance services might account for a proportion of the regional variation in survival of OHCA. [ABSTRACT FROM AUTHOR]

Objective The present study aims to determine the agreement between paramedic and ED or hospital working diagnosis in dyspnoeic patients. Methods Non-consecutive written patient report forms were retrospectively audited for patients suffering from dyspnoea, who were transported to a tertiary hospital ED by ambulance paramedics. Accuracy of the paramedic working diagnosis was assessed by comparing agreement with either the primary or secondary ED diagnoses or hospital discharge diagnosis. Results The study cohort was 293 patients. Exact agreement between paramedic versus ED or hospital diagnosis was 64%, 95% CI 58-69, k = 0.58, 95% CI 0.52-0.64. Only 226 (77%) had a 'clearly documented' paramedic diagnosis. Among these, agreement with either ED or hospital diagnosis was 79%, and there was a trend towards more agreement as paramedic level of practice increased (74%, 78% and 87% for Basic, Intermediate and ALS paramedics, respectively, P = 0.07). Conversely, ALS paramedics were less likely to document a working diagnosis (30/98, 31%) compared with Intermediate (22/102, 23%) and BLS paramedics (15/93, 16%), P = 0.008. Diagnostic agreement varied according to medical condition, from anaphylaxis (100%) and asthma (86%) to acute pulmonary oedema (46%). Conclusions There was moderate agreement between paramedic and ED or hospital diagnosis. The number of cases with no clearly documented working diagnosis suggested that a singular working diagnosis may not always serve the complexity of presentation of some dyspnoea patients: more open descriptors such as 'mixed disease' or 'atypical features' should be encouraged. [ABSTRACT FROM AUTHOR]

Clinical communication and recognising and responding to a deteriorating patient are key current patient safety issues in healthcare. The aim of this literature review is to identify themes associated with aspects of the hospital clinical handover between paramedics and ED staff that can be improved, with a specific focus on the transfer of care of a deteriorating patient. Extensive searches of scholarly literature were conducted using the main medical and nursing electronic databases, including Cumulative Index to Nursing and Allied Health Literature, Medline and PubMed, during 2011 and again in July 2012. Seventeen peer-reviewed English-language original quantitative and qualitative studies from 2001 to 2012 were selected and critically appraised using an evaluation tool based on published instruments. Relevant themes identified were: professional relationships, respect and barriers to communication; multiple or repeated handovers; identification of staff in the ED; significance of vital signs; need for a structured handover tool; documentation and other communication methods and education and training to improve handovers. The issues raised in the literature included the need to: produce more complete and concise handovers, create respectful and effective communication, and identify staff in the ED. A structured handover tool such as ISBAR (a mnemonic covering Introduction, Situation, Background, Assessment and Recommendations) would appear to provide a solution to many of these issues. The recording of vital signs and transfer of these data might be improved with better observation systems incorporating early warning strategies. More effective teamwork could be achieved with further clinical communications training. [ABSTRACT FROM AUTHOR]

Paramedic education has been undergoing major development in Australia in the past 20 years, with many different educational programmes being developed across all Australian jurisdictions. This paper aims to review the current paramedic education programmes in Australia to identify the similarities and differences between the programmes, and the strengths and challenges in these programmes. A literature search was performed using six scientific databases to identify any systematic reviews, literature reviews or relevant articles on the topic. Additional searches included journal articles and text references from 1995 to 2011. The search was conducted during December 2010 and November 2011. Included in this review are a total of 28 articles, which are focused around five major issues in paramedic education: (i) principle on paramedic programmes and the involvement of industry partners; (ii) clinical placements; (iii) contemporary methods of education; (iv) needs for specific programmes within paramedic education; and (v) articles related to the accreditation process for paramedic programmes. Paramedic programmes across Australian universities vary with many different practices, especially relating to clinical placements in the field. The further advances of the paramedic education programmes should aim to respond to population change and industry development, which would enhance the paramedic profession across Australia. [ABSTRACT FROM AUTHOR]

Objectives: 1. To evaluate emergency clinician attitudes towards handover from prehospital paramedics. 2. To determine the content and methods of paramedic handover delivery to emergency clinicians. Methods: Exploratory study comprising questionnaire of emergency clinicians and observation of paramedic-to-emergency clinician handover with associated survey at an adult tertiary referral hospital with approximately 12 000 ambulance arrivals of 37 000 annual attendances. Results: Emergency staff found handover from paramedics on patient conditions relevant, especially for altered consciousness (94%, 95% CI 83.5–98.6), trauma (90%, 95% CI 82.0–98.4) and chest pain (88%, 95% CI 79.0–97.0), but less so for behavioural disturbance (67%, 95% CI 53.7–79.5). A total of 621 handovers from 311 ambulance arrivals were observed. Most arrivals (81%, 95% CI 76.4–85.4) were not preceded by prehospital communication. Paramedics handed over twice 91% of the time (95% CI 88.2–94.4). Doctors received direct paramedic handover for 12% (95% CI 8.0–15.1) of ambulance arrivals, including 19 team handovers, whereas triage nurses took 97% (95% CI 95.6–99.2) and attending nurses, 91% (95% CI 87.5–93.9). Fifty per cent (95% CI 42.7–57.3) of emergency clinicians referred to ambulance sheets. Handover information was perceived to be useful and accurate in more than 80% of instances. Verbal handover occurred before ambulance sheet completion for 78% (95% CI 73.5–82.7). Conclusion: Although there is satisfaction in paramedic handover, prehospital notification and emergency physician contact with paramedics is uncommon for low acuity patients, who constitute the majority of ambulance attendances and hospital admissions. Scope for improved direct doctor–paramedic communication exists. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to compare the Streamlined Liner of the Pharynx Airway (SLIPA; Hudson RCI), a new supraglottic airway device, with the Soft Seal Laryngeal Mask (SS-LM; Portex) when used by novices. Methods: Thirty-six medical students with no previous airway experience, received manikin training in the use of the SLIPA and the SS-LM. Once proficient, the students inserted each device in randomized sequence, in two separate patients in the operating theatre. Only two insertion attempts per patient were allowed. Students were assessed in terms of: device preference; success or failure; success at first attempt and time to ventilation. Results: Sixty-seven per cent of the students preferred to use the SLIPA (95% confidence interval 49–81%). The SLIPA was successfully inserted (one or two attempts) in 94% of patients (34/36) and the SS-LM in 89% (32/36) ( P = 0.39). First attempt success rates were 83% (30/36) and 67% (24/36) in the SLIPA and SS-LM, respectively ( P = 0.10). Median time to ventilation was shorter with the SLIPA (40.6 s) than with the SS-LM (66.9 s) when it was the first device used ( P = 0.004), but times were similar when inserting the second device (43.8 s vs 42.9 s) ( P = 0.75). Conclusions: In the present study novice users demonstrated high success rates with both devices. The SLIPA group achieved shorter times to ventilation when it was the first device they inserted, which might prove to be of clinical significance, particularly in resuscitation attempts. Although the Laryngeal Mask has gained wide recognition for use by both novice users and as a rescue airway in failed intubation, the data presented here suggest that the SLIPA might also prove useful in these areas. [ABSTRACT FROM AUTHOR]

Secondary brain injury may occur early after severe traumatic brain injury due to hypoxia and/or hypotension. Prehospital care by ambulance paramedics has the goal of preventing and treating these complications and, thus, improving outcomes. In Australia, most ambulance services recommend paramedics attempt endotracheal intubation in patients with severe head injury. Even though most patients with severe head injury retain airway reflexes, most states do not allow the use of appropriate drugs to facilitate intubation. In contrast, recent evidence from trauma registries suggests that this approach may be associated with significantly worse outcomes compared with no intubation. Two states allow intubation facilitated by sedative (but not relaxant) drugs, but this has a low success rate and could worsen brain injury because of a decrease in cerebral perfusion pressure. For road-based paramedics, the role of rapid sequence intubation is uncertain. Given the risks of this procedure and the lack of proven benefit, this procedure should not be introduced without supportive evidence from randomised, controlled trials. In contrast, for safety reasons, comatose patients transported by helicopter should undergo rapid sequence intubation prior to flight. However, this is not authorised in most states, despite good supportive evidence that this can be safely and effectively undertaken by paramedics. Finally, there is evidence that inadvertent hyperventilation is associated with adverse outcome, yet only two ambulance services use waveform capnography in head injury patients who are intubated. Overall, current paramedic airway practice in most states of Australia is not supported by the evidence and is probably associated with worse patient outcomes after severe head injury. For road-based paramedics, rapid transport to hospital without intubation should be regarded as the current standard of care. Rapid sequence intubation should be limited to use within appropriate clinical trials, or patients transported by helicopter. For patients who are intubated, waveform capnography is essential to confirm tracheal placement and to prevent inadvertent hyperventilation. [ABSTRACT FROM AUTHOR]

Ramping is the practice of requiring paramedics to continue to care for patients rather than hand over clinical responsibility to the ED. It arose as an alternative to admitting patients to EDs that are deemed to be already operating at or beyond capacity. This paper analyses the ethics of ramping. Ramping has been embraced by some ED practitioners and policymakers as a solution to the problem of ED patients suffering increased risks of harm as a result of waiting times within ED. However, this perspective fails to adequately consider the implications, especially the opportunity cost of requiring paramedics to remain at the hospital rather than make themselves available for other patients. From this perspective, ramping negatively impacts the wider provision of emergency medical services, with potentially serious consequences for people's health. Advocates of ramping must consider people in the community who require a medical emergency response. [ABSTRACT FROM AUTHOR]

Objective To compare chief complaints of the Medical Priority Dispatch System in terms of the match between dispatch priority and patient condition. Methods This was a retrospective whole-of-population study of emergency ambulance dispatch in Perth, Western Australia, 1 January 2014 to 30 June 2015. Dispatch priority was categorised as either Priority 1 (high priority), or Priority 2 or 3. Patient condition was categorised as time-critical for patient(s) transported as Priority 1 to hospital or who died (and resuscitation was attempted by paramedics); else, patient condition was categorised as less time-critical. The χ2 statistic was used to compare chief complaints by false omission rate (percentage of Priority 2 or 3 dispatches that were time-critical) and positive predictive value (percentage of Priority 1 dispatches that were time-critical). We also reported sensitivity and specificity. Results There were 211 473 cases of dispatch. Of 99 988 cases with Priority 2 or 3 dispatch, 467 (0.5%) were time-critical. Convulsions/seizures and breathing problems were highlighted as having more false negatives (time-critical despite Priority 2 or 3 dispatch) than expected from the overall false omission rate. Of 111 485 cases with Priority 1 dispatch, 6520 (5.8%) were time-critical. Our analysis highlighted chest pain, heart problems/automatic implanted cardiac defibrillator, unknown problem/collapse, and headache as having fewer true positives (time-critical and Priority 1 dispatch) than expected from the overall positive predictive value. Conclusion Scope for reducing under-triage and over-triage of ambulance dispatch varies between chief complaints of the Medical Priority Dispatch System. The highlighted chief complaints should be considered for future research into improving ambulance dispatch system performance. [ABSTRACT FROM AUTHOR]