Paramedic Papers Daily — 3 October 2026

Eleven papers to get through today. Paper one — a Dutch trial shows a prehospital risk score can safely guide which chest pain patients stay home. Paper two — Australian linked data shows First Nations stroke patients get less paramedic stroke assessment and less often reach thrombectomy-capable hospitals. Paper three — early defibrillation, prehospital ECPR and termination-of-resuscitation rules all pass the cost-effectiveness test. Paper four — nearly half of prehospital paediatric drug doses deviated from protocol, mostly underdoses. Paper five — prehospital vasopressors in trauma remain unproven. Paper six — methoxyflurane holds up in Canadian real-world use. Paper seven — bigger crews work faster on trauma scenes but don't save more lives. Paper eight — paramedics and emergency doctors barely agree on paediatric asthma signs. Paper nine — two-thirds of stroke patients delay calling for help. Paper ten — direct admission of older patients to geriatric units depends more on geography than need. Paper eleven — US data shows Black trauma patients receive fewer prehospital interventions.

Paper one — Heart. A Dutch pragmatic randomised trial, five thousand one hundred and seventy adults with undifferentiated chest pain, tested whether conveyance guided by the prehospital PreHEART score was safe. It was non-inferior to usual care for serious adverse events at three days — win ratio of one point zero one. Non-conveyance rose to thirty-four point six per cent against twenty-four and a half, thirty-day emergency presentations fell, and costs dropped by three hundred and forty-five euros per patient. Crucially, no deaths within three days among the fifteen hundred and twenty-six patients left at home. The caveat — it ran in the Dutch system with its own consult-and-convey structure, so the safety numbers don't transfer automatically. But it's the strongest evidence yet that risk-score-guided non-conveyance in chest pain can be safe.

Paper two — The Medical Journal of Australia, and it's Australian data. A Victorian data-linkage study of thirty-two thousand one hundred and sixty-three stroke and TIA patients attended by ambulance found First Nations patients had more than double the age-standardised rate of EMS attendance — three hundred and forty-three versus one hundred and forty-four per hundred thousand person-years. They were also less likely to receive a paramedic stroke assessment — fifty-eight per cent against sixty-seven — and less often taken to a thrombectomy-capable hospital, twenty-four versus thirty-three per cent. Adjusted mortality was similar. Only two hundred and eighty-seven First Nations patients, so precision is limited — but the stroke assessment gap is the piece that sits squarely in crews' hands.

Paper three — a systematic review of ten economic evaluations of out-of-hospital cardiac arrest care. Early defibrillation and advanced life support delivered by basic-tier crews were cost-effective, prehospital ECPR was more cost-effective than in-hospital ECPR, and termination-of-resuscitation rules saved money. The numbers come from different health systems and funding models, and equity reporting was poor — but for Australian services weighing defibrillator coverage, ECPR pathways and termination rules, this is useful ballast.

Paper four — a US quality registry, three hundred and eighty-six medication administrations in two hundred and forty children. Forty-six per cent of doses deviated at least twenty per cent from protocol, and eighty per cent of those were underdoses. Ondansetron was the worst offender — eighty-five per cent off-protocol — and the intranasal route wasn't far behind at seventy per cent. Weight-estimation error wasn't the driver, which points at fixed-dose formulations and delivery-device limits instead. Weight-based paediatric dosing and intranasal delivery are standard practice here in Australia, so those error patterns translate directly.

Paper five — a systematic review of five retrospective studies covering nearly thirty-two thousand trauma patients, on prehospital vasopressor infusions before haemorrhage control. The mortality signals were mixed — one military study found markedly lower adjusted survival with vasopressors, and another linked them to more massive transfusion and coagulopathy. Very low certainty evidence with inevitable confounding — but nothing here supports the practice. Continuous vasopressor infusions in trauma aren't something most Australian ambulances run anyway.

Paper six — a Canadian feasibility study of patient-controlled inhaled methoxyflurane in ninety-seven adult trauma patients. Ninety-five per cent protocol compliance, median pain scores fell from eight out of ten to five, side effects in just under a quarter and mostly mild, and no serious drug-related events. No comparator arm, so the pain relief can't be pinned on the drug alone. But with the green whistle already standard kit across Australian services, independent real-world safety data is welcome.

Paper seven — a Korean nationwide registry of seventy-eight thousand two hundred severe trauma patients. Crews of three or more got IV access in hypotensive patients more often and hit ten-minute scene times more often than two-person crews — but survival to discharge was identical after adjustment. Korean staffing and skill mix differ from Australian models, but the message is that a third crew member buys speed and procedures, not lives.

Paper eight — a prospective study of two hundred and ninety-five children transported with asthma, comparing paramedic and emergency department exam findings. Agreement was slight for suprasternal retractions and only fair for tachypnoea and accessory muscle use. Some of that may be timing — the EMS surveys were completed after ED arrival, when the examination may already have changed. But it suggests a prehospital paediatric asthma severity score would be hard to validate anywhere.

Paper nine — a meta-analysis of twenty-seven studies and over two hundred and sixty-six thousand ischaemic stroke patients across fourteen countries. Sixty-eight per cent delayed seeking care before hospital, sixty-five per cent took more than two hours, and seventy-seven per cent more than three. Low-certainty evidence, dominated by Asian studies — but onset-to-call delay is exactly what Australian stroke awareness campaigns target, and this says that work is far from finished.

Paper ten — a Swedish register study from Stockholm, eight thousand two hundred older patients transported by ambulance. Only seven per cent went directly to a geriatric unit instead of an ED, and conveyance rates varied fourfold between hospital service areas — explained mostly by distance, ownership and staffed bed numbers rather than patient need. Australia doesn't have a matching geriatric-unit structure, so this is context for the alternative-destinations debate, not a pathway to copy.

Paper eleven — a US registry of eighteen thousand two hundred and eighty injured adults. Black patients were about half as likely to be intubated prehospital as White patients — seven point nine versus four per cent — and patients from disadvantaged neighbourhoods received fewer prehospital interventions overall, including prehospital blood. The categories and trauma structures don't map neatly onto Australia — prehospital blood is still limited to a few Australian services — but the method is worth borrowing: audit your own service's data for these gaps.

Quick recap. One — a prehospital chest-pain risk score made non-conveyance cheaper, with no extra harm. Two — First Nations stroke patients get less paramedic assessment and miss thrombectomy-capable hospitals more often. Three — defib, prehospital ECPR and termination rules all pass the cost-effectiveness test. Four — nearly half of paediatric doses run off-protocol, mostly underdoses. Five — prehospital vasopressors in trauma remain unproven. Six — the green whistle holds up in Canadian real-world use. Seven — bigger crews work faster on trauma scenes but don't save more lives. Eight — paramedics and EDs barely agree on paediatric asthma signs. Nine — two-thirds of stroke patients delay calling for help. Ten — direct geriatric admission depends more on geography than need. Eleven — US trauma data shows big racial gaps in prehospital interventions.

That's the roundup for Friday the third of October. Papers on the dashboard. Back tomorrow.