Emergency medicine

We present a case of tetanus following a snakebite in Victoria, Australia. An otherwise healthy 58-year-old woman presented following suspected Tiger snake (Notechis scutatus) bite with envenomation. She was not up-to-date with tetanus vaccination and was not offered a booster vaccination. She re-presented 12 days later with features consistent with tetanus infection and was treated with tetanus immunoglobulin and metronidazole with clinical improvement. Snakebites remain a risk for tetanus infection and the assessment of tetanus risk should be included within clinical guidelines for Australian healthcare settings.

Adrian A. S. Doherty, Naomi N. E. Clarke, Sarah Fletcher, Sarah Huffam, Camille V. Awburn, Eugene Athan

Objectives To examine the epidemiology of stroke and transient ischaemic attack (TIA), and quality of care provided to Aboriginal and Torres Strait Islander (‘Indigenous’) patients presenting to emergency medical services (EMSs) with stroke or TIA.DesignRetrospective population-based data linkage study.Setting, ParticipantsVictoria, Australia. Patients aged ≥ 18 years with hospital-confirmed stroke or TIA who presented to EMSs between 1 January 2015 and 30 June 2019 and were successfully linked with hospital or mortality datasets.Main Outcome MeasuresThirty- and 90-day mortality, crude and age-standardised incidence rates, EMS quality of care.ResultsAmong 32,163 patients, 287 (0.9%) were Indigenous. Indigenous patients were younger than non-Indigenous patients (median age, 62 vs. 77 years, p < 0.001). Age-standardised incidence of EMS attendance was higher within the Indigenous population (343 vs. 144 per 100,000 person-years; incidence rate ratio, 2.383 [95% confidence interval (CI), 2.084–2.711]). Rates of call-taker identification of stroke or TIA and hospital diagnoses were comparable; however, Indigenous patients were less likely to receive a stroke assessment from paramedics (166/285 [58.2%] vs. 21,271/31,605 [67.3%]; p = 0.001) and more frequently taken to stroke-capable hospitals (257/275 [93.5%] vs. 27,371/30,647 [89.3%]; p = 0.027), but less frequently taken to endovascular thrombectomy-capable hospitals (67/275 [24.4%] vs. 10,015/30,647 [32.7%]; p = 0.003). Adjusted mortality was similar between groups (30 days: hazard ratio, 0.814 [95% CI, 0.518–1.279]; 90 days: hazard ratio, 0.805 [95% CI, 0.534–1.214]). However, age-standardised incidence of 90-day mortality was higher within the Indigenous population (39 vs. 24 per 100,000 person-years; incidence rate ratio, 1.621 [95% CI, 1.031–2.398]). Indigenous patients also more often recontacted EMSs for any reason within 90 days (subdistribution hazard ratio, 1.548 [95% CI, 1.194–2.007]).ConclusionsThe age-standardised incidence of EMS attendance for stroke in the Indigenous population was more than double that for the non-Indigenous population. Although there was no difference in stroke identification at the time of the emergency call, Indigenous patients were less likely to be evaluated by paramedics for stroke.

Candice Menezes, Ziad Nehme, Luke J. Burchill, Tegwyn McManamny, Angela Dos Santos, Michelle Crilly, Luke P. Dawson, Benjamin Clissold, David Anderson, Emily Nehme

I collapsed at the gym when a massive pulmonary embolism caused my heart to stop. Unbelievably I survived thanks to a clinical trial delivering an extracorporeal membrane oxygenation (ECMO) heart–lung bypass machine directly to me at the gym. Hopefully out-of-hospital ECMO becomes an accepted emergency strategy to save more lives.

Hugh N. Burrill

This study identified and characterised 1207 emergency department presentations related to gabapentinoid overdose in Victoria from 2009–2010 to 2023–2024. Presentation rates increased substantially since 2009–2010, and about half (49.5%; 597/1207) of all presentations were classified as intentional. Co-ingestants were common, although 36.2% (437/1207) of presentations were reported to involve gabapentinoids alone.

Bishaal Tej Gurung, Amy McNeilage, Angus Skeen, Tina Lam, Joanna F. Dipnall, Jane Hayman, Suzanne Nielsen, Ting Xia

Objectives To quantify factors associated with paramedic transport to hospital for older people in residential aged care facilities (RACFs) and supported accommodation, and to identify modifiable drivers of non-transport. Study Type Retrospective cohort study using routinely collected electronic patient care records, analysed with gradient boosting models and multivariable logistic regression. Setting Ambulance Tasmania attendances to RACFs and supported accommodation across Tasmania, 1January 2018 to 31 December 2024. Study Population All eligible ambulance attendances for people aged 65years or older at these facilities. Main Outcome Measures The primary outcome was transport to hospital. Scene time and clinical status at first assessment, summarised using the National Early Warning Score 2 (NEWS2) and Shock Index, were descriptive variables and candidate predictors. Results Of 23,317 attendances, 19,386 (83.1%) resulted in transport and 3931 (16.9%) did not. Most attendances were low risk. Crew skill set, calendar month, initial pain score, respiratory rate and NEWS2 category were the strongest predictors of transport. In adjusted logistic regression, extended care paramedic attendance was associated with markedly lower odds of transport than attendance by standard paramedic crews (adjusted odds ratio, 0.09 [95% CI, 0.07–0.12]), corresponding to an adjusted transport probability of 0.50 compared with 0.85 for intensive care paramedic crews, 0.86 for standard paramedic crews and 0.69 for other crews. Conclusions Paramedic transport decisions for RACF residents were strongly associated with acute illness severity, but crew skill set was also independently associated with transport. Attendances managed by extended care paramedics had lower adjusted probabilities of hospital transport. These findings suggest that extended-scope paramedic models warrant prospective evaluation in this setting.

Sharon Andrews, Pieter F. Fouche, Belinda Flanagan, Michael McDermott, Melanie Greenwood

Ethnocultural minority communities may require specialised emergency response frameworks during mass casualty incidents (MCIs). This article describes the Sydney Jewish community's preparation for, and medical response to, the Bondi Beach terror attack of 14 December 2025. We present a timeline of events during the attack and outline the immediate medical response and recovery actions undertaken in the first hours and days following the incident, including first-hand accounts of responders from the scene. Alongside this account, we present a novel response model implemented by the New South Wales Community Health Support (CHS). CHS is a community-operated, not-for-profit emergency medical response organisation that provides telehealth advice and dispatches volunteer community first responders (including health professionals and trained emergency healthcare workers) to urgent and emergency health incidents within the local community. CHS operates alongside statutory emergency services and is embedded within the community it serves. It is hoped that the lessons identified from this incident may be valuable to the broader international medical community, emergency management agencies and policymakers, and that it may serve as an exemplar for other communities seeking to strengthen preparedness, coordination and resilience in the face of future MCIs.

Aidan Baron, Jesse Lenn, Zachariah Seidman, Matthew N. Lowy, Jeffrey L. Engelman

Thomas Bradley

Objectives To evaluate the effect of hospital occupancy levels on inpatient and emergency department (ED) flow rates, ED length of stay (ED) and access block, and identify critical occupancy thresholds above which patient flow deteriorates. Design Retrospective cohort study using routinely collected administrative data. Setting Twenty-five public hospitals in Queensland, Australia, over a 5.5-year period (1 April 2017 to 31 August 2022). Main Outcome Measures ED presentation and discharge rates, inpatient admission and discharge rates, hospital occupancy levels, length of stay, access block and 4-h rule compliance. Results The analysis reveals a significant performance shift as hospital occupancy levels increase and identifies site-specific critical ‘choke points’ where patient flow deteriorates. Notably, as occupancy rises, we observed a growing divergence between ED presentations and discharge rates, and between inpatient admissions and discharges, indicating system congestion. Additionally, when assessing flow across the 25 hospitals, the data demonstrates that a 10% increase in bed occupancy rate correlates with a 0.32-h (19-min) extension in ED length of stay (or 33min for patients admitted from the ED). Also, significant disparities in hospital operations were observed between weekends and weekdays, with weekday admissions and discharges up to three times higher than weekends, highlighting the increased operational pressure during the work week. Conclusions The investigation challenges the traditional 85% occupancy target, demonstrating that optimal occupancy levels vary by hospital. The study also underscores the strong correlation between hospital bed occupancy and ED access performance, with higher hospital occupancy correlating with longer ED stays and decreased adherence to performance indicators. As hospitals approach full capacity, the pressure on ED resources intensifies, resulting in longer wait times and delays in care.

Vahid Riahi, Justin Boyle, Hwan-Jin Yoon, Hamed Hassanzadeh, Ibrahima Diouf, Sankalp Khanna, Andrew Staib, Mahnaz Samadbeik, Clair Sullivan, Emma Bosley, James F. Lind

Conflicting demands in crisis care units can be alleviated by a flat team hierarchy and clear treatment protocols

Jacqueline P Huber · Alyssa Milton · Matthew Brewer · Kat Fry · Sean Evans · Jason Coulthard · Nicholas Glozier

Aaron BO Wong · Brian H Le

A 62-year-old woman presented to an emergency department with severe pain two hours after rescuing a wild platypus, with two penetrating injuries to her right hand

Irene M Moyer de Miguel · Jennifer C Jamieson · Lori Coulson · Ingrid Berling

Targeted interventions based on further research are needed to reduce differences associated with social determinants of health

for the Australian and New Zealand Intensive Care Society Paediatric Study Group and Centre for Outcomes and Resource Evaluation

Hospital-in-the-home (HITH) models of care provide sustainable, patient-centred, value-based care; but how can we better recognise deteriorating HITH patients?

Mya Cubitt · Seok Lim

New strategies are needed to further improve survival after out-of-hospital cardiac arrest

Emily Nehme · David Anderson · Ross Salathiel · Anthony Carlyon · Dion Stub · Peter A Cameron · Andrew Wilson · Sile Smith · John J McNeil · Ziad Nehme