Differences in Emergency Paramedic Clinical Practice Guidelines across Australia and New Zealand

Words By: Matt Wilkinson-Stokes

The ten Australian and New Zealand jurisdictional ambulance services (JASs) are big businesses – their collective budget was $4.8 billion AUD and $480 million NZD respectively last year, and they treated over 4.5 million of us.^_1–3 At the core of this business are paramedics, mostly in ambulances, working every day and night to respond to any 000 or 111 call that sounds even vaguely medical-ish.

For those of us who work for these services, our clinical practice is regulated – with varying levels of stringency – by Clinical Practice Guidelines (CPGs).^4–12 This is fairly standard for mid-level practitioners across healthcare, and is a critically important safety mechanism. However, one of the quirks of Australasia is that each JAS independently produces their own CPGs, and these guidelines vary wildly across state lines.

This has led to some unusual scenarios. One paramedic works for two different services. Depending on what day of the week it is, she’ll be working either side of a state line, and have to give the same chronic patients completely different medications and dosages. (She describes it as ‘absurd’ and confusing for the patients.) Another paramedic moved from Victoria to Queensland, and technically ‘overdosed’ a patient by giving them a Victorian dose of intranasal Fentanyl (400 mcg) rather than a more conservative Queensland dose (200 mcg).

It's important to state straight away that, when looking at the evidence for many CPG differences, there is regularly no real ‘right’ or ‘wrong’ guideline. Multiple treatments can be appropriate, and – to use the example above – both the Victorian and Queensland maximum doses for intranasal Fentanyl are completely reasonable.

However, hearing these stories did make us curious.

Just how many differences are there? Are there any that do matter? How can a multi-billion-dollar industry find basic out-of-hospital medical treatment so hard to agree on?

What did we do?

We set out to answer the first of these three questions by forming a group of around 40 paramedics, doctors, and nurses – all of whom generously volunteered their time unpaid – to attempt to catalogue the many inconsistencies in paramedic treatment across Australia.¹³ To keep it enjoyable and interesting, we charted the differences using colourful posters, covering 33 of the major pathologies that we all treat.¹⁴  

For simplicity, we only looked at if a treatment is offered, and who by (based on clinical level, such as paramedic, ICP, ECP, etc – levels other than this, such as aeromedical, we put together as ‘specialist’ and provided details in a footnote). Comparing the more complex details like dosages or contraindications (although there were some fascinating differences) proved too time-consuming for our volunteers and too hard to present in simple posters. We also relied largely on the publicly available CPGs; some services still keep some CPGs (such as for ECPs, or aeromedical teams, or where a trial is ongoing) confidential, and weren’t willing to share a copy. So this isn’t a comprehensive or perfect set of work – it’s a rough and ready starting point that aims to raise awareness and kick off a conversation.

These posters have struck a chord, racking up many thousands of readers from nearly 100 countries across the world.

What did we find?

Perhaps unsurprisingly, even a brief glance shows that there is very, very little consistency in paramedic medicine across Australasia. Here are a handful of the differences we found interesting:

• For cardiac arrest, 2 services provide dual defibrillation, 1 service provides stacked shocks, 8 services provide mechanical compression devices, and 3 provide precordial thump.For analgesia during labour, opioids are indicated in 4 services. In another 4, they are contraindicated.
• In fact, across Australasia you’ll get any one of 16 different pain medications; 8 of these are available in less than half the services.
• For sedation of an acute behaviour disturbance, patients will get any one of 6 different tranquilisers, each of which has totally different safety profiles and effectiveness.
• For hyperkalaemia, 5 services provide calcium and sodium bicarbonate, and 5 do not.
• For a TBI, the target systolic blood pressure varies from >90 mmHg to >120 mmHg.
• 13 different tools are used to identify and triage CVAs.
• Thrombolysis is available to paramedics in 6 services, to ICPs in 1, and not available in 3 services.
• PEEP is available to paramedics in 4 services, ICPs in 2, and not available in 4 services.
• Sedation for CPRIC is available to paramedics in 3 services, ICPs in 5 services, and not available in 3 services.

These findings back up a handful of formal peer-reviewed publications on acute behavioural disturbance,¹⁵ anaphylaxis,¹⁶ back pain,¹⁷ cardiac arrest,¹⁸ obstetric emergencies,¹⁹ sepsis,²⁰ and is now being researched by our peak national body, the Australasian College of Paramedicine.²¹  

We didn’t set out to answer our group’s second question with this project (“Are there any differences that do matter?”). However, broadly speaking, we do believe that our time spent comparing the CPGs shows that there is no one service who is fundamentally better than the others – each have their strengths and weaknesses.

We also found that these guidelines are constantly in a state of flux, with the services updating them several times a year. That’s great news, as that kind of rapid adaptability to new evidence is exactly what you want in the healthcare system.

However, the inconsistencies do come in stark contrast to New Zealand (where the ambulance services work together to write a joint set of guidelines that everyone uses) or the United Kingdom (where, in 2000, dozens of different services came together to form a single central research body that creates national guidelines that are then tailored to each region’s needs).^6,22

Why do CPGs matter?

The use of CPGs isn’t just limited to determining what treatment you’ll be giving. They have a constant presence that weaves its way throughout the profession:

• Education. For the nearly 8,000 paramedic university students in Australia,¹ memorising your local CPGs is often a rite of passage (although many universities are proactively moving away from this).^23–25 The same is true for those completing a graduate year within a service, who may be regularly quizzed on their guidelines. Incidentally, for university students, it may end up being an unconstructive chore if you get a job interstate and need to re-learn a completely different set of guidelines – or if, like the paramedic discussed before, you work for two services and need to remember two different sets of (often completely opposite) treatments.
• Discipline. More frighteningly, in several old-school ambulance services, ‘going outside the guidelines’ is grounds for an automatic investigation,²⁶ with the onus on the paramedic to justify that the difference in treatment was necessary. This creates a strong disincentive to vary your treatment,²⁷ even if that is what your patient truly needs. (It’s usually easier to just give your patient a treatment that is ‘close enough’ and avoid the investigation.)
• Legal. Guidelines are even used in Court when things inevitably go wrong. While in the pre-university days paramedics were expected to follow them directly,²⁸ the increase in education has led the High Court of Australia to grant a little more wiggle-room;²⁹ nonetheless, great weight is still given to following guidelines.
• Culture. Less so today, but historically many paramedics were taught to treat their local CPGs as a source of truth – irrefutable and perfect – with a ‘punitive culture that enforces following rules’.²⁶ One Intensive Care Paramedic, when asked about a treatment offered interstate, stated ‘Don’t talk to me about what [service] does… They are killing their patients.’ This mentality, where any variation from your own guidelines is looked on with suspicion rather than curiosity, persists in some quarters.

Given their fundamental place in the profession, many non-paramedics would probably assume that all the States and Territories have come together to join resources and produce rigorous, evidence-based guidelines.

This is – for better and for worse – not the case.

Why are CPGs so different?

Each set of guidelines is written independently by the State or Territory ambulance service, and while they are open access (see the links at the bottom of the page if you’re interested in having a look), they are developed independently.¹³ (The exception to this is St John New Zealand and Wellington Free Ambulance, who collaborate on a single set of guidelines for the country which each service then has minor variations from.)

In reality, as has been discussed for well over a quarter of a century, medicine is not well-suited to rulebooks.^30,31 For those outside of a clinical background, there can be a perception of medical treatment as black and white, and terms like ‘proven’ or ‘evidence’ are readily accepted by patients. However, in practice, most of healthcare is a Sherlock Holmes affair^31,32 of investigation and balancing the probabilities³³ – you can rarely be certain of the exact treatment that will work for your patient, multiple treatments are often equally reasonable, and all treatments carry risks that need to be weighed.

‘Diagnosing an illness is often like trying to put together a complicated jigsaw puzzle with the hitch that you cannot have all the pieces.’^{31 p.33}

What happens if the guidelines don’t cover the treatment you need to give? Writing a single set of guidelines to cover the almost infinite situations paramedics go to is impossible; there is always a regression to the mean. This simplification is a major conundrum for paramedics, particularly when your patient needs a completely safe, simple treatment that isn’t in the guidelines²⁷ – do you risk being disciplined by giving it, or just let their condition continue for a little bit longer and give them an avoidable trip to an overcrowded hospital?

It’s strange to think that you would be treated completely differently in Albury to a few hundred meters south in Wodonga, or on the north side of Dixon Street in Coolangatta to the south in Tweed Heads, but that’s exactly the case. Which ambulance service responds to you – and, consequently, which set of CPGs you fall under – will probably be the single most important factor in your treatment.

Why don’t we work together more?

Given the enormous resourcing of these services, some genuinely remarkable innovations that they are testing, and their widely-stated commitment to evidence-informed practice, there is a relatively small amount of attention given to the guidelines that every single JAS paramedic operates within.

Ambulance services fall under each State or Territory’s government. They have developed largely independently of each other, and continue to work that way. Although there is a lot of camaraderie between the services,³⁴ there are significant disincentives for senior managers to come together when writing guidelines.

• Firstly, doing so would require every service losing control over a critical part of their job. Given that services have a legal duty of care to their patients, this is an anxiety-inducing proposition for most managers. (However, looking at the United Kingdom or New Zealand suggests that this fear is likely unfounded.)
• Secondly, achieving any kind of consistency would of course require a lot of change from most of us – this isn’t easy. Changing what drug you carry doesn’t just mean buying something different from the store; you have to roll out an education program to thousands of paramedics working different schedules, ship drugs across the country (very difficult if they need to be stored a particular way), find a place for it in our often overflowing bags (space is a valuable commodity in the ambulance business), and sometimes even get legislation changed to make it legal.

While joint guidelines would likely be more thorough overall, cost less, be legally stronger, and ethically provide benefits for the less-funded areas of the country, that’s an awful lot of initial work, cost, and a big loss of control to managers for an unknown amount of gain. Given that we can’t even get close to agreeing on what to call ourselves,^35,36 the fact we don’t collaborate on guidelines isn’t that surprising.

Are evidence-based guidelines even possible?

There’s another reason why we don’t see much consistency in guidelines, one which is the dark secret of out-of-hospital medicine: there is little definitive empiric research.

Take these brief examples from three of the more topical interventions:

1. Rapid sequence induction during a TBI. The evidence for this is mixed.³⁷ Done really well, this treatment probably has a minor benefit. Done incorrectly, and it is almost certainly harmful. Should services invest time and money in a treatment that is possibly beneficial?
2. Out-of-hospital extracorporeal cardiopulmonary resuscitation (the addition of ECMO during CPR). It may improve outcomes, but it is both enormously expensive and all existing studies (four datasets) have major risk of bias.^38,39 How should this be weighed against other possible treatments?
3. Mechanical external chest compression devices (which one ambulance service recently installed on every single ambulance at a cost of $55 million). There is no difference in neurologically intact 30-day survival, and previous research has shown them to not be cost-effective.^40–42 How should cost be taken into account?

There are no easy answers, and differences of opinion are completely reasonable.

Running a large, randomised trial when you are dealing with life and death is ethically and logistically a mess, so most of our guidelines are often more of a ‘best guess’ by a handful of experts rather than ‘proven’ treatments. Unsurprisingly, when there is a lack of empirical evidence, experts disagree. During our research, several guideline writers have mentioned the difficulty of being caught between conflicting expert medical opinions – as a paramedic, when several professors of medicine disagree, which one’s advice should you follow?

Of course, having this variation across the country provides a perfect opportunity to run natural experiments, comparing the outcomes across each state to determine which treatment works best. Strangely enough, while this occasionally happens,⁴³ it’s rare – again, there isn’t any centralised research institute to take ownership of such a project, and getting ethics, logistics, and funding to compare a dozen treatments across the country is extraordinarily painful. While some of the larger services have extremely well-equipped and talented research units, many of the smaller services cannot afford this – and in almost all cases, many paramedic services reasonably view it as an adjunct to their ‘core business’ of delivering 000- or 111-services, and research consequently tends to receive secondary attention from the organisations.

The benefits of local guidelines

There are some benefits to this variation.

• Innovation is easier when there’s variation across the country (perhaps helped slightly by some friendly competition), and the services are constantly trying new things out. Remember: different isn’t always wrong.
• Australia is big, and different places need different treatments. The tropical medicine of the far north and the urban population of a major city are totally different beasts, and a one-size-fits-all approach will never be appropriate.
• Paramedics services aim to integrate with their local hospital system. Therefore, if a hospital (or entire health department) has already chosen a particular medication as their preference, it often makes sense to adopt the same medication for continuity of care, even if there is different out-of-hospital evidence.
• Each service falls under completely different laws and regulations. Some are closely tied to the choices of their local hospital system, while others are completely independent entities. Choices regarding guidelines are indirectly influenced by this.
• Having local variations is much easier with path dependence. If a service already has a particular service or technology established, it may be much more efficient to choose new treatments that match nicely with those, rather than rebuilding the system from scratch. For example, if a service already has highly trained primary care paramedic system, it may be easy to introduce a range of treatments for clinicians to deliver. If that system isn’t in place, it may be more efficient to instead invest in telemedicine for all paramedics to use.
• Local guidelines recognises that budgets vary greatly across services: while Tasmania comes in first with a generous $258 per person, Western Australia struggles to keep up with nearly half that at $135.¹ With some of our medications being expensive – the lifesaving Tenecteplase comes in at just under $2000 per dose, multiplied by thousands of paramedics and replaced after shelf-life expiry – some services genuinely just cannot afford to do what others can. (However, it is worth noting that this has not caused any significant difficulties in the United Kingdom or New Zealand, both of whom have local variations to national guidelines.)

The drawbacks of local guidelines

However, of course, there are also problems to this inconsistency.

• While having flexibility is good, having paramedics giving totally different treatments for no reason isn’t. It exacerbates inequalities in healthcare and is confusing for paramedics and patients alike.
• More concerningly, some guidelines are massively out of date with current medical practice (this isn’t a name and shame article, so we won’t point them out here), and patients in those areas are receiving treatments that haven’t been practiced in hospitals in years.
• While this variation provides an opportunity for us to learn from each other, we often just aren’t. During some recent interviews with the writers of CPGs in Australia, one person was shocked when I told them what their neighbour state is doing (‘They do what?!’), showing just how unaware some are about these variations.
• Similarly, when asking one former guideline writer how they came up with their guidelines, they frankly told us that they just make them up, sometimes with a quick Google search. That person is a highly trained doctor, and the treatments are probably correct – but there’s still a risk of error, or bias, or of that one person not keeping up with the mountains of new evidence.⁴⁴ It’s not a good system, and not what you would expect from billions of dollars of investment.
• Above all, our current system is painfully inefficient. With each service producing their own CPGs we are – very literally – continually writing the same book nine times over.

As some recent, unpublished research we have conducted shows, this is compounded by a critical lack of resources to the CPG writers. Given the fundamental nature of CPGs, it would be reasonable to assume that there is a team continually researching the very best evidence and carefully writing guidelines. That just isn’t always the case. Some of the bigger services can support this kind of venture, but smaller services can’t afford it. The majority of services produce guidelines with a team of 1-2 individuals, estimated to be allocated less than 0.001% of the service’s annual budget; a surprisingly small amount to decide what treatment patients are given.

Since we started this series of posters, we have been contacted multiple times by different CPG writers, who have asked us to produce a poster on a particular topic so that they can quickly review what everyone else is doing. While we are happy to do it, surely our emergency healthcare system shouldn’t rely on unpaid volunteers making informal posters. Pooling of resources could allow us to access economies of scale, producing higher-quality medical guidelines for lower overall cost.

Let’s dream.

Given path dependence, achieving consistency nationally would require an extraordinary level of commitment from the services. The services have already demonstrated a great dedication to accountability and transparency, with all ten CPGs now open access. Building on this, what would ideal guideline development look like?

There would be a national research institute – or, better still, a consortium including consumers (patients), paramedics of all levels, researchers, managers, and a variety of other stakeholders – that both produces living systematic reviews on out-of-hospital evidence-based medicine,45 and that runs continual experiments to determine best treatment. From this, a rigorous set of national guidelines could be developed, that each State and Territory can tailor to their local population’s needs, logistics, and budget. Ideally, that tailoring wouldn’t be based purely on State or Territory at all, but on more meaningful factors like how rural a patient is (a separate set of ‘urban’ and ‘rural’ guidelines that cross borders may be more appropriate in Australasia than a separate set for each State and Territory).

Paramedicine exists to treat patients, often in emergencies. If we want that treatment to be good, we need to focus on creating rigorous, evidence-based guidelines.

Enjoy the posters from the Clinical Guideline Series.

Links to Australasia’s emergency paramedic Clinical Practice Guidelines

Australian Capital Territory

New South Wales

New Zealand (both services)

Northern Territory

Queensland

South Australia

Tasmania

Victoria

Western Australia

A few points to keep in mind when reading these posters

• They are a snapshot in time. These services tend to update their treatments multiple times per year (this responsiveness is exactly what we would like to see in medicine), and many of these posters will rapidly become out of date. For example, when the analgesia poster was completed, NZ had removed morphine; it’s now been re-introduced to the national guidelines as some services are continuing to use it while some aren’t. For the current treatments, refer to the open-access CPGs linked at the end.
• There is, for almost all treatments, no objective right or wrong.
• The most popular treatment isn’t always the best.
• The services don’t have the same needs or resources, and differences in guidelines may be in the best interests of patients.

References 

1. Steering Committee for the Review of Government Service Provision. Report on Government Services. Canberra, Australia; 2023 Feb.

2. St John New Zealand. Annual Report. Auckland, New Zealand; 2022.

3. Wellington Free Ambulance. Impact Report. Wellington, New Zealand; 2022 Nov.

4. ACT Ambulance Service. Clinical Management Guidelines. https://esa.act.gov.au/about-esa-emergency-services/ambulance/clinical-management-guidelines.

5. NSW Ambulance. NSW Ambulance Protocols. https://apps.apple.com/au/app/nsw-ambulance-protocols/id1103576564.

6. New Zealand National Ambulance Sector Clinical Working Group. Emergency Ambulance Service CPGs. https://cpg.stjohn.org.nz/tabs/guidelines.

7. St John Ambulance Australia (NT) Inc. Clinical Practice Manual. https://stjohnnt.org.au/ambulance/ambulance-services.

8. Queensland Ambulance Service. Clinical Practice Manual (CPM). https://www.ambulance.qld.gov.au/clinical.html.

9. SA Ambulance Service. SA Ambulance CPG. https://clinical.saambulance.sa.gov.au/tabs/home.

10. Ambulance Tasmania. Clinical Practice Guidelines. https://cpg.ambulance.tas.gov.au/tabs/guidelines.

11. Ambulance Victoria. Clinical Practice Guidelines. https://cpg.ambulance.vic.gov.au/#/entry.

12. St John Ambulance Western Australia Ltd. Clinical Practice Guidelines. https://clinical.stjohnwa.com.au/clinical-practice-guidelines.

13. Wilkinson-Stokes M, Maria S, Colbeck M. A comparison of Australasian jurisdictional ambulance services’ clinical practice guidelines series: An introduction. Australasian Journal of Paramedicine [Internet]. 2021 Sep 15;18.

14. The Shift Extension. The Clinical Guideline Manifesto. https://www.theshiftextension.org/clinical-guideline-manifesto.

15. Nambiar D, Pearce JW, Bray J, Stephenson M, Nehme Z, Masters S, et al. Variations in the care of agitated patients in Australia and New Zealand ambulance services. Emergency Medicine Australasia. 2020 Jun 15;32(3):438–45.

16. Wilkinson-Stokes M, Rowland D, Spencer M, Maria S, Colbeck M. A comparison of Australasian jurisdictional ambulance services’ paramedic clinical practice guidelines series: Adult anaphylaxis. Australasian Journal of Paramedicine [Internet]. 2021 Sep 15;18.

17. Vella SP, Chen Q, Maher CG, Simpson P, Swain MS, Machado GC. Paramedic care for back pain: A review of Australian and New Zealand clinical practice guidelines. Australas Emerg Care. 2022 Dec;25(4):354–60.

18. Colbeck M, Swain A, Gibson J, Parker L, Bailey P, Burke P, et al. Australasian Paramedic Clinical Practice Guidelines for Managing Cardiac Arrest: An Appraisal. Australasian Journal of Paramedicine. 2019 Jan 1;16:1–10.

19. Flanagan B, Pearce J, Barr N, Eastwood K. PP14 An investigation of ambulance clinical recommendations for the management of obstetric emergencies in Australia and New Zealand. Emergency Medicine Journal. 2021 Sep 19;38(9):A7.1-A7.

20. Wilkinson-Stokes M, Ryan E, Williams M, Spencer M, Maria SMS, Colbeck M. A comparison of australasian jurisdictional ambulance services’ paramedic clinical practice guidelines series: Adult sepsis. Australasian Journal of Paramedicine. 2021;18.

21. Australasian College of Paramedicine. Expressions of Interest - College Committees and Working Groups. https://paramedics.org/news/eoi-committee-wg-2022.

22. Joint Royal Colleges Ambulance Liaison Committee. Clinical Guidelines. https://www.jrcalc.org.uk/about/.

23. Long DN, Hobbs L, Devenish S. Rote learning: the ugly duckling of student paramedic education? Irish Journal of Paramedicine. 2018 Sep 26;3(2).

24. Jensen J, Dobson T. Towards National Evidence-Informed Practice Guidelines for Canadian EMS: Future Directions. Healthcare Policy. 2011 Aug;7(1):22–31.

25. Stewart S. Preparedness of Australasian and UK Paramedic Academics to teach Evidence Based Practice [Doctor of Philosophy]. [Melbourne, Australia]: Victoria University; 2022.

26. Maria S. Paramedics’ clinical reasoning and decision-making in using clinical protocols and guidelines [Doctor of Philosophy]. [Adelaide, Australia]: Flinders University; 2021.

27. Eburn M. Treatment outside ‘clinical scope.’ Australian Emergency Law. 2020 Jan 24;

28. Ambulance Service of NSW v Worley [2006] NSWCA 102.

29. Queensland v Masson [2020] HCA 28.

30. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999 Feb 20;318(7182):527–30.

31. Peschel RE, Peschel E. What Physicians Have in Common with Sherlock Holmes: Discussion Paper. J R Soc Med. 1989 Jan 29;82(1):33–6.

32. Rapezzi C, Sinagra G, Merlo M, Ferrari R. The impossible interviews—Sherlock Holmes interviews David Sackett: ‘how much can we trust the guidelines?’ Eur Heart J. 2021 Sep 14;42(35):3422–4.

33. Zehtabchi S, Kline JA. The Art and Science of Probabilistic Decision-making in Emergency Medicine. Academic Emergency Medicine. 2010 Apr 13;17(5):521–3.

34. The Council of Ambulance Authorities. About Us. https://www.caa.net.au/about.

35. Wilkinson-Stokes M. A taxonomy of Australian and New Zealand paramedic clinical roles. Australasian Journal of Paramedicine [Internet]. 2021 Jan 3;18:1–20.

36. Makrides T, Baranowski L, Hawkes-Frost L, Helmer J. Advanced care or advanced life support – what are we providing? Australasian Journal of Paramedicine [Internet]. 2021 Jul 13;18:1–3.

37. Anderson J, Ebeid A, Stallwood-Hall C. Pre-hospital tracheal intubation in severe traumatic brain injury: a systematic review and meta-analysis. Br J Anaesth. 2022 Dec;129(6):977–84.

38. Kruit N, Rattan N, Tian D, Dieleman S, Burrell A, Dennis M. Prehospital Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth. 2023 May;37(5):748–54.

39. Doan TN, Rashford S, Pincus J, Bosley E. Cost-effectiveness of extracorporeal cardiopulmonary resuscitation for refractory out-of-hospital cardiac arrest: A modelling study. Resusc Plus. 2022 Dec;12:100309.

40. Marti J, Hulme C, Ferreira Z, Nikolova S, Lall R, Kaye C, et al. The cost-effectiveness of a mechanical compression device in out-of-hospital cardiac arrest. Resuscitation. 2017 Aug;117:1–7.

41. Chiang C-Y, Lim K-C, Lai PC, Tsai T-Y, Huang YT, Tsai M-J. Comparison between Prehospital Mechanical Cardiopulmonary Resuscitation (CPR) Devices and Manual CPR for Out-of-Hospital Cardiac Arrest: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis. J Clin Med. 2022 Mar 7;11(5):1448.

42. NSW Health. New ambulance package to transform cardiac care. https://www.health.nsw.gov.au/news/Pages/20220819_00.aspx. 2022 Aug 19;

43. Gruen R, Bernard S, Mitra B, Gantner D, Medcalf R, Reade M, et al. Pre-hospital Anti-fibrinolytics for Traumatic Coagulopathy and Haemorrhage (The PATCH Study) (PATCH). https://www.patchtrauma.org.

44. Bastian H, Glasziou P, Chalmers I. Seventy-Five Trials and Eleven Systematic Reviews a Day: How Will We Ever Keep Up? PLoS Med. 2010 Sep 21;7(9):e1000326.

45. The Cochrane Collaboration. Living systematic reviews. https://community.cochrane.org/review-production/production-resources/living-systematic-reviews.

Thanks to everyone who contribute to this resource:

• Robyn Bailey
• Eva Cambridge
• Lawson Chan
• Evelyn Colbeck
• Marc Colbeck
• Deane Coxall
• Tom Gleeson-Hammerton
• Dr Tim Jones
• Jennifer Kelley
• Thomas Lynch
• Dr Sonja Maria
• Angus McLean
• Dr Jacqueline Mills
• Daniel Mitchell
• Jayella Nash
• Kim Nieuwenhuizen
• James Oswald
• Ryan Parry
• Drew Paterson
• Samuel Paton (1)
• Samuel Paton (2)
• Alyssa Pitcher
• Holly Reefman
• Tristan Rhys
• Desiree Rowland
• Elena Ryan
• Maddison Spencer
• Natasha St John
• Alex Telford
• Emma Thompson
• Alana Toso
• Kyle van Loggerenberg
• Andrew van Noordenburg
• John-Paul van Rensberg
• Henry Waldren
• Brayden West
• Sunny Whitfield
• Matt Wilkinson-Stokes
• Michael Williams
• Nelson Yeung
• The Free Radicals team
• The Outback Responders team