Lindsay Mackay [00:00:00]
Welcome to Ambulance Insights, your go-to for the latest conversations covering all things ambulance.  I’m Lindsay Mackay. 

Han-Wei Lee [00:01:00]
And I’m Han-Wei Lee, and this is the Great Divide series where we tackle one of the biggest challenges in the pre-hospital care setting – bridging the gap between urban and rural ambulance services.  

Lindsay Mackay [00:01:13]
Each episode we bring in experts to share their stories and spark conversations that matter. So wherever you are based, there’s one for you.  

Han-Wei Lee [00:01:19}
Today we are honored to speak with a really distinguished guest with nearly four decades of experience. Our guest is a leader in emergency medical services and a passionate advocate for first responder wellbeing. His contributions to ambulance services and resuscitation have been recognised with numerous honors, including the Ambulance Service Medal and the Heart Foundation President’s Award. Since retiring from Ambulance Victoria, he’s remained actively engaged as an academic management consultant and a non-executive director of a number of non-for-profit organisations, allowing him to continue his passion for supporting the community and improving emergency medical services. Welcome, Tony.

Tony Walker [00:01:58]
Thank you very much. 

Lindsay Mackay [00:02:00]
I would say welcome Tony, ASM, but I mean, I think that doesn’t matter in this room. I’ve never been in a room with so many ASMs. We appreciate you coming in. You’ve had an amazing career, and we definitely appreciate you coming. If we dive straight into this, so our podcast theme is around that great divide. Now we aren’t just talking about geography here, it’s really the very real differences and how is care delivered, how it’s accessed and experienced, really depending on where you live around Australia.

Han-Wei Lee [00:02:36]
We’re talking about the gap in resources, response times, workforce availability, technology, and even patient outcomes between metropolitan and rural or remote communities. Today we want to look at equity, and how we can bridge that divide to ensure everyone, no matter their postcode, receives the care they need it. I’d just be interested, Tony, to get your view on the Great Divide as a whole, maybe relevant to what you did in Ambulance Victoria? Or now on, multiple boards and committees. 

Tony Walker [00:03:03]
Well, it’s a really interesting topic because, you know, nearly a third of our population live in, rural and regional Australia. And, as a result of that, their expectations around services are, very similar to people in Melbourne and other urban areas around urban cities, around Australia. So you’re dealing with people who are looking for, a similar experience, particularly sea changes and tree changes. People have moved out to those areas. but the ability of ambulance services to deliver those services the same way they would in say, the middle of Sydney versus, doing it out in Outback Australia is obviously different. And so it’s in, my experience, it’s about, one – recognising that equity actually requires you to do things differently in rural and regional Australia than you would do in urban areas. The outcomes can still be the same, but you have to think differently. You need to harness the incredible community that exists in those areas, to be part of the response system more broadly. And importantly also being open to different ways of delivering services.

So engaging in, you know, to give a quick example – in one of the times in my time at Ambulance Victoria, we worked with remote area nurses and volunteers who were not able to give effective pain relief. Penthrane, most listeners would be aware of, it wears off after about 20 or 30 minutes and so what’s next? They might still have another hour till the ambulance arrives. So we work through a process of implementing intranasal fentanyl, for volunteers and remote nurses who are operating as part of our system. Now, if I tried to do that in the middle of urban Melbourne, I’d be having some pretty significant conversations industrially and with other professional groups. But in rural and regional Victoria it was actually okay. We put in strong clinical governance around it and they were delivering really effective care. And I remember one case in particular, you know, two or three hours in the high country of Gippsland, away from the nearest ambulance, a young kid had fallen into a fire, serious burns. We had a remote area nurse who was there in around 30 minutes who was able to give effective pain relief, support that child, until help arrived with road and air ambulance. So again, it’s thinking outside the square and harnessing what you’ve got in those communities to deliver, not trying to replicate what you’ve got in an urban area because it just doesn’t work. 

Lindsay Mackay [00:05:26]
Yeah, most definitely. And I think what resonates there with me is that, especially with your time in Ambulance Victoria, you were always wanting to continually innovate and think about things that some people would say was a bit different. And when you look at it, Ambulance Victoria is leading in cardiac arrest outcomes. To set the scene, can you describe how cardiac arrest typically differs between urban and rural? 

Tony Walker [00:05:51]
Yep. If we take a step right back, we know that people living in rural areas around Australia, have worse outcomes for cardiac arrest. A landmark study done by a paramedic and other researchers around Australia last year highlighted the fact that the areas that have the highest rates of cardiac arrest, the lowest levels of CPR are in rural and regional parts of Australia. So that creates inequity straight away. The reality of cardiac arrest in urban area is someone dials Triple Zero in a metropolitan area of Melbourne as an example. You’re getting a first responder, potentially activated by Good Sam, you’re getting a fire to correspond program, you’re getting somewhere usually in sub seven minutes, and then backed up pretty quickly by a paramedic crew and an intensive care paramedic as well.

So, you’re getting the gold plated service. If you’re in a rural area, then the reality is you may or may not have access to a first responder that’s near you. The fire services may or may not be part of a co response model in those areas. So you’re waiting for the ambulance to arrive to activate care. And so that activation of care could be an hour away. And we all know that there’s a 10% reduction in survival for every minute that someone’s in cardiac arrest. So just doing the sums, the likelihood of someone surviving in those areas is low unless you’ve got a system that can provide that support. And if we look at the things that make a difference, if we look at the chain of survival and all those links in the chain, are not equal. We look at the evidence, would suggest that, not suggest, actually highlight, that the best outcomes occur in those settings prior to an ambulance arriving. An ambulance makes a difference as well. But beyond that, in the chain, studies don’t demonstrate a significant change in outcomes. So it’s what happens prior to ambulance arriving and when ambulance arrives that makes the difference. And so therefore, if we know what improves survival, what do we need to do about it to actually replicate that in a different way, maybe in a rural, regional community than we do would in the middle of an urban city. 

Han-Wei Lee [00:08:00]
It’s interesting, Tony, I think for all those reasons you’ve just highlighted – out of hospital cardiac arrest, the rates of survival to discharge are 50% lower, in rural versus metro areas. You talked a little bit about that tyranny of distance – what do you think the other drivers of that gap in the rural and remote areas are?

Tony Walker [00:08:20]
If we look at just the health outcomes more broadly, they have by default often lower access to primary health (GPs), can often have untreated co-morbidities that can worsen the risk of cardiac arrest, and they aren’t necessarily surrounded by people who can support them when an event occurs. So, the reality is that their health indicators are more likely to lead to a cardiac arrest than you would see in, say, urban areas where people have got better access to primary health, better access to messaging and other things that may not exist in some of those rural areas.  

Lindsay Mackay [00:09:00]
I think when you think about nowadays, we’ve obviously got big campaigns on AEDs, we’ve got things like Good Sam, which you introduced to Ambulance Victoria. What do you think that role of community responders and Good Sam type programs will really help bridging the gap in those communities?  

Tony Walker [00:08:53]
I think it’s critical, and it’s interesting if you look at cardiac arrest outcomes more broadly, around Australia and internationally, we often put Seattle up there as the penultimate place. The reality is the response frame of Seattle is essentially the size of the Melbourne CBD, and they’re getting around 51% survival in cardiac arrest. You look at Victoria with 41%, that’s for the whole state. Now, interestingly, WA – one of the biggest land masses in the world, its survival rate is 40% for the whole state. And if you look at that and think, that just must be Perth, it’s not, it’s the whole of the state. Why? Because what you end up with is community response occurring to support that early defibrillation, early CPR. So, I think often there’s a sense that ambulance services need to own the complete response in every community. The reality is ambulance needs to govern a system of care, a cardiac arrest system of care. So, Good Sam is a great example. No ambulance service can afford, or have the resources to provide a sub five minute response. But if you look at the best outcomes in cardiac arrest, you’re getting early CPR, early defibrillation in that first give minutes. So to systemise that, in my view, that’s where products like Good Sam, Pulse Point, the St. John WA App, and similar products that are used around the world, make the difference.

So what you do there basically is, when someone dials triple zero, first step is someone at the end of the phone is actually helping them know what to do, to guide them to do CPR. That’s the first thing. The second thing is that they’re immediately dispatching a responder in Victoria, that’s been within a few hundred meters of a cardiac arrest in rural areas, it’s within five kilometers. But what you end up doing there is basically saying, well, you’ve got a system now that if you can hang more responders on that App, you can hang more AEDs on that App. Then what you’re really doing is replicating what you’re seeing in urban parts of Victoria, Melbourne and Sydney or around Australia, major cities into those rural areas. And I think one of the great things that organisations like EMS Victoria have been doing is the Heart Safe Community program. Which is walking into a rural community, ’cause if you’ve visited one rural community, you’ve visited one rural community, it’s not homogenous. You can’t replicate what happens in this town, in this town, it just doesn’t work. So how do you walk into that community, find the leaders in that community, get them engaged in how we as a group improve cardiac arrest in our response area, our town. And then focus on increasing the numbers of people trained in CPR, getting them signed up to Good Sam, increasing the number of AEDs.

Again, if you look at the St. John work at the moment in Defib in your Street. In the communities they’re doing that in Melbourne, they’re getting defibrillators that are three minutes walking distance from people. So, in towns you can do that, as you move out to properties and larger properties, well actually the principals are the same. A colleague of mine has an AED on the front fence of his property and everyone around knows where it is and people are trained up. So, you might not get them there in the five minutes, but you can get someone starting good CPR and you might be getting an AED there in 10. And it gives them a better chance because the ambulance might still be an hour away. So things like Good Sam are the tie that binds, they’re the thing that basically enables you to have an army of responders, built around what your community. It could be a block of flats, that’s a community. So defining community and then working out how you best create a response within that sort of five-ish minutes, then allows you to do something different there than you might do over here.

Han-Wei Lee [00:12:42]
It’s interesting you brought up the King County, which we all cite, and have done for probably the last decade. They’re the pinnacle of survival rates and I probably didn’t really think about the fact that the 41% for Ambulance Victoria in the last few Vakar reports, actually did cover the whole state and, Western Australia as well.  Besides Seattle King County, how do you think we compare to other countries?  

Tony Walker [00:12:56]
I think there’s still a bit of, haves and have-nots, in cardiac arrest, even in Australia. So, we’ve got from some pretty significant differences between the ambulance services that you would argue on all accounts should be relatively equal, even in urban areas. So I think where you leave it to chance, where we bought defibrillators, we’ve got some community CPR programs, and then all of a sudden you have the odd survivor and everyone gets really excited about the fact we’re doing really well, until one day someone looks at the data and goes, well actually we’re not doing that well. And I think if you look at the work the Global Resuscitation Alliance has been doing internationally – built on the work that came out of Seattle King County. The Resuscitation Academy is very much about having a system where cardiac arrest is part of your DNA and the principle being, if you can get to someone quick enough with a defibrillator, almost every case of cardiac arrest is survivable. You know, if you can get someone a defibrillator in the first minute 90% of people survive. So, how do you systemise that and how do you go near enoughs not good enough. It’s that sense that we need to improve, that improvement culture, measure and improve, a culture of excellence, the one percenters that make a difference. Then it’s a matter of not getting excited about your survival rates, that might be weighted towards the high volume cardiac arrest of the current urban areas. But looking at your rural data and looking by local government area and saying well actually our cardiac arrest outcomes in this community should be able to be, (if we create a system effectively), as good as occurring in Melbourne.

I think that’s where the crux of it. So cardiac arrest as an outcome in those areas, can improve if there’s a focus on people actually wanting it to improve, and measuring and improving reporting your data out there. You know, there’s a healthy competition between St. John WA and Victoria, I can assure you. A state the size of WA with 40% survival and were actually leading the pack last year. It’s because they have that built in. They have first responder app. Really significant numbers of community responders and I think that’s the biggest challenge. Denmark, which has some of the best cardiac arrest survivals, I think number two in the world, back compared to King County, has over a hundred thousand first responders attached to the app, a plethora of AEDs distributed. We’ve got Victoria around 16, 17,000. That’s very impressive. You know, of a population of six or 7 million, how do you get that up there to get a few hundred thousand people. When you do that, when you saturate, then you can get an outcome, and that saturation can be by community as well.  So you can be in a rural area and saturate that community with AEDs and with people trained, connected to Good Sam, you get good outcomes.  

Lindsay Mackay [00:16:24]
You talk about that high level strategy and when you think about the future of ambulance and bridging that gap through innovation and real collaboration, what does that look like to you? How do you think we’re going to do that into the future? 

Tony Walker [00:16: 36]
Well, I think the days of ambulance services saying we’ve got this are gone. The reality is that, partnering and collaborating is actually the future of ambulance services. The days of sending an ambulance out to every case is no longer the way ambulance services run and can’t continue to do it that way. So if you’re therefore triaging people via various pathways to the right care at the right time, the reality is the people who provide the right care at the right time are your partners, it’s about a relationship. So you do that through secondary triage and the work that you’ve been intimately involved with, to see increased pathways where you can refer more people safely to those partners. 

Then comes in the community, so how do you work with your community to understand what to do in an emergency? What number to call, how they can volunteer to be part of the system, either as a volunteer or ambulance officer? In many rural areas, or as a first responder, as part of a Good SAM type system. How do you engage the other people in the community, like remote area nurses who are operating in that community independently of ambulance. How do you bring them into the system? They bring that high level advanced life support care.  

So it’s looking for those things in those communities to collaborate and to improve your response, because you can’t do it by yourself. Fire services. I am absolutely amazed that Victoria’s the only state and territory around Australia, where fire services formally respond as a system co-responder to cardiac arrest. Now I know others would say, oh, we’ve got defibrillators on our firetrucks and they can respond, but they’re not automatically responded to suspected cardiac arrest. That shaves two minutes off response. Now, if I went to our government and said, I want to shave two minutes of our response time, it would cost millions and millions of dollars. For me, it’s for who are the other people in your community? Police. Particularly in rural areas, why can’t they carry AEDs and respond? In other parts of the world they do, and they do it very effectively. So I think it’s, again, who are your partners who can be out there and not trying to own it all yourself. You’re a system. You’re responsible for the system, and if you like, ensuring that the various pillars are in place. But then it’s about working with others to deliver the outcomes to community and other partners are critical to that.  

Lindsay Mackay [00:19:26]
I think that’s great. I promise Han-Wei, I didn’t set him up to talk about my previous work, it just came out well. It was funny recently, when Han-Wei and I were chatting around secondary triage, and Han-Wei was saying he was the first person to take the first ever call in Ambulance Victoria. And then he made a comment about 10 peopland the size of the room. And I said, have you seen building recently? He said, no and I said, we need to get you in.

I think one of the big things here when you talk about that connected care and then the big part about innovation it can be bold, but feeling okay to progress with it. Especially what Ambulance Victoria did with secondary triage. I heard about AV secondary triage in the UK and we all thought you were nuts. Then it drove my entire passion, for health and triage across ambulance. But look what’s happening today with telehealth and video triage and they, Victoria have just celebrated one year of video triage. Something they told me that we’d never achieve, so it’s amazing. Tony, I just want to go back to, using police and fire as co-responders. We know there’s a bunch of industrial/role delineation issues that Victoria successfully overcome.  I know the early days were quite interesting. What recommendations have you got to overcome those barriers in some of the other states to get that co-responder model happening. 

Tony Walker [00:21:00}
First thing for me is, you need to pay them. So, this is part of their job, and it’s a different job to what firefighters often signed up for. So often the barrier is that people go, well, they expect them to do that within their normal role. So in Victoria there were negotiations that led to industrial allowances that recognise the impact this has, and I’ve got to say the impact is significant. I mean, fire services now are doing more in Victoria, more EMS calls than they are doing fire calls. We shouldn’t underestimate the psychological impact on people who are responding to cardiac arrest, in Victoria, paramedics would likely see cardiac arrests once or twice a year.  Firefighters may see them more often because the reality is that’s what they’re getting responded to constantly. So, it’s engagement, it’s understanding. This is a professional role for firefighters and their unions, and others believe that, and I support that. So therefore, what are the qualifications they require?  We may have views or that’s not what’s necessary. Well, I think it’s a negotiation if you’re wanting to bring them on board. It’s about recognising that this is about a professional uplift for firefighters. How do you support them, to recognise that? I think that’s one of the first things, and that certainly was the work that Victoria did. People before me like Karen Smith and Greg Seller and others have done that work to get those things up and running. I inherited their excellent work in those spaces. I think that’s a really important thing. And I think then demonstrating the benefit. Showing the benefit that’s out there. I think that’s probably through the lens of fire services.

With police, it’s a lot different. I mean, they’re incredibly busy. The police are doing a lot of calls today, mental health and other things that arguably should be the responsibility of ambulance services and other health services. So, they’re naturally cautious about taking on another role, but I think if it’s properly limited and saying, we don’t expect you to do it in a big urban area, the system should support that with how it works now. But in a small rural town where you are the local police officer, and you may be the only professional responder in that actual town, why wouldn’t we set up a system where they could carry an AED and be a co-responder. And I think if you create those boundaries and recognise that it’s not something you’re gonna be doing every day. It’s going to be a rare event. Then I think that can make a difference. Same with volunteers, firefighters in those communities. Good Sam has maybe replaced the need for some of that in some communities. But equally, working with those fire fighters who are, by their nature volunteering in the system because they want to support their community, are equally happy to support cardiac arrest response beause it’s their neighbors, their friends, their own family. That’s why people volunteer in rural areas. How do you create a system that enables them to do that doesn’t become chance or someone ringing a friend up the road? It’s actually, if I dial triple zero, I know in my community that responders and the system will respond. It might look different to what it looks like in Melbourne or Sydney or Brisbane, but it’s still an effective response – providing good CPR, early defibrillation and therefore the best chance of an outcome.  

Lindsay Mackay [00:24:00]
If you could make one big reform, something in the reform agenda or something you think that would get a positive outcome, do you think it would be something around access to AEDs or more around that actual system coordinating connection with different emergency services? What do you think would be the one? 

Tony Waker [00:24:15]
So if I was King for the day, every state and territory in Australia will be signed up to a first responder app. Now I’m being agnostic in the product because I’ve seen how effective St. John WA’s app is, and it works very well. I mean, there’s a part of me that thinks, wouldn’t it be wonderful that you could cross any border in Australia. We can do that in Tasmania and Victoria and New South Wales and in New Zealand and South Australia. Good Sam recognises you when you cross those boundaries. It would be great to see every state and territory have access to a first responder app, first of all.

And I think therefore what you’ve got is an ability to then say, now we’ve got the ability to put volunteers onto that system. So it’s not a chance, it’s not someone calls another number, it’s people, having that app on their phone and being able to sign up to respond, and then you need to grow the numbers. In those communities, you need to have AEDs within three or four minutes of where people are. I’m excited by, work underway in the rollout of ultra portable AEDs. I think its early days yet, and we’re looking forward to clinical trials coming out, looking at that as part of the Good Sam response in Victoria and New Zealand. I think things like that, are the next level. So technology, Heart Hero in the United States, those smaller, relatively inexpensive defibrillators that can be in a backpack and people could have sitting on the wall at home, well, all of a sudden, you’re changing your whole approach to cardiac arrest. So you’re not having to head down to the local post office for the $3,000 defibrillator sitting there. I’m not saying don’t do that, but I think over the next few years, ultra portal AEDs will take us to a new level in access to early defibrillation.  

Lindsay Mackay [00:26:10]
I remember when Tony was heading off on his retirement, or sorry, semi-retirement. I remember somebody asked you, what was one thing that you felt a bit of trepidation around? And I always remember you saying about not having an AED in my car. And then I remember you went and got one.

Tony Walker [00:26:35]
That’s correct. Yes. It was 20 years of always having a defibrillator in my car so I felt quite naked without one. So I did, get one. And just as a quick aside, last weekend at a soccer game, some poor young child fractured a collarbone and dislocated her shoulder and it reminded me I maybe don’t have as much first aid gear, so I now have a very well equipped first aid kit in the back of my car as well. 

Han-Wei Lee [00:27:11]
Tony, you touched on the ultra-portable defibs, which are very different to the Old Heart DRS that I lugged around. What other advances in technology or innovation do you see as vital? Is it AI triage, is it drones dropping off AEDs?

Tony Walker [00:27:38]
I think the jury’s out on some of them. We know drones in some communities can respond quickly, so I think there is a role for drones. I think there’s emerging technologies that people are playing with, and I think over time they’ll be active in systems and we’ll get to evaluate if they make an impact.  The role of telehealth I think is critical. I think telehealth two opportunities in my view. We’re seeing through the work of secondary triage and virtual emergency departments the ability to bring senior clinicians to a scene, to evaluate a scene. And the ability to video conference to someone’s home at a point of a triple zero call, which would be ideal to the circumstance, you’re literally getting first person on the scene, and I remember the previous CEO of St. John WA, Tony, who many years ago talked about their first responders would be the person at the end of the phone actually starting treatment by guiding people in what to do.  

And so I think Telehealth gives us an opportunity to do more. So you might have paramedics working in isolated rural areas who have the support of senior clinicians and medics and others to enable them to apply advanced skills that they would not originally do in urban areas, but it allows the extension and they feel they’ve got that support to be able to do that. So I think Telehealth’s going to enable both better assessment and better triaging and pathways for people to be cared for. And also support clinicians to provide advanced care in some of those communities where we’re not going to have paramedic practitioners all around Australia. But we’ve got brilliant, well-trained ambos and volunteers in rural communities with the right training, narrow focus on the skill they provide and back up support to guide them through that. And we saw that when we introduced advanced life support into regional Victoria back in the late nineties, early two thousands. One of the things people were talking about intubating patients. That was the thing that needed to happen. We looked at the data. The data didn’t suggest that. I did a review with George Berger, well-known emergency physician, and what we found was actually that wasn’t the issue. The issue was people were not getting effective pain relief. The issue was people who are not getting fluid resuscitation. The issue was people who were dying from chest injuries.

And so the sense of, oh, you have to be an intensive care paramedic to put a chest tube in. No, you don’t. You can put a 14 gauge needle through into someone’s chest and decompress it. And we saw cases occurring like that. I remember seeing paramedics in those rural communities who go, I can now give effective pain relief to someone. And they worked hard, they were vocationally trained and this was hard. We asked them, but they worked so hard because they knew they were going to make a difference to people in their own community and they did, with those skills and techniques. So, I think it’s that sense of, we shouldn’t limit ourselves to what they can do, because the system can provide clinical governance support to enable them to do that. So I think they’re probably the key ones.  

The other really exciting thing for me is what’s happening in stroke care. And you look at the stroke ambulances that are operating in Melbourne, they’re significantly reducing time to early thrombolysis with good outcomes for the right type of stroke, for thrombolytic strokes. And they’re importantly triaging people and getting them to get that clot removed. So I think that’s a good example of we’ve now taken a tool that was hospital based, like monitors and defibrillators were in the first instance, they’re now coming out to a stroke ambulance. And now there are, through Australia Stroke Alliance, trials underway around headsets that can, actually diagnose bleeds, miniaturized CT scanners that will be able to go into helicopters and fixed wing aircraft. Now you’ve started to create equity and, you’ve got the groups like the RFDS who can get out there, respond in a primary response way, the community doing their work and with telehealth and other support, creating an environment where they can respond out there and start providing a treatment that previously would require someone to go to a specialist center to get. 

So I think miniaturization of new technology, point of care testing. So we’ll have paramedics and paramedic practitioners out there with miniaturized, tools. Ultrasound. Now again, you know, these were big, huge machines, now you can put them in a backpack and carry them out there as a small tool.

Exactly. Exactly. Yeah. So, to me it’s diagnostic ability to enable you then to do other treatments, because the treatment’s often limited because you haven’t got the ability to diagnose, well actually the tools are out there for us to do that. You can provide that extra care. So they’re the things that excite me in the sense of these things bringing the hospital environment out to the pre-hospital environment, into rural areas, and then a sense of, well, how do you support the clinician who might do this once every five years?  

Well, that’s where telehealth comes in. And I think if you look at Google glasses and those sort of things that are out there. You know, there it sounds high tech, but there’s no reason at all why a paramedic couldn’t be there treating someone with a pair of glasses on and, you know, having essentially a voice in their ear of a senior physician from somewhere guiding them through a procedure. All the data coming from their monitor, defibrillator and everything else, streamed straight live streaming into the glasses. And so how do we create that environment, where we can apply that, and it won’t be necessarily in urban areas, it will be in rural and regional areas, and then enabling through helicopters, fixed wing aircraft or, large patient carrying drones. You’re seeing those concepts coming to life now. It’s technology out there today that has applicability in the next, I would say five to 10 years, we’ll start seeing some of these things play out. 

Lindsay Mackay [00:33:37]
So is there something that you look back on and you think, that’s the initiative that I’m particularly proud, that’s the one that helped really address the great divide?

Tony Walker [00:33:41]
So I worked in for a large part of my career in regional Victoria. I was in charge of clinical services and education for rural AMS Victoria and worked in southwestern Victoria prior to that. So the things for me were taking skills that were the domain of an intensive care paramedic in an urban area, into rural areas would be the first one. So being able to see advanced life support go out and as I mentioned earlier, see salt of the earth, vocationally trained paramedics in those communities step up. Get the training, get the credentialing, and deliver care in their communities. It, it was a game changer.  

The other big one for me is the cardiac arrest system of care. If I look at the work that occurred in the early MICA implemented defibrillators, in 1972, if you were within the domain catchment of four MICA units in Melbourne, you had a reasonable chance of surviving a cardiac arrest. Then we’re seeing defibrillators rolled out more broadly.  And you mentioned St. John and the MCG before – the reality is that St. John and the MCG was an exemplar of a cardiac arrest system of care. And so, when you look at the outcomes there, and then you look at the outcomes in Melbourne and rural Victoria at the time, they were chalk and cheeses, so St John were leading the way. 

And so it’s a sense of, how do we systemise that? Lead governments to invest in public access, defibrillators, cardiac arrest registries so you can actually start measuring and improving those things. So I think they’re probably the big ones. If I look at the biggest one that I have absolutely no doubt will make a difference, because the data’s already telling us this, is the likes of Good Sam.  So how do you take your way back to ambulance services when they first form groups of members of a community coming together to help their mates at a time when they’re in trouble. And that led to volunteer ambulance services, career ambulance services over time. Realistically, Good Sam is taking us back to the foundations of ambulance services.  People, part of the Australian mate ship coming together to actually help someone in their time of need and not be an accident that you just happen to be walking past someone, but you get responded to them and have the tools with you to make a difference. And I think they’re the things that I look at are probably the biggest things. Cardiac arrest management and enhancing the provision of care in rural areas. Breaking down that sense of urban / metro divide, the haves / the have-nots. I had a number of my colleagues had a lot of work to do to encourage and convince a lot of people to allow paramedics in rural areas to do what were considered micro exclusive skills.  And ultimately, if we’re serious about the patient and that’s what it should be about, then how do we improve, how do we deliver that care to that patient. Volunteers is another example of that. If you live in that community, you deserve as equitable care as possible. What can we use around us to help us do that? And technology is an enabler for that. 

Han-Wei Lee [00:36:27]
Tony, you just touched on my next question, how can data and predictive analytics, big data, how can that help support, new innovations or help bridge that gap?

Tony Walker [00:36:35]
Tt’s a really good question and I think, we don’t know what we don’t know. And so data helps us with that. Data helps us understand, what’s driving what we’re doing, and I think, as clinicians, we’re quick to a diagnosis and quick to a treatment based on a pattern of what we see. Sometimes we have very quick views of what’s driving demand in our services and data helps us understand that better. By time of day, whereabouts, what’s driving it, frequency, those type of things. If I look at cardiac arrest as probably an exemplar and that, and some of the other registries around, stroke registries, STEMI registries and others, if you’ve got the data of the NV end of the patient, from along their journey into hospital, then all of a sudden you can start asking yourself questions about, well, how are we actually going? So all of a sudden you sit there, as in cardiac arrest in Victoria, going, we’re actually not doing that well, seeing 3% survival in cardiac arrest despite investing in all these defibrillators.

Once we established – Karen Smith, established a cardiac arrest registry here in Victoria has changed things. All of a sudden you’ve got data. You can actually see, what is driving cardiac arrest? Where’s the points of difference? Why is that community not seeing the same outcomes as that community? They might be lost in big data in the sense of the reporting on your aggregate data for a state or territory. What’s different about that community? What can we do when that community is different? But you can’t ignore that community when you’ve got the data because it’s screaming at you. Something needs to be done differently and then allows you to test, to measure and improve. Do something. Does it make a difference?

As I mentioned before, a lot of this, the one percenters data drove the implementation of high performance CPR at Ambulance Victoria and that then led to, further marked improvement in cardiac arrest outcomes for the state. So you sit there and go something we take for granted.  We all know how to do CPR, of course we do. We’re all experts at it. It’s how we feel as clinicians. All of a sudden technology and data say, well actually, maybe you’re not, and you need to, and here’s where you can see how you’re going and can improve that either in real time or as part of broader training, all of a sudden what you do is use that data to actually drive that improvement.

Han-Wei Lee [00:38:58]
It’s really interesting you brought up high performance CPR Tony because, you know, we’ve all had real reasonably lengthy careers in the health industry. I was an intensive care nurse prior to ambulance, and when I did my high performance CPR training, I was like, what have we been doing? Even in one of the leading ICUs in Australia, we were doing poor CPR.  And we thought we’re doing good CPR.

Tony Walker [00:39:37]
And then you sitting there going, oh, we just need this other bit of equipment that’ll improve cardiac arrest survival. Actually, it’s us, we are part of the continuum. If we do this, if the call taker can do this differently, the AED is more readily available and connected into a system, then all of a sudden, those one percenters start improving.

That’s how Ambulance Victoria and St. John WA and other ambulance services around the country are now using that information and that approach to actually continually improve and not resting on their laurels. You can see the benefit of that and it doesn’t just apply to cardiac arrest, organisations that focus on improving cardiac arrest do other things well as well. All of a sudden it’s about a culture of excellence, about how do we continually improve? It’s not resting on our laurels, and data drives that. I think, the brave thing is when ambulance services report that data, so cardiac arrest registry outcomes, annual reports to their community. It’s critical and it can be embarrassing. But you know, in some ways where an ambulance service might go, well, my percentage of cardiac arrest survival is, compared to this other state just down the road. But the reality is you’ve got to start somewhere. So what are they doing differently? And the thing for me around these things is, I rarely ever want to be the first person to try something new in technology, but I’m right up there for the second. So if someone else is trying new, I’ll be right behind them. St. John New Zealand led the way with Good Sam, we were right behind them every step of the way. Just health professionals or people trained in CPR? No, no, no, they can’t go into people’s house. Yes, they can. They’re not going to steal the jewels. It’s going to be okay. We know who they are, you know? So now it’s about just having CPR awareness. It’s a sense of any CPR is better than none. Yeah, I’d love someone trained to be able to do it, but hey, I’ll take what I can get, in those circumstances. So, that’s the big driver, I think.

Lindsay Mackay: [00:41:24]
I just love this conversation about Western Australia because in this podcast series, we’re actually meeting with their Medical Director. We’re going to be chatting to Gail. So, you know, there’s nothing like this State, little bit of rivalry that we all love. So, I think we’ll be definitely asking these questions when we get there.

Tony Walker [00:41:36]
I actually think healthy competition is a good thing, you just look over the shoulder, and see what are you doing? How do you do that? I’ll watch with interest to see what the published outcomes will be for cardiac arrest outcomes next year.  Because St. John and AV are neck and neck, and that’s saying something in the context of 40 – 41% and particularly for both of those states, they’re not just an urban area, they’re for the whole state. And I think that’s an important difference. And I think it’s a healthy thing to do. I think we learn off each other, we steal good ideas and we make them work in our environments.  

Han-Wei Lee [00:42:38]
So Tony, we talked about the, the increases of one percents. What does that 1% mean to you in people terms?

Tony Walker [00:42:43]
It’s a really good question. I mean, if you look at the data, you can get lost in it, and you can get lost in it in the differences we’re talking about between services in Australia and around the world, but we’re talking about people, real lives. I mean, you know, one of the hardest things for an ambulance service to be measured by is cardiac arrest. Because essentially you’ve got someone who’s clinically dead, who is alive, and it’s not about, when we talk about the numbers, we’re talking about real people, young people, taken out and often in the peak of their lives. With good cardiac arrest systems of care, what we see is those people return back to normal lives nearly. 80% of people who suffer for cardiac arrest are returning back to their family. 74% are returning back to work. So, you know, we talk a lot about data because it helps us think about the system and measure the system, but we’re actually talking about real people who have been returned back to their families.

Han-Wei Lee [00:43:43]
Talking about real people, we’ve actually got Justine Phillips, who is a cardiac survivor, and a recipient of all those all – important chains of survival. So we’re going to bring her into the conversation. 

Lindsay Mackay [00:43:47]
So thanks Han-Wei and perfect timing to add to the conversation. Welcome Justine Phillips. So this has been about the Great Divide – we’ve had some fantastic conversation. Tony shared about the statistics around cardiac risk survival, the really human stories. And we thought what a perfect time to introduce you and it’d be great if you could share a bit of your story with us.

Justine Phillips [00:44:13]
Yeah, absolutely. So I suffered a cardiac arrest at home back in July in 2020. So it was during the COVID lockdowns. So thankfully for me, because Victoria was in the middle of lockdown, my children were home schooling, so they were both home at the time. When I had my cardiac arrest, my daughter was in the kitchen and just had this feeling that she had to come up and and run something past me, and she came up and found me on the floor, unresponsive.  She alerted my son who was in the bathroom at the time. He came out. So together they called triple zero and my son performed CPR until emergency services arrived, which was between the seven, eight minute mark after the initial call. So once they arrived, they worked their magic, as I like to say. And at the 30 minute mark, they had to make a call. So I was defibrillated eight times, continual CPR, the copious amounts of drugs that they provide you once you’ve had a cardiac arrest. And thankfully for me, because I was showing some minor signs of life, they decided that, you know, they would continue their treatment and transfer me to the local hospital, which was the Frankston Hospital. And by the time I arrived there, it ended up ended up being 93 minutes later after I had my cardiac arrest that my heart started beating again in a normal rhythm. So very thankful and very lucky for the work. Not only from the emergency services, but for that early intervention for my children, because if that hadn’t have happened, I wouldn’t be sitting here today.

Lindsay Mackay: [00:45:44}
How old was your son?

Justine Phillips [00:45:45]
He was, it was actually on his 16th birthday.  He was 16, had no previous training at school or anything. And that year that he was in school, I believe he would’ve had some sort of training, but definitely the following year they had first aid training at school.  

Lindsay Mackay [00:46:02]
Well, you’re obviously here talking to us, which is amazing. I just gotta ask, does your son tell you that you could have gotten him a better present than learning CPR?  

Justine Phillips [00:46:13]
I do get the reminder that the sort of look every now and then that like, you know, just remember who you know. 

Han-Wei Lee [00:46:25] 
Justine, it’s so interesting, that without any training, your son performed essentially, well, it had to have been effective CPR I think we’d all agree. Tony, I think that just goes back to one of your comments, that any CPR is better than no CPR, obviously the CPR was quite good. What are your thoughts on CPR education for early sort of school age children? Because clearly it can make a difference.

Tony Walker [00:46:52]
Oh, absolutely. I think, CPR is a life skill. I mean, everyone should have it and yeah. And there’s a strong argument that it should be taught, every child should learn CPR at school. I mean, it should be mandatory in my view and many others. Because you don’t have to be an expert in it. You just need to have an awareness of it, which often then allows the call taker, to guide you through when they’re saying, put your hand on the chest. You know what that means?  Press like this. You know what that means? I’m sure that’s what’s happened in Justine’s case, that, that the, you know, the Triple Zero Victoria call taker has basically, guided, your son to do that and clearly, effectively, so it’s fully supported. It’s a life skill. Everyone should know how to do CPR. Again, you can argue it doesn’t have to be a, you know, a full-blown CPR course, but everyone should have good awareness and a practice on a mannequin. So in the event they have to do something, they know what that means.  

Han-Wei Lee [00:47:43]
You brought up a really good point, which was remiss of me. Triple Zero Victoria, those true first responders, guide lay people through CPR and, and like Justine, I think you’re a perfect example of how important that call taker role is in one – detecting cardiac arrest, but also providing truly lifesaving instruction.

Justine Phillips [00:48:17]
Absolutely. Beause without those instructions, he wouldn’t have known how to effectively perform CPR until emergency services got there. So, you know, the Triple Zero operators played a huge part in that role of helping a lay person, particularly someone who has had no training.  

Lindsay Mackay [00:48:27]
Tony, earlier we talked about, what’s those big reform pieces and you just mentioned there, that’s one we didn’t talk about that actually should CPR be something that is taught in schools?
I may see you on social media, Justine, what are you doing in this space?

Justine Phillips [00:48:44]
So after my cardiac arrest, for me it was a big learning curve because I honestly thought cardiac arrest was just another name for a heart attack. And it’s not, and they both require different treatments, still emergency treatment, but just different treatment. So after I did my own research, I decided I want to be able to go out there and teach individuals how to perform CPR. So I went and studied. So I’ve got my training and assessment certification, and I now teach First Aid and CPR. My passion is the CPR side of things. And in regards to, you know, talking about children, I’ve just started doing some programs now where I’m going out to sporting clubs. Teaching kids in sporting clubs, you know, this is what CPR is. If you are asked to perform CPR, this is how you do it. And you know, they learn on the mannequins and we have a discussion about it. And you know, at the moment it’s the teenage children. But my passion is to get into the younger ones and just make sure they know to call Triple Zero in an emergency, and work from there. And, we don’t have to scare our young ones. It’s just giving them the basic knowledge that they know that, you know, call Triple Zero, if you need to perform CPR, this is how we do it.  

Han-Wei Lee [00:50:00]
I think, Justine, you touched on something that Tony mentioned. Cardiac arrest care is not just an ambulance, it’s right across the community. Your work with some sporting clubs, St. John does First Aid in schools. In terms of that CPR education, Tony, what are some of the other things to support or advance Justine’s work in that area?

Tony Walker [00:50:002]
It’s a really good question because, how do you reach everybody? How do you reach everyone, and that’s often the challenge. We talked earlier about technology and there are really interesting apps out there now that can teach people to do CPR using a cushion or a relatively inexpensive mannequin that can guide them through it. I think there’s a lifesaver program in the UK that’s a good example of that.

So I think there’s a role for technology to say, well, we want, in the perfect world, everyone can do absolutely perfect CPR. That’s what I think we all, Justine’s doing informal training, and that I think absolutely critical. But then how do you go, but if they’re not doing that, how can we have a baseline where everyone is able to do a simple course so they’re aware of, this is what CPR is, this is the number you call, this is how you do it. If every member of the community had that skill. And ideally then said would you like to sign up for this app? So if someone nearby needs your help, you can do it. Then you start seeing real change. So I think again, it’s technology. Technology can help us not replace a practical skill like CPR, but enhance it so that there’s a baseline understanding for every member of our community. 

Lindsay Mackay [00:51:35]
And Justine, from the work that you’re doing, is there something that you, is there one thing that you think, if I could make one change today, what would it be?

Justine Phillips [00:51:48]
The big problem I notice out in the community is that people don’t really know a lot about cardiac arrest. So it’s the awareness about it and, what treatment is required. So it’s sort of breaking down the barrier, in regards to what cardiac arrest is. And I put my, I’m the first person to put my hand up. I am very naive and will not look at maybe other illnesses if it doesn’t affect me directly.  Whereas, now I can sit here and say, I’ve firsthand seen what cardiac arrest can do and how it affects those around you. So trying to knock down barriers is the biggest thing that I see out in the community. Having apps, as Tony said, using technology where, people don’t think, oh, I’ve got to go do this first aid course to learn CPR. People might not be comfortable, you know, in a grouping setting and so forth. So, you know, having some form of technology where they can just get on the app, on their phone, watch a video, practice on a cushion, or a pillow or a teddy bear. So that would be fantastic to see. And hopefully it encourages more people to step out of their comfort zone and help.




Yeah, for sure. Someone within the community or, yeah. A loved one. Yeah.   Justine, I think you raised a really good point and it’s something we haven’t covered, um, in the discussion yet today, but, um, it’s a really important one because women have a lower. Um, chance of survival from cardiac arrest. Um, and the studies have shown that that’s partly due to people’s concern about not wanting to touch a woman’s chest mm-hmm. Or expose a woman’s chest. Justine clearly had effective CPR, um, from someone. I, I guess I’d open up to both Justine or, or Tony, what are your thoughts around that topic?  I guess for me, speaking from my experience is one thing I do do in my sessions that I teach with CPR is I have these little breasts that I can put on my mannequins and can remove if need be. And it’s just pretty much just saying to people in, in the session that whether it’s a male or female, it’s irrelevant.  That person needs lifesaving attention right now, and that’s what you need to think about. This could be your mother, just think of it [00:54:00] as a mother or a sister. And step in and do what you would do if it was for them.   I fully support what Justine saying. I think it is about having life, uh, like mannequins, so that essentially people feel comfortable and, and, and flagging. The reality of this is, you know, you’re not gonna do any harm. You know, it’s, it’s, it’s a real challenge often for people putting defibrillator pads on and I think for AEDs. So, you know, there’s a lot of conversations going on. Do you need to remove the bra? Can, can there be different modifications? So if these are real barriers and researchers underway to say, well, actually, how can we potentially change some of the approach so that the barrier can be overcome?  But I think it starts with practicing on mannequins that are lifelike and, and, and, and, and will show breasts. And, and I think importantly, Hearing women talk about this issue is critical because ultimately it’s one thing for a guy to be up there talking about, it’s a different thing, particularly for cardiac arrest survivor.  So, well actually I was fortunate ’cause my son did it, but you know, I could be in the street and someone, you know, the data evidence would suggest maybe someone might hesitate and we don’t want them to hesitate. And that [00:55:00] sense of, again, it’s like that awareness, it’s gonna be okay, you know, you might feel a bit uncomfortable, but you’re gonna save someone’s life. But also. Educating the public that, you know, there is the Good Samaritan law out there, that if you step in Yeah, with the intent to help save a life. If there’s gonna be no repercussions, if that’s right, you are working within your scope of training and you are within your knowledge, as long as you’re not trying to be a doctor, a lifesaver, um, and, and do more advanced techniques and, and, and procedures and so forth. If you’re just stepping in as a lay bystander, mm, you’ve got that good Samaritan law there that protects you from anything like that.  Yeah. And I think, you know. I’ve been to so many cardiac arrest patients who, you know, are women. And when I’ve arrived in the public, nobody’s doing CPR. And I’m like, I can remember one walking into a high street of a busy town and people were looking at her and I got straight down and I asked at the end, like I was probably a little bit sure. And I said, like, why didn’t any of you start? And, and they said, oh, because we didn’t know what to do with [00:56:00] our bra. And it was the bra was this thing. And I was thinking, cut it off and expose her. You know, and it’s that not understanding. So I think talking about it and doing things like this. Is where it brings that awareness. So I think it’s really important. And I think with people like Greg Page, from The Wiggles doing a lot of work, and yourself and Tony, you’re out with the Alliance talking about it and you know it is kind of a global conversation. I think that’s great starting young, I’ve got to say that as a mom of a young toddler. Amy Gomez from Queensland, she’s written a book about what paramedics do and I have it on my bookshelf, my 2-year-old has already getting read it and is talking about CPR and, you know, I think that’s great. Start early.  

Justine Phillips [00:55:45]
Absolutely. Just bring down the barriers early and make it an open conversation.  

Han-Wei Lee [00:55:47}
Justine. Thanks for giving us your perspective as a cardiac arrest survivor on CPR and a female. I think that’s really important for all to break down those barriers. If there was one thing that you could do, in terms of cardiac risk care, for the public, for responders, what would it be? 

Justine Phillips [00:57:03]
It would be just learn CPR, go and do a course, because that could be the difference between the life of a loved one or the passing of a loved one. And by just educating yourself, you’ve got the knowledge and the skills. And if anyone is ever in that situation, you know that you are doing the best that you can with the skills that you’ve learn and just help anyone. It doesn’t have to be just a loved one, just step in.  

Han-Wei Lee [00:57:37]
I think for me, bringing you in, Justine has really just reinforced that. You’re a living example of all those components of the chain of survival working in concert and working well.  

Which brings us to the end of this episode. Today we explored the contrast in cardiac arrest care between rural and urban communities, from early CPR and AED access to community engagement and the role of innovation.

A huge thank you to our esteemed guest, Tony Walker, and to our fantastic cardiac arrest survivor, Justine Phillips for sharing your really valuable insights and experience.  

Ambulance Insights is presented by Covanta Mission Critical Technology and the Council of Ambulance Authorities.

If you’d like to see who’s coming up next, although I think Lindsay might have given you a sneak preview, head over to corvanta.com. Until next time, stay safe and stay connected.