Stephen Bernard

Ambulance Victoria, Melbourne, Victoria, Australia

Are you Stephen Bernard?

Claim your profile

Publications (129)697.13 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Although out-of-hospital cardiac arrest (OHCA) is a major public health problem, individual paramedics are rarely exposed to these cases. In this study, we examined whether previous paramedic exposure to OHCA resuscitation is associated with patient survival. Methods and results: For the period 2003 to 2012, we linked data from the Victorian Ambulance Cardiac Arrest Registry to Ambulance Victoria's employment data set. We defined exposure as the number of times a paramedic attended an OHCA where resuscitation was attempted in the 3 years preceding each case. Using a multivariable model adjusting for known predictors of survival, we measured the association between paramedic OHCA exposure and patient survival to hospital discharge. During the study period, there were 4151 paramedics employed and 48 291 OHCAs (44% with resuscitation attempted). The median exposure of all paramedics was 2 (interquartile range 1-3) OHCAs/year. Eleven percent of paramedics were not exposed to any OHCA cases. Increased paramedic exposure was associated with reduced odds of attempted resuscitation (P<0.001). In the 3 years preceding each OHCA where resuscitation was attempted, the median exposure of the treating paramedics was 11 (interquartile range 6-17) OHCAs. Compared with patients treated by paramedics with a median of ≤6 exposures during the previous 3 years (7% survival), the odds of survival were higher for patients treated by paramedics with >6 to 11 (12%, adjusted odds ratio 1.26, 95% confidence interval 1.04-1.54), >11 to 17 (14%, adjusted odds ratio 1.29, 95% confidence interval 1.04-1.59), and >17 exposures (17%, adjusted odds ratio 1.50, 95% confidence interval 1.22-1.86). Paramedic years of experience were not associated with survival. Conclusions: Patient survival after OHCA significantly increases with the number of OHCAs that paramedics have previously treated.
    No preview · Article · Jan 2016 · Circulation Cardiovascular Quality and Outcomes

  • No preview · Article · Jan 2016 · Circulation
  • Z. Nehme · E. Andrew · S. Bernard · K. Smith
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Resuscitation guidelines often recommend ongoing cardiopulmonary resuscitation (CPR) efforts to hospital for out-of-hospital cardiac arrests (OHCA) witnessed by emergency medical service (EMS) personnel. In this study, we examine the relationship between EMS CPR duration and survival to hospital discharge in EMS witnessed OHCA patients. Methods: Between January 2003 and December 2011, 1,035 adult EMS witnessed arrests of presumed cardiac aetiology were included from the Victorian Ambulance Cardiac Arrest Registry. CPR duration was defined as the total sum of prehospital CPR time in minutes. Adjusted logistic regression analyses were used to assess the impact of EMS CPR duration on survival to hospital discharge. Results: 382 (37.3%) patients were discharged alive. The median CPR duration was 12min (95% CI: 11-13) overall, but was higher in non-survivors compared to survivors (24min vs. 2min, p<0.001). The 99(th) percentile CPR duration in patients surviving to hospital discharge differed by the initial rhythm of arrest: 32min (95% CI: 27-44) overall, 32min (95% CI: 23-44) for ventricular fibrillation and pulseless ventricular tachycardia (VF/VT), 34min (95% CI: 30-34) for pulseless electrical activity (PEA), and 28min (95% CI: 21-28) for asystole. There were no survivors after 44min for all rhythms. After adjusting for prehospital confounders, every minute increase in CPR duration was associated with a 13% reduction in the odds of survival to hospital discharge (OR 0.87, 95% CI: 0.84-0.89, p<0.001). The multivariable model predicted no chance of survival at or after a CPR duration of 48min for VF/VT patients, 47min for PEA patients and 45min for asystole patients. Conclusion: Resuscitation efforts exceeding 32min yielded less than 1% of survivors from EMS witnessed OHCA. On the basis of this data, EMS witnessed OHCA patients may benefit from on-going CPR efforts up to 48min in duration.
    No preview · Article · Jan 2016 · Resuscitation
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Supplemental oxygen therapy may increase myocardial injury following ST-elevation myocardial infarction (STEMI). In this study, we aimed to evaluate the effect of the dose and duration of oxygen exposure on myocardial injury after STEMI. Methods: Descriptive analysis of data from a multicentre, prospective, randomised, controlled trial of 441 patients with STEMI randomised to supplemental oxygen therapy or room air breathing. The primary endpoint was myocardial infarct size as assessed by cardiac biomarkers, troponin (cTnI) and creatine kinase (CK). Oxygen therapy was commenced by paramedics, and continued for up to 12 h postintervention in hospital. Supplemental oxygen exposure was calculated as the area under the dose×time curve for oxygen administration over the first 12 h, and then assessed for its association with cTnI/CK release using multivariable linear regression. Results: The median supplemental oxygen exposure was 1746 L (IQR: 960-2858). After adjustment for potential confounders, every 100 L increase in oxygen exposure in the first 12 h was associated with a 1.4% (95% CI 0.6% to 2.2%, p<0.001) and 1.2% (95% CI 0.7% to 1.8%, p<0.001) increase in the mean peak cTnI and CK, respectively. Excluding patients who developed cardiogenic shock, recurrent myocardial infarction or desaturations (SpO2<94%) during admission, every 100 L increase in oxygen exposure was associated with a 1.2% (95% CI 0.2% to 2.1%, p=0.01) and 1.0% (95% CI 0.3% to 1.7%, p=0.003) increase in the mean peak cTnI and CK, respectively. The median supplemental oxygen exposure of 1746 L would result in a 21% (95% CI 3% to 37%) increase in infarct size according to the cTnI profile. Conclusions: Supplemental oxygen exposure in the first 12 h after STEMI was associated with a clinically significant increase in cTnI and CK release.
    Preview · Article · Jan 2016 · Heart (British Cardiac Society)

  • No preview · Article · Dec 2015 · Heart, Lung and Circulation
  • [Show abstract] [Hide abstract]
    ABSTRACT: Early decompression may improve neurological outcome after spinal cord injury (SCI), but is often difficult to achieve because of logistical issues. The aims of this study were to determine (1) the time to decompression in cases of isolated cervical SCI in Australia and New Zealand and (2) where substantial delays occur as patients move from the accident scene to surgery. Data were extracted from medical records of patients aged 15-70 years with C3-T1 traumatic SCI between 2010 and 2013. A total of 192 patients were included. The median time from accident scene to decompression was 21h, with the fastest times associated with closed reduction (6h). A significant decrease in the time to decompression occurred from 2010 (31h) to 2013 (19h, p = 0.008). Patients undergoing direct surgical hospital admission had a significantly lower time to decompression compared to patients undergoing pre-surgical hospital admission (12h vs. 26h, p < 0.0001). Medical stabilisation and radiological investigation appeared not to influence the timing of surgery. The time taken to organise theatre following surgical hospital admission was a further factor delaying decompression (12.5h). There was a relationship between the timing of decompression and the proportion of patients demonstrating substantial recovery (2-3 AIS grades). In conclusion, the time of cervical spine decompression markedly improved over the study period. Neurological recovery appeared to be promoted by rapid decompression. Direct surgical hospital admission, rapid organisation of theatre and where possible use of closed reduction, are likely to be effective strategies to reduce the time to decompression.
    No preview · Article · Dec 2015 · Journal of neurotrauma

  • No preview · Article · Nov 2015 · Resuscitation

  • No preview · Article · Nov 2015 · Resuscitation
  • Emily Andrew · Ziad Nehme · Marijana Lijovic · Stephen Bernard · Karen Smith

    No preview · Article · Nov 2015 · Resuscitation
  • Kylie Dyson · Janet Bray · Karen Smith · Stephen Bernard · Lahn Straney · Judith Finn

    No preview · Article · Nov 2015 · Resuscitation
  • Source

    Full-text · Article · Nov 2015 · Resuscitation
  • Source

    Full-text · Article · Nov 2015 · Resuscitation
  • Source
    Ziad Nehme · Stephen Bernard · Karen Smith

    Full-text · Article · Oct 2015 · New England Journal of Medicine
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Out-of-hospital cardiac arrest (OHCA) remains a major public health issue and research has shown that large regional variation in outcomes exists. Of the interventions associated with survival, the provision of bystander CPR is one of the most important modifiable factors. The aim of this study is to identify census areas with high incidence of OHCA and low rates of bystander CPR in Victoria, Australia. Methods: We conducted an observational study using prospectively collected population-based OHCA data from the state of Victoria in Australia. Using ArcGIS (ArcMap 10.0), we linked the location of the arrest using the dispatch coordinates (longitude and latitude) to Victorian Local Government Areas (LGAs). We used Bayesian hierarchical models with random effects on each LGA to provide shrunken estimates of the rates of bystander CPR and the incidence rates. Results: Over the study period there were 31,019 adult OHCA attended, of which 21,436 (69.1%) cases were of presumed cardiac etiology. Significant variation in the incidence of OHCA among LGAs was observed. There was a 3 fold difference in the incidence rate between the lowest and highest LGAs, ranging from 38.5 to 115.1 cases per 100,000 person-years. The overall rate of bystander CPR for bystander witnessed OHCAs was 62.4%, with the rate increasing from 56.4% in 2008-2010 to 68.6% in 2010-2013. There was a 25.1% absolute difference in bystander CPR rates between the highest and lowest LGAs. Conclusion: Significant regional variation in OHCA incidence and bystander CPR rates exists throughout Victoria. Regions with high incidence and low bystander CPR participation can be identified and would make suitable targets for interventions to improve CPR participation rates.
    Full-text · Article · Oct 2015 · PLoS ONE
  • [Show abstract] [Hide abstract]
    ABSTRACT: This study aims to investigate an association between ethanol exposure and in-hospital mortality among patients with isolated traumatic brain injury (iTBI). Ethanol exposure is associated with a substantially increased risk of sustaining an iTBI. However, once an iTBI has been sustained, it is unclear whether ethanol exposure is neuroprotective or harmful. We conducted a retrospective review of patients who presented between 2006 and 2012 and were entered into the Alfred Hospital trauma registry. The patients who presented with iTBI, as defined by a head abbreviated injury scale (AIS) score ⩾3 and all other body regions with AIS<3, and who had ethanol levels recorded on admission, were eligible for inclusion. The association between ethanol exposure as a continuous variable, and in-hospital mortality, was explored using multivariable logistic regression analysis. There were 1688 patients with iTBI who met the inclusion criteria, 577 (34.2%) of whom tested positive for ethanol. Ethanol exposure was not significantly associated with a change in the in-hospital mortality rate (adjusted odds ratio 1.01; 95% confidence interval 1.00-1.02; p=0.19). A substantial proportion of patients with iTBI were exposed to ethanol, but ethanol exposure was not independently associated with a change in mortality rate following iTBI. Any neuroprotection or harm from ethanol exposure was not conclusive, requiring further prospective trials. Copyright © 2015. Published by Elsevier Ltd.
    No preview · Article · Jul 2015 · Journal of Clinical Neuroscience
  • [Show abstract] [Hide abstract]
    ABSTRACT: The aim of this systematic review was to determine whether ethanol is neuroprotective or associated with adverse effects in the context of traumatic brain injury (TBI). Approximately 30-60% of TBI patients are intoxicated with ethanol at the time of injury. We performed a systematic review of the literature using a combination of keywords for ethanol and TBI. Manuscripts were included if the population studied was human subjects with isolated moderate to severe TBI, acute ethanol intoxication was studied as an exposure variable and mortality reported as an outcome. The included studies were assessed for heterogeneity. A meta-analysis was performed and the pooled odds ratio (OR) for the association between ethanol and in-hospital mortality reported. There were seven studies eligible for analysis. A statistically significant association favouring reduced mortality with ethanol intoxication was found (OR 0.78; 95% confidence interval 0.73-0.83). Heterogeneity among selected studies was not statistically significant (p=0.25). Following isolated moderate-severe TBI, ethanol intoxication was associated with reduced in-hospital mortality. The retrospective nature of the studies, varying definitions of brain injury, degree of intoxication and presence of potential confounders limits our confidence in this conclusion. Further research is recommended to explore the potential use of ethanol as a therapeutic strategy following TBI. Copyright © 2015 Elsevier Ltd. All rights reserved.
    No preview · Article · Jun 2015 · Journal of Clinical Neuroscience
  • [Show abstract] [Hide abstract]
    ABSTRACT: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Prophylactic hypothermia is effective in laboratory models, but clinical studies to date have been inconclusive, partly because of methodological limitations. Our Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury (POLAR) randomised controlled trial is currently underway comparing early, sustained hypothermia versus standard care in patients with severe TBI. We describe our study protocol and the challenges in conducting prophylactic hypothermia research in TBI. We aim to randomise 500 patients to either prophylactic 33°C hypothermia initiated within 3 hours of injury and continued for at least 72 hours, or standard normothermic management. Patients will be enrolled by paramedic services in the prehospital setting, or by emergency department staff at participating sites in Australia, New Zealand and Europe. The primary outcome will be the eight-level extended Glasgow outcome scale (GOSE), dichotomised to favourable and unfavourable outcomes at 6 months after injury. Secondary outcomes will include mortality at hospital discharge and at 6 months, ordinal analyses of 6-month GOSE outcomes, quality of life with health economic evaluations and the differential proportion of adverse events. We will predefine subgroup and interaction analyses. After a run-in phase, recruitment for our main study began in December 2010. When the study is completed, we aim to provide evidence on the efficacy of prophylactic hypothermia in TBI to guide clinicians in their management of this devastating condition.
    No preview · Article · Jun 2015 · Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine
  • [Show abstract] [Hide abstract]
    ABSTRACT: -Oxygen is commonly administered to patients with ST-elevation myocardial infarction (STEMI) despite previous studies suggesting a possible increase in myocardial injury due to coronary vasoconstriction and heightened oxidative stress. -We conducted a multicenter, prospective, randomized, controlled trial comparing oxygen (8 L/min) with no supplemental oxygen in patients with STEMI diagnosed on paramedic 12-lead electrocardiogram. Of 638 patients randomized, 441 were confirmed STEMI patients who underwent primary endpoint analysis. The primary endpoint was myocardial infarct size as assessed by cardiac enzymes, troponin (cTnI) and creatine kinase (CK). Secondary endpoints included recurrent myocardial infarction, cardiac arrhythmia and myocardial infarct size assessed by cardiac magnetic resonance (CMR) imaging at 6 months. Mean peak troponin was similar in the oxygen and no oxygen groups (57.4 mcg/L vs. 48.0 mcg/L; ratio, 1.20; 95% confidence interval [CI], 0.92 to 1.56; P=0.18). There was a significant increase in mean peak CK in the oxygen group compared to the no oxygen group (1948 U/L vs. 1543 U/L; means ratio, 1.27; 95% CI, 1.04 to 1.52; P= 0.01). There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared to the no oxygen group (5.5%vs.0.9%, P=0.006) and an increase in frequency of cardiac arrhythmia (40.4% vs. 31.4%; P=0.05). At 6-months the oxygen group had an increase in myocardial infarct size on CMR (n=139; 20.3 grams vs. 13.1 grams; P=0.04). -Supplemental oxygen therapy in patients with STEMI but without hypoxia may increase early myocardial injury and was associated with larger myocardial infarct size assessed at six months. Clinical Trial Registration Information-clinicaltrials.gov. Identifier: NCT01272713.
    No preview · Article · May 2015 · Circulation
  • [Show abstract] [Hide abstract]
    ABSTRACT: Winching emergency medical care providers from a helicopter to the scene enables treatment of patients in otherwise inaccessible locations, but is not without risks. The objective of this study was to define characteristics of winch missions undertaken by Intensive Care Flight Paramedics (ICFP) in Victoria, Australia with a focus on extraction methods and clinical care delivered at the scene. A retrospective data analysis was performed to identify all winch missions between November 2010 and March 2014. Demographic data, winch characteristics, physiological parameters, and interventions undertaken on scene by the ICFP were extracted. Out of 5,003 missions in the study period, 125 were identified as winch operations. Winter missions were significantly less frequent than those of any other season. Patients were predominantly male (78.4%) and had a mean age of 38 years (±17.6). A total of 109 (87.2%) patients were identified as experiencing trauma with a mean Revised Trauma Score of 7.5288, and isolated limb fractures were the most frequently encountered injury. Falls and vehicle-related trauma were the most common mechanisms of injury. The total median scene duration was 49 minutes (IQR 23–91). Sixty-three patients (50.4%) were extracted using a stretcher, 45 (36.0%) using a hypothermic strop, and 6 (4.8%) via normal rescue strop. Eleven patients (8.8%) were not winched to the helicopter. Vascular access (38.4%), analgesia (44.0%), and anti-emetic administration (28.8%) were the most frequent clinical interventions. Forty-nine patients (39.2%) did not receive any clinical intervention prior to winch extraction. Winch operations in Victoria, Australia consisted predominantly of patients with minor to moderate traumatic injuries. A significant proportion of patients did not require any clinical treatment prior to winching, and among those who did, analgesia was the most frequent intervention. Advanced medical procedures were rarely required prior to winch extraction.
    No preview · Article · May 2015 · Prehospital Emergency Care
  • E Andrew · A de Wit · B Meadley · S Cox · S Bernard · K Smith
    [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Objective. The optimal staffing of helicopter emergency medical services (HEMS) is uncertain. An intensive care paramedic-staffed HEMS has operated in the state of Victoria, Australia for over 28 years, with paramedics capable of performing advanced procedures, including rapid sequence intubation, decompression of tension pneumothorax, and cricothyroidotomy. Administration of a wide range of vasoactive, anesthetic, and analgesic medications is also permitted. We sought to explore the characteristics of patients transported by HEMS in Victoria, and describe paramedic utilization of their skill set in the prehospital environment. Methods. A retrospective data review was conducted of patients transported by the HEMS between 1 July 2012 and 30 June 2013. Data were sourced from the Ambulance Victoria data warehouse and the Victorian State Trauma Registry. Interhospital transfers were excluded. Results. HEMS attended 1,519 cases during the study period. A total of 825 primary transport cases were included in analyses. Most patients were male (69.5%) and the majority of cases involved trauma (86.1%). Rapid sequence intubation (RSI) was performed in 36.8% of pediatric and 29.9% of adult major trauma patients, with a procedural success rate of 100%. Ketamine was administered to 18.5% of all trauma patients. The proportion of patients with a severe pain score (≥7) decreased from 33.8 to 3.2% (p < 0.001) between initial and final paramedic assessments. A clinically significant pain reduction of ≥2 points was achieved by 87.0% (95% CI 82.9-90.4%) of adult trauma patients who had an initial pain score >2 points and a valid final pain score. In-hospital mortality following major-trauma was 7.6% (95% CI 5.0-11.0%). Conclusions. The skill set of HEMS intensive care paramedics in Victoria is broad, including a large number of prehospital critical care procedures commonly utilized by physician-staffed HEMS in other jurisdictions. A high RSI procedural success rate was observed across the study period, as were significant improvements in patient physiological parameters and pain scores.
    No preview · Article · Feb 2015 · Prehospital Emergency Care

Publication Stats

10k Citations
697.13 Total Impact Points

Institutions

  • 2010-2015
    • Ambulance Victoria
      Melbourne, Victoria, Australia
  • 2009-2015
    • Alfred Hospital
      • Intensive Care Unit
      Melbourne, Victoria, Australia
  • 2007-2015
    • University of Vic
      Vic, Catalonia, Spain
  • 2001-2015
    • Monash University (Australia)
      • Department of Epidemiology and Preventive Medicine
      Melbourne, Victoria, Australia
  • 2008
    • SA Ambulance Service
      Tarndarnya, South Australia, Australia