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Dax F, Trentzsch H, Lazarovici M, Hegenberg K, Kneißl K, Hoffmann F, Prückner S. Ambulance deployment without transport: a retrospective difference analysis for the description of emergency interventions without patient transport in Bavaria. Scand J Trauma Resusc Emerg Med 2023; 31:93. [PMID: 38057935 DOI: 10.1186/s13049-023-01159-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/23/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Not all patients who call the ambulance service are subsequently transported to hospital. In 2018, a quarter of deployments of an emergency ambulance in Bavaria were not followed by patient transport. This study describes factors that influence patient transport rates. METHOD This is a retrospective cross-sectional study based on data from all Integrated Dispatch Centres of the Free State of Bavaria in 2018. Included were ambulance deployments without emergency physician involvement, which were subdivided into ambulance deployments without transport and ambulance deployments with transport. The proportion of transported patients were determined for the primary reasons for deployment and for the different community types. On-scene time was compared for calls with and without patient transport. Differences were tested for statistical significance using Chi2 tests and the odds ratio was calculated to determine differences between groups. RESULTS Of 510,145 deployments, 147,621 (28.9%) could be classified as ambulance deployments without transport and 362,524 (71.1%) as ambulance deployments with transport.The lowest proportion of patients transported was found for activations where the fire brigade was involved ("fire alarm system" 0.6%, "fire with emergency medical services" 5.4%) and "personal emergency response system active alarm" (18.6%). The highest transport rates were observed for emergencies involving "childbirth/delivery" (96.9%) and "trauma" (83.2%). A lower proportion of patients is transported in large cities as compared to smaller cities or rural communities; in large cities, the odds ratio for emergencies without transport is 2.02 [95% confidence interval 1.98-2.06] referenced to rural communites. The median on-scene time for emergencies without transport was 20.8 min (n = 141,052) as compared to 16.5 min for emergencies with transport (n = 362,524). The shortest on-scene times for emergencies without transport were identified for activations related to "fire alarm system" (9.0 min) and "personal emergency response system active alarm" (10.6 min). CONCLUSION This study indicates that the proportion of patients transported depends on the reason for deployment and whether the emergency location is urban or rural. Particularly low transport rates are found if an ambulance was dispatched in connection with a fire department operation or a personal emergency medical alert button was activated. The on-scene-time of the rescue vehicle is increased for deployments without transport. The study could not provide a rationale for this and further research is needed. Trial registration This paper is part of the study "Rettungswageneinsatz ohne Transport" ["Ambulance deployment without transport"] (RoT), which was registered in the German Register of Clinical Studies under the number DRKS00017758.
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Affiliation(s)
- Florian Dax
- Institut Für Notfallmedizin und Medizinmanagement (INM), University Hospital Munich, LMU Munich, Schillerstr. 53, 80336, Munich, Germany.
| | - Heiko Trentzsch
- Institut Für Notfallmedizin und Medizinmanagement (INM), University Hospital Munich, LMU Munich, Schillerstr. 53, 80336, Munich, Germany
| | - Marc Lazarovici
- Institut Für Notfallmedizin und Medizinmanagement (INM), University Hospital Munich, LMU Munich, Schillerstr. 53, 80336, Munich, Germany
| | - Kathrin Hegenberg
- Institut Für Notfallmedizin und Medizinmanagement (INM), University Hospital Munich, LMU Munich, Schillerstr. 53, 80336, Munich, Germany
| | - Katharina Kneißl
- Institut Für Notfallmedizin und Medizinmanagement (INM), University Hospital Munich, LMU Munich, Schillerstr. 53, 80336, Munich, Germany
| | - Florian Hoffmann
- Dr. Von Haunersches Kinderspital, Paediatric Clinic and Polyclinic, University Hospital Munich, LMU Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Stephan Prückner
- Institut Für Notfallmedizin und Medizinmanagement (INM), University Hospital Munich, LMU Munich, Schillerstr. 53, 80336, Munich, Germany.
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Greene JA, Goldstein J, Stirling J, Swain JM, Brown R, McVey J, Carter A. Clinical Roles in the Medical Communications Centre: A Rapid Scoping Review. Cureus 2023; 15:e39441. [PMID: 37362545 PMCID: PMC10289204 DOI: 10.7759/cureus.39441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/22/2023] [Indexed: 06/28/2023] Open
Abstract
In recent years, 911 call volumes have increased, and emergency medical services (EMS) are routinely stretched beyond capacity. To better match resources with patient needs, some EMS systems have integrated clinician roles into the emergency medical communications centre (MCC). Our objective was to explore the nature and scope of clinical roles in emergency MCCs. Using a rapid scoping review methodology, we searched PubMed for studies related to any clinical role employed within an emergency MCC. We accepted reviews, experimental and observational designs, as well as expert opinions. Studies reporting on dispatcher recognition and pre-arrival instructions were excluded. Title and abstract screening were conducted by a single reviewer, included studies were verified by two reviewers, and data extraction was completed in duplicate, all using Covidence review software. The level of evidence was assessed using the prehospital evidence-based practice (PEP) scale. The protocol was registered in Open Science Framework (10.17605/OSF.IO/NX4T8). Our search yielded 1071 titles, and four were added from other sources; 44 studies were reviewed at the full-text stage and 31 were included. The included studies were published from 2002 to 2022 and represent 17 countries. Studies meeting inclusion criteria consisted of level I (n=4, 11%), II (n=13, 37%), and III (N=6, 17%) methodologies, as well as 12 other studies (34%) with qualitative or other designs. Most of the included studies reported systems that employ nurses in the MCC (n=29, 83%). Twelve (34%) studies reported on the inclusion of paramedics in the MCC, and five (14%) reported physician involvement. The roles of these clinicians chiefly consisted of triage (n=25, 71%), advice (n=20, 57%), referral to non-emergency care (n=14, 40%), and peer-to-peer consulting (n=2, 4%). Alternative dispositions (as opposed to emergency ambulance transport) for low acuity callers included self-care, as well as referral to a general practitioner, pharmacist, or other outreach programs. There is a wide range of literature reporting on clinical roles integrated within MCCs. Our findings revealed that MCC nurses, physicians, and paramedics assist substantively with triage, advice, and referrals to better match resources to patient needs, with or without the requirement for ambulance dispatch.
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Affiliation(s)
| | | | | | - Janel M Swain
- Emergency Health Services, Nova Scotia, Dartmouth, CAN
| | - Ryan Brown
- Interprofessional Practice and Learning, Nova Scotia Health, Sydney, CAN
- Emergency Medicine, Dalhousie University, Halifax, CAN
| | | | - Alix Carter
- Emergency Medicine, Dalhousie University, Halifax, CAN
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Jensen JL, Travers AH, Carter AJE. Care begins when 9-1-1 is called: the evolving role of paramedic specialists in EMS Medical Communications Centres. CAN J EMERG MED 2022; 24:115-116. [PMID: 35258817 PMCID: PMC8902488 DOI: 10.1007/s43678-022-00284-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/09/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Jan L Jensen
- Emergency Health Services/Emergency Medical Care, Dalhousie University, 239 Brownlow Avenue, Suite 300, Dartmouth, NS, B3B2B2, Canada.
| | - Andrew H Travers
- Emergency Health Services, Nova Scotia Health, Dalhousie University, Dartmouth, NS, Canada
| | - Alix J E Carter
- Emergency Health Services, Nova Scotia Health, Dalhousie University, Dartmouth, NS, Canada
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Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence. Scand J Trauma Resusc Emerg Med 2021; 29:4. [PMID: 33407771 PMCID: PMC7789540 DOI: 10.1186/s13049-020-00821-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/02/2020] [Indexed: 12/02/2022] Open
Abstract
Background The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known. Methods This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent “intermediate” patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages. Results Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood. Conclusions This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.
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Spangler D, Edmark L, Winblad U, Colldén-Benneck J, Borg H, Blomberg H. Using trigger tools to identify triage errors by ambulance dispatch nurses in Sweden: an observational study. BMJ Open 2020; 10:e035004. [PMID: 32198303 PMCID: PMC7103813 DOI: 10.1136/bmjopen-2019-035004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES This study aimed to assess whether trigger tools were useful identifying triage errors among patients referred to non-emergency care by emergency medical dispatch nurses, and to describe the characteristics of these patients. DESIGN An observational study of patients referred by dispatch nurses to non-emergency care. SETTING Dispatch centres in two Swedish regions. PARTICIPANTS A total of 1089 adult patients directed to non-emergency care by dispatch nurses between October 2016 and February 2017. 53% were female and the median age was 61 years. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was a visit to an emergency department within 7 days of contact with the dispatch centre. Secondary outcomes were (1) visits related to the primary contact with the dispatch centre, (2) provision of care above the primary level (ie, interventions not available at a typical local primary care centre) and (3) admission to hospital in-patient care. RESULTS Of 1089 included patients, 260 (24%) visited an emergency department within 7 days. Of these, 209 (80%) were related to the dispatch centre contact, 143 (55%) received interventions above the primary care level and 99 (38%) were admitted to in-patient care. Elderly (65+) patients (OR 1.45, 95% CI 1.05 to 1.98) and patients referred onwards to other healthcare providers (OR 1.58, 95% CI 1.15 to 2.19) had higher likelihoods of visiting an emergency department. Six avoidable patient harms were identified, none of which were captured by existing incident reporting systems, and all of which would have received an ambulance if the decision support system had been strictly adhered to. CONCLUSION The use of these patient outcomes in the framework of a Global Trigger Tool-based review can identify patient harms missed by incident reporting systems in the context of emergency medical dispatching. Increased compliance with the decision support system has the potential to improve patient safety.
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Affiliation(s)
- Douglas Spangler
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala Center for Prehospital Research, Uppsala University, Uppsala, Sweden
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Lennart Edmark
- Department of Anesthesia and Intensive Care, Västmanlands sjukhus Västerås, Vasteras, Sweden
| | - Ulrika Winblad
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Jessica Colldén-Benneck
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala Center for Prehospital Research, Uppsala University, Uppsala, Sweden
| | - Helena Borg
- Ambulance Department, Västmanlands sjukhus Västerås, Vasteras, Sweden
| | - Hans Blomberg
- Department of Surgical Sciences-Anesthesia and Intensive Care, Uppsala Center for Prehospital Research, Uppsala University, Uppsala, Sweden
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Leyenaar MS, Strum RP, Batt AM, Sinha S, Nolan M, Agarwal G, Tavares W, Costa AP. Examining consensus for a standardised patient assessment in community paramedicine home visits: a RAND/UCLA-modified Delphi Study. BMJ Open 2019; 9:e031956. [PMID: 31594901 PMCID: PMC6797257 DOI: 10.1136/bmjopen-2019-031956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Community paramedicine programme are often designed to address repeated and non-urgent use of paramedic services by providing patients with alternatives to the traditional 'treat and transport' ambulance model of care. We sought to investigate the level of consensus that could be found by a panel of experts regarding appropriate health, social and environmental domains that should be assessed in community paramedicine home visit programme. DESIGN We applied the RAND/UCLA Appropriateness Method in a modified Delphi method to investigate the level of consensus on assessment domains for use in community paramedicine home visit programme. SETTING AND PARTICIPANTS We included a multi-national panel of 17 experts on community paramedicine and in-home assessment from multiple settings (paramedicine, primary care, mental health, home and community care, geriatric care). MEASURES A list of potential assessment categories was established after a targeted literature review and confirmed by panel members. Over multiple rounds, panel members scored the appropriateness of 48 assessment domains on a Likert scale from 0 (not appropriate) to 5 (very appropriate). Scores were then reviewed at an in-person meeting and a finalised list of assessment domains was generated. RESULTS After the preliminary round of scoring, all 48 assessment domains had scores that demonstrated consensus. Nine assessment domains (18.8%) demonstrated a wider range of rated appropriateness. No domains were found to be not appropriate. Achieving consensus about the appropriateness of assessment domains on the first round of scoring negated the need for subsequent rounds of scoring. The in-person meeting resulted in re-grouping assessment domains and adding an additional domain about urinary continence. CONCLUSION An international panel of experts with knowledge about in-home assessment by community paramedics demonstrated a high level of agreement on appropriate patient assessment domains for community paramedicine home visit programme. Community paramedicine home visit programme are likely to have similar patient populations. A standardised assessment instrument may be viable in multiple settings.
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Affiliation(s)
- Matthew S Leyenaar
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Ontario Community Paramedicine Secretariat, Toronto, Ontario, Canada
| | - Ryan P Strum
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Ontario Community Paramedicine Secretariat, Toronto, Ontario, Canada
| | - Alan M Batt
- School of Public Safety, Fanshawe College, London, Ontario, Canada
- Community Emergency Health and Paramedic Practice, Monash University, Clayton, Victoria, Australia
- Paramedic Science Discipline, Central Queensland University, Rockhampton, Queensland, Australia
| | - Samir Sinha
- The Ontario Community Paramedicine Secretariat, Toronto, Ontario, Canada
- Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Michael Nolan
- The Ontario Community Paramedicine Secretariat, Toronto, Ontario, Canada
- Paramedic Service, County of Renfrew, Pembroke, Ontario, Canada
| | - Gina Agarwal
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Walter Tavares
- The Wilson Centre and Post MD Education, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Institute of Health Policy Management & Evaluation, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- York Region Paramedic and Senior Services, Newmarket, Ontario, Canada
| | - Andrew P Costa
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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What do community paramedics assess? An environmental scan and content analysis of patient assessment in community paramedicine. CAN J EMERG MED 2019; 21:766-775. [DOI: 10.1017/cem.2019.379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
ABSTRACTObjectivesPatient assessment is a fundamental feature of community paramedicine, but the absence of a recognized standard for assessment practices contributes to uncertainty about what drives care planning and treatment decisions. Our objective was to summarize the content of assessment instruments and describe the state of current practice in community paramedicine home visit programs.MethodsWe performed an environmental scan of all community paramedicine programs in Ontario, Canada, and used content analysis to describe current assessment practices in home visit programs. The International Classification on Functioning, Disability, and Health (ICF) was used to categorize and compare assessments. Each item within each assessment form was classified according to the ICF taxonomy.ResultsA total of 43 of 52 paramedic services in Ontario, Canada, participated in the environmental scan with 24 being eligible for further investigation through content analysis of intake assessment forms. Among the 24 services, 16 met inclusion criteria for content analysis. Assessment forms contained between 13 and 252 assessment items (median 116.5, IQR 134.5). Most assessments included some content from each of the domains outlined in the ICF. At the subdomain level, only assessment of impairments of the functions of the cardiovascular, hematological, immunological, and respiratory systems appeared in all assessments.ConclusionAlthough community paramedicine home visit programs may differ in design and aim, all complete multi-domain assessments as part of patient intake. If community paramedicine home visit programs share similar characteristics but assess patients differently, it is difficult to expect that the resulting referrals, care planning, treatments, or interventions will be similar.
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Coster J, O'Cathain A, Jacques R, Crum A, Siriwardena AN, Turner J. Outcomes for Patients Who Contact the Emergency Ambulance Service and Are Not Transported to the Emergency Department: A Data Linkage Study. PREHOSP EMERG CARE 2019; 23:566-577. [PMID: 30582719 DOI: 10.1080/10903127.2018.1549628] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objectives: Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7-93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods: Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results: The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care (N = 312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5-10.5% of patients were admitted to hospital and 0.06-0.24% of patient died within 3 days of the call. Conclusions: Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.
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Ross L, Jennings P, Williams B. Psychosocial Support Issues Affecting Older Patients: A Cross-sectional Paramedic Perspective. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017731963. [PMID: 28965434 PMCID: PMC5798664 DOI: 10.1177/0046958017731963] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This research aimed to gain an understanding of the psychosocial support needs of older patients in the out-of-hospital setting from the perspective of paramedics. Specifically, we investigate if and how paramedics are able to meet the needs of older adults, and the barriers preventing them from achieving this. This study was a cross-sectional study utilizing a sequential design with both quantitative and qualitative methodologies. All participants agreed or strongly agreed that older patients have needs beyond the physical and that they would like to do more for older patients. Paramedics discussed that psychosocial support issues are rarely in isolation and straightforward but were often coupled with broader, longer term physical health and social support issues. They would like to be able to do more for patients but feel hamstrung by lack of time, resources, and know-how.
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Affiliation(s)
- Linda Ross
- 1 Monash University, Frankston, Victoria, Australia
| | - Paul Jennings
- 1 Monash University, Frankston, Victoria, Australia.,2 Ambulance Victoria, Melbourne, Australia
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