Mohr NM et al. PLoS ONE. 2025;20(4):e0321299.
In this qualitative study, the investigators interviewed 27 clinicians across rural U.S. hospitals and telehealth hubs to explore how provider-to-provider telehealth is used for sepsis management in rural EDs. Although based in the U.S., the findings are relevant for rural Australian and New Zealand emergency clinicians navigating similar workforce, geography, and transfer challenges.
Telehealth was most often activated for support with transfer coordination, surge capacity, or procedural supervision—especially in settings with limited inpatient services or where providers required oversight. Importantly, telehealth provided a “second pair of eyes” in high-stakes situations, often giving local clinicians greater confidence to proceed with pressors, fluid management, or advanced interventions.
Another benefit to using telehealth was real-time education and skill reinforcement. Clinicians described how prior telehealth consultations improved their independent performance in future cases.
Some providers expressed reluctance to consult telehealth, fearing it might signal inexperience. Other barriers to telehealth use were diagnostic uncertainty about whether the patient had sepsis, and the impression that the consult did not add value beyond already existing standardised sepsis protocols and EMR order sets.
For rural clinicians in Australia and Aotearoa New Zealand, this study highlights some important enablers and barriers to telehealth use for a common emergency condition. Used well, it can bolster workforce confidence, improve timely access to care, and support rural clinicians managing complex cases, all without undermining local expertise.
Peripheral ‘Dirty Adrenaline’ in Remote Clinics: Case Series from Central Australia
Braham D, Adams D, Johnson R. Emerg Med Australas. 2025;37(1):e14496. doi:10.1111/1742-6723.14496
This retrospective case series from the Central Australia Retrieval Service provides the first published data on the use of peripheral dilute adrenaline—known colloquially as “dirty adrenaline”—in remote, nurse-led clinics managing fluid-refractory shock while awaiting aeromedical retrieval.
The protocol used 1 mg of adrenaline diluted in 1 L of saline via a peripheral IV. This formulation, long used informally in the bush, offers ease of preparation, minimal equipment needs, and a presumed lower risk profile—making it attractive in resource-limited, unsupervised settings. Yet, until now, there has been no published evidence to support its safety or efficacy.
The series includes 57 patients, mostly with septic shock (70%), many with significant comorbidities—65% were at risk of fluid overload. Infusions lasted a median of 155 minutes, with systolic BP rising from 75.5 mmHg to 91 mmHg. Notably, 86% survived to hospital discharge, and mortality in the septic shock subgroup was just 5%, far lower than national averages (~24%).
Adverse events were rare and mild: one case each of hypertension, tachycardia, and suspected cold peripheries; two fluid overload episodes in patients with CKD. No lasting complications were reported, even with small or distal IV sites.
While not a controlled trial, the findings strongly support the safety and potential life-saving value of this low-tech vasopressor strategy when used with remote physician guidance. The authors propose protocol expansion to include refractory anaphylaxis and status asthmaticus.
For Australian and New Zealand rural and remote emergency clinicians, this paper provides reassurance that peripheral dilute adrenaline—when administered under appropriate protocol and retrieval physician oversight—is both safe and potentially lifesaving when ICU-level treatment is hours away. It also reinforces the value of practical, locally developed solutions that reflect the realities of resource-limited emergency care.
First published in the RRECN Newsletter (June 2025).
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