This question comes from a volunteer first aider who says:
… When phoning 000 for ambulance assistance the operator (ambulance call taker) has a standard line of questions and comments to address e.g “don’t move the patient, don’t splint fractures, don’t give anything to eat or drink”.
My qualification [volunteer first aider (Advanced Responder qualified)] authorises me to splint fractures, apply a cervical collar and move a casualty on/off a spine board if necessary. If I was presented with a situation where I elected to utilise for example, any of these skills, to provide a level of patient care and ambulance assistance was requested, the ambulance call taker would inform me as above – “don’t move, don’t splint etc.”
If a casualty decided that there may be an avenue to pursue some legal challenge regarding their treatment and I had splinted a fracture or moved the casualty, disregarding the advice of the ambulance call taker – how would I be situated legally. I imagine if a challenge was mounted, the ambulance coordination centre’s recordings could be used as supporting evidence.
I await your thoughts and comments.
The principal point is that, believe it or not, the law and in particular courts, are much more concerned with substance over form; in context they will want to know whether your conduct was reasonable in the circumstances, not whether it complied with a direction or not. Let me explore that issue in more depth.
First this issue will only be relevant if there is an adverse outcome. If the patient’s condition is no worse, or better, given your actions the point is, as we lawyers would say, ‘moot’ (academically interesting but no practical importance). So let us assume that your action makes the situation worse. I can imagine three circumstances where that would happen:
1. You provide treatment that is not indicated by the patient’s condition and so make the situation worse;
2. You provide treatment that is indicated by the patient’s condition but do not do so in a reasonably competent manner and so make the situation worse;
3. You provide treatment that is indicated by the patient’s condition, you do so in a reasonably competent manner but there is some inherent risk that occurs (eg in Ambulance Service of NSW v Worley [2006] NSWCA 102, the patient was given adrenaline as required by the treatment protocol but suffered a known, but rare adverse reaction).
In any of those three cases, following the triple zero call taker’s instructions would have avoided the harm; but does that make the action ‘negligent’?
The first scenario is negligent regardless of the triple zero call taker’s instructions; that is one is negligent for providing dangerous treatment that is not indicated by the patient’s condition, so assume you are qualified to administer some drug that has the potential for adverse side effects, you administer it when it’s not indicated (and you knew, or should have known it was not indicated) and the side effects occur, then your negligence lies in administering the drug, not in ignoring the triple zero call taker’s instructions.
The second scenario is the same as the first; if you negligently administer indicated treatment that is where the liability will arise.
The third scenario suggests no negligence, so the only point a plaintiff could rely on would be ‘if you’d done what you were told, this bad outcome would not have happened’ but that only goes to the issue of whether the defendant’s actions (ie your actions) caused the harm, not whether they were reasonable or not.
The question of whether or not one’s actions are ‘reasonable’ depends upon all the circumstances; circumstances that the call taker cannot know. To go back to the words of Mason CJ in Wyong Shirt v Shirt (1980) 146 CLR 40 (at page 48; words that have been quoted often enough on posts on this blog):
… the reasonable man’s response calls for a consideration of the magnitude of the risk and the degree of the probability of its occurrence, along with the expense, difficulty and inconvenience of taking alleviating action and any other conflicting responsibilities which the defendant may have.
Let us assume one is faced with a person with a broken leg and the question of whether or not it should be splinted. Going back to my days as a first aid instructor/examiner I would have advised that if the patient was not in danger, on a stable surface, comfortable, circulation was not compromised and an ambulance was reasonably close there was no need to splint the leg (particularly in the absence of any effective pain relief). If those things were not true, however, then splinting was the appropriate treatment.
Making those decisions requires someone on the spot to assess the patient and to consider their own abilities and resources and these are things the call taker cannot do.
The ambulance service must (or should) also have done a risk assessment and thought about the issues identified by Mason CJ. It is likely (and not unreasonable) that they came to the conclusion that the risk to the patient of being moved by a person who does not know what they are doing it pretty high, their call taker cannot know who they are talking too and may take a call from anyone ranging from an experienced emergency doctor to an 8 year old child. They cannot however identify who is on the phone or develop instructions for all sorts of people so they produce a set of instructions that they give to everyone; including volunteer advanced responders. The reality is, however, any instruction that says ‘always splint’ or ‘never splint’ cannot be reasonable as it doesn’t allow the sort of judgment that Mason CJ, above, calls for.
So if you’re an advanced responder, or in any fact anyone, you have to make a judgment call. Even the unqualified who is told ‘don’t move the patient’ but thinks ‘where that person is located is too dangerous and I have to move them’ would not be negligent simply because they ignored the instruction. The instruction is just one factor that would be considered in asking whether or not their belief, that they needed to move the patient, was ‘reasonable’. For example, assume an unqualified person describes the scene to the call taker who asks relevant questions about whether, say, the vehicle involved in the collision is on fire, whether the road can be blocked etc and then advises ‘there is no need to move the patient’. That person may have no reasonable grounds to believe it is necessary to move the patient and if they do a court may well accept that was ‘unreasonable’. But, assume this time the call is made, and then the vehicle does catch fire, at that point the advice ‘not to move the patient’ is overtaken by events; the fact that the call taker, earlier, said ‘don’t move the patient’ is irrelevant in the changed circumstances.
So now move to my correspondent. The call taker has said ‘don’t splint the patient’ but you determine that their circulation has been compromised and your training tells you that splinting is required. Splinting the patient, even though the call taker said not do, would not be negligent whereas failing to do so, even when you know the treatment is indicated, just because someone else said not to, could be.
Having said all that, if I was the lawyer for the plaintiff, and there had been an adverse outcome, and if I thought of it, I would certainly ask the question that you shouldn’t have done ‘x’ if you were told not to. I would ask that question because if, given my three scenarios, you had followed that advice the adverse outcome would not have occurred; but just because you are asked the question does not mean you will not have a perfectly reasonable answer.
Australian Emergency Law 
Thank you for your informative comments on this important issue. The matter of calltaker instructions is a large but unrecognized problem. We frequently encounter situations where the bystander was given instructions that are clearly wrong, and no attempt had been made to ascertain whether the bystander had any training. The most common example is the collapsed, elderly patient who is sitting in a chair, barely conscious from a pre-syncopal episode. We arrive to find 2 people holding the now unconscious person upright in the chair because ‘the ambulance person told us not to move him’. Descriptions on the mobile data terminal include ‘pale’, ‘faint’ and ‘dizzy’, and it’s usually a warm day. The next most common one is trained first aiders being told not to immobilize fractures. Part of the reason people are heavily influenced by the calltaker is that the caller expects the ambulance service will always give correct advice. Many people also wrongly assume that they are talking to a paramedic. Many people have said ‘I wanted to lay him down but the person who called 000 said she was told not to do that’. I have made 000 calls and have heard how strongly these instructions are given! It is difficult for a trained but inexperienced first aider to go against what they hear as an instruction (rather than advice) from an authority. Even St John members often ask me what they should do. I tell them to ignore calltaker advice and do what they know is best, but that’s not a message I can get out to the community. I feel the ambulance service carries a responsibility to ensure the advice it gives is correct, or at least the best in the circumstances, rather than just giving standard advice. A better alternative would be for the calltaker to ask if there is a trained first aider on scene, or to refer the call to a clinically qualified officer if advice is required, as was done in the past. Whatever legal protection the ambulance service feels it has afforded itself, it will probably bear responsibility for its misleading influence.
Thank you, Malcolm, for that further information. If the gist of the ambulance service advice to triple zero callers is ‘don’t do anything; wait for us’ that is contrary to the ideas of shared responsibility for emergency management and the development of community resilience; both features of the National Strategy on Disaster Resilience. Equally if that is their message, it completely defeats the point of first aid training. I think your advice ‘ignore calltaker advice and do what they know is best’ is sound advice. The call taker isn’t there and can’t assess the patient and if they’re not making any effort to assess the capacity of the people on scene and who are not be making the call (for all they know, three off duty paramedics may be attending the patient whilst an untrained bystander is calling 000) then blanket advice ‘do nothing’ is as bad, or worse, than no advice at all!
It’s hard to understand what lies behind this approach from the Ambulance Service. They may be scared that if they tell people to move someone, or don’t say anything and someone does cause more harm, there could be liability but that fear is unfounded, and certainly there in no better position by telling people not to move someone when they need to be moved! One hopes that their policy is motivated by the best interests of the patient rather than some misguided fear of legal consequences (which does not mean it’s good advice or a good policy, but at least we can hope it’s well motivated.)
Hi Michael, most ambulance services have adopted to AMPDS call taker system from the U.S. This system is designed to employ non-ambulance officers (non-paramedics) to perform the role of call taker and dispatcher utilising a script of questions and instructions. Therefore the call taker can not provide other clinical advice via the phone or deviate from the script.
There are specific pre-arrival instructions given to the caller such as put the dog away, turn the porch light on etc.
First aid information can be offered, usually for emergency cases such as cardiac arrest and severe bleeding etc.
The instruction from the call taker is from a script, not medical advice. I can see no legal standing in this instruction. (You may be able to clarify that point).
I am sure if a caller identifies themselves as a first aider and informs the call taker they want to perform a skill or procedure, they call take will transfer them to a clinical person who is appointed to the comms room for just that purpose.
There are many concerns with the AMPDS system from a wide variety of people which is not subject to discussion on this forum, however it is a US system that provides the ambulance service which purchases the system (at great cost) a level of insurance against legal action.
the reference website is http://www.prioritydispatch.net/
cheers Dave
Thanks Dave; clearly the instructions have no legal standing, and that was the conclusion of my original post and also why I agreed with Malcolm’s advice to ‘ignore calltaker advice and do what they know is best’. I think from Malcom’s post and also Cannulator’s comment (that comes after yours) it’s not the case that the call takers are passing paramedics or others who claim to have first aid knowledge and skills to paramedics for further advice.
My comment that ‘One hopes that their policy is motivated by the best interests of the patient rather than some misguided fear of legal consequences’ is because I can’t see how having a scheme that is rigid in its application ‘provides the ambulance service which purchases the system (at great cost) a level of insurance against legal action’. I don’t know what legal action they have in mind, but giving advice without regard to the actual circumstances is not going to help.
Interestingly, call takers, will tell callers not to move patients etc, however anything that needs doing at a scene is guided by the call taker. A lay person, merely reading a script.
It gets to the point that they don’t even listen to the caller–even paramedics ringing 000 will get the same blah blah blah, through ingrained ignorance.
More frightening is the notion that call takers are now giving instruction on Aspirin being taken, without any notion of contraindication or barriers- to me that would appear to constitute medical advice; we are governed by practice guidelines as paramedics to administer Aspirin (its efficacy is undeniable) that include contraindications and precautions; yet for the sake of a few minutes anyone over 40 with chest pain is ordered to take aspirin!
I’m interested in the original posters comment of being ‘authorised’ to perform certain first aid skills. A person with a bandage and a splint is a person with a bandage and a splint. If they bugger it up they are liable. It is more about being trained appropriately than authorised, so that reasonable competence is expected.
Many complete first aid course even in organisations with specific roles–even paramedics; it doesn’t automatically bestow competence.
Cannulator, thanks for those comments. I don’t see that saying take Asprin is any more, or less, ‘medical advice’ than saying don’t lay the patient down. Whether its called ‘medical advice’ or not doesn’t matter, it’s whether or not the advice is tailored to what’s actually going on. Like anything there are risks, risks in giving Asprin and risks in not giving it; if the expert consensus is that the benefit is worth the risk then that advice may not be problematic even if a paramedic on scene would identify the contraindications. What would be more worrying is that if the consensus is that the benefit is worth the risk but the advice given is ‘give nil by mouth’ or, to go to Malcolm’s example, leave the patient sitting in the chair.
As for the first correspondent’s comment on being authorised, you are correct that ‘It is more about being trained appropriately than authorised’ and I took him to mean he was trained. There is a belief that without training one is not authorised to do something like, splint an injury. In fact authorisation is not needed but one shouldn’t do it if one hasn’t had some training but as you say that’s because law’s demand is for competence, not authority. (Even my example isn’t universally true, a person may be in a remote location, a colleague is injured, and there are some pretty practical people out there who would realise that a splint was required an put together a good one without ever having had training; and that may well be the best thing to do in the circumstances – it all depends on the circumstances.)
Cannulator, I don’t believe your comment “through ingrained ignorance” is a fair or proper statement to be made in relation to call takers.
I have worked in both the call centre and also on road. Due to the nature of, and quality assurance, of the AMPDS system, the call takers are bound by strict governance. Whether we agree with the system or not, or that we have non-paramedics on the phone, it is not fair to judge those working in the positions. They are after all, restricted by their training and guidelines, as we are as paramedics, to meet the requirements of their position description.
I do not know if you have had the opportunity to go and sit with an operator for a few hours, it is not an easy job, if you haven’t, I highly recommend it so you have a better understanding of the conditions in which they work. Our call takers have a minimum of 4 calls per day audited with a requirement of 98% accuracy. If they do not reach that target, they are given further training to ensure they reach that level. We as paramedics are not that closely audited, and we get to give drugs and stick sharp things in people.
With regard to Aspirin, as paramedics we know that a single aspirin in the case of a sudden cardiac incident can reduce the risk of mortality and morbidity by 21%. There must have been a risk/benefit analysis completed by medical practitioners who have decided that the benefits are more significant than the risk. I personally applaud the decision.
The point of authorized or ability to perform an act, (Michael correct me if I am wrong) if challenged in a court is based on what a similar trained reasonable person would do for the same situation. So if a first aider decided to splint the limb in good faith, and something went astray, they would be compared with another first aider presented with the same situation.
Dave you’re right, in a court should the situation arise, one is judged against a person holding or professing to hold similar skills – so a first aider is judged against the hypothetical ‘reasonable first aider’; the paramedic against the standard of the hypothetical ‘reasonable paramedic’ (hypothetical as the ‘reasonable person’ is a legal fiction, it is not the average or ordinary but a particularly wise and cautious individual). The point of authorised or ability is that with the exception of the use of drugs, one doesn’t need legal authorisation for most things paramedics, first aiders or doctor’s do, one just needs to be competent. It’s not that there are say ‘licensing’ conditions so that it’s illegal to splint a limb, or use a defibrillator without the certificate or license; it’s more you have to do it competently and if you’ve got not training one may not feel confident in doing so; having said that to return to an earlier example, there are plenty of very practically handy people around who could probably do a very good job of first aid without ever having been trained. The issue, in most cases (and again the use of drugs is a clear counter-example) is not whether you have the ‘ticket’ but whether you’re competent.
Hello I am going to bring up an issue that needs to be addressed
The call taker directs the caller to commence CPR
The call taker says the person is obviously deceased rigor mortis lividity
The call taker continues to give directions
You need to move the person from the bed to the floor
This is a workplace this is an unsafe practice no lift policy
You need to do 30 compressions and two breaths
This is a typical scenario
Do you legally need to follow these directions
The Ambulance arrives they tell you it is best to stop CPR
They complete a R.O.L.E
Days later you now have flashbacks
This includes seeing the deceased persons glazed pupils looking at you cracking the sternum regurgitation
You are now suffering acute anxiety and PTSDS
We need to let people know that you are within your rights to not commence CPR or do breaths ARC policy if you are unwilling do not do the breaths
The call centre should also be legally liable
If they wish to give coercive directions with no consideration to what the person on scene is seeing
In addition, call takers many if not all do not have any clinical background
Perhaps a First aid certificate
They simply read from a script /algo rhythm
In addition they are directed
Do not deviate from the script by the governing body
In summary you do not have to follow their directions
The litigation should flow both ways
If you do not follow their directions and in a court of law
It is determined you should have and caused harm
Then conversely in a court of law
You are now emotionally dysfunctional it was a client you were a carer
From being coerced into doing CPR by a call taker having nightmares etc
Then the organisation ambulance service
Should also be subject to penalty / litigation
The worst one I encountered was an elderly couple 80 s
The call taker directed the elderly woman to start CPR
When we arrived they were both in Cardiac arrest
A decision to commence CPR on her she would have been the last one to arrest
I am no longer a Paramedic 3 decades ex medic army
Trainer of over 50,000 people First aid all levels
One is not legally obligated to do what the triple zero call taker tells you to do. A person may ring triple zero but say they’re not prepared to touch the patient at all and that would not make them liable. The duty where there is a duty is not to make a situation worse, not a duty to make it better. As for suing the ambulance service for PTSD etc the obligation on anyone is to act ‘reasonably’. The call takers cannot know what the person on the other end can see (though that is changing as I understand it with some capacity to send video to emergency services). They cannot know how the person on the other end will react. The ambulance service is not the cause of the other person’s injuries or the circumstances in which they are found. They have to have a ‘reasonable’ response and part of that is probably to give first aid advice. No-onw is going to be liable either way. People don’t get sued over doing, or not doing, first aid.