This question comes from an event first aid provider in South Australia. My correspondent is required to:
… look at “high risk” event bookings that come into the organisation and review the relevant regulations, assisting us to determine what resources we need to supply to comply with the regulations (and more importantly the clinical needs of the competitors).
One of the major issues I have found when reviewing these is that many regulations appear poorly worded, with seemingly little understanding of the differences in clinical scope of different personnel. I have included some of the more obvious regulations for you to see what I mean.
2015 SA Conditions of Rallying
http://sarally.net.au/wp-content/uploads/2015/01/SA-Conditions-of-Rallying-2015.pdf (2.9.a Safety)
- One or more of the following must be provided, must be incorporated in the safety plan, and must be stationed appropriately.
- First Aid Accredited person
- Medical Intervention Vehicle
- St John Ambulance Medical Vehicle (equipped to the highest level available in the region where the event is being held)
- Ambulance
Per this regulation, you can provide anything from a solitary first aider (with no mention of a vehicle) to an ambulance (I assume they mean staffed with 2 paramedics but it doesn’t say).
Pony Club Association of SA
2.3 MEDICAL A doctor should be present at least during the Show Jumping and Cross Country phases. If it is impossible to obtain the services of a doctor, the minimum alternative is for a current holder of a Senior First Aid certificate to be present. Fall check list to be used by first aider in the event of a fall of rider. (form can be found at rear of this rule book) An ambulance or designated vehicle properly equipped from the doctor’s or first aid personnel’s resources must be in attendance during jumping events.
Per this regulation a doctor is recommended – but if “impossible to obtain” then a first aider is acceptable. Almost all pony clubs are not able to/will not pay for a doctor to be present.
Australian Speedway
3.3.3 At any Race Meeting or Event, the minimum requirements are (for practice sessions for Sprintcars & Speedcars, Refer to Rule 3.3.5):
(a) Regular Race Meeting standard quantity of fire extinguishers and fire crew
(b) Race Meetings and official practice sessions require:
* a minimum of two (2) first aid personnel (paramedics, ambulance service, doctor or qualified first aid personnel);
* a station wagon capable of transporting minor injury cases; and
* an appointed person equipped with an operative mobile phone and supplied with the phone number of the nearest road transport ambulance service.
(c) It is compulsory that an approved State Service road going ambulance is present at all Sprintcar & Speedcar Race Meetings and is highly desirable at all other Race Meetings.
3.3.5 For all Sprintcar and Speedcar Drivers, minimum safety requirements for practice are:
(a) a minimum of two paramedic personnel or persons with a current first aid certificate issued by St John Ambulance Australia;
(b) suitable trained, attired and equipped fire fighters;
(c) a station wagon or vehicle capable of transporting minor injury cases;
(d) an appointed person equipped with an operative mobile phone and supplied with the phone number of the nearest road transport ambulance service;
There is a large difference between the capabilities of paramedics, a doctor and first aiders.
When it comes to determining what level of medical coverage is required, I’m interested to know where a medical provider stands in the event of regulations being so non-specific or varied and determining liability in the event of an incident?
Using the 2015 Conditions of Rallying SA as an example, sending a first aider along without a vehicle is in my mind completely inadequate to deal with a high speed accident that might occur 10km from that person on a country road. But this would seemingly still meet the regulation.
I do believe that it is an important one as inadequate regulation or interpretation of them by providers may cause patients competing in various high risk events to be receiving insufficient medical coverage. Through personal experience involved in these discussions every day, club organisers often have very little knowledge of the regulations and when confronted with a choice of either paying for a health professional (doctor/paramedic) or a first aider they usually only want the cheapest option they can get away with without understanding the clinical reasons behind it. It is always somewhat of a balancing act to satisfy the customer, comply with regulation and provide a sufficient level of coverage to ensure competitor safety.
Let me first deal with some issues of language. As a lawyer, I think of a ‘regulation’ as a subordinate piece of legislation. That is the parliament passes an ‘Act’ but the Act can’t deal with all the details so they authorise someone, the Governor, a Minister or a public official to ‘make regulations’ to fill in the gap. There is a formal process to make a regulation and when it is made it has the force of law.
But regulation includes more than just formal laws. According to the Oxford dictionary (online) regulation means ‘A rule or directive made and maintained by an authority’. In this case the authority can be the Pony Club or speedway association. What they have is a regulation but if it’s not made as subordinate legislation, it is not ‘law’ more like ‘club rules’. I assume the regulations cited above fit that description.
What that means is the regulations don’t bind the event first aid provider, they bind the event organiser. That is it is the organiser who has to plan (which requires actually thinking about the issues) and ensure that the requirements of the regulations as well as the needs of participants, are met. Hopefully the prudent organiser would take advice from the event first aid provider as to the difference in skill levels and the risks involved in their event.
I would suggest the regulations are written the way they are so as not to be too prescriptive as prescription can impose obligations that can’t be met or are unnecessary or that are insufficient. The answer here is that it’s all about risk assessment. Who’s competing? What’s the event? Where is it? In some cases a first aider may be sufficient or the best that can be achieved, in other cases it won’t.
The event first aid provider’s obligations must be:
- Do a risk assessment and form an opinion what skill level is required.
- Communicate with the organiser and work with them, and their own risk assessment, and come to an agreement as to the level of care to be provided.
- If there is a disagreement the event provider must consider whether it will cover the event considering the potential needs of patients and their own staff. If the event first aid provider thinks paramedics will be required, but the organiser only wants to pay first aiders, you have to think ‘what will be the impact on our first aid team if they face the injuries that we think are foreseeable and likely and have to try to deal with those injuries pending the arrival of the state ambulance service?’ If it is unreasonable to put first aiders into that position, then you may have to refuse to provide cover.
- On the other hand, you may consider that participants will be better off with some cover, rather than none, and that the social benefit of being there to allow the event to run is sufficient. That may well be true for a small event in a country town where the cost of bringing paramedics from some other town will be prohibitive.
Conclusion
In my opinion whether the level of cover meets the requirements of the event organiser’s parent body is a matter for the event organiser, not the event first aid provider. The event first aid provider must consider whether the level of skill that the organiser wants to engage is sufficient to deal with the foreseeable risks. If it is not, then the event organiser should advise the event organiser, and consider whether they are being allowed to operate to the professional standard that they think is appropriate. If they are not, or if they think the risk to participants or their own staff is too great, they should consider withdrawing their services.
Australian Emergency Law 
This problem is persistent almost everywhere. Some of our clients insist they only want to hire ‘first aid’ but expect paramedic care, which. Aturally, requires more qualified and experienced personnel, and a higher and more comprehensive range of equipment, which the client doesn’t want to pay for. The higher the risk eg motocross, the higher the level of care and resources that should be applied, in the least, for the sake of an injured competitor. But they just don’t want to engage that care, until the moment comes when it’s actually needed. It’s sometimes hard for us to get that idea through. If a provider accepted the contract offered by a club to provide ‘first aid’ level only, but felt that and advised that a higher level of care was appropriate, who is accepting the risk? The provider, the club, or say even the competitor? Just accepting the clubs request for service and then having to rely on waiting for an ambulance to arrive for more appropriate care, could be problematic
Jason.
In all of the above ‘dribble’ ( written by people who sit at desks ), there is no mention of the ‘registered nurse’.
Nobody with any real experience in such matters would place a ‘first aider’ directly below a ‘doctor’ ….
There are at least two other options much easier to obtain – the registered nurse & the enrolled nurse.
Why don’t organisations who need ‘first aid’ coverage consider ‘nurses’, rather than thinking of doctors ( whom they will never get for under $1,000. a day ).
RNs are briliant in their scope which is working within a hospital or clinic. But where emergency medicine is required are ill equiped and outside their scope. Paramedics were formed to do just that role and do it well. Now there are a lot of paramedics that hold a cetification as RN’s and vise versa and that in itself tells you that there are major differences operationaly and clinicly. Im not putting nurses down in any way but paramedicin is only a recent profession that is constantly evolving and the idea of a site nurse is a left over from a different era.
I don’t actually disagree ….
But …..
There are nurses, and there are nurses.
Not all RNs have ED experience, but those that do are the ones to recruit to non-hospital environments.
There are something like 45 nursing specialties.
By the same token, you wouldn’t be wanting an obstetrics doctor either !
Further to my post below, I offer this specifically regarding Enrolled Nurses.
Enrolled Nurses are unable to practice independently as an Enrolled Nurse in the Event Health Service / Event Medical Service sector – whilst they might elect to undertake internal training (or map their qualifications across) and then hold an internal scope of practice within their EHS/EMS agency, its only at this point that they are afforded independent practice.
It is clear that they are not permitted to conduct themselves as an Enrolled Nurse in the EHS/EMS sector unless they are working under the (direct or indirect) supervision of a named and accessible Registered Nurse, http://www.nursingmidwiferyboard.gov.au/documents/default.aspx?record=WD15%2f18366&dbid=AP&chksum=DQoSSmxeo5w3le87%2fnYjFw%3d%3d
Well, you’ve proved you can quote ‘line and verse’ ….
But I never said an EN would be employed as an EN in any pre-hospital environment.
By the same token, it would be a rare occasion for an RN to be emploted as an RN in the pre-hospital environment.
However, what I was elluding to, is that some RNs & ENs would make good choices for building upon their skill base, in order to gain employment in a pre-hospital environment. Though they are unlikely to be employed as RNor EN.
Gordon – there are First Aiders and FIRSTS AIDERS, Paramedics and PARAMEDICS, Doctors and DOCTORS. All bring a different level of skill and expertise, yet none are equivalent within their field of expertise, and nor should they as each person is an individual, thinking and assessing differently at each incident / event.
As for a regime to implement, each event has different challenges, different risks, and it will be the risk assessment which will determine the level of cover required. .
I have been from time to time invoked in mountain bike events where St John Ambulance have provided the medical cover. The injuries sustained bu the riders, whilst St John treat the individuals professionally, the organisation does not have the capacity nor capability to “extract” the casualty from the scene unless they are capable of walking out of the area. On a number of occasions, and generally at least one person per event, needs to be carried out by a rescue team in difficult terrain. Another agency provides this level of support, with an appropriate donation provided for each event. .
The End State is to provide a safe environment, determined by a quantifiable risk assessment, with the activity supported with the most appropriate resources based on risk. Anything else is meaningless.
Another great article Michael.
Chris, I agree with what you have stated.
However, it tends to be the ‘organisers’ of the event that fails to foresee the risks. They are the ones who place a generic ‘title’ in the role.
Sure, not everyone has the same level of training – doctors included – and thus it’s best left to an organisation to make the decision, as to who gets assigned to the role required. But even a professional event supplier can get it wrong too. That’s where ‘insurance’ is needed …
This post clearly highlights why there is a greater need for formal recognition of the Event Health Services/Event Medical Services sector and some broad, robust standards and/or regulation applied.
Many Sporting and Event Regulatory bodies have failed to demonstrate both a risk management and contemporary, best practice approach to determine and document its ‘minimum’ medical standards/requirements. Where many have attempted to achieve this, they are undone and misled by the EHS/EMS sector providers utilising a range of inconsistent language that doesn’t adequately define and address the skills and attributes of their available workforce, (The only emerging exception to this is the protection offered to the title of Paramedic is some jurisdictions).
It has been my advice to my EHS/EMS organisation that we undertake a risk assessment and determine a ‘reasonable’ minimum medical standard and then compare with any available regulatory body documentation and seek to identify any gaps. Only then, can we determine whether we can adequately and safely provide human and physical resource capability to support the event. There will be times that it is not appropriate for my organisation to accept an event request, or where we may need to seek to recruit/employ a specific, specialised skillset from a limited cohort of Healthcare Professional(s). Further, it may also mean that a holistic medical / resuce capability is shared with another organisation/agency, (as Chris alludes to), such as SES for additional people power and/or difficult terrain rescue.
With regards to the role of Healthcare Professionals and the particular mention above of Registered Nurses, it needs to be remembered that they excel best when there is an opportunity to have them operate in ‘similar’ to their ‘normal’ work environs – this often calls for a medically supervised model where an multi-disciplinary, extended care approach is offered and supported by appropriate access to equipment and medications (in accordance with jurisdictional drug legislation and organisational drug licencing). The notion of having Registered Nurses providing independent care is one that needs to be underpinned by a sound, robust clinical governance framework – use of standing orders or consults for medication and/or Clinical Practice Guidelines for the implementation of clinical skills/interventions. Whilst RN’s can bring a significant amount of ‘soft’ skills to EHS/EMS organisations, they are slightly more restricted in delivering ‘independent’ based practice.
“Independent based practice” ????
… and ‘first-aiders’ can ?
I think the ‘plot’ has been lost now.
This topic has wandered into academics.
I agree that the plot does appear to have been lost, more importantly I don’t like the tone that I infer is coming into this discussion when I don’t think you actually disagree. If I can sum up the debate, the policy document from the Pony Club Association of SA says “2.3 MEDICAL A doctor should be present at least during the Show Jumping and Cross Country phases. If it is impossible to obtain the services of a doctor, the minimum alternative is for a current holder of a Senior First Aid certificate to be present…” Gordon’s point was that to see the skill range as either ‘doctor’ or ‘holder of a Senior First Aid certificate’ was to miss out on a range of people who may be able to provide relevant care. He suggested nurses but to that profession can be added paramedics and advanced responders (ie with more than ‘a Senior First Aid certificate’.
The debate then got into issues of scope of practice. Max said ‘RNs are brilliant in their scope which is working within a hospital or clinic. But where emergency medicine is required are ill equipped and outside their scope. Paramedics were formed to do just that role and do it well.’ But Gordon’s point, at least as I read it, wasn’t that RNs should be considered instead of paramedics, but that RNs might be able to fill a space between a ‘doctor’ and a ‘first aider’. And here we can note that the Pony Club policy didn’t suggest paramedics either. There then follows commentary on what an RN or EN might be expected to do, but that’s where I think the point is lost. The point was that if the Pony Club can’t get a doctor, is a senior first aid certificate holder really the next best option? the point was not that RNs or ENs are a better choice than paramedics or say experienced members of an event care provider. Remember that under teh current policy, a club could send a member or two to do a first aid course and have them there, with no experience.
So the issue, that in fact I think everyone agrees on, is that the ideally (to quote Shane) there should be ‘a risk management and contemporary, best practice approach to determine and document its ‘minimum’ medical standards/requirements’ and then engage those services appropriately.
And with that may I suggest we draw this discussion to a close.
Some interesting reading. Talking event safety in general, not just the first aid aspects, I’ve seen first hand the ensuing arguments between service providers and event organizers when talking EM plans.
I was involved in one event that took a draft 70 page EM plan and cut it down to 11 pages as they deemed everything else in it as unnecessary. Their “plan” was to ring 000 as it wasn’t up to them to manage an incident or do anything till the arrival of the emergency services.
Unfortunately, events don’t work that way. This has been proven recently with the Falls Festival, Melbourne’s White Night at the Sidney Myer Music Bowl and other events.
A definite lack of understanding of risk management, EM planning, law and many other aspects that are crucial to effective event management.