After writing my post MFB First Responders and Withholding Resuscitation (March 7, 2017) I was sent copies of two relevant CFA guidelines – EMR A 180 00 Do Not Resuscitate Orders (Issue 3, November 2004) and EMR A 185 00 Withholding of Treatment (Issue 1, November 2004). These formed the basis of my post CFA Emergency Medical Response Guidelines (March 8, 2017). Because of that post I have now been sent the complete set of CFA Emergency Medical Response (EMR) Operational Guidelines. In that document, there are two more guidelines that causes me concern. They are:
- EMR A 140 00: Medical practitioner at the scene (Issue 2, November 2004) and
- EMR A 140 01: Medical practitioner at the scene (Issue 2, November 2004).
EMR A 140 00 says
1. Firefighters may only hand their responsibility for patient care over to an on-duty AV crew, or a qualified medical doctor.
1.1 Doctors who elect to provide care on scene are accepting legal responsibility for the care of the patient.
EMR A 140 01 says:
1. When a medical doctor offers to provide assistance at the scene of an incident, CFA personnel should adhere to the following:
1.1. Determine if the person is a medical doctor and whether they are licensed to practice medicine in Australia;
1.2. Are they willing to take responsibility for the patient?
2. If yes:
2.1. Document the doctor’s name, address and telephone number on PCR form;
2.2. Hand responsibility over
2.3. Familiarise the doctor with CFA procedures and equipment as required;
2.4. Request doctor to sign PCR form prior to leaving scene; and
2.5. Assist, under the direction of the doctor.
3. If no:
3.1. Respectfully decline offer of assistance
3.2. Continue patient care according to EMR procedures
3.3. Handover patient care to AV crew when they arrive
The problem, and error, with both guidelines is the claim that ‘Doctors who elect to provide care on scene are accepting legal responsibility for the care of the patient’. There’s no basis to believe that. First it assumes that someone has legal responsibility but responsibility can be shared. A doctor who is assisting firefighters is doing just that, assisting. Doctor’s are not magicians nor do they have some fantastic rank or authority over everyone else. They are trained medical practitioners. If firefighters and a medical practitioner are working together in the best interests of the patient they are responsible for their own decisions and actions. Each, too, would have some responsibility to supervise the other, so if the firefighters thought the doctor wasn’t helping it would be incumbent upon them to ask the doctor to leave, and if the doctor thought the firefighters weren’t doing something right it would be incumbent upon them to mention their concern.
That’s how it should work with paramedics and nurses too. In hospitals nurses are responsible for nursing and doctors for medical care but they also have to flag with each other concerns for the patient or their care. Days of subservient respect for doctors and the belief, and fiction, that everyone is working at the direction of the whim of the doctor are long gone.
That is a team work approach to acting in the best interests of the patient. So a Doctor who elects to provide care on scene must accept legal responsibility for his or her actions and decision making, and the firefighters remain responsible for theirs.
The only circumstance where it might be correct to say the doctor is ‘accepting legal responsibility for the care of the patient’ is where the doctor is the patient’s treating doctor. Perhaps someone has found their ‘90 year old, cold, lifeless great grandmother’ and has called both triple zero and the family doctor. In that case the doctor may appear, identify him or herself and satisfy the firefighters that they are the patient’s doctor, and ask the firefighters to cease resuscitation. In that case one could rightly say that the doctor was responsible for the decision to withhold resuscitation. That is however quite different from a doctor observing that firefighters are doing CPR and coming over and offering to help.
EMR A 140 01 builds on that misconception. The first thing to note is that when considering a doctor’s offer of assistance, firefighters are not directed to consider whether or not they actually need any help. Can you imagine being a doctor, seeing firefighters performing CPR, offering to help and being asked ‘are you willing to take responsibility for the patient?’ The shock of realising that the firefighters first thought was a legal issue and not the best interests of the patient would be shocking.
You don’t need to be a doctor to do CPR. Imagine a scene with more than one casualty where firefighters are stretched and a person identifies themselves as an emergency physician on holiday from the UK. There is no reason not to accept that doctor’s offer of assistance and perhaps get him or her to continue cardiac compressions to free up a firefighter to help with other patients or facilitate access by Ambulance Victoria. The questions of whether or not the doctor is registered in Australia or willing to take on responsibility for the patient are simply irrelevant to the question of whether or not the firefighters and patients would benefit from his or her assistance.
The questions should be the same whether an offer of assistance comes from a police officer, an off duty paramedic (from Australia or elsewhere), a nurse (from Australia or elsewhere) or a doctor. Those questions should be:
- Do we need help? and
- Do we think this person provide the help we need?’
If there is a single patient requiring CPR, there is a full fire crew that are experienced, used to working together, who have the situation in hand and with Ambulance Victoria only minutes away it’s quite reasonable to say ‘no thank you, we’ve got it under control’. Trying to incorporate a new member into the team, when you don’t know who they are and what they can do, will just decrease the efficiency of the team and hamper the rescue effort. It would not be in the best interests of the patient.
On the other hand, if there are multiple casualties and access to the site is compromised so firefighters are stretched to the limit, a person who produces their London Ambulance ID and offers to help could be welcomed with open arms. Equally the New Zealand nurse and the South African doctor the local St John volunteer or just a bystander. There is no law that says you have to be licenced or registered to do the sort of things that these people might do in this emergency – cardiac compressions, airway management, bleeding control etc.
There is no guideline about accepting assistance at an emergency from people other than a doctor, and the guidelines on doctors EMR A 140 01 falsely assumes that there has to be a hierarchy not a team approach. An offer to assist is just that, not an offer to take over and there is no reason to think that ‘Doctors who elect to provide care on scene are accepting legal responsibility for the care of the patient.’
The statement ‘Doctors who elect to provide care on scene are accepting legal responsibility for the care of the patient’ in EMR A 140 00 is simply wrong.
EMR A 140 01 repeats and compounds that error. It is unethical as the driving concern is some misplaced fear of legal implications rather than identifying procedures that are in the best interest of those in need of assistance. It is foolish as it means a firefighter might be willing to accept assistance from a paramedic, a nurse, a good Samaritan, but not a doctor unless the doctor is willing to commit him or herself to ‘take responsibility for the patient’. No one is ‘responsible’ for the patient, everyone is responsible for their own actions and decisions. Doctors and firefighters should be able to work together, when required, to advance the patient’s best interests.