A Special Operations paramedic for a state ambulance service has recently been put through training in tactical medicine
… which has included authorisation for use of a needle thoracostomy device when clinically indicated. The employer has placed a caveat on the authorisation that it can only be utilised in a tactical setting and not in day to day Ambulance operations. I have access to the same needle thoracostomy device in my routine, non-tactical, practice setting. Where do I stand legally if I have a patient in the non-tactical setting for whom needle thoracostomy is indicated in accordance with my training and employer practice guidelines, and I withhold the intervention as requested by my employer?
With the imminent arrival of national registration, where would I stand in the eyes of a professional board for withholding treatment I have ready access to and trained for?
I’m told that tactical medicine is ‘prehospital care in high threat environments, basically providing immediate care to police tactical teams and victims of active armed offenders at the point of injury i.e. think Lindt Cafe, Bataclan Theatre in Europe type scenarios’.
A thoracostomy is a procedure for relieving Tension pneumothorax (see https://www.msdmanuals.com/en-au/professional/pulmonary-disorders/diagnostic-and-therapeutic-pulmonary-procedures/how-to-do-needle-thoracostomy). The Victoria Ambulance Clinical Practice Guideline A0802, Chest Injuries says:
If some clinical signs of TPT are present and the patient is deteriorating with decreasing conscious state and/or poor perfusion, immediately decompress chest by inserting a long 14g cannula or intercostal catheter.
See also the Queensland Ambulance Clinical Practice Procedures: Respiratory / Emergency chest decompression – cannula (April 2018).
My correspondent tells me that in the service for which he/she works the procedure is reserved for Advanced Life Support (ALS) and Intensive Care Paramedics (ICP). My correspondent is not yet qualified as an ALS or ICP but the tactical medicine training has given the skill, but subject to the limitations described above. When asked, my correspondent said:
There has been no reason given for the restriction in procedure. In its absence the only conclusion I can draw is that without the restriction it will create significant pressure to train all paramedics in these skills…
The issue is that the equipment is readily available on standard ambulances but we’re being told we cannot use the procedure if we have a patient needing it in a non-tactical setting. The direction given is that we are to call for ALS/ICP backup for decompression, however, the emergent life threatening nature of tension pneumothorax means a patient may very well die in that window for ALS/ICP to arrive, especially in a rural/regional setting.
If we accept that this is a procedure required to deal with a life threatening emergency and that there has been no clinical reason given for the ‘caveat … that it can only be utilised in a tactical setting’ then that caveat has to be indefensible.
Let us assume the patient is in urgent need of a thoracostomy. A request has been made for ALS/ICP backup but they are delayed and the clinical assessment is that the patient is ‘deteriorating with decreasing conscious state and/or poor perfusion’. Consider the scenario from the point of view of 1) the patient and 2) the ambulance service.
Now assume my correspondent applies the tactical medical training and successfully completes a chest decompression. The patient will be happy. What’s the ambulance service going to do? Discipline the paramedic for saving the patient’s life? They may try, an employee is required to obey the ‘reasonable’ directions of an employer. But in the absence of reasons, in particular clinical reasons, this is decision is not ‘reasonable’. An attempt to discipline the paramedic for saving the person’s life is unlikely to be supported by a tribunal such as the Fair Work Commission and would fail the 3AW/2GB/Daily Telegraph shock jock test.
Next assume that they don’t and the delay in ALS/ICP backup means the patient dies or suffers an outcome that is worse than would have been the case had the procedure been done. The patient or their family discover that the paramedic was trained to recognise the need for the procedure, was trained in the procedure and had the equipment to perform the procedure but did not because of the ‘caveat’? The ambulance service is happy, their employee did as directed. Who’s the patient going to sue and or complain about?
The defendant will be the ambulance service. That an ambulance service owes a duty of care to its patient is axiomatic (Kent v Griffiths  QB 36). The function of an ambulance service is to provide ambulance services (whatever that might mean). If we take NSW as an example, ambulance services are ‘services relating to the work of rendering first aid to, and the transport of, sick and injured persons’ (Health Services Act 1997 (NSW) Dictionary). The reasonable provision of those services may not require every paramedic be trained to ICP level, but paramedics, to provide reasonable care have to be able to provide the care that they have been trained to give where that is clinically indicated. Failure to provide treatment that the paramedic is trained to provide in circumstances where it is clinically indicated and where the equipment is to hand has to be a failure to provide reasonable care. As noted, in the absence of a clinical reason for the restriction, it could not be defended. It certainly could not be defended on the basis ‘if we let you do it, we’ll have to train everyone’ or ‘if we let you do it, we’ll have to pay you more for the extra skill’. The reality is that my correspondent has that skill and has it because the service provided that training.
As for professional discipline, I can’t answer that. Assume there is an allegation of ‘unsatisfactory professional performance’ that is ‘knowledge, skill or judgment possessed, or care exercised by, the practitioner in the practice of the health profession in which the practitioner is registered is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience’ (Health Practitioner Regulation National Law Act 2009 (Qld), Schedule, cl 3).
The issue, that I can’t answer, is what practitioners of ‘equivalent level of training or experience’ would expect. On the one hand they would (1) expect a paramedic to use the skills that they have been trained in, and the equipment they have been provided with, to provide the best possible care to their patient. On the other they may (2) accept, or expect, a paramedic to practice as directed by his or her employer. As a potential patient I would hope that they would expect (1) above.
To this end registration may be a useful tool to allow paramedics to negotiate with their employers and advocate on behalf of their patients. Where an edict is given for unknown reasons or reasons such as those suggested by my correspondent (‘they don’t want to train everyone’) the independent professional demands of paramedics can give authority to the claim that the edict has to be removed, or ignored, because of the overriding and independent professional obligations of registered paramedics. This ability to advocate for better patient care is in my view one of the stronger arguments for registration and perhaps part of the initial resistance of NSW Health to the process. As NSW Health said in its submission to the Senate Inquiry into The establishment of a national registration system for Australian paramedics to improve and ensure patient and community safety (p. 9) where it opposed national registration,
Registration can also involve loss of control of the scope of practice and associated workforce flexibility for employers. In NSW this could lead to loss of flexibility in terms of workforce planning, management and cost effectiveness.
If paramedics such as my correspondent can say that they have to be allowed to use the skills and training that they have whenever clinically indicated in order to meet the standards expected by their profession that will indeed limit the power of their employer to ‘control … the scope of practice…’ But that loss of control is for the benefit of patients.
In the absence of a clinical reason, an edict not to use skills that a paramedic has been trained in, where the equipment is to hand and where it is clinically indicated cannot be justified.
See also my ‘Frequently Asked Question’:
What should I do if I’m a registered health professional and the agency for which I volunteer doesn’t want me to use my skills and knowledge when working with them?