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?
To further comment on the statement from Prof Eburn “What’s the ambulance service going to do? Discipline the paramedic for saving the patient’s life?”
The answer would be “yes” on the grounds of “failing to follow a managerial directive ”
Those six little words grouped together has destoryed the careers of many a public servant in the 3 tiers of government and statutory authorities.
From not putting a coffee break on a log sheet night shift to matters such as this in that have achieved a positive outcome when no other was available. Many a good employee has had a career ruined for deviating from policy and procedure.
The FWC has a reputation of taking the employers side on most matters. There is anecdotal evidence to support this claim. That is why the presiding commissioner will often give direction for mediation.
The writer has not specified if the scenario is a remote or a metropolitan incidents or under direction of the RFDS Clinical Advisor. That has been overlooked.
Personally speaking, I have had exposure to training far above the level of first aid qualification I currently hold over the last 40 years. However, I am not a Radar O’Reilly when it comes to “pentop trachiometry”.
This question opens up a whole new can of worms.
M*A*S*H (Season 5 Episode 8, ‘Mulcahy’s War’ where Radar performs a tracheostomy using a pen knife and a biro) – got to be the best known episode at least on this blog – see https://emergencylaw.wordpress.com/2017/01/21/scope-of-practice-previous-posts-explained/ and see also https://emergencylaw.wordpress.com/2018/03/11/performing-an-emergency-tracheotomy-or-life-mimics-art/.
Just to add my two cents….
The Ambulance Service has initially gone beyond what many may consider as reasonable by training paramedics to operate in the tactical environment, thereby providing potentially life saving care to police officers in a setting where previously they would not have had access to care. In this tactical environment the diagnosis of a tension pneumothorax is likely to be clear. Post a gunshot wound to the chest, etc. As such the training that this paramedic received was minimal compared to what an ICP receives.
Tactical Special Operations training is only two days in duration, and it covers more than just tension pneumothorax decompression. ICP training takes 6-12 months in most services, it involves a higher level of clinical knowledge, clinical decision making, clinical reasoning, pathophysiology, supervised practice and in hospital exposure to critical care patients. I feel that this is the reason why the Ambulance Service likely limited the use of the skill. Deciding weather or not a blunt trauma patient, or a asthmatic patient has a tension pneumothorax is a different situation than that of someone who was shot immediately before you.
This is not a new situation. Civilian Ambulance Services in Australia have for decades not always recognized the skills that ADF medics have when they are employed outside of the ADF. This is not because of an inability to perform the motor skills, but rather due to the different training focus (medical vs trauma) and the level of knowledge acquired.
I hope that if this SOT paramedic has a patient dying from a tension pneumothorax post a GSW in front of them, and that there was no ICP backup available, that they would act in the patients best interest. But that scenario does not cover all situations that an needle toracostomy may be considered.
And Marty that certainly implies there are sound clinical reasons for the restriction and that certainly makes a difference
The SOT P1 should understand boundaries and restrictions, I am trained in a lot of things by NSW Ambulance and outside the ambulance, however I cannot use them due to the boundaries put in place by protocols, procedures, position, legislations etc I had to wait 9 years before I could qualify and reuse skills and pharmacology qualified to use in a federal government organisation.
What would the SOT officers reaction be if I abseiled, as a non SOT paramedic, down to a patient before he got there, or handled a tactical situation because of my many years military experience although not being a SOT paramedic, they would let me know I was out of line for sure.
In the case of decompression in a non tactical situation all they would have to do is put in a variation to clinical practice notification (normal NSW Ambulance process) . But they must be sure they followed all other practices and policies and we, in NSW Ambulance road duties, all know how many people don’t complete VCPs when they should.. The other concern for the P1 SOT and similar is that NSW ambulance may also have knee jerk or err on the side of caution and could make the easy decision to restrict P1 SOTs from having needle decompression if it became an issue, and then just respond ALS and ICP SOT officers to cover all tactical situations as SCAT did years ago.
We have to respect the decisions made by the medical director, health department, government authorities and whoever thought that giving SOT P1s this skill was appropriate for Tactical Situations. They are the ones who accept the ultimate responsibility for the tactical patient receiving treatment and also if the non tactical patient does not receive treatment. They just have to be comfortable (or not) with wearing 2 hats – Tactical and non tactical and work within each situations SCOPE of PRACTICE. One of my own saying that helps me get through these situations is I say to myself – ” I don’t have to like it, I just have to do it”. For example – while being trained in rescue skills we need SWMS, JSEA, Risk Assessments, but in a real rescue we don’t need them, 2 hats , 2 different situations, 2 minsets. (I do concede that there is not a risk to life in the training situation, and these are bound by legislation framework but my point stands.)
The discussions also talk about what would happen if the SOT P1 did use the decompression needle and saved someone’s life, the question should be “what would the ambulance service, and legal system and patients lawyers do if he didn’t save the life and caused further injury/death?” as has happened before in NSW Ambulance history with a cardiac laceration and puncture being the outcome. This is the risk the organisation considers.
The SOT officer is talking risk vs gain, I would say completing the Variation to Clinical Practice report would cover the specific rare case where they would have no ICP/ALS support and a needle decompression was absolutely categorically immediately required to save the patients life in NSW. They must also consider the risk to their patient, there own employment and employer if they, with limited training, exposure, expertise, and also that they have nil field mentoring as ALS and Level 5 (ICP) do receive . In this situation the government has considered in making the decision to restrict practice to tactical operations.
Lastly, this discussion did not have to be here and this could have been discussed with many respected knowledgable personal in NSW Ambulance who would have given an answer. However in experience I feel it is not the answer the person would have wanted. and they seem to be looking elsewhere for support of a procedure variation.
In summary the SOT officer’s situation although rare they will be damned if they, do damned if they don’t. A paramedics life is a hard one sometimes
I agree wholeheartedly.
Organizationally speaking, it wouldn’t take to much for the word to get around who is the person.
Prof Eburn does his utmost to defend confidentially, right to free speech and non bias with this blog.
However, I am leaning to the perceived management’s point of view of an employee possibily and wilfully prepared to breech clunical protocols and policy in relatin to any confidentiality agreement in rrlation to making a statement on social media that could bring the service into disrepute.
In summary a “rambo ambo”.
There have been a number of comments on both the WordPress and Facebook site that appear, at first blush, to disagree but I don’t in fact think there is a disagreement. First my response was understanding that there was no clinical reason for the limitation.
Marty said “In this tactical environment the diagnosis of a tension pneumothorax is likely to be clear. Post a gunshot wound to the chest, etc. As such the training that this paramedic received was minimal compared to what an ICP receives… Deciding whether or not a blunt trauma patient, or a asthmatic patient has a tension pneumothorax is a different situation than that of someone who was shot immediately before you.’
If a restriction is justified on clinical grounds, then it can be justified. One has to simply consider the position of a patient who is not treated and who finds that the paramedic could diagnose the problem and had the skills and equipment to deal with it. If the ambulance service cannot point to a sound clinical reason for stopping the paramedic from treating the patient, then the failure would be hard, if not impossible, to justify.
In my post I said “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”. Marty’s conclusion is like mine, though more nuanced given his understanding of the training. He says “I hope that if this SOT paramedic has a patient dying from a tension pneumothorax post a GSW in front of them, and that there was no ICP backup available, that they would act in the patients best interest” and that is the conclusion that I would also draw.
Wayne also notes the need to comply with an employer’s directions but also notes ‘’In the case of decompression in a non tactical situation all they would have to do is put in a variation to clinical practice notification (normal NSW Ambulance process)”. This he says would deal with ‘the specific rare case where they would have no ICP/ALS support and a needle decompression was absolutely categorically immediately required to save the patients life in NSW’. It is that ‘specific rare case’ that I was intending to discuss so Wayne’s comments again give a more nuanced but similar conclusion; in a situation that accords with the paramedics training, they should act even if it’s not strictly in accordance with the directions.
It’s true that it is the Ambulance Service and its management ‘are the ones who accept the ultimate responsibility for the tactical patient receiving treatment…’ Certainly there would be no legal action against the paramedic; if there’s a failure it’s the failure of the ambulance service to restrict the paramedic’s ability to practice skills that they have delivered. As noted however, there could be professional issues once paramedics are registered but that will depend on the assessment of the paramedic’s peers.
Brent asked “Should I start unblocking catheters? Where does an authority to practice vs skill and education end up?” I suppose one should start unblocking catheters if it’s a life and death question. As for authority to practice, see What is a paramedic’s ‘authority to practice’? (August 19, 2014) (https://emergencylaw.wordpress.com/2014/08/19/what-is-a-paramedics-authority-to-practice/)
Simple answer: You should only perform clinical procedures within your scope-of-practice as set forth by the guidelines/policies/protocols as set by the employing organisation (be that in this case the Ambulance service), as well as your clinical experience and competencies.
You can attend as many courses as you like and feel personally/individually competent on how to do a procedure, but that does not necessarily make you are necessarily qualified or competent to perform the procedure in the eyes of the organisation you work for and/or in the eyes of AHPRA or the Coroner should things go badly.
I am a Medical Practitioner (Doctor) who works as a Registrar in Emergency Medicine but also casually as a Paramedic. Where it is within the scope-of-practice as a Doctor in the Emergency Department to perform a variety of procedures, including cricothyroidotomies or thoracostomies (even then, I would always do it with consultation and blessing of my senior specialist colleagues), I would be remiss (and potentially negligent) and not operating within my P1 Paramedic scope-of-practice if I was to go popping in bic-pens and chest drains into patients while working on the Ambulance.
In my opinion, these are obviously life-saving procedures (that is all these advanced resusication procedures: intubation, procedural sedation, chest drains, etc.) but they are also procedures that carry significant risk if unnecessarily and wrongly performed (especially in the pre-hospital setting). They have a role in the pre-hospital care environment, but I think common sense should prevail here: you should only do them if you’re qualified, certified, experienced and competent. Personally I’d reserve this for Senior Paramedics (be that ICP and above) and Senior Doctors (Registrar and Consultants and above); allowing a large pool of clinicians (be that P1s or Interns-Residents) to do these is opening a can of worms.
*Having said that if there was no other clinician on-scene to offer this life saving procedure. Then sure, go ahead; if it works out well, I don’t think anyone can fault you. But if something does go badly, well then, we’re back to people criticising you about your scope-of-practice. Albeit, it would be odd for the Ambulance not to send a ICP or Doctor en route to a job where such critical illness is expected; I’m sure at mass-casualty disaster scenes such as that Lindt Cafe where firearms are involved, they would have numerable ICPs +/- Doctors on-scene pre-emptively; I thought it is almost standard practice to dispatch ICPs to potential significant trauma?
**Also just to clarify: Needle thoracostmies are okay; fairly minimal risk procedure with reasonable benefit for relieving a tensioning pneumothorax. However it is only a temporising measure; that is, the needle cannula will clot-up / block-up quite quickly; people who have been involved in massive trauma (or shootings) tend to have haemothorax (rather than a pure pneumothorax) and that requires a formal thoracostomy (i.e. finger + three-sided dressing or chest drain). … or dare I say… sometimes a thoracotomy (note thoraCotomy is clam-shell opening the chest with rib-spreaders vs. thoracoStomy is simply poking a hole).
With respect Doctor Strange, the fact that it took three posts suggests your answer is not ‘simple’. As you say ‘You can attend as many courses as you like and feel personally/individually competent on how to do a procedure…’ but given my correspondent is authorised to perform the procedure in a tactical setting then one can infer he or she has been assessed as competent to perform the procedure.
As for ‘the eyes of AHPRA or the Coroner should things go badly’ remember that neither AHPRA nor the coroner determine anything. AHPRA supports the various boards, including the soon to be established Paramedicine Board. The test for whether or not conduct is satisfactory lies with the relevant panels and tribunals. A panel at least will include peers in other words it’s a peer review process. But the question of how things are viewed ‘should things go badly’ is equally relevant if a person competent and with the equipment to hand, fails to save the patient’s life in order to comply with an edict not to. No-one can seriously accept that it is better to let the patient die.
As a doctor in emergency medicine there may be many procedures you can perform in hospital, with the greater resources that are available, than out of hospital. You would be ‘remiss (and potentially negligent)’ to do some of those things out of hospital. But equally may be ‘remiss (and potentially negligent)’ not to do them in circumstances where it’s do that or the patient certainly dies. Your discussion about the ‘significant risk if unnecessarily and wrongly performed’ is certainly the issue. If procedures are not clinically indicated or safe in the out of hospital environment that is indeed a reason not to do them. But my correspondent wasn’t threatening to use a pen because of what they’d seen on TV, but to apply skills and training that they have.
As you say “I think common sense should prevail here: you should only do them if you’re qualified, certified, experienced and competent”, but that was the point. My correspondent had been certified in circumstance A but not B but had not been given any clinical reason for the distinction. If the can of works is that it would cost too much to allow P1s to do it so none can do it even though my correspondent is trained, that can’t be justified if it costs the patient’s life.
As you say “if there was no other clinician on-scene to offer this life saving procedure. Then sure, go ahead; if it works out well, I don’t think anyone can fault you”. That was my conclusion too. “But if something does go badly, well then, we’re back to people criticising you about your scope-of-practice” and then the question is would you rather have tried to save their life or do you let them die so you can say – at least I stuck to the rules. Remember the rescue in Scotland where the Fire Brigade IC refused to let his firefighters rescue a woman from a disused coal mine (see Legal confusion leads to unnecessary death (December 8, 2011)). When the rescue was finally effected, several hours later, she died. The Sheriff said:
The Sheriff was critical of this ‘fundamentalist’ view. One can ask what is more likely to be criticised –
1. “It was a successful procedure; I followed my protocols to the letter. I understood that a needle thoracostomy was called for, I was trained in how to do it, I had the equipment to hand, there was no immediate ALS or ICP support available so, in compliance with the procedures I allowed my patient to die”; or
2. “It was a successful procedure. I understood that a needle thoracostomy was called for, I was trained in how to do it, I had the equipment to hand, there was no immediate ALS or ICP support available so, I attempted it”. If the patient dies the situation is as it was going to be anyway; and if the patient survives, ‘no-one can fault you’.
Finally, as you say ‘Needle thoracostomies are okay; fairly minimal risk procedure with reasonable benefit for relieving a tensioning pneumothorax. However it is only a temporising measure; that is, the needle cannula will clot-up / block-up quite quickly; people who have been involved in massive trauma (or shootings) tend to have haemothorax (rather than a pure pneumothorax) and that requires a formal thoracostomy (i.e. finger + three-sided dressing or chest drain). … or dare I say… sometimes a thoracotomy (note thoraCotomy is clam-shell opening the chest with rib-spreaders vs. thoracoStomy is simply poking a hole)’. That may be true but my correspondent was discussing only “Needle thoracostomies … [the] fairly minimal risk procedure with reasonable benefit for relieving a tensioning pneumothorax”.
Again, I don’t think we disagree. Remember the scenario was “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”. And you say, as do I “if there was no other clinician on-scene to offer this life saving procedure. Then sure, go ahead…”
Thanks to Prof. Eburn for his reply.
I think if the scenario is the patient is about to go into cardiac-respiratory arrest due to a clinically suspected tension pneumothorax, it is of course sensible to proceed with releasing the entrapped air with a needle thoracostomy. It’s a relatively straightforward procedure with relatively low risks in return for the enormous benefit to potentially save the person’s life. I can agree that if anyone has appropriate training to do this then it’s suitable; Queensland Ambulance Service allows their Paramedics (be that P1 – Advanced Care or Intensive Care) to do this in trauma cases where a tension pneumothorax is suspected for this reason. Albeit, on a side note, when it was first implemented, there was an increased incidence of Paramedics performing bilateral needle thoracostamies in patients that were found not to have a pnuemothorax, and ironically, by performing a thoracostamy it may have caused a pneumothorax (although, small and negligible). That said, I always carry a large-bore cannula needle in my car in case of a roadside incident where this can occur. As I said, no one can fault you for trying to help by inserting a needle to decompress the entrapped air; I think most would agree this a reasonable course of treatment for all-levels of competently trained clinicians.
However if the scenario proceeded to the situation where the needle decompression-thoracostomy failed (be that the cannula was too short to reach the lung pleura cavity, or there was a haemothorax component and the blood congealed and clot the cannula/needle, which does happen quite often), it raises another question at what point would be the ‘ceiling-of-care’ or ‘scope-of-practice’ for the attending first responder clinician whilst awaiting more senior help. I think in this instance, it should only be performed by appropriately trained clinicians in the pre-hospital environment; that is, if it was to proceed to performing a formal thoracostomy by means of a finger thoracostomy and/or chest drain insertion and/or converting to a thoracotomy.
Nevertheless, I think this is all easier said than done; a lot of us would be compelled by at least morally-ethically to try to save the person’s life with whatever training we have; another example I’ve had to face are patient needed to be intubated and sedated on a overnight shift in a rural Emergency Department, and where was no one else to do it, I would feel compelled to do it even with my relatively airway-anaesthetic skill-sets. However, as someone else said, “damned if you do and damned if you don’t”, should things go wrong, there will inevitably be an audit or review into what happened and if the clinician was operating within their scope-of-practice here.
As you rightly said, its is a complex matter; I retract saying it is ‘simple’. But at the end of the day, sometimes I reflect I often question myself if I’m practicing “defensive medico-legal medicine” vs. “good academic medical practice”.
And I’m not sure if you are ‘damned if you do’ – see Performing an Emergency tracheotomy (or life mimics art?)
Date: March 11, 2018 – https://emergencylaw.wordpress.com/2018/03/11/performing-an-emergency-tracheotomy-or-life-mimics-art/. And whilst there may ‘inevitably be an audit or review into what happened’ that’s not the same as being ‘damned’. Just because a person is asked ‘why did you do that?’ it doesn’t mean that they can’t have a very good answer. Asking what happened and why may (ideally is) a way to find out just that and determine whether perhaps changes are needed to make people feel more comfortable to act.
I am wondering if WHS legislation might impose any obligations in regard to this topic.
In Tasmania for example, section 19 of the WHS Act 2012 has this to say in relation to Primary Duty of Care:
(1) A person conducting a business or undertaking must ensure, so far as is reasonably practicable, the health and safety of –
(a) workers engaged, or caused to be engaged by the person; and
(b) workers whose activities in carrying out work are influenced or directed by the person –
while the workers are at work in the business or undertaking.
In this case health is defined as “physical and psychological health”.
(2) A person conducting a business or undertaking must ensure, so far as is reasonably practicable, that the health and safety of other persons is not put at risk from work carried out as part of the conduct of the business or undertaking.
With regard to 19(1) and (2) let us suppose that an ambulance service imposes, via scope of practice limitations as discussed above, a directive for the paramedic to withhold treatment that the paramedic is both trained by that service and competent to perform, and has the means available to perform, and which would, in the opinion of the paramedic at the time, be of significant (possibly life-saving benefit) to the patient, but where there is no timely assistance available, either in person, or by consult (such time varies with clinical situation).
In such a situation (and these cases arise from time to time), the paramedic is placed in a no-win situation by the directive to withhold treatments outside their scope of practice: either perform the prohibited task and face sanction, or do not perform the prohibited task and face the prospect of having to deal with causing harm to the patient by an act of omission. The latter situation might reasonably cause significant psychological anguish or harm to the paramedic.
In this situation, I wonder if the relevant ambulance service might be in breach of its statutory obligations regarding duty of care to both the paramedic (19(1) – psychological harm), and also to the patient via 19(2) by allowing a situation to occur that increases the risk to the patient (and hence, to the paramedic) via a directive that restricts access to certain treatments that would be available had such a directive not existed.
It would seem that, in some situations at least, the risk of harm to the patient and to the paramedic might be minimised, if not eliminated, by the ‘reasonably practicable’ mechanism of allowing the clinician to exercise their own judgment in such situations as those described above, but without the threat of sanction hanging over their head.
Is it is possible that not doing so might constitute a breach of the relevant provisions of the WHS Act?
Richard, I think that’s a long bow, but not impossible. We know that paramedics suffer high levels of trauma from their work and being torn between complying with a directive and doing one’s best for the patient might certainly add to the cumulative effect that leads to PTSD. To that extent the service does have a duty to their paramedics. The patient would have a harder issue as it’s not actually the ambulance work that causes their injury or loss even if the harm might have been avoided. You can’t take it too far because if you could it would require ever paramedic to be an ICP but it can’t be a breach of WHS legislation to say ‘if you’d sent a better qualified paramedic, I’d have got better care’. WHS is enforced by criminal penalties, I can’t see that anyone would think there was a criminal failure here but if the work culture was a culture of fear, where everyone was afraid to do anything and no flexibility was allowed, then I can see the argument.
Hi, I am an enrolled and Registered nurse in Victoria. I respect my employer’s decision and acknowledge my scope of practice but if I had to step up to save someone’s life (or assist using my skills as a registered nurse until help arrives) do I risk “disciplinary action from AHPRA” and my employer? However, if I let someone die by following policy I don’t feel I would be morally or ethically right. If my skills can help why can’t I use them?
My response here may be more theoretical than real as the law reports are not full of cases of dual registered nurses facing problems in this area but this is a risk that is recognised by the Nursing and Midwifery Board of Australia (see http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/Concurrent-registration.aspx). The Board says “You can reduce these risks by ensuring that you are fully aware of, and always work within, the scope of practice and standards expected within each role. You should also ensure that your employer and colleagues are clearly aware of the role in which you are practicing”. With respect that’s not a very helpful answer.
The first question to consider is what could an RN do that an EN could not in circumstances that are life threatening and where time is so critical it can’t wait for the on-duty RN to get there? One can imagine there’s a drug authority but the EN can’t administer the drugs. The RN, who is working as an EN, probably doesn’t have the key to the drugs cupboard and even if they did they would want another RN to check the drug and dose before administration so that RN could administer the drug. Let us assume however there is some RN skill that the RN/EN is trained in and if they were employed as an RN would immediately do or apply and the only thing stopping them now is that have been told they are an EN.
To consider whether that’s right just put yourself in the patient’s (or their family’s) position. ‘You could have saved my loved one but you preferred a policy based fundamentally on costs (it’s cheaper to pay you as an EN rather than an RN) than on the patient’s best interests?’ If you were in that family who would you complaint about- the RN that tried or the RN who said ‘but today I was an EN and that skill was beyond my pay scale’. And who do you think has acted in a way that meets the standard expected of other registered health professionals? I can’t see how you could be subject to professional discipline to use a skill that you are qualified to use but I can see how you could be for not using that skill. In terms of being an EN you may have stepped above and beyond what an EN might be a expected to do and an EN who attempted to apply higher skills but who was not trained and qualified in them may well be subject to discipline, particularly if the outcome is adverse to the patient’s interests. But you are an RN. Today you may have been working as an EN but that doesn’t deny the fact that you are an RN and the skills and procedures used you were trained in and they were within your scope of practice as an RN.
If you want to say ‘I have that skill but today my employer wanted me to pretend that I didn’t’ then you are acting under a misguided belief that you needed to do what you did to cover your arse; or your employers arse, but your duty is to act in the patient’s best interests and no court will be sympathetic to the argument – “I followed the rules to the letter and let the patient that I could have helped, die”.
thanks sir or your detailed reply I have been arguing several of these points while AHPRA recognizes my ability to give medication as an RN always me to administer meds as an EN my employer states ” as I haven’t done “particular course” Iam therefore not covered so I feel that I would need something “bad” to happen to get change