Today’s question revisits a matter of clear concern:

If a person who is a registered medical practitioner (doctor) also works casually as a registered paramedic, what are their obligations when working as a paramedic?

In the event of a complaint or adverse outcome, or if a case comes before the coroner’s court, will they be expected to practise at a higher standard than would be expected of paramedics in general, or would the standard be that of a careful paramedic of similar skill and experience?

I understand skills would be limited by the equipment and environment of the ambulance and its equipment, however would the clinical knowledge and judgement of the practitioner be held to a higher standard in particular?

Also, more generally, could the answer to the more specific question above be applied to any registered health professional who also works as another registered health professional in a different field?

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and all the posts here

The basic premise is if you are a registered health professional you are a registered health professional regardless of what uniform you are wearing or what you say you are doing today.   Today I’m cooking sausages at the Bunnings Bar-b-q for my kids school – that doesn’t mean you are not a doctor, or nurse, or paramedic, when someone puts their hand on the hot plate.

Don’t look at this question from the perspective of the health professional, look at it from the perspective of a patient and someone reviewing the event afterwards.  It’s hard to imagine what a doctor or nurse is going to do that’s different to a first aider or paramedic if they don’t have specialist equipment at hand but they do bring different knowledge.  Let us assume however that there is something that they could do, or there was something that they observed or knew and didn’t act on that knowledge or apply that skill.  And let us assume it would have made a clinical difference to the outcome.  Also assume that whatever it was is not contraindicated.  A neurosurgeon may know that the patient needs brain surgery but that doesn’t obligate them to do the surgery on the street.   So with those limitations assume there is something that could be done.

A patient suffers adverse outcomes.  They discover that there was a registered health professional on duty with the volunteer first aid group or in this context a doctor on the ambulance even though his or her uniform said ‘paramedic’ not ‘doctor’.  There was something that person could have done that would have benefited the patient. The thing was not illegal and not contra-indicated.  It was practicable to do it, the health professional knew how to do it and knew it was indicated, but didn’t do it.  Why didn’t they do it? The organisation who’s uniform they were wearing hadn’t said they could do it (or perhaps had said they could not).  So what’s the concern? The practitioner’s concern was that they would get into trouble or they would get sued and would be personally liable.

If they’re afraid of getting sued they either don’t back their own competence in which case get another job (fear of getting sued is different to saying ‘in the circumstances it was not the appropriate thing to do given risks/benefits’) or they think that the emergency services are like a row boat on a sea surrounded by sharks.  The sea is the law and the sharks the lawyers and the only thing protecting the practitioners are legislative protection and the vicarious liability of their employer or agency.  As soon as they come out of the boat the sharks are waiting to attack.  This blog hopefully shows that is not the case.  Emergency services aren’t getting sued.  The law is actually calm and the sharks are protecting the boat.

But let us return to the patient who says ‘I came to you for care, you knew that there was some care I needed and you could have provided but you didn’t and I can show that because of that I have a worse outcome’.  If you were that patient would you accept the argument ‘yes I am a doctor, but on that day I was a paramedic and paramedics don’t do ‘x’ even though doctors do and I could have’?

As for the coroner (if that’s your concern) how do you answer the question ‘you let this person die rather than break an employer’s administrative rule?’ That, surely, is a harder question to answer than ‘why did you go beyond this rule?’ A: because that was the best hope I had to save their life (see

When it comes to professional discipline the threshold question is did a health professional practice their profession at ‘a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers…’  As a health professional (whether that’s doctor, paramedic or nurse) what do you think your peers and the public would expect you to do if you were treating a person (regardless of the uniform) there was a procedure that would benefit the patient, was not contra-indicated, was safe to perform in the circumstances, was something you were competent to perform and had the necessary equipment and/or assistance and would improve the patient’s outcome particularly where it was necessary to save life or prevent long term threat to health or wellbeing (not where it would just be convenient or it could wait until the person saw their own doctor or hospital without increase risk).

Registered health professionals need to ask themselves – what should I do in those circumstances? What would others expect me to do?  Your answers to those questions will tell you what to do.

The question was

In the event of a complaint or adverse outcome, or if a case comes before the coroner’s court, will they be expected to practise at a higher standard than would be expected of paramedics in general, or would the standard be that of a careful paramedic of similar skill and experience?

…would the clinical knowledge and judgement of the practitioner be held to a higher standard in particular?

The person will be judged by the standard of a person with similar skills, competence and qualifications.  If the paramedic is also a doctor then they are a doctor.  They have that knowledge and those skills. If there was something else they could have done to save the patient’s life or prevent long term disability they will be expected to do that. If there is a complaint to the medical board the question will be did they practice their profession as a doctor at ‘a lesser standard than that which might reasonably be expected of the [medical] practitioner by the public or the [medical] practitioner’s professional peers…’

POSTSCRIPT

Having written the above I may have come up with an example to demonstrate the point.

Imagine that you have been a member of St John Ambulance for many years so you started as a first aider.  You have gone onto study medicine and have recently graduated so you are a registered medical practitioner but the paperwork has not quite caught up and as far as the St John records show, you are a first aider.

A patient comes into a first aid post and is treated by a first aider colleague. That colleague does their best and says to the person ‘there’s nothing we can do but if symptoms persist you may want to see your doctor’.  Assuming given that person’s skills and training that advice is appropriate.  But you’re a doctor and you have seen many more patients and you look at the patient and think ‘something’s not right here; if I was at work I’d want to ask a few more questions, take a blood pressure and listen to their chest’.  Assume there is a sphygmomanometer and stethoscope available.

You have two options.  First you say ‘today I’m a first aider, if I wasn’t a medical practitioner I would do just what my colleague did and give the same advice. The treatment offered to this person is what might reasonably be expected at a first aid post.  As a first aider I have nothing more to offer so I will offer nothing more.  I know there is a sphygmomanometer and stethoscope available but St John have not endorsed me to use those items even though, at work, I use them every day, but if I use them I will have broken a St John rule and if the person sues me for using them St John may not support me’. The person leaves, 10 minutes later suffers a catastrophic complication and dies.

Your alternative is to step up and say to the first aid colleague and the patient, ‘actually in my day job I’m a doctor and I wonder if I could just ask a couple more questions and take your BP?’   You do that and say ‘look I’m really concerned I think we should call an ambulance as you really need to see a doctor for some definitive tests’.  An ambulance is called the patient is taken to hospital where a diagnosis is made and his life is saved.  Or an ambulance is called, the patient’s taken to hospital and it’s determined that everything’s fine.  Or an ambulance is called and before it gets there the patient suffers a cardiac arrest but at least receives prompt CPR and defibrillation as he was in a first aid post – whether he lives or dies.

As a registered health professional which of those scenarios can you live with?  And what do you think your professional peers would make of either of them?  And who’s going to sue?  The patient who is sent to hospital with its associated expense and inconvenience to be subjected to tests that rule out whatever it was you suspected may be the problem, or the family of the patient who died 10 minutes after leaving a first aid post because you thought you were in a first aid uniform today?

Would you expect to be judged, and would you judge, the person who says ‘today I’m a first aider, if I wasn’t a medical practitioner I would do just what my colleague did and give the same advice. The treatment offered to this person is what might reasonably be expected at a first aid post.  As a first aider I have nothing more to offer so I will offer nothing more…’ as having acted reasonably? Or would you expect more from them because regardless of the uniform and the rules, they are a registered health professional?

I know today’s questions are about dual registration but the principle has to be the same if there is some procedure that the doctor can do, or some knowledge that he or she can bring to the matter, that a paramedic would not and does not have.