This question again revisits the issue of people holding skills and qualifications beyond their current expected scope of practice.
The short answer (before I even get to the question) is ‘no-one is going to reward you for letting someone die when you can stop it.’
The question is:
What about dual qualified paramedics who are also registered nurses
Can they practice their skill set in an emergency department when employed as a registered nurse?
Say for instance a country nursing post. If the patient required intubation or cardiac pacing, which are invasive skills and not in a nurse’s scope of practice, can a paramedic initiate this treatment?
Dual qualified nurses who are also midwives can practice midwifery in the emergency department when employed only as a nurse. Just wondering if the same would apply to paramedics.
Remember that the Health Practitioner Regulation National Law works through protection of title, not strictly defining ‘scope of practice’. Your ‘scope of practice’ is defined by your training and to a lesser extent your employer. An employer cannot however limit a practitioner’s scope of practice to the extent that the practitioner would be guilty of “Unprofessional conduct” (that is “professional conduct that is of a lesser standard than that which might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers…”) if they complied.
A registered paramedic is a registered paramedic even if today they are working as a nurse. They still know what they know, they still have the skills they have. If a paramedic was working in an emergency department and had the equipment required to perform a task that was within his or her skill set why would anyone not do it?
Imagine you are the patient’s family and the person dies. You find out that the nurse on duty was also a paramedic and knew how to intubate, had the equipment, the procedure was not contra-indicated but they refused to cover their employers or their own arse. Ask yourself how persuasive this argument is: ‘today I’m employed as a nurse but I would rather see your family member die than get into trouble’. Are you going to complain about that person and sue the hospital, or are you going to complain about the person who tries even if it doesn’t work?
Putting aside that emotive question, the registered paramedic will be expected to perform to the standard expected of a paramedic. If a panel or tribunal was satisfied that the ‘public or the practitioner’s professional peers’ would expect a paramedic to act to save his or her patient with a procedure was within their skill set, not contra-indicated and where they had the equipment, then the paramedic may be guilty of unprofessional conduct no matter what badge he or she is wearing today. I can’t see that it makes a difference the patient relationship began as a nurse/patient. The nurse/paramedic still has a duty to act in his or her patient’s bests interests and that must include using all the skills and knowledge that they have.
Australian Emergency Law 
Another interesting read. In a similar vein, would the same apply to registered paramedics working as a “volunteer” ambulance officer? For example, if I was a registered Paramedic and volunteered with SJAWA as an ambulance attendant, would my scope of practice be limited to what SJA said I can and can’t do, or that or a registered paramedic?
Of course the same would apply. Remember we’re talking about life threatening situations where you have both the skills and equipment to do something. If you’re a registered paramedic volunteering with St John and you know a person needs intubation or drugs that you would normally have in your ambulance but don’t have today, then of course you can’t do anything. That is why this question is usually at best theoretical – what can a paramedic, or nurse or doctor do in an emergency that’s any different to a first aider if they haven’t got the gear with them.
But if there is something you can do, if the gear is there or it’s a skill or procedure that doesn’t need kit and if it’s a question of life and death you do what you can do. IN what possible world would it be better to let the patient die? What possible organisation that you work or volunteer for would rather you let the patient die for fear of getting roused on? What are the risks – on the one hand the person dies, on the other?
This question has been discussed often on this blog – see all the posts that appear here: https://emergencylaw.wordpress.com/?s=volunteer+scope+of+practice
Thanks for the reply. Always appreciate your well thought out responses and I enjoy reading your articles.
Cheers
Daniel Fogarty 0438 739 979
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A good read which triggered a question I had not thought about until now –
I am employed as a regular paramedic, but I have a tertiary qualification as an intensive care paramedic (although my employer has not yet employed me at that level). You mentioned that level of training is more indicative of scope of practice than the scope given by the employer; because our ambulances all carry intensive care equipment and drugs, could there be any expectation on me to utilise skills above what I am authorised to do by my employer if/when they are indicated?
Thanks again,
Andrew Murphy.
I have to say after quickly looking back over some of the previous posts on similar topics I have probably found my answer. Although I am suddenly now concerned that I will be in one of those unusual circumstances where I will have ready access to equipment to perform skills above what I am authorised to do by my employer.
Any input would still be very much welcomed.
Andrew Murphy.
‘Could there be any expectation on [you] to utilise skills above what I am authorised to do by my employer if/when they are indicated?’ I’ll answer that question by asking you – what do you think ‘might reasonably be expected of [you] by the public or [your] professional peers’?
What would you expect if it was your loved one at risk of dying and the paramedic said ‘I’m trained as an ICP, if I was wearing a different uniform today I’d use those drugs over there as I know what’s needed, the equipment is there and I believe I’m competent to use them, but today my employer and I would prefer it if I let your loved one die because either they don’t want to pay for my skills (and if I’m not getting paid I’m not going to do it) or we’re both afraid I’ll screw up and you’ll sue them or me’. Who are you going to complain about? Who are you going to sue?
Remember in Woods v Lowns, Mrs Lowns sued Dr Woods because he refused to come, not because he came, tried but failed to save young Patrick.
Hi Michael,
You’re virtually describing my daily work day.
I’m a paramedic trained and worked overseas as an ICP, including helicopter training. However I’m currently employed as an ambulance paramedic with a lesser scope of practice in a jurisdictional ambulance service here in Australia. A recognition process has not been offered to me yet by my employer, not because of a lack of qualifications, but simply because that there are currently no ICP positions available in the service. I’m working for the same service as Andrew, with all ICP equipment and drugs available to me on any given ambulance in the service. This often exposes me to either very frustrating or even ethical difficult situations, mostly both.
Any guidance or advice would be much appreciated!
Best regards,
Michael Endres
I’m not sure what further guidance or advice I can give. I’ll try to summarise my thinking but before I do I do want to question why you have ICP drugs available to you. If you’re employer hasn’t endorsed, you to use various scheduled drugs (assuming that the employer has that authority) then why are they in your ‘possession’? It’s an offence to carry or supply scheduled drugs without relevant authority and if there’s no ICP working with you those drugs should not be in your car. If you’re working with an employed ICP paramedic none of what follows will be relevant.
Putting that to one side this is a summary of what I’ve been trying to say:
• 99.9% of the time you’re going to work within the limits imposed by your employer.
• If a patient needs ICP intervention and there are others who can do that, leave it to them.
• But, in extreme cases, a patient is at risk of dying or suffering long term permanent harm to their health, there is a treatment that you know is required, you are trained to administer, you have the equipment at hand and it’s a case of you act or no-one does and the patient dies then I foresee no adverse legal consequences by acting to save the person’s life (and see, for example, Performing an Emergency tracheotomy (or life mimics art?) (March 11, 2018) https://emergencylaw.wordpress.com/2018/03/11/performing-an-emergency-tracheotomy-or-life-mimics-art/
• The idea of ‘scope of practice’ is an employer’s restriction, it is not something set in law and certainly not in the Health Practitioner Regulation National Law. There is nothing that says only a paramedic (or doctor, or nurse or anyone else) may do treatment x (other than some restricted dental acts, restrictions on the prescription of optical appliances and restrictions on spinal manipulation which are not currently relevant) or a paramedic (or doctor, or nurse or anyone else) may not do treatment x. Various health boards do set out minimum standards or expectations that is we expect that anyone registered as a nurse or paramedic can and will do the following (see Nursing standards for practice https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx and Professional capabilities for registered paramedics https://www.paramedicineboard.gov.au/Professional-standards/Professional-capabilities-for-registered-paramedics.aspx) but that’s not a limiting ‘scope of practice’. There’s no law that says I can’t intubate a person, I don’t do it as I don’t know how and don’t have the equipment.
• The Professional capabilities for registered paramedics says that good paramedic practice includes ‘recognising and working within the limits of a practitioner’s competence and scope of practice, which may change over time’ but that doesn’t define what scope of practice is. I suggest it is not strictly defined by the employer, that is the nature of now being part of a profession. If you have ‘trained and worked overseas as an ICP, including helicopter training’ no doubt that overseas experience and qualifications formed part of your registration documents – so your scope of practice that which you are trained and competent to do, is wider than what your employer is paying you to do. Another aspect of good practice is to ‘balance of benefit and harm in all clinical management decisions’. The benefit is you improve the chance of saving the patient’s life, the harm is what?
• Remember too that:
As a paramedic much care will be ‘in an emergency’ but what is an emergency to the patient may not be an emergency to you. But in the extreme situation we’re talking about ‘good practice involves offering assistance in an emergency that takes account of the practitioner’s… skills, the availability of other options’. In the circumstances discussed I’m assuming you have the skills even if your employer has not endorsed them and there are no other options – there isn’t an ICP paramedic working with you.
• It’s a question of risk assessment. Assume the worst thing that can happen to you or your employer is someone chooses to take legal action. Who are you they more likely to sue – the person who tries to help (even if it doesn’t work) or the person who could but doesn’t even though that person is a treating health professional? (Consider the cases of Dr Lowns and Dr Dekker both discussed elsewhere in this blog where the doctor was sued and subject to disciplinary proceedings for not rendering assistance (see as a starting point https://emergencylaw.wordpress.com/2016/09/11/medical-practitioner-refuses-to-assist-at-cardiac-arrest/)).
• If you act and save their life there can be no adverse legal consequences. If you try and the person dies you haven’t made the situation worse, they were going to die anyway. Even if your employer wants to criticise you imagine the news headlines – “paramedic service disciplines officer for saving patient’s life!”
• If you think the treatment may make it worse, that it’s contra-indicated or you’re not confident then don’t do it. The chances of there being legal consequences either way are very low if not non-existent, but I suggest the risk is higher for failing to do what you can remembering that I’m discussing a life and death situation where there is an indicated treatment, it’s within you’re training and experience even if it’s not within the scope of practice defined by your employer, you’re confident in your diagnosis and ability, you have the equipment required at hand and the treatment is not contra-indicated and it’s a case of you act or no-one does.
• As a registered paramedic always ask yourself what would ‘the public or [my]… professional peers’ expect me to do in the situation (remembering that the situation we’re talking about is necessarily one of life or death)?
Thanks Michael for your comprehensive reply!
Your summary is pretty much in accord with how I was thinking about and handling these situations in most cases, coming from a professional belief of acting in good faith and trying to deliver the best possible care for the highest achievable outcome for my patients.
I have worked in other jurisdictional ambulance services in Australia where the equipment is strictly separated depending on the ‘scope of practice’ of the on-duty paramedic, to a certain extent (i.e. cardiac monitor functions like pacing etc included in all monitors and so on). This not the case in all services so. I also have to clarify that all S8 drugs carried in my current service are endorsed for APs (even though not to the full extend of use of course, that’s where it can get complicated with having ICP background), all other ICP drugs are mainly S4 but nevertheless normally need a prescription and are available to APs regardless if they are working with an ICP or AP.
I would like to stress that my concern has nothing to do with any ego of any sort. My objective is that my patient or any patient in general is getting the appropriate and required care in a safely and timely manner for the best possible outcome, regardless of who is providing this in the end. If I’m working with an ICP college normally this does not occur then obviously. If I have to call for backup, then it is an evaluation of benefit and risk in regards of the expected time of arrival of said backup. I have also worked for another jurisdictional service in a very remote setting, same conditions there: no ICP recognition due to no pathway/positions available with ICP equipment and drugs carried on each ambulance. Due to the remoteness with sometimes not even getting a reliable satellite phone reception, I did find myself in situation where I had to ‘step outside’ my scope to reduce either significant harm or suffering to my patient. In all cases the outcome was a good one, no actions neither from my employer nor from the patient (and why would they?) followed. But still it remained an unnecessary uncomfortable position to be in. Luckily in my current service the ICP ratio is high which often results in either working with an ICP college on shift or having the option of ICP backup. But of course this does not cover all cases all the time. And even here with having better resources available comes in a whole new conflict: Now I’m in the situation where I get an ICP as backup, but the then arriving ICP might have less experience and with that less confidence in actually doing the required procedure and rather votes against it. Of course you can always argue what is actually required, there often is some grey area. But let’s talk about a scenario where an unconscious patient unable to maintain his own airway clearly needs intubation to avoid aspiration and associated complications, but the called backup ICP decided against it, not because the patient doesn’t need it but because he/she is lacking of confidence. These situations can be very challenging, as on the one hand you don’t want to make a situation worse by arguing and wasting precious time, but you also do not want to watch somebody get seriously harmed or even die due to failure/fear to help. And this has certainly nothing to do with best possible care and outcome.
Not currently being employed as an ICP despite holding the required qualification has put me in this situation more than once. Easy to decide if it’s life and death. Not so easy if it is ‘just’ pain and suffering. While it is always a risk assessment of course, it puts me in an unnecessary difficult ethical and professional position, which I’m currently trying tor resolve with my employer…
Thanks again for your thoughts, they are highly appreciated!
Have a great day,
Michael Endres