Following the post Treating patients whilst ambulances are ramped (December 28, 2018) another St John (WA) paramedic writes to say:

What is currently happening in WA is highly problematic. Paramedic and transport crews are arriving at hospital, the patients are triaged as normal and are then ramped. However, rather than continuing care in the triage area or airlock as has happened for years, we are now often asked to wheel the stretcher into the waiting room and continue care out amongst waiting room patients and visitors.

There are several concerns regarding this method of ramping, including, but not limited to:

1) Paramedic crews do not have the protection of security windows from aggression/violence in the same way that hospital staff do. With known regular violence/abuse towards paramedics, this is a horrible situation to find yourself in often.

2) We also do not have swipe cards to return to the triage are therefore our only egress from difficulties in the waiting room is the main sliding doors to the car park.

3) If a threat to safety occurs, my human instinct and my paramedic training always urge me to run from danger, however, I can’t just run and leave a vulnerable patient lying on a stretcher in an aggressive environment, but I do not want to compromise my safety by negotiating the stretcher through the public entrance and down on to the pavement to get us all out safely.

4) There is no confidentiality or privacy afforded to the patients on stretchers who are now being treated in a highly public space and in full view of mobile phones/cameras etc.

5) Patient safety is compromised by being suspended at waist level on a rickety stretcher and will be easily toppled should an altercation occur in the waiting (as often happens as we all know).

6) Treatment using opioids and schedule 8 medications has to continue in this public arena and does not feel safe.

7) A patient who is vomiting, defaecating, urinating, PV/PR bleeding, crying etc has absolutely no privacy and suffers a complete loss of dignity as a result, it’s awful to watch.

8) When a crewmate has to visit the ambulance to replace depleting stock from the treatment bag, or change an oxygen cylinder, or get water for the patient, or tend to personal needs, the remaining paramedic or transport officer is now left alone in this public space with the stretchered patient and it’s quite a vulnerable feeling.

I could go on forever with this list the more I think about it, but the problem is, we are given no options.

A) ED staff are adamant that the airlock is a safety risk if there are more than two stretchers therefore advocating for the patient is a complete no-no and garners no success whatsoever.

B) St John Ambulance WA management are adamant that treatment MUST NOT be continued in the safety of the ambulance whilst it is parked outside, no matter how many times this is discussed, it is being strictly forbidden.

With this stalemate in mind, it feels that the patient suffers first and foremost, but the paramedic and transport staff are in a very difficult situation, often intolerable, with nowhere to turn. This has been a problem for a couple of years now, however, with the advent of a registration, I personally feel that I am not upholding my registered practitioner commitment to best patient care.

With the simple solution available of returning to the privacy of an ambulance and continuing treatment within the safe confines of an air-conditioned space which is secure for the patient and staff, as well as maintaining patient privacy and dignity, I wonder if my duty as a registered paramedic is to stand my ground and ensure that this option is taken rather than the two unsuitable options outlined above.

It seems to me that there are two legal issues.  The first is the obligation of the employer to ensure the health and safety of their staff and to ensure that their practices do not expose the patients to an unreasonable risk to health and safety (Occupational Safety and Health Act 1984 (WA) ss 19 and 21).  Persons who have control of a workplace where other people will work have similar duties. This is relevant as the hospital has control of the ED which is a place where non-employees of the hospital (ie the paramedics) will work so the hospital also has duties to ‘take such measures as are practicable to ensure that the workplace, or the means of access to or egress from the workplace, as the case may be, are such that persons who are at the workplace or use the means of access to and egress from the workplace are not exposed to hazards’ (s 22).

To the extent that the paramedics think the work practices of St John or the hospital are exposing them and their patients to an unreasonable risk to health and safety then it would be appropriate to take that up in an organised way under the consultation arrangements that exist under that Act.  That may involve taking the matter up with the relevant Safety and Health representatives, Safety and Health Committees or a Safety and Health Inspector.  Whilst trade unions do not appear to have specific functions under the WA Act, it may also be worthwhile taking the issue up with the relevant trade union.

The other issue relates to the professional obligations of now registered paramedics.  As professionals, paramedics should be advocating on behalf of their patients and putting the patient’s interests first.  The Code of Conduct (Interim), published by the Paramedicine Board, says that paramedics have ‘ethical and legal obligations to protect the privacy of people requiring and receiving care’ ([3.4]).  Generally (at [1.2]):

Practitioners have a duty to make the care of patients or clients their first concern and to practise safely and effectively. They must be ethical and trustworthy. Patients or clients trust practitioners because they believe that, in addition to being competent, practitioners will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion. Patients or clients also rely on practitioners to protect their confidentiality.

Treating patients in a public place where there is a secure ambulance, and in the absence of any clinical reason for the direction ‘that treatment MUST NOT be continued in the safety of the ambulance…’ would seem contrary to one’s obligations to maintain the patient’s privacy and provide ‘good practice’.

It has always been my view that one of the arguments in favour of paramedic registration was to empower paramedics to advocate for their patients.  A registered paramedic’s duty is not simply to follow his or her employer’s directions but also to advance his or her patient’s interests and provide professional, good care. This is an example where the independent duties of paramedic practitioners can be used to bring pressure on the employer and the hospital to address the issue of how ambulance patients’ are treated pending transfer into the care of the hospital.   This may be a matter to take up again with a trade union or with the West Australian chapter of Paramedics Australasia (of which I am a board member).

Conclusion

All those involved in the patient’s care, the paramedics, the nurses, the doctors, the hospital and St John have mutual obligations to ensure that the patients receive appropriate care and that the safety of both paramedics and patients are protected.

It would certainly be interesting to know why St John (WA) ‘are adamant that treatment MUST NOT be continued in the safety of the ambulance whilst it is parked outside, no matter how many times this is discussed, it is being strictly forbidden’.