Today’s correspondent asks:
… if two paramedics respond to a case, and during their care one of them is seriously injured (let’s say they are responding to a patient in cardiac arrest following an unknown industrial accident, and during care one paramedic is accidentally electrocuted and becomes unconscious), is there any legal guidance on the responsibilities of the second paramedic in regards to who they chose to treat?
For example, I would assume that the remaining paramedic would now care for their partner (the paramedic), even if it meant that the patient was not cared for at all until back-up arrives.
Is there any legal guidance on this? I assume that our duty of care to the patient is superseded by scene safety and therefore the patient is always at a lower priority than the crew.
It is certainly NOT the case that ‘our duty of care to the patient is superseded by scene safety and therefore the patient is always at a lower priority than the crew’. If scene safety were the issue and paramedic 2 was electrocuted, then presumably paramedic 1 would withdraw until the scene could be made safe.
The duty to the two patients has to be the duty any paramedic owes in a situation where the number of patients exceeds the number of paramedics on scene. The issue would be determined by the principles of triage and assessing clinical need. Patient and the safety of the treating paramedic will come into it. If there is a patient that ideally should be treated with higher priority but he or she cannot be safely accessed, then a paramedic would treat the other patient first. And if it is too dangerous for the crew to enter then that is fair enough.
In this scenario however, assuming Paramedic 1 is no longer at risk, the decision to treat should be based on principles of need and triage, not that Paramedic 1 owes some predominant duty to paramedic 2 over and above any duty owed to patient 1. A critical ethical principle in medical care is ‘justice’ that is giving aid to those that need it on the basis of their need and not for judgements to do with status, personal loyalty etc. It would be understandable if paramedic 1 sought to treat his or her friend and colleague first, that may be a natural inclination, but it is certainly not going to be a legal duty. And if paramedic 2 is clearly not as badly injured as the original patient, such that triage would say treat the original patient first, it may be a breach of duty to that patient to withdraw treatment in favour of a colleague.
For a related discussion see – Gabriella Marchant ‘Paternal instinct’ led Hindley Street doctor to treat his daughter first, inquest hears’ ABC News (Online) 14 Feb 2019.
Basic rule of triage for the suggested case. 1 patient with 2 resources, the cardiac arrest patient has a Red/P1/critical label.
After the paramedic is disabled and unconscious, we now have a triage event or in fact a ‘reverse triage’ event, ie more demand than resources allow. If the paramedic is very unwell, the paramedic moves to Red/P1/Critical, or even a Orange/P2/Urgent and the cardiac arrest to a Blue/P4/Expected To Die or Black/P5/Dead.
A concept that is often difficult for first responders to overcome morally is the notion of utilising limited resources on those with a reasonable chance of survival, sometimes known as reverse triaging. Otherwise time taken with originally critical patients may have limited avail whilst Urgent patients untreated may deteriorate to critical or worse.
Remember that a patient requiring CPR (with the exception of a bradycardic infant) is in fact clinically dead.
Michael hit the nail on the head – it all comes down to triage.
Glad to see your comments, Brad. I wholeheartedly agree with you, hard though it may be.
Could you provide comment in relation to a single paramedic being assigned to multiple cases, especially now with professional registration and the APRHA code of conduct as it currently exists?
Say a paramedic is dispatched to two cases both of which require cardiac monitoring and only one cardiac monitor is present. In the event of an adverse outcome for the patient who was not monitored – does the paramedic have support from any adverse action being taken?
You can only do what you can do. Whether conduct is negligent or unsatisfactory professional conduct has to be judged in all the circumstances. What would the reasonable paramedic do in the same circumstances not what would a paramedic do in an ideal world.
Quite right. One would need to assess the severity of each and establish greater need. If the other one takes a dive and there’s no monitor to see it then such is the nature of the game.
I was going to say that it is not up to the legal system to knit pick reasonable clinical decision making vs another reasonable possibility, but then I read your link, Michael. I can’t help but feel that the inquest was a bit rough on the doctor involved. In as such and to add another spanner in the works if the paramedic you were working on is your spouse/partner/sibling/other as was the case for the doctor in question I think it unreasonable to expect a clinician to act with complete impartiality and there would need to be an understanding if not an expectation that focus will unfortunately likely be on the one with the highest emotional value in such circumstances.
I think many of us, as pragmatic and or professional as we believe we might be, would probably act similar. What value does punishment or legal reprimand have in such circumstances and what deterrent would we reasonably expect it to play in saving the life of a loved one in future comparatively? Very little I would have thought.
The doctor in that case hasn’t been punished or reprimanded. He’s been asked about his decision making. The Coroner’s findings are yet to be handed down. You can’t expect not to be asked questions in those circumstances but being asked questions is not the same as being punished or reprimanded.
“Dr Kerry was asked repeatedly why he performed CPR on his daughter despite evidence that Mr Pike was in a worse physical state.
He told the court he instinctively went to his daughter, describing his actions as “paternal instinct”.”
The Coroner may, we don’t know, say that was perfectly understandable and the coroner may find that it would have made no difference to the outcome in any event. Don’t confuse the proceedings with the outcome.
True, I didn’t suggest he was punished or reprimanded, I was suggesting a hypothetical, of is it reasonable to punish someone in such circumstances and to what end? In an attempt to deter someone from favouring their critically ill loved one over a critically ill stranger? Would I for example feel once ounce of remorse if my child lived at my hand to see me in prison rather than dying and failing to bare witness to my freedom based on a passable application of medical judgment?
I obviously didn’t make my position clear. Whilst I understand that it is not the questioner’s job to assume anything, to be asked ‘multiple times’ why he favoured his daughter over a stranger in the setting of his son having died recently in similar circumstances, that line of questioning itself would be rough and borderline redundant if not inflammatory in that any clinician receiving such a question recongnises the inference that they chose personal reasons over good clinical judgement which in any other circumstances would be the epitome of unethical/unprofessional.
Whilst we can’t expect not to be questioned in such circumstances one can’t ignore the notion that to simply observe affects the outcome, ie, ask any one of the clinicians investigated by AHPRA over what later turned out to be frivolous accusations how they felt including whether some of them are even still practicing today despite not being found guilty of any wrongdoing what-so-ever.
And fair points. I don’t for a moment discount how traumatic the process can be, that has indeed been the subject of research we’ve being doing on behalf of the Bushfire and Natural Hazards CRC. Legal processes can be far more traumatic than whatever it was that lead to the court room – see also my post https://emergencylaw.wordpress.com/2009/06/26/why-being-called-before-the-coroner-is-worse-than-being-sued/.
However I do like to remind people that the Coroner cannot impose punishment, a coroner doesn’t find anyone guilty or liable in negligence. So a coroner’s inquiry whilst punishing, is not punishment.