Regular readers of this blog may think that sounds familiar to an earlier title- ‘Just Ridiculous’? When is a MICA Paramedic a MICA Paramedic? (March 28, 2013). It is similar because the issue of restricting a paramedics scope of practice in order to save money has arisen again. A correspondent has drawn my attention to a Member Update issued by the Australian Paramedics Association (NSW). You can download the document here, or access it via the APA website.
The critical part of the update says:
Today in the Industrial Relations Commission (IRC), NSW Ambulance (NSWA) took a position that will place patients’ lives, Paramedic registration and Paramedic well-being at risk.
NSWA’s lawyer stated that Intensive Care Paramedics (ICPs) in P1 positions would have their specialist status removed from the Computer Aided Dispatch (CAD) system and equipment and medications removed from vehicles. They would not be responded as ICPs even if a patient required their intensive care skills. Why? So that NSWA will only have to pay them P1 rates instead of ICP rates.
The IRC Commissioner said it would be “absolutely appalling” if an ICP was prevented from using their life-saving skills merely because of their position title.
I’ve looked the Commission’s daily list and I can’t identify what the proceedings before the Commission were, but nothing turns on that.
I have, on many occasions, written on demands by employers or volunteer organisations that people should not use their skills in the best interests of a patient in order to save the employer money or out of some ill-founded fear of liability. See for example
- ‘Just Ridiculous’? When is a MICA Paramedic a MICA Paramedic? (March 28, 2013);
- Nursing standards and assisting in an emergency (May 22, 2014);
- Doctor as volunteer Life Saver and scope of practice (February 6, 2015);
- Volunteering with advanced skills (January 18, 2017);
- Scope of practice – previous posts explained (January 21, 2017);
- I’m trained but am I allowed to use my skills? (May 25, 2018); and
- Don’t let the patient die (June 11, 2019).
I hope I have been consistent. If we are talking about life or death, if you have the skills to save someone you use them. No-one is going to thank you for sticking to the organisations rules but letting the patient die. To quote again from the Sheriff’s Inquiry into the death of Alison Hume [2011] FAI 51:
[The Incident Controller] in particular, considered that the rescue operation was “a success”. In his view he had adhered to the policies and procedures set out by Strathclyde Fire and Rescue Service. He had obtempered to the letter the instruction contained within the Memoranda from Strathclyde Fire and Rescue Service of the 14 and 27 March 2008. There had been no casualties other than the one to whom the Service was called upon to rescue.
Unfortunately this was not a successful operation: a woman died who had … survivable though life threatening injuries…
You can ‘obtemper’ (‘obey, comply with’) the company’s ‘scope of practice’ but no-one is going to think that the outcome was a success if the patient dies when they could have been saved.
What I have also said (I hope consistently) is that a person who is a doctor, or an ICP or has any other skill set cannot be expected to use that set if they do not have the equipment to hand. An off-duty paramedic cannot be expected to treat a patient as he or she would if they had a fully stocked ambulance with them. A paramedic, now a registered health professional, is expected to provide care to their patients in a way that ‘demonstrates the knowledge, skill or judgment possessed, or care… [at] the standard reasonably expected of a practitioner of an equivalent level of training or experience’ (to paraphrase the Health Practitioner Regulation National Law (NSW) s 139B). What’s required depends on all the circumstances.
If an ICP is on an ambulance and responds to a life-threatening emergency, if the ambulance is not equipped with ‘equipment and medications’ then he or she cannot be expected to use that equipment and medication. But that won’t mean that an ICP won’t have extra skills and knowledge compared to his or her partner who is not an ICP. And the ICP cannot simply turn that knowledge and skills off. They know what they know, and the patient gets the benefit of that knowledge and skill set even if the paramedic does not have the equipment to hand that he or she would want. But whatever the person is called, and whatever they are paid, they remain an ICP. And the patient, and therefore the ambulance service get the benefit of an ICP even though they are not paying for it. For example if the crew were supported by an intensive care ambulance, the ‘deskilled’ ICP could and should still access the ‘equipment and medications’ on the intensive care ambulance if that is in the patient’s best interests.
I do not think a paramedic could be held guilty of ‘Unsatisfactory professional conduct’ for not using equipment that he or she does not have and has not been issued. However professional registration should strengthen the arm of paramedics and APA to argue that paramedics should not be restrained from providing the best patient care that they can.
Further, it would be difficult to hold the ambulance service liable both because of difficulty in proving that had the ICP paramedic had the kit it would have made a difference and because the Civil Liability Act 2002 (NSW) s 42 says ‘the general allocation of … resources … is not open to challenge’. It is up to NSW Ambulance to determine how much it spends on equipment that is restricted to intensive care ambulances so the fact that not every ambulance has an ICP drug kit is a matter for Ambulance to determine when allocating it’s budget. Those sorts of decisions are generally not reviewable in a court.
I do however agree with the Commissioner – ‘it would be “absolutely appalling” if an ICP was prevented from using their life-saving skills merely because of their position title’ and because Ambulance did not want to pay their own staff what they are worth. Much better to celebrate that there are so many ICPs that they can be deployed in P1 positions thereby improving community service.
It will be interesting to see if the matter before the Commission goes onto final orders to better understand what the application was about and what the Commission ultimately rules.
What’s the point of having ICPs if you’re only going to utilise them as P1s? Surely maintaining a kit for an ICP isn’t that much more over the standard P1 kit?
this has been an onging discussion within ASNSW for many years, ICP applying for positions that are allocated as “AP” spots. (mostly rural). sometimes it takes action like this to resolve these issues. I hope all involved can recall that the patient comes first and get on with providing good quality clinical care
Obviously if the ICP is still being credentialed at ICP level by the organisation, at annual validation, then there is another question to be addressed…. If not then, there is the answer in itself.
Many thanks for your blog Professor Eburn. I read your articles with great interest.
A situation I face is that I work for an organisation in Australia as an ICP having completed both the degree and post graduate study requirements in NZ. The role is a FIFO role and when I am off swing I return to NZ and work as a Paramedic and Anaesthetic Technician. I am registered as a Paramedic with AHPRA.
Despite my best efforts to be assessed and permitted to practice as an ICP in NZ, when I am back in New Zealand, I am only permitted to practice as a Paramedic due to the casual status of my employment (which means that there are a number of interventions and medications reserved only for the use of ICPs, that I can use in my Australian ICP role that I do not have the “sign off” to use in my NZ role) Furthermore, my work as a registered Anaesthetic Technician affords me the ability to maintain competence in skills such as Intubation. Needless to say this causes me confusion at times when working in NZ as its seems that I am required to withhold treatments that I feel might benefit the patient concerned. Im told by persons representing the organisations that providing treatments, without permission from the Medical director or a Clinical Advisor, outside of a given Authority To Practice (ATP) can result in removal of ones ATP and potentially a loss of job. But if you’re acting in the patients interests providing a skill you have training and competence elsewhere in, surely that’s better for the patient.
Referring to your articles on these matters, if I am in the situation where a life saving intervention is required and equipment/ medications are available and ICP back up is not available in a reasonable time frame then it seems that I would not be wrong in administering a treatment or intervention. Would that also apply to non-lifesaving interventions and treatments?
No, I don’t think the same reasoning applies to non-life saving interventions and treatment.