Today’s correspondent holds:

… registration as Nurse and Paramedic. I am employed as an Intensive Care Paramedic for the ACT Ambulance Service as well as a Clinical Nurse Specialist for NSW Health and work in a rural Emergency Department.

Often when working as a Nurse for NSW Health we do not have a Doctor on duty but still accept emergency patients. I believe it’s only a matter of time before a patient presents at the Emergency Department requiring life-saving skills that I am authorised to provide only as an Intensive Care Paramedic but not as a nurse.

It’s clear to me where I stand morally on the issue but legally and from an employment point of view I’m not sure what would happen if I were to use skills I’m authorised to use in the pre-hospital setting in the in-hospital setting where I am not authorised to use them.

Any advice you could offer would be much appreciated.

I have addressed this type of issue before – with respect to volunteers see

See also

I cannot say what an employer would do, but we can consider some issues.  First let me assume we are talking lifesaving treatment and that my correspondent is in fact (not just in his or her imagination) competent.

I will for the sake of the argument assume that the treatment is intubation, that there is an intubation kit available, that intubation is part of the standard practice of an ACT ICP but not a nurse with general registration employed in a rural emergency department (and don’t feel the need to correct me if those assumptions are wrong, I’m not saying any of those propositions are true, just that I assume to be true in order to tell the story).  I will also assume that a patient presents who requires intubation and is likely to die without that intervention.

The first point of view is the hospital. The patient has come to the hospital for emergency assistance. The hospital has a duty to provide reasonable care to those that present at the emergency department (Barnett v Chelsea and Kensington Hospital Management Committee [1969] 1 QB 428).   What is reasonable depends on all the circumstances.  One of the circumstances in this case would be that there is an ACT paramedic competent to perform the life saving measure.   If the measure is performed and the patient survives it will be accolades all ‘round.  If the patient dies and it is revealed that there is a person there who could have helped and saved the patient’s life but did not, how could that be defensible?    If the hospital did know my correspondence was an ACT ICP but gave specific directions not to use particular skills when indicated how could that be justified?

If we consider my correspondent as a registered nurse then he or she has a duty as a registered health professional to act in the patient’s best interest.  It is in the patient’s best interests to be intubated.  How can it be justified not to give treatment that is required and that the nurse is competent to perform?

The position as a nurse is the same if we consider my correspondent as a paramedic.

But what of the argument that today ‘I was employed as a nurse?’  That may be true but my correspondent is a paramedic, whether he or she is walking across the road, visiting a person in hospital, or working as a nurse.  Today a paramedic is not a person employed as a paramedic but a person registered as a paramedic.  An off duty paramedic may have no duty to rescue a stranger (Stuart v Kirkland-Veenstra [2009] HCA 15) but the person in the scenario described is not a stranger but a person in a therapeutic relationship.

One would have to ask ‘If I was employed as a paramedic what would I do…?  IS there a good reason not do to it now?’  A good reason not to do it now may be that the procedure is not appropriate in this environment, that there is someone else at the hospital who is employed to do that task (eg an emergency doctor but in this case we’re told there is no doctor).  If the answer comes down to ‘it’s me or no-one and if it’s no-one this person dies’ it is my view that the comment ‘but today I’m employed as a nurse and nurses aren’t trained to do this’ is irrelevant if you are also a paramedic regardless of what someone has told you on the employment contract.  You are a paramedic, the patient needs your skills or they’re going to do, treat them.  It would (to quote from the Industrial Relations commission and reported in When is an Intensive Care Paramedic an Intensive Care Paramedic (August 26, 2019)) ‘be “absolutely appalling” if an ICP was prevented from using their life-saving skills merely because of their position title’.

If you save a patient’s life and your employer wants to take some adverse action, that would not doubt be a matter that would entertain the Industrial Relations Commission and your relevant union.  The job of the hospital, a nurse and a paramedic is to save a patient’s life if they can.

As I said in my earlier post Don’t let the patient die (June 11, 2019).

If you can save the patient’s life, do so.  If you’re afraid to do so for fear or repercussions from your employer or because you’re afraid you may step out of the shield of vicarious liability it’s time to stop and rethink whether you believe you are competent and to ask why are you working for this company [or hospital]?  If you aren’t willing to back yourself, then maybe it’s time for a new profession.