Today’s question revisits the issue of going to work as a paramedic without the necessary equipment and in particular, drugs – see

Today’s correspondent says:

Recently NSW Ambulance has sent emails to staff regarding signing onto the Mobile Data Terminal [MDT] at the start of shift so as to display an available resource to the dispatcher in the control centre. The shifts start at 45mins past the hour and we are expected to sign on within 3 mins post this time. Between the 45 minute and hour mark, it is expected we check the ambulance in its entirety, stock the car with our personal belongings and PPE and sign out scheduled medications to the car. NSW Ambulance calls these checks ‘Mandatory checks’. Email from management sent in various forms to all Metro sectors says:

“Following recent significant adverse event investigations, it has shown that failure to sign on was a key contributing factor to a negative patient outcome.

Please allow me to assure you, our dispatchers will always do their best to observe the 15 min mandatory check time and will only task you to a priority case if deemed necessary. If you are sent out close to your finish time you are also able to request a transport car to assist with transport to hospital to reduce your end of shift overtime.

If you do get assigned a job within the 15-minute window, and your checks are not complete or you don’t have your medications yet, please respectfully notify the dispatcher of such and ask how they would like you to proceed. Remember, the dispatcher can see what other resources are available in the area and can then make an informed decision as to whether they will utilise a crew with an unchecked/unstocked vehicle or another crew near to the incident.

Please note, there is no expectation to attend your shift before your start time to check your cars, the expectation IS that we sign on at our rostered start time and checks are completed in the first 15 minutes unless the aforementioned occurs…

The question is, what would be the consequences on personal registration when responding to a job without completing these mandatory checks there was a negative patient outcome such as death or disability caused by a faulty, missing or non-operational piece of equipment or drug?

On the Facebook version of the post Paramedic sent to work without required drugs (August 13, 2023) I was asked “Would this apply to a scenario where an ambulance is responded at the start of shift, without s4/s8 medications signed out/equipment checked.” My response was:

As I like to say, “context is everything”. It could apply; I think most paramedics would think it was ‘unsatisfactory professional performance’ not to check equipment and sign out restricted drugs before the first job of the shift.

But sometimes there may be an emergency – eg bus crash 50m from the station – and the paramedics would have to ask “if we get the drugs we’ll be delayed 5 minutes which could mean the difference between life and death; but equally the absence of the drugs could mean the difference between life and death; but if we get there first we can start and we’ll be backed up by others with drugs so on balance what’s the best option in this extraordinary circumstance – what would ‘a health practitioner of an equivalent level of training or experience’ do? In those circumstances however the issue will simply never arise as I don’t see how anyone would complain and the paramedics who do arrive can start doing the scene assessment, triage etc before other crews arrive.

The real issue is not the one-off emergency but if it becomes a practice, if there is constant pressure to turn out to a ‘regular’ sort of 000 call ‘without s4/s8 medications signed out/equipment checked’ because if there is that suggests that the workload is not being properly managed. Paramedics have to have time at the start of their shift to make sure they’re ready to go before being tasked. If they don’t that’s a WHS, Industrial and professional issue and at same point the reasonable paramedic says ‘I’m not going out until I’m satisfied that we are good to go and if I don’t do that I cannot ensure my patients receive good paramedic care’.

That really answers the question but I want to take some time (and some of your time if you continue reading) to try and make my thinking more explicit.

First, I think everyone would agree that a paramedic who refused to check equipment before proceeding on shift would be guilty of at least ‘unsatisfactory professional performance’ that is (Health Practitioner Regulation National Law (Qld) s 5):

… the knowledge, skill or judgment possessed, or care exercised by, the practitioner in the practice of the health profession in which the practitioner is registered is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience.

Notwithstanding that this is meant to be a national scheme. That definition does not apply in NSW.  In NSW the relevant definition is the definition of ‘unsatisfactory professional conduct’ (Health Practitioner Regulation National Law (NSW) s 139B) that includes

Conduct that demonstrates the knowledge, skill or judgment possessed, or care exercised, by the practitioner in the practice of the practitioner’s profession is significantly below the standard reasonably expected of a practitioner of an equivalent level of training or experience.

I would hope, regardless of the jurisdiction, that everyone would agree that a paramedic who routinely fails to check their equipment to make sure everything is stocked, working, in-date and ready to go is performing below the standard reasonably expected of a paramedic practitioner.

Another extreme is the performance of the employer. A paramedic may seek work at an event health service provider. On arriving at work the paramedic sees the vehicles provided are old, inadequately maintained, and unclean; perhaps even unroadworthy. There is equipment missing and equipment is broken. Drugs are not secured or accounted for.  Perhaps the company is claiming to provide a level of service that it is clearly incapable of providing.  Perhaps the company is giving directions to staff that are inconsistent with good paramedic practice – eg ‘don’t administer the methoxyflurane to patients at this event, we’re only 10 minutes to the hospital they can put up with the pain for that long and it’ll save us money’.  I would think a registered health professional would recognise that to work for that company is to fail to behave at the standard expected of a registered paramedic. That would be true for any paramedic involved in the management of the company but also for an employee who must, at some point, say ‘I’m not prepared to work for this unprofessional outfit’.

Move from those extreme cases (which I put up to hopefully make the point that it could be unprofessional to go to work without checking and having the minimal level of equipment) to somewhere in the middle. There will be times when a paramedic will want to treat a person knowing they don’t have the ideal equipment. The off-duty paramedic only has their commercial first aid kit. A paramedic returning to station at the end of the shift may well know that much of what is in the ambulance is depleted but I think it would be ‘unsatisfactory professional performance’ for that paramedic to refuse to assist at a car accident that they come across because they haven’t yet restocked the ambulance from the last job. They get out and do what they can and if they don’t have what they ideally would have, the use what they have got. To go back to my example from my Facebook comment, they are at the ambulance station, and someone comes in and says ‘someone’s collapsed outside’ I don’t think (or at least I hope) ‘a practitioner of an equivalent level of training or experience’ would go to see what they could do, not say “I’ll be there in 10 minutes after I’ve finished checking this equipment”.

The practice of paramedicine is not just hands on patient care. As the Paramedicine Board says that, at least for the Professional Indemnity Insurance standard, means:

Practice for the purposes of the standard is any role, whether remunerated or not, in which an individual uses their skills and knowledge as a health practitioner in their profession. It is not restricted to the provision of direct clinical care. It also includes using professional knowledge in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession.

Paramedics in the coordination centre and ambulance management are also practicing the profession of paramedicine. They are making decisions about the allocation of resources both generally and in response to specific incidents. As the memo from NSW Ambulance says:

… the dispatcher can see what other resources are available in the area and can then make an informed decision as to whether they will utilise a crew with an unchecked/unstocked vehicle or another crew near to the incident.  

The dispatcher also has information as to the triaged priority of the calls received. He or she has to make a professional decision as to the allocation of resources recognising the need to balance the speed of the response with the effectiveness of the response.  In some circumstances the dispatcher, knowing that mandatory checks have not been completed, will reasonably determine that it is still better to send the crew to start care because that is better than the alternative of nothing. But sometimes it will be better to let the crew complete their checks and the response can wait a few minutes.

The real issue is if the situation moves closer to one of my extremes. If for example paramedics are regularly called on during the time that they are meant to be doing their mandatory checks and for cases that are not life threatening or where there were other resources that could have responded in a timely manner.  If a particular dispatcher always calls paramedics on during that time without following any procedure or giving thought to whether the response can be held back may be acting unprofessionally.  I would think (or hope) that a paramedic called on for a priority 3 case would say ‘no, I’m going to finish these checks first so if you divert me to a P1 case, I know I’m ready to go’.

The question paramedics need to answer is ‘what would they expect both from paramedic dispatchers and on-road paramedics?’ I would think (or at least hope) that the on-road paramedic who finds the are called early nearly every shift would identify that there was an issue and the appropriate professional response is to record it and raise it – whether you call that a professional issue, a WHS issue or an industrial issue – doesn’t really matter. 

Assume a complaint is lodged – “I called for an ambulance and when they go there they said they did not have the equipment they needed and my partner received sub-standard care”.  In NSW they complain to the Health Care Complaints Commission that looks for a response from both the Ambulance service and the paramedics.  If the ambulance service can show this was a rare occurrence, where time was given the priority, that the paramedics were backed up with another crew etc then it’s probably all good.  If, on the other hand, the paramedics says ‘this happens all the time, the arrangements to start the shift are inadequate’ etc then the question I would ask is ‘and what did you do about it?’  The individual paramedic cannot fix the ambulance service’s problems but if they are not being reported then the management may not know about them. So you report them, you move it up the chain of command, you take it up with your WHS consultation group etc.  But if you do nothing, then (and it is up to the paramedics to answer this question) would that be ‘Conduct … below the standard reasonably expected of a practitioner of an equivalent level of training or experience’?  If the answer is ‘yes’, then it could have professional implications.

Conclusion

The question was ‘what [c]ould be the consequences on personal registration when responding to a job without completing these mandatory checks [if] there was a negative patient outcome such as death or disability caused by a faulty, missing or non-operational piece of equipment or drug?’

My answer is that it depends on all the circumstances including how the judgement was made to dispatch the ambulance, how often this is occurring and what would paramedics expect of another paramedic in the circumstances. Sometimes going is going to be the clearly right thing to do; sometimes it will be clearly the wrong thing to do. Most times it will be somewhere in the middle and it depends on the professionalism of everyone involved from the managers that write the sort of email quoted above, to the dispatchers and to the paramedics on the station. Provided everyone acts at the professional ‘standard reasonably expected of a practitioner of an equivalent level of training or experience’ then there will be no issue.

This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.