Today’s question came as a comment but warrants its own post. I’m asked:

Can a paramedic suggest to a patient at hospital  even before seeing a doctor that she needs to see a psychatrist????DO THEY HAVE ACCESS TO RECORDS ?   I BELIEVE WITH OUT knowing what my wife has been through  the botched treatment by a hospital. And medical. Profession over 8 yrs or more WE ARE STILL TRYING TO UNDO DAMAGE DONE  I believe she has crossed boundarys  with her option   a trainee ALSO  was with them AND may have over heard her comment…..your thoughts pls

There is clearly a lot of emotion behind this question. It is easier to answer it if we try and remove the emotion and re-format the question as:

Can a paramedic suggest to a patient at hospital – even before seeing a doctor – that she needs to see a psychiatrist? Do they have access to records? I believe without knowing what my wife has been through, the botched treatment by a hospital and medical profession over8 years or more. We are still trying to undo damage done. I believe she has crossed boundaries with her [opinion].  A trainee was also with them and may have overheard her comment. Your thoughts please?

The answer has to be ‘yes’.  The Royal Australian and New Zealand College of Psychiatrists says:

A psychiatrist is a qualified medical doctor who has obtained additional qualifications to practise in the specialty of psychiatry, and is registered by the Medical Board of Australia or the Medical Council of New Zealand.

So the question is asking whether a paramedic can suggest to a patient that they may need to see a specialist medical practitioner.  If we think of paramedic work as being equal to ambulance work, then we may think that paramedics treat patients and take them to an emergency department to be seen by an emergency physician (at least in major trauma centres; it may be a gp in a country hospital) and only doctors can know what to do.  But a paramedic is a health professional and today a paramedic can and should give advice based on their professional opinion. They may want to advise a patient that a trip to ED is not in their best interest and what they need to do is see their GP or ask for a referral to see a specialist – a cardiologist, a rheumatologist, a dermatologist etc.

Alternatively, a paramedic might, in discussion with a patient who is considering whether they need to go to hospital, give their advice that the patient should consent to transport because they need to see a specialist eg an orthopaedic surgeon, a radiologist, a cardiologist etc.  In either case a paramedic will be giving an opinion to assist the patient to make an informed choice about what course of action to take.

I infer that in this question the author has a view about psychiatrists.  It seems that the author is concerned that the paramedic’s suggestion that his partner needed to see a psychiatrist was unnecessary because she really have suffered as a result of inappropriate health care.

There is an adage I picked up somewhere, I cannot recall where, that says ‘Just because your paranoid, does not mean they are not out to get you’.  The point is that we shouldn’t dismiss the mentally ill or the deluded, there may still be truth in what they say.  (That is why judges have to spend so much time with unrepresented litigants who appear to be making non-sense claims to try and work out whether, underneath it all, there really is some merit to their claim. Just because they are deluded does not mean that there is no merit in their claim).

To return to our context, a person may be mentally ill but that does not mean that everything they say can be discounted. Equally, to reverse it ‘Just because they are out to get you, does not mean you are not paranoid’.   I’m not a mental health practitioner but I understand that mental illness can be caused by chemical issues in the brain and that is where medication can help, but also from traumas and impacts upon one’s life – think PTSD.  So a patient may well have had ‘botched treatment by a hospital and medical profession over8 years or more’ causing serious damage.  To say that such a person needs to see a psychiatrist is not the same as saying they’re wrong or a malingerer or making it up.  A person with a broken leg still needs to see an orthopaedic surgeon even though we know the cause of the injury.  A person with poor outcomes from hospital treatment and then trying to bring that to account may need to see a psychiatrist because those events may have had an impact upon their mental health.

The critical reference is the Code of Conduct.  That code requires paramedics to:

  • assess the patient, taking into account their history, views and an appropriate physical examination where relevant. The history includes relevant psychological, social and cultural aspects, and available electronic records such as My Health Record;
  • formulate, record and implement a suitable management plan (including providing treatment and advice and, where relevant, arranging investigations and liaising with other treating practitioners);
  • recognise and work within the limits of your skills and competence, and refer a patient to another practitioner when this is in the best interests of the patient;
  • practise within an evidence-based and patient-centred framework;
  • communicate courteously, respectfully, compassionately and honestly with patients, their nominated partner, substitute decision-maker, carers, family and friends; and
  • encourage and support patients to be well-informed about their health, and to use this information wisely when they are making decisions, caring for themselves and managing their health, including through informed consent processes.

Provided the paramedic has done this – ie formed the opinion that the patient may benefit from seeing a psychiatrist based on their assessment of the patient, are expressing a genuine opinion that is supported by an evidence base and where their practice is consistent with what may be expected of a practitioner with similar skills and experience, then they are just doing their job.

If, on the other hand, the comment is intended to be disrespectful, is intended to imply that the patient is not really unwell at all but overreacting or making up their complaints, is influenced by the paramedics own prejudices or a belief that the patient has contributed to their own condition then that would not be good practice and could be the subject of an appropriate complaint to the paramedicine board.  From the question asked we can make no determination about that one way or the other.

As for letting the trainee hear, the trainee is there to learn from their more experienced mentors. The trainee may be a university student on a placement, or they may be a recent graduate, now a registered paramedic but going through their employer’s intern program. Either way they are bound by the Code of Conduct and duties of confidentiality etc.  They are part of the health care team.  Allowing someone not involved in the patient’s care to overhear a consultation should be avoided but it’s not always possible (think of the curtains that divide the beds in an ED) and ideally patients should be asked if it’s ‘ok’ if a trainee is involved; but again, that is not always possible. In a public teaching hospital, it is expected that trainees (doctors, nurses and other health professionals) will work with patients. In an ambulance if the trainee is a graduate intern paramedic, they may be one of a two-person crew and a vital part of the treatment team.   Allowing the trainee to observe their mentor in practice is a key part of the training.

Conclusion

We don’t have enough information to form a conclusion in this case but, as a general rule, we can say that paramedics are health professionals. They have moved beyond the days of the ‘stretcher bearer’.  As part of the health care team it may be appropriate to give advice to a patient – it may be that the advice is ‘you don’t need to go to hospital but perhaps you can see your GP and discuss with them whether a referral to a psychiatrist would be in order’.  Or to say ‘I think you are really unwell and we should take you to hospital as you need expert help from a psychiatrist to ensure you are safe’ (or any multiple variations on those themes).  To say someone needs to see a psychiatrist is not to deny that they may have very genuine and serious needs and that they have suffered a serious traumatic event that would cause mental health issues in anyone.

Whether the opinion is appropriate depends on how it is formed and how it is communicated.  Done properly then yes ‘a paramedic [can] suggest to a patient at hospital – even before seeing a doctor – that she needs to see a psychiatrist’.

As for a trainee, if they are part of the treatment team it is appropriate subject again to consent being obtained if that is possible, for them to see and hear their mentor. That is how training works.

As I said there is clearly a great deal of emotion behind this question.  When we take it out and ask ‘can a paramedic suggest to a patient that they would benefit with a consultation with a specialist practitioner’ we can see the answer has to be ‘yes’ provided the opinion is formed and communicated in a way that is consistent with the Code of Conduct applicable to paramedics.

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.