This post is about a union response to ambulance ramping in South Australia.  A paramedic has written and says:

My union has told its members that we must refuse diagnostics being undertaken by nurses/doctors of the emergency department when we are ramped with a patient. Their rationale appears to be they have ‘legal advice’ and the members are protected as it’s also an employment directive. Further, and the key issue raised, is they feel patients may be down-triaged due to diagnostics and therefore crews may be ‘ramped’ longer and therefore community response will be affected. I believe, based upon all of the ramping reviews across the country, that early diagnostics can only help patient safety but ultimately will have no effect on access block either way, as this is a system issue.

I refuse to accept the union opinion on this and feel this will jeopardise my registration and potential employment and is clearly not in the best interests of the patients. I feel I would be breaching a number of areas of the shared Code of Conduct for Healthcare Professionals. I also feel an individual paramedic should not try to solve for system-wide issues in this manner. Keen to get your legal and ethical opinion to support South Australia Paramedics in their decision-making.

A prime example of the above is registrars wanting to undertake ‘bloods’ on septic patients. I have no issues with this. More information and diagnostics is generally good for my patients and encouraged.

This is indeed a difficult issue.  If there is a risk that ‘patients may be down-triaged due to diagnostics’ it must also be the case that patients may be ‘up-triaged’ if the diagnostics identify that the patient’s needs are a higher priority.  Equally it may lengthen the ramping time if people are taking in for a diagnostic procedure and then returned to the care of the ambulance crew, but it could also shorten ramping if it means patients can moved through the system and either onto a ward or discharge because diagnostic tests have been done, and thereby free up resources in the ED to the benefit of the next patient and crew.

The first principle of the shared code of conduct which applies to paramedics says paramedics should ‘Put patient’s first’.  That principle says (emphasis added):

Practitioners should practise safely, effectively and in partnership with patients and colleagues, using patient-centred approaches, and informed by the best available evidence to achieve the best possible patient outcomes.

Principle 5 is about good relationships with colleagues. The Code says (at [5.1]) that

Respect for colleagues and other practitioners … [requires paramedics to]

b. acknowledge and respect the contribution of all practitioners involved in the care of the patient, and

c. behave professionally and courteously toward colleagues and other practitioners at all times…’

Further [5.2] says:

Effective collaboration is a fundamental aspect of good practice and teamwork. Good patient care requires coordination between all treating practitioners. Healthcare is improved when there is mutual respect and clear, culturally safe communication, as well as an understanding of the responsibilities, capacities, constraints and ethical codes of each other’s health professions. Working in a team or collaboratively does not alter your personal accountability for professional conduct and the care you provide.

Principle 6 says ‘Practitioners have a responsibility to contribute to the effectiveness and efficiency of the healthcare system and use resources wisely.’   Application of this principle requires, amongst other things, ensuring that you ‘uphold the right of patients to gain access to the necessary level of healthcare, and, whenever possible, help them to do so’ ([6.1(b)].

Discussion

There could be conflicting views of how these principles apply in the circumstances.  On the one hand what the patient actually needs is to move from ambulance care into hospital care and one might think that allowing diagnostic procedures to be done does not ‘uphold the right of patients to gain access to the necessary level of healthcare’ so the action of the AEA and paramedics may be helping patients to get the care they need.

On the other hand, one could argue that the level of care that they need includes the diagnostic care so, given that there is no hospital bed for them paramedics assisting with diagnostics will advance the patient’s interests and may reduce their time in the ED once they are off the stretcher because treatment has already started.  It could be argued that paramedics should be advocating for nurses or others to come out and start the procedures (and see Paramedics drawing blood for patients whilst ‘ramped’ (January 4, 2023)). 

Collaboration requires ‘… an understanding of the responsibilities, capacities, constraints and ethical codes of each other’s health professions’.  Asking paramedics to look after patients whilst diagnostic procedures are undertaken, particularly if that means taking the patient in for an MRI/CT Scan/X-ray etc and then taking them out to the ambulance might be seen as demonstrating a lack of ‘understanding of the responsibilities [and]capacities’ of the paramedic.  On the other hand refusing to cooperate with those procedures may represent a failure to acknowledge the responsibilities and the capacities of the hospital staff who, through no fault of their own nor even the hospital, do not have the resources to take the patient off the stretcher and get them to the scan. 

I assume that the doctors and nurses at the hospital are also frustrated by ambulance ramping and having to work in over-loaded and under-resourced facilities so want to ‘initiate diagnostic procedures on ramped patients’ for the benefit of the patient and to speed up the process for everyone.  It does not seem appropriate (to me) to put up barriers to those staff doing the best they can in shared, difficult circumstances.

I can therefore make arguments that cut both ways.  On balance, I would take the view that having what is, in effect, a demarcation dispute – that’s not my job – is not putting the patient first nor working collaboratively with the entire health team who are all over-burdened by failures in government policy rather than failures of the hospital or its staff. 

With respect to the particular examples given, I cannot see how paramedics can do anything to stop a nurse taking blood from ramped patients. If the nurse wants to do that, and the patient’s consent to that, then it has nothing to do with the paramedics.  They don’t ‘own’ the patient and cannot dictate to the patient what they can or cannot consent to.  They could, I suppose, refuse to let the nurse into the ambulance but I would anticipate that such conduct would be contrary to any code of conduct as it is not putting the patient first.

I think taking the patient in for a scan and then bringing them back out is a different matter as it requires the paramedics to do something. Paramedics do take patients into rooms and move them on and off stretchers onto beds and scanning machines all the time.  But if we accept that it’s not ‘their job’ then they can be asked to do it and they can refuse.   Whether that’s putting the patient first, acting collaboratively with other health professionals who are also overworked, and contributing to the effectiveness of the health system is I suppose open to debate.   There may be a parallel with a patient who is in critical need of resuscitation, when paramedics bring that patient into the hospital I imagine they agree to stay as long as necessary and to help the medical and nursing staff so if it is a situation where an extra professional can assist, they would stop and do so.  Isn’t this a similar case where the hospital doesn’t have the resources to take the patient but the paramedics themselves are another health professional on scene and clearly not going anywhere. If there’ s no ED bed, and not enough ED nurses to take the patient, but the scan technician is there and could scan the patient now, aren’t the paramedics contributing the patient’s health care by taking the patient?

I ask that as a person who has been a union member everywhere I’ve worked and have worked in institutions that survive because staff take on more than they should rather than demand that the institution is properly resourced, so I recognise the dilemma.  If paramedics become an extra set of hands at the ED, then there is less pressure on the government or hospital administrators to solve the problems.  For a particular patient, waiting for care, no amount of demarcation or ‘work to rule’ is going to see a new bed or more staff appear, and the patient’s discomfort should not be used as a means to putting pressure on the hospital or government.

Conclusion

It is unclear whether the sort of action (or inaction) being pushed by the AEA would be a breach of the code of conduct or not. I can make an argument either way.  Resolution of that issue would therefore depend on a complaint being made and a relevant tribunal considering whether in all the circumstances the conduct complained off fell below the standard to be expected of a paramedic.

I think there is a clear difference between the nurse wanting to take blood and asking the paramedics to take the patient into the hospital for the scan. With respect to the nurse taking bloods there is nothing the paramedic really needs to do other than facilitate the nurses access to the patient and then get out of the way.  If the patient consents, then it’s really got nothing to do with the paramedic.  The paramedic doesn’t ‘own’ the patient until they are moved into the ED.

A paramedic is required to obey the reasonable direction of his or her employer.  If the paramedics are asked to take the patient into the hospital and then bring them out and that is not part of their job description, they are free to say ‘no’.  Whether that is good professional conduct is another matter.

The statement that ‘they have ‘legal advice’ and the members are protected as it’s also an employment directive’ would appear to relate to employment so paramedics won’t be disciplined for conduct in line with the AEA directive.  That does not say what might happen if someone were to complain of less than satisfactory professional conduct or a patient suffers an adverse outcome, and the matter is investigated in litigation or a post-action review.

For related posts (and demonstrating how long this has been an issue across Australia) see:

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.