Today’s question raises concerns about single paramedics transporting patients in Regional Tasmania but I’m sure it’s equally applicable wherever paramedics are responded as single operators without ready access to backup.  The question is:

I’ve recently relocated to Tasmania, where many regional stations operate with a paramedic and volunteer model. However, more often than not, it’s just the paramedic working alone. There is a policy on responding single, but no specific policy on transporting single. That said, it’s commonly accepted — or at least allowed — for a solo paramedic to transport patients alone. Naturally, depending on the patient’s condition or presentation, this carries varying degrees of clinical and personal risk.

Personally, I believe every transport ambulance should have two people: a driver and a clinician. I don’t think ambulance services should rely on other agencies to fill this gap — those agencies have their own duties in the community. Volunteerism in ambulance services isn’t what it once was, and realistically, who wants to volunteer their time on a night shift?

Here are my questions:

1.             Is there — or should there be — a minimum standard or national definition for how a transport ambulance should be crewed?

2.             What responsibility does the service (or the government) have to ensure regional transport ambulances are crewed with both a paramedic and a volunteer?

3.             Transporting patients alone carries risk. While I do conduct risk assessments and will request a second crew member when needed, the reality is that lack of resourcing often makes that impractical. As a registered paramedic, I’m responsible for the ongoing clinical care of my patient — but how safe is it, really, to try and monitor them while also driving? Every time I transport a patient alone, I’m conscious that I could be putting my registration at risk if a sentinel event occurs.

4.             It’s easy to say “just ask for help,” but if under-resourcing is the underlying issue, shouldn’t the service be proactively reducing this risk by ensuring regional transport crews are double crewed?

I’ll deal with the questions in turn.

First there is no ‘minimum standard or national definition for how a transport ambulance should be crewed’.  It would beg the question of who would set a ‘national standard’?  The provision of ambulance services is very much a matter for state governments so there is no federal body that could set a ‘national standard’.   Secondly Australia is a very large, and very diverse country so the capacities are not the same across the country. As the question makes clear, resourcing is the issue so what one might expect in Sydney or Melbourne is clearly different to what can be expected in regional Tasmania or remote Northern Territory.  Setting a national standard would not suddenly increase the number of volunteers or the capacity of an ambulance service to employ more staff. 

Second, there is no clear responsibility upon the government or the service ‘to ensure regional transport ambulances are crewed with both a paramedic and a volunteer’.  First no-one can ensure a volunteer, that is the nature of volunteering.  If there are no volunteers available there are no volunteers available.  Second and more importantly, the government and/or the service do not have a legal duty to the public to meet a ‘two up’ standard.  Governments have a limited budget and they need to allocate that budget to all the services that demand government attention.  Every budget decision comes with an opportunity cost. Spend more on ambulance services and there’s less to spend somewhere else that may also be lifesaving.  How governments allocate budgets is a political and not a legal decision so no-one can sue a government for failing to provide resources to a service even if you can show, beyond doubt, that if the service had more resources it would benefit, in this context, patients (Graham Barclay Oysters v Ryan [2002] HCA 55; Civil Liability Act 2002 (Tas) s 38).

The same rules apply to the ambulance service.  It has a limited budget that has to be allocated across all its roles in all of Tasmania. It not a question for the courts whether it should allocate funds to ensure all regional ambulances are double crewed at the cost to some other area or function (Civil Liability Act 2002 (Tas) s 38).

The only responsibility that could be argued would be under the Work Health and Safety legislation where Ambulance Tasmania has a duty to ensure, so far as reasonably practicable, that it’s work does not expose its staff or patients to a risk to their health and safety (Work Health and Safety Act 2012 (Tas) ss 19(1) and (2)). Being a single operator may be a risk to paramedics but it does not expose patients to risk from their work.  If a patient is critically ill or injured, the failure to have two crew to allow the paramedic to treat en route may mean that the patient does not recover optimal care and may, in the worst case, mean they die, but their injuries or illness was not caused by the lack of crew or by Ambulance Tasmania (AT)  Their health and safety was put at risk by their injury or illness not by AT.  If that were not the case, if the risk was identified as a risk caused by the lack of two crew, then presumably a patient could also sue if there was no helicopter retrieval team and no hospital in closer proximity as the presence of those would lead to a better outcome.  But their cause of injury, illness or death was not the absence of a paramedic, helicopter retrieval or hospital.

In any event AT is only required to take steps that are ‘reasonably practical’ and that requires consideration of, amongst other things (s 18):

(d)           the availability and suitability of ways to eliminate or minimise the risk; and

(e)            after assessing the extent of the risk and the available ways of eliminating or minimising the risk, the cost associated with available ways of eliminating or minimising the risk, including whether the cost is grossly disproportionate to the risk.

If there are not volunteers or staff available there are limited ways to eliminate whatever risk is caused by transporting one up.   And cost is a relevant issue when it comes to considering, for example, employing more paramedics who might spend a lot of time underemployed. 

The issue of risk is that it varies depending on where you stand.  If risk is a product of the probability of the event occurring times the seriousness of the outcome then the risk of a patient suffering less than optimal outcomes because the ambulance that is sent is staffed by only one paramedic might be very high because the consequence of those less than optimal outcomes might be catastrophic.  For Ambulance Tasmania and the Tasmanian government the risk is very low.  The ‘Australian and International Standard for risk management AS ISO 31000:2018 – Risk Management – Guidelines, defines risk as “the effect of uncertainty on objectives”’ (https://www.vmia.vic.gov.au/tools-and-insights/practical-guidance-for-managing-risk/what-is-risk).  Whatever the objectives of the Tasmanian government the death of one person would have a significant effect on their objectives.  Even if their objectives are to save as many lives as possible that still requires resource allocation and spending money in one area may have better outcomes than in others even if that means someone has less than optimal outcomes.  What that means is that the cost of mitigating whatever risk is posed by single paramedics transporting patients may exceed the benefit across the whole of the state’s objectives.

Third, as a paramedic you are ‘responsible for the ongoing clinical care of my patient’ in the circumstances in which you find them.  The law requires you to take reasonable care in all the circumstances.  The Health Practitioner Regulation National Law (Tasmania) requires you to deliver care that is consistent with the ‘the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience’ (s 5 definition of ‘professional misconduct’) or the standard ‘which might reasonably be expected of the health practitioner by the public or the practitioner’s professional peers’ (s 5 definition of ‘unprofessional conduct’).  Both those definitions, by referring to what might be ‘reasonably expected’ requires a consideration of what might be reasonably expected in all the circumstances.  You can only do the best you can in the circumstances in which you find yourself. You might provide different care if there was a volunteer driver, or two paramedics, or a paramedic and a retrieval doctor but that is not the situation in which you are being judged. Your conduct will be judged against what other paramedics of ‘equivalent level of training or experience’ would or could have done in the same circumstances.  The question then is whether the question to transport alone or wait for back up was a reasonable decision taking into account such things as the patient’s condition, the length of time it might take for back up to arrive, what you could do for the patient whilst waiting versus what benefit they would get by being transported sooner to definitive care etc.  

Finally as noted above, the risk to the service and government is quite different to the risk to the patient.  The service should certainly be considering the risk but I cannot say that there is a legal obligation upon the service to be ‘proactively reducing this risk by ensuring regional transport crews are double crewed’ and it may not be possible or feasible or ‘reasonably practicable to ensure ‘regional transport crews are double crewed’.

Conclusion

The law does not require the Tasmanian Government to provide ambulance services at all. They chose to do it because, quit rightly, they understand that the community expect it and no doubt people do choose to enter government as they want to be involved in providing services to the benefit of their community. But how they provide those services including crewing numbers is a political not a legal decision. 

No court will say that an ambulance must be double crewed unless it poses an unacceptable risk to the health and safety of the staff.  And if it does one option is to provide a double crewed ambulance, another is to provide no ambulance at all. 

Proudly supported by (in alphabetical order) the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), the Australian Paramedics Association (Qld), 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 these supporters.

This blog is a general discussion of legal principles only.  It is not legal advice. Do not rely on the information here to make decisions regarding your legal position or to make decisions that affect your legal rights or responsibilities. For advice on your particular circumstances always consult an admitted legal practitioner in your state or territory.