The article, ‘Just ridiculous’, from Victoria’s Midland Express was shared on Facebook by the “Support Aussie Paramedics” and “Ambulance Employees Australia (AEA)” group.

The gist of the article is that

Some of Australia’s highest trained paramedics are unauthorised to practice their higher skills in the Macedon Ranges and Mt Alexander shires despite being employed locally…

MICA-trained paramedics employed in this, the southern Calder region, are employed as lesser-skilled ALS (Advanced Life Support) paramedics.

As ALSs, they are not allowed to use their MICA skills and are paid below their skill level….

“I’m legally not covered (to use MICA training under the Woodend unit). Whilst I’m rostered at Woodend, I only have an authority to practice at an ALS level. That is just a ridiculous situation.

It raises some interesting issues.  Assume a patient calls an ambulance and the paramedics who attend are MICA trained “to perform advanced airway management, intravenous drug therapy for cardiac arrest patients, intravenous fluid replacement for trauma patients and to administer intravenous pain relief medication”.  They recognise the need for this treatment but refuse to administer it and there are adverse outcomes for the patient, could there be legal liability?

First the paramedics could not be liable.  They have to be negligent and they are not negligent for complying with their employers directions. Even if they were negligent as employees it is there employer who must bear the liability.

If the drugs in question are scheduled drugs (Schedule 4 or 8) then the paramedics only have authority to use and administer the drugs as set out by Ambulance Victoria.  If the authority does not extend to their work on these shifts then they have no lawful authority to be in possession of the drugs so could not be liable for not using them.

Ambulance Victoria could be liable in its own right.  It is foreseeable that harm will occur, there are MICA trained paramedics there so there is no issue of having the relevant people on scene so why not let them use their skills?

A government service cannot be sued for not providing a service it cannot afford to provide, how budgets are allocated is a matter for government (see Wrongs Act 1958 (Vic) ss 83 and 84) the remedy if people think ambulance services are underfunded is not to sue the service, but to vote for a different government.   So a decision by AV say not to stock the ambulances in those areas with the necessary equipment and not to staff them with MICA paramedics is not something anyone could sue over.  If a MICA paramedic is doing that shift and the equipment is not there, then there can be no liability for not using what you don’t have.

There may also be clinical reasons eg there needs to be two MICA officers when certain drugs are used and there are only one etc and that could justify the decision.

But let us assume the ambulance does have the necessary equipment or even that the equipment is not necessary what justification can there be for saying that the MICA paramedic can’t use when it is needed. Say for example there is an intubation kit, the patient needs intubating, the MICA paramedic knows how to do it, the gear is there, assuming there are no clinical issues of doing it alone if I was the patient’s family and they died because of a compromised airway I would certainly be taking AV to task because, to put it bluntly, a person who knows how to intubate doesn’t actually need legal authority to do it.  Anyone can do it if they know how, it’s not a regulated or restricted practice.  If the policy of AV is stopping someone to perform a skill that they know how to perform, that’s not contraindicated and that could save a life it would be hard to defend.

The argument would go something like – you’re the ambulance service, we called an ambulance, your staff member attended, your staff member recognised the need for treatment but didn’t administer it because of your rules (not because it was inappropriate, ruled out for appropriate clinical practice reasons or because they did not have the gear) then you failed to act as the reasonable ambulance service and should be liable for any damage that can be proved.

The obvious way around this is for AV not to equip the ambulances with the MICA gear, whether that’s an intubation kit, IV fluids, pain relief etc and if they can show eg that they have a policy about where MICA teams are located and that’s how they chose to provide the service, then the issue is not so much the MICA paramedics aren’t allowed to perform their higher level skills, they just can’t perform them for want of equipment.  As I say those sorts of decisions cannot be examined by a court.

What should happen however, is a MICA paramedic working at an ALS officer should be able to use his or her skills, wherever they are, when they are ‘backed up’ by a MICA car as the ultimate goal should be everyone working together for the patient’s benefit, and the skills the MICA officer has she or he has all the time, they can’t be turned on or off.

This situation would probably be assisted by paramedic registration, then the MICA officers would be registered paramedics with their scope of practice defined by their registration.  When signing onto their shift they would be MICA paramedics and their ability to practice their advanced skills would be clearly defined.

For earlier posts on related issues see:

Medical care and medical emergencies

Volunteer nurses and their skills

Use of medication and procedures as a paramedic outside of employment

Treatment outside the protocol