This question comes from a medical practitioner in WA. I won’t give the details as to where he works as that would readily identify him, but he says:
I live and work in [remote] Western Australia. A place called … which is [over 300km] from Perth … I provide GP medical services to the local practice and also 24/7 oncall emergency services at the local hospital… I have offered to the local police and SJA [St John Ambulance] to be ‘called’ if required to attend emergency situations for the following reasons
- Gold standard door to needle time is trauma is 60 minutes. Most victims of trauma from time of incident to me seeing them can be 3 hours.
- We only have volunteer ambulance officers. Trained in first aid but have a scoop and run attitude to victims which is dangerous when injuries are not known and can be made significantly worse by this approach, this factor is well known and researched in the UK and we have emergency doctors that now attend to stabilise pre transfer.
- I have spoken to local police and the protocol they follow is to ring SJA (point 2).
My background is in emergency medicine, in the UK there is an association called BASICS [the British Association for Immediate Care] which essentially allow doctors with emergency medicine skillset to be oncall but to also have blue lights fitted when the need arises to get to the victim as soon as possible and has been shown to significantly increase survival.
When enquiring about such a service here I was told that it did not exist when asked why rural people should be excluded from gold standard treatment I was told that’s because they live rurally which I find a completely inappropriate answer. Why should your choice affect the quality of care you receive?
My question was as the only trained, emergency personnel for a good and fair distance could I apply or under certain circumstances or indeed if further courses / training was required be in a situation where I could obtain an authority light in order to provide the best evidence based care possible and reverse an unfair treatment based on locality.
With respect to the road rules, they are contained in the Road Traffic Code 2000 (WA). Regulation 281 contains the standard exemption for the driver of an emergency vehicle. It says;
A provision of these regulations does not apply to the driver of an emergency vehicle that is not being used for official duties by a police officer if —
(a) in the circumstances —
(i) the driver is taking reasonable care; and
(ii) it is reasonable that the provision should not apply;
and
(b) the vehicle is a motor vehicle that is moving and the vehicle is displaying a blue or red flashing light or sounding an alarm.
What varies from jurisdiction to jurisdiction is the definition of ‘emergency vehicle’. In Western Australia the definition is set out in the Road Traffic Code 2000 (WA) s 3. An emergency vehicle is a vehicle:
(a) when conveying a police officer on official duty or when that vehicle is stationary at any place connected with the official duty; or
(b) of a fire brigade on official duty in consequence of a fire or an alarm of fire or of an emergency or rescue operation where human life is reasonably considered to be in danger; or
(c) being an ambulance, answering an urgent call or conveying any injured or sick person to any place for the provision of urgent treatment; or
(d) being used to obtain or convey blood or other supplies, drugs or equipment for a person urgently requiring treatment and duly authorised to carry a siren or bell for use as a warning instrument; or
(e) duly authorised as an emergency vehicle for the purposes of these regulations, by the Director General;
Without going through the provisions of the Road Traffic (Vehicle Standards) Regulations 2002 (WA) let us accept that an emergency vehicle can be fitted with red/blue warning lights. Let us also assume that an ‘ambulance’ is a vehicle operated by St John Ambulance (WA) as the ambulance provider in that state. With those assumptions, the doctor responding ‘in order to provide the best evidence based care possible and reverse an unfair treatment based on locality’ is not driving an emergency vehicle and therefore the vehicle cannot be fitted with red/blue lights and even if it was, the driver would enjoy not exception from the Road Rules and other drivers would not be required to make way for him.
So the answer to the question of ‘could I apply … [to] obtain an authority light in order to provide the best evidence based care possible and reverse an unfair treatment based on locality?’ is ‘yes’. One could apply to the Director General of the Department of Transport for the relevant permission. Once ‘duly authorised as an emergency vehicle for the purposes of these regulations’ the doctor would be driving an emergency vehicle with all the liberties that this involves.
The more pressing question is, in my view, why would the Director General do this? First, the point of warning lights and sirens is to warn other drivers so that they can give way, and in certain circumstances, to allow the drivers of emergency vehicles to avoid traffic tickets, eg when they move through a red light or exceed the speed limit. In a remote town, 300ks from Perth, one has to wonder what difference a warning light would make to response times. Who needs to give way, and travelling more than 100km/h is probably not reasonable anyway, so what advantage does it bring?
More importantly, the Director General of the Department of Transport is not going to decide issues of what is required for appropriate patient care, that is going to be determined by the Department of Health, so the Department of Transport would only issue such an authority if the Department of Health, or perhaps the police, said that it was a good idea. And that’s not going to happen on an ad hoc basis for one doctor in one town.
Western Australia has a ‘State Emergency Management Plan for Road Crash’ (June 2008). Under that plan, WA police appoint an incident controller. The Department of Health ‘In conjunction with St John’s Ambulance Australia [sic], coordinate the triage of injured persons at the emergency site’ ([2]) while St John Ambulance Australia – W.A. Ambulance Service.
… manage medical aspects at the emergency site, providing where appropriate:
• initial road transport of medical and nursing personnel to that emergency site;
• primary triage and treatment; and
• road transport of casualties. ([2(b)]).
In country WA St John does depend on volunteers and those volunteers have varying levels of training but even so they are the agency responsible for managing ‘medical aspects at the emergency site’. Having a doctor, who is not part of the training and planning, respond to the incident and assume to take charge of patient care is likely to lead to confusion. That does not mean that having local doctors available is not a good idea, but there are alternatives.
The first is to volunteer with St John. St John Ambulance in other states, and I’m sure in WA too, has procedures to recognise advanced skills that members bring to the service when they volunteer (see however, ‘ALS Paramedic as volunteer with St John (WA)’ (April 5, 2014)).
Second, develop the WA chapter of BASICS (or an equivalent) and/or get the health profession involved. As in all emergency responses, so much depends on pre-existing relationships, so one would need to have established relationships with police and ambulance to be ‘on call’ but they’re not likely to call a doctor as they don’t have a defined role, a defined place in the control arrangements, issues of liability resolved etc, but building those relationships would be necessary but needs to be more coordinated. Any agency, such as St John or WAPOL is going to want to know who they are dealing with and that they people they are dealing with are professional and they will fit within the plan. Having a state-wide move to allow country doctors to assist, under the auspices of an umbrella organisation, is going to give the Department of Health, St John and WAPOL an entity to work with to ensure that doctors that wanted to be involved were trained and understood their role in the EM scheme. If that were to occur then a doctor would not need an ‘authority light’ as they could be transported by St John, but even that was required, its much more likely to be approved if there is a plan, and a governing position in place, rather than approving this doctor, or that doctor, on an ad hoc basis.
Why should a choice to live in remote WA affect the quality of care you receive? Providing care is costly. WA can’t afford to have fully staffed paramedic ambulances within ½ an hour of any point on its road network. Most of those paramedics would spend their entire career doing nothing. In the UK there is talk of the ‘postcode lottery’, raised when people object to getting a lower standard of care outside the metropolitan areas. The United Kingdom is 243,610 square kilometres with an estimated population of 64,100,000 or 263 people per square kilometre. Western Australia, on the other hand, is 2,645,615 square kilometres with a population of 2,565,600. So WA is 10.8 times bigger than the UK, has a population equal to 0.04 of the UK population and a density of 0.96 people per square kilometre. The comparisons are significant and with a population that small, spread over a land mass that large, there can be no doubt that a choice to live in remote WA must affect the level of care you would receive compared to that available in Perth or anywhere in the UK.
My correspondent’s suggestion won’t change that postcode lottery. People who chose to live in a town where the local doctor is willing to provide an emergency roadside service will get a different level of care to those that ‘chose’ to live elsewhere. A person in urban Perth with access to advanced life support paramedics and equipped tertiary hospitals with get another level of care.
Conclusion
- It is possible to apply to the Director General of the Department of Transport to recognise a doctor’s vehicle as an emergency vehicle.
- I have no doubt that without endorsement from the Department of Health, St John and WAPOL, such authority would never be granted.
- That authority would not be granted on a case by case basis; to gain that authority it would be necessary to formally enter the state’s emergency management arrangements and that would require a more coordinated effort, such as forming a WA chapter of BASICS.
- In the meantime there is an agency that has authority to proceed to an emergency and is a fundamental part of the response to road accidents in WA; that is St John Ambulance (WA). As my correspondent has noted they depend on volunteers, and so the immediate solution is to volunteer with St John. As a St John volunteer he will be part of the local emergency arrangements and called as part of the St John response; but he does not stop him being a skilled and know (see again however, ‘ALS Paramedic as volunteer with St John (WA)’ (April 5, 2014)).
POSTSCRIPT
After writing the above post, a regular contributor and expert on the relevant road rules, Geoff Birkbeck drew my attention to the publication ‘Warning Lamps: A guide for installation and operation‘ published by the Department of Transport. That document says, at p 7:
Medical Doctors’ Vehicles
Medical Practitioners who are required to respond to emergencies on a regular basis may, on application, be authorised by the Department to utilise a removable red flashing warning lamp. Authorisation is conditional upon vehicle users completing an approved training course in emergency response driving. All applications should be made through the Australian Medical Association (AMA). Membership of the AMA is not a prerequisite for approval.
I’m sure if St John and WAPOL agreed to call my correspondent, as he’s asked them to, that would constitute being ‘required to respond to emergencies on a regular basis’. I’m not sure self-responding would meet that criteria, but that would be up to the DG.
The fact that applications have to be made via the AMA would be consistent with my view that applications aren’t going to be entertained by individuals (but see the comment attached to this post, presumably that individual did go via the AMA).
I may have overstepped the mark here; the law (my area of claimed expertise) is as I stated it, that one can get these things ‘on application’. My prediction that such an application is unlikely to be granted may not reflect the way that law is applied in WA.
Australian Emergency Law 
From experience I would say all your correspondent would have to do here in West Australia is contact the director general directly as I do know of one person who applied for authorisation due to the person being a self employed medic, and he informed me that he just applied for the authorisation and it was granted.
Dodge, not doubting you but, I dare say the ‘One person’ you know may be stretching the truth. The process for gaining approval to operate private emergency vehicles is quite stringent and difficult to navigate without a significant process.
Mr Eburn, you state “Let us also accept that an ‘ambulance’ is a vehicle operated by St John Ambulance (WA) as the ambulance provider in that state.”
The Road Traffic Code in WA does not require an ambulance in WA to be operated by St John. Granted, St John as a private provider hold the Government contract to answer emergency calls in Metro Perth, they are not the only private company who hold authority to operate emergency ambulances in WA.
There are a multitude of industrial and mine sites, along with at least two other private ambulance providers, who operate registered ambulances as emergency vehicles in accordance with r.281 and s.3 of the Code.
Jaymes, your correct and I should have said ‘accept for the sake of the argument’ but for brevity’s sake I’ve changed the post to read “Let us also assume that an ‘ambulance’ is a vehicle operated by St John Ambulance (WA) as the ambulance provider in that state.”
I agree that there are multiple providers in WA given the large size of that state and the booming resources industry that requires paramedic services beyond that which can be provided by St John. My assumption was for the purpose of this discussion where my correspondent noted that the local ambulance service was provided by St John volunteers.
One solution for my correspondent, given there is no ‘Ambulance Act’ (or equivalent in WA), would be to register his vehicle as an ‘ambulance’. What is an ambulance? According to the oxford Dictionary it is ‘A vehicle equipped for taking sick or injured people to and from hospital, especially in emergencies’ but that can’t be the definition intended in the road rules as we know that ambulance services operate vehicles other than those designed for patient transport (think of supervisors and rapid response cars and motorcycles). That is why, in NSW, an emergency vehicle is not an ‘ambulance’ but a vehicle driven by a ’member of the Ambulance Service or the ambulance service of another State or Territory…’ (Note that the reference is to ‘the Ambulance Service’ not ‘an ambulance service’ so the implication is that is the Ambulance Service of NSW established by the Health Services Act 1997 (NSW)).
Given an ambulance need not be a vehicle for transporting patients, a doctor could set him or herself up with an ambulance, equipped with whatever kit they chose and are qualified to carry, and if that was accepted by the Department for registration as ‘an ambulance’ the problem is solved as the relevant lights could be fitted (again based on an assumption ‘that an emergency vehicle can be fitted with red/blue warning lights).
That would not solve the problem that St John and WAPOL have not agreed to notify my correspondent that his services may be required to allow him to respond. And whilst local arrangements could be made, the Westplan-Roadcrash does say that it is St John who are the ambulance providers for motor vehicle accidents the subject of that plan. So for the purposes of responding to a ‘road crash’ St John are the ambulance providers. That is why I said ‘let us accept’ – but now say ‘let us assume’ that for this discussion, the reference to an ambulance means ‘St John Ambulance’. But I did not intend to deny that there are other ambulance providers operating in WA.
Hi Michael,
Having worked in rural and remote regions of Queensland, I have had experience in response to emergencies and taking patients to the local hospital. Taking a patient with serious medical issues (medical or trauma) places an additional workload on the doctor as he still has a medical practice with a busy workload to continue, plus the time at the hospital with the patient who I have just bought him. This obviously puts the appointment times well behind, affecting both the patients and the doctor. (This is an accepted and unfortunate aspect of a single doctor town), There is hesitancy therefore of the local doctor responding to emergencies out of town as there is no doctor for the medical practice and hospital for that period.
There are many examples of the scoop and run method of treatment and transport leading to expedient treatment by a doctor at the hospital. In the US the police have many times put the victim of a shooting in the back of their vehicle and raced to hospital due to lack of ambulance resources. (One has to wonder about the treatment on scene or en-route, however these are time critical patients who require surgical intervention.)
I agree wholeheartedly with your statement regarding the availability of medical services in rural Australia. With our large geographical area and small population, it is not financially possible to provide every town with all specialties. Many rural towns do not have a doctor, let alone, xray or other services.
My recommendation to the doctor would be
1. Develop a local work practice that if a case is called that is serious, the ambulance picks the doctor up and responds in that manner. There would then be the doctor and ambulance officer available in the back to treat the patient on the way back to hospital.
(If he took his own car, then it would be left at the scene, and would have to be retrieved later.)
Develop a better ambulance response matrix so RFDS is activated at the same time. This would provide a doctor and nurse and rapid aeromedical evacuation to a larger receiving hospital.
Negotiate with St John to develop a local clinical work practice to train the local ambulance officer in ALS procedures such as IV access, fluids, narcotic analgesia, advanced airway.
This is similar to the process of Triage. Where can the single doctor do the most good? In town with the patients in his practice and the current patients in the hospital and the general population, or at the scene of an incident looking after one patient?
Thanks Dave for those comments and details. I do note that one of the functions of St John is to provide ‘initial road transport of medical and nursing personnel to that emergency site’ so your proposal to ‘Develop a local work practice that if a case is called that is serious, the ambulance picks the doctor up and responds in that manner’, whilst it doesn’t address the issue of who is there then to receive the patient at hospital and manage the health issues that arise in the interim, is consistent with that Westplan-Roadcrash and incorporates the response into the local emergency management arrangements.
There are a number of system issues that need to be explored
Your correspondent talks about door to needle tome in trauma – it is door to needle time for heart attack and thrombolysis and door to surgery for trauma
1. Where is the doctors best skill set needed- at the hospital not at the roadside
2. It is well studied that medical staff at the roadside increase time on scene with minimal effect on outcome
3. Does the doctor have drivings skills appropriate for driving code 1, where were they trained and how often assessed- the potential is increased risk to the public
4. does the doctor have the training to work in the pre hospital environment, and how often does this happen
5. paramedics are trained to work in this area as their day to day job. In times of emergency you want people doing their normal job. Will tthe doctor take his own PPE and equipment? is is it compatible with ambulance?
6. Most importantly what skills will the doctor take to the scene that are above what the responding paramedics can supply that will improve patient care. In the vast majority of cases the answer is none
PS I am not a paramedic but a doctor who works in this field
What we do know from the original post is that the area where this doctor operates is serviced by St John volunteer ambulance officers, not paramedics, but as their website notes, those volunteers may be trained up to ‘Advanced Ambulance Care (AAC)’. We don’t know what skill level that entails, but we might presume it’s a lower level than the paramedics that we expect with permanent ambulance crews; but even so all the points that Malcolm raises are worth noting and are relevant and important.
Meanwhile in South Australia. Pre hospital Doctors trained, coordinated, equipped and paid to respond in conjunction with SA Ambulance Service in rural areas supporting volunteers. It should be noted SA Ambulance volunteer have much more training than WA SHA ambulance volunteers, but still appreciate having these Doctors as back up.
http://ruraldoctors.net/rern/