A query from a Victorian paramedic.

My query is about where our ability to manage a patient starts and stops in the hospital environment. I took a patient into the A+E department who became highly agitated as we started wheeling him in.  He was screaming and swearing but was in police handcuffs and police were in attendance. Nurses and doctors came running to see what all the fuss was about and then the hospital called a Code “grey” (a personal unarmed threat). The patient was at the “triage desk” but had not been triaged. Meanwhile the police, two ambos and PSA’s were holding this patient down and trying to stop him from tipping the ambulance stretcher over.

The nurses and doctors were talking amongst themselves trying to find an appropriate place for this patient whilst we were battling to keep him from hurting himself and spitting and trying to bite ourselves and others. My suggestion to the doctor at the scene was that maybe we should give him something and then sort out an appropriate place for him. His terse reply was that he would get a handover first and then look at something for the patient. It took probably 10 minutes for a sedative to be administered.

My question relates to when the hospital actually assumes responsibility for the patient in the emergency department:

  1. Is it when the patient gets in the emergency door and then hospital protocols kick in?
  2. Is it when the hospital triage nurse has triaged the patient, and then hospital protocols kick in and then the triage nurse assumes responsibility?
  3. Is the patient  our responsibility whilst in the hospital, whilst being triaged, after being triaged and still falling under our guidelines  and protocols until they are handed over to the cubicle nurse/and or doctor?

My belief is the 3rd point and maybe I should have taken the initiative and administered the sedation rather than wait for the doctor. The doctor never got a handover from ambulance as we were too busy subduing this patient.

It is not unusual for ambulance to continue to manage and treat patients in the emergency department for hours at busy times of the day.

It would be nice to hear your thoughts on the rights and responsibilities of Ambulance patients in the hospital.

The answer is ‘all of the above’.  There’s never going to be a hard and fast rule here, it’s all about acting reasonably in the best interests of the patient.   The patient is ‘your’ patient until he or she is no longer in your care and I would suggest that is when you have packed up and left the room.  Imagine if you have given your handover to the triage nurse and have been asked to place the patient on a bed in a cubical in A+E.  You do that, there’s a nurse in the room, you get your gear together and go to leave and say ‘goodbye’ and you notice something about the patient’s condition that the nurse has not.  Could it be the case you have no legal duty to say something because they are no longer your patient? I do not think so.

Take the example you have given, you’ve arrived at hospital and have not been able to give a hand over. That may be quite understandable, the hospital staff are fully engaged so it is ‘reasonable’ they have not yet got to you.  Clearly you have to continue caring for your patient.  Maybe it’s not reasonable, the staff are distracted by an irrelevant consideration, you still have to care for your patient as best you can.  Think about this case, if there was no good reason for the doctor not to have authorised sedation and as a result the patient, or someone else was injured, then the doctor may well be negligent for not having acted in a reasonable time frame.  But if the doctor has not acted, what is there to stop the paramedic administering sedation if that is called for in the protocols?  The matter would be different if the doctor had clinical grounds for not wanting sedation issued but there is a difference between saying ‘I won’t make a decision until after a formal handover’ and ‘I’ve made a clinical decision not to administer sedation’.

If we want to get to some law, the leading case here is, in my opinion, the English decision of  Barnett v Chelsea And Kensington Hospital Management Committee [1969] 1 QB 428.  In this case three security guards reported to the hospital complaining of vomiting over three hours.  There was no doctor at the hospital but the nurse rang the on-call doctor who advised her to tell the men to go home to bed.  They did and one died as a result of arsenic poisoning.  Neld J said that he had to

… determine the duty of those who provide and run a casualty department when a person presents himself at that department complaining of illness or injury and before he is treated and received into the hospital wards.

He said:

In my judgment, there was here such a close and direct relationship between the hospital and the watchmen that there was imposed upon the hospital a duty of care which they owed to the watchmen. Thus I have no doubt that Nurse Corbett and the medical casualty officer were under a duty to the deceased to exercise that skill and care which is to be expected of persons in such positions acting reasonably …

He found the failure of the doctor to get out of bed, get dressed, come and see the patients and take a history and conduct an examination was negligent but there was no liability as the evidence was that any treatment that would have been administered would not have saved the poor man’s life.  We need not explore that further.

Let us return to the scenario given by my correspondent.  The A+E is open and an ambulance arrives.  The hospital, acting through its staff – the doctors and nurses and security staff – owes a duty to act reasonably toward the patient even ‘before he is treated and received into the hospital wards’.  Failure to act reasonably, eg by not having procedures in place to receive the patient or on being aware that the patient needs urgent care, failing to provide that care, could all be negligent regardless of the formalities of handover that have, or have not been met.

Equally the paramedics owe a duty to their patient again regardless of the formalities that may or may not have been met.  The question is always ‘what could anyone reasonably do in the circumstances?’  The doctor could have acted more promptly, the paramedic could have intervened according to the treatment protocols.

Conclusion

In summary, in my view the hospital owes a duty to the person in all three circumstances identified by my correspondent.  So do the paramedics.  The content of the duty may change, for example a paramedic on the street can decide to administer sedation in accordance with the standing protocols of Victoria Ambulance; once at hospital there isn’t some magic line at the casualty door that says they can’t do that but common sense would suggest that at that point one should leave the treatment decisions to the medical practitioners who will have to take a longer term view of the care and may have clinical reasons for not wanting sedation.

But the paramedic doesn’t need a doctor’s order to administer treatment under their protocols, so if the doctor refuses or fails to make a decision then the paramedic can still do so as the paramedic still has a duty to act in the patient’s best interests and a failure by the casualty doctor to examine the patient or provide needed care won’t relieve them of that duty.  The case would be different if the doctor actually examined the patient and determined that sedation was not indicated or contra-indicated in which case it would not be ‘reasonable’ for a paramedic to act contrary to that order.

So, does the hospital have a responsibility for the patient in circumstances 1, 2 and 3 described above- the answer is yes.

Do the paramedics have a responsibility for the patient in circumstances 1, 2 and 3 described above- the answer is also yes.

In a particular case how would a court assign responsibility, it would depend on what happened, and who had the last chance to avoid the event that caused the harm.  It would depend on who could have done what.  The view that once a doctor is in the room no-one else can or should do anything have long gone and have been challenged by nurses for I’m sure as there’s been a nursing profession.  Paramedics too are, or should see themselves as, independent health professionals who also owe a duty to their patients and need to act in their best interests even if that means stressing to a doctor the need to get involved or acting on their own judgment and skills.