I have previously written about how the law might view limitations on a registered health practitioner’s ability to treat people when they are working for a volunteer health organization.  See:

See also:

Those posts all deal with qualified health professionals – medical practitioners, nurses and paramedics – but what of students?  A first year medical student and a volunteer with St John (WA) can see the potential for role conflict and asks:

… a question about the responsibilities of student doctors who volunteer with St John Ambulance (WA) (“SJA”). All members are required to treat according to their SJA scope of practice and according to the clinical practice guidelines (CPGs) when with SJA.

My understanding is that in the case of doctors SJA cannot discharge them of their responsibility to a patient, and cannot prevent that responsibility from extending beyond what is covered by the CPGs. However, what of student doctors? Obviously the entire premise of being a student doctor is that one eventually becomes a doctor, and so may in some situations may have a greater understanding of a medical situation than can be covered in a CPG.

For example, consider a situation where a complex patient requires attention and the treatment prescribed by the CPGs differs from the ideal management in that case. Would it be permissible for student doctor to rely on the CPGs rather than forming an independent clinical judgement? Would it be permissible to disregard the CPGs in favour of an independent clinical judgement?

There are two types of situations where I see there might be a conflict:

  1. Acting expressly against the CPGs: One of our GPGs states that adrenaline auto-injectors “must not be used for treatment of asthma.” There is evidence, however, that adrenaline may be helpful in severe asthmatic cases. One could hypothesize that this requirement is in the CPGs to prevent overzealous use of adrenaline, a drug that requires caution. What is the student doctor, who has come to the decision that adrenaline would be appropriate for this patient, ought to do?
  2. Acting outside of scope: In addition to the CPGs, we have a skills matrix which outlines the skills that each clinical qualification has access to. For example, no volunteers are permitted to cannulate or administer IV fluids. The equipment is, however, sometimes stocked in our vehicles and kits. Would it be permissible for a student doctor who has been taught cannulation skills, faced with a severely dehydrated patient, to cannulate and begin IV fluids?

In each of these situations assume, for sake of argument, that there is no person better qualified (paramedic, doctor) immediately present, and that it is either inexpedient or impossible to call for clinical advice from an appropriately qualified health practitioner.

Further, if something went wrong in the course of such a treatment, who would be liable? Does St John remain vicariously liable? Many student doctors hold professional indemnity insurance which includes cover for Good Samaritan acts, would they need to rely on this?

This is the sort of question where the answer will depend entirely on the circumstances and, unhelpfully, on the outcome.   Assume at first instance that the student doctor does use an ‘adrenaline auto-injector’ or cannulates and administers IV fluid and in either case saves the patient’s life or at least improves the outcome.  Assume also that in a review the expert medical opinion is that what the student doctor did was entirely appropriate and represented best quality care in the circumstances.  That’s all well and good – even if SJA wanted to counsel the student they would have some difficulty in counselling someone for not following the rules but by so doing, advancing the patient’s best interests.  That’s the sort of conduct that gets a person labelled a ‘hero’ and is portrayed on TV shows (like ‘Chicago Fire’) as being virtuous and putting good practice and best interests above petty rules, but that doesn’t mean there won’t be repercussions.

There is another alternative here, and that that is where the student administers appropriate treatment using appropriate skill but there is still a poor outcome, for example the patient dies, but as a result of their injuries, that is the treatment although appropriate just wasn’t effective. Not everyone can be saved even with the best treatment.  That is not negligence so the legal issues would be the same as if the student does act and there is a good outcome

What if there is a bad outcome because of the student’s decision?  There are, again, two possible alternatives.  The first is that the treatment does improve the patient’s condition, or at least does not make it worse, but on review it is agreed that it was the wrong thing to do and the good outcome was the product of ‘sheer dumb luck’ rather than good practice.  The second alternative is that the patient suffers an adverse outcome, either because the treatment was not in fact called for or even if it was good treatment, it was poorly administered, eg the cannula misses a vein and instead sees the IV fluid pumped into muscle tissue.

The final scenario is where the medical student does not give the treatment he or she thinks is called for in circumstances where the equipment is available and the student believes that he or she would be competent to administer it.  Further, on review, it is found that the student was correct, the treatment was called for and would have, on balance, led to a better outcome for the patient.

We can summarise the scenarios that will be discussed as:

  1. The student does act and the action is appropriate and competent, regardless of the outcome;
  2. The student does act and there is a bad outcome because the action was either inappropriate or not competently delivered; and
  3. The student does not act and there is a bad outcome.

Scenario 1: The student does act and there is a good outcome;

The patient’s not going to sue if they suffered no harm or, better yet, got a better outcome but there could still be repercussions.  First adrenaline is a scheduled drug.  “ADRENALINE in preparations containing 1 per cent or less of adrenaline except in preparations containing 0.02 per cent or less of adrenaline’ is listed in Schedule 3 of the Poisons Standard 2009.  All other preparations of Adrenaline are listed in Schedule 4.

It is an offence for a person who is not authorised to supply scheduled drugs (poisons) – Poisons Act 1964 (WA) s 32(d).    A medical student is not a medical practitioner and we can infer that a student has no authority to supply a scheduled drug.  It follows that ‘supplying’ adrenaline may be an offence.

A student medical practitioner must be registered and is subject to disciplinary proceedings, that is a student can be disciplined or have his or her student registration cancelled if they engage in professional misconduct.  Professional misconduct means:

(a) unprofessional conduct by the practitioner that amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(b) more than one instance of unprofessional conduct that, when considered together, amounts to conduct that is substantially below the standard reasonably expected of a registered health practitioner of an equivalent level of training or experience; and

(c) conduct of the practitioner, whether occurring in connection with the practice of the health practitioner’s profession or not, that is inconsistent with the practitioner being a fit and proper person to hold registration in the profession.

A student doctor is not a doctor so acting contrary to guidelines which the person has agreed to follow and supplying a drug contrary to law might be unprofessional conduct.  On the other hand, administering a drug that is in fact required and in the client’s best interests, in circumstances where the student did not have the opportunity to seek guidance from a more experienced or qualified person and where the judgement was indeed correct, sounds like it is meeting the highest ideals of the profession.   Such action would also be justified by the common law doctrine of ‘necessity’ that justifies action that is, prima facie illegal, if on balance the (illegal) action taken is intended to prevent a serious harm and is proportionate to the harm avoided.  Giving a drug that a person is trained to use, in circumstances where it is warranted in order to save a life (not just because it is convenient or might be ‘nice’) and where the legal problem is a lack of licence, is likely to be accepted as ‘necessary’.

Getting it wrong of course, sounds like a failure to exercise proper judgment and action below that expected of other medical students.

This is how law, and lawyers work.  The lawyer for the Medical Board (if they were seeking to punish the student) would make the arguments in favour of a finding of unprofessional conduct.  The lawyer for the student would make the arguments in favour of the student.  How the disciplinary tribunal would see it would depend on all the circumstances surrounding the student’s knowledge, level of training, thought processes and ultimately what happened.  As I say the legal outcome will depend on the actual outcome, which makes it hard for anyone to predict what would happen.

Scenario 2: The student does act and there is a bad outcome

This has got to be negligence.

The first question is what is the standard of care of the ‘reasonable medical student’?  According to decision of the High Court of Australia in Rogers v Whitaker (1992) 175 CLR 479, [6] ‘The standard of reasonable care and skill required is that of the ordinary skilled person exercising and professing to have that special skill.’   A court may well think that a medical student who chooses to go against the CPG’s of the organisation that he or she volunteers for is holding him or herself out as have the skill of a medical practitioner in which case the standard he or she would be judged against is the standard of the ‘reasonable medical practitioner’ not the ‘reasonable medical student’.  (See also Imbree v McNeilly [2008] HCA 40 where the High Court said, in quite a different context, that the standard of care expected from a learner (driver) was that of a reasonable driver: ‘Knowledge of inexperience can thus provide no sufficient foundation for applying different standards of care…’[54]).

The reasonable doctor and even the reasonable medical student is not going to administer treatment that is not warranted by the patient’s condition or do so badly.

Scenario 3: The student does not act and there is a bad outcome.

This is the toughest case.  The patient, or his or her family, are likely to be aggrieved if they believe they, or their loved one, could have benefited from treatment that the student recognised they needed, had the means to administer, but chose not to deliver.  But what could their remedy be?

In the scenario painted by my correspondent they’ve come to the St John first aid post to be treated by St John first aiders.  My correspondent tells me that doctors have the word ‘Doctor’ on their uniform but there is nothing to identify a medical student.  A medical student is not a doctor.  Like a doctor they will have obligations to persons who come into their care but in a clinical placement that is a duty to act subject to supervision rather than entirely on their own initiative (though not doubt their power to exercise their initiative grows with their experience and standing).   There will always be a duty to act in the patient’s best interests but that is limited by the phrase ‘to the best of their ability’.    A medical student who is a volunteer with St John agrees to act in accordance with their clinical practice guidelines and can’t be under a duty to administer treatment that they are not generally authorised to administer on their own initiative.

On the other hand not all treatment requires authority.  Adrenaline may be a scheduled drugs, but there is no law on who can or cannot cannulate or administer non-scheduled IV fluids.  In this case the medical student is there, has the knowledge and the capacity to administer the treatment.  And let us assume the case is extreme and the patient dies but would have been saved if that treatment had been given. In that case the person had come to St John for care so St John owed them a duty of care.  The person administering the care knew what was required, knew they could give the treatment, had the resources to give that treatment in circumstances where the risk to the patient was catastrophic, they could take no further action to protect themselves but the person who was providing the care could take appropriate action.  In the circumstances it would be reasonably easy to argue that the failure to give that treatment was negligent.

St John doesn’t really have the capability to assess each person’s skills, rather it might accept that a ‘doctor’ has certain skills that a first aider does not, but medical students range from those in their first week of study to those in their last week.  Trying to work out when they acquire particular skills seems impracticable.  And a policy that says ‘administer treatment you think you are competent in’ is hardly reasonable as that would invite people to say ‘well I looked it up on Google and thought I could do it’.  So it would also be possible to argue that a policy banning everyone other than a registered nurse, doctor or paramedic (when they are registered) from performing certain treatments is quite a reasonable response to the various risks that could occur with untrained people applying treatment.

There may be cases where it is appropriate for a medical student to go beyond first aid, a senior student, in a remote area who can cannulate a patient who will otherwise dehydrate is in a different position to a student at a first aid post in an urban centre with an ambulance 10 minutes away.    Even in that urban environment there are things that a medical student can and should do that perhaps a first aider may not.  The medical student may well recognise that a case is more complex than others and so may be the one who says ‘we need to call an ambulance for this person’ when first aiders may think the person can be treated in the first aid post.  The medical student who gives the handover to paramedics as he or she is able to explain the circumstances and the signs and symptoms that cause them to suspect that certain treatments are required.

As always the answer to what should the student do will come down to what is ‘reasonable’.  What’s going to happen with no action?  What could happen if the action is wrong?  What alternatives are there?  Would waiting for an ambulance make a critical difference (it might in remote WA, less likely in urban Perth) etc.  How experienced is the student? How certain are they of their diagnosis, prognosis and treatment decision?  A medical student would, I suggest, want to be very sure that the decision they were going to make was necessary to save the patient’s life, not just convenient or even optimal.  It should not be ‘but this is what we’d do in hospital’ because he or she is not in a hospital.

Who would be liable

The person who comes to a St John first aid post is looking for help from St John Ambulance, not from the particular members on duty.  St John is representing by its corporate badging, both on the post and on the members’ uniforms that they are St John.  If the members are negligent then it would be St John that would be liable for the sub-standard care that the patient receives at the hands of ‘St John’.  They would be entitled to seek any remedy from St John.

St John would not normally seek recompense from its volunteers partly because they couldn’t afford it and St John, like any organisation that depends on volunteers, must realise that to do so would mean that tomorrow there would be no volunteers.  Where the volunteer does carry private insurance however, the St John insurer (rather than St John) may well take a economic view that it would like to shift its losses to the other insurer so that might happen. The presence of insurance will no doubt increase the chances of being sued (see Insurance for first aiders (August 13, 2014)).

I presume personal indemnity insurance for medical students is a condition of their student registration.  Insurers would extend that to ‘good Samaritan’ acts because it sounds good whilst being virtually no risk.  To be a good Samaritan however is to provide emergency care without expectation of fee or reward.  I have argued elsewhere that I don’t think those Acts are intended to apply to members of an organisation like St John who are in uniform, holding themselves out as experts in first aid and where both St John and the members do get a reward for their service (see Who to treat? A question for St John first aiders (June 30, 2013)).  The more interesting question would be whether or not the insurance medical students have does actually apply if they are volunteering for a service like St John.  I imagine it would but one would need to see the exact terms of the policy.


In earlier posts I’ve discussed restrictions on medical practitioners, nurses and paramedics.  I have argued that those professionals should not be restrained from providing care that they know is required, they are trained to provide and where they have the resource available.  To do so would be to fail to act in the patient’s best interests and fail to allow that professional to meet his or her professional obligations.  If the agency insists that a health professional does not provide care to the best of his or her ability, consistently with their professional standards and the expectations of their peers, then the health professional should reconsider their volunteering.  In all those discussions I was working on the premise that the care the health professional wanted to provide was warranted and was delivered with proper professional competence.

This discussion raised a new issue – the student health professional.  There were 3 scenarios raised:

  1. The student does act and the action is appropriate and competent, regardless of the outcome;
  2. The student does act and there is a bad outcome because the action was either inappropriate or not competently delivered; and
  3. The student does not act and there is a bad outcome.

In each case there could be legal consequences for the student.   The critical issue is that although a medical student may have knowledge and skills, a medical student is not a medical practitioner.  They will still owe duties to those that come into their care consistent with the professional expectations of their peers, but that is still to be a student, not a doctor.

One cannot give a definitive answer.  As noted at the start, this is the sort of question where the answer will depend entirely on the circumstances and, unhelpfully, on the outcome.   A medical student, like any St John first aider or doctor, has to ask, fundamentally ‘what can I do that is in this patient’s best interests?’   If they genuinely believe the patient will die or suffer serious and permanent complications without their intervention and they feel competent to perform that intervention and are sure that it is required, then I think anyone would expect them to act.  Refusing to act because ‘St John says I can’t but I know what to do and know that the person will die if I don’t’ (and they do in fact die) is never going to go down well, but most courts would accept ‘I applied my advanced knowledge, I knew the circumstances were dire and this was the best and only option’ and if that is confirmed by post-event opinion, then that is likely to be accepted as both reasonable and justified – certainly if the patient survives but even if they do not.

If, on the other hand, the thought process is ‘well the optimal treatment that we’ve talked about in class is ‘x’, but we don’t do that here, but I could because it would be ‘nice’; or I could wait for an ambulance which is nearby and it won’t really make any difference to the outcome’ then I think no-one would expect the medical student to act.  Between those two extremes are an infinite number of variables.