SCENARIO FOR THE eARF
Jason is a 35 year old male employed by Kilcoy Mining Enterprises as a truck driver at their quarry. Jason transports equipment and materials around the industrial site in his truck. Four hours into his shift, Jason drives a 300 tonne dump truck over the edge of the quarry high-wall, falling 80 metres to the bottom of the pit. You are the on-call paramedic in the area and are called Code 1 to the scene as a single officer response. You are told an ICP is on standby if needed. You arrive after 10 minutes.
Jason has suffered extensive injuries as a result of the fall and is trapped by the legs. You arrive just as he is extricated from the crushed cabin by employees at the site. You treat Jason for multiple fractures and internal injuries. Jason’s supervisor, Barry, tells you he went out with Jason the night before and they consumed significant amounts of alcohol. Barry also reluctantly admits they took ecstasy. Barry tells you he is still hungover and believes Jason would be as well.
Initial observations indicate that there is no head injury although Jason is somewhat confused and you put this down to the drugs and alcohol. You ask Barry whether he is aware of any relevant medical history for Jason. Barry tells you he is Jason’s best friend and knows him pretty well. He reports Jason has a severe allergy to penicillin and had a knee reconstruction 3 years ago. He also tells you Jason is infertile but gets quite embarrassed about that. He is not aware of anything else but has sent someone to go and check Jason’s file in the office.
To alleviate Jason’s pain, you tell him you intend to administer Morphine and establish an IV to commence fluid resuscitation. Jason tries to resist and tells you he doesn’t want any more treatment. When you ask why, he tells you “I just can’t take it”. You ask Barry to hold Jason down so you can administer Morphine. Jason continues to struggle and object but you manage to inject him with the drug.
You decide Jason needs urgent transfer to hospital. You call in the helicopter but are told it is attending to a 3 vehicle traffic crash in Maryborough. You realise you never called for an ICP and are told they are 40 minutes away. You ask Comms for the ICP to meet you on the way to hospital.
You ask Barry if there is someone that can drive the ambulance and he tells you he is the only one who is available to leave the site at that time but he has an open licence. He tells you “Jason’s my best mate. I have to go with you”. You advise Barry to drive the ambulance under lights and siren from the scene to the hospital. En route to hospital, Jason’s condition deteriorates further and you notice a blown pupil with signs that the remaining pupil is also starting to dilate. You ask Barry to ‘step on it’ and shortly after the vehicle is caught travelling at 150 km/h by a speed camera hiding in the trees at the bottom of a hill.
You decide to administer Manitol for a closed head injury whilst en route and commence an infusion. Shortly after commencing the infusion of Manitol, Jason’s breathing becomes laboured and his pulse rate becomes unpalpable. At this point you place Jason on a cardiac monitor which prints an ECG indicating asystole. You ask Barry to pull over and you commence CPR. The ICP arrives at this point. You manage to resuscitate Jason and then take over driving the ambulance.
On arrival at the hospital, you do a handover with the staff who advise you Jason is a recovering drug addict and abused heroin for many years.
eARF Report Analysis Example
An electronic Ambulance Form (eARF) is a legal document that Queensland ambulance uses to identify a patient event within the provided clinical data system. There are a number of legal principles, which must be complied with when writing an eARF. In this example the following were used:
Queensland Ambulance Service employees work within certain legislations that enforce judicial decisions that regulate their job role. In regards to treatment of patients, it’s vital to gain consent. The ethics of the paramedic depends on the SELF-test and bioethical principles in making a decision for gaining or disregarding consent. Consent was determined through case law and defined through legislation and allows for thee elements:
1. Voluntary and freely given
3. Person must have capacity to give
Defined under the Guardianship Administration Act 2000 (Qld) and Powers of Attorney Act 1998 (Qld)
Without consent from a person, the defendant could be accountable for assault under the Criminal Code Act 1899. The elements needed to prove a battery assault has occurred are found under section 246:
1. Direct Act
2. Bodily Contact
3. Without consent
Criminal Code Act 1899 (Qld)
Consequently, Jason (patient) was forcefully held down by Barry (Jason’s supervisor) to establish IV and commence fluids by the single paramedic officer after requesting assistance from Barry. This can be considered as battery assault, the offenders being Barry and the treating officer due to the fact the patient did not consent to the treatment or the physical contact. In exceptional circumstances Queensland Ambulance allows for this offence to be ineffective as an outcome of further legislations protecting powers of paramedics.
Note, that there is no mention within the scenario of permission for treatment. Also note, that Jason expressively denies treatment which conflicts with legislation. Whilst this does not satisfy the elements of consent, making the defendants liable for battery assault, the third element of consent can be argued due to the ‘capacity’ of Jason. Capacity is defined under the Guardianship Administration Act by:
A person for a matter, means the person is capable of—
(a) Understanding the nature and effect of decisions about the matter; and
(b) Freely and voluntarily making decisions about the matter; and
(c) Communicating the decisions in some way.
Guardianship and Administration Act 2000 (Qld)
There is a brief mention of confusion from the patient following the incident, which consisted of a significant fall. Jason’s supervisor also mentions that Jason had taken ecstasy last night, which can be additional to his thought process capacity. Due to the circumstances it is likely the capacity of the patient can be compromised and will depend on clinical judgement. Furthermore the injuries sustained can be considered as urgent care. Under section 63 of the Guardianship Administration Act defines that treatment can be carried out without consent if the health care provider reasonably considers the following elements:
1. Impaired capacity
3. Prevent significant pain/distress
4. Not reasonably practicable to get consent
Guardianship Administration Act 2000 (Qld)
Because clinical judgement determines capacity, this section applies in defence of the health care providers to prevent further pain/distress of the patient. Due to the mechanism of injury and sustained head injuries, if left untreated Jason could potentially result in further compromise. Whilst this can be considered a defence in court, according to the Queensland Ambulance Clinical Practical Guidelines states that any physical restraint of a patient requires an ICP on scene. Whilst an ICP was available, the single officer did not consider this as part of protocol when asking for assistance for physical restraint (CPM).
If left entirely untreated by paramedics, there then could be the issue of negligence by not providing this patient with a duty of care. This is discussed further in relation to the transport of this patient.
Due to limited crews within the scenario, the paramedic had no choice but to request assistance from Barry (Jason’s supervisor) who claimed he was the only person on site that could go with Jason, to drive the ambulance to hospital. Note, however Barry admits to using elicit drugs the night before and is caught speeding at 150km/h en route. There is no mention of this within the eARF as this is not relevant in regards to the patient. If there were more serious damages that occurred during the transport, the paramedic or Barry could be found negligent to the patient or whoever else involved.
Case law defined negligence in Donohgue v Stevenson where the judge ruled negligence to be determined by the following elements:
1. Duty of care was owed
3. Damage as a result of the breach
Donoghue v Stevenson 1932
Although considering the ‘reasonable foreseeability test’ a duty of care can be proven, along with the breach of excessively speeding however there were no ‘damages’ caused as a result of the breach. Therefore can the defendant cannot be found negligent. However if damages were to occur (injured bystander, financial costs due to vehicle damage etc) then Barry could be found negligent. His defence to this could however result in the paramedic being a contributory cause as the paramedic was aware of Barry’s previous night of drinking and drug use which may have contributed to excessive speeding and possible damages. This can be defined under section 10 of the Law Reform Act
1995 (Qld) A standard of care in this situation would apply, however applying the ‘objective’ test the paramedic would be found to have not reasonably approached the situation compared to a reasonable paramedic acting within accordance to their accepted practice. This was defined in Sidaway v Board of Governors of the Bethlem Hospital 1985, which applies this principle known as the Bolam test. (Health Care and the Law). A reasonable practicing professional would have called for the ICP before the physical restraint was conducted which therefore would have allowed for further backup and appropriate transport. This can be explained further under section 22 of the Civil Liability Act 2002.
Note that the scenario did not meet the elements of negligence, however the issue still remains that Barry was caught speeding at 150km/h.
There are exemptions for emergency vehicles under section 306 of the Transport Operations Act under the circumstances:
1. The driver is taking reasonable care; and
2. It is reasonable that the section should not apply; and
3. If the vehicle is a motor vehicle that is moving–the vehicle is displaying a red flashing light or sounding an alarm.
Transport Operations (Road Use Management – Road Rules) Regulation 1999 (Qld)
Emergency vehicle, which means, an emergency worker is driving the vehicle within his/her duties, whilst emergency worker is defined as an officer of the Queensland Ambulance Service or an ambulance Service of another state. (Transport Act). Therefore Barry would not be exempt from this section due to the fact he is not considered an emergency worker nor is it reasonable the section should apply. It was noted that the driver was still under the influence of the drugs and alcohol from the previous night, which could have contributed to the excessive, speeding. Under section 328A of the Criminal Code, Barry could be liable for charges meeting the standards of operating a vehicle committing a misdemeanor:
1. At the time of committing the offence is adversely affected by an intoxicating substance; or
2. At the time of committing the offence is excessively speeding or taking part in an unlawful race or unlawful speed trial; or
3. Has been previously convicted either upon indictment or summarily of an offence against this section
Criminal Code Act 1899 (Qld)
However, common law defence may prevail Barry from being found guilty of this misdemeanor. Necessity is considered a defence in a criminal prosecution for failing to comply with legislation (Eburn M, 2013). This may be applied when a person is faced with a choice to comply with the law and see harm done or minimize this harm but in doing so, break the law. (Elburn M, 2013). The defendant (Barry) must be able to prove it was reasonably necessary in the circumstances was not out of proportion to avoid Jason’s health deteriorating. This defence however would have to be investigated and justified in accordance to the risk taken and how emergent the situation was.
Elements excluded from eARF:
Elements that were left out of the eARF included the PMH of Jason’s infertility, which was deemed irrelevant to the scenario, and the use of Mannitol and infusions for treatment purposes. This was because Queensland Ambulance officers currently do not consider this as part of their drug therapy protocols, going against clinical guidelines for treatment.
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