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Pre Hospital Perspectives in Emergency Management

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Introduction:

The following essay will be based and structured upon the suggestion that forcing professional obligations like the duty to respond on paramedics and healthcare workers is similar to expecting them to behave like “supreme Samaritans”(Clark, 2005). The standard of care and duty of care that they are faced with will also be explored, along with the consequences they face if not followed. Australian paramedics along with paramedics around the world are faced with issue of the acceptable standard of professional engagement in and during public health disasters, and whether that standard is supreme, good or decent. This essay will discuss this engagement level; focusing on the ideology that Australian paramedic’s standard should be based on “good” as opposed to “supreme or decent”.

Body

The belief that a paramedic or any healthcare professional should work in disasters ranging from terrorist attacks such as 9/11 to natural disasters can be a subjective one depending on each individual in question and what kind of ethical and moral beliefs they hold. It may be assumed that the public expects that healthcare workers are individual’s trained and willing to do just about anything for the greater good. This assumption includes risking their own health and well-being to do so. Even though this may merely be a perception of the role of a paramedic, it is not always necessarily true for the healthcare workers involved. With this belief can come the suggestion and perception that paramedics are required to work as ‘supreme Samaritans’. Paramedics do indeed have an important role to play in a disaster as they are the frontline of emergency medicine; administrating critical care, however cannot always operate at a supreme level as they may not always be prepared for the disasters they could face.

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To get a better understand of what the term disaster means, many definitions can be used to describe the event. One point of view to help understand it is explained by Psychologists stating that disasters can be viewed as an event that occurs “unexpectedly without warning, suddenly and uncontrollably; that is catastrophic in nature, involves threatened or actual loss of life or property, and disrupts the sense of community, and often results in adverse psychological consequences for the survivors”(al-Madhari & Keller, 1997). When a disaster arises, those who are responsible for executing life altering healthcare are subjected and exposed to the same adversities as others in the affected area, due to this paramedics have a high risk for a variety of injuries which include physical injury, death, and psychological effects (Smith, Burkle Jr, Woodd, Jensen & Archer, 2010).

A study conducted in the form of a structured interview questionnaire to support the statement that not all healthcare workers and paramedics are willing to work during a disaster was presented to Victorian paramedics asking them to perceive risk in their own way and the situation they are placed in. The focus of the interviews were the use of three scenarios: ranging from train derailment to explosion, with supposed chemical, biological, and radiological involvement. The analysis of the results discovered that paramedics are not always inclined to undertake their role due to perceived risks associated with the type of disaster that was involved. Stating that they felt there was a higher potential for the disaster to impact on their family, health and wellbeing and safety of themselves and their colleagues depending on the disaster. Additionally, a common response being that the scene might not be safe and could pose possible risk of exposure to illness, infection and death (Smith, Morgans, Qureshi, Burkle & Archer, 2008).

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An example of these concerns and responses that paramedics and healthcare workers are not willing to work under such circumstances may be seen in the SARS outbreak in 2002 through 2003 where unprecedented demands were placed on their skills and resources where their personal commitment to their jobs was severely tested. Many were exposed to serious risk of morbidity and mortality, as shown by the World Health Organization figures showing that approximately 30% of reported cases were amidst healthcare professionals, some of whom died from the infections (Ruderman et al., 2006). The infection of SARS was considerably higher among health care providers than the general population, with the death rate primarily higher with those working in hospitals and Prehospital care. Following the epidemic many of those who treated SARS patients brought up concerns about the protections that were provided to ensure their own health and safety (Maunder, 2004).

Another reason why paramedics are unwilling to undertake their role could be the threat of legal action due to the unclear standards of care during disaster responses. Disasters can be overwhelming and often put a strain on medical resources as they are not often encountered in everyday healthcare. In these situations, the focus of disaster care is on the population or the community rather than the normal focus on an individual patient. Paramedics may fear litigation as there are many unclear standards of care and ethics. These can span from infringing individual rights when enforcing quarantine to things such as the rights of life to a pregnant woman’s fetus and whether she takes priority, who gets evacuated first and even who receives things such as ventilators or blood first. In extreme disaster cases some people will not receive the care and treatment they need. An example of unclear standards of care and why paramedics may now be unwilling to undertake their roles from threat of legal action may be seen in the case study of Hurricane Katrina where healthcare workers faced criminal charges for euthanasia and patient abandonment on patients who were unlikely to survive the evacuation and those who were seriously ill (Okie, 2008).

Each year there is a roughly 7 to 17 misconduct claims filed for every 100 physicians (Moffett & Moore, 2011) and because of this it is essential to be aware of how the legal system defines and holds paramedics responsible to standard of care. Nationally, legislation and regulations outlining paramedic responsibility and their duty to respond during disasters are lacking. The National Health Act (1953) does not state and outline the role and responsibilities of paramedics and national ambulance guidelines do not exist in order to outline a paramedic’s liability during a disaster, or what the penalty is of failing to respond to work (Smith, Morgans, Qureshi, Burkle & Archer, 2008). The ethical foundations of “duty to care” and “duty to respond” are grounded in several longstanding ethical principles. Foremost among these is the principle of beneficence, which recognizes and defines the moral obligation on the part of health care workers to further the welfare of patients and to advance patients wellbeing (Ruderman 2006).

It is also of concern that numerous existing professional codes of ethics do not present explicit guidance concerning professional responsibilities through public health emergencies. The Canadian Medical Association published a revised Code of Ethics following the SARS epidemic in 2004. However, the code does not touch on the subject of “duty to respond” regardless of their direct experience with the SARS epidemic.(“CMA Code of Ethics,” 2004)

Conclusion/Summary

Although paramedics are obliged to do their job it is evident from the arguments suggested above that healthcare workers are just as susceptible to the real risks and dangers as the individuals they are trying to protect. Assuming that paramedics should act as “supreme Samaritans “is an unfair request as this causes a variety of problems. A decent standard of engagement could involve unnecessary negligence from the healthcare workers themselves and may increase the threat of legal action. Taking this into consideration, it is also arguably impossible to provide a supreme standard of care in a disaster situation. Unlike supreme or decent care, a good standard of care is capable of being maintained and upheld from committed and enthused medical professionals utilizing their equipment and upholding a standard of care as much as they are able to in the situation they are in.

References

al-Madhari, A. F., & Keller, A. Z. (1997). Review of disaster definitions. Prehosp Disaster Med, 12(1), 17-20; discussion 20-11.

Clark, C. C. (2005). In harm’s way: AMA physicians and the duty to treat. J Med Philos, 30(1), 65-87. doi: 10.1080/03605310590907066

CMA Code of Ethics. (2004). Retrieved 6, 2014, from http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf

Maunder, R. (2004). The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: lessons learned. Philos Trans R Soc Lond B Biol Sci, 359(1447), 1117-1125. doi: 10.1098/rstb.2004.1483

Okie, S. (2008). Dr. Pou and the hurricane–implications for patient care during disasters. N Engl J Med, 358(1), 1-5. doi: 10.1056/NEJMp0707917

Ruderman, C., Tracy, C. S., Bensimon, C. M., Bernstein, M., Hawryluck, L., Shaul, R. Z., & Upshur, R. E. (2006). On pandemics and the duty to care: whose duty? who cares? BMC Med Ethics, 7, E5. doi: 10.1186/1472-6939-7-5

Smith, E., Burkle Jr, F., Woodd, C., Jensen, S., & Archer, F. (2010). Paramedics and public health emergencies: is there a’duty to respond’in Australia?[Smith, Burkle Jr, Woodd, Jensen, and Archer examine the concept of’duty to respond’in the Australian SARS context.]. Australian Journal Of Emergency Management, 25(2), 46.

Smith, E., Morgans, A., Qureshi, K., Burkle, F., & Archer, F. (2008). Paramedics’ perceptions of risk and willingness to work during disasters. Australian Journal Of Emergency Management, The, 23(2), 14.

30 July 2012