BP2004/4285, Transcript of Proceedings [2005] AIRCTrans 563 (7 March 2005)

1800 534 258

TRANSCRIPT OF PROCEEDINGS

---

Workplace Relations Act 1996 10657

VICE PRESIDENT LAWLER
SENIOR DEPUTY PRESIDENT WATSON
COMMISSIONER HOFFMAN

BP2004/4285,BP2004/4286

s.170MW(8a) - power of the commission to suspend or terminate bargaining period

Metropolitan Ambulance Service
and
Liquor, Hospitality and Miscellaneous Union
(BP2004/4285)

s.170MW(8a) - power of the commission to suspend or terminate bargaining period

Rural Ambulance Victoria
and
Liquor, Hospitality and Miscellaneous Union
(BP2004/4286)

MELBOURNE

THURSDAY, 24 FEBRUARY 2005

Continued from 23/2/2005

PN7345

MR FRIEND: I have to raise something with the Commission. I had a brief conference with Mr Cooper this morning outside court preparatory to his cross-examination, and he informed me that the transcript of this matter as it has been proceeding has been posted on the MAS intranet, and he has been reading it. He has obviously been instructed not to talk to people about what is happening in the case, but it didn't occur to us that the transcript would be readily available when people logged onto the website. We have informed my learned friends of this, and we will take steps to tell all the other witnesses that they shouldn't be doing that, and we apologise to the Commission.

PN7346

VICE PRESIDENT LAWLER: That's fine, Mr Friend, thank you. Ms MacLean?

PN7347

MS MACLEAN: Thank you, your Honour.

<JAMES ARTHUR SAMS, ON FORMER OATH [10.02AM]
<CROSS-EXAMINATION BY MS MACLEAN, CONTINUING

PN7348

MS MACLEAN: Mr Sams, could we turn to the position of the ambulance flight paramedic, that is, the non MICA flight paramedic. You say from about paragraph 33 of your first statement that they have skills that are not part of the on road ambulance paramedic skill set, that is at paragraph 33, do you see
that?---Yes.

PN7349

You are aware, aren't you, that Mr Young, disagrees with that proposition. You have read his statement, haven't you?---Yes, that's correct. I would have made a response I think to that.

PN7350

Yes, you do. And he says that the skills of the flight paramedic are not more difficult or sufficiently distinct from those performed by a regular on road paramedic, the clinical skills are very similar to those of an on road paramedic. That's Mr Young's position, you understand that?---Yes.

PN7351

And you disagree with that?---I do disagree with him.

PN7352

Yes. How often would you, Mr Sams, be rostered to work with a flight paramedic or would respond to an emergency call with a flight paramedic and so could observe the work they do?---It's quite frequent. We often send two of us to certain cases where the patient may be quite ill, or sometimes we might go to two patients. The flight paramedic would look after one patient that doesn't require my level of care, and I'd be looking after the other patient that does require a MICA flight paramedic level of care, so it's not uncommon at all.

PN7353

All right. And you would agree, wouldn't you, that some of the work of the flight paramedic is non emergency transport work, particularly in a fixed wing
aircraft?---Some of it is what you would call routine sort of work, yes.

PN7354

Yes. And that is work that typically on road ambulance paramedics don't any longer do?---Generally there's a non urgent, like private transport service contracted to do that in the road ambulance area.

PN7355

Yes, all right. Now, you list at paragraph 33 a number of the skills that you say are outside the road ambulance skill set?---That's correct.

PN7356

When you refer to the arterial blood pressure transducer, setting up and changing and maintaining that, you're not suggesting that the flight paramedic is actually performing arterial cannulation, are you?---No, not the procedure of the cannulation, but quite a few other steps are involved with maintaining and monitoring and changing art-lines, as we call it.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7357

Yes. And the transport of patients with suspected or known spinal injuries would not be something outside the work of an on road paramedic, would it?---Yes. The difference is that we do use a specialised vacuum mattress, and the environment is a little different as far as the care of the spinal patient in flight because of the aero-medical environment, turbulence, et cetera.

PN7358

And the aero-medical environment, as you refer to it, is something that the flight paramedic receives 4 per cent flying allowance in the way of compensation for, isn't it?---That's for things like turbulence, noise, vibration. But there are things such as ministration of Stemetil would be commonly given as an anti-nausea drug in a spinal patient, because you don't want the patient moving or vomiting, so they would do things like give Stemetil if necessary to a spinal patient that may not always require a MICA level of care.

PN7359

And the ambulance paramedic would give the Stemetil to the patient inconsistently with the clinical protocol in relation to the administration of that drug like any drug that they might be given?---Yes. It is a drug unique to our ambulance, but as per the guidelines for our ambulance you would give that drug, yes.

PN7360

Yes, all right. Now, you also refer to the intra-aortic balloon pump transport. Now, this is a transport where you would always, or certainly most frequently have a medial escort?---There will always be a medical escort with the intra-aortic balloon pump, yes.

PN7361

And the issue for the paramedics, the flight paramedics and MICA flight paramedics is a transport one, that is, how to safely load and unload the patient with one of those on board?---There needs to be an awareness of the batteries and disconnection of the various tubes and so forth that connect to the patient. It's a very critical, difficult movement or logistically a difficult movement of the patient on and off aircraft, and securing things in flight, of course.

PN7362

Yes. Now, you understand that in relation to the flight paramedic, the non MICA flight paramedic, that the claim, one of the claims in this case is that the flight allowance be paid for all purposes, that is, that even when the flight paramedic was not performing duties at the Air Ambulance they would receive the flight allowance, do you understand that?---That's correct.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7363

And Mr Young says, doesn't he, that that would provide a significant disincentive for people to work at the Air Wing?---I don't see why it causes disincentive because the Air Wing is their rostered home or branch, management roster them there and can keep them rostered there, and it's not like they want to leave there. I mean, they occasionally leave there onto reserve, not by choice, because we have too many to put on the roster, but they are part of the ambulance team and that's their home, and that's where they would work unless they are directed to work elsewhere.

PN7364

Would you agree with this proposition; that if there is no financial compensation over and above their ordinary pay when working on road, that there is not as significant incentive for them to work with the Air Ambulance to perform flight duties, if I can put it that way?---I really don't think that current allowance would come into the equation there. I don't quite see where you're coming from there.

PN7365

Well, if I can earn the same money by doing only road work and I don't have to go and do flight, then perhaps I might choose not to fly?---But they are part of the ambulance team, they don't have anywhere else to go back to. They have left their stability at a branch and are now part of their ambulance branch, so if they are rostered to Air Ambulance then they are required and expected to work there. They can't turn around and say I want to go and work out a branch.

PN7366

They can be on reserve though, they can be doing work on reserve?---Well, they get put onto reserve, like we discussed yesterday, are reasonably meant to go on reserve but, I mean, they don't like that because they end up floating all over Melbourne, getting rung up at 6 o'clock in the morning to start perhaps the other side of town for a 7 o'clock shift. It's not their choice to want to be on reserve.

PN7367

And I think we also discussed yesterday that you don't know what they're told in induction about the time they will spend on the road and the time they will spend in the air?---I'm certainly aware that they are told that they will be spending some time on reserve. That is part of how the system works. We're all told that. I mean, I must also spend some time on reserve.

PN7368

Not as much as a flight paramedic?---Not as much.

PN7369

No, all right. Now, if I can take you to your statement in reply, which is a fairly lengthy document that you've prepared to respond not only to the matters raised in relation to Mr Young's statement, but also in relation to a number of others, Dr Kennedy and some of the medical witnesses, and I will just take you through that now. You refer at paragraph 1 to the crewman, and responding to Mr Young's comments that the crewman is able to assist the MICA flight paramedic if required. Are you aware of the training that's undertaken by the crewmen?---Yes, I'm very aware of it. In fact, I think it was last year I, in fact, ran the three day course for the crewmen so, in fact, I was a teacher in the course, so I'm very well aware of the course content.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7370

So you're aware that that person is trained to be of assistance to the MICA flight paramedic or flight paramedic, or MICA flight paramedic if required?---Yes, they certainly are trained to be of assistance, but as I said in my reply, of somewhat limited assistance.

PN7371

Yes. But it's not true to say that the MICA flight paramedic has available to them no assistance at all when they're responding, as you put it I think in paragraph 2 of your statement, your working alone. That's overstating the situation a little, isn't it? The crewman is there to enable to provide assistance should you require
it?---Look, they can provide assistance but, as I said, it's limited. It's not like having another paramedic or a MICA paramedic to call upon to assist you, which is the ideal situation. Logistically we can only put like three people in the aircraft, and a crewman is required, so that we have no choice but to train the crewman in first aid and assistance to us because otherwise it would be even more difficult, but there's a limit to what they can do.

PN7372

Yes. And there's never been a situation in the helicopter where there have been two paramedics, two MICA paramedics rostered for that duty?---Not rostered, but we have on occasion taken one from the scene in extremely awkward or difficult situations. Perhaps two critically ill patients have been loaded. And I can think of myself and others who have taken a paramedic with them to assist on the basis that the crewman may not have the skills, or won't have the skills needed to maintain care of two patients.

PN7373

It's an unusual situation, can I suggest to you, that the MICA paramedic would not be working as the only paramedic on the helicopter?---Most of the time he works on his own, true.

PN7374

And the training of the crewmen is such that they are familiar with the drug box that's carried on the helicopter?---Reasonably familiar. Like, at the end of my three day training course they have a reasonable knowledge, but remember they are not rostered constantly to work in Melbourne at least, work constantly with the MICA flight paramedic. They have other duties. So you may not see them for a month, two months, even three or four months before they come back onto the ambulance, what we call the ambulance roster, and often they become understandably very rusty. Now, some of them may come up to you and ask you to go over it again, but we often find we need to be fairly directive, the best way to call it is very directive about what you want, what you want drawn up. Yes, they can draw up drugs, but you can't expect, you can't turn and treat them like a paramedic as in draw me up such and such, knowing it will be done correctly. Sometimes they can make a mistake, you have to look out for that and make sure everything is done correctly.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7375

They can provide you with a person to direct, to perform tasks of a non clinical nature, drawing up drugs, preparing equipment, matters of that kind which free you up to perform the clinical and high level skills that the MICA paramedic
has?---I don't deny that they are of assistance, particularly in loading and unloading, and up to a point they can help us with setting up some of our equipment, but other equipment that we use is definitely outside of their range of skills.

PN7376

Yes, because their primary responsibility is to assist the pilot on the
aircraft?---That's correct.

PN7377

Yes. Having conducted this course you would be aware that they're also trained in the, well, with a familiarisation with the airway management tools that are kept on the helicopter?---Airway management as in they would - normally if you point to the airway box and said, hand me laryngoscope, yes, they would know what you wanted, true.

PN7378

And they're also familiarised with the operation of the Propack monitor and ventilators, defibrillators, those sort of equipment that you're carrying?---I think you would have to say defibrillators and ventilators they really have very little knowledge of at all. They're not expected to get involved in those two areas, other than put in the ECG, what we call the dots on their chest, yes, they know how to do that and connect the leads up. Defibrillation process itself, no, they can't do that.

PN7379

No, I'm not suggesting that?---Ventilators they don't really touch at all, and the Propack, the monitoring device that we carry, they are able to do certain things with that, but when we get into more invasive procedures sometimes they are not sure what to connect or to do, and we take over there.

PN7380

All right. And they can set up IV fluid under direction?---Generally they will be able to do that, yes.

PN7381

And they can utilise the spine board, various splints and know how to secure the vacuum mattress, patient restraints, matters of that kind?---Again, most of the time, but sometimes they may have forgotten how to do it, or things like a Donway traction splint which goes on a broken leg, usually a lot are taught at a - don't get enough refresher training to really keep their skills up, so we'd usually find they can assist us but only under a lot of direction, like hold this or hold that type of thing.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7382

All right. Can I show you this document, Mr Sams. It's the non MICA air crew currency checks. You've seen that document before?---Yes. I'm very familiar with it.

PN7383

Yes. And this goes through, doesn't it, the areas of training and familiarisation which are received by the crewman in order to provide the assistance to the MICA flight paramedic that we've just been discussing?---Now, that's correct.

PN7384

Yes. I tender that, if the Commission pleases.

PN7385

MR FRIEND: No objection.

EXHIBIT #CC AMBULANCE HELICOPTER NON MICA AIR CREW CURRENCY CHECK DOCUMENT, JULY 2003

PN7386

MS MACLEAN: Also, Mr Sams, if we could turn to paragraph 2 of your statement. We were discussing a little earlier the requirement of the MICA flight paramedics to generally work alone, and you refer there to the concerns that you and presumably others experience in relation to that from time to time. It's true, isn't it, that there are fairly rigorous selection processes applied in order to be successful to join the Air Wing, particularly for a MICA flight paramedic involving psychological testing and matters of that kind, do you agree with
that?---There is quite a rigorous selection process, yes.

PN7387

Yes. And applicants are tested in order to determine whether they are physically and mentally suited to the work that is performed in the Air Wing by MICA flight paras?---They're tested as well as you can test someone when you haven't actually got a real life scenario. It's sort of tested on the basis of simulated scenarios and things of that nature.

PN7388

Yes. But they're something that is looked at, is the psychological suitability of the person to perform that kind of work?---I guess what they're looking at is, can you handle stress is the key, and stay cool, calm and collected is probably the way we put it.

PN7389

And whether you can handle the winching in and out of aircraft?---Yes.

PN7390

Heights, aero-medical environments?---That's right. There's tests to cover all those aspects.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7391

All right. Now, at paragraph 3 you refer to rapid sequence intubation, where you discussed this at some length yesterday. The position is, isn't it, that the MICA flight paramedics began performing RSI, and at least as a pilot or a trial program in about 1999?---Correct.

PN7392

And that it became standard practice within Air Ambulance around about 2000, 2001?---About 2001. Well, I don't think it was any earlier.

PN7393

All right. And that following the 2001 enterprise agreement, which we also discussed yesterday, the situation is that MICA flight paramedics are paid when they're flying 12 per cent more than a MICA road paramedic would be?---That's correct.

PN7394

Yes. And that the 8 per cent allowance that was struck in 2001 is paid for all purposes, that is, while the MICA flight paramedic is performing road work or air work?---Yes.

PN7395

So even on the road, if you go back to road duty, the MICA flight paramedic is paid 8 per cent more than the MICA road paramedic?---In recognition of the course and qualification they had achieved, and their skills and so on.

PN7396

All right. Now, you refer in paragraph 5 to the work of flight paramedics, and you respond there to the statement of Mr Young that I took you to a little earlier, that is, that flight paramedics skills are really no more different or distinct from those performed by road paramedics, and you refer to the carrying of multiple patients. Can I suggest to you that there would only be at one time in a particular transport situation one monitored patient, that is, not a walk on, walk off situation - there might be more than one of those - but there would only be one person that required the assistance of the flight paramedic with monitoring or something of that kind?---In general unless it's - in general you would try to have only monitored patient but, however, it has been known where they are located somewhere where they are already, let's say Mildura, another patient needs to be moved at the same time, they could end up with two monitored patients. It does happen on occasions.

PN7397

But that would be an unusual situation?---Yes, more unusual. But they can certainly have multiple patients and still requiring observations, care, case sheets to be written up and so on.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7398

Yes. If there was a more complex case that the fixed wing aircraft was responding to, can I suggest to you that then there would be a MICA flight paramedic, doctor or an ICU nurse will travel with that particular patient to be transported?---I don't agree with that, because certainly what happens, a case will come in and then usually the MICA flight paramedic is asked to - what's the word? - vet it, make an inquiry, ring up the hospital that's sending the patient. It could be a patient with chest pain who has had a heart attack and he is having various drugs administered, and his pain is now resolved, although maybe had not long ago had some chest pain, and on the basis of that inquiry I have to make a decision about whether I should go or the flight paramedic should go. In most situations those type of patients would often be a MICA paramedic's job, but the level of training that we give the flight paramedics for the course they do and their knowledge of drug infusions, means that despite having two or even three drug infusions running, I would send the flight paramedic to that patient as long as I was reasonably confident that they were stable and not likely to need intervention. However, intervention can occur sometimes, they do sometimes have to intervene with drug therapy in flight.

PN7399

Yes. And if it was the case, if you're talking about a pick up from a hospital in the rural area - - -?---In the fixed wing aircraft.

PN7400

In the fixed wing aircraft. If it was the case that that patient, by the time the aircraft had arrived had destabilised or deteriorated for some reason, then what I am suggesting to you is that a doctor or an IC nurse would travel with them if a MICA paramedic hadn't responded to that particular call, if there had been a change in that situation?---I'm not quite sure - - -

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7401

In the patient's condition. By the time the aircraft had arrived, if there had been a change in the patient's condition such that it would destabilise but still required transport, then a doctor or IC nurse would travel with them?---That's very, very infrequent because almost always the country hospitals cannot spare staff, especially not their doctors, and really there's nothing much gained by sending a nurse when the flight paramedic's level of training is already probably fairly similar or equivalent to. So what would normally happen is they would take that patient on. I have seen them come back to land with patients that I would have said would probably have been my level of care, but they've ended up having to transport and manage that patient because they were there, the patient needed to be moved, and the delays in bringing the plane back to take me back to that distant hospital would have been worse for the patient outcome than for them to fly the patient, even though it probably a bit - it would be the sort of patient you normally would not expect them to have to care for.

PN7402

All right. Now, you go on then to refer in paragraph 6 to what you describe as over-stocking the roster. We discussed yesterday, didn't we, the need for there to be a pool of both MICA flight paramedics and flight paramedics in order to cover periods of absence, leave, illness, matters of that kind. You can't delve back into the pool of paramedics who are not trained in the aero-medical environment and expect them to fill vacancies in the roster. You need to have, you would agree, wouldn't you, a pool of people who are sufficiently trained and experienced to fill vacancies of the kind I have just outlined?---Look, I have no argument with the need for a small pool of people. Obviously sick leave, WorkCover, long service leave, you have to have more than the roster can accommodate. The key to that, to keep it fair for everyone is not to have too many floating on the reserve roster.

PN7403

Yes. And you say, do you, that there are now too many floating on the reserve roster in both MICA flight paramedics and flight paramedics; is that your position?---And particularly with the fight paramedics. They are spending quite long periods on reserve.

PN7404

Are you aware that there has been difficulty filling shifts for MICA flight paramedics in recent times, that that has become an issue of insufficient numbers of MICA flight paramedics available to fill available shifts?---There is sometimes difficulties in Melbourne, not difficulties in the bases at Bendigo and Latrobe Valley. In Melbourne we have a different - - -

PN7405

You're aware of difficulties in Melbourne?---A sort of different environment to work in, and sometimes people need days off, they do not always want to come back to work, they have other commitments anyway on their day off.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7406

Mr Young will say that in recent times there has been difficulty filling the available shifts from the pool of MICA flight paramedics, and you are aware of that at least in Melbourne, as I understand what you just said?---Well, there can be difficulty filling shifts at Air Ambulance, but there also can be difficulty filling shifts on the road, and sometimes ambulances on the road cannot be fully staffed. It doesn't matter. Anyway the Ambulance Service can have problems filling shifts.

PN7407

What you're saying though, Mr Sams, is that the Air Ambulance management have over-stocked the roster, there are too many people in the pool. What I am putting to you is, that Mr Young will say - and I don't take it that you disagree, at least in respect of Melbourne - that there are difficulties, or have been difficulties in recent times filling the shifts that are available from the available pool?---There are occasionally difficulties fillings shifts, I don't deny that.

PN7408

All right. If I could take you to paragraph 15 of your statement - firstly if I could take you to paragraph 12. Do you agree - and we touched on this yesterday - that there is a, in respect of the flight paramedics, a high turnover of staff?---Are you saying there is a high turnover of staff of flight paramedics?

PN7409

I am asking you to comment on that. Would you agree that there is a high turnover in respect of MICA - flight paramedics, not MICA flight
paras?---There is probably - look, I haven't got the facts in front of me, the exact figures. There is probably a high turnover of flight paramedics, but I still also think that maybe due - it's partially or definitely partly due to the lack of stability they have at Air Ambulance, and the time they spend out on reserve frustrates them and eventually they decide to call it a day and go back to road work at a branch closer to home, they get frustrated.

PN7410

All right. And that level of frustration is presumably something that evidence will be called about in this case, is it?---Pardon?

PN7411

Do you have any awareness of whether there is a flight paramedic going to give evidence in this case?---I'm not sure, I can't answer that.

PN7412

All right. Perhaps if we could then move to paragraph 15. Am I right in concluding that this issue that you refer to about road response from Essendon is no longer an issue because MICA flight paramedics have a limited response role, as you describe in the last full sentence? Is that the tenor of paragraph 15? This is no longer a problem, is what I am suggesting to you?---No longer a problem in relation to having to do road duties, you're saying?

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7413

Yes?---It has certainly improved. I can recall giving some evidence on that in '96.

PN7414

You did?---Our work load has diminished considerably, but there is several reasons why. The Ambulance Service has placed more MICA response units in the surrounding suburbs where there was a lack of cover, which we used to cover from Air Ambulance at Essendon Airport, and in addition as a comment there, there is the change of status in the hours from 11 pm until 7 am, where it's sort of life threatening type of emergencies where you would be turned out on the road, so that has improved the situation.

PN7415

And if you're rostered to then crewing the helicopter, then the MICA flight paramedics don't respond to road cases at all, do they?---In Gippsland, Latrobe Valley, occasionally the RAV control room does call out the MICA flight paramedic, similar to what we do in Melbourne, to a case where they may not have MICA coverage and they need to use them on a road ambulance. They have a road ambulance that they can respond to from the airport.

PN7416

Yes. You're referring here in paragraph 15 though, aren't you, to the situation at Essendon?---Yes. Essendon has always been a little different, in that we were doing a lot of road work on the fixed wing side, a lot of road work as well as the flights.

PN7417

But you're not now?---The road work side has diminished.

PN7418

That's right?---But it needs to be pointed out that one of the reasons that we wanted to bring this system in was that we were finding we were getting more flights, more MICA flight paramedic flights, and so therefore we felt it was like robbing Peter to pay Paul. You would be out on the road getting paged to return to do a flight that might take many hours, so it was felt that the right way to do it, especially in those early hours of the morning, was to have pretty much on standby for flights only unless there was a life threatening emergency in the local area.

PN7419

And, in fact, that is what happens now, and if you are rostered for crewing a helicopter you don't respond to road cases at all?---No, you don't respond to road cases on the helicopter, except at Latrobe Valley on occasions.

PN7420

Yes. But at Essendon, which you were talking about in paragraph 15, you
don't?---You don't, no.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7421

Okay. Now, the issue of blood transfusions you deal with in paragraph 16, and we talked about this also yesterday, the situation at the moment is that MICA flight paramedics do not give blood unless they have a hospital or doctor approval?---Yes, that's correct. I mean, we may initiate it by consulting with a doctor, suggesting this is what we want to do, but we must have their approval.

PN7422

Exactly. And that the giving of blood by MICA flight paramedics may begin as a trial in the next three to six months?---Yes, I understand that would probably be the case, yes. That's actually having blood available at our bases that we can take with us.

PN7423

Yes. Now, we talked about the matters that you raise in paragraph 18 yesterday in relation to the new helicopters that have been introduced, and you set out in paragraph 18 the wide range of communication devices that are carried on board that particular helicopter. It's the case, isn't it, that the MICA flight paramedic would only be communicating or monitoring one of those - let me start again. The MICA flight paramedic would only be communicating on one of those radios at a time?---No, that's just not correct. It's a shame that their Honours have not had a chance to actually look at our environment out at Air Ambulance, but helicopters, when I'm sitting there going to a case I can be monitoring the, for example, the mass UHF radio, I may also be needing to monitor the country radio frequencies, the VHF RAV country frequencies, I will also have the internal intercom in my head with compensation within the cabin, and I also will need to monitor the pilot's communications because the last thing a pilot needs is for me to but in about landing sites or something when he is having a conversation with the traffic control. So you can have one, two, three radios plus intercoms, that's four things going at once in your ears, while you only have one ever in a road ambulance.

PN7424

But in the helicopter previous to this, or in the fixed wing aircraft - let me deal with the helicopter first - that would have also been the case, wouldn't it, Mr Sams, that you've had a number of communication channels to monitor and to keep an ear on, if I can refer to it that way?---Are you saying that we need to monitor and keep an ear on a variety of channels?

PN7425

No. In the previous helicopter that was in place prior to this it was also the case, wasn't it, that there were a number of communication channels, et cetera, that the MICA flight paramedic could monitor if they needed to?---The additional things that have come in, in the country helicopters they have satellite phones. We all have the SMR radio, and they have been fairly recent introductions to the communications.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7426

Yes. And if you wish to use any of these communication devices to call or to speak to anyone, you're only using one at a time, aren't you?---Well, obviously can only use one at a time but you may need to, in fact, communicate with two different radios, and you're constantly switching between them, reaching up to the knobs to change frequencies, et cetera.

PN7427

And that's part of the nature of the aero-medical environment, isn't it?---It's one of the more difficult things. When I train the students out there, and I have been training many years, along with the ventilator this would be the other area where they have the most trouble, is coping with all the almost overload of communication they get as they take off on a task, and it's quite demanding.

PN7428

And there is nothing new in that, is there? That's part of the aero-medical environment and always has been, with more sophisticated communication coming in over time presumably as communications generally have
improved?---A lot of it has been around for a while, yes.

PN7429

Yes. Now, we discussed the Beacon tracker and FLIR yesterday. You say in paragraph 23, you talk about the use of syringe pumps by flight paramedics. It's the case, isn't it, that the flight paramedics manage the delivery of various drugs that are not part of the on road paramedic's capability. It's the case, I would suggest to you, Mr Sams, that they do so under instruction either by a MICA flight paramedic or by a medical practitioner of some kind?---No, actually that's not true. It would not be uncommon, for example, in fact very common for a flight paramedic to go to a country hospital - I will refer back to a cardiac patient who has had a heart attack - and that patient would have a - I don't want to confuse people with terminology, but they would have a drug called GTN infusion running, they would have another drug called Aggrastat running, and they would have another drug called Heperin running, so they may manage three drug infusions. Now, normal paramedics on a road would not manage those type of infusions as part of their routine daily operation.

PN7430

Those drugs have already been given by the medical practitioner at the dispatching hospital?---That's correct.

PN7431

And the flight paramedic has to monitor their rate of flow, et cetera, during the course of flight?---That's right.

PN7432

But they are not required to initiate the giving or administration of any of those drugs, are they?---They may be required to change the administration in flight. For example, if a patient has no chest pain and gets a return of chest, then the drug called GTN, they may have to increase the dosage in incremental amounts, which is part of their course and their training, and also check things such as their blood pressure and so on to make sure that doesn't drop, so they can, in fact, get involved in - without consulting ultra in those drug administrations in flight.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7433

And that is something that they have been trained to do?---As part of their medical course, yes.

PN7434

Yes. Now, we discussed yesterday the use of the Propack monitor by the MICA flight paramedic. Can I suggest to you that the flight paramedics are not required to use the Propack monitor for all its applications, all of the things that it can
do?---On the patients that they transfer on their own they would not use all of the features of the Propack, but when they are escorting patients with doctors or MICA flight paramedics then we would expect them to be able to set up and use all features of the Propack, they are trained in all features.

PN7435

Yes. I am referring to the situation where the flight paramedic is transporting a patient on their own without medical or MICA assistance or teamed with
such - - -?---In that situation there is probably one feature probably in particular they probably would not be involved in using.

PN7436

All right. Now, the changing of arterial lines we discussed yesterday. I think you agreed that the monitoring of arterial blood pressure is something that is not commonly done in the aero-medical environment, it's not a routine
procedure?---Well, no, actually I disagree there definitely. Look, we transfer a lot of ventilator patients, and most of our ventilator patients would have arterial blood pressure lines inserted, in fact, it's almost a standard expected by the receiving hospital, as the only times we generally don't see arterial lines in is because sometimes the skills of the GPs perhaps who are looking after the small country hospitals hasn't enabled them to do it, in the case that we'd get to do it, in that situation.

PN7437

All right. But it's not going to be in case, is it, Mr Sams, that a flight paramedic, that is a non MICA flight paramedic, is going to be required to transport a patient with arterial lines requiring monitoring in the way you've just described?---It would be unusual for them to do that on their own, although they could. They are trained to do so. It is usually with a medical escort or a MICA flight paramedic, in which case, again, we expect - their training is such that I can expect them to do everything to do with the arterial line, except insertion.

PN7438

To assist the monitoring of those lines?---To assist.

PN7439

Yes, all right. Now, if I can take you to paragraph 27, where you talk about the vacuum mattress. Can I suggest to you that if you have an unstable spinal injury or suspected spinal injury that is not properly secured and positioned, and a spine board, then that could well be equally as catastrophic as you describe in relation to the vacuum mattress?---There is a bit of a - I need to explain the difference between road transport of spinal patients and air transport. The reason we use the vacuum mattress and not a spine board, which is the common device used throughout the road ambulances, is because we're in a very confined space, you know, your head is almost touching the roof as you're sitting in the aircraft. If the patient has airway problems, that is, they are conscious but need to vomit, we have to have them in a very specialised packaging so that we can roll them and protect their airway. If we encounter turbulence, turbulence where you normally would want to be buckled up, I have on occasions had to release my buckles to treat the patient because of the risk of airway obstruction because they want to or need to or start to vomit. That's a much more difficult situation, and it's very important that we apply the vacuum mattress in a very secure way in which we can then roll them, release buckles and roll them in flight. And I think the turbulence you encounter and continue in turbulence while you're trying to treat your patient in that situation is quite different to road ambulance spine board transport.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7440

I understand. What you say is, if the patient with an unstable spinal fracture is not correctly positioned and secured they may incur catastrophic spinal cord damage during transport. What I am suggesting to you is that that would be the case no matter what the means by which you're transporting that patient. If you don't position them and secure them properly then you could risk and, indeed, incur further spinal cord damage, couldn't you?---You could. But there is definitely a higher risk of catastrophic spinal cord damage in aero-medical transport as opposed to road transport, which is why I always send two people to be with the patient at all times during the flight.

PN7441

And that's the nature of the aero-medical environment that you have just been describing, turbulence, people potentially air sick, that sort of thing?---That's true.

PN7442

Rather than the means by which you've secured their spinal injury?---Well, the vacuum mattress is an excellent device, we use the best available, and I think the best thing on the market is the vacuum mattress, and that's why we use it in the aero-medical environment.

PN7443

And have long have you been using the vacuum mattress?---It would be, I would say around 10 years. It's difficult to put exact timeframe on that.

PN7444

All right. And if I could then just take you briefly to the comments you've made with respect to the medical evidence. You've made some comment in respect to Dr Kennedy's statement and Dr Bacon's statement. In paragraph 30 you deal with Dr Kennedy's assertion that there is no additional complexity to clinical judgment making and procedural skills for RSI, you take issue with that. What I would suggest to you, Mr Sams, is the clinical judgment and decision making that is of a high order is the question of whether intubation is necessary, and not the means by which it will be delivered. What do you say about that?---Could you just repeat that question please?

PN7445

The question that requires the decision making and the skill is the question of whether intubation will be attempted or not, and then there are a number of options by which that might be achieved. Would you disagree with that as a proposition?---The point I was making here, that Dr Kennedy was saying that there has really been no change from the past intubate or just intubate alone as far as making a decision.

PN7446

Yes, that's right?---In actual fact we now make decisions to proceed with a procedure of RSI on patients that previously were not even allowed to do it.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7447

This is the closed head injury patients?---For example, the most common, which is the closed head injury patient with hypotension and what we call jaw tension, which makes it difficult to intubate. And we now have to make a decision on these sort of patients, yes, we can now proceed, but the crucial thing that is - I personally have found, and I know others do, have found the hardest with the RSI protocol is assessing the patient's conscious state. We're now able to intervene when a patient has a lighter conscious state than previously and in also the type of patients such as closed head injury where before the protocol would not allow it, the guidelines would not allow it.

PN7448

Well, you understand the assessment of the patient's conscious state is by means of the Glasgow coma score?---That's correct.

PN7449

Yes. And you understand that the purpose of the trial of RSI in the road MICA paramedic setting is to assess the effectiveness of RSI in the patient cohort that you have just described, that is, the closed head injury with a Glasgow coma score and a particular level, that's the particular group that is being looked at to see whether RSI affects patient outcomes in a positive way, you know that, don't you?---Yes, I'm aware of that, that's correct.

PN7450

All right. Then in paragraph 31 you respond to some comments that Dr Kennedy has made about capnography. You agreed yesterday that capnography is a confirmation tool to ensure that the endotracheal tube is in the correct position and allows a more accurate assessment or monitoring of the expiration of carbon dioxide, that's its purpose?---It's part of its purpose. I think my concern with Dr Kennedy and also Dr Bacon later was that they suggested that capnography was purely, are you in the right hole or not, are you in the oesophageus or the trachea? It's more than that. Yes, it's a very important test to know that you've passed a tube in at the right place, but then after you've got the tube in the right place the readings that you get and the actual graph pattern that you get tells you a lot more things about the patient's condition and how you should continue to treat them as far as ventilation modes and so on.

PN7451

Yes. Prior to having capnography available, which in the aero-medical environment as we were discussing yesterday, is a considerable time ago that capnography was in the Air Ambulance in the monitor?---Well, it's only really been the gold standard since about 1999, although it was used intermittently prior to then. It would depend on whether you had the right equipment or not at the time.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7452

It was a feature of some of the monitors I think we discussed yesterday?---Mm.

PN7453

Yes. But prior to that being available there were a number of observations and tests that the paramedic could apply to ensure that the endotracheal tube was, in fact, correctly positioned, and the capnography eliminates the doubt and the guesswork, if I can call it that. It's a means by which you can confirm accurately that the tube has been placed in the correct position?---Yes, it definitely does that.

PN7454

Now, you talk about, in relation to Mr Walker's statement, the failed intubation drill. It has always been part of MICA paramedic training whenever intubation was in place or attempted and failed, there has always been a process by which that failed intubation would be handled, that is, to maintain ventilation and transport quickly to hospital. Now there are other options such as the laryngeal mask airway, et cetera, that can be tried. Would you disagree with that as a proposition, failed intubation has always been part of intubation training and practice?---The failed intubation drill, the term failed intubation drill and the whole page, which I am sure was in the notes somewhere produced as an exhibit, really was only drawn up at the time that we wanted to introduce RSI.

PN7455

Yes. I am not talking about that?---Yes, people were taught some conservative strategies if they failed, but a lot of the actual true drill came in with the introduction of RSI.

PN7456

Mr Sams, what I am suggesting to you is, that if intubation failed you wouldn't all just pack up and go home?---No. You would go back to conservative airway management.

PN7457

Yes. And that was part of ambulance training from the time that intubation was available to be used by MICA paramedics back in the seventies?---There has always obviously been, yes, recourse to, what will you do if you can't do the tube in, yes.

PN7458

All right. Now, finally can I take you to the claim that's made in this particular case by the union. Do you have an understanding of what the claim is in respect of MICA flight paramedics?---I haven't actually got anything in front of me. I have a broad overview, but if you want to repeat it to me?

PN7459

Did you have any involvement - I took you to a document that you and your colleagues had prepared back in 2001, which was the submission, if you like, for the inclusion of the classification and the increased rate of pay. Did you have any involvement this time around in the formulation of the claim that's made on behalf of MICA flight paramedics?---I was aware of what was being claimed, but I did not have as direct an involvement as what I did in 2001.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7460

All right. And are you are aware of the magnitude of the pay rise that is being claimed on behalf of MICA flight paramedics in this particular round?---I'm aware, yes.

PN7461

Yes. And what is it?---Well, when you say that to me, I'm aware it's got some magnitude to it, but I can't remember the exact figure. Perhaps if I have a look at the paperwork in front of me.

PN7462

Have you got a rough idea of how much is being sought on this occasion?---Well, with the risk of - I would probably start to guess. I would rather not guess.

PN7463

I wouldn't want you to guess, Mr Sams. Perhaps we will go through it step by step. At the moment the MICA flight paramedic is paid a weekly base rate of a year three MICA paramedic, that's right, isn't it, which is about, for argument's sake, $880, that's the base rate?---That would be correct.

PN7464

Yes. Then there is an amount equal to 8 per cent of that year three MICA paramedic, that's the allowance, paid for all purposes?---Mm.

PN7465

And there's the flying allowance when flying is actually being performed of 4 per cent of the rolled in rate?---Yes.

PN7466

Sound about right to you?---In other words a total of 12 per cent.

PN7467

Yes. And the claim that is being advanced here is for the weekly base rate that we just said for argument's sake is about $880, that's to increase to the rate for a year six MICA paramedic, so from a year three to a year six, and that takes it up to somewhere around $970. Is that consistent with your understanding?---Yes, because you would have at least six years of experience before you even get to Air Ambulance, and many people have 10 years plus experience or, in my case, 28.

PN7468

So that's about $100 in round terms on a weekly base rate, then the allowances go up to 8 per cent of that year six rate as opposed to the year three rate, which is the present situation?---Yes.

PN7469

And then there's a further flying allowance of 10 per cent of the year six MICA rate, and that's a new allowance to replace the 4 per cent flying allowance that's in place at the moment, that's the position, isn't it, and the flying allowance is at the rolled in rate?---That's correct.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7470

Yes. And can I suggest to you that that involves an increase in the rate of pay for the MICA flight paramedic of somewhere in the vicinity of 20 per cent?---But it would probably be around about those figures, but remembering that MICA flight paramedics are often doing the role that an intensivist or doctor would be involved in, and we do these jobs on our own because of our level of care, so I don't think it's unreasonable if you start to compare it with doctors wages.

PN7471

I'm sure you don't think it's unreasonable, Mr Sams, and I'm not asking you to comment on whether it's reasonable or not. What I'm asking you to agree is, it's in the vicinity of around 20 per cent?---That will be correct.

PN7472

Yes. And in 1997 there was a work value increase given to MICA paramedics which flowed into the flight wing?---'97 you're saying?

PN7473

Yes?---That would probably be correct.

PN7474

You gave evidence in the '96 case, and that led to a wage rise?---Sorry, you're talking about the work value?

PN7475

Yes?---Yes, absolutely, yes, that's right.

PN7476

And in 2001 there was also an increase in the rate of pay for MICA flight paramedics consequent upon the insertion of the classification into the EBA for the first time?---But as I said earlier, it did not recognise the skills.

PN7477

I'm not asking you what it recognised. I'm just asking you to comment on the fact or otherwise that there was another pay rise awarded?---Yes, there was another pay rise.

PN7478

And can I suggest to you - or let me ask that in another way. Your earnings, Mr Sams, and those of MICA flight paramedics would be in the vicinity of a package amount of about $100,000 a year?---I see what you're - yes, that's right. You're saying that the total - - -

PN7479

The earnings of a MICA flight paramedic in a package term would be about $100,000 a year give or take?---I haven't got, as I said, I haven't got a calculator with figures in front of me, but - - -

PN7480

That doesn't sound too out of the ball park for your earnings, does it?---Sorry, you're saying this is what I'm currently earning right now, is that what you're saying?

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7481

The MICA flight paramedic, you, would earn about $100,000 a year in package terms?---You mean now on my current wage with overtime, et cetera?

PN7482

Yes?---I don't think it's in - well, certainly not that high in my example. You only get to those sort of figures if you constantly come back and work on your days off, that's the only way of getting anywhere near there.

PN7483

That's a gross amount that I'm talking about?---Pardon?

PN7484

Gross earnings I'm talking about?---Yes, with a lot of overtime.

PN7485

Yes?---A lot of overtime.

PN7486

Around about $100,000 a year?---Well, some people probably get to that figure if they are prepared to come in on two of their four days off, but I don't.

PN7487

You don't?---Come in that regularly to work that much overtime.

PN7488

Mr Sams, in respect of your earnings, the evidence will be that in the financial year 2003-2004 your total gross income was somewhere in the order of $103,000?---My personal income by working overtime would have been close to that, yes. If you're saying that - - -

PN7489

That's what I was asking you, Mr Sams?---Okay, yes, with overtime, because I've just bought a new house I was prepared to work a lot more overtime the last couple of years and - - -

PN7490

Yes. And your earnings in the financial year 2002-2003 were around about $102,000?---So my figures for the last couple of years. I think prior to that you will find they drop back quite a bit.

PN7491

Are you suggesting, Mr Sams, that those figures that we have just been discussing include an unusual amount of overtime for you?---More than I would really like to work.

PN7492

I'm not saying that. But are you saying that you've worked an unusual amount of overtime in the last couple of years so that those figures are not representative of the sort of earnings that you would be receiving in the time before that, is that what you're suggesting?---It's difficult for me to recall how much overtime I've worked over the last few years. I certainly worked overtime not always because I want to, but we all have our financial reasons. In my case I have been trying to get into another house, a new house, so I've worked more than I probably would like to have worked in recent times.

**** JAMES ARTHUR SAMS XXN MS MACLEAN
PN7493

And that's been for reasons of your family's situation?---Family situation, yes.

PN7494

Rather than that being imposed on you by the Ambulance Service?---Well, I'm frequently rung, and I will say I frequently say no to overtime.

PN7495

And you can say no, can't you?---If I had worked all the overtime I was offered I would be much higher than $100,000, because they do contact you a lot, not just Air Ambulance but elsewhere as well. They do have shortages at times.

PN7496

Yes. And you have the ability to say no when you want to, to shift overtime?---I do find that difficult at Air Ambulance. In fact, I've probably said yes more often that I would like to, because they ring you up - and they do have a small pool of people that you discussed earlier - and they might say to you, look, I've rung everyone, we're really stuck covering this shift tomorrow, there's no one else left, can you do it? And occasionally I haven't really wanted to, but I know they get stuck so I've gone in to help them out, because they don't have a lot of - it's obviously a restricted area of qualification, and they do get a bit stuck, so I think we've all said yes at times when we would rather not.

PN7497

No doubt the figures will disclose the amount of overtime that you have worked. I have nothing further. If the Commission pleases.

PN7498

VICE PRESIDENT LAWLER: Thank you, Ms MacLean. Mr Friend?

<RE-EXAMINATION BY MR FRIEND [10.59AM]

PN7499

MR FRIEND: Mr Sams, you were asked this morning about whether payment of the 4 per cent flight allowance to flight paramedics operate as an incentive for paramedics to do flight work rather than be on reserve. Can you explain to the Commission how it is a flight paramedic comes to be on reserve?---How he comes to be on reserve when he's working at Air Ambulance normally, you mean?

PN7500

Well, someone who works at Air Ambulance normally, yes, how they come to be on reserve?---Okay. The rosters are organised by a designated manager who looks after rostering at Air Ambulance, an Air Ambulance manager, and they look at the roster some months, not always some months ahead, things change, it can be quite short notice, but they look ahead and some people will continue to work in Air Ambulance and others will be sent out of Air Ambulance. There's not much choice in that. It's just if they can't accommodate you in the roster then you are sent out.

PN7501

And are there flight paramedics who aren't stationed at Air Ambulance?---Sorry, there are?

PN7502

Are there flight paramedics whose job is not normally at Air Ambulance?---There are some people who have left Air Ambulance officially, but occasionally called upon to cover overtime, for example.

PN7503

Thank you, Mr Sams, I have nothing further.

PN7504

VICE PRESIDENT LAWLER: Thank you, Mr Sams, you are free to go.

<THE WITNESS WITHDREW [11.00AM]

PN7505

MR CAMPBELL: I call Mr Geoffrey Solomon.

PN7506

VICE PRESIDENT LAWLER: Thank you. We might adjourn for a few minutes while you track Mr Solomon down.

<SHORT ADJOURNMENT [11.03AM]
<RESUMED [11.08AM]

PN7507

VICE PRESIDENT LAWLER: Yes, Mr Campbell?

PN7508

MR CAMPBELL: We have found Mr Solomon.

<GEOFFREY SOLOMON, SWORN [11.08AM]
<EXAMINATION-IN-CHIEF BY MR CAMPBELL

PN7509

MR CAMPBELL: Mr Solomon, you've made two statements in this
matter?---That's correct.

PN7510

And the first statement is 30 paragraphs long with one exhibit?---That's correct.

PN7511

And that statement is true?---It is. There is a little change just on the second page in paragraph three, where it says south eastern region. It should read south western region.

PN7512

South western region. Save for that one change?---The rest is correct.

PN7513

The rest is correct. I seek to tender that.

EXHIBIT #33 STATEMENT OF GEOFFREY SOLOMON

PN7514

MR CAMPBELL: And you made a second statement in this matter of nine paragraphs with no exhibits?---That's correct.

PN7515

Is that statement true?---Yes, it is.

PN7516

I seek to tender that also.

EXHIBIT #34 SECOND STATEMENT OF GEOFFREY SOLOMON

PN7517

MR CAMPBELL: Thank you, your Honour, that's the evidence-in-chief of this witness.

PN7518

VICE PRESIDENT LAWLER: Thank you, Mr Campbell.

<CROSS-EXAMINATION BY MS MACLEAN [11.10AM]

PN7519

MS MACLEAN: Mr Solomon, you are presently a communications officer with the Rural Ambulance Service?---That's correct, in Geelong.

PN7520

Based in Geelong. You were until 1996 a flight coordinator with the Air Wing of the Metropolitan Ambulance Service?---That's correct.

PN7521

You have not performed any duties of a flight coordination type since
1996?---That's correct.

PN7522

You say in your statement that there ought to be pay parity between the communications officer, that is the role that you perform presently, and that of the flight coordinator?---That's correct, yes.

PN7523

Can you tell the Commission what that means in money terms?---My bloke gets around about $4000 on a rolled up rate.

PN7524

Per annum?---Per annum.

PN7525

Yes. And that would be an increase to the rate of pay of the communications officer?---That's correct.

PN7526

Now, you have formed the view that that pay parity is justified or something that your union is seeking on this occasion by an analysis of the work of the flight coordinator, have you?---Sorry, I misunderstand that.

PN7527

Have you analysed the work that the flight coordinator performs at the Air
Wing?---I have seen - there's a document that I have that was handed to me in respect to the Commission case that was done a couple of years ago, and I've read through that, and we're very similar to what our roles are.

PN7528

What I asked you, Mr Solomon, is whether you had actually analysed the work that on a day to day basis the flight coordinator does at the Air Wing?---My experience at Air Ambulance and my experience in communications, I believe I can form an opinion between the two.

PN7529

And you formed that opinion based on the fact that you were an MAS flight coordinator until 1996?---That's correct, for my eight years I did there, seven years.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7530

And would you agree that the role of the flight coordinator has changed since 1996, or has it stayed the same in your view?---I believe the role of the coordinator has been the same with an increase of resources to their role.

PN7531

Yes, the role of the coordinator is the same, an increase in resources however, there has been a change, is that what you're saying?---I'm saying that the role that I did back in '87 - sorry, '96, and I finished there, I believe the role now is about on par to what I was doing then except for an extra resource.

PN7532

All right. And you know that the flight coordination role is now performed on a 24 hour, seven day a week basis?---Yes, I am aware of that.

PN7533

In your day it wasn't?---There was a staffing issue, that wasn't my responsibility. We worked 16 hour shifts.

PN7534

Yes. But the fact is that the flight coordinator now works - not the same person - 24 hours a day, seven days a week, when previously when you performed that role that wasn't the case?---I believe the work load needed a 24 hour basis, and I believe MAS decided to take that upon - - -

PN7535

What I'm asking you is a fairly simple question, Mr Solomon. When you were the flight coordinator until 1996 it was not a 24/7 operation?---That's correct.

PN7536

Right. Now, you know Mr Young, do you, familiar with who he is?---Mr Keith Young, not personally, but yes, I know who he is.

PN7537

He is the operations manager, aero-medical for Metropolitan Ambulance
Service?---Yes.

PN7538

And he says, in relation to the flight coordinator claim that's made here, that there is no comparability between the duties performed by the communications officer and the work performed by the flight coordinator now. You're in no position to disagree with that, are you?---I don't know if Mr Young has done both roles. All I'm saying is I've performed both roles, and I believe I have made a judgment that they are similar in their roles.

PN7539

Yes. And you're saying that on the basis of the fact that you stopped doing this particular flight coordination role in 1996, that now in 2005 you have a working understanding of the work that the flight coordinator does now?---I don't have a full understanding because I don't work there any longer. I have dealings with Air Ambulance on a daily basis, I still have people in the communications section at Air Ambulance who I still personally associate with, and I understand what they deal with at the moment.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7540

Have you been to the Air Ambulance operation and observed the work that the flight coordinator does on a day to day basis and analyse that in comparison to the work you do on a day to day basis?---No, I haven't.

PN7541

What you've done is to look at the position description for the flight coordinator and tick off the things that broadly correspond to the work that you do?---That's correct.

PN7542

And that's the basis upon which you've formed the opinion that the jobs are the same?---I've formed that opinion from working in the two roles.

PN7543

Yes. And I think we've established that you haven't worked in the flight coordination role since 1996, and you haven't analysed the work they do now in 2005, that's right, isn't it?---I am not employed at Air Ambulance any longer, but I believe my time spent there allows me to make that comparison.

PN7544

All right. Now, are you aware, Mr Solomon, that there has been introduced into Air Ambulance a flight coordinator training course?---I believe so, yes.

PN7545

Yes. Are you aware of the contents of the training that are provided to flight coordinators?---No, I haven't been privy to that, no.

PN7546

No. And have you made any inquiries when you see that it's mentioned in Mr Young's witness statement that such a course has been put in place, have you made any inquiries as to the content of that course?---No, I haven't.

PN7547

No. Can I suggest to you that the flight coordinator has training in a number of aspects of the role that they perform on a day to day basis which has no place at all in the role that the communication officer performs, such as yourself, such as pilot issues, you wouldn't have to deal with those, would you?---What are you referring to with pilot issues?

PN7548

Is it any part of your work, Mr Solomon, to dispatch pilots?---No, I don't dispatch. I work in a road ambulance part.

PN7549

Yes. Is it any part of your work, Mr Solomon, to have a working understanding of the weather requirements for the dispatch of Air Ambulance Services in Victoria?---My dealing is not directly with the pilots, but it's directly with the coordinator who will call us and make crews. We will send crews out to places like Casterton, Hamilton, because checking weathers for pilots.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7550

Yes. Is it any part of your work to look at the particular regulatory framework in which flights are conducted in and out of Victoria?---I don't have any dealings with that, no.

PN7551

Is it any part of your training and knowledge to be familiar with aircraft operation?---I don't have to deal with the aircraft.

PN7552

Flight planning?---No, not flight planning.

PN7553

An understanding of the duty limitations that are placed or imposed by the regulatory authorities on pilots as to when they can and can't fly?---I don't deal with the pilots, no.

PN7554

No. Do you have any need to be familiar with the pilot rostering?---No. I don't deal with pilots. It's only one aspect of the role.

PN7555

What I'm putting to you, Mr Solomon, is that there are great differences between the work that you perform, important though it is to dispatch road ambulances, they are not comparable with the sort of issues that the flight coordinator has to also be responsible for. There are additional aspects of this role is what I'm suggesting to you that are not present in your job?---No, I don't deal with aircraft. I deal with road ambulances, I have responsibility for ambulance officers, paramedics. They may be working certain hours and I need to look after their well-being. They can't work 16, 17 hours straight.

PN7556

And you're paid, Mr Solomon, as a station officer in control of ten or more persons, aren't you?---That's correct.

PN7557

You're not paid as a call taker?---No, I'm not. And I have more than 12 people to - in a broad basis - - -

PN7558

You have a significant responsibility and you are paid accordingly?---I have a big responsibility.

PN7559

Yes. And what I'm putting to you is that the flight coordinator, in addition to the matters which you've already said in your statement are comparable, has a number of other responsibilities which you do not have?---Which is the pilot, as you referred to.

PN7560

The air environment, the regulatory environment, the particular considerations that need to be applied to the dispatch and receival of aircraft?---Yes, which is - - -

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7561

Is something you do not do?---No, I don't. But I can put that in the respect of the paramedics on the vehicles. I also have regulatory constraints with them too.

PN7562

Yes. You say that you are not familiar, nor have you made any inquiries as to the nature of the flight coordinator's course?---That's correct.

PN7563

Now, if I could take you to Mr Gough's statement. You know who Mr Gough
is?---Yes, I do.

PN7564

You've read his statement?---Yes, I have.

PN7565

He goes into some detail, doesn't he, in relation to the differences as he perceives them between the role of the flight coordinator and the communications officer?
---Yes, that's correct.

PN7566

You've seen the distinctions that he draws in relation to those two roles?---Yes.

PN7567

And presumably you disagree with the observations that he makes?---Some of those I do disagree with, yes.

PN7568

Yes. Can I take you to the observations that he makes at paragraph 232, where he outlines a number of the differences as he sees them between the role of the flight coordinator and the role of the communications officer. I know you haven't got a copy of this, Mr Solomon, and if you want to have a look at one I can provide you one, but I will read them out and then ask you to comment on them. The first difference he identifies in addition to the ones that are raised in relation to the particular matters in your statement are:

PN7569

The flight coordinator interfaces with many health professionals and are required to obtain details sufficient to triage a request often far more detailed than the RAV communications officers, and then often negotiate transport times.

PN7570

What do you say about that?---Can I actually see the - it's just that when you were reading it back to me.

PN7571

Yes, you can?---Yes, if I can see it, thank you.

PN7572

It's paragraph 232 that I'm referring to.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7573

VICE PRESIDENT LAWLER: Which document are you looking at, Ms MacLean?

PN7574

MS MACLEAN: This is Mr Gough's statement. Mr Gough is the general manager operations at Rural Ambulance Victoria.

PN7575

VICE PRESIDENT LAWLER: Sorry, I thought you were looking at Mr Young's statement.

PN7576

MS MACLEAN: Yes, you've got that?---Yes, I have. So on the first one in respect to the flight coordinator interfaces, I believe we interface with as many health professionals as the flight coordinator as an RAV communications officer.

PN7577

You've got no basis upon which you could say how many health professionals or of what type of health professional a flight coordinator interfaces with on a day to day basis, have you?---From my past experience when I was working there for those seven years I interfaced with MEARs, PETs, NETs, hospitals, doctors. I still interface with those people at present.

PN7578

Yes, all right. Now, we'll move on:

PN7579

The flight coordinator role has additional complexities, in that they must take into account the flight physiology issues with patients.

PN7580

That's not something you have to do, is it?---That's correct.

PN7581

Right:

PN7582

Equipment requirements and the flight consideration such as the regulatory requirements for the pilot's flight and duty times.

PN7583

Those are the matters we've just been discussing?---That's correct.

PN7584

Not a part of your job?---Not with pilots.

PN7585

Not part of your job?---No, I don't have pilots.

PN7586

All right. And:

PN7587

The linking of tasks to match aircraft capabilities and issues such as weather.

PN7588

Also no part of your present role as a communications officer?---Not with aircraft, no.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7589

No. Presumably, Mr Solomon, the weather conditions in Geelong and its surrounding environments, depending on what was happening at Kardinia Park, of course, would not be the subject of a great consideration to be made by you on a day to day basis?---I believe it could be in respect to places like Apollo Bay and places like that where the weather does cloud in, Air Ambulance are unable to attend at these locations.

PN7590

Yes. But when you're dispatching road ambulances the weather conditions are not going to be a highly significant factor in your - - -?---Not in that respect, but I have to be careful what vehicle I send. We have four wheel drives available now down at Lorne, so whether those vehicles are needed to be sent, and those requirements.

PN7591

Yes. And that would be communicating to you, using your judgment and your experience in training, by the nature of the response required?---That's correct.

PN7592

Yes, all right. Now, if we can move on to the next one:

PN7593

Often a flight coordinator is called upon to negotiate and clarify the specific medical need for the transport with the hospital staff requesting.

PN7594

?---Yes. We do that on a daily basis.

PN7595

With many more resources at your disposal, I would suggest to you, than the flight coordinator has a fixed number of aircraft?---I would disagree there. I could take a place like Hamilton that has one resource for its whole population, and up to 1800 hours at night.

PN7596

Are you responsible for dispatching in Hamilton?---I am responsible for dispatching in Hamilton.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7597

All right, okay. Now, the next one:

PN7598

Flight coordinators also coordinate search and rescue tasks for AAV rotary wing aircraft -

PN7599

That's the helicopters:

PN7600

- and monitor aircraft status on such tasks.

PN7601

Search and rescue in that sense is no part of your role, is it?---Not in the sense of sending out aircraft, but we do actually have requests, say from the police, if they have someone missing up in the Grampians, where we will dispatch crews to an extent - - -

PN7602

Yes. But they're not part of the search and rescue operation in terms of looking for the person they're searching for?---No. I'm sure in most instances if police said to the ambulance officer, will you come with us and help us look in case we find them, our paramedic would go with that officer.

PN7603

Yes. But it's no part of your coordination role to be responsible for a particular search and rescue activity?---No, that's correct. But if we're requested as Air Ambulance would be requested by the national, I believe it's come out of Canberra, there's one body, they request for that aircraft, and Air Ambulance would make that aircraft available, that's correct, and the same that I would make an ambulance available if I was requested by a service, a police service or whatever.

PN7604

Yes. But you don't have search and rescue capabilities such as the helicopter fitted with the search beacons, night vision, that sort of thing?---No.

PN7605

That search and rescue capability is not at your disposal?---That is not at my disposal on the road ambulance, but we are involved at times with people being lost.

PN7606

Yes, of course. Now, the next matter is:

PN7607

The flight coordinator has a finite number of very expensive resources available to him or her.

PN7608

?---Yes.

PN7609

You wouldn't disagree with that at all.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7610

No.

PN7611

The cost of deploying an air ambulance is significantly higher than an RAV ambulance.

PN7612

That would also be true, would it not?---Yes.

PN7613

And:

PN7614

The flight coordinator must prioritise tasking to optimise the use of the very scarce resource as well as being aware of the contractual requirements for the use of air ambulance resources.

PN7615

Now, those are matters that are peculiar, I would suggest to you, to the flight coordinator role?---I believe we have resources that is not an infinite amount. An ambulance costs a lot of money to run and to equip, therefore we have limited resources in certain areas and we have to best use those resources also.

PN7616

Is it any part of your job, Mr Solomon, to say that when an ambulance is requested that they're not coming?---In most cases and probably nearly all cases we accept the request for an ambulance, and we will dispatch the best appropriate vehicle for that person.

PN7617

As quickly as you can?---That's correct.

PN7618

Now, the flight coordinator is a trained flight paramedic, you're aware of
that?---That's correct, yes.

PN7619

And he or she is required to keep up their certification as a flight paramedic by undertaking the physical requirements of that particular certification, the physical fitness checks, swimming, I think there's a swimming exam or testing of some kind held on a yearly basis, is that your understanding?---That's right. When I was there that was my understanding, yes.

PN7620

Yes. You don't have to undertake any of that physical fitness training, do you Mr Solomon?---Only for my own personal needs.

PN7621

Yes. But not as part of a certification for the performance of your work?---That's correct, I don't.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7622

All right. And you say that you attend in-service days, I think they're described as?---That's correct, yes.

PN7623

Yes. And that is because, I would suggest to you, the communications officers have from time to time still performed on road paramedic duties?---That's correct.

PN7624

To keep up your paramedic skills?---Yes.

PN7625

Yes. Nothing to do with the maintenance of your communications officer skills, although communications issues will be covered from time to time?---But I believe updating my skills on the road allows me to be more familiar with the road crews, what they're actually doing these days.

PN7626

Yes. But the performance of your work as a communications officer is not the reason that you attend the in-service days. They are for the maintenance of your clinical skills, aren't they?---That's correct.

PN7627

Yes, all right. Now, could I suggest to you in relation to the matter you raise at paragraph 8 in your reply statement, and you're talking there about communications with health professionals, is it the case that the flight coordinator receives calls from the public to dispatch the air ambulance to respond to a particular need?---My understanding would be that the public may ring to make inquiries about moving a patient from an interstate location or something.

PN7628

Yes. But it's not the majority of calls by way of contrast to the communications officer or, indeed, to the dispatch at MAS would be from members of the public, would they not?---No. Maybe half would be, yes. The other half would be from health professionals, doctors and other nursing staff.

PN7629

You're suggesting that half of the calls to RAV - - -?---Okay, let's say - I haven't got the statistics in front of me, but on my dealings on a day to day basis a lot of calls are generated from doctors, hospitals, police, and not just members of the public.

PN7630

Yes. And if you received a call from a health professional that would be for a more non urgent transport than might be the case for an aero-medical retrieval from a hospital, would you agree with that?---Every day is different, but I would say that calls that we get even from doctors may be in an emergency situation because he is unable to attend to that patient, therefore they may call us to respond to an emergency situation.

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7631

All right. Now, are you familiar, Mr Solomon, with a document called the OSLA agreement?---No, I'm not familiar I don't think, no.

PN7632

Do you recall that there was a dispute surrounding the working conditions, rest breaks in particular, on operations centre employees such as yourself?---Yes, I do, yes, remember that.

PN7633

Yes. And you're aware that that went to the Commission?---Yes.

PN7634

And as a result of that there was an agreement reached about various strategies that would be put in place to address the issues that had given rise to the dispute, the rest breaks for communications centre employees?---That's correct.

PN7635

I will just show you this document. This is exhibit SG9 from Mr Gough's statement. Have you seen that document before?---I believe I must have, yes, if it's been a standard document.

PN7636

Were you part of the Commission proceeding that gave rise to the formulation of that agreement?---I wouldn't have been. I don't believe I was part of the Commission parties for that.

PN7637

All right. You though were a member of a working group that was established to go through the issues that were raised in that agreement and formulate strategies to bring about the implementation of those matters that had been agreed, weren't you?---Okay, yes.

PN7638

Yes. And on that working group with you were Mr Kennedy from RAV?---Yes.

PN7639

Mr Magee from the union, Ms Forbath from the union and a number of communications officers, Mr Copok, yourself, Mr O'Brien, Mr Bramble, ring a bell?---Yes, they do, yes.

PN7640

And you had a number of meetings, did you, to discuss the matters that are set out in that agreement?---Yes, we did.

PN7641

And the measures that are identified in that agreement have been implemented, have they not?---Yes, I believe they have, yes, been implemented. I haven't read the document fully, but I'm happy with what - - -

**** GEOFFREY SOLOMON XXN MS MACLEAN
PN7642

Please take your time if you want to?---Okay.

PN7643

But as far as you know?---Yes, they've been implemented.

PN7644

Yes. There is no ongoing controversy about any of this?---No, there is not.

PN7645

Can I also show you this document. Have you seen that?---That's one of our Rural Ambulance operational procedures.

PN7646

Yes. And this was brought in when, have you got any idea?---I've got version one 2002 on this.

PN7647

That might be about the time it was brought in then?---Okay.

PN7648

This deals, doesn't it, Mr Solomon, with the issues that arose out of that particular dispute, that is, the taking of rest breaks by communications officer, fatigue issues, matters of that kind?---That's correct.

PN7649

Might I just draw your attention to paragraph 5.2.2. That makes it clear that rest periods are to be taken and can include power naps and matters of that kind by communications officers to avoid fatigue. Do you agree with that, it's what it says?---Yes, I do.

PN7650

Okay. I will tender that, if the Commission pleases.

PN7651

VICE PRESIDENT LAWLER: Mr Friend?

PN7652

MR FRIEND: No objection.

EXHIBIT #DD RURAL AMBULANCE VICTORIA OP SEND OPERATIONAL READINESS PROCEDURES

PN7653

MS MACLEAN: I have nothing further for Mr Solomon, thank you.

PN7654

VICE PRESIDENT LAWLER: Mr Campbell?

PN7655

MR CAMPBELL: Yes, just a couple of matters.

<RE-EXAMINATION BY MR CAMPBELL [11.38AM]

PN7656

MR CAMPBELL: Mr Solomon, you were asked a number of questions about whether particular activities were done as a communications officer - sorry, a couple of activities that were done as flight coordinators were also done as a communications officer at Geelong, can you recall that?---Sorry, just do that again.

PN7657

Do you recall being asked about a number of activities that were undertaken by flight coordinators, whether they were done by communications officers?---That's correct, yes.

PN7658

Okay. Now, I just want to ask you, when you were a flight coordinator was it part of your - this is pre-1996, I understand - as a flight coordinator were you involved in checking the weather for planned flights?---I would probably check, yes, the same as ringing up if the pilot had asked me to check the weather out of other locations, I would have done it then by ringing up a Rural Ambulance communications centre.

PN7659

And also prior to 1996 as a flight coordinator were you involved in the regulatory framework for pilots, ensuring the regulatory framework?---No, I wasn't.

PN7660

And prior to 1996 were you involved in flight planning?---Yes, I was.

PN7661

And prior to 1996 were you involved in rostering of the pilots?---Not of the pilots, no.

PN7662

You were asked some questions about search and rescue. While you were a flight coordinator were you ever involved in search and rescue matters?---I do believe once or twice. I can only sort of recall once that we went out across the bay, I think it was a missing plane or something, that was the only time I can recall where we were requested by the national rescue in Canberra to dispatch an aircraft or aircrafts.

PN7663

No other questions.

PN7664

VICE PRESIDENT LAWLER: Thank you, Mr Campbell. Thank you, Mr Solomon, you're free to go.

<THE WITNESS WITHDREW [11.40AM]

PN7665

MR FRIEND: I call Mr Kevin Cooper. If the Commission pleases, Mr Cooper was given some folders which were provided to him by my learned friend, Mr Parry. I think he was in the other courtroom reading them.

<KEVIN WILLIAM COOPER, SWORN [11.43AM]
<EXAMINATION-IN-CHIEF BY MR FRIEND

PN7666

MR FRIEND: Is your full name Kevin William Cooper?---That's correct.

PN7667

You live at (address supplied)?---That's correct.

PN7668

And you're employed as an ambulance paramedic?---That's correct.

PN7669

You've prepared two statements in relation to this matter?---Yes, I have.

PN7670

And is the first statement of some 43 paragraphs with five attachments?---That's correct.

PN7671

Are the contents of that statement true?---Yes, they are correct, they are true.

PN7672

I tender that, if the Commission pleases.

PN7673

VICE PRESIDENT LAWLER: Any objection?

PN7674

MR PARRY: None but the standard one, your Honour.

EXHIBIT #35 STATEMENT OF KEVIN COOPER, WITH 5 ATTACHMENTS

PN7675

MR FRIEND: And is your second statement some 53 paragraphs long with an additional five attachments?---That's correct.

PN7676

And are the contents of that statement true and correct?---Yes, they're true and correct.

PN7677

I tender that also, if the Commission pleases.

EXHIBIT #36 SECOND STATEMENT OF KEVIN COOPER, WITH 5 ATTACHMENTS

PN7678

MR FRIEND: If the Commission pleases. If you would wait there, Mr Cooper.

PN7679

VICE PRESIDENT LAWLER: Thank you, Mr Parry.

<CROSS-EXAMINATION BY MR PARRY [11.44AM]

PN7680

MR PARRY: Mr Cooper, you're on the state council of the union?---That's correct.

PN7681

How long have you been on the state council for?---I think at least perhaps two terms which are, I think, four years each.

PN7682

About eight years?---Well, this is during the second term, so I think it's halfway through, so approximately six years I think.

PN7683

You've been involved as a member of the state council in drafting the claims in the current matter?---I don't know that I have done that directly, no.

PN7684

Were you involved in approving the course of industrial action taken last
year?---Yes, I would have been part of that as state council.

PN7685

I think you were a cadet ambulance officer back in the seventies, were
you?---That's correct. I started at age 17, straight from school.

PN7686

And that cadetship involved - it took about three years, did it?---That's correct.

PN7687

And that was a structured cadetship of being on the road and teaching as
well?---That's correct, yes.

PN7688

And you have also in your statement, your first statement, referred to being involved in teaching and assisting the introduction of all continuing education programs?---That's correct. The CEPs numbered one to seven, I was involved in the training of staff at a local level and within the regional training unit.

PN7689

Now, this morning you were provided with a couple of folders that I think you've taken some time to look through?---That's correct.

PN7690

And one of those deals with the CEPs?---That's right, one to seven.

PN7691

One to seven. And do you still have a copy of that document, that
folder?---Brenda has got it.

PN7692

If the Commission pleases, there is a folder which is about an inch and a half thick which contains the details of the CEP units one to seven. This morning through my learned friend I gave a copy to Mr Cooper to hopefully make the process a bit quicker. I have one extra copy of that that I can provide to the Bench. I can get a further copy over the luncheon adjournment of another two copies for the members of the Bench, but if one is satisfactory for this morning's purposes I will proceed on that basis.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7693

VICE PRESIDENT LAWLER: Yes, that's fine, thank you, Mr Parry.

PN7694

MR FRIEND: Well, I haven't got a copy. If the Bench is going to be looking at it while - - -

PN7695

VICE PRESIDENT LAWLER: Well, I think it's probably more important Mr Friend has the copy at this stage than the Bench does, is it not?

PN7696

MR PARRY: I'm sorry, your Honour?

PN7697

VICE PRESIDENT LAWLER: It's more important for Mr Friend to have a copy at this stage than the Bench, isn't it? In other words, you don't need to hand up the copy for the Bench.

PN7698

MR PARRY: I think I can give one copy to my learned friend.

PN7699

MR FRIEND: Might I say I don't mind my learned friend asking the questions if no one has a copy. I am not insisting on being given one, but if it's going to be followed I would like - - -

PN7700

VICE PRESIDENT LAWLER: We're happy to do without it at the moment, Mr Parry.

PN7701

MR PARRY: Perhaps just while we're on - - -

PN7702

VICE PRESIDENT LAWLER: If it gets to the point where it's hard to follow the evidence then we can re-visit this.

PN7703

MR PARRY: Perhaps whilst we're on this issue, If the Commission pleases, the Commission will recall a couple of days ago Mr Stevenson was taken through graduate volumes, five volumes. Now, I have given a copy of those to my learned friend, Mr Friend. I would propose and I will be seeking to tender at some stage those volumes. Now, does the Full Bench want three sets or just one set, because there is a lot of copying obviously, and I would hope that - - -

PN7704

VICE PRESIDENT LAWLER: I don't think the trees need to be slaughtered. We can have a reference set which each member of the Bench can have access to.

PN7705

MR PARRY: If the Commission pleases. We have one that we can hand up to the Bench of the material that's before Mr Cooper.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7706

Now, these CEP units were taught in the late eighties and now they form part of the training of ambulance paramedics in the courses they go through now, that's your understanding of the position?---As I understand, that would be correct. There would be some perhaps minor changes and amendments from when these were originally put to the training of today, but I wouldn't imagine they would have changed greatly from the dates that are set out.

PN7707

No, I'm not suggesting that they would be precisely the same, and I think we would all accept that there would be revision and updating of these units. But the substance and content of them is now taught in the course at the university?---I believe that's correct.

PN7708

And what I've handed you, you've looked through, is that, to the best of your recollection, the program that you taught and were involved in, in the late eighties?---Yes, that appears to be correct.

PN7709

And the first one, volume one - I'm sorry, number one, I think about four pages in there is a heading on the left How to Use This Unit, and on the right a resources list, and the How to Use This Unit refers to reading the objectives, going through the exercises, and on the right there were required texts set out. Was it the position with this first unit that that sort of approach was applied, that people would have to go through the exercises, be evaluated, and read the texts?---That's correct.

PN7710

And this first unit dealt with the patient with chest pain. And if one goes on, the next page I think has a page, Patient with Chest Pain Objective, and you have the objectives of the course, and over the page, I think the numbers are 9 through to 24, the objectives of the course involve being able to identify heart disease and its causes, correct?---That's correct.

PN7711

And one of those I note on the right hand side was confirming the diagnosis, this is the 24/20 electrocardiograms; do you see that?---Yes.

PN7712

What is an electrocardiogram?---An electrocardiogram is a reading or an ECG of a printout of the electrical system of the heart. Routinely we would carry that out in the field with what is called a three lead cardiograph. We've had several different monitors over the years, but they all perform basically a similar function, and it's an emergency guide in the field, if you like, looking at three different directions of a heart of the electrical pathways, whereas a hospital type cardiograph or a local doctor would perhaps have what is called a 12 lead cardiograph, which would be a definitive and diagnosing tool, not - more than an emergency guide in the field that we possess.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7713

Right. And also in this first unit, if you go on, the next page has the patient with chest pain, preliminary exercises, and over that page the overview is the heading Anatomy and Physiology of the Heart, and thereafter and through the rest of that unit there are various pictures of the heart and its anatomy. I take it this was a subject taught in a fair bit of detail in this unit?---That's correct.

PN7714

And to go to the next unit, it starts with Pulse and Blood Pressure. The next tab, this is unit two, Pulse and Blood Pressure, Mr Cooper?---That's correct.

PN7715

And the contents, there is a front page and then a second page which deals with an overview, practical skills program, a bibliography, evaluation. And, again, this was a unit which involved being introduced to the full details of blood pressure and its assessment?---That's correct.

PN7716

And the anatomy, as it says on that page, the Anatomy and Physiology of Blood Vessels?---Sorry, which page are we on now?

PN7717

I'm still on the contents page, I think item 4.3, the Anatomy and Physiology of Blood Vessels?---Yes.

PN7718

And also in item five there is reference to a bibliography, which I think appears on page 23, where there are various texts set out dealing with anatomy, human physiology and so forth. Were those texts ones that paramedics were referred to in this unit?---That's correct.

PN7719

And the next unit is unit three, which is Approach to an Incident, a Primary Survey. There's a first page which is a front page, and a continuing education program reference, and then there is acknowledgments on the following page. Do you have the acknowledgments page?---Yes.

PN7720

And there is reference there to Dr Andrew Bacon. Was he one of the people that you were aware of was involved with this course?---Yes.

PN7721

And then it goes on over the page, if I can take you to the foreword, he has:

PN7722

The program will provide the essential framework from which flows each new skill of life support. Before developing the new skills it is desirable to review and update the framework.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7723

And then you have that box which has Danger Response, airway, breathing, circulation. Now, that airway, breathing, circulation is A, B, C, isn't it?---That's correct.

PN7724

And that's a common term used in ambulance practice to refer to the essential steps of approaching an incident?---That's correct.

PN7725

And also on that page, on the opposite page, it has the reference to the primary survey, and that is, I think there is a second line there. The first line refers to the modified approach known as the primary survey, below that:

PN7726

Restoring problems involving the airway which require immediate attention. This will involve reviewing existing skills and add new methods, including the use of the laryngoscope and the Magill forceps.

PN7727

And they were instruments that were - were they in use in the Ambulance Services at this time?---They were in use by MICA paramedics and carried on some road ambulances from various services for use by doctors or in case MICA paramedics in the service that I was in, which was Peninsula Ambulance Service at that time. We had carried laryngoscopes on the vehicles for the use of doctors or MICA paramedics at the scene, or on the vehicle.

PN7728

All right. So was it the position that you yourself didn't know how to use a laryngoscope at that time?---I would say that I knew how to use one, but only MICA paramedics perhaps were accredited to use them.

PN7729

Right. And it goes on, the next line down below that there is:

PN7730

Reviewing the use of resuscitation equipment and ensuring technical competence in using the bag mask system to ventilate a non breathing patient.

PN7731

That bag and mask system, was that a system in operation at this time in the late eighties?---It certainly was again in many parts of the state, and I know where perhaps some confusion will come in with the Metropolitan Ambulance Service people is that I actually was in Peninsula Ambulance Service which it was pre 1987, so during the eighties some equipment that we carried may not be carried on Melbourne type ambulances, may be different throughout some parts of the state. I know that throughout the eighties all but Peninsula Ambulance Service at the time pre 1987, that we were the first service in the state to have the oxysaver bag and mask on every emergency type ambulance, whereas in Melbourne at the time I believe perhaps only half of their ambulances operated with this type of equipment, perhaps only their true dedicated emergency ambulances, and not their transport ambulances.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7732

Did you know how to use a bag mask system in the late eighties?---Yes, that's correct.

PN7733

You did. Now, also on this page there is reference further down, about halfway down the page there is a box, How Sick is the Patient? and then there is a reference to vital signs, and below that a Glasgow coma scale and trauma score. Were these taught as part of this or were they in existence beforehand?---I believe they were all new information. The Glasgow coma scale, if that was the time that was introduced, I believe that that would be new information for ambulance. It may have been in practice before that elsewhere, but I believe that was the introduction to us.

PN7734

Right. And if I can just go onto the next page, is an index page which goes through a number of matters, and then if I can take you onto the next page, page 1 has at the bottom of the page it has General Objectives. At the end of this unit:

PN7735

Having attended an in-service training session and completed private study and practice the ambulance officer will be able to demonstrate competence in (1) the approach to an incident primary survey, (2) managing acute upper airway obstruction, (30) cardiopulmonary resuscitation for ventilating using resuscitation equipment.

PN7736

Now, at the end of this unit you were required to be assessed, weren't
you?---That's correct. I was one of the assessors.

PN7737

Right. So presumably people had to demonstrate competence in those four areas to pass?---That's correct.

PN7738

And on the opposite page it has structure of the unit, it has tasks, section one, and task (1), pre-reading (2) practical skills, (3) tutorials, (4) in-service practicals supported with a video sequence. This seems like a fairly detailed and complicated course that paramedics were put through?---Just part of the structured continuing education that certainly had a lot of involvement in the areas described.

PN7739

It had a lot of detail, didn't it?---That's correct.

PN7740

And it involved practical assessment of paras?---That's correct. They had to examine an airway, remove a foreign object from an airway using the laryngoscope and the Magill forceps.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7741

And there is also reference in section 2 to part 4, the oxysaver and IPPV skills. What is IPPV?---Intermittent positive pressure ventilation.

PN7742

That's the bag, is it?---The bag can be used for different things. It's the oxy resuscitator I believe was designed by Dr David Komasaroff, who is in the paperwork there as being next to Dr Andrew Bacon, and it's based on the Boyle's anaesthetic machine, so it's a re-breathing apparatus. So if a patient is conscious with the mask on, may breathe in and out, and the bag will open and close. If a patient is unconscious and stops breathing, to take over the breathing one would merely breathe the bag, squeeze the bag, hold the seal to inflate the lungs, intermittently applying positive pressure into the lungs, ventilating them, hence the IPPV. So that would be in CPR, for instance, if we have a full cardiac arrest we would be applying cardiac compressions and applying respiration via intermittent positive pressure ventilation at a specified rate, breathing in between the compressions.

PN7743

Yes, it's part of ventilating the patient?---That's correct, at varying levels. There may be assisted positive pressure, and in this case it's the intermittent, perhaps for the assist - giving respiration for the non breathing patient.

PN7744

And also on this page it has:

PN7745

Skills in this unit has an update of existing skills.

PN7746

Which refers to various E numbers there, the third one down being insertion of an oropharyngeal airway?---That's correct.

PN7747

What is that?---Prior to the LMA there were two other different types of airway maintenance that non MICA people utilised, and when I first started this was the only type of airway that we had. Originally they were rubber, I think they're like a plastic now, and it's a small malleable plastic item that's inserted into an unconscious patient's airway through to the back of the tongue to keep the tongue from the back of the throat and keep the airway patent, keep the air flow going in and out so that the patient can breathe. It's only inserted in a deeply unconscious patient.

PN7748

Is that one of the forms of the Guedel airway?---The Guedel airway, that's correct.

PN7749

That's had different models over the years, has it, the Guedel airway?---I think the Guedel is perhaps just a brand name, a common brand name that's been utilised even though that may have changed over the years, I'm not sure. But certainly oropharyngeal airway would be the main generic term, and perhaps the Guedel may be a brand name for an airway. But they've certainly - they haven't changed a great deal in time, perhaps from rubber through the a plastic clear type instrument.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7750

All right. Now, to the next page, over the page it has:

PN7751

New skills, inspection of an upper airway using a laryngoscope as a lighted spatula, removal of an impacted foreign body using Magill forceps.

PN7752

They were the new skills taught as you understood it?---That's correct, yes.

PN7753

Then there is, to move through this document, this unit, there is a pre-reading segment and there is various pictures of the anatomy, of the larynx and the trachea and breathing organs, isn't there?---That's correct.

PN7754

And they were part of this unit teaching about anatomy?---That's correct.

PN7755

And I think it's page 14, have you got page 14?---Correct, yes.

PN7756

And there is in-service tutorial, practical, laryngoscope, Magill forceps. Over the page Presented by Dr Andrew Bacon, it says on page 16. Did Dr Bacon present this unit, or don't you recall?---I can't recall.

PN7757

And I think further down that page 16 it refers to laryngoscope and Magill forceps, and it has Airway Training Mannequins. Mannequins are, well, models of human upper bodies with the airways on which these skills are
practised?---That's correct.

PN7758

And that occurred back in this unit?---That's correct.

PN7759

And if we move, I think the next - there is then on page 26, the primary survey. Sorry, I will move on to page 39, the upper airway, and there is then reference to the upper airway, over the page more pictures of the anatomy. And if I could take you to page 43, there is then reference to the Penlong laryngoscope. Is it still the Penlong laryngoscope that's used?---No. That's just a brand name. That was a plastic one. We've now gone to metal handles and, in fact, the latest that we have had, disposal blades, plastic blades that attach to a metal handle.

PN7760

It's been through a few models, the laryngoscope, since the late eighties?---I would imagine so.

PN7761

Well, you know that's the case, don't you?---I would say certainly that often when types of equipment is replaced for whatever reasons owing to the supplier, some things will be slightly different, but in essence they're the same piece of equipment.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7762

And, indeed, over the page there is a picture of a laryngoscope and also Magill forceps. Now, if I could go over the page after those pictures to page 46, halfway down it has the position of the head, and there it says:

PN7763

The correct positioning of a patient's head is a crucial step in the visualisation of the upper airway.

PN7764

The position of the head was presumably a fairly important practical and theoretical training?---That's correct.

PN7765

Now, if I could take you to the next unit, the next tab hopefully, that's the Ambulance Management of a Patient with Acute Asthma, and again if I could take you, I think it's page iv at the bottom, it's an index page?---Yes.

PN7766

And again can I take it that this was a detailed course that involved pre-reading, practical and assessment?---That's correct.

PN7767

And the matters covered in the index were presumably covered in the
course?---That's correct.

PN7768

And if I could take you to page 5, the top of the page has Airway Anatomy Review:

PN7769

The previous unit of the CEP -

PN7770

And I'm sorry, I'm jumping a bit, but:

PN7771

- review the components of the upper airway, the nose and pharynx and its divisions, the nasopharynx the oropharynx and the laryngopharynx. In this unit a review of the structure and function of the lower airway will be covered before considering the problems of asthma.

PN7772

Do you see that?---Yes.

PN7773

Now, that was the way these CEPs went, wasn't it, that they would review existing learning and confirm and refresh and then build on it?---That's correct.

PN7774

And then we have over the page pictures of lungs and breathing vessels?---Yes.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7775

And over the page there is then page 8 and 9, the mechanisms for
breathing?---Yes.

PN7776

It refers there to what ventilation is and a respiratory cycle?---Yes.

PN7777

Telling an important part of this course, I take it?---That's correct.

PN7778

And on the other side of the page, page 9, gases and gas exchange. Again can we take it, an important part of the course was learning the molecular exchange that occurred in the lung, correct?---That's correct.

PN7779

And that was the important part of this?---That's correct.

PN7780

And that gas exchange I think is also referred to on page 11, and I don't - again, for the same effect. Now, if I could then take you on a bit further in this same volume, we then deal with, on page 27, it has the clinical problem of asthma. Do you have that page?---Yes.

PN7781

And it has contents halfway down the page:

PN7782

Pathology and patho-physiology, trigger factors, a clinical picture.

PN7783

These were matters that were taught in this unit?---That's correct.

PN7784

And perhaps if I could take you through to page 32, this deals with salbutamol, and there is reference there to Ventolin?---Just trade names for salbutamol, Ventolin and Respulin.

PN7785

Yes. But here we're dealing with drugs that were mixed at the scene?---That's correct. For a short time we had to mix them, then I don't think it was very long at all before they became in pre-mixed units.

PN7786

Yes. But back in the eighties when you were being taught this - we're not talking here about the Ventolin that asthma users carry with them, we're talking about drugs that had to be mixed by the ambulance paramedic at the scene?---That's correct. I believe within a year or so they went to pre-mixed and plastic ampoules, so it was no longer a requirement for that, within perhaps a year or so. But that was certainly the case when it was introduced.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7787

Right. And this salbutamol could be, after being mixed, as part of this course, it could be given through the oxygen or the airway placement?---Several different types of masks, the standard oxygen mask which is different to what we were referring before in the oxysaver, which was then a black rigid mask, whereas the low pressure oxygen delivery is normally a disposable light weight plastic mask attached to oxygen tubing, and in the case of delivery of Ventolin a nebuliser is attached at the base of the oxygen mask to be able to deliver, with high pressure oxygen, to deliver the Ventolin or the salbutamol in a nebulised form or an aerosol type form.

PN7788

Right. And another way it could be given was intravenously?---By MICA paramedics or doctors.

PN7789

Yes. And, indeed, I think on page 32 it says intravenous endotracheal MICA only?---That's affirmative. I think that would be in relation to where they were unable to gain IV access. I think there were perhaps several drugs they may place directly down the tube.

PN7790

Yes. But as part of your course as a paramedic in the late eighties you were taught that IV injection was one way of inserting salbutamol, weren't you?---We were to, in assisting MICA, that that's how it was used.

PN7791

Yes. And when you assisted MICA did you assist them in mixing up the drug to be inserted IV?---Most commonly probably no in the early years, but we could have been called on to draw up drugs or assist if required. More often than not I think in the early days of MICA it was something that the MICA officers did, but certainly if they're under pressure we could be called upon to assist to do those things under their supervision.

PN7792

Yes. When you say in the early days of MICA, that's back in the seventies. Here we're mid eighties, late eighties. You're nodding your head. You agree that by that stage you could be assisting MICA by assisting in drawing up the
drugs?---Under their supervision.

PN7793

Yes. They could say draw up a salbutamol for this patient, and you go ahead and do it?---We could draw it up and have them - they would certainly cross-check it. I don't think it was a common thing.

PN7794

All right. And the mixing up of the salbutamol, did that involve the use of drawing it out with a syringe from the glass container?---It did I believe. We had plastic malleable drawing up cannulas, so I believe there was no needle or anything like that attached, so the syringe would have what looked like a needle but was made out of soft plastic to be able to drop into the bottle and suck the Ventolin up into.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7795

Right. And I think to go on a bit further in this unit on page 47, it has, indeed, on page 47 the activity, and halfway down that page it has number 5, prepare salbutamol solution, and it refers there to, number 3, attaches drawing up cannula to syringe, doesn't it?---Sorry, we're looking at point number?

PN7796

On page 47, a bit over halfway down the page it refers on the left column to preparing the salbutamol solution, and on the right, attaching the drawing up cannula to a syringe, right?---Have you got, sorry, the number there. I can see prepare patient to assess.

PN7797

I'm sorry, yes. Prepare patient, assess respiratory, prepare equipment for - number 5 I've gone to - prepare salbutamol solution. On the right it has reference to check stock solution?---Yes.

PN7798

Number 2, opens normal saline plastic ampoule, (3) attaches up drawing cannula to syringe, right?---That's correct. I think the drawing up cannula, I believe, was the soft plastic cannula rather as opposed to a needle.

PN7799

Right. And these were skills that were taught and practised in this unit?---That's correct.

PN7800

Now, the next unit, if I could take you to the next unit. I'm sorry, perhaps before leaving that unit, there is on page 60 of that manual, of that unit, a list of pharmacological agents?---Yes.

PN7801

And it's referred at the top of the page, Further information about bronco-spasm relaxant drugs. Bronco-spasm, what is that?---Bronco-spasm is the spasm of the main bronchus as it leaves the main airway. The trachea divides into two, the left and right main bronchus into the lungs, so they're the main feeding tubes for air getting into the lungs and going into spasm.

PN7802

And it was part of this course that paramedics were told about the existence and effect of these drugs?---That's correct. These would be at the time perhaps commonly used drugs by the patients prescribed by their medical practitioners.

PN7803

Such as Atrovent, I think that's the third one down?---That's correct.

PN7804

And these are drugs that the paramedic may well haven't counted at this time in the field being used by, for example, asthmatic patients?---That's correct. We were basically just given the basic information that these are the drugs that we may come across when we're looking through patient's medications, and Atrovent was one of them, but just the basic knowledge of the name of the drug, what it does.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7805

Well, you were given not only the name of the drug, you were given its use, weren't you?---That's correct.

PN7806

Yes. Now, if I could go to the next unit, it's Approach to an incident, primary survey, paediatric resuscitation. This is the resuscitation of children, and they have, I think, they have particular issues that arise with regard to the treatment of young patients, isn't there?---That's correct. This was the actual introduction of the first actual child or paediatric resuscitator unit prior to that on ambulances. We didn't carry, or wasn't routinely carried, even a child resuscitator.

PN7807

Right. So this was a significant step, was it, Mr Cooper?---That's correct. It was much more pleasing to be able to have the correct equipment to be able to actively resuscitate prior to this. If a baby was not breathing I would have to do mouth to mouth resuscitation probably on the baby before this child or paediatric resuscitation equipment was introduced.

PN7808

Yes, indeed. I think on page 2 of that it says:

PN7809

The aim is to review skills in resuscitation of the adult patient; (2) to adopt the primary survey flow chart for paediatric resuscitation; (3) to introduce skills and new equipment for the ambulance management of paediatric resuscitation.

PN7810

That was the aim of the course that was presumably what the course
achieved?---That's correct.

PN7811

And I think on page 12 of that there is various references to the paediatric patient and their particular features, and I note also on page 16 there is a competency assessment. Again, this was a course that you had to pass as competent?---That's correct. It involved new skills and new equipment, and you were required to pass competency assessments.

PN7812

And the following, if I could go to the next unit, this is unit 6, Approach to an incident, vital signs survey. And I think the aims of this are in - or perhaps in (iii) there is an index, and over the page (iv), the aims of this, halfway down the page - well, perhaps before doing it. There were prerequisites, you had to pass the other CEP units 3 and 4, and the aims were:

PN7813

To review and consolidate the approach to an incident, primary survey, to review and consolidate the patient care record and Glasgow coma scale, to extend the approach to an incident to include the vital signs survey.

PN7814

That was the aim of the unit, and presumably that was achieved by the
unit?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7815

And there is then, I think it has page 4 at the top a bit further on. If you could just flick through and find page 4?---Yes.

PN7816

It has overview at the top, down the left side it has Primary survey, vital signs, secondary survey, and there is then halfway down that page reference to the vital signs survey, and then towards the - I think the last full sentence there reads:

PN7817

This total picture tells how sick the patient is and enables judgment about the urgency of treatment and whether to continue on site care or consider early transport to the emergency department, ie. is the patient time critical?

PN7818

That assessment of time critical was an essential part of this unit, wasn't
it?---That's correct.

PN7819

And it was an important part of the assessment of paramedics working for this unit in any event, wasn't it?---It's perhaps a more formalised way, the way that it's been structured, and perhaps had it been carried out in a fashion other than that prior, but a more formalised form when this was introduced.

PN7820

Yes. Perhaps on that, perhaps if you could go to page 8, I think it says halfway through that comment there:

PN7821

This continuing education program unit is an update for ambulance officers to bring our ambulance practice into line with current principles and practices in emergency medicine and pre-hospital care.

PN7822

In reality it is an update on something all ambulance officers are currently doing. Is that a fair comment?---I would say that would be correct.

PN7823

And if you move on, I think it's on page 27, there is this heading Segment 6, assessment of physiological statement. There is a reference to a trauma score. That is not so much a score that's relied on now, I take it?---There has been several different types of scores over time. I believe different hospitals compete to have us use different scores at different times.

PN7824

And perhaps if I could go to page 36, Summary and application, it has a pattern of injury, 1.1. These are people that are - these are specifications that are of significance in this assessment of time criticality. Number 1, point 1, is location of penetrating injury. That assessment of the location of a penetrating injury has always been an essential part of one of the first assessments an ambulance paramedic makes, isn't it?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7825

Yes. Perhaps if I could then take you to the next unit. This is the unit 7, the ambulance management of the pulseless patient, monitoring and defibrillation, and there is the first page, which has a continuing education, then a second page with various acknowledgments, and then an index with unit outline, halfway down the page, part 1, pre-entry revision, and then part 2, new material. And then there was a wide variety of matters that was described as new material for the paramedic, and that is what was taught in the course?---That's correct.

PN7826

And paramedics were assessed on that new material, correct?---That's correct, and continued to do so, yes. There is a requirement every 12 months to be re-accredited for defibrillation.

PN7827

Right. Well, if I could go over the page. When you say accredited in defibrillation, and it says on the page following the index, overview:

PN7828

This unit is presented to introduce cardiac monitoring and defibrillation of standard ambulance practices.

PN7829

And then it has the aims. And the second aim is to review essential knowledge and demonstrate competence in the basic life support skills relevant to the resuscitation of a patient. Do you know what basic life support there referred to are?---They would be the basic life support skills prior to defibrillation of, I would imagine, the CPR, IPPV, intermittent positive pressure ventilation, the cardiac compressions, clearance of an airway, use of a laryngoscope and Magill forceps to ensure the airway is clear, and control of major haemorrhage would be the basics of basic life support.

PN7830

Yes. But it wasn't just the mechanical skills of defibrillation that was taught here, it was a raft of indicators as to when it was appropriate, anatomy, physiology, heart operation, wasn't it?---That's correct.

PN7831

And as it says at the bottom of the aims:

PN7832

To develop clinical problem solving skills to an extent that facilitates a high level of clinical judgment.

PN7833

Presumably that was the aim of the course, and in your view that was
achieved?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7834

And if you go over to the next page, the resources, there is Skills maintenance at the top of the page, and then it has resources, and there is a wide variety there, being workbook videos?---Sorry, what page are we on?

PN7835

Sorry, I think it's numbered 3 at the bottom of the page, but you might not have number 3?---It's very hard to see the page numbers.

PN7836

Yes. It has Skills maintenance on the top of the page?---Yes, I can see that now.

PN7837

Right. So Skills maintenance, and below that, resources, there is reference there to workbook videos, workbook companion. Now, I assume that these were other materials that were referred to each of the paramedics going through the
unit?---That's correct.

PN7838

And presumably the paramedics were intended to refer to these other
resources?---That's correct.

PN7839

And they did?---Yes.

PN7840

And there is also reference here to other general resources required, and then there is a range of equipment, the resuscitator, defibrillators, other accessories, cardiac rhythm simulator and, fortunately, an ambulance vehicle. And they again were general resources that were to be referred to in the course by the students?---That's correct.

PN7841

Well, not students, these are paramedics. And I think part of this course was - and it's towards the - I don't have a number on this one, but there is then a number of - it's about three quarters of the way through the unit, and it has at the top Task cardiac monitoring via cable electrodes leads in the Hewlett Packard monitor. Perhaps I don't need to take you to the particular page, but you would accept that there was fairly detailed instructions in this unit on the use of cardiac monitoring?---That's correct.

PN7842

Now, that was the CEP course that was taught by you and others in the late 1980s. Now, thereafter there were various clinical updates provided, wasn't
there?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7843

And they were provided on a regular basis?---I suppose the CEPs by another name most people would refer them to. The service had just changed the name of them in continuing the education to professional development days.

PN7844

Yes. And the professional development days are days that I think occur reasonably regularly in the ambulance or the Metropolitan Ambulance
Service?---In Metropolitan I believe we're to do approximately two a year.

PN7845

And that has been the position back for how long?---Perhaps ever since CEPs stopped and they changed the name. It probably hasn't changed much, just the name of what it was from continuing education program to a synonym of professional development day.

PN7846

And some of those will be refreshers and some of them will be updating, and some of them will be new matters?---That's correct.

PN7847

Now, I tender the folder that I've just gone through.

PN7848

VICE PRESIDENT LAWLER: Mr Friend?

PN7849

MR FRIEND: Just one small matter, and probably nothing turns on it. The first tab, we only seem to have the top half of the pages.

PN7850

MR PARRY: That's a very cunning plan on our part.

PN7851

MR FRIEND: I'm sure it's not a cunning plan, but I would still like to look at the body.

PN7852

SENIOR DEPUTY PRESIDENT WATSON: Weren't the pages presented in that way initially? They seem to follow on from - - -

PN7853

MR FRIEND: No, I don't think they do. If you look at the one headed Overview, but the third page in it's just - - -

PN7854

MR PARRY: I think I have the same thing as my learned friend.

PN7855

VICE PRESIDENT LAWLER: Well, I suggest that we postpone the tender.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7856

MR FRIEND: I'm happy for it to be tendered. I would just ask my learned friend to provide us a complete document.

PN7857

MR PARRY: Well, perhaps, your Honour, I will get my learned instructing solicitor to check that we all have the same document.

PN7858

VICE PRESIDENT LAWLER: Certainly the observation that - - -

PN7859

MR PARRY: I put on the record that we will give my learned friend the full document, and the Commission.

EXHIBIT #EE AMBULANCE SERVICES VICTORIA AMBULANCE OFFICERS TRAINING AND CONTINUING EDUCATION PROGRAM WORKBOOKS

PN7860

MR PARRY: Now, does the Commission want other copies of those? I am not going back. I think we established before.

PN7861

VICE PRESIDENT LAWLER: No. This copy suffers from the same defects as Mr Friend's appears to suffer from, if it is a defect.

PN7862

MR PARRY: I think we're letters, your Honour. We're letters, they're numbers.

PN7863

VICE PRESIDENT LAWLER: I'm sorry, yes, thank you. My mistake. I withdraw that marking of exhibit 37. Exhibit EE is the workbook.

PN7864

MR PARRY: We're proposing now to go to another folder which Mr Cooper has dealing with clinical updates. Everyone is telling me it is a quarter to.

PN7865

VICE PRESIDENT LAWLER: Yes. I will adjourn until 2.15.

<LUNCHEON ADJOURNMENT [12.43PM]
<RESUMED [2.18PM]

PN7866

MR PARRY: Mr Cooper, do you have a folder before you which has some clinical updates in it?---Yes, I do.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7867

That folder, as I understand, has a number of clinical updates that were distributed through the nineties, but I'm not suggesting all of them. And the first one of those is a clinical update dated August 1990, regarding the psychiatric patient. And perhaps if we go to the second page of that, on a general note at the top of the page it says:

PN7868

Clinical update units are provided to facilitate the maintenance of state of the art in ambulance practice. This is achieved by periodic review of current practice in selected areas and introduction of changes where appropriate.

PN7869

Do you see that?---Yes.

PN7870

And that is your understanding of the role of clinical update units?---I believe so, yes.

PN7871

Now, this particular unit, do you recall it being taught in around 1990?---Yes, I do.

PN7872

And this dealt with changes to the Mental Health Act and how to deal with psychiatric patients?---That's correct, and also changes in legislation that affected us, and the introduction of physical restraints for the patient.

PN7873

Right. I assume previous to this the Ambulance Services had attended to and transported psychiatric patients?---That's correct. But I believe prior to this legislation the primary group responsible for patients that were required to be restrained were the Victoria Police.

PN7874

But it was a position that before this Ambulance Services had transported psychiatric patients?---That's correct, but in the category where someone was restrained we were not legally able to restrain anyone. If it was deemed between the police and the ambulance together when they were there that they were better off in the ambulance, they may have been arrested, handcuffed and placed in the ambulance perhaps, and if they were too violent they were taken away in the divvy van.

PN7875

Right. So before this clinical update, Ambulance Services would have transported on occasions restrained patients?---Not restrained by Ambulance, only restrained by police, but they may have been - who would have needed to accompany in the ambulance and take responsibility for restraining. I believe it was illegal prior to this introduction and change to legislation for paramedics to physically restrain psychiatric patients.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7876

And this made sure that ambulance paramedics could restrain in certain circumstances psychiatric patients?---That's correct.

PN7877

And this unit or this clinical update unit dealt with methods of restraint and circumstances where restraint was appropriate?---That's correct.

PN7878

Now, you have given in these proceedings two statements?---Yes.

PN7879

And in your second statement at paragraph 6 you respond to paragraph 133 of Mr Walker's statement, and Mr Walker's statement says in paragraph 133, and he is responding to your first statement, he says:

PN7880

I state in respect of transporting psychiatric patients, I am not aware of any evidence to support the proposition that there has been a marked increase of the daily dangers of the job for paramedics.

PN7881

Right. And you respond to that, and you say:

PN7882

In general there has been a steady increase in violence towards ambulance paramedics over many years.

PN7883

And you refer to the daily danger for paramedics in the course of their duties, and then you attach COOPER6, which is extracts from the Patient with abnormal behaviour management and primary transport, October 2003?---That's correct.

PN7884

Now, this attachment COOPER6 deals with the 1990 changes to the Mental Health Act, assessment of patients, doesn't it?---That's correct.

PN7885

And it deals with the mechanical restraint also, doesn't it?---That's correct.

PN7886

In a way it is a development of what the unit in 1990 dealt with?---That's correct.

PN7887

It deals with the same material in effect, doesn't it?---Yes, that's correct.

PN7888

Right. And between 1990 and the present are you aware of any figures that show increased acts of violence to paramedics arising from the transport of psychiatric patients?---Yes.

PN7889

There are figures for that effect?---I don't know of figures. I have been - - -

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7890

That's why I asked you if you knew of any figures?---Okay. I can quote from just recently as yesterday that I was looking through our intranet 4 figures, and I did come up with a document from the old OH&S from the minutes, which clearly states that of HIAs, which are the hazard injury accident forms which must be filled out when someone is assaulted, that the number one cause for the filling out of these forms is through aggression and potentially violent patients.

PN7891

Yes. Do you remember I asked you about the transport of psychiatric
patients?---Yes.

PN7892

Right. Now, you're not aware of any figures showing an increase in violence arising from the transport of psychiatric patients, are you?---I believe also in that paperwork there is a group, there was a group formed by MAS to look into the aggression from psych patients and the like of people who had been assaulted. I'm not aware of sighting the actual paperwork, but I believe that there is a group and that MAS may have the answers to that.

PN7893

VICE PRESIDENT LAWLER: If the paramedic is assaulted by such a patient it would be profoundly unlikely that that fact wouldn't find its way into some management record; there would be a report about the incident?---That's correct. I believe I've been - I've filled out paperwork having been assaulted since this has come in several times. It requires filling out of a hazard injury accident report, which a copy goes directly to the WorkCover officer for MAS, and has to be sighted by your direct supervisor, and depending on whether or not police action is to take place there would be WorkCover forms and perhaps police reports.

PN7894

In any event the Service records then would be a reasonably reliable and accurate indicator of the incidence of these events?---Perhaps aggression and minor assaults. There would perhaps be many that wouldn't be recorded, and I would say since the 1990s people have been encouraged more to ensure they fill out these forms so that statistics can be gained, how many people have been, how many paramedics have been assaulted or aggression towards them. And perhaps minor instances people might think, well, I won't, it's too much trouble, I won't fill it in, where they should. And I've been inclined more and more over the last 10 years or so to ensure that I fill them in, or encourage other staff to fill them in. But there would be definitive records in MAS.

PN7895

Okay. Put aside the minor instances, the records would be an accurate indicator of the occurrence of events like this, at least so far as something other than minor is concerned?---Well, of those that have been recorded there is certainly - they would certainly hold the figures. In the training that we've had recently to do with updates, to do with this, we've been given verbal instructions that there has been an increase towards the level of violence towards ambulance paramedics, and that's why they run such things as the AMOS, I think it's called, and have aggression and assault cycles on how we're to be careful in treating our patients. That's in the attachments.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7896

Yes, Mr Parry?

PN7897

MR PARRY: If the Commission pleases.

PN7898

The next clinical update in the folder deals with a clinical update for the patient with chest pain and the pulseless patient, and this is said to be, I think as we move through the contents section and over the page. I'm sorry, before we get there, in the introduction section there is reference to the Medical Advisory Commission recommending the use of glycerol trinitrate, anginine by ambulance officers, correct?---Sorry, which paragraph?

PN7899

Sorry, this is just over the - clinical update starts, and then over the page there is reference to the heading, Introduction, section 1, the patient with chest
pain?---Yes.

PN7900

And they refer to the Medical Advisory Committee as recommending the use of glycerol trinitrate or anginine by ambulance officers on a state wide basis, and the purpose of this update was to introduce the use of anginine into general ambulance practice, and that was the position, wasn't it, that in - I think the second page has a date?---1990.

PN7901

That in or around 1990 anginine was introduced into ambulance
practice?---I would say that is correct.

PN7902

And this particular unit, if we go over the page, there is the index contents page, and over the page:

PN7903

The aims of the update are review the cardiac conducting system, the natural history of ischaemic heart disease and the concept of referred pain, review the current ambulant management and to introduce the admission of anginine into ambulance management.

PN7904

And that is what occurred in 1990, wasn't it?---That's correct.

PN7905

And in this there is then reference to the heart and the anatomy of the heart, and on page 17 there is reference to anginine, an introduction, and its effects, and as it says at 5.2:

PN7906

The introduction of anginine into the ambulance management of a patient with chest pains/discomfort of a cardiac nature does not significantly alter our current management regime, but replaces the use of Penthrane as the first line drug.

PN7907

Is that your understanding of the position back then?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7908

And if I could go to the next clinical update, that's referred to as Patient with an actual or - I'm sorry, Trauma care, the patient with an actual or potential spinal injury, and this had, I think, if you go to the introduction page on page 4, this had as an aim:

PN7909

Revise and update practice and introduce new protocols for the management, equipment and techniques to maintain excellence.

PN7910

And I think that particular session involved, if I could take you to page 17, detail of spinal injury and the musculo-skeletal structure, that was part of the
unit?---Yes.

PN7911

And I think on page 43 part of this deals with physiological assessment, vital signs survey, and at the top of - I think it follows on from the effects - perhaps I should take you back to back 41. At the bottom of page 41:

PN7912

The indirect effects are largely due to the inability of the body to affect the sympathetic compensatory response to stress, eg, hypovolemia.

PN7913

What is hypovolemia, Mr Cooper?---Hypovolemia is a low blood volume.

PN7914

The detection of that is something fairly basic ambulance practice?---That's correct.

PN7915

And, indeed, over the page it refers to the usual symptoms and the signs of the shock process, eg, response to hypovolemia cannot occur. I take it an ambulance paramedic would not need great instruction on the usual symptoms and signs of the shock process?---That's correct.

PN7916

Now, the next clinical update, the patient with chest pain into hospital transfer. Now, this has as a date on page 1, at the bottom of page 1:

PN7917

Reproduce the clinical, from clinical update. The patient with chest pain into hospital transfer, ambulance officers training centre, Victoria, 1992.

PN7918

Can we accept that this was a unit that would have been taught around about 1992?---I would accept that.

PN7919

And as it says, it deals with into hospital transfers, and on page 4 it deals with the introduction to this and, as it says there, it reviews in the three dots points on the page 4 at the top of the page, it reviews updates and introduces new protocols, equipment and techniques, and presumably that's what the unit did?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7920

And as it says there?

PN7921

This particular clinical update is concerned with the ambulance transport of patients with intravenous infusions, in particular those with the drug additive glycerol trinitrate, GTN.

PN7922

And there was then activities, as it is said, in three major areas, and without going through each of the three I can take it that you would accept that this was an outcome for paramedics of going through this course?---That's correct.

PN7923

And on the right hand side, page 5, it says:

PN7924

Patients receiving GTN infusions tend to be physiologically unstable.

PN7925

And they then deal with why that's the case. And below that:

PN7926

Although an escort may not be required in some cases, do not underestimate the potential complications in respect of the transfer of such patients.

PN7927

It was stressed in this unit that that particular proposition, wasn't it, that potential complications can arise in transfers?---That's correct.

PN7928

And that's well understood with regard to into hospital transfers, isn't it, in ambulance practice?---That's correct. They come in several levels. There is into hospital transfers, as document with our level of practice, some levels require ambulance paramedics, some levels require MICA paramedic or a doctor to be with a patient. Prior to the introduction of the training for intravenous GTN a registered nurse division one had to accompany the patient to take responsibility for the intravenous drug during transport. These would generally be stable patients but still require a division one nurse to transport to take responsibility for the drug. If the patient was unstable it would require, under the same circumstances but unstable, ie. a patient who had had a heart attack, who had been given thrombolytic drugs but was now pain free and stable, a division one nurse would come with us, and if they weren't stable it would require a doctor and the drug box, a doctor's drug box to accompany and use resuscitation equipment to accompany us, and on the odd occasion perhaps in the absence of a doctor being available, MICA may be required to do that transfer. But generally to save resources MICA would not do it, it would be a doctor come out in a car.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7929

All right. Page 6 says The aims of this clinical update:

PN7930

(1) the maintenance of intravenous infusions; (2) infusion control devices; (3) the review of the buccal -

PN7931

I suppose it's pronounced:

PN7932

- glycerol trinitrate.

PN7933

?---Buccal.

PN7934

That's by the mouth, is it?---There is two ways of giving it. SL is sub lingual, under the tongue, and buccal I think just means inside the cheek, between the cheek and the tongue.

PN7935

Right. And then it refers to chapter 4, Glycerol trinitrate infusions, and has there described the pharmacology of intravenous GTN. This was a part of this
unit?---That's correct.

PN7936

And finally there was case histories. Now, if we could go to that first - sorry, firstly there is the objectives. I'm sorry, if we go onto the next page, it deals with the maintenance of intravenous infusions and the course notes, and on page 12 it deals with the equipment and assembly, and that's the intravenous therapy equipment that would hanging in the back of the ambulance attached to the patient. I'm on page 12?---Yes, I see that, but I'm not sure in reference to what type of patient we're talking or what the circumstances are.

PN7937

All right. But there is a picture there, figure 1.1, of equipment that's used for intravenous therapy?---Correct.

PN7938

And that's a picture of it, and that was taught in the course?---Yes.

PN7939

And presumably shown to ambulance officers?---Yes.

PN7940

Right. And the next one is calculating drip rates. Now, indeed, if one goes to page 14, in the part of dealing with calculating drip rates, it has there, halfway down the page:

PN7941

(iii) to make up a required volume of solution to a required strength or concentration.

PN7942

Then sets out some mechanisms for that, and below that it has:

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7943

A number of calculation exercises are provided in the self assessment section that will allow you to practice your skills.

PN7944

Do you see that?---Yes, I can see that.

PN7945

So as part of this course paramedics were making up, mixing up volumes of solution in different concentrations, weren't they?---No.

PN7946

You don't agree with that?---No.

PN7947

That wasn't part of the course?---We don't - at that stage we don't mix anything up. This was to do with perhaps following doctors instructions about if a drip was set at a certain rate, and your instructions are, Mr Cooper, to take this patient from Frankston Hospital to the city, it's a two hourly drip and you're to run it at 20 drips per minute, in case we had to have an understanding of how those drip rates worked. But we didn't actually give anything, any fluid to a patient, we weren't able to alter the rate or anything like that of an IV that was up on a, for instance, a simple into hospital transfer where there was no escort required, but perhaps an IV was up, and not even an IV pump. If something went wrong with that IV, the basic, we could do basic fault finding, but we weren't allowed to change the rate of the IV and, you know, for instance, we couldn't calculate a different rate and say we wanted it at a different rate and move it if we thought it was the best thing. We could only what was instructed under doctor's instructions during that transfer.

PN7948

Yes. I'm not suggesting you could change concentrations or change the strength of things. What I'm suggesting is that you were taught in this course how to mix up certain concentrations of solution?---Sorry, I see. For salbutamol, yes.

PN7949

You accept that, don't you?---Yes.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7950

Thank you. Now, you mentioned problem solving, and that appears on the next page, as it says there on page 15:

PN7951

There is the potential for many problems to occur associated with the maintenance of intravenous infusions, particularly environment of an ambulance vehicle. Most of these problems are only readily addressed following common problems and their possible solutions.

PN7952

And there is then set out some problems, a patient giving set position, a blocked cannula. And I note that in the blocked cannula part the solution there - do you see in that part on the right says:

PN7953

Attempt to flush through by drawing fluid into a syringe obtained from the IV kit at the injection port and flush.

PN7954

You were taught that as a technique to address the problem of a blocked cannula, weren't you?---That's correct.

PN7955

And the IV kit is the intravenous kit that was carried in the ambulance on these transfers?---That's correct.

PN7956

And you would take the syringe out of that and use it to address the problem of a blocked cannula?---That's correct. And if not successful, as I stated, but if we weren't able to get it going we couldn't start a new IV or anything like that, we would just have to switch it off.

PN7957

Well, there are a number of problems set out there and there are a number of potential solutions set out, aren't there?---That's correct. We went through various problem solving to try and sort the matter, and if it couldn't be sorted the instructions were to switch it off.

PN7958

Yes. Have you got your second statement with you?---Yes.

PN7959

If I could take you to paragraph 26 of that. Do you have that?---Yes, I do.

PN7960

You say there, you respond to Dr Bacon, where he states, Dr Bacon states:

PN7961

They have previously been responsible for monitoring such therapy during basic transportations.

PN7962

You say:

PN7963

I say this mainly involves switching off the IV if there was a problem.

PN7964

Well, that's simplistic, isn't it?---Now that I've reviewed that, that's correct. I could go through that problem solving before switching off but, again, if I was unable to be successful the main solution was to switch it off.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7965

Well, once you had been through all the other things that had been taught in the course, the final step was to turn off, wasn't it?---That's correct. These things are very temperamental sometimes they are known to shut down, and there have been quite many occasions over the years where, after going through problem solving, I would have switched the IV off because I was unable to solve the problem.

PN7966

All right. Now, with regard to adjusting, in paragraph 26, adjusting IV rates, could you change the rates of GTN infusions?---Yes.

PN7967

Right. So when you say IV rates could not be adjusted at the ambulance paramedic's discretion, you accept that that proposition doesn't apply to
GTN?---We're able to, once the new introduction of the guidelines for intravenous GTN, we're able to operate underneath the hospital's guideline, and the normal practice would be once we would load the patient we would speak to the transferring doctor who was in charge of this patient, get his instructions and get them to notate that on our patient care record as to how much we could alter it and under what circumstances. This was a large increase in our skills, it was a first even well prior to ALS, adjusting intravenous drugs without the supervision of a division one nurse or a doctor.

PN7968

Now, if I could take you on a little bit further in this. On page 25 it has:

PN7969

Review of buccal, glycerol trinitrate, GTN.

PN7970

And it says on page 25, that:

PN7971

The introduction of buccal GTN into the ambulance protocol occurred over 12 months ago.

PN7972

That would put the introduction of this in around 1991, correct?---That sounds correct, yes.

PN7973

Right. And there is then, this particular part of the unit deals with the administration of GTN, and over the page it deals with the administration of it on the - at page 26 it says, in the first major paragraph:

PN7974

From the commencement of the implementation of this protocol there have been very few apparently inappropriate dose administrations in the use of GTN.

PN7975

Does that accord with your understanding back in the early nineties following the introduction of GTN?---I believe that to be the case.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7976

And there is then set out the side effects, and on the right hand side it deals with this concept of leaving the patients at home, and it says there that, on the right hand side, 27:

PN7977

Perhaps the major error evident in the audit of PCRs is the decision by some officers to leave patients at home.

PN7978

?---Sorry, what paragraph are we reading from there?

PN7979

I'm sorry, on page 27, paragraph 2.4. Now, this was taught:

PN7980

Perhaps the major error evident in the audit of PCRs is the decision by some officers to leave patients at home following the administration of GTN. There have been a significant number of cases recorded where patients have responded to the fresh anginine provided by the ambulance officer and subsequently have either declined the offer of transport or have been offered and accepted the option of remaining at home. A number of these patients have later been transferred either by ambulance or by private means to hospital where they have been subsequently admitted in the coronary care unit with either crescendo, angina or infarction.

PN7981

As part of this course you were discouraged to leave patients at home following the administration of GTN, weren't you?---I believe that's the case thinking back to then. Certainly now the case is different.

PN7982

Well, I think you say in your first statement in paragraph 34, the first dot point:

PN7983

Anginine is used to treat cardiac chest pain and pulmonary oedema. Patients obtain significant relief from pain and can be stabilised.

PN7984

Perhaps just stop there for a second. You well accept that relieving somebody from pain and addressing the problems or the underlying cause of cardiac chest pain and pulmonary oedema are significantly different concepts, aren't
they?---Sorry, can you just repeat that?

PN7985

Yes. There is a significant difference between relieving somebody from the pain of chest pain or pulmonary oedema and treating such a cause of the pain?---That would be correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7986

So when you say a patient may not need to be taken to hospital, you would accept that that would be a very circumstance in the case of cardiac chest pain and pulmonary oedema?---I would state that they can be two different things, although they can be treated simultaneously. I would say patients with cardiac chest pain who take anginine under the guidelines separate for a minute to pulmonary oedema, those that have a history of cardiac chest pain and are being treated by their doctor with anginine, and take the anginine as prescribed by the doctor, and call the ambulance, when we arrive there they have become pain free through the use of their own anginine, or we give them anginine whilst we're awaiting MICA paramedics or waiting to load to transport to hospital and meet MICA paramedics en route, if this patient responds and becomes pain free and is stable and doesn't wish to go to hospital, it is now within the guidelines to leave that patient at home, separate to a patient who would certainly be, with cardiac chest pain with pulmonary oedema who would certainly need transport to hospital and further treatment, and would certainly require to be in a MICA vehicle if that was available.

PN7987

I think you also deal with this in paragraph 4 of your second statement, where I think you say the MICA backup can be cancelled. I'm sorry, to put that in context, paragraph 4 of your second statement responds to paragraph 131 of the witness statement of Mr Walker of RAV, who said it would be very rare that you wouldn't go to hospital. You respond by saying, well, MICA backup will be cancelled, in your second statement?---That's correct. This is a common occurrence, that once we arrive at the scene and assess the patient, and it occurs not just with cardiac chest pain but in relation to any job, once we've assessed that the patient is stable we may still be deciding to transport this patient to hospital, but if we believe that the patient is stable, pain free or with very minor pain and stable, we may cancel MICA or we decide to transport without them. But in most instances where a patient has recurrent pain or severe pain they would certainly go in a MICA unit.

PN7988

Well, you can't force them to go to hospital, can you?---No. If a patient, pretty much under most circumstances, unless someone is in a life threaten and we decide to call the police to try and get them to arrest them to force them to go, they would generally want to come with us if they're of sound mind when they realise how sick they are.

PN7989

All right. Now, back to this protocol. I'm sorry, not the protocol, the unit course. In 31 there is reference - there is then dealt with the infusion of GTN, and this is a drug that, on that page 31, as it says halfway - it talks about intravenous glycerol trinitrate, and that is, of course, inserting it intravenously, it says there:

PN7990

Drug and equipment. GTN must be diluted. It is never given by direct IV administration.

PN7991

Now, as part of this course, were paramedics taught to mix up the required dosages?---Never. This would always be done in the hospital.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN7992

Done beforehand and then provided to the paramedic. So during this course the paramedics are taught about the effects of GTN and how it could be administered, and its effect on the body?---That's correct.

PN7993

Now, if I could take you to the next clinical update, and that is dated June 1993. This deals with a patient in acute respiratory distress, and this is dated June 1993. Would that have been about the time it was commenced to be taught to
paramedics?---I'm not exactly sure what this one contains.

PN7994

All right. Well, we will go on, and perhaps it has on page (iii) the contents of the course. I'm sorry, have you got page (iii)?---Yes, I do.

PN7995

Review of the respiratory system, patho-physiology, respiratory assessment, does that bring back some memories of all this?---Yes, starting to ring a bell.

PN7996

And would it be fair to say it's around June 1993?---I would say that to be correct.

PN7997

And over the page on page 2 it has the aim of the clinical update and it has various reviews and so forth. At point 6 it says:

PN7998

Introduce the use of stethoscopes and the skill of chest auscultation as an aid to respiratory status assessment.

PN7999

Now, had there been stethoscopes used before this?---Officially a stethoscope didn't belong on a standard piece of equipment on, certainly perhaps in Ambulance Service Melbourne or Peninsula Ambulance Service up until that date, I believe, although there may have been stethoscopes carried for the use of doctors or MICA on the vehicles, and they may have had stethoscopes in some cars, some of the emergency vehicles. There is certainly lots of - it was not an official piece of equipment that was supplied by the Service.

PN8000

A lot of paramedics carried stethoscopes, didn't they?---Some.

PN8001

And they used them in their practice?---Perhaps for the purpose only really of taking blood pressure via auscultation rather than palpation, the palpation method just by taking the radial pulse and inflating the blood pressure cup and waiting for the pulse to come down, and a more reliable method but perhaps not taught until the introduction of stethoscopes used to use a stethoscope to listen to the brachial artery for it to come back in pulsating.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8002

And chest auscultation is listening to the chest?---That's correct. They certainly wouldn't - it wouldn't be common practice at all, or certainly - or, sorry, it would have been common for those people who had them to try and diagnose asthma, but certainly for the purposes of the differential diagnosis of pulmonary oedema.

PN8003

All right. But certainly by this time, around 1993, stethoscopes and the skills of chest auscultation were introduced and taught?---I believe so, yes.

PN8004

And the use of glycerol trinitrate in the ambulance management of acute pulmonary oedema, I think we can accept that that was already certainly introduced as part of the previous units in any event, wasn't it?---I'm confused by the question. Can you rephrase it?

PN8005

Sorry. Yes. Well, I've just taken you through the previous unit to do with the patient with chest hospital with into hospital transfers, this made the use of GTN beyond that, didn't it, beyond the into hospital transfers?---The same drug, different, totally different use in this aspect, yes.

PN8006

Right. And this particular - I think on page 14 I was asking you about chest auscultation, and on page 14 that's where details of that were set out?---Yes.

PN8007

And there is a video which accompanied the workbook, right?---Yes.

PN8008

I'm sorry, when I've been going through these units, I take it that often there were videos accompanying them?---With some of these ones, yes.

PN8009

Yes. And I think on page 15 there is introduction to the stethoscope and a picture of it?---Yes.

PN8010

And I think there is then a bit further on GTN, I think it's the third last page or fourth last page in that, there is a page headed Glycerol trinitrate anginine, its contraindications and its effects and so forth?---Sorry, which page is that, sorry?

PN8011

About the fourth back one from the end?---Glycerol trinitrate anginine presentation, is that the one?

PN8012

Yes. So this was presumably distributed and talked about during this course, as you recall?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8013

If I could go to the next unit, the patient with epilepsy. I think on page 2 - I'm sorry, I withdraw that. It's said on the first page, July 1995. Would that have been about right?---I would say that to be correct.

PN8014

And on page 2, which is further on, it has the objectives, and at number 5:

PN8015

Introduce the use of the patient's prescribed per rectal Diazepam and the general management of continuous and recurrent seizures.

PN8016

And this allowed the ambulance paramedic to treat epileptic, people suffering from epileptic seizures with their own drugs, correct?---That's correct, under a doctor's prescription at the scene.

PN8017

Well, when you say under a doctor's prescription, having these drugs, the patient having these drugs, they would have been so prescribed?---That's correct, but they also had to possess a physical prescription that had to be given to the paramedics at the scene. So for us to be able to administer it we would have to sight their physical prescription stating that this child can be given this drug by this amount, signed by the doctor.

PN8018

And you were given in that course, and I think it's about the third back page, you were given the pharmacology, the effects, the contraindications of Diazepam or Valium?---I'm a bit confused by the question again. We were given this document, we weren't given the drug, we were given the document detailing what the drug, how the drug presents.

PN8019

Yes?---Yes.

PN8020

I'm sorry, that's what I meant, not what I said, but what I meant. Now, the next unit is accreditation in the use of the Zoll 1600 monitor defibrillator?---Yes.

PN8021

And that was a new sort of defibrillator?---It's a new type of defibrillator that the Service got. I believe one aspect of it was that has an element of safety for the operator greater than the use of the previous models that required paddles to be attached to the patient's chest physically with the operator holding them. The Zoll monitor has stick on pads, electrodes attached by cable to the machine, so it takes one element of danger from the procedure.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8022

All right. And the next update is one headed Clinical update, October 1997. It refers to a major revision of the clinical practice guidelines:

PN8023

Previously drugs from protocols has recently been undertaken, and this document provides a summary of those changes which significantly affect all ambulance officers' clinical practice.

PN8024

And there are then on the following page set out the contents of matters that have been changed and, firstly, there is defibrillisation, the second one is time critical guidelines, that is on page 7 and 8. I think when I took you to the time critical guidelines you were taught in the CEP course, you mentioned earlier this morning, that there had been some changes to those. Are these the changes you referred to then?---That would be correct.

PN8025

Right. And those, I think they are on the following pages 9 and 10, there were respiratory assessments, and on page 11 the Glasgow coma scale. I don't know whether that had changed or not. Had that changed via this revision around 1997?---I can't recall whether it's exactly the same or not.

PN8026

All right. And there is also, on page 14, there is - I'm sorry, on page 13, into hospital transfers, there is patients - I think I had already taken you to some patients were receiving anginine infusion as part of their management. This allows, I think, the ambulance paramedic to transport a patient receiving infusion of Heparin?---That's correct.

PN8027

And, again, this was a drug that was being administered in the transfer intravenously?---That's correct.

PN8028

And in this course you were taught about, again, the pharmacology of the drug, it's effects, side effects, contraindications and so forth?---That's correct.

PN8029

And to go on, I think it's on page 20, there is a patient in respiratory
distress?---Yes, in reference to acute ..... failure.

PN8030

Right. And there is then over the page there is reference to basic care, call for MICA paramedic, if the blood pressure is over 110 systolic, anginine, and then there is a fourth dot point:

PN8031

If patient will accept mask, assist ventilation with oxysaver and bag and mask whilst the patient is in a sitting position.

PN8032

Do you see that?---I do.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8033

Was that a new step?---I believe that that was there or on abouts the introduction of new for us, not new to medicine, of what is called PEEK as an acronym, which is positive expiratory end pressure ventilation.

PN8034

Yes. That, an introduction to PEEK, didn't involve new equipment, as I understand. It still involved the bag and mask?---It's a very significant and difficult task to perform.

PN8035

Yes. You see, the only time it's mentioned in any of the material actually that's been put out in this case that I can recall is in your second statement, in paragraph 4 of your second statement. And I think you say there it's a form of manually assisted ventilation with the oxysaver. The oxysaver had been an instrument that had been around for some time, correct, isn't it?---That's correct.

PN8036

And I suggest that this, the technique is basically as set out on page 21, that it's a technique which involves making sure the bag and mask is kept on and ensuring that ventilation takes place, keeping the pressure up in the lungs?---It's a very difficult thing to describe, it's a very - it's a complex procedure to carry out. If you've got a patient who is most likely in some stage of acute pulmonary oedema, fulminating oedema where there is fluid bubbling up in the lungs, they're aware that they're in a critical situation, they're fighting to breathe, and to help them breathe we have to put a mask over the face of someone who is fighting to breathe, and this is a terrible, terrifying thing, they're terrified. The main object is for us to try and calm the patient, and what we have to do in essence is to time the ventilation in assisting their breathing as they go to breathe, and at the end of their expiration applying pressure to their breathing to try and force the fluid out of the lungs. This is a very difficult thing to do with someone who is in a critical condition just sitting here with us perhaps, it's quite a complex thing to gain the confidence of a person who realises that perhaps they're dying, their lungs are filling up with fluid, that you want to put something covering their face while they're fighting to breathe, and the trust me, I have to take over your breathing for you for a minute and you need to relax and just let me breathe for you and assist, it is a very complex thing to do. We load this patient then with MICA perhaps into a moving ambulance, they're giving drugs, I'm now in the back of MICA, the MICA paramedic is administering drugs, his hands are full, so it's my job to perhaps deliver the PEEK. You can't actually sit in the moving ambulance. I can't even sit in the - most likely I'm in a half standing, hanging onto the bed, hanging on to the patient, hanging onto the mask situation trying to keep this patient calm on the way to hospital. So it's a very daunting - it sounds easy on paper, but it's a very complex and daunting task to try and achieve it, so much so when we get to the hospital this procedure isn't carried out manually for very long. They would use an automatic machine called a CPAP machine to physically take over driving forceful oxygen into the patient's lungs.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8037

It was taught as part of the updates in 1997 as part of one professional development day, wasn't it?---That's correct.

PN8038

It wasn't even a full day, was it?---I cannot recall whether it was a full day or not.

PN8039

It was using equipment that you were well used to using, correct?---That's correct.

PN8040

Right. It was dealing with symptoms that you were well used to dealing
with?---That's correct.

PN8041

Now, the next unit is patient care record documentation, and this involved the introduction of a new patient care record around about 1996, is that right?---That looks to be correct.

PN8042

And that's the patient care record that exists at present?---Probably in varied form, a few advances since then, a few small changes.

PN8043

All right. I think that's come to the end of that document. I tender that document, that bundle.

PN8044

MR FRIEND: No objection.

EXHIBIT #FF CLINICAL UPDATES

PN8045

MR PARRY: Now, in your first statement at paragraph 10, you say you practice your ALS skills on a nearly daily basis, and in your second statement at paragraph 19 you expand on that in some senses, at paragraph 19, and say:

PN8046

I say if I see 10 patients in a day and treat one with an ALS skill, then I use ALS skills daily.

PN8047

Mr Cooper, it would be a rare day that you would see 10 patients in a day, isn't it?---I did last week.

PN8048

You heard the question. It's a rare day?---I don't know that it's a rare day that I see 10 patients.

PN8049

If we go back over your records for the last three months, apart from last week, the one day, will we find one other day where you've seen 10 patients in a day?
---You probably would. I would say it's probably uncommon, I wouldn't say it was rare.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8050

Indeed, I would suggest the more common number of patients per day would be three to five?---It's very hard to ascertain for me from day to day where the work load is quite variable, where you may see 10 patients in a day, you may see one or two patients in a day.

PN8051

On average in the last three months it would be about three or four, wouldn't
it?---I would say on average in the last three months that I can recall being - discounting this month, January, not December because I was on holidays, but certainly October, November, January that I've treated and transported quite a number of patients. In fact, I've got the numbers if you want to see them. I've actually gone through my patient care records thinking this may come up.

PN8052

It would be about three or four, wouldn't it, on average?---I can't recall currently. Would you like me to look at my paperwork now?

PN8053

No. We'll work that out. You can't recall. But the ALS skills that you practice, I suggest, most commonly, as you say in your second statement, is the administration of morphine?---That's correct.

PN8054

And when you say:

PN8055

The most common ALS level clinical judgment I make is whether to administer Penthrane or morphine.

PN8056

Both Penthrane and morphine are given for pain relief?---That's correct.

PN8057

And pain relief was always being part of paramedic practice?---Since I've been around, yes.

PN8058

Well, one of the most important parts, isn't it?---That's quite correct, pain relief is a very important part of our job.

PN8059

And morphine has largely replaced Penthrane?---No, I wouldn't say that at all. I would say that it works alongside of it, it's another choice, and it's another pathway we can take.

PN8060

You are confronted by a patient with pain, and it's effectively to give them relief that you make a choice between Penthrane and morphine?---I make a choice between giving them Penthrane, morphine, perhaps just oxygen or nothing.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8061

And morphine is a more effective drug?---In a lot of cases, not all.

PN8062

All right. In your first statement you say you regularly administer morphine to patients in severe pain through intravenous injection, and your second statement in paragraph 28, you refer to morphine having potentially serious side effects. Morphine has similar side effects to heroin?---Similar family, yes.

PN8063

Same family of drugs. Paramedics have been attending to people with heroin overdoses for certainly the last 20 years?---Yes.

PN8064

And ambulance paramedics are well trained to identify the effects of heroin overdose?---Yes.

PN8065

And they have been treating, in effect, heroin overdose for 20 years?---That's correct. Just I might raise one point. But I didn't see the - did we go through Narcan, as one of these documents in these two folders? I can't recall that.

PN8066

I haven't seen Narcan there?---Which was one of the drugs which I would have thought would have been in these folders, and its introduction.

PN8067

That was introduced as part of the intravenous IM - sorry, intramuscular package in about '97-98?---Was that in one of those documents?

PN8068

No, that wasn't there. Now, that package, there was a package that was introduced at professional development days in about '97-98?---Can I ask why that's not in these documents?

PN8069

Because as I said earlier, they're not total, we don't have them all, they're not all in that?---I believe that to be another major, one of the most major drugs of the introduction of all intramuscular injection drugs that we've been given.

PN8070

You had an IM, I think, training that took place in '97-'98, is that right?---I believe that's correct.

PN8071

And you were then taught about intramuscular injections?---Yes. Do we have a copy of that?

PN8072

No. As I said, I don't have a copy of that. Perhaps I will just ask you about it. You were taught about - part of that was Narcan?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8073

Perhaps I will go back. I mean, we've got onto a different topic, but my proposition to you earlier was, leave aside Narcan, you as an ambulance officer had been dealing with heroin overdose for 20 years?---Yes.

PN8074

And I think we agreed the side effects of morphine are similar to heroin?---Yes.

PN8075

And when I say heroin, I mean similar to heroin overdose?---Yes.

PN8076

Now, I was going to come to your intramuscular course because you refer to that in your first statement. I think in paragraph 32 you refer to the intramuscular administration of drugs, and I think your evidence would be that that took place at a couple of professional development days in '97 and 98, would that be about
right?---I believe that to be the case, yes.

PN8077

And it was part of that course that I think Narcan was introduced?---I think Narcan and Glucagon.

PN8078

Glucagon?---Were the two drugs, and perhaps even glucose paste as an oral drug.

PN8079

And in that time there was training of how to administer drugs
intramuscularly?---That's correct.

PN8080

Was that something you had done in the eighties with the Ambulance
Services?---No. I had completed my training prior to the start of the 1980s.

PN8081

Yes. You, as I asked you earlier, were a cadet?---Yes.

PN8082

And you did, I think, a hospital placement at one stage in your training?---That's correct.

PN8083

But you weren't taught to do intramuscular injections in that hospital placement, or were you?---I can't recall, almost 30 years ago, I can't recall.

PN8084

You may have been or you may not have been, you just can't recall?---That's correct.

PN8085

I don't believe so.

PN8086

Are you aware that in the 1980s paramedics going through the applied diploma course were taught the theory of intramuscular injections?---Yes, I'm aware of that.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8087

That was using what, oranges and mannequins?---I would say that would be correct, yes.

PN8088

And, indeed, the course that you went through in 1997-98, did that involve oranges and mannequins as well?---Yes, that would have been something similar.

PN8089

I think oranges are not uncommonly used in the teaching of intramuscular injections?---I would say that is correct.

PN8090

Right. And so you had a couple of days being taught about intramuscular injections, Narcan, Glucagon, and anything else associated with that?---Not injection wise, but I believe at the same time the glucose paste and perhaps the blood glucose monitor would have been introduced as a package at the same time. The blood glucose monitor is a device which punctures the skin and allows blood to be analysed for the purpose of whether the patient is hypoglycaemic and needs the treatment, being IM Glucagon or the paste, and, in fact, we can't deliver the drug until we've done the analysis.

PN8091

All right. Well, did that also cover some sharps disposal?---Sharps disposal would have come in at the same time. We would have been issued sharps containers and gone through a process of the dangers and handling sharps.

PN8092

With regard to handling sharps, I assume that as an ambulance paramedic through the seventies and eighties you would have not uncommonly come in contact with needles, would you?---In which respect?

PN8093

Treating, perhaps attending a heroin addict that had a needle?---We would certainly be aware not to stick ourselves with it or to be careful. We didn't - we would perhaps have to put it in a milk bottle or something like that, not having a sharps container, or being careful. We would try not to leave those sorts of things at the scene for a child or something like that to injure themselves upon.

PN8094

Well, you would often be, in the 1970s and 80s helping out a MICA paramedic perhaps use needles?---That's correct, under their instructions, and it would be rather the rare option rather than anything. We were actually given the needle to dispose but it would be under their direct supervision and instruction that we did.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8095

Yes. In paragraph 32 of your statement, your first statement, you talk about learning a technique for the requirements for safe disposal of needles. You would accept - I'm sorry, I withdraw that. You go on to say:

PN8096

Paramedics were exposed for the first time to new health and safety risks from needle stick injuries.

PN8097

You would accept that the - - -?---I can accept that that's perhaps a little bit incorrect, but as you've stated, we have been exposed to that area, but certainly this has become heightened now that we are primarily dealing with the needles ourselves.

PN8098

All right. And just go back in your statement a little bit. I think you deal with the use of adrenaline in paragraphs 14 to 17, and you say in 17:

PN8099

Incorrect use of adrenaline can be life threatening.

PN8100

Indeed, that's not uncommon for many drugs that paramedics use, is it?---Sorry, I'm just grabbing my adrenaline sheet. Adrenaline is one of the most, I suppose the most dangerous of our drugs that we use with conscious patients.

PN8101

I think my proposition was, all drugs are dangerous if given in long
dosages?---Varying levels of danger. You could say that giving a full aspirin instead of half an aspirin may be dangerous to the patient, giving half an ampoule instead of a full ampoule to the patient, giving adrenaline might be life threatening.

PN8102

Yes. But giving aspirin would be at one end of the continuum, wouldn't
it?---That's correct. And what you're saying is that all drugs are dangerous, that some drugs have little side effects and are quite safe, other drugs are quite dangerous and require you to be paying lots of attention to what you're doing, and adrenaline being perhaps the prime one that we - one of the prime ones that we use. For instance, if I gave adrenaline to a patient who is having a heart attack this could, in fact, extend the size of their myocardial infarction and send them into a life threatening situation.

PN8103

Yes. But you're trained and have been trained for a number of years to recognise whether a patient is having a heart attack, aren't you?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8104

Right. So that would be a pretty big error to make, wouldn't it?---That's correct, it would be a big error. But there are big dangers with these drugs, and the utmost of care, the more dangerous the drug the more attention you certainly make and ensure that you're paying attention to what you're doing.

PN8105

Now, you go on also in your first statement and then refer to the application of intravenous crystalloid fluids being a part of ALS training, and you then make a statement in paragraph 19 - I'm sorry, in paragraph 20, that:

PN8106

Potentially the ambulance paramedic can almost totally replace the - - -

PN8107

?---Sorry, are we in one or two?

PN8108

I was in number one:

PN8109

Potentially the ambulance paramedic can almost totally replace the circulating blood volume of the traumatically injured patient. This is a very considerable responsibility.

PN8110

Now, you're aware that Mr Maski has said, well, that patient would be a dead patient, in fact. And you've gone on and responded to that in the second paragraph of your second statement, where you refer there to - you seem to suggest that you conceive a circumstance where you could give six litres of Cartman's fluid to a patient whose normal blood volume is seven litres. That is simply not a realistic scenario, is it?---That is absolutely correct.

PN8111

Thank you?---No. Absolutely correct that I am correct in what I'm saying.

PN8112

I see. So you're saying a patient, you a giving six litres to a patient. I suggest that that patient would be carrying very little oxygen at all in their blood?---In the - - -

PN8113

Do you agree with that?---That's correct.

PN8114

And a patient carrying very little oxygen in their blood is going to suffer brain damage, correct?---Perhaps.

PN8115

Well, almost certainly, correct?---Perhaps.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8116

Right. Have you ever given six litres to a patient?---No.

PN8117

No. All right. It is, can I suggest, a sort of absurd hypothetical you have advanced?---No. I think if Mr Maski had a chance to re-look at his statement. I don't think you can see how he would say it. I'm sure if he was here he would reconsider it, because what I've stated is merely, in my first statement in paragraph 20:

PN8118

Potentially an ambulance paramedic can almost totally replace the circulating blood volume of the traumatically injured patient, and that is a very considerable responsibility.

PN8119

Which I agree. And in my second statement where I reply, how I'm replying is that, in fact, this is the limits of the clinical practice guidelines under CPGA0603, which dictates how I will follow, when someone is traumatically injured and is suffering from hypo bulimia, that that is the level that I am allowed to respond in treating that patient, that I can treat the patient and giving the scenario under the guidelines, 100 kilo patient is required to receive 20 mls per kilogram, and in a 100 kilogram patient that equals two litres of fluid. This can be repeated three times.

PN8120

Can I pick you up on that. You said what I am allowed to do?---That's correct.

PN8121

I think if you have obviously looked at the guideline, once you get to that stage you are on consult with a doctor, aren't you?---That's correct.

PN8122

When I consult with the doctor I consult without - in MAS it's consulting with the clinician, and the clinician would consult with the doctor. If I can't get through by phone or by radio I am empowered, in fact, I am instructed to give a third administration, which would be a third administration of two litres, which would total six litres administration to that patient, and according to the Anatomy and Physiology, Anthony and Tibbert edition at page 351, the formula is 70 ml per kilogram equals the circulating blood volume of a healthy adult. And in a patient where I've delivered three lots of two litres, being litres for a 100 kilo patient to a patient whose normal circulating blood volume, which would be 7.1 litres, I would say replacing six out of 7.1 is to almost totally replace their circulating blood volume. Now, this would be at the upper limits of the protocol. I'm talking about someone who has had their leg cut off and they're bleeding to death in front of you, and it's not normal circumstances, or they've slit their wrists and they're lying in a blood full of bath, which is one of our scenarios when we get to the scene, and there is blood everywhere and bleeding in the bath, this person is going to die. My instructions are to put in two large bore IV cannulas, load the patient, control the haemorrhage and get them to MICA or the hospital, but in doing so I'm going to pump as much fluid as I can within the guidelines following the instructions, and I say for this case that is what I can potentially do. So I'm quite astounded that Mr Maski makes such a statement and, in fact, given that if he could now look at the limits of the protocol, and I say it wouldn't be a common occurrence, but I have been with MICA crews who have given four litres or more to people who have had their leg nearly cut off by a train and so on and so forth, and what I say is that under the circumstances where we arrive and there is no MICA in attendance, yet we must take responsibility and treat these patients who are severely traumatically injured, and within the guidelines, 100 kilo patient, I am going to continue pumping fluid into them as I am following the guidelines, and my limits are that I can deliver six litres. And yes, this patient would be in a time critical, an actual time critical situation where they would be in an extreme life threatening situation, and yes, they may not survive. For Mr Maski to say this is incredible because all I am doing is in following my instructions of how I'm taught and the guidelines that are written by doctors for us to perform in this level, which are in this instance the same as MICA paramedics.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8123

The most you've ever seen given, four litres?---Four to five litres, yes.

PN8124

You said four litres. Are you adding another litre, are you?---No.

PN8125

MR FRIEND: With respect, he did not. He said four and more, and then more. My learned friend was listening.

PN8126

MR PARRY: I think we can move on from this. Let's go to the laryngeal mask airway. I think you say in respect of your first paragraph, your first statement in paragraph 22:

PN8127

The pre 1990 level of airway management was the use of an oropharyngeal airway.

PN8128

And we accept, having taken you through the CEPs this morning, that it rather undersells the training that you received in the CEPs to say advanced airway procedures were simply the use of an oropharyngeal airway, it rather undersells it a bit, doesn't it?---Sorry, I'm confused by the question.

PN8129

The question is, I took you through the CEPs this morning - I'm sorry, and this afternoon, and you received a fair bit of training with regard to airway management procedures, didn't you, in the CEP procedure?---That's correct.

PN8130

And it wasn't just the use of an oropharyngeal airway, was it?---No. What I'm referring to in those three levels of airways are that there are three actual instruments. It doesn't detail the actual associated instruments that go with them, but pre 1990 that it was the main instrument of the actual airway management that was inserted was an oropharyngeal airway, and post 1990, when after Midazolam, when Midazolam was introduced simultaneously, the nasopharyngeal airway was introduced, I believe, for the patients with trismus, where the jaw can't be opened, and an oropharyngeal airway can't be inserted, and so a soft rubber airway is inserted down the nose to the back of the airway to be able to get oxygen to the patient, and then the third level. So that would be certainly in advance only. It's not done any where pre hospital certainly that I'm aware of, the nasopharyngeal airway, and then going on to the ALS and introduction of the LMA.

PN8131

Your training in an LMA involved, as you say in paragraph 24, a review of airway anatomy, and that was a topic you had been given a fair bit of training on over the last 15 years?---That's correct.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8132

And the practical skill of its insertion is taught in about one hour, one to two hours, isn't it?---It's something that - that would be correct, but it's something we have to - I've practised many times in trying to attain a good skill level.

PN8133

You were dealing with intramuscular administration, and I think you mentioned Glucagon, and in your first statement, paragraph 33, the dot point on page 8:

PN8134

Glucagon is administered by intramuscular injection to treat unconscious diabetics with low blood sugar. Consciousness is usually restored, and MICA resources can be withdrawn for use elsewhere. Transport to hospital admission is not required if the patient is stable.

PN8135

I think you accept in your second statement, paragraph 34, that that statement of transport to hospital not being required is incorrect?---I think I would just qualify that rather than saying it's incorrect, qualify it and perhaps - sorry, what paragraph was it in the second one?

PN8136

Thirty-four of your second statement?---Yes. Certainly the decision whether a diabetic would be left at home is, according to our guidelines, we would transport the patient whether they recovered or not. But most of these patients when they are recovering become stable and we cancel MICA, and we sit in there talking to them, making sure that they've got something to eat and there is a relative with them, deciding what they wanted to do, but we would like them to go to the hospital. And, in fact, I've seen the doctor's statement saying that these patients may deteriorate, they should go to hospital, it's part of our guidelines to transport them. This is correct, but most of these patients, they're sick of hospitals and they don't want to attend the hospital if they're stable, and they often decline to go to the hospital even though we would encourage them.

PN8137

I'm only dealing with where you say transport is not required. And we can accept that that statement is not correct in paragraph, page 8, first dot point, fourth line, that's simply not correct, right?---I would agree with that.

PN8138

Right. Now, the next, the final dot point at the bottom of the page:

PN8139

Midazolam is a central nervous system depressant and anti-convulsant drug used to treat continuous or recurrent seizures. The drug renders the patient unconscious thereby stopping the seizures.

PN8140

That's incorrect, isn't it?---I think I was over simplifying the way it's termed. It's quite a complex drug, Midazolam, and if we read the Midazolam sheet it actually states that there are several concurrent actions it takes. And I agree, I think in my second, in my response to that to that paragraph in my second statement. I agree that the patient is actually already unconscious, and that perhaps I over simplified that, and that the Midazolam acts as an anti - I agree that it affects the central nervous system and acts as an anti-convulsant on the central nervous system to stop a seizure, but I also say that other simultaneous actions of Midazolam as a sedative lead to the depression of the level of consciousness and respiratory depression especially in small children to the extent where they may actually stop breathing and require resuscitation. And I note that four out of the six primary emergency indications for Midazolam, four of them relate to MICA sedating patients to a lower level of consciousness to assist MICA in sedating patients using Midazolam to assist in rendering the patient unconscious prior to attempting emergency procedures such as RSI.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8141

Midazolam replaces Valium?---Only on MICA, not for standard paramedics because we never had the drug. We've had authorisation to use the drug if a doctor's prescription was at the scene, but we've never carried Valium. That's incorrect.

PN8142

You were authorised to use Valium on a patient if the patient had Valium prescribed, correct?---That's correct. But it still doesn't replace it.

PN8143

And that had been the position for quite some period of time before the late 1990s?---That we would?

PN8144

That you could use a patient's prescribed Valium?---I'm not sure of how many years that had been going around. It may have only been within the nineties.

PN8145

You were taught the pharmacology of Diazepam, Valium, weren't you?---That's correct.

PN8146

And that was in the past before you could use it. I think I took you to one of the practice notes earlier, that you accept you were taught the pharmacology of Diazepam?---That would have been whenever that was introduced for us to - whenever authorisation came for us to be able to use a doctor's prescription would have been the first time that we would have had to study that, although it may have been within the guidelines for a long time.

PN8147

And I think we can accept that Diazepam is from the same - I'm sorry, I withdraw that. The Midazolam is from the same family of drugs as Diazepam?---Perhaps similar.

PN8148

Thank you. Now, to deal with your first statement, you then go and deal with your roster work arrangements and shift locations. This is in paragraph 39. Now, you're opposed to provisions giving the employer the right to change the roster, and you say on page 40 - in paragraph 40, I'm sorry, that, halfway down, about the eighth line:

PN8149

The MAS proposal to send employees to any location according to operational need is unreasonable and unfair. Rosters are work location should be negotiated and agreed between MAS and employees at each work location.

PN8150

Do you accept that ultimately the employer should have the right to direct an employee to either go to a reserve roster or to another location on another
roster?---At the end of the day whatever is agreed is agreed. I would hope that similar conditions are maintained.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8151

I don't think that really answers the question. You see, your position is that you don't accept, do you, that ultimately that decision can be taken by Metropolitan Ambulance Service?---Which decision?

PN8152

The decision to transfer an employee to a reserve roster for a period, do you accept?---I think that's been a point of contention over many, many years.

PN8153

You don't accept that MAS can direct an employee to go onto the reserve roster, do you?---Our workplace has taken a vote not to rotate through the reserve, and currently reserve I believe is only worked by mutual agreement from our branch at Langwarrin and Frankston.

PN8154

All right. My question is pretty straightforward, isn't it? Your answer is you don't accept that MAS have the right to so direct?---I believe that's what I believe, yes.

PN8155

Right. When you say unreasonable, you say proposal to send employees to any location according to operational need is unreasonable and unfair. Again, you don't accept that MAS should have the right to direct you to go to another branch?---No. I believe it should be by mutual agreement.

PN8156

And if it's not agreed it doesn't happen?---I believe that is the case at the moment, otherwise it ends up going through the process of grievance procedure.

PN8157

But why would it be unfair to transfer you, who is at Langwarrin or Frankston, to Mornington or Seaford or Rosebud or Berwick, why would that be unfair and unreasonable?---Are you talking about a permanent transfer or a transfer just for a shift?

PN8158

It could be - well, let's deal with each. A permanent transfer, say there was a need at those places for an experienced paramedic, a transfer on a permanent basis from Frankston or Langwarrin to Rosebud or Mornington, why would that be
unfair?---Because I suppose as students coming through or people waiting to qualify coming into branch stations you, I suppose, do your penance as you come through as a student, and then while you're waiting to qualify placing your name on a list for a branch station. Once you can gain a position of stability, commonly the staff depend on being able to settle into an area, buy a house, raise their children, send their kids to school, by having stability, knowing that you live and work within a similar area, and being able to travel from a reasonable timeframe from your home to your place of work.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8159

Yes. Sorry, where did you give your address as? Sorry, just generally, not specifically?---I live in Frankston.

PN8160

You live in Frankston. How far is Mornington from Frankston?---Fifteen or so kilometres.

PN8161

How far is Langwarrin from Frankston?---Probably seven kilometres.

PN8162

And you would say it is unreasonable and unfair to ask you to go to Mornington against your wishes?---I believe that that is the process currently, that people apply for stability, gain stability at a branch station, and to move elsewhere is by negotiation.

PN8163

But you can accept that its not going to make any difference to your children or your family if you so transferred, is it?---It does. Extra travel. I mean, Mornington is a smaller type of time for location, but say you said you were going to transfer me to Altona, where I was required to cross the Westgate Bridge and travel for an hour and a half to two hours each way, then I would be very concerned that if I lived in Frankston that I would have extreme costs in travelling over the Westgate Bridge and using e-tags and stuck in heavy traffic, and I would be concerned with OH&S safety of perhaps leaving for - if it's as proposed, that I had to travel from Frankston to, say Altona, perhaps taking up to two hours in the morning, home from a night shift from Altona to Frankston, and then having to return for 5 o'clock that night to Altona, that I may not be able to get an eight hour rest break in between, seeing that the travel may take two hours either way, I may only have six hours when I get from when I'm home to when I have to leave, have a shower, go to bed and have some rest, which would in no way brand me safe to be able to travel or, indeed, be fit when I returned to work in Altona. Apart from the extreme time and safety of perhaps crashing my vehicle on the way back after being up extreme hours on a night shift, perhaps even getting an overtime job at the end of a 14 hour night shift, and then being required to drive home two hours in the morning and - - -

PN8164

Well, let's leave Altona out of this?---Okay.

PN8165

What about Seaford, how far do you live from Seaford?---Probably similar to Frankston - pardon me, similar to Langwarrin perhaps.

PN8166

How far? It's about seven k's?---Approximately.

**** KEVIN WILLIAM COOPER XXN MR PARRY
PN8167

Berwick?---Probably 30 minutes or so travel perhaps, 25, 30 minutes.

PN8168

From Frankston to Berwick, it's not that far?---It depends on time of day I suppose. I haven't got the exact kilometres in my head.

PN8169

But your position on opposing any transfers applies whether it's Berwick, whether it's Altona, whether it's Prahran, wherever, doesn't it?---That's what I would say, that it's commonly thought that we had the right to negotiate, that it would be by mutual agreement.

PN8170

All right. Well, I'm in the Commission's hands.

PN8171

VICE PRESIDENT LAWLER: Is it a convenient time?

PN8172

MR PARRY: Yes, your Honour.

PN8173

VICE PRESIDENT LAWLER: Yes. We will adjourn until 10 tomorrow. I'm sorry, it's 9.30 tomorrow.

<ADJOURNED UNTIL FRIDAY 25 FEBRUARY 2005 [3.58PM]

LIST OF WITNESSES, EXHIBITS AND MFIs

JAMES ARTHUR SAMS, ON FORMER OATH PN7347
CROSS-EXAMINATION BY MS MACLEAN, CONTINUING PN7347
EXHIBIT #CC AMBULANCE HELICOPTER NON MICA AIR CREW CURRENCY CHECK DOCUMENT, JULY 2003 PN7385
RE-EXAMINATION BY MR FRIEND PN7498
THE WITNESS WITHDREW PN7504
GEOFFREY SOLOMON, SWORN PN7508
EXAMINATION-IN-CHIEF BY MR CAMPBELL PN7508
EXHIBIT #33 STATEMENT OF GEOFFREY SOLOMON PN7513
EXHIBIT #34 SECOND STATEMENT OF GEOFFREY SOLOMON PN7516
CROSS-EXAMINATION BY MS MACLEAN PN7518
EXHIBIT #DD RURAL AMBULANCE VICTORIA OP SEND OPERATIONAL READINESS PROCEDURES PN7652
RE-EXAMINATION BY MR CAMPBELL PN7655
THE WITNESS WITHDREW PN7664
KEVIN WILLIAM COOPER, SWORN PN7665
EXAMINATION-IN-CHIEF BY MR FRIEND PN7665
EXHIBIT #35 STATEMENT OF KEVIN COOPER, WITH 5 ATTACHMENTS PN7674
EXHIBIT #36 SECOND STATEMENT OF KEVIN COOPER, WITH 5 ATTACHMENTS PN7677
CROSS-EXAMINATION BY MR PARRY PN7679
EXHIBIT #EE AMBULANCE SERVICES VICTORIA AMBULANCE OFFICERS TRAINING AND CONTINUING EDUCATION PROGRAM WORKBOOKS PN7859
EXHIBIT #FF CLINICAL UPDATES PN8044