A physician who has contributed to the general care standards (GCS) that direct the actions of Hamilton paramedics characterized the 2017 shooting of 19-year-old Yosif Al-Hasnawi as a potential “load-and-go” case.
Over a two-day period, Sunnybrook Hospital’s Dr. Pieter Verbeek was asked by Crown counsel for his opinions on how the two accused primary care paramedics, Christopher Marchant and Steve Snively, handled the suspected shooting victim.
The trial for the two former paramedics charged with failing to provide the necessaries of life is now 19 days old.
Steve Snively of Hamilton and Christopher Marchant of Whitby were charged in connection with the death of Al-Hasnawi following a Niagara police criminal investigation in January 2018.
Al-Hasnawi was shot outside a Hamilton mosque near Main Street East and Sanford Avenue in December 2017. Witnesses claim the paramedics told Al-Hasnawi he’d been shot by a pellet gun and that he should stop faking his injury.
The police investigation also alleged the pair took too long to take the victim to hospital, and transported him to a non-lead trauma centre.
On Tuesday, Verbeek suggested any patient with an abdominal or pelvic injury, whether it’s blunt or penetrating, can qualify under the GCS to be a “load-and-go” hospital case despite not displaying unusual vital signs.
“So proper application of the field trauma triage standard, understanding that the patient did have a penetrating wound to the abdomen,” he said.
“This patient qualified to be transported to the trauma center, that being Hamilton General.”
Verbeek later told the Crown a sound principle when caring for a patient in the field is to always assume the “worst-case scenario.”
“That’s generally meant to provide, I would say, the safest approach or the safest way to take care of a patient,” he said.
Verbeek went on to say anyone encountering a victim with a penetrating injury to the chest or abdomen should maintain a “high index of suspicion.”
“So there’s a lot of vital structures, as one might imagine, in the chest and abdomen and with a penetrating injury, which by definition is an injury that you can’t see to the bottom of their penetrating injury,” Verbeek said.
“You don’t know how deep it is. You don’t know what direction it went.”
During much of his time on the stand, Verbeek educated the court on general care practices and how paramedics typically start medical calls.
In the case of an “undifferentiated” diagnosis call, where the problem is not immediately clear, the crew will begin an initial assessment stage around the “ABCD” model for patient care – A for airway, B for breathing, C for circulation and D for disability.
Paramedics are then expected to apply measures to correct any disruptions, then determine the need for rapid transport.
As a Crown witness, Verbeek was asked by counsel Linda Shin to comment on Al-Hasnawi’s case as a field expert.
‘The important information is not the BB gun or the pellet gun’
On Day 6 of the trial, the emergency physician on duty at St. Joseph’s Hospital, Dr. Andrew Healey, told the court that the description “pellet gun” wound when he was preparing for Al- Hasnawi’s arrival on Dec. 2, 2017 provided “no useful information.”
On Tuesday, Verbeek concurred with that statement, telling the Crown that it would be “extraordinarily difficult” for anyone to “know for certain” what the nature of the weapon was.
He also said patient care guidelines don’t define what causes a penetrating injury due to the fact the information would likely be unreliable.
“So for paramedics, the important information is not the BB gun or the pellet gun. The important information is this was a penetrating injury to the abdomen because the patient care standards provide information and guidance to them as to how to manage this kind of case,” Verbeek said.
‘That is not a patient who is in no obvious distress’
In Snively’s incident report, he marked down that there was “no obvious distress” when the paramedics encountered Al-Hasnawi at Main Street E. and Sanford Avenue in 2017. Shin asked Verbeek to elaborate on the term and what a primary care unit could expect from such a patient.
Verbeek called usage of the term “contradictory” considering a follow-up sentence described the patient as “unco-operative and extremely combative.”
“That is not a patient who is in no obvious distress or no immediate distress,” Verbeek said.
The doctor went on to say that reports of the victim speaking only three to four words at a time was a sign of respiratory distress and should have been considered a “critical finding.”
Surveillance video of the scene was shown to Verbeek who said it appeared the working zone was managed fairly efficiently.
However, he did see attempts to lift Al-Hasnawi a couple of times, once by his arms, which he suggested was not how he should have been moved considering his injury and the potential for a drop in blood pressure.
“The way to move this patient is to do a log roll of sorts,” Verbeek said.
“Roll them on a backboard or use a stretcher, which actually can be applied to the patient without having to do a lot of work.”
‘Firefighters on a call like this should not be dismissed’
On Day 16 of the trial, Hamilton firefighter Grant McQueen told the Crown he and his crew were dismissed after just a few minutes at the scene where Al-Hasnawi was shot.
He remembered the paramedics telling them they could leave.
“So they said, ‘You’re good, you can go,’” McQueen said. “And that’s why I started picking up our equipment to leave.”
Verbeek told the court on Tuesday that keeping the firefighters on scene would have been “helpful.”
“Typically firefighters on a call like this should not be dismissed from the case until the paramedics have actually assessed the patient,” the physician said.
Verbeek said firefighters are normally expected to remain on scene when paramedics care for critical patients like Al-Hasnawi.
“It’s typical for them to take a firefighter with them to help manage the patient and whether that would be to secure the patient safely, to get further information,” Verbeek said.
“Even firefighters, they’re trained in some medical procedures (like) attaching oxygen, so they can be quite a helpful person in the back of the ambulance on the way to the hospital to increase the efficiency of getting the patient to that destination.”
‘Falling off the cliff’
In a three-and-a-half-minute span during Al-Hasnawi’s ride to St. Joe’s on Dec. 2, the patient’s racing heart rate began to drop significantly over a short period of time.
Verbeek said the medical term for the condition is “decompensated shock” – when the body’s compensatory mechanisms are unable to maintain adequate passage of blood to vital organs.
The physician said the drop was large enough that the paramedic should have been able to detect it and report to the emergency physician receiving the patient.
“We call this ‘falling off the cliff’… the patient in shock,” Verbeek said.
The doctor told the court such a decrease likely meant the patient had just minutes to live.
Day 20 of the trial will resume on Wednesday.
Hamilton lawyer Jeffrey Manishen is representing Marchant and St. Catharines lawyer Michael DelGobbo is representing Snively.
The trial is expected to take a break after Wednesday for the Christmas holiday and return in January.