An expert on pre-hospital and emergency medicine took to the stand for the third day in a row in the trial of two former Hamilton paramedics on Wednesday, accused of failing to provide the necessaries of life after the 2017 shooting of Yosif Al-Hasnawi in Central Hamilton.
On Day 20, the defence attorney’s line of questioning was aimed at a June 2018 report submitted by Dr. Pieter Verbeek, a medical director from Sunnybrook hospital who is a contributor to the province’s primary care program for paramedics.
Steve Snively of Hamilton and Christopher Marchant of Whitby are the paramedics charged in connection with the death of Al-Hasnawi following a Niagara police criminal investigation in January 2018.
The pair’s charges stem from an incident outside a Hamilton mosque near Main and Sanford streets in which the 19-year-old was shot by a .22-calibre handgun instead of a pellet gun, originally reported by the paramedics on the night of Dec. 2, 2017.
During a line of questioning from the Crown on Tuesday, Verbeek suggested that Al-Hasnawi was a potential “load-and-go” case since any patient with an abdominal or pelvic injury, whether it’s blunt or penetrating, can qualify under the general care standards (GCS) for paramedic treatment.
Referring to Verbeek’s report, defence counsel for Marchant Jeffrey Manishen argued the criteria for the load-and-go scenario wasn’t actually met since there was no evidence that a proper abdominal exam was carried out at the scene.
Referring to Verbeek’s report, Manishen said that left respiratory distress as the only potential criteria for an expedited trip to hospital.
“That’s the way I’ve written it. Yes,” Verbeek replied.
Hamilton police records documented it took 38 minutes for Al-Hasnawi to reach the trauma centre at St. Joseph’s hospital. Verbeek’s report calculated an on-scene time of 23 minutes for the paramedics before transporting the victim.
Verbeek suggested that was 13 minutes too long.
However, both Manishen and Snively’s counsel, Michael Del Gobbo, argued that 23 minutes was a reasonable amount of time to spend on scene for a trauma injury based on the doctor’s own analysis of 46 North American EMS agencies that suggest a median time of 19 minutes for penetrating injuries.
“The range may be up to 23 minutes, it would mean that ten minutes would be better, but in terms of North American wide standards that would be within what we might expect.’ Verbeek said.
Reciting basic care guidelines, Manishen pointed out that, if a patient appears stable, a paramedic has the option to perform a further assessment at the scene before transporting the patient to hospital.
Verbeek agreed that is true, but said the important aspect of the point is the patient “must be stable.”
‘No obvious distress’
During testimony on Tuesday, the physician characterized entries from Snively’s incident reports as “contradictory” when the paramedic said Al-Hasnawi had “no obvious distress” yet observed him to be “unco-operative and extremely combative.”
In an attempt to “resolve the contradiction”, Manishen suggested to Verbeek that Snively’s comments may have indicated that the patient was not in any physical or emotional distress.
However, Verbeek insisted that any patient exhibiting combativeness is in distress.
“A patient that is is agitated and aggressive is not a patient who is in no obvious distress. It’s quite the contrary,” Verbeek said
Manishen went onto suggest that a paramedic might explore different pathways to try and find other causes for what the patient’s medical problem may be through a process called “differential diagnosis.”
However, Verbeek said making a differential diagnosis is not something expected of a paramedic in the field.
“So they can’t work that way. The way that they have to work is at the level of presenting problems, such as shortness of breath,” Verbeek said.
“That’s not a diagnosis. That’s a presenting problem or a symptom.”
Verbeek told the court 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” by paramedics.
On Wednesday, Manishen argued that perhaps Al-Hasnawi’s answers to questions from the group around him would make sense to only be three or five words.
“Yes, but they would do that not complaining of feeling shortness of breath.,” Verbeek responded citing witnesses who recalled Al-Hasnawi saying he couldn’t breathe after the shooting.
‘Discretion to transport’
Verbeek’s said attempts made to lift Al-Hasnawi, seen on surveillance video, were not recommended according to care standards considering the nature of his wound and the potential for a drop in blood pressure.
Manishen then asked the doctor if recalled telling the court that earlier that having family present during the incident was “not an easy situation” for paramedics to manage.
The defence also targeted a statement in Verbeek’s report where he says the standard of care requires patients to be carried to a stretcher and not walked but admitted this scenario could be “challenging” for paramedics to follow in certain situations.
Manishen also pointed to a documented change in policy that was set to take effect nine days after Al-Hasnawi’s shooting which would allow paramedics to use their “discretion to transport” patients to the ambulance.
He asked Verbeek whether the paramedics potentially were already aware of the new operating standard since it’s their responsibility to “get familiar” with the protocol.
“Yes, that’s right,” Verbeek responded.
Verbeek also suggested during Al-Hasnawi’s encounter with paramedics the patient appeared to suffer “decompensated shock” – when the body’s compensatory mechanisms are unable to maintain adequate passage of blood to vital organs.
Referring to Verbeek’s report on the incident, Manishen pointed out that shock was never mentioned in his report.
“If we don’t see the word shock, in the report, the reasonable conclusion is it’s it didn’t come to your mind as a factor in this case whether it was a load and go or other. Would that be a fair statement?
The doctor disagreed, saying the issue of shock was “unequivocal” in this case.
“I do bring up the point of clinical deterioration compatible with progressive cerebral and cardiac ischemia, which is from shock,” Verbeek said.
“I have may not have mentioned the word at that point, but that’s inherent in what it causes.”
The trial is now on hold for the Christmas holiday and is expected to return on Jan 11, 2021.