An emergency medicine specialist and author who chronicles medical errors agreed in cross-examination with the Crown that two former Hamilton paramedics made a “wrong decision” the night that Yosif Al-Hasnawi died of a gunshot wound in 2017.
The evidence portion in the trial of Christopher Marchant and Steve Snively, accused of failing to provide the necessities of life, ended on Tuesday with more testimony from Dr. Pat Croskerry, author of over 80 journal articles and 30 book chapters on patient safety and clinical decision making.
Circling back to testimony from the physician on Monday, the Crown’s Linda Shin suggested that the problems on the night of Dec. 2, 2017, started with a form of “anchoring bias,” and paramedics relying too heavily on the assumption the victim was shot by a pellet gun which “cascaded” into other mistakes.
“We know that the decision that was made was wrong because we know what Yosif died from,” Croskerry agreed.
Al-Hasnawi was shot outside a Hamilton mosque near Main and Sanford streets in 2017. Believing Al-Hasnawi had been shot by a pellet gun and was suffering from psychiatric issues, the victim was transported to St. Joe’s hospital. It was later discovered he died from a .22 calibre gunshot wound.
Although he agreed the assessment was wrong, Croskerry was reluctant to characterize it as a “mistake,” saying that description is the result of “outcome bias” — judging a past decision by an outcome rather than the quality of the decision made at the time.
“As soon as you know the outcome, you’re always faced with this problem of attributing blame or fault or describing it as a mistake, partly because it turned out bad,” Croskerry said.
In testimony on Monday, Croskerry said the paramedics made a fundamental attribution error — assuming the patient is responsible for what they’re doing — when Al-Hasnawi’s behaviour became “combative” due to lack of oxygen to his brain.
Croskerry said attempts by the paramedics and Hamilton police Sgt. Nesreen Shawihat to reassure Al-Hasnawi in the back of the ambulance was an example of attribution error by assuming he could consciously stop his behaviour when he was likely suffering from hypovolemic shock.
“But of course, they didn’t know those circumstances behind his behaviour and they were interpreting his behaviour as though he was responsible for it,” Croskerry said.
Shin suggested the error also likely had an effect on the 17 minutes the paramedics spent in the back of the ambulance before transporting Al-Hasnawi to a hospital, which the Crown submits was excessive.
Croskerry acknowledged the time spent in the ambulance could be connected to the error but said he was “not sure of that,” proposing that attaching a 12-lead electrocardiogram (ECG) monitor and checking blood sugar levels was “not aimless” in relation to patient management.
“Sometimes, those sorts of more extended assessments can be very beneficial. For example, if you found that his blood sugar was bourn very low, you could immediately fix it,” Croskerry said.
Suspicion of penetration
On Monday, Croskerry believed the paramedic’s observation of Al-Hasanwi’s wound — characterized by a number of witnesses in the trial as small — likely didn’t contradict the theory he had been shot by a pellet gun.
In cross-examination on Tuesday, Crown counsel Linda Shin asked the physician if a medical professional should consider the possibility of internal bleeding in a patient who’s become “altered” with a high heart rate and a small penetrating injury to the torso.
Croskerry replied, “not necessarily,” and said with the mechanism of injury being trivial, “suspicion of penetration” would be “very, very low.”
“If you’re in a context where you don’t think you’re dealing with a mechanism of injury that can cause penetration, then you’re less likely to be suspicious about it,” Crosskerry said.
Dispatch information often tenuous and inaccurate
Earlier in the trial, dispatcher Janice Mcmeeken told the court the paramedics were given a priority call by another staffer at the base hospital describing a male with “superficial wounds” to his abdominal area after being shot with a BB gun.
On the way to Aikman and Sanford Avenue South in 2017, Marchant radioed the call centre to ask why their dispatch was prioritized as a “code four” emergency if the victim’s injury was “superficial.”
In the follow-up call, Mcmeekin told Marchant it was a “penetrating wound” that justified a high priority code.
Despite “inconsistent information” from dispatchers, Shin asked Croskerry if he thought the nature of the call pointed to a more serious situation paramedics should have considered.
The physician said it’s a safe practice to always “overestimate” the seriousness of such a call but also said he didn’t hear information that justified a significant injury.
The Crown countered with the suggestion that dispatch information is often tenuous and inaccurate, a possibility acknowledged by Marchant and Snively in trial evidence.
Croskerry agreed, suggesting there are all kinds of scenarios where “alarm bells go off, ” and are turned off later. However, he said the “slightly incongruous” call appeared not to be a fit for Marchant.
“From the outset, as soon as you were told that this is a BB gun injury, then you may not take the ‘code four’ status as seriously as you would if they just left it as a gunshot wound to the abdomen,” Croskerry said.
The trial is expected to resume on March 10 when both the Crown and the paramedics’ counsel make final submissions to the court
Justice Harrison Arrell is expected to make a ruling following the submissions.