Paramedics should have treated Al-Hasnawi's gunshot wound as primary problem, doctor says
Ontario Superior Court trial adjourned until Jan. 11, 2021
The defence of one of the paramedics accused of not properly caring for a dying patient in Hamilton says he's "not disputing it was a mistake" when the ambulance went to St. Joseph's Hospital.
Jeffrey Manishen said it appeared the former Hamilton paramedics in the landmark trial — Christopher Marchant, 32, and Steven Snively, 55 — thought the primary problem for gunshot victim Yosif Al-Hasnawi was a psychiatric emergency.
That's what they reported to the dispatcher on Dec. 2, 2017 with a request to go to St. Joseph's Hospital, which would've been appropriate for that kind of issue, he said.
Paramedics and others at the scene thought the teenager had been shot with a BB gun or pellet gun, the court has heard in the judge-alone trial in the Ontario Superior Court of Justice.
But Al-Hasnawi was shot with a hollow-point bullet from a .22-caliber handgun near Main Street and Sanford Avenue at 8:55 p.m. He was pronounced dead about one hour later.
The former paramedics are charged with failing to provide the necessaries of life for the 19-year-old.
Dr. Richard Verbeek, a medical director for Toronto paramedics at the Sunnybrook Centre for Prehospital Medicine, testified for three straight days.
He is the last witness for the Crown, and court will be adjourned until Jan. 11, 2021, when the defence is expected to present its evidence.
Verbeek said if the paramedics thought a psychiatric emergency was Al-Hasnawi's top problem, it would be a "wrong conclusion."
But saying that to a dispatcher, Verbeek said, triggers a destination algorithm. That's how you get to go to St. Joseph's, he said, because a dispatcher would "never" authorize it otherwise.
Manishen started his cross-examination on Wednesday morning by saying that paramedics can make mistakes.
The doctor replied, "We can all make mistakes."
Verbeek said on Tuesday that the ambulance should have gone to the lead trauma hospital — Hamilton General Hospital — as soon as possible for its expertise and the teen's better chances of survival.
But it didn't. The paramedics were on scene for 23 minutes and went to St. Joseph's Hospital instead. That didn't follow the field trauma triage guidelines for a penetrating abdominal wound, Verbeek said.
In terms of North American-wide standards, he said that 23 minutes would be "within what we might expect given average circumstances at a trauma scene" for blunt and penetrating wounds as a combined category.
Manishen said the primary problem identified by paramedics informed their decisions that night, such as how they moved Al-Hasnawi to the ambulance and even the hospital they picked.
According to the Basic Life Support Patient Care Standards used by Ontario's Ministry of Health at the time, Verbeek said, medical and trauma patients were required to be lifted or carried, including someone with a psychiatric emergency.
The court has seen footage of the scene showing a police officer and paramedic pulling Al-Hasnawi's arms to bring him to his feet. After the pair struggle, Al-Hasnawi's younger brother picks him up, and with the help of others, lift him out of the camera's view toward the stretcher.
Manishen pointed out that the standard changed just over a week later, which gave paramedics some discretion in the matter. He asked if paramedics would have to become familiar with a standard before it came into force, and Verbeek said, yes.
He also suggested that "human nature" would cause someone to believe others on scene, who in this case said that Al-Hasnawi had been shot with a BB gun or pellet gun.
Verbeek, the physician who edited the standards of care Hamilton paramedics must follow, said paramedics aren't trained that way.
According to the standard, Verbeek said, paramedics aren't expected to make a diagnosis nor do they have to determine what weapon caused a wound to guide their next steps.
They need to treat presenting problems, prioritize them, and evaluate using "all available sources" and "all available senses."
"We can't wait to make decisions based on certainty. We have to make decisions on likelihood, probability and taking... a cautionary approach," he said.
Once a paramedic saw it was a penetrating injury, he said, information on whether it was even a "play gun" would become less important from a medical perspective.
Call to hospital didn't focus on psychiatric emergency, doc says
Verbeek also said physicians rely on paramedics to be their eyes and ears. Patch calls from the ambulance to the hospital are supposed to convey the primary information so the emergency department can prepare.
But the call from the ambulance to St. Joseph's, Verbeek pointed out, didn't outright say Al-Hasnawi was having a psychiatric emergency.
The paramedic said Al-Hasnawi was "shot in the abdomen with a pellet gun," and had a "small, penetrating wound to his lower abdomen that was controlled."
The paramedic also said the reason for an urgent score, which they put at CTAS 2 — though Verbeek said it should have been higher at CTAS 1 — was that Al-Hasnawi was "extremely altered," confused, and had a high heart rate at 145.
Being extremely altered meets a psychiatric emergency, but it's the "whole picture" that matters, Verbeek said.
"The picture that is painted here to me is fairly clear," he said of Al-Hasnawi's bullet wound being the primary problem.
Trial resumes January 2021
Also of question during the trial is whether paramedics brought equipment to Al-Hasnawi's side. In a note to the Crown that was read in court, Verbeek said they don't always have to do so, especially in a public settings where the patient can be moved into the ambulance in a very short time span.
The trial, expected to last five weeks, began on Nov. 24 in Hamilton before Justice Harrison Arrell. It will break for the holidays and continue in January 2021.
Hamilton lawyer Jeffrey Manishen is representing Marchant and Michael DelGobbo of St. Catharines, Ont., is representing Snively. The prosecutors on the case are Linda Shin and Scott Patterson.