A physician who edited the standards of care that Hamilton paramedics must follow says there were multiple signs that shooting victim Yosif Al-Hasnawi should have been transported to a lead trauma hospital as soon as possible.
But that didn’t happen. In fact, the two former paramedics, who are now charged in connection with Al-Hasnawi’s death, took 23 minutes to leave for St. Joseph’s hospital on Dec. 2, 2017.
Dr. Richard Verbeek, medical director for Toronto paramedics at the Sunnybrook Centre for Prehospital Medicine, continued testifying on Tuesday at the trial of the two former paramedics. He is the latest and possibly last Crown witness in the landmark case, where first responders are criminally charged for their treatment of a patient.
Christopher Marchant, 32, and Steven Snively, 55, are accused of failing to provide the necessaries of life for Al-Hasnawi, who was shot with a hollow-point bullet from a .22-calibre handgun outside his mosque, near Main Street and Sanford Avenue, just east of the city’s downtown, at 8:55 p.m. that night.
Paramedics and others at the scene thought he had been shot with a BB gun or pellet gun, the court has heard. The 19-year-old was pronounced dead at 9:58 p.m.
Paramedics should have seen signs of shock, doctor says
Using reports written by Marchant, Verbeek pointed out “critical findings” of Al-Hasnawi’s dangerous condition, which he said paramedics are trained to recognize.
Of utmost importance was that Al-Hasnawi was speaking in clipped sentences, saying he couldn’t breathe. Verbeek compared it to running a race and only being able to get a few words out at a time.
“Understanding the significance of a patient saying they can’t breathe is core to the whole approach of 911 patients,” he told the judge-alone trial in the Ontario Superior Court of Justice.
Verbeek also called statements in reports written by Marchant “contradictory.”
The paramedic wrote in two reports that Al-Hasnawi didn’t appear to be in “obvious” or “immediate distress,” but he also said that the victim was “unco-operative” and “aggressive.”
An altered level of consciousness with shortness of breath and a penetrating abdominal injury, Verbeek said, showed Al-Hasnawi could have been in shock.
Verbeek testified that he would have assumed that the teen was in “severe distress,” even without knowing the cause.
The paramedics should have thought “this patient is severely injured and we have to go forward using a load-and-go protocol,” he said.
There isn’t documentation that a full abdominal exam was conducted, Verbeek said. But if the abdomen was tender and distended, that also would have been grounds to leave for the hospital immediately — even if it meant completing procedures en route.
The paramedics conducted two tests in the ambulance as it idled in the area — glucometry to measure Al-Hasnawi’s blood sugar and a 12-lead electrocardiogram, which Verbeek said, in his opinion, wasn’t needed.
The paramedics shouldn’t have waited, he testified.
Verbeek, who edited the Basic Life Support Patient Care Standards used by Ontario’s Ministry of Health, told the court on Monday that the standards are written specifically to discourage paramedics from making assumptions about weapons.
Paramedics are trained to assume the worst on every call, he said.
“What I say to trainees is you start with saying to yourself, ‘What could kill this patient?'” Verbeek told the court.
‘The patient’s falling off the cliff’
When the ambulance finally did leave, the paramedics didn’t take Al-Hasnawi to the appropriate hospital, Verbeek said.
According to the triage standard, he said, Al-Hasnawi should have been brought straight to Hamilton General Hospital because of his penetrating wound.
Even if a gunshot victim had no vital signs and was two blocks away from St. Joseph’s, Verbeek said, they must be taken to the lead trauma hospital for the expertise, which provides the best chance of surviving.
“There’s a possibility. It may not be high, but it’s not zero,” he said.
Paramedics reported the incident to dispatchers as a psychiatric emergency and requested St. Joseph’s. Verbeek said he couldn’t think of “anything that would take precedence” over Al-Hasnawi’s gunshot wound, since it was more immediately dangerous.
But the standard also allows for paramedics to change their destination if the patient’s condition deteriorates along the way, which Verbeek said they should have done.
Al-Hasnawi’s heart rate quickly plummeted from 143 to 45 during transport, which is “exactly what happens” when you have decompensated shock and the body shuts down, Verbeek said.
It’s documented that the only type of conscious reaction Al-Hasnawi was showing at this point was a withdrawal to pain.
“The patient’s falling off the cliff,” Verbeek said of his condition.
That deterioration was too fast for a drug overdose and didn’t match a panic attack, he said. There was “nothing” in this case that would cause such a drop in heart rate, Verbeek said, other than his body not being able to keep up any longer.
If the paramedics at some point had changed their mind and started to think it was a trauma problem — not an emergency psychiatric situation — then the option was to “divert from going to St. Joe’s,” he said.
Firefighters would have helped
Verbeek said the paramedics also made a mistake in releasing a crucial resource from the scene: the firefighters.
All three Hamilton firefighters who attended the call have testified that they were stopped by a police officer from approaching Al-Hasnawi and were later told by a paramedic, “We’re good.”
Verbeek said if Al-Hasnawi was as combative and aggressive as described by the paramedics in their reports, a firefighter would have been helpful in the back of the ambulance. Their assistance also would have gotten the teenager to the hospital faster.
The court has seen video of first responders and bystanders at the scene, which Verbeek called “uncontrolled” because of the people milling about. When police gestured to them to back up, he said the situation appeared calm.
The footage shows a police officer and a paramedic attempting to lift Al-Hasnawi off the ground by grabbing his arms.
“Lifting a patient like this is honestly the last thing you should do in terms of how you would move them,” Verbeek said.
According to the standard, Verbeek said the paramedics should have used a log-roll technique so Al-Hasnawi’s body wouldn’t twist. This allows the paramedic to put a backboard behind the patient before rolling their body back and lifting as safely as possible.
Paramedics should have been the ones to move Al-Hasnawi, and they should have recognized that what was happening was unsafe, he said. Al-Hasnawi’s younger brother, Mahdi, also stepped in to lift the teen off the ground, which Verbeek said wouldn’t have been an easy situation for paramedics.
When Al-Hasnawi’s vitals were taken in the ambulance, he was disoriented and had a high heart rate of 143, which Verbeek said meant he was already likely into Stage 4 hypovolemic shock.
“You’re bordering on total body, physiological collapse,” he said.
The paramedics also assigned Al-Hasnawi an incorrect level on the triage scale, which is used to communicate a patient’s priority to the emergency department so that it can get prepared.
All of Al-Hasnawi’s signs and symptoms should have been taken into account together for the highest urgency, a triage level one, Verbeek said.
Paramedics are trained “not to cherry pick,” he said. “We are trained to put everything together to form a picture that makes sense and go forward on that basis.”
The paramedics reported that Al-Hasnawi’s vital signs were lost when he was passed to the emergency department. Verbeek said it was possible that he “slipped” into that state during the ambulance ride, and the paramedic was too busy to notice and the patient was quiet.
You could not function as a trained paramedic without understanding the nature of shock, Verbeek said.
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 2021.
Hamilton lawyer Jeffrey Manishen is representing Marchant and Michael DelGobbo of St. Catharines, Ont., is acting for Snively. The prosecutors on the case are Linda Shin and Scott Patterson.