In previous posts I’ve talked about the professional responsibility of paramedics to act in their patient’s best interest, not just as a doctor’s servant – see:

Today’s question comes from:

… a qualified Paramedic (and also a Registered Nurse) currently working for a state based emergency ambulance service. My question was in regards to the legal standing of Paramedics following Doctor medication prescription, even if the management is not particularly covered in the Clinical Practice Guidelines.

Attending a transfer case from a doctor’s surgery to a hospital the other day, I found myself in the position of the Doctor requesting transport of the patient to hospital for IV antibiotics, for a diagnosed infection. This patient was otherwise well, was haemodynamically stable, and the Doctor had already commenced management by inserting a cannula, administering analgesia and IV fluids to this patient. Prior to leaving the scene, I asked the Doctor whether he had commenced antibiotics, to be told that he wished for antibiotics to be administered intravenously, and that he did not have access to any IV antibiotics at the surgery. Understanding that the patient had already been waiting for the transfer for an extended period of time (>5 hours), that the transport time to hospital was over 1 hour, and that the patient would likely be triaged to the hospital waiting room (where the wait would again, likely be well over an hour), I mentioned that we carry Ceftriaxone, which is a broad-spectrum antibiotic that we administer intravenously or by intramuscular injection in the case of Meningococcal Septicaemia or severe sepsis (by consult).

While normally our consult process involves calling the duty Ambulance Service Medical Officer, in this instance the GP on scene asked whether we could administer some of our antibiotics to the patient. The Doctor noted the prescription of the medication (including all requirements of prescription- name, DOB, indication, drug, dose, route, time etc) on his paperwork for the hospital, and the GP’s name and provider number were listed on the paperwork. I also copied this information to the ‘Doctor at Scene instructions’ section of our VACIS (electronic patient record).

Other than this management option perhaps being against ambulance service consult policy, is administration of medication (that Paramedics already carry) legally justifiable if following Doctor on scene prescription? This situation comes up from time to time when there are Doctors on scene. Can Paramedics follow medication orders if they wish to?

I will infer from the acronym VACIS for the electronic patient record that the relevant ambulance service is Victoria Ambulance. Ceftriaxone appears in Schedule 4 of the 2015 Poisons Standard. Details of its presentation, use and contraindications are set out in Ambulance Victoria’s CPG D005 (p 306). Importantly the use is contraindicated if the patient has an “Allergy to Cephalosporin antibiotics” and there is a precaution noted where the patient has an “Allergy to Penicillin antibiotics”.   The use of the drug is provided for in a number of CPGs – A0705; A0706; P0102 and P0706.

An operational staff member of Ambulance Victoria (which includes a paramedic) can carry and use ‘Those Schedule 4 poisons or Schedule 8 poisons listed in the health services permit held by that ambulance service …’ (Drugs, Poisons And Controlled Substances Regulations 2006 (Vic) r 5(10)).

It follows that, at this point, a paramedic is entitled to carry and possess Ceftriaxone but the use is dictated by the CPGs which, as my correspondent has noted, was not in the circumstances that then applied. Is that legal? The answer has to be ‘yes’ and we can find it elsewhere.

First regulation 26 sets out what must be included on a prescription for a schedule 4 drug; and without going through them I’m going to accept that ‘all requirements of prescription’ were set out in the various documents completed by the doctor. In that case the person had a ‘prescription’ for Ceftriaxone. Further a doctor may ‘order the administration’ of a schedule 4 drug, but such ‘order’ must be in writing (r 46). A person may lawfully be in possession of a scheduled drug if it has been prescribed for them or if they are caring for a person for whom the drug has been prescribed (Drugs, Poisons and Controlled Substances Regulations 2006 (Vic) r 5(5) and (7)).

Finally one can imagine many circumstances where ambulance officers are called on to transport patients who are being treated with drugs that are outside the paramedic’s scope of practice but as part of the health service they don’t ‘remove’ the IV line on the basis that they are not authorized to carry or use the drug.

What follows is that it must be lawful for the doctor to authorize the use of the drug and the paramedic to use it. What is important however is to remember that everyone has responsibilities here. It is up to the doctor to determine whether or not the patient’s condition warrants treatment with that drug (Drugs, Poisons and Controlled Substances Regulations 2006 (Vic) r 8).   It would be incumbent upon everyone to ensure that the question of known allergies has been asked. The paramedics en-route remain responsible for the patient’s care so if they observe an allergic reaction or that the IV line is misplaced they have an obligation to do something about it not just say ‘well the doctor put it in so it’s not my problem’.

In essence doctors can’t tell paramedics not to treat patients in accordance with their protocols, at least they can’t if they haven’t seen the patient and made a clinical determination (see Victorian Paramedics treating patients inside the A+E (June 12, 2015)) but that doesn’t mean that they can’t prescribe a particular treatment for the patient. This conclusion is not inconsistent with my earlier post (Doctors delegating authority to carry drugs (August 20, 2014)) where I said doctors can’t give some general authority to carry and use restricted drugs. Here we have a doctor making a clinical judgment as to the patient’s therapeutic needs and authorizing the use of the drug for that patient alone.

Of course situations vary. My correspondent asked ‘Can Paramedics follow medication orders if they wish to?’ and I think that is important. In this case the person was under the care of a medical practitioner and being transported for further, definitive care. It is axiomatic that a doctor may prescribe that sort of treatment for a person under his or her care. The situation would be different at a medical emergency or trauma where a person stepped forward and said “Step aside – I’m a doctor” (October 17, 2014) and then gave certain prescriptions. First, in that case the paramedics would have difficulty resolving that the person was a doctor and that they had sufficient knowledge and expertise. As a stranger to the patient they are unlikely to be able to make an better diagnosis than the paramedics and will have no ongoing responsibility for the person. They could not give the sort of details, in writing, that were described here. Doing what the doctor at the scene suggests may well conflict with other guidelines and may not be appropriate during transport that is during the part of the process that paramedics are experts in. At that point there can’t be an ‘obligation’ to follow those orders or suggestions.

Equally even if transporting the person from one health care facility to another the doctor’s ‘orders’ may not be compatible with the safe transport or be impossible – eg if the drug requires some sort of constant specialist monitoring or administration along the way, the paramedics may well say ‘we can’t do that’.

In this story the line was in, the drug was a drug the paramedic was used to and its use was not obviously inconsistent with their training. Presumably any issues that might arise would also be within their training as it would be if they were using the drug in accordance with their CPGs.   I can’t see how, in this case, there could be any issue.

As is so often the case, the issue will be ‘is the use of the drug reasonable and in the patient’s best interests?’