Today’s question is:

…  a query relating to the legalities of operating on a poison permit in QLD.

I am currently a Registered Paramedic working in the QLD resource sector… Naturally in the remote and isolated environment that we work there is a significant distance for additional ALS resources to respond if required.

My question relates to cardiac arrest management. All training I have undertaken in regards to ALS arrest management includes the use of IV Amiodarone administration for refractory VT/VF.

However on my employers poison permit only P4 or Critical Care Paramedics are authorised to administer. As we have no CCP personnel on site or near the area I work in I was wondering why we have them available in our drug bags.

So I have asked my Medical Director the following.

– what would the consequence be for a paramedic (P3) to use Amiodarone when indicated according to best practice, acknowledging that a P3 Paramedic is not authorised according to the permit?

– what would the consequence be for a paramedic who chooses not to use the medication when indicated in the same scenario?

– Could a P3 Paramedic request authorisation via the Medical Director for administration if clinically indicated?

My medical director replied and simply stated that the answer is no because it’s illegal.

I’m wondering if you could elaborate on this? I am curious to see for example in a coroners enquiry, if the Paramedic had the medication, was able to administer & knows it may have an impact on patient outcome, chooses not to administer. Would he/she be liable.

I know of no coronial inquiry where these issues have arisen.  Coroners do not investigate most deaths and this sort of matter is unlikely to attract a coroner’s attention.  We can however look at the law.

According to the Poisons Standard (June 2019) Amiodarone is a schedule 4 drug.  In Queensland the relevant law is contained in the Health (Drugs and Poisons) Regulation 1996 (Qld).   Amiodarone is a ‘restricted drug’ (ie a schedule 4 drug) that can be used by a ‘paramedic 4’ employed by Queensland Ambulance (Health (Drugs and Poisons) Regulation 1996 (Qld) Appendix 2A and Appendix 9, definition of ‘ambulance officer’).

If an employer has an endorsement to allow them and their staff to possess, supply and administer a schedule 4 drug and the terms of that endorsement do not include a person with qualifications below ‘P4 or Critical Care Paramedics’ then the ‘other’ paramedic who administers the drug is someone who is not endorsed.

A person must not possess, obtain, dispense, issue, prescribe, purport to prescribe, sell or administer a restricted drug without an appropriate endorsement (Health (Drugs and Poisons) Regulation 1996 (Qld) r 146).  The maximum penalty in each case is 60 penalty units. (A penalty unit is currently $133.45 so the maximum fine is $8007.00).   An endorsement is not required to deliver a drug to a person for whom the drug has been prescribed or to assist a person to take a drug that has been prescribed for them (Health (Drugs and Poisons) Regulation 1996 (Qld) r 183).

That does indeed beg the question of ‘why we have them available in our drug bags’?  If my correspondent is in control of the drug bag but does not have an endorsement to be in possession of amiodarone then he or she commits an offence by being in possession of that drug.

In terms of the other questions the consequence of using the medication is that prima facie the paramedic commits an offence.  That does not mean that he or she would be charged or that a defence of necessity would not prevail where the illegal conduct (supply and administer the drug) was proportional to the risk to the patient and reasonable in the circumstances.  It may be illegal to possess a handgun but that doesn’t make it illegal to use it in self-defence.  But the starting point is that it is an offence to supply and administer amiodarone without an endorsement.

There could be an argument that a paramedic that did not use the drug when indicated and according to best practice could be guilty of ‘unsatisfactory professional performance’ that is ‘the knowledge, skill or judgment possessed, or care exercised by, the practitioner in the practice of the health profession in which the practitioner is registered is below the standard reasonably expected of a health practitioner of an equivalent level of training or experience’.  It would be very hard however to sustain an argument that the ‘standard reasonably expected’ including using drugs that the paramedic is not endorsed to use and where to do so would be an offence. Committing an offence is itself evidence of ‘unprofessional conduct’ and one can’t have it both ways – it cannot be both ‘unsatisfactory professional performance’ to not commit an offence and ‘unprofessional conduct’ to commit the same offence.  It follows that I don’t think there would be any consequences for a paramedic who chose not to use the medication in the scenario described but there may well be a defence if they did so choose – see also A duty to break the law? (July 25, 2019).

As for the medical director ‘A prescriber may give a dispenser an oral prescription for a restricted drug the prescriber is endorsed to prescribe’ (Health (Drugs and Poisons) Regulation 1996 (Qld) r 192(1)) but a paramedic is not authorised to dispense the drug nor is he or she authorised to be in possession of the drug.  It follows that the Medical Director cannot authorise the administration.  A doctor cannot override the law, the law says a person must not administer a restricted drug without endorsement.  See also Doctors delegating authority to carry drugs (August 20, 2014).

Conclusion

The medical director is right, it is illegal for a person to possess, obtain, dispense, issue, prescribe, purport to prescribe, sell or administer amiodarone without an endorsement issued under the Health (Drugs and Poisons) Regulation 1996 (Qld) Chapter 3, Part 2.