Today’s question relates to
… Paramedics in NSW [who] are often required to do inter-hospital transfers of patient with intravenous medications from the emergency department ongoing. Many or most of these medications (and the equipment used to infuse these medications) are not in the scope of practice of paramedics in our ambulance service…
My questions are this: what is the medico-legal risk to paramedics if harms come to a patient with one of these infusions in situ? Given that we are not formally trained in any of these medicines … can we get into trouble if something goes wrong during the transfer? Also, is it true that we can take over any medications started in the ED? Does this extend to medical equipment such as ventilators and other machines we are not trained in as well?
I recently transferred a paediatric patient and they asked me to start an infusion during the transfer of a drug that has the potential for serious adverse events. I had no training in this medicine, and I don’t have training in most of the drugs they ask us to infuse during transfer. I felt uncomfortable with this and said so. But if I felt okay with doing this, despite not really knowing this drug well and something went wrong, will the coroner hold me culpable?
Let me again remind people that the coroner cannot hold anyone ‘culpable’. Coroners cannot determine guilt or innocence of a crime; they cannot determine whether there has been negligence or not; they cannot sentence anyone or award compensation. They can make recommendations which, in the context of the question, may be directed to NSW Ambulance or NSW Health with respect to training or the like. I will not address the question ‘will the coroner hold me culpable?’ further.
It’s true that one needs authority to possess, administer or supply a scheduled drug (The last word on scheduled drugs? (September 29, 2019)). Paramedics employed by NSW Ambulance can possess, supply and administer those schedule 2, 3, 4 and 8 drugs that they are approved to carry by the Director General (Poisons and Therapeutic Goods Regulation 2008 (NSW) r 101 (with respect to schedule 8) and Appendix C, cl 7 with respect to schedule 2, 3 and 4 drugs). What we are told however is that the drugs that are in situ or that the paramedic is asked to start are not the normal drugs provided for by NSW Ambulance and we can infer therefore that those clauses don’t apply.
So where is the authority? It’s found in the various provisions of the Poisons and Therapeutic Goods Act 1966 (NSW). For example s 16 provides that a person must not
… have in his or her possession or attempt to obtain possession of a prescribed restricted substance [ie sch 4] unless:
(d1) the person is a person who has the care of, or is assisting in the care of, another person (for or to whom the supply of the substance has been authorised by the prescription of a medical practitioner, nurse practitioner, midwife practitioner, optometrist, podiatrist or dentist) and has the prescribed restricted substance in his or her possession for the sole purpose of administering, or assisting in the self-administration of, the substance to the other person in accordance with that prescription…
Section 23 says:
Despite any other provision of or made under this or any other Act, a person who has the care of, or is assisting in the care of, another person (for or to whom the supply of a drug of addiction [sch 8] has been authorised by the prescription of a medical practitioner, nurse practitioner, midwife practitioner or dentist) is not guilty of an offence in relation to the possession or supply of the drug if the person is in possession of the drug for the sole purpose of administering, or assisting in the self-administration of, the drug to the other person and does so in accordance with that prescription.
If I can get somewhat personal here, I like most people have had family members undergo treatment for cancer. Some of that treatment has been palliative care only. I have been in possession of and administered drugs that I have no qualifications in and in some cases have no idea what the drugs did. But I did not commit any offence as the drugs were prescribed for those persons and I administered them in accordance with the (verbal) instructions I received from their doctor or nurse.
If paramedics collect a patient and there are ‘infusions in situ’ it is not the paramedics decision as to what drugs are being administered or the route used. Those drugs are prescribed for the patient and to the extent that the paramedic is in possession of the drugs (they are in the ambulance that he or she is in control of) there is no offence.
If a paramedic is asked to start a drug en route there are differences if the patient is being accompanied by a nurse or doctor and they are asking the paramedic to assist versus the paramedic is given the drug and asked to use it en route in particular circumstances such that the paramedic will need to make the call as to whether those circumstances have arisen. In either case the fact that the drug is not within the paramedic’s scope of practice is irrelevant as they are administering a drug that has been prescribed for that patient. The latter case may, however, call from some clinical judgement.
The rule is that you are only responsible for the decisions you make and the actions you take (or don’t take). The decision to infuse the patient prior to transport is not made by the paramedic so he or she cannot be responsible for that decision. He or she can be responsible for the decisions he or she takes en route, so if the patient suffers a cardiac arrest a paramedic can probably infer that this was not the intended outcome from the drug and therefore would be expected to take some action. There may be consequences that are obviously adverse that the paramedic will need to act on. In minor cases that may be no more than noting that the patient developed redness or complained of pain at the site or some such, and report that when delivering the patient to their destination. In more serious cases more intervention may be required. That is not really about the drug but about the symptoms and I have no doubt that a paramedic can contact their comcen for medical advice if it appears that the patient is not responding well to the drug (Inquest into the death of Scott Cayirylys (3 March 2020)).
Where the paramedic is asked to start the drug the critical skill he or she is being asked to exercise is the technical skill – if it’s meant to be IV making sure that the drug does in fact go into a vein and not surrounding muscle etc.
A paramedic as part of the health team should also be willing to question a prescription. If they are asked to administer 30ml of a drug but they understand that this is a massive dose and perhaps the doctor meant 3ml, then they should raise that as that is what any reasonable member of the health care team would do.
The ultimate question will always be ‘was the paramedics’ conduct reasonable in all the circumstances’ and, from a professional discipline, did the paramedic demonstrate skill care and knowledge that could be expected from a paramedic of similar skill and training. That does not mean you have to know the pharmacology, indications and contra-indications of every drug prescribed by the patient’s treating doctor or nurse practitioner. The paramedic is not responsible for the doctor’s or nurse practitioner’s choice of drug or route of administration.
‘Does this extend to medical equipment such as ventilators and other machines we are not trained in as well?’ Absolutely. In these cases the paramedic is not being asked to exercise clinical skill, if the machine’s there it’s there. If it stops working the paramedic would be expected to realise that and do something – whether that’s call for assistance or start their own protocols for cardiac arrest; but you can only be responsible for what you are responsible for. A paramedic, or a doctor, or a nurse, is not required to guarantee that there will only be good outcomes.
Conclusion
There is no issue in being in possession of and supplying a drug to a patient that has been prescribed for the patient even though the person holding and administering the drug has no formal training in that drug. The reason for the drugs authorities for paramedics and others is to allow them to carry drugs ‘just in case’ for people not yet identified and where the paramedic has to make the clinical decisions of diagnosis and treatment. That is not the case described by my correspondent.
The question was ‘what is the medico-legal risk to paramedics if harms come to a patient with one of these infusions in situ?’ and the answer is there is none if it’s the drug that causes the harm. If the paramedic recognised or should have recognised that harm was occurring and did nothing that is a different matter. But if it turns out that the patient cannot tolerate the drug the fact that this becomes apparent in the ambulance and not in the hospital will not make the paramedic liable for that outcome.
Australian Emergency Law 
I’m then left wondering about transmitting patients between crews. A long time ago, when paramedics didn’t exist, a seriously ill patient needed to get from Hospital A to Hospital B. Crew 1 were told give these drugs to Crew 2 and have them call Hospital A on the radio. I was Crew 2 and spoke with hospital A and was given instructions as to in Situation H give drug X, in Situation I give drug Y and in Situation J give drug Z (and all drugs were beyond my scope of practice). I then transported for 4 hours (HF radio was only communications available) and meet Crew 3 for the final twenty minutes to get to Hospital B.
Crew 3 were uncomfortable about taking the drugs and instructions (I had taken notes from the conversation with Hospital A), and instead insisted on taking me and the drugs with the patient to cover off Situation H,I & J. If this were to happen again now this would still be the correct behaviour as they had no direct advise from the prescriber? Should the instructions had been written down by the hospital A and then passed along each step to avoid this?
It would certainly be better that instructions are in writing. There would be a legitimate concern that by the time the instructions get to crew 3 they have been modified by the process of ‘Chinese whispers’. Hopefully today the communication is better than HF radio only.
pieter.fouche@monash.eduThanks Dr Eburn! That clarifies things from the medico-legal perspective. It sounds like it is okay to take over any drug or machine attached to the patient, as long as it is under the directions of the doctor in the ED. Of course, just going along with whatever the ED want us to do is often a bad idea, as we might think we know the drug or machine, but we don’t, and things can go awry. The truth is, we often “don’t know what we don’t know”, and the ED can be assured in our (unjustified) confidence leading to harm to the patient caused by our lack of knowledge of the particular drug or equipment. Clear clinical guidelines are still a good idea!
Absolutely ‘Clear clinical guidelines are still a good idea’ and given NSW Health operates both the hospitals, and the ambulance service, getting together to make sure everyone understands what the others can and cannot do is a good idea.
If the Ambos aren’t comfortable with continuing the infusion (i.e. unfamiliar with the drug or how to administer it), I give them two choices: a) if the infusion isn’t critical and the patient is likely to remain stable for the transfer, the infusion does not need to continue; or b) if the infusion is critical to ensuring patient remains stable during the transfer (e.g. noradrenaline), then I or another doctor or nurse will go with the Ambos, or we call the Specialist AeroMedical Team or NETS (for kids) to retrieve the patient. I personally feel Ambos shouldn’t be put in a position to administer a medication they’re unfamiliar with, and if they’re that unwell to require a life saving infusion to continue en route, then the clinician intiating the transfer should consider a higher level of medical care for the transport.