Today’s question relates to a perceived contradiction between two NSW Ambulance policy documents. My correspondent says:

There is ongoing confusion in NSW Ambulance regarding paramedic authority to administer medications. 

 NSW Ambulance has reiterated that Paramedics and Intensive Care Paramedics (ICPs) are not permitted to administer medications they do not have the authority to carry or administer. In the CPGs there is a pharmacology matrix (attached)

outlining authority to administer.  Furthermore, ICPs cannot request paramedics to administer ICP pharmacologies under supervision. Instead, ICPs medications must be administered by an ICP.

However, the Interfacility Medication Monitoring Module Medication Information Reference 20 document (attached), states  

“During interfacility transfer, paramedics (Clinical level P1 and above) may be required to transport patients with medications not covered by NSW Ambulance Pharmacology. This reference list provides paramedics with information about monitoring requirements and precautions with the administration of some of the more common specific medications.”

For example, only ICPs are approved to commence and maintain an adrenaline infusion ‘in the field’, yet during an interfacility transfer, per Reference 20 document paramedics are told they can manage the same infusion. For our regional and remote paramedics this could see and infusion running over 2-3 hours, with no access to ICP.

Given the conflicting messaging from NSW Ambulance, how do paramedics navigate this complex area? Would it be prudent for paramedics and ICPs to limit medication infusions during interfacility transfers to only those medications included in their approved pharmacology matrix?

The relevant law says that paramedics can possess and supply those drugs that they are authorised by the Heath Secretary to use (Poisons and Therapeutic Goods Regulation 2008 (NSW) r 101 (for Schedule 8 drugs) and Appendix C, cl 7 (for Schedule 2, 3 and 4 drugs)). 

This means that paramedics can head out on their shift with a drug box, full of schedule 2, 3, 4 and 8 drugs that they are carrying ‘just in case’. At that time there is not particular patient that they drugs are for.  When the paramedics get to a scene they need to diagnose the patient’s condition, consider what drugs are indicated, and what are contra-indicated, calculate the appropriate dose and administer the drug via the correct route. The paramedics here are exercising their discretion and judgement (Queensland v Masson [2020] HCA 28). The Pharmacology Clinical Level Index supplied (presumably) indicates the drugs that the secretary has approved for paramedics at different clinical skill levels.

Where a patient is being transferred between facilities by ambulance, then it is not the paramedic that has determined what drugs are indicated by the patient’s condition, what the relevant dose is etc.  This has all be determined by others.  Anyone can possess and assist in the administration of drugs that have been prescribed for a person under their care (Poisons and Therapeutic Goods Act 1966 (NSW) s 16(d1) (Schedule 4) and s 23 (Schedule 8)).  

Consider too the circumstances where a patient is to be transferred and the treating team advise the paramedics that the patient has received a dose of a drug that may have side effects that the paramedic needs to watch for.  In that case the drug is already ‘on board’.  There is no (legal) difference if the drug is running through an IV.

The Interfacility Medication Monitoring Module – Medication Information does imply that paramedics may be required to administer drugs but again they are not making the decision about those drugs. They are being asked to administer drugs that have been prescribed for the patient.  Consider too a familiar reality, carers have no legal authority to possess or supply drugs, but carers may have a supply of scheduled drugs eg when caring for a family during chemotherapy or palliative care, that they can and do administer in accordance with the prescriber’s instructions.

It is this situation that the supplied Interfacility Medication Monitoring Module – Medication Information relates to. It does not give paramedics the authority to possess, supply and administer the drugs as the paramedics are not doing that. Someone else has supplied and administered the drugs. The paramedics are no more in the paramedic’s possession than the patient’s clothes are. But if I’m wrong on that analysis the paramedics have the necessary authority under the Regulations cited above. 

Conclusion

Legally there is no inconsistency between the two documents.  Paramedics are allowed to carry and supply, on their own initiative, those drugs that they are authorised to carry by the health secretary.

They can transport a patient what whatever drugs are already ‘running’ and the Interfacility Medication Monitoring Module – Medication Information gives advice on the monitoring required to ensure the best health care for a patient.  A paramedic, like anyone, can possess and administer any drug that has been prescribed for the patient.

For a related post, see Transporting patients with drug infusions in situ (June 29, 2020).

This blog is made possible with generous financial support from (in alphabetical order) the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), the Australian Paramedics Association (Qld), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.