Today’s correspondent says:
As a [Tasmanian] paramedic I have been advised that medications or drugs cannot be left with a patient for later use. Examples might be Ventolin (S3) for a person with mild asthma who has used a metered-dose inhaler supplied by the paramedic, but who does not require transport to hospital. In this case, the patient may have run out of their own medication and the paramedic may be considering leaving the MDI with the patient until such time as they can secure their own supply at a pharmacy.
Under the Poison’s Act 1971 an ambulance officer, a paramedic, or an interstate ambulance officer is able to administer a substance [drug] (i) at the direction of a medical practitioner; or (ii) in accordance with the Field Protocols applying…
Does any part of the Act or Regulations prohibit or prevent the supply of a medication by an ambulance officer or a paramedic for self-administration at a later time, such as when the paramedic is no longer present?
S47A(3) notes that ““administer” includes making available for self-administration”. Does such self-administration have a time limit attached?
Section 26 of the Poisons Act 1971 (Tas) deals with the ‘Sale and supply of potent substances and hazardous and medicinal poisons’. Potent substances are schedule 3 medications, hazardous poisons are listed in schedule 1 and medicinal poisons are listed in schedule 2. A person must not sell or supply to another person a schedule 1, 2 or 3 drug unless authorised. Restricted substances are those listed in schedule 4 and again it is an offence to possess, sell or supply schedule 4 drugs (s 36) unless authorised.
A ’volunteer ambulance officer, an ambulance officer, a paramedic or an interstate ambulance officer’ acting:
(i) at the direction of a medical practitioner; or
(ii) in accordance with the Field Protocols applying with respect to the administration of scheduled substances as approved by the Commissioner of Ambulance Services from time to time.
may administer a schedule 2, 3 or 4 drug (s 38(1)(h)). A similar exemption applies for the administration of a narcotic (schedule 8) substances (s 47(1)(dd)).
What does it mean to administer a drug? Section 38(1)(c) refers to the ‘the supply of a restricted substance by a registered nurse …’. The authority for a paramedic (s 38(1)(h)) however, only refers to ‘administration’, not supply. The terms ‘administer’ and ‘administration’ are not defined in the Act or the regulations nor are they defined in the Poisons Standard or the Therapeutic Goods Act 1989 (Cth). The definition of ‘supply’ in the Poisons Act includes to ‘administer a substance, whether orally, subcutaneously, or by any other means’ (s 3). So one can infer that an authority to supply includes administer, but an authority to administer does not include the broader concept of supply.
Section 47A of the Act says that the regulations may allow for others to administer S2, 3, 4 or 8 drugs. For the purposes of that section the term ‘administer’ ‘includes making available for self-administration’ (s 47A(3)). Regulations have been made under s 47A to allow paramedics (and others) to administer vaccines (Poisons Regulation 2018 (Tas) r 54(a)) and for dental assistants to administer sodium fluoride varnish (r 54B).
What follows is I don’t think one can infer that the use of the term ‘administer’ to include ‘making available for self-administration’ applies except when regulations have been made under s 47A – and that is not the case with respect to a paramedic’s drug authority. Paramedics have the authority to administer various drugs (ss 38(1)(h) and 47(1)(dd)) but in those sections ‘administer’ is something less than ‘supply’ and the best definition is that it is an authority to ‘administer a substance, whether orally, subcutaneously, or by any other means’.
If the authority to ‘administer’ included an authority to ‘available for self-administration’ then it would mean that a paramedic could leave a patient with, say, Ventolin (schedule 3) but also morphine (a schedule 8 drug) given the same language is used in both s 38(1)((h) and s 47(1)(dd). I do not think anyone would suggest paramedics are authorised to leave morphine for future self-administration though that may be quite a reasonable step for extended or community care paramedics.
Finally I note that the authority of paramedics to deal with drugs is to act ‘in accordance with the Field Protocols applying with respect to the administration of scheduled substances’. Those field protocols do not appear to be publicly available (although Ambulance Tasmania’s Clinical Practice Guidelines are -see https://www.health.tas.gov.au/hospitals/ambulance/ambulance-information-health-professionals/ambulance-tasmania-clinical-practice-guidelines-cpg). It may be that the Field Protocols have something to say on this subject but I am not able to access them.
Conclusion
Although it may be a good idea for paramedics to ‘supply … a medication … for self-administration at a later time, such as when the paramedic is no longer present’ I do not think that is authorised under the Poisons Act 1971 (Tas). It would be permissible if the paramedics were acting under a regulation made to further s 47A of the Act, but that is not the basis for a paramedic’s authority to administer a drug. In sort paramedics have authority to ‘administer’ a drug but not ‘supply’ it.
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Australian Emergency Law 
A great and thorough answer; I (a Paramedic + now Educator) always shorthand explained it as essentially the difference between Prescribing, Dispensing and Administering.
I’ve recently been chewing over some of the considerations for “Refusals” when it isn’t a refusal of everything, but rather a refusal of transport to ED or the “best” or “safest” (for the patient) option.
Ethical decision aside, is there legislation in this case? To use the situation above, let’s say that this patient was having a potentially life threatening asthma attack. We have managed them, and they are now in a position where we believe they have capacity and competency to refuse transport. Despite best efforts, no amount of convincing will get them to come to ED for further assessment and management.
My interpretation is that a Paramedic in this situation has the professional (+ legal?) duty to safety net this patient as best as possible, and ensure they are able to take the “least bad” option.
What is the legal view if part of that was leaving a medication along with instructions for use with the patient / family, even if outside the current scope of the clinican? Assuming as well that it is documented as well as possible, including risk assessment (perceived risk of med v. risk to life without having it etc).
Thankyou!
There’s no legislation on the point of the extent of the duty of care. The principles are common law but your analysis is correct. The duty is not just a duty to offer the services you want to offer on a take it or leave it basis. If a person refuses some treatment or transport that does not mean you can just wash your hands. You have to think about what else you might offer in the patient’s best interests whilst respecting their right to make autonomous choices. To give a simple example a patient might refuse transport so that may impose a duty on you to warn them of the dangers and identify signs and symptoms they should watch out for or give advice on what to do if their situation gets worse (see the discussion on the very first post on this blog about the alleged duty NSW ambulance paramedics owed when their patient refused treatment – see Ambulance Service v Neal (January 29, 2009) .
But you cannot be under a duty to do what you are not empowered to do (and see the multiple discussions on the case Stuart v Kirkland-Veenstra). If it’s illegal to supply the drug then you cannot be duty bound to do so. But again to go back to your point about a duty to safety net the patient there may be away around it. If you have access to a doctor through your comcen then maybe the doctor can issue a prescription to a local pharmacist?
Thanks for the time and reply. All very useful.
It would be nice to have that ability via Comms but, unfortunately in that respect at least for me (or my colleagues), in my service its Paramedics like myself on the other end of that phone.
That said, Ambos being the resourceful bunch they are there are all types of stories of people getting prescriptions, telehealth consults and the like for patients through any number of ingenious means.
I’ve had a paramedic crew in Adelaide metro leave their whole drug bag at my house after attending. Lets just say there was some frantic phone calls being made by team leader. 🙂
Thank you Michael.
I note with interest your comment in relation to “Field Protocols”, specifically as it relates to s47(1)(dd):
(ii) in accordance with the Field Protocols applying with respect to the administration of scheduled substances as approved by the Commissioner of Ambulance Services from time to time.
I also note your comments that while the Clinical Practice Guidelines are available for public access, the “Field Protocols” are not, but that if they were, they might have something to say on the matter.
The implication is that the Act appears to relate to the “Field Protocols” but not to something else, i.e. the Clinical Practice Guidelines.
While clinical practice by salaried paramedics in Tasmania used to be regulated by documents called “Field Protocols”, this is no longer the case, and documents titled as such are no longer in effect as they related to salaried paramedics. Instead, salaried paramedics operate under documents called Clinical Practice Guidelines (the ones you referenced). On the other hand, volunteer ambulance officers operate under documents termed “clinical field protocols”.
The distinction between the two is reinforced here: https://www.health.tas.gov.au/hospitals/ambulance/ambulance-information-health-professionals/ambulance-tasmania-clinical-practice-guidelines-cpg
This leads me to a couple of possible interpretations of the wording of the Act and therefore to distinct implications:
(1) The term “Field Protocols” means a specific ‘class’ of documents that would include such documents as the published Clinical Practice Guidelines. In this case the administration of scheduled medications in accordance with the Clinical Practice Guidelines would be protected under s47.
(2) The term “Field Protocols” is a specific document or set of documents which is distinct from the currently published Clinical Practice Guidelines. In this case s47(1)(dd) related to “Field Protocols” does not apply to the currently published Clinical Practice Guidelines.
If (1) is the case, would the Clinical Practice Guidelines (as published) potentially allow scheduled medications in certain circumstances to be left with a patient for later administration?
If (2) is the case, does this mean the administration of scheduled medications in accordance with the Clinical Practice Guidelines, but which does not take place at the direction of a medical practitioner, is not protected by the s47(1)(dd)?
Many thanks, Richard.
Richard, an interesting question and it is always a worry when the executive arm of government (ie Ambulance Tasmania) for whatever reason chose to use words that are not in their Act. The problem could be solved by calling the Clinical Practice Guidelines ‘Field Protocols’ but someone somewhere thought a different title meant something without regard to the Act.
You’re right in that what you describe as (1) and (2) are the options that a court faced with the issue would have to chose from. I expect, applying the idea that the interpretation that gives best effect to the legislature’s intention is the one to chose, a court would accept that the legislature intended that paramedics would administer drugs in accordance with the directions from the Commissioner and the exact title doesn’t matter. I think think the preferable and likely interpetation is (1). What the sections mean is that drugs must be administered in accordance with the protocols ‘applying with respect to the administration of scheduled substances as approved by the Commissioner of Ambulance Services from time to time’ and teh fact that AT now calls them clinical practice guidelines doesn’t change the fact that they are the protocols to be applied in the field. If that is correct then administering drugs in accordance with the CPGs is what is meant or intended or is covered by ss 38(1)(h) and 47(1)(dd).
There is nothing that I can see in the CPGs (as published on teh web) that talk about leaving drugs so it would not be possible to argue that leaving say a ventolin inhaler with a patient was administering the drug in accordance with the Field Protocols approved by the Commissioner.