I am a paramedic, not a doctor! Was the failure of the paramedic to administer adrenaline inconsistent with the exercise of reasonable care? Which case won?

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The patient's guardian initiated a negligence lawsuit against the State of Queensland as provider of ambulance services.

Australia Litigation, Mediation & Arbitration

The Facts

Ambulance called after woman suffers severe asthma attack

On the evening of 21 July 2002, a 25-year-old chronic asthmatic woman drove to her friend's home in Cairns. She was wheezing badly as she walked into the house, so she walked back to the car to look for her Ventolin puffer.

Returning from the car after using the puffer, the woman requested to be taken to hospital.

As she and her friend were walking towards the car, she collapsed on the front lawn.

Her friend performed mouth-to-mouth resuscitation whilst awaiting the arrival of the Queensland Ambulance Services.

Patient's condition improves after paramedic administers Salbutamol

Two ambulance crews arrived on the scene within six minutes and found the woman in respiratory arrest.

She had tachycardia, ie a rapid heartbeat of greater than 100 beats per minute. Her blood pressure was also very high.

The paramedic tasked with the making the treatment decisions concluded that the patient was "hypoxic and deprived of oxygen" and so he ventilated and oxygenated her.

He also administered Salbutamol, and found that it improved the patient's condition, allowing air movement in and out of her lungs.

Patient's condition worsens on way to hospital and paramedic administers adrenalin

The patient was placed in the ambulance for transport to hospital.

However, on the way there, her heart rate dropped markedly, her respiratory rate reduced and her blood pressure became absent.

The paramedic assessed cardiac arrest as imminent, and so administered adrenaline.

The initial dose had no effect but the second dose produced some return of cardiac output for 30 seconds.

It was at this point that the ambulance was directed to stop. The patient had air trapped in the pleural space, causing the lung to collapse, and so the paramedic performed an incision in the chest wall to allow the air to escape. This action decompressed the left lung and prompted an immediate improvement in the patient's heart rate and blood pressure.

However, on arrival at hospital the patient had no respiratory effort and no carotid (neck) pulse.

More adrenalin was administered by hospital staff, provoking an immediate response with a carotid pulse becoming discernible and increasing.

Patient survives, but oxygen deprivation results in vegetative state

The medical staff had saved the patient's life. However, she sustained severe brain damage as a result of oxygen deprivation.

She lived in a vegetative state for the next thirteen and a half years until she passed away in 2016.

Patient's guardian initiates negligence lawsuit against State of Queensland

Prior to the patient's death, her litigation guardian commenced negligence proceedings against the State of Queensland as the provider of the ambulance services.

After her death, the claim survived in the hands of her estate.

The case was decided by the Supreme Court of Queensland is in favour of the ambulance service, but this decision was overturned by the Court of Appeal. The case then made its way to the High Court of Australia.

case a - The case for the patient

case b - The case for the paramedic

The paramedic failed to follow the instructions for treating asthmatic patients set out in the ambulance service's clinical practice manual ("CPM").
The CPM's asthma flowchart required that for patients in imminent arrest, such as this patient, the treating paramedic must "consider adrenaline".
According to the CPM glossary to "consider" means that an ambulance officer is to make a clinical judgement regarding application of treatment modalities based on potential benefits and adverse effects.
This paramedic failed to consider adrenaline. He misunderstood the asthma flowchart in the CPM, believing wrongly that he was precluded from administering adrenaline to a patient who was tachycardic, not bradycardic (i.e. did not have heartbeat of less than 60 beats per minute). This is clear from his 2009 statement where he said, "In view of the fact that [the patient] was tachycardic, that is she had a heart rate that was greater than 100 beats per minute and peripheral pulse were palpable, intravenous Adrenaline was not permitted under the Asthma protocol. I therefore elected to administer intravenous Salbutamol."
The CPM also made it clear that adrenaline was the preferred drug to achieve a fast dilation of the bronchial passages to avoid death or irreversible brain injury. Adrenaline starts to work in 30 seconds, whereas Salbutamol takes one to three minutes to start working. Had the paramedic applied his clinical judgement on arrival at the scene, he would have concluded that he must give this patient adrenaline in the circumstances.
Further, the majority of specialist emergency physicians operating in hospital emergency rooms in 2002 would have chosen adrenaline from the outset.
The paramedic is therefore negligent in failing to meet the required standard of care, the state is vicariously liable and the appeal should be dismissed.

I did "consider adrenaline." I made a reasonable clinical judgement that adrenaline would have been unsafe given the patient's high heart rate and high blood pressure.
A responsible body of medical opinion at the time supported the administration of Salbutamol in the circumstances. As my medical expert told the court: "You don't give adrenaline to somebody who has got a rapid pulse and a high blood pressure, because it is a dangerous drug that will cause, in the face of hypoxia, a dangerous arrhythmia . that's why Salbutamol is given."
I am a paramedic, not a medical practitioner specialising in emergency medicine. I operate in the field without the assistance and certitude of the facilities of an emergency room. It is irrelevant that emergency room practitioners may have chosen adrenaline from the outset.
I was not negligent, since I met the required standard of care, and therefore the appeal should be allowed.

So, which case won?

Cast your judgment below to find out

Megan Sault
Medical negligence
Stacks Goudkamp

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