Duty of care to patients: the Supreme Court clarifies the duty of ambulance paramedics

The Queensland Supreme Court has recently clarified the content of the duty of care owed by paramedics to their patients. The standard is not the same as that expected of a medical practitioner or an emergency physician in the hospital setting. The standard of care is that of an ambulance officer operating in the field in an emergency.

Background to the case

The patient, Ms Masson, was aged 25 years and had a history of chronic asthma, including previous severe attacks which had successfully been treated by the administration of adrenaline. On 21 July 2002, the patient suffered a severe asthma attack at her home and collapsed on the front lawn. Her partner immediately commenced CPR. An ambulance was called and paramedics arrived on the scene some six minutes later. On examination, the patient was flat and unresponsive, with a cyanosed appearance (her face was blue), and locked jaw. Her eyes were open and her pupils were responsive to light. She was tachycardic (abnormally high heart rate) and hypertensive (abnormally high blood pressure). A heart rate monitor was applied, and confirmed the presence of sinus tachycardia.

The attendant intensive care paramedic concluded that the patient required immediate oxygen therapy. He applied a bag valve mask to administer oxygen, and inserted an intravenous cannula to enable administration of drugs. The patient was administered 2 milligrams of intravenous salbutamol (a short acting bronchodilator commonly used in the treatment of asthma) within a period of 21 minutes. The patient's condition clinically improved and she was loaded into the ambulance for transportation to hospital. However, on route to hospital, her condition deteriorated, characterised by a marked drop in heart rate and respiratory rate, and absent blood pressure. The paramedic administered 100 micrograms of adrenaline and intubated the patient. An emergency left sided thoracotomy was also performed to relieve a tension pneumothorax. A total of 300 micrograms of adrenaline was administered before the patient's arrival at hospital.

Unfortunately, the patient suffered hypoxic brain damage, and remained in 24-hour care until the time of her death in 2016.

Claims against the Ambulance Service

The patient's family (plaintiffs) brought a claim against the Queensland Ambulance Service (QAS) alleging negligence by the paramedics on the basis that they:

1. should have administered adrenaline, rather than salbutamol; and
2. failed to follow the QAS Clinical Practice Guideline (QAS Guideline).

The plaintiffs alleged that if the paramedics had administered adrenaline and not salbutamol when they first arrived on scene, this would have been effective to reverse the patient's condition, allowing her to breathe, and she would not have suffered permanent brain damage.

In its defence, QAS contended that the administration of salbutamol was a reasonable response to the known circumstances at the time, particularly given that the patient had a high heart rate and high blood pressure.

The paramedics had not breached their duty of care

The Court concluded that the paramedics had not breached their duty of care in this instance. Notably, the trial judge opined that the standard of care was not as high as that expected of a medical practitioner or an emergency physician in the hospital setting. The standard was that of an ambulance officer, operating in the field, in an emergency. The treatment which was administered to the patient did not fall below the standard of crew and was not contrary to the QAS Guideline. The QAS Guideline did not require the administration of adrenaline. Instead, it prompted only consideration of the administration of adrenaline, which was considered and rejected in this instance by reason of the concerning presence of elevated heart rate (tachycardia) and elevated blood pressure (hypertension). It was held that the presence of those conditions would have been regarded, by a responsible body of opinion in the medical profession, as supporting the view that in the context of the patient's overall condition, there was a medically sound basis to prefer the administration of salbutamol over adrenaline at the time of initial treatment. Opting to administer salbutamol in preference to adrenaline in such circumstances was therefore a reasonable response to the known risks.

The trial judge specifically noted that while many doctors who are presented with the patient's condition in the hospital setting may have elected to administer adrenaline, it is important to bear in mind that ambulance officers are not medical practitioners who are specialists in emergency medicine.

The trial judge went on to consider the issue of causation (although not strictly required) and concluded that given the evidence of the patient's past positive response to the administration of adrenaline, it was more likely than not that the timely administration of adrenaline would have avoided the injury.

The trial judge also noted that the purpose of the QAS Guideline was to provide paramedics with a comprehensive guide to pre-hospital clinical practice. The QAS Guideline was not intended to be prescriptive, but to leave room for individual clinical judgment.

Key learnings from the case

The case includes a useful restatement of the standard of care applicable to paramedics and, most importantly, confirms that their actions must be judged by reference to their peers and the clinical setting (being an emergency and not a hospital). Further, paramedics are expected to exercise clinical judgment within their scope of practice, and to have regard to Clinical Practice Guidelines to facilitate good clinical decision making, rather than as a mandate as to the applicable treatment in each case.

Citation: Masson v State of Queensland [2018] QSC 162.