Paramedic’s standard of care receives the High Court’s treatment

Nov 2020 |
In State of Queensland v Masson1 the High Court made a number of important findings on the standard of care owed by paramedics in emergency situations.

In doing so, the High Court overturned a decision of the Queensland Court of Appeal and found a paramedic was not negligent in deciding between two competing forms of treatment.

Facts

Ms Masson was a chronic asthmatic, who in 2002 suffered a severe asthma attack. The attending paramedic treated her immediately by administrating the drug salbutamol. After 20 minutes, while Ms Masson was being transported to the hospital, her condition deteriorated and the paramedic administered adrenaline. Both drugs are used to treat asthma attacks by expanding the airways in the lungs to facilitate breathing. By the time Ms Masson arrived at the hospital, she had suffered irreversible brain damage due to oxygen deprivation. She remained in a vegetative state until her death in 2016.

Ms Masson brought proceedings against the State of Queensland as the provider of the services of the Queensland Ambulance Service (QAS). After Ms Masson’s death, the claim survived in the hands of her estate.

Ms Masson alleged (relevantly for the purpose of the High Court appeal) that the paramedic was negligent for failing to administer adrenaline immediately, rather than only doing so 20 minutes after initial treatment. An essential element of Ms Masson’s case was the paramedic’s failure to comply with the Clinical Practice Manual (CPM) provided by the QAS for field use. The CPM’s asthma flowchart listed pre-hospital treatment options for asthmatic patients in three categories, which in descending order of severity were labelled ‘Imminent Arrest’, ‘Severe Asthma’ and ‘Moderate Asthma’. Ms Masson was within the ‘imminent arrest’ category. The guidance that the flowchart provided in relation to patients in this category was to ‘consider adrenaline’, while the guidance for patients in the ‘severe asthma’ category was to ‘consider salbutamol’.

First Instance

The trial judge found that had adrenaline been administered immediately, Ms Masson’s brain damage would have been avoided. However, Henry J held that in the circumstances, the paramedics had not been negligent in delaying the application of adrenaline as they did.

Henry J concluded the treatment administered did not fall below the standard of care to be observed by paramedics, and was not contrary to the CPM. The CPM, when outlining the treatment necessary to treat asthma attacks, required only that the paramedics consider adrenaline as a treatment option. His Honour was also satisfied that in 2002 there was a responsible body of opinion within the medical profession which supported the view that Ms Masson's high heart rate and high blood pressure, in the context of her overall condition, provided a medically sound basis to prefer the administration of salbutamol to adrenaline at the time of initial treatment.

Court of Appeal

Ms Masson was successful in an appeal to the Queensland Court of Appeal.

McMurdo JA (with Fraser JA and Boddice J agreeing) found that the standard of care required of paramedics is not as high as that expected of a medical practitioner or emergency physician in hospital settings. It was commented that unlike a medical specialist, a paramedic does not have the requisite competence to make their own professional judgment about the merits of competing views within a field of specialised medical practice.

His Honour therefore held that it would be inconsistent with the exercise of reasonable care for an ambulance officer to depart from the guidance of the CPM.

McMurdo JA disagreed with the trial judge that the paramedic adequately considered whether adrenaline should be administered. His Honour reasoned that the CPM required the paramedic to consider adrenaline, not to consider adrenaline or salbutamol. The CPM did not suggest salbutamol as an alternative to adrenaline, but only suggested salbutamol as the drug to be considered in the circumstances of a less serious case. His Honour held that the trial judge's finding, that in 2002 there was a responsible body of opinion in the medical profession supporting the administration of salbutamol to a patient in Ms Masson's condition, was not supported by the evidence.

The State of Queensland appealed to the High Court.

Issues

The primary issues on appeal where whether:

  • Treatment in accordance with the CPM was determinative of the paramedic’s standard of care; and

  • The paramedic properly considered the administration of adrenaline in accordance with the CPM.

Decision

The High Court unanimously upheld the State’s appeal.

Standard of care

In a joint judgment Keifel CJ, Bell and Keane JJ held that the standard of care expected of the paramedic was ‘that of the ordinary skilled intensive care paramedic operating in the field in circumstances of urgency'.2 Their Honours observed that, self-evidently, this is a less exacting standard than that expected of specialists in emergency medicine, and agreed with the Court of Appeal that intensive care paramedics cannot be expected to make fine professional judgments of a kind that require the education, training and experience of a medical specialist.

However, their Honours found that does not mean an intensive care paramedic is not expected to exercise clinical judgment. The guidance in the CPM was posited upon the assumption that ambulance officers would exercise clinical judgment and that officers may depart from its guidelines where the departure is justified and is in the best interests of the patient.

The CPM was not expressed to be, and was not, determinative of the range of reasonable responses for an intensive care paramedic treating an asthmatic patient in imminent arrest who presented with Ms Masson's symptoms.3

In a separate judgment, Nettle and Gordon JJ similarly held that the Court of Appeal erred in construing the exercise of reasonable care required no more or no less than the administration of adrenaline in accordance with the CPM, without the exercise of clinical judgment taking into account Ms Masson’s discrete conditions.4

Clinical Judgment

Flowing from the Court’s findings regarding the paramedic’s standard of care, the question for determination was whether the election to administer salbutamol and not adrenaline was within the range of clinical judgments that an ordinary skilled intensive care paramedic might make.

The Court unanimously held that the paramedic’s decision to administer salbutamol as opposed to adrenaline, in the face of Ms Masson’s high heart rate and high blood pressure, was supported by a responsible body of medicine (and so not was negligent).

Keifel CJ, Bell and Keane JJ considered there was no evidentiary basis for the Court of Appeal concluding, in the case of an asthmatic patient in imminent arrest, that the ‘consideration’ of adrenaline in accordance with the CPM was not to be informed by the ambulance officer's clinical judgment, allowing that in the case of a patient with Ms Masson's high heart rate and high blood pressure IV salbutamol might be preferred.5 Their Honours accepted, contrary to the Court of Appeal’s analysis, that there was ample evidence to support the trial judge's finding that, in 2002, a responsible body of opinion within the medical profession favoured the administration of salbutamol in the initial stage of treatment for a patient in Ms Masson's overall condition, with her high heart rate and high blood pressure.6

Nettle and Gordon JJ found that while Ms Masson had established that in 2002 the majority of emergency specialists would have chosen adrenaline from the outset, that does not mean that the minority who would have chosen salbutamol as first preference would have been regarded as negligent. Their Honours reasoned that for a body of option to be regarded as responsible, required only that it have a logical basis (which they found to be the case), not that it align to majority opinion.7

In that context, their Honours likewise observed that the overall effect of the evidence was that a responsible body of opinion in the medical profession in 2002 supported the view that Ms Masson's high heart rate and blood pressure in the context of her overall condition provided a medically sound basis to prefer salbutamol to adrenaline at the time of initial treatment.8

Comment

The decision provides useful guidance on the standard of care expected of paramedics, which is less exacting than that of specialists in emergency medicine, however still requires the exercise of clinical judgment taking into account a patient’s particular condition. It is expressed in a way that reflects a paramedic’s education, training and experience, and the practical realities of paramedics operating in the field as opposed to a hospital setting.

Of interest to medical professionals more broadly are the High Court’s finding that:

  • The provision of treatment in accordance with practices or guidelines that do not have binding legal effect will not be determinative of the standard of care; and

  • The standard of care will be discharged where treatment accords with a responsible body of opinion, which requires that it has a logical basis even if it does not align with the majority view.

Although the present case fell for determination by reference to the common law as the events in question occurred prior to the commencement of the Civil Liability Act 2003 (Qld), the High Court’s reasoning nonetheless draws some analogies with the standard of care of professionals now prescribed by section 22, which operates as a defence in circumstances where a professional acts in a way that (at the time the service was provided) was widely accepted by peer professional opinion by a significant number of respected practitioners in the field as competent professional practice.

.....

1 [2020] HCA 28.
2 State of Queensland v Masson [2020] HCA 28 at [10], citing Rogers v Whitaker (1992) 175 CLR 479 at 487.
3 Ibid [11].
4 Ibid [136].
5 Ibid [70].
6 Ibid [72].
7 Ibid [134]
8 Ibid [139].

This article may provide CPD/CLE/CIP points through your relevant industry organisation.