June 28, 2019 | 422 ViewsAdrenaline ruling reversed: brain damaged patient treated with wrong drug

The Court of Appeal has overturned the acquittal of QAS’s handling of an emergency asthma casualty who suffered a catastrophic hypoxic brain injury en route to Cairns hospital for treatment.

In July 2018 – after nine days of testimony and argument – Justice Jim Henry sitting in the Queensland Supreme Court in Cairns, interpreted the expert evidence as holding “adrenaline is and likely was regarded as preferable to salbutamol for administration to asthmatics in extremis.”

On that basis he dismissed the claim for damages – agreed by the parties at $3 mil – argued in court by Jenny Masson’s estate following her death about 12 months before the trial.

The case turned on whether or not the administration of IV salbutamol, an agent generally used for acute episodes of bronchial asthma, was contrary to QAS guidelines and contra indicated in those circumstances.

Competing opinions of emergency medicine experts as to which of the two frontline agents available to treat an acute asthma onset – adrenaline and salbutamol – were presented.

For the plaintiff Professor Gordian Fulde – who literally wrote the book on the subject, Associate Professor John Raftos and Dr John Vinen all attested to Adrenaline to being the agent of “first resort” for patients “in extremis”.

Their Queensland counterparts Professor Anthony Brown, Associate Professor Rob Boots and Dr Geoffrey Ramin eloquently explained that although a large part of the medical profession would favour adrenaline, that preference was not premised on scientific facts.

Justice Henry concluded that the early administration of adrenaline would likely have avoided the injury but excused the ambulance officer for his preference for salbutamol because the standard of care in an emergency to be expected of a first responder in the field, should not be regarded as high as that of a hospital physician.

On appeal Justice Phillip McMurdo – in delivering the lead judgment – thought the trial judge’s conclusion that there “was a responsible body of opinion to support the administration of salbutamol to a patient with Ms Masson’s high heart rate and blood pressure” was not justified on the evidence.

Further, the QAS guideline “made sufficiently clear that adrenaline was the preferred drug to achieve a fast and effective dilation of the bronchial passages to avoid death or the permanent effects of the deprivation of oxygen to the brain”.

The flowchart in its guideline “required the officer to ‘consider adrenaline’, not to ‘consider adrenaline or salbutamol’,” he reasoned “and showed salbutamol as the drug to be ‘considered’ only in the circumstances of a less serious case”.

The evidence of Drs Flude, Raftos and Vinen was consistent and authoritative in the appeal judges’ view.

Prof Flude had made it quite clear that “adrenaline was the drug of choice for a case of a patient at risk of death. “Though salbutamol has its place, but if the patient is not breathing, it is adrenaline which must be administered,” his testimony clearly stated.

The State of Queensland must now pay Ms Masson’s estate the agreed $3 mil in damages plus a large portion of its legal costs.

Masson v State of Queensland [2019] QCA 80 Fraser and McMurdo JJA and Boddice J 10 May 2019

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