Written by Peter CarterUpdated on July 20, 2020
Jenny Masson was already wheezing when she came through the front door of her friend’s Brinsmead home. She turned back round to get the Ventolin spray from the front seat of her car but things got worse quickly.
The 25-yr-old chronic asthmatic collapsed unconscious on the lawn on her way back up to the house.
Two ambulance crews arrived, the first just six minutes after the 000 call was made.
Intensive care paramedic Clinton Peters observed she was in respiratory arrest, had lockjaw and her face was blue. She was already flaccid & unresponsive.
Unknown to the rescuers, she had previously been successfully treated over many years for acute attacks with adrenaline.
Peters concluded she was “hypoxic and required oxygen immediately”. His response was to ventilate by the application of a ventilation mask. He then administered IV salbutamol, an agent generally used for acute episodes of bronchial asthma.
Her condition improved enough that by 17 minutes after the first crew’s arrival, she was loaded up to be ambulanced to Cairns Base Hospital.
En route, Peters saw her rapidly deteriorate.
Fearing a cardiac arrest was imminent, he administered adrenaline via an injection which resuscitated her with a heart rate 60 or so beats per minute.
On arrival in the emergency room – severe brain damage as a result of oxygen deprivation from the events earlier in the evening – was diagnosed.
That was in July 2002.
The episode was life changing: she came away from the hospital to be forever confined to a wheel chair in need of permanent round-the-clock personal care.
Jenny sued the employer of the first responders – the State of Queensland – contending her brain injury would have been avoided if the rescuers had administered adrenaline in the first instance.
Alleging that their decision not to do so was contrary to QAS guidelines, she died in 2016 leaving her estate to pursue the claim to court.
Prior to the February 2018 trial – compensation was agreed at $3 million including for care, loss of income to the date of her death and medical expenses incurred. What remained to be determined at trial was the State’s liability, ie whether the ambulance officers had in fact been neglectful.
QAS submitted first, that the hypoxic brain damage had likely occurred prior to the first responders’ arrival; and second, giving salbutamol was a reasonable response in the context of the patient’s rapid heartbeat (tachycardia) and high blood pressure.
The court decision was to turn on the 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 indicated at the time the ambulance officers arrived on the scene.
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.
“It is clear from the expert evidence,” observed Justice Jim Henry sitting in the Queensland Supreme Court in Cairns, “that adrenaline is and likely was regarded as preferable to salbutamol for administration to asthmatics in extremis.”
He also went on to say conclude that the early administration of adrenaline would likely have avoided the injury.
That conclusion was however not enough for the estate to receive the $3 million agreed compensation.
The court acknowledged the “responsible body of medical opinion” in support of the preference for initial treatment by salbutamol for patients like Jenny presenting with a rapid heart rate and high blood pressure.
Contrary to the estate’s assertion that the QAS guideline mandated adrenaline, Judge Henry reasoned that the guideline requirement was for that drug to be “considered”.
This had indeed occurred.
“Mr Peters did make such a clinical assessment,” the judge wrote in the course of his 47 page decision. “Deciding not to administer it because of the risk of serious adverse reaction to it raised by the tachycardia and hypertension was a reasonable response to the risk associated with worsening Ms Masson’s already dire condition”.
The judge also reminded the parties – after nine days of testimony and argument – that the standard of care in an emergency to be expected of a first responder in the field, was not as high as that expected of a hospital physician.
Choosing salbutamol over adrenaline was therefore – in his view – a perfectly reasonable response in the circumstances that confronted the ambulance men.
Accordingly, the estate’s claim failed to establish any breach of duty on the part of the rescuers.
To put the contest beyond any further dispute, Justice Henry also dismissed the estate’s argument that the QAS had failed to provide its officers with sufficient training and instruction as to the preference for the use of adrenaline in the particular circumstances.
There was no evidence of such failure, he ruled.