This question from a a volunteer Advanced Responder with St John Ambulance Australia (NSW):
We recently had a very interesting discussion around the medications we are allowed to administer, depending on our qualifications.
At a national level, the policy for the administration of medications are set by the ‘First Aid Services Medication Procedures – March 2013’
The document starts off stating:
Introduction
Increasingly, the use of medications is becoming a routine component in delivery of first aid and health care provided by St John for the community. The use of medications in any health service, ambulance provider or health-related organisation (including St John) is subject to authorised availability and State and Territory legislation and regulation.
The First Aid Services Medication Procedures (as amended) contains information relating to the administration of approved medications as clinically indicated and where available.
This document contains procedures to be followed by St John members when administering medications. These procedures are for use by all St John members with appropriate training and certification.
Authority / Governance
The Medical Advisory Panel (MAP) is responsible for authorising and routinely reviewing the availability and use of medications by St John clinical members. For the purpose of this document, a clinical member refers to a St John First Aider, First Responder, Advanced Responder or health professional (using these procedures at one of the previous clinical levels outside of the credentialing process).
Changes should be suggested by State/Territory Professional Officers to the Chief Professional Officer.
It goes on to state:
Availability/Authority
The purchase, storage, handling, transport and administration of these medications are strictly subject to State or Territory legislation and regulation. This usually occurs in the form of a Health Services Permit or Drugs and Poisons Licence. The availability of these medications in States and Territories will vary; this can be due to drugs and poisons licences, legislative requirements or State and Territory policy.
For the administration of Panadol Elixir, the document states:
Child under 7 years
Do not administer paracetamol tablets — Advanced Responders may administer elixir as per instructions on bottle, dispense using a sterile 10ml syringe.
Now recently we were told that in NSW, we are not permitted to administer Panadol Elixir under any circumstances.
When I asked whether there is a specific guideline or policy that specifically states this, I was informed that there was not. I was however told that, because the medication (Panadol Elixir) was not on the approved St John Ambulance order form, it is generally accepted that you are not able to administer it. My argument was that an order form does not constitute a policy or guideline, and therefore St John (NSW) would have no legal grounds to take any action against a member that carried/administered Panadol Elixir, specifically since it clearly states that an Advanced Responder is allowed to.
I am wondering what the correct legal stance on this is?
That’s a question that I cannot give a definitive answer to as it depends on the corporate structure of St John and the relationship between the National and the State branches. It also depends on St John’s internal rules about the authority of officers to give directions and the commitment of members to comply with them. I make no comment on any of those matters.
My answer is limited to the law in NSW. As noted ‘The purchase, storage, handling, transport and administration of these medications are strictly subject to State or Territory legislation and regulation’. In this case the relevant state law is the Poisons and Therapeutic Goods Act 1966 (NSW). That Act provides for the NSW Poisons list that puts poisons into one of eight schedules. Panadol elixir is in Schedule 2 (see NSW Ministry of Health, Poisons List 2013 http://www.health.nsw.gov.au/pharmaceutical/Documents/poisons-list-alpha.pdf, accessed 1 April 2014).
Schedule 2 is for ‘Substances which are dangerous to life if misused or carelessly handled, but which should be available to the public for therapeutic use or other purposes without undue restriction’ (Poisons and Therapeutic Goods Act 1966 (NSW) s 8). It is an offence to supply a schedule 2 poison without an appropriate authority. The maximum penalty is a fine of $1650 or imprisonment for 6 months, or both (Poisons and Therapeutic Goods Act 1966 (NSW) s 10; Poisons and Therapeutic Goods Regulation 2008 (NSW) reg 17). Both the Act and the Regulation (in particular Appendix C to the Regulation) set out various exemptions and authorities that allow doctors, nurses, optometrists and others to carry and use scheduled poisons. St John first aiders are not mentioned in any of these exemptions. Notwithstanding this, the Director-General of Health may issue authorities to allow people to supply various drugs (reg 170). Presumably the Director-General of Health has issued authorities to St John that allows St John to, in turn, authorise members who have done the relevant training to carry and use various scheduled drugs.
Does that authority extend to Panadol elixir, a schedule 2 drug? I can’t answer that without seeing the authority but what must be noted, as my correspondent has already pointed out, is that the State authority takes priority over the national policy. So the national policy may say that Advanced Responders may issue Panadol elixir but that must be if, and only if, the authority of the Director-General of Health allows NSW St John members to supply that Schedule 2 poison. I am unable to say whether it does, or does not.
It follows that I cannot answer the question but I can set out a flow chart on how to answer it – see Answering the question about Panadol elixir.
Australian Emergency Law 
Having worked on road as a paramedic and VAO, this question is answered as part of the training. It should also be raised with your department head.
We all, including nurses and paramedics give medication based on CPGs. We are giving medication which actually belongs to the chief medical officer, on his/her poisons license. You are to issue medication as per the CPGs only. If you do not have a particular medication, that is simple, dont give it. The proviso is that you cant get hold of it. Child’s panadol is mainly used as an antipyretic and had no real evidence to suggest it works as well as we think.
Clinical practice guides are really an insurance issue as well, if you treat as per the guides then you are fine. The clinical governance team have deemed this accurate. If you do your own thing or read the bottle, then you are in breach and you are on your own.
As a lawyer follows the law anyone medical follows the rules of practice.
If you do not have a CPG for a medication DO NOT use it and write to the clinical governance office. There is no medication that the Saint uses that is not covered. YOU may not have access to it so if I were you, I wouldn’t administer. Make sure you ask in writing and not over the phone. CYA..cover your a…
Hope this bells 🙂
This idea that ‘We are giving medication which actually belongs to the chief medical officer, on his/her poisons license’ may once have been true, but isn’t any more – if it was I’d advise any medico not to authorise other people to give drugs to a patient they haven’t seen. If we stick with Appendix C to the Poisons and Therapeutics Goods Regulation 2008 (NSW) it has all sorts of exemptions, such as “A person who holds a current occupational first-aid certificate approved by the WorkCover Authority in accordance with the regulations under the Occupational Health and Safety Act 2000 is authorised to possess and use methoxyflurane and nitrous oxide if required in connection with the carrying out of first aid” (Appendix C, clause 9). The authority to carry and use drugs is their’s not someone else’s. I haven’t seen the St John authority but the authority for the Ambulance Service of NSW says
The trigger is the approval by the Director-General who gets to say who is approved, and what drugs, but the right to carry and use them is vested in that approved officer. It is not the case that a medical practitioner who is allowed to carry, use and prescribe drugs, can authorise someone else to carry and use them on his or her behalf.
There may be underlying clinical reasoning by the medical advisory team for the withholding of authority for administration of panadol elixor by volunteer first responders such as St John officers.
It may appear on a superficial level of assessment that the patient may require panadol as an analgesia or antipyretic, however administration may mask underlying medical conditions which are not recognised by the responder. There have been cases in the media in the past of mis-diagnosed febrile patients who subsequently died due to an underlying condition such as meningococcal disease.
I think this is more an issue of clinical governance, recognition of clinical ability of the responders and the safety of the patient.