Waiting for an ambulance

By Elia Petzierides

Take one severe allergic reaction to a wasp sting, two overly-protective dogs, a longer than average ambulance response time and a shot of adrenaline and you have the narrative of Mr Tony Bugeja’s final minutes. The Coroner investigating the 50-year-old’s death provided some interesting advice for those wanting to improve ambulance resourcing and also made a unique and surprising recommendation for the ambulance service which the media latched onto.

What happened?

On Wednesday March 5th 2014, Mr Tony Bugeja, a 50-year-old truck driver and father of three, was at home with his wife and young children. His family left home at 9:00am and Mr Bugeja worked on the construction of their new family home (adjacent to their existing house) on the large semi rural property in Wilberforce, 60km Northwest of Sydney, New South Wales, Australia.

Mr Bugeja had an allergy to wasp stings which he had known about for approximately 15 years. His usual symptoms involved trouble breathing and hot and sweaty skin. After two hospital admissions he was prescribed an EpiPen (a portable adrenaline injector) which he was required to keep with him and use in the event of a wasp sting to counteract the severe allergic reaction known as anaphylaxis. He had successfully used this a few times to resolve his symptoms following wasp stings, an ambulance was not called and he did not require hospitalisation. Occasionally he would vomit and sometimes would need to use the toilet following EpiPen use.

At 1:00pm Mr Bugeja called his wife and told her he had stopped work and was going in for lunch. He sounded well and did not mention that anything was wrong.

At 2:42 Mr Bugeja called ‘000’ from his mobile telephone and advised the operator of his name and address. It was apparent that he had trouble breathing and after 65 seconds the call dropped out. An urgent case was generated requiring a lights and sirens response. The operator attempted two callbacks immediately after which went unanswered.

At the time of the call there were 11 operational ambulances in the region and two of these were available to respond. An ambulance paramedic crew were dispatched from 35km away at 2:46pm and two minutes later a single responder paramedic was dispatched from 22 km away.

The single responder paramedic arrived on scene 25 minutes after Mr Bugeja’s call to ‘000’. He entered the property via a metal gate, drove down the long driveway where he encountered another metal gate. Behind this gate were the Bugeja family’s two Italian Mareema sheepdogs which were barking at the single responder paramedic who immediately requested urgent police assistance via his ambulance radio as he felt threatened by the dogs. Mareema sheepdogs have been used for centuries to protect sheep from wolves. The paramedic did manage to make some progress through the gate however as he approached the front door of the main house his initial attempts to build a rapport with the dogs then later shoo them away had failed and the dogs began barking and growling at him again.

At 3:26pm (44 minutes after Mr Bugeja’s ‘000’ call) the ambulance paramedic crew arrived. Upon their arrival the single responder paramedic successfully managed to distract the dogs to enable the other two paramedics to enter the house. Mr Bugeja was located sitting up on the floor of the toilet cubicle next to a used EpiPen which had an expiry date of February 2014. It was apparent that Mr Bugeja was deceased. A second unused EpiPen was later found in the kitchen cupboard.

A post mortem examination revealed a cause of death of “Acute Anaphylactic Reaction” (sudden and severe allergic reaction) with an antecedent cause listed as “Wasp Sting Allergy”. Two elevated areas of skin were noted on Mr Bugeja’s right lateral thigh that may have been consistent with an EpiPen injection site or wasp sting/s. Adrenaline was not detected on toxicological testing however this is likely explained by its rapid metabolism.

A consultant allergist advised the Coroners Court that how quickly a person deteriorates from anaphylaxis following an insect sting depends on a number of factors:

number of stings
amount of venom absorbed
whether the patient remains upright or lies flat
time taken for adrenaline and treatment

When the human body experiences a reduction in blood pressure it collapses to the ground. Gravity then assists the heart pump blood to the brain which is now level with the heart. Conversely, collapsing in the upright position against the toilet wall was deemed to be a factor that hastened Mr Bugeja’s death. The consultant allergist explained a reduction in blood pressure experienced in anaphylactic shock resulted in Mr Bugeja’s heart attempting to pump blood up to his brain against gravity.

The consultant allergist believed it was most likely Mr Bugeja died within 15 minutes of making the call to ‘000’ and cited a study where death had been reported to occur within as little as 2 or 3 minutes from insect stings with a mean time of 10 minutes.

Mr Bugeja’s death raised several questions which the inquest sought to answer. These are addressed below.

Expired EpiPen

Did the use of an expired EpiPen impact on Mr Bugeja’s prognosis? The EpiPen was deemed to have only recently expired and this was not thought to have affected the adrenaline’s effectiveness.

The expiry date listed on medications is the last date which the manufacturer will guarantee the medication’s effectiveness. In this case the EpiPen was marked as expiring ‘February 2014’. The consultant allergist advised the Inquest that medications lose their efficacy very slowly and given it was used days after expiry this would not have made any difference. The real question was how much venom had been absorbed and how much adrenaline was required to counteract it?

Given the adrenaline was deemed to still be efficacious, the Coroner noted it must have been insufficient to reverse the effects of the quantity of venom. Despite it being evident that Mr Bugeja required another shot of adrenaline, it appears the Coroner chose not to pursue the possibility of educating people with EpiPens to consider keeping a 2nd EpiPen within reach. Especially those likely to experience an ambulance response time on the longer side of average. This is particularly important when considering the unpredictability of fatal reactions.

Ambulance response time

Did the ambulance response time affect Mr Bugeja’s chances of survival?

During 2013-2014 the NSW Ambulance Service achieved a median response time of around 11 minutes to Priority 1 cases. The Coroner quite simply pointed out that this meant half the response times were less, and half were greater than 11 minutes. Which side of this average a response time falls depends on a number of factors such as:

Availability of ambulance crews
How many other high priority cases are in the queue
Distances to be travelled
Road and weather conditions
Accuracy of information concerning addresses, and
Access to patients

In Mr Bugeja’s case the Coroner pointed out that a number of factors combined resulting in a response time of 25 minutes for the first ambulance to arrive at Mr Bugeja’s property.

The Coroner turned his attention to the availability of ambulances within the Hawksbury area surrounding Mr Bugeja’s suburb. Of the four closest ambulances, two were at hospital, one was responding to another emergency and the other was already in attendance at an emergency. It is not known from the inquest summary how long the ambulances were at hospital and if hospital ramping was an issue.

After evidence from the acting director of NSW Ambulance Service and a visit by the Coroner to the Sydney region control centre the Coroner learned that ambulances are stationed across NSW in various locations and they are not confined to a geographical area. The closest available ambulance is dispatched and the Ambulance Service continuously monitors the locations and availability of ambulances using a well-managed and highly sophisticated computer system which enables movement of ambulances from areas of low demand to areas of higher demand.

According to the Coroner, Mr Bugeja’s family expressed their ‘natural and reasonable concern’ that the Hawksbury area may be under-resourced. To this the Coroner gave an eloquent snapshot of his role and its limitations. The Coroner believed it was not possible for him to second guess the Ambulance Service’s allocation of its current resources. He then highlighted that allocation of more resources to the Ambulance Service was a role of government which would require an allocation of a greater proportion of the government’s budget to the Ambulance Service. This was described as both a political and a technical financial question.

The Coroner cited the doctrine of “separation of powers” as the reason it is inappropriate for members of judiciary to comment on political issues and added the technical aspect of the question was beyond the expertise of a Coroner.

The Coroner made one final point on this issue. Governments have to make decisions on how best to allocate their finite budget on competing priorities. Governments largely respond to media and community demands. Despite falling crime rates in NSW, the Coroner asserted that governments from both sides and courts responding to media and community demands have become progressively more punitive. The result of this is the allocation of money to the building and running of prisons. The unintended consequence is that this money is unable to be spent on infrastructure and services such as ambulance services. Adding the finishing touches to his point, the Coroner explained that some may argue that it would be better to have fewer people in jails and more ambulances on the road. The Coroner’s advice to those wanting this to happen: lobby your government directly or through the media, community lobby groups or your own MPs.

The Coroner was unable to make any recommendation regarding ambulance resourcing but expressed his hope that Mr Bugeja’s death would prompt government to increase the Ambulance Service’s resources.

Dogs

The delay caused by the barking dogs was also considered by the Coroner. Already having established that they were unlikely to have adversely impacted on Mr Bugeja’s survival the Coroner still wanted to know if the Ambulance Service had a policy to deal with accessing patients guarded by aggressive animals? Various strategies and ideas were considered by the Coroner.

The idea of equipping paramedics with a device to deter aggressive animals (a baton or capsicum spray) was rejected by the Ambulance Service on the grounds that it could be misused by a drunk or drug-affected person who might use this to attack paramedics. The Coroner accepted this argument.

As a result of the input of a veterinarian with specialist qualifications in animal behaviour the Coroner formally recommended the Ambulance Service educate paramedics with some strategies for dealing with aggressive dogs. Namely, building a rapport by:

Talking calmly to the dog,
Avoiding direct eye contact
Keeping noise to a minimum
Using treats or toys to positively reinforce the the desired response of the dog.

The Coroner then went on to make a recommendation that caught the media’s attention: That the Ambulance Service consider equipping its ambulances with a stock of dog treats or a dog toy to be used to distract dogs when attending emergencies.

Conclusion

Anaphylaxis can be a rapid killer. The antidote is adrenaline and as we have learned in the case of Mr Bugeja one EpiPen is not always enough. While it is tempting to focus (as the bulk of media reports did) on the Coroner’s ‘doggy treat’ recommendation, this case raises an important question for our community to consider and discuss regarding the allocation of limited government funds: Given the choice between a more punitive judicial system and more ambulances on our roads, which would we prefer? It’s worth giving some thought, because when the people lead, the leaders follow.

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The author Elia Petzierides is a Victorian based Advanced Life Support Paramedic and Registered Nurse with a Graduate Diploma in Advanced Clinical Nursing.

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