Case report:

“Patient presented with sudden onset severe breathlessness, severe type 1 respiratory failure despite 15L Non-rebreather mask. likely cardiogenic in nature. Patient was tiring, respiratory rate 45+, tripoding, HR 130, BP 110/70. Called ITU SpR on Call to refer for NIV/review. States as patient only had 1 dose of furosemide, they would not come and see the patient as would only document this and not give NIV. I explained again that my concern the patient was tiring and on maximal oxygen therapy in resus. Again, refused to come and see the patient stating they had spoken to their consultant who agreed with their plan and to refer to medical SpR, who can see the patient and refer back if needed. Escalated to ED Consultant in charge who advised to speak to medical SpR. Medical SpR in resus at the time, details given and referral accepted. [Later, but timescale not indicated]… Call placed in ED for me to come to resus to see the patient. On arrival patient was unresponsive, agonal breathing. Cardiac arrest was confirmed, buzzer pulled, compressions started and 2222 call placed. Thrombolysis given in ED but after protracted CPR attempt patient died.”               

Commentary:

It is hard to comment specifically on this case as we know nothing about the workloads and availability of the various clinicians at the time, and perhaps it is better just to let the story do the work. One thing that stands out is the ‘refusal’ to see a patient who is by the description in extremis; one might argue it is better to at least lay eyes on a patient like this – they cannot be assessed over the telephone and sometimes the reality might prompt a more conciliatory reaction. A structured communication tool can help make clearer the severity (or otherwise) of a patient’s condition. There is a role for medical emergency teams or rapid response teams, with clear lines of communication (for instance a deteriorating patient bleep).