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Treating asthma over the phone

01 September 2010

Mr P was a 35-year-old mechanic with a wife and a young child. He had suffered from asthma since he was a boy and his asthma was poorly controlled. He had been admitted to hospital several times over his life with exacerbations of his asthma.

Mr P had been registered with his single-handed GP practice all his life and had attended many times about his asthma. However, there was no record in his notes that his inhaler technique had ever been checked or that his peak flow had been measured, despite widespread mechanisms to standardise and improve the management of chronic diseases such as asthma.

Mr P developed a cough with green sputum and his breathing became more difficult than usual. He felt tight-chested and wheezy and his salbutamol inhaler did not help. He rang his GP, Dr T, and asked for advice. Dr T took a brief history over the phone and left him a prescription for some antibiotics.

By the next day, Mr P’s chest felt tighter so he rang Dr T again. Dr T advised him that the antibiotics may need a few days to start working and to see how things progressed. Mr P had a very disturbed night with a great deal of coughing. He noticed that he was out of breath walking around his house and had called in sick at work.

He allowed another two days to see if the antibiotics would take effect but then rang his GP again. Dr T left a prescription for some steroids to collect but again did not ask him to come to the surgery to be examined. He had not documented a full history of Mr P’s asthma and was thus unaware that his usual control was poor or that he had attended the Emergency Department (ED) twice over the last year, resulting in admission. He was also unaware that one of those admissions had necessitated a stay on the high dependency unit and there was no hospital follow-up.

Mr P contacted the surgery again in the same week, worried that his breathing seemed to be deteriorating rather than improving. Despite him sounding short of breath on the phone while speaking to the GP, he was still not offered an appointment at the surgery. His wife became concerned because he was having difficulty speaking in full sentences without becoming short of breath, so she booked him an emergency appointment at the surgery.

Mr P was exhausted but attended the emergency appointment the same day. He became extremely short of breath and collapsed in the surgery with a respiratory arrest. Dr T phoned the emergency services for an ambulance but did not attempt to start resuscitation. Mr P was declared dead after 45 minutes of attempted resuscitation by paramedics and ED doctors. Dr T admitted that he had panicked at the time of Mr P’s collapse because he felt de-skilled in his resuscitation knowledge.

Mr P’s wife was devastated and made a claim about the long-term management of Mr P’s asthma and the acute incident. The case was settled for a substantial sum.

An independent investigation was highly critical of the long-term and acute management of the asthma and of the de-skilling, lack of equipment and of practice management. The investigation report was forwarded to the regulatory authority.

Learning points

  • The United Kingdom’s BTS (British Thoracic Society)/SIGN (Scottish Intercollegiate Guidelines Network) guidelines, updated in 2008, offer some useful pointers on the management of asthma. From an organisational and delivery aspect, it states that people with asthma should be reviewed regularly by a nurse or doctor with appropriate training in asthma management. It recommends structured reviews, incorporating a written action plan. It states that inhalers should only be prescribed after patients have received training in the use of the device and have demonstrated satisfactory technique. The guidance explains that many of the deaths attributable to asthma occurred in patients with inadequate objective monitoring of their asthma. 
  • Patients with badly controlled asthma need to be carefully assessed to find out the real reasons for it. Could it be due to poor compliance? Is there an occupational trigger? What are the psychosocial aspects affecting this patient’s asthma control? 
  • It is important to keep up-to-date with basic life support skills, particularly when not regularly used, making sure you comply with requirements in the jurisdiction in which you are working. 
  • Doctors should do all they can in an emergency, including attempting resuscitation.