Case studies and articles
Estimated read time: 4 mins
When the pandemic reached our shores, it was a challenging time for doctors, both clinically and personally. GPs were advised by the Royal New Zealand College of General Practitioners (RNZCGP) to pivot to telehealth overnight and to conduct a virtual consultation prior to an in-person one.1 A steep learning curve followed.
Now, telehealth is very common, and it can feel like it is ‘just a phone consult’. Most of the time phone consultations are very straightforward and can be relatively quick. But not always. This case demonstrates some of the factors to consider when conducting a phone consultation and when to convert to in-person.
I have changed some of the details to ensure anonymity of the patient and member involved.
This case took place during the Covid 19 pandemic lockdown. At that time there were serious concerns about the transmissibility and severity of the Delta variant in New Zealand. Rapid Antigen Tests (RATs) were not approved for use and PCR tests took days to return a result.
Mr T, a 49-year-old Niuean man was seen in the ‘Red zone’2 of the clinic. He was not enrolled at the clinic, so previous medical notes were unavailable. The triage notes state the patient had chest pain and shortness of breath. The patient looked unwell. His observations were taken showing pulse 120bpm, temperature 36.7o, BP 140/100, respiratory rate 18 breaths per minute, oxygen saturation on room air was 97%. Mr T was categorised as triage score three (to be seen within 30 minutes).
As per the RNZCGP guidelines, the GP called the patient on the phone. Mr T spoke limited English, so his sister translated for him. He complained of shortness of breath and chest and back pain initially which came on while gardening, later becoming generalised. His breathing was worse lying down but did not improve by sitting up. His whole body felt sore. He had fever but no cough, runny nose or sweating. Apart from smoking he had no significant medical history of note. Given the generalised body aches, fever, shortness of breath, and tachycardia the doctor assessed this as likely Covid 19 infection and prescribed paracetamol, codeine, and ibuprofen and ordered a PCR to confirm Covid 19 infection. The GP provided safety-netting advice to call an ambulance if Mr T became more short of breath.
The GP phoned the patient the next day and spoke to the patient’s relative who said that Mr T was improved and no longer short of breath. The GP advised the relative to wait for the PCR swab result and to call Health Line (afterhours phone service staffed by nurses) or the clinic if they had any concerns.
Later that day Mr T collapsed with chest, abdominal, and back pain. An ambulance was called but sadly Mr T died shortly after arrival to hospital. Postmortem showed cause of death was acute peritonitis and shock secondary to perforated duodenal ulcer.
The coroner took jurisdiction and held an inquest.
At first glance, it appears that the GP made a terrible error. However, as Medical Protection gathered information, it became clear that there were many factors that explained the care provided and that for the most part the care was appropriate.
Medical Protection assigned a medicolegal consultant to the case and instructed a lawyer to assist at inquest. Our lawyer assisted the member to finalise their statement. Medical Protection was careful to provide information about the Covid 19 situation two years prior to the inquest, as much had changed in that time. In addition, the approach to telehealth had matured considerably by the time the inquest took place. Medical Protection also obtained our own expert opinion to counter what we considered to be an unbalanced expert opinion obtained by the coroner. We were able to explain the cultural context in this case which influenced the outcome. This put the member’s actions into the appropriate context, exposing hindsight bias in the coroner’s expert opinion and which clearly explained the rationale for the decisions made at the time. Our lawyer was present throughout the inquest to ensure that our member’s interests were protected.
The coroner made only a mild criticism of the member. They found that the GP’s decision not to convert to in-person consultation was materially and adversely influenced by the restrictions imposed by Covid 19 at the time: lockdown, concerns about the Delta variant, low vaccination rates, and concern of transmission to staff and their families. There were no RATs available in primary care. No equipment for video consultation was available.
There were extenuating circumstances in this case that led to mild criticisms in this case. There are lessons that we can take from this even now outside of the Covid 19 pandemic. Use your clinical judgement whether to convert to in-person consultation taking into account:
Limited English language skills
Use of untrained interpreters who often not only partially translate but answer for the patient
Poor health literacy
Limited access to clinical notes
The cultural context of the patient. Pasifika people are well known to be very stoic. In some cultures it is usual to say what they think you want to hear and tend to simply acquiesce those they believe to be in authority.
Limited access to and knowledge of how to use technology such as video