A patient who changed my practice: Always check the respiratory rate

BMJ 1997; 314 doi: (Published 24 May 1997) Cite this as: BMJ 1997;314:l
  1. P Burdett-Smith, consultant in accident and emergency medicine
  1. Liverpool

    The young lad had been injured riding a motorbike “off road.” He was complaining of lower chest pain and had tenderness suggestive of blunt injury but with no obviously fractured ribs. His pulse and blood pressure were normal but he was breathing at 40 per minute. A drip was put up and he was sent to have an x ray examination. While being transferred to the trolley his blood pressure dropped and he became unconscious. He was rushed back to the resuscitation room and what had seemed to be a controlled situation became an emergency.

    Despite intravenous fluids and ventilation he remained hypotensive. The on call surgical registrar was called and examined his abdomen. “Nothing for us in there,” was the verdict. He was transferred to intensive care where despite full resuscitative measures, he died that night. A necropsy showed a ruptured spleen and liver lacerations. He came in talking and died.

    I was not involved in his treatment but his death shocked me. Trauma resuscitation was one of the hot topics and advanced trauma life support programmes were just beginning to be talked about. Although no courses had yet been run in the Britain, trauma scoring was starting to show promise, and the Royal College of Surgeons' report on 1000 trauma deaths was soon to be published. His death reinforced that it is the young who die from trauma, but also illustrated several other points, now thankfully much more widely recognised.

    Young people will maintain normal blood pressure and even pulse rate until they suddenly decompensate; they are then almost impossible to resuscitate. Most importantly the respiratory rate is an accurate reflection of severity of illness.

    Of the 16 physiological variables measured by the original trauma score, only three–the Glasgow coma score, blood pressure, and respiratory rate, have a positive correlation with mortality. The next two years saw advanced trauma life support programmes start throughout Britain, the start of the major trauma outcome study, and a move towards centralising trauma care in larger departments with x ray facilities in accident and emergency departments. Ultrasound and peritoneal lavage are now used rather than simple examination to evaluate abdominal trauma, and fewer young people die from treatable injuries.

    I now always check the respiratory rate in patients with serious medical or surgical conditions, but while we have electronic means of measuring pulse, blood pressure, temperature, and oxygen saturation, respiratory rate is still calculated by eye and is still the most commonly omitted observation.


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