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Sunday, June 22, 2008

A guideline is just a guideline

The Happy Hospitalist wrote a neat post about guidelines from a doctor's perspective. But he reminds us that while a guideline is a good tool, it is just a guideline.

We'll make this RT Cave Rule #15:

RT Cave Rule #15: A guideline is just a guideline. It is not a substitute for experience and common sense. For the most part, that guideline is just a tool.

I've written on this blog about how sometimes asthmatics require a bronchodilator more often than is recommended on guidelines.com. Sure the guideline states that if a rescue inhaler is needed more than 2-3 times a week, your asthma is not controlled. But just because someone uses his inhaler more often, does not always make for uncontrolled asthma.

Look at it this way. What if a person had bad asthma, and used his inhaler 10 or more times in a day. As time goes by he and his doctor eventually find a better medicine routine, and the patient makes a few changes in his life, that allows him to only need to use his MDI 2-3 times a day instead of 10.

This same person is active in the community, and stays physically active. You cannot tell me that this person has uncontrolled asthma.

In fact, this brings us to RT Cave Rule #16:

RT Cave Rule #16: If you have asthma and you do not miss work, and you do not miss school when you are a kid, and you are able to lead a relatively normal life, then your asthma is controlled. That's how we define asthma control. It's not based on how often you use your rescue inhaler.

The same is true of COPD:

RT Cave Rule #17: Whether someone has controlled COPD is not based on how many times a rescue inhaler is used, or how much oxygen the patient is on, but whether or not that patient can continue to be a productive member of society.

Ideally, however, you want your asthma and COPD patients to not need to use their rescue inhalers, but in the real world, many lung patients get short-of-breath when they wake up in the morning, and might need a few puffs. I don't see a problem with that.

I can use myself as an example here. I have asthma. I work out just about every day, and I jog (not walk) four times a week. And I rarely use my inhaler during the day. However, I do use it a few times during the night, most particularly first thing in the morning. And, most important, I have never missed one day of work due to my asthma. I'd consider my life as normal; my asthma stops me from doing nothing.

However, I have had a few people email me and tell me my asthma is not controlled because the asthma guidelines state that if you use your MDI more than twice a week, then your asthma is not controlled. That might be true of most asthmatics, but there are exceptions to every rule that doctors have to be prepared for.

The same can be said of COPD patients. If you measured COPD control based on how often a rescue inhaler is used, then there would be very few COPD patients who have control of their illness. As we learn in RT school, the goal with COPD patients is to help them remain productive members of society.

Sure, Mrs. Beady might need to use oxygen 24 hours a day, and may even go through an inhaler every month, but her disease does not stop her from performing the daily routines she has been doing her entire life. She is a productive member of society.

Another example of how guidelines are sometimes misused is with ACLS. We have some doctors here who go by ACLS as though it were the Bible.

The other day, for example, I was bagging this little-old-lady with one hand while holding the mask with the other. There was no problem. Air was going in easy.

Then Dr. Krane decided to hold the mask with her two large hands, and I let go and used two hands to bag the same tidal volume. Air started squirting out the edges of the mask: BLLLLLLLLPPPPPPPP.

I looked through the mask, and saw that poor little old ladies facial features all squeezed together. Air wasn't getting in.

"I think you better ease up a bit," I said.

She said, "ACLS recommends one person hold the mask, and one person bag." Yeah, but this lady was ventilating just fine until you grabbed the mask. Let go!

She did not. She had to live up to those ACLS guidelines to a tee, even if it was to the detriment to the patient. The patients sats dropped suddenly.

Now I was in a predicament, because I certainly didn't want to overrule a doctor when she was standing right next to me. Finally, she let go to grab the ETT, and I pumped in some nice easy breaths real fast, and our patient pinked up just fine.

Our doctors are also particular to doing three Q20 minutes treatments. Or, in Dr. Krane's case, Q1 hour treatments. One day I asked Dr. Krane why she does that, she said, "Because it's in the asthma guidelines."

That's fine and dandy, I thought. But what if that first treatment worked and a second wasn't needed. Do I still need to give a second treatment when that first one worked just fine? The patient's all shaky and jittery from the first, do we have to give a second?

According to her guidelines the answer is yes. According to my RT Cave rule, common sense says no.

This brings me to another RT cave rule #18:

RT Cave #18: While guidelines should always be considered, each patient and each patient situation should be assessed and treated individually. We cannot treat all patients the same, as most guidelines portray.

It all comes down to common sense. Guidelines are only as good as the paper they are written on. While they can be a great tool, common sense is the key.

1 comment:

Amy said...

Oh yeah, this is a great one for parents, especially--trust your own common sense! I've had 2 different pediatricians look at me funny when I explain how I use albuterol every 4 hours when AG has a cold, even if she has no asthma symptoms, rather than use it as needed.

When I then explain how she'll end up on prednisone when I don't do this and then look through her records they say, "Okay. Sounds good."

Couldn't agree more on this one!