Real Doctor's Creed: Appendix Z: Problem Solving
Section 982: Pediatric Croup.
By Dr. Richard Crank, Shady Health Medical Center, January 7, 1982
The boy had croup. Even without auscultation I could hear the inspiratory stridor. Upon auscultation, I could hear it radiating throughout the lung fields. The emergency room physician reported giving the patient a shot of decadron. Upon admission, I ordered Q2 hour racemic epinephrine if needed.
The child did very well during the night, with the exception of one episode where the child became croupy in his sleep. His sats were always 98% or better on room air. During the day today the child has gotten progressively worse, per the respiratory therapist, with the need for Q2 hour racemic epinephrine over the past six hours. The therapist said the patient's SpO2 remains 98% on room air. The therapist also suggested that perhaps the decadron was wearing off, and another one should be given. He suggested maintenance doses.
Question #1: So, what do you do next? What medicine do you order?
Understanding the Code 787 of the Creed recommends that we never let anyone with an associate's degree tell us what to do, I did not immediately respond to the request. This bought me time to remember a study that was done in 1981 where pulmicort was given to four patients with croup. Withing a day or two of one dose the patients went home. The logical conclusion was it was the Pulmicort.
So I ordered a one time dose of pulmicort.
The respiratory therapist called an hour later. He said he gave the pulmicort reluctantly, and that 90% of the medicine was wasted because he gave the medicine to the infant via blowby. So the child only had a chance to get 10% of the medicine. However, he said, the child cried throughout the treatment, so 90% of that 10% was wasted. This means the child only got 1% of the medicine. Then the child writhed and turned, resulting in 90% of this 10% being wasted, and this gets us down to, he said, the patient getting only 0.1% of any mist produced by the nebulizer. He also said it takes Pulmicort 2 weeks to get into the system and start working, so it would have no immediate effect on croup anyway. He said what was needed was a systemic steroid to resolve the stridor, because the nebulizer route wasn't going to work for this kid.
In other words (my words, not his, although this is what he was thinking), the treatment was a waste of time and I'm a dummy for ordering it.
This brings us to question #2: What do you do next?
I did nothing. I simply wrote on the chart: Discharge patient in the morning if stable.
Conclusion: There is no need to doubt this study even though nearly every other study and clinical evidence suggests that it's poppycock. If it sounds good it is true. Period. Ignore rants of silly respiratory therapists who think they know all.