Is it asthma, or croup?

I was called to the emergency room to give a breathing treatment to a 1-year-old who was having mild retractions with an audible stridor. Notice I didn't say I was asked to assess the patient, I was called because the nurses believed the doctor would want me to give a treatment, and probably a racemic epinepherine treatment.

The patient to me sounded quite diminished, and I suspected bronchospasm. I told this to the doctor, and he disagreed with me. He thought it sounded like croup, and he ordered for me to give a racemic epi treatment. I didn't have a problem with this on the grounds the race epi would also dilate the bronchioles if they were, as I suspected, truly spasming.

See, I have learned through the course of my experience that asthma sometimes sounds like croup. There are times, especially in children (yet occasionally in adults), audible stridor, coupled with diminished lung sounds, is sometimes indicative of asthma.

After the treatment the patient was obviously breathing better. The retractions were gone. And, when I listened with my stethescope, lung sounds were markedly improved, with much improved air movement.

Satisfied, I went upstairs, where I sat at my desk and the phone rang. It was the nurse of the baby. She said she thought I should set up a cool mist aerosol for the baby. "Don't you think that would help his croup," she said.

Again, I was thinking this was reactive airway and not croup, but I said, "Well, I think you better run that by the doctor, because every doctor has a different plan of action for croup." And this was true. As I set the phone on the receiver I almost made myself laugh as I thought, "Yep, every doctor believes in a different fallacy."

This is why I like to say medicine is an art more so than a science. It's based on science, although when it comes down to it medicine is an art.

We have a lot of policies, and order sets, and dogmatic doctors all that treat all patients the same, or from the same cookbook. Much of this, or so they say, is based on best practice medicine. This is great for most cases.

Doctors who treat all patients from the same cookbook often mistreat and over treat. A perfect example is my asthmatic patient here with stridor and no wheezes.

Yet there are fallacies too. For example, for croup one doctor likes to give race epi, and another xopenex, and another albuterol, and another likes to set up a cool mist, and another a shot of steroid (the actual only thing that really works). Worse, some doctors and nurses (and RTs) can't see outside the cookbook. They don't think.

It's almost funny the fallacies in medicine. It's even funnier that there is no consistency of fallacies, and it's this reason we RTs sometimes get vexed, are often apathetic, and why we call for protocols.

Thankfully the doctor on duty that night was not a cookbook doctor. He did not order a cool mist aerosol. In fact, later when I discussed with the doctor, he told me I was right. Later, as I was leaving the ER to the RT Cave, I couldn't help but to smile.