The following is applicable to all medical specialties...
While most of our clinical choices are largely based on sound evidence, there is always the occasional decision we take that is based on what we have assumed to be right simply because we haven’t seen it being done any other way. These decisions are based purely on the dogmas in our practice: ideas or beliefs accepted as authoritative – unquestioned, undisputed, and unchallenged. These dogmas could be based on anecdotal evidence, hearsay, words handed down by seniors during training, or simply in practice just because “everybody does it this way.”
Ironically, this seems to reflect more of an old-fashioned “keeping up with the times” mentality, with a general premise of breaking away from perceived dogma. As to specifically what these “times” are that seem to be passing the rest of us by, and what has become problematically dogmatic in training, I admit I have been unable to locate in any of the proposals other than the broader, “timely” rubric of change for change’s sake.
Cricoid pressure is a time-honored maneuver based in decades of dogma, but had never been tested in randomized trials.
Concerns that too little antibiotics could lead to the survival or “selection” of resistant bacteria can be traced back to the discovery of antibiotics. However, there is a lack of evidence to show that failing to complete a course of antibiotics leads to resistance in that bacteria.
Taking it did not lower their risks of cardiovascular disease, dementia or disability. And it increased the risk of significant bleeding in the digestive tract, brain or other sites that required transfusions or admission to the hospital.
Lidocaine is not proven to prevent a rise in ICP during RSI. While it may not directly harm patients, its administration does delay the completion of RSI, which puts the patient at risk for continued hypoxia.
In critically ill patients, with hemodynamic instability, vasopressor infusion through a proximal PIV (antecubital fossa or external jugular vein), for <4hours of duration is unlikely to result in tissue injury and will reduce the time it takes to achieve hemodynamic stability.
The traditional teaching of withholding pain medication in patients with acute abdominal pain stems from a time when medicine was without modern diagnostic techniques and when the intravenous titration of opiates was not routinely practiced. Early and appropriate pain relief for patients with acute abdominal pain is humane, does not adversely affect diagnostic acumen or clinical decision making, and should be considered part of the initial management of every such patient.
However, stopping the use of epinephrine in OHCA is still an academic musing, unfortunately at this time ACLS still recommends epinephrine in OHCA, which means we still give epinephrine for OHCA but the ACLS algorithm should be readdressed as epinephrine results in more ROSC, but no increase in “good” neurologic outcomes after OHCA.
The oft quoted 10% “cross-reactivity” rate between penicillins and cephalosporins is inaccurate based on the best available evidence. The true rate is somewhere between 1-3%.
VBG can be used in place of ABGs.
After starting IVF, the next step in DKA management is electrolyte replacement, NOT Insulin.
We are far more likely to harm patients with strep pharyngitis by giving antibiotics than to help them in developed countries. This does not apply to developing countries with poor public health.
Dogma is a belief generally held to be true by a group, organisation or professional body that is put forth as authoritative without adequate grounds.
If initial direct pressure fails to control hemorrhage, remove the dressing and apply well-aimed direct pressure onto the hemorrhage location. When this fails, a tourniquet or hemostatic agent should be used.
According to Bottrell, modern evidence suggests that the hypercapnic drive is never completely blunted, and therefore even COPD patients with chronically elevated PaCO2 will not stop breathing in the presence of higher oxygen levels. "There is such a thing as the hypoxic drive, but the hypoxic drive theory is a myth," he said.
Multiple different sources support the use of proper nasal airway placement for patients with head injuries; the key here being using proper technique and stopping when resistance is met and directing the airway along the base of the naval cavity. Directing any nasally placed device upward toward the eyes increases the likelihood of complications.
Given the absence of any significant benefit, particularly in the emergent setting, and the potential for serious harm, this recommendation from the nephrology literature seems very reasonable: “It would be wise to exhaust other alternatives for managing hyperkalemia before turning to these largely unproven and potentially harmful therapies.” (J Am Soc Nephrol 2010;21:733.)
The evidence demonstrates that not only does the Trendelenburg position not help patients experiencing hemorrhagic shock, but it can actually be harmful because of effects on both ventilatory and circulatory systems.
Intravenous normal saline plus observation does not decrease ED length of stay compared with observation alone in uncomplicated, alcohol intoxicated patients.
Another way to state this is, if using ATLS guidelines to guestimate BP, we are grossly underestimating the degree of hypovolemia our patients have.
In patients with no cardiovascular risk factors the use of epinephrine in digital nerve blocks is SAFE.
In patients with cardiovascular risk factors the use of epinephrine in digital nerve blocks is PROBABLY SAFE
Clinical Take Home Point: A more appropriate approach to simple hyperglycemia, may be ensuring appropriate outpatient follow up for long-term glycemic control, just as we currently do for asymptomatic hypertension, instead of reaching a “safe” glucose threshold before discharge.
Six accepted ED practices that are potentially harmful, costly, inefficient, or just don’t work.
#1 Nasal Airways
#2 Lidocaine use in RSI
#3 Kayexelate in Hyperkalemia
#4 Trendelenburg Position
#5 Bleeding Control
#6 COPD and the hypoxic drive
There have been many examples in pulmonary medicine and respiratory care of dogma perpetuating poor care for our patients. We begin by demonstrating that even great minds can make great mistakes. To quote Nikki Giovanni, “Mistakes are a fact of life. It is the response to error that counts.”
NG lavage DOES NOT help patients in the emergency department with acute upper GI bleed and is an outdated practice.
Iodine is not a component of tropomyosins and parvalbumin, therefore it is not the iodine that is the source of people’s allergies to seafood…Iodine is NOT an allergen!!!
The cause of anaphylactoid reactions from radiocontrast is not from the iodine, but thought to be from the hyperosmolarity compared to blood.
Low-Osmolar Contrast Media (LOCM) has significantly reduced the number of severe reactions to radiocontrast.
Topical anesthetics did a better job of controlling pain and in all but one of the studies no statistical difference in cornea epithelial healing at 72 hours.
The myth that you can, however, is genuinely dangerous.
The medical fraternity must learn how to ask questions systematically, how to find the answers in literature, how to critically appraise the literature, and how to eventually apply the results to practice. Only when clinicians rise above the mundane, think out of the box, and come up with new ideas, will science progress. After all, nobody gets a Nobel Prize for maintaining status quo!
Hence, do not let sleeping dogmas lie, kick them and drive them out!