The fight against dogma in critical care
Whenever I have residents rounding with me, there are a few exercises I have them go through. Often the most revealing to them is when I ask them to spend a day recording each diagnostic or therapeutic act they do, and classifying them as based on either evidence, physiology, or culture - meaning they learned it somewhere along the way as common practice but really have little idea as to how valid it is. They are usually quite shocked by the end of the day when, by their own calculation, 40-60% or so of their practice is essentially dogmatic!
Take the routine use of (ab)normal saline - usually by internal medicine types (such as myself) - despite the considerable amount of data available since Dr. John Kellum brought to the medical field's attention the work of chemist Dr. Peter Stewart, including finally recent research on renal injury, and the pH of 5.6 which can be read on the label, remains in wide use in large bolus amounts. It's the main part of many physicians' fluid resuscitation, yet is neither evidence-based nor physiological in the least.
Should we mention NaHCO3? Any one physician who bothers scratching the surface of its use quickly realizes its appropriate use is exceedingly limited, yet, in my practice, I routinely stop i.v. bicarb drips aimed seemingly at correcting a low serum bicarb...
It is unlikely that we will ever completely eradicate dogma from our practices. Medicine is simply too complex to have every facet completely and correctly broken down. But we should try to limit it, especially in our common practices, and the above-mentioned exercise, first assigned to me a decade and a half ago, is a great way to start. Still working on it.
For anyone remotely interested, our annual symposium, this year, is entitled 'Challenging Dogma in Adult and Pediatric Acute Care' and takes place in Montreal on may 25th and 26th. More info at www.ccusinstitute.org.
Dr. Philippe Rola is Chief of Service of Intensive Care, Santa Cabrini Hospital and President of the Critical Care & Ultrasound Institute. He blogs at thinkingcriticalcare.com.