> Last week one of our residents came to me
> visibly shaken after responding to such a code as she felt
> the attending physician did not treat the patient
> appropriately and among other things, gave drugs which were
> not indicated and shocked the patient while they were in asystole.
>
This is exactly the problem with ALS: here you have a member of staff upset,
coming to talk to you (i.e. not working at their best and taking up time of
2 doctors) about a breach of guidelines that would not make any difference
to patient outcome. The trouble with guidelines is that once they are there,
people think they are a) correct and b) important. Neither view is
necessarily correct. My experience of the advanced life support courses is
that each lecture is usually preceded by a spiel on how important that
lecture is (indeed, this is how we are taught to give them). A small change
to preceding and concluding each lecture with a mention of the presumed
effect of its recommendations on absolute mortality and the margin for error
in that estimate (strength of evidence base) might prevent this type of time
wasting argument.
> I suppose one could argue that you cannot harm a person once
> dead (and they won't vote either, right Patrick!), however it
> is clear that this particular physician knows the contents of
> the ACLS guidelines but does not have an adequate
> understanding of them to apply them appropriately.
Are you referring to the ward based physician or your own resident here? If
the latter, apologies for restating your point.
> PS I sometimes become very rebellious and order an ankle
> film when Ottawa Ankle Rules would have me refrain from doing so.
>
Has this ever altered your management? Ottawa ankle rules are evidence
based. There is a big difference between class 1 evidence based protocols
where it is clear what risks are being run by their breach and class 3
evidence based treatment options where there is no way of knowing how
accurate or important they are.
Matt Dunn
Warwick
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