Dogmalysis and Pragmatogenesis #WILTW

This is the 147th #WILTW

I was first introduced to the idea of dogmalysis by Cliff Reid. It’s the break down (-lysis) of a widely held belief (dogma-). As Cliff points out numerous cognitive biases “prevent us from conducting an impartial analysis of objective clinical data“.  Essentially some of the things we do in clinical practice have no real foundation and persist despite evidence to the contrary. When I started in paediatrics all children with wheeze received a dose of steroid and a nebuliser regardless of age or severity of illness. This practice has altered significantly in my career but dogmaphiles still do exist.  Whether Cliff truly invented the term might need to  be subject to some dogmalysis itself but it’s a wonderful concept to consider in medicine.

I reviewed a recent publication with two registrars this week.

Wilson et al. Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study. Ann Emerg Med 2017 doi: 10.1016/j.annemergmed.2016.12.010.

This concise paper takes on a very common issue which has been surprisingly under explored. The last decade has seen a huge increase in the value placed on observations as markers of severity of disease. This is in part driven by the increase in Early Warning Systems but also repeated demonstration that physiological changes which may predict death often occur in patients hours before they deteriorate.

It’s a relatively well designed study in which, although the disposition and treatments of patients in North America may be different from the UK and Europe, the number of patients and granularity of the reported data make the study findings externally valid.  While there was a slight increase in return rates for children discharged with high heart rates; overall outcomes were not different i.e. in isolation a high heart rate at discharge was not predictive of patient harm.

Admittedly it’s retrospective study (A non concurrent cohort study sounds a little more sexy), we don’t know the interplay of a high heart rate with other physiological features and the overall incidence of serious negative outcomes was low. This for me means that the dogma you should never discharge a child with a tachycardia can not be ‘lysed’ just yet. But even before reading this paper I’d not had a high heart rate and do not pass go attitude myself. There are rarely absolutes and contextualising each case you see is vital.

Pragmatism is really important. When you realise that admission is not always the safe option basing your judgements on one clinical finding doesn’t seem to be in the patients’ best interest. This study supports a balanced approach to the care of the acutely unwell child and should help aid decision making around the discharge process. Why am I sending this child home with these observations?  In the absence of other identified risks, and appropriate experienced review, then it’s probably safe to send the child home.

I’m looking forward to reading some more pragmatogenic papers in the future.

What have you learnt this week? #WILTW

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Related Reading:

A Pre-mortem to prevent a post-mortem 

Sepsis and Self-Doubt

Have we forgotten to teach doctors how to think? 

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