Wednesday, 25 January 2017

The Well Covered Wheezer

Guidelines almost always dedicate themselves to 'what to look out for'- the red fags and risk factors.  Often, we go to a guideline in order to learn about a condition, only to find that we should be afraid, very afraid.  I think that the tendency for the glass-half-empty factor in guidelines is almost certainly due to the understandable desire to err on the side of caution.  When you are writing a guideline, you are very aware that if (when) a patient has a bad outcome, the guideline's recommendations will be critiqued.

However, I don't want my doctor to intentionally err at all. To be honest, the error being on the side of caution is very little consolation.  Unnecessary tests, treatments, referrals and admissions are not what I want.  I want my clinician to be thoughtful and careful, but courageous, not risk averse.   I believe  that calculated risk is a necessary part of practicing medicine well, and so struggle with guidelines that give us the impression that we have to follow a certain pathway even when our instinct tells us that this is not needed.

Of course, I know that many of you will now be thinking, “Guidelines are just guidelines.  You don’t have to follow them.”  While this is of course a true statement, try telling this to a clinician who has been to court regarding an adverse outcome.

I don't want to return to an era bereft of guidelines.  That was no fun at all.  Someone else knew what you were supposed to do, most of the time.  It was your job to guess what was expected of you and then find out afterwards if you were right, rather that to be told beforehand.  However, we need to be aware of the negative effects of guidelines, so that we can protect against these.  (1,2)

I do feel that the guideline era has taken some of what used to be taught and allowed this to drift into mythology.  So, in the interest of history, I thought that I would explore what the guidelines often miss out – the signs that are reassuring.  When marking some assignments for the Primary Care Paediatrics course at Sheffield Hallam University, I was delighted to find the oldest reference that I have ever seen in one of these submissions.

Cassell’s Household Guide to Domestic Medicine (1886) - “…on the minutest air-tubes the cells of the lungs are placed… inflammation of these tubes is one of the most fatal diseases in our climate…The child is quickly bereft of its usual liveliness… the breathing is quick and the nostrils expand more or less… All these symptoms are worse if they occur in delicate children…”(3)

The first thing that struck me about this was that in Victorian Britain, the pathophysiology of bronchiolitis was already known.  The second was that they recognised that scrawny babies with bronchiolitis were the ones to worry about.  This brings me onto the well covered wheezer.
In the days before guidelines, I learned paediatrics by trial and error with a degree of question and answer.

Me: “This child is very wheezy.”
Consultant:  “They’ll be fine.  They’re a fat, happy wheezer.”
Me: “So because they’re a bonnie baby and smiling, they’ll be fine?”
Consultant: “Pretty much.”

I don’t know of any research demonstrating the protective benefits of an extra pound of subcutaneous fat when suffering with bronchiolitis.  What I can tell you is that 20 years on, I’ve never had cause to feel misled by this conversation.  That is partly because I leaned the difference between red flags and those that were more of a blood orange colour.

I would say that it is only the 'significant tachypnoea or recession' which could be negated by other reassuring factors such as being well covered and cheerful.  I also think that this is probably self fulfilling: children with the other red flags are too significantly affected to actually have any reassuring features.

What is also interesting is that, in a straw poll of ten junior doctors, none had heard the term ‘fat happy wheezer.’  This is not down to modernity either.  None of the doctors in question had heard it said that habitus was worth considering when assessing a child with bronchiolitis.  I put this down to an overemphasis on red flags and risk factors, without justice being given to reassuring signs.

So, I am going to appeal to two groups of clinicians to help restore balance to The Force:

Firstly – all you experienced, common sense clinicians, please comment below and let me know what other things are reassuring signs which might be unproven but tell you not to be so worried.

Secondly – all you academics, please research these things and get us the evidence to back up what we all know to be true.  After all, this stuff has been known for 130 years now. It’s time we proved it.

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