Reading posts from multiple listservs is much like Cold War-era CIA monitoring of Russian phone calls—you have to scan through a lot of unrewarding material to find a nugget of interesting material. But that nugget, once found, can be a revelation.
Recently, the American Academy of Pediatrics (AAP) released an update to its clinical practice guideline (CPG) for bronchiolitis in Pediatrics. The 2011 incarnation had made concessions to the “do something” crowd, allowing for a “carefully monitored” trial of either albuterol or epinephrine, but the 2014 version quashed all hopes of pharmacologic intervention by eradicating that possibility.1 The AAPHOSPMED listserv, which goes out to the members of the AAP Section on Hospital Medicine, predictably bloomed with a flurry of entries opining about the 2014 guidelines, many of them from academic leaders in pediatric hospital medicine (PHM). But one entry, submitted by Scott Krugman, MD, chairman of pediatrics at MedStar Franklin Square Medical Center in Baltimore, caught my eye:
While the hospitalist medicine group celebrates, I’d thought I’d let you all in on the reaction from the Peds EM list serve (2 emails follow with redacted names….):
Date: Thu, 30 Oct 2014 15:17:57 -0700
Subject: My name is Dr. Indigo Montoya, You Killed Albuterol…
...prepare to die.
In face of the recent AAP Guideline on the management of bronchiolitis, I am recruiting other Peds ED centers who will be endorsing this set of practices to serve as the treatment group in my non-randomized observational study. Our center will serve as the ‘out-of-control’ group and we will be initiating a new clinical pathway entitled... ‘Empiric therapy for the treatment of undifferentiated respiratory distress in infants.’
It is my hypothesis that our group’s admission and bounce-back rates will be the same as last year.
I anxiously await the data from the centers who adopt the AAP approach!
Subject: Re: My name is Dr. Indigo Montoya, You Killed Albuterol…
Date: Thu, 30 Oct 2014 20:07:51 -0400
I am pretty sure it is Inigo Montoya.
Best movie ever.
How about this:
Trial of Duoneb
If you see a positive clinical response, great, if not...well...don’t give it anymore. If a very strong positive clinical response, consider steroids in addition. Can you believe I said that? I understand the studies for “traditional” bronchiolitis, I also understand there is a subset of these patients that I see that have a very favorable response to this treatment. I also see some variation to the response year by year. Have also heard and (think I have, as we have no rapid test for this) seen very good response with EV D68 to Albuterol + steroids.
At first read, I was surprised by the evident mastery of satirical humor manifested by our peds ED physician colleagues. Then it began to dawn on me that perhaps these comments were not purely in jest. But, then again, this is not so terribly inconceivable to any pediatric hospitalist—the ED is the last great bastion of nonstandardized medical practice (or maybe that’s the ICU). If any group of physicians were to thumb their noses at the AAP bronchiolitis CPGs, clearly they would be ED docs.
As I was vacillating between horror and indignant vexation, I began to realize that our peds ED colleagues are perhaps more intelligent than we give them credit for. Just the prior month, in the September 2014 issue of Journal of Pediatrics, a group of researchers, led by Vineeta Mittal, MD, associate professor of pediatrics at UT Southwestern in Dallas, had found that, despite the scholarly, evidence-based implementation of bronchiolitis guidelines across 28 U.S. children’s hospitals, these CPGs had not significantly moved the needle on ordering nonrecommended therapies and diagnostics.2 My only comfort was that Dr. Mittal had at least been able to lower the ordering of chest radiographs, bronchodilators, and steroids through the use of a bronchiolitis CPG at her own institution, Children’s Medical Center in Dallas, as described in the March 2014 issue of Pediatrics.3 Truly, Dr. Mittal, “you have a dizzying intellect!”
But the fact remains that PHM thought leaders, despite their best intentions and dedicated pursuit of research to improve bronchiolitis outcomes, have begun to alienate peds ED physicians and likely many pediatric hospitalists as well. In the Country of (Todd) Florin, MD, MSCE, otherwise known as Cincinnati Children’s Hospital ED, researchers led by Dr. Florin found that the release of the AAP bronchiolitis CPG in 2006 had not significantly changed the utilization of nonrecommended resources in bronchiolitis, despite the fact that use of these nonrecommended resources only increased length of stay without reducing readmission rates.4 Once again, we find that simply releasing high-minded CPGs without appropriate local multidisciplinary active implementation is as ill-fated as a land war in Asia.
Perhaps we shouldn’t be surprised that individuals trained for years to trust their gut feelings about the patient in front of them would begin to buck the tidal wave of regulation, oversight, and standardization that has begun to define how medicine is practiced in the 21st century. Many pediatric hospitalists and pediatric ED physicians would take issue with the outcomes cited by CPGs as not taking into account the therapeutic benefit of even short-term symptomatic improvements achieved through bronchodilators use. As Dr. Inigo Montoya might say, doctors have been in the thinking-independently business so long that, now that it’s over, they don’t know what to do with the rest of their lives.
Yet, is that really true? Have clinical pathways, practice guidelines, and high-minded academic pediatric hospitalists snuffed the life out of our quick-thinking, sword-wielding heroic physician?
Perhaps, but mostly dead is slightly alive.
I would posit, however, that our heroic physician, instead of viewing the local hospital’s creator of CPGs and clinical pathways as a condescending Prince Humperdinck, should consider him more of a Fezzik, who would do their heavy lifting for more mundane tasks, leading the charge against more worthy adversaries. Who wants to enter all those orders anyway?
For who could resist storming the castle of Kawasaki Disease? Hand-to-hand combat with metabolic defects? The Fire Swamp of PHM is still lurking with Diseases of Unusual Size that haven’t been tamed by AAP CPGs. Even our old nemesis, sepsis, has been found to be less susceptible to the arrows of early goal-directed therapy (EGDT) than we thought.5 By reporting in the October 16, 2014, issue of New England Journal of Medicine that EGDT may not reduce mortality in sepsis after all, fearless Aussie and Kiwi ARISE investigators may have opened a path for pediatric hospitalists and intensivists to follow in the battle against pediatric sepsis.
So, fear not, brave PHM warrior. There are still dragons to slay, ogres to battle, ED docs to debate as to whether to admit the kid with iocane poisoning. Do not worry about CPGs, and have fun storming the castle!
I would like to thank Drs. Scott Krugman, Jay Fisher, and Todd Zimmerman for giving their permission to reproduce their listserv posts, which inspired this column.
- Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.
- Mittal V, Hall M, Morse R, et al. Impact of inpatient bronchiolitis clinical practice guideline implementation on testing and treatment. J Pediatrics. 2014;165(3):570-576.e3.
- Mittal V, Darnell C, Walsh B, et al. Inpatient bronchiolitis guideline implementation and resource utilization. Pediatrics. 2014;133(3):e730-737.
- Florin TA, Byczkowski T, Ruddy RM, Zorc JJ, Test M, Shah SS. Variation in the management of infants hospitalized for bronchiolitis persists after the 2006 American Academy of Pediatrics bronchiolitis guidelines. J Pediatrics. 2014;165(4):786-792.e1.
- ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal-directed resuscitation for patients with early septic shock. New Engl J Med. 2014;371(16):1496-1506.