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“Benefit” of the doubting and the “risk” of doubting in cardiac care !

Posted Jun 19 2009 4:15pm

When  a doctor is confronted by serious  doubt  ,  what will be the outcome for the patient  ?

Can  doubting  be beneficial for a patient ?  . It seems so ,  according to  EBM which  stresses   about statistical outcome at every turn of events in a  patient who  is critically  ill .

Is  something ,   always  better than  nothing   ?   Our  limbic  system tends to think so .  It  may not be true. But  in  dire situations ,   anything has to be tried  however doubtful it may be  , like an   emergency in  an air plane. Even here there need to be a logic.

Then , this question  arises . How do we make  sure ,  we have a  dire situation on hand  ?

This is the central issue in clinical decision making .That needs  experience ,  only experience. Though the principle of uncertainty  is the fundamental rule ,  EBM  aims to bring some degree of certainty in medical therapeutics.

ebm evidence pci coronary

Benefits of doubting in coronary care unit.

In  a  sinking patient  with cardiogenic  shock  try  the maximum treatment .Even if the patient is  in severe shock  , take him to the cath lab ,  try  open the coronary artery . Give the benefit of dobut to him even though the chances of reviving him is less than 20%.

Risk of doubting in Coronary care unit.

A.Elderly STEMI  with SHT,(Arriving late ,  with  an unknown time  window  after an MI ) To thrombolyse or not ?  . There is  no benefit of doubt here.  Do not thrombolyse.

B. Chest pain with  LBBB (Thought to be new onset LBBB ) don’t ever rush to thrombolyse  your doubts ! wait for the enzyme result .

C. Patient with persistent ST elevation following thrombolysis ,in an  otherwise asymptomatic and stable patient. Don’t  pass on  ” your doubt ” of salvaging  at least  some myocardium  by an rescue PCI .

Final message

The concept of   giving  the  benefits of doubt  to the patient   is a widely prevalent practice  in medicine .This concept is alive  and popular , not because it has proved effective, but because of the primitive   human perception and cognition  , namely “Something is better than nothing ” !

Common sense and logic would suggest , whenever  there is  a benefit  for doubting there would be a  equal  or  more  hazards and unmeasured risks . This  becomes  especially  true ,  when   the  physician makes  a therapeutic move  based on doubting than on conviction .

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