PCORACION’S MAR [15-02]:Should Clinical Decision Making Be Overruled By Clinical Practice Guidelines?

Medical Anecdotal Report
Indexing Title: PCORACION’S MAR [15-02]
Title: Should Clinical Decision Making Be Overruled By Clinical Practice Guidelines?
Date of Observation: February 2015
Tag:  Recommendations are never absolute
Category: Professional/Ethical – Reinforcement


A 27-year-old male was admitted for medical management of hemorrhagic contusion of the frontal lobe and closed linear fracture of the frontal bone secondary to vehicular accident.  He had a GCS (glasglow coma score) of 14 (Eye movement spontaneous, verbal response confused, motor is follows command) but had a slightly volatile temperament. On his first hospital day he had an episode of melena. His abdomen was soft, nondistended and nontender. He did not have hypotension and tachycardia. I asked a co-resident to insert a foley catheter. The procedure was explained and the patient followed the instructions. While the catheter was being inserted, the patient became combative. I told him to calm down but he did not. He began cursing continuously and was restless. I instructed a nurse to give him a sedative. He calmed down and we proceeded with insertion of the catheter. A mixture of lidocaine and lubricant was injected into the penile urethra prior to insertion but when the catheter was being inserted, he jerked. The nurse, clerk, intern and I held his extremeties. The catheter was inserted successfully but before I could let go of his hand, he bit me.

I sustained a small paired abrasion on the knuckle of the second digit of my right hand. I had an injection of tetanus toxoid. A co-resident advised me to take clindamycin as a prophylactic antibiotic. I did not take any for the wound was small, superficial and was not grossly infected. I had a small doubt if I should have taken the antibiotic in light of my colleagues advice. I reassessed myself and what happened. My resolve was that I used rational thinking in not taking antibiotic prophylaxis. The wound, though located in the hand, was small and was superficial. It did not have discharge. I did not see any increased risk of developing sepsis by not taking the medicine.

(Physical, Psychosocial, Professional/Ethical)
(Discovery, Stimulus, Reinforcement)

Discoveries are made every day and theories or principles are always tested. What we know now might not hold true in the years to come. Clinical trials can either dismiss a current recommendation or support it. Medicine is always evolving. As they say, nothing is permanent except change. Despite all of these, we must bear in mind that clinical correlation will help us in choosing the best option for a patient.

According to an article on human bites treatment and management by Barrett et al., antibiotic prophylaxis is warranted if the wound is believed to be at higher risk for infection (eg, significant contamination is present; bone, tendon, or joint space is involved; the bite is on the hand; deep puncture wounds are present; or bites occurring in high-risk patients). The article also said that the Infectious Diseases Society of America (IDSA) clinical practice guidelines state that ALL human bite wounds require antibiotic prophylaxis.

Based on the recommendation, I should have taken antibiotic prophylaxis. However, I think that there is room for clinical decision making to supersede a recommendation given by a recognized body of scientific researchers and experts in some instances. I think that some recommendations cannot apply to everything. Guidelines have been created to standardize clinical practice and to give directions on how to best manage a disease condition but patients are varied. Management to be proper must be tailored for an individual and grounded on scientific principles. Bear in mind the recommendation but clinically correlate if it is proper. If done so, no one can truly say that you are wrong.

ROJoson’s Notes (17jan4):

Clinical practice guidelines provide guides for problem-solving and decision-making by the physicians based on the situation on hand.  Physicians just have to justify whatever decisions they make, if they did not follow the established guidelines (of course, with the consent and in partnership with the patients).

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