Archives: BETs

A 17-year-old male presents to the Emergency Department with a unilateral loss of vision and orbital swelling a day after an altercation outside a community college with weapons-carrying students. The patient is not forthcoming with details. The pupils are equal and reactive to light. You want to establish the extent of orbital/ocular damage. There is a wait for a CT scan so you wonder if using the bedside ultrasound scanner (USS) for a focused ocular ultrasound would provide useful imaging for either safely reviewing the patient later or making an informed prioritisation for CT.

A 30 year old chap presents to the ED following a jump fom height, sustaining a right undisplaced extra-articular calcaneal fracture. He is not severely swollen, and you are happy to discharge him, with out-patient follow up. You wonder whether he should be placed in a below knee POP, or remain NWB without a POP, as then he will not lose movement at the ankle joint.

A baby is born by spontaneous vaginal delivery at 29 weeks gestation. The infant's mother had a previous child born at 28 weeks gestation, who died due to late onset sepsis. The obstetrician clamps the cord immediately after the baby is delivered. Later the paediatrician, whom was present at delivery, asks why the cord was clamped immediately instead of delaying to 30-45 second. The paediatrician highlights the numerous benefits of delayed cord clamping including the prevention of late onset sepsis. A debate ensues as to the best practise and evidence behind the paediatrician's argument.

Bubble baths are common products used by parents. Medical professionals, from students to consultants, can be heard across clinics throughout the country, advising parents to avoid the use of bubble bath to help prevent another urinary tract infection in their child. In our simple survey we could not find any labels on bubble baths intended for children or babies that reinforced this advice. Are we, as general paediatricians, providing unsubstantiated advice to our patients and parents?

You see a 12 year old boy with cerebral palsy (CP) in outpatients. His mother is concerned about his drooling. He has tried hyoscine patches with little effect. His mother has heard a radio programme about botulinum toxin (BTX-A) injections and asks you whether it would be beneficial.

You are assessing a 7 year old boy with attention and behaviour difficulties, and poor school performance. He has an average IQ and meets the diagnostic criteria for attention deficit hyperactivity disorder (ADHD). There is no evidence of developmental delay, dysmorphism, or other physical abnormalities and no relevant family history. Parents are keen on investigation for a "cause" for his problems. You are aware that some chromosomal and cytogenetic abnormalities may be associated with ADHD. You wonder if you should check karyotype and look for cytogenetic abnormalities with genetic implications for the family.

An 8-year-old boy presents to the emergency department with an isolated midshaft femoral fracture. You were previously taught to use a combination of lignocaine and bupivocaine, as the lignocaine would have immediate effect followed by the longer action of bupivocaine. The anaesthetic registrar disagrees and wants to use bupivocaine alone.

A 35 year old triathelete presents to the emergency department following a long distance event. He feels dizzy, nauseated, fatigued and has some degree of confusion. A clinical diagnosis of symptomatic hyponatraemia is made when his arterial blood gas sample shows a sodium level of 120 mmol/L.

A 2 year-old girl is brought into the Emergency Department with vomiting and watery diarrhoea. She has dry mucous membranes, reduced skin turgor and her central capillary refill time is 3 seconds. You estimate that she is moderately (4-6%) dehydrated. She is refusing oral fluids. Beds on the wards are limited. You wonder whether rapid nasogastric rehydration (RNGR) with an oral rehydration solution (ORS) is an effective and safe strategy to try and avoid the need for hospital admission?

Another day as hotshot Clinical Director, another day of corporate meetings and complex decision-making: Is alcohol a significant contributor to ED presentations? Would I be able to justify the implementation of an Alcohol Health Service within the department? Is this really as big a priority as the Government makes out? Luckily, you have your resident Professor to hand, a man of many talents - he is able to conduct robust literature searches at the touch of a button. You decide to find out the prevalence of alcohol misuse across UK EDs as a first step in deciding whether to jump on the 'Preventive Emergency Medicine' band-wagon and offer brief intervention to eligible patients

Your ED has recently instituted an Alcohol Health Service comprising two designated Alcohol Health Workers who administer brief psychotherapeutic interventions to children and adults presenting with alcohol-related events. You wish to find out whether such intervention is cost-effective...

A 16 year old male arrives at the ED having sustained a head injury after falling over whilst intoxicated. You have heard about the recent institution of an Alcohol Health Service in the department comprising two designated Alcohol Health Workers who administer brief psychotherapeutic interventions to children and adults presenting with alcohol-related events. Having assessed and treated the patient, you wonder whether you should refer him on to them...

A 31 year old male presents with a 3 month history lateral epicondylitis. You are planning to use standard treatments of electrotherapy, ICE, and exercises to improve his symptoms. You have heard from a colleague about an exercise regime based on eccentric muscle contractions and you wonder if there is any evidence of greater efficacy than the usual treatments.

A 33 year old male arrives at the ED having been involved in a road traffic accident whilst driving under the influence of alcohol. You have heard about the recent institution of an Alcohol Health Service in the department comprising two designated Alcohol Health Workers who administer brief psychotherapeutic interventions to children and adults presenting with alcohol-related events. Having assessed and treated the patient, you wonder whether it is worthwhile referring him on to them...

You are at a weekly hospital lecture meeting and a guest lecturer has come to discuss the current treatment of pulmonary embolus. The discussion turns to prophylaxis protocols for DVTs in your hospital. It becomes evident that the general physicians, and all non-cardiac surgeons are routinely using low-molecular-weight-heparin for all their patients. The lecturer asks one of your colleagues why you do not use it in cardiac surgery, and he replies that the incidence is very low in cardiac surgery due to the clotting derangements post-operatively and anyway we would give all our patients pericardial effusions if we did. You are not sure that he is correct and therefore resolve to look up the answer.

You have been asked to perform urgent CABG on a 72 year old gentleman who has just undergone angiography for acute coronary syndrome. He had been admitted that day with chest pain at rest for 24 hours, and the Troponin T was found to be 0.95. The cardiologist has found a 30% left main stem disease and severe triple vessel disease with good LV function. He received 300mg of clopidogrel on admission. He has chest pain on minimal exertion although he has no ECG changes and his blood pressure is 140/70. The cardiologists are keen for you to get on with his surgery, but you would like to delay this gentleman's surgery 7 days, thus you decide to summarize the evidence for this decision.

You are about to perform an urgent aortic valve replacement in a 32-year-old male who has been treated for endocarditis with destruction of the native aortic valve, leading to congestive heart failure. The patient has been an i.v. drug user (IVDU) for several years. He has a supportive family and has already been accepted into a methadone program in your community. In order to decide whether you should insert a mechanical heart valve or a tissue valve, you would like to learn about the long-term results of valve replacement in this clinical setting.

A young girl presents in the emergency department with right iliac fossa pain, anorexia, nausea and vomiting for the past 12hours. On examination she has significant right iliac fossa tenderness but no rebound or guarding. Her temperature is 37.3„aC and the inflammatory markers are normal. You are not entirely certain if she has acute appendicitis and would not like her to go through an unnecessary operation. You are wondering whether Ultrasound or CT is better in confirming the diagnosis of acute appendicitis.

You are consenting a 64-year old lady for AVR. She is quite keen to go for a bioprosthesis as her mother was on warfarin in the past and it had 'never agreed with her'. She is then quite disappointed when you tell her that she will actually have to be on warfarin for 3-months after the operation, and asks what would happen if she didn't take it. You can't quote her a figure of increased risk and therefore resolve to look up the answer.

An elderly lady presents to the emergency department following a fall onto an outstretched hand, sustaining a Colles' fracture. The fracture is manipulated and you need to apply a backslab. Many departments would use a dorsal backslab, but you have seen a radial backslab used for these fractures and were impressed. Believing that the radial backslab may hold the reduction more effectively, you search the literature for an answer.