Archives: BETs

A 39 year old man with sickle cell disease presents to the emergency department with a 24hr history of pain in his arms and legs. His pain is consistent with his usual painful crisis. You wonder to yourself how long on average does a painful crisis last .

A 26-year-old man presents to the emergency department with a 2-day history of urethral discharge. He had unprotected sex a week previously. You want to take a urine sample from him straight away, but a colleague tells you that the sample must be taken four hours from his last urination. You wonder if there is any evidence for this.

A 30 year old male with sickle cell disease presents to the emergency department with pain in the arms and legs for the last few days. The pain was in keeping with her standard painful crisis. As you promptly treat her for the pain you wonder if subcutaneous morphine is a more appropriate way to administer pain relief compared to I.V morphine

A 16-year-old male presents to the emergency department on a Friday night with a one-day history of urethral discharge following unprotected sex. The GUM clinic is closed. You wonder if urine based nucleic acid amplification testing will be sufficient to give an accurate diagnosis.

A 45-year-old man has been diagnosed with non-gonococcal urethritis. He needs antibiotics, and you wonder whether he should be given azithromycin or doxycycline.

A 27 year old male with sickle cell disease presents to the Emergency Department with pain in the arms and legs with onset over the last 24hrs.He claims the pain is in keeping with his usual painful crises. The nurse tells you she is suspicious as he is requesting a specific dose of morphine. You wonder to yourself if there is a higher incidence of morphine abuse in people with sickle cell compared to the general population.

A 24 year old woman presents to the emergency department with sickle cell painful crisis. The pain is in both arms and legs and is consistent with her normal crisis. As you promptly administer intermittent pain relief medication, you wonder to yourself would a PCA be more effective method of pain relief.

A four year old child is brought to the emergency department in moderate to severe pain. You have a protocol for using intra-nasal diamorphine1 in such children, but have been unable to apply it for some time because of a nationwide shortage2. You wonder whether any other opiate could be administered in a similar manner ?

A 3-year-old girl is brought to the emergency department by her parents. She has vomited multiple times and has been feverish and lethargic over the last 24 h. On examination, she is feverish, she has a stiff neck and Kernig's sign is positive. You are concerned about the possibility of meningitis but do not want to put a child through an unnecessary lumbar puncture. You wonder how accurate the above signs of meningeal irritation are in detecting bacterial meningitis in children.

You are the anaesthetist assessing a 75-year-old current smoker with an exercise tolerance of only 200 yds, who is due to have coronary grafting tomorrow. You approach the surgeon to suggest that you place a thoracic epidural prior to induction. He is reluctant for you to do this as he says that epidurals can be dangerous with full heparinisation and anyway he isn't aware of any evidence that it speeds recovery. You decide to summarize the evidence for him.

A 50 year old man is found collapsed in the snow on a very cold winter's night. He is admitted to hospital unconscious with adjuvant cardiopulmonary resuscitation and a low reading rectal thermometer measures his core temperature to be 26 oC. He is in ventricular fibrillation. Should an attempt at defibrillation be made at this temperature or should he be re-warmed first and then defibrillated?

A 32-year-old woman with no significant medical history presents to the emergency department with chest pain and dyspnoea. A pericardial friction rub is heard on examination. The ECG shows PR depression and widespread saddle shaped ST elevation. You diagnose acute pericarditis and prescribe a course of non-steroidal anti-inflammatory drugs (NSAIDs). However, recalling that colchicine may be useful for recurrent pericarditis, you wonder whether it is effective for a first episode of acute pericarditis.

A 34-year old lady presents to the Emergency Eye Centre with a recurrent episode of a painful red left eye. You diagnose episcleritis and wonder whether steroid eye drops might be indicated in this particular case. The very experienced Emergency Eye Nurse Practitioner, however, discusses various treatment options with the patient. These are: a) No treatment b) Artificial tears c) Steroid eye drops d) Oral NSAIDS You wonder how much evidence there is for option d).

A 65 year old lady presents to the emergency department having fallen onto the outstretched hand. She sustains a distal radial fracture with dorsal angulation and displacement. You consider that it would benefit from manipulation and arrange for her to have a Bier's block for anaesthesia. You are about to place the venflon on the affected arm in the ante-cubital fossa when you stop and wonder if it would be better placed in the hand, closer to the fracture site.

You are a paediatric specialist registrar on a Sunday late shift in the accident and emergency department. A 4 year old boy presents with a two day history of fever (maximum temperature 38.8°C) and clinical signs of an upper respiratory tract infection (URTI). At home, his mother gave regular paracetamol to treat his fever and extracts from ivy to alleviate the cough. She asks you about Echinacea purpurea therapy for her son's illness.

A 7 year old girl with sero-negative polyarticular juvenile idiopathic arthritis (JIA) has recently commenced weekly methotrexate (MTX). Within six months she develops painful apthous ulcerations, alopecia, and generalised gastrointestinal upset. Her hepatic transaminases (AST/ALT) are now raised. Her parents are obviously distressed and have read on the internet about the role of folate supplementation in counteracting the adverse side effects of MTX. They have also read however, that this beneficial effect may be at the expense of the efficacy of MTX. They ask you, the prescribing physician, if this additional medication is warranted, and if so in what form?

A small child with a scalp laceration presents to the Emergency Department. You wonder whether the less painful technique of closing wounds with hair apposition will produce as good as a result as suturing.

A 32 year old male presents to the Emergency Department with a laceration on his right forearm. He accidentally cut his forearm with the sharp edge of a metal can 14 hours ago. The wound appears clean and there is no evidence of any foreign body. Neuro-vascular and tendon examination are normal. The wound is irrigated with saline and repaired with nylon sutures. You wonder whether this wound is at a higher risk for infection because of the time lapse from injury to repair.

A well appearing 4-year-old child presents to the emergency department with a fever and a non-blanching rash. There have recently been several missed cases of meningococcaemia at your institution. As a result, local practice has been changed to include giving empiric antibiotics to all suspected cases. You wonder whether a procalcitonin level would help you identify those patients who do and those who do not need antibiotics?