Archives: BETs

You are about to perform a coronary artery bypass graft (CABG) on an obese 65-year-old man who has triple-vessel disease involving the left anterior descending (LAD) artery, the first obtuse marginal (OM) branch, and the posterior descending artery (PDA), and an akinetic inferior wall with an estimated ejection fraction of 40%. You wonder whether you should use the saphenous vein (SV) or the radial artery (RA) to graft a heavily diseased PDA or OM to achieve long-term patency.

You are at a clinical research meeting when you hear presentations comparing the use of magnetic resonance imaging (MRI), plethysmography and Doppler ultrasound techniques to assess adequacy of ulnar collateral flow in patients scheduled for radial artery graft conduit harvesting for CABG surgery. You decide to review the literature to identify just how good these techniques are and to find out whether they offer any advantage in identifying satisfactory collateral flow in the forearm over the Allen's test which you currently use in your own practice.

You have just started working with a consultant in a new firm. The consultant you had previously worked with uses topical papaverine to prevent vasospasm of the left internal mammary artery. Your new consultant never does this. On the first theatre day in your new firm you have completed harvesting the internal mammary and noted the flow to be poor. You are contemplating using topical papavarine to improve the vasospasm of the mammary artery. However, your consultant stops you and asks you to show him the evidence that topical vasodilators significantly improve mammary arterial flow before using any vasodilators in his cases.

You are performing an aortic valve replacement in a 78-year-old lady, with poor lung function, and who was smoking up until the day of the operation. You are keen to keep the pleura intact for this operation to optimise her post-operative recovery. During the sternotomy you ask the anaesthetist to deflate the lungs and you perform the sternotomy from the sternal notch to the xiphisternum. You are disappointed to find that despite these manoeuvres, you have widely opened the right pleura with the saw. The anaesthetist comments that deflating the lungs makes no difference and that you should have gone the other way with the saw as a colleague does this and 'never' has this problem. You resolve to search for the evidence for these comments.

A 45-year-old male presents to the emergency department with active epistaxis. It is determined he will require nasal packing. You have a choice of using a moistened, gel-coated, balloon inflated nasal tampon or a dry hydrophilic nasal tampon, and wonder which is less painful on insertion and removal?

A 32 year old man presents to the emergency department. He has a 5 day history of back pain that came on after a long bike ride. He has no red flag symptoms and there are no neurological signs on clinical examination. You advise him to take analgesia and stay active. He is keen to cycling as soon as possible and wonders if there are any specific exercises or program of exercises that he can do to get him back to cycling quicker.

A seventy year-old man presents to the Emergency Department with a thirty-minute history of chest pain. ECG shows left bundle branch block (LBBB) and you are not sure whether it is pre-existent. You have heard of the scoring system derived by Sgarbossa for use in this situation but you wonder if it will enable you to accurately decide whether this man is having an acute myocardial infarction (MI), in order that thrombolytic therapy may be considered.

An 18 month old female is brought to the emergency department by her mother. She has been suffering from repeated vomiting and diarrhoea for the past 24 hours. Over the past eight hours she has vomited approximately 12 times. The vomitus has not contained any bile or blood. The little girl appears mildly dehydrated. Her stool tests positive for rotavirus. You wonder whether administration of an antiemetic may lessen her symptoms and increase the likelihood that oral rehydration therapy will be successful.

Chronic constipation is a frequently encountered problem in the paediatric wards and clinics. Your usual line of management has been to prescribe adequate doses of regular lactulose and use sodium picosulphate as a second line laxative or as add on treatment. Recently, you have become aware of a new drug—polyethylene glycol (PEG). As you have not prescribed this drug earlier, you want to appraise the evidence before using it in your clinical practice.

A term baby is admitted to the neonatal unit with a history of grunting 1 hour after birth. You are the SHO on call and plan to start the baby on antibiotics-Benzylpenicillin and Gentamicin for suspected sepsis. One of the Neonatal Nurses asks you about once daily dosing and multiple dosing of Gentamicin and you wonder which of these regimens would be more safe and effective?

A 55 year-old man has had an anterior myocardial infarction. His symptoms started twelve hours ago. He has already been given aspirin, thrombolysis, nitrates, opiates, beta-blockers and clopidogrel. You know he ought to start statin therapy. Having read about the 'pleotropic effects' of statins, you wonder if there is any benefit in starting this therapy within the first 24 hours.

A 55 year-old man has had twenty minutes of central chest pain. ECG shows acute anterior myocardial infarction. Having read about the so-called 'pleiotropic effects' of statins, you wonder if there is any evidence that their immediate use in acute coronary syndromes confers any mortality benefit.

A thirty-five year-old man has presented with 12 hours of chest pain. ECG shows widespread T wave inversion and troponin T is 1.0. In view of his ongoing chest pain and young age the cardiologists decide to perform immediate angioplasty. You have given aspirin, oxygen, nitrates and morphine. As he is about to go for angioplasty, you wonder if a loading dose of clopidogrel will still confer any added benefit.

Your are an emergency medicine resident in a busy downtown tertiary care facility. Your 14th patient of the night is a 23-year-old male with a clinically obvious anterior shoulder dislocation. The dislocation was spontaneous and is his third this year. As a matter of routine a pre-reduction x-ray is ordered. ED beds are scarce and the the nurse asks if this is really necessary. Is it?

A patient presents to the emergency department following an isolated chest injury. He is not dyspnoeic and recorded observations are normal but chest xray demonstrates a simple pneumothorax. You wonder does this patient require formal chest drain insertion or can he be treated conservatively?

A 41 year old car driver was involved in a major road traffic accident, sustaining injuries to his head, a fracture of his right femur and multiple bruises on his chest. On scene he had altered sensorium and his GCS was estimated to be 5. He was intubated by the paramedics and brought to the Emergency Department. You wonder about the evidence in favour of endotracheal intubation as compared to bag and mask ventilation in trauma patients.

A 24 year old woman presents to the Emergency Department with a corneal foreign body. You wonder which topical anaesthetic agent will provide adequate anaesthesia for removal of the foreign body with the least amount of stinging on instillation.

A 35 year old man presents to the emergency department with acute back pain sustained whilst lifting a heavy box. He complains of low lumbar spine pain. There are no neurological symptoms or signs and no "red flags" to indicate a potentially serious cause of his back pain. You diagnose a simple acute low back strain and advise analgesia and mobilisation. He tells you that he knows a local acupuncturist who could see him for acupuncture but wonders if it is worth spending the money. He asks if you are aware of any evidence for it's effectiveness.

You performed a difficult Aortic Valve replacement and triple-coronary arterial-bypass-graft on a 77-year-old man, with a 30-year history of smoking. The operation proceeded uneventfully, but in the Intensive care it was not possible to extubate him on the first night due to basal collapse, and over the next few days he develops a ventilator-associated-pneumonia (VAP). You search the internet for manoeuvres that may avoid this frustrating complication and find that continuous subglottic suction would avoid pooling of secretions around the endotracheal tube and thus perhaps reduce VAP. Thus you resolve to search for evidence for this simple intervention.

You are a first year cardiothoracic registrar who is starting to work for a consultant surgeon who always prefers the pleura to remain intact whilst harvesting the internal mammary artery (IMA). The surgeon avoids pleurotomy to reduce pulmonary complications after cardiac surgery, but you wonder whether there is any evidence in the literature to support this practice