Archives: BETs

A young man has been drinking all night with his friends and staggers home. He is found snoring on the pavement and is brought to hospital by ambulance. Clinical examination is unremarkable and there is no evidence of trauma or other injuries. His blood tests are normal. He smells heavily of alcohol and is not fit for discharge. Would IV fluid therapy increase ethanol clearance facilitating his discharge?

You are evaluating a patient who has just been punched on the jaw. He is having difficulty opening his mouth and talking but you can see no step deformity or loose teeth. You recall that while you were on elective you saw the tongue blade test being used routinely in America to select patients for mandibular imaging. For this test the patient is asked to bite on the tongue blade and if the examiner can break the blade while the patient grips it, the patient does not need a radiograph. You wonder whether this is a sensitive test to use in this patient.

A mother brings her five year old son to the Emergency Department (ED) with a deep scalp laceration having fallen onto the corner of a coffee table. The wound requires sutures. For various reasons the option for procedural sedation in this department is limited to midazolam. Due to your past experience, you are more comfortable using ketamine. Although there is a large amount of data in the Emergency literature to show efficacy and safety for both agents, you are not aware of direct comparisons to back your preference for ketamine in children in the ED setting.

A 28 year old woman presents with acute suspected pulmonary embolus (PE). You wonder whether normal arterial blood gases are sufficient to rule out pulmonary embolus.

An 18 year old student is brought to the Emergency Department having been found collapsed in her room. She had been seen by her friends earlier in the day, when she reported that she had a severe headache. On examination, she is found to have a temperature of 38.40C, a GCS of 12 (E3 M6 V3) and slight neck stiffness. She is noted to be more settled with the lights out. There is no papilloedema and no focal neurological signs. You make an initial diagnosis of bacterial meningitis, but in view of the depressed level of consciousness request a CT Brain before lumbar puncture is carried out. This will take at least one hour to be organised, and in the meantime, you decide to proceed with intravenous ceftriaxone. You are unsure whether she would benefit from the administration of dexamethasone prior to her antibiotics.

A 62-year-old man presents to the emergency department with a 45-minute history of chest pain that is beginning to abate after aspirin and buccal nitrates in the ambulance. As he has a 1 mm ST depression in his anterior leads you give him low molecular-weight heparin and refer him to the medical team. While waiting to be transferred to the ward his 12-h troponin level is reported as negative; the medical senior house officer feels he is therefore fit for discharge. You disagree saying he remains high risk and needs further investigation and/or intervention. During the ensuing discussion you wonder if there is any evidence to back up your assertions

You are called to see a patient who is 1 hour post CABG. The patient has bled 300mls since theatre and the nurse performed an ACT which was prolonged at 150 seconds. You know that the heparin had been reversed in theatre using 1.3mg of protamine to every 1mg of Heparin, and that an additional 25mg was also given after checking the ACT. You are keen to give another dose of Protamine but you have heard that high doses of protamine can cause increased bleeding. You wonder whether this is true.

A 30 year old man presents to the emergency department with a spontaneous onset of atraumatic pleuritic chest pain. He has no previous medical history and has no shortness of breath or haemodynamic compromise. You wonder whether his clinical features and risk factors can help to safely exclude a pulmonary embolus.

A 40 year old woman presents to the emergency department with pleuritic chest pain. She comments that she has had 'cramp' in her left leg since discharge from the surgical ward, post hysterectomy. Her ventilation-perfusion scan shows a high probability of pulmonary embolism. You have scored her as a high clinical probability of PE and therefore diagnose pulmonary embolic disease. She is comfortable with normal oxygen saturations, and keen to return home to her family. You wonder whether treating her as a outpatient would be an option.

A 38 year old man presents to the emergency department with left posterior pleuritic chest pain. He had a DVT 8 years ago and his D-dimer levels are elevated. He is haemodynamically stable with normal oxygen saturations, ECG and chest Xray. You would like to rule out a pulmonary embolism, but it is 8pm. You wonder whether it would be safe to discharge the patient home overnight before his VQ scan tomorrow.

A 76 year old patient attends the Emergency Department following a fall in the street. She has a wound over her left lower leg that can be treated with steristrips. You enquire about her tetanus immunisation state and discover that she has had a full course of ATT and two booster doses. The last was 15 to 20 years ago. You are sure you have read somewhere that not only should this provide lifelong immunity but also that booster doses may cause severe local side effects in such individuals. You wonder whether this is correct.

You are evaluating a 90kg acutely dyspnoeic diabetic woman in the emergency department. She has a history of left ventricular failure and was an inpatient 2 weeks ago with a small myocardial infarction. Her BP is only 90/50 and you feel that she is a high risk patient with poor peripheral venous access who may need high dependency care possibly with inotropes, and you therefore decide that a central line would be of great benefit. Your department has just bought a handheld USS probe and you wonder whether it is worth having a go with this rather than your usual blind landmark technique.

You are the attending neonatal consultant. It is 6 pm on a Friday after a busy week on the unit. A rather flustered midwife appears from the postnatal ward with a baby and two anxious parents. The baby is full term and appropriately grown, following a normal vaginal delivery and just 8 hours old. Mum has been attempting to breast feed but the baby is reported to have been "not feeding well" and "jittery". There are no prenatal risk factors for sepsis. Your examination of the baby is normal—he is now not "jittery". A capillary heel prick blood test (Medisense) done on the postnatal ward has given a blood glucose reading of 2.6 mmol. Because this result is perceived to be abnormal (low), one of the neonatal trainees has suggested to the parents that he may need admission to the neonatal unit. As she has had three previous babies, the mother was hoping for an early (six hour) discharge from hospital. The midwife asks you to "sort out the situation". Some hours later, the laboratory plasma glucose result (taken at the same time as the Medisense capillary sample) is available. This result is 3.4 mmol/l. The mother agreed to stay overnight with the baby on the postnatal ward, received breast feeding support, and was discharged home next morning. No further blood samples were taken. A phone call to the mother on day 3 confirmed that the baby remained well and fully breast fed.

The son of one of the authors came home from school with a letter explaining that prior to swimming each term, children would have their feet checked for verrucas. School policy stated that if a verruca was discovered a protective sock must be worn. Many public swimming pools have no restrictions on children swimming with verrucas, and in view of conflicting policies we wondered whether verrucas were transmitted during swimming and if wearing verruca socks was a necessary intervention.

You are the child health lead in a primary care trust. The manager of the local Children's Fund comes to ask your advice about how best to meet the Children's Fund sub-objective of reducing inequalities in child health for children aged 5–13. A local child safety organisation has applied to the Children's Fund for a grant to arrange traffic safety education sessions in the local community, teaching children how to cross roads more safely. The manager wonders whether this is the best way to reduce inequalities in child traffic injuries. Meanwhile, the Children's Fund has done some preliminary work on one of its other objectives of involving the local community. In their consultations with workers, children and families, they have found that: Children say it is unfair that they don't have enough safe places to play. They don't like cars speeding through their neighbourhood. Parents feel under stress when the kids are in all the time but worry about sending them to the playground on the far side of a busy road. The Children's Fund is charged with delivering preventive services, listening to what children and families say they need, and reducing inequalities in child health. Traffic education might well help to address this. But will it actually reduce child traffic injuries and increase the local community's sense of safety on the streets? Is there something else—perhaps targeting the traffic rather than the children—that might be more effective, and more responsive to the local community?

A 20 year old student presents to the emergency department with a three day history of urinary frequency, dysuria and lower abdominal pain. Examination is unremarkable and dipstick urinalysis is normal. You wonder whether normal dipstick urinalysis is sufficient to rule out a UTI, or whether antibiotics anyway should be prescribed whatever the result.

A 75 year old man presents to the Emergency department after collapsing at home with a sudden onset of back pain. On examination he is fully conscious, distressed with pain and has an expansile pulsating epigastric mass. His blood pressure is 80/40 mmHg. While you are waiting for the surgical consult you wonder whether it would be worthwhile administering a large I/V fluid bolus. This should raise his BP and may improve his tissue oxygen delivery. However, it may also increase bleeding from the aneurysm and will dilute clotting factors.