Archives: BETs

A 40 year old pedestrian is stuck by a car travelling at 40mph. On primary survey she is shocked and hypotensive with signs of significant pelvic and intra-abdominal injury. FAST shows large volumes of peritoneal fluid and pelvic radiograph shows marked disruption of the pelvic ring. Despite four units of pRBCs and FFP you are unable to obtain a radial pulse. You wonder whether Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) might be helpful.

A 66 year old female presents to the emergency department (ED) after a motor vehicle crash. Radiographs reveal an acute posterior dislocation of the right hip. Although her hip was successfully reduced in the ED, you sustain a lumbar muscle strain while applying the necessary force to the patient's hip to accomplish reduction. The following day during a hospital conference you hear about a new method for the easy and safe management of hip dislocation called the "Captain Morgan" technique.

Patient seeking a relatively safe, non surgical cosmetic treatment to the upper eyelid.

During a morbidity and mortality conference at a local Emergency Medical Services (EMS) agency, a paramedic questioned the effectiveness of a new mechanical device used for chest compressions during cardiac arrest. As the EMS medical director, you recall at least one recent randomized clinical trial that addresses this question.

A 30-year-old man with a history of remote shoulder dislocation presents with left shoulder pain and decreased range of movement after quickly reaching for the telephone. There was no direct trauma and the clinician is wondering if a shoulder radiograph is necessary.

A patient presents with a lower limb stress fracture and you wonder what the best first initial investigations should be. You arrange an X-ray of the lower limb, but wonder what the sensitivity and specificity of this investigation is.

A 24 year old female presents to the emergency department with atraumatic bony pain in her left foot. She tells you that she is a keen runner and is in the process of training for a marathon. You wonder if her previous activity levels or current increase in activity are a greater risk factor for a stress fracture.

A patient has bee diagnosed with a lower limb stress fracture following an MRI scan. You wonder if early mobilisation is better than non-weight bearing in managing this patient and reducing complications.

A 24 year old professional football player presents with a hamstring strain grade 1-2 to the long head of biceps femoris. You have heard from a colleague who works in sports medicine that eccentric loading can be used as an alternative to lumbopelvic movement control retraining. Therefore, to try and improve function and reduce recovery time, you wonder if it should form part of your management plan.

A 6-year-old child was brought to hospital as a major trauma having been hit by a reversing car. The actual incident was not witnessed but the tyre tracks across the child's chest and the petechiae on his face and neck give credence to the theory that the car rolled over him. The child has an obvious head injury with a history of a period of consciousness but is haemodynamically stable. After immediate assessment and initial resuscitation you discuss the appropriate imaging with the radiologist. The radiologist agrees to perform a CT of the child's head and neck but declines to do a CT of the child's thorax. He quotes the Royal College of Radiology guidelines that state that for children who have suffered major trauma, CT scans of the thorax are not indicated for the haemodynamically stable child with a normal CXR (https://www.rcr.ac.uk/sites/default/files/publication/BFCR%2814%298_paeds_trauma.pdf). The child subsequently has a normal looking CXR and so you admit him for a period of observation while wondering if a plain film has the sensitivity to rule out significant injury.

A 72-year-old gentleman presents to ED with symptoms of a Stroke arisen within the last hour. His wife rushed him to ED. A middle cerebral artery infarction is confirmed on diffusion weighted MR scan. The Stroke Team Consultant is called to consider thrombolysis. On noting that the patient has a high blood pressure, he wants the patient started on a Labetalol infusion prior to administration of thrombolytic agent. Amongst other things the question of evidence on the best anti hypertensive drug to be used in such a situation arises

Whilst working at a local hospital ED, I was asked to review a 72-year-old lady by my F2. She had attended with chest pain and then had later collapsed. Her chest x-ray showed a widened mediastinum and a CT scan confirmed Thoracic Aortic Dissection. She was hypertensive with different blood pressure readings in either arm. On referring this patient to the on-call Cardio-Thoracic registrar, he asked for her to be started on a Labetalol infusion to control the blood pressure. Not being available in the ED immediately, it took a little while to get IV Labetalol from the hospital pharmacy. It just made me ask whether it is the best drug to be used.

A 35 year old man has been out drinking alcohol all night. He is brought in to the Emergency Department in the early hours of the morning after having fallen asleep in the back of a taxi and appears extremely intoxicated. Clinical examination is otherwise unremarkable and reveals no external evidence of a head injury. His observations are all within the normal range. You are asked to prescribe some intravenous fluids to “flush out the alcohol” but the nursing staff and wonder whether it will actually make any difference to his recovery and discharge.

A 4 month old infant presents to the ED with a 2 day history of coryza and cough. His mother reports he has become breathless over the last 24 hours and is no longer feeding as well as usual. You make a clinical diagnosis of bronchiolitis. You are aware that bronchodilators are not recommended in bronchiolitis but are keen to give some treatment. You wonder if hypertonic saline is effective.

A 66 year-old man suffers a witnessed out of hospital cardiac arrest. He is given immediate bystander cardiopulmonary resuscitation (CPR) until a paramedic ambulance crew arrives. The first recorded cardiac rhythm shows ventricular fibrillation. The ambulance crew continues CPR in accordance with current Advanced Life Support guidelines. Initial resuscitation attempts including three defibrillation attempts fail. Each time the patient is defibrillated, there is a necessary interruption in chest compressions. As medical director, you question the safety of a rescuer remaining in contact with a patient being shocked with modern defibrillation equipment.

A 2 year old child with history of prematurity with NICU stay presents with cough, runny nose and fever. She has not had an influenza vaccination this year. Parents have been using antipyretics without resolution of symptoms. The child has chest x-ray and laboratory studies performed. A nasal swab is positive for influenza A. The family is concerned about her prognosis given the past medical history.