Archives: BETs

To guide learning and training the Intercollegiate Surgical Curriculum Project implemented workplace based assessments promoting supervised observation, self assessment, reflection and feedback and emphasising a trainee focused and centred approach to surgical training. The underlying driving force of this review is to address training and education to gain an insight into what underpins effective learning for the surgical trainee in the operative environment. The most objective and meaningful assessment of good training is an assessment of the learning achieved, however as Iwaszkiewicz underlines such’ measures of learning are seldom available’. A significant trend amongst researchers in medical education and particularly surgical education is to canvass and analyse learner opinions of training so providing a window into evaluating teaching effectiveness and infer on how effective learning can be achieved.

A 48-year-old man attends the emergency department intoxicated and with a head injury. He is kept overnight and develops symptoms of alcohol withdrawal in the morning. He is a frequent attender to the emergency department with similar presentation and has been treated repeatedly with chlordiazepoxide in the past. You recently attended a postgraduate lecture where the “kindling effect” was discussed. You wonder whether his repeated treatments with chlordiazepoxide are actually having this effect and thereby increasing his risk of alcohol withdrawal seizures.

It's the end of a particularly eye-rending nightshift. You're looking forward to bed but are called to minor injuries where one of the ENP's friends' feet are on display with either leprosy or athlete's foot, you can't decide. He tells you he's tried over-the-counter (OTC) daktarin (miconazole 2%). When asked for advice, instead of inwardly screaming and recommending a trip to see his GP or pharmacist, you admit you don't know, recommend OTC terbinafine and shuffle off to a warm and comfy bed (mmmm, bed!). For some reason you can't sleep that night and eventually get up at 2 am (perhaps it's that itch between your own toes) to find the answer to the question.

You are the Emergency Department physician seeing a 76 year old gentleman who reports short-lasting episodes of debilitating dizziness. Upon further questioning you elicit that these usually occur in the morning or at night when he is in bed and turns to the right. His physical examination is normal, as is an ECG, postural blood pressure testing and other baseline observations. You suspect that he has benign paroxysmal positional vertigo from semicircular canalithiasis in the right ear but wonder whether a positive Dix Hallpike test in the right ear would provide you with a definitive diagnosis of posterior semicircular canal BPPV. This will enable you to discharge him having performed an Epley manoeuvre to alleviate his symptoms.

A 22 year-old female presents with lacerations on her hands after slipping and breaking a window with both hands. The wounds appear superficial on inspection. You wonder if these wounds can be adequately treated without the use of x-rays to rule out retained foreign bodies.

A 26 years old man presents at the ED after a blunt trauma. His vital signs are normal except for a heart rate at 110. His labs are normal except for an abnormal base deficit. The doctor wonders if the abnormal base deficit means that this patient could be at risk of complications or death.

Your consultant is about to operate on a 48-year-old patient with moderate to severe mitral regurgitation (MR) due to degenerative disease of the mitral valve. The scrub nurse asks you about the type of ring that your boss is going to use. You say that he always uses a flexible ring. She asks you why and your boss overhears your rather unconvincing response and suggests that you go and look up the evidence rather than cannulating today.

A 22 year old female presents to the emergency department with a positive home pregnancy test. She had been sexually active and her last menstrual perior only 2 weeks ago. She wants to know if her home test is correct.

You see a baby on the neontal unit. There are no contraindications to feeding and you would like to start feeds. Mum is not available for feeding but is keen to breast feed. The nurse suggests that the baby should be cup fed as bottle feeding will interfere with successful breast feeding You wonder if this is based on evidence..

A patient two hours after a double valve and grafts suddenly goes into ventricular fibrillation as you are passing by his bed in the intensive care unit. Three rapid attempts at defibrillation fail and the nurse who was looking after him said that he had been very unstable with a high CVP prior to the arrest. You elect to perform an emergency re-sternotomy, which relieves a tamponade and the heart spontaneously cardioverts into sinus rhythm. A vein proximal anastomosis was bleeding and you repair this and you are eventually happy to re-close the chest. The anaesthetist asks you if you want any more antibiotics and the scrub nurse asks you if you want a betadine washout. You do this as you are not sure how sterile one of your scrubbed colleagues were, but you are not sure if this is necessary.

A 9 year old boy with osteogenesis imperfecta is admitted having fallen out of bed and sustaining a left fractured femur. He is in considerable pain. He is given intranasal diamorphine and cannulated to be given systemic analgesia. You are aware that it is recommended that femoral nerve blocks should be performed with ultrasound guidance and that you are not competent to perform this procedure. You are competent to perform a fascia iliaca blocks and wonder if this would give adequate analgesia.

You have always used blood cardioplegia but you start to work for a consultant who uses crystalloid cardioplegia. He evangelically states that crystalloid is cheaper, quicker and gives you a better view when performing distal coronary artery anastomoses. You have always been told that blood is superior as it is a more physiological buffer and has an important oxygen carrying capacity. You then realise that you have never actually read a single paper on the comparison between these two solutions even though you use it every day and resolve to look up the evidence.

A multisystem trauma victim arrives in the emergency department and the trauma team is activated. After initial resuscitation, you wonder if whole-body CT scan would benefit this patient by improving his chance of survival.

A 25yr old pregnant woman is admitted to delivery suite in early labour and has a lumbar epidural sited for analgesia. Four hours later the CTG shows prolonged, late decelerations (fetal distress) and clinical examination demonstrates cervical dilatation of only 7cm. The woman is transferred to obstetric theatre for an emergency (Grade 2) caesarean section. The epidural has provided excellent pain relief in labour.

A shocked multiply injured patient is brought into the emergency department following a road traffic collision. There are a number of open fractures as well as chest, abdominal and pelvic injures. Furthermore, the paramedics report a great deal of blood at the scene. A trauma call is initiated and circulatory resuscitation begins immediately with transfusion of warmed universal donor blood. You have recently been to a presentation by a military surgeon who has just returned from a combat zone. You recall that mention was made of early component therapy in massive transfusion being beneficial and wonder whether you should start such therapy now.

18 year old woman attends the ED with DKA but no signs of shock. She weighs 50kg and is over the age limit for paediatric guidelines. However you realise that the volume difference between the two protocols is almost double. You wonder if in an adult a lower volume regime would be safer.

A 38 year old man with insulin dependent diabetes presents with a reduced conscious level. Bedside BM stick test shows a blood glucose of 2.3. You want to know what concentration of dextrose to give him to restore his blood glucose quickly and safely.

You see a thirty year old male colleague who has fallen on to his dominant outstretched hand. He is complaining of tenderness in his anatomical snuffbox. His scaphoid views do not show an obvious fracture, but he is reluctant to be in a splint for a fortnight. He asks you if there is any role for further imaging to rule out a fracture. You wonder whether CT would be better than MRI at diagnosing a scaphoid fracture

A 55-year-old patient with high BMI and known COPD is brought to the Emergency Department by paramedics, complaining of sudden onset of severe difficulty in breathing. The patient has decreased air entry on the right side, the trachea is deviated to left and hyper-resonance is noted on the right side. A clinical diagnosis of tension pneumothorax is made and immediate needle decompression is indicated. You wonder which approach is better for immediate needle decompression - the anterior approach (2nd intercostal space, mid-clavicular line) or the lateral approach (5th intercostal space, anterior or mid-axillary line).