Archives: BETs

A 6 month old baby is admitted to hospital with a 4 day history of coryzal symptoms, increasing cough, wheeze and decreased feeding. Respiratory syncytial virus was detected in nasopharyngeal secretions. She is needing oxygen and is on nasogastric feed. You wonder whether starting physiotherapy will improve her clinical condition.

You are the Head of Emergency Department (ED) and are currently facing the problem of overcrowding at the ED. Many Emergency Departments (EDs) also face the problem of overcrowding.1-3 According to the Joint Commission on Accreditation of Healthcare Organisations (JACHO) in the United States, ED overcrowding was a contributing factor for 31% of cases of mortality or permanent injury from delayed treatment.2 Many measures have been taken to reduce waiting time in the ED, including increased staffing of doctors and nurses, increased trolleys and beds for short stay.4 Some studies have even explored the effect of "fast-track"5-6 or rapid assessment clinics7 on reduction of ED overcrowding. Triage has traditionally been performed by nurses.8 Putting a doctor at the triage area may potentially relieve congestion in the EDs as the doctor can promptly assess the patients and initiate treatment, especially for those with minor injuries and illnesses. The objective of this study is to review the evidence for putting a doctor at the triage area of an Emergency Department.

A patient presents to the emergency department with history of recurrent daily 4 grams of acetaminophen use. Blood work shows elevated liver function tests. Can his daily acetaminophen account for this abnormality?

A 60 year old female presents to the emergency department with severe sudden onset chest pain that radiates to her back. Her exam, 12-EKG and initial cardiac enzymes are normal. The patient has an elevated creatinine at 2.0. You are concerned about an aortic dissection and wonder which test would be the best to evaluate for this suspected diagnosis.

A 52 year old man who has been diagnosed with gastrointestinal obstruction requires a NGT to be inserted. Is nebulised lidocaine the most clinically efficacious and safe agent to reduce pain and discomfort associated with the procedure?

A 25 year-old man presents to the Emergency Department with central sharp chest pain that is eased by sitting forward. ECG shows widespread saddle shaped ST elevation consistent with acute pericarditis. The patient is clinically stable with normal heart rate and blood pressure and no signs of left ventricular failure. You wonder whether it will be worthwhile sending blood for troponin to rule out significant myocardial damage in relation to myopericarditis. As such you wonder whether a normal troponin will reassure you that the patient is at low risk of complications and suitable for out-patient treatment. Similarly, you wonder whether a raised troponin would indicate the need for hospital admission.

An adult male is brought to the Emergency Department following a significant tricyclic antidepressant overdose. While in the Emergency Department he has several seizures. You wonder whether to load with intravenous phenytoin or simply manage prolonged seizures with benzodiazepines.

You are the neonatal doctor covering the labour ward. A woman who is 38 weeks pregnant and in early labour reveals a recent history of genital warts. She asks the midwife if this could affect her baby and if it should influence the mode of delivery. The midwife is unsure and so asks you

You see an elderly lady who has sustained a fractured neck of femur and remains in discomfort following administration of opiates. You wish to perform a femoral nerve block. The department's ultrasound machine is currently in use and there is no nerve stimulator. You wonder how successful a nerve block guided by anatomical landmarks will be, or whether you should wait for the ultrasound machine to be free.

As part of a bench-marking exercise in your neonatal network, the length of stay (LoS) for babies born at 30+0 to 34+6 weeks' gestation was measured over a 12-month period (only babies who were inborn and admitted within the first 24 h and had their care on the same unit were included). Corrected gestational age at day of discharge was compared between the seven units. The bench-marking results show variation of LoS in these babies from 35.5 weeks to 36.7 weeks with a network average LoS of 36.2 weeks. Although this is less than the UK mean LoS of 36.3 weeks, it is higher than the California average of 35.9 weeks.1 You decide to review the LoS in your own unit for this same defined group for the years 1995, 1998, 2001 and 2004. The median LoS for these years is fairly constant at 36.4, 36.6, 36.8 and 36.1 weeks, respectively. You note that 60% of all neonatal admissions comprise babies in this group and that they account for 6000 cot days per year. You wonder whether you can implement any changes locally to reduce the LoS, safely, for these babies.

A 15-year-old girl with acute renal failure was found to have class IV systemic lupus erythematosus (SLE) nephritis on renal biopsy. A decision was taken to start her on the routine National Institute of Health protocol of pulsed methyl-prednisolone and monthly intravenous cyclophosphamide (CYC) (0.5–1.0 g/m2 of body surface area). With her post-pubertal status and the possibility of CYC induced gonadal toxicity, the question was raised as to whether she should be put on gonadotropin releasing hormone analogue (GnRH-a) therapy for ovarian protection.

Fraser is an 8-year-old boy well known to everyone in A&E and the hospital. He has severe dystonic cerebral palsy as a result of his premature birth at 26 weeks' gestation. Although he was ventilated for 5 weeks he did not develop chronic lung disease. He is gastrostomy fed and had a Nissen's fundoplication 5 years ago. He has copious secretions and a poor cough reflex. These are made worse by nitrazepam which he requires for his dystonia. Evidence from previous barium studies and swallow assessments show that he chronically aspirates his secretions. He has no symptoms of upper airway obstruction. Over the last year, he has had increasingly frequent lower respiratory tract infections, requiring admission and intra-venous antibiotics. His weight and height have fallen from the 10th to the 3rd percentile. A chest x ray shows chronic changes suggestive of underlying bronchiectasis and he is now colonised with Pseudomonas aeruginosa. Immune function and a sweat test are normal. He has not had a recent pH study or barium swallow. He awaits a CT scan of his chest. He has daily physiotherapy and regular suction and usually produces copious muco-purulent secretions. He is on maximal anti-reflux medication already. Would prophylactic azithromycin reduce his risk of further lower respiratory tract infections? Or might it increase growth of multi-resistant organisms within his sputum?

A 3 year old boy presents to the Emergency Department not using his left arm after a fall. He has a bruise over his left clavicle and is clinically tender over this area. X-ray reveals a mid-clavicular fracture. From your experience in adult Emergency Departments you wish to put him in a collar and cuff, however this seems to distress him. You wonder if it is necessary to immobilise him at all.

You are asked by the interventional cardiologist on-call to discuss a 73 year old gentleman still on the table in the angiography lab. He was admitted with a non-ST myocardial infarction with a small troponin rise, has had clopidogrel, aspirin and reopro and is currently stable. The coronary angiogram shows a tight proximal left main stem lesion of about 70%. The patient is mildly obese and diabetic with some varicosities of the left leg and has prostate carcinoma which is currently well controlled. The cardiologist would like to stent this lesion if you thought that he was not a good surgical candidate and asks for your opinion.

A 73 year old patient with a history of COPD and diabetes, 2 days after a right upper lobectomy for lung cancer asks you why he has not got an incentive spirometer by his bed when the 2 patients opposite him both have them. You can’t answer him and when you look more deeply into this find that administration of spirometers on your ward is sporadic. We decide to check the literature and decide who should get them.