Archives: BETs

A 45 year old man presents to the emergency department with a painful shoulder following a direct fall with hyper extension of the shoulder. After examination and appropriate investigations a tear of the rotator cuff is diagnosed. You wonder whether conservative management is suitable for this patient.

A 4 year old patient presents to the ED with a lip laceration, you decide to repair it under ketamine sedation and prepare an appropriate dose of ketamine and atropine. However, before administration your colleague (who has recently returned from Australia) tells you that it is a waste of time and that the Antipodeans never use it. You wonder if this is true.

A 53 year old male is brought in by ambulance from a nearby building site after a collapse, on an uncharacteristically hot day. In the resuscitation room he has a GCS of 3. He is found to be warm and dry and to have a temperature of 42.3°C. You diagnose heat stroke and wonder if Dantrolene would be useful in this scenario.

An 82 year old lady has been brought to ED complaining of hip pain having been found on the floor at her residential home. Clinical examination indicates likely fractured neck of femur. Plain AP and lateral radiographs of the hip demonstrate to obvious fracture. What is the most accurate investigation to rule out fracture?

A 47-year-old woman presents to the emergency department with left calf pain which came on suddenly, making walking difficult. Typical DVT risk factors are present and the examination is consistent with this. Being proficient with the portable ultrasound unit you decide to perform a "rule-in" compression test of the vasculature in the left leg. However, a colleague challenges this decision, questioning whether the test itself could cause an embolus when compressing the thrombus. You therefore wonder if there is any evidence for this adverse effect, in which case you would prefer to start anticoagulation without this information and defend your diagnosis on clinical grounds.

You are dispatched to a house in which a 45yr old man has collapsed. He is in cardiac arrest when you arrive. During the resuscitation process, you and your team wonder if the use of the mechanical autopulse device to provide chest compressions during the resuscitation will result in a better outcome for the patient.

An 80 year-old man is admitted on the medical take with a three day history of melaena. He is on aspirin 75mg following an MI 18 months ago. He is not on a PPI and from his risk factors he does not seem to have any other risk factors for an upper GI bleed? DO you continue the aspirin?

A baby is brought in to ED, by concerned parents, with high fever and history of generally being unwell with no clear history pointing towards any clear diagnosis or focus of infection. You wonder whether you need to proceed with a full septic screen, or whether a positive diagnosis of influenza on rapid bedside testing would be sufficient to allow safe discharge directly from the ED.

A patient presents to the Emergency Department with acute onset of a left sided hemiplegia. The blood glucose is measured and found to be 12mmol/l. Would using insulin to control the blood glucose closely improve the patients outcome?

A child presents with acute asthma. You start standard treatment with salbutamol, ipratropium and steroids. Your medical student points out that nebulised epinephrine is used for children with acute severe bronchiolitis, and wonders why you do not use the same treatment in asthma.

A 23 year man was due to undergo a VATS procedure with talc insufflation for recurrent spontaneous pneumothorax. While preparing the patient for theatre he asks you about how the talc that will be insufflated in the operation works. After explaining how the talc causes an inflammatory reaction that causes the pleura to adhere together, he asks that since the talc causes a reaction, can it cause any long term problems.

You are seeing a 65 year old patient who has been referred for aortic valve replacement due to aortic stenosis. He has no symptoms of angina but smoked for 25 years, finally quitting 10 years ago. His father also died of a heart attack when he was 60 years old. You tell him that you would like to get an angiogram to check his coronary arteries. He is not that keen on the idea and asks if there are any other scans that could do the same thing without the risks of angiography. You wonder whether a CT angiogram would be as sensitive a test for this patient

A 25 year old man with his second spontaneous right-sided pneumothorax has undergone VATS bullectomy and talc pleurodesis this morning. Patient controlled analgesia (PCA) was set up at completion of surgery and oral paracetamol prescribed. You are asked to see him on the ward later that evening because he is in a lot of pain, and his morphine PCA is making him feel very sick. You think the pain is likely to be muscular and aggravated by his chest drain, and you think he would benefit from a NSAID such as diclofenac, but the thoracic surgical nurse looking after him is unhappy to give it. She was told that it may reduce the chances of a successful pleurodesis.

You are referred a fit 66-year old man with a 2cm lesion in the periphery of his right lower lobe on CT scanning. Bronchoscopy was normal, and a CT guided biopsy has confirmed non-small cell lung cancer. His lung function is satisfactory for lobectomy. You have just been on a Video-assisted Thoracoscopic (VATs) Lobectomy course and he seems an ideal candidate for this procedure. The patient seems quite keen but then asks you if it cures his cancer just as effectively as the usual way. You reassure him, but resolve to check this in the literature.

A bomb explodes in a busy downtown building. When emergency medical care arrives there are 70 casualties on the ground and 50 standing or sitting. The prehospital team knows the START triage system and classifies seven patients as black, 12 as red and 51 as yellow or delayed. The 12 casualties classified as red are transported to the hospital with all the vehicles that were available. You wonder whether using focused abdominal ultrasound would help in further prioritising the transportation of the remainder patients.

A 6-year-old girl presents to the emergency department with complaints of a painful foot, and the history of having stepped on an unknown foreign body. You wonder whether an x-ray or ultrasound would be better at detecting this.

A 3 month old books in to the Emergency Department with a 4 day history of a coryzal illness followed by breathing difficulties and decreased oral intake. It is December. Inwardly you sigh heavily, berating the fact that bronchiolitis season is upon you and all you really have to offer is supplemental oxygen, nasogastric feeding and paediatric admission. Just then, one of your colleagues mentions perusing the Cochrane Database recently and seeing something about the use of nebulised hypertonic saline in bronchiolitis. The paediatricians in the department are sceptical. A spark of hope alights in you that there may be an evidence-based treatment out there after all. You quickly decide to find out for yourself one way or the other.....

A 56 year old lady has a convulsion whilst waiting in her cubicle in the emergency department. She collapses to the floor and maintains her own airway. You wonder whether an oropharyngeal is better than a nasopharyngeal airway in providing initial airway protection.