bestBETs

The Implantable Cardioverter Defibrillator (ICD) has been proven to save lives through prevention of lethal ventricular dysrhythmias and sudden death. The ICD is not only for candidates who have been resuscitated from these conditions, but now is also being implanted in high-risk cardiology patients such as patients with bradyarrhythmias for pacing, tachyarrhythmias and those with heart failure and low left ventricular ejection fractions. One would assume placement of such a device that could aid in halting or postponing death would result in a sense of security and comfort. However, research reveals the opposite is likely to occur in a vast majority of recipients of the ICD. Many suffer post-implantation fear, anger, anxiety and a loss of desire to participate in any activity. It is clear that a post-operative intervention is imperative, and Cognitive Behavior Therapy (CBT) may be the solution for these ill effects toward this cardiac device. CBT could quite possibly have global application if determined to have a positive bio-psychosocial effect on this population.

A 27 year old male with sickle cell disease presents to the Emergency Department with pain in the arms and legs with onset over the last 24hrs.He claims the pain is in keeping with his usual painful crises. The nurse tells you she is suspicious as he is requesting a specific dose of morphine. You wonder to yourself if there is a higher incidence of morphine abuse in people with sickle cell compared to the general population.

A previously healthy overweight 38-year-old female comes to your Emergency Department complaining of postprandial right upper quadrant abdominal pain and vomiting for the last two hours. She appears to be in pain and is mildly tachycardic, but vital signs are otherwise normal. She has tenderness in the right upper quadrant without guarding. You want to know if glycopyrrolate is a reasonable medication to use to treat her pain initially.

A 60 year old man with known COPD presents to the emergency admissions unit with a history of breathlessness, worsening cough with expectoration. He is hypoxic, blood gases show ph 7.36, PaCO2 6.7, PaO2 7.0 on 24% oxygen. You start him on regular salbutamol and ipratropium nebulisers, steroids and antibiotics. He appears still breathless after 2 hrs with respiratory rate of 36/ min. You wonder whether addition of intravenous aminophylline would hasten his recovery and discharge.

You wish to investigate the cause of severe abdominal pain in an elderly diabetic female in the emergency department. You determine she needs a C.T. scan of her her abdomen/pelvis. You would like to use I.V. contrast to evaluate for mesenteric ischemia or diverticulitis, but her baseline creatinine is 1.7. Not using I.V. contrast could cause you to miss the diagnosis, yet using I.V. contrast could be devistating to her kidney function. You wonder if anything other than hydration could prevent contrast associated renal failure.

A footballer presents to the ED having sustained a foot injury in a blatant and unnecessary foul on the edge of the opponents penalty box. The X-ray confirms a fracture of the 4th meta-tarsal which you decide can be treated conservatively. The patient mentions to you that he has heard of certain footballers with similar injuries having 'oxygen therapy' to speed up their recovery. You wonder if there is any evidence to support this form of treatment.

A 65 year old man presents to the ED with a large, fresh upper GI bleed. He has a history of non-steroidal anti-inflammatory drug (NSAID) use and complains of increasing indigestion over the last few months. On examination, he has no stigmata of chronic liver disease and is unwell with a BP of 80 systolic and tachycardia of 140. In view of his history and lack of positive examination findings you feel that the most likely diagnosis is a bleeding peptic ulcer. You wonder if there is any evidence to support the use of vasoconstrictor therapy in non variceal upper GI bleeds.

A 35 year-old non-pregnant female presents to the emergency departement with symptoms of dysuria and frequency. You suspect she has a UTI, however the urine dipstick is negative for both leukocyte esterase and nitrite. Will treating this patient with empiric antibiotics alleviate her symptoms?

You are in a multidisciplinary team meeting, discussing a 76 year old lifelong smoker who has a T2 right upper lobe adenocarcinoma. She has COPD and arthritis and is quite a frail lady and lung function testing showed that she would not tolerate a pneumonectomy. The CT scan shows a 5cm tumour that may be resectable by lobectomy and there are no obviously enlarged mediastinal nodes although the radiologist reports that there are a few nodes there that are 0.8cm in diameter. A consultant surgeon accepts her for lobectomy, but the anaesthetist suggests a mediastinoscopy first to reduce the likelihood of an 'open and close' thoracotomy. The chest physicians state that this would be contrary to current guidelines and thus you suggest that you could look up the evidence and present it at the next week's meeting.

A 34-year old lady presents to the Emergency Eye Centre with a recurrent episode of a painful red left eye. You diagnose episcleritis and wonder whether steroid eye drops might be indicated in this particular case. The very experienced Emergency Eye Nurse Practitioner, however, discusses various treatment options with the patient. These are: a) No treatment b) Artificial tears c) Steroid eye drops d) Oral NSAIDS You wonder how much evidence there is for option d).

A 56 year old female with a diagnosis of rheumatoid arthritis has benefited from a course of 6 hydrotherapy sessions. She asks if she should have some more. You wonder if there is any evidence to support the number of sessions provided.

A 33 year old female with morbid obesity presents to the emergency department with a 2 hour history of severe sharp pleuritic chest pain. She smokes and is on birth control pills. Her vital signs suggest mild hypoxia and tachycardia. With pulmonary emboli at or near the top of your differential, the patient requires a peripheral IV for contrast material during a CT scan of the thorax. The nurse, and colleagues have made multiple attempts at IV access and return to tell you an IV could not be obtained. You contemplate the efficacy of ultrasound to obtain peripheral intravenous access under these circumstances.

A 65 year old lady presents to the emergency department having fallen onto the outstretched hand. She sustains a distal radial fracture with dorsal angulation and displacement. You consider that it would benefit from manipulation and arrange for her to have a Bier's block for anaesthesia. You are about to place the venflon on the affected arm in the ante-cubital fossa when you stop and wonder if it would be better placed in the hand, closer to the fracture site.

A 7 month old boy is undergoing primary repair of his cleft lip. Before the operation the parents were concerned about the cosmetic result from using sutures (cross hatching) and also the discomfort of removing them. You wonder whether the use of wound glue would be an acceptable alternative, given the high mobility of the area and need for accurate approximation of the wound.

A 7 year old girl with sero-negative polyarticular juvenile idiopathic arthritis (JIA) has recently commenced weekly methotrexate (MTX). Within six months she develops painful apthous ulcerations, alopecia, and generalised gastrointestinal upset. Her hepatic transaminases (AST/ALT) are now raised. Her parents are obviously distressed and have read on the internet about the role of folate supplementation in counteracting the adverse side effects of MTX. They have also read however, that this beneficial effect may be at the expense of the efficacy of MTX. They ask you, the prescribing physician, if this additional medication is warranted, and if so in what form?

You are a paediatric specialist registrar on a Sunday late shift in the accident and emergency department. A 4 year old boy presents with a two day history of fever (maximum temperature 38.8°C) and clinical signs of an upper respiratory tract infection (URTI). At home, his mother gave regular paracetamol to treat his fever and extracts from ivy to alleviate the cough. She asks you about Echinacea purpurea therapy for her son's illness.

A 75 y/o gentleman presents at 5am with a 2h history of sudden onset of shortness of breath. It is difficult to obtain a clear history as the patient is too breathless to speak. He is tachypnoeic, tachycardic, cold, clammy and is sweating profusely. Chest auscultation and CXR are consistent with pulmonary oedema and you start treatment for this, giving high flow oxygen, diuretics and a GTN infusion. The patient improves vastly over the next 30 minutes. You have heard of a new treatment for heart failure called nesiritide and wonder if it would have been useful in this situation.

A 40 year old alcohol dependent male is admitted to the short stay ward from the emergency department. Whilst recovering from his head injury he starts to withdraw from alcohol. You treat this with a chlordiazepoxide regime, and at the end of this he states he wants to stay off the booze. He has failed to do this previously. You recommend he engages with alcohol support services. You also wonder whether he'll benefit from acamprosate treatment.

You are anaesthetising a high risk CABG patient. Before coming off bypass, the surgeon requests that you give some thyroxine. You have never heard of this strategy before and thus while you give the thyroxine, you decide to review the literature to see if there is any evidence to back up this strategy.

A 22 year old male presents to you in Accident and Emergency complaining of sudden onset of shortness of breath and right sided pleuritic chest pain. He has clinical signs in keeping with a pneumothorax and is not currently tensioning. You request a plain PA erect chest radiograph which shows a small right tided pneumothorax. After aspirating 200ml of air, you repeat the chest radiograph which shows no improvement in the pneumothorax. Can you rely on the x-ray ?