bestBETs

A 22-year-old woman presents to the Emergency Department (ED) with suicidal ideation and ongoing Medically Unexplained Symptoms (MUS). This is her second attendance today, and her fourth this week. This patient is a known high-intensity user/Frequent Attender (FA) due to multiple previous episodes of Deliberate Self-Harm and intentional overdose. She has a background of emotionally unstable personality disorder, depression & anxiety, and a learning disability- all of which contribute to her distress while in the department, meaning she frequently leaves before being seen by a clinician. You wonder if there is an effective intervention that you could implement, to reduce her number of ED visits.

A 49 year old man presents to your family medicine office with signs and symptoms of alcohol use disorder. He is willing to explore pharmaceutical support to reduce his drinking.

Patient is a previously healthy 8-year-old male who presents to your emergency department as a level II trauma activation after being involved in a motor-vehicle collision. The patient was a restrained back-seat passenger when their vehicle was T-boned at a suspected speed of 45 mph. There was no loss of consciousness on scene. EMS report his vital signs have been stable enroute. The child has some moderate abdominal tenderness, and you consider whether to order computed tomography (CT) or perform point of care ultrasound (POCUS) to evaluate his abdomen.

Climate change is the biggest global health threat of the 21st century. According to the recent Intergovernmental Panel on Climate Change, the global mean temperature is projected to rise by 1.4 to 5.8 degrees by the end of the century. Extreme temperatures overwhelm the body's heat regulatory mechanism, and multi-system organ dysfunction results. In light of recent global heatwaves, it is imperative that emergency care clinicians appreciate the diversity of climate sensitive emergency health conditions and their impacts on emergency care systems.

A 5-year-old child with presented to the emergency department following an motor vehicle collision. He was a restrained passenger of a vehicle going approximately 30 mph when the collision occurred. Air bags deployed at the time of impact. His workup in the emergency department was significant for atlantooccipital dissociation and the patient was eventually pronounced dead on arrival. During your review of the case, you wonder whether airbag deployment contributed to his cervical spine injury.

A 12-year-old Vietnamese speaking female with a complicated past medical history presents to the emergency department (ED) with complaints of dizziness. History and physical exam are obtained from the patient and her family using a professional interpreter. You wonder how using an interpreter impacts ED utilization (incidence and costs of diagnostic testing, admission rate, and length of ED visit).

Patient is a 45-year-old with a history of alcohol abuse who presents to the emergency department intoxicated. On your initial assessment, the patient’s eyes are closed and only open to pain; he only moves when a painful stimulus is applied; he is not speaking. You give the patient a GCS of 8 and you question whether this patient would benefit from being intubated.

Fascia iliaca blocks (FIB), first described by Dalens et al in 1989, have become a key method of managing pain in patients with fractured neck of femur. In your department FIB tend to be performed using a landmark (loss of resistance) technique. However, it has been noted that there have been a number of ineffective blocks recently, leaving patients still in need of opioids to manage their pain. At clinical governance one of the consultants, a point of care ultrasound enthusiast, suggests that the department should move to performing FIB under ultrasound guidance as he believes they are more likely to succeed. You leave the meeting wondering if he is right.

A 65-year-old male with a history of hypertension, hyperlipidemia, stage 4 chronic kidney disease (CKD) and daily smoking presents to the emergency department (ED) complaining of chest pain. Vitals show that he is hypertensive with a blood pressure (BP) of 170/95, with otherwise normal vitals. He has no neuro deficits. Workup completed shows an EKG with a normal sinus rhythm and non-specific ST-T wave changes but without evidence of acute ischemia. Troponins are normal. You wonder if he may have an aortic dissection, but he is well-appearing without neuro deficits and equal pulses. Given his CKD you wonder if there is a way to rule out an acute aortic syndrome without having to give a contrast load for a computed tomography (CT) angiogram. Will using the aortic detection risk score in conjunction with a d-dimer help either rule out or increase suspicion for acute aortic syndrome?

A 50-year-old male/female with a past medical history of rheumatoid arthritis attends pre-operative clinic prior to an elective right upper lobectomy. Amongst the regular medications is methotrexate. You wonder whether the patient should continue methotrexate to reduce risk of flare-up and problems with post-operative pain control or stop this medication prior to surgery due to concerns about immunosuppression and increased risk of post-operative complications; especially wound infections and air leaks. If you were to stop it, how long should it be discontinued for and when should it be re-started?

A 65 year old male presents to the ED with a 3 day history of cough and breathlessness. You are unsure of whether this is likely to be COVID-19 or something else. You worry that sending this gentleman into the hot zone of the department will expose him to COVID-19. You know that a nasopharyngeal swab will take a long time to come back, and wonder whether LUS will help you decide whether this gentleman is likely to have COVID-19 or not, in order to triage him safely.

A 74-year-old male with a history of diabetes and COPD presents via EMS in acute distress. EMS reports the patient was found somnolent and minimally responsive by a family member who came to check on him. He has a productive cough. Vital signs initially are significant for a rate of 122 BPM, a temperature of 39 degrees C, respiratory rate of 56, SpO2 of 89% and blood pressure 88/45. He has a GCS of 14. You suspect sepsis and begin your workup and treatment, including placing him on 6L nasal cannula. The patient is fluid resuscitated with 30 mL/kg of normal saline, cultures are drawn, and antibiotics are started. As the second liter is finishing, the patient becomes progressively less responsive and his SpO2 begins to drop. His blood pressure is now 82/38. As you prepare to intubate, you are concerned about his fluid-refractory hypotension in the peri-intubation period and consider a bloused dose of phenylephrine to bridge him to more definitive therapy.

A 23-year-old male presents with right shoulder pain after falling and catching himself. Physical exam demonstrates a squared off right shoulder with anterior fullness, with the patient holding his arm in slight abduction and external rotation. Anterior shoulder dislocation is suspected. The x-ray department is backed up, and you are wondering if point-of-care ultrasound is appropriate for diagnosing a shoulder dislocation.

25 year old male patient presenting to ED 3 days after a head injury where a heavy wooden door swung into his head. He presented with ongoing symptoms of nausea and headache

A 45 year-old female presents to the ED with a 3-day history of cough and breathlessness. You wonder whether this patient has COVID-19. You worry that sending this lady into the hot zone of the department may result in a potentially vulnerable patient being exposed to COVID-19. You know that a CT scan is the gold standard imaging choice for COVID-19 pneumonitis, but its practicality, cost, and irradiation cause you to wonder whether LUS would be an appropriate alternative to facilitate safe triage of this patient.

A 2 year old boy presents to the emergency department with a large laceration to his temple after he fell onto a corner of a coffee table. He will require procedural sedation to suture the laceration. You ask the bedside nurse to start an IV to administer ketamine. As the child squirms and cries getting the IV, you wonder, is there a better option?

You are referred a 55 year old woman for a mobility assessment. She was diagnosed with an acute calf DVT yesterday and started on anticoagulation therapy. Is it safe to complete a mobility assessment today?

A 5 year old girl presents to your paediatric ED with a one day history of abdominal pain and an acute episode of haematemesis. Her mother explains that she is unable to locate a button battery she left on the kitchen table. She is tachycardic (heart rate 150 beats per minute) but normotensive (blood pressure 105/55 mmHg). A chest x-ray identifies a button battery in the proximal oesophagus. You are worried about the potential for this child’s haematemesis to worsen and consider whether any novel strategies could be used to mitigate deterioration prior to endoscopic removal.