bestBETs

A pregnant female presents to the emergency department with repeated episodes of vomiting. She has not used any medications at home for relief. She has been unable to tolerate fluids. While a nurse prepares to place a peripheral IV, you begin to wonder if ondansetron or metoclopramide would be more beneficial for a pregnant woman with vomiting.

An 11 year old male presents to the emergency department after jumping for a rebound at basketball practice. He falls to the ground striking his head against the floor. He briefly loses consciousness and comes to emergency department with repetitive questioning, vomiting, and complaining of headache. You order a head CT which is unremarkable, symptoms improve during a brief observation period, and as you prepare for discharge the patient’s parents question about returning to physical and cognitive activities.

A 60 year old male suffering from low back pain and numbness in the posterior thighs, has been found to have a low grade spondylolisthesis at L5-S1. You wonder if a course on core staability exercises would help to improve pain and function.

A 41-year-old male with a past medical history of symptomatic paroxysmal atrial fibrillation (on metoprolol), hypertension, diabetes, morbid obesity, and chronic alcoholism was BIBA to the ED for palpitations and light-headedness that started one hour prior. Electrocardiogram and labs showed atrial fibrillation without RVR and ST changes, and a normal CK, troponin level, and chemistry panel. The patient claimed to be adherant with all medications and was on the maximum dose of metoprolol. He last ate a large meal one hour ago. The patient claims that flecainide, propafenone, amiodarone, and procainamide have been ineffective in the past for cardioversion and that he does not want to try any of them again. In an attempt to cardiovert this patient back to normal sinus rhthym, you wonder if ibutilide should be used.

A 28 year old patient with a past medical history of type II diabetes and irritable bowel syndrome currently taking a SGLT-2 inhibitor for his diabetes presents to the Emergency Department with the chief complaint of nausea and vomiting with associated fatigue. The patient is evaluated and treated for their nausea and vomiting. The patient continues to have intractable vomiting despite conventional therapy. On laboratory evaluation they are found to have a blood sugar of 162, pH of 7.2, elevated betahydroxybutyrate and large ketones in the urine.

-A 35 y/o male presents to the ER following a low speed MVA. Patient was a restrained driver hit on the front passenger side while turning into a parking lot. He had no LOC and was able to ambulate following the accident. He presents with chest pain on the right and pain with inspiration. Patient is GCS 15 on arrival with HR 88, BP 145/75, RR 18, O2 sat 97% RA, T 37.

A 75-year old man is referred to you for elective cardiac surgery. He has already been taking simvastatin for many years. You know that preoperative statin therapy improves post-operative outcomes in statin-naive surgical patients. You consider whether you should prescribe him additional preoperative statin doses in an attempt to recapture this benefit. To answer this question, you carry out a literature search for the evidence.

A 24-year-old woman presents to the ED with shortness of breath and pleurisy. She is otherwise healthy and on no medications except the birth control pill for the past year. There are no other clinical signs or symptoms suggestive of DVT, and her heart rate is normal. You wonder whether as an emergency room physician with some training in bedside ultrasound, reliably confirm or refute the diagnosis of a pulmonary embolus using point-of-care ultrasound (POCUS)?

You attend the scene of a vehicle collision and find a 23 year old male unbelted in the drivers seat, slumped over the steering wheel unconscious. As the patient is rapidly extricated to the waiting ambulance, you note spidering of the windshield from the patient’s head and airbag deployment. Rapid ATLS exam reveals that the patient requires thoracostomy for a suspected tension pneumothorax. You have recently heard about finger thoracostomy as an alternative to needle decompression and wonder if this would be effective.

You are part of an EMS crew dispatched to the scene where a construction worker has fallen from a rooftop onto the concrete below. He was initially reported as combative when a basic life support crew arrived, and they now report that he has just lost vital signs. You quickly think about your ATLS approach to the trauma patient and wonder if a finger thoracostomy would be effective and safe in this environment to rule out tension pneumothorax as a cause of his arrest.

It is Friday evening and a 2-year-old child presents to the ED with colicky abdominal pain. The ultrasound technician has left for the evening and no ultrasound imaging will be available over the weekend. You wonder whether you can use a fecal occult blood test to rule out intussusception in this patient.

A 25 year old man comes to the ER with an injury to his right ring finger. It is a Monday and the waiting room is full, you wonder if there is a way to diagnosis nailbed injury without removing the finger nail.

A 68 year-old male is brought to the emergency department with tachypnea (32 breaths per minute), tachycardia and a core temperature of 39.2°C. He complains of a progressive back pain since 3 days and recently noticed hematuria. In the emergency department, his systemic arterial blood pressure is 80/56 mm Hg and his heart rate 136 beats per minute. You suspect a severe sepsis from an acute pyelonephritis. To restore the blood pressure, you administer a first bolus of intravenous crystalloid. To guide your fluid therapy, you wonder if bedside lung ultrasound will help you assess the interstitial fluid status of your patient to avoid over-hydration.

You are a final year medical student visiting US for a Month long clinical rotation in the department of cardiothoracic surgery. During the Grand Rounds the attending surgeon makes a statement that the use of cerebral oximetry is not clinically significant and puts an extra burden on the patient’s medical bills. He tells you that there is not much evidence regarding effectiveness of Cerebral Oximetry (Transcranial Near-Infrared Spectroscopy-NIRS to monitor ScO2) for Cardiac Surgery and about its potential applications, overall clinical value and whether to keep using it or not. You take the issue at hand to check the literature yourself and reach a conclusion.

An 86 year old man is admitted to the respiratory ward with his third pneumonia in 6 months. A bedside swallow exam is abnormal however; no overt signs of aspiration / penetration are evident. The next available date for videofluoroscopy is in a week. We wonder if there is a sensitive predictor of silent aspiration that could be used at bedside. We have heard of cough reflex testing but wonder about its evidence base.

The Trust introduced a new blood collection system that stated the tourniquet should be removed prior to blood collection during routine venepuncture. You conducted a quick survey of staff that revealed all clinicians (apart from one nurse who had recently attended her venepuncture training) leave tourniquets in place throughout the blood collection phase. You checked the current Trust policy, which also states that tourniquets should be removed prior to blood sampling. No rationale for this instruction is given and you wonder why tourniquet removal is recommended in the Trust policy. You carried out a quick Internet search that seemed to indicate serum electrolytes (potassium in particular) can be affected if the tourniquet is left on during blood collection.

A 56 yo homeless man with a history of alcoholism and stroke is brought to the ED after he was seen sleeping on a park bench in the snow without shoes. He is rousable but 34 F [not sure about this - reads more like Celsius] and is clearly intoxicated with a blood EtOH of 0.22 mg/dL. After giving the patient initial re-warming treatment with warmed blankets, you notice his toes appear severely frostbitten. You know tPA therapy is absolutely contraindicated in this man, but wonder if something else will decrease the likelihood of this man’s toes being amputated.

Very few environments rival the complexity, unpredictability, acuity, time pressures and decision density of the Emergency Department (ED)1,2. Unsurprisingly it has been described as a natural laboratory for human error3. Despite the skills of the Emergency Physician in making decisions, an unacceptable number of decisions made in the process of medical diagnoses are wrong with error or diagnostic failure rate estimated to occur in 10-15% of decisions in the ED4. Expert opinions within Emergency Medicine have highlighted the role of cognitive debiasing strategies5 and cognitive forcing strategies6 to decrease the error attributable to cognition. The need to take all available steps to prevent error and harm from occurring has been highlighted as a moral and professional obligation in order to honour the ethical principles of beneficence, non-maleficence, fairness and justice7.

A 30-year-old male attends the Emergency Department with a dislocated shoulder, confirmed by plain film x-rays. This requires manipulayion and reduction under conscious sedation. You prepare your drugs, drawing up propofol. The patient however mentions that he had experienced some severe pain on the injection site during a previous sedation with a propofol. You remember one of your colleagues mentioning lidocaine use to prevent pain on propofol injection and wonder if there is any evidence for its use.