bestBETs

A 30-year-old woman comes to the emergency department presenting with sore throat and low-grade fever. Physical examination reveals a non-toxic-appearing woman with mild trismus and uvular deviation. As you consider whether the symptoms represent cellulitis or a true abscess, you wonder if using intraoral ultrasound could help establish a definitive diagnosis and assist in needle aspiration.

A male patient presents to the emergency department with acute urinary retention requiring urethral catheterisation. You ask the nursing staff where the local anaesthetic gel is and they tell you that it has been removed following a safety alert as it contains chlorhexidine, which may cause anaphylaxis. You catheterise the gentleman who appears to suffer a lot of pain with the procedure. Following this you decide to look at the evidence for the use of local anaesthetic lubrication in catheterisation.

A 40-year-old man is brought into the emergency department in cardiopulmonary arrest. It is agreed by the cardiac arrest team that endotracheal intubation is now appropriate to manage the airway. You usually use end-tidal CO2 (ETCO2) waveform analysis to confirm tube placement—but are aware that it is not so reliable during cardiac arrest. You wonder if transtracheal ultrasonography is a good tool to confirm endotracheal intubation in this situation.

A 62-year-old man presents with an acutely swollen left calf. You suspect that he may have a deep vein thrombosis (DVT). Can a 2-point bedside compression ultrasound, performed at the bedside by an Emergency Physician confirm or refute this diagnosis accurately?

A 49 year old male, who was previously fit and well, attended the Emergency Department as a trauma patient after being involved in a road traffic collision. He underwent whole-body computed tomography (CT) scanning and was found to have an incidental, sub-segmental pulmonary embolism (PE). You wonder whether this finding warrants anti-coagulation treatment as is protocol for larger, symptomatic pulmonary emboli, or whether the patient would have a similar outcome if they were to be discharged without treatment.

A patient is referred for voice therapy with dysphonia. There are many exercises available which will facilitate efficient phonation. Is the use of semi-occluded vocal tract exercises using a straw likely to lead to improvements in the quality of the person’s voice?

A 40 year old male presents with moderate obstructive sleep apnea. He is frustrated and non-compliant with his continuous positive airway pressure (CPAP) and does not want to have surgery. There are no complicating factors.

Therapists assess and treat patients following surgery for fractured neck of femur (NOF). Hip precautions (no hip flexion above 90 degrees, no adduction beyond midline and no rotation of the operated leg) are routinely adhered to in those having undergone hemiarthroplasty and total hip replacement. This has time and cost implication for example waiting for equipment delivery for discharge can increase length of stay. To ensure that following hip precautions is evidenced based practice, the orthopaedic therapy team wanted to conduct a BestBETs.

You are the specialty emergency trainee doctor working in the emergency department. The next patient is a 42 years old female who is referred by her General practitioner with confirmed diagnosis of Carpal tunnel syndrome since last six months, for symptom management especially pain. She complained of pain, tingling and numbness in the left hand which gets worse at night. She mentioned about disturbed sleep due to aggravating symptoms. She was concerned because she was unable to return to work and look after her family. There was no significant past medical history. On examination there was sensory impairment in the first three digits, Phalen sign was positive. You discussed with the orthopedic Specialty registrar on call who requested to discharge the patient on oral analgesia and refer to the orthopaedic outpatient clinic for further evaluation for surgical intervention. You wonder whether non surgical intervention is better than surgical.

A 22 year old student is sent from the Walk-In Centre because she has complained of pleuritic chest pain. In the referral letter the GP asks you to rule out a Pulmonary Embolism. She is low risk, has no abnormal chest signs and has a normal chest X ray. To your great surprise her d-dimer is reported as >10,000. She has a V/Q scan which is reported as low probability for a PE. You wonder whether her raised d-dimer could be caused by menstruation?

A 34 year old man has been fishing on a Sunday afternoon at his local pond. He has lost his footing and fallen in. A passing dog walker has seen him struggle and managed to pull him out, unconscious. He is resuscitated at the scene. He is brought to the Emergency Department still coughing up brown water, but not obeying commands. One of your colleagues, nearing retirement age, suggests a barbiturate-induced coma.

A 65 years old male, with known liver cirrhosis, portal hypertension and oesophageal varices, present with hematochizia at your emergency department. Given the probability of a upper gastro-intestinal bleeding in this patient, you want to perform a diagnostic aspiration with a nasogastric tube, but wonder if the risk of triggering a variceal bleeding with the tube because of mechanic trauma really exist or if it is only a myth.

You are taking some time after your CT3 year to learn some extra skills that would be useful to your job as an EM consultant. One of the jobs you felt would be useful is palliative care. Intuitively, you feel that uncontrolled pain is an emergency we often see and personally you feel there is much for you to learn in the appropriate management and subsequent referral pathway of palliative care patients. You feel pain management is one of our biggest roles, in common with end of life care specialists. You have no evidence base to show to others how Emergency medicine doctors feel about their knowledge in palliative care and if an Educational intervention would lead to increased knowledge of and confidence in this area and hence a better patient experience.

You are the medical officer intern on-call for paediatrics in a small district general hospital in rural Kenya. You are called to see a young girl with meningitis who is actively convulsing. Her blood sugar is normal. She has already had one dose of IV diazepam 5 minutes ago. The nursing staff ask about giving her a second dose dose as per the Kenyan paediatric protocol book, but you are worried about the risk of hypoventilation in a hospital without high dependency or intensive care facilities. What do you do?

A previously healthy 8-year-old boy, with a three-day history of flu-like symptoms presents to your emergency department. He was admitted with dehydration and hypothermia in the context of persistent vomiting. The following day he developed heart failure secondary to viral myocarditis.

A 43 years old man presents to the emergency department with a moderate cellulitis with lymphangitis of the forearm following a trivial skin trauma in the previous days. The patient is not known for any health problem nor does he have any risk factor for CA-MRSA. You wonder if daily intravenous cefazolin following oral probenecid is as effective as two or three times a day intravenous cefazolin treatment.

A 42-year-old previously healthy woman presented to the emergency department with chest pain and was found to have an ST elevation myocardial infarction. Cardiac catheterization revealed a dissection in her left anterior descending artery. You wonder what is the prevalence of spontaneous coronary artery dissection (SCAD) in patients with acute coronary syndromes.

20 year old student radiographer is brought to emergency department by ambulance after being involved in a RTC a few hours earlier. It’s a busy Friday afternoon and she’s been sat in waiting room. You call her through to be seen and you notice she obviously has difficulty walking; her concerned looking mother helps her in to a nearby wheelchair and brings her through. She is complaining of lumbar back pain. On examination you are concerned by your neurological findings in her lower limbs: clonus, 4/5 power throughout and some subtle paraesthesia. You explain you would initially like to perform an x-ray and that she may require a CT. She asks her mum to go and get her a drink of water and quietly reveals to you she’s 8 weeks pregnant. You think that MRI is likely to be safer but are not sure if there any significant risks?

A 20 year old patient presents to the ED with low mood and suicidal ideation. The patient has been assessed and is for admission by the psychiatric team once medically cleared. You wonder whether the use of mandatory screening studies in the ED actually affects morbidity and mortality in such patients.