bestBETs

A 46 year old lady attends the Emergency Department with significant epistaxis from the right nostril - this started spontaneously. Her nose is packed using a Rapid Rhino. She feels better and would like a hot cup of tea - you know the policy is to avoid hot food and drink for 24 hours to prevent further bleeding, however you would if there is any evidence to support this?

A three year old boy presents to his local district general hospital with a one day history of fever and shortness of breath. He is admitted to the paediatric ward for on-going observation and management. The nursing staff calculate a paediatric early warning score, based on physiological parameters, with each set of nursing observations. The student nurse on the ward notices that your chart is different to the one used by the paediatric ward on her last placement. She asks you how accurately paediatric early warning systems predict serious clinical deterioration, particularly cardiopulmonary arrest, paediatric intensive care admission or paediatric high dependency care admission.

A patient who works as a model, presents to the A&E with dog bite lacerations to the hand and arms. You check tetanus status and clean and irrigate the wounds. Having recently read the Cochrane review on not providing prophylactic antibiotics in dog bites, you wonder whether this also means you can primarily close the wounds.

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 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 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 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.

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?

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.

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.

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.

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.

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 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?