bestBETs

You work in the emergency department as a consultant and your rota currently does not include night working. Nationally it has been recognised that there is a deficit of senior decision makers in emergency departments at night and inevitably it is suggested that care would be safer and more effective if (work-shy) senior emergency physicians stepped off the golf course and into the gap to work shifts. You have heard that this will increase your chances of a heart attack and shorten your life but wonder whether this is just union propaganda or hard actuarial fact.

A 41-year-old woman with a history of intravenous drug abuse and hepatitis C is brought to the emergency department with altered mental status. She is somnolent but opens her eyes to loud verbal stimuli and localises pain. She is breathing spontaneously with good effort. She has evidence of track marks along her upper extremities. The nursing staff are having difficulty obtaining intravenous access. The respiratory technician happens to be walking by the room and asks you if there is anything he can do to help—he has heard of patients having nebulised naloxone when in this state. You wonder if he is right.

An 87 years old man presents to the Emergency Department with acute onset of central abdominal pain.. The pain is mild and was relieved by simple analgesia. you noticed that he had a temp of 37.8 and whit cell count of 13,000 with elevated neutrophil count. examination revealed no tenderness, guarding or rigidity and there was no masses but bowel sounds were sluggish. You wonder if this patient can go home or need to be admitted for observation and if so why?. The patient's medical history included hyperlipaedemia, hypertension, and that he is a smoking 10 cigarettes every day for the past 55 years..

A 45 years old man came to emergency department with sever epigastric pain and vomiting, he was tachycardic and hypotensive, immediate fluid resuscitation stabilized his hemodynamic status. Labs revealed high lipase and amylase suggesting acute pancreatitis; he was kept NPO on intravenous fluid and was treated with analgesics and anti-emetics. The case was referred to gastroenterologist for admission who on further discussion, was enquiring why antibiotic was not started in ED for a better outcomes? This stimulated my thought, if starting prophylactic antibiotics in case of acute pancreatitis improve the outcome in term of morbidity and mortality.

A 56 years old male, who is a smoker and known case of hypertension not on any medication as well as known case of severe Gastro-eosophageal reflux disease attended emergency department with sever tearing pain retrosternally radiating to back. Examination did not reveal anything significant, and he remains heamodynamically stable through-out . Serial ECG and troponine are negative. Chest x-ray does not show any widening of mediastinum or any other evidence suggestive of Aortic dissection. Still the possibility of aortic dissection was considered due to the nature of the pain hence; D- dimer was send and the result was negative. I was wondering is it sensitive enough to rule out aortic dissection?

A five year old girl presents with mild vincristine neuropathy (peripheral neuropathy of common peroneal nerve) affecting bilateral Tibialis Anterior muscles. She is able to actively dorsiflex but walks with an affected gait. You wonder whether kinesiotaping would be of benefit to facilitate these muscles and retrain gait.

A 4-week-old term baby is brought into your DGH ED by his mother. He is crying inconsolably, and examination reveals a swollen and deformed right femur. Xrays confirm a midshaft fracture. You want to alleviate his pain and discuss strong analgesia. The ED nurses tell you that opiates are unsafe in his age group and state that paracetamol is the only option. You wonder about the evidence for this.

A 64 years old woman is suddenly unresponsive and pulseless. A few minutes after prompt cardiopulmonary resuscitation initiation by her husband, the paramedics arrive on site. Defibrillation is performed twice with an external defibrillator. Return of spontaneous circulation is achieved but she stays unconscious. On emergency department arrival, her vital signs are stable and she is normothermic. The electrocardiogram is not showing any ST-elevation. You decide to put this patient on therapeutic hypothermia. You ask yourself if a coronary angiography with or without percutaneous coronary intervention could improve her chances of survival.

A 34 years old man presents to the emergency department at 11:00PM with severe left flank pain and vomiting which began abruptly 4 hours ago. The patient is not known for any health problem nor does he take any medication. He denies fever of chills. You suspect obstructing renal colic. His creatinine level is normal. You administer him NSAIDs and opioid medication, which relieves his pain. You wonder if this patient can safely be discharged at home if your bedside ultrasound is reassuring, with outpatient imaging and follow-up.

Ward 32 is an acute rehabilitation ward. Many patients that come across for further rehabilitation have had hip surgery following a fractured neck of femur. It had been observed that several patients had a leg length discrepancy following their surgery and so an audit on the prevalence of post-surgical leg length discrepancy demonstrated that 50% of patients transferred to ward 32 post hip fracture had a LLD and these patients were routinely referred to orthotics for correction. On discussion with both Podiatrist and Orthotist it was established that common practice would be to correct half the LLD. The physiotherapists delivering rehabilitation on the ward felt that clinically patient’s functional improvements were greater following LLD correction.