bestBETs

Your consultant is about to operate on a 48-year-old patient with moderate to severe mitral regurgitation (MR) due to degenerative disease of the mitral valve. The scrub nurse asks you about the type of ring that your boss is going to use. You say that he always uses a flexible ring. She asks you why and your boss overhears your rather unconvincing response and suggests that you go and look up the evidence rather than cannulating today.

A 20 year old man presents to the ED following exposure to an unknown chemical. On route to the ED he has a cardio-respiratory arrest. You are waiting to greet the patient wearing full PPE - you wonder what the best method of obtaining circulatory access is.

A 4 year-old is brought into the Emergency Department after a fall from a slide in a playground. The clinical diagnosis of a left mid-shaft femoral fracture is confirmed by X-ray. Having become familiar with regional anaesthesia techniques during a recent placement it is decided to carry out a femoral nerve block prior to placing the child’s leg in a Thomas’ splint. Can the departmental ultrasound machine be of assistance when compared to the anatomical or nerve stimulator techniques?

A 60 year old man presents to the emergency department in cardiorespiratory arrest. Numerous attempts to secure peripheral intravenous access are attempted without success. You decide to attempt intraosseous (IO) access to deliver resuscitation drugs and fluids. You have equal experience in using both a manual needle and the EZ IO battery powered IO insertion device for achieving IO access and wonder which method is best.

A 27 year old athlete presents with acute rupture of his Achilles tendon, which is treated surgically. What is the best rehabilitation regimen for optimising his recovery and returning him to competitive sport?

You are on duty in the Emergency Department when you see a 20 year old woman who has perforated her left tympanic membrane with a cotton bud. You wonder if the ENT SHO is right when he suggests prophylactic antibiotics.

A 72-year-old woman with a past history of untreated hypertension presents with palpitations, shortness of breath and ankle swelling for the past 72 h. Examination shows that she has atrial fibrillation with a ventricular rate of 162 bpm, a blood pressure of 146/78 mm Hg and signs of mild left ventricular failure (LVF), both clinically and on the chest x ray. ECG shows atrial fibrillation with a ventricular rate of 160 bpm and voltage criteria for left ventricular hypertrophy. You decide that ventricular rate control is the most appropriate therapy for her. You have been told recently that the chronotropic effects of digoxin are of slow onset and amiodarone runs the risk of cardioversion. You wonder therefore whether diltiazem, a calcium antagonist, may be of use.

A young adult who is keen on sport asks you about a suitable stretching routine for the lower limb in order to prevent injury. You are unsure which, if any, is effective and seek out the evidence.

A 22 year old woman attends the accident and emergency department immediately following a deliberate injestion of 8 ibuprofen tablets. You have no reason to doubt her story of impulsive overdose taken with suicidal intent. You wonder whether her management should include 4 hour paracetamol levels.

An asthmatic patient is admitted to the emergency department with severe asthma. Despite conventional treatment they are not improving. You wonder if the use of inhalational anaesthetic would have any benefit in outcome.

To guide learning and training the Intercollegiate Surgical Curriculum Project implemented workplace based assessments promoting supervised observation, self assessment, reflection and feedback and emphasising a trainee focused and centred approach to surgical training. The underlying driving force of this review is to address training and education to gain an insight into what underpins effective learning for the surgical trainee in the operative environment. The most objective and meaningful assessment of good training is an assessment of the learning achieved, however as Iwaszkiewicz underlines such’ measures of learning are seldom available’. A significant trend amongst researchers in medical education and particularly surgical education is to canvass and analyse learner opinions of training so providing a window into evaluating teaching effectiveness and infer on how effective learning can be achieved.

A 38 year old man with insulin dependent diabetes presents with a reduced conscious level. Bedside BM stick test shows a blood glucose of 2.3. You want to know what concentration of dextrose to give him to restore his blood glucose quickly and safely.

A twenty four year old woman attended clinic after a routine referral from her GP. She had become ill at home and presented to the GP the following day with partner. Her partner was a witness to what had happened and explained how she had said she had felt dizzy and then all of a sudden fell to the floor, with all four limbs shaking, which lasted for around fifteen minutes. There was no tongue biting and no incontinence. As soon as the shaking ceased she sat up and was able to hold a conversation. She was orientated in time and place and didn't seem to be confused, however she was fairly drowsy. In clinic she was given a diagnosis of non epileptic attack disorder. Her partner was wondering whether there was any evidence to support behavioural treatments as a means to reducing seizure frequency.

A 65 year old man arrives at the Emergency Department with a history of crushing chest pain and shortness of breath. His EKG demonstrates ST elevations the inferior leads, his JVP is elevated and you hear inspiratory rales on lung exam. You have read about the benefits of beta-blockers in the acute phase of MI, but are concerned about the risk of cardiogenic shock in this patient with signs of congestive heart failure.

A 3 year old child accompanied by his mother presents to the emergency department with symptoms of pulled elbow following a minor slip on the stairs where he grabbed the bannister. Mum is quite annoyed when you examine the child as you reduced the same elbow 5 days previously. Happy that the elbow was in full use before the initial discharge you wonder if splinting the elbow in some way would have prevented recurrence.

A 72 year old woman is brought in to Emergency by the paramedics after a fall from her own height at home. She slipped and hit her head on the edge of the bathroom sink and presents with a hematoma above her left eye. Her current Glasgow Coma Scale is 11 (E3M3V5), and she is only oriented to person (not place or time). She is on warfarin for atrial fibrillation and her other medications include metformin, gliclazide, ramipril, atorvastatin, metoprolol, nitroglycerin patch and furosemide. Urgent CT of her head reveals a left sided subdural hematoma. You want to reverse her anticoagulation with a prothrombin complex concentrate, but you are unsure of the evidence around their efficacy.

A 14 year old male is under your care and being treated for diabetic ketoacidosis. Fluid resuscitation occurred and insulin was commenced. However, his blood gases continue to reveal a severe degree of acidaemia (pH<6.9). You wonder whether this patient will benefit from bicarbonate therapy and if there is any evidence to prove its efficacy.

A 10 year old boy comes to the Emergency Department with dehydration, polydipsia and polyuria. He is unwell. A provisional diagnosis of diabetic ketoacidosis is made. IV access is gained and fluid resuscitation is commenced. You wonder whether the venous BM reading of 25 is accurate enough to commence insulin or whether you should wait for a formal lab glucose.