#TipsforEMexams: Heather Murray’s Exam Tips

Survivor of the 1997 exam (wow… does the exam really go that far back?)

There is not much to add to the excellent tips already posted. But here I go with my tips. Incidentally they are the same things that I frequently tell my children!

  1. Answer practice questions – over and over again. There is a whole pile of evidence which supports what you already know: highlighting an article or a textbook is a low level retention strategy. Writing out the content is better. But if you really want that information to stay in your head, practice retrieving it. Create practice questions for yourself and the others in your study group, find old practice exams, and ask your program to make questions during teaching sessions. Every time you retrieve the information, the neural pathway in your brain becomes clearer and better developed. This goes for oral examinations too.
  2. Get rid of distractions. Take yourself somewhere where no one can find you, turn off your phone and email, and focus on whatever you have decided to learn. You will be pleasantly surprised how rapidly you can get through what you need to do when you are not constantly interrupted buy the lure of a text, facebook post or an email. Or the sudden inexplicable need to reorganize your kitchen cutlery drawer.
  3. Study strategically. You can predict some of the exam content if you think about it carefully. Guess what? You might need to manage a difficult airway and a pediatric critically ill patient. There are certain emergencies that are core competencies, and guess what? They show up on the exam that is intended to test those competencies. These cases are coming and it is clearly an appropriate expectation for graduating emergency physicians to manage these well. So, have it down to a fine art – rehearse the cases you know you will see again and again, and take them to their worst possible conclusion. Your difficult airway will need a cricothyroidotomy and your pediatric case will arrest… eventually. Be ready to rock it like a champion.
  4. Reward yourself. You do not have unlimited stamina to crush information into your brain. Set yourself a time limit, study hard and then reward yourself with something – exercise, coffee with a fellow exam study sufferer, or a nice meal with your lonely partner. Repeat. Those little psychological boosts can get you through even the most tedious of study topics (workplace environmental toxicology, anyone?).

Good luck!

I tag …

1. Rachel Poley (St. Mike’s)

2. Conor McKaigney (Queen’s / KGH)

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #TipsforEMexams: Heather Murray’s Exam Tips appeared first on BoringEM and was written by Teresa Chan.

Boring Questions: Do you even dip?

Urine is boring so we are doing a follow up post to Brent’s first ever post on BoringEM “Urinalysis Voodoo”. Less voodoo, more evidence.

The case:

Jane, a 23-year-old, sexually active female presents to the emergency department with a two day history of dysuria and urinary frequency. She has not experienced vomiting, fevers or changes in vaginal discharge. Her abdominal review of systems is negative. Her LMP was one week ago and she has had no new sexual partners in the past year. She has had one previous UTI two years ago. Her vital signs are normal and she has a temperature of 36.7. On abdominal exam she has mild suprapubic tenderness and no CVA percussion tenderness. Clinically, you suspect a urinary tract infection. Her urine dip is negative for nitrites, leukocytes and blood.The clinical question:

The clinical question:

Does a negative urine dip rule out a urinary tract infection in the presence of isolated lower urinary tract symptoms in an otherwise healthy, young female?

The Search Strategy: 

Search terms input to Pubmed and Google Scholar were:

  • “Test characteristics AND urine dip”
  • “sensitivity AND urinalysis”
  • “negative predictive value OR positive predictive value AND urinalysis”.

These terms were also searched with “systematic review” in Google scholar. The references of relevant papers were also reviewed. “Urinary tract infection” was searched in the The Cochrane Review Database but no relevant article on diagnosis was found.

The Evidence:

Pre-test probability: a JAMA systematic review [1] estimated that when a woman presents with one symptom of a UTI the baseline probability of infection is 50%. The review went on to outline the likelihood ratios (LR) associated with the presence and absence of symptoms associated with diagnosis.

  • Increase likelihood of UTI: dysuria (LR=1.5), frequency (LR=1.3), hematuria (LR=2.0) and back pain (LR=1.6).
  • Decrease likelihood of UTI: absence of dysuria (LR=0.5), absence of back pain (LR=0.8), history of vaginal discharge (LR=0.3), history of vaginal irritation (LR=0.2).
  • Non-contributory: Fever, abdominal pain, flank pain

*Jane’s pertinent positives and negatives, give her a pre-dipstick probability for UTI of 99% (50% x 1.5 x 1.3).

Test characteristics: A large systematic review [2] of 51 studies evaluated the combined test characteristics of leukocyte esterase/nitrites and two more recent studies [3,6] examined the test characteristics of each test independently.


LR (+)
LR (-)
Leukocyte esterase and/OR Nitrite75%82%4.10.3
Leukocyte esterase44.2%85.2%2.90.53

 Post-test probability

  • Because of the high pre-test probability even a negative dipstick does not rule out a urinary tract infection.

NB: Jane’s urine dip was negative giving her a post-test probability of 33% [99% x 0.3].

The Bottom Line: 

Urine dipstick analysis does not have a high enough negative LR to rule out urinary tract infection in those with a clinically high pre-test probability [6]. We will treat Jane’s symptoms with a short course of antibiotics and will not culture her urine [4, 5] something we would consider with any features suggesting a complicated infection, pyelonephritis or if she had recent antimicrobial treatment.


The not so boring question:

If the test is not going to change management then why do we continue to order it in this specific population?


Other FOAM on this topic

  • Best Bets “Accuracy of negative dipstick urinalysis in ruling out urinary tract infection in adults.”
  • Abbo et al. “Antimicrobial stewardship and urinary tract infections”
  • Brent Thoma’s first ever post on BoringEM “Urinalysis Voodoo


  1. Bent S, Nallamothu BK, Simel DL et al. Does this woman have an acute uncomplicated urinary tract infection? JAMA 2002;287(20):2701-2710. PMID: 12020306.
  2. Hurlbut T, Littenberg B. The diagnostic accuracy of rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol.1991;96:582-588. PMID: 1951183.
  3. Schulz, T., Machado, M. J., Treitinger, A., Fiamoncini, A., & de Oliveira Niederauer, L. M. (2014). Risk associated with dipstick urinalysis for diagnosing urinary tract infection. pinnacle biochemistry research. Accessed at: http://www.researchgate.net/publication/260870381_Risk_associated_with_dipstick_urinalysis_for_diagnosing_urinary_tract_infection
  4. Takhar, S. S., & Moran, G. J. (2014). Diagnosis and Management of Urinary Tract Infection in the Emergency Department and Outpatient Settings. Infectious disease clinics of North America, 28(1), 33-48. PMID: 24484573
  5. Johnson, J. D., O’Mara, H. M., Durtschi, H. F., & Kopjar, B. (2011). Do urine cultures for urinary tract infections decrease follow-up visits?. The Journal of the American Board of Family Medicine, 24(6), 647-655.

Reviewing with the Staff (James Ahn)

Eve Purdy presents a compelling argument for discarding the urine dipstick when we have a high clinical pretest probability for a urinary tract infection (UTI). This is a viable strategy when approaching young and non-pregnant women who are otherwise healthy. If the sensitivity of a urine dipstick is not robust enough to dissuade treatment, then why waste the time and money?

UTIs are one of the most common infections seen in emergency department (ED). This is not an infrequent diagnosis; in the uncomplicated patient, UTIs should be rapid dispositions from the ED. A patient with a high pre-test clinical probability for UTI should be empirically treated with antibiotics. This strategy circumvents the need for urine from the emergency department, which at times can be harder to obtain than CSF! In the ED, the most precious resource is bed space, and any measure we can develop to increase turnover in a safe manner should be considered. Further, preforming a urine dip cost money to the patient and hospital, as well as provide a distraction to allied health professionals from other tasks.

In summary, the young, uncomplicated, and non-pregnant female who has high-risk factors for a UTI should be treated with antibiotics without the performance of a urine dip. The urine dipstick still holds a place in our diagnostic armamentarium for other patient populations and those who do not have such compelling historical risk factors.

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post Boring Questions: Do you even dip? appeared first on BoringEM and was written by Eve Purdy.

Boring Question: Is this patient seeking opioid analgesics for non-medical use?

Clinical Scenario 

A 35-year-old woman presents to the emergency department with severe, generalized abdominal pain. She has had two prior visits in the past ten days with discharge diagnoses of “abdominal pain, not yet diagnosed”. As you try to clarify the history, the patient begins screaming in apparent severe pain.

The patient’s vital signs are: T 36.4, HR 75, BP 121/84, RR 20, SpO2 99% on room air.

You have already reviewed the patient’s laboratory investigations drawn at triage, and imaging from prior visits; you identify no abnormalities. You attempt to examine the patient’s abdomen, which appears soft and non-distended, but even the lightest of palpation elicits a severe pain response from the patient. You inform the patient you would like to listen for bowel sounds; applying a similar and increased amount of pressure to the abdomen with the stethoscope does not elicit discomfort.

The patient begins crying unconsolably and angrily screams, “Why are you making me suffer in so much pain?”


Boring Question:

Is this patient seeking opioid analgesics for non-medical use?


Prescription drug misuse — a more liberal term than the formalized ‘substance abuse’ and ‘substance dependence’ described in the Diagnostic and Statistical Manual of Mental Disorders V (1) — is defined as the use of a prescribed medication outside of the intent for which it was prescribed (2). Estimates of the prevalence of prescription drug misuse vary. In 2011, more than 1.2 million emergency department visits in the United States involved the misuse of pharmaceuticals (3). These patients tend to be young (less than age 40), have longer average emergency department lengths of stay, and are more likely to be admitted or return to the emergency department (4).

In 2009, Dhalla and colleagues published some alarming data regarding prescription opioid analgesics in the province of Ontario (5). In 2007, nearly six of every 10 Ontarians had been prescribed an opioid analgesic in the previous year. Between 1991 and 2004, opioid-related deaths doubled to 27.2 per million. Emergency department visits were common in this population, with nearly 60 percent of patients visiting an ED in the year prior to death.

A more recent September 2014 population-based study by Gomes and colleagues suggests high-dose opioid prescribing continues to rise dramatically in Canada. Over the six-year study period, a total of 180 889 223 high-dose opioid formulations — one of morphine, oxycodone, hydromorphone, and fentanyl, exceeding daily dose thresholds of 100 mg, 80 mg, 20 mg, and 75 ug/h, respectively — were dispensed across Canada. The rate of high-dose opioid dispensing increased by 23.0%, from 781 units per 1000 population in 2006 to 961 units per 1000 population in 2011. Among provinces, Ontario demonstrated the highest annual rate of high-dose oxycodone and fentanyl dispensing (756 tablets and 112 patches per 1000 population, respectively) (6).

Though emergency physicians cannot solely be held responsible for this prescription opioid crisis, 2013 data from the Centers for Disease Control and Prevention in the United States suggests that ten percent of opioid prescriptions in the emergency department are inappropriate, with high daily dosage and long-acting opioids for acute pain being the most commonly identified inappropriate practices (7).


Search Strategy

Using PubMed, two separate searches were performed. These were:

  1. “opioid” OR “prescription” AND “misuse” OR “abuse” AND “emergency department”
  2. “drug seeking” AND “emergency department”

The resulting article titles and abstracts were screened and relevant articles reviewed. In addition, relevant sections in Tintinalli’s Emergency Medicine were reviewed (8).


The Evidence

Drug-seekers are persistent and successful. In one study, suspected drug-seekers were explicitly informed they “would receive no further narcotics” from a particular academic emergency department (9). During the one-year study period, each patient averaged more than 12 visits to an average of four regional hospitals. Ninety-three percent of individuals in this cohort ultimately received narcotics from at least one of the seven regional hospitals surveyed. It is important to keep in mind that some patients might legitimately require frequent encounters or opioid analgesia and the reason for narcotic prescription was not provided in the study.

A 2013 study by Lee and colleagues retrospectively reviewed patients formally diagnosed with substance dependence following visits to the ED (10). Compared to the control group, ED patients later diagnosed with substance dependence received higher doses of opioid analgesia in the ED and more frequently returned to the ED within 24 hours of initial visit. These patients were also more likely to repeat a previous injury; report severe or uncontrolled pain; report allergy to an analgesic; request specific analgesics; and display aggressive behaviour. A similar 2012 study by Grover and colleagues identified the following as being associated with suspected drug-seeking patients: non-narcotic allergy; requesting medication by name; requesting medication refill; lost or stolen medication; out of medication; three or more pain related visits in different parts of the body; 10 out of 10 pain; three ED visits in 7 days; headache; back pain; and dental pain (11).

A 2014 prospective observational study by Beaudoin and colleagues followed a cohort of discharged emergency department patients aged 18 to 55 who received prescription opioids to determine factors predictive of misuse (12). Of the patients studied, 42% reported misuse. Misuse included at least one of non-prescribed self-escalation of dose, taking prescription opioids without a doctor’s prescription, or taking pain medications for a reason other than pain. In this cohort, the following were associated with misuse: presence of disability; chronic pain; pre-existing prescription opioid use; oxycodone use; or past 12-month risk of substance abuse as per the Drug Abuse Screening Test (DAST-10) score (13), which is shown in the table below.

The drug abuse screening test (DAST) is a measure of problematic substance use developed and validated by Dr. Harvey A. Skinner at the Addiction Research Foundation in Toronto, Ontario (now the Centre for Addiction and Mental Health). The DAST-10 version of the screening test performs comparably to the original 28-item score (14). In the Beaudoin and colleagues study, a DAST-10 score of 1 or higher was associated with prescription drug misuse.


One of the several printable versions of the DAST-10 accessible online can be downloaded here.


Summary of the Evidence



Returning to the Case

This is an uncomfortable, yet common ED scenario. It is important to realize that no single risk factor or behaviour is highly predictive of prescription drug misuse (15). This particular patient is less than age 40, has multiple recent ED visits, severe pain and is demonstrating aggressive behaviour. While multiple concerning features are present, the context of the patient presentation must also be considered.

In this particular case, there are no objective findings in the patient’s vital signs, prior imaging, or laboratory investigations to suggest a dangerous abdominal disease process. With most abdominal pathology, you would typically expect pressure applied with the stethoscope and hand to cause similar discomfort for the patient. Discussing the case with nursing colleagues can be helpful in gathering more data on the nature of this patient’s pain and might identify discrepancies in the history. If during daytime hours, you can attempt to obtain collateral history from other health care professionals or facilities this patient has previously encountered. When in doubt, there is no shame in explaining the situation to another ED physician and asking him or her to perform an independent abdominal exam.

Pressure can mount on the ED physician to prescribe an analgesic in this scenario. For example, a nursing colleague might express concern about the patient’s pain and ask if we can give her an opioid. If an opioid analgesic is being refused — as it probably should in this case — you should have an informative, calm and respectful explanation as to why the medication is being refused. Even still, patients can become unpredictably aggressive and you must be prepared to involve security where appropriate.


Bottom Line

Opioid misuse contributes significantly to ED visits. Though the emergency medicine literature leaves more to be desired, an evidence- and context-based approach can help emergency physicians identify at risk patients and more confidently refuse prescription of an opioid analgesic. When drug-seeking behaviour is suspected, the facts should be well-documented in the chart to aid colleagues both in the ED and outpatient primary care setting. Emergency physicians must be part of the solution to this public health crisis—both local and national strategies are needed.

p.s. There is this at the SGEM (woo Canada & #CanFOAMed).  I think our piece compliments and adds some perspective not covered here, though.


  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. Web.
  2. Defining Prescription Drug Abuse. Canadian Centre on Substance Abuse, What We Mean By Prescription Drug Misuse, Abuse, Addiction and Dependence. Web.
  3. United States Department of Health and Human Services. Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. Rockville, MD, 2013. Web.
  4. Brubacher JR, Mabie A, Ngo M, Abu-Laban RB, Buchanan J, Shenton T, Purssell R. Substance-related problems in patients visiting an urban Canadian emergency department. CJEM. 2008 May;10(3):198-204.
  5. Dhalla IA, Mamdani MM, Sivilotti ML, Kopp A, Qureshi O, Juurlink DN. Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone. CMAJ. 2009 Dec 8;181(12):891-6.
  6. Gomes T, Mamdani MM, Michael Paterson J, Dhalla IA, Juurlink DN. Trends in high-dose opioid prescribing in Canada. Can Fam Physician. 2014 Sep;60(9):826-32.
  7. Logan J, Liu Y, Paulozzi L, Zhang K, Jones C. Opioid prescribing in emergency departments: the prevalence of potentially inappropriate prescribing and misuse. Med Care. 2013 Aug;51(8):646-53.
  8. Ducharme J. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed. Analgesia, Anesthesia, and Procedural Sedation, 2011: pp 296-97. New York: McGraw-Hill.
  9. Zechnich AD, Hedges JR. Community-wide emergency department visits by patients suspected of drug-seeking behavior. Acad Emerg Med. 1996 Apr;3(4):312-7.
  10. Lee WC, Lin HL, Kuo LC, Chen CW, Cheng YC, Lin TY, Soo KM, Chan HM. Early predictors of narcotics-dependent patients in the emergency department. Kaohsiung J Med Sci. 2013 Jun;29(6):319-24.
  11. Grover CA, Close RJ, Wiele ED, Villarreal K, Goldman LM. Quantifying drug-seeking behavior: a case control study. J Emerg Med. 2012 Jan;42(1):15-21.
  12. Beaudoin FL, Straube S, Lopez J, Mello MJ, Baird J. Prescription opioid misuse among ED patients discharged with opioids. Am J Emerg Med. 2014 Jun;32(6):580-5.
  13. Yudko E, Lozhkina O, Fouts A. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treat. 2007 Mar;32(2):189-98. Epub 2006 Nov 21. Review.
  14. Yudko E, Lozhkina O, Fouts A. A comprehensive review of the psychometric properties of the Drug Abuse Screening Test. J Subst Abuse Treat. 2007 Mar;32(2):189-98. Epub 2006 Nov 21. Review.
  15. Grover CA, Elder JW, Close RJ, Curry SM. How Frequently are “Classic” Drug-Seeking Behaviors Used by Drug-Seeking Patients in the Emergency Department? West J Emerg Med. 2012 Nov;13(5):416-21.

Photo credit:
Photo by Sage Ross, CC by-sa

Reviewing with the Staff (Dr. A. Pardhan)

This piece was reviewed by Dr. Alim Pardhan MD FRCPC.  Dr. Pardhan is the Program Director of the McMaster University Royal College Emergency Medicine Program

The challenge of determining which patients presenting to the ED are seeking opioids for non-medical use is one without an easy solution. On one hand, we want to treat patients who present with pain; on the other hand, we don’t want to prescribe opioids when they are unnecessary or may be abused. This challenge is exacerbated in the fast-paced, information-poor ED setting.

A few considerations:

  • Have you adequately worked up the patient to rule out potential life threatening conditions? Even “drug-seeking” patients present with real physical illness and have the potential to be written off as “just drug-seeking”.
  • When prescribing opioids, have you considered the risk of dependence? Have you considered non-opioid analgesics as an alternative?
  • If you are going to refuse to prescribe pain medications, have you documented your rationale for doing so?

It is also important to remember that when patients who have an opioid dependence do require analgesia, they may require significantly higher doses than those who don’t.


Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Boring Question: Is this patient seeking opioid analgesics for non-medical use? appeared first on BoringEM and was written by Teresa Chan.

Thank-you from the BoringEM.org

Hey everyone,

This is Teresa Chan writing on behalf of the BoringEM team to wish everyone a very happy Canadian thanksgiving today!  We would like to thank all of our readers for their clicks, follows, reads, and shares.  It has been very exciting to help to grow this blog in these past few months.

First, I would also like to thank our fearless leader, Dr. Brent Thoma, without whom BoringEM would not exist.  We are very proud to announce that Dr. Thoma will be in Toronto next weekend to receive a much deserved leadership award.  On behalf of the whole BoringEM team, we salute you good sir, and thank you for all the work you have done (and will continue to do) in the future.

Next, I would like to thank the tireless Associate Editors that we have had this past year – Dr. Sarah Luckett-Gatopoulos and Soon-To-Be-Dr. Eve Purdy.  Without all of their work, we would be lost.

Finally, we would like to thank all of the writers who have submitted pieces (whether they are posted or still undergoing peer review.  Your pieces are what bring BoringEM to life.

Therefore, in alphabetical order, we would like to thank:


Jacob Avila, Chris Byrne, Erin Dahlke, Danica DeJong, Anton Gervaiev, Alana Hawley, Chris Hicks, Andrew Petrosoniak, Eve Purdy, Romesa Khalid, Heather Murray, Rob Woods,Ross Morton, Aaron Sibley, Brent Thoma, Corey Veldman, Ping Yu Xiong, Amna Zaki.

Attending Reviewers:

Alim Pardhan, Andrew Petrosoniak, Dan Kim, Heather Murray, James Ahn, James Huffman, Joanna Bostwick, Nadim Lalani, Paul Olzynski, Ross Morton, Seth Trueger.

Thank-you to everyone who has made BoringEM a great place to volunteer and contribute.

Yours truly,
Teresa M. Chan
Managing Editor,

p.s. If you would like to contribute to BoringEM, please click here to find out how!

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post Thank-you from the BoringEM.org appeared first on BoringEM and was written by Teresa Chan.

#TipsforEMexams: The Psychological Science of Exams

So, I ran into my friend Meghan McConnell the other day and we got chatting about how to make examinations less of a horrible experience. Dr. McConnell is a PhD researcher in the world renowned Program for Education Research & Development at McMaster University. Her research interests are in the area of how emotions influence training, assessment and performance of healthcare professions.

Considering her interests and expertise, I thought it would be great to interview her for the BoringEM blog, and get some insights into how we might actually harness our own psychology to conquer the exams.

You can listen to our conversation here:

But, for all of busy residents ACTUALLY studying for your exams, here is a summary so you can quickly gleam all the info quickly.

Transcript of Podcast (The Psychological Science of Exams)

TC: What are some things that we can do as people challenging exams to not “psych ourselves out”?

MM: So, a big thing in the emotions research is what we refer to as appraisal. So you can look at an event as stressful or …you can appraise it as a positive or a negative thing. So, classic example is they did this research where they looked at the effects of stress, so if you found that stress had a negative impact on your life then when you followed these people forward you found that they died a lot sooner. If you found that you had a stressful life, but you viewed the stress as a positive thing, then the[se people] actually out performed a lot of their peers. So the idea is that by looking at stress as a positive thing, so it oxygenates your blood, helps focus your attention …

TC: You’re riding an adrenaline high, right?

MM: Exactly. Stress has developed and evolved for a reason, so if you can appraise it as a positive thing – sure, you’re a little antsy, but you know what? That’s going to likely enhance your performance, and that’s really it.

TC: So in other words, don’t let stress get to you, but rather ride that adrenaline high.

MM: Exactly. Ride the wave.

TC: And considering that we’re talking to emerg residents that’s very applicable because, I mean, we ride the adrenaline high all the time, right? Like, in the emergency department … I mean who doesn’t get super psyched up for a really extra interesting case, right? Someone patches in, and needs our help, and is there…

MM: Yup.

TC: So it’s just channelling that …

MM: Well it’s finding that excitement.

TC: So can you get excited about the exam in the same go-getter way that we do every day in the department. Okay. Perfect.

MM: Yeah.

TC: What about [memorization]. There’s a lot of stuff we’ve got to cram in our brains. Honestly, it’s the biggest complaint I hear about the exam. So what can we do to better cram stuff into our brain?

MM: Best thing that I can think of – and I tell everybody this – is …. Testing, testing, testing. It’s not about different ways of encoding the information, which is what studying does, but retrieving information – because that’s what you have to do when you’re testing. You actually have to access the information.

TC: You mean, like, quizzing yourself? Is that what you mean?

MM: Yup. So flash cards – that was my go-to for all of school, and it was really great. Even just, a big part is – and I haven’t go to test this (and I would love to study it) would be to use different parts of your brain. Speaking is one thing, versus reading, versus writing – all of these are accessing different neural networks. And the more accessible this information is, the less stressful it’s going to be, and the easier it is going to be to come out.

TC: Do you think that if you’re going to be challenging a multiple-choice exam, then you should probably try to do as much multiple choice as possible?

MM: Yes. Although research has suggested that even if you … the more elaborate the processing is the better. So it’s just as efficient to test yourself using short answer questions and things like that. Because if you’re making your own quizzes, it’s kinda hard to come up with alternative options.

TC: Yeah. It’s really hard to make up multiple-choice questions.

MM: Right. They have experts on these committees that spend years doing that.

TC: We hope so, anyways!

MM: But even just doing short answer questions still shows an enhancement [in performance] in multiple-choice tests. And even, [with] Meredith Young and Christine St. Onge recently, [I’ve] published something that testing [can have an effect on] a mock licensure exam with multiple-choice questions

TC: In other words, just practice pulling this stuff out of your brain.

MM: Exactly. In as many different ways as you possibly can. Pretend you’re giving a lecture. It doesn’t have to be just be cue cards. Pretend you’re explaining it to someone.

TC: Exactly…

MM: Call up your mom like we were talking about, say: “Okay mom, I’m going to explain this to you. You’re probably not going to understand it… but…”

TC: If your mom is a doctor then she can correct you!

TC/MM: Laughter.

TC: As yours is! And my dad is… so… Obviously, that makes sense. And you can explain things to your learners, if you’re a senior in the department. Finding a learner and tell them you’re going to tell them about some esoteric thing that I need to know for myself. Think of it as both teaching and learning at the same time.

MM: Exactly, it’s about accessing that information. Retrieval practice.

TC: So you want to retrieve things out of your brain. Dust of the cobwebs and really just take it out as much as possible. Alright. And then, my final question to you would be: What do you think are things you can do for mock oral exams? Now, those are a slightly different technique, they tend to be a bit more grounded in reality – most people find them more user friendly. Obviously, it’s not quite like an OSCE – it’s more about your cognition. So, any insights on how to optimize that?

MM: So, I think, if you’ve got the knowledge base so use your testing… Well, you’ve got your comfort there, practice has to be one of the most beneficial things. Again, if you just read over the text, that’s great, but you have to – in the context of an oral exam – actually verbally access [read: represent] that information. You have to also practice the process of speaking and articulating that. And I think a lot of the time, [it’s how you get] more comfortable with it. And if you get stuck in a moment, just take two seconds – remember it’s just ride that adrenaline. So practice, and if you get stuck, it’s not [the end of the world].

TC: Like, do you think it matters if you practice with a faculty member or just with one of your buddies?

MM: I think you could practice in the mirror. I think you could practice on your cat!

TC: Laughs.

MM: The point is getting that information to flow verbally, because a lot of the time you can access it, but being able to say it is a whole other ballgame.

TC: Yeah. It’s kinda like you can watch and know how to do a dance routine but until you actually dancing… Or we’ve all been there, and on platform speeches. Where you have to give a speech – I may know the words but it’s not the same as being on stage. And I guess in some of my earlier days, I may have done some acting… And so memorizing the speech – you know a monologue from Shakespeare -is not the same performing it really well. So that performance part is what you’re talking about. It’s the practicing of that performance. You may know your stuff, but you need to practice performing.

MM: And, you even the bonus of doing it with yourself is that you need to come up with your own questions. It makes you think critically about the same material. And again, variety is the spice of life. Practice with a senior colleague, a junior colleague – they’re all going to ask different questions, and it’s all about accessing that information.

TC: And one of the things that I found was that doing those practice exams, honestly, the quizzes that my friends gave me – some of them have actually impacted on patient care. They didn’t immediately interact on it, but for sure I found that there were some mock oral exams that my friends gave me that resonated with me so much that a couple months later when I was first year staff, it probably saved someone’s life.

MM: Huh!

TC: So, I think that is worth it all. So practicing mock oral exams, learning the material… it’s all important! Well, thank you very much – this is Teresa. And…

MM: Meghan!

TC: Meghan… And thanks for tuning in! Bye!


1.  TED Talk by Kate McGonigal.

2.  McConnell, M. M., St-Onge, C., & Young, M. E. (2014). The benefits of testing for learning on later performance. Advances in Health Sciences Education, 1-16.

Other Resources

1.  Strategies that Make Learning Last 

3.  To remember a lecture take notes by hand 


Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #TipsforEMexams: The Psychological Science of Exams appeared first on BoringEM and was written by Teresa Chan.

Posterior Shoulder Dislocation: Radiographic Evidence

The Case

You’re in the final stretch in an overnight fast track shift at your local emergency department andsleepily contemplating whether to invest in another energy drink when you glance over at the triage desk and your natural endorphins kick in.

A 25-year-old male with the presenting complaint of left shoulder pain is being seen – and the dude has obvious pathology.

shoulder dislocation

(Not actual file photo – this image shows similar patient with pathology on opposite arm – From Imagine courtesy: http://thesportsphysio.wordpress.com/2013/08/20/shoulder-instability-part-2-trauma/)

You immediately suspect an anterior shoulder dislocation and gleefully attempt a Cunningham reduction while taking your history. The patient notes a one-week history of increasing left shoulder instability. His past medical history is significant for previous dislocations of both shoulders. He is otherwise well and takes no medications. He awoke with the shoulder discomfort and came in straight away.

Unfortunately, your reduction is not successful and you start thinking about that energy drink again. You slink off to order a series of shoulder films. 

Play along! For the following images (actual file photos), name the view and note the presence of any abnormalities. Discussion below.

What is this view? Any abnormalities?

What’s this view? What bony anatomy comprises the important landmarks?

What’s this view called? How do we know which direction is anterior and which is posterior?

Acute Posterior Dislocations of the Shoulder

This patient presents with an acute posterior shoulder dislocation.

General Information & Incidence

Posterior shoulder dislocations are rare, accounting for only 2-4% of all shoulder dislocations (anterior dislocations make up the vast majority). The shoulder support provided by the scapulae and their thick muscular associations is what makes this type of dislocation so uncommon. Posterior shoulder dislocations are generally associated with the ‘3 Es’: ethanol, epilepsy, and electricity. The mechanism of injury is nearly always indirect traumatic force, such as a fall or seizure.

Delays in the diagnosis of posterior shoulder dislocation are common due to subtle clinical and radiographic findings. ED physicians must be vigilant and look for them.

Clinical Assessment & Presentation

This patient presented classically, with an internally-rotated arm held in adduction, with reluctance and pain on external rotation.

Image courtesy Roberts & Hedges Clinical Procedures in Emergency Medicine (6th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 49

Other findings in posterior dislocation may include:

  • Anterior contour of the shoulder absent (flattened anterior shoulder),
  • Prominent coracoid and acromion,
  • Rounded posterior shoulder,
  • Palpable posterior humeral head

Radiographic Examination

In the setting of a suspected posterior shoulder dislocation, radiographs should be surveyed for several subtle findings. In particular, a full shoulder series (anterior-posterior (AP), scapular ‘Y’, and axillary views) is an essential part of the diagnostic workup. Occasionally, a patient’s inability to externally rotate for the ordered views (as noted by the radiology tech) may be a helpful clue in the case of a unsuspected posterior dislocation.

AP View

Subtle signs on the AP radiograph include:

  • ‘Light Bulb sign’
    • Internally rotated humeral head appears symmetric on AP film (due to rotation of the greater tuberosity).
  • ‘Empty glenoid sign’
    • Widened space between articular surface of humeral head and anterior glenoid rim.
  • Trough sign
    • Dense vertical line on AP indicating compression fracture of medial aspect of humeral head.
Abnormal Image A
Normal AP View
Un-Boring Finding
Empty glenoid fossa and widened joint spaceHumeral head well-positioned and overlaps with glenoid fossa'Lightbulb Sign' due to rotation of greater tuberosity of humeral head; 'Trough Sign' on humeral head

Scapular View

The scapular view is generated by superimposing the humeral head over the coracoid, acromion, and scapular body and spine. A posterior dislocation is represented by the humeral head lying posterior to the glenoid fossa.

Abnormal Image B
Normal Scapular 'Y' View
Un-Boring Finding
Humeral head appears misleadingly well-positioned in this view - this is why multiple views are essential!Humeral head overlying intersection point of coracoid, acromion, and scapular spinePosterior dislocation of humeral head (HH - humeral head; G - glenoid, SP - scapula)

Axillary View

Abnormal Image C
Normal Axillary View
Un-Boring Finding
Posteriorly displaced humeral head with reverse Hill-Sachs lesionHumeral head well-positioned in relation to the glenoid fossaCoracoid process points anteriorly; note posterior displacement of humeral head; arrow shows reverse Hill-Sachs lesion

The axillary view is generated by placing the arm in abduction, with the image taken through the axilla at 45 degrees. This is arguably the most important view for posterior dislocations, as it easily visualizes a posteriorly situated humeral head. It may also reveal the presence of a reverse Hill-Sachs lesion (also known as a McLaughlin defect), which is an impaction fracture of the humeral head following posterior dislocation.

Tip: Use the coracoid process to orient yourself to the anterior direction on the film!

Reduction Technique


From Roberts & Hedges Clinical Procedures in Emergency Medicine (6th ed) – Chapter 49

As with any dislocation, be sure to check neurovascular status prior to reduction! Fortunately, neurovascular injury is rare in posterior dislocation because the nerves and vessels serving the area are protected due to their anterior location. Consider ortho involvement as posterior dislocations are rare and they may want to be involved in the reduction. Reverse Hill-Sachs lesions occur in >20-25% of posterior dislocations and may require open reduction and internal fixation (ORIF) under general anaesthestic, which is another good reason to consult orthopaedic surgery. Patients in whom you suspect a reverse Hill-Sachs lesion may require further imaging (CT) prior to reduction.

To reduce a posterior dislocation, apply traction to the internally-rotated and adducted arm in conjunction with direct pressure on the posterior aspect of humeral head. The mechanics are relatively similar to the traction-countertraction technique sometimes used to reduce an anterior dislocation.


Consider procedural sedation with or without an intraarticular block for adequate muscle relaxation and patient anxiolysis.

Post-reduction care

Repeat neurovascular examination and post-reduction radiographs are key. On assess of shoulder ROM the patient should now be able to place palm of injured arm on the opposite shoulder. The patient will require post-sedation monitoring, shoulder immobilization, and follow-up with ortho.

Case Resolution

After your refreshing energy drink, you review the case with your attending. You note the presence of a subtle empty glenoid sign on AP film, and posteriorly displaced humeral head with a reverse Hill-Sachs lesion on axillary view. You suspect a posterior shoulder dislocation.

After further discussion with the patient, he confides that he is worried that he may have seized prior to presentation because when he awoke with the shoulder pain he felt groggy and his bedding and bedside items were on the floor. Apparently he’s had a few of these before with unremarkable neurology workups.

The shoulder reduced without issue and the patient is referred to neurology for further workup of for his possibly recurrent seizures.

Peer reviewed by Dr. Sarah Luckett-Gatopoulos (@SLuckettG) and staff reviewed by Dr. Heather Murary (@HeatherM211)


  1. Roberts & Hedges Clinical Procedures in Emergency Medicine (6th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 49
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed) 2011. New York. McGraw Hill Companies Inc. – Chapter 268
  3. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 53

More Posterior dislocations on FOAMed..

  1. Life in the Fast Lane – Posterior Shoulder dislocation (Great images of the radiographic signs mentioned above)
  2. The Blunt Dissection – ‘In or Out?’
  3. EM Resident Blog – Case Discussion
  4. Radiopaiedia – Posterior Shoulder Dislocations

Author information

Corey Veldman
Corey Veldman

The post Posterior Shoulder Dislocation: Radiographic Evidence appeared first on BoringEM and was written by Corey Veldman.