A femoral arterial blood gas sample is obtained from a 41 year old man.

• Describe and interpret the results
• What interventions does he require ?

pH                     7.53

PaO₂                       24.6    mmHg

paCO₂                   13.3    mmHg

HCO₃                10.8    mmol/L

SaO₂                       54%

Show answer

You are just about to see the next patient waiting in your ED – a 3 year old boy brought in by his concerned mother after she noticed the appearance of a generalised skin rash overnight. He had already been unwell for two days with a sore throat and fever, and had started a course of oral antibiotics the previous day at his GPs surgery. The triage nursing observations show his vital signs to be normal but note he is a little lethargic.

1. Before you go in, how do you think about the differential diagnoses you might encounter? (Or do you just go in without a plan and see what you find?)

My approach

2. Describe and interpret this photograph of his rash

Show image

Answer

3. More information

A 57 year old man presents to the ED with 18 hours of severe upper abdominal pain, fever, nausea and vomiting. He looks jaundiced, his HR is 120bpm, BP 110/60, RR 22 and his temperature is 37.8^oC. He is tender and guarded in his right upper quadrant on abdominal palpation.

• Describe the blood test results
• What is the most likely diagnosis?
• What treatment is required in ED?
• What ongoing management is required?

Show answers

Short Answer Questions (SAQs) are one of the three sections of the ACEM Fellowship written examination, wherein ACEM examiners assess the candidate’s ability to:

• Demonstrate factual knowledge
• Analyse, synthesise and prioritise diagnostic and management options in EM
• Discriminate between various assessment and management options based on evidence based principles
• Apply safe decision making
• Demonstrate skills in team/resource management and EM administration
• Apply principles of clinical governance
• Communicate competently in written medium at professional level
• Demonstrate time management skills to deal with a range of topics in limited time

The ACEM format for SAQs is eight questions in 130 minutes (approximately 15 minutes per question) with no reading time. All questions are evenly weighted, and marked out of 10 by two examiners to give a single agreed mark. An overall pass in this section requires a score of 5 or more in a minimum of five questions, and a combined score across the 8 questions of 40 or greater.

I have already outlined the creation and testing process for new Visual Aid Questions and this is essentially the same for SAQs. A subcommittee of the Fellowship Examination committee creates new questions with an eye on the overall curriculum, then workshops them internally, and lastly roadtests them on blinded examiners to fine tune the final version used in the exam. There is a range of commonly used types of SAQs – typically these focus on broad assessment or management, or ask the candidate to discuss or contrast/compare different options or conditions.

It’s vitally important to read and analyse what the question is actually asking before you commence writing.

As there is now no reading time, I strongly advise you to spend the first minute or so of your allotted time for each question deciding on the key issues, and carefully answering exactly what the question asks you. This will help to prevent you spending valuable time writing on aspects of the topic that have NOT been asked. This is a very common error and one that can be avoided largely with good technique.

Ensure that the style and content of your answer is appropriate for the actual question setting.

By this I mean that few questions in the exam are about immediately life threatening emergencies, and thus to use a template style approach that starts with “team approach, full monitoring, two large bore IVs and ABC’s” for most questions is inappropriate, and risks sounding generic/non-consultant like. These statements aren’t wrong in themselves, but try your best to use them when that is in fact what you would do in real practice in the setting of that question. I don’t like them as  ”safe mode” template statements in non-emergency scenarios.

Conversely, there are some words or phrases that I find do work well in most answers and strike the right consultant tone include “seek and treat…”, “consider…”, “calm professional approach”, “minimise time to definitive care”, “ensure thorough documentation” and “assume leadership, and control situation by…”

Tips for success at SAQs

1. Practise to time – this appears obvious but repeatedly doing SAQs to the time limit is vital. Performance will improve and gradually evolve to a concise style that highlights important positive and negative elements in a “consultant” style.
2. I believe there is much to be gained by dedicating some sessions to writing SAQ answer outlines rather than always doing full answers to time. Allow yourself 7-8 minutes for each question and put the focus on quickly assessing the key elements required in the answer, listing the section headings, and the most important “bullet point” components of each section.
3. Do some SAQs from previous ACEM examinations – I suggest you focus mainly on those from the last few years. There are published examiner comments on these in the relevant examination reports online to guide you
4. Don’t stick just to previous examination questions though – create your own and share with other trainees who are preparing like you. Try and predict areas of recent prominence or controversy perhaps that may generate SAQs, or important areas of the curriculum that haven’t been asked for a while.
5. Show your questions and answers to ACEM examiners or trusted, experienced FACEMs and listen to their feedback
6. At least once before the exam, do eight SAQs to time and get them marked, its very different to one or two at a time, and a real test of your technique. This could be as part of one of the organised practice exams, or a self-organised version.
7. Your writing must be legible. Examiners can’t mark what they can’t read.
8. Don’t ever rewrite the question at the start of your answer.
9. A list of key points on the first page can be valuable to set the scene and demonstrate to the examiner that you understand the major issues raised by the question. They are not always necessary, but if included, I recommend that there never be more than three, and that they should be no more than a sentence each. During my marking of the last Fellowship examination, many candidates had introductory key issues that ran to two pages that were then duplicated later in the answer – this is extremely poor technique and can lessen the potential overall mark because of the flawed time management.
10. Whenever a question is framed using one of the ACEM defined words, (eg Discuss, Assess, Manage…), ensure that your answer addresses this correctly and includes the relevant sections therein. This is exactly what the examiners do when deciding on their pass criteria before marking.
11. Leave spaces between each major section of your answer, and have a heading and/or underlining for all important areas. This makes the answer neater, more structured and organised, and allows you to easily add additional points if they come to you later
12. If time and your knowledge permits, the inclusion of a final section in your answer aimed at identifying controversies/pitfalls, or emerging areas of knowledge of the topic always reads well.
13. During the examination itself, always move on to the next question at the end of each allotted time interval (approximately 15 minutes) as it’s virtually impossible to make up time once you’re behind the clock. If however this still happens, put all the information you would have expanded on in your last question as a bulleted outline so the examiner will at least see the scope of your intended answer – it might still be enough for a pass! This is much better than writing an unfinished answer for the, say 6 minutes, that was all you the time you had remaining.

If you have other tried and true techniques I’d love to hear your contribution.

A 24 year old man is brought into the ED with an injury suffered playing touch rugby. He tried to stop and turn suddenly just as another player collided with him. He felt immediate right knee pain and has only been able to hobble a few steps since.

• What abnormality can be seen on his AP Xray?
• Explain the significance of this finding
• What treatment is required?

Reveal the ICE answer

A local doctor refers an active well 78 year old man to your ED. He had just attended for his regular blood pressure checkup that morning and mentioned in passing that his pacemaker had been a bit red for a few days. Intrigued, the doctor suggested he take a look at it…

Describe and interpret his image

He’s currently well, with normal vital signs and general examination. He’s a little surprised at all the fuss this has caused… What are the next steps to take now?

Management

A 27 year old man had a dizzy spell and then collapsed while playing indoor soccer. Bystanders thought that he had a brief loss of consciousness but he woke up quickly and now feels well. He denies any current symptoms.

• Describe the abnormal features on his ECG
• What is the likely diagnosis and underlying abnormality?
• What ongoing investigation and treatment may he need?

Reveal the ICE answer

A 10 year old boy is referred to your ED from a nearby country town for orthopaedic management of a fractured left wrist. This was sustained in a fall from playground monkey bars earlier that day, and is his only injury. At the country hospital, he had been splinted and Xrayed, had oral analgesia administered, and a sling applied. He’s an otherwise well boy who last had oral intake 5 hours earlier, just before his accident.

Describe his Xrays

Xray interpretation

What are the important steps to take now?

ED management

On this occasion, the surgeon requested a CT to help make a decision on best approach to reduction.

CT, report and outcome

More information: Wheeless’ textbook

A 64 year old man attends the ED after developing chest pain radiating to the jaw and right arm while playing tennis. The pain has now been present for nearly half an hour and continues unabated.

• Describe his ECG
• What are the most important interventions for this man in ED?
• What is his likely subsequent treatment?

Reveal the ICE answer

A 64 year old man attends the ED after developing chest pain radiating to the jaw and right arm while playing tennis. The pain has now been present for nearly half an hour and continues unabated.

• Describe his ECG
• What are the most important interventions for this man in ED?
• What is his likely subsequent treatment?

Reveal the ICE answer

I have of late been reflecting on times past in EM, on how some things persist but others become part of the “good old days” that men of my age start to drone on about if given half a chance. I thought I’d try and create two shortlists, the first one composed of facets of daily 1980’s Casualty life that are now never (or rarely) encountered, and the second my Nostradamoid predictions of innovations to come in the 2020’s ED.  The former was pretty easy, the latter not so much… I do wonder too which routine aspects of practice now will be extinct in 2025?

The 1980’s    

“I think we agree the past is over”    George Bush

• Epiglottitis   just the odd unimmunised and adult ones now
• Perforated Peptic Ulcer with board-like rigidity
• AAA rupture
• Flail chest from steering wheels in MVA
• Intracardiac adrenaline for cardiac arrest
• IV Aminophylline for asthma
• Orogastric lavage for OD (? therapeutic, ?punitive)
• Ipecac syrup for childhood poisoning
• Diagnostic Peritoneal Lavage
• Venous cutdown for difficult IV access
• ICC insertion with trocars
• CVC insertion without Ultrasound
• IVP for diagnosis of renal calculi
• Death certification for out of hospital deaths

The 2020’s 

“Trying to predict the future is like trying to drive down a country road at night with no lights while looking out the back window.”                Peter Drucker

• An immediate sensitive + specific bedside test for chest pain
  (so no chest pain units, serial measurements or provocative testing)
• Wireless ECGs with expanded number of leads
• Wireless monitoring, no spaghetti to disentangle
• Accessible and synchronised individual patient medical information
• Paperless workplace – no written notes
• Novel non-invasive analgesia modalities – topical/electronic…
• Self guided lines – will sense/scan patient anatomy and guide themselves to specific designated point eg intrathecal/intra-arterial
• Rationing of expensive medical therapy and interventions

I’d love to see some comments on my lists, and your suggested additions, particularly  for the next decade. I’ll post the best ones, and maybe bury them in an e-time capsule for unearthing in 2025 or so…

A 37 year old woman presents to the ED with a week long history of a tender rash on the lower limbs and feeling non-specifically unwell. There is no history of trauma.

• What is the most likely diagnosis and what features in the clinical history and image point towards this ?
• What diagnoses are associated with this condition ?
• What investigation and treatment is required in ED ?

Reveal the ICE answer

A 19 year old woman presents to your ED with two hours of rapid palpitations and lightheadedness. She has not had chest pain and has no past medical history of note.  On arrival, she is alert, afebrile with a supine BP of 85/60 mmHg.

Describe and interpret her initial ECG

ECG 1

Interpretation

A 9 year old boy fell while trampolining and struck his head on the trampoline frame. There was definite loss of consciousness but just for how long is unclear as the only witnesses were friends his age. The clinical image shows findings on the left side of his head.

• What does the image show and what does it represent ?
• What other features should be sought on history and physical examination ?
• What is your plan of investigation and management for this child ?

Reveal the ICE answer

A 24 year old woman fell on an outstretched hand while playing netball. She comes to the ED via her GP who has put on a temporary plaster splint.

• Describe the findings on the X-ray
• What complications are associated with this injury ?
• What is the preferred management ?

https://gmep.org/media/11512

Reveal the ICE answer

Today I’m really pleased to introduce the first of a new series, the “ICE” quizzes, which have been kindly provided by Professor Ian Rogers from St John of God Murdoch Hospital and University of Notre Dame in Perth, Western Australia. He is one of the best academic emergency physicians in Australia, an excellent teacher, and a great mentor and supporter of my career for over a decade. So welcome to tjdogma Ian!

Here’s his intro to the series:

These cases are designed to appeal to a broad range of learners from undergraduate to advanced post graduate, and across a range of health disciplines. Each has a clinical scenario, a series of questions, a clinical image and finally some professorial ponderings to highlight key learning points. In every one we trust that you will find a few clinical pearls or reminders that you could apply to your patients that you care for in your emergency department or other health setting

The very first in the series, ICE 001 is up and running…

See the complete ICE series:

• The Complete ICE Clinical Emergency Series

A 64 year old woman is brought by ambulance to the ED for assessment of central chest pain lasting 30 minutes at her home that morning. This occurred at rest, was non radiating and had fully resolved on arrival to the ED after administration of parenteral Morphine, sublingual GTN and oral Aspirin en route. She has no significant past medical history, and there are no previous ECGs for comparison. On examination she is now pain free, looks well and has normal vital signs.

Describe and interpret her ECG:

How will you manage her now?

What happened next

Tomorrow, I’ll be one of 24 cyclists riding 800km over the next week around North eastern Victoria in the Great Alfred BIke Ride to raise funds for the Alfred Hospital Emergency Trauma Centre. We’ll summit Falls Creek and Mt Buller, and circumnavigate Lake Eildon. This is a very worthy and deserving cause and it would be hugely appreciated if anyone wishes to lend their support by making a small (tax deductible) donation here:    Great Alfred Bike Ride

Medical education both undergraduate and postgraduate mostly takes place in small group settings with less than 20 learners, and those of us who teach regularly become comfortable in this setting and proficient in the techniques and skills to make it effective. There is a large education evidence base in a range of disciplines that supports this learning format and it’s popular with learners. Over the last decade, most of my medical teaching has been in small groups and focused on two areas, guiding ACEM trainees to completion of their emergency physician training, and coordination of Continuing Medical Education sessions for medical staff in a large tertiary urban ED. These were both very homogeneous groups of learners – all medical, all on a similar career path to ACEM Fellowship and most from a first world medical training background in either Australia or the UK.

But my career move to a smaller private urban ED earlier this year has presented several new challenges, one of which I want to discuss here with a view to my approach so far, and to seek contributions from readers who may have other better techniques.

This challenge is commonly encountered in interprofessional teaching and I’ll just elaborate some of the education considerations when planning the session. To some degree it must always be a compromise compared with presenting material to learners at the same level, but there are some unique benefits too.

• Inclusiveness for all participants, aiming to value input from all levels of learner, and to minimise barriers to them making contributions.
• Good topic selection, to optimise suitability and relevance as there are widely varying ages, experience and endpoints of learners
• Flexibility in teaching methods to accommodate a range of learning styles
• Careful content and pace considerations, to try and achieve balance with new / known and simple / complex material.

I’ve found very little published data on planning and conducting sessions in this area of medical education although I believe it to be a challenge for many of us. An article by Certain et al in 2011 is a well-written review in the clinical setting of ward rounds but in the slightly less dynamic setting of a CME session, I’ve found the following to be most useful and successful so far.

• Case-based studies, where we dissect a patient presentation in terms of diagnosis, clinical reasoning, investigation strategies and outcomes. These can be selected to highlight a serious or rare presentation, or explore in detail a common less acute one, with questions pitched at different levels. They might have a predominant focus on the treatment or investigation as a key theme. In these I try to encourage the learners to be their own teachers, so my role becomes more facilitator than educator. “Why?” and “How?” questions work well here as they encourage flow of questions and exchange of experience. Medical students who have most recently done basic medical sciences can often provide that underpinning to discussions,  where more advanced learners provide detail around their knowledge and accumulated experiential wisdom.

• FOAM, Free Online Access to Meducation, is a great way to add some “colour and oomph” to CME by using some content from the rapidly expanding online community of international educators within your session – multiple ways to do this including video, images, powerpoints etc. We’re just at the beginning of knowing how best to incorporate these but I regularly use material from LITFL and many others that have content applicable to all stages of learner. Its a great way to achieve high quality education when you have limited time for lesson preparation, and there’s the huge bonus of showing your students how and where to go exploring for themselves in their own time.

• Investigation analysis, always popular and relevant, and a key component of most sessions I teach. It can be as simple as ECG or blood gas interpretation or as organised as a Radiology review hour. Questions can be targeted at multiple levels to both establish adequate basic background understanding through to high end and emerging concepts. (so if we take a blood gas as an example, might explore basic approach first, then touch on HH equation and strong iron difference for higher level learners…)

• Procedure and Equipment reviews, wherein we explore both standard and evolving techniques and technology. In regard to the latter, younger students are often better equipped to contribute, and are vital in demonstrating to older learners how to incorporate new techniques to their education and practice. Role play and simulation are great for learning about equipment, helping to break down barriers between learners and fostering more cohesive and functional teams

• Journal club, discussion of evidence, and the techniques/pitfalls in its interpretation. These can be great to teach initially how to find and assess/use data, then building to review new and important articles, and to talk around implementation of emerging practices, guidelines and recommendations.

For now I think this is working in my setting, but I’m going to throw it to you and await your tips and tricks! Hopefully you’ll have some other exciting techniques to share.

It was a special and wonderful day for my daughter Laura’s wedding

Félicitations à Laura et Aaron, 17th Octobre 2012!

I’m a guest at a very special event in France next week, so today a little of the journey down to Burgundy, next time the big day itself!  Then back to downunder EM education…

A 38 year old truck driver is brought to the ED at 0900 with a dislocated left ankle after inadvertently stepping into a hole and twisting on it when alighting from his truck. He is well with no past medical history, and it’s an isolated injury with no complaints of pain other than that joint.

Examination of his foot is reassuring with good volume DP pulse, normal CRT and no sensory deficit. The skin overlying his distal tibia medially is however stretched and a little pale. In the good old bad old days when I was an intern, I remember vividly seeing this exact injury summarily reduced in Casualty (well it was called that then) without analgesia by orthopaedics on grounds of needing to deal immediately with a compromised joint. Have we evolved from those days? How would you proceed now to relocate this joint in your ED? Do you Xray first?

 My approach

A 56 year old woman re-presents to the ED with profound right arm weakness, one day after having been assessed and treated for five days of right shoulder pain. She is a right-handed accountant, who had just been discharged after uncomplicated elective coronary artery grafting, on a background of hypertension and type 2 Diabetes. She had no prior shoulder problems or arthritis.

The pain had initially commenced three days post-op and had been mild but after discharge had worsened, being maximal over the lateral shoulder and unresponsive to oxycodone and paracetamol. There had been no known trauma, other joints involved or associated symptoms. The notes from her previous examination stated that she had been afebrile, with tenderness over the deltoid, full active ROM, and no neurovascular abnormalities in the arm. Investigation with a plain radiograph had been normal, but a shoulder ultrasound had shown the following:

Radiologist report
Appearances strongly suggest a small full thickness tear of the distal supraspinatus tendon measuring approximately 5mm, with substantial bursal thickening. On abduction, there is no obvious impingement and the patient’s pain does not worsen.
Conclusion:
Small full thickness cuff tear with bursal thickening.

Analgesia had been improved by NSAIDs and a sling, and a phone consultation with an Orthopaedic surgeon had led to offer of a steroid/LA injection, but this had been declined by the patient. She had been discharged with the diagnosis of Supraspinatus tendinitis/tear, and an outpatient follow up with the surgeon scheduled for three days later.

When now (unexpectedly) reviewing her in the ED, she is sitting comfortably supporting her right arm with her left, and complains of severe weakness in the arm. She is unable to lift it actively and is pain free with normal observations. Her shoulder to inspection appears normal, but there is no active abduction at all, weak external rotation and flexion, and normal power in extension and internal rotation. There is full passive ROM and neurovascular examination reveals normal pulses, tone, power and reflexes in the limb, with diminished sensation in the right axillary nerve distribution.

What is your diagnosis?

Visual aid questions (VAQs) are employed widely in medical and other biological science examinations as these environments have a wealth of visually analysed material in daily practice. VAQs comprise one of the three sections of the ACEM Fellowship written examination, in which ACEM examiners assess the candidate's competence to:

1. Recognise and describe visual data encountered in Emergency Medicine practice
2. Synthesise relevant and negative features of this data
3. Interpret the data within a specific clinical context.
4. Display knowledge consistent with safe contemporary Emergency Medicine practice in  questions relating to the data.
5. Consistently and adequately interpret a range of medical data in a limited time period

The ACEM format is eight questions in 80 minutes, no reading time, with a typical breakdown being two ECGs, two investigations, two radiology and two clinical images. This section has historically demonstrated lower overall pass rates by candidates than the other two written sections. (MCQs and Short Answer Questions) Several reasons contribute to this, but I believe the most important is insufficient practice (to time) of the typical range of material, leading to poor time management and answer structure when under fire on the day. In an attempt to demystify the VAQ, especially for those of you approaching the lower slopes of Mt FACEM, I'll firstly outline how VAQs are created, then try the process with some new images, and finally list my tips to help improve your success at this domain of the quiz.

 Creation

An ACEM committee of experienced FACEMs source original props from their daily work in a wide range of Australasian EDs. One will usually generate a draft question for the prop, then disseminate to the others for editing/changes/comments to create a final draft. All VAQs have the initial question "Describe and interpret"…, but less complex props will require a second question, either specific such as "Outline your further investigation", or broader "Outline your management" to fully utilise the 10 minute timeframe. (In the most recent VAQ examination 2012.2, there were three of the eight questions with just "Describe and interpret", and five with an additional second question.) After reaching final draft stage, that question is road tested by ACEM examiners who haven't seen it before, and after considering their feedback, the question is finalised and banked for use in a future exam.

Let's try this ourselves - say we wish to create an orthopaedic VAQ on the topic of knee fracture. We have three knee Xrays available and our question stem is: "A 74 year old woman is brought to your ED with a painful knee after a mechanical fall at her home. There are no other injuries, but she is unable to bear weight on it so an Xray is performed." Decide which image is most suitable for use in the ACEM exam (that is, at a level of difficulty/complexity suitable for an emergency physician) and whether it would be  "D + I" for 100% of the ten minutes, or require an additional question. I'll put my thoughts on their merits as well as a description for each.

Image 1

Image 2

Image 3

My thoughts

Tips for success

1. Practise to time - this appears obvious but repeatedly doing VAQs to the 10 minute limit is vital. Performance will improve and gradually evolve to a concise style utilising a  "dot point"/ bulleted format, with highlighting of important positive and negative elements. Don't rewrite question or do "key points" at the start of your answer.
2. Certain types of props are used in every exam, for example ECGs, so becoming adept at ECG interpretation will clearly serve you well. Similarly with common imaging (CXR, CT Brain) and investigations (ABGs and electrolytes) Many of these VAQs are completely predictable and you can be ready to nail them. ECGs lend themselves well to a template style approach, here's an example: LITFL ECG template
3. Create your own and share with colleagues - it's also a good, fun way to study and revise topics.
4. Do VAQs from previous ACEM examinations; I suggest you focus mainly on those from the last few years.
5. Show your questions and answers to ACEM examiners or experienced FACEMs and listen to their feedback
6. Write legibly. Write legibly. Write legibly!
7. Be very careful with ABG and other calculations, its very easy to get these wrong when you're in a hurry, so take a few extra seconds to check them twice
8. At least once before the exam, do eight VAQs to time and get them marked, its very different to one or two at a time, and a real test of your technique.
9. Always move on at the end of each allotted 10 minutes as its virtually impossible to make up time once you're behind the clock. If however this still happens, put all the information you would have expanded on in your last question as a bulleted outline so the examiner will at least see the scope of your intended answer - it might still be enough for a pass! This is much better than writing an unfinished answer for the, say 6 minutes, that was all you the time you had remaining.