ICE 016

The previous evening, a 59 year old man experienced an hour long episode of chest pain which resolved spontaneously. He has had no further chest pain, but encouraged by his family he presents to ED the next morning. A bedside cardiac troponin test is negative. This is his ECG taken at the same time.

ECG 1Describe his ECG

What do the ECG findings signify ?

How should this patient be managed?


The ECG shows sinus rhythm at 60 /minute, with abnormal ST/T wave changes in V1 through V5 but most marked in leads V2, V3 & V4. There are biphasic T waves in V2 & V3 with the negative component of the T wave being deeply so. In V4 there is very deep T wave inversion.

These particular ECG findings are called a Type 1 Wellens’ pattern. (The other and more common Type 2 Wellens’ pattern with only deep T inversion in V2 – V4 is shown in the ECG underneath this answer) Wellens’ pattern ECGs very likely signify severe stenosis of the left anterior descending coronary artery. They were only first described as an ECG syndrome in the early 1980s and named after the author of the first publication on it. At other times it has been called Wellens’ sign or Wellens’ warning. The last name emphasises the usual clinical course, which is to progress to full occlusion and a completed anterior infarct unless intervention occurs.

This patient should be admitted, not sent for outpatient follow-up. Stress testing should be avoided as it may precipitate a completed infarct. Antiplatelet agents and heparin should be commenced but the key intervention is early coronary angiography/angioplasty.


Wellens type 2 ECG

ECG 2More information on Wellens syndrome: LITFL

 ICE Ian's Clinical Emergencies

2015 ACEM Fellowship Short Answer Question (SAQ)

The new format Short Answer Question (SAQ) will be introduced in the first written ACEM Fellowship examination in February 2015. The ACEM website has included an unchanged outline under the “2015 Onwards” tab for some time, but recently some detailed information has emerged on the DEMT online forum and in the Trainee e-bulletin. To aid dissemination of this, here are the ACEM released sample questions and associated comments from the ACEM Fellowship Examination Committee (FEC).

Firstly, a summary of the SAQ format for the first examination of 2015

  • 30 questions in one paper over 180 minutes*
  • All questions of 6 minutes duration*
  • A single question may have between 2 and 5 parts or sections requiring responses
  • Answer booklet to be provided with spaces for specific number of responses required

(* Has only been guaranteed for the 2015.1 FE, different formats may apply thereafter)

New information

  1. Around Australia and New Zealand, there are many individuals creating questions and resources for the new formats required from 2015, and many of these have been uploaded for free sharing and use on the ACEM DEMT e-forum. (Additionally, there are many sites like this one, with material for free use by trainees and their coaches. All material on tjdogma is part of the FOAMed world, and I encourage readers to use and share it as they wish)

Recently the College collated this material into a single document and released it via the DEMT forum (although it may find its way on to ACEM website at some stage in the future)

ACEM_SAQ_ example_items_DEMT_Discussion_Group

This was released with the following statement:

Here are around 110 SAQ questions in a single collated document. We hope that this will be useful when working with your trainees and helping them to prepare for the new exam format.

There are also some EMQs at the end of this document too that have been submitted.

Please note:

  • X-rays, clinical images and ECGs are reproduced in this document without owner’s consent

  • There are some questions in the document without model answers

  • Items have been briefly reviewed and some typographical errors amended and small changes to increase consistency provided. Detailed quality assurance by the exam sub-committees has not been undertaken.

  1. Shortly thereafter, a second document was released directly from the SAQ subcommittee of FEC, with six questions and suggested answers. These are currently the most accurate representation of what we can expect in 2015.

SAQ Examples New exam format_SAQ_SCv2

This statement accompanied the release:

Dear DEMT’s

Here is a sample of six questions that are equivalent in structure and length to what your candidates sitting 2015:1 can expect. Bear in mind that they have not been workshop-ed and therefore may not be considered ‘exam ready’ but hopefully they give the flavour of the new format exam.

On behalf of the SAQ subcommittee, I apologise that we cannot provide more samples at this time. Our focus has been on ensuring a high quality exam for 2015:1 and given the short turn around time between old and new format exams and meeting printing and quality assurance deadlines, we have been time poor.
We have not been involved in setting the standard for the 2015:1 exam: that will be done by an independent group between now and the time of the exam.

I recommend the following guidelines to assist your candidates.

Answer the question asked (if asked for four options – give four but be mindful of what would be most relevant to the topic being examined). Extra credit will not be given for listing five! If asked to list, the answers will mostly be words or short phrases. Detailed explanation will not be expected.

Keep to the six minutes per question. The standard setting will be based on this time allocation.

To prepare candidates I recommend picking topics to examine and look for ‘packets’ of information that may be the answer to a question. Then come up with the most appropriate question to have the candidate give you that information. Much smaller topics can be examined in this way.

The terms used in the exam are unchanged however you can expect that rather than have an assessment question, the question will focus on x features of history or x diagnoses with supportive investigations. Rather than use ‘discuss’, the question will ask for x pros and cons for the topic. Management features will be very specific with no scope for long-winded descriptions and formulaic responses.

David Cruse

Chair: ACEM SAQ Sub-committee

To finish, I wish to highlight some points arising from these releases – this is entirely my personal assessment of this information:

  • number of responses – note the emphasis on the number of responses to a given question. The provided booklet will contain preformatted space for the number of responses requested. Additional responses will not be marked. If there are more correct responses to a question than spaces provided, the candidate should answer with the most important/likely/encountered in practice.
  • time – it will be exceptionally hard to complete this paper to time. Note that within some of the released questions there were as many as 22 components to a full response to all options within the question. It is vitally important that candidates practice multiple back to back questions like these strictly to time to try and prepare for this both physically and mentally.
  • detail – please note that last comment “Management features will be very specific with no scope for long winded descriptions and formulaic responses”   This is the major change that all candidates must understand and comply with if they wish to be successful. The new format demands and will reward broad superficial responses, not depth, explanation or justification.
  • defined question wording – thus far it has been stated that the current list of defined words such as interpret, describe, list etc will still be used as before. I believe there will definitely be a move towards subsections of these, so asking history, examination, or investigations specifically rather than assessment for example.
  • standard setting – there is a SAQ standard setting meeting scheduled for examiners in February, so currently I’m unclear exactly how this will officially play out. But if it echoes the ACEM MCQ standard setting process, a group of examiners will work through FEC provided SAQs and determine the standard of response we would expect from a borderline pass candidate. That is, how would a candidate at that level be expected to perform on that question in six minutes? The data from this exercise is then collated and used to determine the pass requirement for each question and then to that specific SAQ examination collection of questions overall.
  • pass requirement – so what will the definition of a pass be for the SAQ section? No information released on this as yet. In the past it was 5 out of 8 SAQs passed, with a total of 40 marks or more. With the above standard setting process applied, it will vary (but only a little probably) from examination to examination. I guess like so many other details on the new formats, we’ll have to wait and see…