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AUSTRALASIAN COLLEGE FOR EMERGENCY MEDICINE

48th FELLOWSHIP EXAMINATION

REPORT

August/ October 2011 This report is circulated to:

candidates – successful and unsuccessful

examiners involved in the examination – written, clinical and observers

DEMTs across Australasia

official observers (listed on Page 2)

clinical site organisers

Board of Education

Fellowship Examination Committee

The report is not confidential and its wide dissemination is encouraged.

The questions alone (without examiner comments or answers) are published in Past Papers and can be

accessed on the ACEM website. Recent previous examination reports are also available on the ACEM

website.

1. INTRODUCTION

The 2011.2 examination was held on 10 August (written sections – all regions) and on 29 October

and 30 October (clinical sections – Gold Coast). The clinical sections were held at 2 sites.

(Southport Hospital for Long Cases and Short Cases, and the Robina Hospital for the Long Cases,

Short Cases and SCEs).

Overall, 43 candidates passed the examination from the 81 who sat the written sections (overall pass

rate (53.1%). More detailed analysis of pass rates is included in subsequent sections of this report.

2. EXAMINERS

Examining in the Fellowship exam is a substantial commitment in time. All of the examiners are

thanked for their efforts. The examiners were:

Writtens only

Shalini Arunathy Diana Egerton-Warbuton Paul Pielage

Tony Brown Craig Hore Philip Richardson

James Collier Belinda Leigh Eric Van Puymbroeck

David Eddey

Clinicals only

Gary Browne Sean Lawrence Ian Summers

Bernard Foley

Andrew Singer

Writtens and Clinicals

Sylivia Andrew-Starkey Adam Chan Tim Gray

Philip Aplin Matthew Chu Barry Gunn

Neil Banham Herman Chua Wayne Hazell

George Braitberg Jennifer Davidson Anna Holdgate

Jennifer Brookes Steve Dunjey Chanh Huynh

48th Fellowship Examination

Report of Chair Fellowship Examination Committee

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Trevor Jackson Richard Mulcahy Drew Richardson

Tony Joseph Lindsay Murray John Roberts

Fergus Kerr Colin Myers Pamela Rosengarten

Tony Lawler Yuresh Naidoo David Symmons

Paul Mark Debra O’Brien James Taylor

Sally McCarthy Scott Pearson Graeme Thomson

Mark Miller Stephen Priestley Garry Wilkes

David Mountain David Richards

Peer Support Examiners

George Braitberg, Matthew Chu, Pamela Rosengarten, Graeme Thomson

3. OBSERVERS

The official observers were Doctors:

Simon Craig (Monash Medical Centre)

Jonathan Dowling (Monash Medical Centre)

Semsudin Hasanovic (Dandenong Hospital)

Don Liew (SCE Chair)

4. MULTIPLE CHOICE QUESTIONS

77/81 (95.1%) candidates passed the MCQ section of the exam. To achieve this a candidate has to

pass 33/60 questions (55%). The mean score obtained was 42.1235 (SD ± 4.7444). The grade

frequencies were:

Grade ( / 10) Frequency (N)

9 10

8 14

7 30

6 17

5 6

4 4

5. SHORT ANSWER QUESTIONS

44/81 (54.3%) candidates passed the SAQ section of the exam. To achieve this a candidate has to

pass 5 or more of the 8 questions with a total mark of at least 40/80. The grade frequencies were:


8 4

7 5

6 20

5 15

4 14

3 14

2 7

1 1

0 1



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SAQ 1

A 24 year old woman presents with a left sided spontaneous pneumothorax.

Discuss the treatment options for her pneumothorax (100%)

The overall pass rate for this question was 72/81 (88.9%)

Pass Criteria

1. Candidates must explain/mention that treatment depends on

Size of pneumothorax

Primary vs. Secondary (i.e. pre morbid lung condition)

Whether patient has symptoms

2. Candidates should describe insertion point

3. Must decompress unstable patient immediately

4. Must discuss at least 4 techniques adequately

5. Must not claim that any technique allows for the discharge of a secondary Ptx

Features of Unsuccessful Answers

Failing answers will not address one or more of the 5 points made above.

SAQ 2

A morbidly obese but otherwise healthy 30 year old woman is brought to your emergency

department suffering from shortness of breath after a 3 day viral prodrome. You estimate her

weight to be 150kg.

Her vitals signs are

HR 125 /min

BP 80/60 mmHg

RR 34 /min

Temperature 38.8 0C

O2 Saturation 85 % 8 litres of O2 /min

A chest X-ray reveals an extensive bilateral infiltrate

Describe your management of this patient (100%)


The examiners felt this question required management of a critically ill, shocked patient with

respiratory compromise due to severe respiratory illness (e.g. CAP or influenza). The patient’s

morbid obesity was flagged twice in the question and also needed to be considered in

management.

Pass Criteria

Perspective = recognise critically ill patient with need for urgent resuscitation

Treatment required, with satisfactory detail; Treatment of hypoxia

i. Consider RSI & Difficult airway

ii. Provide adequate fluid regimen

iii. Consider Pressors / Inotropes



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iv. Provide appropriate Antibiotics

v. Include goals / end points for treatment

Obesity taken into account, including anticipated difficult airway

Disposition = ICU

Fail Criteria

Failure to address all PASS criteria satisfactorily

Unsafe drug doses for critical drugs in this patient (NB pt weighs 150 kg)

i. Pressors / Inotropes doses

ii. Suxamethonium e.g. maximum dose 100 mg


Not considering significance of obesity (150 kg) for treatment regimens e.g. suxamethonium,

“maximum 100 mg”, TV 8ml/Kg, gentamicin 7mg/Kg, “NS 20 ml/kg and repeat”

Significant error in inotrope dose

Failure to administer appropriate antibiotics in patient with likely pneumonia / septic shock

Dangerous airway management e.g. If failed intubation, BVM and transfer to theatre

Lack of perspective e.g. “ICU as likely to deteriorate” in a critically ill patient with multiple

possible indications for ICU

Illegible writing

Features of Answers Scoring > 5

Consider possible viral aetiology ( e.g. influenza) e.g. Universal precautions / PPE / antiviral Rx

Respiratory management additional detail e.g. NIV, anticipated airway difficulty and

management options given obesity, ventilator settings

Details of pressor / inotrope choice and correct dose

Considering EGDT

Bariatric issues, in addition to difficult airway e.g. difficult IV access, US, equipment,

significance for drug dosing

Other issues e.g. consultation, pregnancy

In general, high scoring answers include (correct) drug doses for critical treatment drugs

SAQ 3

A 55 year old man collapses on emerging from the water after snorkelling on a Queensland beach.

He is rapidly transported to the emergency department.

a. List your differential for this man's condition (30%)

b. Outline the features on your assessment that would indicate a marine envenomation

(70%)

The overall pass rate for this question was 47/81 (58%)

Pass Criteria

Part A: Structured response

Include range of non-marine causes including acute cardiac or neuro events and broad

differential for ‘collapse’

Include a range of marine related causes including swimming related injury (e.g. near drowning,

attack by large marine life such as stingray (Steve Irwin syndrome), shark crocodile) and marine

envenomation naming at least two of sea snake, box jelly fish, irukandji, blue ringed octopus

and stone fish.



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Part B:

Structure approach using Hx, Ex and investigations (VERY good candidates will be able to

describe the specific clinical syndromes of various envenomations but I don’t think most

candidates should be expected to do this)

Hx –

1. local epidemiology of the area

2. of event (witnessed sea snake, jellyfish etc.)

3. of symptoms – esp timing of onset, presence and location of pain, presence of

weakness/diplopia

4. background hx which may influence severity of symptoms e.g. pre-existing IHD or HT

Ex –

1. Evidence of cardiovascular collapse with tachy/brady cardia, and hypotension

2. Physical evidence of tentacles, sting wheals, bite marks, puncture marks

3. Evidence of pulm oedema

4. Evidence of paralysis/resp compromise

Link at least one envenomation syndrome with a specific organism e.g. BJF with pain/CVS

dysfunction or BRO with paralysis

Ix –

None that specifically confirm envenomation but ECG/CXR to determine extent of cardivasc

involve


Part A: Poorly structure, lack of appropriate prioritisation of likely causes (e.g. DKA, hyponatraemia but

not seizure and MI), inclusion of irrelevant ddx (e.g. dive related syndromes).

Part B: Lack of specifics relating to at least one envenomation syndrome, lack of linkage between

assessment features and envenomation syndromes, lack of specific knowledge.

SAQ 4

A 72 year old man presents from a nursing home with 4 days of increasing confusion. His GP

letter notes that he has a history of dementia, hypertension and ischaemic heart disease.

The following laboratory results were obtained on his arrival in the emergency department.

Sodium 114 mmol/L (135-145)

Potassium 3.8 mmol/L (3.5-5.2)

Chloride 105 mmol/L (95-110)

Urea 6.2 mmol/L (3.2-7.7)

Creatinine 98 umol/L (60-105)

Glucose 7.6 mmol/L (3.4-5.4 fasting)

Calcium 2.15 mmol/L (2.10-2.55)

Albumin 40 g/L (36-50)

His vital signs are

GCS 13 (E3,M6,V4)

HR 70 /min

BP 150/85 mmHg

RR 16 /min

O2 Saturation 99 % (Room air)



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Describe your further assessment of this patient (100%)


History

Essential information

a) Recent intake or losses (GI, Urinary)

b) Medication history. Must mention diuretic + 1 other medications (neuro type)

c) Baseline mental status/function

d) Past medical history: renal/heart/liver disease (any one of them)

Bonus information

a) Symptoms/features/complications of hyponatraemia:

i. Headache

ii. Lethargy

iii. Seizure

b) History of any lung or brain disease that may predispose to SIADH

c) History of recent systemic disease or signs of sepsis

d) Psychogeriatric illness – e.g. polydypsia

e) Recent falls or other/coexisting pathology (cannot assume that decreased conscious state is due

to sodium alone

f) Past history of electrolyte disturbance (usual sodium level if known)

Physical Examination

Essential information

a) Assessment of hydration status:

i. Hypervolaemia

ii. Hypovolaemia

iii. Euvolaemia

b) Look for features of disease which cause fluid overload (anyone of them)

i. Cirrhosis

ii. Nephrotic syndrome

iii. Heart Failure

c) CNS or mental status examination – signs of altered mental state/focal neurology

Bonus Information

a) look for signs of head trauma

b) look for evidence of malignancy

i. clubbing, effusion, collapse, PANCOAST syndrome

ii. ascites

c) evidence of recent diarrhea/vomiting

Investigations

Essential Information

a) Need to discuss urine sodium and urine osmolality in the setting of extracellular fluid volume.

Mentioning one in context of hydration status is sufficient, mentioning both is additional

information

b) CT scan for both causation and investigation of altered conscious state (e.g. oedema)

Bonus information

a) CXR

b) ECG



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c) UA

d) Rest of LFTs

e) Lipids/Proteins

f) TFT

g) Cortisol

h) Effect of lipid and glucose on assay

Scoring

If 2/3 sections well passed then candidate can score a 5

If hydration status/fluid status is not mentioned in any section clear fail

Frequent errors

focus made on differential of delirium without addressing assessment of hyponatraemia causes

assumptions made that given some past medical history in stem, no further past medical history

should be explored

no focus of medication history for causes of hyponatraemia

assumptions made that given normal renal function and vital signs that dehydration was not

possible

unable to correlate investigations with volume status

SAQ 5

A 21 year old man is brought in by ambulance after being struck in the anterior midline of the neck

with a hockey stick. Initial evaluation reveals he has a hoarse voice, large haematoma and

tenderness of the anterior neck. He is alert and has no other injuries.

His vital signs are

GCS 15

HR 105 /min

BP 150/90 mmHg

RR 22 /min

O2 saturation 98 % on 6L O2/ min

Temperature 37.2 0C

a. Outline the important clinical issues that would affect your airway management of this

patient (30%)

b. Discuss the airway management options for this patient (70%)


Pass Criteria

A. Outline the important clinical issues that would affect your airway management of this

patient (30%)

Fail if do not include any one of the following numbered points:

1. Need to secure airway in a safe and timely manner

2. Risk of laryngotracheal injury

3. Risk of injury to at least two other structures including

vascular

neurological



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cervical spine

soft tissues with expanding haematoma

B. Discuss the airway management options for this patient (70%)

Fail if do not include any one of the following numbered points:

1. Need to balance urgency and optimising personnel (incl Anaesthetist), equipment (e.g.

fibreoptics) and location (ED vs. OT)

2. Need for preparation for surgical airway as back up

3. If candidate includes RSI as an option, then fails if does not include the significant risks

associated with this technique

Features of Unsuccessful answers

Did not convey need for safe and timely intervention

Did not mention the potential for other injuries in the neck that would effect airway

management

Did not discuss, i.e. provide the pros and cons of, various airway management options

Did not include need to preparation for surgical airway as backup plan

If the final agreed mark is less than five, a brief comment must be added to the accompanying

excel marking sheet explaining the reason(s) for this, to aid in feedback to unsuccessful

candidates

Failure to consider types of injuries potentially present

Failure to provide a clear perspective in relation to urgency, preparation, personnel and back

up plans

Failure to consider requesting assistance from other specialities e.g. anaesthetics, ENT

SAQ 6

You are working in an urban district hospital with no obstetric or neonatal service. A 28 week

pregnant woman presents in premature labour. Examination reveals an absence of bleeding and a

closed cervical os.

a. Outline your initial management in the emergency department (50%)

b. Outline the arrangements required for transfer to a tertiary centre (50%)


Pass Criteria

On the information provided the patient was considered to be in premature labour; however with a

closed cervical os this was an urgent rather than an emergent issue with respect to delivery. As a

minimum, candidates were expected to cover the following in their initial management:

Consultation with an obstetric service (i.e. with respect to notification, management plan etc.)

Slow or cease premature labour if appropriate with a tocolytic (nifedipine, magnesium or B2

agonists were deemed acceptable)

Administration of corticosteroids for foetal lung maturation

Better answers would provide: specific information on contraindications (maternal and foetal) to

slowing / ceasing labour with tocolytics; specific drug dosing regimes for tocolysis; dosing of

corticosteroids (betamethasone); use of antibiotics (penicillin) for Group B strep prophylaxis;

monitoring of foetal well-being (e.g. CTG – although it was noted this could be considered

‘assessment’); and supportive cares for the mother (e.g. analgesia). Examiners accepted variable

management algorithms with respect for tocolytics and steroids.



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(a) With respect to the arrangements for transfer to a tertiary centre, the examiners were flexible in

terms of whether this was to occur as a transfer with ED staff or via a retrieval team collecting the

patient. As a minimum, candidates were expected to cover the following with their transfer

arrangements:

Appropriate communication (e.g. with patient / staff / and the receiving unit at the tertiary

centre)

Staffing – to escort the patient during transfer (e.g. number, type, experience, skills etc.) or use

of a retrieval team

Preparedness for potential delivery during transfer

Better answers would provide: a comment on the over-riding principle of the benefit of in-utero

transfer and avoidance of delivery in transit; more detailed information concerning the above

minimum criteria; consideration of mode of transport (likely to be via road given the urban district

setting); information on the drugs and equipment they would arrange to take; documentation; and

monitoring arrangements during the transfer.


Main features was no consultation with Obstetric service in Part A and no preparation for

delivery during transfer in Part B

Didn’t answer questions

Failed to adequately prepare for transfer with regard to specific problem. Generic transfer

answer not helpful

Fatal errors dangerous drugs

drug doses or combinations of drugs. e.g. 20mgIV salbutamol stat !!

SAQ 7

After a recent significant adverse event following the insertion of a central venous line you have

been asked to investigate emergency department central line insertion.

a. List the factors that may contribute to such adverse events during central venous line

placement (30%)

b. Describe the measures that may be used to prevent or minimise these events occurring (70%)


Pass Criteria

a) Structured list that included patient/ environment / equipment and operator factors. Better

answers included factors in each of these sections and ranked them in order of prevalence or

importance.

b) Examiners expected description of measures that demonstrated application of quality

improvement principles to this clinical adverse event scenario. This required sections relating to

information gathering, review of existing guidelines with involvement of relevant ED and non-ED

stakeholders, and creation and implementation of a documented departmental process that

emphasised safe, competent line placement with emphasis on infection prevention at all times.

Additionally there would be education and accreditation processes for line placement techniques

highlighting importance of ultrasound guidance, and regular audit and revision of process to

maximise patient safety and clinical effectiveness.



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No inclusion of proven role of vascular ultrasound in reducing complications of CVL placement.

Failure to include measures that prevent or minimise CVL associated sepsis.

No description of quality improvement processes in measures to reduce adverse events.

SAQ 8

A 5 year old boy presents with an acute exacerbation of asthma. On examination there is reduced

air entry bilaterally with expiratory wheeze. He has tracheal tug, sub costal recession and is

tachypnoeic. Initial pulse oximetry reveals oxygen saturation of 85% on room air. He has had no

treatment prior to arriving in the emergency department.

Describe your management of this patient (100%)


Suggested pass fail criteria

Must address specific treatment, supportive care and disposition as per management definition

Recognition this is severe asthma by criteria (patient stated to have asthma)

Elements of paediatric friendly approach with calming influence including addressing parental

concerns

Recognition that no treatment prior to arrival may mean rapid response to therapy but prepare

for slow response or deterioration

Child weight calculation –except 18-20 kg

Apply oxygen to keeps Sats > 94%

Continuous Ventolin (max 5 mg per neb) –my preference is for nebuliser over spacer initially in

this severity but PEMSoft states either

Prepare for an IV but do not rapidly insert IV as this may distress child– apply topical

anaesthetic

Oral prednisone/prednisolone 1-2mg/kg – give orally if patient can swallow and not vomiting as

delayed onset of action and just as effective as IV hydrocortisone 4mg/kg

Ongoing assessment and monitoring for response to management –tailor management to

response:

1. Patients responds rapidly to treatment (must address this adequately and could include):

Patient may not require IV

Start to lengthen out ventolin intervals and swap to spacer

Due to initial severity patient will as a minimum need prolong stay in ED short stay or

paediatric admission is likely still be preferable –note why did child have no treatment prior to

arrival?

Discharge criteria include need no greater than 4 hourly spacers, asthma plan, GP review and

social/parental circumstances that allow discharge

2. Patient responds slowly to treatment and/or deteriorates (must address this adequately and

could include):

Patient will require IV

Continuous Ventolin (max 5 mg per neb) and space to frequent as per response

Nebulised ipratropium ( dose not pass fail)

IV hydrocortisone if not suitable for oral therapy, this has failed or IV already

Progress to IV bolus salbutamol (dose not pass fail 10mcg/kg over 2-5 minutes)

Progress to IV salbutamol infusion (dose not pass fail 1-5 mcg/kg/min )

Seek and treat pneumothorax or additional diagnosis such as pneumonia

IV NSaline to treat dehydration (10-20mls/kg and repeat)

Consider magnesium (dose not pass fail 25mg/kg slow infusion over 30 minutes)

Consider CPAP

Consider second IV access



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Intubation and ventilation last resort but prepare for intubation – ETT age/4 + 4 and size on

either side, ketamine, suxamethomium, team ready (avoid histamine releasing drugs such as

morphine)

Patient will require paediatric medical admission at least and may need Paediatric Intensive

Care Unit (PICU)

Patient may need transport if no PICU on site –liaison with transport team

Additional marks to 10 can be given depending on detail, doses and expansion on the above

themes

Pass Criteria

Recognition that child has moderate-severe asthma

Administration of hi flow oxygen

Nebulised salbutamol and oral steroids

Tailoring of subsequent management according to response with provisional plan for

management of deterioration (including IV salbutamol

IV magnesium, intubation and ventilation as last resort)

Disposition plan

Candidates were expected to consider implications of lack of pre-hospital treatment noted in

stem but failure to did not mandate failure


Failure to administer steroids

Failure to address disposition

Over-enthusiastic treatment without waiting to assess response to initial therapy

Failure to consider implications of lack of pre-hospital treatment as noted in stem



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6. VISUAL AID QUESTIONS

36/81 (44.4%) candidates passed the VAQ section of the exam. To achieve this a candidate has to

pass 5 or more of the 8 questions with a total mark of at least 40 / 80. The grade frequencies

were:


8 1

7 8

6 17

5 10

4 18

3 15

2 7

1 4

0 1

VAQ 1

A 4 year old boy is brought to your emergency department following an injury sustained to his

right eye from a small rubber ball thrown by his brother earlier that day.

a. Describe and interpret his photograph (30%)

b. His mother asks you; “What are the possible complications”

Outline your response ` (70%)


Photograph available on ACEM website

Pass Criteria

Identifies hyphaema and offers a reassuring explanation to the mother quantifying the risk of

permanent visual loss as small ( in laymans terms).


Long lists of potential complications of blunt eye trauma without any effort to explain in a

reassuring layman’s fashion that such complications are unusual. Failure to identify the hyphaema

or the most common complications (re bleed and raised IOP).

VAQ 2

A 3 month old girl is brought to your emergency department after three days of diarrhoea and

vomiting. She appears very unwell and lethargic, with sunken eyes, a sunken fontanelle and dry

mucous membranes.

Describe and interpret her blood test results (100%)

Her serum biochemical results are as follows



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Reference Range

Venous Blood Gas

FiO2 50 %

pH 7.12 mmHg (7.35-7.45)

pCO2 12 mmHg (40-52)

pO2 103 mmHg

O2 Saturation 98 %

Base Excess -25.0 mmol/L (-3 - +3)

Bicarbonate 4 mmol/L (24-32)

Lactate 3.6 mmol/L (0.5-2.0)

Electrolytes

Sodium 155 mmol/L (135-145)

Potassium 3.0 mmol/L (3.5-4.8)

Chloride 136 mmol/L (95-110)

Urea 15.4 mmol/L (3-8)

Creatinine 45 mcmol/L (50-120)

Glucose 6.1 mmol/L (3.0-6.0)


Pass Criteria

Severe acidaemia

Mixed metabolic acidosis, with features of normal AG / hyperchloraemic acidosis

(predominant) and slightly raised AG

Appropriate respiratory compensation

Hypernatraemia & hypokalaemia with adequate interpretation

Consistent with severe dehydration / hypovolaemia / GI loss of bicarbonate and hypoperfusion


Failure to appreciate predominant non-anion gap metabolic acidosis

Description of abnormal parameters not followed by adequate interpretation

Failure to recognize that blood was venous (not arterial), and therefore parameters such as A-

a gradient is unreliable

Inability to integrate the various information when interpreting

Answers included management, which is not required

VAQ 3 A 28 year old male driver is involved in a high speed motor vehicle accident. He is complaining of

chest and abdominal pain.

His observations are:

HR 100 /min

BP 110/65 mmHg

RR 18 /min

O2 Saturation 97 % (room air)



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a. Describe and interpret his photograph (50%)

b. Outline the role of emergency department bedside ultrasound in his further evaluation.

(50%)

Photograph available on ACEM website


Section A

Pass Criteria

Interpretation with good diff and important management issues

Describe seat belt pattern and potential consequences e.g.

Internal injuries/particular patterns associated with this injury

Fail Criteria

No Interpretation/minimal synthesis

No differential or very poor differential

Section B

Pass Criteria

Understands utility for recognising abdominal bleeding + pneumothorax

Some discussion of US limitations/including details not normally seen/guidance for

management and poor at ruling out major non-bleeding injuries

Fail Criteria

Pure list of views and no understudy of limitations of US both technically or for clinical

management

VAQ 4

A 50 year old man presents following an episode of palpitations and syncope.

At the time of the ECG shown he is asymptomatic.

a. Describe and interpret his ECG (100%)


ECG available on ACEM website

Pass Criteria

ECG description to include:

SR, regular, rate 85 to 90 /min, left axis

P waves normal with short PR ≤ 0.12, QRS ≥ 0.12 borderline widened, RSR V1and 2 - RBBB

pattern

QTc normal ( 0.32 QT), Delta wave V2

ST depression V2 to V5 and T wave inversion inferior II, III, AVF and V1 to V5

Interpretation include sinus tachycardia short PR interval left axis RBBB pattern inferolateral

ST,T changes presence delta waves

Re entrant arrhythmia secondary to aberrant pathway: WPW evidence by short PR, RBBB and

delta wave – other most likely, DDx: Myocardial Ischaemia, Right heart strain e.g. PE



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In this answer candidates failed mostly due to an inadequate description of the ECG – including

incorrect assumptions e.g. LBBB, incorrect description of ST elevation, incorrect axis, no mention

rhythm, no mention or inadequate description of ST T changes, no mention WPW, incorrect

diagnosis of STEMI and no mention possible ischaemia in differential diagnosis.

VAQ 5

A 23 year old man has been brought to your emergency department after a fall onto his

outstretched right hand from a height of three metres.

a. Describe and interpret his X-rays (100%)


X-Rays available on ACEM website

Pass Criteria

Accurate description of complex fracture dislocation of wrist

Including dislocated carpal bones and dislocated lunate

Must mention neurovascular risk

Good answers also included- additional comments regarding complications, prognosis


No mention of neurovascular status

Inaccurate description of injury

Failure to recognise lunate

Answers were marked down for- No mention of open injury; choosing urgent reduction in ED

(without rationale)

VAQ 6

A 30 year old man undergoes a lumbar puncture in the emergency department for investigation of

fever, headache and vomiting.

a. Describe and interpret his results (50%)

b. Outline the further investigations you would consider in order to identify the cause of these

findings (50%)

His cerebrospinal fluid and serum glucose results are as follows:

Reference Range

Opening pressure 220 mm H2O (supine) (50-200)

Colour: mildly turbid

WCC 400 /ml (predominance of lymphocytes) (0-2)

RBC 10 /ml (0)

Protein: 1.2 g/L (0.2-0.5)

CSF glucose 2.2 mmol/L

Gram stain No organisms seen

Serum glucose 6.2 mmol/L (3.0-8.0)



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Pass Criteria

Part a-Correct interpretation of results, with a brief discussion and differential diagnosis

Part b a reasonable range of investigations and reasons for these incl PCR, bloods, radiology


CSF interpretation:

Candidates who failed tended not to actually answer the question, and particularly did not

allocate enough time and effort to the part b even though the mark split was 50/50. Many

candidates just stated the abnormal results without actually interpreting them Overall we found

candidates answered the question at only a very basic level , and there was little in the way of

consultant level discussion or interpretation

VAQ 7

A 54 year old man presents to your rural emergency department with chest pain. An initial ECG

reveals an inferior STEMI. Fifteen minutes after receiving intravenous thrombolysis the following

ECG is taken.

His observations are:

BP 150/80 mmHg

Temperature 36 0C

O2 Saturation 98 % on room air

a.Describe and interpret his ECG (100%)


ECG available on ACEM website

Pass Criteria

Rate 54bpm; regular

Wide complexes ~120msec; non-specific IVCD

No apparent P-waves (?present in alternate T-waves)

Inferior Q–waves

Widespread ST/T changes

Comment on clinical context – likely accelerated idio-ventricular rhythm (AIVR) secondary to

reperfusion and widely considered benign, though some recent evidence that it may indicate

increased chance of further intervention such as PCI.


A high standard was expected for this answer. Features of unsuccessful answers included:

Failure to recognise that there were no P waves before each QRS

Saying that the rhythm was irregular or that there was AV dissociation

Failure to mention the (obvious)—ST elevation inferior changes consistent with the provided

history of recent inferior MI

Failure to mention the associated ST depression / T wave inversion consistent with reciprocal

changes and /or posterior extension

Giving clinical information rather than answering the question asked

Failure to recognise that this is a not uncommon and often benign rhythm following reperfusion



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No single issue above was considered a fail criteria in itself- failed candidates did not describe a

number of the required key criteria and included features above.

VAQ 8

A 25 year old man presents to the emergency department with a three day history of spreading rash

and painful oral lesions. He has the following observations:

HR 90 /min

BP 110/60 mmHg

RR 15 /min

O2 Saturation 97 % on room air.

a. Describe and interpret his photographs (100%)


Photographs available on ACEM website

Pass Criteria (underlined = pass)

Description

Painful oral mucosal lesions characterised by haemorrhagic blistering and ulceration Symmetrical

extensor target lesions of arms with some facial involvement.

Diagnosis

Erythema Multiforme Major on basis of skin plus mucosal lesions affecting at least one site,

Stevens Johnson Syndrome less likely– more widespread, multiple mucosal involvement expected

Aetiology

Idiopathic (50%), infections (herpes, mycoplasma), drugs (antibiotics, anticonvulsants, NSAIDS),

malignancy, immunological diseases

Differential Diagnoses

Toxic Epidermal Necrolysis - extensive skin loss and abnormal vitals

Other conditions - disseminated herpes infection, pemphigus, drug reactions


Failure to mention “target’ lesions on upper limbs or to note the combination of skin and mucosal

lesions

Failure to recognise diagnosis as EM major or Stevens Johnson Syndrome

Failure to mention infections and drugs as possible causes

7. CLINICAL EXAMINATIONS



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These were held in Gold Coast on Saturday October 29 and Sunday October 30 2011.

The Clinical examination site coordinators were Steven Grant at the Robina Hospital and Leo

Marneros at the Southport Hospital.

7.1. LONG CASES

43/52 (82.7%) passed the long cases. The pass mark is 5/10. The grade frequencies were:


10 1

9 2

8 9

7 12

6 14

5 5

4 8

3 1

7.2. SHORT CASES

42/52 (80.8%) passed the short cases. The pass mark is a mark of 5/10, which can be obtained by

passing 3 cases with an aggregate of 15-18/40 inclusive or at least 2 of 4 cases with an aggregate of

19/40 or more. The grade frequencies were:


8 2

7 6

6 16

5 18

4 8 3 2

7.3. SCEs

50/52 (96.2%) passed the SCEs. To pass, a candidate needs to score 30/60 and pass at least 4

stations. The grade frequencies were:


10 5

9 5

8 13

7 14

6 8

5 5

4 2

SCE 1

A 47 year-old woman presents to your emergency department complaining of a gradual onset

generalised headache and vomiting since yesterday. Her past history includes a renal transplant 2

years ago. She appears disorientated and memory impaired.

Her observations are

Pulse rate 100 bpm BP 160/90 mmHg

RR 14 bpm Temp 37.8 deg C tympanic



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GCS 14 (disorientated) SaO2 98% (room air)

Her medications are perindopril, caltrate, prednisolone and azathioprine.

Outline the key features in your history

A non-contrast CT brain is normal. The radiologist suggests a contrast CT. The patient’s

creatinine is 135 (ref. range <110), which is normal for her. Outline your approach to renal

protection in this case

The CT Brain with contrast is normal. What are the key issues to consider regarding a lumbar

puncture in this patient?

Prior to the LP the patient has a generalised seizure. Describe your management

Overall pass rate for this question was 45/52 (86.5%)

This SCE tested assessment and management of an immunosuppressed patient with probable CNS

sepsis. Poor candidate performance was due to inadequate grasp of consultant issues in clinical

management.

SCE 2 You are on duty in a small urban district hospital. You attend to an 8 year-old boy who was rescued

from the bottom of a saltwater backyard pool, unconscious. He was resuscitated by pre-hospital

personnel and presents with the following vital signs:

HR 72 bpm, regular

BP 90/60 mmHg

RR 24 bpm

SpO2 100 % on high flow oxygen

Outline the key features in your examination of this child

Describe the factors which determine THIS child’s prognosis

The child’s GCS is now 14, but he shows signs of respiratory distress from aspiration

pneumonitis. Describe your treatment

The child is stable on BIPAP but will require transfer to the paediatric hospital 25km away. No

retrieval team is available and you elect to transfer the patient. Describe how you will prepare

for transfer

What are the advantages of intubation prior to transfer in this child?


Assessment and management of paediatric near-drowning were the emphases of this SCE.

Examiners regarded it as a good discriminator. Poorly performing candidates failed to communicate

effectively and/or demonstrated key deficiencies in clinical management.

SCE 3

An 82 yr old woman presents with 10 hours of abdominal pain, fever and diarrhoea. Her past

history includes ischaemic heart disease, chronic atrial fibrillation, Type 2 diabetes mellitus and

chronic renal impairment. Her vital signs are: Temperature of 39.1˚C; HR of 110/min and irregular;

BP of 90/ 66 mmHg. A plain abdominal XR is taken. She is in a monitored cubicle of your

Emergency Department.

Describe and interpret the x-rays



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Your clinical assessment leads to suspected mesenteric ischaemia. Discuss the options for

further imaging in this patient.

Describe and interpret the patient’s CT scan of abdomen.

Outline the factors affecting the decision regarding operative treatment for this patient


This SCE focused on investigations for acute abdomen in an elderly patient. It was felt by

examiners to be a good discriminator above pass (ie above 5 out of 10) level.

SCE 4

You are the ED consultant receiving morning handover, when you receive a request for your

immediate help from the Emergency Short Stay Unit. You attend a 25 year-old female who is

receiving her first unit of packed red cell transfusion, for anaemia complicating menorrhagia. Her

vital signs are:

HR 120 (thready) BP 60/40 mmHg

RR 40 /min, with mod. increase in work of breathing T 40 degrees C

Outline your differential diagnosis and your initial response to the scenario

She is now in the resuscitation room. After 2L of IV Normal Saline, she remains hypotensive,

with a BP 80/40 mmHg, but a stronger pulse of 100/min. Your examination has excluded

vaginal bleeding, and her Beta HCG is negative. What are the issues in her ongoing treatment?

Please describe and interpret her blood tests:

ABG on 6L/min O2:

pH 7.1 (7.35 – 7.45)

pCO2 20 mmHg (34 – 45)

pO2 120 mmHg (80 – 100)

HCO3- 10 mmol/L (20 – 26)

BE -10 (-3 - +3)

Lactate 7.0 mmol/L (0.5 – 2.2)

WCC 17 x 109/L (4 – 11)

Hb 88 g/L (130 – 185)

Platelets 170 x 109/L (150 – 450)

The patient is admitted to ICU for further management of a severe transfusion reaction. What

measures can be taken in the ED to prevent transfusion reactions?


The ability to recognize and manage transfusion reaction was tested in this SCE. Poorly performing

candidates failed to demonstrate understanding of key issues at consultant level, particularly around

clinical management.

SCE 5



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A 73 year-old woman is brought into your urban district Emergency Department after a fall at

home. Her husband witnessed the fall; he reports that she fell forward, striking her forehead on a

coffee table. Currently her heart rate is 90, her systolic blood pressure is 110 and her GCS is 15.

Neurological findings:

Weakness and hyporeflexia in all limbs, worse in upper limbs than lower limbs

Reduced sensation in parts of the upper limb but normal in the lower limbs

Outline the key features in your history

You suspect a spinal cord injury. Outline your management of the patient

Just prior to transfer, nursing staff alert you to a deterioration in the patient. Her HR is now

101 bpm and her SBP 88 mmHg. Outline your response

Compare and contrast CT versus MRI in the evaluation of suspected acute spinal cord injury


This SCE depicted an elderly patient with acute central cord syndrome. Examiners expected high

standard responses, as it covered core topics. Candidates who inadequately assessed or managed the

complications of this injury (particularly hypotension) performed poorly.

SCE 6

You will ROLE PLAY a consultation with Julie, who will be played by an ACTOR.

The examiners will NOT be asking any questions and do NOT expect you to interact with them.

You are the consultant in charge of the ED.

4 yo Alana Morris presented via ambulance with her mother after a febrile convulsion. She suffered

a viral URTI for the preceding 2 days, with a temperature of 38deg C. The child suffered a

generalised convulsion lasting approximately 2 minutes. Her mother, Julie, called the ambulance

immediately.

The ambulance crew arrived promptly to find the child in a drowsy, post-ictal state. Delivered to

your ED soon after, Alana remains drowsy, with a persistent fever of 38.5 deg C. Your assessment

deems that she has an isolated viral URTI. All biochemical and metabolic parameters are normal.

The child is recovering, and you anticipate full recovery.

Julie was present during initial care in the resuscitation bay. She began to feel unwell so was taken

to the Family Room shortly after their arrival. 10 minutes have elapsed since then, and she awaits

your arrival to discuss Alana’s condition.


Professional actors were employed in this SCE, which depicted a child with febrile convulsion and

her anxious mother. Communication is a core skill, and high (ie consultant) level interactions were

expected of candidates, especially for a common scenario as this. Failed candidates did not

demonstrate warmth, empathy or understanding of the parent’s concerns.

8. SUMMARY PASS RATES



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MCQ 77/81 (95.1%)

SAQ 44/81 (54.3%)

VAQ 36/81 (44.4%)

52 /81 passed 2 or more sections and were invited to the clinicals

LC 43/52 (82.7%)

SC 42/52 (80.8%)

SCE 50/52 (96.2%)

At the examiners meeting, 43 of the 52 (82.7%) candidates at the clinicals passed

automatically.

The overall pass rate for this examination was 43/81 (53.1%)

9. ISSUES ARISING DURING THE CONDUCT OF THE EXAMINATION

Two candidates were found to be using mobile phones whilst in quarantine. Investigation

failed to identify a breach of security therefore the candidates were not subject to disciplinary

action. As a result of the breach a more stringent policy for the handling of portable

telecommunication devices will be introduced.

9. ACKNOWLEDGEMENTS

The Fellowship examination is a huge logistical undertaking, and I would like to acknowledge

and express my gratitude to the many people involved for the time and effort contributed – to

all my colleagues on FEC in its development, the multiple site organisers of the written

examination, to all written and clinical examiners who contributed their time. I would

particularly like to thank Steven Grant and Leo Marneros the site coordinators of the clinical

sections. They capably headed teams of their colleagues, nurses, clerical staff and orderlies

with the resulting examination proving to be an efficient and successful event.

Finally I wish to highlight the meticulous work throughout with regards to the logistics of the

examination at the College secretariat level. I wish to especially thank our Fellowship

Examination Officers, Virginia Cunsolo & Claire Ridgway for their tireless activity in

bringing this examination to a successful conclusion.

Dr Sheila Bryan

Chair, Fellowship Examination Committee

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