AUSTRALASIAN COLLEGE FOR EMERGENCY MEDICINE 47th

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AUSTRALASIAN COLLEGE FOR EMERGENCY MEDICINE 47th FELLOWSHIP EXAMINATION

REPORT February / May 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 2011.1 examination was held on 16 February (written sections – all regions) and on 30 April and 1 May (clinical sections – Wellington). The clinical sections were held at 2 sites. (Kenepuru Hospital for Long Cases and Short Cases, and the Wellington Hospital for the Long Cases, Short Cases and SCEs) Overall, 51 candidates passed the examination from the 82 who sat the written sections (overall pass rate 62.2%). 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 Neil Banham Anne-Maree Kelly

Paul Mark David Mountain

Debra O'Brien Garry Wilkes

Clinicals only Matthew Chu Bob Dunn

Eric Van Puymbroeck

Leo Marneros

Writtens and Clinicals Peter Aitken Philip Aplin Shalini Arunanthy Michael Bastick Simon Brown Sheila Bryan Betty Chan

Bill Croker Steve Dunjey David Eddey Lou Finnel Bernard Foley Chris Gavaghan Mark Gillett

Richard Harrod Wayne Hazell Ruth Hew Craig Hore Trevor Jackson Tony Joseph Diane King

47th Fellowship Examination Report of Chair Fellowship Examination Committee __________________________________________________________________________________ Debbie Leach Belinda Leigh David Lightfoot John Maguire Jennie Martin Sally McCarthy Greg McDonald

Richard Mulcahy Lindsay Murray Tonia Nicholson Bhavani Peddinti Michael Ragg Drew Richardson Philip Richardson

John Roberts Andrew Singer Mark Smith James Taylor Graeme Thomson Kim Yates

Peer Support Examiners Diane King Graeme Thomson

Richard Harrod Matthew Chu

Greg McDonald

3. OBSERVERS

Gina DeCleene

The official observers were Doctors:

Leo Marneros (Gold Coast Hospital)

Steven Grant (Gold Coast Hospital)

Don Liew (SCE Chair)

Jennifer Davidson (Observer Examiner)

Herman Chua (Observer Examiner)

Barry Gunn (Observer Examiner)

Sean Lawrence (Observer Examiner)

Ian Summers (Observer Examiner) 4. MULTIPLE CHOICE QUESTIONS

76/82 (92.7%) 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 38.7 (SD ± 5.7 ). The grade frequencies were:

Grade ( / 10) Frequency (N) 9 4 8 11 7 23 6 24 5 14 4 4 3 2 5. SHORT ANSWER QUESTIONS

57/82 (69.5%) 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:

Grade ( / 10) Frequency (N) 8 5 7 11 6 24 5 17 4 12 3 10 2 2 0 1

47th Fellowship Examination Report of Chair Fellowship Examination Committee __________________________________________________________________________________

SAQ 1 A 6 year old boy is brought into the emergency department with a 3 day history of colicky abdominal pain which has been distressing him. His mother says he has a history of constipation but has never had pain like this before. Describe your assessment (100%) The overall pass rate for this question was 69/82 (84.1%)

Pass Criteria

To pass, a candidate had to pass 3 of 4 sections: Differential Diagnosis, History, Examination and Investigations. Differential had to include at least 4 likely diagnoses in this age group. There could be a separate list or diagnoses mentioned in the body of the answer. History had to focus on the nature of the pain, other symptoms that could help make the diagnosis and fluid intake/output. Social history was desirable. Examination had to include vital signs and hydration plus some detail on the abdomen, hernias and scrotum. If mentioned, rectal exam had to be done sensitively at this age. Investigations had to include BSL and urinalysis. Other tests needed justification and limited radiation exposure.

Features of unsuccessful answers

Failed or marginal candidates wrote very brief answers in most sections. Differentials were too brief, missed common things and included rare things. Histories were brief. Examinations lacked detail on the abdomen or mention of hernias or scrotum. Rectal examination appeared to be routine. Investigations were just unjustified lists. BSL or urine were missing and radiation exposure was unlimited. SAQ 2 A 23 year old man is brought in to the emergency department by ambulance with an isolated stab wound to his left anterior chest. He is alert, sweaty and taking shallow breaths. The weapon is not in situ upon his arrival in the emergency department. His examination findings are: HR 105 /min BP 95/60 mmHg supine RR 30 /min O2 Saturation 93 % on room air

Describe your assessment (70%)

Outline your management (30%) The overall pass rate for this question was 60/82 (73.2%)


Pass Criteria

a) Assessment (70%) Main issues to be highlighted in answer - Life threatening injury - signs of shock and respiratory compromise - Likely causes to inc. tension PTx, cardiac tamponade, haemothorax History - MIST type handover to inc. weapon/events/prehosp treatment Exam - Vitals: - Primary survey approach looking for signs of tension/pneumothorax/haemothorax/cardiac

tamponade - Secondary survey to follow as appropriate Investigations (prioritise) - CXR: pneumo/haemothorax - FAST : Pericardial fluid b) Management(30%) Treatment - Resus/Team/Early surg or cardiothoracic consult - ABC approach - Breathing: 100% 02 - Rx tension Ptx appropriately - ICC for PTx / Hthorax - Circulation: Good IV access, IV fluid resus with some rationale - Treat confirmed/suspected tamponade: options and indications (OT, aspirate, ED thoracotomy) Disposition - urgent OT or ICU


- Unstable patient taken to CT - Ward disposition


SAQ 3 Describe the indications for initiating and terminating antidotal therapy with N-acetylcysteine in the treatment of suspected or actual overdoses of paracetamol.

(100%) The overall pass rate for this question was 45/82 (54.9%) Pass Criteria

Toxic Dose 150(version 1 of Tox Handbook) or 200 mg/kg (MJA article and I suspect ver 2 of Tox Handbook) – must identify a toxic dose Nomogram – new Aust/NZ nomogram – however V1 of Tox Handbook still goes into detail re Prescott and Rumack nomograms, Pass / Fail – must identify a toxic dose range 150-200 mg/kg plus some discussion re nomogram use: absolute paracetamol levels not pass/fail due to discrepancy with references 1. Single Ingestion/ Known Time

a) less than 8 hours – do not treat until paracetamol level (taken at 4hours or more) shown to be in toxic range

b) greater than 8 hours – initiate NAC if possible toxic ingestion; continue if toxic paracetamol

level or raised ALT, Pass/Fail – identify circumstances a) and b) with correct management strategy, 2. More Complex Circumstances

a) Extended Release Preparations – NAC if > toxic dose on history, check paracetamol levels at 4 and 8 hours post ingestion ( or 4 hours apart – one half life) , if both levels below the nomogram line then cease infusion , otherwise continue 20 hr infusion

b) Paediatric – less likely to incur hepatic in kids < 8 yrs, massive ingestions rare c) Time Indeterminate with possible/probable signif OD – do baseline ALT, commence 20 hr

NAC in all cases. At 20 hrs if ALT Normal, cease infusion. If ALT elevated/rising – continue until LFT normalize

d) High risk patients – not really defined under the new nomogram which takes them into

account, extra marks if candidate recognises this

e) Stuttering Ingestions

(i) Several ingestions at known times – take whole exposure as occurring at earliest time and treat as Single Ingestion/Known Time exposure as above

(ii) Several ingestions at unknown times (repeated supratherapeutic ingestions) signif if > 10g/24hrs or >6g / day for 2 days or more– nomogram useless, perform paracetamol level plus ALT; if ALT raised or Paracetamol > 120umol/L then start NAC, cease at 20 hrs or when ALT normalises

Pass / Fail is reasonable/correct description of 3/ 5 of the above circumstances 3. Indications to Cease NAC

i) Single Ingestion , known time > 8 hrs, level comes back below toxic range ii) End of 20 hr protocol with Normal ALT. Note ALT not indicated in circumstance of

single exposure treated at less than 8 hours


iii) For those with abnormal LFT at 20 hrs, infusion continued and ceased when ALT normalises

iv) Significant anaphylactoid reactions with airway or BP involvement. In all cases, attempt to recommence with halved dose

Pass / Fail – 3 of 4 of the above


Nil Noted

SAQ 4

A 5 year old boy presents to your emergency department with a deformed right wrist after a witnessed fall in the playground. He last ate 2 hours ago. X-ray shows a fracture of the distal radius with 30 degrees of dorsal angulation.

Discuss the anaesthetic options for reducing this fracture

(100%)

The overall pass rate for this question was 56/82 (68.3%) Pass Criteria

1. The candidate must address the pros and cons of in-department sedation Vs in theatre GA. This should be at specialist standard with most of the multiple considerations outlined below mentioned: a. Consideration to parental input, preferences, acceptability, consent and requests to access

private care. b. Consider department status, capabilities, staffing numbers and level, and orthopaedic access. c. Accepted standard for orthopaedic manipulation in hospital/region. d. Neurovascular status (although compromise is unlikely in this scenario).

2. The candidate must competently address the pros and cons of a GA. 3. The candidate must competently address the pros and cons of the commonly used paediatric

dissociative procedural sedative – ketamine (either IV, IM or both);

4. Given the time limit on the question the candidate must competently address the pros and cons of at least 2 other relevant agents/techniques such that it puts them into perspective with GA, ketamine and this age specific scenario.

5. For points 2, 3 & 4 “competently” would be defined as most of the following points (relevant to each drug/technique) being addressed accurately such that safe knowledge and practice is conveyed. (Items with an * should be addressed for each). a. Need for fasting* b. Mode of administration/need for IV access* c. Age appropriate* d. Parental/child acceptability e. Type of sedation +- analgesia f. Depth of sedation g. Antidotes available Vs not available h. Antiemetic action i. Protection of airway j. Side effects specific to each agent k. Contraindications specific to each agent –allergies l. Combining agents – analgesic/sedative, ketamine /other


m. Training or credentialing needed for staff n. Impact on ED-staff number, time and use of appropriate space o. Onset/offset p. Duration of procedure q. LOS in ED and/or hospital r. Cost s. Ease of manipulation

6. Safe practice in the ED must be conveyed at all times – unsafe practice or options deemed to be unsafe in any part of the answer (i.e. deep sedation without mention of staffing/facilities/fasting consideration) would not be accepted as a pass regardless of the standard of the rest of the paper.

7. The candidate could discuss local anaesthetic techniques such as haematoma block, Biers block or

axillary block. However the examiners felt that these techniques are not age appropriate. Failure to indicate this clearly and/or preference these techniques would be considered a fail.


Paucity of pros and cons for ketamine and/or GA or not even mentioning these options at all

No consideration to paediatric specific and departmental issues

Poor hand writing and/or disorganised answers such that there was a paucity of detail and lack of consultant knowledge conveyed

SAQ 5

There have been a number of incidents in your emergency department short stay unit where patients have unexpectedly deteriorated during their stay. You have been asked to find solutions to this problem.

a. List the factors that may contribute to this situation (30%) b. Describe the strategies you could implement to prevent their recurrence (70%)


Part a 3 marks maximum 1. List to contain System factors, Individual factors and Process factors with at least one example

of each. 2. Do not need to actually mention the terms (process, individual and system) to pass 3. Better answers will be systematic with factors grouped under appropriate headings Part b 7 marks maximum The Examiner group felt that answers were likely to be variable and that candidates may approach this question from different angles. It was felt that a multi-pronged approach with a clear understanding of issues was important. Giving the likelihood of variability in approach, a mark breakdown with appropriate weighting to the important issues was felt to be a reasonable approach, rather than being absolutely prescriptive with pass /fail critreria.


Mark breakdown ; Maximum 4 marks I. Discussion of processes in RCA / contributing factors for what’s gone wrong II. Importance of transparency /no blame culture in investigation III. Ideally looking at process, individual and system factors. IV. Again, specific terminology not needed to pass, but trainees need to display an understanding

that the problem areas are potentially multi-faceted in the areas of problems with people, problems with the local process or problems with the global system

V. Description of strategies in these domains Maximum 1 mark I. Importance of vital signs as an objective trigger to recognition of the deteriorating patient II. This then leads to description of strategies such as escalation criteria / MET teams / specific

observation charts with stated escalation criteria Maximum 2 marks I. Ongoing risk management and quality improvement II. Audit and regular monitoring of Unit with appropriate feedback mechanisms III. Emphasis on prevention of further problems / early detection IV. Description of strategies in these domains


1) Failure to Investigate the reasons for the unexpected deteriorations 2) Generic answers which described either a generic quality cycle answer or a generic complaint

answer without specifically addressing the question asked 3) Failure to broadly consider strategies in all areas ie focussing only of clinical issues SAQ 6 A 57 year old man with chronic renal failure has been brought to your emergency department following a syncopal episode post-haemodialysis.

GCS 15 HR 90 /min BP 95/50 mmHg RR 16 /min Temperature 37.4 0C O2 Saturation 98 % on room air

Describe your assessment of this patient (100%)

The overall pass rate for this question was 68/82 (82.9%)


Pass Criteria:

History: 1. HPC - at least some enquiry about events before syncope eg chest pain; dialysis schedule 2. PHx - check for comorbidities with diabetes and ischemic heart disease as minimum 3. Meds - enquire about meds especially blood thinners and antihypertensives 4. Systems enquiry - would need some indication to show looking for infection, bleeding, and

cardiac causes as minimum Exam: 1. Given initial vitals but monitor vitals for change esp temp 2. CVS exam looking at volume status as well as causes 4. Some indication from exam of other systems that looking for infection and bleeding as a

minimum, including vascular access (fistula) Investigations: 1. Bedside glucose 2. ECG looking for ACS, heart block, arrhythmia 3. Bloods - Hb, K+ as minimum, although higher level answers will discuss reliability of

different troponin tests in CRF 4. Micro - some sort of indication that considering infection eg urine, cultures 5 Echo and/or radiology - some indication that directed by history and exam


Unsuccessful answers were missing more than one of the features of history, examination and/or investigations as outlined in the pass criteria. Some answers were very non-specific and better answers specifically related their differential and assessment to the case presented rather than just giving a broad outline of the assessment of any patient presenting to the ED with syncope. Some answers were difficult to read. SAQ 7 A patient attends to the emergency department following an episode of haematemesis. He is tremulous and confused. He has a past history of liver disease and oesophageal varices secondary to chronic alcohol abuse. He has the following vital signs:

GCS 13 (E4 M6 V3) HR 125 /min BP 95/40 mmHg Temperature 35.5 oC O2 Saturation 99 % on 6L O2 by Hudson mask

Describe your management of this patient (100%) The overall pass rate for this question was 68/82 (82.9%)


Pass Criteria

1. Recognition of life threatening upper GI bleeding with shock and confusion. 2. Adequate resuscitation of haemorrhagic shock recognising likely presence of coagulopathy and

need for early factor replacement with blood, and potential need for airway protection. 3. Medical supportive management of upper GI bleeding, with at least Octreotide and/or

Terlipressin 4. Urgent Gastroenterology consultation to facilitate early endoscopy Higher scoring answers also included consideration of: 1. Potential presence of hepatic decompensation / alcohol withdrawal / hypoglycaemia

contributing to confusion/GCS 13. 2. Other upper GI sources of bleeding than varices. 3. Urgent surgery and ICU consultation. 4. Role of balloon tamponade when endoscopy delayed or unavailable


1. Inadequate resuscitation of shock with blood and blood products 2. Failure to recognise urgency of situation and need for early Gastroenterology consultation 3. Insufficient or absent medical supportive management with Octreotide and/or Terlipressin SAQ 8 Outline the differences in rapid sequence induction and intubation of an adult and an infant, in the setting of a head injury.

(100%) The overall pass rate for this question was 52/82 (63.4%) Pass Criteria

Structured response incorporating information on differences between infants and adults in anatomical, physiological equipment and drugs used


Poorly structured answers and inadequate detail or understanding demonstrated in one or more areas especially anatomic and/or physiological Require some 3-4 specific details across areas eg: anatomic differences / drugs/ equipment / degree of difficulty.

47th Fellowship Examination Report of Chair Fellowship Examination Committee __________________________________________________________________________________ 6. VISUAL AID QUESTIONS

45/82 (54.9%) 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:

Grade ( / 10) Frequency (N) 7 8 6 21 5 16 4 18 3 12 2 6 1 1

VAQ 1 A 64 year old man presents to your emergency department with chest pain and shortness of breath. Describe and interpret his ECG (100%) The overall pass rate for this question was 46/82 (56.1%) ECG available on ACEM website Pass Criteria

Identify 2 different rhythms and rates including underlying atrial fibrillation and a paced ventricular rhythm or other ventricular rhythm.

Identify acute inferior myocardial infarction Demonstrate an understanding of the role of the rythm strip in identification of the paced and native complexes

Reciprocal ST depression across lateral leads


Did not identify 2 different underlying rhythms or rates (atrial fibrillation and a paced or other ventricular rhythm

Did not identify acute inferior myocardial infarction


VAQ 2 A 65 year old woman has been brought to your emergency department after being struck by a car at a pedestrian crossing. She has a painful right leg. Her AP and Lateral X-rays are shown a. Describe and interpret her X-rays (50%) b. Outline potential complications (50%) The overall pass rate for this question was 65/82 (79.3%) X-rays available on ACEM website Pass Criteria

a. Tib/Fib fracture

2 out of 4 other findings

Interpretation regarding mechanism

b. Common peroneal nerve injury

Popliteal artery-injury

at least 3 other complications


Incorrect xray reading no interpretation

Missing important complications particularly neuro/vascular

VAQ 3 An 87 year old man from a nursing home presents following a generalized seizure. Serum biochemistry is performed. His observations are: GCS 12 (M 5, V 3, E 4) HR 100 /min BP 120/70 mmHg Temperature 36.8 0C O2 Saturation 97 % on room air a. Describe and interpret his results (70%) b. Outline your treatment priorities (30%)


His serum biochemical results are as follows

Reference Range

Na+ 183 mmol/L (135-145)

K+ 4.9 mmol/L (3.2-4.3)

Cl- 137 mmol/L (99-109)

HCO3- 25 mmol/L (21-28)

Urea 23.5 mmol/L (2.7-8.0)

Creat 105 micromol/L (50-100)

Glu 6.9 mmol/L (3.0-6.0)

PO4- 2.41 mmol/L (0.65-1.45)

Ca2+ 2.39 mmol/L (2.0-2.55)

Mg2+ 1.12 mmol/L (0.70-0.95)


Adequate description and interpretation should include: - calculation of osmolarity / anion gap, interpretation of pre-renal failure, dehydration as cause

for biochemical picture Treatment priorities should mention: - resuscitation or seizure management, fluid therapy, monitoring of fluid / electrolyte status Features of unsuccessful answers

Candidates listed abnormalities without describing or interpreting each of them or as a whole. Candidates failed to answer the treatment part of the question by giving details about specific aspects of management rather than “outlining “ the priorities. Some candidates failed to monitor rate of change of sodium which is an important aspect of management of hypernatraemia


VAQ 4 An 80 year old man presents to the emergency department after a fall. He is on warfarin following an aortic valve replacement. His observations are: GCS 15 HR 80 /min BP 130/70 mmHg O2 Saturation 98 % on 2L/min nasal oxygen Describe and interpret his photograph (100%) The overall pass rate for this question was 57/82 (69.5%) Photograph available on ACEM website Pass Criteria

Describe: Supraorbital lac, Bilat periorbital bruising, Sub-conjunctival haemorrhage, ?Globe rupture, Mydriasis

Interpret: Increased bleeding risk due to warfarin, ?#BOS, ?Globe rupture, ?#Orbit


- Wasted time on management / treatment

- Showed poor perspective

- Too little detail of abnormalities

- Made up signs

VAQ 5

A 13 year old boy is brought to your emergency department 30 minutes after sustaining facial injuries when putting petrol on a barbecue to light it. He complains of severe face and throat pain. His only injuries are as shown in the photographs.

His observations are:

HR 120 /min BP 110/70 mmHg supine RR 20 /min O2 Saturation 95 % room air Describe and interpret his photographs (100%) The overall pass rate for this question was 54/82 (65.9%)


Photograph available on ACEM website Pass Criteria

- Adequate description of burns including extent/BSA and depth

- Recognise airway and lung involvement/recognition of life threatening nature of injuries

- Need for transfer /Mx in Burns unit in view of airway and “special areas” burnt


- Under appreciation of seriousness of airway injury and burns

- Inadequate description of burns and other details above

VAQ 6 A 64 year old man has a seizure two hours after receiving thrombolytic therapy for a stroke. He has become more drowsy with increased right sided weakness and is intubated prior to repeat CT. A non contrast CT head is performed Observations: HR 75 /min BP 180/100 mmHg Temperature 36.6 0C O2 Saturation 100 % on 50% FiO2 a. Describe and interpret the CT image provided (50%) b. Outline your treatment (50%)

The overall pass rate for this question was 60/82 (73.2%) CT Image available on ACEM website Pass Criteria

1. Description of midline shift to right or comment that evidence or raised ICP/mass effect.

2. Interpretation that the patient has an acute intracerebral haemorrhage.

3. Rx must include supportive care (eg.oxygen / CO2 30-35 / head up 30 degrees / mannitol etc.)

4. Rx must include consideration of reversal of thrombolysis


No one failed on giving a poor description alone – it was the treatment section that was the discriminator.

Failure to give supportive care or failure to consider reversal of thrombolysis, were reasons to fail.


VAQ 7 A 46 year old man is brought to your emergency department by ambulance following an overdose of unknown medications. He has had a brief generalized seizure en route. On arrival his observations are: GCS 12 BP 85/60 mmHg Temperature 37.0 0C O2 Saturation 100 % on 8 L/min O2 a. Describe and interpret his ECG (50%) b. Outline your treatment (50%) The overall pass rate for this question was 68/82 (82.9%) ECG available on ACEM website Pass Criteria

Part A Needed Rate, Axis, Rhythm, R Prime AVR , Interpretation – consistent with Na Channel Blockade – also that QRS upper limit or slightly prolonged, QT almost half the RR along with examples gave extra marks

Part B Needed – Mx in resus area, treatment with NaHCo3 and the doses, Fluid Mx for hypotension and Benzodiazepines for seizures.

Use of RSI to assist is accepted but was felt that in this Stem was secondary to above


Lack of detail & precision or systematic approach to part A

Inadequate management – focus was NaHCo3 is the antidote and 1st line treatment. No titration or endpoints – to pH 7.55 & QRS , and no detail in doses or utalising cardioversion in Mx

VAQ 8 An 84 year old man is brought to your emergency department following a high speed car accident. He has signs of multiple left rib fractures. Two hours after arriving in the emergency department he becomes more breathless and distressed. Arterial blood gases are performed His observations are: GCS 14 HR 75 /min BP 100/60 mmHg RR 24 /min


Describe and interpret his results (100%) Arterial blood gases

Reference Range

pH 7.14 (7.35-7.45)

pCO2 60 mmHg (35-45)

pO2 114

HCO3- 17 mmol/L (21-28)

Lactate 1.4 mmol/L (< 2.0)

FiO2 50 %

Na+ 139 mmol/L (135-145)

K+ 4.8 mmol/L (3.2-4.3)

Cl- 116 mmol/L (99-109)

Glucose 11.3 mmol/L (3.0-6.0)

The overall pass rate for this question was 50/82 (61%)

Pass Criteria

Uncompensated respiratory acidosis;

Non-anion gap metabolic acidosis;

Increased A – a gradient;

Clinical correlation: mainly A-a gradient, with fractured ribs, possible flail segment, pulmonary contusion, haemopneumothorax, depressant drugs, occult tension pneumothorax


Poor organisation of information, random or incorrect calculations, poor clinical correlation, listing generic causes of NAGMA, failure to mention causes of V/Q mismatch, extremely brief incomplete answers

47th Fellowship Examination Report of Chair Fellowship Examination Committee __________________________________________________________________________________ 7. CLINICAL EXAMINATIONS

These were held in Wellington on Saturday April 30 and Sunday May 1, 2011. The Clinical examination site coordinators were Craig Wallace at the Wellington Hospital and Paul Quigley and Michael Scott at the Kenepuru Hospital.

7.1. LONG CASES 56/60 (93.3%) passed the long cases. The pass mark is 5/10. The grade frequencies were:

Grade ( / 10) Frequency (N) 9 6 8 11 7 13 6 8 5 18 4 2

3 2

7.2. SHORT CASES 54/60 (90.0%) 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:

Grade ( / 10) Frequency (N) 8 2 7 5 6 19 5 22 4 3

7.3. SCEs 57/60 (95.0%) passed the SCEs. To pass, a candidate needs to score 30/60 and pass at least 4 stations. The grade frequencies were:

Grade ( / 10) Frequency (N) 10 5 9 8 8 7 7 16 6 9 5 12 4 1 3 1

2 1


SCE 1 A 65 year-old man is brought to your urban district ED from a burning factory. Firefighters found him unconscious within the building. His observations are as follows Pulse 110 beats / min BP 104/58 mmHg Resp Rate 10 / min O2 saturations 99 % on a non re-breathing mask GCS 6 (E1, V1, M 4) Arterial blood gases on 15 l of oxygen. pH 7.2 7.35 - 7.45 paCO2 55 mmHg 35 - 45 paO2 144 mmHg 80 - 95 HCO3 20 mmol/L 22 – 28 Base Excess -8 -3 - +3 List possible causes for his reduced conscious state. Describe and interpret the ABG results. What features in the assessment of this patient would support a diagnosis of CO poisoning ? Outline the key issues in the airway management of this patient. The patient is safely intubated. COHb = 15% Discuss the role of hyperbaric oxygen therapy in

this setting. Overall pass rate for this question was 52/60 (86.7%) This SCE examined core elements in CO poisoning, and high standards were expected of candidates. Good candidates synthesized information well, and prioritized key issues before addressing details. Those who performed poorly failed to demonstrate basic knowledge in this area, and/or were unable to interpret the ABGs. SCE 2 A 24 year-old multiparous woman who is 36 weeks pregnant presents to triage in labour. She is transferred to the resuscitation room and the nurse tells you the head is on show. The maternity ward is located in an separate building to the ED. Outline your actions in response to this situation. The baby is delivered within minutes. The cord is clamped and cut. Outline your routine initial

management of the newborn infant. The cord has been clamped and cut and the placenta is still in-situ. The midwife is yet to arrive.

Describe how you would manage the third stage of labour. The placenta is delivered. It appears incomplete and the patient has very heavy PV bleeding.

Outline your actions in response to this. Following this incident you decide to review the contents of the emergency delivery pack in

your ED. Describe how you would undertake this review. Overall pass rate for this question was 49/60 (81.7%) Examiners regarded this as a discriminatory SCE; candidates who performed poorly did not demonstrate sufficient knowledge / familiarity with emergency delivery. Strong candidates showed good knowledge in management of labour, including an ability to prioritize key issues.


SCE 3 A 15 year old girl presents from school after her art teacher was concerned by her behavior in the classroom. She was found seated at her desk cutting her wrists with a craft knife. What are the key features of assessment in this patient? What factors would place this patient at increased risk of suicide? Your assessment reveals superficial injury only in a previously healthy girl who has been

subjected to cyber bullying over the past few months. She states her boyfriend broke up with her last week. Outline your approach to this patient’s treatment and disposition.

Whilst waiting for psychiatric services, she becomes agitated after receiving a text message on her phone. She throws the phone, starts swearing and screams at the nurse to get out of the way as she is leaving. How would you respond?

Overall pass rate for this question was 53/60 (88.3%) Examiners felt this SCE examined a core topic in emergency mental health. Well-performing candidates demonstrated a highly structured approach to the scenario, recognizing and prioritising the key issues. Those who performed poorly by contrast, were disorganised in their verbal discourse. Additionally, the number of candidates who were unfamiliar with a Mental State Examination was notable; this was typically a fail criterion. SCE 4 A 27 year old woman presents to your Emergency Department with left calf swelling for the last 2 days. She is a smoker who had a left knee arthroscopy approximately 10 days ago. She is otherwise healthy, takes no other medications, and has no drug allergies. How would you assess this patient’s risk of a DVT? Discuss the investigations available for DVT. The scan confirms the presence of an isolated, below-knee DVT. Describe and justify your

management. If this patient was pregnant, how would this influence your management? Overall pass rate for this question was 56/60 (93.3%) Key elements of risk assessment and anticoagulation in thrombo-embolic disease were tested in this SCE. High standards were expected, as these are core knowledge in emergency medicine. Not surprisingly, candidates who performed poorly did not demonstrate proficiency in these areas. Strong candidates were able to discuss the investigation options in the context of this particular patient.


SCE 5 You are the Consultant in an urban ED, on a busy shift. You receive ambulance pre-notification about a domestic dispute. They are transporting 2 patients both with shotgun wounds. ETA is 10 minutes. Patient 1: 46 year-old male with wounds to his left chest and abdomen.

GCS 12 (E3, V4, M5); HR 110/min and thready BP 80/p He is on high flow oxygen and has IV saline running.

Patient 2: 43-year-old female with minor wounds to her left forearm. Her vitals are stable. Outline the issues involved in this scenario. The ambulance arrives. The male patient is in shock despite 2 litres of normal saline; his GCS

has fallen to 8. His chest is hyper-resonant on the right, with bilaterally reduced breath sounds. He has an acute abdomen. Outline your approach to his management.

You have initiated management of this patient. A CXR is ordered. Describe and interpret this film.

The male has been transferred to theatre. While you are reviewing the female, the police ring to advise you of her husband’s possible arrival. He is the suspected perpetrator, and may be armed. Outline your response.

In general, outline the principles of forensic evidence collection. Overall pass rate for this question was 56/60 (93.3%) This SCE involved a complex major trauma scenario, requiring consultant-level skills and perspective. Candidates were expected to manage issues beyond the immediate case. Poorly performing candidates failed to demonstrate this, and/or failed to interpret the x-ray in the context of the clinical scenario. SCE 6 A 10 year-old boy re-presents to your ED with right iliac fossa pain and vomiting. He presented late the previous evening, with the same condition. Seen by a junior medical officer, he was discharged with analgesia. His mother is concerned about persistent symptoms. Outline the key features in your history and examination, including a differential diagnosis. Examination of the child’s genitalia reveals the following. Describe and interpret this

photograph. You are concerned about testicular torsion. The Urology registrar requests that an ultrasound is

done before they see the patient. Discuss the role of ultrasound in this setting, and your response to the registrar.

The child is found to have a non-viable testicle at operation, leading to an orchidectomy. The next day, his mother contacts you to complain. What actions will you take?

Overall pass rate for this question was 56/60(93.3%) This SCE comprised a clinical scenario with clinical governance / risk management issues. However, these were regarded as core knowledge by examiners, and consultant level answers were expected. Candidates who performed poorly failed to address important issues in complaints handling or colleague liaison, and/or were unstructured and disorganized in their answers.


8. SUMMARY PASS RATES

MCQ 76/82 (92.7%) SAQ 57/82 (69.5%) VAQ 45/82 (54.9%)

60/82 passed 2 or more sections and were invited to the clinicals LC 56/60 (93.3%) SC 54/60 (90.0%) SCE 57/60 (95.0%)

At the examiners meeting, 51 of the 60 (85.0%) candidates at the clinicals passed automatically.

The overall pass rate for this examination was 51/82 (62.2%)

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 Paul Quigley, Craig Wallace and Michael Scott 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 Officer, Virginia Cunsolo for her tireless activity in bringing this examination to a successful conclusion.

Dr Sheila Bryan Chair, Fellowship Examination Committee

AUSTRALASIAN COLLEGE FOR EMERGENCY MEDICINE 47th

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