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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
Tony Brown
James Collier
David Eddey
Diana Egerton-Warbuton
Craig Hore
Belinda Leigh
Paul Pielage
Philip Richardson
Eric Van Puymbroeck
Clinicals only
Gary Browne
Bernard Foley
Sean Lawrence
Andrew Singer
Ian Summers
Writtens and Clinicals
Sylivia Andrew-Starkey
Philip Aplin
Neil Banham
George Braitberg
Jennifer Brookes
Adam Chan
Matthew Chu
Herman Chua
Jennifer Davidson
Steve Dunjey
Tim Gray
Barry Gunn
Wayne Hazell
Anna Holdgate
Chanh Huynh
34 Jeffcott Street  West Melbourne  Victoria 3003  Australia  Telephone: (03) 9320 0444  Fax: (03) 9320 0400
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Trevor Jackson
Tony Joseph
Fergus Kerr
Tony Lawler
Paul Mark
Sally McCarthy
Mark Miller
David Mountain
Richard Mulcahy
Lindsay Murray
Colin Myers
Yuresh Naidoo
Debra O’Brien
Scott Pearson
Stephen Priestley
David Richards
Drew Richardson
John Roberts
Pamela Rosengarten
David Symmons
James Taylor
Graeme Thomson
Garry Wilkes
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)
9
8
7
6
5
4
Frequency (N)
10
14
30
17
6
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:
Grade ( / 10)
8
7
6
5
4
3
2
1
0
Frequency (N)
4
5
20
15
14
14
7
1
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
BP
RR
Temperature
O2 Saturation
125
80/60
34
38.8
85
/min
mmHg
/min
0
C
%
8 litres of O2 /min
A chest X-ray reveals an extensive bilateral infiltrate
Describe your management of this patient
(100%)
The overall pass rate for this question was 43/81 (53.1%)
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.
v.


Provide appropriate Antibiotics
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
Features of Unsuccessful Answers
 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
Features of Unsuccessful Answers
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
Potassium
Chloride
Urea
Creatinine
Glucose
Calcium
Albumin
114
3.8
105
6.2
98
7.6
2.15
40
mmol/L
mmol/L
mmol/L
mmol/L
umol/L
mmol/L
mmol/L
g/L
(135-145)
(3.5-5.2)
(95-110)
(3.2-7.7)
(60-105)
(3.4-5.4 fasting)
(2.10-2.55)
(36-50)
His vital signs are
GCS
HR
BP
RR
O2 Saturation
13
70
150/85
16
99
(E3,M6,V4)
/min
mmHg
/min
%
(Room air)
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Describe your further assessment of this patient
(100%)
The overall pass rate for this question was 39/81 (48.1%)
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)
d)
e)
f)
g)
h)
UA
Rest of LFTs
Lipids/Proteins
TFT
Cortisol
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
HR
BP
RR
O2 saturation
Temperature
15
105
150/90
22
98
37.2
/min
mmHg
/min
%
0
C
on 6L O2/ min
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%)
The overall pass rate for this question was 52/81 (64.2%)
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%)
The overall pass rate for this question was 57/81 (71.6%)
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.
Features of Unsuccessful Answers
 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%)
The overall pass rate for this question was 55/81 (67.9%)
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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Features of Unsuccessful Answers
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%)
The overall pass rate for this question was 53/81 (65.4%)
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
Features of Unsuccessful Answers
 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:
Grade ( / 10)
8
7
6
5
4
3
2
1
0
Frequency (N)
1
8
17
10
18
15
7
4
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%)
The overall pass rate for this question was 38/81 (46.9%)
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).
Features of Unsuccessful Answers
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
Her serum biochemical results are as follows
(100%)
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Reference Range
Venous Blood Gas
FiO2
pH
pCO2
pO2
O2 Saturation
Base Excess
Bicarbonate
50
7.12
12
103
98
-25.0
4
%
mmHg
mmHg
mmHg
%
mmol/L
mmol/L
Lactate
3.6
mmol/L
(0.5-2.0)
155
3.0
136
15.4
45
6.1
mmol/L
mmol/L
mmol/L
mmol/L
mcmol/L
mmol/L
(135-145)
(3.5-4.8)
(95-110)
(3-8)
(50-120)
(3.0-6.0)
(7.35-7.45)
(40-52)
(-3 - +3)
(24-32)
Electrolytes
Sodium
Potassium
Chloride
Urea
Creatinine
Glucose
The overall pass rate for this question was 30/81 (37.1%)
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
Features of Unsuccessful Answers
 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 Aa 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
BP
RR
O2 Saturation
100
110/65
18
97
/min
mmHg
/min
%
(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
The overall pass rate for this question was 67/81 (82.7%)
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%)
The overall pass rate for this question was 31/81 (38.3%)
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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Features of Unsuccessful Answers
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%)
The overall pass rate for this question was 48/81 (59.3%)
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
Features of Unsuccessful Answers
 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
Colour:
WCC
RBC
Protein:
CSF glucose
Gram stain
220
mm H2O
(supine)
mildly turbid
400
/ml (predominance of lymphocytes)
10
/ml
1.2
g/L
2.2
mmol/L
No organisms seen
(50-200)
Serum glucose
6.2
(3.0-8.0)
mmol/L
(0-2)
(0)
(0.2-0.5)
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The overall pass rate for this question was 50/81 (61.7%)
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
Features of Unsuccessful Answers
 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
Temperature
O2 Saturation
150/80
36
98
mmHg
0
C
%
a.Describe and interpret his ECG
on room air
(100%)
The overall pass rate for this question was 61/81 (75.3%)
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.
Features of Unsuccessful Answers
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
BP
RR
O2 Saturation
90
110/60
15
97
/min
mmHg
/min
%
a. Describe and interpret his photographs
on room air.
(100%)
The overall pass rate for this question was 58/81 (71.6%)
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
Features of Unsuccessful Answers
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:
Grade ( / 10)
10
9
8
7
6
5
4
3
Frequency (N)
1
2
9
12
14
5
8
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:
Grade ( / 10)
8
7
6
5
4
Frequency (N)
2
6
16
18
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:
Grade ( / 10)
10
9
8
7
6
5
4
Frequency (N)
5
5
13
14
8
5
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
RR
14
bpm
bpm
BP
Temp
160/90 mmHg
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?
Overall pass rate for this question was 49/52 (94.2%)
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
Overall pass rate for this question was 47/52 (90.4%)
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)
RR 40 /min, with mod. increase in work of breathing




BP
T
60/40 mmHg
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
pCO2
20
pO2
120
HCO310
BE
-10
Lactate
7.0
mmHg
mmHg
mmol/L
mmol/L
(7.35 – 7.45)
(34 – 45)
(80 – 100)
(20 – 26)
(-3 - +3)
(0.5 – 2.2)
WCC
Hb
Platelets
x 109/L
g/L
x 109/L
(4 – 11)
(130 – 185)
(150 – 450)
17
88
170
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?
Overall pass rate for this question was 50/52 (96.2%)
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
Overall pass rate for this question was 45/52 (86.5%)
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.
Overall pass rate for this question was 50/52 (96.2%)
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
SAQ
VAQ
77/81
44/81
36/81
(95.1%)
(54.3%)
(44.4%)
52 /81 passed 2 or more sections and were invited to the clinicals
LC
SC
SCE
43/52
42/52
50/52
(82.7%)
(80.8%)
(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