FRCEM -Intermediate (SAQ)

So I took the Intermediate exam back in September 2017 (the SAQ bit only, I did not book the SJP or the OSCE) and I am happy to say I passed it. That’s two down and…err…about 6 more to go? or is it 5? Sheesh! give me a break!
Anyway – this post is a long time coming, I thought I had written this already but turns out I had done so only in my head.

Having passed the FRCEM Primary in June that same year (thank you thank you *takes a bow*) I was in no way in the right mind to take another exam so soon. The next available attempt for the SAQ was end of September, which meant that I had little over 2.5 months to prepare for yet another exam – along with a new rotation change (I was about to enter the wonderful world of anaesthetics and ITU in August) new responsibilities and the very many issues related to portfolio hassles. Not to mention my wife would not be too happy at literally having had to raise our 2 year old on her own these past few months as I juggled preparing for the primary, and then right after finding out I had to prepare for a second exam. Flowers. And chocolates. lots of them. problem solved. I spoke to my colleagues and my friends and specially my mentor back home in Pakistan. He really really I mean REALLY pushed me to seriously attempt this. This being a clinical oriented syllabus of this exam, he was of the opinion that I just had to build on my standing knowledge and based on my experience having worked in ED these past few years I would not find preparing or taking the exam too hard. I had my doubt but he impressed upon me the need to give it my best shot – if I pass then that’s good, if I don’t then it will be a learning experience. He felt that if i gave it my all there was no reason 2+ months of prep time (sincerely) couldn’t help me pass.

I discussed it with my wife who to my surprise pushed me to go for it! I applied for the exam about 2 days before the deadline to apply. And here is where I found out how every little thing you do, even the smallest tiniest thing, can help out in the long term. It is a long and boring story, but the long and short of it is that someone from an exam prep website saw my blog posts and were interested in sharing said posts on their own website – as a gesture of good faith and in lieu of my contribution to their site, they offered to ‘allow’ me to use their vast question bank free of charge to help me prepare for the intermediate examination! It felt like a sign from above (yes I am that superstitious!) and I decided to do the questions from WWW.FRCEMEXAMPREP.CO.UK

The SAQ is an interesting exam in that I have never taken an exam like this before. As it’s name suggests, you have to write short answers to each of the questions. There are 60 questions in all, each carrying 3 marks. Each question can be one solid question requiring a lengthy answer, for 3 marks, or it can be divided into 2 or even 3 parts, with varying marks for each part but the total for that whole question would be 3. You have 3 hours (180 minutes!) in total but essentially 3 minutes to read each question’s stem (or the stem in each part or each question), think of and formulate your answer or the order of your answer and THEN WRITE IT ALL DOWN. It sort of leaves not much room for any errors or erasing and re-writing or thinking a lot. This I found the toughest thing to do: TIME MANAGEMENT. Since you are not used to writing answers out to questions, you do not realise how time consuming it is to think about your answer and then to write it down so that the examiner can read it and find all the required information that was asked in the question.

The practise questions were good, but like any practise question bank for this sort of exam, it only gives you a key of answers that are deemed correct. There may be other answers/varieties of the same answer worded differently that may be correct, or indeed a completely different answer might be correct. For example, in a scenario of a young male patient with appendicitis apparent as the clinical picture, if the question asks for 4 steps of management in ED, the answers could be: 1) analgesia 2)surgical consult/referral 3)fluids 4)antiemetics 5)antibiotics 6)urine dip and other investigations to rule out other causes for similar clinical picture 7)NBM till further orders – now if the key shows only options 1/2/3/4 as the only steps in management, someone writing the other steps could be deemed correct as well, or any combination of the above options. They essential bit to understand is that the more you practise these questions, the better you become at thinking about the answers and formulating the correct answer and writing them down in a concise and legible manner, with the addition of time constraints.

There were recommendations to read some textbooks as well – but I found I had no time to read anything, I only focussed on practising as many questions as I could. The questions I got wrong, I did read up on a few of those concepts, but mainly I found the explanation in the website to be quite sufficient, it gave you a broad overview of the topic at hand, and it gave all relevant information related to the query at hand. With each question I got more and more confident, and the explanations were very very helpful in preparing for these. I first utilised the option of doing the questions subject wise – there were a wide variety of them, including paediatrics and gynae and medicine and pharmacology etc – I found I didn’t do too well when I knew what the subject matter was. After I had gone through all the questions in the subject wise manner, I then opted for the shuffled questions – The site rang up a mixture of all subjects and gave me 20 or 50 or whatever number of questions I needed to do or had the time for.

On my days off I did approximately 10-14 hours of these question banks, approximately 50-100 questions with their explanations – my days off were very few and far between. On my days at work, while I was still in A&E I found myself unable to do more than 20 or a maximum of 30 questions a day – but I made it a point to do atleast some if not too many, every day. I think the trick to this exam is to be consistent in your prep. In the last 5-6 weeks before the exam I started in my new rotation in anaesthetics – and I found a great rota, one with weekends off and no nights or on call commitments. Granted, I was paid a lot less than I expected but I got a good time to do those questions! Once I had finished the questions subject wise, and then again as a mixture, I just randomly kept doing questions – I still got a few wrong, I only read explanations for those, the ones I got right I didn’t waste time reading up on them unless I felt it was a weak subject for me.

I took 5 days of study leave (not including the day of the exam) and the day before the exam I did not study anything. I do not believe in cramming till the last second. I spent the day with my family, went out with them to the town centre, had an educational supervisor meeting, made a few phone calls to family back home in Pakistan, watched the Minions movie with my son for the thousandth time, cooked a meal and just generally relaxed and enjoyed and rested – before the trauma of the next day.

Even though it was an early start for me, I was almost 7 minutes late to the exam (effing traffic jams on the way to London where my station was!) and I rushed in and totally convinced myself that there is no way I am passing this exam now – but I did, and so can you! Just…make sure you do not convince yourself that time is too short and there is no way I can prepare for this in such a short time…just make sure you atleast attempt it, you may end up surprising yourself. I did, and so can you. Just…make sure you do as many questions as you can, as frequently as you can, in as timely a manner as possible. Again. And again. And again.

Good luck!

My first EM conference in the UK – The Northern Emergency Medicine Conference 2018

NEMC18

1) RCEM President address – pertinent points extolled were: good practice guide; duty of candor; work ethics; reiterated how the quality of care that we provide to patients has improved over the years; members have gone from 7 to 7500 in a matter of a few years!
He also talked about the ED exit block, what problems it created and how it wasn’t really the department itself that caused the block, but the flow out of the department, and that was basically a matter of funding and resources.
He addressed a few ‘elephants’ in the room – key concerns were the fact that demand has increased, with a 30 percent rise in ed attendances in 12 years; variations in staffing, variations in systems, variations in support/behavior of management/colleagues. He re-iterated that improvement starts at leadership at the top. Creating environment for support, momentum, culture was key in establishing good support systems for all staff – also quoted by Edward Demming in stressing the need to ‘reduce variation for optimum management.’
high quality improvement projects key to chip away at bad or lesser effective practices.
workforce is key- planning. need multidisciplinary workforce with senior decision maker layer on top, consultant cover has increased in past few years, still only about halfway there.
grow it to create depth and breadth, create strategies to reduce attrition in training, maximise retention for consultants, increase training numbers by 33 pc (80 pc from baseline to 400/year for 4 years)
plans to start dedicated leadership programs
plans to start clinical educator programs
plans to start and further increase fellowships – geriatric EM, humanitarian EM, ambulatory EM.
he also spoke about how to retain older consultants 50-55 age before the retirement age, because it can get tiring, as well as ways to support the new generation of EM consultants.

2- MacMillan Nurse John Sheridan – Palliative care
He spoke about and clarified a few terms about end of life, palliative care. He defined palliative care as ‘living as well as possible for as long as possible (usually 12 months)
33 percent bed base in every hosp, palliative at any time.
patients usually end up in ED due to poor planning, portrayal in media
usually PC is thought to be malignancy related. wrong assumption. can be any disease causing possible/probable death in 12 months. gp should e informed.
SPICT score
on call OOH Palliative care opinion always available everywhere
think about an emergency care plan upon discharge or transfer of care to home or other service. contact district nurses. dedicated palliative ambulance, dedicated palliative care nurses, bellflowers, deciding right app
scenario presented.

3- PHEM/ED consultant – shared scenario – video of resuscitation of stabbing victim – cardiac tamponade relieved prehospital. making unexpected survivors to expected survivors.

coffee break

4 – trauma network – geography, what it entails, MTC, ambulance services (usually multiple, coordinating between them, air ambulance.overnight cover. approved by nhs england.
take on calls for advice. every aspect of clinical journey. clinical guidelines education.training, sui, audits, make sure standards are maintained across the board.

5 – GEM
frailty scoring – E FRAILTY INDEX./edmonton frailty scale/CHAMP/rockwood or clinical frailty score
why? multidisciplinary. NNT 13-17 TO AVOID DEATH OR ADMISSION TO CARE HOME WITHIN 6 MONTHS. vs 17 for stroke thromb 42 for aspirin post-MI.
admtted vs discharged from ED – improves care for both/further planning etc
frail = complex. (plus sheer numbers in ED adds to danger for frail patients)

frailty scenario
delirium – VERY IMPORTANT. getting it wrong – due to our perceptipn, helpfulness of older person, lack of family carer with patient – 11 pc screening completed in 2015 audit. if missed in ed, 70 percent missed during rest of admission
another scenario
every time you chicken out of a DNACPR discussion god kills a kitten.
atul gawande
scenario

dangers of non specific general vague presentations – over 80? falls, confusion, weakness, fatigues, inability to cope – falls, usually multifctoria. MI AND PNEUMONIA DONT PRESENT IN ELDERLY TYPICALLY
major trauma USUALLY CALLED SILVER TRAUMA – is usually NAN DOWN. likely to be seen in trauma units. likely to be seen by juniors.
HECTOR
future of GEM

6- EM Trainee presentations x 3
dislocated shoulder management – shoulder relocation bench? 77 percent reduction successful without sedation
stroke vs stroke mimics (how to differentiate)
ketamine sedation audit

LUNCH

7 – “Tactical team medics”
8 – GP with EM specialist interest
9 – ACP sharing experiences and progress

COFFEE

10 – ALS – Cardiac arrest beyond the algorithm – ITU/ANAESTHETICS CONSULTANT
goodsam
children – cpr training/sweden/danish/germany/france
immediate bystander cps good – improved outcomes
less than 60 years of age good outcome
e-cpr no confirmed survivors
summary – routine application of also not leading to early rosc
focus should shift entirely in certain cases
charge defib early
always use echo
think in parallel
ecpr

11 – burnout
1/3 will have depressive episode
1/12 will consider suicide
shared personal experience

maslach burnout inventory
depersonalisation – cynicism, sarcasm, compassion fatigue
exhaustion – not sure how much longer i can go on
lack of efficacy

sources of burnout – ourselves, blame culture, NHS structure complexity
positivity of juggling this stress of work
negative stress – same things same sort of day totally different mood

how to handle the stress – time management, checklist – headspace – (physical/emotional/spiritual banks)
notification fatigue
events + rections = outcome
let it go

12 – keynote speaker – hospital response to a major incident
when you fail to prepare you prepare to fail

The perks of PERC

The really worrying question sometimes arises (or depending on your luck, most times arises) while you are in an ED, and you see a patient who comes in with ‘some chest pain’ that’s maybe a little pleuritic in nature, but pleuritic chest pain could result from a punch to the chest, or if you cough too hard or too long (I unfortunately speak from experience!) and you don’t know what to do and someone’s already done a D-Dimer on the patient’s initial bloods as they were triaged, before you saw them, if you are lucky enough to work in a department as great as ours (or unlucky, depending on how you view the over-testing of D-Dimers!) – I have been handed the most amazing tool: the PERC score, or the Pulmonary Embolism Rule-out Criteria. For those of you already aware of the existence of such a magic wand – bravissimo and kudos to you, and no need to read on any further. For the ones like me who until very recently hadn’t even heard of it, please proceed further.

Patients who present with clinically low risk for development of a PE can be subjected to the PERC. This is a pre-test probability type situation, whereby you assess a patient based on clinical parameters (which you obviously already do!) but you mentally check them off a list of specific parameters, and if they meet all 8 (yes EIGHT!) criteria, then you can safely say they do not need further assessment RE:pulmonary embolism, D-dimers, CTPA route etc. This creates a warm and fuzzy feeling in me, because almost every patient in the past 3 years of practising emergency medicine in the UK that presents even remotely with pleuritic sounding chest pain, regardless of whether they have a clinical indication or not, automatically had a D-dimer, and, God forbid, should they have an ever-so-slightly-raised D-dimer level, they were referred to the acute medical team faster than you could say enoxaparin. These were then possibly unnecesarily given doses of enoxaparin, until the gold standard rule-out test could be performed, which is the CT PA (CT pulmonary angiography). That’s just the way things worked, because a positive D-dimer can indicated possible pulmonary embolism, but it needs to be taken with the complete clinical picture, and a (very large) grain of salt. D-dimers can, unfortunately or fortunately, be raised in a number of different situations, e.g an underlying active malignancy (which gives the double whammy of raising your chances of getting a PE in the first place), an infection anywhere in the body, certain medications and inflammatory medical conditions.  This lead to over treatment of many patients with anticoagulants till the CTPA was performed to finally confirm the existence or absence of the offending clot. Things may have changed for the better with the PERC, though.

The parameters you base your PERC score on are Age (< 50 years), O2 sats (greater than or equal to 95%), Heart Rate (less than 100 BPM), Absence of Hemoptysis, Absence of Oestrogen usage (Contraceptive pills), Absence of history of surgery/trauma requiring hospitalisation/immobilisation within past 4 weeks, Absence of lower limb swelling (unilateral), and absence of prior personal history of clots/emboli/thrombi.

These parameters and this score are widely used now and available as calculator/apps on most phones.

So the way I understand is, low-risk patients meeting the PERC score criteria need not be further assessed (even if they have had a D-dimer done that’s slightly raised, you can ignore it because the pre-test probability was extremely low). Low-risk patients not meeting the PERC criteria may then go on to be assessed on the D-dimer route, and the high risk patients go directly to CTPA without faffing around with PERCs and WELLS and GENEVAs.

Good luck, and happy PERC-ing!

Another day, another training…

Attended another training/teaching day sponsored/arranged by the deanery – was a very, VERY useful and informative day – and though it dragged on for hours, it was very interesting and explained quite a few things that I had not known previously – gist of the major salient points of each of the talks are listed below – may expand on 1 or more of these topics in the near future – so inspiring!

There were 4 speakers

PUBLIC HEALTH PROMOTION – how to explore facets of public health while in ED, because most people interact with someone in the ED, and that may be the only point of medical contact they have had up until that point.
smoking cessation, weight loss, exercise, pre-diabetes identification –
screening programs are fixed, inflexible , protocoled care, applied across a particular age group- safeguarding, frailty, VTE, dementia screening, hypertension, alcohol issues, obesity, domestic violence, smoking

case scenario of overweight person presents with orthopaedic problems, upon discharge do you speak to them about their weight? as an ED physician

case scenario of unwell child who has never been vaccinated – what will you do? How do you approach the subject with the parent, or do you even approach it at all?

case scenario of alcoholic patient with head injury – would you address the alcohol issue? (unit is 8 gm or 10 ml) 25 in whiskey, 10 in wine and 40 in spirigel
alcohol problems discussion
(having withdrawal symptoms when not drinking is being dependant on alcohol)
who should you be screening for problem drinking – selected presentations
how do you ask for alcohol intake?- use PAT scale – CAGE questions are useful in establish alcohol related problems.
important because intervention is helpful

PUBLIC HEALTH AND EMERGENCY MEDICINE
as doctors/physicians it is our ethical duty to reduce injury and illness, wherever we interact with patients.
we tend to have more interaction with the general public
you are more likely to see violence/injuries than the police – some studies show more than 3 times!
how can you help as doctors? injury survielance, mandatory reporting, better design, improve treatment, collate data and improve conditions – location of assault, date/time of assault, weapon, age
is anonymous,
crime rates went down because of data collected due to targeted policing
what are barriers to implementation? – police expectations, IT issues, governance, receptionist, leads
pitfalls – mission creep, fatigue, silos
conclusion? violent injury surveillance and control is effective in reducing violence. implementation can be challenging

QI (Quality Improvement)
audits are important but rarely work
why do they fail? – tick box exercise, temporary staff, lack of feedback, career advancement a priority rather than care advancement, lack of collective responsibility (if your rotation ends, the audit ends with you, no continuity)
has now become quality assurance rather than improvement. “maintaining/meeting set standards” rather than “improving the standards”
RCEM guide to QI is the QI bible.
do less, do it better
choose a standard to improve:is it important?, is it fundamental?, is it fixable?
talk to the stakeholders (nursing staff, frontline staff, triage, juniors, etc), ask them why this is not happening – how to improve conditions?
measure the standard
intervene to implement a change, and then re-measure after a suitable timeframe.
establish or convey a sense of crisis – reiterate how important/imperative this measurement is.
rapid cycle

CARDIOLOGY – ACS
definition of ACS
reiteration of importance of history – onset and character
repeat ecg, compare with previous
do not delay treatment waiting for biomarkers in “cardiac-sounding” chest pain.
consider bedside imaging if hemodynamic instability
escalate appropriately, consider involvement of tertiary care
dissection a differential? CT aorta stat (discussion about d dimer as useful in this scenario – some people say a negative d dimer rules out a dissection – research shows that is not the case)
management – analgesia+dual antiplatelet therapy, GP2B3AI, antihypertensives (b blockers) ACEI. statin, REGARDLESS OFWHETHER AN INTERVENTION TAKES PLACE LATER ON OR NOT, GIVE THE MEDICAL TREATMENT. if already on aspirin, 300 or 225 of aspirin either way doesn’t matter, 600 of clopidogrel and 80 of tigacrelor (not to use if warfarinized – MAKE SURE INR IS THERAPEUTIC)
immediate management – angio +/- PCI (for STEMI within window, ongoing symptoms, cariogenic shock, for NSTEMI – hemodynamic instability, ongoing schema or shock, IF REFRACTORY TO INITIAL MEDICAL THERAPY)
high risk/labile/recurrent schema – urgent angio
all others get routine angio
12 hours stemi – def PPCI, greater than 12 hours – if symptoms, PPCI, greater than 48 hours – no PPCI.
<30 mins door in door out in non pic centers. <60 mins door to wire crossing in PCI centre. and LBBB/RBBB considered equally. no o2 if >90 sats on RA.
consider CPAP, IF DISTRESS. iv amiodarone for AF, Look for hyperglycaemic states, MRA if CF.

if unable to decide if LBBB is new or old, compare to previous but if none available to compare, look at the patient. vast majority are not acute, unless they’re in cariogenic shock.

 

DIARRHOEA
definition
types
causes
symptoms
may be a symptom of sepsis – does not mean primary focus is gastrointestinal- particularly in the elderly
rotavirus most common in children – vaccine now available, rotarix at 8 and 12 weeks, seasonal
COD – dehydration/acidosis
use dioralyte instead of pure water for replacement. diluted juice.
norovirus and c.difficile has to be reported.
electrolyte disturbances – hypo/hypernatremia, acidosis, acidosis, hypoklemia (3-3.5: oral replacement or 20/1000 ml saline over 2-3 hours; 2.5-3: 40/litre over 4-6 hours; <2.5 or with ecg changes at any low level such as prolonged QTC, flat t waves at risk of arrhythmia; <1.5 will be paralysed, muscular weakness, apneoic. ECG-CARDIAC MONITOR-CONSIDER RESUS
discussion about hyponatremia and its management

 

PALPITATIONS
multiple cases discussed and shown, along with rhythm strips, interactive 1 hour session with responses from the audience tailoring the talk. VERY interesting.

FRCEM Intermediate (SAQ) – “Revisiting the recent past (recalling the nightmare!)”

  1. picture of a bruised foot. fallen off horse, foot stuck in stirrup and dragged upside down. now unable to weight bear. bruising evident on medial dorsal area and lateral plantar area of involved foot. what is the mechanism of injury? what is the injury?
  2. patient with small stab wound to epigastrium. X-ray (picture shown) shows air under diaphragm on right side. what is the finding on X-ray and what does it signify? what is the management plan for this condition? how will you investigate/comfirm diagnosis next?
  3. image of bilateral knees of a middle aged patient. presented with sudden swelling and painful left knee, which is shown as slightly swollen. cause? treatment/management?
  4. paeds patient, infant, barking cough every time they cough. sniffling viral like symptoms …diagnosis? management?
  5. anaesthetic machine shown with knobs for respiratory rate and tidal volume adjustment, rest rate set at 8/min. scenario given of patient with head injury, aside from other measures, what will you do to ventilator settings to help, and how will it help.
  6. picture of pneumothorax (right sided) shown. what are the 2 abnormalities in the radiograph? (i could only see the pneumothorax) management questions about where to insert the seldinger, and what common complication can happen and how will you avoid it (what measures will you take to ensure it doesn’t happen)
  7. elbow posterior dislocation image shown. how will you manage in ED (explain/summarise maneuver) and what nerve tends to be damaged and what will you look for on neurological examination. what x 2 steps will you do after reduction
  8. image of posterior dislocation of shoulder shown. radiological sign?
  9. young child, accidental ingestion of paracetamol syrup. asymptomatic. previous history of similar episode last year. what steps will you take? when will blood need to be drawn?
  10. wife presents to ED with injuries sustained from beating by husband. has minor children but are not currently living at home with her or husband and have not witnessed abuse. she self discharges and does not want to press charges. what steps do you need to take
  11. image of open mouth, what is the malampatti scoring?
  12. young male, fallen from 30 foot height, complaining of back pain. otherwise normal examination. what is the first reasonable investigation?
  13. head injury patient, subdural hematoma. gcs 13/15 initially, on revaluation, drops gcs to 10/15, what will be your next step in management? how will you proceed? if they initially are ventilating well, and then drop sats, how will you proceed further?
  14. transferring patient who is intubated and ventilated suddenly notice significant drop in sats, blood pressure OK, what is likely cause, how will you manage/proceed?
  15. sudden onset painful testicular swelling in young male – likely cause? management? what time frame? if not this, then what is the next likely cause
  16. young girl – dizziness and fainting spells. biochemistry shows hypoglycemia, borderline raised potassium, borderline low sodium. diagnosis? what investigation will you do?
  17. renal failure patient, sudden worsening. ecg shown, hyper acute t waves seen. diagnosis? management? mechanism of action of 1 drug that you will prescribe
  18. pregnancy 3rd trimester. abdominal trauma. abdominal pain, hypotension, diagnosis? management?
  19. middle aged female, found with suicide note and empty pill packets. low gcs. blood gas shows alkalosis, low co2, high bicarb. likely drug?
  20. paeds with sob, not eating, generally unwell but appears well, playing with toys, interacting, low sats but other jobs all normal no fever. cxr shown (normal looking?) ? diagnosis?
  21. elderly patient, hip fracture, fascia iliac block administered for pain relief. sudden dizziness, followed by cardiac arrest. cause? how will you manage? (dose and name of drug)
  22. how will you immobilize/pull femur on child with fracture femur? analgesia options?
  23. image of facial trauma during RTC – airway concerns? how will you manage complications/difficulty? what will you advise your colleagues to do or not do
  24. post vomiting, chest pain, car shown, findings? (subcutaneous emphysema)what 2 causes can be attributed to this condition? how will you investigate further to find out which cause this is
  25. ecg shown ? LBBB?
  26. ecg shown – VT – conscious patient with palpitations. shocks given x 3 not reverted, how will you manage further.
  27. epipen administered. what total dose in MG of adrenaline administered in single dose?
  28. seizure activity in epileptic patient, already on phenytoin. status epilepticus. diazemols/lorazepam 1 dose given. allergic to valproate. what is the next 2nd line drug to give?
  29. patient on warfarin, routine blood tests high INR of 8-9 no bleeding, recent antibiotics. what possible antibiotics would have been used? first step in management?
  30. female child from african country, returning from trip, feeling unwell, crying, not interacting. c/o ado pain etc. no fever, all obs normal. nurse noticed bloody discharge on underpants. likely diagnosis? who will you inform? how will you manage?
  31. hip pain, limping child, non traumatic? X-rays shown. what view is it? what is the diagnosis? what are x 2 common causes of hip pain without trauma in paediatric age group?
  32. renal colic clinical picture. analgesic of choice? investigation to confirm? complications?
  33. paracetamol overdose patient. what x2 investigations will you perform?
  34. elderly patient present with a fall. what bedside investigation can you do to rule out dehydration
  35. patient with ascites, fever, abdo pain. diagnosis? where will you put needle in for ascitic tap?
  36. patient with red eye shown (image) presents with sudden onset headache, vomiting. diagnosis? management? what topical drug will you administer in ED?
  37. elderly patient, agitated, needs cannula. what will you give to the patient? what will you tell the helping nurse to do?
  38. patient with chest pain. ecg shows inferior MI.
  39. IVDU. c/o back pain. tender lumbar region. diagnosis? investigation?
  40. question about intraosseous access
  41. young male with rectal bleeding and diarrhoea travelling from african/middle eastern country. cause? give non infectious/non inflammatory cause
  42. scenario is patient has ingested amyl nitrate. picture of patient’s wound site with swab on – showing bleeding, blood is ?darker color than usual? identify what the abnormality is, and how will you treat it
  43. high BMI (50) patient, unconscious/collapsed – what factors affect her airway and what makes it a difficult airway for her – what manoeuvres will you do to improve/mange these factors
  44. do not remember the question but size of cannula given and rate or time 1 litre of saline gets completely given through it