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

A Catheterisation Conundrum

Hmm…I gave much thought to how I wanted to go about posting about this experience I had the other day, and I decided to just lay into it. So here it is: I have probably done dozens of urinary catheterizations in my almost decade of being a doctor – male, female and ranging in difficulty level from easy to ‘I-give-up-lets-call-urology – but what I learnt this time was a truly unique experience, atleast it was for me. It really reiterates my motto of ‘learn something new everyday’.

My patient was in his 70s, had just recently been discharged from hospital after suffering from a myocardial infarction x 4 weeks back. He had come in with abdominal pain, so everyone at triage was understandably freaked out because they thought it may be related to a cardiac situation. I went in to see him and he was writhing in agony, it was clear this pain was not cardiac in origin, and it was localised to the lower part of his abdomen, which was very distended. One hand on the suprapubic area confirmed the firm mass which was quite tender and dull to percussion was in fact his bladder – he had not been able to pass urine for the past 15 hours! Currently under treatment for a UTI x 2 days, which was diagnosed when he began to have first pinkish and then dark red, painless hematuria. It was very likely that a clot had obstructed the bladder outflow tract, and caused him to go into retention. Simple solution, pass a 14 or 16 French catheter into the urethra, and relieve the obstruction.

And I began prepping for it: catheterization trolley, catheter set, catheter itself, instillagel, water for injection, cleanie wipes, some saline solution and gauze. I took consent, which he almost yelled out in agreement. I walked him through the steps of the procedure, and he declined my offer of a chaperone. I requested him to expose himself from the waist down. I cleaned the genitalia with some saline soaked gauze, and cleaned around the foreskin. As I tried to retract the foreskin back to bring the glans out to put the catheter tip in, I realised I had run into a problem that I had never encountered before. The foreskin had shrivelled up and had a minuscule opening at its tip, but there was no way the head of the penis was going to protrude itself from under it – it just would not retract. I asked him when was the last time his foreskin had retracted and he replied that that had not happened for atleast 5 years! I could not see how I was going to insert a catheter into the tip of the penis if I could not see where the tip was. I ungloved myself and went to seek counsel of my elders – which in this case was my consultant who was very busy almost elbow deep in resus – I briefly described my situation. He very nonchalantly informed me that I should attempt going in blind, and should it by unsuccessful, to inform Urology. I had serious doubts and considerable reservations of blindly pushing a catheter in where I could not be sure was an orifice – but he reassured me saying that the hole was there ‘somewhere’ I just had to…look around for it a bit. Well, maybe feel would be a better word.

Anyway, so I went back in, regloved myself, and took a deep breath, before explaining to the patient what had transpired and what I was going to now attempt. I then took another deep breath and tried poking the catheter in through the opening in the foreskin, and it almost atonce met with resistance – the head of the penis presumably. I tried coaxing the catheter in further, but it wouldn’t budge. I pulled out and tried a different direction slightly angled differently. No luck. I tried a seventh time. Still nothing. I was literally feeling beads of sweat form on my brow. I was very aware of how uncomfortable the patient was feeling, and of how traumatic a catheterization can be, even when you can see the penile head. Added to that the fact that this patient had recently had a heart attack and was on oodles of blood thinners, I did not want him to bleed out through a urethral injury of my doing. I decided to try one last time, a deep breath and it went in, the patient yelled and then bit his lip and this very VERY murky, dark brown coloured urine tarted pouring out through the tip of the catheter into the kidney dish I had in front of it – at first I thought I had injured him and it was blood coming out, but I was reassured when it started collecting in the bag – though very dark, brownish, it was very old blood, definitely not fresh and definitely, reassuringly, not my doing. I cleaned up and went off to bleep the urology team. The patient kept thanking me, with look of content on his face as he lay back and let the catheter relieve him of his obstruction of 15+ hours. I left the room feeling very good about myself (catheterisation is one of those procedures that can make a sudden distinct difference in your patient’s situation, for the better) not only because the patient was very happy and comfortable and no longer writhing around in pain, but also because I had learnt something new today, and I couldn’t shake the feeling that even after doing a procedure hundreds of times (OK I may have exaggerated a little bit) you could still be surprised and be presented with something that may require a bit of out-of-the-box thinking.

Excuse me while I go pee.

Anesthetics introduction – teaching day

(very rough edit of the knowledge gained from this teaching day – will edit by tonight.)

Introduction given by first speaker – (I missed out the first 10-15 minutes of it, maybe longer, was searching for parking) Gave a few pearls of wisdom, in particular, the Royal College of Anesthetics e-learning website link

2nd speaker – Difficult Airway
objective is to oxygenate – help with ventilation
can be by mask, tube through nose or through mouth, or through trachea
airway assessment — HISTORY -check for pathology – burns etc, identify previous anaesthetic history, charts etc, visualisation of laryngoscope views – grades
clear is grade 1, partial block is grade 2 (take home message was that 1+2 easier) EXAMINATION – multiple airway assessment tests – none accurate enough – 5 things most important to be done – 1)-how likely to face mask ventilate, tight seal etc, facial trauma, elderly, dentures, sunken face, high BMI, snorers/sleep apnea – /2)-mouth opening – 3 cm magic number, estimation usually, LMA/laryngoscope fit, foreign objects, tumors, masses – 3) – neck movement ‘sniffing morning air position ‘ flex neck, extend head trying to align the axes for optimum visualisation, 4)-malampatti score (4 classes – first gen reassuring. upright,mouth maximum open and tongue protrusion max, visualise tongue, posterior, uvula, tonsillar pillars
DAS difficult intubation guidelines – 4 plans need to be aware of
(5)-cricothyroidotomy explained theoretical but not practically ever used – worth knowing in case ever required – explained cartilages etc and neck surface anatomy – I noticed everyone palpated their neck involuntarily, including me!)
priority is ventilation not intubation – whichever way that may be achieved

3rd speaker – PRE-ASSESSMENT
HISTORY (what surgery, elective/emergency, major/minor, PMH, systemic review, medications, allergies, anticoagulants, any prior problems with anetshetics/personal or familial – any surgery to same site, starvation time, risk of reflux, dentition, how they have been in last few weeks, assessment of fitness (climb upstairs) , less than 4 mins exercise tolerance is not good for anaesthesia/ EXAMINATION (gpe, murmurs, chest, vascular access, airway, the back, high BMI, positioning)/INVESTIGATIONS (confirm, assess or alter risk – depends on patient)/MAKE A PLAN (think about conditions cvs -heart failure,aortic, mitral stenosis, ACS/MI within 3 months; fracture NOF)
Preassessment is your own personal way to do things, no perfect way: “there are many ways to skin a cat” (!!!)
patients risk of undergoing surgery/undergoing anaesthesia (?high risk patient, ?high risk surgery, ? high risk anaesthetic) for each problem identified, has it been optimised as much as possible, or how can the risk be reduced/optimized, and do you need to change your plan.
PLANNING
– pre-operative – optimisation any more investigations, treatments, fluids/inhalers etc, ask for help if needed.
intra-operative – technique, induction, maintenance, wakeup
post op

CONSENTING THE PATIENT – Royal college website (anesthetics rcoa pils) details consent information for any medical condition/procedure
complications – sore throat, dental damage, cuts to lips etc, pain, nausea, anaphylaxis, death, loss of airway, awareness and regional complications – low bp, particularly with obstetrics, itching, urinary retention, headache, failure of procedure, infection, bleeding, nerve damage (1/50000 spinal, 1/13000 epidural)

4th speaker(s) – scenario enacted by actual anaesthetic consultants and fellows from the department – to give an idea about how things go in theaters. walking though an actual scenario – from introduction, consent, explanation of steps to patient, end tidal co2, patient under, putting tube in under vision – grade 1 view – inflating cough, good chest rise – end tidal trace, fix tube. looking at the monitor —–smooth induction

5th speaker – anaesthetic drugs
induction agents – 1)propofol -lipophillic, stings a bit, onset 20-30 seconds, 2-3mg/kg generally 300mg given, bradycardia, propofol infusion syndrome 2)thiopental -4-5mg/kg onset 10-20 seconds, tachycardia
muscle relaxants – neuromuscuar blocking agents – depolarising (suxamethonium, succinylcholine) and non depolarising (atracurium, rocuronium, pancuronium, vecuronium)
inhalation – no2 (not very common), sevoflurane, isoflurane, desflurane
reversal – anticholinesterases (neostigmine usually, sugamamadex – newer drug)
other drugs
MAC – minimum alveolar concentration of anaesthetic agent which is required to prevent movement in 50 percent of patients.

6th speaker – anaesthetic equipment

LMA – must have absent airway reflexes, cuff deflated, muscle relaxant not required – but is not a definite airway (vomit, aspirate)
i-gel – preferable
ETT – SIZE – 8 FOR MEN, 7 FOR WOMEN, AGE/4 +4 PAEDS – definitive airway
uncuffed for smaller children; RAE tube – out of the way of head neck surgeries.
bougies – angle tipped rubber tube, aid intubation
laryngoscopes (under direct visualisation)- mac (size 3 adult, size 4 for large adults), mccoy (lever to lift epiglottis), miller (paeds)
indirect laryngoscopy -in cases where visualisation is not optimum. e.g. airtraq, mcgrath (video laryngoscope)

breathing circuits –
APL VALVE
Bain circuit – most commonly used
BMV – AMBU BAG
WATERS CIRCUIT

Anesthetic machines
PENLON NUFFIELD 200
draeger primus – main anaesthetic machine
explained the charts etc – lots f abbreviations lots of number, lost of values and waveforms and colours – confusing but will become second nature to us! reassuring? not really!

7th speaker – chat with an ODP who tells us about his experience and his duties and what is required of them and of us – they check the instruments, the machines prepare trolleys, the tubes, the drugs etc for each interaction – make sure everything is clean or new or usable, batteries etc, lights of the laryngoscopes etc, and going through the checklist, who’s checklist – (something that he asks the whole room if they know about and they all say yes, but I have never heard of. yikes.) they also offer suggestions, ideas, but the final responsibility of what is happening is the anaesthetists. they won’t draw the medication, they won’t give meds (unless emergency situation) here to help you, work with you and make sure your training opportunities are met and are fulfilling – someone asked what pisses you off – lots of laughter – nervous, me thinks?

8th speaker was just the first speaker again – qualified the previous talk with “know your ODP, they will be your best friend”

BREAK FOR LUNCH (not provided *frown*)

Coming back in from lunch to another scenario that started off as a smooth induction but then went on to become a critical incident (penicillin administered to a patient with no known allergies – while undergoing surgery) – some hilariousness ensued as the “surgeon” put her hands up when the patient became critical and watched as the “anesthetist” dealt with it all, even exclaiming “oh is that what is done?” when the anesthetist administered epinephrine as part of the anaphylaxis treatment. *titters of laughter*

9th speaker – vasopressors/pharmacology
background – vasoconstriction, inotropic effect, sympathomimetic – alpha 1 blood vessels, beta 1 in lungs, beta 2 are in lungs, blood vessels
indications – hypotension due to whatever reason – treat if >30mm hg drop from baseline systolic BP or MAP <60, or any evidence of hypo perfusion/end organ damage – always fluid resuscitate before chronotropy.
most commonly used agents – ephedrine (synthetic sympathomimetic), metaraminol (mainly alpha effect, can be given peripherally, reflex bradycardia) and noradrenaline (usually for very sick patients in profound circulatory failure, both alpha/beta actions, needs to be given via central lines)
others – adrenaline (all adrenergic receptors, asystole, anaphylaxis), dobutamine (beta 1 agonist – cardiac effect, should be given through central line), dopamine (central neurotransmitter)
Points to consider -access : peripheral vs central ? arterial line if needed, boluses, side effects, tachyphylaxis (with long term treatment, receptors become desensitised), arrhythmias

another qualification from speaker 1 who I feel might be the head of the department or atleast leading this day. “These drugs are your best friend!”

10th speaker – one of our peers from an ACCS program currently rotating in aesthetics/itu somewhere : hemodynamic monitoring
NIBP, HR, pulses, mental status, etc do the basics
Invasive – ARTERIAL LINES (continuous BP monitoring, trends etc with drug administration, ABGs, posy-major surgery) commonly put in the radial artery (always do the allens test) discussion of types of art lines followed by a discussion of how to put up and put in an art line (OFF TO PATIENT OPEN TO AIR), complications (air emboli), can stay in for a week; CENTRAL LINES (cvp measurements, medications that can’t be given in peripheral lines), goes in a big vessel, should all be usg guided, patient positioning important, aseptic non touch technique, explanation of the technique (excellent explanation and demonstration, including usg) followed by blood gas, transduction image and a car – also discussed complications, how to measure cvp (normal cvp 0-8) – web links provided – frca
session in the middle about us being able to handle the instruments and ask questions

11th speaker – introduced himself as the last speaker of the day (thankfully!) with 9 slides to his presentation and the first slide was his name and he reported the last slide is thank you and any questions.
analgesia – definition – unpleasant sensation associated with emotional connotation related to tissue damage
types/managements/etc etc This part was particularly vague for me as I was just checking the clock by this time, looking forward to the long drive home.

Sometimes it is the smallest things that make you the saddest

Ever notice how you can go on being an automaton, robotically engaging in work stuff, moving from one patient to the other, each one a statistic on your ever growing list of patients to see or having had seen – no interaction long enough to actually create a connection other than that of patient/doctor and you professionally enter and exit the cubicle and move on to the next job, next patient, or indeed next shift. And yet sometimes it does happen that something hits the mark, and there is a chink in the armour, the professionalism slips (not outwardly, but it surprises you that you feel something other than empathy towards the patient in front of you – you really look at the patient, not as just a patient but an actual human being with feelings, and thoughts start milling around your head – or your heart? – and you think of the patient’s feelings, their desires and weaknesses, the consequences of their actions – and you realise with a jolt that you are not an automaton, that you are, indeed, human.

I am usually a happy presence at work (if I may say so myself) but I was having a particularly ‘smiling-from-ear-to-ear’ day a few days back. A recent couple of professional achievements, along with being well rested from a full night’s sleep meant I was walking around with a bit more bounce in my step. I was working a late shift, but from the broad smile on my face you would have thought I was about to go home on a 2 week holiday! (I was not, but yes, I am a bit weird – I actually have fun at work!) – I was assigned to see paeds patients in ED, all the minors, majors, ENP ones etc – and I was going about my day when the consultant asked me to come out of Paeds for a bit and see the next adult patient, who was already at 3 hours (that much time had elapsed since she had come in to the hospital) – the brief note from triage nurse said that this was a young female between 25-35 years of age, who had come in with a self harm injury or injuries – she was categorised as a ‘yellow’ which meant there was no imminent threat to her life but she did warrant a thorough assessment.

Treatment/management of such cases is usually 2-pronged: one, manage the obvious injury or insult and treat the current presentation, and two (and more importantly) try to deal with and manage the longterm/shortterm psychological aspects of the presentation (not an ED thing but there are certainly specialist who are better equipped to deal with this and who very kindly assess and evaluate patients from that perspective after they have been treated from a physical ailment point of view. So anyway – I went in to see the patient – it had been mentioned in the notes that she was accompanied by her support worker – but the woman who stood up when I announced the name in the waiting area was alone. And she stood up at once and followed me into the cubicle to be assessed, along the way I introduced myself, and thanked her for her patience in waiting. She was extremely polite, and even offered me a smile, but she kept looking anywhere but at me directly. I asked her what had brought her to the ED that evening and she matter of factly stated that she was here because she had self-harmed. Again. She did not seem to be in any sort of pain, so I assumed (wrongly) that she had a superficial sort of wound that wouldn’t really require too much medical attention. I smiled at her and said something along the lines of ‘well, let’s see what we are dealing with here, and I will try to help you any way I can.” She exposed her left arm unto her shoulder, and I took off her temporary dressings from her upper arm (above her elbow) – while I was doing so, I kept making small talk, and registered the many, many scars from previous self harm attempts there before me were 4 very large, very long, and VERY gaping full thickness lacerations to her upper arm. In places where normally the skin/muscle sags a bit, it was really using the lacerated margins to gape quite widely. The patient had something like an hour left before they breached? NO WAY was I going to be able to administer local anaesthetic AND suture all 4 of these wounds in under an hour. Alone.

This patient completely threw me off my game. I have closed wounds in numerous ways, and in all sorts of weird and wonderful places – I have once years ago even raced my mentor consultant orthopaedic surgeon in bilateral knee replacements to see who closed up their respective knee first! – But this time was different. This patient was different. And the reason will become apparent up ahead.

I called my consultant because he may have been under the impression this was a quick ‘tape-wound-shut-refer-to-psych-move-on’ kind of situation – he stepped into the cubicle and hemmed and hawwed. I was silent throughout. This felt like an operating table scenario with a patient’s body cavity open up in front of me – The smell was exactly the same. Flesh. Blood. Sadness.

Right then, the consultant asked me to stitch the wounds up – I gave the wounds a good thorough clean with some saline and the patient did not flinch. She did however, apologise quite sincerely for wasting my time. I will not go into the details of why she thought she needed to do this today – absolutely no judgements to be passed here on that account. But I did assure her she was well within her rights to be there. I said I would go calculate the amount of local anaesthetic require and get it and get it all ready – and her polite demeanor stiffened up. She absolutely refused any local anesthetic. She said, and I quote: ‘ I am not here to waste any of your valuable resources. Please use them for someone who really deserves it – and anyway, I am not in pain and the stitching can’t hurt me more than I have done myself – also (and I was surprised that she knew this) the amount of local anaesthetic required would be a bit too much and wouldn’t be safe for me – and it would wear off by the time it was done being administered!” She was right on all counts – but I requested my consultant to give me an opinion, since she had me absolutely flummoxed. He agreed, no need for the anaesthesia – and that I would achieve better results with a skin stapler rather than suturing the wounds. I had never used skin staplers outside of an OR before, and never on a patient who was conscious and sitting up and talking to me and FEELING THE STAPLES GOING IN! I took a few deep breaths. Got the stuff ready. Took a few more deep breaths. And a few more. And dove in. I put in upwards of 45 or so staples (yes metallic pins sharp enough to stab through the superficial tissues of skin etc and pull them close to optimise wound healing) – did I mention the wounds were exceptionally gaping? Each staple gun comes with 30 or so staples – and I had to use a second one about halfway as well. Wow. My mind was already blown after the first 2-3 staples. But I went on putting more in. I did my best – and to her credit she did not flinch. There was silence. And that smell. And sometimes she would talk to me.

She kept thanking me, and apologising to me, and kept pushing her other hand through her hair as if berating herself mentally. She told me she had a masters degree in something (I forget what – my ears still start ringing everytime I think back to that cubicle) and we chatted about how I wanted to pursue another degree, maybe a masters of some sort and hadn’t quite decided what. She guided me about which staple to remove because it had been bent at an awkward angle due to how gaping the wound was initially, and so when I had ‘scaffolded’ it with staples next to it either side, I removed the offending staple and put another one in. Like I said, she didn’t flinch. At all. She kept that small polite smile in place, was very respectful and I learnt something new about myself that day. That this had gotten to me beyond what I can express here or anywhere. I had seen dead and dying people almost on a daily basis. People in pain, people vomiting with pain, people trying to process bad news or loss or a shock. I have been the villain in so many stories in peoples lives – the bringer or the news that someone they loved had passed away, or what the reports had shown or why we feel that further aggressive measures would be futile – But I had not been affected by those things as much as this calm young woman had affected me. What about her affected me? Nothing about her situation. It was sad, no doubt. But what really affected me was what I realised about myself: I judge people, I am cynical about them, about their diagnoses, about their mental health problems – I never fully appreciated that when someone comes in to hospital following an overdose or some deliberate attempt at self harm, I focus solely on the physical aspect of the case, and let someone else deal with the mental/psychological/psychiatric aspect of it. But this time, I was metaphorically chained to the situation I usually avoid and judge as a spectator – and I could not escape how normal this young woman appeared. She was well read, had a grace and calm in her manner that belied a good upbringing – yet she was obviously in this mental pain and it got so severe sometimes that like this day, the thought of cutting herself and so brutally was her only way to cope with it, and possibly caused her less pain that she was already in. And to be able to get sutures or staples without any anaesthesia on board – how remarkably strong a pain threshold would you have to bear that? Or that you were so used to it that this was all just commonplace occurrence to her. And this wasn’t even the worst part. The worst part was that this was neither the first time, nor (we both knew) the last time that she went down this route. I could help her physically, suture/staple everything – but did I actually do anything at all to really, truly help her?

So like I said – we are usually automatons, going about our daily drudgery – and then one day a patient really opens our eyes and makes us sit back – and question …absolutely everything we know and believe in and understand. Or don’t understand.

(Edit: The rest of the shift went by in a blur or a haze, I don’t know if it was all too fast or all too slow for me. I am I think back to my usual self now – albeit with one difference. I am maybe not so quick to judge – and maybe not so quick to dismiss mental anguish based upon my perception of the physical consequences of that mental anguish. I admit to not knowing enough – and hope I can change my practise in a way makes all of this worthwhile.)

Guest Blog Post by Dr. Bilal A. Jadoon: “Guidance about FRCEM Intermediate – SAQ”

This is a guest post by Dr. Bilal A. Jadoon – Emergency Medicine Trainee, Ireland (email: bilalicp@gmail.com)
________________________________________________________________

Hi fellow,
This would be my first ever writing in the form of a blog and I hope it would be informative for all the ED fellows appearing in the FRCEM Intermediate SAQ exam. Before I move forward, you need to know the eligibility for this part of the exam, which you can see in detail on the RCEM website in detail but the least requirement is successful FRCEM primary exam and work experience in the Emergency department as you will need a supervisor to give approval for this exam.
​Before every exam, you need to know the content that is going to come up in the exam, which is available on the RCEM website with the name of blueprints (link given below). As you go through the curriculum you will notice that the exam not only test your knowledge about the diseases diagnosis and management but also tests your theory for the practical procedures and the various rotations (especially paediatrics and anaesthetics) stuff. It also incorporates the very less commonly read topics like infection control, medical ethics and medico-legal aspects etc too, which is the most difficult and extensive part of the exam. The paper is 60 SAQs with all questions atleast 2 parts and most will have 3 parts with marks written in front of each part/question. The available time is 3 hours and this exam is time critical.
​Most of the questions which come up are your routine ED patients presentation, however to cover up the course and get successful in exam, you would have to read/ listen to the following material.
1. MRCEM B revision notes by Victoria stacy
2. FRCEM intermediate SAQ paper book (recently available)
3. FRCEM Intermediate SAQ by Moussa Issa
4. Bromely webinars videos
5. Frcem exam prep online course/SAQs
6. NICE guidelines (relevant and latest ones)
I have no idea about the FRCEM intermediate SAQ books as, they were not available by the time I was appearing in the exam, but I would say they would be worth reading as one of them is the newer version of victoria stacy book.
As the course is extensive and difficult to cover ED calls, you will have to cover the major portions of the blueprints and give less time to parts like common competencies and anesthetics etc, because if you cover up the major portion of the course you will certainly pass the exam.
Preparing for exam is always different for everyone and my suggestion would be to start preparing atleast 3-6 months before the exam and do study on daily basis or otherwise whatever suits you.
Last 2-3 days before exam, just get relax and if you can revise well and good, if you can’t, don’t worry and don’t panic. You will always think that you have forgotten everything but in reality you remember most of the stuff. Reach the examination city 1 day before and have plenty of sleep 8-10hrs on the night before the exam.
During examination, timing is the most important and essential component, which is you didn’t manage properly, you will end up in a disaster for sure. Try not to spend more than 3 mins on each question. Write a single word to a single line answer at max. Those questions which are time demanding due to any reason, just skip them and mark them for later, if you get a chance to do them. You should aim for reach all 60 questions, even if you have to skip a few because they are time consuming as you will end up doing max questions and attain max question.
I hope this benefits all you and best of luck for those appearing in the exam.
Please do let me know about the short comings or any suggestions/corrections in this writing and that would help me write better stuff in the future.

https://www.rcem.ac.uk/docs/Exams/2.2FRCEMIntermediateCertificateInformationPack.pdf