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

Last shift as an ST1 – bittersweet to say the least

So for ACCS we have 6 monthly rotations for the first 2 years, and tomorrow I go for my last shift as part of my A&E rotation (yay, yes I made it to the end!) AND  it will be my last ever shift as a year 1 trainee (or ST1) – even more yay!

This year has been wonderful – I got to know the slightly different other side of the coin as an acute medicine doctor the first 6 months of this year, and got to see firsthand what happens when you refer a patient to the medical specialty: what they look for, how they assess them, what investigations do they do and what is there mindset – and I learnt there were things I could do while the patient was in ED as my patient, and I could tweak certain things and maybe request something that would help the acute medicine department deal with the patient and make an informed and safe decision about their medical care – and maybe stop them from being admitted in the first place! This last bit was especially a unique experience, trying to sort out a patient with the 4 hour time pressure, but sometimes you picked up a patient that usually would be referred to the medical specialty, but if you had the time in ED you could potentially start a treatment that may actually make them better before their 4 hours were up and you could end up sending them home rather than in-hospital – like for a second troponin or someone who is slightly tachycardia with a fever, treat them and re-evaluate, obviously if they still warrant it, get them admitted but if they improve and can continue treatment at home, then let them go into their own familiar surroundings (sometimes the best option for patients with dementia and other cognitive impairment) – and the it doesn’t go unappreciated by the medical team!

The next 6 months were truly wonderful – learning experience from the get go – and since emergency medicine is my chose poison, my specialty of interest, I really was looking forward to it – and it did not disappoint. I learnt so many new things, and not just about the medical bit of it, but about myself as well. I gained confidence. I passed an exam (again, yay!). I realised I was interested in paediatrics, with a possible PEM (paediatric emergency medicine) fellowship consideration seriously for the future). I realised it wasn’t JUST about the resus patients, the cardiac events and the rest pains and the low-GCS and the stabbed-in-the-groin and the 3 passenger trauma call  – those were the interesting and the adrenaline pumping stuff you think of when you think emergency medicine. But I also realised that on a day to day basis you may not even see any of those heart-pumping sort of cases, and may have to deal with accidental overdoses and dental pains (!!!) and minor injuries (oh how I loved the minor injuries – really loved learning there!) and the beautifully vague C?C or ‘Collapse query cause’ and an amazing amount of geriatric and elderly care cases. And I realised I had chosen the right field. Because you don’t just treat the stuff of legend – crack open a chest or put a tube into the chest or restore alignment of a broken or dislocated bone, but you also end up (mostly) sorting out the more mundane cases and they teach you patience and empathy and make you also realise that these cases are also equally important: passing a catheter may be considered a legendary feat by the patient who comes in with 15 hours of urinary retention, or the wrist brace you put on an elderly patient with a sprain may make a world of difference to an elderly patient who has been unable to sleep due to the pain. It is the sorting of these cases which some may consider to be ‘boring’ or ‘brander’ or ‘not exciting’ that is truly the bread and butter of the ED physician.

And now I stand at the cusp of transitioning from year 1 to year 2 – going onwards to a 6 month rotation in aesthetics followed by ITU for 6 months. Am I excited? Yes. Am I nervous? You bet! Why excited, you ask? because: new things to learn and do that I have never known/done before. Why nervous? Because…exactly the same reason! But I am certainly looking forward to airway skills and critical care assessment, and gaining more confidence by adding to my skills – I hope its not too steep of a learning curve! Onwards and upwards, eh?

(Also – no weekends or nights for the first three months in aesthetics, and Friday half day –  somebody pinch me! I might just die of excitement at the prospect of that routine after the A&E rota! So yeah, joy!)

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.

Guest Blog Post by Dr. Hassan Alraee – “My MRCEM OSCE Experience”

This is our second guest blog post from esteemed colleague Dr. Hassan Alraee – Emergency Medicine Registrar (Ireland). I take no credit for the following text.

Dear Colleagues,
I am sharing my MRCEM OSCE experience with you guys as I realized while preparing for the exam there was not much guidance available online. The aim of this post is to familiarize everyone with what the exam entails and a few tips which may be helpful in your preparation for the OSCE.
This may not be a structured or typical guidance post, it may come out as a random collection of thoughts but I will try my best to note down everything that was helpful to me during the preparation for the OSCE.
First of all to be eligible to appear in the exam you need to have passed the FRCEM Primary exam, passing the FRCEM Intermediate SAQ exam is NOT one of the eligibility criteria. However, in my experience passing the FRCEM Intermediate SAQ exam gives you a baseline in theoretical knowledge that is required for the OSCE. So it would be ideal to attempt the exams in the sequence that has been set, i.e. Primary, Intermediate and OSCE.
Before beginning your preparation for the exam have a look at the MRCEM Information Pack available on the RCEM website. A list of study material that may be helpful includes;
1. MCEM Part C: 125 OSCE Stations by Kiran Somani
2. Mastering Emergency Medicine: A Practical Guide by Mathew Hall
3. Bromley Webinars
4. At least 1 (if not more) of the following courses; The London Clinical Course, The Bromley Course or the Manchester Course.
The exam itself feels like a daunting task during the preparation phase as it is completely different to the previous parts and reading books alone is not the best way to get through it. My advice would be to stick to one of the above mentioned books and go through it once. The next step would be to create a practice group which should comprise of at least 3 members. This would mean all 3 of you would be able to rotate through different roles during the practice sessions, i.e. The candidate, The actor and The examiner. In my humble opinion this practice group is the key to being successful in the exam. The final step would be to book one of the above mentioned courses. In order to maximize the courses you need to be fully prepared for the exam by the time you attend the course and treat it as a Mock Examination.
Each of the courses has their own pros and cons but all of them are helpful in preparing you for the OSCE.
Each OSCE comprises of 18 stations, 2 of which are rest stations. The exam does not test your theoretical knowledge to a great extent, the stations in the OSCE are designed to test various skills. Like all OSCE exams there is a fair degree of play acting and exaggeration of your daily practices is required. By this I mean that the examiner will only mark you on the actions you perform during the exam, so make sure you show every step and tick most boxes in the examiner’s checklist.
The basic outline of the stations encountered within the OSCE are;
1) There are 2 to 3 history taking stations, remember to complete the station by giving the patient a management plan based on the history.
2) A Systemic examination station (CVS, Respiratory, Abdominal, Cranial Nerve or Peripheral Vascular examination)
3) A Joint examination station (Hip, Shoulder, Knee, Back, C-spine or a limb examination)
4) A Breaking Bad News scenario
5) There are 2 or 3 teaching stations which may include teaching a procedure or examination to a student or a junior doctor.
6) There is always a Conflict Resolution in the OSCE as well, which may be a missed fracture or pneumothorax or a difficult referral. This station also includes talking to a patient with Alcohol Dependence or Binge Drinking.
7) 2 scenarios within the OSCE are always Resuscitation Scenarios and test your skills in ACLS, APLS or ATLS. These stations seem like they are the most difficult ones while preparing for the exam, but in my opinion you can easily pass these if you make a good approach towards resus stations during your practice sessions. The Key to the resus scenarios is sticking to the ABCDE approach.
8) ENT and Eye station; in the exam they can check your knowledge on these in various ways it can be a simple otoscopic or ophthalmoscopic examination, teaching may be incorporated into it or history taking could be tested but there will always be a station that will involve ENT or Eye.
9) A quick assessment station; this one is a tricky one, it usually has the task of taking a short history, performing a focused examination and formulating a management plan based on your findings and summarizing it to the patient.
10) An Information Providing station; this station usually involves a relative of the patient to whom you have to explain a new diagnosis or management of a medical condition. Juvenile Diabetes Mellitus and Addision’s Disease are 2 examples that I can recall.
11) A Psychiatric Station is always present in the OSCE, you may be asked to performed a Mental state examination on a patient or assess suicide risk, they may add a conflict resolution component to this station as well.

In my opinion if you divide your preparation according to these 11 types of stations you will be able to cover most of the things required to be successful. Some additional topics that are tested in different ways and I haven’t categorized under the stations include; DVT, major incidents, seizures and driving advice. It would be wise to look up the NICE guidelines on these.
I would also suggest that you reach the city where the exam is being held one day earlier and have a look at your examination center that day. Just so you know how long it takes to get there and don’t have the extra stress of finding the center on the morning of the exam. Please spend your last 2 days traveling and relaxing, there is no point in trying to cram in stuff over the last 2-3 days as this is not a theoretical exam where they expect you to know everything.
On the exam day itself it is understandable to be anxious and stressed and believe me the examiners know that the candidates are under pressure and are not there to fail you. You should know that staying cool and calm is the most important feature that will enable you to be successful. It usually takes 1 or 2 stations to get into the groove of the exam as the 1st station comes up it is normal to feel a little nervous or blank out temporarily. Do not act bold and wing it if you are unsure about something, be safe at this stage and say you are unable to recall at this point in time and that you will consult the department policy or your consultant before implementing it.
Do not worry if any of your stations don’t go as well as you expected them to, leave the previous station behind you and move on to the next one. Do not let your performance on the previous station affect your performance on the next one. I know this is easier said than done but it has to be said as it is human nature to dwell on the past. You should also know that there is not a minimum number of stations that need to be passed to pass the exam, that was how it used to be in the past. The marking scheme has changed to a cumulative score now and a different passing mark is set for every OSCE day so even if you fail a station you carry forward marks from it towards your overall score. Therefore it is imperative that you score marks for the basic things on each station. Some of these include greeting the actor, washing hands before and after examination, wearing personal protective equipment (or at least mentioning it to the examiner), being warm and courteous and thanking the actor at the end. These simple things may be the difference between a pass and fail score in your OSCE.
I hope it was helpful for all those that are reading this post, good luck with your exam, with a bit of structure and practice I’m sure you will pass the OSCE.

The Intestinal Obstruction That Wasn’t

84 year old male – known to have chronic constipation, and on warfarin for atrial fibrillation – referred in by his GP for ‘inability to open bowels for 2 weeks’ – yes you read that right folks, T-W-O W-E-E-K-S! – ‘increasing abdominal distension and abdominal pain, along with decreased appetite and a possible mass in the pelvis/abdomen going above the umbilical area’.
The nurse triaging him came to me, asking for some pain relief for the patient ‘and an enema because that’s what he usually has for his constipation’ – I decided to go see the patient myself. I stepped into the cubicle and the gentleman seemed to be in some discomfort, but he kept saying that he was in an uncomfortable position/posture rather than anything else causing him discomfort. I introduced myself and asked him what had brought him to ED – he replied by telling me he had not opened his bowels for 2 weeks now, and though was still passing wind and had passed some today, he was drinking very little and felt nauseous and omitted a few times in the past 3 days. I asked him if he had been passing urine normally, and he reported that yes he was peeing fine, but that he was drinking so less due to the nausea that only small amounts were trickling when he needed to go. I took that statement at face value and moved on. He was lying in a trolley, awake but lethargic and completely oriented. His observations were all within normal limits except for a systolic BP of 89, and his GP notes reported a background of chronically low blood pressure. I examine him, of particular note is his visibly very distended tummy – which assort but distended, feels like gaseous distention from the percussion notes, and with tinkling infrequent bowel sounds – and is quite sore particularly in the lower half of the abdomen, and I can also palpate a mass in the lower part of the abdomen – the patient reports that’s been going on for atleast 3-5 days, possibly when the vomitting began as well. This seemed very much to me to be a classic case of intestinal obstruction – and the management plan is – do baseline bloods (already very kindly done by the triage nurse), get venous access (also done), start some fluids, abdominal X-rays, nasogastric tube and surgical referral, and also catheterise patient, to monitor intake and output.
I speak to my registrar who agrees with said plan of action and while I request the X-rays and take the patient down for it, the lab apparently calls back and my registrar takes the call – the patient’s urea is 44, and the creatinine is 469, last creatinine 3 weeks ago was 141 – so he is going into renal failure, if not there already. While I seemingly faff around with the surgical consult, my registrar gets an ultrasound machine, and I assume it is to rule out a AAA, so I walk into the cubicle with him. And he explains to me a great pearl of wisdom that clearly comes with experience but is such a simple thing that I am left berating myself for not thinking about it earlier. He told me that if someone comes in with such significant renal function decline so acutely, always think of and rule out an obstructive cause for this presentation before moving on to other more sinister things. He was doing an ultrasound to look for hydronephrosis or hydroureter, which is basically the dilated urine collection channels in the kidney downwards and the reason they are dilated is due to an obstruction further down the channel. And that is exactly what he found. The left kidney was moderately enlarged but the right kidney was massive and its ureter was like a fire hydrant pipe rather than the small thin tube – and the mass in the lower part of the abdomen, going from pelvis and extending up from the umbilical area? His urinary bladder!!! I was in shock – as my registrar then gave me the second pearl of wisdom: never believe anything you are told, do not take it for granted until you have objective evidence. The patient felt he was peeing less and less because he wasn’t drinking enough. Yet he was peeing less because the channels beyond his bladder were so narrowed and obstructed that they did not allow emptying of the bladder and it just kept filling up till it was a massive huge thing floating in his belly. I at once made arrangement to catheterise the patient, whereby 2000 ml (that’s 2 litres!!!) of dark brownish urine poured forth out of him.

He had been in urinary retention for the better part of 3-4 days, possibly due to an enlarged prostate that had just gotten worse, and his constipation (though being chronic) was either a factor of his massive bladder pressing on his rectum/colon and not allowing the contents to move ahead; or (a bit like the chicken and egg thing, of which came first?) he was constipated, which gave him some abdominal pain (expected) and that pain had the added effect of causing urinary retention – anyways, after passing the catheter and draining all that urine the patient felt quite comfortable, and the surgeons took him away to do their wonderful things.