FRCEM (Primary) – Done and dusted!

So I am happy to report that the results of the recent FRCEM (primary) exam were announced this evening – and I am proud (read ecstatic!) to share that I passed it! *takes a bow* (if you are interested in questions from the exam, read about that in a separate post here)

This is why I have been slightly out of the blogging scene for the past few weeks – prepping for the exam, juggling the ARCP for my first year of training and what has been very likely the hardest and longest and hottest summer stretch I have ever endured (and I am from Pakistan!) But I am back with the proverbial bang!

And I bring with it the novelty of experience.

It’s not a difficult exam per se – but it is an exam that requires commitment, and time and energy. Be ready to make that commitment. It’s a new exam, only started in Autumn 2016 I believe.

Back in the good old days when I was a (very) junior doctor back home in Pakistan, I had the luxury of having ‘many’ weeks off in lieu of exam prep – the job itself was intense but i had no other commitments; i.e training, portfolio, assessments, ARCP, etc. For this exam, I was working in your regular, run-of-the-mill A&E department in the UK, as a 1st year trainee. I decided to take the exam, decision was taken in January, I booked an online question database then, and I booked the exam in mid February, but I didn’t really get a good momentum going initially, and was still in 2 minds. Why? Because of the ARCP which is an assessment of all your competencies for a required year of training that you have managed to accumulate over the period of the past year, and a panel of judges basically sits and decides whether your performance (based on these signed competencies) is good enough to warrant your progression to the next stage/year of training. So this year was to be my first ever ARCP and coincidentally the exam fell on the exact same date as the ARCP, so in addition to the preparation of the exam, I had to focus on my assessments/requirements for ARCP – all to be juggled along side a full time job in the A&E as one of the juniors. It is doable folks.

So in bits and bobs I started my prep. I had that textbook of emergency medicine, but I must admit I never got beyond the first 5-7 pages of it! Doing the questions from the question bank is what helped me pass along with (as I said) youtube videos. I took a 4 month subscription for the FRCEM exam prep website – previously known as MCEM exam prep website. (‘tom-aye-to, tom-aah-to’). They have a good database of questions fortunately of the SBAQ type as well as the older true/false format. I have ready in many places that you could use any of the other websites/question banks as well.

On my days off, I aimed to do 50-100 question (see, I made you laugh there!) Who am I kidding, I barely got 30 done on a good day – these questions came with explanations, why this option is right, and why the others are wrong, along with a short description of the topic that the question deals with. I inevitably began making a habit of taking pictures of the explanations in my cellphone, and I went back to them again and again, for example before going to bed, or while waiting for my wife/son to wake up in the morning on my rare days off. I found this habit helpful, as you may not retain some of the information that you read, but if you go back and go through it again, or atleast if not all of it, then maybe just the major salient points, it is bound to stick to you.

On my days where I was working, I tried doing a few questions while at work, on my phone, between patient. That was a bad idea. Not only did I not have enough time to do even a single question justice – I also did not retain too much due to the lack of concentration in a busy A&E department. Ditched that idea fast. I did however vow not to waste any of the days I was working though, so after a busy shift, I used to come back, rest, recuperate or sleep (mostly slept) thanks to my wife who really upped her support game and banished me to a separate room in the house at all hours of day or night, waking or asleep – no diaper duty, no bath time no sleep time with the baby – just the books, fooding and my laptop. Where was I? Yes – days I was working, depending on what shift I had done, I still tried to get a good solid 3 plus hours of ‘mcqsing’ as I called it. On days that I was on morning shifts, I came home by 5 pm, straight to bed, slept for an hour and a half or 2 – woke up – tea/food/family time for an hour or 2 and then hitting the books (or laptop in this case) from 10 pm onwards up until 2-3 am – then 5+ hours of sleep and a repeat of this. Or on the afternoon shifts (2pm/4pm to 10 pm or midnight) similarly I used to come back home, freshen up, spend a minuscule amount of time with the family before they dropped off to sleep and then ‘mcqsed’ till the wee hours of morning, going to bed at 5 am or thereabouts, to wake up just in time for lunch and off to work. Night shifts were a bit more difficult, and I sort of gave up on trying to cram anything in my head during the 4-5 night stretch we have – the hangover like state I was in during the night shift stint was not really amenable for any further insult to the brain by forcing it to swallow any other bits of information/mcqs.

I also youtubed a lot of videos – specially anatomy ones, and one or two for physiology and microbiology. There are a lot of good ones out there. I focussed on upper and lower limb anatomy the most, along with the plexuses. You can just search for them under ‘anatomy, mcem or mrcem’.

My strategy towards the middle/end of my prep was to focus mostly on the maximum yield subjects – broadly anatomy and physiology which carried the most weightage in the actual exam, with 60 questions from each subject (out of a total of 180 questions!) Followed by significant input from microbiology/pharmacology/pathology. I used to do 3 sets of 20 questions in a row – the first set being anatomy, second physiology and the 3rd annoys the others, but I kept the first two sets the same, due to its weightage. Anatomy threw me, as it was basically learning a new something I had learnt almost 13-14 years back in the early medical school years! I think it was safe to say I had forgotten most of it, despite having a refresher course during my stint at the USMLE exams. But I digress. I found the following topics high yield, and got an inkling from my various forays into the question banks that these were important enough to be tested and warranted more attention (or repetitive attention) from my end.


– Upper limb (muscles -attachments and function, nerves, bones, blood vessels) -Lower limb (Same as above) – brachial plexus – abdominal wall layers – blood supply of the heart – borders of the heart – contents of spermatic cord/inguinal canal – Sacral plexus – Optic nerve lesions – cranial nerve basics – triangles of the neck – foramina of the skull and their contents – diaphragmatic openings – Facial nerve – spinal cord lesions based on presentation – stuff going on at T4 level – brain blood supply


Lung volumes – cardiac cycle – hormones (renin, angiotensin, mineralocorticoid, cortisol, adrenal medulla, pancreas, PTH, calcitonin, Vit D and its metabolytes) – renal physiology – 


Vaccination program – Drugs that induce/inhibit cytochrome p450 – broad microbiology – allergic/hypersensitivity reaction types – types/examples of vaccines – immunoglobulin types – 

I also attended a course arranged very kindly by our deanery for candidates interested in the FRCEM primary. It was purported to be a tough exam, as the previous attempt had had a passing percentage of 43 percent. Yes, only 43 % of the candidates who appeared for the previous attempt passed. We gulped down our fears, and while the course gave us a broad idea of what wee needed to be doing (which was a lot!) it served no greater purpose than to tell us that we were not alone in being scared and that everyone seemed to be equally stumped by their performance in the questions – slightly reassured by the fact that during practise mcq sessions, when the consultants tried to solve the questions they were mostly unable to. Slightly reassuring, and mostly horrifying, as how were we supposed to pass the exam?! Yikes. What threw most people was that the exam format had been changed – from the previous true or false format, to the  Single Best Answer Question or SBAQ format. All options in a given question may be correct in different ways, but select the answer which is most appropriate according to the stem. Which basically translates to “guess what the examiner was thinking when he/she made this question” – so no pressure!

By the last few weeks, I was about to pull my hair out – the amount of mcps I was doing wasn’t too much, and I didn’t seem to be ding all that well if you calculated the number of questions I was getting right – overall a 52-55 percent of correct answers. Abysmal. I did not let that disappoint me, however, knowing full well that practicing questions was the way to go in such an exam format.

I used up all of my 2 weeks of annual leave and 3 out of 5 days of study leave for this exam, which brought me to just about 20 days of uninterrupted preparation (coupled with MANY visits to the department for ARCP related issues). That I feel was the single best thing in way of preparation – the time off was focussed, and I wasn’t tired from running around – preparation is mentally exhausting as it is, coupled with the physical exhaustion of day-to-day ED life – it takes a toll. All I did was sleep, eat and study. Lather, rinse, repeat.

But I will reiterate here what I have said before as well – you can never do enough questions as practise – just keep doing as much as you can, every waking minute make sure you are doing questions. Whether its 5 or 50 questions, make sure you stay consistent and do not get laid-back and forget to do questions – keep doing them, whether right or wrong, as long as you are also focusing on the explanations of those questions, its a learning experience.

Advice about the exam itself: Time management – 180 questions, 3 hours. The way I did it was divided it into 3 parts, so I needed to have completed 60 questions in 1 hour, and preferably even faster than that, since I needed to allow some time at the end to go back and tackle the more difficult or confusing questions. Keep track of time as well – if you seem to initially be on track, keep checking the clock every 10-15 minutes and make sure you are on track. If you feel you need to think more than 20 seconds for an answer and are still unable to do so, then mark the question and move on, return to it later. Do not waste minutes on a single question, causing a delay and jeapardising multiple other questions. Read the stem carefully – often we do not read the ‘except’ ‘all’ which’ ‘most appropriate’ next step’ gold standard’ ‘not included’ bits of the stem and inadvertently end up selecting the wrong option. In case of long stems, read the last bit/question and the skim over the rest of the stem, to gauge what they are looking for. If you don’t know the answer, go through the options by the process of elimination. Eliminate the blatantly wrong options. Think about the rest, if possible eliminate another 1 or 2 till you are left with one. If you read the stem and know the answer, look for that in the options, if you see it, select that. Always attempt all questions, no use leaving a question blank and lose an opportunity of a lucky guess. Feel free to draw, make flowcharts, write things down in the margins of the question paper if it helps you remember, calculate, reach a conclusion (I remember I drew the whole optic nerve/tract/radiation diagram to help me diagnose where a lesion was based on the hemianopia referred to in the question paper!) The questions may be easier than your practise question bank – don’t worry!

And I had the support of good friends. I don’t know, there is something about prepping for an exam (or anything in life for that matter!) and knowing that there is someone else going through the exact same thing as I am – it creates an interestingly unique bond. I had 2 such colleagues and friends, and I am pleased (and incredibly proud) that they have passed as well. We used to work together in the same ED department back home in Pakistan, and are now in different parts of the UK pursuing careers in emergency medicine. Onwards and upwards!

FRCEM (primary) – recall questions

So these are the recall questions from my attempt at this exam – June 2017 (happy to report that I passed the exam – if you are interested in my experience with the exam, do read about it here Good luck!)

  • achilles tendon rupture – ciprofloxacin
  • msuculocutaneaous nerve – stab wound to axilla, causing weakness of elbow flexion and supination
  • platysma – stab wound to anterior triangle of neck – which muscle would be injured (choices were sternocleidomastoid, scalenous anterior, trapezius, platysma and one other)
  • head injury with fractured internal acoustic meatus, which TWO nerves would be affected – facial and glossopharyngeal
  • female with mass on anterior 2/3rds of tongue, where is lymph drainage? i chose submental because tip of tongue drains there but rest of anterior tongue drains to submandibular, so I am not sure, both were in the options
  • ankle movement loss – ? location of lesion
  • lower lip numbness, nerve involved? inferior alveolar
  • scenario of impetigo in child, what factor causes its spread? fecal- oral, droplet, intact skin, broken skin – i chose broken skin.
  • swollen painful knee joint youngish male (35 or so?) no other history, what would you find on gram stain? gram positive pairs of cocci in clusters, or gram positive cocci in chains, or gram negative rods or gram positive rods or gram negative intracellular organisms arranged like kidney beans (correct answer – gonococcal arthritis)
  • small wound on ankle, swollen acutely inflamed next day – what is the most abundant cell type present? neutrophils
  • neck of fibula fracture – common perennial nerve injury
  • valgus deformity of knee joint following football injury i think, ?ligament damaged – medial collateral
  • hyperextension of knee joint – horse-riding incident, unable to weight bear swollen painful knee etc, injury to? – anterior cruciate
  • scenario of pancytopenia ? causative drug? – choices included celecoxib and mefenamic acid – i chose celecoxib
  • lip/peri-oral swelling not improving with adrenaline, which drug implicated mainly as cause? – ramipril (don’t remember specifically – one of the ‘prils’)
  • anaphylaxis, adrenaline dose? 1:1000
  • optic tract lesion, right or left – scenario depicting right homonymous hemianopia
  • headache, increased intracranial pressure symptoms, bitemporal hemianopia ? lesion site – optic chiasm
  • mass in optic chiasm, symptomatic, hyperglycemia, likely hormone excess? growth hormone
  • hemorrhage, life threatening, what will be the effect on kidneys? – decrease urine production
  • scenario of heart failure, furosemide given, site of action? – loop of henle
  • someone in type 2 resp failure, how will body realise it needs to increase breathing rate? – chemoreceptors
  • picture of a weird target lesion like rash on hand of young male, said to have been acute in onset over last two days started on limbs now involving trunk etc ? cause – options were HIV, Herpes simplex, staph aureus (my answer because I thought it was scalded skin syndrome and nothing else really fit)
  • newborn with eye discharge, mum under treatment for chlamydia, what is newborn at risk of? pneumonia, encephalitis, corneal ulcer, meningitis, and one other option – i chose corneal ulcer
  • 3 month old, diagnosed pertussis, most horrible complication? – apneic spells
  • alcoholic male, cough, bloody sputum, fevers, consolidation on xray, microorganism? – klebsiella
  • alcoholic, male, ascites, cause? – portal hypertension
  • ascitis in female, lung function tests, which would be increased? FEV1/FVC
  • stab 5 cm above iliac crest left lateral abdomen – deepest structure before peritoneum? – transversus abdominis
  • loud s1? cause – opening of pulmonary valve, closing of aortic valve, vibration, opening of mitral valve, closure of tricuspid valve
  • cholera scenario, profuse watery diarrhoea, mechanism of action? – chloride ions leakage?
  • scenario of steattorhea – defect in exocrine pancreas
  • 35 yo woman with fatigue, icteric sclera, unconjugated bilirubin – hepatitis
  • acute infection with hepatitis B – raised ALT
  • terminal ilium resection, absorption of which will be affected – vitamin c, zinc, proteins, carbohydrates, vitamin d
  • cause of prolonged PR interval
  • cause of prolonged QT interval – clindamycin? (scenario of patient recently using antibiotic for skin infection, ECG shows QT prolongation
  • digoxin toxocity, when to give digiband? – prolonged seizures, severe bradyarhythmia
  • hyperkalemia, ECG changes just before cardiac arrest?
  • ECG shown, which vessel involved based on ECG changes?
  • Angiography of chest pain patient, occlusion of left circumflex branch, which cardiac area affected
  • megacolon found in 7 day old infant, passed meconium at 3 days of both and no bowel movements since then, which system affected? – myenteric plexus
  • gout scenario – negatively bifringent crystals on aspirate
  • glucagon secreted from- alpha cells
  • young patient with DKA – which pancreatic islet cell dysfunction? BETA
  • glucagon site of action for gluconeogenesis and glycogenolysis?   liver
  • factors that increase gastric emptying – cholecystokinin, histamine, secretin, duodenal distension, astral distension
  • shingles rash scenario, seen in ED, what would you do to confirm before beginning treatment? – history and clinical judgement
  • scenario of herpes zoster ophthalmicus, which nerve involved? – trigeminal
  • orbital blowout fracture, diplopia on upward gaze. which is entrapped? superior oblique, inferior oblique, inferior rectus, superior rectus, medial rectus
  • orbital blowout fracture – inferior orbital fissure fracture, which will be damaged?
  • something about starling’s law
  • oculomotor nerve – consensual light reflex scenario where light shined in right eye, reflex present, light moved to left eye but right pupil dilates, lesion?
  • precipitant of gout in a patient’s drug regimen? – hydrocholothiazide
  • gout treatment, scenario given elderly, heart failure, diabetes, acute gout treatment? – colchicine, allopurinol, diclofenac, etc etc
  • rationale for steroid use in asthma- reduce bronchial inflammation(duh?)
  • adenosine contraindication (scenario of SVT) – recent severe exacerbation of asthma
  • scenario or warafrinized patient with head injury? reversal with? – FFP
  • patient with von willibrand disease scenario – what is the dysfunction? – platelet aggregation
  • patient fully uptodate with tetanus injections according to UK protocol, presents to ED with very dirty soiled open wound with open fracture of tibia fibula, treatment options? no tetanus treatment, tetanus immunoglobulin only, tetanus immunoglobulin and vaccine now, tetanus immunoglobulin and vaccine now and 1 month later, tetanus vaccine only
  • 8 month old child, fully updated with jabs for age. what has he still not received yet? men a, men b, hiB, rotavirus, mumps
  • patient has been bitten by someone who is hep b positive, she herself has never received vaccination for it, management plan? immunoglobulin now, immunoglobulin plus vaccine course over three months, immunoglobulin plus vaccine course over 6 months
  • child with proven meningitis being intubated in ED, who needs prophylaxis (post-exposure) clinician intubating, nursing staff in ED, children at party with child, classmates and teachers in school
  • boy with hemophilia scenario, deficiency? – factor 8
  • digoxin toxicity, worsens – hypokalemia
  • succinylcholine mechanism of action – depolarizing neuromuscular blockage
  • propofol, mechanism of action – GABA receptors
  • cause of warfarin to be potentiated – clarithromycin?
  • cause of pregnancy despite oral contraceptive pills – carbamezepine
  • ectopic pregnancy scenario, site of likely pregnancy? – ampulla of fallopian tube
  • direct inguinal hernia, defect? –
  • middle aged male, struck in anterior abdomen with steel girder, fast scan shows intra-abdominal fluid, which organ would be injured? – spleen injury (other options were kidney, pancreas, colon, aorta, none likely to be injured than spleen)
  • woman presents with right shoulder weakness, difficulty in raising it above her head and also shoulder contour different – which nerve implicated? accessory (deltoid)
  • scenario of elderly male involuntary tremors in one hand, gait changes, rigidity in muscles, expression changes, where is the lesion? substantia nigra
  • lithium toxicity – ataxic gait
  • scenario of TB, how to diagnose? – options were CT chest, sputum culture, monteux test,
  • tapeworm infection, how to diagnose? IgE levels raised, eggs in stools
  • diarrheal illness, ascending paralysis scenario, organism implicated? – campylobacter jejuni
  • pre oxygenation for intubation, which lung volume needs to be replaced with o2?
  • proton pump inhibitor acts on- parietal cell
  • MAP calculation formula
  • duodenal/gastric ulcer – likely cause? Gastrin
  • 48, male, perforation, pneumoperitoneum on CT, likely organ to be perforated? – duodenum, sigmoid colon, transverse colon, ascending colon, oesophagus
  • elderly patient, abdominal pain, high lactate, very unwell, scenario of ischemic bowel. CT shows ascending colon affected, what blood supply?-  right colic artery
  • DKA treatment commenced, what will be low as a consequence – potassium
  • dka scenario, what causes drowsiness – sodium
  • in patient with addison’s disease, scenario and lab results given what specifically is deficient? – mineralocorticoid
  • osmolality, major contributor? – sodium
  • froments sign
  • scenario of tachycardia at 135/min, weight loss, diarrhoea, in a patient with grave’s disease, what will be lab finding supportive of it? increased T3
  • hyponatremia, hyperkalemia – hypoadrenalism
  • scenario of ADH secretion, location? posterior pituitary
  • FAST scan in patient RTA, hypovolemic shock, where will fluid likely be seen when supine? – paracolic gutter? para-aortic gutter? between liver and diaphragm, between liver and right kidney, between spleen and left kidney
  • blood volume? 5 litres
  • scenario of scalp laceration, what will cause clotting – conversion of prothrombin to thrombin, conversion of fibrinogen to fibrin, activation of external clotting cascade
  • pulmonary surfactant function – increase surface tension
  • pulmonary surfactant produced by? – pneumocytes
  • picture of winged scapula, which muscle likely to be affected? – serratus anterior
  • winged chapel scenario in hiker, which nerve is damaged? long thoracic nerve
  • recurrent pneumonias in chronic smoker, what is the factor causing him to have recurrent pneumonias? – decreased mucociliary clearance
  • hilar lymphadenophathy on CXR? bronchopulmonary? paratracheal? tracheobronchial? superior thoracic? pulmonary?
  • dentures stuck in trachea at T4/5 level, what causes the constriction? – arch of aorta
  • plumber/painter, right elbow lateral condyle tenderness/painful movements of elbow, what movement will be affected? wrist extension
  • swollen tender knee joint, known recurrent joint problems elderly female, what blood test will be raised? – rheumatoid factor
  • contact dermatitis scenario? – type 3 hypersensitivity reaction?
  • anaphylaxis, which immunoglobulin? – IgM
  • trancutaneous pacing, skeletal muscle contractions of anterior chest wall ? cause – voltage gated sodium channels opening
  • slip and fall on outstretched hand, wrist pain, lunate dislocation, also c/o severe pain in hand, what is likely to have been injured? – distal radius, radial artery, ulnar nerve, scapholunate dissociation, radial nerve
  • fall on outstretched hand, elbow injury, posterior dislocation of bow, what is likely fractured? – capetellum, trochlear part, olecranon, radio head, supracondylar region
  • volar wrist aspect injury, laceration, possible injury to structures above flexor retinaculum, what will be injured?
  • slip and fall landed on back/hip, painful movement of hip adduction but hip flexion is normal, what muscle is injured
  • 14 year old fell from horse, numbness and tingling to medial 2 fingers and ulnar border of hand ? lesion where?
  • patient with spinal cord injury, central cord suspected syndrome suspected, clinical signs to be expected? – proximal musculopathy? upper limb muscles affected worse than lower limb muscles,
  • unable to move below waist, wrist elbow  and  shoulder movements intact, unable to flex fingers or grip anything, lesion?
  • football injury young male – snapping noise when hip joint moved, avulsion of anterior superior iliac spine ? muscle involved – sartorius
  • fracture base of little finger metacarpal, which muscle injured?
  • anterior aspect of thigh numbness – lateral cutaneous nerve of thigh
  • fifth metatarsal base fractured – muscle?
  • fibular neck fracture, which muscles is injured?
  • stabbed through adductor canal, injury to what structure? saphenous nerve, femoral nerve, obturator nerve
  • patient is stabbed in abdomen, diaphragmatic injury at region where oesophagus enters the diaphragm, what other structure would be injured? vagus, azygos, thoracic duct, aorta, vena cava
  • neck surgery on thyroid, which nerve is damaged? recurrent laryngeal nerve
  • there was a graph shown – this question I most likely got wrong – and I don’t even remember the stem – they asked us to label what we thought was on the x- and y- axes! I had no clue!
  • some scenario of a patient requiring a test for a disease – and then they went on to ask, in order for the patient to be discharged safely, what factor of the test was most significant in deciding whether or not it was safe for him to go home : sensitivity, specificity, negative predictive value, positive predictive value, or odds
  • patient with stroke symptoms,weakness, sensory loss and poor coordination – which vessel likely to be blocked? anterior cerebral, middle cerebral, posterior cerebellar,anterior communicating posterior communicating
  • facial nerve exits through which foramen
  • trochlear nerve exits through which foramen
  • insulin causes glucose to be transported into the cells, mechanism? active transport, passive transport, facilitated diffusion, osmosis, cotransport
  • mechanism of ketoacidosis in young girl with DM type 1
  • drug causing extrapyramidal side effects
  • child has taken grandmother’s medications, based on symptoms what medication has he taken?
  • effects of which drug causes patient to be dry, warm, psychotic
  • post splenectomy which organisms will cause problems – encapsulated bacteria (do not remember was probably strep pneuma or meningococcus)
  • patient with peptic ulcer – whats the mechanism? decreased prostaglandins, increased arachidonic acid metabolites,
  • patient with pulmonary embolism, which lung volume/space will be affected
  • discussion of an x-ray 1-2 weeks post fracture with fracture line surrounded by hazy area ? cause bone formation, calcium deposition, refractor, failed hearing, malunion
  • patient recently back from swimming, ear canal painful discharge etc what caused it? swelling of wax in ear canal
  • innate immunity
  • ascending paralysis with diarrhoeal illness, organism? campylobacter jejuni

Rant (I have a feeling this is going to be a series!)

OK – here is something I have been meaning to get off my chest for a while now. Always remain true to your oath. Never forget, you are here – as part of a team – to help people at their most vulnerable. Do NOT become arrogant, or cocky. Do not think you know more, or enough even. It is always going to be a learning curve. You will always find something new, a different perspective, a different set of circumstances, a different allergy spectrum, a different way to treat and a different response. Always be open to suggestion, and NEVER assume the tone of ‘Me, Myself and I” – You are part of a team. Say it after me. T-E-A-M. TEAM. You can not and will not be able to see, treat, investigate, counsel, manage and completely sort out ANY patient thoroughly on your own. You will need to be part of a team, whether it is the nurses, the junior (or senior) doctors around you – in your specialty or in another specialty who you call upon to ask for advice, or whether its the janitor or the lovely lady who makes the tea and sandwiches for the patients. You can not do without any of them. We are all cogs in an intricate system, and should you feel the urge to think you are the most important cog or the biggest or the brightest – just remember, even the smallest nut can cause a whole plane to come down.

*OK. Deep breaths. You got this. Keep it together*

Where is this coming from? This is coming from an increasing number of experiences I have had interacting with colleagues from different specialties, whereby as soon as they answer the bleep or pick up the phone for a potential referral or even an opinion, you can almost hear the wheels turning in their heads in trying to pick out any reason to refuse the referral or bounce it on to someone else. But wait – I did not bring this patient from my home. I have assessed and tried to sort him out – and based on my assessment with the tools I have, I am obliged (in the interest of patient care and safety) to refer to your expertise in the matter. Not your expertise in how to NOT accept a patient into your services, but the actual expertise of your specialty, which you have signed a contract for and willingly and knowingly have signed up to provide!

Case in point: 80-something year old female, with some medical history which I now forget, admitted with non specific symptoms of progressively worsening mobility issues over the past few weeks, acutely deteriorating over the past week to become completely bed bound and unable to get out of bed – associated with a very poor oral intake of food as well as water. Husband called the paramedics that day because she was literally unable to lift up her head to have a drink of water. There were no other symptoms – no pain anywhere according to the patient, no recent fevers, no vomiting and normal bowels. Paramedics found her to be very tachypneic (higher than normal respiratory rate – hers was about 55) but the rest of her observations were all within normal parameters. She arrived into ED where I was the first one on scene along with the resus nurse. We quickly connected her to a monitor, and established an IV line, taking some baseline blood tests including a very quick blood gas, which gives us a very quick assessment of anything acutely going on. We found her lactate levels to be 11 (yes, ELEVEN – classified as sky-high in my dictionary!). I thought on examination her abdomen was slightly protuberant (?distended?) but not tender – thought she did appear slightly uncomfortable when I examined her. She was conscious, but drowsy – yet was able to answer all my questions. I got my registrar to come in and review her (sky-high lactate!) even though I basically knew my plan of action. He felt that the patient’s tummy was actually distended, with diffuse tenderness instead of discomfort. He advised I urgently get x-rays of the abdomen and an erect chest film, to rule out bowel obstruction/perforated bowel loops. As I was requesting said scans, the consultant was sat beside me on the next computer, she overheard the words ‘high lactate’ and ‘abdominal pain’ and immediately wanted me to drop everything, call the surgeons and get a ct scan of the abdomen to rule out bowel ischema. I requested the CT scan first, spoke to the radiology consultant, who (surprise surprise!) wanted the patient to first be seen by the surgical team and then be considered for the scan. I then bleeped the surgical team, this was a registrar, and our very pleasant conversation went thus:
Hello there, sorry to bother you – I am one of the ED SHOs, I would like to refer a patient to you please.
*give him the patient’s details*
after being interrupted 4 times during the whole history etc he asked me 3 things: Have you requested a CT scan? (yes) Have you discussed it with the medical team? (no, why would I do that? abdominal pain/tender abdomen with a high lactate, medics won’t touch her with a barge pole) and have you at least rung up ITU? (No, once again, why would I – patient is unwell I agree, but she is stable aside from a high resp rate, she may progress to needing ITU care but currently would really benefit from an opinion/referral to surgeons, and should you see fit to inform ITU you can let them know as part of a pre-op thing) No this patient does not sound surgical (excuse me? what part of abdominal-pain-high-lactate did you not understand? I hate using the ‘because my consultant wants you to see the patient’ card – and I rarely, if ever, use it. But I had to this time. He was not happy, but he came down to review the patient)

And still did not think they had a significant surgical problem. So my consultant had a word with him, and he still insisted the patient needed to go to medics. To which he was reminded that we have referred tot he specialty we think is appropriate for patient care in this patient’s current condition, so if he felt that the patient required to come in under a different specialty, he would have to convince that specialty himself. There was a bit of an argument – and he conceded. He saw the patient in detail, and informed us he had referred to the medical specialty who had accepted the patient, and that he had booked a contrast scan for the patient to rule out bowel ischemia – but unless something horrible showed up on CT, this patient was not to come under surgery. It seemed like the case was sorted, I made sure the patient had adequate analgesia on board, antibiotics and fluids ongoing and then went for my break.
I came back after half an hour, and picked up the next card – but my consultant reminded me that the medical team still hadn’t come down to see the patient, could I give them a call and find out what the situation was. THE MEDICAL REGISTRAR WAS NOT AWARE OF THE PATIENT! I could have almost cried. I had worked with her, though, so she very kindly listened to the story, but understandably (well, maybe not) asked that I get that CT done before she gets moved from ED on to the medical ward. I felt like banging my head against the wall. My shift was about to end in 45 minutes, but we got a CT scan requested, vetted by the radiology consultant who finally agreed because the surgeons had touched the patient and given me their blessing (so to speak) – and the last thing I did before my shift ended was confirm that the patient had had the scan, she had come back from it, I said good bye to her and told her and her husband that the results were still awaited, but since my shift was ending, it was over to the surgical team then.

Questions –
-Was the event survivable from the beginning when she first came in? Unlikely, based on how acidotic she was, and her lactate and kidney functions were through the roof.
-Could I have done anything more? There is always something that can be done to improve outcome – but I was hitting roadblocks left right and centre. In the event of each one, I escalated to the appropriate seniors, but all that did was save my back. It did nothing for the patient, and that is something that I had (and am still having) a hard time accepting.
-Was this case mis-managed? Not at all. The patient was treated adequately as and when we were finding things, thoroughly investigated, and seen/reviewed by 2 different specialties aside from ED – ITU and surgeons. She was at the ceiling of care when she passed away. The reason I am ranting here is that sometimes, or more often than not, it is a multistep process to achieving optimum care for each patient, and at every step of the way there are potential hurdles, things that are the rate-limiting factors that if the pieces do not fall into place in a timely manner, everything gets delayed. And the reason I am ranting is also – please be humble. If someone asks for your opinion or an assessment of a patient based on a skill set you have, then you should be honoured, and also honour the ethics behind the title. It is a huge responsibility, and you need to make sure that every step of the way, every day, you are discharging that obligation with humility and respect. Your patients, unaware of your moral standards and ethical beliefs, rely on you bringing your A-game. They are usually already fighting a battle, and they need you to fight for them, because they won’t be aware of the minutiae of the battle. That is where your responsibility comes in. And your A-game. Bring it. Or don’t come at all.

(Edit: I came in to work the next day, and due to force of habit I check up on the online patient database of admitted patients what had come of the case. The patient’s CT Abdomen/pelvis with contrast had been reported: “Intra-abdominal air, likely due to perforation in the sigmoid colon, secondary to probable diverticular disease. ”

My patient had passed away about 45 minutes after my shift ended.)