FACEM VAQ 2008.2 Examiners Report

VISUAL AID QUESTIONS

• 51/81 (63%) candidates passed the VAQ section of the exam.
• To achieve this a candidate has to pass 5 or more of the 8 questions with a total mark of at least 40 / 80.
• The grade frequencies were:

Question 1

An 82 year old man is brought to your emergency department after having been found on the floor of his home. He was last seen by his neighbor 18 hours earlier.

(a) Describe and interpret his ECG. (50%)

(b) Outline the investigations you would perform. (50%)

• ECG showing a junctional bradycardia with wide QRS, deep anterior Q waves and tall anterior T waves.
• The overall pass rate for this question was 62/81 (76.5%).
• The examiners felt that this was a straight forward question requiring a structured description and a focussed differential including structural heart disease, metabolic, toxicological and environmental causes.
• Most answers were considered adequate but lacking extra detail.

Question 2

A 45 year old man is brought to your emergency department with severe pain in his right hip after a fall from his bicycle an hour earlier. He has no other obvious injuries.

(a) Describe and interpret his X-ray. (50%)

(b) Outline the analgesia options. (50%)

• X-ray of complex orthopaedic injury showing comminuted mid shaft femoral fracture, hip dislocation, acetabular fracture and fracture into the pubic symphysis. Air splint in place.
• The overall pass rate for this question was 62/81 (76.5%).
• Good answers demonstrated a systematic approach to x-ray interpretation and recognized the high likelihood of significant blood loss and significant analgesia issues.
• Poor answer missed one or more injuries and/or failed to take into account the haemodynamic instability in suggesting analgesic options. Many candidates failed to answer the question as set.

Question 3

An 83 year old woman presents with a three day history of malaise and polyuria. She has a past history of Type 1 Diabetes and Hypertension.

Describe and interpret her investigations. (100%)

• The overall pass rate for this question was 58/81 (71.6%).
• The examiners felt that this was a good question testing core knowledge of metabolic emergencies.
• Good answers identified the primary abnormalities, made appropriate secondary calculations and committed to a diagnosis of DKA with renal failure and hyperkalaemia.
• Failed answers did not undertake secondary calculations and synthesised the abnormalities poorly.
• It is of concern to the FEC that one examiner failed candidates if they if they “failed to give calcium and bicarbonate” when the question asked the candidates to “describe and interpret” the biochemistry.

Question 4

A 65 year old man is brought to your emergency department. He was starting a fire in his fireplace when his clothes caught on fire.

(a) Describe and interpret his photograph. (50%)

(b) Outline the principles of his fluid management. (50%)

• Clinical photograph showing extensive burns of variable thickness to the anterior neck, chest and abdomen plus face in a middle aged male receiving oxygen and non-invasive monitoring.
• The overall pass rate for this question was 48/81 (59.2%).
• Both examiners felt that this was a good question testing core emergency medical knowledge.
• Good answers described the burn in terms of area, depth and the likelihood of airway, other special area and circumferential limb burns. Fluid management priniciples included use of a recognised fluid replacement regime and monitoring response with vital signs, urine output and CVP.
• Poor answers failed to recognise the risk of airway injury, the need to monitor fluid therapy response and/or suggested hypotonic fluids. Some failed candidates seemed to ignore the suggested 50/50 time allocation or failed to answer the question as set.

Question 5

An 8 year old boy is brought by his parents to your emergency department 20 minutes after a motor vehicle accident in which he was a restrained rear seat passenger.

Describe and interpret his photograph. (100%)

• Clinical photograph showing a young boy with a wide area of bruising/abrasion to his entire anterior neck.
• The overall pass rate for this question was 31/81 (38.3%).
• The two markers felt that this was a very straight forward question which was largely very poorly answered. Successful answers described the photograph and interpreted a likely cause/mechanism and suggeste possible associated underlying injuries.
• Failed answers described the photo without providing further interpretation as above.
• The examiners questioned whether an explicit part b) such as “list possible associated injuries” would have improved the pass rate.

Question 6

A 50 year old man presents with shortness of breath and sharp central chest pain of 24 hours duration. He has no past medical history and is on no medication.

Describe and interpret his ECG. (100%)

• ECG showing narrow complex tachycardia with electrical alternans.
• The overall pass rate for this question was 46/81 (56.8%).
• Both examiners felt that this was a good question, poorly answered by many candidates.
• High level answers showed a structured approach to ECG interpretation and stated conclusions within the clinical context.
• Poor answers failed to calculate rate, identify alternans or interpret within context.

Question 7

A 74 year old man is brought to your emergency department after three days of persistent vomiting.

Describe and interpret his investigations. (100%)

• The overall pass rate for this question was 65/81 (80.2%).
• The examiners felt that this was an excellent question yielding a wide spread of marks.
• Good answers showed a structured approach to ABG/electrolyte interpretation, made appropriate secondary calculations and recognised the complex nature of this abnormality with its possible differential diagnoses.
• Poor responses failed to recognise the metabolic and respiratory alkaloses, the raised A-a gradient (and its possible significance) and did not suggest a reasonable differential.

Question 8

A 47 year old man presents to your emergency department with a two day history of a painful rash on the back of his neck.

(a) Describe and interpret his photograph. (70%)

(b) List the investigations you would perform. (30%)

• Clinical photograph showing a large area of clustered vesicles with associated erythema. Rash crosses the midline.
• The overall pass rate for this question was 56/81 (69.1%).
• The examiners felt that this was a good question based on a high quality image. Good answers identified a vesicular rash with a reasonable differential of causes plus a focussed investigation of these causes.
• Failed answers misdiagnosed non vesicular rashes (eg carbuncle). It appeared that some candidates did not allocate their time as per the question recommendation leading to inadequate detail in one or other section.

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