FACEM VAQ 2009.1 Examiners Report

VISUAL AID QUESTIONS

• 58/81 (55.6%) 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:

A 72 year old woman is brought to your emergency department after a syncopal episode.

a. Describe and interpret her ECG (50%)

b. Outline your disposition considerations (50%)

• The overall pass rate for this question was 26/81 (32.1%).
• ECG showing first degree heart block, left axis deviation and RBBB.
• The examiner pair felt that this was a core EM scenario that was done very poorly by the majority of candidates. Pass criteria were to identify the ECG features above plus appreciate the conduction implications of this in the presence of syncope with need for monitoring and potentially pacing.

Question 2

A previously well 23 year old man is brought to your emergency department acutely short of breath after developing right sided chest pain at work. On arrival, he appeared pale and sweaty and was hypotensive. A Chest X-ray was taken immediately after a procedure was performed to stabilise his condition. His vital signs are now normal.

a. Describe and interpret his Chest X-ray (30%)

b. Outline your treatment options (70%)

• The overall pass rate for this question was 71/81 (87.7%).
• Chest X-ray showing a pneumothorax with needle thoracostomy catheter in situ and no evidence of radiological tension.
• The examiners viewed this as a good prop investigating a core emergent condition. Pass criteria were to identify the X-ray features, institute definitive drainage and organize appropriate inpatient disposition. Fail criteria included failure to adequately describe the X-ray, treating the remaining pneumothorax conservatively and sending the patient home.

Question 3

An 86 year old woman is brought to your emergency department from her nursing home with two days of drowsiness and decreased oral intake.

Describe and interpret her investigations (100%)

• The overall pass rate for this question was 62/81 (76.5%).
• The examiners felt that this was fair and straight forward question that was poorly answered by a relatively large number of candidates. Pass criteria were recognition of the raised WCC with neutrophilia, impaired renal function, obstructive liver function test abnormalities and the likehood of underlying sepsis. Poor answers failed to synthesise the abnormalities into likely differential diagnoses.

Question 4

This 25 year old man has been brought in to your emergency department after he crashed into a fence on his motorcycle. He did not sustain loss of consciousness, but has left sided chest pain and laboured breathing.

a. Describe and interpret his photograph. (30%)

Your secondary survey does not reveal any other injury

b. List your immediate management priorities (70%)

• The overall pass rate for this question was 46/81 (57%).
• Clinical photograph showing open chest wound.
• Poorly answered question by a large number of candidates. Pass criteria were an adequate description of the injury plus including potential underlying injuries, management priorities of closing the wound, insertion of an intercostal catheter, analgesia, IV fluids/antibiotics and appropriate referral.

Question 5

A previously well 2 year old boy is brought to your emergency department by his mother after he ingested 1.8g of liquid Paracetamol at 0700 hours. Serum biochemical investigations were performed four hours after the ingestion; it is now 1200 hours. He is asymptomatic with normal vital signs.

a. Discuss the utility of the nomogram (50%)

b. Outline your disposition (50%)

• The overall pass rate for this question was 48/81 (59.3%).
• The examiners felt that this was a good question requiring core EM knowledge. They were disappointed with the standard of replies. Pass criteria were to recognise that the nomogram was reliable in a situation of a known ingestion dose at a specific time and that the ingested dose was sub-toxic. Fail criteria were treatment with NAC and admission based on the nomogram results.

Question 6

A 25 year old man is brought to your emergency department after a motorcycle accident. His only complaint is severe right arm pain.

a. Describe and interpret his X-ray (30%)

b. Outline your management (70%)

• The overall pass rate for this question was 50/81 (61.7%)
• X-ray showing a comminuted, displaced, angulated fracture of radius with dislocation of the distal radio-ulnar joint.
• Pass criteria were an accurate description of all the injuries plus a management plan addressing analgesia, potential neurovascular complications and early operative intervention.

Question 7

A 35 year old man is brought to your emergency department following two seizures.

His observations are: GCS 8 and BP 75/40 mmHg supine

Describe and interpret his ECG (100%)

• The overall pass rate for this question was 52/81 (64.2%).
• ECG showing regular broad complex tachycardia with widened QRS and abnormal terminal R wave in aVR.
• Again the examiners were disappointed with the response to this straight forward question.
• Pass criteria were identifying the abnormalities listed plus considering toxic ingestion (espec TCA) as a cause in this scenario. Fail criteria were absence of the above.

Question 8

An 89 year old woman presents to your emergency department with a two week history of several falls and new right sided weakness. A non-contrast CT head scan is performed

Describe and interpret her CT scan. (100%)

• The overall pass rate for this question was 68/81 (84%).
• Cerebral CT scan showing a subacute/chronic subdural haematoma with mass effect and midline shift.
• Pass criteria on this question were an adequate description of the CT scan and interpretation in light of the clinical history. Failed answers did not adequately describe the scan, misdiagnosed the condition or viewed the haemorrhage as acute.