Welcome to ED Exam

It was only a matter of time: the LITFL team have started recording some audio interviews and posting them on the site as CITFL: Conversations in the Fast Lane.  The first is an interview by Mike with Casey Parker from BroomeDocs, a great blog about remote emergency care in north-west Western Australia.  Check it out now, and I hope Mike, Chris & the rest of the LITFL team will bring us more audio-goodies soon!

 

iPhone App Review: Drug Doses

 

 

This is the iphone version of the famous Drug Doses pocket-book by Frank Shan from the Royal Children’s Hospital in Melbourne, Australia.  Many of us grew up with this book, and it is the quintessential paediatric drug dose guide.  The app takes things further however, with many useful functions that make it a “must have” app for anyone working with children in medical environments.

What does it do?
The main functionality is a searchable list of drugs.  Each is linked to a dose page which contains all of the doses per kg, with most of the indications and the related dose adjustments and maximum/adult doses. It is essentially the same as the printed version, with no additional content, but it is nevertheless the most comprehensive and succinct paediatric clinical drug tool out there.

Bonus Features
Also in the app are a “Code Blue” function, in which the child’s weight is entered, and the doses of all of the main resuscitation drugs are displayed.  Paediatric arrests are hard enough without having to remember doses, so this is a great feature.

There’s also a “Ped Calc” function, which contains all of the main physiologic formulae that you may need in general and critical care paediatrics.  Add to this an incredible set of normal lab values for pretty much every lab test you’ve ever heard of, and a “Cardio” section, which has descriptions of, and normal values for all sorts of paediatric cardio-thoracic procedures and physiologic minutiae that you won’t need outside of a PICU.

Any Negatives?
The only downside for this app is the cost.  It is currently discounted (by 50%) but is still around $5.00 (AUD) placing it in the higher cost bracket for an app, and this only entitles you to a 1 year “subscription”, at which point you need to use the in-app purchase to update your subscription (which I couldn’t get to work despite numerous tries), or uninstall it and buy it again.  The advantage of this is that you are forced to update it, which saves it going out of date, although I doubt the recommended doses of the stock paeds ED drugs such as Cephalexin suspension or Amoxycillin are going to change any time soon!

Conclusion:
Drug Doses is a must have app for anyone working in paediatric Primary Care, Emergency or Critical Care medicine.  It is succinct, easy to navigate, and has some bonus features that make it worth the cost (for which it loses one star).  Don’t be put off if you can’t renew your subscription from inside the app, just delete it & buy it again.

EDExam App Rating:

Oh, and for those non-Apple users, (does anyone not have an iPhone?) there's an Android version too!

In the members section of EDExam you can find an article I wrote a while ago about general life tips (login required) to consider when preparing for the exam, including a section on using meditation and visualisation.

Well my new favourite blog Expert Enough has an interesting article that talks about the utility of visualisation, and then goes through the actual techniques you can use to perform visualisation to improve your skills.  I think for a task as hard and as mind-frazzling as the ACEM Fellowship exam, doing something as simple as spending 5-10 minutes a day, say just before bed, calming your mind, putting yourself into a positive mindset and seeing yourself being successful will not only help you overcome performance anxiety, but will help you get to sleep after those intense study sessions, and may also improve your chances of getting through!

Ifyou're bored with doing VAQ's and want something interesting to do that will hone your VAQ skills, or if you just want some more clinical images (photos, radiology & ECG's) to look at, then check out the New England Journal of Medicine Image Challenge.  It has a "spot diagnosis" multi-choice question (& answer) for each image, and you can practice "describing & interpreting" the images too.

Great for a bit of variety if you need to mix things up a bit with your VAQ practice.

Those of you who have your finger on the Emergency Medicine Twitterverse pulse, or who follow Scott Weingart on EMCrit will most likely have come across Ming Le Cong and his fantastic contributions to online Emergency Medicine education, in particular Airway and Pre-hospital topics.  Well he's now bitten the bullet and started his own blog Prehospitalmed.  He has a podcast (that you can subscribe to in iTunes) and is posting regulalry about his favourite topics.  Worth a look/listen if you have a spare 5 minutes and want to keep abreast of the latest in prehospital, retrieval, aeromedical and airway medicine.

Here's the answer to VAQ 7, in video format!  I've discovered some great programs on the iPad that allow you to make "virtual whiteboard" sessions very quickly and easily, so I thought I'd try the tutorial-feel of a video instead of a boring written answer for this VAQ.  Let me know what you think in the comments section!

 

In the style of Talley & O'Connor (who's multi-edition classics Clinical Examination: A Systematic Guide to Physical Diagnosis, 6e and Examination Medicine: A Guide to Physician Training, 6e (The Examination) have been the staple guides for clinical medical exams for many years), some very dedicated Australian Emergency Physicians have put together a guide to the ACEM Fellowship Exam.  Examination Emergency Medicine: A Guide to the ACEM Fellowship Examination, 1e is a fantastic book for anyone who is considering sitting the exam, either to be read a long while beforehand, so you have time to drop out of Emergency and do something simpler like Orthopaedics if you get freaked by the enormity of the challenge, or for those who are committed, I'd suggest reading this 12-18 months before you plan to sit.

The book is written in an upbeat style, and is easy to read.  It is a bit wordy and could do with a few more lists instead of lengthy descriptive paragraphs, but it gives you the feeling that the authors are speaking from first hand experience, and are providing personal insights rather than a simple "how to" guide, and there is very much a positive, "can-do" vibe that runs through the book.

Prefaced by a chapter on preparing yourself for the exam (what I like to call "life tips"), the book moves on to a chapter on each section of the exam (MCQ, SAQ, VAQ, short case, long case and SCE).  These vary in usefulness, with some providing not a lot more than common sense advice, whilst others (for example the VAQ section) have some great tips on preparation and answering technique.  All sections for the written components have practice questions, and the chapters on the clinical components give a good insight into preparation and presentation. There's also some chapters on the 4.10 project (which is less relevant now the alternative path is being taken by 90% of trainees), and a section on Evidence Based Medicine and summaries of groundbreaking papers in Emergency Medicine.

Of note, the short case section goes through the main system examinations you are likely to get, including a detailed section on neurological examination (which is obviously done poorly in exams!), as well as a few "curve-balls" that have been known to come up, including pregnancy and neonatal examinations.  The SCE section is also quite good, with several practice questions and advice about how to handle things if you are asked to reconsider an answer, or forget something.  It has what I think is a great piece of advice too: "When the bell rings, its time to move on, physically and mentally.  Each station is marked independently.  The next pair of examiners does not know whether you have just gunned or bombed"!

Overall I'd highly recommend Examination Emergency Medicine: A Guide to the ACEM Fellowship Examination, 1e for anyone considering sitting the ACEM Fellowship Exam.  Especially for those who are unable to attend an exam course, as it will give you a non-threatening insight into the exam design, process, and objectives.  While a lot of the advice in it will be gleaned from sites like EDExam and asking a few colleagues for tips, as well as applying common sense, it is a good resource to keep on hand, and I'd recommend reading it early on before you start studying, as it will definitely help guide you in the right direction when your proper exam preparation starts.

For those going paperless, here's a link to the Kindle Edition: Examination Emergency Medicine: A Guide to the ACEM Fellowship Examination (Kindle Edition)

I've recently discovered a new blog called Expert Enough, by a guy called Corbett Barr.  It's a great site with lots of articles on educational and learning theories.  One recent post stood out to me, and that was the post on Deliberate Practice, as I think it contains a lot of good advice for people studying for Fellowship Exams.

In the article, Corbett discusses some research which shows that deliberate practice which you are motivated to do and intentionally concentrate on, which takes into account your pre-existing knowledge and current skill level, which you repeatedly perform and receive immediate feedback on will lead to better results.  Sounds like common sense right?  The point is that simple practice is not enough.  Thos who have spent hours at their desks sweating over VAQ and SAQ answers will recognise that you will improve faster and get better results if you apply these principles.

There's some other great articles on how shortcuts to becoming an expert don't really exist, and a great discussion of the much quoted 10,000 hour rule for becoming an expert (which is incidentally 40 hours a week for about 5 years - the average length of a specialty training program!)

Expert Enough is a great site, with plenty of interesting reading for those interested in becoming an expert and learning about how to learn, highly recommended.

Here's the 2nd epsiode of the EDExam Podcast.  I was lucky enough to have a fantastic study partner when I went through the Fellowship Exam, in the form of Dr Luigi Marino.  Luigi is a FACEM from Melbourne, and in this, the first of a multi-part interview he dishes out a whole heap of pearls about preparing for the exam, from dealing with feelings of animosity toward the exam process, to being strategic about where you're working when you sit the exam, through to some specifics about study technique.  He was so generous with his time that I had to keep picking his brains, so I've split the interview into a few parts. Watch out for part 2, coming soon! 

Enjoy.

(Click on the play button to stream it, or hit Download to save it)

Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.

Episode_2_Luigi_Marino_Part_1 Download

You can also subscribe in iTunes, and if you like it be sure to give it a 5-star rating, thanks!

For those coming to Melbourne for the ACEM clinical exams this weekend, good luck!

The exams are being held in an outer suburban area of Melbourne, so the options for fine dining are a bit limited.  If you’re getting in to town a day or two early (as we strongly recommend) it’d be worth your while to catch a cab in to Chapel Street, WIndsor, and have a stroll around, there’s loads of good restaurants there, or pick your favourite venue in the city and catch a train in.

You could also cab it in to StKilda, and I’d highly recommend going to Cicciolina on Acland Street.  You can’t book a table, but if you arrive early (before 6pm) you’ll  likely get a seat.  Alternatively if you want to go a bit more upmarket, you can’t go past Donovan’s down on the waterfront.  Great atmosphere, great food & wine.

If you’d rather stay local, and like asian food, I’d recommend going to The River Kwai, in Clayton (it’s just down the road from Monash Medical Centre).  It’s a great Thai & Burmese restaurant, but is very busy, so make sure you book.

If you need any tips on Melbourne this week/weekend feel free to drop me a line, and I’ll be helping out at the short & long cases on Saturday (at Moorabbin), so may see you there!

I only recently learned about this technique, and thought I'd share it as it seems to be a quite useful technique for lower limb analgesia, and potentially easier and more likely to succeed than a standard femoral nerve block.

The ultrasound geeks will already know how to do this block, but for those of us that are less proficient with the "stethoscope of the 21st century" for nerve blocks there is a quick & easy landmark technique you can use.

Rather than reproduce what's already been written, I suggest you download this document (link to the authors site is here) and have a read, and then watch this video (which has no narration, but clearly demonstrates the landmarks & the  "2-pop" technique), and then you can watch Al Sachetti (of EMRAP fame) do one on a real patient.

I'll definitely be trying this on my next femur fracture or NOF patient and will let you know how it goes.

Got any tips for a fascia iliaca block? Leave a comment below.

Ever had a sick baby that you need to get IV access on quickly?  I recently had an underweight, dehydrated febrile 2 month old, who clearly needed a prompt IV for bloods and antibiotics/fluid.  They were dark-skinned and also had pretty bad scabies, making the skin very rough, so it was essentially impossible to feel or see a vein.  On paper you'd say "just go for the I/O", but this baby was alert, still taking small breast feeds and despite the description did not seem shocked, so I wanted to try for peripheral IV access first. So how do you find a vein?

Some paeds ED's or paediatric wards will have special transilluminators with red LED's that you can use to help you find a vein (such as the Wee Sight Transilluminator ).  Unfortunately I couldn't access one of these, so thought I'd have a go with a standard piece of ED equipment - the otoscope, and got surprisingly good illumination of the hand. (click on image to enlarge)

In this pateint it revelaed a lack of peripheral veins worth trying, (indicating a degree of peripheral shutdown that raised my level of concern for the child) so we ended up going for a cubital fossa "blind stab" which worked, (and we were one step away from an I/O!), but I was pleasantly surprised at the level of illumination provided by the standard bedside bit of ED kit.  Worth a try if you're struggling with a peripheral IV in a baby.  Just be aware the light does get quite warm, so make sure you don't hold it there too long, as it may start hurting (not sure it's hot enough to burn the skin, but be careful nonetheless).

TIP: turn the room lights off to get maximal contrast.

Here's the link to VAQ 7. 
Everyone seems to dislike assessment questions, so here's good one that will test your trauma skills!

I was going to do a post about this, then I found these nice lists over at Emergsource.com

It's a list of the causes of painful and painless visual loss.  Visual loss is a relatively rare presenting complaint to ED, so it's good to be able to whip out this list of differentials when a patient comes in with it, and it does occasionally come up in SCE's and VAQ's.

 

Here it is, the first ever EDExam Podcast!!

Why record a podcast?
One of the cornerstone pieces of advice for anyone sitting the ACEM Fellowship Exam is "get lots of advice from lots of people", as everyone has different tips that worked for them, and if you only ask one or two people for advice, you may not get advice that works for you.  I was mulling over this concept recently, then it hit me.  Of course! Why not start recording different people's advice on preparing for the exam, and that way we can have a permanent record of the different approaches that people have taken, with tips on what worked for them, what didn't, and things to definitely avoid.

For the inaugural podcast I selected a guest who took a very different approach than most to the exam.
Dr Amit Maini is a FACEM from Melbourne (via the UK), creator of the excellent ED Trauma & Critical Care website, who used some rather unorthodox techniques when preparing for the exam, and he overcame several obstacles such as choosing a bad, external rotation for his exam period, a paucity of study buddies and even tenosynovitis in his writing hand.  For those in out of the way places or who like to do things a bit differently, Amit's very candid interview will be inspirational, and for the maintream folk, there's still plenty of great exam preparation tips. Enjoy.

(Click on the play button to stream it, or hit Download to save it)

Audio clip: Adobe Flash Player (version 9 or above) is required to play this audio clip. Download the latest version here. You also need to have JavaScript enabled in your browser.

Episode_1_Amit_Maini Download

You can also subscribe in iTunes, and if you like it be sure to give it a 5-star rating, thanks!

I found myself going over some abnormal LFT's with a medical student at work the other day, and once again pulled out my summary that I wrote for the Fellowship Exam.  It's a summary I wrote with information compiled from textbooks, some review articles, and even some old hand-written notes from a tute I had with the Gastro Reg at Box Hill Hospital when I was a final year medical student (over a decade ago...).  I frequently print these out at work and give them to students/RMO's/Registrars, so I thought I'd make them freely available to anyone who wants them.  While you can argue that studying from someone elses notes is not a great way to learn, I reckon this is a pretty good point-form summary on a frequently confusing and mis-understood topic that has a lot of lists (at the least you can print the lists out, and stick them up on your bathroom mirror to help your memorisation).

These notes will not be useful for people who need to improve their conceptual understanding of liver disease. You will need to read through a few textbooks or DrGoogle for this.

These notes will be very useful for those who understand the pathophysiology of liver diseas and just need the fast facts, particularly for the VAQ and SCE exams.

Click here to download a copy of my Hepatic Diseas notes, and feel free to leave a comment (below) if you like them or can suggest any improvements.

Not many things that come through the door of the ED phase me anymore, but I have to say that tracheostomy complications still make me very, very nervous.  Mainly because once you know what some of the bad complications are (eg the tip eroding into the subclavian artery = patient exsanguinates while drowning on their own blood), and that they have the trache because they have a terrible airway to start with (ie going in from the top is likely to be impossible), you realise that these things are just plain dangerous.  I could also envisage a great SCE question relating to trache complications in the Fellowship exam as well.  Add to that the fact that the educational resources on traches are sadly lacking, and you have a tricky topic on your hands.

Anyway Kane Guthrie (ED Nurse extraordinaire, tweets as @antidoped) sent me a link to a great post on how to manage the trache patient with respiratory distress.  It goes through the different types of trache tubes, and what to do in various combinations of situations depending on the type of tube, how long its been in and whether the patient can be orally intibated. 

Recommended reading for your daily ED practice and for the exam.

For those attending the first part oral exam in Brisbane this weeked (especially the crowd from RDH), good luck.  Remember, sit up straight, smile, be positive (even if you don't know the answer), and hopefully we'll see you with some good news on the other side!

Cheers

Andy

The Toxicology Handbook: Murray, Daly, Little & Cadogen is a "must-read" for the exam, and a "must have a copy on-hand at work", locally written, up to date, concise, easy to read, chock-full of practical evidence based advice on Emergency Department toxicology gem. Phew! Can I say anyting else good about it?

Written by some of the leaders in the Australian toxicology and medical education scene, this small but detailed book contains just about everything you'll need to know to pass the ACEM Fellowship exam tox questions, as well as manage a broad spectrum of toxicological emergencies in the ED.  For some topics (for example - Paracetamol Overdose) you may want to look up an encyclopedia of toxicology like Goldfrank's Toxicologic Emergencies just to get that little bit of extra detail, but given the sheer volume of what you need to read for the exam, it's nice to have a succinct but detailed reference like the Toxicology Handbook on hand.

Each section is written in the same format, making it easy to skim through and find what you're looking for, there's sections on Approach to the Poisoned Patient, Specific Considerations (for a range of toxicological situations), Specific Toxins (in alphabetic order), Antidotes, (again, in alphabetic order), Envenomation, Antivenoms, as well as some useful appendices (containing things like the TCA overdose ECG and more!).

All up I'd give Toxicology Handbook: Murray, Daly, Little & Cadogen a 10/10. I would not have passed the Fellowship exam without it, and I'd strongly recommend you get yourself a copy, you will use it again, and again, and again.

NB: Kindle version now available if you want to read it on your iphone/ipad/e-book reader.

Toxicology Handbook - Kindle Edition

My ECG content has been a bit lacking on the site, mainly because so many other sites do it so well, but alas you will get ECG's in the exam, I got two in the VAQ and one in the SCE, and none of them were easy, so I've decided to beef up the ECG quota and get teaching.

As the ED Consultant you are the last bastion of ECG diagnosis in the ED, and if you don't have a list of "if I miss it, no-one else will pick it & the patient may die" ECG's then fear not, in this 2-part video whiteboard session I run through 6 of the most serious and subtle ECG's that you can't afford to miss, in the exam, or in real-life!  Of course there's ischemic ECG's, electrolyte abnormalities and toxicologocal ECG's, and I'd hope by now you can pick those, but here is a collection of rare but important ECG's that frequently get missed (one of these cropped up in my written exam, and the pass rate was around 30% - go back to the 2009.1 writtens to see which one it was), so don't be slack, watch & learn, & you may just save someone's life one day with this knowledge! 

Every time I see a patient with syncope, unexplained collapse or altered conscious state - I run through this list, it applies to children and adults.

NB: Videos best watched in Full Screen Mode (click on bottom right corner of video player)

Don't Miss These ECG's - Part 1

Don't Miss These ECG's - Part 2