VAQ

As the name suggests, this section uses a visual prompt and a one or two point question. 
With correct preparation this section can be a source of valuable marks, and an exciting reinforcer that you “know your stuff”.  Done incorrectly it can be an angst-ridden nightmare.  The theory is that it tests knowledge of common, serious, uniquely dangerous or classic Emergency Medicine topics.  The topics that come up are often the ones that “if you miss it/get it wrong the patient dies”, so high level answers are expected.

VAQ TIPS:
This section is divided up into different sections based on the type of visual prop used.
It is a difficult section as you need to write, non-stop, extremely fast, for approximately one hour.  It requires a fair amount of practice just to get your hand used to writing that much.

You need to target your study and answering techniques based on the type of prop. The main types of props include:
 

ECG’s
There will be at least one, usually two ECG’s in the VAQ. ECG interpretation is regarded as “Expert” level knowledge by the College.  You need to approach your ECG study with the level of a consultant Cardiologist, and then add a bit extra.  The reason for this is there is a short-list of conditions that “if you miss it, the patient dies”, and as the consultant on the floor you are often the last point of call with ECG interpretation, and often need to teach the Cardiology Registrars about what’s on the ECG…  The examiners therefore expect high-level answers to ECG questions. 

STUDY TIPS:

  • Get the book “ECG’s for Emergency Physician’s” by Amal Mattu, and do every question at least twice. This book has hundreds of ED ECG’s with short question stems (which are similar to the stems in the VAQ’s) and the answers at end of the chapter. You can photocopy the ECG’s and paste them onto cards, with the answers on the back, and use them as “flash cards” 
  • Use every ECG you see at work as a “mini-VAQ”.  Photocopy the good ones and share them amongst your study group 
  • Most departments have a folder or cache of “exam ECG’s” floating around somewhere.  Make sure you find this and practice answering them
  • Get the iphone app ECG Guide by QxMD. It’s excellent, and is a great way to brush up on your ECG’s

PATHOLOGY RESULTS
 

Pathology result interpretation in the VAQ is one of the more notoriously difficult sections.  There are some classic sets of results that come up, such as blood gases, but some odd things pop up every now and then, so you must have a bullet-proof system for describing and interpreting path results.  Much of this will come from study and learing painful lists, but it will also come from your day to day work.  Think how many path results you will look at over the course of the year. It will literally be thousands. These are all oppourtunities to practice your path result interpretation skills.  If you happen to do an ICU term your percentage of grossly abnormal results will be higher, and you should pick the brains of the ICU consultant & get them to teach you as much as they can during the rotation.

 

Ask anyone who’s sat the exam, and look at our note repository, for lists of the common metabolic & electrolyte conditions that pop up in the exam.

 

STUDY TIPS:

  • This is perhaps the hardest section to study for as there is no single book that you can read that will give you adequate knowledge.  You need a combination of one of the main ED texts, and a physiology textbook, notes/summaries from our Note Repository,


X-RAYS: Study & answer tips coming soon

 
CLINICAL PHOTOGRAPHS: Study & answer tips coming soon

 

VAQ ANSWERING TIPS
Point form is OK
With only 7 minutes to write 3-4 pages you don’t have time for waffling paragraphs of text (save this for the SAQ…).  Your answers need strike the balance between enough content to demonstrate your (expert) knowledge yet be concise enough that you don’t waste time with unnecessary words/phrasing.  This takes a lot of practice, and can be achieved by doing plenty of practice, by reading/listening to the answers of your study group and by getting your papers marked regularly.  Getting feedback is crucial to structuring your answers well.

Avoid generic answers
If you write “Resusc room/A/B/C/IVx2/O2/monitor” for the obstructing angio-oedema photo and the same thing for the WPW-AF ECG, you are showing a lack of knowledge and a lack of perspective.  You still need to put “Resusc room/A/B/C/IVx2/O2/monitor” in your answer or you don’t get marks, but target your responses to the question, and elaborate on the important aspects/context of that particular condition.  Highlight or prioritise what you think is the IMPORTANT part of your answer.  For example: (click on photo to enlarge)

angioedema

 

 

For a photo of a patient with airway-obstructing angio-oedema, you could phrase it thus (for a “management” question):

LIFE THREATENING AIRWAY EMERGENCY
Resusc Room

Airway:
Position of comfort
Difficult airway trolley to bedside
Urgent anaesthetic/ENT/ICU attendance
Nebulised Adrenaline 5mg stat (may repeat)
IM Adrenaline 0.3-0.5mg stat (may repeat)
Consider IV Adrenaline infusion (caution if past Hx IHD/hypertensive)
Surgical airway kit open at bedside
Breathing:
High flow O2 via mask
Aim sats > 94% (NB Desaturation = late sign)
Nebulised Salbutamol/Adr if co-existing bronchoconstriction
Circulation:
Large bore IV x 2
Full monitoring
N.Saline bolus aim systolic BP > 100mmHg

…and go on to describe the rest of your ED management, down to & including evaluating risk factors/trigger (eg ACEI), epi-pen prescription and allergist referral

COMPARE THIS TO: (click on photo to enlarge)

wpw-af

 

The ECG showing WPW-AF with a BP of 70/40 (Management):

CIRCULATORY EMERGENCY/HIGH RISK ECG

Resusc room 

Airway: Ensure patent/protected, intubation equipment to beside
Breathing: High flow O2 via mask aim sats > 94%
Circulation: Definitive Mx = Cardioversion

Full monitoring, attach defib pads.

Large bore IV x 2,  N.Saline boluses (aim SBP > 100mmHg)
Urgent VBG (Check & Rx reversible causes eg Hi or Low K+)
**NB:  Definitive Rx = Reversion to sinus rhythm 
If stabilises consider drug therapy/reversion:
Procainamide – check dose
Flecainide: (if structurally normal heart): check dose
NB: AVOID: AV-node blockers: B-blocker, Ca2+ blocker, Digoxin, Adenosine 

…right through to (& including) post reversion care/admission/cardiology consult, Echo if needed and followup.

Can you see how these answers still have Resus room…etc in them but with vastly different content/priorities.

WHEN PRACTISING & ON THE DAY

TIMING IS KEY – BE VERY CLEAR ABOUT THIS – MUCKING UP YOUR TIMING ON THE DAY CAN COST YOU THE EXAM

You must practice getting your answers out in 7 minutes, using the 30 seconds between questions to shut one booklet, open the next, and read the next question. Buy a stopwatch or timer, and force yourself to stop writing at 7 minutes. Over the course of the year you will be amazed how much you become able to write and how much your answers improve if you are strict with your timing from the start.

Take note when you are practising if there are certain ways you are writing that are “too wordy” or if you could make the same point with less words, with a list or by being more succint.  In between practice sessions re-read your answers and see if you can “trim them down” or re-arrange them in a more succinct way.  By analysing your answers in this way you will find that you are able to pack more into them and get more marks. 

Another way to improve your timimg is to practice in a group setting, by doing a full VAQ exam (8 questions) in an hour on a regular basis.  Many hospitals in the capital cities run weekly sessions just for VAQ’s, for 6 months before the exam. That way you will become conditioned to the stress of the exam conditions and realise where your weaknesses lie when trying to do 8 of these in a row (and you will pick up tips from other people as well). If you are studying on your own, make the effort to track down the nearest place that has regualr VAQ sessions (and that may be interstate), and get to as many as you can. They are invaluable.  Failing this get your DEMT to arrange weekly full VAQ sessions for you, stick to the timing above, and get your answers marked.

DO NOT ROB PETER TO PAY PAUL

Whatever you do DO NOT eat into the time of the next question by writing more on the previous question.  You will already have gained the bulk of your marks by the 5-6 minute mark, and you should use the last minute to ensure you have addressed all points in the question (for example if you don’t write anything for “Disposition” on the end of a “Management” question you lose marks) and remember that going even 30 seconds overtime, on one or two questions, could cost you a full minute on another question, and that’s 13% of your time, meaning 13% of your marks down the drain! And if it’s a hard question that you lose the time on, 13% can make the difference between a pass and a fail.

ALSO:
Make your answer stand out:
Remember the examiners will be marking loads of the same question, and you want your answer sheet to stand out.  You can do this in several ways:
Make your writing legible. 
Nothing sinks the heart of the examiner more than when they open a booklet and see pages of messy scrawl. make sure your valuable answer achieves maximal impact by making it readable.
Prioritise your responses:
A well prioritised answer shows perspective about what’s important and unique the particular problem. (as above).  You need to cover all the aspects of the condition, but make sure you let the examiners know that you know what’s important/unique about that condition, and make them feel that if it was their mother/child you were treating that they’d be happy for you to treat them. If you’re not confident handling the care of anyone that comes into your ED, including your examiners mum, then you’re not ready to be a consultant and should probably postpone your exam until you are at that level.
Be thorough:
Even if it’s just point form, cover every base. That means knowing the glossary well so that your answer addresses the specific point of the question, but also try and think about what a good consultant would do in the particular situation.  Adding “extras” like communicating with family, department education after an adverse event or See the section on “Fluffy Bunnies” to see
Answer Every Question:
As with every section, there are no marks deducted for bad answers, and every mark counts. A 3/10 is still more use than a 0/10, although remember you must pass ___ (number) of questions and get at least ___ marks to pass the VAQ section.  If it comes down to the crunch getting two 5/10’s is better than getting a 10/10 and a 0/10…

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