It’s really important to structure your thought processes when studying for the exam or working on the floor in ED. The process of thinking about how you think is called metacognotion. Understanding metacognition is essentially what the acem Exam, and patients on the ed floor, tests in a rigorous and sometimes unforgiving way - how does a good ED Physician think ...
This blog will be updated regularly with good strategies for thinking under pressure.
Administration or troubleshooting scenarios
Personnel ( doctor, nurse etc)
Patient ( characteristics, medical history etc)
Disease Process ( is it getting worse, complications etc)
Equipment ( ventilator failure, lead misplaced etc)
Environment ( how busy is the ed / regional vs tertiary)
Generating valid Differential Diagnoses
There are multiple strategies for this key skill in medicine, but here is my take on things:
Diagnostic reasoning is a process difficult to study - it’s a fluid organic process that gets better with age, experience and exposure to more complex and difficult scenarios.
A Process Sieve/ sorter could include :
C - congenital
H - hormonal / endocrine / metabolic
I - infective / inflammatory
N - neurological
N - neoplastic
P - psychogenic
A - autoimmune
R - respiratory / renal
V. - vascular
O - ortho
S- social / sexual
T - trauma / toxin
D - drugs
CHINNPARVO STD - was a mnemonic I created at Med school when I knew very little and it’s stuck with me for 20 years !
SYNDICATE is one I have seen used in Oz.
Create your own pathophysiological sieve.
A second option to use or combine is an anatomical approach:
Head / cns
Git - oesophagus stomach duodenum
Liver pancreas gallbladder
Sexual organs / reproductive
Muscles / bones and nerves.
The neuro system is particularly difficult and a good approach includes the following :
Upper motor neurone
Lower motor neurone
Motor cortex - homonculus
Wernickes and Brocas speech areas
Pond and midbrain lesions
Basal ganglia systems ( Parkinson’s etc)
Medulla and resp Centre
Spinal cord and it’s architecture
Spinothalamic tracts (sensory from cord to brain)
Corticospinal tracts ( motor from homonculus to spinal to muscle)
Posterior columns ( proprioception)
Motor end plate
This blog entry will be updated as we move along through the ACE the ACEM course.
Please review the blog entries on first steps and the cognitive matrix for starting your exam processes.
The exam committee usually provides 30-35 question topics with some suggested details and specific modifiers to the SAQ question setters to follow as a guide. All questions must be referenced to syllabus approved resources.
The topics are usually interrogated in the following modalities:
1. core knowledge
- eg treatment of meningitis - dexamethasone 4mg IV, ceftriaxone 2g IV stat
this is content that needs to be accurate, specific and detailed
eg - csf fluid lab result provided - interpretation required - this requires much practice in answering questions, but also understanding what consultant level thinking and clinical reasoning entail
databases on ECG's, imaging, acid base, lab results, skin and clinical photos are important to be reviewing regularly
eg list a differential of organisms likely responsible in an elderly patient vs neonate
or state your management steps
4.Using consultant level language in answers
a regular error made in exams and stated in most exam reports published by the college - this 'language' can only be gained by reading good resources such as Rosens and UpToDate
It is important to focus on these modifiers and create some standard documents for yourself on each modifier
The modifier list is available in the curriculum framework document
eg Alcoholic patients: - I use an ABCDEFGHIJKLM.... approach
A - poor dentition, friable mucosa / bleeding- usually no issues with laryngoscopy but low FRC reserve means less time achieve intubation. Beware RSI and hypotension re cardiomyopathy or encephalopathy, chronic dehydration / unrecognised GI bleeding.
B - aspiration pneumonia, klebsiella pneumonia - immunocompromised
C - cardiomyopathy , AF, high cardiac output failure
D - encephalopathy, wernickes, unrecognised chronic subdural, cerebellar ataxia, risks of aspiration
E - cellulitis risks, hypothermia, poor skin barrier, electrolytemia Na.
F - dehydration, postural hypotension
G - peptic ulcer disease / varices / GI haemorrhage/ portal hypertension / ascites / spontaneous bacterial peritonitis / pancreatitis
H - bleeding diathesis - Childs Pugh score dependent
I - immunocompromised - lung, sepsis, klebsiella, staph skin, SBP, tooth abscess related endocarditis
Metabolic - alcoholic ketoacidosis - multiple medications, noncompliance / polypharmacy
Psychological - depression, suicidal, aggressive in ED
Social - itinerant / isolated / substance abuse
common modifiers in the exam include (but not a complete list)
ex premature neonate graduate
Neonates, toddlers and children
metabolic disease in children
syndromic children esp Trisomy 21
spinal patients / spina bifida
chemotherapy / bone marrow transplant
coad / asthma / CF
cardiomyopathy / vasculopath
IBD / chronic liver disease
severe autoimmune - RA or SLE or scleroderma - steroid dependent
chronic renal failure / dialysis patients / Peritoneal Dialysis
Stroke / parkinsons / schizophrenic
chronic pain / frequent attenders / recurrent abdominal pain
Violence / NAI / foster care / elder abuse / institutionalised / prisoners
NESBackground / refugees
hope that helps - happy studying!
We finished the first airway webinar today - I think it was fun - but the candidates preparing for the exam probably didn't share the exactly the same sentiment 😩
Key lessons discussed:
Decide if a CRASH airway is appropriate
Decide if a DIFFICULT airway is expected by reviewing :
Difficult Laryngoscopy ? - LEMON mnemonic
Difficult BVM - MOANS mnemonic
Difficult LMA - RODS mnemonic
Difficult Cricothyrotomy - SMART mnemonic
What is your standard RSI technique ?
mine is :
Preoxygenate / Denitrogenate
Position well - head elevated / ramped
CMAC for laryngoscopy with bougie and ETT
Suxamethonium 1.5mg/kg for NMB
Ketamine 2-4mg/kg for induction
What is your standard rescue technique?
mine is :
BAG V mask ----- spo2 >90%
intubating LMA ---- spo2 >90%
FAILED AIRWAY algorithm / options need to be ready to roll
Know the steps for Cricothyrotomy ( or needle cricothyrotomy in child <5 with jet insufflation)
Have a plan for AWAKE ORAL INTUBATION - indications ? - likely Ketamine dissociation with local anaesthetic and CMAC or fiberoptic option to 'have a look'
- chords seen - intubate or perform standard RSI
-chords not seen - 'have one go' at intubation - then proceed to surgical airway options
Have a look at the learning pack from Rosen's:
Please review the site page ‘Intro to ACE the ACEM as these resources are listed there with some active links.
1. Use Rosen’s to review the core detail of a topic
2. Use Cameron for local context
3. Use UpToDate or Emedicine for detailed knowledge
4. Use Dunn when answering specific SAQ exam questions.
5. Acid Base resources are listed on the website
6. Radiology resources including suggested ultrasound and CT resources are listed on the ‘I tro’ section
7. Frank Shan’s App - Drug doses is an awesome resource for paediatric and adult dosages and infusions. It also has great formulae for Paediatrics which need to learnt for paeds questions.
8. Openairway is an excellent online free resource for airway management questions and resources
9. Harrison’s is very good for cns infections, and specific medical sections eg copd, arrythmias, GIT, Haem Onc etc.
10. EMCrit is a great online resource for specific critical care topics.
Hope that helps. Happy studying !
There are certain types of information for the exam and for practicing Emergency medicine that you simply have to have pre-prepared and ready to roll out at a moments notice.
My airway Template:
Below is an example of my basic airway template. It starts out with simple manoeuvres and progresses all the way to a complicated procedure such as retrograde needle cricothyroidostomy seldinger intubation.
This serves as my 'go to' approach in most situations, a progression from the simple to the extremely complex.
Along with this template, it is important to develop a list of modifiers that you can preplan a change to this standard approach.
Common modifiers include:
neonates and children
chemotherapy / immunocompromised
abnormal neck morphology - acquired or inherited
this is not a comprehensive list
you will need to creat an "A4" document for this too!
Other topics that will benefit from A4 documents include:
RSI - standard approach and variations based on modifiers
Resuscitation - standard approach and when to modify
List of modifiers
Transplant patients - list 15 things to modify or watch for
Obesity - may an A3 document
Spinal patients in ED
Chemotherapy patients / HIV positive immune compromise
IV drug users
Good chapters on these challenging patients exist in Rosens but also in UpToDate
Hope this helps - happy studying!!🧐😰
We completed the first webinar today and most things ran smoothly !
Main points discussed :
Rosen’s and Tintinalli are good for average levels of knowledge
UpToDate or Emedicine are excellent for detail core knowledge
Local info from Cameron is useful for context
Reviewing local ED guidelines is essential
Particular journal review articles are important to review eg
ACS guideline MJA
arrhythmia guidelines eg brugada guidelines from AHA.
Pneumothorax guidelines - us vs British
Pneumonia guidelines - British thoracic society
Specific articles or links or guidelines will be posted in the blog or attached to the specific session
For most of the expert topics in the syllabus, a certain level of core knowledge is required to pass the written SAQ or MCQ type questions, as well as the case based type OSCE questions.
This Blog entry should be used in conjunction with the 'Intro to the ACE the ACEM course' session as part of the ACE the ACEM program.
For example, if we consider 'Retropharyngeal abscess' as a topic. It has been asked under various guises in the both the osce and written :
Paediatric case core knowledge - including clinical presentation
Airway catastrophe with emphasis on airway management aspects
Imaging question with CT or X-ray provided
Considering the key aspects of the topic (see blog on 'the cognitive matrix' )
history and examination
management - resuscitation and airway
management - medical or surgical specific mx
These domains of knowledge can be sourced best by:
1. Review of UpToDate article on retropharyngeal abscess or a suitable review article
2.Review of chapter in Rosen's
As a general rule, to simplify study approach, each expert topic should be reviewed by:
1. Review of UpToDate or Emedicine / Medscape or a suitable review article
2. Review of a core text - eg rosen's or tintinalli - my preference is usually Rosen's because it is comprehensive but easy to digest
3. Review of relevant imaging - use radiopedia online or another suitable imaging database
4. Review of local guideline if applicable eg therapeutic guidelines australia for antibiotic choice
Hope that helps!