Indigenous Health, make it a priority

Having just returned from the face-to-face meeting of the ACEM Committee on Indigenous Health, I think it’s a good time to highlight the brilliant resources out there on this important topic. Australia’s Reconciliation Action Plan (RAP) aims to provide “meaningful, yet practical plans to develop relationships, show respect and increase opportunities for Aboriginal and Torres Strait Islander peoples”. As a result of the RAP, the topic of Indigenous Health will hopefully come to the foreground over the next year, and rightly so. If you have an interest in Indigenous Health, please check out the resources below.

The Niche Portal: a brand new website, developed by ACEM, to consolidate activities, resources and case studies for professionals working in Indigenous Health

ACEM Educational Resources: ACEM provides a Promoting Cultural Safety program, multiple e-learning modules, videos and podcasts that can be performed for free.

Mauiora: provide free online educational modules, certificates, diplomas and more

The Lime Network: Leaders in Indigenous Medical Education, with an annual conference coming up soon in Townsville, Australia

AIDA: the Australian Indigenous Doctors Association

Te Ora: the Maori Medical Practitioners Association

A Note About Factsheets

To any users of the Factsheets, I am going through and reformatting them so that they should all be in docx format, and should all be editable from a reasonably recent version of Word.

If you find any links that don’t work for you, please do let us know and I can try and get working versions of the documents to you.

Happy studying!

About the DEMT Resources…

You will have noticed there is a new “DEMT Resources” page which is password protected.

This has been created for the use of FACEM’s and DEMT’s to provide a private area to share new exam format questions that will not be visible to Trainees. This is not a cunning ploy to be mean to the Trainees! It allows DEMT’s to have the resources to perform their weekly teaching and mock exams with fresh material. After a number of months, when DEMT’s have had time to use the questions, we will transition them across to the Trainee Resources.

It is an enormous task to create a fresh new bank of questions in the new format. My thanks goes to all the FACEM’s who have created material for this project. If you have material you would like to share with Trainee’s or DEMT’s only, please email it to elspeth.frascatore@gmail.com and I will put it up.

If you would like the password to the DEMT Resources site, please email me at elspeth.frascatore@gmail.com – I will need to confirm your identity then will provide the password.

The Fellowship Examination is changing…

The following information is taken directly from the ACEM Page regarding the upcoming changes to the structure of the Fellowship Examination:

From 2015 onwards, the structure of the Fellowship Examination (FEx) will be revised. The written and clinical components of the FEx will be divided into separate, stand-alone assessments. All components of the FEx will continue to be assessed at consultant level. These two assessments are summarised in the table below.

Image

Fellowship Examination (FEx) – Written

Focus:
The FEx (Written) will:

  • Continue to examine at consultant level, with a focus on knowledge-application
  • Be a separate assessment from the FEx (Clinical)

Format:
The FEx (Written) will comprise two components:

1. Select-choice Question

  • Multiple Choice Questions (MCQs) – Each MCQ comprises a stem (i.e. a short lead-in phrase) and a number of alternative options for response. The correct response is presented, along with a number of plausible distractors. The MCQs will be written to current best-practice guidelines.  In the ACEM format, trainees select one best option from four options.
  • Extended Matching Questions (EMQs) – Each set of EMQs comprise a theme (e.g. a particular presentation, investigation, diagnosis, or treatment); a list of possible options (i.e. options related to the theme), and a number of stems requiring a response chosen from the list.  In the ACEM format, trainees select one best option from the options provided (which could be up to 20 options).
The proportion of MCQs to EMQs in each paper is not fixed. It is likely that the proportion of EMQs will expand over time. The total number of items in each exam will remain constant.

2. Short Answer Question (SAQ)

The revised SAQ component will incorporate the previous Visual Aid Question (VAQ) format and be structurally modified to align with current best-practice guidelines. The revised format SAQs will use questions that are highly structured and specific, with responses that will require single words or short phrases, rather than mini-essays. The key feature of SAQs is that they allow the trainee to demonstrate the integration of their knowledge and application of this knowledge to clinical scenarios. SAQs will generally be of the format where the candidate is given a clinical or ED related scenario, followed by specific related questions that can be answered using relatively few words or short statements. When asked for a defined number of answers, additional marks will not be given for additional responses. The most relevant/highest priority responses should be listed.

The written examination will be held on a single day and comprise 2 x 180 minutes papers with a break in between.

FEx (Written) Example Questions:

  • Multiple Choice Questions (MCQs)
  • Extended Matching Questions (EMQs)
  • Short Answer Questions (SAQs)

Eligibility Requirements:
Candidates for the FEx (Written) must meet the following criteria:

  • They must be a registered and financial trainee of the College
  • They must hold current registration to practice medicine in Australia or in New Zealand
  • They must have successfully completed the ‘Early-Phase’ WBA requirements, which includes completion of at least 12 months (of the 48 month minimum) of accredited ED time in Advanced Training

Candidates must have met these eligibility criteria, as per official College records, by the closing date for the relevant examination sitting.

Fellowship Examination (FEx) Clinical

Focus:
The FEx (Clinical) will:

  • Continue to examine at consultant-level, with a focus on knowledge-application, skills and attributes
  • Be a separate assessment from the FEx (written)

Format:
The FEx (Clinical) will comprise one component:

1. Objective Structured Clinical Examination (OSCE)
A set of clinical examination stations. The OSCE stations may include standardised patients, observation stations, clinical scenarios, communication scenarios and simulations of management of critically ill patients. Most stations will be of ten minutes duration. Where appropriate, there may be ‘double length’ OSCEs allowing assessment of more complex competencies such as a simulated resuscitation station or sequential management aspects of the same clinical scenario. The administration of the test may include rest stations. There will be either one or two examiners in each station appropriate to the case. Where an examiner is required to role play, the other examiner will be present to observe and assess. The format of the OSCEs will be as current, with candidates moving sequentially from one station to another in a timed fashion.

OSCE Examples:

Eligibility Requirements:
Candidates for the FEx (Clinical) must meet all of the following criteria:

  • They must be a registered and financial trainee of the College
  • They must hold current registration to practice medicine in Australia or in New Zealand
  • They must have completed at least 36 months of the 48 months of accredited Advanced Training time prior to the examination (not including any required ED remediation time)
  • They must have satisfied the trainee research requirement
  • They must have successfully completed the FEx (Written)

Candidates must met these eligibility criteria, as per official College records, by the closing date for the relevant examination sitting.

Standard Setting for all formats
The examination pass mark for each examination will be set by formal standard setting processes by a panel of experts (consultant emergency physicians). These processes enable a consistent standard to be set across different examinations, ensuring the examination is maintained at the level of consultant, and that an appropriate pass standard is applied to all trainees irrespective of the difficulty of the particular examination they attempt.

Candidate Feedback
The open release of examination questions after each examination will cease. The Fellowship Examination content will be used to create robust and validated item banks for the examination use. There will be a timely and detailed examination report released after each examination. Unsuccessful candidates will have access to this report and their results to assist in developing a learning plan with their DEMT. To assist with exam preparation, the practice of providing example questions will be ongoing.

Need further information?
If you would like more information about the ACEM Fellowship Examination contact the Assessment Team at E: Fellowship.Exam@acem.org.au 

Dunedin University is the most awesome university known to man. Fact.

We are at Dunedin university today lecturing to the clever 2nd and 3rd medical students. Did I mention that they’re incredibly good looking. They would like to share some educational materials with you about lumbar punctures, despite the fact none of them have ever done one. 

Here is a great video they found which they will watch later:

 

Here is an illustrated picture showing you the landmarks:

Image

Finally, the clever side found some relevant literature for you to browse through:

J Emerg Med. 1985;2(3):199-203.

Lumbar puncture.

(they were too hungover to find anything better, I apologise for them). 
 
Please comment on this so they can feel good about themselves. 

 

Part 2 Notes are looking prettier…

As part of an overhaul to our Part 2 notes (which in the future will also be available via Life In The Fast Lane), you will discover that the Part 2 notes will become far better looking than the old. At the moment there won’t be a great deal of change in actual content, but they will be more pleasing on the eye.

… think going from Drew Barrymore to Scarlett Johanssen. That’s the kind of change we’re looking at.

Enjoy!

Elspeth.

MacGyver’s Do-It-Yourself Nasal ETCO2 Cannula

Many thanks go to Dr Finn Coulter for his ingeniously designed nasal ETCO2 cannula. We currently are awaiting shipment of these vital procedural sedation adjuncts… but in the meantime, in true Kiwi fashion (although strictly speaking Finn isn’t Kiwi), Finn has worked out a cheap alternative. I’ve yet to give it a go, but seemingly this works!

Displaying image.png

Step 1: cut the end off some normal ETCO2 piping…

Displaying image.png

Step 2: pierce a hole as shown in some normal nasal cannulae…

Displaying image.png

Step 3: tape the ETCO2 tubing too the outside of the nasal cannulae…

Displaying image.png

Step 4: …but poke the end of the ETCO2 piping through the hole into the nasal prong part of the cannulae. Tape accordingly.

Displaying image.png

Step 5: step back and look at your beautiful ETCO2 trace… and continue with your procedural sedation paying usual diligence to all other vital patient parameters!

Displaying image.png

Step 6: watch an episode of McGyver when you get home. It’s classic 80’s entertainment for the whole family.

ACME Course Content

Core Modules

  1. Human Factors: To improve the understanding of Human Factors and their impact on the quality of team-based clinical care, in the complex, uncertain, dynamic and time pressured environments characteristic of emergency medicine
  2. Cardiovascular Instability: Reviews principles of diagnosing and managing cardiovascular instability
  3. Airway and Respiratory Emergencies: Revises and develop skills in the management of acute airway and respiratory emergencies
  4. Shock and Complex Emergencies: In the challenging ED environment to practise managing patients with complex illnesses including shock.

Inter woven throughout the modules are core themes of effective teamwork, teaching, professionalism, safety and quality. In addition, where relevant, paediatric content will be included in the modules. Pre-reading is required.

The following additional modules will also be available as rotating options with the overall course design depending on where you complete the course.

Centre-Selected Additional Modules:

  1. Altered conscious state
  2. Toxicology
  3. Death, dying and grief counselling
  4. Musculo-skeletal and spinal injury
  5. Toxinology
  6. Obstetric and gynaecological emergencies
  7. Transport of the critically ill patient
  8. Ear, nose and throat and ophthalmological emergencies
  9. Behavioural emergencies

ED pitfalls: Posterior malleolar fractures

Scott Orman, ED Specialist, and Jacob Munro, Orthopaedic Surgeon

Posterior malleolar fracture - image from wikiradiography.com

Posterior malleolar fracture – image from wikiradiography.com

The x-ray above shows what could be interpreted as a relatively innocuous injury – an apparent isolated undisplaced fracture of the posterior malleolus of the ankle.

Suitable for conservative management, discharge from ED, and follow-up in fracture clinic?

Probably not!

The posterior malleolus is typically fractured by rotational injury an/or axial loading. Posterior malleolar fracture WITHOUT other injuries to the ankle or lower leg is uncommon – only 4% in one case series examining all ankle fractures. More commonly, posterior malleolar fractures occur in combination with proximal fibular fractures (Maison-Neuve), syndesmosis injury, posterior tibiofibular ligament injury, and/or spiral tibial diaphyseal fracture. These injuries commonly require surgical intervention, and the presence of a posterior malleolus fracture with them worsens prognosis.

Syndesmotic injury: a potential association with posterior malleolus fracture - image from drchiodo.com

Syndesmotic injury: a potential association with posterior malleolus fracture – image from drchiodo.com

Even if another injury is NOT present with a posterior malleolar fracture, criteria for surgical intervention are complex and highly surgeon-dependent.

THE BOTTOM LINE

Upon discovery of a posterior malleolar fracture in the ED – maintain a high index of suspicion for associated injuries.  There is a high chance that other structures are injured also and that surgical intervention is required for an unstable ankle. Careful clinical examination is required, (including the proximal lower leg), and the threshold for further imaging (especially CT) should be low.

In accordance with this, the orthopaedic department at Auckland Hospital have requested that we refer all posterior malleolus fractures to them acutely for review, even if no associated injuries are immediately apparent.

References:

Rockwood and Green – Fractures in Adults: 6th Edition

 Diagnosis of an isolated posterior malleolar fracture in a young female military cadet: Int J Sports Phys Ther. 2012 Apr 7(2): 167-172

 Posterior malleolus fracture: J Am Acad Orthop 2013 Jan 21(1) 32-40

Emergency Medicine Literature of Note

Feeling rusty? Preparing for a big interview and scared they will ask that dreaded “what interesting medical literature have you read recently?” when in fact you don’t care about medical literature at all? Take a look at Emergency Medicine Literature of Note: where all that boring stuff is broken down into tasty titbits that will help you sound impressive…

‘Oxylog 3000 plus’ resources

AED will shortly be transitioning from the venerable Oxylog 2000 to the Oxylog 3000 plus.

The video below is a superb introduction to the Oxylog 3000 series, covering anatomy, settings, and connections:

.

The Oxylog 3000 plus has some additional features, including embedded capnography and a feature called Autoflow – you can read the official Draegar infomation about Autoflow HERE, or you can read the Sydney HEMS take on it HERE ‘PRVC isn’t a country in Sout East Asia’.

Prior to testing your newfound knowledge on real live patients, you can have a go at the Draegar Oxylog Simulator by clicking HERE. (This page takes a while to load, select ‘manual simulation‘ from the ‘simulation‘ menu once the page has loaded)

George Douros (Emergency Physician from the Austin Hospital in Melbourne, ) has created these charts to help you ‘own the Oxylog 3000’ (sourced from the superb lifeinthefastlane.com) – click the images to enlarge:

volume control

pressure control