Visual aid	Likely VAQ topics	Other VAQ topics
ECGs	• Dysrhythmias • tachycardias — narrow/broad complex (e.g. AF, SVT, VT, torsades, VF) • bradycardias (including heart blocks) • Conduction abnormalities (e.g. Wolff-Parkinson-White, Lown-Ganong-Levine, Brugada, prolonged QT syndromes) • Acute coronary syndrome • Electrolyte abnormalities • Toxicology/poisoning

• Environmental effects — hypothermia

• Pacemaker failure

• Low-voltage QRS

• Electrical alternans (pericardial effusion)

• Paediatric ECG

• Normal morphological variants

• Crossed limb leads

Arterial blood gases

• Respiratory failure (acute, chronic, acute on chronic, hypoxic only, combined hypoxaemic hypercapnoeic)

• Metabolic acidosis

• Metabolic alkalosis

• Mixed respiratory-metabolic patterns (e.g. salicylate toxicity)

• Compensated respiratory alkalosis

• Triple disorders

• Venous blood gases to monitor acid-base disturbances (e.g. DKA)

• Co-oximetry results (e.g. carboxyhaemoglobinaemia, methaemoglobinaemia)

Electrolyte profiles

• Severe hyper- or hypokalaemia

• Hypo- or hypernatraemia

• Anion and osmolal gap disorders

• Hepatobiliary disorders — obstructed and non-obstructed patterns

• Glycaemic disorders

• DKA

• hyperosmolar hyperglycaemia

• Addisonian crisis

• Starvation

• Patterns seen in late pregnancy (e.g. HELLP syndrome)

• Hyper- and hypocalcaemia, albumin corrected or ionised

• Changes associated with rhabdomyolysis

• Cushing’s syndrome

• Diabetes insipidus (including head injury)

• Renal failure (acute, chronic, acute on chronic)

• Changes associated with normal bone growth in children

Haematology profiles

• Anaemia with MCV interpretation

• Coagulopathy related to anticoagulation or DIC

• Isolated thrombocytopaenia (e.g. ITP, post-viral)

• Normal changes in pregnancy

• Haemolytic conditions

• Normal ranges in neonates or children

• Haematological malignancy — acute blast crisis

Microbiology results

• CSF — meningitis: viral, bacterial, TB, fungal

• Joint aspirate — inflammatory, non-infective, infective, crystal-related

• Urinalysis

• Urine microscopy

• Preliminary Gram stains on biological specimens

• PCR of CSF/urine and their validity

• Sputum and endotracheal aspirate analysis

• Stool m/c/s and ova, cyst, parasites, C. difficile toxin

• Peritoneal and pleural aspirate m/c/s

• Cytology for malignancy

Biochemistry results

• Hepatitis results

• Hep A

• Hep B core and surface Ab/Ag

• Thyroid function tests

• Iron studies

• deficiency

• overload (haemochromatosis)

Chest X-rays

• Abnormal placement of ETT, OGT, CVL

• shoulder girdle injuries

• subcutaneous emphysema

• widened mediastinum

• Diaphragmatic hernia

• Hiatus hernia

• Alveolar infiltrates

• Interstitial infiltrates

• Cardiac silhouette alterations

• valvular heart disease

• cardiomyopathy

• chamber dilatation

• Inhaled foreign body (insp/exp films), especially paediatric

• Lung abscess

• Mass lesions

• single/multiple

• benign/malignant — primary/secondary

• Subdiaphragmatic gas

• Hilar lymphadenopathy

• Prosthetic heart valves

• TB

• primary (including Ghon complex)

• neonatal lung disease

• necrotising enterocolitis

Cervical spine images

• Trauma-related

• fracture

• dislocations/subluxation (uni-/bifacetal)

• atlanto-occipital distraction

• atlanto-axial disruption

• eponymous fractures (e.g. hangman’s, Jefferson’s, clay-shoveler’s)

• flexion/extension views

• Swimmer’s views

• Pre-vertebral soft-tissue abnormalities

• foreign bodies (adult — fish/chop bone; paediatric — coins, other objects)

• parapharyngeal infection

• epiglottitis

• Paediatric trauma series — normal developmental variations

• CT C-spine for trauma including reconstructed views

Abdominal X-rays

• Bowel obstruction — small/large

• Free gas — under diaphragm/outlining bowel/on decubitus film

• Volvulus — sigmoid/caecal

• Biliary tree gas

• Button battery ingestion (paediatric)

• Hepatic lesions (hydatid cysts)

• Ischaemic bowel

• Body packers

• Intussusception (paediatric)

Limb X-rays

• Paediatric growth plate fractures (Salter–Harris)

• Shoulder — dislocations (anterior/posterior/luxatio erecta), may have rib fractures or pneumothorax

• Elbow — supracondylar fractures (paediatric)

• Forearm — Galleazi/Monteggia fracture dislocations

• Wrist — Colles’ fracture, scaphoid fracture, (peri)lunate dislocation, avascular necrosis lunate

• Hand — mallet finger, game-keeper’s fracture, Bennett’s fracture

• Hip — NOF, dislocation (native or prosthetic), slipped femoral epiphysis (paediatric)

• Knee — patella, tibial plateau, proximal fibula fractures

• Ankle — malleolar fracture, diastasis of joint, talar fracture, calcaneal fracture

• Foot — Lisfranc injury, march fracture, fifth metatarsal fracture

• Pelvic fractures — stable/unstable

• Intra-articular fractures

• Smith’s/Barton’s fractures

• Non-accidental injury in children

• Bilateral posterior shoulder dislocation (electrocution, seizures)

• Pathological fractures/cysts

• Foreign bodies within joints

CT head scans

• Traumatic haemorrhage e.g. extradural, subdural (acute, chronic, acute on chronic)

• Non-traumatic haemorrhage (e.g. intracerebral, subarachnoid haemorrhage)

• Intracranial tumour, infarction, abscess, infective collection

• Non-accidental injury with diffuse traumatic changes

• Skull X-rays in children

• Non-brain injury — facial, orbital, mid-face fractures

• Diffuse cerebral abnormality (e.g. cerebral oedema)

CT neck

CT thorax

• Hilar lymphadenopathy

CT abdominal scans

• Traumatic injuries (e.g. ruptured spleen or liver; kidney ruptured, avascular or absent)

• AAA

• Nephrolithiasis

• Acute appendicitis

• Retroperitoneal pathology

• Base of lung pathology (e.g. atelectasis, pleural effusions)

• Pneumoperitoneum

• Inflammatory or ischaemic colitis

• Acute or chronic pancreatitis

MRI

• Brain — MS, CT isodense subdural

• Spine — MS, abscess, disc protrusion

• Knee — cruciate/meniscus injury

V/Q scan

• PE with segmental defects

Ultrasound

• Intra-abdominal fluid

• AAA

• Pericardial fluid

• DVT

Adult clinical images

• Cranial nerve palsies

• Horner’s syndrome

• Rashes

• Burns — depth and extent

• Trauma images

• Eye disorders

• Classic facial appearances

• Graves disease with proptosis

• acromegaly

• Cushingoid appearance

• Trisomy 21

• Myaesthenia

• Hands with joint deformities

• Wounds/lacerations in specialised areas (e.g. dominant hand, face, lip, eyes, ears)

• Visible masses (e.g. goitre)

Paediatric clinical images

• Infectious diseases (e.g. toxic drooling child, meningococcal rash)

• Other important rashes (e.g. erythema multiforme, allergic reactions)

• Foreign bodies (e.g. aural, nasal)

• Traumatic injuries

• Nappy rash

• Non-accidental injury

• Mucosal conditions (e.g. Kawasaki disease, herpes simplex gingivostomatitis)

• Archetypal viral exanthema (e.g. measles, rubella, fifth disease)

Equipment

• Oximeter

• Oxylog ventilator

• Capnograph waveform

• ICC with trochar

• Heimlich valve

• Intraosseus access devices

• Bougie

• Tympanic thermometer

Other images

• Snakes — various types

• Spiders — red-back, funnel-web, white-tail

Sample VAQs can be sourced in a number of ways. A small number can be obtained from the College website or your DEMT, or your colleagues can write some for you, but the best way to prepare for this section of the examination is to write some VAQs yourself. We strongly encourage you to work your way through the topics in Table 4.1 to become familiar with the images and/or laboratory results associated with these conditions. The process of identifying suitable material that lends itself well to VAQs is excellent exam preparation.

Google Images (images.google.com.au) can help you to easily find images pertaining to virtually any condition — including clinical photographs, radiological images and abnormal ECGs. In addition, excellent collections of thousands of emergency medicine-related clinical photographs, covering all subspecialty areas, are available in atlases such as:

• Knoop K, Stack L, Storrow A. Atlas of Emergency Medicine, 2nd edn. McGraw-Hill Professional, New York, 2002.

• Greenberg M, Hendrickson R, Silverberg M, Campbell C, Morocco A. Greenberg’s Text-Atlas of Emergency Medicine. Lippincott, Williams & Wilkins, Baltimore, 2004.

Once you have selected your images and/or laboratory results and made up your questions, spend some time practising writing your answers. Remember to think as the examiners would when considering your responses. The examiners have not selected the questions and do not know the cases themselves, so they do not have any ‘hidden agenda’ or other special knowledge. You see what they see, so answer as they would, as a ‘real’ FACEM.

When practising VAQs, it is worthwhile doing them under exam conditions wherever possible. Do at least four in a sitting and include a proportional amount of preparation time (i.e. five minutes’ reading time (without writing) for four VAQs). Ask someone to mark them for you —preferably an examiner or DEMT, but otherwise other FACEMs or your study buddies.

As with other sections of the exam, you can incorporate your day-to-day practice into your preparation for the VAQ section. Each time a nurse, medical student, junior doctor or consultant asks you to interpret an ECG, an X-ray or a pathology result or you see a patient where the diagnosis can be made on initial inspection, you have an opportunity to practise your VAQ answering skills.

On the day

Reading time

No writing is allowed during the 10 minutes of reading time prior to the commencement of the exam. Use this time to read through the whole paper carefully and plan your overall structure for each question. Decide which questions you are more likely to be able to answer well. It is best to decide before the examination whether you will tackle the questions in the order they appear or start ‘easy’ and finish ‘hard’. In either case, it is imperative you have a good method of timekeeping so that you do not run out of time and miss answering some questions.

Remember, the scoring system rewards consistency over high marks on individual questions — passing only seven of the eight questions will limit your highest possible score to seven, passing only six limits it to six and so on. For this reason, we strongly recommend that you spend an equal amount of time on each question. Extra time spent on a question you are comfortable with may not improve your overall score, but the penalty for not providing an answer to a question is severe! You will score some marks just by taking a logical and systematic approach to your answer.

Answering the questions

Seven and a half minutes is a short time to impart as much information as you know for each question. However, the questions are designed to be answered in this time frame by asking you to address specific issues.

Ensure that you answer the question that is asked using the College’s glossary of definitions. The wording is deliberately chosen, and details such as age, gender, the specific location of symptoms and whether conditions are isolated or not are all important considerations for your answer. Pay special attention to whether you are asked about ‘investigations’ or ‘management’ and so on to ensure you answer appropriately: you will not score points by answering about management when investigations have been requested.

Structure your answers in such a way that they are as easy to understand and provide as much information as possible in a readable and interpretable format. Legibility and rational organisation of your answers cannot be overemphasised. Point-form answers using standard abbreviations are preferred as they allow you to say more and are easier for the examiners to read. Inclusion of tables, flow charts and diagrams is also encouraged, as they can present substantial amounts of information efficiently and in a visual format that makes it easy for the examiners to find the relevant information.

Where appropriate, include a very brief synopsis with headings at the beginning of your answer to remind you of the key elements and to minimise omissions of important information. It is also a good idea to write on every second line, so that you can easily insert any information you recall later.

Use the experience you have gained from sitting practice VAQs. It is not uncommon to have tackled one or more similar VAQs during your preparation. Be aware, however, of subtle differences in the way the questions are asked. The most commonly cited reasons for candidates failing VAQs are failure to answer the question asked and/or providing ‘general’ answers to a specific question (e.g. discussing general trauma management when told the injury is an isolated one). Answer the question that is asked, not what you would like it to be!

Sample VAQs

To help with your preparation, some worked sample VAQs have been provided. Draw on these as a framework to develop your own practice VAQs, using the topics in Table 4.1 as a guide. In addition, a range of VAQ props are presented as ‘problems’ for you to ponder with sample questions. We suggest that you use these to develop further questions using standard terminology and then write full answers using the templates suggested in Table 3.2 (see pages 25–27). Suggested answers to some of these questions are provided towards the end of the chapter. A broad range of material is included. Some items are presented to stimulate you to cover topics that may otherwise be glossed over (e.g. therapies and equipment that are now less likely to be assessed as VAQs, but are most easily studied using this format and may be examined in other sections of the exam).

VAQ 1

A 27-year-old roof tiler is brought to ED by ambulance following a fall from a ladder. After a primary and second ary survey, his only injury is shown in the photo.

Outline your management of this patient. 100%

Sample answer

The image shows an open fracture/dislocation of the right ankle.

Management

• Analgesia — options include the following, either alone or in combination:

• aliquots of IV morphine to obtain adequate analgesia — 1–2 mg every minute until desired result obtained, with observation of other clinical signs

• inhaled methoxyflurane or nitrous oxide (e.g. Entonox)

• IV ketamine in 25 mg increments

• Immobilise after reduction in a short leg back-slab with a moist non-adherent dressing covering the wound.

• Perform post-reduction X-ray.

• Administer early prophylactic IV antibiotics to reduce incidence of wound infection (e.g. cephalothin 2 g).

• Tetanus prophylaxis if indicated.

• Disposition — admission under care of orthopaedic team for:

• elevation of limb

• probable formal washout of wound in theatre

• definitive operative management of fracture/dislocation as required

• ongoing IV antibiotics

• neurocirculatory observation and possible vascular intervention if required.

VAQ 2

A 10-year-old female presents to a regional ED with a history of increasing headaches over the period of a month and difficulty walking. Observations:

T	36.8°C
P	89/min
GCS	15/15

(a) Describe and interpret this image from her contrast CT brain scan. (50%)

(b) Outline your management priorities. (50%)

Sample answer

VAQ 3

	Value	Normal range
pH	6.80	7.32–7.43
pCO₂	36 mmHg	37–50 mmHg
pO₂	47 mmHg	36–44 mmHg
Bicarbonate	6 mmol/L	22–28 mmol/L
Base excess	–28 mmol/L	–3 to 3 mmol/L
Sodium	136 mmol/L	134–146 mmol/L
Potassium	6.7 mmol/L	3.4–5.0 mmol/L
Chloride	90 mmol/L	98–108 mmol/L
Urea	13.8 mmol/L	3.0–8.0 mmol/L
Creatinine	210 μmol/L	< 105 μmol/L
Glucose	54.0 mmol/L	3.0–5.4 mmol/L

A 78-year-old woman is brought to ED with a history of increasing confusion over a period of four days. Venous blood gas and U&E results are shown to you by the resident assessing her.

Describe and interpret her listed investigations. (100%)

Sample answer

Listed investigations

Venous blood gas and U&Es show:

• severe raised anion gap metabolic acidosis

• severe hyperkalaemia

• renal impairment

• marked hyperglycaemia

• high calculated osmolality (2(Na + K) + urea + glucose = 353)

Interpretation

• The most likely principal diagnosis is hyperosmolar hyperglycaemic state (HHS), formerly known as hyperosmolar non-ketotic diabetic syndrome (HONK).

• This does not explain the severe acidosis, which is usually not a major feature of HHS — possibilities include:

• severe lactic acidosis — along with other causes (e.g. shock, ischaemic bowel), in a type 2 diabetic it could be related to metformin

• diabetic ketoacidosis (DKA) — this is less common in the patient’s age group; urinary ketones would be helpful in distinguishing between the two diabetic emergencies — ketones may occur in both conditions, although to a greater degree in DKA

• a mixed picture is possible with tissue hypoperfusion, renal failure and/or sepsis contributing to the acidosis.

• The hyperkalaemia with renal failure will be exacerbated by drugs such as ACE inhibitors, potassium-sparing diuretics and NSAIDs.

VAQ 4

A 6-year-old girl is referred to ED by her GP with a rash on her buttocks.

Outline your assessment. (100%)

VAQ 5

A 52-year-old woman is brought to ED by ambulance from a nursing home, as she is acting confused. Her medications include perindopril, frusemide, metformin, allopurinol, ibuprofen and Slow K.

(a) Describe and interpret her ECG. (30%)

(b) Outline your pharmacological treatment. (70%)

VAQ 6

A 32-year-old man presents to ED after slipping and landing on concrete on his outstretched hand. This is his only injury.

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

(b) Outline your management. (70%)

Sample answer

(a) Description

• Plain X-ray of right wrist

• Crowded carpal appearance on the PA film with overlap of proximal and distal rows

• Dorsal displacement of the carpi around the lunate, which is tilted but has maintained alignment with the distal radius

Interpretation

• Perilunate dislocation

VAQ 7

A 12-year-old boy walks into ED with his mother complaining of a feeling of ‘bees buzzing in his chest’. An ECG is performed.

Discuss the treatment options. (100%)

Sample answer

This answer would be well suited to a table, as this enables each option to be discussed in a systematic manner.

VAQ 8

O₂via nasal cannulae 2 L/min	Value	Reference range
pH	7.13	7.35–7.45
CO₂	7 mmHg	36–45 mmHg
O₂	146 mmHg	8–110 mmHg
Bicarbonate	< 3 mmol/L	21–28 mmol/L
Glucose	15.7 mmol/L	3.0–5.4 mmol/L
Lactate	4.3 mmol/L	< 1.3 mmol/L
Sodium	142 mmol/L	134–146 mmol/L
Potassium	5.2 mmol/L	3.4–5.0 mmol/L
Chloride	103 mmol/L	98–108 mmol/L
Urea	2.4 mmol/L	3.0–8.0 mmol/L
Creatinine	107 μmol/L	< 120 μmol/L