SAQ ANSWER GUIDE 1. A basic understanding of different triage systems in current use for example the Australasian triage scale, Canadian triage scale, Manchester triage scale, Disaster and mass casualty triage, reverse triage, chronological, stream based etc. To compare the scenarios they may be used in and some of the advantages/disadvantages of each system. To include some of the KPIs associated with each system. It’s a dynamic process and is regularly reviewed and adjusted dependent on clinical situations at any one time. 2. Although there are two patients the focus of this question is on management of a neonate in the ED immediately after the delivery. Knowledge of APGARs and a systematic approach to the resuscitation. Decisions regarding vascular access and methods to obtain. When CPR is required and when and how to intubate the infant. Any drugs and fluids must be in correct doses with a correct estimated weight (2.5-3.5kg). 3. The assessment of an intoxicated individual who is threatening self harm/suicide is with difficult and may require multiple interactions to establish consistency of the history and physical examination. Identification of ‘red-flags’ that heighten your clinical concern. Suspicion for other forms of self harm in particular ingestions which can be treated or need observation. A set of investigations that may be used to ‘medically clear’ this patient. Whether candidates mention the ability to detain this patient under ‘Duty of Care’ or mental health act does not really form a part of the assessment, more a management question but I suppose it may be considered to differentiate high quality answers. 4. This patient is partially resuscitated – a. Requires intubation, circulatory support, and post resuscitation care. This should include the use of hypothermia, chest physiotherapy, airway ‘toileting’ etc. A discussion on the role of antibiotics in relation to backyard swimming pool water ingestions. b. Most important factor is ROSC and a reasonable GCS to predict a high likelihood of survival with short time to ROSC most likely leading to good neurological outcome. Factors to be included may be time in the water, time to ROSC, initial GCS post, temperature of water and child, metabolic effects of the submersion etc. 5. This question has been in the ACEM exam before. It would be expected that anwers would make clear the causative agents, time course, and classic clinical features of both syndromes. Better answers should make clear the distinguishing and common features to both. The management questions were expected to include both general supportive measures such as IV fluids, cooling, and prevention of muscle breakdown induced renal impairment, as well as syndrome specific drug treatments. Failure to address the differences between the syndromes and/or lack of knowledge of specific treatments such as bromocriptine, cyproheptadine and chlorpromazine will prevent a pass in this question. 6. A basic understanding of the mechanism of the drugs particularly the cardio toxic flecainide (class 1c) which even if not knowing specifics candidates should be able to work out. A general concept of the resuscitation of a toxic patient should be standard fare and a discussion on some of the newer experimental therapies should be included and be able to distinguish basic pass responses from the higher quality response. 7. A general administration question regarding the poorly performing registrar who has previous form for under performance. Better answers may also link in with ACEM guidelines on the poorly performing registrar which are found on the ACEM website. Candidates are expected to have studied this section of the syllabus. Answers may utilize the QA loop approach, have a meeting with the registrar, identify the problems, investigate the causes, establish a mechanism for improvement, address the problems, review the situation within a timeframe. Use of ACEM resources such as regional censors and board of education etc. 8. Always difficult to get good written answers but candidates should address the reasons one particular type of wound closure is utilized over another. The grade and type of suture used, alternatives to suturing where appropriate. Referral to other groups if required although I think all these wounds should be initially managed in the ED, candidates may utilize GPs, out-patient settings, ambulatory care for wound reviews. When tetanus prone wounds, infectious wounds require other specific treatments. Some of the caveats to each scenario. a. Suture with a non-dissolvable monofilament suture sufficient to withstand constant flexion and extension of the joint. b. Use of different suture materials for different aspects of the wound, dissolvable braided suture and use of buried suture techniques as well as the finer non-dissolvable monofilament to the skin. c. This wound may or may not require some sutures to assist with tacking the wound but generally minimal sutures will be the way to treat. Use of wound tapes, glue and dressings. Complications due to the shape of the wound and whether this is “V” shaped or inverted “V” shape. How does this make any difference?