How to pass the Fellowship MCQ Exam. That's the question on everyones lips as we head towards the pointy end of studying for the exam.
If you have never sat this exam before, let me tell you, the ACEM Fellowship exam, is a long day, so be rested. 3 hours of SAQ exam and 3 hours of MCQ/EMQ exam. You need to be able to think.
Here is some simple exam strategy for the MCQ. This is revision for all the Fellowship Exam Course candidates, but important to remember.

1. There are no tricks. The examiners don't try to purposefully trick you into picking the wrong answer. This set of questions is to test your knowledge. But really it is a bit of a trick, as the very nature of having distractors, obstacles to steer you away from the correct answer, is a trick. But that's playing within the rules. There is no other overt trickery, no Machiavellian plot to deceive you all.....just some of you.
2. Gone are those things that irritated us, as well as those hints that helped us all get a few more answers right, purely by technique:
   1. Those beautiful words 'ALWAYS' and 'NEVER', that made us exclude an answer.....gone!
   2. "All are correct EXCEPT" and the irritating, 'pick the INCORRECT answer", which were always confusing.... gone forever!
   3. The Double Negative... Vanquished!
   4. The LONG response full of qualifying adjectives, which was almost always the correct answer...it is also gone!
   5. The grammatical clues, where distractors just seemed to flow from the stem...gone!
   6. The verbal associations, where like words in both the question and answer usually meant it was right...wiped out!
   7. 'None of the Above' or 'All of the Above'.....never to be seen again!
3. Every word in the Question(stem) is there for a reason, so READ EVERY WORD. There is a process by which these questions are written. They are shaped and re-shaped, to make them less vague and more appropriate, so that that they don't disadvantage you.
4. Once you have read the question STOP and think of potential answers to this for 10-20 seconds. It is imperative that you do this, so that you are not swayed by what is in the distractors.
5. Then read the distractors(answers) and eliminate those that are wrong.
   1. The sort of things that will lead you to the wrong answer include, choosing a distractor that has familiar terms in it. Although this may be in fact right, it may also be wrong. Scrutinise the whole answer.
   2. Beware the answer that is partly right. For example you may have a question that says: "You have just seen a 46 yo female patient patient with a previous history of hyperthyroidism, that now presents with symptoms and signs that you believe are those of thyroid storm. Some of the findings you would expect wound be":... and one of you answers may be "A widening of the pulse pressure due to hormone relate vasoconstriction". You know that the first part of this answer is correct, the pulse pressure widens, however the second part of the answer is incorrect.
6. DO NOT change your answer unless you have had an epiphany. Your first answer is usually the right one.
7. There is no negative marking so if you are not sure, guess. This is not so bad, given that in most cases we tend to get down to two answers. Your real chance is then 50%.
   1. Devise your own system i.e., mark D for every one you don't know
      1. As much as I hate to say it, A is usually not the right answer
   2. Have a random way of choosing i.e., dice with only 1-4 corresponding to a - d taken into consideration.
   3. My favourite, choose (b) or (c)- you can choose one and then the other alternatively.

HOW TO PREPARE FOR THE MCQOne final word on how to prepare....Do a lot of MCQ's and study around them i.e., study the topic area. Even more importantly, write MCQ's, as this gets you into the examiner's head.
Create a 'Hard Facts' File, where you keep the facts you need to have for the exam.

​Peter Kas

Three times in every six month course we send out formal exams to our students. Each of them provides valuable feedback in terms of exam technique.

Every year, I give my predictions of the top questions for the Fellowship Exam. Usually, my hit rate is good. One of my students recently said, "I should have just studied your top 30 list". I don't recommend this, but here is another year's predictions.
The predictions are based on:

1. Questions that have been asked since the new exam began
2. An understanding of how the examiners think, in terms of how soon an area can be asked again and
3. The very structure of the new exam making some questions not suitable for SAQs.

Without an understanding of the above, the probability of picking all 30 questions is fruitless, about  1 in 10000000000000000000000000000000000000000.......... and few more zeros. Happy to discuss this with the mathematicians.
When you understand the above behaviours, the chances drop significantly.
Although I do give all my guys in the Fellowship Course the top 30, the list I'll give here is:

"You're Crazy If You Don't Know these Seven" 

​1. ECG: MOBITZ BLOCKS
The Mobitz block is one of the most popular questions in the exam and a sure bet. In fact two ECG's are a sure bet. Any person with syncope and an ECG, remember the 'ECG's of Syncope'. 
Beware the hidden p waves.
Understand the significance of clumping of QRS's
Know the importance of the p-p interval. 
Try some examples 

2. FLUID MANAGEMENT IN CHILDREN
Understanding fluid resuscitation in children has become very popular recently. Nowhere moreso than in the area of DKA in children. The fear ( regardless of some saying it is irrational) of cerebral oedema in children has resulted in some states producing specific Emergency Department Guidelines for the management of DKA. For a quick review complete the module DKA in Children.

3. SEIZURES IN CHILDREN
This is always a good area. The progression down the seizure algorithm, the knowledge of the various drugs and the ability to know when and how to secure the airway make this an area that is 'choc full of goodness' for the examiners. Certainly some areas, such as airway are more suited to the OSCE, however this kind of question suits both.
​
4. TRAUMA
Trauma is one of the major areas in the Emergency syllabus. Although the big topics such as chest trauma and management of the unstable pelvic fracture are great exam questions, I think its also important to look at the slightly smaller stuff. Burns have been asked before, however electrical burns are a great topic. An understanding of the difference in AC versus DC current, the different types of burns including, flash, arc and thermal burns, as well as the futility of the Parkland Formula for fluid resuscitation, in these presentations, makes this a great area to draw questions from.

5. ANYTHING TO DO WITH EYES
The examiners have a long standing love affair with the eye and repeat the questions often. I suppose that this is because they make great pictures. This about all the different conditions they can ask:

1. Abrasions around the eye
2. Hyphaema(ultimo favourite)
3. Glaucoma
4. Orbital/peri-orbital cellulitis
5. Retinal vein/artery occlusion

and so many others, including all the causes of red-eye, painful/ painless visual loss.

6. ANYTHING TO DO WITH THE NECK
Just when we think, we've done the neck and we won't get that any more, we get the neck again. Why? It can represent a true emergency and it make a great picture. This can be abrasions, penetrating injury or lacerations.

7. THE BLOOD GAS
This has been, is and will always be a favourite. If you've done the Fellowship Course or The ABG MODULE here on Resus if you've read Luke Lawton's great book 'Own The ABG', with example after example to practice on, you know just how simple interpreting the ABG/VBG can be.
Get ready for the triple abnormality; look for it. Know the cause of more than RAGMA. Know the NAGMA. If they give an osmolality, its almost alway going to be an alcohol issue.

Ok there you go. There are no surprises there I hope. This is 'bread and butter' stuff. Good luck in the exam. See you at the Course and see you as FACEMs soon.
​
Peter Kas

Hello to all of you planning to sit the Fellowship Exam in August.
This is a critical time for your preparation. This is about the time that you get sick of it and don't want to continue. You say "I've had enough and won't do this any more. I'll just locum for the rest of my life!"
You and I know its not true. You need a couple of days off before you begin again. Take a few days and just study one topic. Plan to be an expert in that topic i.e.., hypothermia. The key is to give yourself a break, but to also study a potentially high yield topic.
As you get closer to the exam and at about this time, I put together what I think may be a list of topics that will appear. For those that have done the Fellowship Course in the past, my strike rate is between 30% and 50%.

How to approach this list: Don't just study this list! Study as you normally do, however spend a little more time on these topics.

What are they?
For those of you doing the Fellowship Course, They will come out next week, on that week's resource page. Enjoy and good luck!

Two days after speaking at the EMCORE Conference on blood pressure control in intra-cerebral bleeds the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Haemorrhage II) has been published.
We know that intra-cerebral bleeds are dynamic, with up to 40% of patients having growth in haemorrhage volume, in the first 3 hours(Stroke 1997:28:1-5). We also know that bleed volume is a determinant of mortality and that bleed volume increase, is related to increased blood pressure(Neurosurgery 1994). Because of this, there has been a push to lower systolic blood pressure(SBP) in acute bleeds. I am not including subarachnoid bleeds in this discussion.
I recently wrote a blog titled the ‘Penumbra Conundrum‘ and pointed out that hemorrhagic strokes are very different to ischaemic strokes. Hemorrhagic strokes have no ischaemic penumbra around the haematoma. Cerebral blood flow slows in the region as does metabolic rate (Stroke 2013:44;620-6).
The INTERACT 2 trial(NEJM 2013: 368: 2355-2365) randomised over 2000 patients into two systolic blood pressure groups:

1. SBP < 140
2. SBP <180

Patients were included within 6 hours of symptom onset. They found no reduction in death or severe disability when lowering blood pressure. There may have been some benefit in subgroup analysis at 90 days for the more intense lowering of SBP. It is important to also mention that no harm was found from lowering the SBP in this study.
The original ATACH-I trial used Nicardipine to lower SBP safely down to 110-140 (Crit Care Med 2010;38:637-648).
The ATACH-II Trial just released, was a randomised multi centre trial that recruited patientswithin 4.5 hours of symptom onset. The blood pressures were kept at one of two levels for 24 hours:

1. 140-179 mmHg
2. 110-139 mmHg

The primary outcome was disability or death within 3 months.
1000 patients were randomised equally into the two groups. The study was stopped early, short of its 1280 patient target, due to futility. There was no difference in survival or benefit between the 2 groups i.e.., the intense lowering of SBP group and the less aggressive group. There may have been some increase in renal adverse events (not statistically significant) in the first 7 days in the more aggressive group, however the clinical implications of these are unclear.
Both INTERACT -II and ATACH-II show no benefit in lowering blood pressure in intra-cerebral bleeds.
So where to now? What about the patient with SBP of 220mmHg? The only evidence so far is a study by Kazui S et al(Stroke 1996:27:1783-7) showing that SBP > 220mmHg was directly related to haematoma enlargement.
The American Heart Association recommends 140mmHg. I stick to 140 as my goal for SBP in spontaneous intracerebral haemorrhage. If I get 140-160mmHg i’m happy. If I go below 140, I know that studies have shown no harm.  I try to not have fluctuations, but keep it steady. It is also important to monitor the patient as the SBP is lowered. Some patients with chronic hypertension will have a right shift in their auto regulation curve and lowering their SBP may produce neurological symptoms. They should  have a higher SBP titrated.
Which antihypertensive to use? Remember that the SBP increases due to an increase in systemic vascular resistance (SVR):

• Nicardipine (5mg/hr IV, increase every 5-10 min by 2.5mg/hr)
• Labetalol- 10-20mg bolus, every 15 minutes up to 300mg
• GTN infusion or
• Hydrazine 5 mg bolus IV and a hydrazine infusion.

Beware Sodium Nitroprusside as it can increase cerebral vasodilatation, increasing intracranial pressure.
​Peter Kas From the RESUS Blog

We really enjoyed our second face to face in Melbourne a week or so ago.

A big focus was on understanding the exam, and unlocking the questions. More on this in the next blog. We also took the chance to revisit the ABG, and were struck again (as we always are) by the importance of context.

Take the following ABG for example....

A few things generally about this exam
Its a thinkers exam, so you need to be rested enough to think. Remembering is the order of the day:
Follow these simple rules:

1. Get 7-8 hours of sleep for the few days before the exam. If you get nervous and can't sleep the night before, then put some sleep in the bank, the few days before.
2. Do not use alcohol or sleepers to help, especially the few days before the exam.
3. On the day before the exam put in at most 3-4 hours of work. This can be going over your 'hard facts file'( a collection of facts taken on each subject- that we discuss on the website). Then go for a walk on the beach, or have a workout.
4. An excellent thing to do the day before is look at the file you've created of tables from Cameron.
5. For those that have done the 6 Month Fellowship Course, the few days before are excellent for going over the books you have been given i.e.. 'E is for ECG' 'T is for Tox', Every Xray you can be asked' as well as the ABG book.

THE MCQ ITSELF
People put together rules etc. I find that these don't work. I have 4 rules for the MCQ

1. Start at question 1 and finish at question 60. You are not there to try and find the ones that you can do and then try the others....The mindset is that of a specialist. You are there to answer the exam. Start at the start and do each question.
2. Read the stem. Read every word in the stem and understand it. Then think of the possible answers, or differentials or wherever the question is leading you. THEN have a look at the distractors. Remember they are called distractors for a reason. So don't be distracted first off.
3. Never change an answer unless you have had some kind of epiphany.
4. If there is time at the end, go back and look over the questions to make sure that you have read the stems properly. Don't leave early, unless you have done this. Getting this exam will change your life!

Good Luck

At fellowshipexam.com we've spent a lot of time on ABGs. They remain one of the most feared and poorly understood props used in the fellowship exam.

So we were thrilled when one of our candidates had the confidence to ask a really hard question on the VSG. Keep reading for the question and the commentary.