Category: Fellowship

Shoulder dystocia

Shoulder dystocia is a relatively uncommon obstetric emergency. Despite this, care providers, particularly at Sunshine Hospital, must still be aware of the steps to take to address dystocia in the event obstetric support is unavailable.

Shoulder Dystocia guideline (WH – last review 2013)

 

Watch a short video filmed by Dr Neil Long FACEM, in collaboration with the midwifery education team of Sunshine hospital (5min)

 

 

Mechanically, shoulder dystocia occurs due to a mismatch between the antero-posterior width of the baby’s shoulders relative to the mother’s pelvis, causing obstructed labour. All techniques seek to manipulate these dimensions and correct this mismatch.

Key points:

  1. call for help early (obstetric as a given but remember paediatric/neonatal support and anaesthetic support)
  2. manipulate (widen) pelvis: McRoberts position (hips flexed)
  3. manipulate (relatively reduce) shoulders: suprapubic pressure / shoulder rotation / deliver arms
  4. consider episiotomy
  5. try on all fours position if safe
  6. consider salvage manuevers

 

Additional resources

watch: longer video also describing salvage techniques (10min)

 

watch: a dramatisation, solely to stimulate your adrenaline response (4min)

 

How to: the Exam

Exams are one of the constant hurdles of medical life.

Reproduced here are Dr Neil Long’s summary notes from the recent Regional teaching at the Northern Hospital about the fellowship exam, as well as tips regarding the Primary Exam from Cynthia

 

Primary exam:

Primary Viva tips pdf

 

Fellowship exam:

The Biggest hurdle – an interactive lecture about the different phases of exam preparation and how to go about it

Written advice:

  1. Most importantly of all, everyone has an opinion on how you should study. Remember you have been through 100+ exams all on your own. Whatever revision method works for you carry on.
  2. Decide if you are going to cram revision into 6 months, or a full 12 months. Think about whether you are working full time, part-time and what are your family commitments.
  3. Talk to your significant other or friends. Everyone will need to make sacrifices while you revise and having their support is important. You also need to plan time out to spend with them so you can unwind. I sat down with my partner and stated she would need to be like a 1970s house wife, fortunately after some furrowed brows she understood what I was saying and was able to support my exam campaign. Don’t underestimate how much friends and family are impacted by your revision.
  4. Make a revision plan and stick to it. Here is an example plan from Sir Charles Gairdner Hospital.
  5. You will quickly see there is not a lot of time to go into vast depths on each topic therefore join an exam group, this will help keep you on track but also help discuss concepts or areas where people constantly make mistakes. There are also not a lot of MCQs out there so this is time well spent in your group quizzing each other.
  6. Talk to examiners to give you the tips on the high yield topics and how best to answer the questions. Understanding the game is half the battle. For example with a hypotension question there is no point writing “1. IV access, 2. Noradrenaline” Everyone knows noradrenaline has to go IV, the examiner will get annoyed. Better still write “Noradrenaline 1-10 mcg/minutes titrated to a MAP of 65”. Remember to think how can I write the most succinct information on one line. Anything outside these lines will not be marked and the first answers will be marked in order.
  7. Write your own questions. now you do not need to go over the top here but at least try it a few times. You will be amazed at how long it takes and what short cuts you take. For example, an MCQ is hard to write, when you see a table it is so much easier to create. This is exactly what the examiners do. Once you start noticing how to they would think you read the textbooks with a different mindset.
  8. Textbooks. Now this divides opinion, some of us read them cover to cover, while others will never open one. We have a list of recommended textbooks and as Joe Lex states ‘it is worth you reading one cover to cover at least once during your career’. For those that despise textbooks I would recommend using one to reference when you are struggling with an answer or concept particularly with MCQs. Also its worth looking at all the tables, as mentioned in point 7. This is where the examiners’ lists will come from.
  9. Go on a course, there are a few around and we have a list of courses. Speak to colleagues before signing up, they are varied and slightly different in style, they also cost a lot of money and some are better value than others.
  10. Practise, practise and practise. This sounds stupid but the best advice I got was from Jo Dalgliesh an examiner in Melbourne who gave me a Nike enema when I’d only done 2 full practise exams 2 months out from the written. By the time the exam came I had done 3o full papers to time and was able to complete a paper in 2.5 hours. By doing the exams you will see what your common mistakes are, what the examiners are looking for and your answers will become more concise.

OSCE advice:

  1. As per point 3 from above, make sure you have the support of your loved ones.
  2. Although your knowledge should have been tested in the written, now is not the time to take your foot off the break. The OSCE sometimes feels a bit like the hunger games and they can ask you about anything in the curriculum. They want to combine your knowledge with everyday practice.
  3. Consider going on an OSCE course or at least making sure you have done one full OSCE set, preferably a three day event. Doing one and then getting feedback does not prepare you for the mental fatigue and stamina required for a full three days.
  4. Develop a coping strategy for when you bomb on a station. Remember not even the prize winners make it through unscathed. It is important to keep going over the three days and to enter each station hungry for those FACEM letters.
  5. Develop a strategy for stress, particularly on the day. I don’t believe anyone had a heart rate less than 120 about a minute before stepping into the exam corridor. My technique was using mindful square breathing (hey whatever works for you) or doing the “power pose” outside the room (see the TED talk – Fake it til you become it).
  6. Develop a framework for the different OSCEs but not a script. You need to know an approach to breaking bad news or a complaint but you also need to come across as a caring human being. The examiners will not like it if you come across pre-formatted or like a robot.
  7. Do what the tasks ask for. Nothing more and nothing less. It was my technique to read the tasks first, then the start of the question. Finally pick out the discriminators, i.e. its late at night, a rural hospital, your talking to a consultant/intern/registrar.
  8. Remember your agenda may not be the same as the examiners agenda. Listen to the cues, if you get asked a question, do not dodge it, they are trying to get you marks.
  9. When the one minute warning goes, change tact, either thats summarising or asking if there are any other questions but you must make sure you have left the room with a consultant plan. Do not tell the intern 20 different management strategies without summarising and giving them a to do list.
  10. Practise, practise practise, it does become very personal and you can feel like you are always being attacked but the more stations you do the better you will be on the day answering them. Who else gets this much attention to learn while getting paid at the same time (think of the positives).

Other wise words:

Fellowship exam resources and contacts

How to: talk the talk

Presenting in front of our peer group is usually about as fun as pulling teeth, but it is a valuable experience – both for the speaker – in the act and practice of information transfer, and for the audience – a chance to receive new information and new ways of thinking about existing problems.

Dr Hans Hollerer provided his take on how to deliver impactful presentations. Review his talk:

 

to-talk-the-talk

 

There are plentiful guides to public speaking online.

Key points from the following TED video – skip to around 5min

  1. limit the number of key ideas (this suggests one only – a bit of a hard task in medical presentations)
  2. give people a reason to care
  3. build your ideas with familiar concepts
  4. make your idea worth sharing

EM: RAP

Dr Keith Nallaratnam has graciously extended the use of his CD collection of EM:RAP podcasts to all staff.

For those unfamiliar with EM:RAP, it is a monthly American podcast hosted by Mel Herbert. Each episode usually covers about 3 topics with edited audio lectures from different prominent speakers and with Mel’s animated but useful commentary throughout. Here’s an excerpt from their associated YouTube channel:

 

8min

 

Keith’s CDs will be kept in Narelle Farrugia’s office. Please borrow responsibly so we do not have to bring these back:

 

librarycard

 

Acid-base and Fluids

https://youtu.be/pLCmPaINPi4

Acid-base and its practical application, according to the quantitative (Stewart) approach + the effects of fluids on acid-base.

Summary:

  • pH is determined by the need for electrical neutrality
  • Strong ions and weak acids determine acid-base, not H+ and HCO3-
  • The Stewart approach allows you to quantify the contribution of different abnormalities (e.g. lactate) on metabolic acidosis
  • Fluids have an effect on acid-base – saline is strongly acidotic and therefore may not be the most sensible choice!

If you want to learn more on the ‘ideal’ generic fluid, have a read of this post by Josh Farkas on the Emcrit website.

Fellowship study plan

This study plan has been reproduced and modified from TJDogma. It is suggested as a roughly 6 month programme. Other candidates have used 9-12 month programmes.

Before beginning, discuss with your DEMT regarding your campaign and your timing as individual strategies will vary.

Before beginning, collect past papers and revise the ACEM learning and processes document to note ‘expert level’ topics to prioritise your learning.

 

Week Subject Topic
Intro FE process, texts. Collect past papers. Check curriculum
1 Resuscitation Resuscitation
2 Medicine 1 CVS 1  (ACS, failure, syncope)
3 Surgery 1 Trauma 1  (head and neck, chest, abdomen)
4 Anaesthesia Anaesthesia / procedural sedation
5 Toxicology 1 General  Toxins
6 Medicine 2 CVS 2  (Arrhythmia, TED, HT)
7 Surgery 2 Trauma 2  (Pelvis, spine, limbs)
8 Psychiatry Psychiatry
9 Medicine 3 Respiratory
10 Surgery 3 Chest + abdo / Urology
11 Toxicology 2 Medical Drug abuse
12 Medicine 4 Neurology Immunology
13 Revision 1
14 Disaster / Opthal Disaster/Pre-hospital  / Eye
15 Surgery 4 Orthopaedics 1  (Fractures)
16 Medicine 5 Renal, metabolic  Endocrinology
17 Surgery 5 Orthopaedics 2  (Dislocations)  Rheumatology
18 Break week
19 Revision 2 warm up OSCEs
20 Medicine 6 ID  GI
21 Paediatrics General
22 ENT  O+G ENT  O+G
23 Medicine 7 Haematology  Oncology  Environmental
24 Administration Administration  Education
25 Surgery 6  Med 8 Burns + wounds  Neuro  Vascular  Dermatology
26 Revision 3
27 Revision 4 ACEM FE Written examination

New ANZCOR resus guidelines

ANZCOR have updated their guidelines.

The main changes – as summarised by Dr Stacy Turner:

ALS
Defibrillation – can increase 2nd shock energy to maximum available on defib, if first shock unsuccessful.
Cooling anywhere between 32-36 degrees.
Post-ROSC PCI – immediate in STEMI, new LBBBB and selected patients if coronary ischaemia is considered the likely cause on clinical grounds (although Level of Evidence III – poor)

BLS
Chest compressions now 100-120/min instead of 100

Neonatal
For term babies, start with air, not oxygen; for pre-term babies start at 21-30% O2, then titrate O2 to sats (minimum at 1min 60%, 2min 65%, 3min 70%, 4min 75%, 5min 80%, 10min 85%)

Paediatric
Chest compressions now 100-120/min instead of 100
Cooling anywhere between 32-36 degrees post ROSC

First Aid
C-spine collars for suspected spinal injuries by any first aid provider in the pre-hospital environment no longer recommended