Emergency medicine guides · Examiner reports

Why candidates lose marks in the ACEM exams

ACEM examiner reports repeat themselves from sitting to sitting. Most marks are not lost on rare facts; they are lost on how answers are written and on the same core gaps. These are the themes that come up most.

  1. Vague SAQ answers ("supportive care", "consider antibiotics") instead of the drug, dose, route, threshold and disposition the key rewards.
  2. Poor SAQ time allocation: over-writing the early questions and leaving the later ones thin or blank.
  3. Resus case-based discussions without prioritisation: listing everything instead of saying what you do first, second and why.
  4. Running out of the 7-minute OSCE window because there was no plan made in the 4 minutes of reading time.
  5. Scripted, generic communication that does not adapt to the particular patient, relative or staff member in the station.
  6. Teaching stations turned into a lecture: no check of what the junior already knows, no practical take-home points, no safety net.
  7. Applying a decision rule outside its population (PERC in a moderate-risk patient, the Canadian CT Head Rule in an anticoagulated patient).
  8. Primary viva: describing rather than explaining mechanisms, and not linking the basic science to an ED patient when the examiner leads there.

What this looks like when it is marked

A SAQ question, an answer of the kind examiners see every sitting, and how a point-by-point marking guide scores it.

Question · 4 marks

A 24-year-old woman presents 9 hours after an intentional ingestion of 40 tablets of paracetamol 500 mg (20 g); she weighs 60 kg. List your immediate management of the paracetamol ingestion.

Answer

This is a significant overdose. I would give supportive care, check a paracetamol level and liver function tests, start N-acetylcysteine if the level is above the nomogram line, and refer to psychiatry.

✗Start acetylcysteine now, without waiting for the level: presentation is more than 8 hours after a potentially toxic ingestion (≥ 10 g or ≥ 200 mg/kg)0/1
✗Regimen stated: 200 mg/kg over 4 hours, then 100 mg/kg over 16 hours (two-bag)0/1
✓Paracetamol concentration and alanine aminotransferase (ALT) on arrival1/1
✗Plan for the level: if above double the nomogram line, double the second bag to 200 mg/kg over 16 hours; no activated charcoal at 9 hours0/1

The level does not decide whether to start acetylcysteine after 8 hours: the dose ingested does. "Start NAC if above the line" scores nothing here, and "supportive care" never scores. Name the regimen and the decision point.

How to practise against these

Reading a list of mistakes changes little. What changes the score is writing or speaking answers under exam conditions and being marked against specific points, so you can see exactly which one you missed. Do that for every area, weakest first, and repeat the ones you got wrong until they stick.

Know the references examiners expect: Australasian Triage Scale (ATS); ANZCOR / Australian Resuscitation Council guidelines; Therapeutic Guidelines and Australian Medicines Handbook; Poisons Information Centre (13 11 26) and Australian toxicology practice (e.g. Murray's Toxicology Handbook); Australian snake and spider envenomation practice and CSL antivenoms; Australian Immunisation Handbook (tetanus, rabies and Australian bat lyssavirus post-exposure); State and territory Mental Health Acts and guardianship law; ED access targets (4-hour rule / NEAT; NZ shorter stays in ED) and ACEM policies and standards; RACP paediatric emergency medicine curriculum (for the Paediatric Emergency Requirement).

Where do you stand?

Thirty questions across every area, scored by area with a plain verdict. Free.

Am I ready? Free check →Read a marked sample

Next: The ACEM exams explained: format, timing and how they are passed →

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