Emergency Medicine (Added Competence): Stabilise, Then Diagnose
What the exam rewards
The EM added-competence exam assumes you can run a resuscitation while thinking diagnostically. Prioritise the primary survey (ABCDE) and resuscitation before diagnosis in unstable patients. Be fluent in airway decision-making (when to intubate, predicted difficult airway, rapid sequence intubation principles), shock physiology (distributive, hypovolaemic, cardiogenic, obstructive), sepsis recognition and early antibiotics, ACS pathways, stroke time-critical assessment, trauma (primary/secondary survey, imaging decisions), toxicology, and procedural sedation. Understand disposition - admission, observation, or safe discharge with clear return precautions.
Traps
- Anchoring on a single vital sign or a normal one: a normal blood pressure can coexist with compensated shock; look at trends, lactate, mental status, urine output.
- Premature closure on a benign diagnosis before ruling out the dangerous alternative (e.g., calling chest pain "musculoskeletal" without considering ACS or PE).
- Forgetting the reassessment: many stems reward a repeat exam or repeat vitals after an intervention.
- Sedation/analgesia without monitoring plans, or paralysing without a sedation plan.
- Discharge without safety-netting - return precautions and follow-up are often the discriminating option.
Rule of thumb
Treat the patient, not the number. In an unstable patient, the answer is almost always an action (airway, fluid, blood, antibiotics, defibrillation) rather than a test. In a stable patient, choose the test that most changes disposition.
Worked example
A hypotensive patient with fever and tachycardia: the correct next step is resuscitation and early broad-spectrum antibiotics with cultures, not waiting for imaging to confirm the source.