MRCEM Intermediate Tips

The MRCEM Intermediate examination is the second part of the new MRCEM examination and is sat twice yearly.
The MRCEM exam has recently been restructured. Previously, the FRCEM Intermediate exam followed a short answer question (SAQ) format. Following the name change to the MRCEM Intermediate exam, the format of the paper has now changed to a Single Best Answer (SBA) paper, which is the same as the MRCEM Primary.
The MRCEM Intermediate Exam Breakdown
The MRCEM Intermediate exam consists of two papers, each of which is two hours long and comprises 90 single best answer questions. The examination is conducted in English, and candidates are advised that IELTS Level 7 is the expected standard for completion of the MRCEM examinations.
The MRCEM Intermediate exam is based on the Royal College of Emergency Medicine Clinical Syllabus. The exam is mapped to the Specialty Learning Outcomes (SLO) of Years 1-3 of the RCEM Curriculum, with each domain tested in the following proportions:
SLO1 Complex Stable Patient – 55 questions
SLO3 Resuscitate – 40 questions
SLO4 Injured Patient – 30 questions
SLO5 Paediatric Emergency Medicine – 25 questions
SLO6 Procedural Skills – 20 questions
SLO7 Complex or Challenging Situations – 10 questions
The exam is marked using a modified Angoff method, where a cutoff score is defined as the score a minimally acceptable candidate is likely to achieve. One standard error of measurement will be added to the cutoff scores identified using the Angoff method to calculate the required final pass mark for the paper.
The MRCEM Intermediate Question Style
The questions in the MRCEM Intermediate exam are single best answer questions (SBAs). Detailed advice on how to approach answering SBA style questions can be found in our MRCEM Primary tips article.
An example of a typical MRCEM Intermediate SBA is shown below:
Chest trauma:
A 21-year-old lady is brought in by ambulance after having been struck by a car as a pedestrian. She is quickly moved to the resuscitation area of your Emergency Department complaining of abdominal and left-sided chest pain. There is bruising on the left side of her chest, but no open wounds visible. She is extremely breathless, and observations are HR 112, BP 88/51, SaO2 88% on high flow oxygen. On examination of her chest, you note that her trachea is deviated to the right, and there are absent breath sounds and a hyper-resonant percussion note on the left side of her chest. She also has distended neck veins.
What is the SINGLE most likely diagnosis?
A. Simple pneumothorax
B. Massive haemothorax
C. Open pneumothorax
D. Tension pneumothorax
E. Cardiac tamponade
Answer: D. Tension pneumothorax
A tension pneumothorax occurs when a ‘one-way valve’ air leak occurs from the lung or through the chest wall. There is a progressive build-up of air within the pleural space without any means of escape. This results in a progressive rise of pressure in the pleural space, which pushes the mediastinum into the opposite hemithorax. This can impede venous return to the heart and cause cardiovascular instability and cardiac arrest if untreated.

The following clinical features are characteristic of tension pneumothorax:

  • Respiratory distress and cardiovascular instability
  • Tracheal deviation away from the side of injury
  • Unilateral absence of breath sounds on the side of injury
  • Hyper-resonant percussion note on the side of injury
  • Distended neck veins
  • Cyanosis (late sign)
Both tension pneumothorax and massive haemothorax are associated with decreased breath sounds on auscultation. Differentiation on physical examination can be made by percussion; hyper-resonance supports tension pneumothorax, whereas dullness suggests a massive haemothorax.
Tension pneumothorax is a clinical diagnosis, and treatment should be delayed for radiological confirmation. Treatment is with IMMEDIATE decompression via needle thoracocentesis.
Traditionally, this has been performed by inserting a large-bore needle or cannula into the 2ndintercostal space in the mid-clavicular line of the affected hemithorax. Cadaver studies, however, have shown improved success in reaching the thoracic cavity when the 4th or 5th intercostal space in the mid-axillary line is used instead of the 2nd intercostal space in the mid-clavicular line in adult patients. ATLS now recommends this location for needle decompression in adult patients. The location in children remains unchanged, and the 2nd intercostal space in the mid-clavicular line should still be used. Needle thoracocentesis is a temporary measure only, and definitive treatment is the insertion of a chest drain.
Preparing for the MRCEM Intermediate 
Although the MRCEM Intermediate exam does not have the daunting volume of knowledge required for the MRCEM Primary, it is still complex and challenging. Many of the questions take on the form of data interpretation, with questions based around blood tests, an X-ray or an ECG. Candidates should start preparing at least six months before the examination.
Many questions in the MRCEM Intermediate examination take the form of data interpretation questions, such as X-rays
The Oxford Handbook of Emergency Medicine is an excellent resource for the MRCEM Intermediate examination and, once purchased, will probably remain at your side for much of the years that follow during your Emergency Medicine training.
Other frequently tested aspects of the MRCEM Intermediate examination are scoring systems and clinical guidelines. It is a good idea to familiarise yourself with the various scoring systems used in the Emergency Department setting, for example, CURB-65 for pneumonia. You should also attempt to read relevant NICE and SIGN guidelines.
The MRCEM Intermediate examination is very closely matched to your everyday work in the Emergency Department, so it is a good idea to read around interesting and relevant cases that you come across in day-to-day practice as this will help you to achieve a better understanding of current practice and guidelines.
Good luck with your exam preparation!
Header image used on licence from Shutterstock

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