How it works

It is not a quiz. It is a case, and it is running.

Five beats, in a loop, over a typical twelve to eighteen minutes — exactly as they happen in the room. Everything below is the real interface, the same components the exam renders.

What you are about to watch is a clinical case. Communication, procedure and ultrasound stations run the same five beats and end the same way; what changes is the rubric they are graded on — communication, procedure or ultrasound.

01 / You speak

You say what you would actually do.

Out loud or typed. No multiple choice, no menu of orders to click — you ask for the history, you call for the lines, you commit to a diagnosis. Same as the room.

Case in progresslive
You“Blood pressures in both arms, and a 12-lead — now.”
02 / The examiner responds

It tells you nothing you did not ask for.

Every finding is written down before you start. It surfaces when you earn it — not one second earlier. The examiner will not hint, will not lead, will not save you.

Examinerspeaking
Examiner“Right arm 174 over 96. Left arm 128 over 70. The ECG is at the bedside. What do you make of it?”
03 / Real time

Real time. No countdown on the screen.

The patient does not wait for you to think. Results return when they return. There is no clock to watch — when the case has run its course, the examiner asks you to wrap up, then closes the case.

Vitals — livedeteriorating
Examiner“Let's start bringing this case to a close, doctor. Tell me your disposition and plan for this patient.”

No countdown, no warnings. The examiner closes the case.

04 / The patient evolves

The patient changes whether you're ready or not.

Give the right treatment and the numbers turn the corner. Miss it, or reach for the wrong thing, and they slide — the patient doesn't wait for you. The monitor tells the truth in real time.

MonitorHR 81 · BP 122/74
05 / The debrief lands

Then it shows you the clinical case you actually ran.

Every critical action, in order. What you did, when you did it, what you never got to — and the one thing that would have failed you. This is a real debrief from a real run of this case, exactly as the examiner returned it.

Emergency Medicine (ABEM): in 2024, nearly 1 in 5 first-time candidates failed the written qualifying exam. And in 2023, 15% of repeat oral-exam candidates failed — well above the first-time rate. Reps are how the first attempt becomes the only attempt.

Source: ABEM published statistics.

Clinical case debrief · from a real runClosed by the examiner

Pass — completed 7 of 8 scored actions

Every action that fails a case was completed.

Ended by you
The case

Sudden severe chest pain in a middle-aged man

Stanford Type A aortic dissection with left subclavian/carotid involvement (BP differential, transient neuro deficit), presenting as an ACS mimic.

Critical actions · the timeline
  1. Obtained bilateral upper-extremity blood pressures or assessed pulse deficitData acquisition
    02:30by 12:00
  2. Verbalized aortic dissection in the differential before CTA resultDiagnosis
    06:00by 14:00
  3. Ordered CTA (or TEE) to confirm dissectionData acquisitionfails the case
    06:00by 16:00
  4. Initiated rate control FIRST (esmolol/labetalol) targeting HR ~60 and SBP 100–120, before or with vasodilatorTreatmentfails the case
    07:30by 18:00
  5. Emergent cardiothoracic surgery consult / transfer initiated for type ADispositionfails the case
    10:30by 22:00
  6. Provided adequate analgesia (reduces sympathetic drive)Treatment
    09:00
  7. Did not start vasodilator before beta-blockade (reflex tachycardia / shear force)Treatment
    07:30
  8. Communicated diagnosis and plan to patient/wifeCommunication
    —
By category
Data acquisition2/2
Diagnosis1/1
Treatment3/3
Disposition1/1
Communication0/1
What you missed
  • MissedCommunicated diagnosis and plan to patient/wife
Debrief
  • Chest pain + any neuro symptom = dissection until proven otherwise. The transient hand clumsiness was the giveaway hiding in the ROS.
  • A mildly positive troponin and lateral ST-T changes are how this case kills candidates: dissection flaps can involve coronary ostia. STEMI criteria were deliberately absent.
  • Anti-impulse therapy order matters: beta-blockade first (target HR ~60), then vasodilator to SBP 100–120. Vasodilator-first is a scored error — it does not fail the case outright, but it is deducted and it forfeits credit for correct sequencing. Anticoagulation, by contrast, is an outright fail.
  • Bilateral BPs are cheap, fast, and a hard critical action. Say it out loud early in every chest pain case.
  • Type A = surgery, not medical management. The disposition action is calling the surgeon and moving the patient, and boards examiners score the phone call.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease · Rosen's Emergency Medicine, 10th ed., Ch. 74: Aortic Dissection

How it works — DOME