Dengue Epidemic: Why are we unable to walk the talk?

Like every year, its again time for another dengue epidemic. Isn't it really surprising how we repeat history over and over, suffer from the same illness every year. Media highlights it, politicians and bureaucrats are called upon and then starts the "blame game"...

Its the same story, hospitals get packed with patients, lack of beds, patients get shunted among various hospitals when they are critically ill before they succumb to death. And we cannot even imagine how the parents of a 7 year old feel when they witness their child going through such pain. Horrifying..

We (Physicians) cannot increase the capacity of hospitals after a certain extent, there are already two sometimes three patients occupying a single bed. 

So as healthcare providers, what can we do about it?

As physicians, one of our responsibilities is to teach. We must create awareness and educate laypersons about this disease. This can be by various mediums like television or organising community workshops. We all do get apprehensive during epidemics when issues are sensationalised. It is again our duty to do some "COMMUNITY EMERGENCY MEDICINE" here. 

In my opinion, a bulk of this problem can be solved by following simple measures like Community Participation/ Education and just following the treatment guidelines. 

Unnecessary admissions for mild infections are not justified, these can be managed as outpatients. Again this needs community education and participation of laypersons.

Check out the podcast and show notes (dengue fever)
This is a review of "Guidelines for the management of Dengue", minimum that all of us should know.

Dengue Fever

If you want to read more on how all of us can work together and prevent these deadly epidemics, then check out this awesome link 

https://communitymedicine4asses.wordpress.com/2015/09/22/outbreak-of-dengue-in-new-delhi-who-is-responsible-what-should-one-know-and-do/

Prevention is better than cure

Cracking the tough nut: MRCEM Part A

Many of you would agree with me on this that Part A is the toughest one to get through.  Now accept this, that these subjects won't let you go further unless you master them. The sooner you understand this, the better it is. 
Basic Sciences make the foundation of what we do everyday. For instance, there is no fun in treating DKA with fluids/K/Insulin, if we fail to understand the different metabolic pathways.

Now lets look at what MRCEM Part A demands:

Exam Pattern

Basic Sciences 

2 hours/ 50 questions with 4 stems under each question (50x4=200 stems)

Each stem is marked as True/False

Passing Marks: Around 70% 

Important Subjects:

1. Anatomy (Upper Limb/ Lower Limb)
2. Physiology (Cardiac/ Renal/ Respiration/CNS)
3. Pharmacology (Cardiac/ Renal/ Respiration/ NSAIDs/CNS/Hematology )
4. Microbiology (Bacteriology/HBV/HIV/Basic Immunology)
5. Pathology (General Pathology)
6. Statistics/ EBM 

(High yield topics are mentioned in parenthesis)

Note: Exam tests a lot of physiology and anatomy. About 60% of the exam consists of questions from these two subjects. So master these two subjects. 

This is a tough one to crack and I would even say that if you take this one seriously, then part B and C can be piece of cake. 

This is how I look at it.

T/F pattern: Lets presume, If you land up unprepared for this exam, then with every question there is a 50% chance of being right and 50% chance of being wrong because it is either true or false. So you are expected to get a score of around 50% . Scoring the next 20% (50-->70) is a big challenge.

No negative marking: Attempt all the questions. Even if you have no clue, you can still be right (its either True or False)

Time for preparation: Depends on whether you are doing full-time preparation or working and preparing, It should take about about 4-5 months.

Material for preparation

1. USMLE Step 1 Kaplan Notes + USMLE tapes : This is outstanding stuff. Recommended for those who are "okay" with their basic sciences knowledge to start with. After watching these tapes you will have a good grasp over these subjects. The videos come to about 100 hours roughly for the above mentioned subjects. Do go through the notes provided along with these videos. USMLE Step 1 is a much much harder exam as compared to MRCEM Part A. So you have an advantage if you are using this stuff for your preparation.
2. Dr. Najeeb's Videos: Dr. Najeeb is blessed. If you come from a medical college where you did not learn anything i.e if your basics suck, then pick these videos. He is a fantabulous teacher, makes things really simple and easy to understand. (You don't get any ready made notes when you subscribe for these videos). These videos go a bit slow and start about 5-6 months before if you are going to use them.
3. Other basic sciences textbooks (Snells, Netters Atlas, Guyton, BNF, Robbins etc)
4. Mark Harrison (Revision Notes): This text is for revision. Stay in touch with this as you are going through different subjects. Read it at least three times before the exam. One thing that I highly recommend to do is to keep adding the important points in this book as you are preparing right from the very beginning. This can become a great resource for revision during the last few days before the exam.
5. OHEM: Cover to cover OHEM is not required for part A. Exam often tests on ECGs, Toxicology, Anaesthetic agents and Resuscitation.
6. Statistics/ EBM: You get a couple of questions on this. These are the questions that can make a difference by pushing your score from say 66-->70%. This stuff looks hard but if you spend a day or two with statistics, its worth it. Once you get this, it is going to stay with your forever. Kaplan notes cover this under Behavioural Sciences. It should take about a day to finish this OR you can checkout Statistics by Philippa J. Easterbrook from the basic medical sciences MRCP Part 1. 
7. Practice papers for MCEM part A 

Clinical Emergency Medicine
Exam is getting more and more clinical. You have an advantage if you have been exposed to an ED for at least 6 months. OHEM should cover most of this stuff. Expect questions on:

1. ECGs (Arrythmias, Blocks)
2. ACLS/ALS
3. PALS
4. Electrolyte disturbances (HyperK, HypoNa etc)
5. ABG Interpretation 

This is what I used:

Kaplan USMLE Step 1 (Anatomy, Physio, Pharm, Micro, Path)

OHEM

Mark Harrison for revision

Practice papers for part A

Online Q bank

Online Q bank

Don't expect to get the same questions that you see on the Q bank. This is just to understand the exam pattern. Once again, set up a timer while doing the questions. There are plenty of options now, check out the trial questions and take your pick. 

Stick to the curriculum

Have a copy of the curriculum as you prepare for the this exam. Don't spend too much time on Biochemistry, Systemic Pathology. You rarely get questions from these topics. Having a basic knowledge of these subjects should be fine.

1-2 weeks before the exam

Set up your study schedule in such a way that you finish two revisions 10-15 days before the final exam. In the last two weeks, just stick to Mark Harrison (that also includes the important points that you have been adding over 3-4 months). If this gets too monotonous, so add a bit of OHEM (Resus/Toxicology/Anesthesia/ECG). 

Go through the curriculum once again and make sure that you have not missed out anything. 

What about workshops for Part A?
It is really hard to cover the exam curriculum over a couple of days. These workshops for part A can be a good source of revision, particularly the high yield material. So if you are choosing one of them, make sure you are done with the syllabus at least once before attending.

• Focus on the High Yield Subjects (Anatomy and Physiology) 
• Attempt all the questions
• Do not skip Statistics/ EBM

So, this was about what you should probably do to pass part A. If you want to read more on things that you should NOT be doing, then check out this link on "how to fail the MRCEM part A"  

http://www.emergencymedicine.in/current/downloads/eminside_how_to_fail_the_mcem_part_a_examination_d.pdf

Also go through the RCEM website for more info: http://www.rcem.ac.uk/Training-Exams/Exams/MRCEM

Thanks!

Best Wishes

Lakshay Chanana

MRCEM Part B: Do you know the exam well enough?

We are going to hop on to Part B this week. Once again, this is just how I think about it, there are many ways of preparing for MRCEM part B examination and this is just one of them. I prepared in a group three. We used to read individually and do the questions together. 

MRCEM Part B

Exam Pattern

This exam comprises of short answer questions (SAQs) and tests your ability to make the diagnosis, request investigations, give differential diagnosis and management. ECGs, CT scans and X-Rays are often provided with a short history. Usually, each question carries about 10 marks distributed over 4-5 stems (a/b/c/d/e). Each of the stems are marked individually (for instance: 2+1+3+2+2 for a five stemmed question). You have about 7:30 minutes for each question. Exam gives you a total of 16 questions (7:30minutes x 16 = 120 minutes).  

Preparation Material

• Oxford Handbook of Emergency Medicine (OHEM) - Read cover to cover
• MCEM Part B Revision Notes by Victoria Stacey (More of Part B examination pattern, bullet points, easily digestible esp the chapter on "Resuscitation" in this textbook is amazing)
• Get through MCEM Part B: Data interpretation questions (SAQs)
• Oxford Handbook of Clinical Medicine (OHCM) - not mandatory
• Oxford Handbook of Clinical Specialties (OHCS) - not mandatory

Read OHEM and revision notes by Victoria Stacey at least three times. If you want to choose one out of these two, that's a tough call. I personally like Stacey more than OHEM but OHEM is kind of difficult to read and a MUST for the exam. Choose OHEM over Stacey if you are really short on time and read just the paediatrics section from Stacey + also read the intro to the examination from Stacey to understand the "language" that the exam speaks. 

I still recommend doing both thoroughly and that is the key to success. 

Decision Rules: These are often tested on the exam. Here is list of decision rules that we went through and this by no means is a complete list. I know this is painful, just remember them for a day then continue using your smart phones. (Please excuse me for the terrible handwriting, but I am sure you can read most of it once you have read OHEM/Stacey)

Time required for preparation: 2-3 months (guesstimate!) in addition to the 2-3 years of experience in an ED/ Critical Care setting. You would be familiar with most of the stuff mentioned in these texts if you have been working in an acute care setup. 

Do we need to read Tintinalli/ Rosen's for Part B?

These are the core EM textbooks, you cannot just mug them up and regurgitate in the exam. The matter provided in these texts is assimilated over years of residency and then used in clinical practice. If you are in touch with these texts from day one of the residency program, you definitely have an advantage over others. Undoubtedly you need to read one of them for your clinical practise, but not for this exam (not in my opinion!). 

We used Oxford Handbook of Emergency Medicine (OHEM), Revision Notes for MCEM (Victoria Stacey) and Get through MCEM Part B - SAQs (Q bank). In addition to this, we had   already covered a good bit of Tinitinalli (over two years) before we took the exam.

Online Q banks

They cost a lot of money but they are definitely helpful. With Q banks, you get an idea of how you are expected to answer. To start with you will make mistakes even if you know the answer to a question (Yes!). But with time, learn the technique to write. When doing these questions set a stop watch. Give yourself 6-6:30 minutes/ question when practicing these Q banks. Do sets of 16 questions at least three times (over a 2 hour period) before the final exam.

Bottom-line: With Q banks, get a sense of how quick you need to be and learn the trick to write the exam.  

I don't recommend any specific online Q banks, go through the trial questions on each one of them and then take your pick. They all look more or less similar to me!

What the major issue with Part B? Why do candidates get stuck here?

The sole reason why people don't make it here is due to poor time management. Please remember that you are just given 7:30 minutes for each question. Time just flies during the examination and if don't move at a good pace you will probably end up attempting 12-13 questions out of 16 questions and that's not a happy ending.

My solution to this problem

Remember that nobody is perfect and even in the exam you are allowed to make a few mistakes. There is no negative marking here so your only goal should be to attempt all 16 questions.

Biggest Point from this post: This is something that I have observed over time.

In the question paper, say there are 16 questions with five stems under each question i.e 1a/b/c/d/e to 16a/b/c/d/e.

Now, the difficulty level increases with every stem as we move further in a particular question (Order of difficulty for stems in general is e>d>c>b>a) i.e. stem "e" is the most difficult one to crack and stem "a" is usually a cakewalk. This applies to all the 16 questions.

Suppose you get stuck on Q5e and Q8d (d/e are the tough ones) and took about 15 minutes to answer them. Essentially now it is less likely that you would be even attempting Q14a/b/c, Q15a/b/c and Q16a/b/c (a/b/c are the easy ones to crack) due to time constraints. So, NEVER waste too much time on a single stem. Keep going, Keep moving. 

If you are not sure about something, give it 30 seconds to a minute maximum and then move on. Get back to these tough ones "d/e stems" once you have attempted all the 16 questions. If you have attempted all the questions, it is likely that you are make it through. So your goal is to attempt all the questions.

Bottom-line : Don't waste time on the relatively difficult d/e stems, attempt all the questions first and then review the tough ones.

Write legibly, to the point, in order of priority. If you ask me, these are the skills that you should acquire during the preparatory workshops. One thing that you need to walk away with from these workshops is "the trick to write the exam". Having knowledge is not sufficient to pass here, you must know how to convey your thoughts to get through.

On the day of exam:

• Reach well before time
• Relax
• Expect one or two vague/ unexpected questions. Don't freak out, go back to the very basics and I am sure you will come up with an answer
• Attempt all the 16 questions. 

Key Points:

• OHEM, Victoria Stacey + a Q bank is must (OHEM>Stacey)
• With the help of your Mentors/ Preparatory Workshops : Learn how to write the exam
• Time management - Your goal is to attempt all the questions
• OHCM/ OHCS/ Tintinalli/ Rosens - not mandatory

Hope this was useful. If you have anymore questions, please e-email me at drlakshay_em@yahoo.com. I would be more than happy to help.

Best Wishes

Lakshay Chanana

The smarter way of preparation : MRCEM Part C

Exams are approaching and I thought September would be a good time to talk about the preparations for Membership of College of Emergency Medicine (MRCEM) Part A, B and C.  So, the next three posts are about MRCEM Exam preparation. I am going to share the way how I prepared for these exams. There may be other better ways to brace up for these exams, this is just one of them.

We are going to start with Part C today followed by part B and then part A.

MRCEM Part C

The exam gives 18 stations (16 patient encounters + 2 Rest stations), each one lasting for about 7-8 minutes. You are given about a minute to read the question and then proceed. You are required to pass 14/18 stations and each station is recorded as either Pass or Fail.

Prep Material for part C (This is what I used)

• 110 OSCE Station MRCEM Part C
• Chet Trivedy - Mastering EM

Stations

• History taking
• Resuscitation 
• Communication Skills
• Teaching
• Examination (Orthopeds + Other systems)
• Psychiatry
• Procedure stations

Time required for preparation: At least 2-3 months hardcore preparation in addition to your two-year of EM experience.

This exam will not only test your theoretical knowledge, but also your resus skills and communication skills. So what you have learned over years is going to help. Candidates who are not working in an acute care set up (ED/ Critical Care) often find these OSCEs difficult despite having a strong background knowledge because the exam heavily relies on testing you communication skills and etiquette.

How to get started

Go through Chet Trivedy Mastering EM once and have a solid background EM knowledge before you start doing the stations. The other book (110 OSCEs) just gives the questions with instructions for the actors.

Youtube has some great stuff for preparation:

1. Mcleods Examination videos (Basics of examination)
2. OSCE guides by "Geeky Medics" videos (immensely helpful, highly recommended)
3. Psychiatric Interviews for teaching by Nottingham University (lengthy videos, tailor them as per your requirements)

Again, this is just some of the stuff that we used and it worked well for us.

Watch each one of these videos at least once before you start your practise sessions and repeatedly as you are practising the stations. It is best to have a group of maximum three persons to study for this exam. Here, three is company and four is a crowd.

Role Play:

1. Patient (Read the instructions for the actor, from the textbooks and act)
2. Exam Candidate
3. Examiner (Observes, marks the checklist, gives immediate feedback)

Start doing stations 2-3 months before the exam with your colleagues or while you are on a shift. 

Work as the patient, exam candidate and the examiner. Rotate, take turns and do the stations. I recommend to set up time limit of about 6:30 minutes while you are preparing. Set up the timer and get a sense of how fast or how slow you need to be to finish by 7 minutes. It gets really awkward in the exam if you are super fast and finish much before 7 minutes.

Have a simulation software (not mandatory) on one of your devices (tablet/phone) that can be operated with bluetooth and change vitals in response to the treatment while doing the resuscitation stations. Auditory and Visual Stimuli add realism and can take your prep to the next level though these are not a must for the preparation. We used it and it worked really well for our group. These are available on Apple Store for <1000 INR.

Make it as real as possible. Have your PPE, have bedside knee hammer, tuning fork and other equipment to make it look and feel real. While you are preparing, keep that in your mind that none of these checklist in the above mentioned resources are PERFECT. 110 OSCEs checklists is more of  an etiquette kind of checklist and Mastering EM checklist is hardcore theory knowledge/ reasoning type of checklist. If you have ample time make your own checklists combining big points from both these resources and create your own checklist. To begin, as you practise, look at the checklists after you do each station and find out if you are missing anything.

After each one of you have gone through all the stations twice/thrice, then 2 weeks before the exam, run a set of 18 stations (2:30 hrs per candidate, So total 07:30 hrs) continuously as you are expected to do on the day of exam with an elaborated feedback after the eighteenth station. This can be exhausting and may consume a full day but it is worth doing at least once (better twice) before you turn up for the exam. This gives you a sense of what are going to feel like on the day of exam. Do this for all the three group members. Make sure you take a written feedback from your group members and see what you need to work on (Intro, Examination, Body Language, Winding up - The four crucial areas that can improve your global score).

If the feedback thing is not working for you, another method that you can try out is by video recording yourself as you so the stations. In my opinion, the best way to learn and correct yourself is by watching yourself committing the errors. Record (Video) and watch yourself - the way you enter, move, talk, express, your non verbal cues, body language. Everything matters and influences you global score on the exam. This is the most powerful technique to improve your skills.

Another way to work on your skills and body language is to have one of your non-medical colleagues around while you are preparing and ask them for the feedback. They can also work as actors and provide a genuine feedback about your performance and what you need to work on. This can really transform your performance.

In addition to all this, there are various workshops organised on these exams. Look at who is on the faculty list and choose any one of such workshops. They are of tremendous help if you prepare yourself well and take their mock exams seriously. And this can also be utter waste of money if you attend these workshops without any sort of preparation. So keep yourself prepared well before time and then go ahead….

On the day of exam

• Reach before the expected time
• Don't think about the station that you have screwed up. If a station was difficult or unexpected, then it must have been difficult for all the candidates. Get rid of these thoughts and move on..
• With every station, questions almost always gives you a pie chart (see 110 OSCEs) mentioning what exactly you are expected to do. For instance. It may mention something like 75% communication skills and 25% examination. So, on this one don't waste too much time on examination. Examine briefly and more importantly talk to the patient, get out the information what is required (concerns, questions) and communicate well.
• One key question that can save you esp in History stations "Is there anything else that I need to know from you?"

Many thanks to Nikhil Goyal and Naveen Sundaram for contributing towards this post. 

I hope this stuff was useful. If you have anymore questions, please e-mail me at drlakshay_em@yahoo.com. I would be more than happy to help.

Best Wishes
Lakshay Chanana