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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, July 31, 2017

The nomenclature of EM postgraduate qualifications in India - Simplified

As Emergency Medicine is a new specialty and there has been a lot of buzz around it, if you are a medical graduate in India wanting to take up Emergency medicine you would definitely be perplexed by the myriad of nomenclatures of EM postgraduate qualifications. As an MBBS pass out when you are vaguely starting to understand what different specialties are and what EM is, just when you think you might have a thing for EM, you probably are bombarded with countless names (of qualifications), each claiming to be superior to one another. Everyone seems to have an opinion about EM (like everything else) - One with a qualification in EM, one without, a doctor who has no idea what emergency medicine is, that homeopath on the crossroad, EVERYONE! Just yesterday when I was walking down the road I even overheard the samosa guy explain to the chaiwala (No no..not Modi!) how one course is better than the other while he unknowingly obstructed an Ambulance passing by with his cart although the ambulance had it's sirens and lights on !!!

So what's this confusion about ? And how does a MBBS student or aspiring EM physician analyze this and make an informed decision and decide what course to join ? Whom to trust when people are claiming everything like popular news channels - "First on EM tv", "You saw it first on nautanki now", "We are the undisputed No.1" and "Exclusive" ?!
So let me just try to dissect each of the popular EM qualifications in India. I will try to list the advantages, drawbacks of each of them. I will try to be as unbiased as possible and try to touch upon some facts pertaining to recent controversies step by step.


1. MD Emergency Medicine:
Like all other MD qualifications, this degree is given by Medical Council of India. Course is run in many medical colleges across India. There are fixed number of seats.
Q: What are the advantages:
- Needless to say it is recognized by MCI as it is run by MCI (kind of dumb point ;-P Filling up the answer sheet will fetch me some extra marks isn't it? Anyway!)
- You can be a faculty in medical colleges and hospitals running DNB after the completion of the course.
- Getting a job after MD shouldn't be a problem at all as MD is a brand in itself irrespective of how good you are.
- Like any other MD final exam, passing is probably not very difficult (well, I don't have a first hand knowledge here but I haven't heard of someone flunking the MD final exams multiple times nevertheless)
- Entry is through NEET. So you definitely have to work hard to earn a seat** (conditions apply)
- You can write MRCEM exam and DNB exam while you are at it! So can be a triple degree holder (if you are a degree fanatic) at the end of your course! (Will explain MRCEM in a bit if you do not know what that is or confused about it)
- On a lighter note you don't have to explain your degree to relatives unlike most other degrees. (Although there's no escaping from explaining what EM is!)

Q: Wow!!! Then is this the perfect, irrefutable, most 'legitimate' EM degrees of all ???
A: Hold on. The answer might not be an absolute no or a blanket yes. There are downsides of course!
- There are many medical colleges where the department of EM is not completely established or to put it in another way there's no concept of emergency medicine. The primary faculty for teaching are not from EM.
Although it can be argued that the origin of EM roots back to surgical specialties and different skills required for an emergency physician can be taught by different specialties, the lack of primary teaching faculty from EM would definitely hamper the 'EM-culture'. While an anesthetist can be a great teacher of airway skills, an orthopod can teach reducing a shoulder like none other, none of them can teach the 'EM-mindset' like an emergency physician, which is the heart of practicing as an emergency medicine doctor.  (Enough, I think I did too much talking there!)
-**Varmaji's beta worked hard, passed MBBS with distinction, studied again, got good rank in NEET, was an adrenaline junkie who wanted to bring a change in people's lives, was interested in EM, got a MD EM seat in a reputed medical college. Passed with flying colors.  Well done. LEGITIMATE!
Sharmaji's beta passed MBBS after Salman threatened him that he will get married before he passes. He once tried to memorize the full form of NEET but then he felt that was completely unnecessary. He thought he would do MD EM because someone said he didn't have to admit patients under him if he did that. He was rich, Sharmaji owned 2 BMWs, he spilled 1.5 crores and BOUGHT a MD EM seat in the same college as Varmaji's beta like you buy a kilo of brinjal (Baingan - I can't kill the Hyderabadi in me) from the market. He also somehow passed. Sharmaji's beta is also MD Emergency Medicine now! LOL! Legitimacy!? LOLOLOL!
--> So, on a serious note, I'm not saying that MD EM is all bad. Neither it's sacred and the BEST just because it is run by MCI. Making blanket statements won't help!
So the bottom-line is - Good score in NEET --> Good college with good EM dept. with preferably faculty from EM --> MD EM --> Good.

2. DNB Emergency Medicine:
Run by NBE (National Board of Examinations) across different hospitals and some medical colleges across India. Like MD, they have fixed number of seats.

Q: What are the advantages:
- Recognized by MCI.
- Can be faculty in medical colleges (There has always been some controversy regarding DNB candidates being asked for some additional experience to work as assistant prof in medical colleges, I'm unsure of the present status) and DNB institutes.
- Entry is via NEET.
- Main factor which might increase the 'LEGITIMACY index' of DNB is that there are no 'management seats'. That means no one can 'buy' DNB seats. You will have to earn them! That's commendable.
- Again getting a job shouldn't be a problem. DNB programs are well known for churning out good doctors historically.
- Final exams are not easy as MD is the general perception. Which is kind of good. When you pass, people know you deserve it.
- You can of course write MRCEM exams while you are at it!

Q: Well, then there are no downsides? That's amazing, isn't it?
A: Nothing is completely blot free! Again some downsides are:
- This one is common: Some hospitals might not have primary faculty from EM.
- Secondary DNB eligibility: Dude, this is a JOKE! Anyone with ANY diploma is eligible for secondary DNB EM. Like Dip microbiology, pathology etc. can take up DNB EM (secondary). What on the earth were they thinking while they made these criteria?! What are they trying to do/achieve ?! Bizarre!
Bottom-line: Good hospital --> DNB EM --> Very Good.


3. MRCEM (UK): Membership of Royal College of Emergency Medicine, United Kingdom.
There has been lot of confusion regarding this. So let's make few facts clear.
1. This is NOT an Indian qualification. This is awarded by RCEM, UK.
2. It is recognized by MCI as an additional postgraduate qualification and can be added to your certificate in state medical councils (I personally know many people who have registered their qualifications)
3. You can apply for faculty positions in medical colleges with MRCEM as per the latest notification by MCI. You can find it here: https://www.mciindia.org/documents/e_Gazette_Amendments/TEQ-11.03.2017.pdf
(I don't have first hand info about anyone who have done so yet - So unsure of the process involved)
4. You can get job in any hospital after MRCEM easily.
5. You are eligible for working in UK/Ireland and/or undergo higher specialty training in UK towards FRCEM. (You are exempted from PLAB). FRCEM is recognized in Australia as well.

Note :  With MRCEM in your pocket, you are eligible to work as a Registrar in UK, NOT as a consultant. However, in India - you will be offered consultant posts by many hospitals after you pass MRCEM exams. MRCEM is half way through training. Emergency Medicine training lasts for 6 years in UK and FRCEM is required before you start working as a consultant.  Here is UK training pathway in Emergency Medicine: 



6. Do you have to be in a specific residency or training program to attempt MRCEM exam? The answer is NO. You need to have the evidence of structured training/experience in EM and allied specialties as per RCEM requirements - Emergency medicine, Intensive Care medicine, Anesthesia, Acute/Internal medicine (For roughly 3 years) and you can attempt the exam.
Follow the RCEM link for minute details of exams and everything else: http://www.rcem.ac.uk/

7. Is the exam easy? Hell no! You would know this if you speak to the people who have either passed or attempted the exam. Also if you look at the pass percentage of the exam you will have a fair idea how difficult the exam is.  The pass percentage in each part is roughly around 25-30. (The exam has 3 parts - A, B, C - Recently changed to FRCEM primary, intermediate and OSCE - Will not get into the details and add to the confusion - Refer website for finer details)

8. What's the Apollo connection with MRCEM ?
This has always been a longstanding doubt of many. Simple. Apollo was the first in the country to collaborate with RCEM and start the MRCEM exams in India and started a structured training program in EM providing training to pass MRCEM back in 2005 (During a time when EM was not even a MCI recognized specialty in India), pioneering the development of EM in India.
Apollo runs a structured 3 year EM residency program training you for MRCEM.
So MRCEM exams are usually held at Apollo hospitals. Recently there have been few other centers like Max Hospitals, Delhi.

9. So is it mandatory to get training in Apollo to be eligible for MRCEM ?
No. Absolutely not. College (RCEM) doesn't mind where you do your training from as long as you are competent and can show the evidence of same neither they RECOMMEND any specific training program.
So basically you can write MRCEM after MRCEM residency in Apollo, DNB EM, MD EM, MEM, or not enrolling yourself into any of the courses per se and just gaining the necessary experience/training in the specialties mentioned above.

10. So is doing residency in Apollo useless if my aim is doing MRCEM ?
Definitely not! They have a very good EM dept. where there are seniors/registrars/consultants who have completed MRCEM who can guide you. It's a JCI accredited hospital and you have defined protocols. You have a decent patient load and fair amount of independence. You are rotated through different specialties ALMOST as per the RCEM curriculum. They can train you before the exam. Having expert guidance is the key to pass MRCEM apart from having good training and experience. + The EM culture in Apollo is good and you will have your identity as an emergency physician. (This is only with Hyderabad where I worked and Chennai where I have few of my friends - I can't comment about other Apollo Centres)
Having said that just because you have enrolled for the residency program doesn't automatically mean that you will pass MRCEM exam. You are not joining a 'course' where you will be spoon-fed. You will have to earn it!

11. Can I join any other hospital, college without enrolling into a course/training program and still clear exam ?
Well, nothing is impossible. You CAN do that as well provided you have a very good guide and you exactly know what you are doing. There are people who have done that as well. So it is completely up to you! Thinking out of the box is a core quality of an emergency physician! But you have to judge how much out of the box!

12. What in UK after MRCEM ?
Most of the UK training programs run for 6 years (ST1 - ST6). So you will be entering as a middle grade registrar (ST3/4 level) after MRCEM. You can complete rest of the years in UK and can also apply for subspecialty training in Pediatric EM and Prehospital EM. You can also opt for dual accreditation in ICM which is for 6 years post MRCEM (FFICM). (Again, not getting into the different pathways after MRCEM for higher specialty training - Refer to college website for the same)

Downsides:
- Some of the corporate hospitals with training programs for MRCEM pay very (very) less! (So you will be devoid of money for 3 years and the restaurant owner will be singing 'Abhi na jao chodkar ye bill abhi bhara nahi'). Some of the hospitals do not pay residents for first 6-8 months of training (Zero – Yeah! You will be doing some charity work for the poor and needy corporate hospitals.....Smirk, smirk!)
-No leaves for the entire 3 year (almost 1100 days) duration except for the post night offs. (Note that this is a common problem with most courses and not specific to this)
- Training can become dull/not-so-happening sometimes especially if there's shortage of staff.
-The place you choose for training is extremely important. Especially if it is not a structured training program – High chances of losing focus, getting lost and getting discouraged by ill informed peers, colleagues and 'experts' from other specialties.
-There are only a handful of MRCEM qualified doctors in India. Choosing the right guide in a right hospital out of a training program might be a tedious task.

Bottom-line: You need to find a very good hospital and have adequate training/experience to clear MRCEM. A good guide/team is equally important. Exam is definitely not easy. You will have to earn this qualification. Scope: Very good! MRCEM opens up many doors for work/training in India and abroad.
PS: One other major downside would be explaining MRCEM to everyone after you are half dead explaining what emergency medicine is.  Whenever that new uncle goes "Beta, kya kar rahe ho aajkal?" You will be like 'Maar daalo mujhe...Maar do!'

4. MEM (Masters in Emergency Medicine):
MEM (Masters in Emergency Medicine) is a three year course run by 2 societies - George Washington University, USA and SEMI - Society for Emergency Medicine, India. Probably this is the most 'controversial' of them all.
Before I start, I'm making it clear that I'm not jumping into the argument of whether or not these societies can give masters degree , universities act, it's just a certificate, should it be called something else etc. Etc. - I'm not a legal expert. Period. Now that these courses are being run and people have enrolled into them let's see how can they be assessed by a trainees perspective.

The overview of MEM programs:
1. Are they recognized by MCI ?
A: An absolute NO.
2. Is the GW MEM recognized in USA?
A: No again. A big NO.
3. Is it recognized in UK?
A: NO man, NO! Nooooo!
4. Can you get a job after MEM ?
For now, of course you can get a job with fairly good pay as there's a shortage of doctors to man the EDs. But future is unclear.
5. Can i write MRCEM after MEM ?
Yes. Of course you can, like anyone else with similar experience. But your MEM tag has nothing to do with MRCEM exam!
6. So is MEM completely useless ?
Well, No! Again it's unfair to give such a blanket statement. MEM programs have a good curriculum (Although not all the centers adhere to it or have a notable training program). There are quite a few centers running MEM programs with very good training which produce very good EM physicians and also high success rate in MRCEM. (Example: MIMS Calicut, KDAH Mumbai, MaxCure Hospitals Hyderabad. There may be other hospitals which have good training programs and these are just examples of hospitals I'm aware of which have good training as per few friends and colleagues who had worked there).
Many of the courses conduct regular classes/academic sessions, some even with overseas faculty.
7. So are MEM trained doctors are all incompetent ?
No. 'Unaccredited program does not equal to incompetent trainees' and vice versa (I hate blanket statements, please clinically correlate - Also remember Sharmaji's son's story)

Downsides:
- Fee for most of GW MEM courses are high.
- Although the training in some hospitals is good, ultimately everything boils down to success rate in MRCEM! So the importance of MEM as a standalone qualification is minuscule especially with it's 'Unrecognized' status.
- Many hospitals use MEM as a way to get cheap labor - To prevent understaffing of their EDs and ICUs without actually training them and also underpaying them - Which definitely is a major concern.
- Many people opt for it because they are not able to get into anything else. (Ease of entry). Which again is detrimental to the specialty.
- Most of the MEM programs are advertised saying they are eligible to write MRCEM after MEM which is of course true but what is the role of MEM per se needs to be seen. Only time can tell the answer ?!
Bottom-line: Joining MEM might not be a very bad idea if you like the training in a particular hospital running MEM course and IF THEY ALSO (ACTUALLY) TRAIN YOU FOR MRCEM.
'Only MEM' is probably like a Limbo in Inception! You are nowhere! (At least in the present scenario)

Few words about the nomenclature war:
The cause for this confusion is complex. It may range from personal interests to governmental insufficiency in uprooting the corruption in the system + the mismatch between supply and demand and everything in between – Corporate greed, personal agenda, petty politics, lack of manpower, funding, infrastructure and the extremely complex system of Indian healthcare. Frankly I don't have one answer for this neither can I think of one single solution for this. But definitely conflict and 'rational thinking loss' are detrimental to the growth of EM as a specialty!

There has been a lot of buzz in the social media after few reports were published in prominent newspapers about EM qualifications in India. The newspaper articles although highlighted few problems, it failed to make an unbiased approach and made it appear as if everything is right with the MD and DNB courses and everything else is wrong with the other courses. Many polarized opinions were being circulated with everyone claiming how certain degrees/qualifications are all good and how others are all bad. This is just an honest attempt to provide an unbiased approach towards these qualifications which might help an aspiring EM doctor!

I hope there will be less chaos in the days to come and hope that the Governmental bodies and non-governmental professional bodies work together instead of working against each other so that EM grows further as a specialty in India. Hope there will be common ground of assessing the competencies and logical conclusion to this without jeopardizing the aspirations and dreams of people wanting to take up Emergency Medicine. In EM we trust :)


Summary:
A. There are different ways of achieving something. No one path is perfect for everyone. So what do you want to choose?
B. DO NOT believe people giving blanket statements about things/issues. It's not just black or white!
C. Don't even believe this article. Do your own critical appraisal!!!
D. Visit the college/hospital, speak to residents/trainees, consultants before joining any program. Know what you are doing and what you want to be!
E. Personally, depending upon all the above info, I would rank the qualifications as follows:
1)DNB EM 1)MRCEM  2)MD EM  3) MEM

References:

Disclosures and Conflict of interest: I have done my 3 years EM residency from Apollo Hospitals Hyderabad and have completed MRCEM. So there might be a slight positive bias towards Apollo in the Article although a conscious effort has been made to avoid the same. The views expressed here are the opinion of author only.


Author:
Dr. Apoorva Chandra
MBBS, MRCEM(UK)
Specialist Registrar – Emergency Medicine
Northwick Park Hospital

London, United Kingdom

Monday, July 24, 2017

Femoral Nerve block and Three-in-one block

Three-in-one nerve block may be used to block the femoral, obturator, and lateral femoral cutaneous nerves with a single injection. The femoral nerve runs down the thigh in a fascial sheath that is continuous with the nerve sheath that contains all three nerves more proximally. Just like FICB, the idea is to inject a large amount of local anaesthetic that will track proximally, medially, and laterally and thereby block all three nerves and provide more complete analgesia of the femoral neck and hip joint. 

The technique for performing both a femoral and three-in-one nerve block is identical except that the three-in-one block requires a larger volume of local anesthetic (25 to 30 mL versus 20 mL). Three-in-one nerve block provides better analgesia of the femoral neck and hip joint. 



Anatomy
The femoral nerve is formed from the posterior branches of L2-L4 and is the largest branch of the lumbar plexus. The nerve emerges from the psoas muscle and descends between the psoas and iliacus muscles. It passes under the inguinal ligament in the groove formed by these muscles lateral to the femoral artery and divides into anterior and posterior branches. 

The anterior branches innervate the anterior aspect of the thigh, and the posterior branches innervate the quadriceps muscle and continue below the knee as the saphenous nerve to provide sensory innervation from the medial side of the calf to the medial malleolus.




The lateral femoral cutaneous nerve arises from the second and third lumbar nerve roots. The nerve emerges from the lateral border of the psoas muscle and travels under the iliac fascia, across the iliac muscle, and under the inguinal ligament 1 to 2 cm medial to the anterior superior iliac spine. It branches into anterior and posterior branches 7 to 10 cm below the anterior superior iliac spine. The anterior branch innervates the skin over the anterolateral aspect of the thigh to the knee, whereas the posterior branch of the nerve innervates the lateral part of the thigh from the greater trochanter to the middle of the thigh.

The obturator nerve arises from the anterior divisions of L2-L4. It descends through the fibers of the psoas muscle and emerges from its medial border near the brim of the pelvis. It then passes behind the common iliac arteries and runs along the lateral wall of the lesser pelvis, above and in front of the obturator vessels to the upper part of the obturator foramen. Here, it enters the thigh through the obturator canal and divides into an anterior and a posterior branch. The obturator nerve is responsible for sensory innervation of the skin of the medial aspect of the thigh and motor innervation of the abductor muscles of the lower extremity.



Technique
  • Arrange the equipment and take verbal/written consent
  • Place the patient in a supine position
  • Do a quick neuromuscular exam 
  • Prepare the skin overlying the femoral triangle following usual aseptic precautions 
  • Palpate the femoral artery 1 to 2 cm distal to the inguinal ligament and inject a subcutaneous wheal of local anaesthetic (1% Lignocaine) 1 to 2 cm lateral to this point. Keep the nondominant hand on the femoral artery throughout the remainder of the procedure. 


  • Insert a 22-gauge needle just lateral to the artery at a 30-60 degree angle to the skin. Slowly advance the needle cephalad until one of the following occurs: 
  1. a “pop” with sudden loss of resistance (signifying penetration into the femoral nerve sheath) is felt
  2. a paresthesia is elicited, 
  3. the needle pulsates laterally, which signifies a position adjacent to the femoral artery. Inject 25 to 30 mL of aesthetic (0.25% Bupivacaine). 
  • The block usually takes 15 minutes to take effect. If proximity to the nerve is uncertain (e.g., a pop is not appreciated, a pares- thesia is not elicited, or the needle does not move with pulsa- tion of the femoral artery), inject the anesthetic in a fanlike distribution lateral to the femoral artery in an attempt to anesthetize the nerve.

  • It is also recommended to apply finger pressure 2 to 4 cm below the injection site to help spread the local anesthetic proximally to the obturator and lateral femoral cutaneous nerves. 


How is three-in-one block/femoral N block different from FICB?

The injection site for FICB is more lateral as compared to Femoral/Three-in-one block and thus FICB is less likely to injure the vessels. Additionally, FICB is a compartment block and thus requires more volume of local anaesthetic. 


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     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic