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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, November 5, 2018

Prep for DNB Emergency Medicine (India) - by Manasa Seshadri

I cleared my DNB EM Practical Exam and with that, I have successfully completed my Post Graduation in Emergency Medicine. 
If you are pursuing the emergency medicine course in a hospital with inadequate/ negligent bedside training and academics or have faced discrimination and / or oppression while working in your department, I will tell you straight away that YOU ARE NOT READY to face the practical exam conducted by NBE and you have to gear up, right now. Most of you are likely to belong to the above mentioned group, given the current political debacle and bureaucracy trends in EM in our country, which hopefully will change in years to come. That topic, for another day, another time. Now, only about the preparation for the practicals.
I was sure as hell not adequately prepared for the exam. If given 3 months from now to prepare and give the exam again, I still won’t be adequately prepared. Most of what I am writing here is from the understanding I gathered after the exam and not before! Even saying that loud sounds scary to me, but it’s true!

First things first, the DNB EM practicals is a 2 day marathon. It is quite a lot. So grab an energy drink. The guidelines for conduction of the practical exam are sincerely followed in all centres where the exam is conducted. The order (cases, spotters, OSCE, viva) may get shuffled, however that is not your concern. You have to be prepared for all stations and equally. Like theory, every point you make to the examiner should count.

You will be given 4 long cases and 4 short cases. You would be given 15 minutes to take history, examine, and format a diagnosis and plan of care for a long case. You will be given 5 minutes to do the same for a short case, however the history and the examination will be limited to the organ / part of body in question.

Long case 25 marks each case – total 100 marks
Short case 10 marks each case – total 40 marks

The viva for the long case will be taken for 15 minutes and the short case for 5 minutes. There was a bell at the end of time and the viva did not exceed this time limit where I gave my exam.
The long cases are one case each in:
a. Medicine
b. Surgery
c. Trauma and Orthopaedics
d. Paediatrics 

You will have to be aware of Medicine, Surgery, Trauma and Ortho, Paediatrics format of examination and know what specific questions to ask in history. This will require you to touch upon basic clinical aspects of these subjects from the respective books other than reading only the standard EM books. I would have written the above sentence in bold, but I don’t want to scare you 
Understand here that the viva may will not be ABCDE that you are so fond of and familiar with as an Emergency physician, it may not include any part of ABCDE at all depending on your exam centre and your examiner. For example, my long case in Medicine was an acute exacerbation of COPD and LRTI. I was revising the resuscitation algorithms for the same before I was called for viva. 10 out of 15 minutes of my viva was to enlist the indoor and outdoor pathogens causing COPD. Beyond vehicular smoke, cigarettes and kerosene, I was lost. I dug into my memory from MBBS to find more points and my examiner only waited for me to respond and did not ask me anything else. What my examiner wanted to elicit from me was the various ingredients of gober gas that can cause COPD. The longest 10 minutes of my life. Not because the question was tough, but I was not oriented to react to that question in the last 2 years of my training.

Pick up the recent editions of Kundu / Algappan and /or Hutchison and brush up on the basics. Similarly for Surgery- you will have to know examination of let’s say, a chronic venous insufficiency or amoebic liver abscess the way you did when you were preparing for Surgery practicals in MBBS. 

The short cases are one case each in 4 out of the 5 subjects below:
a. Dermatology
b. Ophthalmology
c. Obstetrics & Gynaecology
d. ENT
e. Psychiatry 

As with the long cases, you will have to be aware of an Ophthalmology, ENT, Psychiatry, and OBG format of examination and know what specific questions to ask in history. This will require you to touch upon basic clinical aspects of these subjects from the respective books other than reading only the standard EM books. 

You need to be familiar with using an ophthalmoscope, a nasal speculum, an otoscope. These instruments were just kept on a table outside, and it was upto us to use them as required. So no visual cues of these instruments on the bed to alert you to use them, be warned  You may be asked to demonstrate the use of these instruments on your patient. So obviously you need to be aware of what normal looks like and what pathology looks like with the use of these instruments.

Summary for case presentation, you have to prepare for the cases (enlisted in the GUIDELINES FOR CONDUCT OF DNB EMERGENCY MEDICINE PRACTICAL EXAMINATION INCLUDING OSCE) both from respective subject clinical books (MBBS clinical reference books would suffice, speciality clinical books on the same are not required) and EM books. I did not do the former, and it was difficult for me to answer the viva.

The EM books that I read for cases were:
• Tintinallis 8th edition
• Emergency Medicine Oral Board Review , 2 nd edition

Other books that may help are:
• The RESUSCITATION CRISIS MANUAL Scott D. Weingart David C. Borshoff
• The Atlas of Emergency Medicine by Kevin J Knoop , Lawrence B Stack , Alan B Storrow, R Jason Thurman
• Clinical books used as reference in MBBS

It is an objective assessment, so gather all your points here. You say the right thing in the right order and narrate your resuscitation algorithm, you are awarded points. Each right point mentioned, will fetch you a mark and grab them all. It is very doable with repeated revision. These are listed under OSCE stations and called Skill stations in the “GUIDELINES FOR CONDUCT OF DNB EMERGENCY MEDICINE PRACTICAL EXAMINATION INCLUDING OSCE”. Like most of you would have, I had completed BLS, ACLS, ATLS, PALS provider courses and had revised the respective manuals for this station.

Algorithms you need to be prepared for include:
1. BLS (5 marks)
2. ACLS (10 marks) the examiner may take you from a stable patient with stable rhythm to stable tachy to unstable tachy to brady to arrest. Be well versed with drugs and doses, and defib or cardioversion joules. 
3. ATLS (Core case scenario/primary and secondary survey/Helmet removal/Spine board applications/ cervical spine stabilization) (10 marks)

I got a hypothetical polytrauma case with extremity fracture, tension pneumothorax and FAST positive internal bleeding, and had to go through the entire ATLS format.
After that I was asked to demonstrate Helmet removal for another hypothetical case. I thought the question was straight forward and went ahead to remove the helmet according to the protocol, when my examiner interrupted asking me if Primary assessment was not important before I proceeded with the helmet removal. So treat the mannequin as a real patient and do what you would do in real life scenario. These approaches are however subject to the exam centre and your examiner, and you will get familiar with what he/she wants on call.

4. PALS/NALS (10 marks)
Yes, you have to know NALS, as perfectly as you know ACLS. No compensation.

5. Airway (10 marks)
I was given a case scenario by the examiner, and I was required to arrive at the diagnosis (mine was anaphylaxis) and list down the assessment and approach to a difficult airway. This will require you to read an anaesthesia book for the same. Any suitable handbook would do. You need to be familiar with all the assessments of the airway, all the devices used and their indication for use, advantages and disadvantages of each over one another, surgical airways and narration of the surgical procedures for the airway. Watch videos on youtube and familiarise yourself with verbalising the procedures. You may include MRCEM PART C videos as a preparation material for this, but it won’t suffice as a sole source.

6. Surgical skill station (Suturing/Central line insertion/ICD/wound care) (10 marks)
If you are given a suturing scenario, it begins with assessment of the wound, which will include the depth, character of the wound, indication for suturing, wound cleaning, need for prophylactic antibiotic or not, consent, types of suture materials, advise for suture removal, types of sutures, demonstration of suturing technique (you will have to be familiar with atleast a couple of different suturing techniques other than simple interrupted sutures). Whether you will be asked all of this is left to the discretion of the examiner, but your preparation will have to include all this. Watch appropriate videos online for this station as well. You may include MRCEM PART C videos as a preparation material for this, but it won’t suffice as a sole source.

7. Ortho skill station (Hemorrhage control/log roll/splints/pelvic binder) (10 marks)
I was asked to demonstrate application of a pelvic binder , and here again my examiner expected me to go through the primary survey of ATLS , I had to determine a hypothetical pelvic bleed with the ultrasound machine , stabilise vitals with basic resuscitation , and end the examination with the observation that BP had improved a little with the binder placement. To what length he wants to keep the station active and assess you is completely upto the examiner, but never fail to be in your most alert senses to answer the questions and use presence of mind.

Don’t expect to be provided with clues if you are fumbling with order of examination or assessment. The examiner is more likely to keep silent and mark you than help you with clues to move forward.

8. Communication skills (10 marks)
This is one thing that I had prepared for from only one source the MRCEM part C OSCE book, Communication skills chapter. But what you need to know is you can only gather the format of dealing with these situations from the OSCE book, but the actual way of answering an Indian relative/patient in stress can be more beneficial from practicing with friends or seniors.

My scenario was talking to an angry parent whose son had developed complications of dengue on day 3, and had been sent home from ER on day 1.
My job was not just “talking to an angry relative”, but it included arriving at a diagnosis of a probable viral hemorrhagic fever from the history and hypothetical examination, answering about risks of dengue in Indian environment and what I planned to do with the patient further.

Similarly, if your scenario is breaking bad news or death of the patient to the relative and you want to address organ donation with him/ her, you have to be familiar with laws regarding the same in the Indian scenario.

III.SPOTTERS: (4 marks for each spotter, 40 marks total)
A good area to score points, but needs a good amount of preparation.
We had 10 spotters, 2 minutes for each spotter, and 2 questions to be answered for each spotter.
The areas that you need to cover are :
1. USG (image / video)
2. X-ray chest and Ortho related X ray
3. CT brain
4. ECG
5. ABG
6. Clinical photograph
I don’t think there are any standard books for all of these, but you need to read books which teach you basics of how to read an X-ray, how to read a CT scan, how to read an ECG, how to read an ABG to start with. Then, you need to solve these problems from any number of sources online or apps which offer tests for the same. There is no end to prepare for these spotters, do it every day for some time during your preparation.

Some books that may help are:
• ECG made easy
• X ray made easy
• Emergency ultrasound made easy
• Paul Marino ICU book for ABG

Kindly don’t limit yourself to only the above-mentioned books, keep reading anything relevant that you find online.

Another good station to score points. We did not have a separate station for ultrasound, for us it was clubbed with the ATLS station.so only USG we had to demonstrate was EFAST. Will not be the case with all centers. Don’t rely on it.

Things you need to be familiar with are:
Use of the machine
Use of different knobs.
Optimization of the image
Focusing of the image
Lung ultrasound
Abdomen ultrasound
Leg ultrasound
Diagnosis based on the ultrasound findings and treatment
Ultrasound protocols in shock

The viva where my exam was held consisted of Thesis, Waste Disposal and Recent advances in Emergency Medicine. This again may be subject to the choice of different centers, but the thesis is very likely to be included and it is one of the things you can prepare for. Carry your thesis, obviously. I had carried a completed logbook as well, but it wasn’t asked for, at my center.

Thesis: you are required to be familiar with study population, study methods, main findings, why you chose to do this study, what results the recent studies in your topic have shown (remember your thesis would be a year old before you take the viva  )
Waste Disposal: which articles, which colored bags.
Recent Advances: well, any area of EM. You either know it or you don’t and it’s ok if you don’t. The entire viva lasted for about 10 minutes although the bell rang at 5 minutes.

And then, I was done.
In the end, I have to acknowledge and all of us did, that the standard for conducting the DNB EM practicals is quite high and we are not trained to face it in most institutes. The only reason I cleared the exam, and I say this with all honesty, is because of the help and assistance provided by seniors who had previously cleared the exam and discussed these things on WhatsApp about 3 weeks before the exam. And the assistance of friends who took the exam with me, who were well trained and well advised by their superiors, who helped me with insight and learning in the last minute. Please don’t make your practical exam preparation as haphazard as mine.

Begin your preparation in the first year and take help from well-meaning seniors.
All the best.
Be better every day.

Manasa Seshadri 

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