An overview of GWU MEM exit exam 2016 in AsterDM health care group of institutions: write up by Dr.Vivekshnu Varma Delhi

MEM EXIT EXAM- Calicut- a bird's eye view.

Today It was my pleasure to monitor the MEM exam in calicut.

With good grace of Dr Venu sir, who has organised the event so well.
It was flawless Multiple choice question paper with 200 questions.

We had all the 3 batches from 1st year to final year EM residents of  around 50 in number sitting with writing pads, pencil & eraser at 9.30am.
Final years were writing their exit exam and others were giving year exam.
There were different sets of questions for each batch.

All candidates were provided with juice packets as refreshment before onset of exam to keep them charged up, which was innovative effort.

Than Examiner's team brought sealed packets of question papers from Ronald Reagan Institute- George Washington University.

At 10am sharp, we distributed the question papers & answer sheets.

Every candidate was looking confident, comfortable, and excited to score the best in exam.

Exam was well arranged in seminar hall with everyone sitting at a distance of 5 seats, & seats were well labelled with the name of participants.

All mobiles, electronic devices, books and bags were not permitted in exam hall.

So there was pin drop silence for 4hrs with stop watch showing time on main-screen.

I observed that all the candidates were honestly writing exam, without any cheating or asking anyone else.

That proved that all the candidates were well prepared with theory and well versed due to frequent mock tests every month in internal exam.

Questions were lengthy with clinical photos of patient's bodypart, Xray, ECG,  USG, & lab reports just like in USMLE and MRCP exams.

MCQ were based from typical indian emergency scenario like we daily see while working in Medanta- the Medicity since last 4yrs.

MCQs covered are all medical Superspeciality emergencies in tertiary care including emergencies in dialysis, post organ transplant in kidney, liver & heart; upper GI bleed in CLD; STD diagnosis and treatment;
Obs gyne about normal delivery,  perimortem caesarian, neonatal pediatrics about croup, ENT, eye injuries and grades of burn in acid, neurosurgery & head trauma management,  orthopedic trauma, assault,  gunshot, electrocution, kerosene burn, acid burn face, suicidal & homicidal poisoning with sedatives, cardiotoxicity, drug overdose, polytrauma, choking, pneumothorax,  cardiac tamponade, liver rupture and the ATLS protocols in handling Mass casualties by -START rapid triaging.

Questions also covered decision making by using BLS, ACLS, PALS guidelines while managing medical emergencies including cardiac arrest & stroke in different age group of patients & treatment.

Answer options were meticulously drafted based on recent evidence based journal articles & Tintinalli's emergency medicine.
Multiple options were so similar but different on deep thought- it was playing with words to confuse the participants.

In last there were Questions about Medical ethics in emergency, MCI code of ethics & recent updated regulations for free treatment in emergency situations,  breaking bad news to relatives,
Quality of care, medical negligence, unethical conduct, SEMI guidelines for ethical practices in emergency were a new entry in pattern, as most medical exams in India rarely ask questions on ethics- similar to GCP guidelines asked in Europian exams- Good Clincical practice guidelines

One unique feature I noticed that all candidates after completion of exam were having winner's smile over face with pace of a lion walking back to their den after mind blowing session to today's written MEM exam.

Thanks to Dr Venu and his team of expert doctors,  nurses & paramedics - who are perfect in co-ordinating academic events on time, even when it was raining continously outside in calicut.

Oral Boards in MEM Exit Exam, calicut today

To maintain the practice of Fair & just Oral boards- All the Examiners in today’s session were externals from Emergency departments of premier institutes outside kerala & no one was examiner from the MIMS Institute. 

Dr TV Ramakrishnan was from Ramchandra Medical college Chennai, Dr Srinath Kumar TS from Narayana Health Bangalore, Dr Vivekanshu from Medanta- the Medicity, Gurgaon. Dr Tenagne Haile Mariam was international examiner from George Washington University, USA.

It was divided into 4 modules- 3 long cases in first 3 modules- One of case of acute trauma needing emergent surgery, one pediatric emergency requiring immediate intubation, one case of witnessed cardiac arrest – Mega code & last module was- Triple case with triple emergencies in the same patient.

The Goal of Oral Boards was to monitor that candidates – “Do No Harm to patient in Emergency” by either wrong drug in wrong dose via wrong route at wrong time.
Or doing wrong procedure in wrong manner via wrong approach following wrong protocols.
Neither there should be delay of the necessary Treatment.

The motto of the Examiners was that the participants should remember the common presentation of uncommon emergencies & uncommon presentation of common emergencies.

In trauma case, we monitored that the student is proceeding sequentially with primary survey, cervical spine protection, secondary survey & necessary interventions on right time, in right manner.

Most of students were efficient in following the ATLS protocols during simulation. Students were shown CT-scan, X-rays, ECG, ABG & Lab values for assessing their practical know-how while managing without documented interpretation of CT, Xray reports by radiologists.

In Mega code, Examiners assessed the timely application of BLS & ACLS protocols with using Defibrillators, Antiarrhythmic & Inotropes in simulated scenario by reading ECGs & Bedside Echo during CPR as per latest 2015 AHA guidelines.

Triple case was challenging task for the student as well as the examiner- a new entry in MEM exams 2016.
In this the patient has multiple independent emergencies as the same time, & the student has to judge & decide what to treat first with surgery & what emergency can be managed conservatively in the same patient. 

So it was time management, involving multiple medical super-specialties, but the Emergency physician remains the captain of the ship in decision making.

Most of the students were able to identify the emergencies, & managed confidently.

 Questions were rapid fire while managing the long cases, judging clinical decision making in acute emergencies & recalling evidence based protocols with proper logic of using every medical intervention.

Most of students were performing with flying colours in demonstrating life saving skills, even when majority, i.e. 6 out of 10 candidates were fasting due to ongoing ramzaan.

Examiners were quite impressed by the extensive level of medical knowledge of students.

Examiners noted even small errors of the candidates while managing emergencies, although these errors didn’t harm the patient-
E.g.,

- In case of unconscious witnessed cardiac arrest patient with Ventricular Fibrillation on monitor, should we shock or should check pulse & shock?

 - inappropriate dosage calculation for high alert medications like Amiodarone, Epinephrine etc.

- What size of the Endotracheal tube to be used in kids of particular age during intubation?

- Arranging blood in Obstetric Emergencies, & relying on bedside investigations in decision making in unstable patients.

- Use of Anti-Tetanus immunoglobulins & vaccines in trauma & delivery cases.

-  Antibiotic policy of your Hospital for using broad spectrum antibiotics & specific antibiotics in curing acute infections & for prophylaxis.

- judiciously Using Analgesics in emergency.

- Communication skills in Emergency – explaining risks & benefits to patient, & their relatives- Breaking bad news.

-Procedure for taking written informed consent & explaining risks & complications of procedure.

- Hospital policy in Reporting Adverse events in case if anything goes wrong with the patient during treatment in emergency- How to proceed ethically & document ?

- Etiquettes with fellow consultants, seniors of different Speciality & staff during managing emergencies, &
- read back policy for following verbal orders on telephone to avoid errors.

After completion of viva, there was summary session in afternoon meeting among all examiners with all participants to discuss their plus points & their lacunae in sessions without disclosing their individual performance.

So that brought a platform for self-assessment, self- realization of their knowledge assimilation for all the participants. It was a precious moment to all the participants to have a face to face chat with expert examiners- getting practical tips to lead a successful clinical practice in Emergency & trauma care.

All the interactive assessment sessions were organized perfectly well by International Expert Examiner -Dr Tenagne, Dr Venu sir, Dr Shibu Varghese, Sister Reeshma & MIMS team.

Final day of MEM Exit Exam in Calicut- Day of Triple Celebration.

On the auspicious occasion of Eid today, we started scrutinizing the 3 yr period Logbooks of MEM candidates describing their 5 P’s:-
-Performance skills in handling patients in ED.
-Participation in academic activities.  
-Progress in Research & paper presentation.
- Personality development by extracurricular activities. - Public awareness work in sort of organizing camps & trainings.

 Everyone was out-forming in their own way, someone in ATLS/ ACLS instructor, some had cleared their MRCEP part 1/2/3, some had attended all the conferences, some had organized workshops.

Than all the MEM 3rd year were called to Seminar hall to present their academic thesis in 20 min duration for each.Examiners were happy to see good quality clinical research on innovative topics-
-Identifying high risk factors of Hep A infected progressing to Fulminant hepatic failure.
-Upper airway USG for locating ETT correctly.

-Use of Empiric Antibiotic in ED to control infections.

- Age as a risk factor for outcome on patients on ventilators.
-Study of comparison of RBS by glucometer & lab in ED.
-Echo for identifying shockable rhythm in cardiac arrest.
- Patient controlled Analgesia used in ED.
- Use of antibiotics in controlling SBP in CLD patients in ED.
- Using USG for diagnosing pulled elbow in kids.Every EM candidate did extensive research before starting the study, got approval from ethics committee of their hospital, conducted thorough recording of findings & came out with relevant statistically significant results.

And the award & Gold medal for Best thesis went by the name of Late Dr Pashupati Pandey to the Best student of 3rd yr MEM resident- Dr Shihana Saifuddheen, Award given by none other than the eminent teacher Dr TV Ramakishanan from Ramachandra Medical college & Dr Mariam from GW university of USA. 

Convocation Ceremony was chaired by Chief guest – CEO of Aster DM Healthcare- Prof KK Varma, SEMI National President Dr Srinath, SEMI Tamil nadu President Dr Sai Surendra , Dr Kingsley, Dr Vivekanshu from Medanta & other dignitaries.Chief Guest Prof KK Varma enlightened all of Aster family & examiners with his thought provoking anecdotes & insight.Dr Rahul Menon, Aster MIMS guided students with his tips to maintain dedication to save lives, determination to serve patients, devotion to duty as key areas for successful future.

A special guest was invited for giving certificates to all passed candidates- Survivor giving certificates to his saviors.

Mr Adarsh who came to ED in cardiac arrest, was revived after 45 min CPR in MIMS ED team including the MEM candidates & came out alive after staying 30days in ICU. 

There was the emotional turmoil of empathy & matter of pride for ED, when the whole story was shown on screen with expert comments.

Credit goes to Dr Venugopal Sir, Dr Shibu Varghese & his team of expert doctors & smartly trained nurses.So it was Triple celebration- Convocation, Eid &  celebrate saving life of Adarsh successfully.

With regards, Dr.Vivekanshu 
Medanta-The Medicity,Gurgaon