MD Emergency Medicine: Here are NMC Guidelines for Competency-Based PG Training Programme

New Delhi: Through a recent communication directed to the Directors/Principals/Deans of all medical colleges/institutes under the National Medical Commission (NMC), the Apex Medical Education Regulatory Body in India has notified guidelines for the competency-based postgraduate training programme for MD in Emergency Medicine.

These guidelines include subject-specific learning objectives, subject-specific competencies, syllabus, teaching and learning method, assessment etc.

Emergency Medicine is a speciality dedicated to diagnosing and treating all emergency medical disorders and injuries. "It encompasses a unique body of knowledge as defined by its scope of practice of Emergency Medicine includes the initial evaluation, diagnosis, treatment, and disposition of any patient requiring expeditious medical, surgical, or psychiatric care," the Commission mentioned.

Writing to the Heads of all the medical institutes across the country, the Secretary of the Apex Medical Commission Dr B Srinivas mentioned, "Reference is cited to Guidelines For Competency-Based Postgraduate Training Programme for M.D. In Emergency Medicine dated 20-09-2024 of the Post Graduate Medical Education Board (PGMEB) enclosed herewith. All concerned stakeholders are requested to kindly take note of the same."

Emergency Medicine encompasses acute aspects of almost all subspecialties and it is designed to ensure the management of patients in life-threatening emergencies by providing immediate and definitive care till the patient is taken over by the concerned specialty department.

"This curriculum aims to prepare an M.D. in Emergency Medicine to acquire the competencies pertaining to knowledge, skills, and attitude necessary to function independently and effectively under any circumstances. This will enable them to deliver high-quality emergency care and function effectively as educators, researchers, and administrators in Emergency Medicine," NMC mentioned in the guidelines.

Subject-Specific Learning Objectives: 

• Care for physiologically stable patients presenting to acute care across the full range of complexity

At the end of the MD Emergency Medicine Course the student should be able to: o Develop expertise in history taking, o Develop expertise in Physical examination, o Develop expertise in decision making and o Develop expertise in emergency management full range of disorders.

• Identify sick patients, be able to resuscitate and stabilise and know when it is appropriate to stop.

At the end of the Course the student should be able to:

♦ Deliver the role of emergency physician as an expert in resuscitation and stabilisation of critically ill patients.

♦ Lead or participate as a member of the resuscitation team.

♦ Communicate with the patients and their caregivers with empathy.

♦ Support and guide the resuscitation team. o Know when not to resuscitate and when to stop resuscitation.

♦ Care for the patients at the end of their lives.

• Care for acutely injured patients across the full range of complexity

 At the end of the Course the student should be able to:

♦ Anticipate and recognize the Life threatening, limb threatening trauma presentations. In all age groups

♦ Organize and alert the trauma team and ancillary laboratory and blood bank and other support systems

♦ Collect and analyze the information from the EMS and prepare the adjuncts and be ready to receive the trauma victims.

♦ Resuscitate, stabilize and manage the trauma patients as per ATLS guidelines and make correct and timely decisions in patient care.

♦ Refer to appropriate specialist care as indicated once the patient is stabilized.

♦ Decide and transport under supervision and after proper communication.

♦ Document the injuries, Notify medico legally if indicated.

♦ Be prepared for any disaster/ mass casualties

• Care for children of all ages in the ED, at all stages of development and children with complex needs

At the end of the Course the student should be able to: o Evaluate the paediatric patients and investigate appropriately.

♦ Make decisions, safeguard, resuscitate and care the paediatric patients.

♦ Communicate with empathy and clarity to the parents or guardians of the paediatric patients.

• Support the ED team by answering clinical questions and making safe decisions:

At the end of the Course the student should be able to:

♦ Understand the key steps in diagnostic reasoning, how to make clinical decisions and to recognize the factors that have a negative or positive impact on patient care.

♦ Acquire the skills to recognize and rectify cognitive errors that can cause harm and threaten patient safety.

♦ Acquire the knowledge-base and apply the core principles of evidence-based medicine to everyday clinical problems.

♦ Formulate safe plans of management and decisions on disposal.

♦ Effectively communicate with and seek opinion from the seniors in profession, subordinates and supporting staff for collective decision making.

• Deliver key procedural skills

At the end of the Course the student should be able to:

♦ Perform key emergency skills that are time critical and/or life/limb saving.

♦ Organize the equipment and manpower for the procedure concerned.

♦ Acquire knowledge, skills and attitude in Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Advanced Trauma Life Support (ATLS), Pediatric Advanced Life Support (PALS), Point of Care Ultrasound (POCUS) training, Neonatal Advance Life Support (NALS), Basic Disaster Life Support (BDLS) Advanced Disaster Life Support (ADLS), HAZMAT life support, or Equivalent Courses etc, by enrolling standard training courses with periodic updation

• Deal with complex and challenging situations in the work place

At the end of the Course the student should be able to:

♦ Anticipate and manage specific situations or circumstances that can have the potential to significantly impact patient care.

♦ Manage situations or circumstances that can affect the functioning of the Emergency Department like unpredicted events in relation to the interactions with patients attending the ED, other agencies attending the ED, challenging professional interactions or events that impact on the delivery of Emergency care.

♦ Document and timely report to the authorities if there are medico legal implications involved.

• Lead the ED shift

At the end of the Course the student should be able to:

♦ Lead the Emergency team during the ED shift o Organize the duty schedules for the ED

♦ Alert the response team and organize the functioning of the rapid response team in case of disaster or mass casualties.

♦ Ensure proper documentation and maintenance of registers.

♦ Communicate effectively with other departments.

• Support, supervise and educate

At the end of the Course the student should be able to:

♦ Support and give relevant suggestions to the superiors and management authorities.

♦ To Support, appreciate and supervise the subordinate staff in patient care and collective decision making.

♦ Educate and train the learners /juniors / undergraduates /public coming under his/her sphere.

• Participate in research and managing data appropriately

At the end of the Course the student should be able to:

♦ Participate in and undertake research

♦ Acquire fundamental knowledge. skills and attitude to collect, manage and analyze data from clinical materials.

♦ Develop the attitude towards sharing and disseminating information with presentations, posters and publication in indexed journals.

• Participate in and promote activity to improve the quality and safety of patient care

At the end of the Course the student should be able to:

♦ Participate in activities to improve the quality and safety of patient care by monitoring and evaluation of the system.

♦ Periodic review and feedback to identify the strength and weakness and to make corrective measures.

♦ Involve in patient education and public awareness programs.

♦ Suggest steps of improvement to the administrators so as to implement patient safety measures.

• Manage, Administer and Lead

At the end of the Course the student should be able to:

♦ Acquire the basic knowledge in the principles of ED administration

♦ Acquire the knowhow on how to establish and develop an Emergency Department with the necessary infrastructure and manpower as per accreditation standards.

♦ Lead all the activities in the Emergency Department, Academic, research and patient care activities.

♦ Participate in Conferences, workshops, curriculum improvement programs and peer group activities.

♦ Keep abreast of the recent advances in the field and incorporate in the patient care.

Subject Specific Competencies: 

By the end of the M.D. course in Emergency Medicine, the student should acquire the following competencies:

Cognitive Domain:

1. Prehospital Care - Comprehend the key features of emergency medical services, the role of prehospital equipment and adjuncts, air medical transport, neonatal and pediatric transport, and the dynamics of mass gatherings. Reflect upon their implications in the broader framework of emergency medicine.

2. Disaster Preparedness - Familiarize yourself with the conceptual and practical aspects of disaster preparedness and response mechanisms. This includes understanding the management of natural disasters, comprehending the medical response to bomb, blast, and crush injuries, becoming proficient in mass casualty and chemical agent management, and gaining knowledge about bioterrorism recognition and response, as well as radiation injury management.

3. Resuscitation - Grasp and internalize the principles and methodologies surrounding sudden cardiac death management, adult cardiopulmonary resuscitation, neonatal and child resuscitation, resuscitation in pregnancy, ethical concerns in resuscitation, cerebral resuscitation, therapeutic hypothermia, acid-base disorders, blood gases, fluid and electrolyte balance, cardiac rhythm disturbances, pharmacology of antiarrhythmics and vasopressor agents, patient evaluation in shock, fluid and blood resuscitation, anaphylaxis, acute allergic reactions, and angioedema management.

4. Resuscitative Procedures - Acquire skills and understanding in non-invasive airway management, pediatric airway management, tracheal intubation, mechanical ventilation, surgical airway management, neonatal and pediatric intraosseous and central venous access, adult venous and intraosseous access, hemodynamic monitoring, cardiac pacing, defibrillation, cardioversion, and pericardiocentesis.

5. Analgesia, Anesthesia, and Procedural Sedation - Learn to effectively handle acute pain in adults, pain in infants and children, and to administer local and regional anesthesia. Develop the ability to perform procedural sedation and analgesia, and manage adults with chronic pain

6. Emergency Wound Management - Attain a comprehensive understanding of wound evaluation, wound preparation for treatment, and different wound closure techniques. Learn to manage injuries to the face, scalp, arm, hand, fingertip, nail, leg, foot, and handle soft tissue foreign bodies. Gain knowledge about the management of puncture wounds, bites, and post-repair wound care.

7. Cardiovascular Disease - Enhance your knowledge and expertise in the evaluation, diagnosis, and management of a broad spectrum of cardiovascular conditions such as chest pain, acute coronary syndromes, cardiogenic shock, low probability acute coronary syndrome, syncope, congestive heart failure, acute pulmonary edema, and valvular emergencies. Learn about the evaluation, diagnosis, and management of cardiomyopathies, myocarditis, pericardial disease, thromboembolism, systemic and pulmonary hypertension, aortic dissection, related aortic syndromes, aneurysms of the aorta, major arteries, and occlusive arterial disease.

8. Pulmonary Emergencies - Understand and become proficient in managing respiratory distress, hemoptysis, acute bronchitis, upper respiratory tract infections, communityacquired pneumonia, aspiration pneumonia, non-infectious pulmonary infiltrates, empyema, lung abscess, tuberculosis, spontaneous and iatrogenic pneumothorax, acute asthma in adults, and chronic obstructive pulmonary disease.

9. Gastrointestinal Emergencies - Deepen your understanding of the evaluation, diagnosis, and management of acute abdominal pain, nausea, vomiting, disorders presenting primarily with diarrhea, acute and chronic constipation, upper and lower gastrointestinal bleeding, esophageal emergencies, gastroesophageal reflux disease, swallowed foreign bodies, peptic ulcer disease, gastritis, pancreatitis, cholecystitis, hepatic disorders, jaundice, hepatic failure, acute appendicitis, diverticulitis, bowel obstruction, volvulus, hernias in adults, anorectal disorders, gastrointestinal procedures and devices, and complications of general surgical procedures.

10. Renal and Genitourinary Disorders - Become adept at understanding and managing acute renal failure, rhabdomyolysis, emergencies in renal failure and dialysis patients, urinary tract infections, hematuria, acute urinary retention, male genital problems, urologic stone disease, and complications of urologic procedures and devices.

11. Obstetrics and Gynecology - Develop a solid knowledge base for managing vaginal bleeding in the nonpregnant patient, abdominal and pelvic pain in the nonpregnant female, ectopic pregnancy and emergencies in the first 20 weeks of pregnancy, comorbid diseases in pregnancy, normal pregnancy, emergencies after 20 weeks of pregnancy and the postpartum period. Learn about the emergency delivery process, vulvovaginitis, pelvic inflammatory disease, breast disorders, urogynaecology disorders, and complications of gynaecologic procedures.

12. Paediatrics - Cultivate a comprehensive understanding of the assessment procedures for children in the emergency department, care strategies for neonatal emergencies and common neonatal problems, sudden infant death syndrome, serious bacterial illness associated with fever, and various disorders related to the ear, eye, nose, mouth, and throat in infants and children. Further, enhance your skills in managing specific conditions like stridor, drooling, wheezing, pneumonia, heart diseases, gastrointestinal issues, and urinary tract infections in children. Learn about the intricacies of dealing with seizures and status epilepticus, headaches, altered mental states, minor head injuries, musculoskeletal disorders, rashes, sickle cell disease, oncology, hematology emergencies, hypoglycemia, and metabolic emergencies in infants and children.

13. Infectious Diseases - Develop a solid understanding of the evaluation process for sexually transmitted diseases, toxic shock syndrome, septic shock, soft tissue infections, and disseminated viral infections. Gain proficiency in managing HIV infection and AIDS, infective endocarditis, tetanus, rabies, and malaria. Become conversant with the assessment procedures for foodborne and waterborne diseases, zoonotic infections, medical issues of world travellers, occupational exposures, infection control, and standard precautions. Understand the pharmacological aspects of antimicrobials, antifungals, and antivirals.

14. Neurology - Attain expertise in the diagnosis and management of a variety of neurological conditions, including headache, facial pain, subarachnoid and intracerebral hemorrhage, stroke, transient ischemic attack, cervical artery dissection, altered mental status, coma, ataxia, gait disturbances, vertigo, dizziness, and seizures. Learn about the evaluation of acute peripheral neurologic lesions, chronic neurologic disorders, central nervous system and spinal infections, and comprehend the operations of central nervous system procedures and devices.

15. Toxicology - Enhance your understanding and skills in the assessment and management of patients with poisoning from various substances including a wide range of drugs, alcohols, pesticides, metals, industrial toxins, vitamins, herbals, and antimicrobials. Deepen your comprehension of the concept of dyshemoglobinemias.

16. Environmental Injuries - Gain knowledge about the diagnosis and management of environmental injuries like frostbite, hypothermia, heat emergencies, bites and stings, reptile bites, trauma from marine fauna, dysbarism, diving complications, drowning, thermal and chemical burns, electrical injuries, lightning injuries, mushroom poisoning, poisonous plant exposures, high-altitude medical problems, and carbon monoxide exposure.

17. Endocrine Emergencies - Understand and manage cases involving patients with type 1 and type 2 diabetes mellitus, diabetic ketoacidosis, alcoholic ketoacidosis, and hyperosmolar hyperglycaemic state. Learn to deal with thyroid disorders including hypothyroidism, myxoedema crisis, hyperthyroidism, and thyroid storm, and how to diagnose and manage adrenal insufficiency and adrenal crisis.

18. Hematologic and Oncologic Emergencies - Develop a thorough understanding of how to recognize and manage anemia, interpret tests of haemostasis, and handle acquired bleeding disorders. Acquire skills in managing clotting disorders, hemophilias, von Willebrand disease, sickle cell disease, other hereditary haemolytic anemias, and acquired haemolytic anaemia. Familiarize yourself with the details of transfusion therapy and the management of anticoagulants, antiplatelet agents, and fibrinolytics. Learn to manage emergency complications of malignancy

19. Eyes, Ears, Nose, Throat, and Oral Surgery - Develop proficiency in managing a wide spectrum of emergency conditions concerning the eyes, ears, nose, throat, and oral region. Learn about the diverse emergencies linked to the facial structure and jaw, epistaxis, nasal fractures, and rhinosinusitis. Enhance your understanding of the various oral and dental emergencies, infections and disorders of the neck and upper airway, and potential complications associated with airway devices.

20. Skin Disorders - Acquire in-depth knowledge about diagnosing and treating a multitude of skin disorders presenting in the emergency department, including serious generalized skin disorders. Learn to address disorders of the face and scalp, hands, feet, extremities, and disorders of the groin and skinfolds. Handle common skin disorders found on the trunk effectively.

21. Trauma - Enhance your capabilities in managing trauma in adults, children, geriatric patients, and during pregnancy. Gain expertise in handling various forms of trauma such as head, spine and spinal cord, facial, neck, and pulmonary trauma. Learn to evaluate cardiac trauma, abdominal trauma, penetrating trauma to the flank and buttocks, genitourinary trauma, and penetrating trauma to the extremities.

22. Orthopaedics - Cultivate your skills in the initial evaluation and management of orthopedic injuries, including those to the hand, wrist, elbow, shoulder, pelvis, hip, knee, and foot. Gain understanding of the diagnosis and management of neck and back pain, shoulder pain, hip and knee pain, systemic rheumatic diseases, nontraumatic disorders of the hand, acute disorders of the joints and bursae, and soft tissue problems of the foot.

23. Psychosocial Disorders - Attain expertise in understanding and handling behavioral disorders. Gain a thorough understanding of emergency assessment procedures, diagnostic criteria, psychotropic medications, rapid tranquilization, anorexia nervosa bulimia nervosa, panic disorder, conversion disorder, and the management of substance abuse.

24. Abuse and Assault - Develop a sensitive and informed approach to managing issues related to child abuse and neglect, female and male sexual assault, intimate partner violence, and abuse of the elderly and impaired. Understanding the medicolegal aspects of abuse and assault in the state 25. Special Situations - Learn to manage health concerns for special populations such as injection drug users, transplant patients, morbidly obese patients, and patients facing grief, death, and dying. Gain knowledge of the legal aspects of emergency medicine.

26. Principles of Emergency Imaging - Acquire knowledge about non-invasive myocardial imaging, computed tomography, magnetic resonance imaging, and emergency ultrasonography. 27. Point of Care Ultrasound - Develop expertise in the use of point of care ultrasound in a variety of clinical scenarios. Understand its application for intubation and tube placement confirmation, guidance for venous access, echocardiography, transoesophageal echo, cardiac arrest, heart failure, valvular pathologies, lung and pleural assessment, hemodynamic status, FAST/E-FAST examination, peripheral nerve blocks, musculoskeletal ultrasound, joint aspiration, DVT screening, paracentesis, obstetric conditions, paediatric access, airway ultrasound, ocular ultrasound, and intracranial pressure measurement.

28. Medicolegal Aspects of Emergency Medicine Practice in India - Understand and apply the best standards of case documentation, consent, signs of established death, medicolegal proceedings, brain death criteria, validity of DNR/DNI/DNT orders, and various acts related to transplantation of human organs, MTP, PCPNDT, POCSO, Mental Health, Clinical Establishments, Sexual Harassment of Women at Workplace, Consumer Protection, Domestic Violence, Good Samaritan Law, Hospital Protection Act. Learn about court procedures, dying declaration, expert witness roles, inquests, subpoenas and summons, medicolegal autopsy, wound and injury documentation, associated offenses, rape case procedures, and the role of the Clinical Forensic Medicine Unit.

29. Administration - Understand and apply concepts related to credentialing, career development, recruitment, budgeting, health care financing, managed care, personnel management, public relations, marketing, hospital administration, practice management, contracts, work schedules, cost containment, NABH, JCI, NMC, NBE requirements, and hospital and Emergency Department administrative organization.

Psychomotor Domain:

Clinical assessment skills:

1. Elicits a focused clinical history

2. Perform a thorough physical examination of all the systems

a. Respiratory system

b. Cardiovascular system

c. Neurological system

d. Abdomen including hernia and rectal examination

e. Ophthalmologic examination

f. ENT examination

g. Obstetric examination

h. Dermatologic examination

Procedural Skills (Minimum number of procedures that a candidate needs to perform): 

These skills include (1) Airway Management and Cervical Spine Control, (2) Cardiopulmonary resuscitation, (3) Electric Therapy, (4) ECG interpretation, (5) Ventilator management, (6) Basic trauma management and Advanced, (7) Pulmonary procedures, (8) Cardiovascular procedures, (9) Decontamination procedures, (10) Paracentesis, (11) Neurological: Lumbar puncture, (12) Wound management, (13) Orthopedic emergency procedures, (14) Local and regional anaesthesia: Conscious sedation and analgesia, (15) Ear, nose and throat procedures, (16) Maxillo-facial techniques, (17) Ocular techniques, (18) Gynaecological and Obstetrics, (19) Others, (20) Transportation of Patients, (21) Communication Skills, (22) Ultrasonography and echocardiography (both diagnostic and therapeutic), (23) Interpretation of laboratory investigations/plain X-rays/CT/MRI, (24) Major incident planning.

Affective Domain:

1. Communication and Interpersonal Skills:

This involves empathetic communication with patients and their caregivers, effective collaboration with team members, and the establishment of effective relationships with other departments and staff members.

2. Leadership and Teamwork:

The ability to lead effectively in an Emergency Department (ED) setting, including managing duty schedules, coordinating response teams, and handling disaster or mass casualty situations. This also includes functioning collaboratively as part of a team.

3. Informed Decision Making and Professionalism:

The capacity to make informed decisions based on sound diagnostic reasoning and to act with professional integrity and responsibility, including timely and accurate reporting of medico-legal implications.

4. Commitment to Patient Care and Lifelong Learning:

The commitment to improve the quality and safety of patient care, emphasizing a patient-centered approach, along with a dedication to self-improvement, self-directed learning, and staying abreast of recent advances in the field.

5. Ethics in End-of-Life Care:

Sensitivity and understanding towards ethical issues in end-of-life care, including making informed decisions about resuscitation and providing empathetic care for patients at the end of their lives.

Apart from these, the guidelines include the syllabus of the subject and the teaching and learning methods- including formal teaching sessions in Emergency Medicine Department, list of recommended textbooks, journals, Log Book, etc.

Further, the guidelines also include details of Assessment such as formative assessment, summative assessment. The NMC guidelines also include a format of Emergency Medicine Workplace Based Observation Direct Observation of Procedural Skills, Emergency Medicine Workplace Based Observation Shift Based Assessment, Emergency Medicine Workplace Based Observation Clinical Skills in annexures.

These guidelines come amidst the recent controversy and ongoing legal proceedings against the NMC decision to remove three departments- Physical Medicine and Rehabilitation (PMR), Respiratory Medicine, and Emergency Medicine from the list of departments that every medical college/institution must have to be approved for undergraduate medical admissions on an annual basis. Currently challenging the decision, Indian Chest Society and Indian Association of Physical Medicine and Rehabilitation have filed a PIL before the Nagpur Bench of Bombay High Court.

To view the guidelines, click on the link below:

https://medicaldialogues.in/pdf_upload/nmc-guidelines-256262.pdf

Also Read: What Will Happen if Respiratory Medicine Dept Goes Away from 706 Medical Colleges? HC to decide on NMC Decision