DNB Emergency Medicine in India: Check out NBE released Curriculum

The National Board of Examinations (NBE) has released the Curriculum for DNB Emergency Medicine. 

Emergency Medicine (EM) is a vital specialty which provides an essential service for patients and communities and fulfils a unique and crucial remit within the national healthcare system. International Federation for Emergency Medicine defines Emergency Medicine (EM) as a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioral disorders. It further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development.

I. INTRODUCTION:

Introduction to Emergency Medicine

Emergency Medicine is an inter-disciplinary specialty, one which is interdependent with all other clinical disciplines. The overarching aim of the Emergency Medicine Programme (EMP) is to improve the safety and quality of care and reduce waiting times for patients in Emergency Departments (EDs) throughout the country. It encompasses a large amount of general medicine and surgery including the surgical sub-specialties. Some of the competencies identified for Emergency physicians are those required of a hospital specialist in any medical discipline whilst others are more specific to the practice of Emergency Medicine.

Emergency Medicine has a unique field of action, both within the Emergency Department and in the community. The practice of Emergency Medicine includes the pre-hospital and in- hospital reception, resuscitation and management of undifferentiated urgent and emergency cases until discharge from the Emergency Department or transfer to the care of another physician. It also includes involvement in the development of pre-hospital and in-hospital emergency medical systems.

The emergency physician requires a broad field of knowledge and advanced procedural skills often including surgical procedures, trauma resuscitation, advanced cardiac life support and advanced airway management. Emergency Physicians are able to look after patients with a wide range of pathologies from the life-threatening to the self-limiting. They are experts in identifying the critically ill and injured, providing safe and effective immediate care. They are also expert in resuscitation and skilled in the practical procedures needed.

Emergency medicine is a relatively new academic discipline in its infancy in India. As the medical field is an ever growing field, and emergency medicine is rapidly progressing, there is a need to update the knowledge and practice evidence based approach. A dedicated Emergency Medicine faculty will be the key factor in developing a national skilled emergency care workforce.

II. PROGRAMME GOALS:

The goal of the training program is to produce Emergency Physicians with the necessary knowledge, skill and attitude to diagnose and manage a wide range of clinical problems in Emergency Medicine as seen in the community or in secondary/tertiary care setting in an effective manner.

The qualities to be absolutely necessary: 

1. Sound knowledge and skills of the emergency aspects of medical and surgical speciality, and its application within the golden hour.

2. Competent in life saving emergency interventions and appropriately use various diagnostic tests, and interpret their results intelligently & promptly.

3. Be familiar with the fundamentals of research methodology.

4. Possess humanistic qualities, attitudes and behaviour necessary for the development of appropriate patient-doctor relationship.

5. To assist and if necessary train juniors.

6. To keep up-to-date and be familiar with all recent advances in the field of Emergency medicine.

PROGRAMME OBJECTIVES

1.KNOWLEDGE & SKILLS-

As a result of the training under this program, at the end of 3 years of postgraduate training, a resident must acquire the following knowledge, skills and competencies:

 A thorough knowledge of pathological abnormalities, clinical manifestations, and principles of management of a large variety of medical and surgical emergencies of pediatrics, adults and geriatrics, affecting any organ system.

 Skill and competence to choose and interpret correctly the results of the various routine investigations necessary for proper management of the patient. While ordering these investigations, a resident must be able to understand the sensitivity, specificity and the predictive value of the proposed investigation, as well as its cost- effectiveness in the management of the patient.

 Skill and competence in emergency interventions like end tracheal intubations, needle cricothyrotomy, tracheostomy, needle thoracocentesis, Intercostal drain placement, pericardiocentesis, defibrillation, mechanical ventilation, hemodialysis, ultrasonography, Echo so on and so forth.

 Skills and competence to perform commonly used diagnostic procedures, namely, lumbar puncture, bone marrow aspiration/biopsy, liver/nerve/muscle/skin/ kidney/ pleural biopsy, fine needle aspiration cytology of palpable lumps, pleural/pericardial/abdominal/joint fluid aspiration.

 Skill and competence to choose and interpret correctly the results of specialized investigations including radiologic, ultra-sonographic, biochemical, hemodynamic, electro-cardio graphic, electrophysiological, pulmonary functional, hematological, immunological, nuclear isotope scanning and arterial blood gas analysis results.

 Skill and competence to provide consultation to other medical and surgical specialties and sub-specialties, whenever needed.

 Skill and competence to function effectively in varied clinical settings, namely emergency/critical care, ambulatory care, out-patient clinic, inpatient wards.

 Skill and competence to take sound decisions regarding hospitalization, or timely referral to other consultants of various medical sub specialties recognizing his limitations in knowledge and skills in these areas.

 Proficiency in selecting correct drug combinations for different clinical problems with thorough knowledge of their pharmacological effects, side effects, interactions with the other drugs, alteration of their metabolism in different clinical situations, including that in the elderly.

 Skill and competence to advise on the preventive, restorative and rehabilitative aspects including those in the elderly, so as to be able to counsel the patient correctly after recovery from an acute or chronic illness

 Skill and competence to understand research methodology in Emergency medicine and to undertake a critical appraisal of the literature published in various emergency medical journals and be able to apply the same in the setting in which the resident is working.

 Skill and competence to work cohesively in Resuscitation team along with paramedical personnel, maintain discipline and healthy interaction with the colleagues.

 Skill and competence to communicate clearly and consciously, and teach other juniorresidents, medical students, nurses and other paramedical staff, the theory as well as the practical clinical skills required for the practice of Emergency Medicine.

2. INTEGRATION

The entire educational program will be conducted in an integrated and co-ordinated mannerin association with various pre-clinical, para-clinical and clinical departments.The senior staff members of these departments will be requested to give lectures on various topics in relation with Emergency medicine, and focus on applied aspects.

III. TEACHING & TRAINING METHODS:

The fundamental components of the teaching programme in the department of Emergency Medicine should include:

1. Case presentations & discussion- once a week

2. Seminar – Once a week

3. Journal club- once in 2 weeks

4. Grand round presentation (by rotation departments and subspecialties)- once a week

5. Emergency case discussions – once a week

6. Statistical & mortality meet- once a month

7. Clinico-pathological meetings- once a month

8. Clinico-radiological meetings- once a month

9. Faculty lecture teaching- once a month

10. Clinical Audit-Once a Month

11. A poster and have one oral presentation at least once during their training period in a recognized conference.

The rounds should include bedside sessions, file rounds, documentation of case history and examination, progress notes, round discussions, investigations and management plan), interesting and difficult case unit discussions. 

 CLINICAL ROTATIONAL POSTING

The residents will rotate through both the emergency department and other clinical services. The residents will spend 7 months on the first and second year and in the third year will spend 8 months in the Emergency Department and of the remainder time rotating through other services. The rotations in the other departments will provide the residents with opportunities to develop important knowledge and skills in the core subjects. Expected rotations will be as follows: 

Year I

Emergency Department: 7 months

Orthopedic & wound care: 2wks/2wks

Pediatric EM: 1 month

ICU-1 month

CCU- 1 month

Anaesthesia-1 month

Year II

Emergency Department: 7 months

Ophthalmology/ENT- 2wks/2wks

OBG/Psychiatry – 2 wks/2wks

PICU- 1 month

Trauma- 1 month

Pediatric EM: 1 month

Year III

Emergency Department: 7 months

Trauma- 1 month

Research – 1-month

Radiology & Ultrasound- 2wks

Administration (EM Services)-2 wks

Elective- 1 month

PRACTICAL AND CLINICAL TRAINING

Apart from the clinical training of emergency cases in the Emergency Departments, practical hands on training in the various procedures are required: (Minimum number of procedures that a candidate needs to perform are:)

1. Advanced Life Support procedures in support of CPR- 10

2. Advanced Trauma Life Support procedures in support of stabilization of the traumatized patient- 10

3. Tracheal intubation with the use of paralyzing and induction agents as appropriate for rapid sequence intubation- 20

4. Cardioversion and defibrillation -10

5. Paediatric resuscitation- 10

6. Venous cutdowns -1

7. Closed chest cardiac massage- 10

8. Open chest cardiac massage -1

9. Emergency cricothyroidotomy- 1

10. Pacemaker placement- external, transvenous and transthoracic, E = 4, TV=2

11. Emergency pericardiocentes -1

12. Central venous catheter insertion- 5

13. Pulmonary artery catheter insertion- 1

14. Management of oxygen therapy and ventilators- 10

15. Incision and drainage of abscess, hematoma, furuncle and hemorrhoid-5

16. Wound debridement and laceration repair -10

17. Local field block, hematoma block and peripheral nerve block anesthesia -4

18. Preservation of served extremities- 2

19. Nail trephination -1

20. Tube thoracostomy -4

21. Closed reduction of hernias -1

22. Peritoneal lavage- 1

23. Arthrocentisis -2

24. Culdocentesis- 1

25. Thoracentesis- 2

26. Application and removal of splints and casts -10

27. Closed reduction of dislocated joints -2

28. Use of emergency immobilization and traction techniques- 10

29. Compartment pressure measurement -1

30. Management of epistaxis- 1

31. Removal of foreign bodies -2

32. Drainage of peritonsillar abscesses- 1

33. Stabilization of traumatically avulsed teeth- 1

34. Direct, fiberoptic and indirect laryngoscopy- 10

35. Emergency delivery of babies- 1

36. Removal of intrauterine devices- 1

37. Introduction of urethral catheters- 10

38. Suprapubic catheterization- 2

39. Lumbar puncture- 2

40. Sigmoidoscopy and anoscopy -2

41. Use of the slit lamp- removal of conjunctival and corneal foreign bodies- 4

42. Ocular tonometry -1

43. Insertion of Blakemore tube -1

44. Insertion of nasogastric, orogastric or intestinal tube- 10

45. Peripheral arterial puncture and cannulation- 25

46. Intraosseous infusion and administration of sedation and analgesia- 1

47. ECHO and emergency ultrasound

48. Correct documentation in the electronic medical record (EMR)

IV. RECOMMENDED CORE SYLLABUS

SYSTEM-BASED CORE KNOWLEDGE

This section of the curriculum gives an index of the system-based core knowledge appropriate to the management of patients presenting with undifferentiated symptoms and complaints. This list is mostly given in the following sequence: congenital disorders; inflammatory and infectious disorders; metabolic disorders; traumatic and related problems; tumors; vascular disorders, ischaemia and bleeding: other disorders. These lists cannot be exhaustive.

1. CARDIOVASCULAR EMERGENCIES IN ADULTS AND CHILDREN

• Arrhythmias

• Congenital heart disorders

• Contractility disorders, pump failure

• cardiomyopathies, congestive heart failure, acute pulmonary oedema,

• tamponade, valvular emergencies

• Inflammatory and infectious cardiac disorders

• endocarditis, myocarditis, pericarditis

• Ischaemic heart disease

• acute coronary syndromes, stable angina

• Traumatic injuries

• Vascular and thromboembolic disorders

• aortic dissection/aneurysm rupture, deep vein thrombosis, hypertensive

• emergencies, occlusive arterial disease, thrombophlebitis, pulmonary

• embolism, pulmonary hypertension

2. DERMATOLOGICAL EMERGENCIES IN ADULTS AND CHILDREN

• Inflammatory and Infectious disorders

• Skin manifestations of immunological disorders, systemic disorders, toxic disorders

3. ENDOCRINE AND METABOLIC EMERGENCIES IN ADULTS AND CHILDREN

 Acute presentation of inborn errors of metabolism

 Adrenal insufficiency and crisis

 Disorders of glucose metabolism hyperosmolar hyperglycaemic state, hypoglycaemia, ketoacidosis

 Thyroid disease emergencies hyperthyroidism, hypothyroidism, myxoedema coma, thyroid storm

4. FLUID AND ELECTROLYTE DISTURBANCES

• Acid-Base disorders

• Electrolyte disorders

• Volume status and fluid balance

5. EAR, NOSE, THROAT, ORAL AND NECK EMERGENCIES IN ADULTS AND CHILDREN

• Bleeding

• Complications of tumours, airway obstruction

• Foreign bodies

• Inflammatory and Infectious disorders angio-oedema, epiglottitis, laryngitis, paratonsillar abscess

• Traumatic problems

6. GASTROINTESTINAL EMERGENCIES IN ADULTS AND CHILDREN

• Congenital disorders Hirschsprung's disease, Meckel's diverticulum, pyloric stenosis

• Inflammatory and infectious disorders appendicitis, cholecystitis, cholangitis, diverticulitis, exacerbations and complications of inflammatory bowel diseases gastritis, gastroenteritis, gastro-oesophageal reflux disease, hepatitis, pancreatitis, peptic ulcer,peritonitis

• Metabolic disorders hepatic disorders, hepatic failure

• Traumatic and mechanical problems foreign bodies, hernia strangulation, intestinal obstruction and occlusion

• Tumours

• Vascular disorders/Ischaemia and bleeding: ischaemic colitis, upper and lower gastrointestinal bleeding, mesenteric ischaemia

• Other problems complications of gastrointestinal devices and surgical procedures

7. GYNAECOLOGICAL AND OBSTETRIC EMERGENCIES

• Inflammatory and Infectious disorders mastitis, pelvic inflammatory disease, vulvovaginitis

• Obstetric emergencies, abruptio placentae, eclampsia, ectopic pregnancy, emergency delivery,

• HELLP syndrome during pregnancy, hyperemesis gravidarum, placenta praevia, post-partum haemorrhage

• Traumatic and related problems ovarian torsion

• Tumours

• Vascular disorders/ Ischaemia and bleeding: vaginal bleeding

8. HAEMATOLOGY AND ONCOLOGY EMERGENCIES IN ADULTS AND CHILDREN

• Anaemias

• Complications of lymphomas and leukaemias

• Congenital disorders haemophilias and Von Willebrand's disease, hereditary haemolytic anaemias, sickle cell disease

• Inflammatory and Infectious disorders neutropenic fever, infections in immuno-compromised patients

• Vascular disorders/ Ischaemia and bleeding: acquired bleeding disorders (coagulation factor deficiency, disseminated intravascular coagulation), drug induced bleeding (anticoagulants,antiplatelet agents, fibrinolytics), idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura

• Transfusion reactions

9. IMMUNOLOGICAL EMERGENCIES IN ADULTS AND CHILDREN

• Allergies and anaphylactic reactions

• Inflammatory and Infectious disorders

• Acute complications of vasculitis

10. INFECTIOUS DISEASES AND SEPSIS IN ADULTS AND CHILDREN

Common viral and bacterial infections

• Food and water-born infectious diseases

• HIV infection and AIDS

• Common tropical diseases

• Parasitosis

• Rabies

• Sepsis and septic shock

• Sexually transmitted diseases

• Streptococcal toxic shock syndrome

• Tetanus

11. MUSCULO-SKELETAL EMERGENCIES

• Congenital disorders dislocated hip, osteogenesis imperfecta

• Inflammatory and Infectious disorders arthritis, bursitis, cellulitis, complications of systemic rheumatic diseases, necrotising fasciitis, osteomyelitis, polymyalgia rheumatica, soft tissue infections

• Metabolic disorders complications of osteoporosis and other systemic diseases

• Traumatic and degenerative disorders back disorders, common fractures and dislocations, compartment syndromes, crush syndrome, osteoarthrosis, rhabdomyolysis, soft tissue trauma

• Tumours: pathological fractures

12. NEUROLOGICAL EMERGENCIES IN ADULTS AND CHILDREN

• Inflammatory and Infectious disorders brain abscess, encephalitis, febrile seizures in children, Guillain-Barrè syndrome, meningitis, peripheral facial palsy (Bell's palsy), temporal arteritis

• Traumatic and related problems complications of CNS devices, spinal cord syndromes, peripheral nerve trauma and entrapment, traumatic brain injury

• Tumours common presentations and acute complications of neurological and metastatic tumours

• Vascular disorders: carotid artery dissection, stroke, subarachnoid haemorrhage, subdural and extradural haematomata, transient ischaemic attack, venous sinus thrombosis

• Other problems acute complications of chronic neurological conditions (e.g. myasthenic crisis, multiple sclerosis), acute peripheral neuropathies, seizures and status epilepticus

13. OPHTHALMIC EMERGENCIES IN ADULTS AND CHILDREN

• Inflammatory and Infectious disorders conjunctivitis, dacrocystitis, endophthalmitis, iritis, keratitis, orbital and periorbital cellulitis, uveitis

• Traumatic and related problems foreign body in the eye, ocular injuries,

• Vascular disorders: retinal artery and vein occlusion, vitreous haemorrhage

• Others like acute glaucoma, retinal detachment

14. PULMONARY EMERGENCIES IN ADULTS AND CHILDREN

• Congenital cystic fibrosis

• Inflammatory and Infectious disorders asthma, bronchitis, bronchiolitis, pneumonia, empyema, COPD exacerbation, lung abscess, pleurisy and pleural effusion, pulmonary fibrosis, tuberculosis

• Traumatic and related problems foreign body inhalation, haemothorax, tension pneumothorax, pneumomediastinum

• Tumours common complications and acute complications of pulmonary and metastatic tumours,

• Vascular disorders pulmonary embolism

• Other disorders: acute lung injury, atelectasis, ARDS, spontaneous pneumothorax

15. PSYCHIATRIC AND BEHAVIOUR DISORDERS

• Behaviour disorders affective disorders, confusion and consciousness disturbances, intelligence disturbances, memory disorders, perception disorders, psycho-motor disturbances, thinking disturbances.

• Common psychiatric emergencies acute psychosis, anorexia and bulimia complications, anxiety and panic attacks, conversion disorders, deliberate self-harm and suicide attempt, depressive illness, personality disorders, substance, drug and alcohol abuse

16. RENAL AND UROLOGICAL EMERGENCIES IN ADULTS AND CHILDREN

• Inflammatory and Infectious disorders epididymo-orchitis, glomerulonephritis, pyelonephritis, prostatitis, sexually transmitted diseases, urinary tract infections

• Metabolic disorders acute renal failure, nephrotic syndrome, nephrolithiasis, uraemia

• Traumatic and related problemsurinary retention, testicular torsion

• Tumours

• Vascular disorders: Ischaemia and Bleeding

• Other disorders comorbidities in dialysis and renal transplanted patients, complications of urological procedures and devices, haemolytic uraemic syndrome

17. TRAUMA IN ADULTS AND CHILDREN

• Origin of trauma: burns, blunt trauma, penetrating trauma

• Anatomical location of trauma: head and neck, maxillo-facial, thorax, abdomen, pelvis, spine, extremities

• Polytrauma patient

• Trauma in specific populations: children, elderly, pregnant women.

Common Presenting Symptoms

This section of the Curriculum lists the more common presenting symptoms of patients in the emergency setting. The differential diagnoses are listed according to the systems involved and then in alphabetical order.

1. Acute Abdominal Pain

 Gastrointestinal causes

Appendicitis, cholecystitis, cholangitis, acute pancreatitis, complications of hernias, diverticulitis, hepatitis, hiatus hernia, inflammatory bowel disease, intestinal obstruction, ischaemic colitis, mesenteric ischaemia, peptic ulcer, peritonitis, viscus perforation

• Cardiac/vascular causes

Acute myocardial infarction, aortic dissection, aortic aneurysm rupture

 Dermatological causes

Herpes zoster

 Endocrine and metabolic causes

Addison's disease, diabetic ketoacidosis, other metabolic acidosis, porphyria

 Gynaecological and Obstetric causes

Complications of pregnancy, ectopic pregnancy, pelvic inflammatory disease, rupture of ovarian cyst, ovarian torsion

 Haematological causes

Acute porphyria crisis, familial mediterranean fever, sickle cell crisis

• Musculo-skeletal causes

Referred pain from thoraco-lumbar spine

• Renal and Genitourinary causes

Pyelonephritis, renal stones

• Respiratory causes

Pneumonia, pleurisy

• Toxicology

Poisoning

 Trauma

Abdominal 

2. Altered Behaviour and Agitation

• Psychiatric causes

Acute psychosis, depression

• Cardiac/Vascular causes

Hypertension, vasculitis

• Endocrine and metabolic causes

Hypoglycaemia, hyperglycaemia, electrolyte imbalance, hyperthermia, hypoxaemia

• Neurological causes

Cerebral space-occupying lesions, dementia, hydrocephalus, intracranial hypertension, CNS infections

• Toxicology

Alcohol and drug abuse, poisoning

3. Altered Level of Consciousness in Adults and Children

• Neurological causes

Cerebral tumour, epilepsy and status epilepticus, meningitis, encephalitis, stroke, subarachnoid haemorrhage, subdural and extradural haematomata, traumatic brain injury

• Cardiovascular causes

Hypoperfusion states, shock

• Endocrine and metabolic causes

Electrolyte imbalances, hepatic coma, hypercapnia, hypothermia, hypoxia, hypoglycaemia/ hyperglycaemia, uraemia

• Gynaecological and Obstetric causes

Eclampsia

• Infectious causes

Septic shock

• Psychiatric causes

Conversion syndrome

• Respiratory causes

Respiratory failure

• Toxicology

Alcohol intoxication, carbon-monoxide poisoning, narcotic and sedative poisoning, other substances

4. Back Pain

• Musculo-Skeletal causes

Fractures, intervertebral disc strain and degeneration, strain of muscles, ligaments and tendons, spinal stenosis, arthritides, arthrosis

• Cardiovascular causes

Aortic aneurysm, aortic dissection

• Infectious causes

Osteomyelitis, discitis, pyelonephritis, prostatitis

• Endocrine and metabolic causes

Paget's disease

• Gastrointestinal causes

Pancreatitis, cholecystitis

• Dermatological causes

Herpes zoster

• Gynaecological causes

Endometriosis, pelvic inflammatory disease

• Haematological and Oncological causes

Abdominal or vertebral tumours

•Neurological cause

Subarachnoid haemorrhage

• Renal and Genitourinary causes

Renal abscess, renal calculi

• Trauma

5. Bleeding (Non Traumatic)

• Ear, Nose, Throat causes

Ear bleeding (otitis, trauma, tumours), epistaxis

• Gastrontestinal causes

Haematemesis and melaena (acute gastritis, gastro-duodenal ulcer, Mallory Weiss syndrome, oesophageal varices) rectal bleeding (acute diverticulitis, haemorrhoids, inflammatory bowel disease, tumours)

• Gynaecological and Obstetric causes

Menorrhagia/metrorrhagia (abortion, abruptio placentae, tumours)

• Renal and Genitourinary causes

Haematuria (pyelitis, tumours, urolithiasis)

• Respiratory causes

Haemoptysis (bronchiectasia, pneumonia, tumours, tuberculosis)

6. Cardiac Arrest

• Cardiac arrest treatable with defibrillation

Ventricular fibrillation, pulseless ventricular tachycardia

• Pulseless electric activity

Acidosis, hypoxia, hypothermia, hypo/hyperkalaemia, hypocalcaemia, hypo/ hyperglycaemia, hypovolaemia, tension pneumothorax, cardiac tamponade, myocardial infarction, pulmonary embolism, poisoning

• Asystole

7. Chest Pain

• Cardiac/vascular causes

Acute coronary syndrome, aortic dissection, arrhythmias, pericarditis, pulmonary embolism

• Respiratory causes

• Pneumonia, pneumomediastinum, pneumothorax (especially tension pneumothorax), pleurisy

• Gastrointestinal causes

Gastro-oesophageal reflux, oesophageal rupture, oesophageal spasm

• Musculo-Skeletal causes

Costosternal injury, costochondritis, intercostal muscle pain, pain referred from thoracic spine

• Psychiatric causes

Anxiety, panic attack

• Dermatological causes

Herpes zoster

8. Crying Baby

I - Infections: herpes stomatitis, meningitis, osteomyelitis, urinary tract infection T -Testicular torsion, trauma, teeth problems,

C - Cardiac: arrhythmias, congestive heart failure R -Reaction to milk, reaction to medications, reflux I - Immunisation and allergic reactions, insect bites

E - Eye: corneal abrasions, glaucoma, ocular foreign bodies

S - Some gastrointestinal causes: hernia, intussusception, volvulus

9. Diarrhea

• Infectious causes

AIDS, bacterial enteritis, viral, parasites, food-borne, toxins

• Toxicological causes

Drugs related, poisoning (including heavy metals, mushrooms, organophosphates, rat poison, and seafood)

• Endocrine and metabolic causes

Carcinoids, diabetic neuropathy

• Gastrointestinal causes

Diverticulitis, dumping syndrome, ischaemic colitis, inflammatory bowel disease, enteritis due to radiation or chemotherapy

• Haematological and Oncological causes

Toxicity due to cytostatic therapies

• Immunology

Food allergy

• Psychiatric disorders

Diarrhea "factitia"

10. Dyspnoea

• Respiratory Causes

Airway obstruction, broncho-alveolar obstruction, parenchymal diseases, pulmonary shunt, pleural effusion, atelectasis, pneumothorax

• Cardiac/vascular causes

Cardiac decompensation, cardiac tamponade, pulmonary embolism

• Ear, Nose, Throat causes

Epiglottitis, croup and pseudocroup

• Fluid & Electrolyte disorders

Hypovolaemia, shock, anaemia

• Gastrointestinal causes

Hiatus hernia

• Immunological causes

Vasculitis

• Metabolic causes

Metabolic acidosis, uraemia

• Neurological causes

Myasthenia gravis, Guillain Barrè syndrome, amyotrophic lateral sclerosis

• Psychiatric disorders

Conversion syndrome

• Toxicology

CO intoxication, cyanide intoxication

• Trauma

Flail chest, lung contusion, traumatic pneumothorax, haemothorax

11. Fever and Endogenous Increase in Body Temperature

• Systemic infectious causes

Sepsis and septic shock, parasitosis, flu-like syndrome

• Organ-specific infectious causes

Endocarditis, myocarditis, pharyngitis, tonsillitis, abscesses, otitis, cholecystitis and cholangitis, meningitis, encephalitis

• Non-infectious causes

Lyell syndrome, Stephen-Johnson syndrome, thyroid storm, pancreatitis, inflammatory bowel disease, pelvic inflammatory disease, toxic shock

• Haematological and Oncological causes

Leukaemia and lymphomas, solid tumours

• Immunological causes

Arteritis, arthritis, lupus, sarcoidosis

• Musculo-Skeletal causes

Osteomyelitis, fasciitis and cellulitis

• Neurological causes

Cerebral haemorrhage

• Psychiatric causes

Factitious fever

• Renal and Genitourinary causes Pyelonephritis, prostatitis

• Toxicology

12. Headache in Adults and Children

• Vascular causes

Migraine, cluster headache, tension headache, cerebral haemorrhage, hypertensive encephalopathy, ischaemic stroke

• Haematological and Oncological causes

Brain tumours

• Immunological causes

Temporal arteritis, vasculitis

• Infectious causes

Abscesses, dental infections, encephalitis, mastoiditis, meningitis, sinusitis

• Musculo-Skeletal causes

Cervical spine diseases, temporomandibular joint syndrome

• Neurological causes

Trigeminal neuralgia

• Ophthalmological causes

Optic neuritis, acute glaucoma

• Toxicology

Alcohol, analgesic abuse, calcium channel blockers, glutamate, nitrates, opioids and caffeine withdrawal

• Trauma

Head trauma

13. Jaundice

• Gastrointestinal causes

Cholangitis, hepatic failure, pancreatic head tumour, pancreatitis, obstructive cholestasis

• Cardiac/Vascular causes

Chronic cardiac decompensation

• Haematological and Oncological causes

Haemolytic anaemias, thrombotic thrombocytopenic purpura, haemolytic uraemic syndrome, disseminated intravascular coagulation

• Infectious causes

Malaria, leptospirosis

• Gynaecological causes

HELLP syndrome

• Toxicology

Drug induced haemolytic anaemias, snake venom

14. Pain in Arms

• Cardiac/Vascular causes

Aortic dissection, deep venous thromboembolism, ischaemic heart disease

• Musculo-skeletal causes

Periarthritis, cervical spine arthrosis

• Trauma

15. Pain in Legs

• Cardiac/Vascular causes

Acute ischaemia, arteritis, deep venous thrombosis, superficial thrombophlebitis

• Immunological causes

Polymyositis

• Infectious causes

Arthritis, cellulites, necrotising fasciitis, osteomyelitis

• Musculo-Skeletal causes

Sciatalgia

• Neurological causes

Sciatica

• Nervous system causes

Peripheral nerve compression

• Trauma

16. Palpitations

• Cardiac/Vascular causes

Brady-arrythmias (including sinus bradycardia and AV blocks), extrasystoles, tachyarrythmias (including atrial fibrillation, sinus tachycardia, supraventricular tachycardia,ventricular tachycardia)

• Endocrine and metabolic causes

Thyrotoxicosis

• Toxicology

Drugs

17. Seizures in Adults and Children

• Neurological causes

Generalised epilepsy, partial complex or focal epilepsy, status epilepticus

• Cardiac/Vascular causes

Hypertensive encephalopathy, syncope, dysrhythmias, migraines

• Endocrine and metabolic causes

Metabolic seizures

• Gynaecological causes

Eclampsia

• Infectious causes

Febrile seizures in children

• Psychiatric causes

Narcolepsy, pseudo-seizures

• Respiratory causes

Respiratory arrest

• Toxicology

Drugs/toxins

18. Shock in Adults and Children

• Anaphylactic

• Cardiogenic

• Hypovolaemic

• Obstructive

• Septic

• Neurogenic

• Cardiac/Vascular causes

• Cardiogenic shock, arrhythmias

• Endocrine and metabolic causes

Addison's crisis

• Fluid and Electrolyte disorders

Hypovolaemic shock

• Gastrontestinal causes

Vomiting, diarrhoea

• Gynaecological causes

Toxic shock

• Immunological causes

Anaphylactic shock

• Infectious causes

Septic shock

• Neurological causes

Neurogenic shock

• Trauma

Hypovolaemic shock, neurogenic shock.

19. Skin Manifestations in Adults and Children

• Dermatological causes

Eczema, psoriasis, skin tumours

• Immunological causes

Vasculitides, urticaria, Stevens-Johnson syndrome, Lyell syndrome

• Infectious causes

Viral exanthemata, meningococcaemia, herpes zoster/simplex, abscesses of the skin

• Psychiatric causes

Self-inflicted skin lesions or from abuse

• Toxicology

• Haematological and Oncological causes

Idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura

20. Syncope

• Cardiac/vascular causes

Aortic dissection, cardiac arrhythmias (including brady-tachy syndrome, Brugada syndrome, drug overdose, long QT syndrome, sick sinus syndrome, torsade depointes,ventricular tachycardia), other causes of hypoperfusion (including ischaemia, valvular, haemorrhage, obstruction: e.g. aortic stenosis, pulmonary embolism, tamponade), orthostatic hypotension

• Endocrine and metabolic causes

Addison's disease

• Fluid and Electrolyte disorders

Hypovolaemia

• Gastrointestinal causes

Vomiting, diarrhoea

• Neurological causes

Autonomic nervous system disorder, epilepsy, vasovagal reflex,

• Toxicology

Alcoholic or drug consumption

21. Urinary Symptoms (Dysuria, Oligo/Anuria, Polyuria)

• Renal and Genitourinary causes

Acute renal failure, acute urinary retention, cystitis and pyelonephritis, prostatitis

• Cardiac/Vascular causes

Cardiac decompensation

• Endocrine and metabolic causes

Diabetes mellitus, diabetes insipidus

• Fluid and Electrolyte disorders

Hypovolaemia

22. Vertigo and Dizziness

• Ear and Labyrinth causes

Benign postural vertigo, Meniere's disease, otitis, vestibular neuritis, viral labyrinthitis

• Cardiac/Vascular causes

Arrhythmias, hypotension

• Endocrine and metabolic causes

Hypoglycaemia

• Haematological and Oncological causes

Anaemias

• Nervous system causes

Acoustic neuroma, bulbar or cerebellar lesions, multiple sclerosis, temporal epilepsy

• Psychiatric causes

Anxiety

• Respiratory causes

Hypoxia

• Toxicology

Alcohol abuse, drugs and substances

23. Vomiting

• Gastrointestinal causes

Appendicitis, cholecystitis, gastroparesis, gastric obstruction and retention, gastroenteritis, hepatitis, pancreatitis, pyloric stenosis, small bowel obstructions

• Cardiac/Vascular causes

Myocardial ischaemia

• Ear, Nose, Throat causes

Vestibular disorders

• Endocrine and metabolic causes

Diabetic ketoacidosis, hypercalcaemia

• Fluid and Electrolyte disorders

Hypovolaemia

• Gynaecological and Obstetric causes

Pregnancy

• Infectious causes

Sepsis, meningitis

• Neurological causes

Cerebral oedema or haemorrhage, hydrocephalus, intracranial space occupying lesions

• Ophthalmological causes

Acute glaucoma

• Psychiatric causes

Eating disorders

• Renal and Genitourinary causes

Renal calculi, uraemia

• Toxicology

SPECIFIC ASPECTS OF EMERGENCY MEDICINE

1. ABUSE AND ASSAULT IN ADULTS AND CHILDREN

• Abuse in the elderly and impaired

• Child abuse and neglect

• Intimate partner violence and abuse

• Sexual assault

• Patient safety in Emergency Medicine

• Violence management and prevention in the Emergency Department

2. ANALGESIA AND SEDATION IN ADULTS AND CHILDREN

• Pain transmission (anatomy, physiology, pharmacology)

• Pain assessment

• Pharmacology of sedative and pain relieving drugs

• Psychological and social aspects of pain in paediatric, adult and elderly patients

3. DISASTER MEDICINE

• Disaster preparedness

• Major incident planning/procedures/practice

• Disaster response

• Mass gatherings

• Specific medical topics (triage, bioterrorism, blast and crush injuries, chemical agents, radiation injuries)

• Debriefing and mitigation

4. ENVIRONMENTAL ACCIDENTS IN ADULT AND CHILDREN

• Electricity (electrical and lightening injuries)

• Flora and Fauna (injuries from exposure, bites and stings)

• High-altitude (medical problems)

• NBCR (nuclear, biological, chemical and radiological:, decontamination, specific aspects)

• Temperature (heat and cold related emergencies)

• Travel medicine

• Water (near-drowning, dysbarism and complications of diving, marine fauna)

5. FORENSIC ISSUES

• Basics of relevant legislation in the country of practice

• Recognise and preserve evidence

• Provide appropriate medical documentation (including forensic and clinical photography, collection of biological samples, ballistics)

• Appropriate reporting and referrals (e.g. child abuse or neglect, gunshot and other forms of penetrating wounds, elder abuse, sexual assault allegations)

• Medico-legal documentation

6. INJURY PREVENTION AND HEALTH PROMOTION

• Collection and interpretation of data related to prevention and health promotion

• Epidemiology of Accidents and Emergencies

• Formulation of recommendations

7. PATIENT MANAGEMENT ISSUES IN EMERGENCY MEDICINE

• Emergency Department organization (administration, structure, staffing, resources)

• Management of specific populations: Children in special circumstances including child protection Elderly patients Homeless patients Mentally incompetent adults Psychiatric patients

8. PROBLEMS IN THE ELDERLY

• Atypical presentations (e.g. abdominal pain, infections, myocardial infarction)

• Delirium

• Dementia

• Falls (causes & investigations)

• Immobility

• Multiple pathology and multiple therapies

• Self-dependency

• Trauma & co-morbidity

9. TOXICOLOGY IN ADULTS AND CHILDREN

• General principles of toxicology and management of poisoned patients

• Principles of drug interactions

• Specific aspects of poisoning

• drugs (including paracetamol, amphetamine, anticholinergics, anticonvulsants, antidepressants, antihypertensives, benzodiazepines, digitalis, monoamine oxidase inhibitors,neuroleptics) industrial, chemicals plants & mushrooms alcohol abuse and alcohols poisoning drugs of abuse

• Local poisonings such as OPC, aluminium phosphide, yellow phosphorous, heavy metal poisoning, plant poisonings, paraquat poisoning, cyber methrine poisoning, corrosives petroleum products, methanol and ethanol, dyes and nitrobenzene.

• Organization and information (e.g. poison centres, databases)

10. PRE-HOSPITAL CARE

• Emergency Medical Services organisation (administration, structure, staffing, resources)

• Medical transport (including neonates and children, air transport)

• Paramedic training and function

• Safety at the scene

• Collaboration with other emergency services (e.g. police, fire department)

11. PSYCHO-SOCIAL PROBLEMS

• Social wellbeing of specific populations

• Patients with social issues

• Frequent visitors

• Social care following discharge

B. CORE CLINICAL PROCEDURES AND SKILLS

1. CPR SKILLS

• Cardio-pulmonary resuscitation procedures in a timely and effective manner according to the current ILCOR guidelines for adults and children

• Advanced CPR skills (e.g. therapeutic hypothermia, open chest CPR)

2. AIRWAY MANAGEMENT SKILLS

• Open and maintain the airway in the emergency setting (insertion of oropharyngeal or nasopharyngeal airway)

• Endotracheal intubation

• Alternative airway techniques in the emergency setting (e.g. laryngeal mask insertion, surgical airway)

• Difficult airway management algorithm

• Use of rapid sequence intubation in the emergency setting

3. ANALGESIA AND SEDATION SKILLS

• Assessment of the level of pain and sedation

• Monitor vital signs and potential side effects during pain management

• Provide procedural sedation and analgesia including conscious sedation (including

• testing of life support equipment)

• Use of appropriate local, topical and regional anaesthesia techniques

4. BREATHING AND VENTILATION MANAGEMENT SKILLS

• Assessment of breathing and ventilation

• Oxygen therapy

• Interpretation of blood gas analysis, pulse oximetry and capnography

• Bag-mask-valve ventilation

• Thoracocentesis

• Chest tube insertion, connection to under-water drainage and assessment of

• functioning

• Non-invasive ventilation techniques

• Invasive ventilation techniques

5. CIRCULATORY SUPPORT AND CARDIAC SKILLS AND PROCEDURES

• Administration of fluids including blood and substitutes

• Monitoring of ECG and the circulation

• Defibrillation and pacing (e.g. cardioversion, transcutaneous pacing)

• Emergency pericardiocentesis

• Vascular access (peripheral venous, arterial, and central venous catheterisation, intraosseous access)

6. DIAGNOSTIC PROCEDURES AND SKILLS

• Interpretation of ECG

• Appropriate request and interpretation of laboratory investigations (blood chemistry, blood gases, respiratory function testing and biological markers)

• Appropriate request and interpretation of imaging (e.g. x-rays, ultrasound, CT/MRI)

• Focused Assessment of Sonography in Trauma (FAST).

• Emergency Ultrasound and Echocardiology

• Gastrointestinal Procedures: Shangstaken tube insertion, endoscopic banding, scelerotherapy in UGI bleed

7. ENT SKILLS AND PROCEDURES

• Anterior rhinoscopy

• Insertion of nasal pack

• Inspection of oropharynx and larynx

• Otoscopy

• Removal of foreign body if airway is compromised

• Insertion and replacement of tracheostomy tube

8. GASTROINTESTINAL PROCEDURES

• Insertion of nasogastric tube

• Gastric lavage

• Peritoneal lavage

• Abdominal hernia reduction

• Abdominal paracentesis

• Measurement of abdominal pressure

• Proctoscopy

9. GENITOURINARY PROCEDURES

• Insertion of indwelling urethral catheter

• Suprapubic cystostomy

• Testicular torsion reduction

• Evaluation of patency of urethral catheter

10. HYGIENE SKILLS AND PROCEDURES

• Decontamination of patient and the environment

• Patient isolation and staff protection

11. MUSCULOSKELETAL TECHNIQUES

• Aseptic joint aspiration

• Fracture immobilisation

• Reduction of joint dislocation

• Log roll and spine immobilisation

• Splinting (plasters, braces, slings, tapes and other bandages)

• Management of compartment syndrome

• Fasciotomy, escharotomy

12. NEUROLOGICAL SKILLS AND PROCEDURES

• Evaluation of consciousness including the Glascow Coma Scale

• Fundoscopy

• Lumbar puncture

• Interpretation of neuro-imaging

13. OBSTETRIC AND GYNAECOLOGICAL SKILLS AND PROCEDURES

• Emergency delivery

• Vaginal examination using speculum

• Assessment of the sexual assault victim

14. OPHTHALMIC SKILLS AND PROCEDURES

• Removal of foreign body from the eye

• Slit lamp use

• Lateral canthotomy

15. TEMPERATURE CONTROL PROCEDURES

• Measuring and monitoring of body temperature

• Cooling techniques (evaporative cooling, ice water or slush immersion)

• Internal cooling methods

• Warming techniques

• Monitoring heat stroke patients

• Treatment and prevention of hyper- and hypothermia

16. TRANSPORTATION OF THE CRITICALLY ILL PATIENT

• Telecommunication and telemedicine procedures

• Preparation of the EMS vehicle

• Specific aspects of monitoring and treatment during transportation

17. WOUND MANAGEMENT

• Abscess incision and drainage

• Aseptic techniques

• Treatment of lacerations and soft tissue injuries

• Wound irrigation and wound closure

Competencies to be attained by the end of 3 years

By the end of their first year, emergency medicine residents will:

1. Demonstrate the ability to provide appropriate care to patients with non-emergent problems:

Obtain an accurate and complete clinical and psychosocial history and perform a comprehensive physical examination

• Develop appropriate differential diagnoses

• Know the available investigative and therapeutic options

• After review, implement an appropriate investigative and therapeutic plan

• Develop and, after review, implement an appropriate written and verbal discharge plan

• Demonstrate an awareness of the available information systems to support patient care and discharge planning

• Demonstrate competency (including an understanding of the indications, contraindications, and techniques) in the core procedures used on non- emergent patients (eg, laceration repair, reduction in or immobilization of extremity

• injury, pelvic examination, slit-lamp examination)

• Demonstrate an understanding of the concepts of disease prevention as it applies to emergency medicine

• Properly document all historical, physical examination, and diagnostic test findings

2. Demonstrate a level-appropriate knowledge of the biochemical, clinical, epidemiologic, and social-behavioural basis of diseases seen in the emergency department:

• Demonstrate a basic understanding of the principles of evidence-based medicine

• Demonstrate mastery of minor acute and nonemergent conditions

• Demonstrate mastery of the principles of ACLS and ATLS

• PALS and NALS (paediatric advanced life support and neonate advanced life support)

• Demonstrate a level-appropriate understanding of the core curriculum

3. Demonstrate the ability to appraise and assimilate scientific evidence and analyze and improve their own practice:

• Demonstrate the ability to critically assess their competency in managing minor acute and on emergent cases

• Demonstrate the ability to apply published studies to their own practice

• Demonstrate the ability to use available information technology appropriate to the care of their patients

4. Demonstrate effective interpersonal and communication skills with:

• Patients and their families

• Other physicians

• Other health care providers

5. Demonstrate the professionalism required of a physician:

• Accept responsibility for continuity of patient care

• Demonstrate respect for patients' privacy and autonomy

• Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities

• Demonstrate a commitment to sound ethical principles regarding the care of patients

• Demonstrate respect for the dignity of patients and colleagues as persons

6. Demonstrate a basic understanding of the role of the emergency department in the larger context of health care delivery:

• Demonstrate an understanding of the principles of a cost-benefit analysis

• Know the relative costs of the various tests and treatment contemplated

• Serve as an advocate for the patient in their dealing with the complexities of the health care system, specifically with regard to appropriate referral and followup

By the end of their second year, residents will, in addition to the objectives achieved during the first year:

1. Demonstrate the ability to provide appropriate care to patients with emergent and life threatening conditions:

• Obtain an appropriately focused history and perform an appropriately focused physical examination

• Develop comprehensive differential diagnoses

• Develop an investigative and therapeutic plan

• Develop and, after review, implement an appropriate written and verbal discharge plan

• Demonstrate competency (including an understanding of the indications, contraindications, and techniques) in the core procedures used on patients with emergent and life-threatening conditions (eg, endotracheal intubation, tube thoracostomy, defibrillation/cardioversion, etc.)

2. Demonstrate a level-appropriate knowledge of the biochemical, clinical, epidemiologic, and social-behavioural basis of diseases seen in the emergenc

 department:

• Apply the principles of evidence-based medicine

• Demonstrate mastery of the emergent and life-threatening conditions that present to the emergency department

• Demonstrate a level-appropriate understanding of the core

3. Demonstrate the ability to appraise and assimilate scientific evidence and analyze and improve their own practice:

• Demonstrate the ability to critically assess their competency in managing the emergent and life-threatening conditions that present to the emergency department

• Use published studies to improve their own practice

• Use available information technology appropriate to the care of their patients

4. Demonstrate a level-appropriate understanding of the role of the emergency department in the larger context of health care delivery:

• Demonstrate the ability to divide his or her time and energies appropriately to provide optimal care for several patients concurrently

• Develop plans for evaluation and treatment that, without compromising patient care, acknowledge the patient's particular health care system

By the end of their third year, residents will, in addition to the objectives achieved during the first 2 years:

1. Demonstrate the ability to provide appropriate care to patients

• Listen to a history and physical examination presentation from a junior resident and provide appropriate feedback and guidance

• Perform an appropriately focused history and physical examination, taking into consideration the previous evaluation of the junior resident

• Implement an appropriate investigative and therapeutic plan

• Implement an appropriate written and verbal discharge plan

• Demonstrate understanding of the indications, contraindications, and techniques in uncommonly performed but lifesaving procedures (eg, cricothyroidotomy, burr craniotomy) and mastery of all other core procedures

• Demonstrate an understanding of documentation as it applies to billing and reimbursement requirements

2. Demonstrate a level-appropriate knowledge of the biochemical, clinical, epidemiologic, and social-behavioural basis of diseases seen in the emergency

department:

• Demonstrate mastery of all conditions that commonly present to the emergency department

• Teach courses such as ACLS as a certified instructor

• Demonstrate an understanding of the core curriculum

3. Facilitate the learning of others

• Teach and appropriately supervise medical students and junior residents

4. Demonstrate an understanding of the role of the emergency department in the larger context of health care delivery

• Triage patients and direct the attention of junior-level residents so as to provide optimal care for all patients in the emergency department. Plan and participate in a mass-casualty disaster drill

V. LOG BOOK:

The logbook should show evidence that the previously mentioned subjects were covered (with dates and the name of the teachers). The candidate will maintain the record of all academic activities undertaken by him/her in logbook.

1. Personal profile of candidate

2. Educational qualifications/ professional data

3. Record of case histories (15 cases) studied by him/her. (Model should be given in the log book) Three case histories pertaining to predominantly 4 Medical problems,

3 predominantly Surgical, 2 pediatrics, 3 trauma while the rest 4 may pertain to other disciplines like Obstetrics and Gynecology, Ophthalmology, ENT,Dermatology, Psychiatry etc.

4. Procedures learnt- the candidates are expected to learn Medical and Surgical procedures during their training in Emergency Medicine. The record should depict medical and surgical procedures observed, assisted and performed during the period of training

5. Record of case Demonstration/ Presentations

6. Record of Participation in CME activities- Direct contact activities (Lectures, seminars, workshops, c conferences); indirect contact activities (Correspondence journals, books, audio-video tapes)

7. The log book should also bear record of the training in the following:

• Emergency Life Support (ELS)- 2 DAY COURSE

• Advanced life Support- 2 day Course

• Advanced Trauma Life Support (ATLS) - 2 DAY COURSE

• Advanced Pediatric Life Support (APLS)- 3 DAY COURSE

• Emergency radiology for Emergency Physicians- 2 day course

• Neonatal Life Support- 1 day course

8. Other courses such as:

• Ultra sound scan

• Communication skill workshops

• Research methodology workshop

• Audit workshop

• Child Protection

VI. ILLUSTRATIVE STUDY MATERIAL:

Recommended Text Books

1. Emergency Medicine: a comprehensive study guide. Tintilli, J et al, New York: McGraw- Hill

2. Emergency Medicine (latest edition) Anthony FT Brown, Michael D Cadgan, London, Hodder Arnold

3. Medicine Textbook of Adult Emergency (Latest Edition) Peter Cameron, George Jelinek, Anne- Maree Kelly, Lindsay murray, Anthony FT Brown, Jhon Heyworth eds. Edinburgh, Churchill Livingstone

4. Oxford Hand Book of Accident and Emergency Medicine (LLATEST Edition) JP Wyatt, RN Illingworth, CE Robertson, MJ Clancy, PT Munro eds. Oxford, oxford University Press

5. Text book of pediatric Emergency Medicine (Latest edition) Peter Cameron, George Jelinek, Ian Everitt, Gary Browne, Jeremy Raftos. London, Churchill Livingstone.

6. Textbook of Adult Emergency Medicine, Edinburgh: Churchill Livingstone.

7. Rosen's textbook of emergency Medicine

8. Accident & Emergency Radiology, A survival guide- Nigel Raby

9. Harwood-Nuss' Clinical Practice of Emergency Medicine, Wolfson, A (Editor), New York: Lippincott, Williams & Wilkins.

10. Textbook of Emergency Medicine, David, S (Editor), New York: Lippincott, Williams & Wilkins.

11. Goldfrank's Toxilogic Emergencies, Nelson, L et al., New York: McGraw-Hill.

12. Modern Medical Toxicology, Pillay, V.V.

13. Textbook of Critical Care, Fink, M (Editor): Philadelphia, Elsevier Saunders.

14. ECG For Emergency Physician, Mattu and Brady (Editors), London: BMJ Publishing.

15. An Introduction to Clinical Emergency Medicine, Mahadevan, S.V. (Editor), New York: Cambridge University Press.

16. American Heart Association Basic Life Support, Advanced Cardiovascular Life Support and Pediatric Life Support manuals

17. Advanced Trauma Life Support manual published by the American College of Surgeons

JOURNALS

1. The journal of Emergency Medicine- Elsevier (the official journal of the America Academy of Emergency Medicine)

2. American Journal of Emergency Medicine

3. European Journal of Emergency Medicine (the official journal of the European Society for Emergency Medicine)

4. Annals of Emergency Medicine (the official journal of the American College of Emergency Medicine)

5. Emergency Medicine Australasia

6. Academy Emergency Medicine

7. Emergency Medicine Journal

8. Emergency Medicine Australasia

9. National Journal of Emergency Medicine published by SEMI

10. American Heart Association journal, Circulation

Online Resources

1. American Academy Of Emergency Medicine- Position Statements

2. American College Of Emergency Physicians- Practice Resources

3. Association Of Emergency Physicians- Policy And Position Statements

4. Australasian College For Emergency Medicine - Policies And Guidelines

5. Australian And New Zealand Intensive Care Society- Policy Statements

6. Council Of Emergency Medicine Residency Directors- Position Statements

7. Emergency Management Australia- Publications

8. European Resuscitation Council- Guidelines

9. Intensive Care Society (UK)- Standards And Guidelines

10.National Electronic Library For Health (UK) Emergency Care

11.Resuscitation Council (UK)

12.Society For Academic Emergency Medicine - Position Statements

13.Society Of Critical Care Medicine- Guidelines

14.Triage - Injury, Treatment And Recovery, Shoestring Graphics