DNB EM practical exam experience

DNB EM practical exam experience

Dr. Krishna Prasad G, DNB EM, MRCEM

Few of my juniors had enquired regarding DNB EM practical exams. Being part of the first batch of DNB EM, I would like to share my experience with all of you.

Hall ticket, date and venue of examination

Usually, the first information regarding the conduct of exam is through a phone call from NBE office. They usually call only once, and the number would look like spam, and in case you couldn’t take it, you will miss the chance of knowing your centre and date. You can later use Truecaller to find out that the call came from NBE office. Calling back to NBE is a tedious task, and you have to take a day off to embark on that journey (Seriously!). Then follows an email much later on and later the hall ticket gets uploaded on the website. 

Suppose, it doesn’t get uploaded (such instances do happen!), try to forward a letter through your HOD, or simply appear at the exam centre and tell your situation. 

Last year the centers were at Bangalore, Pune and Ahmedabad. NBE had brought out guidelines for the conduct of exam and we all got a copy of it. It basically gives you the marking scheme and overall structure of the exam. Usually exam will be conducted over three days, with the second day being a common day for OSCEs and spotters. The first and third days are for long and short cases, the whole batch being divided into two.

Stay and accommodation

 It’s always better to choose a place of stay near to the exam center. I had chosen an Oyo apartment (Aspen Woods serviced apartments) near Baptist Hospital, Bangalore for my stay with my friends. I had shared this place with my friends from other hospitals, and they too had booked the same place. 

One advantage is you can practice your ACLS, ATLS scenarios at the last moment, the previous evening of your exam here. So, my advice is to book a place in groups near to your center, where you can practice scenarios at the last minute.

The day before exam

Simple tips – have a moderate dinner, have a good sleep, read only your handy notes, don’t read anything new, keep your clothes ready, keep your alarm, plan to reach early at the center (My center had canteen inside the campus, so breakfast was not a problem). Also, if you can’t find sign boards to your exam venue, just go to the emergency department, the staff will guide you (We had a group of candidates who lost their way, that’s why).

My first day

Initially, we were assembled into a hall and the HOD of emergency medicine (Baptist Hospital, Bangalore) had come and briefed us regarding the exam pattern. It was well organized and there was no delay during the exam. 

Everything was being conducted according to the guidelines put forward by NBE.

Knowledge based skill stations – Basically, this was conducted as spotters. All were seated together and questions were put up on the projector screen. Those having refractive errors, better to sit in front.

This is the recommendation - It is recommended to have at least 10 knowledge based skills stations which require interpretation of emergency radiology and lab reports. Each candidate would get same amount of time as of the skill stations. (4 marks for each station)

1. X-ray (minimum of 2 x-rays, one from medical side and one from surgical/orthopedics side) The candidates would be required to identify the radiological abnormality and answer the relevant questions.

2. ECG : A minimum of 2 ECGs with one rhythm abnormality. The candidate would be required to identify the abnormality and answer the relevant questions.

3. CT Scan: 1 CT Scan

4. ABG analysis: A minimum of 2 different arterial blood gas reports to be analyzed by the candidates.

5. Clinical Photographs/ Videos-2

6. Ultrasound (Image/Video)-1

Now, for us the questions were (No non-disclosure clause was signed!):

1.    USG FAST – presence of free fluid image – 2 sub questions each of 2 marks  [4 marks]

2.    USG CRANIUM infant – ?EDH-  difficult one, since it wasn’t mentioned where the probe was kept – 2 sub questions each of 2 marks [4 marks]

3.    ABG [4 marks] – interpretation and sub question

4.    ABG [4 marks] - interpretation and sub question

5.    Swelling of tongue – ?Angioedema – diagnosis and sub question [4 marks]

6.    ECG – AF with 2:1 block – Diagnosis and sub question [4 marks]

7.    ECG – CHB – Diagnosis and sub question [4 marks]

8.    CT Brain – SDH – Diagnosis and sub question [4 marks]

9.    XRAY chest - ?Pneumothorax- Diagnosis and subquestion [4marks]

10.  XRAY chest - ?Lung abscess – Diagnosis and sub question [4 marks]

Disclaimer: Above information is recollected from the long term memory and not 100% accurate.

After that you get a tea break, when they prepare you for the OSCEs

OSCEs – otherwise called objective structured clinical examination is the most rewarding or maximum scoring part of the whole practical exams. The reason is – it’s all task asked, you get each tick mark for every step you perform. And it’s difficult to fail in OSCEs.

Here’s what the guidelines say - It is suggested that OSCE should focus on testing the skills of the examinees in a variety of ways. It is recommended 8 essential skills stations should be mandatory. For each skill station, there should be an examiner/OSCE Coordinators and should have checklist for each skills station. 

The examinee would be given a case scenario and would be expected to perform the necessary skills. The scenario and the checklist for skills stations would be prepared and provided to the exam coordinator by National Board of Examinations. Each candidate will get minimum of 10 minute at each skill station.

The 8 skill stations recommended are:

1. BLS (5 marks)

2. ACLS (10 marks)

3. ATLS (Core case scenario/primary and secondary survey/Helmet removal/Spine board applications/ cervical spine stabilization) (10 marks)

4. PALS/NALS (10 marks)

5. Airway (10 marks)

6. Surgical skill station (Suturing/Central line insertion/ICD/wound care) (10 marks)

7. Ortho skill station (Hemorrhage control//log roll/splints/pelvic binder) (10 marks)

8. Communication skills (10 marks)

Ultrasound skill will be tested during evaluation of Medicine/Surgical/Trauma patients using the following OSCE based assessment criteria:

i) Whether the candidate is able to select the appropriate probe for the

target scan (2 marks)

ii) whether the candidate is able to acquire the image of the target area

(2 marks)

iii) whether the candidate is able to optimize the image (5 marks)

iv) whether the candidate is able to interpret the image correctly (4 marks)

v) Whether the candidate is able to take critical treatment decision based on ultrasound findings (4 marks)

vi) In addition to the target scan relevant in this patient, the candidate should demonstrate the sonographic findings in other areas such as cardiac, lungs and FAST.(8 marks) (Total 25 Marks)

Now for us, the OSCE stations were:

1.    USG – This is a station with the maximum marks – 25 marks. There was a demo patient lying in bed and I was asked to demonstrate specific things regarding FAST. These are pretty basic questions, but make sure not get tensed and use medical terminologies such as where will you place the probe and how do you optimize the image etc. After that video clipping of USG will be shown in laptop and you need to answer questions based on that. If you answer well, the examiner might want to go further and further. If not, they expect you to say at least the damn diagnosis!. Images were related to USG FAST, USG pelvis and, subxiphoid ECHO -?PE

2.    PALS station – Read thoroughly the PALS booklet.

3.    BLS in an in-patient child – who suddenly becomes unresponsive in the ward – according to BLS protocol.

4.    ACLS – in an adult – Read thoroughly ACLS manual for this station.

5.    Airway station – Explain the steps of RSI and intubation skills.

6.    Ortho station – Placing pelvic binder using a bed sheet.

7.    Communication skills – Speaking to an angry bystander.

8.    Suturing skills – suture on a rexine sheet and later dispose the gloves and needles according to biowaste protocol.

9.    ATLS – pneumothorax and long bone fracture scenario. Read thoroughly the ATLS manual.

You will get 30 seconds to read the instructions before you enter the station. Each station is walled off by curtains and on the sound of bell signals you to shift positions. There will be a rest station as well. Reading MRCEM Part C OSCE books are very useful for the communication skill station.

This was followed by lunch and after that we had 4 stations comprising of Thesis review, Instruments and drugs, log book and procedures and latest updates. Of which, the latest updates station was the toughest.

For the thesis review station, make yourself prepared to explain your work briefly for about 5 minutes. One of the most repeatedly asked question will be ‘Why did you choose this topic?’ Give a wise answer.

For the instruments and drugs station, you will be asked to pick up an instrument/drug of your choice and speak on it. It’s better to read specific books on instruments and drugs for this purpose. I recommend objective anesthesia review for this station, because we and anesthesia share most of the instruments and drugs. 

For latest updates, read latest info on sepsis, cardiac arrest, trauma, asthma etc in details, especially name of trials, study population, inclusion and exclusion criteria etc.

Your log book should be complete. They will turn the pages and will randomly ask you any procedure of interest.

My second day

The second day started with all of us assembling inside the medical wing of the hospital. There are sign boards which help you to reach the exam ward. We were told to pick a lot from allotted cases. Each paper picked with contain 4 allotted cases – one each from medicine, surgery, trauma/ortho and pediatrics.

According to the guidelines - Clinical examinations will consists of 4 short cases (25 marks each-total 100 marks).Each candidate would be allotted 15 minutes for taking history and clinical examination. He would be evaluated by minimum of two examiners for at least 15 minutes. The clinical cases would be from the following domains and it is mandatory for the centre to have at least 2 sets of clinical cases. At least one of these cases should have positive ultrasound finding. There is no cap on the maximum number of sets.

a. Medicine

b. Surgical

c. Trauma and Orthopedics

d. Pediatrics

The cases selected would need to be validated by the external examiners before being allotted. A list of the cases which can be included for the clinical examination will be provided to the internal examiner. It is expected that the clinical case viva would focus on the presentation in the emergency and subsequent management as would be appropriate in the emergency department.

Each candidate will be allotted a nursing assistant who will be your translator as well (but believe me, not all assistants are good translators!). We will be directed to the first case by the nursing assistant. You will get only 15 minutes per case. It is advised to carry necessary instruments and stuff, even if you won’t get the time to use any of them (esp. ophthalmoscope!). 

There will be no bell. You are expected to move to the next case after 15 minutes. Take note of the time, it’s important. Looking at case sheets (even if it is kept in front of you!) is not advised. There will be invigilators walking around. Ask for BP instrument, saturation probe monitor and thermometer as soon as you start seeing the case. Give more emphasis on history. Present as if the patient came to the ED. Initial Assessment, followed by Primary survey ie. ABCD followed by SAMPLE. In the ‘S – Signs and symptoms’ part, say only the relevant history and then the relevant examination. Tell things which you will do in ED and nothing else. For example, don’t mention things such as vocal fremitus and vocal resonance; you won’t be doing such tests on a patient with asthma exacerbation (logical!). 

A paper will be given to you to document your findings. Don’t stress much on filling the paper. Write only points. They just want the paper to be sent back to NBE. Paper is not evaluated. Your presentation will only be evaluated. Basically, after your presentation, their questions will be mainly focused on your approach, how you will manage the patient. The questions will range from investigations to management and so on. For e.g. in a case of bronchial asthma exacerbation, if you mention peak flowmetry as an investigation, the examiners will go into its details, what are the markings – lower limit and upper limit etc. So, be careful and be prepared accordingly. If you utter blunder, things might tend to go out of your hands. 

Two cases were presented before two examiners and the rest two before another two examiners. I had examiners from Fortis Noida, JIPMER Puducherry and Baptist Bangalore. I had got the following cases – bronchial asthma exacerbation [ICU patient/medical], Blunt trauma abdomen [trauma], acute diarrheal disease [paediatrics] and right upper quadrant pain ?cholecystitis [surgical].

This was followed by lunch. After lunch we had 4 short cases.

According to guidelines - There will be another 4 Short cases (10x4 =40 marks). These cases can be selected from the following domains:

a. Dermatology

b. Ophthalmology

c. Obstetrics & Gynaecology

d. ENT

e. Psychiatry

For these short cases each candidate would be allocated 5 minutes for a brief history and examination. Each candidate would then be examined by at least one examiner for a period of 5 minutes. The cases selected would need to be validated by the external examiners before being allotted. 

A list of the cases which can be included for the clinical examination will be provided to the Centre Coordinator/examiner. It is expected that the clinical case viva would focus on the presentation in the emergency and subsequent management as would be appropriate in the emergency department.

We were taken to their simulation lab. When bell rings, you are required to go to the station where cases from obstetrics, dermatology, otolaryngology and psychiatry were present. In some stations, you will be give n specific task and in some, you will have to take a short history and present.

The cases put forward were:

1.    Psychiatry – A case of deliberate self harm. Take short history and risk assessment for suicide and then present.

2.    Obstetrics – A case of UTI in first trimester pregnant lady. Take short history, examination and present.

3.    Otolaryngology – A child sitting on the lap of the mother. Child had swallowed a coin. This was a case of FB throat [coin]. Take a short history and explain management.

4.    Dermatology – A patient with diffuse erythematous scaly rashes. Take short history, examine and give your differential diagnosis.

So, to summarize – preparation and practice is the key to success in passing DNB EM practical exam. It’s a two day tedious process but once you finish and come out, the relief is just pure bliss.

So friends, remember, practice your OSCEs stations and be focused always. It’s always ABCDE Period.

Good luck!

KP