BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY
SHAHBAG, DHAKA-1000
NAME OF COURSE:   DOCTOR OF MEDICINE (MD)
CRITICAL CARE MEDICINE (CCM)

RESIDENCY BASED PROGRAM

FIVE YEAR COURSE

PHASE A -2 Years
 PHASE B -3 Years

Department of Anaesthesia, Analgesia and Intensive Care Medicine.
Bangabandhu Sheikh Mujib Medical University

SUMMARY

Curriculum is a total plan of a whole program for education. So it encompasses the learning methods, assessment methods, resources, & time tabling. The Curriculum provides guidelines for creating educational environment, facilitates learning opportunities and finally evaluates the learning out comes.

This Curriculum for Doctor of Medicine (MD) in Critical Care Medicine (CCM) contains the introductory chapter  with rationale of CCM course, learning objectives, pre-requisites for admission and other policy and finally assessment strategy and tools.

The Curriculum has been designed according to Residency program which has laid down by the Bangabandhu Sheikh Mujib Medical University The total 5 Yrs residency course is divided in to two Phase:  Phase A and Phase  B. Phase A has been designated as Basic Medical  training’ (CMT), where the resident will have to rotate the three acute subjects like- General Inter Medicine (Acute), Anesthesiology and Emergency Medicine within 2 years composed of  seven blocks- each of 3 months .During this rotation   student acquires Applied Basic Science and subject related  knowledge to develop different form of  competencies and skill with changes the attitude and behavior  which will  help to manage the national  and international medical demand . In Internal Medicine- with its subspecialty the competencies have been presented in four parts to be completed within 1 year. Symptoms competencies- define the knowledge skills and attitudes. System specific competencies- associated with development of knowledge of system specific competencies and in particular, the common or important problems and clinical sciences. Investigation competencies and Procedural competencies.

The Anesthesiology with its subspecialties  within 9 months of duration will have to complete the basic component of Anesthesia and ICU. In Emergency Medicine the resident of MD- CCM will be able to learn the acute and urgent aspects of illness and injury affecting patients of all age groups. Virtually they should develop their competencies in Emergency Medicine but in absence of the subject, these aspects will be expected to learn from emergency service station of different specialties like- Neurosurgery, Orthopedic Surgery, Obstetrics, Cardiac emergency and trauma & casualty department

The Phase ‘B’ designated as ‘specialty training’ (ST), has been divided into three levels that allow the trainees to track the progression of their learning from preliminary or basic, through core or intermediate to advanced  or enhanced level. It is not intended that lists and tables be used for the assessment of competence but simply to facilitate self directed learning and help trainers to identify the deficiencies in clinical experiences within 3 years composed of  eleven  blocks- each of 3 months  among  preliminary or basic, through core or intermediate ( four block)to advanced  or enhanced level.(seven block)

Finally in specialist/Enhanced level of training nine block duration, the trainee will complete an educational agreement for their own and their trainer’s guidance. A copy of these agreements should be included in the trainee’s portfolio, together with other documents describing educational and professional development such as weekly meetings attended or organized, lectures and other presentation given, audit projects, research reviews and publications/ thesis preparation. The trainee will also have to gain experience in external courses and meetings both in regional, national and international aspects.

 In addition to all described above this Curriculum also contains the whole domains of CCM, each of which is presented as Knowledge, skill, attitude  & behavior and work place training objectives. It has an appendix where the leave policy, Portfolio, logbooks and assessment forms and sheets have been incorporated..

 This curriculum  also include  continuous evaluation and   assessment(Generic and Specific) with  a standardassessment tools(Formative assessment, Summative assessment🙂Formative assessment  isconducted by training units/clinical and educational supervisors. Summative assessment is conducted by the University Examination department. Finally examination is conducted  by two phase (A & B ) and Method will be prescribe by the University.

 Rationale of Critical Care Medicine course:
The services of the Critical Care Medicine shall not be limited to BSMMU. This can be developed at all medical college hospitals and subsequently at larger district level hospitals. Critical Care Units in these government and autonomous hospitals and gradual development of private sector will demand trained manpower. Therefore this is the high time to develop these courses in our country.

Since 1998, BSMMU is trying to ensure quality heath care by improving the educational process continuously to maintain high standards of care. The university’s core values are to assure people of the highest quality patient care, professionalism and excellence in the practice of medicines, evidence based medicine and intellectual drive, following evaluation procedures, high quality standards setting and maintain autonomy to preserve these values.
The department of Anesthesia, Analgesia and Critical Care Medicine of BSMMU felt the need to start a Course on Critical Care Medicine to produce specialists in this regard of highest standards, who will be able to provide quality care to the patients. Therefore the Curriculum was developed by a group of subject specialists and medical educationists.

 Pre-Requisites for admission and other policy:
1. Pre requisites for admission: (Entry criteria):
1. (1)     Medical graduates or equivalent degree, registered from Bangladesh Medical and Dental council (BMDC) will be eligible for admission in to the course under going admission procedure, in phase ‘A’. Those candidates who have completed the diploma `in anesthesiology will be selected in separate admission criteria.
1. (2)     Medical graduates who have passed doctor of medicine (MD) in Anesthesiology, Internal Medicine, Neuro Medicine, Pulmonology, Cardiology or fellowship from Bangladesh college of physicians & Surgeons (BCPS) in Anesthesiology, Internal medicine, Neuro Medicine, Pulmonology, Cardiology orany alike subjects; or Fellowship from Royal college of Anesthesiology or equivalent degrees in Internal Medicine, Neuro Medicine, Pulmonology or cardiology and registered from Bangladesh Medical & Dental Council (BMDC) will be eligible for admission directly in Phase  ‘B’. Those candidates entering into part ‘B’ directly, may have to be placed initially in different department according to their needs and deficiencies but not exceeding more than six months.
1. (3)     Admission test will be held once a year in the month of Nov/Dec as per arrangement by the concerned authority-Medical Education Unit (MEU) of BSMMU.

 Learning objectives of the course:
General:

• To promote quality standards education in Critical Care Medicine in Bangladesh.

Specific:

• To promote the advancement of modern technology in Bangladesh.

• To identify and analyze the strategic deficits in the management of critically ill patients.

• To establish the new strategies to develop skilled and trained manpower who are likely to be successful to implement these training materials into reality.

• After completion of the residency course candidate will be able to run a multi disciplinary Critical Care Unit efficiently.

• To develop knowledge skill and attitude.

• To develop clinical practice which is based on an analysis of relevant clinical trials and to have an under standing of their methodologies.

• Will be able to identify and take responsibility for their own educational needs and the attainment of these needs.

• To be developed the skills of an effective teacher.

The principles of residency program are:

1. Competency based

2. Planned

3. Evaluated

4. Supervised

5. Defined objectives

6. Allows time for study.

7. National need based

8.  International  Standard

 There is certain generic professional skill that includes:

1. Attitude and behavior

2. Communication

3. Audit

4. Presentation

5. Teaching

6. Ethics and law and

7. Manage

Competencies to be obtained by the resident:

The competencies to be developed through the CCM course are as follows:

• • Medical Knowledge.

  • Clinical competency.

  • Communication skills.

  • Teaching skills.

  • Conducting research.

  • Team player.

  • Humanism.

  • Professionalism

  • Ethical and legal issues.

a. Medical Knowledge:
Include an appropriate content in the Curriculum.

b. Clinical competencies:
At the end of specialist training (ST) and assessment, the resident will acquire the following clinical skills-

• Data gathering skills- Interviewing the patient, physical examination, data interpretation.

• Selection skills- Patient studies, laboratory and imaging.

• Clinical reasoning skills- Formulating diagnosis, planning further investigation.

• Therapeutic decision making- Out line of therapeutic management and patient education, risk benefit and pharmaco-economic, interventional and surgical consideration.

• Procedural skills- diagnostic and therapeutic procedures common to the practice of CCM.

• Cardio pulmonary and other life saving procedures.

c. Communication skills:
Both verbal and written communication skills are necessary with patients and family members of patients admitted in ICU.

d. Teaching skills:
They should develop themselves in teaching and learning. The resident should achieve under standing and competency in different adult learning systems, principles of teaching and learning, use of effective teaching aids and assessment methods. They should be at times prepared to facilitate the learning sessions.

e. Conducting research:
A period of supervised research of good quality is considered a highly desirable part of MD (CCM) course. The resident will be competent in dealing with the principles of research ethics and contribute to the process by which ethical research in human subjects is ensured.

f. Team Player:
As a team player specialist should effectively work with in a health and social care team to achieve optimal patient care.

g. Humanism: 
This should signify a set of defined knowledge, skills and attitudes that bring about admirable clinical process and desired health out comes. With in the broad topic of humanism reside several core topics, some of which will be dealt like medical interview, counseling with the patient attendant, behavioral medicine and medical ethics. These competencies are essential to deal with patients to meet the needs associated with medical problems and processes and the lifestyle issues that contribute to health and disease.

Competencies for humanistic practice of medicine are essential for the intensivist to:

• Create and sustain doctor patient relationship that maximizes the likelihood of the best out come for the patients and the greatest personal satisfaction for the physician.

• Be able to identify the types of patient physician relationship, factors promoting their relationship and one’s own relating style, preference and limitations.

• Deal with dying critical patients, demonstrate knowledge and skill in obtaining and interpreting advance directives for care at the end of life, and providing comfort care and managing the family’s grieves.

• Recognize one’s own personal reactions to difficult situation; use these reactions to generate explanatory hypothesis and to under stand potential barriers to communication.

h. Professionalism:
Professionalism in medical practice requires the physician to place the interest of the patient above the physicians self interest. Professionalism aspires to self sacrifice, accountability, excellence, service, honor, integrity and respect for others. The resident should develop further development of qualities of professionalism and respect for patients, peer and paramedical personnel.

i. Ethical and legal issues:
Ethics is the systematic application of values. Medical ethics focuses on the prevention, recognition, clarification and resolution of ethics issues and conflicts that arise in the care of particular patients and on the prevention and resolution of conflicts associated with ethical issues. Topics in clinical medical ethics include professional responsibility, informed consent, determination of decision making capacity, truth telling, confidentiality and the physician’s role in cost containment.

 The learning process:

• Principal teaching/learning methods.

  • Supervised direct patient care activities:  Clinical training rotations.

  • Educational activities: learning in non clinical aspects of the curriculum.

• Learning experiences:

  • Experiential learning opportunities.

  • Training in practical procedures.

  • Small group learning opportunities.

  • One to one teaching.

  • Regular teaching and external course.

  • Personal study.

  • Teaching to other juniors.

  • Research.

 Block and units of training:
The training for MD Course of Critical Care Medicine will be comprised of four modules. Internal Medicine (Acute), Anesthesia, Emergency Medicine and CCM each of which is composed of units and sub units of training. This unit and subunit is regarded as block and each block is composed  of 3 months.

Each block is described in terms of:

• The subject area.

• The required knowledge.

• The required skills.

• The required attitudes and behaviour.

• Work place training objectives for the trainees/residents.

• For some specialist areas, the training environment.

Each trainee must complete an educational agreement in block with his/her supervisor with in three months of the start of each placement in which the training goals of the placement are clearly established.

Because of the fundamental synergy between the four specialties, this format inevitably results in the same topic appearing in more than one place; similarly there is inevitable cross over between the knowledge and skills lists.
Assessment:
Principles of assessment:

• Assessment process will reflect the aims and objectives of the curriculum.

• There will be provision for external assessors for quality assurance.

• The assessment methods will be reliable and valid.

• The assessment may be done individually or as a member in a group.

• Assessment will be both formative and summative.

• Assessment will emphasize on the following areas.

  • Practical procedures.

  • Patient management, assessment, investigation, monitoring and diagnosis of majority of patients.

  • Out reach and transport care.

  • Communication skills, Attitudes and behaviour.

  • Cardio pulmonary resuscitation.

 Methods of assessment:
Resident’s progress through the curriculum is to be measured by an integrated framework of workplace assessment, review of competence progression and examinations. The assessment instruments are designed to provide a mixture of formative feed back to residents and supervisors and summative assessments which must be completed to a satisfactory standard in order to progress. The over all assessment strategy and individual assessment tools will confirm to the assessment principles laid down by the university and the assessment tools are designed to measure all the domains of medical practice.

The frame work encompasses the complex and ever-evolving roles the physician is expected to play in present day medicine. It describes seven roles of the ideal physiciam-1) Medical expert 2) Communicator 3) Collabator 4) Manager 5) Health advocate 6) Scholar and 7) Professional. In the curriculum each of the seven roles is briefly defined, nature of the role is described, competencies deemed to be key for the role are listed, specific training requirements are described, and teaching learning and assessment methods are suggested.
Assessment strategy:
A. Generic:
These assessments are not specific to any particular clinical problem or procedure.

• Reports from supervision & work based assessment.

• Reflective observation from other team members (360? multi source feedback).

• Patient satisfaction questionnaires.

B. Specific:
These methods will be applied to particular clinical problems or procedures and are largely built around performance assessment.

• Mini clinical evaluation exercises (Mini-CEX).

• Direct observation of practical skills. (DOPS)

• Case based assessment (CBA).

 GENERAL AND SPECIFIC OBJECTIVES RELATED TO EACH TRAINING YEAR:

Phase A:  (Two Years)
The aims are to give the resident a foundation for the ongoing development of knowledge, clinical skills and abilities in Critical Care Medicine. This includes the followings:

1. Getting the sSkill of basic principal of history taking, patient examination and initial   diagnosis of  Acute and Emergency Medicine .Also  getting the knowledge , sSkill , competence for peri-operative anesthetic management.

2. Understanding anatomy, physiology and biochemistry, pharmacology, pathology, biostatistics, physics, clinical measurement, and monitoring as applied to Critical Care Medicine

3. Understanding the principles of acute management.

4. Establishing a professional team approach with patients, families, colleagues and staffs.

5. Appraising evidence-based approaches to clinical problems.

6. Establishing a personal learning portfolio and self-education skills.

Residency Year 1

At the end of the first year residency program, the resident will be expected to:
1.  Understand the basic principles of Acute Medicine

• • Eexposure to clinical disciplines like radiology and imaging, cardiology, Internal Medicine, Nephrology, Neurology, Respiratory Medicine, Rheumatology, Endocrinology, Neuro Surgery, Physical Medicine and Traumatology Department (s).

3.   Attend basic sciences (organized by basic science faculty) related to Acute and emergency Medicine.
4. Attend BLS and ACLS course run by the department

  Residency Year 2

• To learn and practice the basic principles of safe anaesthesia including preoperative and postoperative care of the patient.

2.  Attend basic science topics (organized by basic science faculty) and physics and clinical measurement related to anesthesia, critical care medicine, and pain at Department of Anaesthesia, Analgesia and intensive care Medicine.  The department will also arrange some biostatistics classes that are pertain to his / her reseasch work.
3.  At the end of second year, the resident will undergo summative assessment organized by competent authority (Central Examination Department) of Bangabandhu Sheikh Mujib Medical University for phase A final completion.

Phase B (3 years )

Residency Year 3

At the end of the 3rd year the resident should:

• Choose elective major for 06 months training and thesis on this subspecialty. During the first six month, the resident will write up their protocol, submit the protocol for ethical clearance. This work will go on simultaneously with prescribe rotation.

• Demonstrate clinical competence in handling all types of Acute  and emergency  patient  which need Critical care service.

• Understand the basic principles of  Biophysics  of human related to  Artificial Ventilation and monitoring system

Residency Year 4
At the end of 4th the year the resident should:

• Demonstrate clinical competence in handling majority of organ supportive therapy and anesthetic problems related management.

• Have undergone a comprehensive training program in most of the sub-specialties of critical care medicine ,(Medical ,  General Surgical , Neuro.and Cardiac ICU)

        Residency Year 5

• Demonstrate CLINICAL competencies in handling all elective or emergency cases in all specialties  of  Critical care including  Anaesthesia, Pain and Palliative Care patients.

• Complete research work as thesis and sit for MD Final examination organized by the competent authority (Central Examination Department) of Bangabandhu Sheikh Mujib Medical University with complete and submit ion all documents ( portfolis) .

I. TEACHING PROGRAM

      i)    KNOWLEDGE (DIDACTIC TEACHING PROGRAM)

Didactic teaching will be held on every day or determined by the respective department / in the rotating department and also in central basis. It comprises of applied basic sciences, clinical topics related to Critical care (acute and emergency medicine ,organ support  and monitoring ) anesthesia, pain and palliative care.
   ii)   Departmental Academic Meetings

The residents are expected to participate in all departmental meetings and conferences, journal club and research activities of the department preferably on every Thursday and it will be notified in advance:

• Journal Club

• Morbidity and Mortality meeting

• Case presentation

• Audit meeting

• Research meeting

• Anaesthesia Quality Care Issues

• guest lecture (s)

II.  CLINICAL TRAINING (skill development)
Phase A will be regarded as Core Medical Training (CMT) with basic principle of Anesthesia and Critical Care Medicine consisting of two years. The trainee will have to rotate to cover the three modules- General Internal Medicine (Acute and Emergency) and it’s all subspecialties, Anesthesiology and Critical Care Medicine.

The trainee will have to complete 7 blocks within two years of CMT program. Each block will be of 3 months duration covering different units and subunits as follows.

                 Phase -A: Core Medical Training (CMT): 2 years:

a.	General Internal medicine (Acute and Emergency Medicine) with sub specialties	– 12 months.
b.	Anesthesiology	–   6 months.
c. d.	Critical Care / Medicine Care Preparation for Exam.	–   3 months. –    3 months

 Detail block distribution of Phase A
COMPOSITE BLOCK(01-07)

Block No.- 01.
	Internal  Medicine		45 days
	Cardiology		45 days
	Total	=	90 days
Block No.- 02.	Gastroenterology	–	15 days
	Haematology Hepatology	— —	15 days 15 days
	Nephrology		15 days
	Physical Medicine Endocrinology	–	15 days 15 days
	Total	=	90 days

Block No.- 03.
	Pulmonology	–	45 days
	Neurology	–	45 days
	Total	=	90 days
Block No.- 04.	Radiology Oncology Medical emergency		30days 15days 30days
	Psychiatry	–	15 days
	Total	=	90 days
Block No.- 05.	Anesthesia: Basic
	Pre-operative assessment	–	30 days
	Operation theater (General , Obstetric Emergency, Otolaryngology)	–	60 days
	Total	=	90 days
Block No.- 06.	Anesthesia:
	Emergency and Primary Trauma Care	–	30 days
	Neuro surgery emergency	–	30 days
	Post operative and pain	–	30 days
	Total	=	90 days
Block No.- 07.	Critical Care  Basic	–	90days
	Total	=	90 days

3. Phase – B, 3 Years
The resident successfully completing CMT program will have a solid platform in all subject  specially in Internal Medicine, Emergency Medicine & Anesthesiology with it’s subspecialties, from which to continue in to specialty training (ST) for 3 years after successful attainment of CMT.
Detail block distribution of Phase B.
Block  8 -13   General  Critical care unit                    18 months
Block   14      Post surgical   ICU                               3 months
Block   15      Neurosurgical  ICU                              3 months
Block 16       Pediatric and Neonatal ICU                  3 months
Block  17      Cardiac and post surgical   ICU            3 months
Block 18     Transplant                                              3 months

Residents will choose their field of thesis work from any specialty listed 8-18 and placed for a period of six month as major block.
ii    CASE LOGBOOK
The Residents will maintain LOGBOOK from their enrolment to finish the residency program and duely signed by supervisor / facilitator in each block. This logbook should be handed over to the Residency Coordinator at end of the block.

The Content of Learning during Training (Syllabus)

The competencies are presented in four parts:   During whole period of residency the trainer must have gone through :

Part I : Symptom Competencies- define the knowledge, skill and attitude required for the symptoms competencies are broken down in to emergency presentations and other  common presentations. This presentations are listed together to emphasize the frequency with which these problems are encountered in clinical practice.

Part II : System specific competencies- The knowledge associated with the development would be expected to be known by the residents planning a career in CCM. Knowledge of these system specific competencies and in particular, the basic science associated with these conditions would not be expected to be so extensive.

Part III : Investigation competencies- lists investigations that a resident must be able to describe, order and interpret by the end of training.

Part IV : Procedural competencies- lists of procedures that a resident will be competent by the end of training.

 TEACHING PROGRAM 

KNOWLEDGE (DIDACTIC TEACHING PROGRAMME)

Phase A
A.  Applied Basic Science Class: Trainees should be able to demonstrate a good understanding of human anatomy relevant to the practice of Critical Care Medicine at basic level to support progress to special training.

• Anatomy

• Physiology and biochemistry

• Pathology

• Microbiology including immunology:

• Pharmacology

• Physics and clinical measurement

• Statistical methods

1. Contents : Anatomy
a. Anatomical organization of human body
Cells and tissues
b. Respiratory System

Mouth, nose, pharynx, larynx, trachea, main bronchi, segmental bronchi, structure of bronchial tree: differences in the child

Airway and respiratory tract, blood supply, innervations and lymphatic drainage

Pleura, mediastinum and its contents

Lungs, lobes, microstructure of lungs

Diaphragm, other muscles of respiration, innervation

The thoracic inlet and 1st rib

Interpretation of a normal chest x-ray

 b. Cardiovascular system

Heart, chambers, conducting system, blood and nerve supply

Pericardium

Great vessels, main peripheral arteries and veins

Fetal and materno- fetal circulation

c.Nervous system

Brain and its subdivisions

Spinal cord, structure of spinal cord, major ascending and descending pathways

Spinal meninges, subarachnoid and extradural space, contents of extradural space

CSF and its circulation

Spinal nerves, dermatomes

Brachial plexus, nerves of arm

Intercostals nerves

Nerves of abdominal wall

Nerves of leg and foot

Autonomic nervous system

Sympathetic innervations, sympathetic chain, ganglia and plexuses

Parasympathetic innervations

Satellite ganglion

Cranial nerves: base of skull: trigeminal ganglion

Innervation of the larynx

Eye and orbit

d. Vertebral column

Cervical, thoracic, and lumbar vertebrae

Sacrum, sacral hiatus

Ligaments of vertebral column

Surface anatomy of vertebral spaces, length of cord in child and adult

 e. Surface anatomy

Structures in antecubital fossa

Structures in axilla: identifying the brachial plexus

Large veins and anterior triangle of neck

Large veins of leg and femoral triangle

Arteries of arm and leg

Landmarks for tracheotomy, cricothyrotomy

Abdominal wall (including the inguinal region): landmarks for suprapubic urinary and peritoneal lavage catheters

i. Relevant anatomy of imaging to :

• describe the anatomy of the x- ray chest (P/A, A/P and lateral view)

• explain the anatomy of x- ray of abdomen/ extremity/ skull/neck

• understand the anatomy of echocardiogram, vascular ultrasound, angiogram, CT-scan and MRI.

2 PHYSIOLOGY AND BIOCHEMISTRY

Trainees should have a good general understanding of human physiology, be able to apply physiological principles and knowledge to clinical practice at basic level and to support progress to intermediate and specialist level training.

Knowledge
General

Organization of the human body and control of internal environment

Variations with age

Function of cells; genes and their expression

Cell membrane characteristics; receptors

Protective mechanisms of the body

Biochemistry

Acid base balance and buffers

Ions e.g. Na + , K+, Ca++ , Cl-, HCO3

Cellular metabolism

Enzymes

Capillary dynamics and interstitial fluid

Osmolarity: osmolality, partition of fluids across membranes

Lymphatic system

Special fluids especially cerebrospinal fluid: also pleural, pericardial

and peritoneal fluids

Haematology and Immunology

Red blood cells: haemoglobin and its variants

Blood groups

Haemostasis and coagulation

White blood cells

The inflammatory response

Immunity and allergy

Muscle

Action potential generation and its transmission

Neuromuscular junction and transmission

Muscle types

Skeletal muscle contraction

Smooth muscle contraction: sphincters

Motor unit

Heart/Circulation

Cardiac muscle contraction

The cardiac cycle: pressure and volume relationships

Rhythmicity of the heart

Regulation of cardiac function; general and cellular

Control of cardiac output (including the Starling relationship)

Fluid challenge and heart failure

Electrocardiogram and arrhythmias

Neurological and humeral control of systemic blood pressures, blood volume and blood flow (at rest and during physiological disturbances e.g. exercise, hemorrhage and Valsalva maneuver)

Peripheral circulation: capillaries, vascular endothelium and arteriolar smooth muscle

Characteristics of special circulations including: pulmonary, coronary, cerebral, renal, portal and foetal

Renal tract

Blood flow and glomerular filtration and plasma clearance

Tubular function and urine formation

Assessment of renal function

Regulation of fluid and electrolyte balance

Regulation of acid-base balance

Micturition

Path physiology of acute renal failure

Respiration

Gaseous exchange: O2 and CO2 transport, hypoxia and hyper- and hypocapnia, hyper-and hypobaric pressures

Functions of haemoglobin in oxygen carriage and acid-base equilibrium

Pulmonary ventilation: volumes, flows, dead space

Effect of IPPV on lungs

Mechanics of ventilation: ventilation/perfusion abnormalities

Control of breathing, acute and chronic ventilatory failure, effect of oxygen therapy

Non-respiratory functions of the lungs

Nervous System

Functions of nerve cells: action potentials, conduction and synaptic mechanisms

The brain: functional divisions

Intracranial pressure: cerebrospinal fluid, blood flow

Maintenance of posture

Autonomic nervous system: functions

Neurological reflexes

Motor function: spinal and peripheral

Senses: receptors, nociception, special senses

Pain: afferent nociceptive pathways, dorsal horn, peripheral and central mechanisms, neuromodulatory systems, supraspinal mechanisms, visceral pain, neuropathic pain, influence of therapy on nociceptive mechanisms

Spinal cord: anatomy and blood supply, effects of spinal cord section

Liver

Functional anatomy and blood supply

Metabolic functions

Gastrointestinal

Gastric function; secretions, nausea and vomiting

Gut motility, sphincters and reflex control

Digestive functions

Metabolism

Nutrients: carbohydrates, fats, proteins, vitamins and minerals

Metabolic pathways, energy production and enzymes; metabolic rate

Hormonal control of metabolism: regulation of plasma glucose, response to trauma

Physiological alterations in starvation, obesity, exercise and the stress response

Body temperature and its regulation

Endocrinology

Mechanisms of hormonal control: feedback mechanisms, effect on membrane and intracellular receptors

Hypothalamic and pituitary function

Adrenocortical hormones

Adrenal medulla: adrenaline (epinephrine) and noradrenalin (nor epinephrine)

Pancreas: insulin, glucagon and exocrine function

Thyroid and parathyroid hormones and calcium homeostasis

Pregnancy

Physiological changes associated with normal pregnancy

Materno-fetal, fetal and neonatal circulation

Functions of the placenta: placental transfer

Fetus: changes at birth   3. Pathology: Acute and Chronic inflammation Acute inflammation Chemical medications of inflammations Outcome of acute inflammation Morphologic pattern of acute inflammation Chronic inflammation Systemic effects of inflammations Tissue renewal and repair; Regeneration, healing and Fibrosis: Definition Control of normal cell proliferation Mechanism of tissue regeneration Extracellular matrix and cell matrix interaction Repair by healing, scar formation and fibrosis Cutaneous wound healing Fibrosis Haemodynamic disorder, Thromboembolic disease & Shock: Oedema, Hyperemia, congestion, haemorrhage, Haemostasis & thrombosis, Embolism, Infarction, Shock, Pathogenesis of septic shock, Porphyria Environmental and Nutritional pathology: Obesity and systemic disease Acute lung injury: Pulmonary oedema Classification Causes: haemodynamic oedema, oedema due to alveolar injury, oedema of undetermined injury, oedema caused by micro vascular injury. Acute Respiratory Distress Syndrome: Causes Pathogenesis Clinical Course Acid aspiration syndrome: Aetiology Causes Clinical features Liver Drug & toxin induced liver disease Jaundice and cholestasis Bilirubin and bile formation Causes of jaundice Alcoholic liver disease Heart failure & IHD: Cardiac hypertrophy and myopathy Pathophysiology and progression of failure Left-sided heart failure Right-sided heart failure Congenital heart disease Left to right shunts Right to left shunts Obstructive congenital anomaly Hypertensive heart disease Valvular heart disease-causes, pathogenesis Renal: Acute & Chronic failure Glomerulonephritis, ATN Nephritic syndrome Definition and classification Mechanisms of microbes and antibiotics Definition of immune system Natural immune system. Path physiology of immunological disease. Recent immune therapy 4. Microbiology including immunology: Definition and classification Mechanisms of microbes and antibiotics Definition of immune system Natural immune system. Path physiology of immunological disease. Recent immune therapy

5.PHARMACOLOGY Trainees should have a good understanding of general pharmacological principles, together with knowledge of drugs likely to be encountered in (a) anesthesia, GIM & EM and (b) current treatment of patients presenting at ICU. The level of knowledge should be sufficient to enable clinical practice at basic level and to support progress to intermediate and specialist level training.

Knowledge
Applied chemistry

Types of intermolecular bonds

Laws of diffusion. Diffusion of molecules through membranes

Solubility and partition coefficients

Ionization of drugs

Drug isomerism

Protein binding

Oxidation and reduction

Mode of action of drugs

Dynamics of drug-receptor interaction

Agonists, antagonists, partial agonists, inverse agonists

Efficacy and potency. Tolerance

Receptor function and regulation

Metabolic pathways; enzymes; drug: enzyme interactions; Michaelis-Menten equation

Enzyme inducers and inhibitors

Mechanisms of drug action

Ion channels: types: relation to receptors. Gating mechanisms

Signal transduction: cell membrane/receptors/ion channels to intracellular molecular targets, second messengers

Action of gases and vapours

Osmotic effects. pH effects. Adsorption and chelation

Mechanisms of drug interactions

Inhibition and promotion of drug uptake. Competitive protein binding. Receptor inter-actions

Effects of metabolites and other degradation products

Pharmacokinetics and pharmacodynamics

Drug uptake from: gastrointestinal tract, lungs, transdermal, subcutaneous, IM, IV, epidural, intrathecal routes

Bioavailability

Factors determining the distribution of drugs: perfusion, molecular size, solubility, protein binding

The influence of drug formulation on disposition

Distribution of drugs to organs and tissues: Body compartments

Influence of specialized membranes: tissue binding and solubility

Maternal-fetal distribution

Distribution in CSF and extradural space

Modes of drug elimination

Direct excretion

Metabolism in organs of excretion: phase I & II mechanisms

Renal excretion and urinary pH

Non-organ breakdown of drugs

Pharmacokinetic analysis:

Concept of a pharmacokinetic compartment

Apparent volume of distribution

Clearance

Pharmacokinetics and pharmacodynamics (continued)

Clearance concepts applied to whole body and individual organs

Simple 1 and 2 compartmental models: concepts of wash-in and wash-out curves

Physiological models based on perfusion and partition coefficients

Effect of organ blood flow: Fick principle

Pharmacokinetic variation: influence of body size, sex, age, disease, pregnancy, anesthesia, trauma, surgery, smoking, alcohol and other drugs

Effects of acute organ failure (liver, kidney) on drug elimination

Pharmacodynamics: concentration-effect relationships: hysteresis

Pharmacokinetics: familial variation in drug response

Adverse reactions to drugs: hypersensitivity, allergy, anaphylaxis, anaphylactoid reactions

Systematic Pharmacology

Anesthetic gases and vapors

Hypnotics, sedatives and intravenous anesthetic agents

Simple analgesics

Opioids and other analgesics; and opioid antagonists

Non-steroidal anti-inflammatory drugs

Neuromuscular blocking agents (depolarizing & non-depolarizing), and anticholinesterases

Drugs acting on the autonomic nervous system: cholinergic and adrenergic agonists and antagonists

Drugs acting on the heart & cardiovascular system (including inotropes, vasodilators, vasoconstrictors, anti arrhythmic, diuretics)

Drugs acting on the respiratory system (including respiratory stimulants & bronchodilators)

Anti hypertensive

Anticonvulsants

Anti- Diuretics diabetic agents

Antibiotics

Corticosteroids and other hormone preparations

Antacids. Drugs influencing gastric secretion and motility

Antiemetic agents

Local anesthetic agents

Plasma volume expanders

Antihistamines

Antidepressants

Anticoagulants

Vitamin K, B12 and thiamine

6.PHYSICS AND CLINICAL MEASUREMENT
Candidates should have a good understanding of the principles of physics and clinical measurement with an emphasis on the function of monitoring equipment safety and measurement techniques.

Knowledge

Mathematical concepts: relationships and graphs

Concepts only of exponential functions and logarithms: wash-in, wash-out and tear away

Basic measurement concepts: linearity, drift, hysteresis, signal: noise ratio, static and dynamic response

SI units: fundamental and derived units

Other systems of units where relevant to anesthesia (e.g. mmHg, bar, atmospheres)

Simple mechanics: mass, force, work and power

Heat: freezing point, melting point, latent heat

Conduction, convection, radiation

Mechanical equivalent of heat: laws of thermodynamics

Measurement of temperature and humidity

Colligative properties: osmometry

Physics of gases and vapors

Absolute and relative pressure

The gas laws; triple point; critical temperature and pressure

Density and viscosity of gases

Laminar and turbulent flow; Poiseuille’s equation, the Bernoulli principle

Vapor pressure: saturated vapor pressure

Measurement of volume and flow in gases and liquids

The pneumotachograph and other respirometers

Principles of surface tension

Basic concepts of electricity and magnetism

Capacitance, inductance and impedance

Amplifiers: band width, filters

Amplification of biological potentials: ECG, EMG, EEG

Sources of electrical interference

Processing, storage and display of physiological measurements

Bridge circuits

Basic principles and safety of lasers

Basic principles of ultrasound and the Doppler effect

Principles of cardiac pacemakers and defibrillators

Electrical hazards: causes and prevention

Electrocution, fires and explosions

Diathermy and its safe use

Principles of pressure transducers

Resonance and damping, frequency response

Measurement and units of pressure

Direct and indirect methods of blood pressure measurement

Principles of pulmonary artery and wedge pressure measurement

Cardiac output: Fick principle, thermo dilution

Measurement of gas and vapor concentrations, (oxygen, carbon dioxide, nitrous oxide, and volatile anesthetic agents) using infra-red, paramagnetic, fuel cell, oxygen electrode and mass spectrometry methods

Measurement of pH, PCO2 , PO2

Measurement CO2 production/ oxygen consumption/ respiratory quotient

Simple tests of pulmonary function e.g. peak flow measurement, spirometry

Capnography

Pulse oximetry

Measurement of neuromuscular blockade

Measurement of pain  Applied physics Ventilators: Basic principles Humidity, humidification Basic modes of ventilation and terminologies Anaesthesia machines Basic configuration Flow principles Alarms Ergonomics Pre use anaesthesia machine check Breathing circuits, components of breathing circuits and their geometry, intra circuit gas mixing, CO2 absorption

7. STATISTICAL METHODS
Trainees will be required to demonstrate understanding of basic statistical concepts, but will not be expected to have practical experience of statistical methods. Emphasis will be placed on methods by which data may be summarized and presented, and on the selection of statistical measures for different data types. Candidates will be expected to understand the statistical background to measurement error and statistical uncertainty.

Data Collection

Simple aspects of study design

Defining the outcome measures and the uncertainty of measuring them

The basic concept of meta-analysis and evidence based medicine

Descriptive statistics

Types of data and their representation The normal distribution as an example of parametric distribution Indices of central tendency and variability

Deductive and inferential statistics

Simple probability theory and the relation to confidence intervals

The null hypothesis

Choice of simple statistical tests for different data types

Type I and type II errors

 

B.   Basic Anesthesia

    1. Operating theatre suite environment.

• Lighting, safety, and infection and pollution control in operating rooms.

• Services and equipment in operating rooms and post-anaesthesia recovery room.

• Requirements of other anaesthesia environments outside operating rooms.

• Informed consent..

• Principles of occupational health and safety such as lifting and positioning patients, infection control and sharps handling policies.

2. Preoperative assessment

• Pre-anesthesia assessment

• Appropriate history taking.

• Physical examination including airway assessment, respiratory, cardiovascular and neurological examinations.

• Referral to other specialists when necessary.

• Establishment of a rapport with the patient to provide reassurance, disclosure of risk, information, and discussions on complementary medicine and informed consent.

• Communication and consultation skills face-to-face, by phone and in writing.

• Pulmonary function tests.

• Measurement of cardiovascular function.

• Interpretation of common radiology and imaging scans and investigations.

• Other investigations as appropriate.

3. Conduction of anesthesia

• Selection and planning of the anesthetictechnique.

• Decision-making relating to postponement or cancellation of surgery.

• Routine inhalation and intravenous inductions.

• Maintenance of anaesthesia.

• Correct use of anaesthesia delivery systems.

• Application and interpretation of monitored variables and neuromuscular blockade.

• Use of muscle relaxants.

• Application of mechanical ventilation.

• Management of the airway and intra-operative complications as standard algorithm

• Common regional anaesthesia techniques (for example, epidural and spinal anaesthesia and upper limb blocks).

• Maintenance of records.

   3.Postoperative care

• Safe recovery transport and handover in the post-anaesthesia recovery room.

• Postoperative consultations.

Management of postoperative pain,
Regional Blocks:

•  Basic sciences applied to regional anaesthesia: anatomy, physiology and pharmacology

• Advantages/disadvantages, risks/benefits and indications/contraindications of different blocks

• Assessment, preparation and management of the patient for regional anaesthesia

• The principles of minor and major peripheral nerve blocks (including cranial nerve blocks) and central neural blocks

• Desirable effects, possible side effects and complications of regional anaesthesia

• Management of effects and complications

• Clinical pharmacology: choice of local anaesthetic, additives, systemic effects and avoidance of toxicity

 c.  Acute and Emergency  Medicine
    1. Internal Medicine:

• • Principles of history taking

  • Clinical examinations

  • Common investigations related to medical conditions

     2. Cardiology
         Common and / or important Cardiac Problems:

• Arrhythmias

• Ischaemic Heart Disease: acute coronary syndromes, stable angina, atherosclerosis

• Heart Failure

• Hypertension – including investigation and management of accelerated hypertension

• Valvular Heart Disease

• Endocarditis

• Aortic dissection

• Syncope

• Dyslipidaemia

      3. Nephrology
     Common and / or Important Problems:

• Acute renal failure

• Chronic renal failure

• Glomerulonephritis

• Nephrotic syndrome

• Urinary tract infections

• Urinary Calculus

• Renal replacement therapy

• Disturbances of potassium, acid/base, and fluid balance (and appropriate acute interventions)

     4. Respiratory Medicine
        Common and / or Important Respiratory Problems:

• COPD

• Asthma

• Pneumonia

• Pleural disease: Pneumothorax, pleural effusion, mesothelioma

• Respiratory failure and methods of respiratory support

• Pulmonary embolism and DVT

• Tuberculosis

• Interstitial lung disease

• Respiratory failure and cor pulmonale

• Pulmonary hypertension.

     5. Endocrine Medicine
       a. Important Diabetes Problems:

• Diabetic ketoacidosis

• Non-acidotic hyperosmolar coma / severe hyperglycaemia

• Hypoglycaemia

• Care of the acutely ill diabetic

• Peri-operative diabetes care

b.Important other Endocrine Problems:

• Hyper/Hypocalcaemia

• Adrenocortical insufficiency

• Hyper/Hyponatraemia

• Thyroid dysfunction

• Dyslipidaemia

• Endocrine emergencies: myxoedema coma, thyrotoxic crisis, Addisonian crisis, hypopituitary coma, phaeochromocytoma crisis

B. Radiology
   Plain radiology

• • Chest, Abdomen,

  • Computed Tomography (CT)

a. Brain, C-spine, Thoracic and lumbar spine
               Magnetic Resonance Imaging (MRI)
a. Brain, Spine, Joints – wrist, knee
Ultrasound
Medical precautions in Radiology

• Contrast and allergic reactions

• Pregnancy and shielding

• The unstable patient – transfer and monitoring in radiology

  

 C. Critical  Care Medicine

Organization of intensive care services and standards of ICUs
Transport of the critically ill patient
Supportive care of critically ill patients
Inotropic therapy

• Recognise when to use inotropic or vasopressor therapy.

• Choose an appropriate agent, dose, physiological endpoint, rate and route of administration.

• Review the efficacy of inotropic therapy at regular intervals.

Nutritional support

• Provide appropriate nutritional support.

Monitoring of the critically ill patient

• Principles of monitoring.

• Monitoring of the cardiovascular, respiratory, renal and central nervous systems.

• Complications of monitoring.

• Electrical safety.

Specific disorders
         Acute circulatory failure
        Respiratory failure
 Haemorrhage

• Recognise and assess severity of diseases and its manage the condition.

• Manage cardiorespiratory arrest using the Australian Resuscitation Council’s and other accepted international protocols.

      D. Trauma and emergency management

• Use a systematic, priority-orientated approach in resuscitation, assessment, investigation and emergency management.

• Recognise differences between management of the injured child from that of the adult.

• Effectively transfer injured adults and children within and between hospitals.

• Continue management including preventing, recognising and managing complications.

• Common neurosurgical emergencies

• Common orthopaedic emergencies

     E. Basic and Advanced cardiac life support

 

                      TEACHING PROGRAMME 

KNOWLEDGE (DIDACTIC TEACHING PROGRAM)

Phase B
A. Systemic diseases  with Critical management Which include in Phase -A
B. Complication, Prognosis and outcome of CCM patient
C .  Specific condition

1. Resuscitation and initial stabilization

2. Clinical assessment

3. Investigation, data interpretation and diagnosis

4. Organ system support and related practical procedures

5. Monitoring and clinical measurement

6. Safe use of equipment

7. Specific circumstances 7.a) General medical conditions 7.b) Perioperative care 7.c) Trauma and burns 7.d) Paediatric care 7.e) Obstetric care 7.f) Transport care 7.g) Sepsis and infection control 7.h) Comfort care

8. Pre and Post CCM care

9. End-of-life care

10. Professionalism

                                     Examination:
Assessment tools:
Formative assessment: After completion of each block

• Conducted by training units/clinical and educational supervisors.

• This can be provided in a variety of ways. including

  • Presentation at ward rounds and grand rounds.

  • Journal reviews.

  • Performance of practical/surgical procedures.

  • Audit of morbidity and mortality.

  • Review of patient’s medical records.

  • Mock Examination (ME).

Summative assessment:

• Conducted by the University Examination department.

• Examination format will be:

  • Written test: MCQ, SEQ & essays.

  • Vivas.

  • Clinical examination: Short cases.

Long cases
OSCEs
OSPEs

• • Logbook/Portfolio/RITA

  • Projects/Thesis.

After completion of each Phase there shall be final  Phase A & B exam has to be appear by the resident.

• • • • • • Examination date for written, oral/clinical and practical for each paper shall be declared by the controller of the examination of BSMMU.