MSF-OCB Emergency Medicine – Intensive Care

Emergency Medicine and Intensive Care DoctorsCheck list

Name of applicant: .......................................................

Date of application: .......... / .......... / ..........

Did you pass a post-graduate training program in Emergency Medicine ? Yes No

Did you pass a post-graduate training program in Intensive Care ? Yes No

If Yes, what was the duration of that training ? .......... ..........

If Yes, when did you qualify ? .......... /.......... / ..........

Please specify the name and address of the University where this program was delivered:

..........................................................................................................................................

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As a full-time Emergency Medicine doctor, how many years of experience do you have ? ............ years

As a full-time Intensive Care doctor, how many years of experience do you have ? ............ years

If you have not passed any training in Emergency Medicine, how many years of experience working in an Emergency Department do you have?................. years

If you have not passed any training in Intensive Care Medicine, how many years of experience working in an Intensive Care Unit do you have?................ years

Are you ALS certified ? Yes No

(Please provide your valid certificate)

Are you ATLS certified ? Yes No

(Please provide your valid certificate)

Are you PALS or APLS certified ? Yes No

(Please provide your valid certificate)

Are you an instructor in any of these specific trainings ? Yes No

(Please specify).............................................................

Are you qualified in disaster medicine or multiple casualty management ? Yes No

(Please specify).............................................................

Any other qualification you would like to mention ?

(Please specify).............................................................................................................

MSF-OCB Emergency Medicine – Intensive Care

Technical skills :

Not trained Only under supervision

Autonomous practice Expert

Bag-valve-mask ventilationNon-invasive ventilation IntubationVentilator settings Procedural sedation Anaesthesia Chest drain insertionFAST ultrasound scanPICC accessIntra-osseous accessCentral venous accessECG interpretationThrombolysis for ACS Conservative fracture managementBurn managementWound carePsychiatryPre-hospital careEnd of life careNormal deliveriesCaesarean sectionFasciotomy

Signature of applicant:

Many thanks for completing this form.