MSF-OCB

Emergency Medicine Intensive Care

Emergency Medicine and Intensive Care Doctors

Check 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:
..........................................................................................................................................
..........................................................................................................................................
..........................................................................................................................................
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
Bag-valve-mask
ventilation
Non-invasive
ventilation
Intubation
Ventilator settings
Procedural sedation
Anaesthesia
Chest drain insertion
FAST ultrasound scan
PICC access
Intra-osseous access
Central venous access
ECG interpretation
Thrombolysis for ACS
Conservative fracture
management
Burn management
Wound care
Psychiatry
Pre-hospital care
End of life care
Normal deliveries
Caesarean section
Fasciotomy

Signature of applicant:

Many thanks for completing this form.

Only under
supervision

Autonomous
practice

Expert