FRCEM -Intermediate (SAQ)

So I took the Intermediate exam back in September 2017 (the SAQ bit only, I did not book the SJP or the OSCE) and I am happy to say I passed it. That’s two down and…err…about 6 more to go? or is it 5? Sheesh! give me a break!
Anyway – this post is a long time coming, I thought I had written this already but turns out I had done so only in my head.

Having passed the FRCEM Primary in June that same year (thank you thank you *takes a bow*) I was in no way in the right mind to take another exam so soon. The next available attempt for the SAQ was end of September, which meant that I had little over 2.5 months to prepare for yet another exam – along with a new rotation change (I was about to enter the wonderful world of anaesthetics and ITU in August) new responsibilities and the very many issues related to portfolio hassles. Not to mention my wife would not be too happy at literally having had to raise our 2 year old on her own these past few months as I juggled preparing for the primary, and then right after finding out I had to prepare for a second exam. Flowers. And chocolates. lots of them. problem solved. I spoke to my colleagues and my friends and specially my mentor back home in Pakistan. He really really I mean REALLY pushed me to seriously attempt this. This being a clinical oriented syllabus of this exam, he was of the opinion that I just had to build on my standing knowledge and based on my experience having worked in ED these past few years I would not find preparing or taking the exam too hard. I had my doubt but he impressed upon me the need to give it my best shot – if I pass then that’s good, if I don’t then it will be a learning experience. He felt that if i gave it my all there was no reason 2+ months of prep time (sincerely) couldn’t help me pass.

I discussed it with my wife who to my surprise pushed me to go for it! I applied for the exam about 2 days before the deadline to apply. And here is where I found out how every little thing you do, even the smallest tiniest thing, can help out in the long term. It is a long and boring story, but the long and short of it is that someone from an exam prep website saw my blog posts and were interested in sharing said posts on their own website – as a gesture of good faith and in lieu of my contribution to their site, they offered to ‘allow’ me to use their vast question bank free of charge to help me prepare for the intermediate examination! It felt like a sign from above (yes I am that superstitious!) and I decided to do the questions from WWW.FRCEMEXAMPREP.CO.UK

The SAQ is an interesting exam in that I have never taken an exam like this before. As it’s name suggests, you have to write short answers to each of the questions. There are 60 questions in all, each carrying 3 marks. Each question can be one solid question requiring a lengthy answer, for 3 marks, or it can be divided into 2 or even 3 parts, with varying marks for each part but the total for that whole question would be 3. You have 3 hours (180 minutes!) in total but essentially 3 minutes to read each question’s stem (or the stem in each part or each question), think of and formulate your answer or the order of your answer and THEN WRITE IT ALL DOWN. It sort of leaves not much room for any errors or erasing and re-writing or thinking a lot. This I found the toughest thing to do: TIME MANAGEMENT. Since you are not used to writing answers out to questions, you do not realise how time consuming it is to think about your answer and then to write it down so that the examiner can read it and find all the required information that was asked in the question.

The practise questions were good, but like any practise question bank for this sort of exam, it only gives you a key of answers that are deemed correct. There may be other answers/varieties of the same answer worded differently that may be correct, or indeed a completely different answer might be correct. For example, in a scenario of a young male patient with appendicitis apparent as the clinical picture, if the question asks for 4 steps of management in ED, the answers could be: 1) analgesia 2)surgical consult/referral 3)fluids 4)antiemetics 5)antibiotics 6)urine dip and other investigations to rule out other causes for similar clinical picture 7)NBM till further orders – now if the key shows only options 1/2/3/4 as the only steps in management, someone writing the other steps could be deemed correct as well, or any combination of the above options. They essential bit to understand is that the more you practise these questions, the better you become at thinking about the answers and formulating the correct answer and writing them down in a concise and legible manner, with the addition of time constraints.

There were recommendations to read some textbooks as well – but I found I had no time to read anything, I only focussed on practising as many questions as I could. The questions I got wrong, I did read up on a few of those concepts, but mainly I found the explanation in the website to be quite sufficient, it gave you a broad overview of the topic at hand, and it gave all relevant information related to the query at hand. With each question I got more and more confident, and the explanations were very very helpful in preparing for these. I first utilised the option of doing the questions subject wise – there were a wide variety of them, including paediatrics and gynae and medicine and pharmacology etc – I found I didn’t do too well when I knew what the subject matter was. After I had gone through all the questions in the subject wise manner, I then opted for the shuffled questions – The site rang up a mixture of all subjects and gave me 20 or 50 or whatever number of questions I needed to do or had the time for.

On my days off I did approximately 10-14 hours of these question banks, approximately 50-100 questions with their explanations – my days off were very few and far between. On my days at work, while I was still in A&E I found myself unable to do more than 20 or a maximum of 30 questions a day – but I made it a point to do atleast some if not too many, every day. I think the trick to this exam is to be consistent in your prep. In the last 5-6 weeks before the exam I started in my new rotation in anaesthetics – and I found a great rota, one with weekends off and no nights or on call commitments. Granted, I was paid a lot less than I expected but I got a good time to do those questions! Once I had finished the questions subject wise, and then again as a mixture, I just randomly kept doing questions – I still got a few wrong, I only read explanations for those, the ones I got right I didn’t waste time reading up on them unless I felt it was a weak subject for me.

I took 5 days of study leave (not including the day of the exam) and the day before the exam I did not study anything. I do not believe in cramming till the last second. I spent the day with my family, went out with them to the town centre, had an educational supervisor meeting, made a few phone calls to family back home in Pakistan, watched the Minions movie with my son for the thousandth time, cooked a meal and just generally relaxed and enjoyed and rested – before the trauma of the next day.

Even though it was an early start for me, I was almost 7 minutes late to the exam (effing traffic jams on the way to London where my station was!) and I rushed in and totally convinced myself that there is no way I am passing this exam now – but I did, and so can you! Just…make sure you do not convince yourself that time is too short and there is no way I can prepare for this in such a short time…just make sure you atleast attempt it, you may end up surprising yourself. I did, and so can you. Just…make sure you do as many questions as you can, as frequently as you can, in as timely a manner as possible. Again. And again. And again.

Good luck!

My first EM conference in the UK – The Northern Emergency Medicine Conference 2018

NEMC18

1) RCEM President address – pertinent points extolled were: good practice guide; duty of candor; work ethics; reiterated how the quality of care that we provide to patients has improved over the years; members have gone from 7 to 7500 in a matter of a few years!
He also talked about the ED exit block, what problems it created and how it wasn’t really the department itself that caused the block, but the flow out of the department, and that was basically a matter of funding and resources.
He addressed a few ‘elephants’ in the room – key concerns were the fact that demand has increased, with a 30 percent rise in ed attendances in 12 years; variations in staffing, variations in systems, variations in support/behavior of management/colleagues. He re-iterated that improvement starts at leadership at the top. Creating environment for support, momentum, culture was key in establishing good support systems for all staff – also quoted by Edward Demming in stressing the need to ‘reduce variation for optimum management.’
high quality improvement projects key to chip away at bad or lesser effective practices.
workforce is key- planning. need multidisciplinary workforce with senior decision maker layer on top, consultant cover has increased in past few years, still only about halfway there.
grow it to create depth and breadth, create strategies to reduce attrition in training, maximise retention for consultants, increase training numbers by 33 pc (80 pc from baseline to 400/year for 4 years)
plans to start dedicated leadership programs
plans to start clinical educator programs
plans to start and further increase fellowships – geriatric EM, humanitarian EM, ambulatory EM.
he also spoke about how to retain older consultants 50-55 age before the retirement age, because it can get tiring, as well as ways to support the new generation of EM consultants.

2- MacMillan Nurse John Sheridan – Palliative care
He spoke about and clarified a few terms about end of life, palliative care. He defined palliative care as ‘living as well as possible for as long as possible (usually 12 months)
33 percent bed base in every hosp, palliative at any time.
patients usually end up in ED due to poor planning, portrayal in media
usually PC is thought to be malignancy related. wrong assumption. can be any disease causing possible/probable death in 12 months. gp should e informed.
SPICT score
on call OOH Palliative care opinion always available everywhere
think about an emergency care plan upon discharge or transfer of care to home or other service. contact district nurses. dedicated palliative ambulance, dedicated palliative care nurses, bellflowers, deciding right app
scenario presented.

3- PHEM/ED consultant – shared scenario – video of resuscitation of stabbing victim – cardiac tamponade relieved prehospital. making unexpected survivors to expected survivors.

coffee break

4 – trauma network – geography, what it entails, MTC, ambulance services (usually multiple, coordinating between them, air ambulance.overnight cover. approved by nhs england.
take on calls for advice. every aspect of clinical journey. clinical guidelines education.training, sui, audits, make sure standards are maintained across the board.

5 – GEM
frailty scoring – E FRAILTY INDEX./edmonton frailty scale/CHAMP/rockwood or clinical frailty score
why? multidisciplinary. NNT 13-17 TO AVOID DEATH OR ADMISSION TO CARE HOME WITHIN 6 MONTHS. vs 17 for stroke thromb 42 for aspirin post-MI.
admtted vs discharged from ED – improves care for both/further planning etc
frail = complex. (plus sheer numbers in ED adds to danger for frail patients)

frailty scenario
delirium – VERY IMPORTANT. getting it wrong – due to our perceptipn, helpfulness of older person, lack of family carer with patient – 11 pc screening completed in 2015 audit. if missed in ed, 70 percent missed during rest of admission
another scenario
every time you chicken out of a DNACPR discussion god kills a kitten.
atul gawande
scenario

dangers of non specific general vague presentations – over 80? falls, confusion, weakness, fatigues, inability to cope – falls, usually multifctoria. MI AND PNEUMONIA DONT PRESENT IN ELDERLY TYPICALLY
major trauma USUALLY CALLED SILVER TRAUMA – is usually NAN DOWN. likely to be seen in trauma units. likely to be seen by juniors.
HECTOR
future of GEM

6- EM Trainee presentations x 3
dislocated shoulder management – shoulder relocation bench? 77 percent reduction successful without sedation
stroke vs stroke mimics (how to differentiate)
ketamine sedation audit

LUNCH

7 – “Tactical team medics”
8 – GP with EM specialist interest
9 – ACP sharing experiences and progress

COFFEE

10 – ALS – Cardiac arrest beyond the algorithm – ITU/ANAESTHETICS CONSULTANT
goodsam
children – cpr training/sweden/danish/germany/france
immediate bystander cps good – improved outcomes
less than 60 years of age good outcome
e-cpr no confirmed survivors
summary – routine application of also not leading to early rosc
focus should shift entirely in certain cases
charge defib early
always use echo
think in parallel
ecpr

11 – burnout
1/3 will have depressive episode
1/12 will consider suicide
shared personal experience

maslach burnout inventory
depersonalisation – cynicism, sarcasm, compassion fatigue
exhaustion – not sure how much longer i can go on
lack of efficacy

sources of burnout – ourselves, blame culture, NHS structure complexity
positivity of juggling this stress of work
negative stress – same things same sort of day totally different mood

how to handle the stress – time management, checklist – headspace – (physical/emotional/spiritual banks)
notification fatigue
events + rections = outcome
let it go

12 – keynote speaker – hospital response to a major incident
when you fail to prepare you prepare to fail

*bleep* holder – First Anaesthetic on-Call

So I have just come back from my first call as an anaesthetic doctor (or more specifically, an emergency medicine trainee rotating in anaesthetics who is holding the dreaded anaesthetic bleep very much reminiscent of a hand held grenade with the pin taken out. It may go off any second, heralding news which may be good or bad, usually bad).

So, I started the day taking a handover from my colleague who was the previous bleep holder. Or, I should rephrase that and tell you what actually happened. I waited for them to turn up to the operating theater for emergencies, and when they didn’t turn up after 20 minutes, I bleeped them. I found out they were in the middle of trying to help out a consultant with a dodgy arterial line for an elderly patient (who apparently at 92 had everything under the sun going wrong with her, and having managed to break her femur, was getting it surgically corrected), they rushed to meet me, handed me the bleep and a quick handover of the patients on the list (none!) and 2 patients that might require some analgesia maintenance sorting out later, and headed out the door. My first port of call was the consultant currently in the trauma theater dealing with the dodgy 92 year old. Old lady with CCF, AF on warfarin, small bilateral pleural effusions, past history of CVA (just last year) and a CABG 9 years back. She currently was using a frame to walk, and had tripped over an overturned edge of her carpet and ended up (long story short) on the operating table that evening. Anyway, the procedure went swimmingly, and she landed in recovery wihout any significant problems. My presence, though not directly helpful to the case, was atleast helpful in the sense that my consultant was able to grab a quick meal and some semblance of a hot beverage, and she mentioned she appreciated the chance to talk to someone. So far, so good, the call was going.

I was then bleeped about a potential appendix that was rumoured to have surfaced in A&E and the surgeons were contemplating taking it out. Young male, fit and well I was told. I took the opportunity to go round and see the patient myself, but as I was walking out of the recovery room, Cardiac arrest bleep goes off. In the heart centre (yes, ironic, isn’t it? I couldn’t make this up if I tried!) Apparently just a vasovagal syncopal episode though, as I ran down to the heart centre I saw the ITU registrar motioning me to relax as he seemed to have it under control.

Phew! On to the appendix…but first…ANOTHER CARDIAC ARREST BLEEP! Where is it? Second floor you say, oh the ward FURTHEST FROM WHERE I AM CURRENTLY STANDING? THANKS! I run to said ward, find CPR in full action on a what I understand is a 70 something year old gentleman found unresponsive on the ward (it is an orthopedic ward) and the rest of the history is a little late in coming, so CPR is in full progress, the ITU Reg enters almost at the same time as I do, he asks me if I have control of the airway, I reply in the negative as I am finding it difficult to bag mask ventilate. He chucks an I-gel towards me, which I insert successfully and ventilation is now adequate, as evidenced by the now rising saturations. CPR still ongoing, and there is now return of spontaneous circulation. He is intubated in the interim and post-resuscitative conversations/management are taking place (all this happens within the first 90 seconds of our arrival!) and someone then pipes up with the history (finally) that this patient is a known epileptic, admitted with multiple c-spine and other fractures, s/p corrective surgery for the spinal fractures 5 days back, was last seen alright 3-4 hours prior to being discovered unresponsive/in cardiopulmonary arrest. Based on the absence of pupillary reflexes, absence of any respiratory effort on the patient’s part, and cardiac function likely in response to the drugs given by us during the CPR, as well as the pre-morbid situation of the patient, it was the collective decision of the whole team involved to withdraw treatment. This was also agreed upon by the ITU consultant who we telephoned to ask for advice. The ITU reg offered to write up the notes as I took the tube out, and I went to see the appendix.

Very straightforward appendix – never had any anaesthetic, no family history of anaesthetic complications, last eaten/drunk something 11 hours back and that too vomitted up. Allergic to penicillin, otherwise fit and well young male with a slight language barrier, through which I discerned straightaway that he wasn’t happy about the surgery. He did not wish to proceed with the surgery for now. I stepped out of the room and let the surgical resident handle the situation. They would let me know if he still wanted the surgery. For now I would keep him on our list with an almost question mark. The staff in theaters would know what that code meant!

Bleeped again, this time from A&E RE an elderly female, Hmeatemesis with massive hemorrhage protocol in place, could we rush them into theaters for an urgent endoscopy +/- surgery? Her HB had dropped from a last known reading of 125 a few months prior to 49 on today’s blood gas. She already had a couple of IV lines secure, and the ED team had been excellent in pushing fluids, arranging blood and 2 units PRBC had already been given to her as well as 4 units of FFPs. I quickly pre-op assessed her, gave my consultant a quick phone call: he was happy to drive in (20 mins away) and assured me he would be ready and waiting by the time we got to the theaters. We did, and he was there, and it was an RSI, 4 more units of blood went into her, her last Hb was 98 and they found the bleeding point and treated it endoscopically, there was no need to open. Out into recovery where the ITU consultant also eyeballed her quickly, deemed to have no need for ITU support at that time and then moved to the ward after stable. He did ask me to give her the rest of the blood/FFPs booked for her, and afterwards send off clotting and FBC profile whenever transfusions over. Crisis averted (this took 2.5 minutes to write and around 2.5 hours to manage from start to finish, in which time I was bleeped 4 more times!)

One of those bleeps was from the surgical reg – appendix guy was agreeable and we would proceed for the surgery next. The consultant offered to do the RSI for this next one as well, I drew up the drugs for the case, and left to deal with the 2 pain patients from the handover (which seemed such a long time ago now!) and also deal with the 4 other bleeps that I had while we were dealing with PR bleed lady. 2 were urology cases apparently cystoscopies needed to be done for 2 elderly males, both with long term urinary catheters in place but unable to be taken out as the ballons werent deflating – eerily similar weird cases that were as much of an embarassment for the urology registrar as they were a hassle for the rest of the theater staff. Also while dealing with the bleeding lady, another consultant who was running the trauma list and who is now going home after his procedure has ended hands over 2 of his patients who are in recovery “shouldn’t be a problem but if there is just so you know about them” and walked out. I quickly scribble down their details so they don’t fall out of the back of my mind.

During my assessments of those 2 cystoscopies I got bleeped to remind me to do the bloods for the previous lady. I added it to my growing list of things to do.

I get called back to the theater because one of the other post-op patients in recovery (that the trauma consultant handed over) was being a bit…ummm…difficult. I quickly go see them. One of the other consultants prescribes some haloperidol. He is an elderly gentleman who has had a hip DHS, no prior known comorbids but slight cognitive impairment previously. But nothing as dramatic as how aggressive he was being right now. he was trying to get out of bed, he accused me of stealing his clothes and he accused the blushing nurse of having an affair with his wife, and he had quite a few choice words for how we were treating him. The halloperidol seemed to not do anything at all. It took all of our combined efforts (and a little bit of his analgesia) to calm him down and he went off into a deeply snoring snooze. Sigh. Phew.

9th bleep (or is it the 11th?) Urology registrar (sounding to be at the end of her thether, bless her) calling to tell me the first urology case cancelled as they were able to remove the catheter successfully, but the second case (similar) added to list, yet the consultant urologist was coming in to try to deal with it – should he fail, this was to be done cystoscopically so could we please keep the patient on our emergency list.

Another bleep – another story. A new bleeding patient, this time an esophagael variceal rupture potentially? Has not been booked on to the list but this is the theater staff calling to tell me there is a potential case – and to await further instructions. I swear I stared at the reciever of the phone to register my incredulity. At the end of the conversation I still wasn’t sure if there was or wasn’t a patient with a bleeding/hematemesis situation that needed to be urgently anaesthetized for their procedure. *DEEP BREATHS*

Another lap. appendix. Another x2 bleeps from pain relief point of view: something about a rectus sheath catheter that had dislodged, and another about someone who’s pain wasn’t being controlled despite adequate analgesia (problem was solved by a simple look at the drug chart which informed me that they WEREN’T in fact adequately analgesed!). 3 bleeps from various wards about cannulation difficulties. And finally, the last bleep of the day:

“Oh Hi there, it’s XYZ, coming to take handover – whereabouts are you?” I could have screamed in relief, but I managed to restrain myself till she got to the office where I handed over my bits and pieces. She was more senior than me, and asked how my first on call went, and then looked a more thorough look at me and said, “you know what? I know exactly how it must have gone – go home and get some rest. See you tomorrow!” Uncanny how she could discern from my expression and my hair and the overall dishevelled look and the stains on my OR shoes exactly how my first on call shift as an anaesthetic SHO went.

Just as I was stepping out of the office, I heard the bleep go off. And I was reminded of my own favourite pearl of wisdom: There is nothing worse than the sound of a bleep going off. And there is nothing better than realizing that it is someone else’s bleep that has gone off. I was smiling as I exited the office, and the hospital.

The perks of PERC

The really worrying question sometimes arises (or depending on your luck, most times arises) while you are in an ED, and you see a patient who comes in with ‘some chest pain’ that’s maybe a little pleuritic in nature, but pleuritic chest pain could result from a punch to the chest, or if you cough too hard or too long (I unfortunately speak from experience!) and you don’t know what to do and someone’s already done a D-Dimer on the patient’s initial bloods as they were triaged, before you saw them, if you are lucky enough to work in a department as great as ours (or unlucky, depending on how you view the over-testing of D-Dimers!) – I have been handed the most amazing tool: the PERC score, or the Pulmonary Embolism Rule-out Criteria. For those of you already aware of the existence of such a magic wand – bravissimo and kudos to you, and no need to read on any further. For the ones like me who until very recently hadn’t even heard of it, please proceed further.

Patients who present with clinically low risk for development of a PE can be subjected to the PERC. This is a pre-test probability type situation, whereby you assess a patient based on clinical parameters (which you obviously already do!) but you mentally check them off a list of specific parameters, and if they meet all 8 (yes EIGHT!) criteria, then you can safely say they do not need further assessment RE:pulmonary embolism, D-dimers, CTPA route etc. This creates a warm and fuzzy feeling in me, because almost every patient in the past 3 years of practising emergency medicine in the UK that presents even remotely with pleuritic sounding chest pain, regardless of whether they have a clinical indication or not, automatically had a D-dimer, and, God forbid, should they have an ever-so-slightly-raised D-dimer level, they were referred to the acute medical team faster than you could say enoxaparin. These were then possibly unnecesarily given doses of enoxaparin, until the gold standard rule-out test could be performed, which is the CT PA (CT pulmonary angiography). That’s just the way things worked, because a positive D-dimer can indicated possible pulmonary embolism, but it needs to be taken with the complete clinical picture, and a (very large) grain of salt. D-dimers can, unfortunately or fortunately, be raised in a number of different situations, e.g an underlying active malignancy (which gives the double whammy of raising your chances of getting a PE in the first place), an infection anywhere in the body, certain medications and inflammatory medical conditions.  This lead to over treatment of many patients with anticoagulants till the CTPA was performed to finally confirm the existence or absence of the offending clot. Things may have changed for the better with the PERC, though.

The parameters you base your PERC score on are Age (< 50 years), O2 sats (greater than or equal to 95%), Heart Rate (less than 100 BPM), Absence of Hemoptysis, Absence of Oestrogen usage (Contraceptive pills), Absence of history of surgery/trauma requiring hospitalisation/immobilisation within past 4 weeks, Absence of lower limb swelling (unilateral), and absence of prior personal history of clots/emboli/thrombi.

These parameters and this score are widely used now and available as calculator/apps on most phones.

So the way I understand is, low-risk patients meeting the PERC score criteria need not be further assessed (even if they have had a D-dimer done that’s slightly raised, you can ignore it because the pre-test probability was extremely low). Low-risk patients not meeting the PERC criteria may then go on to be assessed on the D-dimer route, and the high risk patients go directly to CTPA without faffing around with PERCs and WELLS and GENEVAs.

Good luck, and happy PERC-ing!

My PLAB experience (a VERY long time coming!)

Very recently, I was asked by one of my friends if I could share my experience about the PLAB exams, as guidance for prospective candidates. Having taken the exams quite a while back (2014!) I found it hard to address the issue, so they sent me a questionnaire to make things easier to explain to someone not very familiar with the way forward when contemplating taking the PLAB exams. I am sharing the whole Q&A session here (with a few minor adjustments/deletions with the author’s permission). Thank you @Sadaf Taymor (http://sidtay.blogspot.co.uk) for the opportunity to express myself and to share an important experience with everyone!

The curious case of PLAB (09/10/2017)

What is the PLAB exam and how does it help in initiating a medical career in UK?
There are many routes of entry into the UK for doctors who wish to train here. The easiest and most common one is to take the PLAB  (or Professional and Linguistics Assessment Board) exam and become GMC certified. Let me tell you a bit about this – basically any country that you work in has their own authority that confirms that you are good to practice in that country. For Pakistan, that authority is the Pakistan Medical and Dental Council, for the UK it is the General Medical council. Passing BOTH PLAB 1&2 gets you the license for the GMC to practice. After you get those out of the way and are certified then you are basically allowed to practice in the UK. That’s what people usually do.
The PLAB exams are the basic, entrance-level exams. You could potentially also get GMC certified by taking any of the more advanced membership exams for any of the Royal Colleges (but more about that at a later juncture – let’s keep this simple!)
The bottom line is you can not practice medicine in the UK without being GMC certified, and the easiest and most common route of entry to get that is to take the PLAB exams.
What kind of a format does this exam follow and what time limit does the candidate have for the exam
The PLAB has 2 parts – both are compulsory to pass individually. The first part is theoretical, and is based on the multiple choice questions format (or should I say, the single best answer format). You are given three hours to answer 200 questions. I have often heard people lament that the time is not enough, but I think it is doable. It may be difficult if you are not used to such a format, but in this field, better get used to this format, because later exams are also going to be in the same manner, same time frame (possibly even worse!)
The second part is interactive and consists of multiple stations. It is OSCE-based format, where each candidate rotates in 14 stations, each station assessing a different skill. Examples of such interactive sessions include taking a proper history, examining certain system, counselling a patient about something, and so on.
You can attempt the PLAB 1 as many times as you wish. Once you pass it, you have three years to pass the second part, failing which you will have to take the PLAB 1 again. You have 4 maximum attempts to take the PLAB 2.
Does the test have a certain validity?
Once you pass both parts of the exam and are GMC certified, you do not have to retake it again. You just have to keep up to date your assessments and your competence and you get re-validated automatically every 5 years.
 Any specific tips on cracking the test?
For the first part, I would advise go back to your roots, back to the basics. The whole syllabus is available on the GMC/PLAB websites. Try to practice as many questions as you can, get your tempo going, get used to this format before you take the exam. 2-3 months of prep should be enough.
For the second part, it can only be taken in the UK so make sure you have everything sorted before you travel for the exam. There are course available which guide and prepare and help practice the various stations that may come in the exam. These preparatory courses are much recommended before you take the PLAB 2 (if you have never worked in the UK or similar circumstances before).