A free online resource for Intensive Care Medicine.
An unofficial Fellowship Exam (CICM Part 2) preparation resource.
Deranged Physiologyis a slowly growing archive of discussions and study notes relevant (or if not relevant, then at least interesting) to the practice of intensive care medicine. The content provides an introduction to the fundamental themes in intensive care: mechanical ventilation, vasopressors, electrolyte management, hemodynamic monitoring, dialysis, and so forth. Attention is directed at equipment in intensive care, and there are attempts to revisit interesting pharmacology and physiology. The aim of this resource is to supplement the bedside teaching of senior staff, and to consolidate resources for intensive care trainees in the initial stages of their training.
This is a brief overview of the process of taking over the job of somebody's circulatory system. ECMO has made a few appearances in the past papers: Question 23 from the first paper of 2014, Question 11 from the second paper of 2010 and Question 7.1 from the second paper of 2009.
Unsurprisingly, this topic appears frequently in the exam. For instance, a broad approach to the topic was interrogated in Question 10 from the first paper of 2002: "Outline the aetiology, clinical manifestations and possible preventative measures for nosocomial infections in Intensive Care."
This is an altered level of consciousness attributed to the effects of an extracranial infection.
An excellent article on the subject earns significant brownie points by quoting Tolstoy in the opening paragraph.
"The doctors said that it was puerperal fever and that it was ninety-nine chances in a hundred it would end in death. The whole day long there was fever, delirium, and unconsciousness. At midnight the patient lay without consciousness, and almost without pulse.
The end was expected every minute."
Septic encephalopathy is present in up to 80% of septic patients. When graded using the Glasgow Coma Scale, it is associated with an increased mortality, ranging from 20% for a GCS of 14-13 to 63% for GCS of 8 and below.
This topic has never been examined in the written paper, but an entire chapter of Oh's Manual is dedicated to it. It seemed important to include a summary of it in the Required Reading section. Unless otherwise stated, the information below is derived from Oh's Manual.
This chapter deals with the nightmare which ensues when a patient without an immune system encounters the angry soup of multi-resistant organisms in a large teaching hospital. It has not been updated for some number of years, and is viewed by its author as derelict. The newer summary of sepsis in the bone marrow transplant recipient covers virtually the same territory, but better.
This chapter deals with the management of sepsis in somebody without an immune system. The bone marrow transplant recipient is a good model of such a situation. Question 11 from the first paper of 2014 uses the bone marrow transplant as a backdrop for some sort of infectious-asounding diarrhoea.
The asplenic state is a favourite topic of the examiners. Septic complications of asplenia featured in Question 9 from the first paper of 2013. Question 12 from the second paper of 2008 asked about pneumococcal meningitis in the post-splenectomy patient.
This is mentioned in Sivakumar and Pelly's chapter on tropical diseases in Oh's Manual. Thus far, the College has not asked about it in the SAQs, and it has not appeared among the differentials suggested for a febrile patient with a decreased level of consciousness. All thing considered, its appearance in the CICM SAQs would therefore constitute a sadistic assault on the candidates. However, it would not be the first such assault.
Cholera is mentioned in Sivakumar and Pelly's chapter on tropical diseases in Oh's Manual, barely a paragraph nested between typhoid fever and leptospirosis. It has not been interrogated in the SAQs directly, and is an infrequent differential. In Western ICUs, it is so infrequent that most physicians will not have seen one. Beyond Oh's Manual ICU literature concerning cholera is almost non-existant. It is usually mentioned as a footnote by authors discussing electrolyte and acid-base disturbances.
Typhoid fever is the third topic of Sivakumar and Pelly's chapter on tropical diseases in Oh's Manual. It has not been interrogated in the SAQs directly, and is an infrequent differential. As an alternative, the 2003 WHO document on this disease offers a detailed overview.
Question 7 from the second paper of 2014 asks for a substantial amount of detail regarding leptospirosis, including clinical features, diagnostic criteria, natural course of the disease, and specific treatment. It is one of the tropical diseases listed in Sivakumar and Pelly's chapter of Oh's Manual (Ch. 73, p.743). Literally two paragraphs are spent on it; but the detailed model answer gives one the impression that the college expects a much more indepth knowledge of these tropical pathogens than a mere familiarity with the limited content of the Manual.