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ECG interpretation questions in the CICM Fellowship Exam

Saturday, August 28 (2021); Cardiology

Of the cardiology questions in the Part II exam, a large proportion consists of ECG interpretation exercises. There really is no satisfactory way to short-cram in preparation for such questions. One might be tempted to make the facetious remark that people at this level of training would be confident in ECG interpretation, and that no further preparation would be required for the true ICU fellow in the final stages of their training. One might even say that good solid basic knowledge is the key to success in this ECG interpretation section. Of course, this would be complete bullshit. The College seem to have a database of perhaps twenty or thirty ECGs. The cynical trainee will focus on becoming familiar with this selection. If a repeat question comes up, the cynic will be rewarded for counting on the lazyness of  question writers. If the ECG is brand-new, the cynic will not be disadvantaged any more than anybody else.

In the spirit of cheating and cynicism, this chapter offers a list of ECG abnormalities which have appeared prominently in the previous papers.

Critical incident debriefing

Saturday, August 28 (2021); Communication and Ethics

"Critical incident defriefing" is the term used to describe a formal method of managing people who have been exposed to some sort of traumatic situation. In the history of the CICM Part II Exam, the trainees have been put in that position twice - in Question 28 from the second paper of 2014 and the identical Question 18 from the second paper of 2010. In these questions the candidates were asked to conduct a discussion with a junior trainee who had killed (or almost killed) somebody. 

Timing of renal replacement therapy

Saturday, August 28 (2021); Renal Failure and Dialysis

In the absence of serious urgency for dialysis, the kidneys should be offered a chance to recover before the intensivist resorts to the use of dialysis. This strategy does not seem to change mortality and offers the opportunity for up to half of the patients to get away without any RRT whatsoever, without extending their ICU stay or hospital stay. Moreover it allows time for the patient to be pampered with the sort of refinements which only the ICU has to offer With careful haemodynamic resuscitation and biochemical correction a proportion of patients (those less sick at baseline) will probably never need dialysis, and be grateful for having fewer holes in their necks and groins.

A short list of definitions for the lazy exam candidate

Saturday, August 28 (2021); Research methods and statistics, Statistics and Interpretation of Evidence

The college loves to include "define this" or "calculate that" questions in the exam paper, largely because the definitions of statistics terminology are usually quite fixed, not open to interpretation, and therefore easy to grade (i.e. you either get zero or you get full marks). The only exception was the ancient Question 2b from the first paper of 2001, which asked  "What is the relevance of Evidence Based Medicine to your patients and how will you apply this?" which is equivalent to asking a high school English class to write essays on the topic of "What does freedom mean to me?". Fortunately, this sort of thing has not been seen for a while. Even raw definitions of such pleb items as sensitivity and specificity have not been seen since about 2008 (i.e they disappeared around the same time as the CICM Part I appeared on the scene; this primary exam then seems to have absorbed many of the EBM definition questions). These days, Part II tends to feature "fellow-level" questions about interpreting funnel plots and examining meta-analysis articles for validity.

At-risk extubation

Saturday, August 28 (2021); Airway Management

"At-risk extubation" defines a situation where there is some uncertainty as to whether or not the patient will stay extubated for any prolonged period of time. This state is characterised by the expectation of difficult reintubation or by the presence of incompletely met criteria for extubation, be it a full stomach, haemodynamic instablily, poor neurological performance or metabolic derangement.

Interpretation of abnormal coagulation studies

Saturday, August 28 (2021); Haematology and Oncology

This is a fascinating topic, and one which has surprising amount of herpetology in it. A more indepth discussion of the reptilian contribution to coagulation tests is available elsewhere. Also, there is an excellent article which details a stepwise approach to the coagulopathic patient, and the manner in which the diagnosis of an isolated coagulation abnormality should be approached. An even greater depth of explanation (and more detailed references) can be found at Practical-Haemostasis.com.

Morphological abnormalities of red blood cells

Saturday, August 28 (2021); Haematology and Oncology

This topic is a constant feature of CICM Fellowship SAQs. The questions usually take the shape of "Here's a blood film; it's abnormal. What's wrong with the patient? Give differentials." Probably the most favourite topic is macrocytosis (i.e. "what are the different causes of macrocytosis"). Nucleated red cells, rouleaux formations and inclusion bodies have also made several appearances.

Delirium in critical illness

Saturday, August 28 (2021); Miscellaneous Topics

Delirium among the critically ill has been discussed in Question 6 from the second paper of 2013 and the more detailed Question 29 from the second paper of 2009. The more recent question was more general and did not expect any information regarding the prevalence or prognostic significance of delirium. Delirium is defined as a disturbance of consciousness, characterised by inattention, which develops acutely, and fluctuates in severity; there are specific investigations, acute management issues and pharmacological or nonpharmacological solutions.

Antibiotic dosing as continuous infusion

Saturday, August 28 (2021); Infectious Disease Antibiotics and Sepsis

The real question of continuous antibiotic infusion dosing is, "why isn't this clearly beneficial?" Theoretically, a continuous infusion should have all sorts of pharmacokinetic and pharmacokinetic advantages. But thus far, these have not translated into outcome improvements among large multicentre trials. The answer, obviously, is to design even larger trials.

Miscellaneous multi-system diseases

Friday, August 27 (2021); Miscellaneous Topics

Often, the college asks the candidates to discuss diseases with a significant community prevalence which have some sort of serious impact on the ICU management of affected patients. it makes sense to expect final-stage CICM trainees to be able to discuss SLE or scleorderma, and the attention directed at these diseases is understandable. On the other hand, there are occasionally questions in the Fellowship Exam which cannot be explained by this framework. There is a group of rare diseases which have only ever appeared once and which can reasonably be expected to never appear again. These are grouped here in no particular order, basically because there is nowehere else to put them.

Immersion submersion and drowning

Friday, August 27 (2021); Trauma, Burns, Drowning

For a critical care college in a country with this much shoreline and such a vibrant beach culture, the CICM is strangely unconcerned with drowning. Certainly, the author can conceive of a seaside ICU where perhaps half of the inpatient population is recovering from a near-drowning, but this pathology does not seem to form a very large proportion of our daily workload out here in the Western Suburbs of Sydney, where the people are too poor to afford pools. Uneducated social remarks aside, the drowning SAQs consist of Question 25 from the second paper of 2012 and Question 1 from the first paper of 2009. Thus far, the issues examined have been acute management of the drowning victim, potential complications of near-drowning, and risk factors for severe neurological injury arising from the hypoxia of submersion.

Uraemia; its causes and consequences

Friday, August 27 (2021); Renal Failure and Dialysis

"Uraemia" is a term that tends to be applied to describe the syndrome associated with an accumulation of all sorts of renally cleared waste products, and is not necessarily referring to the accumulation of urea alone. However, urea is the most abundant waster product among those which accumulate, and it seems to have some important toxic effects.

Applications of ECMO in brief summary

Friday, August 27 (2021); Cardiothoracic Intensive Care

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.

Care for the brain-dead organ donor

Friday, August 27 (2021); Cardiac Arrest and Resuscitation

Care of the patient preparing for organ donation after brain death is essentially the support of organ systems which have lost central autonomic and endocrine regulation. The intensivist must step in to the role of the pituitary and hypothalamus, making gross adjustments to parameters which were previously handled by this apparatus. This support consists of pituitary hormone replacement and support of the functions which were formerly performed by the autonomic nervous system. Aggressive support in general (including CPR) is justified on the grounds of it being the fulfilment of the patient's wishes, who presumably would have supported any measures which facilitate their incredibly generous act.