The 2004 Experience

The 2004 Experience

My thanks to the kind (and successful!) candidate who submitted this detailed account. Feedback from other 2004 candidates concurs with this experience.

I thought that I would give you some feedback on the exam and suggestions to help future candidates.

1. The Dissertation Viva: I submitted the research that I am writing up for an MD, on the effect of IV glutamine supplementation on monocyte and lymphocyte function in enterally fed patients. I had been advised in the initial letter from the board that the numbers of patients were small and that they also wanted a comprehensive literature review. This was quite a tame viva but they were quite critical of the stats, and some of the conclusions. Otherwise OK - I discussed the Annane steroid paper and NEJM glucocorticoid paper out the week before!

2. The ETR Viva: I was asked entirely on my training record for half an hour; if I had ticked it then I was asked! I had ticked cardiac pacing, so was asked all about it, as well as critical illness neuropathy including steroids and NMBs (ended up discussing the NEJM insulin paper and critical illness neuropathy, which they didn't agree with, but I justified my agreenent with the paper); management of smoke inhalation (did I think that lung lavage with bicarb worked, did it often cause ARDS etc - they agreed no to both); ventilation for ARDS (ARDSnet and Amato NEJM papers); ventilator acquired pneumonia (recent NEJM paper on TREM-1 and VAP); indications for activated protein C (NEJM paper discussion); and mechanism for activated protein C (review of DIC by Toh in BMJ recently very useful here). I had ticked obstetric problems and was asked about management of preeclampsia and when I would use a PA catheter. When I said I would use a PiCCO, we had a discussion on the PA catheter papers and then I had to explain how lung water was derived from measurement by the PiCCO (article from B J Int Care this month [no link available - ed.] - I'd also lectured to our SHOs in ICU on this!)

3. Ten Cases Viva: I don't think I performed awfully well here - I didn't know my references as well as I should have done. Asked about prediction of survival from cardiac arrest followed by coma, including definitions of specificity, positive predictive values etc.; also asked about CSF biochemical markers from my references but I didn't know them as well as I should have done. Discussed principles of treatment withdrawal and when to admit to ICU following cardiac arrest. Then pancreatitis (lexipafant and other novel therapies) - papers on antibiotic prophylaxis, treatment of necrosis, pseudocysts. Enteral feeding versus TPN in pancreatitis, problems with enteral feeding generally and prokinetics including evidence from meta-analyses. Then asked about ARDS pathophysiology and HFOV briefly.

4. General Viva I: This was definitely based on the 'domains' rather than the syllabus. I was asked about transfusion related lung injury (TRALI) and its pathophysiology; tetanus (none of the candidates I talked to had a clue about these first 2 topics, nor did I!); scoring systems (APACHE, SOFA); sepsis definitions; pathophysiology of sepsis and endothelial dysfunction (good review in BMJ on sepsis last year helped here); Rivers NEJM paper and its flaws; goal directed therapy and relevant papers; Surviving Sepsis Initiative paper from Crit Care Med; and the pathophysiology of ARDS and ventilatory strategy.

5.General Viva II: Topics included poisoning (paracetamol, ethylene glycol); pathophysiology of pre-eclampsia; magnesium and drug interactions; management of status epilepticus; outreach and medical emergency teams and all the relevant papers (esp. the ICS document on outreach). They then announced that they had run out of questions a few minutes early!

Useful books for revision (none were ideal ) were: Critical Care Secrets 3rd edition, Key Topics in Critical Care (new edition now out - Ed.), the Handbook of ICU Therapy by McConachie (very useful and soon coming out in 2nd ed [now due in June 2007!- Ed.] - excellent references and discussions), Core Cases in Critical Care (highly recommended), Radiology for Anaesthesia and Intensive Care by Peden (a domain topic), The ICU Handbook (link corrected - Ed.) by Paul Marino (useful for some pathophysiology), all the ICS publications (esp on outreach, budgeting, sedation) [not to mention their Critical Care Focus series - Ed.], and the BMA guide to Treatment Withdrawal (link renewed - Ed.). I gather Neil Soni has published a little known book on Classic Papers in Critical Care - I've not seen it but some candidates had managed to get it.

Your choice of papers was spot on. I agree that Current Opinion in Critical Care is essential reading. I would emphasize to candidates the need to know pathophysiology of various conditions - I got a lot of questions on this. Also, as you say, you must know the ramifications of topic reviews and be able to critique the important papers. I revised for three months solidly for this exam (having already submitted the dissertation and already had the 10 topics approved for intermediate level recognition) and I was sweating in the last week as I thought I had left it all a bit late. I felt that this was a tough, searching exam but it has enormously helped my clinical practice.

I do hope that all the above is of some help - please alter it a bit and anonymise if you put it all on the web! Once again many thanks.