Format an exam with practical relevance with none of the esoteric
Questions are divided equally into ‘Type A’ and ‘Type K’ questions typical of the MRCP examination.
questions. Type A questions consist of a stem with ﬁve possible Candidates may choose to prepare by obtaining a copy of
answers, from which the candidate must select the most the COBATRICE syllabus (available to download from the
appropriate (example shown in Table 1). There is no negative ESICM website) and reading around its topics. Alternatively,
marking; a correct answer in a type A question scores one the ESICM offers a distance learning course, Patient-Centred
point, a wrong answer nil. Acute Care Training (PACT). This consists of four learning
modules divided into four themes:
• clinical problems (eg arrhythmias)
Regarding the properties of sedative medication used on the
intensive care unit which of the following statements is
• organ-speciﬁc problems (eg hepatic failure)
FALSE? • skills and techniques (eg nutrition)
• professionalism (eg ethics)
A Propofol does not accumulate significantly in renal failure
While this covers the exam syllabus in comprehensive detail, it
B Fentanyl has a longer context-sensitive half-life than is a considerable expense (currently 700 for ESICM
remifentanil members). It may be worth exploring whether your institution
C Midazolam exhibits metabolism-dependent kinetics X wishes to purchase a subscription, enabling multiple
candidates to beneﬁt as well as acquiring a useful learning
D Clonidine is an alpha-2 agonist
resource for all ICM trainees. Another means of preparation is
E Ketamine raises intracranial pressure attendance at the ESICM congress, an international meeting
held in the autumn in a major European city. A selection of the
Table 1 Typical type A question.
content at this meeting is educational, and geared towards the
EDIC examination, one sitting of which is held during
Type K questions consist of a stem followed by four related congress. While this is not a ‘spoon-feeding’ session and
statements, each requiring a true or false response. For type K attendance does not guarantee a pass, attending the congress
questions, all four responses must be correct to score a full gives the candidate an international meeting to add to their
mark, with a half mark being scored if three out of four curriculum vitae, exam preparation and an attempt at the
responses are correct. A sample of type K question is shown in EDIC Part 1 all at the same time.
Dedicated MCQ books are in short supply, although some
anaesthesia MCQ books have a selection of ICM questions.
Perhaps the simplest way of preparing is to read through an
The following are expected physiological effects of a bolus of
intensive care textbook, paying close attention to ‘examinable’
sections. Oh’s Intensive Care Manual and Critical Care Secrets are
A Bronchodilation T popular choices. Bear in mind that such reference books
B Raised intracranial pressure T become out of date quickly; the examiners do not expect a
detailed knowledge of the minutiae of ICM, but will expect the
C Apnoea F
candidates to be up to date in topical areas such as the use of
D Hypotension F activated protein C for sepsis, and the role of therapeutic
Table 2 Typical type K question.
After taking the examination, results take one to two
months to arrive by mail; results include a score as a
percentage, the pass mark and a breakdown of the candidate’s
Questions for the part 1 examination are based on the
performance in each question area. Candidates failing the part
COBATRICE syllabus previously mentioned. While any area of
1 EDIC examination are not allowed to re-sit the exam for 12
this syllabus is ‘fair game,’ the exam is weighted towards
months, so proper preparation is essential, especially for those
certain areas such as cardiovascular, respiratory, sepsis and
trainees who wish to gain the full diploma prior to applying for
neuro-critical care. The vast majority of the questions are
a consultant post. The pass mark is around 56%, with about
medical in nature, but a small number cover areas such as
70% of candidates passing in any one sitting.
management, ethics, law and quality assurance.
Preparation Part 2
UK trainees with a background in anaesthesia will have already Entry requirements
completed the FRCA or FFARCI examination prior to sitting The minimum entry criteria for the part 2 examination are:
the EDIC, and will be familiar with much of the content of the • A pass in the part 1 examination
examination. Trainees from other disciplines will also have • Completion of at least 24 months’ ICM training, of which a
completed specialty examinations previously, and will be aware maximum of six months may be in complimentary
of the standard required. In addition to keeping up to date with specialties.
the major topics (eg ARDS, sepsis, ﬂuid management) and In practice, this means that UK trainees may sit the
attending local educational meetings and events, much useful examination towards the end of their step 2 training.
information can be gained from daily ICM experience – this is The part 2 examination can be taken up to four years after
JICS Volume 10, Number 1, January 2009 17
The exam took place on a busy, working ICU. My centre was Birmingham City Hospital and local consultants were the examiners. My long case
patient was about to be extubated and was rolled and washed during my exam time! The exam was fairly relaxed and with very clinically
based topics and practical questions such as ‘what would you do now...?’ I was taken to the bedside and given 30 minutes (but could have had
40 if required). The patient’s own medical notes were available in full including that day’s entry. Diagnosis and treatment to date were clearly
documented, nothing was hidden. X-rays and CT scans were available to view. Drug and fluid balance charts were also available. An ICU nurse
present was very helpful. The patient was an intubated, ventilated, 64 year-old man who had been on the ICU for seven days. He had initially
been investigated for painless jaundice, and CT abdomen had shown pancreatic carcinoma. Following a failed ERCP, he had presented con-
fused and hypotensive to the emergency department. Biochemistry showed acute hepatic and renal failure with an INR of 10. A percutaneous
biliary drain had been inserted. Klebsiella had been isolated from biliary fluid, blood and urine cultures. Chest X-ray was consistent with ARDS.
Continuous veno-venous haemofiltration was in progress.
Questions and topics discussed
Summarise the case, and outline the underlying problem
Discussion of circulatory support, pattern of LFTs, modes of renal replacement therapy
What would your initial choice of antimicrobial therapy be?
Is he ready to wean?
Would you readmit this man? Who makes that decision?
Back to initial presentation in the emergency department: how would you resuscitate him?
Fluid choices, discussion of normal saline and hyperchloraemic acidosis
Pros and cons of central venous line with severe coagulopathy
Figure 1 One candidate’s long case.
passing the part 1, providing the candidate has accrued examining centre. During this time they will have access to the
sufﬁcient ICM experience as stipulated above. Fortunately, patient’s case notes, charts and bedside monitoring, and will
there are many more centres examining candidates for the part also have the opportunity to examine the patient and review
2 than part 1, and the candidate is unlikely to have to cross blood tests, imaging and other investigations. The aim is to
international borders. However, the part 2 is a much more simulate as closely as possible the process of real life
labour-intensive process for the examiners, and most centres assessment of a genuine ICU patient. The candidate will be
can only accommodate a few candidates for a particular sitting. asked to summarise the clinical course of the patient before
This means that booking well in advance is necessary. Two being questioned on speciﬁc areas of management. A sample
attempts are allowed initially; if a candidate has not succeeded case with associated questions is shown in Figure 1.
at the second attempt, a further two attempts are allowed 12 In addition to the long case, two or three bedside short
months later. cases will be examined. These may focus on a clinical sign (eg
Format a heart murmur), a procedure (eg chest drain insertion) or a
clinical examination (eg brainstem death testing). Each short
The part 2 examination consists of a clinical and an oral
component. The clinical examination takes place at the case will take around 15 minutes. A selection of recent
bedside, lasts 60-90 minutes and consists of one long case and candidates’ short cases is show in Table 3.
two or three short cases. The candidate will then be examined The oral component
orally for 30-40 minutes on clinical material, testing aspects of This will take place in a quiet environment away from the
ICM not explored in the long and short cases.
bedside, and may explore themes derived from the clinical
The clinical component component or new topics. It may follow on from the short
During both long and short cases the candidate will be cases or be scheduled at a separate time on the same day.
expected to demonstrate: Visual material such as chest X-rays, ECGs, blood tests or
• Ability in eliciting clinical information which is accurate photographs may be provided. Abbreviated case histories may
and comprehensive also be used to explore areas not readily tested in the clinical
• A professional approach preserving patient dignity component, such as ethical dilemmas. A sample of recent
• Integration of clinical information to form differential questions is provided in Table 4.
diagnoses The role of the candidate is to convince the examiners that
• Ability in constructing a management plan and discussing he/she would be competent as the ICM physician in charge of
therapeutic options. these patients’ care. As with all intensive care patients, there are
During the long case the candidate has 30-40 minutes to certain themes which are recurrent, for example ventilation
familiarise themselves with a patient on the ICU of the strategies, sepsis care bundles, therapeutic hypothermia, and a
18 Volume 10, Number 1, January 2009 JICS
Acute severe asthma Care bundles
I was shown a patient being ventilated with acute severe asthma. What is a care bundle? Can you name some?
Questions were based on the emergency management of asthma
Tell me about the elements of the sepsis/ventilator care bundles.
including the British Thoracic Society guidelines, and the problems
that might be encountered in mechanically ventilating such Tell me about the indications for activated protein C in sepsis.
patients. I was also asked whether I would insist on an arterial Hypoxic brain injury
blood gas sample on a distressed asthmatic patient in the emer-
gency department. How would you manage a patient with hypoxic brain injury?
Metabolic encephalopathy What is the role of therapeutic hypothermia?
I was asked to perform a neurological examination on an elderly What treatable conditions should you exclude in a comatose
lady sedated with propofol. She was hypotonic with bilateral upgo- patient?
ing plantars and unreactive pupils. I was asked for the differential What evidence is there to guide prognostication in such patients?
diagnosis of this presentation, and was subsequently told that she
had a plasma sodium of 108 mmol/L. I was asked about the initial How would you proceed with a patient who hasn’t regained con-
management, and then how to determine the cause of hypona- sciousness after several days?
traemia in this patient. A discussion of correction of hypona- Pneumocystis jirovecii pneumonia
traemia and complications then followed.
Tell me about this chest X-ray from a young man with a short his-
Pulmonary oedema tory of respiratory failure. What is the differential diagnosis?
I was asked to perform a cardiovascular examination on a lady of What are the features of Pneumocystis carinii pneumonia?
60 who was uncooperative and receiving CPAP via a helmet. Very
little was audible on examination due to ambient noise, but she How would you confirm the diagnosis?
had bibasal crackles and ankle oedema suggesting pulmonary What are the management options?
oedema. I was questioned about the causes and acute manage-
Discuss the ethics of HIV testing in the ventilated, sedated patient.
ment of pulmonary oedema, the relevance of any scars and the
role of the cardiologist in such patients. The role and timing of Table 4 Typical oral examination topics.
secondary therapies including ACE inhibitors and beta-blockers
was then discussed.
with a fellow trainee who plans to sit the exam, each testing
Table 3 Typical short case topics. the other. As important as factual knowledge is the ability to
communicate it effectively and this improves with rehearsal.
sound knowledge of the evidence base in these areas will be Most ICU patients can serve as the focus for either a long or
expected in the discussion. short case; some may have an unusual diagnosis or clinical
The candidate receives a mark for both the clinical and oral sign, but even the ‘bread and butter’ sick patient with sepsis
parts of the examination of either Fail, Bare Fail, Pass or and ARDS is a rich source of material: what is the evidence for
Excellent, based on the criteria outlined above. A Pass or better using activated protein C in such patients? What strategies can
in each component confers a pass overall, and a Fail in any be used to oxygenate the patient? Which are evidence-based?
component ensures failure overall. A Bare Fail in one What are the issues to be considered when contemplating
component may be compensated for by a good Pass or withdrawal of treatment? Is this patient a candidate for non-
Excellent grade in the other component at the discretion of the heart beating organ donation?
examiners. A candidate who has clearly done well or very In addition to hands-on practice, it is crucial to stay up to
poorly may be notiﬁed of the outcome at the end of the date on major topics. The major ICM journals such as Intensive
examination; more borderline cases will require a period of Care Medicine, Critical Care Medicine, Journal of the Intensive
discussion by the examiners and they will receive their results Care Society and the online journal Critical Care often carry
by mail at a later date. good review articles of the major topics. It is useful to sign up
to receive the tables of contents of these journals by e-mail to
Preparation avoid missing something recent and topical. It may be worth
Candidates sitting the part 2 examination will have completed writing a list of examinable ‘hot topics’ and then seeking out
24 months of intensive care training and will be close to recent reviews and classic papers on these subjects. It is a fair
applying for consultant posts; a sound level of knowledge and bet that steroids in sepsis, therapeutic hypothermia, and
judgement is therefore expected. Much of the required factual management of the patient with ARDS might all come up, and
knowledge will have been gained through preparation for the it would be unwise to be under-prepared in these areas. While
part 1, but more importantly the candidate will have a bank of review articles are a useful means of keeping up to date with
practical ICM experience on which to draw. the hot topics, a good textbook is also a must. Areas such as
Those lucky enough to work alongside EDIC examiners hepatic failure in critical care lend themselves less well to
should seize the opportunity for practice whenever it occurs. evidence-based review articles, but the basic management of
Most departments have experienced consultants willing to such conditions changes little from one year to the next.
provide exam practice, and word soon gets around regarding It would be sensible to ﬁnd out in advance whether the
who is ‘good value’ for this sort of thing. It is useful to pair up examining centre has any specialist interests: if the hospital has
JICS Volume 10, Number 1, January 2009 19
an infectious disease unit, then a case concerning HIV-related abnormalities in results should be interpreted just as you do
medicine is more likely; if there is a large neurology on a daily basis.
department, a case of myasthenia gravis is a distinct possibility.
Ultimately, the candidate must be prepared to deal with any
1. COBATRICE: http:// www.cobatrice.org
topic thrown at them, and be able to convince the examiners
2. Bersten A, Soni N, Oh TE. Oh’s Intensive Care Manual. Edinburgh:
that they would be a worthy colleague in their own Butterworth-Heinemann. 2003.
department. 3. Parsons PE, Wiener-Kronish JP Critical Care Secrets 3rd Edition. London:
Elsevier Health Sciences. 2003.
Top tips 4. DICM webpage: http://www.dicm.co.uk/papers.htm
• Review articles from the major journals are a good source of 5. ESICM website: http://www.esicm.org
6. ICS website: http://www.ics.ac.uk/
information. Both the EDIC and the journal Intensive Care
Medicine are afﬁliated to the ESICM
• Practice makes perfect when preparing for the part 2
• While a limitless number of diseases may precipitate Steve Benington SpR Anaesthesia & Intensive Care, Royal
intensive care admission, there is a ﬁnite list of ICU-related Preston Hospital
problems that patients display once there email@example.com
• Treat the clinical exam as if you were on the daily ward
Brendan McGrath DICM EDIC, SpR Anaesthesia & Intensive
round, presenting your long case and proposing and
Care, Manchester Royal Infirmary
justifying your management. Clinical signs and common
20 Volume 10, Number 1, January 2009 JICS