ICU Fellowship – How to Approach a Neuro Hot Case?
Blog Written by Dr Swapnil Pawar Outside the room – some of the common stems – …yr M/F admitted with …. trauma/ loc/ confusion/ seizures and its day < week […]
An Approach to Hot Case
Written by Dr Swapnil Pawar
First thing – understand the exam process and expectations. The technique is the key.
In the CICM fellowship exam, you will be asked to examine 2 different ICU patients with 2 different sets of examiners.
Broadly categorising, there are 3 distinct stages in fellowship exams – Outside the Room, inside the room and again outside the room/ presentation.
Let’s talk about the first stage – Outside the room —
For Each hot case, you get a written stem outside the room explaining the basic details of the patient. This includes – name, age, sex, number of days in ICU, HPI, past medical history and THE Question.
All of this information is relevant and important especially the Questions at the end.
Most of the candidates are nervous and tend to forget the important Details including THE Question.
In these 2 minutes, take a deep breath, find your composure and try to imagine the pattern that you are likely to see inside the room.
I broadly categorise ICU patients into 3 groups – Trauma patients, Neuro patients and Non-trauma, non-neuro patients. The reason for this is because each of these groups will have specific requirements w.r.t to clinical exam. We will talk about each group in subsequent videos.
Once you complete your 2 minutes reading time, you will be asked to proceed with the clinical examination component. you are expected to comply with the PPE policy of that particular unit and usually, examiners/ observers will get you ready prior to your reading time. I call this as Inside the room stage —
During this stage- there are 2 distinct phases – 1) Observation phase 2) Clinical exam phase.
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Observation phase – before you enter the room, always pay attention to important clues outside the room such as – MRO poster, Difficult airway poster,
Once you enter the room, always go and greet the patient, introduce yourself and explain what’s your plan for next 10 min. It applies to all patients irrespective of their conscious state.
Usually, you got 1-1.30 minutes for observation and my sequence is –
First i. Start at the monitor – interpret the numbers and waveforms
Ii. Then look at the infusions – ask questions if you are in doubt. Depending on the context, it’s not unreasonable to ask how long these infusions are running for and whether the requirement of a specific drug has one up or down in the last 24 hours.
Iii. Then look at the ventilator. Don’t just stare – interpret the settings and waveforms.
Iv. Look for special equipment such as temperature management devices, dialysis machines, or any other devices in the room such as IABP, ECMO etc.
V. Look for any other clues – information is written on the board inside the room, care plan, family photos etc
There is no right or wrong approach to whether you should verbalise everything that you see or not. The most important thing is how to synthesise and interpret the available information.
Once you complete the observation phase, you move to the next stage i.e clinical exam phase –
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Clinical exam phase –
You will have approximately 8 minutes for this stage and you have to complete a thorough examination of all 4 systems. The only way to get better at this stage is by practising more.
As I mentioned before, I use 3 big templates to decide which template I am going to start with.
Neuro – any patient admitted with primary Neuro problem – Start with Neuro exam f/b CVS then Resp and Abdo exam in the last.
Trauma – Examine as if you are doing a secondary survey to identify all the relevant injuries including an attempt to find or exclude C-spine injury f/b relevant system exam ..e.g if the patient got TBI – Neuro first, if b/l rib # – reps first. Etc.
Non-Trauma, Non-Neuro patient – start with general exam first f/b relevant system.
Once you finish the exam, the third stage begins that is – outside the room ( presentation stage)
At this stage, you are expected to present your findings to the examiner and answer the question that was asked in the written stem.
There are different ways you can present your case –
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Talk about the clinical examination findings first followed by synthesis of key issues and then answer the question.
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Answer the question up front and explain why you think so by correlating it with your exam findings.
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It’s okay to say I don’t know or I need more information in order to answer the question and justify why you need more information.
There is no right or wrong approach. It’s just that what suits you the best.
Remember the examiner is expecting a consultant level discussion and not just a registrar level handover. So don’t be afraid to talk about the bigger picture e.g will you consider tracheostomy in this patient, will you propose palliation. Especially in your management plan, make sure you present the holistic management approach – housekeeping such as a fast hug, the specific management e.g ventilatory weaning plan or delirium management plan etc and then family update plan – i.e what will you tell the family.
This is very similar to what we do as a consultant on day to day basis.
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