Hot Case General Approach

OVERVIEW

The ‘Hot Case’ is the most challenging part of the FCICM exam

• those who pass the written exam are invited to the clinical exam, which includes 2 ‘hot cases’
• Hot cases are real ICU patients in a real ICU
• The Hot Case is overseen by 2 FCICM examiners who are practicing intensivists
• The candidate is given a clinical question including limited clinical information about the patient
• The candidate has 10 minutes to examine the patient and his or her surroundings and may ask occasional, appropriate questions to clarify the findings
• Immediately following this, the candidate has 10 minutes to give his or her answer to the question the present the case; examiners may ask further questions to clarify the candidates answer and to guide further discussion

General approach to the Hot Case involves

• question
• introduction
• cubicle
• ventilator
• monitor
• infusions
• drains
• equipment
• question specific examination
• relevant investigations
• case presentation and discussion

GENERAL APPROACH TO HOT CASE EXPLAINED

Question

• Listen to question and remember it!
• Look at the examiner, not around the room
• repeat the question
• ask for lights to be turned on
• ask if there are movement restrictions
• ask if there are language barriers

Introduction

• “Hi Mr X, I’m Dr Y, I’m going to examine you”
• even if unconscious
• ask to expose patient

Cubicle

• therapies
• NIV
• wheelchair
• RRT: mode, settings, lactate/bicarbonate buffer, anticoagulation strategy
• photos

Ventilator

• weaning history
• settings
• sputum quantity and quality
• plateau
• PEEPi
• rapid shallow breathing index
• A-a gradient
• VC (maximum inspiratory manoeuvre)
• P:F ratio

Monitor

• trends in last 24 hours
• temperature
• intra-abdominal pressure

Infusions

• drugs
• rates
• feed
• recent paralysis

Drains

• urine output: dipstick and microscopy
• drain output
• EVD

Equipment

• RRT
• IABP: timing, trigger
• PiCCO/PAC
• pacing: mode, output

Question specific examination

• ask to expose patient (including dressings)
• ask prior to moving neck
• ask prior to inflicting pain
• GCS: verbal response -> touch -> pain, supraorbital stimulation, all four limbs
• be systematic
• tailor approach to the specific question and according to what you find
• lie patient flat before assessing abdomen
• ask to examine back, sacrum and rectal examination

Relevant Investigations

• Bedside — blod gas, ECG, urine
• Laboratory — bloods, microbiology, cytology
• Imaging — XR, CT, MRI, radionucleide scans
• Other — e.g. bronchoscopy, invasive diagnostics

Case presentation and discussion

• answer the question
• do not repeat the question or say “I was asked to…”
• Provide a synthesis of the clinical findings to show what  you know, what further information you need, and what the likely explanations are
• provide relevant positives and negatives
• If uncertain, be honest and say ” This is a complex case, I’m not certain of the diagnosis, but I note (the follow organ failures, etc,… I would do… I wil lget help from… etc”)
• Express your degree of concern “I am worried about this patient because….”

WHY PEOPLE PASS OR FAIL THE HOT CASE

In general, success on the Hot Case depends on readiness to work as a consultant and requires sufficient:

• knowledge
• clinical experience
• Hot Case practice
• an ability to interact with examiners as a junior colleague, rather than a trainee

People fail because of the following:

• Failure to address the question posed by the examiners
• Poor examination technique
• Missing important clinical signs
• Disorganised presentation
• Poor interpretation of investigations
• Poor discussion and management plan

People do well  because of the following:

• Respect and consideration for the patient;
• Competent and efficient examination technique;
• The seeking of information that was relevant to the case;
• Ability to interpret and synthesise their findings appropriately;
• Presentation of their conclusions in a systematic fashion, addressing the issue in question
• Discussion of management issues in a mature fashion, displaying confident and competent decision-making
• Overall performance at the expected level (competent Senior Registrar / Junior Consultant)

Remember, that only ~25% of candidates pass both their Hot Cases… This part of the exam deserves the most emphasis in preparation!