Primary FRCA OSCE SOE qs Nov 2016 - · PDF file · 2016-12-08OSCE 1. Picture of...

Primary FRCA OSCE/SOE Questions November 2016 Exam

SET 1 SOE Pharmacology: 1. What is propofol? Can you draw it? What does the phenol ring do? Describe the pharmacokinetics. How does it act at a cellular level? 2. What are cholinergic receptors? What are muscarinic receptors? Where are they located? Can you describe drugs that act at these receptors? What are the effects when these receptors are activated? 3. Tell me about blood products. What other plasma expanders do you know? Physiology 1. Tell me about the immune system? Can you classify it? What types of sensitivity are there? What immunoglobulins predominate in each of these types of hypersensitivity? 2. What happens when you lose 20% of your blood volume? (I started talking about baroreceptor reflex etc which they didn't seem too impressed by, wanted to know specifically how messages from baroreceptors travel to vasomotor centre) 3. Draw a graph describing how minute ventilation would change when a patient is breathing 100% o2 (this confused me, essentially I think they were getting at the fact that pt was rebreathing and so wanted to explain that increasing co2 increases mv) We then talked about chemoreceptors. Clinical: Woman in 60s for a vaginal hysterectomy. Heavy smoker stopped 'a few days ago' with kyphoscoliosis. How would you anaesthetise her? Talked through spinal vs GA. What pre-op investigations do you want? She has a GA, becomes hypoxic in recovery, what are the causes? Which patients need o2 in recovery (again this stumped me,I said all but they wanted me to expand and I didn't really) Physics 1. Shown pictures of 3 different laryngoscopes, asked to name parts of each and what they were. Specifically asked about light source and how it worked. (I guessed fibre optics and was told that wasn't right, haven't looked it up since but I'm sure there's a very simple explanation I just didn't know!)


2. Shown n20 isotherm, asked to describe it, define crit temp and pressure and why gas in various stages. Straightforward. 3. Given a bell curve and told this represented the saturations of a population. Asked about calibration and drift, two different bell curves given to right and left of curve and asked to describe them. Talked about bias in stats. OSCE: -Peripheral pulses examination -Arterial line check -History taking VV surgery with asthmatic (previous ITU admission after beta blockers) -Anatomy 1st rib -Paeds ENT (Inc airway/boyles Davies) -Resus station bronchospasm/laryngospasm (IM suxamerhoniun) -CXR miliary TB/Viral pneumonitis -ALS management SVT algorithm -History taking for TKR (COPD, PPM, warfarin etc) -Anaesthetic machine check -Spinal -Resus station: burns pt in VF arrest (tubed but with no co2 trace) -Anatomy diaphragm -Comm skills: explaining sickle cell testing to patient with needle phobia. -Temp probes Set 2 SOE Pharmacology; - what do you use paracetamol for in your anaesthetic practise? How does paracetamol work? Does it work peripherally or centrally? Tell me about the pharamacokinetics of paracetamol. Can you draw the hepatic metabolism? What is the toxic metabolite? How should you treat an overdose? - How do you define bioavailability? Can you describe the properties of a drug that make it suitable for transdermal administraion? what is the benefit of giving a drug sublingually? - what is co-amoxiclav? how does antibiotic resistance develop? what can we do to reduce antiobiotic resistance? Physiology; - tell me about CO2 carriage in the blood ( I drew a diagram describing chloride shift etc. and they seemed happy with this), draw Co2 dissociation curve - how is this affected by Hb 02 saturation? Please superimpose shape of HBO dissociation curve - what hormones does the thyroid gland produce - talked about TSH & TRH


also. Asked about anatomical specifics of where in thyroid gland hormones produced. Then they wanted to know molecular basis of T4/T3 increasing metabolic rate. I talked about nuclear receptors & gene transcription but they seemed to want more, not sure what - draw action potential of cariac myocyte cell. Can you point out the relative and absolute refractory period? Clinical; - woman who was 34 weeks pregnant with fractured tib/fib. How would you approach this case? What are your concerns? Talked about physiological changes with pregnancy and anaesthetic concerns. Briefly talked about trauma & emergency cases. They asked who else to involve and I said obstetrics and neonatologist. Then was asked how the obstetricians would know if the woman was in labour?! Then are there any drugs that can stop labour? - critical incident was a high spinal - discussed loss of consciousness and need to intubate and ventilate. Asked about differential diagnosis with hypotension after spinal placement Physics; - what is low flow anaesthesia? Can you describe the components of a circle system? How do vapourisers work? How is the concentration of vapour regulated? How is desflurane vaoupriser different? - I was shown a picture of 6 different graphs. Asked what each showed and to give an example - e.g. straight line, exponential growth/decay. Then asked which could represent Boyle's law? Which could represent Charles' law? What was a wash in curve? OSCE 1. Picture of scavenging - asked to label & talk about COOSH 2. nerve supply to larynx, four different end-tidal C02 tracings - which one is Bain circuit, name three pieces of equipment (NOT clinical signs) that can confirm tracheal tube placement 3. anatomy of diaphragm - difficult! not what I'd revisied from the book - they wanted to know attachment points of right and left crus and also what passes through the diaphragm with aorta, vena cava etc. 4. examine the cardiovascular system but specifically pulses and auscultate chest 5. Communication - pt presenting for nasal surgery with hx of OSA 5. spinal anatomy - diagram different to the one in my book so despite knowing all the different tracts and functions was difficult to match them with picture provided, signs of spinal cord hemisection and thrombosis of anterior spinal arteries 6. questions on analgesia for a 40kg child, questions re paracetamol - dosing 7. assemble a circuit - Bain - attach filter, etC02, APL valve, more questions on etC02 traces (was one of these a test station?!) 8. radiology - pharyngeal pouch 9. critical incident - TURP syndrome 10. ALS - bradycardia with hypotension 11. temperature questions - kelvin versus celsius, what is triple point of water, which graph represents thermistor 12. communication - pt with needle phobia (careful - I spent far too long talking about this and didn't get to any other points in the hx, I suspect did poorly) 13. fetal circulation - basically label the diagram. What changes occur at birth? Why does ductus arteriosus


close? 14. Bradyarrythmia - both pharmacological & pacing treatments SET 3 OSCE Stations Station 1: - Technical skill: Caudal Block (on a 5 year old child). - Model of sacrum. - Asked specific anatomy (cornu / sacral hiatus / membrane). - Asked about embryological development of hiatus. - Level of termination of spinal cord in children. - Informed child asleep during operation, consented and positioned - asked to perform block on model (equipment available was 2ml syringe, pink cannula and blue needle). - Then asked what LA you would inject. - Given strength of LA (0.25% bupivacaine) and weight of child – had to calculate how many mls to inject (pushed for time at this point). Station 2: - Scenario - Blurb: You have been asked to review a 25 year-old gentleman involved in a motorcycle accident who had a GCS of 7 on scene. He is currently in ICU. Please verbalise your findings. - Manikin on bed – intubated and ventilated via anaesthetic machine. Separate monitor showing physiological parameters (HR 40, BP 201/111, SpO2 97%, EtCO2 5.4). - A-E assessment however I was moved quite quickly onto D where I checked pupils (dilated, non-reactive). - Cause for following (Cushings, could be light on sedation, could be pain). - What 6 neuroprotective measures should I follow. - Mannitol – how does it work, how is it prepared, what is the dose. Station 3: - Equipment: Gas Cylinders - Shown cylinder of entonox (picture). - Name the cylinder and quote size. - What it contains and how much of each gas. - How is it made. - What kind of analgesia does entonox produce. - Shown a further picture of tubing connecting cylinder to breathing apparatus. - Pressure inside tubing. - What is the pseudocritical temperature? - What would happen if a patient used it below its pseudocritical temperature? - Shown a picture of demand valve / 2 stage pressure regulator. - Asked for function of valve. Station 4:


- Radiology: XR Chest - Blurb: A 35 year-old gentleman is 12 hours post-laparotomy for sigmoid colectomy secondary to colitis. You have been called to see him as he has desaturated to 89%. Performed on Computer screen – note - you can start your questions before the 5 minutes start. There is a timer on the side of the screen that will lock you out once 5 mins is up. You cannot go back. - XR Chest showed early consolidation changes to both lungs? - The most likely cause is: 5 options – I chose aspiration. - The immediate treatment should be antibiotics (T/F). - This patient requires a bronchoscope (T/F). - This patient has been on predsol and requires cover with additional steroids (T/F). - Something about antibiotics? Station 5: - Data Interpretation: ECG - 81 year old gentleman has become very unwell on the ward following a hernia repair. You have been asked to assess him. - Shown ECG (which looked like sinus bradycardia – rate 40bpm). - What is the rhythm? (5 options). - What further management should this patient receive (pacing / atropine / additional observations etc) - Then further questions regarding the ALS bradyarrhythmia algorithm in general (you have given atropine but still slow, what next). Station 6: - Equipment & Data Interpretation: Pacemaker - Shown XR Chest of patient with pacemaker – single lead going to left ventricle. - Initial questions on pacemaker on X-Ray. - All further questions on pacemakers – what different letters represent etc. Station 7: - History - Lady has attended pre-assessment clinic for hysteroscopy. Please take a history. You do not need to examine her. - English was not entirely clear. - Laparoscopy for heavy periods. - Had anaemia – turns out to be thalassaemia – does not know much more about it. - Has had cough / weight loss / night sweats / recent travel abroad. Not treated for TB. - Other history unremarkable. Station 8: - Equipment: Gas Cylinder - Asked questions regarding an oxygen cylinder (size J). - Pressure / tare weight. - Yoke and pin index system. - Shown Bodok seal – asked regarding function and use.


Station 9: - Technical Skill: Chest Drain Insertion - Patient present on bed. - Asked how to examine patient for tension pneumothorax. What clinical findings I would expect. - Asked to demonstrate needle decompression on patient demonstrating landmarks. - Asked to demonstrate chest drain insertion – equipment provided. - What are the complications? - What is swinging? - When would you use suction? Station 10: - Anatomy: Cross section C6 - Shown diagram of C6 cross section – asked to name structures (approx. 10 marks). - Scalene muscles highlighted – asked to name - Asked indications of interscalene block - Asked regarding complications of block Station 11: - Resus: ALS - A 15 year-old boy has been found in a lake. A bystander has commenced CPR. [Shown picture of defibrillator] You should use this piece of equipment in your management. - Bystander doing chest compressions slowly and ineffectively. - Stopped for pulse check – continued CPR. - Managed airway while pads applied. - Rhythm check – VF - Shocked patient - 4Hs and 4Ts - Patient’s temperature is 29oC – asked questions regarding when to shock and when to administer adrenaline. Station 12: - Equipment: Blood - Shown a bag labelled ‘whole blood’ but only containing a clear solution (no blood). Assume this was CPGA solution into which whole blood is collected. - Asked for components of this. - Shown picture of PRCs – what are the constituents in this (SAG-M). - What is the purpose of mannitol? - What is the definition of a massive transfusion? - What are the complications of a massive transfusion reaction? - If a reaction occurred, where would you report this (SABRE)? Station 13: - Communication: Analgesia - This 32 year-old lady is due a knee arthroscopy. Please discuss her options for pain management post-operatively.


- When trying to take a bit of history the actor quickly moved me on. - Exploring options for pain relief. Did not want to be awake for the operation. Station 14: - Examination: Cardiovascular System - Straightforward cardiovascular system examination on actor. - No further questions asked. Station 15: - History Taking - Please take a history from this 30 year-old gentleman due to have a tonsillectomy. - Had well controlled T1DM and possibly OSA. - Worried about post-operative going back to University and studying immediately. - Briefly counselled re: managing DM post-operatively. Station 16: - Anatomy: Larynx - Shown picture of larynx, asked to name different parts. - Asked about vertebral levels of hyoid / thyroid / cricoid and where larynx starts and ends. - Focussed mostly on external muscles of larynx (what depresses / raises larynx). - Nerve supply of intrinsic muscles. - Unilateral damage to recurrent laryngeal – what happens? - Bilateral damage – what happens? Station 17: - Equipment: Gas Sampling - Very peculiar station. Asked about gas sampling line. - Asked what gases are analysed. - Asked about infrared analyser. - Asked what happens when sevoflurane is sampled in the presence of isoflurane. - Shown FiN2O + EtN2O and FiIsoflurane + EtIsoflurane – asked to describe differences due to partition coefficients. Station 18: - Anatomy: Surface Anatomy - Most likely a test station. - Asked many questions on random surface anatomy and landmarks (from inguinal ligament to ACF). - Very erratic and pushed for time – had to click through the last screens very quickly. SOE Pharmacology: 1. Propofol (routine questions)


2. Blood (how its prepared, transfusion reactions, different blood products) 3. Antimuscarinics (questions regarding Acetylcholine Receptor – mostly Muscarinic GPCR) and anticholinesterases. Physiology: 1. Physiological changes when breathing from a bag only containing 100% O2 – peripheral and central chemoreceptors, rebreathing + graphs. Affects of raised CO2 on the body. 2. Immunology – innate vs specific. Hypersensitivity reactions. 3. Physiological changes when you lose 1L of blood – early (baroreceptors and stretch receptors), late (RAAS – asked to describe) and later (EPO). Clinical: - You have been asked to pre-assess a 68 year-old lady for a vaginal hysterectomy for prolapse. She has severe kyphoscoliosis and has been a heavy smoker all her life but stopped very recently. - Asked about lung function tests / ABGs. - Asked about effects of stopping smoking on the body. - Anaesthetic techniques (spinal). - Critical Incidence: Have tried spinal 7 times but failed. Intubate her and transfer her to the operating theatre. Her airway pressures are very high. What do you do? – Talked through management. Physics: 1. Shown different laryngoscope blades. Asked to describe components and cross-sectional areas of the blades. Shown Macintosh / Magill / Miller / McCoy. Asked to discuss use of Polio blade. 2. Gas laws. Pressure in N2O vs Oxygen cylinder. Working out volume of gas remaining in a cylinder. Latent heat of vaporisation. Adiabatic change. 3. Statistics. Shown a graph of “response” on y-axis vs “values” on x-axis. Results of 3 pulse oximeters plotted (normal distributions). 2 plotted around a point called ‘true value’, one shifted to left. Asked to interpret the graph. Distribution shifted to left due to ‘bias’. Asked to talk about bias and calibration. SET 4 OSCE


- Check Anaesthetic machine and circle circuit with 2 bag test - cardiac arrest; burns patient - in PEA, asked most likely causes of arrest in burns patient. Asked for treatment of hyperk+ and then fluid management in burns (Parkland formula ) and how to calculate %burn area. - Spinal Anaesthetic; what level for a turpt, which needles, asked to demonstrate technique on patient. Asked questions about bloody tap - diaphragm anatomy ( superior view) asked about attachments and what structures pass through each level - ENT shared airway, asked about boyles Davis gag and problems. Asked drug doses in paeds anaesthesia and asked to identify different types of ETT and their uses. - First rib anatomy computer station - airway assessment on a patient, malllanpati scoring system, questions on airway anatomy and sensory innervation - simulation - laryngospasm - communication skills; needle phobic needs sickle cell test - history taking - old asthma - computer station; AF/ resus - history taking ; cardiac history - temperature measurement; asked to name different devices and how they work and modes of temp loss during anaesthesia - Cardiac anatomy station; asked to identify arteries and vein drainage SOE Paracetamol Pharmacokinetics (bioavailability etc) Thyroid physiology Cardiac action potential. SOE2: Pregnant patient with #tib/fib (GA vs CSE) High spinal/total spinal management Vapourizers Circle systems (asked to draw and explain) Mathematical curves with examples. SET 5 Osce

1. Anatomy - base of skull foramina, cranial nerve function, nuclei location and innervation of tongue

2. Equipment - oxygen cylinders (letters, differences, safety features), oxylog 1000 - calculate entrainment ratio, oxygen consumption and available oxygen (boyle's law)

3. Cricoid pressure on a manikin 4. Anatomy - ankle block, doses of LA


5. Giving sets/ filters/ epidural filter (filter/ mesh size) and HMEF (differences between adult and paediatric)

6. Bain circuit - put it together and check, side stream analyser (pros & cons/ problems of using wider bore tubing), common CO2 traces

7. Examination - unconscious head injury (AC-spineBC), GCS - signs of raised ICP, what nerves involved in pupillary reflex

8. X-ray - brachial plexus (roots, trunks..), interscalene block and stellate ganglion

9. Skills - epidural insertion, block height and why - how would you test it, pudendal nerve perineum, calculate dose of adrenaline in LA

10. VF arrest scenario, recognise rhythm, appropriate rate/ depth CPR, operate defibrillator, ALS algorithm & paediatric doses

11. Tension pneumothorax, needle decompression & chest drain insertion 12. BP oscillometric (trace & function) 13. History - Diabetic presenting for cystoscopy, doesn't want spinal but

recent chest pain not investigated 14. History - AF on warfarin (stopped 5 days) for lap right hemi, also on

ventolin, smoker, had dccv, lung function tests and echo 15. CXR - Pul oedema 16. CXR - ASD, VSD, coarctation aorta (rib notching) and tetralogy of

fallot 17. Cervical spine X-ray - history of RA atlanto-occipital subluxation,

inadequate view 18. Communication - sux apnoea

SOE Physiology

1. Effects of altitude - alveolar gas equation, OHDC shift, physiological response e.g. raised Hb, oxygen content equation, metabolic acidosis

2. Motor unit draw - muscle contraction (excitation contraction coupling and calcium effect - calcium induced calcium release)

3. Renal filtration - graphs for inulin, glucose, sodium, starling forces Pharmacology

1. Cell membrane transport mechanisms - ficks law of diffusion & lipid solubility, diffusion, facilitated diffusion, cotransport, active transport, secondary active transport

2. Induction agents - classify and compare thiopentone vs propofol 3. H1 antagonists - uses/ side effects. What is an inverse agonist and

draw graph Physics

1. Diathermy - hazards, draw diagram of circuit and safety features, frequency and waveform of coagulation & cutting, current density

2. How to measure flow - ficks principle, thermo/ dye dilution, pneumotachograph, vanemeter, rotameter, Hagen-poiseuille laminar flow equation

3. SVP and variable bypass vaporiser & diagram, splitting ratio and bimetallic strip


Clinical 6 year old 'fit and well' 30kg for circumcision. Desaturates in recovery - ABC/ call for help, likely causes, how to manage laryngospasm. Fluid requirements for weight, working out weight/ tube size for children, circulating blood volume in child, drug doses. SET 6 SOE Pharm NSAIDs - difference between Cox 1 and 2 and about specific cox inhibitors, draw the action of COX and lipoxygenase Exponential washout curve - what is half life, time constant, rate constant? How do you work out Vd, could you work out conc at T0 by logging the curve? Crystalloids and colloids - table comparing crystalloid components, is lactate a problem in Hartmann's Phys Pacemaker action potential - which ions are involved, what happens with parasympathetic and sympathetic stimulation? How does glucagon act as an inotrope? What happens when you stab your finger on a pin? Pain pathway - are there alternative routes other than spinothalamic pathway?! Anaerobic and aerobic respiration, how much ATP is produced, draw out the process Clinical 63 year old man w. Aortic stenosis and gradient of 30mmHg for prostatectomy. Preop - inx and what drugs may he be on and why, optimisation. Op - regional? Why may epidural be better than spinal? Decide GA with arterial line before induction, Critical incident of tachycardia - what could be cause? Fast AF, tx of stable and unstable fast AF Physics WHO checklist, go through each part Why do anaesthetists make mistakes, how can they be reduced?


Pressure - compare two forces/areas: 1MN/m2 and 0.01N/mm2, what happens to a manometer at 10M depth under water. Shown a water displacement spirometer and asked how it works OSCE - Oesophageal and IF temp probes and how they work, Stefan Boltzmann law discussion - CXR with bilateral patchy infiltrates in a smoker - ards? - CXR of pulmonary artery (in small hospital!) with large PE - SVT rhythm strip and treatment - Hx - strangulated inguinal hernia with pacemaker and prev MI - Explain process of spinal and demonstrate on someone's back, say layers

- Resus - burns and intubated but no pulse and VT! I didn't feel for pulse , then discussion about rule of 9's and Parkland formula -Comm - needle phobia - Hx - varicose veins with asthma and allergic to propranolol and nsaids - Art line - explain calibration - how would you high point calibrate and demonstrate problems with setup - Laryngospasm post op in recovery after polypectomy with LMA - 1st rib anatomy - coronary artery and venous drainage of heart on a diagram - airway assessment and discussion on sensitivity and specificity of Mallampati SET 7 SOE Pharmacology 1- What factors affect the speed of onset of a volatile anaesthetic? Wash in curves, choice of agent. 2- Define volume of distribution, Clearance. Compare fentanyl and alfentanyl 3- Antibiotics Bacteriostatic vs bacteriocidal How they have their actions. Effective concentration. Physiology 1- Ventilation /perfusion, West zones How V/Q changes with exercise 2- Vomitting afferents/efferents


Mechanism of vomiting 3- Buffers, types in different body compartments Properties of ideal buffer. Hendersen-Hasselbach equation SOE2 Clinical 37 year old woman with chrons disease for elective hemicolectomy on sulfasalazine and prednisolone, pyrexial, anxious. Pre-assessment Intra-operative plan Post-op pain, epidural not working. Assessment and plan. Physics 1- Oxygen measurement, what types are there? Paramagnetic analyser, fuel cell, Clarke electrode 2- Flow, natural frequency and damping. 3- Define energy, types of energy. Define force. Hysteresis. OSCE - Dinamap. How does it measure? What does it measure? What does it calculate? - CXR. Co-arctation of the aorta. “3” sign. Rib notching. Collateral vessels. - C-spine lateral x-ray. Atlanto-axial subluxation. - Resus (PC station). Rhythm recognition. ALS protocols. - Communication station for a patient for a hemicolectomy. Admitted for last 4 weeks, PR bleeding , transfused. Rhematoid disease. - Cylinder sizes - C+D volumes, differences, what made of, pressures. Volume in a C cylinder for certain pressure. -Cricoid, pressure. How much (30N= 3 bags of sugar), contraindications. -Ankle block. Nerves involved. Route of saphenous nerve through the entire leg. Cutaneous distribution in the foot. -Communicating Sux apnoea to mother of child. -Filters. Blood mesh filter, IV, epidural, HMEF (adult and paeds). What they filter out. Pore size. -Epidural. Consent. Technique. Doses -Bain circuit. Definition, flow rates, HMEF, capnographs. -Resus patient with burns and crush injury. VF, paramedic giving compressions too slow and too shallow, need to give him instructions. ALS algorithm. -History station. Patient for hysterectomy, previous history of awareness.


-Simman. Tension pneumothorax, chest drain insertion technique and triangle. SET 8 SOE Pharmacology 0. Premedications Benzos how do they work etc 0. Factors affecting oral drug absorption 0. Drugs used in heart failure - mainly ACEi Physiology 0. Alveolar gas equation - what can we use for it? what affects the different aspects? what is RQ? How does pao2 and paco2 affect MV- graphs 0. Starling forces graph showing different pressure arterial to venous. Net filtration etc different areas in the body 0. Neuronal AP - different stages, refractory periods, Nernst and Goldman equation (thankfully not write them but someone else did get asked to write the Nernst and asked what each bit meant) how does it differ to cardiac myocyte AP (ran out of time) Clinical 24year old insulin dependent diabetic has a motorbike accident and #femur. He had insulin and breakfast an hour before the accident. What are concerns -wanted loads and loads related to the femur #specifically. Diabetic, meds risk of hypoglycaemia Wrong blood administered -what do you do? What do you see? What do you expect, what is involved in a datix What do you do post operatively Physics 0. Pulse oximetry what's the physics, draw the graph, what affects reliability 0. Disconnection monitors what alarms would go off, how does it vary, what if spontaneously breathing vs not. What's most severe outcome? What monitor would you wanna have? 0. Doppler cardiac output monitor how does it work? Lots of physics OSCE


Simulation - seizure and low gcs in TURP, Temperature measurement, Unmanned: Barium swallow - pouch or restriction? Unmanned: Ct head - subarachnoid, Unmanned: ECG - looked like AF, Fetal circulation, History - chemotherapy Hickman line insertion, Airway technical equipment, Bradycardia and then VT - als, Spinal anatomy from college book, Paediatric drug doses and paracetamol overdose, Bain system and capnography traces, History - Ent - OSA, Peripheral nerve stimulators, Cardiac exam - focus on arterial system, Scavenging, Who checklist.

SET 9

SOE

Pharmacology 1. NSAIDs -mechanism of action (i was asked to draw the prostoglandin and leukotriene pathway) -details about the antiplatelet mechanism of NSAIDs -mechanism of aspirin induced asthma -examples of leukotriene antagonist drugs and their applications -selective COX2 inhibitors and their uses -adverse effects of NSAIDs

2. Intravenous crystalloid fluids -examples -ionic composition, pH and osmolarity of 0.9% NS vs Hartman's vs 5%dextrose -adverse effects of using too much of 0.9% NS (they wanted to know details behind how it causes hyperchloremic metabolic acidosis)

3. Drug kinetics - was given a concentration vs time curve for a first order kinetic reaction and asked -equation to describe it -half life, time constant, clearance, volume of distribution, semi log


transformation - definitions and equations -what is zero order kinetics? Examples

Physiology: 1. Draw the action potential curve of sinoatrial node and explain -each phase, ions etc -effect of sympathetic and parasympathetics on SA nodal function -autonomic innervation of heart -cellular mechanism (receptors, secondary messengers etc) of adrenergic and cholinergic stimulation of heart

2. Pain stimulus and withdrawal reflex -basic pathway -neurotransmitters involved -what is reciprocal innervation -descending pain inhibition pathway (briefly about endogenous opioids - didn't want to know more other than the term endorphins) -spinothalamic tract pathway

3. Cellular respiration -glycolysis pathway and energy yield -Krebs cycle and energy yield (did not want to know the intermediates of the cycle) -electron transport chain (asked in more detail than expected) - redox reaction, final equation, coupling of phosphorylation, ADP pumps

Clinical: 65 year old man with BPH for elective TURP - h/o exertional angina and dyspnoea - k/c/o moderate aortic stenosis with ECHO showing aortic transvalvular gradient of 30 mm Hg 1. Preop evaluation - specific points in history taking, what are the clinical features of AS, specific investigations that would be needed, concept of transvalvular pressure gradient

2. Anaesthesia management - plan (i said GA with ETT with invasive arterial monitoring and bed booked in HDU/ICU). They were happy with that plan. So asked about the actual induction process - drugs, procedures, intraop maintainence of anaesthesia etc

3. Intraoperative hypertension - differential diagnosis and causes, they asked in brief about TURP syndrome Then patient develops tachycardia that is AF with ST segment and T wave changes - differential diagnosis and management

Physics 1. Depth of anaesthesia -why is it important to monitor -clinical parameters to determine anaesthetic depth -what are the problems with too light anaesthesia (awareness - special groups where it is common) and too much anaesthesia (geriatric and delirium etc)


-monitors of depth of anaesthesia - just a broad classification and fundamental concept - didn't go into too much detail

2. Pressure (this part did not go well at all) -define pressure and its equation -units of pressure -was given some numerical problem about 2 different magnitude of forces acting on 2 different areas and asked which pressure was higher - the units were all different and i messed up the conversions -then asked another numerical problem where the density of water was given and then made to work out what the pressure of that quantity of water would be at a depth of 10 Meters!! I could not recollect any formula for that and i got really flustered at this point (probably got a zero for this question)

3. Safety checks and human factors -WHO safely check -components - sign in, time out and sign out -individual questions asked in each stage -importance of team brief

SET 10

SOE

Pharmacology -‐ Opiates: Specifics on receptor and mechanisms of action, receptor

sites and actions, side effects and how they were mediated -‐ Pharmacokinetics: Asked to draw a graph with time and concentration

when an infusion is started. Definitions of Clearance, Half time, time constant, volume of distribution.

-‐ Diuretics: Draw a nephron and where certain diuretics worked. MOA for each (wanted more detail than just which pump they inhibited, went into how that actually led to a dieresis.) Indications for diuretics and side effects of bendroflumethiazide.

Physiology -‐ Neuromuscular junction: Details of sequence of events from action

potential to muscle contraction. Wanted specifics on how an action potential actually led to Ach release. Led onto types of receptor – examples, differences, natural ligands

-‐ Control of respiration: Asked to draw a diagram to represent the mechanisms involved in control of respiration (afferents, control centres + locations, efferents and effector organs). Shown a graph with pO2/pCO2 on the x-axis and MV on y-axis and asked to explain.

-‐ Stress response: Started with asking details of the hormones involved (allowed me to give a definition and discuss all components without


really stopping me), the role of the stress response - Benefits and negative effects.

Clinical scenario -‐ 32F, drug abuser, ETOH XS and mild asthma for lap sterilisation. What

more information would you want to know/investigations, how would you anaesthetise? (including discussion around specific drugs), what issues do you anticipate?. Clinical incident: Child abuse (?!), how would you proceed if you found out she had young children at home. What types of child abuse are there/how would you recognise each/ what are the risk factors?

Physics -‐ Defibrillators: Shown a circuit and asked to explain, definitions of

capacitor, charge, coulombs, farads. How to calculate energy stored. Safety features.

-‐ Transport equipment: What are the ideal properties of transport ventilator, how are different ventilators powered, pros and cons of each. What would you take with you on a transfer. How much gas can you take in an ambulance, what type of electricity is available?

-‐ CPET: How can you measure O2/CO2 – first wanted a list of ways and then chose a couple to expand on (paramagnetism and IR). What is CPET? What can be measured?

OSCE:

1) Unmanned computed station on surface anatomy – unfortunately most questions a blur, not something I had prepared for and ran out of time.

2) Caudal block – demonstrate on sacrum and questions surrounding local doses.

3) Interactive resus – Head injury patient with cushings sign. Fairly standard but asked what in the presenting complaint made me most concerned re poor outcome, explained I could not recall the details in the scenario outside (kind of expecting to be shown again) but just advised that I should have read it more carefully!

4) Entonox cylinder and details regarding specifics of entonox and cylinders

5) CXR: ?RUL collapse 6) CXR: Pacemaker and questions about pacemakers including codes 7) Computer T/F resus scenario, bradycardia management 8) History taking for lap hysterectomy – Anaemia, ?thalassaemia,

SOB/cough 9) Blood components – whole blood and PRBC, types of reaction 10) Interactive resus – 15yo, drowning victim, VF 11) Cardiovascular examination


12) Laryngeal anatomy 13) Oxygen cylinder, cylinder details 14) History taking for tonsillectomy, diabetic 15) Communication – asked to discuss options for anaesthetic and

analgesia to a patient for ACL reconstruction. Felt as though slightly missed the point, discussed spinal/GA and patient adamant wanted to have GA. Not sure if we were supposed to try to persuade one way or another. Forgot about nerve blocks until right at the end...

16) Chest drain insertion – had to demonstrate on model. 17) Gas analysis – how gas analysis done clinically on anaesthetic

machine.

SET 11 OSCE 1 capo graphs and larynx anatomy nerve supply 2 resus Brady questions, alternatives to atropine doses and rates. Then went tachy and needed DC cardioversion demonstrate this. Defib sync button is hard to see but they give you picture of defib before and 3 Spinal cord, identify diagrams ?dorsal root, questions on brown-sequard, anterior artery ischaemia 4 Examination of patients radial pulse and precorrdium with questions on different findings, Aortic stenosis, aortic regurge, mitral valve regurg. 5 Who checklist sign in: Form given and had to identify the steps grumpy patient at having been asked questions again and arrow on wrong leg 6 Bain system: put it together, questions it 7 septoplasty history, mild asthma, 8 paediatric prescribing, analgesia, how many millilitres of paracetamol would you give to the patient in question? not milligrams. 9 diaphragm anatomy unmanned station. Attachments, nerve supply, orifices, 10 ulnar nerve placement periph muscular nerve stimulator. What is supramaximal stimulus? Identify TOF, Double burts, Post tetanic count on the sheet. Asked questions about the duration between peaks, herts. 11 resus sim Had Spinal for TURP. Became unresponsive, assess. Bibasal crackles. Manage. What are differentials? TURP syndrome, High spinal. Name of patient was Alan sugar on drug chart. Pathophysiology of TURP syndrome, management of TURP syndrome 2x. 12 temperature measurement. Oesophageal probe, thermistor, identify graph for it. What is kelvin, how does it relate to celcius? 13 pharyngeal pouch unmanned station, barrium swallow image, would RSI pt? would you use cricoid? 14 Atrial fibrilation unmanned station, managements, if broad complex what's different. Features of compromise? What is management 15 Unmanned station: Subarachnoid. Questions on features, management, alert well, 16 fetal circulation: saturations at each of the labelled points. What happens at birth. How oxygenated blood get to left side of heart


17 history taking station for a Hickman line. Pt kept trying to talk about needlephobia seeking reassurance, deviating away from history taking. Definitely not comms station. 18 scavenging. Identify picture, features of system, where would you find it SOE Pharm 1 opioids - oxycondone 2 antiemetics: inputs, ondansetron 3 metabolism of drugs in places not liver, examples. Sux, mivacurium Physiology 1 coronary arteries, blood flow. Identify points on Ventricular pressure graph and draw LEFT atrial pressure waveform 2 spirometer trace, label. Function of FRC, storage of oxygen, where else is oxygen stored? 3 starvation: timeframe, what is utilised first 24hr, and then, and then, how low does it last Clinical 1 ppm patient laparotomy high airway pressure. Specific considerations, who would you go about anaesthetising, who to contact for pacemaker info. Mid way the airway pressures go up what do you do? What is differential. Last rocuronium was 40mins ago. Importance of Anaesthetic chart, what do you consent for? dental, medico legaly… Physics 1 pipelines to the machine (don't forget the suction) and VIE how it works. Where else is O2 stored. 2 laminar and turbulent flow. Equation for each, explain, 3 ph meter how work. Didn't like mercury/mercury chloride happier with Silver/silver chloride. What errors can you get with samples and how to minimise them

SET 12

SOE Pharmcology

1. What are the side effects of morphine What receptors does it act on and how do they work Oxycodone – how is it different to morphine What kind of drugs are excreted by the kidneys

2. How do anti-emetics work What receptors Examples of drugs for each receptor

3. Other than the liver, where are drugs metabolised? Tell me some drugs metabolised by esterases (discussed esmolol, sux, remi) What do these drugs have in common


Physiology 1. Cardiac cycle

Gave me a graph with LV pressure trace on it, asked me what it was, asked me to talk me through what happens throughout, draw ECG on it, draw aorta and atrial traces Coronary circulation. Venous drainage of heart. Coronary O2 extraction - equation

2. Lung volumes Handed me a spirometry trace, asked me to put values on the y axis and label the various volumes and capacities. Asked 'why do we have an FRC? What would happen if we didn't? Struggled a bit before realising they wanted me to talk about position on the compliance curve, so if no FRC then at the bottom – difficult to inflate, increased work of breathing

3. What are the metabolic changes that occur in starvation. Particularly interested in hormonal changes. What is BMR? What is basal oxygen consumption (wanted number)

Clinical 65 year old man for emergency surgery with perforated bowel. Has a pacemaker. Basically asked me how I would manage this man. Specifically interested in pacemaker. Asked how I could get information about pacemaker, then told me no access to old notes/previous records etc and patient couldn't tell me – how else? (I suggested CXR which could give some information about leads, chambers, defib function, could ask cardiology to look too!). Asked what equipment I'd want available in theatre (defib with pacing function). Asked if I'd use a magnet (no!). I mentioned bipolar diathermy and they said surgeon insists on monopolar – I said I'd discuss with my consultant, and if it was necessary then make sure return plate is far from pacemaker site and situated so that current shouldn't flow via the pacemaker. Then said in theatre airway pressures rise – what would I do? Talked about assessing patient, anaesthetic machine. Bagging patient to feel compliance etc. A little bit on modes of ventilation. Discussion about anaesthetic chart. What should be recorded, why and how often. Preop/intra/post op information. Why is it useful – record for others, can be used in legal proceedings to demonstrate appropriate things done! Other information – responsible consultant's name etc. Physics

1. What gases are supplied to theatre via pipeline. What else is supplied via pipeline (vacuum). How is gas supplied to the hospital. Cylinder manifolds (what size cylinders, how are they stored) and VIE. Gas pipelines – what are they made out of. Who is responsible for servicing and maintaining them. Safety features of supply (talked about Schrader valves, NIST, colour coding). What are the colour codes?

2. What is a Venturi? Discussed Venturi and Bernoulli. Clinical applications. Laminar and turbulent flow. Hagen-Poiseuille equation. Reynold's number and equation. Wanted a formula for turbulent flow


too. Asked where in the body turbulent flow happens. Asked whether flow is laminar/turbulent in aorta and trachea.

3. Define pH and how does it correspond to H+ ion concentration. Asked me to tell them H+ ion concentration at pH 7.0 and 8.0. How is pH measured. How does pH electrode work. How is oxygen measured by Clark electrode – how is it different to pH (needs a battery). How is CO2 measured (Severinghaus). What causes inaccuracies in these systems. What causes inaccuracies in blood gas sampling. If you took an ABG a long way away from the lab/machine, how could you store/transport it to minimise inaccuracy?

OSCE stations

1. Central line insertion – landmark technique. Why do we prefer using right internal jugular (I said thoracic duct on left, they wanted more so I said shorter and less tortuous distance to IVC/RA junction). Describe and demonstrate on model. Describe Seldinger technique (equipment present). 3 immediate complications of jugular central line insertion

2. Simulation. Lady received 20ml 0.5% bupivicaine epidural top up for cat 2 section. Epidural only just inserted. Now unresponsive. Confirm PEA arrest, start CPR – have to explain how to do CPR to assistant. How would I manage situation. What dose adrenaline. What are my differentials for arrest (LA toxicity, total spinal proceeding to haemodynamic collapse). Treatment. Intralipid – what dose, what infusion rate, how often can boluses be given.

3. Cardiac anatomy – coronary arteries and veins. Where do coronaries start. What is the ratio of thickness LV vs RV. Showed me an angiogram – what vessel is this (LCA). What are sinuses of valsalva. Where exactly are the SA and AV node. Oxygen extraction.

4. Equipment. Infusion pump and fluid bag attached to a single cannula. What are the problems with this set up (Fluid bag had air in it, giving set was for blood, both attached to a three way tap at the cannula, no anti-reflux/anti-siphon valves, syringe in pump had a blue 'fentanyl' sticker on it – was meant to be remi, no concentration written, no patient details/date/time/signature. Why anti-reflux valve – where would you put it in circuit. What is siphoning? What is 'backing off' feature of pump. What pressure would you expect pumps to alarm at

5. Communcations station. Patient for elective hysteroscopy. Worried about mask on her face – had a GA as a child and was held down and black mask held on her face, nasty smell, generally traumatic experience. Just discussed our nice modern masks, letting her hold it, doesn't need to be tight, the fact that it's the injection that puts her to sleep (not gas – sounded like was gaseous induction as a child). Briefly touched on the possibility of a spinal instead – wasn't keen!

6. Respiratory exam. Exam was normal. Patient histoy provided was cough, shortness of breath. What investigations would I do? Showed me a vitalograph with FEV1 and FRC given (normal)

7. ECG monitoring. How can we improve signal. Sources of interference (showed me an ECG with constant interference – what is causing this. Thought probably mains intereference). How we can improve signal. What is a differential amplifier. Show me on diagram where leads go


for CMV5 (which colours go where!). What is this on ECG (calibration signal). What is paper speed? What is the significance of 0.5 – 40 Hz printed on ECG.

8. History taking. Patient for cystoscopy for ?prostate problems. Previous GA nil problems. Chronic bronchitis, not on any treatment. Ex-smoker (40 pack years). Good exercise tolerance (plays golf 3 times a week). Brings up sputum (none currently). On Nifedipine for HTN – was on propanolol, stopped because made him faint a few times. Nil cardiac history, nil known complications from HTN, believes HTN well controlled. His daughter had an epidural for labour 3 years ago and now has chronic back pain – are these things related?

9. Computer station. Picture of C2 vertebrae. What ligaments cross the atlanto-axial joint. What movements happen here? What syndrome predisposes to subluxation (a choice of various genetic disease: Downs, Pierre-Robin, a trisomy etc). What is this called (pointing to odontoid peg). What is this (tranverse foramen) and what passes through it? (vertebral artery and vein).

10. Paediatric IO. What is this (Cook Manual needle). Describe how you'd insert it. Two places you can insert. Why would you insert it. How would you confirm correct position. Demonstrate insertion on a model. Formulae for estimating weight of child (4 year old). What plasma volume would this child have? What fluid bolus would you give a child, and how much would that be for this child?

11. Simulation station. 65 year old COPD patient on ITU with trache (put in 48 hours ago), displaced when rolling patient. Patient is sedated, not making respiratory effort. Algorithm for displaced trache. Unable to pass suction catheter. Able to ventilate BVM orally with stoma covered. Want to intubate, paralyse patient, then find laryngoscope light isn't working! What do you do now. Then questions on options for managing this airway. Who might we want involved (ENT!).

12. Humidity measurement. Define relative and absolute humidity. Identify hair hygrometer and Regnault's hygrometer. How does Regnault's work? Then asked to look at a Regnaults chart and work out the absolute/relative humidity

13. Computer station. Lateral CXR on obese patient for laparoscopy. Odd questions – was hemi diaphragm raised, could you see a bulla, can you see abdominal contents in thorax, would you pass an NG intra-operatively.

14. Computer station. Elderly lady on SSRI and clopidogrel head injury in resus. GCS 4. Hypotensive. CT of facial/skull fracture shown. Questions: Priority is max fax opinion? Proptosis should be management conservatively? May have high ICP? Is hypotension just due to blood loss from head injury? Is it likely she has a c-spine fracture?

15. Computer station. Apologies, racking my brain but can't remember this one.

16. History taking. Young woman for elective laparoscopy for severe abdo pain around her periods. Chronic cough. Rheumatic fever as a child. Heart murmur. Not treated or investigated in this country. Does sometimes get SOB. Has a fixed plate for two front upper incisors.


17. Describe pain pathway from painful stimulus to sensory cortex. What modalities carried by lateral and anterior spinothalamic tracts. What is normal spinal CSF pressure. What is normal CSF volume. Shown cross section of cord. Identify lat spinothalamic tract, corticospinal tracts, dorsal columns. What modalities carried by dorsal columns?

18. Equipment Had to check equipment for RSI:

· Magill forceps – stuck shut · Laryngoscope – light doesn't work · ET tube – cuff won't inflate (leak ?in cuff or ?pilot tube) · facemask attached to tubing – blocked with blue-tac at interface · Guedel airway – not sure if there was an issue (only one size

though) Then asked generally about what other equipment needed for RSI – difficult airway trolley, tipping trolley, cannula, fluids, bougie. Wanted to know contents of difficult airway trolley, what you use for plan D (10 blade, 6.0 tube). Then talked me through an RSI – can't see anything at first attempt, what do you do. Can't see anything with second attempt. Move on to oxygenation via facemask/LMA whilst maintaining cricoid, then make decision about whether to wake/continue.

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