Primary FRCA exam: January 2009 VIVA Physiology and Pharamacology paracetamol. toxicity,treatment G receptors Penicillin. mechanism of action,modes of action of antibiotics, aminoglycosides and toxicity Modes of actions of other antibiotics What is the toxicity and hypersensitivity with penicillin What is drug resistance. What are the mechanisms for drug resistance? Physiology Showed me a picture of ODC and asked to label different points Enumerate different types of Hypoxia. What changes occur on various points in different types of hypoxia? What is the Normal BMR? how do you calculate It. Normal values Factors affecting BMR Why is the energy utilised for wanted me to tell the important organs that uses BMR What happens when 1 litre of Normal saline is infused Asked about Baroreceptors in detail and Total Body Water I felt my examiners were quite helpful and lead me in the right direction. But eventhough i was put off by the first question on paracetamol managed to come out with some explanation . Physics name some suraglottic airway devices. In detail about LMA. types Advantages of LMA and Compare with ET tube What are the gadgets you keep in difficult airway trolley What is Pressure, Force Methods to measure pressure Bourdon gauge, Atmospheric pressue different units Ultrasound and doppler effect in detail Primary FRCA OSCE/VIVA questions, University Hospitals Coventry & Warwickshire NHS Trust Page 1
Transcript
Primary FRCA exam: January 2009VIVAPhysiology and Pharamacology paracetamol. toxicity,treatmentG receptorsPenicillin. mechanism of action,modes of action of antibiotics, aminoglycosides and toxicityModes of actions of other antibioticsWhat is the toxicity and hypersensitivity with penicillinWhat is drug resistance. What are the mechanisms for drug resistance? Physiology Showed me a picture of ODC and asked to label different points Enumerate different types of Hypoxia. What changes occur on various points in different types of hypoxia? What is the Normal BMR? how do you calculate It. Normal valuesFactors affecting BMRWhy is the energy utilised for wanted me to tell the important organs that uses BMR What happens when 1 litre of Normal saline is infused Asked about Baroreceptors in detail and Total Body Water I felt my examiners were quite helpful and lead me in the right direction. But eventhough i was put off by the first question on paracetamol managed to come out with some explanation . Physics name some suraglottic airway devices.In detail about LMA. types Advantages of LMA and Compare with ET tubeWhat are the gadgets you keep in difficult airway trolley What is Pressure, Force Methods to measure pressure Bourdon gauge, Atmospheric pressue different unitsUltrasound and doppler effect in detail
Working pressure of anaesthetic machine there is something else i felt my physics viva was never ending. but really enjoyed it Clinical A 65 year old man for TURP with Aortic Gradient of 30 mm Hg Anaesthetic Considerations and management, Critical incident Hypercapnia OSCE We had 17 stations only 1 station was not active Chest Xray Collapse Neck Xray ? Ankylosing spondyliti s and related questions youmg man Anesthetic machine check, Not old Boyles but a new drager machine. Had no blanking plug, oygen analyser overreading , vaporiser not filled Pictures for measurement of oygen and to identify different reactions Perform epidural SimmanMI VF Asystole rhythm strip Capnograph Diathermy Anatomy of trachea, lung , diaphragm nerve supply interscalene block demonstrate on actor Anatomy of sacrumCommunication. Heroin addict coming for surgery. worried about taking morphine
History Leukaemic patient for insertion of Hickman line under GA
Asian lady with Beta thalassemia And T.B. Very difficult to elicit h/o thalessemia/ she had menorrhagia and said was on iron pills so i thought t was iron deficiency i asked about blood transfusions but denied to have had it.
Set 2• Simman - 34yr old male, head injury on itu, exam (hypertensive, bradycardic etc) explain to st1
what was going on – cushing reflex, prognosis, tx of head injury• Xray – large retrosternal goitre, qu re difficult intubation• Technical skill - Tension pneumothorax mx & insertion of chest drain – talk through• Anatomy – diaphragm• Hx – swanson arthroplasty (college book)• Follow on – questions re – RhA, mx etc• the history station was directly from the new college book - 60yr female with RhA, multiple joint
involvement, previous joint replacements, prev TB with R upper lobectomy, PONV follow on station - which joints were being replaced ( R 1-4th MCP) which HLA is assocd with RhA, what meds did she take (included "Frumil"), what is Frumil, what pre med (steroid bolus), which regional blocks, complications of interscalene blocks, description of axillary block, how had compensated for her SOB (moved into a bungalow)
viva 1.Physics (really really nice reassuring examiners)i was asked about how i measure temperature on my patientsand then shown pictures of various thermometers (mecury,
oesophageal) and then talked about the principles ofelectrical monitoring.second question was about blood pressure monitoring..although straight forward topic the questions were a bitobscure and was nt really sure what they wanted but i justtalked about the various techniques i knew of.thirdly..about resonance and damping, wheatstone bridges.. butinstead of asking directly about them she showed me reallyobscure squigly tiny rubbish pictures and asked me to talkabout them. I had no clue but mentioned the word dampingand resonance and she seemed pleased so prattled on aboutthem both for a while. Clinical scenario 20 year old boy with downs syndrome for a GA for dentalabcess.Asked about the considerations for anaesthetic andconcerns:Methods of induction and asked in detail about gasinductionAsked about the advantages and disadvantages of usingnitrousthe critical incident was bronchospasm in recovery but didnt really go into it very much as the bell went. Physiologyquestion 1 on lung compliance, definitions, draw the graphand descibe it. i succumbed to the pressure a bit in thisquestion and got myself very muddled despite thinking iknew the topic reasonbly well... the examiners were notespecially friendly and in fact i found their questionsreally vaguequestion 2 asked in great detail about the autonomicnervous system.. the anatomy the name of differentganglia, actions, question 3: muscle reflex- monosynaptic and polysynactic-as well as draw diagram OSCE
Anatomy: coronary circulation:diaphragm!!!!!communication:epidural and spinal for a woman for LSCS who wanted tobe awake2 history taking station including follow on= reallyrequire you to take a very detailed history regarding thereason why they are having surgery technical: chest drainresucitation: bradycardia and VTclinical equipment: bourdon gauge, different types offilters, ECGxrays- chest and c spine (unmanned)check of breathing circuit. they had blue tacked thevalves down... sneakycapnograph and interpreting the trace
Set 4
Viva physiology/ pharmacologythey asked me everything about adrenal glands, anatomy, blood supply, zones of the cortex, which hormones are produced where, what are the actions of glucocorticoids and mineralocorticoids, how is the secretion of these hormones regulated, what is CRH, ACTH etc then about the function of the medulla and he asked me to draw the synthetic pathway for catecholamines. He also asked how the secretion of adrenaline from the medulla is regulated. The second question waa about dead space, definitions abnd to describe fowlers method and to derive the bohr equation.Pharmacology was about induction agents started with thiopentone, he asked me to draw the structure, to describe the differences between oxy and thiobarbiturates and to compare thiopentone to propofol.second question was about drug interactions: what is interaction, what type of interactions do I know, basically they asked about all the types of physicichemical, pharmacokinetic, pharmacodynamic and examples for every type. also asked what is summation, potentiation, synergism.third question was about antiemetics, he asked me to draw the diagram , what receptors are involved and what are the common side effects.
Viva clinical/ physics
I was given a scenario about a 24year old male who was a type I diabetic and got involved in a motorbike accident and had a fractured femur. I I was asked about the anaesthetic considerations and how I would pre-op assess espesially in respect to his diabetes, what investigations etc. Then
how i would do my anaesthetic ( Ga vs regional ) then I was told that it was decided between me and the surgeon to do a CSE. And I was asked about the compication of an epidural and to classify them as immediate and delayed, they asked about incidence of PDPH and neuro dammage. Also how I would manage PDPH and what are the possible risks of a blood patch. And what would make me suspect an epidural abcsess as late complication and how I would manage it. Then I was taken back to my previous scenario and I was told that the man with the # femur was given the wrong blood intra op, what are the signs and symptoms and management.
Physics was about pressure , SI unit of pressure, what would I use to flush a clot fron an iv catheter a small syringe or a big syringe? the I was asked about the difference of a barometer from a manometer and the difference of gauge pressure from absolute presure. They asked me ti draw a bourdon gauge and to explain why the pressure makes the tube to uncoil.Second question was about dead space, to derive the bohr equation and to describe fowler's method. I was specifically asked about the final increae of concentration of expired nitrogen, what it represents an where this gas comes from, the top or the botton of the lungs? what are we doing during the anaesthetic that affects the dead space?Third question was about flow, laminar and turbulent, Haegen-Poiseulle law, RN etc, and I was asked to draw a diagram flow/ pressure for laminal and turbulent flow. why is turbulent floe important to the anaesthetist ans say one example.Last question was about the rotameter and what would happen if a rotameter was moved to high altitude?
OSCES
1) Check an arterial line ( there were air bubbles in the tubing and it was connected ti on iv cannula). Explain the risk of air bubbles. Also explain why a venflon is not suitable for invasive bp monitoring ( I explained about the material and the mechanical features that would affect damping etc, but what he was trying to grt is that the iv catheter has a port to inject, which carries the risk of intra- arterial injection ) Then he asked why the pressure from the pressure bag is not tramsmitted to the transduced and what are the risks assoiciated with it?
2) ALS scenario: 42 year old man collapsed on the ward few hours post lap chole. The showed me an ECG which was sinus tachycardia and asked if the patient had no cardiac output what type of cardiac arrest this is and what is the management. The specifically asked about possible reversible causes in this scenario
3) History taking: 70 year old man for carotid endarterectomy ( from what i got seemed thet he had two episodes of amauross fungax , last four months ago, no previous medical history but questions abot his systems revealed that his exersise toerance was limited by intermittent claudication) When he had his previous anaesthetic he "needed a lot of anaesthetic to go to sleep" , he was a very heavy drinker in the past and now he shares 5 bottles of wine a week with his wife, he is an active smoker 20 cig/day. No allergies or dental work- did not have more time to ask detail about his smoking and
4) Clinical examination: You are going to pre- assess a patient on the ward with your consultant and you are asked to examine his cardiovascular system and measure his blood pressure whilst the consultant asks you questions. It was on a dummy which after doing the whole examnation I found to have a systolic murmur. I was asked about the possible cause and what I was shown an ECG which had inverted T waves in the lateral and inferior leads. What other investigations would you like to order for this patient?
Set 4
VIVAPHYS - Draw & describe pacemaker & cardiac action potentialGastric secretion & emptyingA blood gas showing respiratory acidosis - give potential causes; define standard bicarb, base excess.PHARM - benzodiazepinespharmacogenetics (inc sux apn)antidepressants PHYSICS - Non-invasive BP measuringVarious needles & fluidicspH & its measurementCLINICAL - Pregnant 26yr old with RIF pain (differentials & management)Critical incident - tension pneumo after IJV line insertion OSCE1. Resus - PEA arrest (SIM-MAN interactive)2. Resus - VF arrest (discussion only)3. SIM-MAN critical incident - trauma pt just induced - hypovolaemia or thromboembolic event4. Equipment station - gas analysis - capnograph & methods of measuring volatiles5. CXR - ?miliary TB6. Lat c-spine XR - trauma case, #C27. Equipment check station - Mapleson F circuit8. Equiment station - rotameters9. Technical skill - change trache tube on ITU
10. Technical skill - subclavian central line insertion11. Clinical examination - respiratory system12. History taking - lap chole patient13. Follow - on feedback station from station 1214. History taking - knee arthroscopy (previous RTA & splenectomy)15. Communication station - pt having elect lap chole, concerned re awareness & PONV16. Anatomy - spinal cord17. Anatomy - ANS18. Clinical safety - peripheral nerve injuries & pressure sores
Set 5
Physio viva
Frank starlings curve,
Liver blood flow, effect of hypoxia on liver blood flow and metabolism,
Clinical 20-year-old man with Down’s syndrome for dental abscess drainage
Qns: Preoperative assessment
What problems? Qns on difficult airway- details of awake fibreoptic intubation, inhalational induction, end point of inhalational induction, recovery room desaturation causes and management
PhysicsTemperature measurement methods, BP measurement and vaporisers
PhysiologyRespiratory system compliance, graph of total lung compliance and compliance at tidal volume, other organs- ventricular compliance
ANS – differences and neurotransmitters
Withdrawal reflex- draw pathway
PharmacologyInhalational anaesthetics- compare and contrast isoflurane and sevoflurane, MAC, blood / gas partition coefficient, oil / gas partition coefficient Isomers
Drugs that control acid secretion compare and contrast antihistamines and proton pump inhibitors, which is more active? Why? Sodium citrate, draw a graph of Ph versus time after administration of sodium citrate
OSCE
1. Examination- cranial nerves 3- 122. Resuscitation- VT3. ECG-qns on differential amplifier, common mode rejection, difference between monitoring
and diagnostic modes etc4. History taking- abdominal hysterectomy patient almost the same we did there on 7th
5. History taking with follow on station-6. pnemonectomy patent for digital surgery, asked chronic bronchitis definition, digital block7. Sinman- head injury patient explain pathogenesis to ST1- same as the OSCE on 7th
8. Anatomy- picture of diaphragm and structures piercing- identify structures, level of IVC and oesophagus piercing diaphragm, motor and sensory supply of diaphragm, origin of muscular part of diaphragm
9. Machine- breathing system check- circle system- breathing system check – leak +, valve stuck.
10. Picture of bourdon gauge- qns, units of pressure, units of inductance, luminosity, filling ratio11. Filters- blood filters, HME, epidural filter12. Capnograph- different traces13. Tension pneumothorax, diagnosis, immediate management, chest drain insertion-
demonstration14. Heart- anatomy and qns15. X ray of chest16. X ray of neck and chest with tracheal deviation, patient for thyroidectomy17. Communication station- patient for LSCS for placenta previa, previous LSCS under GA, wants
to be awake this time, concerned about epidural, discuss with the patient and make an anaesthetic plan
1. Cricoid pressure- plastic model, how to apply, contraindications in application
2. Anatomy- larynx
3. Anatomy- cardiac
4. Lateral CXR- RML consolidation, pt with GB empyema
5. Lumbar spine CT- L1 ? prolapsed disc, trauma
6. Pre history station- 20 yo male, impacted wisdom teeth for extraction, blocked nostrils following previous fracture nose
7. Follow-on history
8. Photo of O2 cylinder- features, bodok seal
9. Humidity- graph, pictures of hygrometers
10. Picture of Cormack & Lehane gr II, Mackintosh blade + where it’s inserted during laryngoscopy, different capnography traces
11. Communication- ‘unmanned station’, asked to phone number for haem technician using phone available, ask for further 6u blood, FFP, platelets for unstable pt in theatre, obstructive technician!
12. Blood transfusion- process of administering blood
15. History station- bilat vv, asthma, irregular HR as teenager
16. Sim man- ITU asthma pt, PTx, chest drain insertion
17. DIY stethoscope!- looked like diaphragm end of stethoscope attached to 3-way tap, attached to hearing aid via tubing, when it would be used during anaesthetic
1. 45yo F, BMI 40, smoker for cholecystectomy (unspecified open or lap)
2. Critical incident- high airway pressure, PTx
3. Transfers- what critical incidents can occur, what preparations, what to do if pt is unstable (ie. Speak to ITU to identify more suitable pt)
Physics
1. Osmoles/osmolality/osmolarity, examples, how to measure
2. Picture of Ambu bag- features of
3. Picture of O2 cylinder, how to calculate how long it will last for if giving 4l/min, gas laws
Physio
1. Dead space- Fowler’s method, Bohr equation- how to apply if oesophagus intubated (ie. Dead space volume=tidal volume)
2. Foetal circulation
3. Buffers- Henderson hasselbalch equation
Pharm
1. Vecuronium vs rocuronium
2. Cholinergic receptors- what types, where, atropine + how it acts, organophosphorus cpds + how they act
3. Antihypertensives- classification, effects, SEs, what to be aware of wrt anaesthetic
Set 8
Viva 1 Physiology 1. Tell me how the perfusion of the lung varies from dependent to non-dependent regions.Have you heard of West's Zones? Can you draw me a diagram to help explain this concept?Please compile a table of factors affecting pulmonary vascular resistance?Can you explain what happens to PVR with changes in
luing volume? 2. Tell me about Haemoglobin (they were not interested in red blood cells at all, and quickly moved me back onto Hb).What would you need to make haemoglobin?Tell me a bit more about Haem. How is it made?(Eventually moved me on when I started to struggle) 3. What fluid compartments do we have in our body?How is fluid divided between them?What factors influence the partition of fluids into these various compartments?How much would your IVF expand by, if I infused 2L of Normal Saline?Over the following hours, what would happen to this extra fluid, and why? Pharmacology 1. Why do we give drugs by various different routes?Tell me a bit more about the pharmokinetic factors.What do you mean by bioavailability? How do you define it, and how might we work it out for a drug?What presumption do we make when we use this method of working bioavailability out? (First order elimination, apparently!) 2. Tell me how NSAIDS work? What pathway do they work on?What are the end products of this pathway, and what are their effects?Can you tell me a bit more about COX? What are the consequences of inhibiting COX-1 rather than COX-2 and vice versa.How might you classify NSAIDS?What are the side-effects of NSAIDS? 3. How do B-blockers exert their anti-hypertensive effects?How do you classify B-blockers?What effect might a B-blocker with intrinsic sympathomimetic action have on the blood pressure?Give some examples of B1 selective B-blockers.What side effects do B-blockers have? Viva 2 Clinical
Scenario 1: You are asked to anaesthetise a 6 year old for a circumcision. He is "generally fit and well". His weight is 30kg. How would you preassess this patient?Issues:- Elective Surgery- Overweight- Blocked nose (no URTI/LRTI symptoms; no sleep apnoea symptoms)- Poor IV access Would you pre-medicate this child? With what?What is Ametop? What does EMLA stand for? What is in it? Which of the 2 do you prefere, and why? You anaesthetise this child without any problems. Procedure is unremarkable. As you wheel him into recovery, he begins to go blue. What do you do? Laryngospams critical incident, then discussion about whether I should tube the patient with 1.5mg/kg of sux, or just use 0.25mg/kg to break the spasm. V. quick discussion about analgesia for circumcision (inc. penile and caudal blocks). Scenario 2: 10 year old in A&E scheduled for urgent appendicectomy. How would you assess her fluid balance pre-operatively? How would you resuscitate this child? Physics 1. What base SI units do you know?How do we define a second?How do we define a kilogram?What is force? What are its units?What is Capacitance? What are the units?What are the units of pressure? What is that in base SI units?What other units do you know for pressure? How many kPa in 1 atm; how many cmH20 in 1 kPa? 2. What is humidity?What is the difference between relative and absolute?
What methods do you know of humidifying air?Why do we humidify inspired gases? 3. What do you use a PNS for?Tell me a bit more about assessing NMB.Can you demonstrate a TOF for a non-depolarising relaxant?
Set9
Viva 1cardiac cycle and effects of T4 spinaleffect of breathing 100%local anaestheticspharmocokineticsanti convulsants Viva 265yr old with pacemaker needs laparotomyhigh airway pressurebreathing circuits A,D,EFRC and body plesmographyFuel cell and clark electrode OSCESim man x2 one was PEA and one was intubated tachycardic, low CO2 and hypotensive having femur operationSpinal cord anatomyANS anatomyRun through ALS protocolVolatile / CO2 analysisAyres T-piece checkRotameterTrache changeCommunication- awareness and PONVHistory- Lap chole and also young man for knee arthroscopySubclavian line insertionXray- C spine and chestNerve damage under anaesthesia
Set 10
) OSCE
1. 25/M, Afro Carribean for knee arthroscopy(diagnostic), footballer Did not have sickle cell but had polytrauma 4 yrs ago with rib fracts, had splenectomy done then.
2. Sinman, Polytrauma, tibial fract, adult male, hypotension and tachy after GA, ? anaphylaxis, bleeding, etc. rhythm changed to PSVT3. Cut section of spinal cord with tracts, etc.4. XRC - Pulm TB, ARDS5. 35/F, lap chole had hiatus h, smoker, this was a h/o follow on stn.6. Subclavian vein cannulation on sinman demonstrating seldinger tech, complications, anatomy, etc.I did many of those lines in India during my residency, so found it easy but people were cribbing bout this stn.7. Jackson Reees circuit, nothin' else on machine.8. Rotameter photograph and related q's9. Tracheostomy changing on sinman, again, do it in pract, hence, did not have a prob.10. Nerve injury pics.11. pic of autonomic nervous system with related q's.12. CPR - young ectopic in A and E in PEA( Red Herring, this stn mentioned details of the defib on the information outside but the rhythm was never shockable, BEWARE OF SUCH DISTRACTORS)13. CPR ALS scenario, details of adrenaline and magnesium ???14. Examination of Respiratory system.15. X ray of cervical spine C2 frac and related q's16. pic of gas monitor that we use in OR, co2, etc. was fine but got asked details bout isoflurane, ins and exp cons, etc. seemed like a very diff OSCE, everyone felt that.
B) Viva1. Pharmac - Local anaesthetics Heparin Dose and log dose response curves
2. Physio -
1. Liver physiology with blood flow, sinusoids, bile canaliculi, the works, everyone felt it was harsh, just remembered what I had read a while ago.2. Left ventricular function curve(Starling) with related q's.3. Control of breathing, details on chemical regulation
3. Clinical-
1. 52/F for open cholecystectomy with 2 finger mouth opening, went on inhalational induction, did not want to know about fibreoptic.2. CI - Anaphylaxis after induction3. PONV
1. Bernoulli, venturi, coanda2. Heat loss and measures to prevent, warmers and other methods of intraop warming3. Pressure regulators, adams valve, entonox valve,etc.
Let me know if any other information needed. Feel free to call me on 07984115577.Once again, many thanks for everything
Set 11
VIVA and OSCE examination 21.01.2009 (FRCA primary)
OSCE.
1. Demonstrate how to change a trachy tube on a manikin.
Examinar asked Qs on preparation , procedure and how to confirm the tube position, how to check the tube , back up plans if failed to insert the tube.
2. Picture shown of a pressure effects on the head following position on the theatre table. to identify the injury and causes for it.
Pictures shown of patient positioning on tabel and Qs on possible injuries, demonstrate on your self the areas affected, nerves compressed etc.
3. Resuscitation - Old lady , Periarrest, PEA scenario.
4. History taking. - Young ASA 1 patient for Knee Arthroscopy.
5. Photograph of a monitor screen.
Qs on what gases are measured, gas analysis methods, partition coefficients.
6. Resuscitation - Picture of an ECG with VF. Asked Qs on the management.
7. Communication station.
46 Yr lady for Lap Cholecystectomy. Her cousin had experienced awareness under GA for Em LSCS. Anxious about awareness. Reassure.
8. Simman station- Young man has had RTA - # femur. SHO has induced with RSI for fixation. you are called in to help to manage. Patient is tachycardic, desaturating. Ultimate finding is patient is in hypovoleamic shock.
9. Simman - To demonstrate the technique for subclavian CVP insertion. complications.
10. Picture of a spinal cord cross section. Qs on ascending and descending tracts, blood supply and complications of ischaemia.
11. Chest XR - Old lady, heavy smoker, acutly unwell, SOB, in resp failure.(information given) True/ false Qs on diagnosis/ management.
12. Cervical spine - Lateral XR- # C2 - young man following a fall?
T/F Qs on paralysis/ breathing/ vent support/ management.
13.History taking- 26yr old young female for lap chole. Take a full history.
Findings - Smoker/ Reflux/previous surgery under sedation/ prev GA uneventful/ Caps+/ family history of drug reaction under GA- ITU admission/ social history/
15. Breathing system check - Mapleson F system. Found a leaking bag. Qs on flow rates.
16. Respiratory syst. examination of a young patient. Had B/L thoracotomy scars/ IC tube scars.
17. Picture of Pons and Medulla. picture of parasympathetic and sympahtetic out flow.
Qs asked on- to identyfy nuclei and nerves, neurotransmitters, ganglions.
18. Flowmeters.- Pictures shown of a anaesthetic machine flowmeters and wall oxygen flowmeters.
Qs on bobins, physical principals, at high flow and low flow relationships between bobin and flowmeter walls.
Pharmacology viva.
1. Differences in drug action in different people
2. Benzodiazepines- uses, classification, mechanism of actions (MOA) of each class, describe drugs in each class.
3. Antidepressants- classification, MOA, describe drugs eg: Lithium, TCA overdose clinical features and management.
Physiology viva
1. GI physio: - Composition of gastric juice, protective mechanisms, draw parietal cell, ion pump descriptions, H2 receptor mechanism and drugs used to block them.
1. History taking: woman with previous rheumatic fever from Africa now with cough, night sweats and recently had a CXR results unknown ?TB. For laparoscopy but doesn’t know why
2. Follow-on history station – where does this woman come from, how long has she been in this country? Has she been tested for sickle cell disease? What infective conditions are you concerned about?
3. Xray of barium swallow in woman for emergency laparotomy with pharyngeal pouch. Does it contain solid matter, does she need cricoid pressure, at what level is the obstruction (above C6)?
4. Machine check – Bain circuit with detached inner tube. Questions on what happens if reservoir bag comes off and what happens if you double the length of the circuit. What volume is in outer tube?
5. Temp measurement- picture of thermistor/ thermocouple. Pictures of current vs temp for resistance thermometer, thermocouple and thermistor. Why do children lose more heat than adults
6. Neuromuscular monitoring station – demonstrate where on arm you would place electrodes, talk through TOF, BDS, titanic stim and post tetanic count. Differences between depol and non-depol block, what lies med-lat to ulnar nerve at the wrist? What muscles does it supply?
7. Anatomy station- demonstrate on actor where cricoid, hyoid, thyroid cartilages are, where elective/ mini-trach would be performed. Early complications of insertion.
8. Electricity/ microshock – diagram with ECG/ CVP and patient on table all connected to earth. What is potential across earth wire if fault in ECG line? What is threshold for microshock, choose electrical symbols and explain what they are. MRI- how do we monitor ECG and pulse ox in MRI scanner.
9. Actor –examine the peripheral arterial and venous pulses on this patient. Take BP. Which Karotkoff sounds did you use?
10. Resus – called to assist an ST1- pt just induced – now in VT with pulse but compromised. Reverts to SR after 1 shock. A to E approach of the patient after cardioversion.
11. Arterial line station – check this equipment and tell me if you would use it…no pressure in bag, lots of air, wrong cannula and wrong (compliant) tubing. How do you zero? How do you calibrate it? What happens if there is a defect in the valve at the flush?
12. Resus station –talk through a PEA arrest in a patient 2 hours after laparoscopy
14. Simman – examine this patients CVS system – needed to take BP and examine chest – mixed mitral valve disease. What anaesthetic method is contraindicated? What pre-op investigations would you want?
15. CXR in 2 year old with dyspnea after party. White out L side. Likely foreign body. Questions on management – would you use Heimlich manoeuvre, keep on ward for 24 hours with antibiotics, do bronchoscopy.
16. Actor – where would you perform a spinal anaesthetic in this patient. What level would you want block at for TURP, what structures do you go through? What needle would you use and why?
17. Base of skull – point out cribriform plate and optic foramen. What structures go through both. How do you do a peribulbar block, what needle do you use and how long is it? Where do the optic tracts terminate? What is the main connection of the optic nerve?
Vivas
Physiology
1. draw a graph of minute vol vs time for a patient breathing in a closed circuit with a 6litre bag 5% CO2 – what happens to the patient (wanted symp stimulation and physiological effects of hypercapnia)
What happens if soda lime is put in the circuit but the patient is breathing air?
2. Tell me about iron intake and absorption? How much iron do we ingest in 1 day (4g-they told me the answer), how is it taken up (ferric or ous form and transport in the blood) and how it is regulated
3. Tell me about body fluid compartments, what happens if you give a litre of 5% dextrose and normal saline. What happens to body osmolality and what does this cause? What is osmolarity, osmolality and tonicity?
Pharmacology
1. Tell me about ways of reversing neuromuscular blockade- specifics of easily reversible, carbamylated complex formation and organophosphates concentrating on what was
happening to the enzyme. What are side effects of anticholinesterases? How do we prevent them? Side effects of anticholinergics.
2. Dose response and log-dose response curves and definitions of agonist, antag, partial agonist, affinity, intrinsic activity and potency. Examples of each and all the graphs
3. Adrenoceptors – actions at cellular level including whole G protein cycle. Name agonists and antagonists at each subtype.
Physics
1. Which syringe would you use to unblock a blockage - 2ml or 20 ml and why. Definitions of mass, force, pressure and units. How do we measure pressure? Draw barometer, how does a bourdon guage work?
2. What is dead space. Explain about Fowlers method and explain the graph which they provided. What other methods of measuring dead space are there? Full derivation and explanation of Bohr equation
3. What size cannula would you use for a laparotomy and why? Tell me about flow. Diagrams of laminar and turbulent flow and relevant equations. What happens to anaesthetic equipment (rotameters) at altitude and why?
Clinical
1. Scenario: 24 year old man, insulin-dependent diabetic who took his insulin and ate 1 hour ago now in RTA with broken shaft of femur. What is your approach to this patient? How would you anaesthetise for surgery? What are they particular problems you may expect in this patient.
2. Critical incident – wrong blood. Your approach and management and investigation.3. Complications of an epidural including shivering causing increased oxygen consumption.
- Ketamine- didn’t know much about, went into NMDA receptors a bit, tried to get me back onto Ketamine – uses, effects on CNS, Resp, emergence effects, isomers of ketamine
- Routes of drug administration – starting with topical – examples of, and factors affecting, other routes etc and factors affecting, first pass metabolism ,hepatric extraction ratio…
- Drugs affecting gastric motility – wanted to start with Metochlopromide – uses, effects, receptors act on, side effects – mechanism of oculo-gyric crisis. Domperidone- which receptors act on
Clinical:
6 year old boy for elective circumcision – 30 kg. Pre-asessment, factors of concern – overweight, general problems with anaesthetising paeds. Critical incident of post-op desat and obstruction in recovery. Then went onto fluid management in an unwell child – calculation of resus, maintenance etc
Physics:
- SI units – just name them. Then onto derived units – definition and derivation.
- Humidity – what is the humidity in upper airway, alveoli, how can we measure it. HME’s, waterbaths, nebulisers etc and Bernouilli principle…
- Nerve stimulators – what is supramaximal stimulus, shown pictures of dep and non-dep block – identify – DBS, TOF etc and explain
1) Humidity – graphs of 50 and 100%, define absolute humidity, identify wet and dry bulb from pictures
2) Laryngoscope blades, capnography – Bain circuit would show which type of capnograph trace…Clinical ways to know had intubated oesophagus
3) Blood transfusion – odd questions – wanted to know what checks before giving blood – ie: before checking actual bag – think wanted check prescribed, appropriate indication, patient consent.
Examiner felt embarrassed as questions very badly worded
4) Resus station – anaesthetised patient in fast AF – for dc cardioversion – forgot to press synch button! Examiner holding onto bed had to ask her to stand away before shocking patient. Likely electrolyte imbalances – K, Mg
5) Anatomy of the coronary circulation
6) Communication – telephone conversation with lab haematologist to request blood – nightmare! – very stroppy, didn’t actually get any blood, no idea what was supposed to say to get the marks
7) Examination of a trauma patient – although didn’t actually touch actor – just explain to examiner. Chest drain insertion – wasn’t happy with 5th intercostal space mid-axillary line
8) Paediatric stethoscope thing – no idea what it was - one end had earpiece and other diaphragm bit. What might be used for…
9) ECG of sinus bradycardia – bradycardia algorithm, treatment of – drugs, pacing etc
10) History taking – bilateral varicose vein surgery, asthmatic, previous ITU admission… - actor very helpful and forthcoming
11) Simman – intubated asthmatic, high airway pressures – but difficult to hear reduced airway on simman – despite obviously supposed to be a pneumothorax. How put in chest drain…
12) Lateral CXR – gall bladder empyema
13) Anatomy of the larynx, blood supply to…
14) +15) History and follow-on. 20 year old for wisdomteeth extraction. Day surgery, but drove to hospital and examiner asked any contarinidctaions for day case – not sure if getting at this….
16) X-ray of lumbar spine – saggital 3-d reconstruction from trauma patient. Wedge fracture
EXAMINERS – Very friendly, relaxing. Positive interaction, nodded to answers. Happy to let me talk.
Q1. What do NDMRs do?
I started discussing competitive blockade with acetylcholine at nicotinic receptor in NMJ but they stopped me, asked the question again. I stated ‘muscle relaxation’ and they seemed happy. Then went onto discuss what you would see on TOF and how this is different to TOF response with Suxamethonium. They then asked about the role of the pre-junctional Ach receptor.
Q2 Statistics - Can you define null hypothesis?
Moment of panic – although I had read statistics weekend before exam I had hoped it wouldn’t come up. I couldn’t recall exact textbook definition but gave an example and then I went onto discuss alpha and beta error – they didn’t stop me so I kept on going. Then discussed power of study. They then asked what is the difference between statistical and clinical relevance? I gave example of comparing of 2 anti-hypertensives.
Q3 Diuretics – Asked to explain how different diuretics work?
Drew a nephron and worked from Bowman’s capsule to collecting ducts and explained action of different diuretics along the way. They asked me to describe mannitol in more detail.
Q4 Lung volumes – shown a spirometry trace and asked if I recognised it and if I could label it
I marked out tidal volume, ERV, IRV, RV and capacities. They then asked why FRC is important to anaesthetists – discussed pre-oxygenation etc. Then I was asked about closing capacity and what affects it.
Q5 – What is the resting membrane potential of nerves and how is it determined?
Discussed anion/cation balance and Nernst equation. They asked if I knew another equation so wrote down Goldman equation as well. Then moved onto to discuss action potentials.
Q6 – Asked to draw a nephron – then they laughed as I’d drawn one for the pharm viva so used that one. Asked to explain how filtrate produced - discussed Starling’s forces and how composition differed to plasma.Asked what GFR was? How can you measure GFR?
EXAMINERS – Stern, not at all like pharm/phsyiol viva. Quite scary and felt like they disapproved of everything I said.
SCENARIO – 50 year old woman for elective laparoscopic cholecystectomy. On pre-operative examination she was found to have mouth opening of 2 fingers. How will you proceed?
I divided into pre-op and intra-operative management. Pre-op history, examination and investigations etc. I stated I would discuss awake fibre-optic intubation or gaseous induction with patient. They asked which one I would do. I stated awake fibre-optic. Then they told me that I had proceeded with a gaseous induction and that intubation had been fine but ventilation was difficult. Discussed high airway pressures and the possible aetiology. Went on to discuss management of anaphylaxis.
PHYSICS
Q1 What happens to a patient’s temperature under general anaesthesia and why?
Discussed methods of heat loss – they wanted details of the mechanism of each type (radiation, convection, evaporation and conduction). How can heat loss be minimised – discussed recent NICE guidelines.
Q2 Valves – Asked to draw a pressure relief valve and an APL valve and discuss clinical applications of both.
Q3 Venturi effect – Shown a picture of HAFOE mask. Asked if I knew what it was and could I discuss how it worked. Talked about Bernouilli principle, They asked for other clinical applications in anaesthesia. Then I was asked about the Coanda effect and the practical applications – I mentioned fluid logic ventilators and then thankfully I was saved by the bell!
