Exam Intelligence

I am very sorry I haven't been able to put more detail up
more quickly, but I'm afraid it was a dive straight back
into work. Also, it appears the del.icio.us link is not
working.
I will try to sort that later on.

Just to cover the further questions…

The remaining question in the morning was about epidural
abscess:

-Why do people get them? Predisposing factors?
Looking for usual: cleaning, asepsis, repeated attempts,
duration of catheter in situ, diabetes, pre-existing
infection
-How do you recognise it?
Signs and symptoms.
-How do you diagnose it?
-Investigations?
Make sure you get in that it is an emergency.

In the afternoon: "Here comes the science bit…"

-What is the anatomy of the pleura?
-What is the clinical significance to the anaesthetist?
-What is its function?
-What are the problems associated with eg.
pleurodesis/pleuradhesis (pick your spelling!)?
-What can accumulate in the pleura?
-How do we manage that?
-How would you manage a man with a small pneumothorax
before surgery who requires a GA? (What about RA?)
-Tell me a bit about work of breathing.

Then, next up:
-What are the functions of the placenta?
-Tell me abot diffusion. (What are the principle factors
influencing it?)
-What drugs cross the placenta?
-How?
-What other mechanisms of things crossing the placenta do
you know?
-What drugs cross by facilitated diffusion?
-Tell me about local anaesthetics and the placenta.
-What about neuromuscular blockers?
-What hormones does it produce? (Stumbled a bit over
saying beta-human chorionic
gondaotrophin/gonadotropin…!)
-What are their functions?
-Tell me about oxygen crossing the placenta. (Me: "Ah,
we're talking about the difference between fetal and
maternal/adult haemoglobin now, aren't we…so the thing
here is…." - made the examiner smile!)

Then switched examiners and had standard latex allergy
question, as per Bricker, pretty much, with a little
sideline into types of adverse drug reaction, type 1,2,3,4
allergic reactions and management of anaphylaxis, and
finally onto delivery of oxygen/medical gases to the
operating theatre. For this, make sure you know about
VIE, how it works, where it's located, why, and about N2O
cylinder manifolds and any special considerations to do
with temperature.

Reports from other sources tell me that a question
involving a certain kyphoscoliotic lady for
cholecystectomy (though elective this time) has appeared,
and also questions on management of a child with fractured
tib/fib and head injury (short case)….

Watch this space for developments.

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First things first, I PASSED SUCCESSFULLY.

Everyone has been asking me what I was asked, so here is a
brief breakdown. Other people got asked slightly
different questions.

Long case: (essentially the same case as in The Clinical
Anaesthesia Viva Book for Rhabdomyolysis).

24 year old male.
Recently been admitted to medical ward, weak and drowsy
(GCS 14).
History of depression, alcohol abuse and ??intravenous
drug use.
Conscious level improved with 200 mcg naloxone - became
agitated
His blood pressure is 80/40 mmHg and he has cool and
clammy peripheries.
He has a heart rate of 56.

Arterial blood gases on air after dose of naloxone:
pH 7.27
pO2 8.2 kPa
pCO2 5.72 kPa
HCO3- 20 mmol/L
SaO2 87.6%

U&E
Na 131 mEq/L
K 7.9 mEq/L
Ur 13.? mmol/L
Cr 331 umol/L
CK 49,960 IU

ECG Charcateristic low flat P waves, Broad Bizarre QRS
and Tall Tented T Waves with HR 56

CXR CVP line in situ in RIJ. Bilateral ?lung base
shadowing (difficult to see on photocopy, but Right
Cardiac Border vague, ?consolidation/collapse) No
pneumothorax seen. Left base ?increased opacity

Questions

(They never asked me to summarise the case)
- He is drowsy, and you've been told his GCS is 14. How
would you assess his GCS?
- What are the components of GCS?
- Can you tell me what makes up the Motor component of
GCS? (What movement gives you what score?)
- What could be causing his depressed GCS?
- What about other metabolic causes? (Looking for BM)
- What do you think of his ABG? Does the PaO2 worry you?
(Yes, he's a young fit healthy guy who should have a much
higher PaO2
- So, how are you going to manage this patient when you
first see him? (ABC, 100% O2, IV access, CaCl2,
Insulin/Dextrose, IV NaCl (avoiding K+)).
- Anything else? (Having established his GCS is 14 and
maintaining own airway).
- What about his airway? What if he was not opening his
eyes, making incomprehensible sounds and flexing to pain?
(Intubate, Thio 375mg, cricoid pressure, Roc 50mg
(assuming no predictors of difficult airway present), size
8.0 COETT and off to ICU).

I made sure I got the point that this was rhabdomyolysis
across, and mentioned I would fluid resuscitate, encourage
urine output to avoid depositions in the kidneys, and
would do CVVHF. They never went into any detail with me
about the management of it though, and never asked the
differences between CVVHF and dialysis (though they did
ask some people).

Next up:
- You're anaesthetising a young, fit healthy chap, you
give him Fentanyl and Propofol and then you are unable to
ventilate him with a facemask.
They were looking for simple airway adjuncts first, I
mentioned an LMA as well (they said they'd come to that
later).
- What's the problem with a nasopharyngeal airway?
Trauma to the nasal mucosa.
- What other things might be stopping you from
ventilating?
Laryngospasm, bronchospasm, chest wall rigidity
(fentanyl), foreign body (unlikely/rare in this instance),
secretions/plugging???
- What about more proximally? Any non-patient factors?
Machine, gas supply, obstruction in circuit.
- How would you deal with that?
(I wouldn't bloody have them because I check my machine!!)
Erm, check each part of the connections of the circuit, if
in any doubt, switch to ventilating with Ambu Bag from
back of machine and oxygen cylinder.
- If you still can't ventilate him, what are you going to
do? What about a laryngoscopy?
Not in a patient with just fentanyl and propofol. I would
consider giving him suxamethonium and then laryngoscopy?!
And if I can't intubate him? That's can't intubate,
can't ventilate, so cricothyroid puncture.
- Could you just let him wake up?
Yes, but in the meantime, he needs to be oxygenated, so I
would do the cricothyroid puncture.

Okay, so then a flexion/extension C-Spine X-ray, which
made my heart sink.
- What is this?
- What are the changes?
- What's this at C1-C2? (Subluxation)
- Where else do you get subluxation? Is it just C1-C2?
Erm….no, it could happen at other places to.
- Where?
C7-T1….? (Didn't really know the answer to that one.
Almost lost the plot at this point and was very gratified
to get a smile from the examiner).
- How would you manage this patient?
Carefully, not too much flexion/extension.
- Are there any ways of predicting difficult airway?
Mallampatti, Sternomental, Thyromental, Wilson.
Combination is better, one alone is poor predictor.

This one the examiner had to prompt me a bit with the
X-ray, pointing things out and asking what the abnormality
was, what this and that were, which was obvious once I saw
it, but was annoying, and was my worst moment in the whole
exam.

(I'm afraid that I will have to stop writing here due to
work commitments, but hopefully that helps a
little….more will follow…..)

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Good luck!

So just had clinical anaesthesia viva and want to warn you all.When
you walk into the long case prep bit and see a case you think you
recognise from the books,expect it to go nothing like the book.They
will ask you different questions like how do you assess this or that
rather than managing it, for example. They have obviously caught on to
what's in the books. Later i will post what they asked,but this is
from a mobile,and my thumb aches!

Oh dear, today is the day of the beginning of the vivas.
Good luck to everyone having a viva this week, and please, when you’ve finished, share your experiences.