Exam Intelligence

I just wanted to reiterate what I’m sure you’ve heard before if you’re revising for the exam, and that is that anything in the CEACCP supplement that comes with the BJA is “Fair Game” for a SAQ or for MCQs in the exam (…as if they didn’t have enough to worry about - Ed.)

In the April 2009 issue we think that the following articles are high possibilities:

Exomphalos and Gastroschisis

Arterial Tourniquets

Fast-track surgery and anaesthesia (after all, isn’t this what the government would love us to do for every kind of surgery???)

Gastrectomy for Adenocarcinoma

Management of Cardiac Disease in Pregnancy (though we think this is lower than the others mentioned so far - it appeared in the October 2008 paper).

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Someone asked me to produce an answer for a question that gave an idea of how much needed to be written.

I’ve shown you examples of good and bad layout, but here is an answer that could be considered as having sufficient content to gain a pass.  It must have done, because I wouldn’t have passed the April 2008 SAQ paper otherwise!

The question I am answering is about pre-oxygenation and is question 5 in the April 2008 paper which you can find by clicking here.

A)    Method of Pre-Oxygenation

• Ask patient to breathe normally (normal tidal volume) for 3-5 minutes,
• Via face mask tightly applied to face,
• Connected to circle-absorber system,
• With fresh gas flow of 100% oxygen of >minute volume.

B)    Physiological basis

• O₂ consumption is approximately 250ml min^-1.
• FRC is ≈ 2500ml
• Preoxygenation replaces nitrogen containing air in the lungs with oxygen and generate reservoir of ≈ 2500ml oxygen.
• Oxygen saturation therefore maintained in apnoeic patient for 5-10 minutes.
• Also, small increase in oxygen reserves within body tissues.
• Duration required for preoxygenation is dependent on washin of oxygen and washout of nitrogen and can be decreased by patient increasing per breath volume (4-breath and 8-breath techniques).

C)    Assessment of adequacy

• Measure end-tidal oxygen concentration (>85% indicates good preoxygenation)
• Measure time for SpO2 to drop below 90% from onset of apnoea
• Measure arterial oxygen tension using arterial blood gases
• Mass spectrometry of expired gas

D)    Advantages of PreO₂

• Increases time to desaturation during securing an airway

Disadvantages

• Absorption atelectasis (airway closure followed by absorption of distal gas)
• Atelectasis due to airway narrowing (gas in alveolus absorbed faster than can be replaced through narrow airway)
• Patient anxiety heightened by tight fitting face mask (”I can’t breathe”) (increases oxygen demand)
• Potential to mask oesophageal intubation by delaying desaturation (offset by EtCO₂ monitoring in modern practice).

Now that’s my answer to the question.

It isn’t perfect, but I think it’s pretty good (and I want to hear from anyone who thinks it needs modifying: help-me@examintelligence.com).

I don’t think you need to write any more than that.

On another note:

James has written a Sexy Topics list over at Passing The Final, which I highly recommend you read.  It contains a lits of topics which are prime fodder for the SAQ.  Like him, though, I urge you not to underestimate the MCQ!

Good luck!

As a working man/woman you will spend most of your week, like me, giving anaesthetics. Some days you will be on call long-days, some days you will be on call nights. Depending on your rota this may or may not be called on-call anymore. You could technically be working a partial or full shift, but for the purposes of this blog, I’m going to refer to on-call when you work outside the hours of 8am to 5pm.

Unfortunately you still have to read, mark, learn and inwardly digest a whole host of information, in preparation for what one of the Consultants I have worked with insisted on referring to as

“a little test”.

Slap.

One of the things that will make your life easier in setting out to study is setting aside regular time to read. Now personally I’m not much of a revision planner, and I don’t go in for those large wall charts people at college used to have in the run up to the exam. (They used to be elaborately coloured and precisely drawn, and took up more time to plan than it took to revise, I believe).

In any case, the point I’m trying to make is that you need to set aside time.
I had the luxury of 1/2 hour in the morning on the train and 1/2 hour in the evening on the train, in which to read a book or journal article, do some MCQs or listen to a podcast, which meant that of my 2-3 hours a day, 1 hour was conveniently scheduled for me, as there was not much else I could do!

If you don’t have a commute, or you drive, however, this makes things a bit more tricky. You need to sit down with your rota and significant other and decide when you are going to work. Plan out what evenings you are going to cook (use our recipes!) and which you are not. Perhaps get together with friends to both learn together and share the cooking. (Choose friends who have a large dining table and a dishwasher, for maximum efficiency here!)

The important thing is to make a schedule about when you are going to study, not necessarily what it is exactly you are going to study, at least, not until the point where you are about to sit down. (Although having said that, of course, you do need to make sure you cover the knowledge…)

And then stick to it.

Are you about to embark on an expensive course to try and help you pass the final?
You’ve hoarded your study leave, swapped your nights into doing 7 nights in a row, left your significant other and shipped yourself off for a week in strange parts of the country you’ve never seen and never will again?
Or you’ve managed to escape the humdrum day to day work of the operating room to get yourself onto a day release course?

Well, here’s a tip.
Don’t take any notes.

Okay, perhaps that’s a little exaggeration. Let me go into more detail.

EI previously noted the potential for Mind Maps in another post, and described how to use those. Here’s another cunning ploy. Use only essential keywords. Take your mindmaps to the next level and only write down a few really key central points during the lecture, and focus your entire mind on what the speaker is saying. Even better: interact with the speaker (this will give your brain an extra “hook” to hang the lecture on.

Instead of keeping a record of the lecture on paper, use a dictaphone to record the lecture. From the recording, using very simple software, almost always already on your computer, you can transfer the file from the dictaphone to an MP3 file which any player can play back. You can then take a look at your keywords document whilst you’re eating breakfast in the morning, and listen to the lecture on the train/bus/walking/car journey to work, when you come to revise.

Robert Whitaker over at InstantAnatomy.net has some excellent podcasts and audiovisual lectures on his CD, which you can use as an example (though his AV presentations are much more detailed than your notes ought to be). These were staple listening in the run up to the exam (MCQ/SAQ and the vivas).

You might think that this won’t work for things like physiology/pharmacology etc, but you’d be surprised at how effective it can be. Try just jotting down graphs without the masses of detail, or the drug molecules off the board. Don’t write down every single point, because that’s where you get distracted. Give it a try….

Anything could happen in the next 24 hours, but one way or another, by this time tomorrow I will have walked out of the viva hall and be on my way to the pub for a stiff drink (although the College warn you not to be too liberal with your “social refreshment”, as the signing of the register of Fellows is a very solemn occasion etc….
Fair enough if you think you’re going to pass!

Anyway, my last tip before the exam (and more will follow, whatever the outcome) is practicing what is known as “The 60-Second Elevator Pitch”. Actually a “sales” technique for “pitching” your idea to e.g. Donald Trump or Richard Branson to get them to give you hard cash for a business when your only chance to persuade them is jumping into the lift with them on the way down from their office in whatever tall building they work in, I think it can be adapted to delivering your spiel in a viva, or at least practicing a way of being succinct in a viva.

Imagine you have one chance and one chance only to impress someone with your knowledge on a single subject. Your entire pass/fail rests on this one chance. And you only have 60 seconds. There are clearly a number of factors which will influence your passing or not as well as your knowledge.

1. Make sure you speak for 60 seconds. No longer, as that’s over time and will lose you marks, and no shorter, because even 1 second is long enough for 2-3 extra words.
2. Be confident. You want to pass. So pitch to pass.
3. Be calm and speak at the right pace. Too fast and words become garbled, too slow and you can’t get enough information in, and you won’t come across as knowledgeable or confident.
4. Breathe! You can’t (realistically) speak under pressure for one minute without running out of breath before the end.
5. Choose your words. Even if you have to take 5 seconds before you speak, choose the right words. Remember the Five Word Viva Game? It pokes its head in here as well.
6. Use intonation to emphasize, rather than raising your voice or strong gesturing. Gesturing is important, but it might be useful to practice in front of a mirror or using a camcorder (or webcam, this being 2008), just to see exactly what your body language is like. Don’t play with pens, it’s distracting….
7. Dress right. Wear a suit, don’t deceive yourself into thinking that you might be able to wear anything more casual; you are supposed to be a professional.

I wish anyone who has a viva this week the very best of luck.