Primary FRCA SOE October 2008 - MEDICAL EDUCATION at ...

University Hospitals Coventry & Warwickshire NHS trustPrimary FRCA exam October 2008SOE 11) pharm tell me about isoflurane and sevoflurane and the factor that affect the speed ofuptake with in the alveolus to do with FA/FI build up, cardiac output, ventilation, blood gassolubility, airway irritant tell me about heparin, uses, differences between lmw and ufh. tellme about ionisation of drugs with respect to kidney excretion tell me about esterases, whatesterases do your know, where are drugs metabolised in the body, and give examples of eachwhat can affect the esterases2) physiology tell me the alveolar gas equation, why is it important? what happens ataltitude? what is the RQ about tell me about what affects the ion concentration differencesacross cell membranes give numbers for the concs of Na and K what about magnesium? whatis it? what does it do? wanted me to say antagonist for calcium. draw me the valsalvatechnique, what is it, with respect to bp and heart rate. what happens in autonomicdysfunction. what about cardiac failure3) physics tell me how you classify ventilators. had to go into detail about. Nuffield andManley. what is a vacuum? how do we use it in medicine. how do you measure pressure5) clinical 78yr old with elective hernia repair, pacemaker 6 yrs ago, smoker or twenty years,weight 51kg. what are the mains concerns about anaesthetising this gentleman, asked aboutpacemakers in detail. what techniques could you employ? what would happen if the surgeongave to much a toxic dose of local anaesthetic .. what would you do. intralipid, and doses.Set 2osceresus: trach came out plus CICV drillVT arrest in ED with people not doing chest compressions properly, shockPEA talk through with ECG and what drugs if bradyhistory: old lady for cataract with typme 2 DMpartial thyroidectomy for follow on history taking, with questions re what anticipatedprobs and comps of surgComm: emergency AAAExam: lady for ga/epidural for C section: looked at back, cvs/rs and airwayothers:diathermyput in and epiduralvery old machine checkentonox cylinder and valveinterosseous access in baby n resus fluidsspinal anatomycoronary arteries with angiogramlat C-spine in RAExtradural haematoma n ED management on CT scan1

University Hospitals Coventry & Warwickshire NHS trustthere was one more but ive forgotten at the mo!viva:physio: cardiac cycle, RAAS, starling forces, sodium balancepharm: local anaesthetics, antimuscarinics, g prot receptorsclinicsl: 22 year old girl right iliac fossa pain, tach and hypotensive: cause, management,hypovaolaemia crit incident, jehova witnessphysics; temperature control, vapourisers:des and iso, electric potentials: EEg, ECG, EMG,amplifiersSet 3I had my OSCE on 6th and the stations were.1.Entonox cylinder and standered questions on pressure use and supply etc,2.Intraosseous infusion ,technique and complications.3.Defbrillator and uses.4.Diathermy and diff unipolar and biploar5.CPR adult PEA post cholecystectomy collapsed.6.History taking from 80 yrs old for cataract surgery7.History taking from hyperthyroid pt and8.Followon station9.Sim man Trachestomy tube fallen out and to manage airway.10.Epidural uses and calculations off doses toxic dose.11.Examination of pregnant lady with grade MP-4 and also having Scoliosis.12.Radiographs off subdural heatoma.13.Radiograph C spine14.Coronary Angigram amd questions where are what and what supply and same15.Pain pathway and CSF pressure and volume.16.17.18.Viva sPhysiologythey asked me about Ventricular presssure curve and cardiac cycle and superimposition ofAortic curve and LAP curve.Kidney and starlings equation and diff in glomerular bed and pulmonary bed.pharmocologyReceptors diff kinds and then g proteins in detaillocal anaesthetics in detailhenderson hasselbach equation,cholinergic drugsuses of anticholinergic drugsclinical22 yrs old girl sudden onset on RIF pain and bp 95/45 mmhg and 120/min hrmanagement and going to massive bloodloss and correction .intraop loss and hypotension.physicstemp measurement biological potentialvaporisers bi spectral index2

University Hospitals Coventry & Warwickshire NHS trustSet 4PhysicsDead space – how to measureAnatomical – Fowler’s methodPhysiological – Bohr equation and derivation ofDisinfection, Decontamination, Sterilisation.Definitions of eachTimes and temperatures of Pasteurization and Autoclaving.Picture of two LMA’s – which one would you use (the one with stripes on indicatingit was sterile)Blood warmersTypes and differences betweenHow would you design a blood warmer – large surface area and low flow to maximiseheat exchange. Thermistor to regulate tempHagen Pouiseille equation for flowPhysiologyCerebral blood flowMonro-Kellie doctrineGraphs of CBF changes with MAP, PaCO2, PaO2Myogenic and vasoactive theories of autoregulationCardiac cycleDiagram of left ventricular pressure wave. Asked to draw on aortic waveform, rightventricular pressure waveform, ECG and CVP waveform.Left ventricular flow volume loop explanations of and how to derive cardiac workfrom it. How loop changes in heart failureEnzymesDefinition ofExamples of enzymes – intracellular and extracellular. I used carbonic anhydrase,tyrosine kinase and pancreatic enzymesMichaelis-Menten kineticsPharmacologyWhat factors affect speed of onset of anaesthesiaBlood:gas coefficientsOther factors – alveolar ventilation, cardiac output, second gas effect, FiAA.Why speed of onset quicker in children specificallyDoes size of molecule affect speed of onset – wanted to talk about XenonLog dose response curvesFull agonist, agonist with lower potency, partial agonist, agonist with competitive andnon-competitive antagonists (and examples of)Definition of an inverse agonistACE inhibitorsMechanism of actionUsesSide effectsOther drugs that can be used in heart failure and their mechanisms of action3

University Hospitals Coventry & Warwickshire NHS trustClinical60 year old lady scheduled for emergency retinal detachment repair. Asthmatic on inhaledsteroidsDiscussed Regional vs GAAvoidance of drugs which cause bronchospasmPONV prophylaxisOther considerations in eye surgery – avoid raised IOP, oculocardiac reflex.Critical Incident - Failure to breatheMentioned relaxants and reversal, opioids and reversal, bronchospasm, hypercarbiaOSCE1. Resus – Sim man anaesthetised patient SV with LMA – rhythm change. Monitorshowed AF with BP 75/30. Cardioversion and what else to do if cardioversion didn’twork after 3 shocks (amiodarone and shock again)2. CVP – USS pictures of IJV and carotid. Asked what type of transducer used???Which side of neck looking at. How to make sure line in correct place and what iscorrect tip placement. CVP waveform waves and descents3. Resus – Just talk with examiner. Pt collapsed on ward, nursing staff doing CPR.Wanted you to confirm cardiac arrest first. Rhythm strip asystole – how would youmake sure it was true reading (check leads and gain). Management of asystolic arrestwith reversible causes4. History – 25 year old Nigerian woman for hysteroscopy. Been unwell as child andstayed in hospital, had murmur, not as tall as other siblings (not sure if they weregetting at rheumatic fever?). Dry cough for 18 months, had recent chest x-ray in clinic5. Sim man – 16 year old elective spinal surgery still in anaesthetic room. Colleagueasking for help. MH with low SpO2, hypertension, tachycardia, high PaCO2, raisedtemp. (Only thing I forgot was to change anaesthetic machine!!)6. CXR – pulmonary venogram from patient hypotensive and tachycardic. Post op NOF#. Questions on management of PE.7. Airway management. – demonstrate correct position for bag mask ventilation ofanaesthetised patient. Differences in children. Nasopharyngeal airway – complicationsand contraindications8. Anatomy – Antecubital fossa and wrist. Relations of radial nerve, brachial artery anddirection it takes down the arm before branching. Relations of median nerve at wrist.Where would you block the ulnar nerve at the elbow9. History follow on – 60 year old man scheduled for left hemicolectomy. Extensivecardiac history including MI 2 weeks ago as a result of bleeding. Lots of info to get inshort space of time – I ran out of time!10. CXR – 75year old lady with pansystolic murmur at apex c/o increasingbreathlessness. (mitral regurg)11. Equipment – epidural set. Given epidural packet with hole in top and out of date andasked if would use (No!). How to check catheter and filter. Size of filter and uses.Complications12. Temperature measurement – shown picture of thermistor. Principles of thermistor.Heat loss under anaesthesia. How to minimise loss through radiation (4 ways – Icould only think of 3)4

University Hospitals Coventry & Warwickshire NHS trust13. Axillary nerve block – show on actor positioning for nerve block. How would youperform? Dermatomes in arm. Nerves not blocked in axillary nerve block and whatproblems may it cause. (tourniquet pain)14. Anatomy – autonomic nervous system. Nerve roots, ganglions and receptors.15. Communication – 55 year old woman for TAH – discuss method of postoperativeanalgesia – epidural vs PCA. Very worried about nausea and vomiting16. Examination – Examination of airway in man with limited neck extension. Lateral Cspine x-ray and questions on atlanto-occiptal and atlanto-axial distances17. Laser – Definition of. Laser resistant tubes. Patient safety and personnel safety. Howlaser works. Different types of lasers (CO2, Nd-YAG, Argon)Set 6OSCE/SOE 7 th October 2008VivasPhysiology/ Pharmacology1. Local anaesthetics- classify , draw linkage structure-differences between them-what affects lipid solubility, how does this affect potency-things affecting speed of onset & duration of action-compare lignocaine and bupivacaine for the above, wanted figures2. Antacid drugs-Name different classes of drugs-Went into detail about PPIs, named examples, wanted doses-Talked about physiology of acid secretion-Why are there no anti gastrin drugs?3. Interindividual variation for drug metabolism-Different reasons overall first- age, sex, genetics, organ failure-details about genetics eg: cytochrome P450, sux apnoea4. Control of respiration-Effectors, controller, receptors-discussed different receptors5. Vomiting-reason for vomiting-process of vomiting-difference between vomiting vs regurgitation-Vomiting centre, receptors there, CTZ – what’s different about this part of the brain,receptors there, drugs that could act there, role of vestibular apparatus6. Catecholamines-Adrenaline vs noradrenaline, draw response on sats probe tracing to HR and BPClinical/ Physics5

University Hospitals Coventry & Warwickshire NHS trust60 yr old for emergency retinal detachment surgery, known asthmatic for years. Onbronchodilators- preassessment: what questions for asthma-how would you anaesthetize her, what to avoid-in recovery develops resp depression, what would you do? Asked about cause of respdepression specific to retinal detachment surgery.Physics1. Dead space-definitions, explain Fowler’s method for anatomical, derive Bohr equation2. Fluid warmers- why need to warm fluid- ideal characteristics of fluid warmer- shown photos of different kinds eg: coaxial, water immersion, hot plate warmer- differences between them, narrow bore vs wide bore (leading to questions abt flow)3. Cleaning, disinfection, sterlisation-definitions, methods and markers used to tell if sterlisation completeOSCE1. Collapse on ward with asystole,-no sim man, shown asystole ECG rhythm, asked what you would do2. History taking-young lady for hysteroscopy for painful periods, recently migrated from Zimbabwe, drycough for months3. Simman 1-MH, tachy + high EtCO24. Radiology 1-pulm venogram5. Follow on history taking-70 yr old for left hemi, severe PR bleed causing MI previously, on warfarin for AF, OA ofknees taking brufen,6. Ditto7. Radiology 2-CXR cardiomegaly8. Equipment-Epidurals shown set, talk about what would do if could not thread catheter9. Equipment6

University Hospitals Coventry & Warwickshire NHS trust-Temperature measurement, shown thermistor, asked to choose graph of resistance over timefrom selection10. Anatomy 1-ACF anatomy, wrist anatomy, perform median n and ulnar nn block at wrist, radial arterycannulation, Allen’s test (on actor)11. Anatomy 2- Brachial plexus, perform axillary block (on actor)12. Simman 2- cardiovert from fast AF12. Anatomy 3-anatomy of ANS13. Communication-explain post op analgesia options, esp epidurals vs PCA14. Skills-CVP line insertion using ultrasound, what does the transducer contain-shown images using sonosite, which side of neck is it from-how would u confirm placement-CVP waveform15. Examination-airway assessment-limited neck flexion-shown c-spine lateral, identify atlanto axial and atlanto occipital gaps16. Equipment 3-Lasers – what is it, what is it used for-safety for lasers-shown laser resistant tubes, what are its features, why double cuffSet 7OSCE 8/10/20081- Epidural Anatomy & demonstration of technique on a manikin- Straight forward questions- Demonstration on the manikin- How much lignocaine in 20 mls of 2%- How much adrenaline u need to add to the 20 mls to make it 1:200,0002- Cardiac anatomy- Layers- Pressure in RA & RV- Where are the SA & AV nodes- Blood supply of SA node7

University Hospitals Coventry & Warwickshire NHS trust- Origin of Rt & Lt coronary arteries- Venous drainage of the heart- Chordae tendinae (what is it made of & function)- What is the sinus of valsalva- Coronary angio (to identify one of the coronary arteries)3 – Follow on History station (no examiner)- 36 female for subtotal thyroidectomy- Thyrotoxic with weight loss, increased appetite, exophthalmos, irregular heartbeats, swollen gland- No hoarsness of voice, no swallowing or breathing difficulties- Carbimazole & Propranolol- TFTs not checked for 4 months- No other medical history- Smoker, 2 glasses of wine/day- Allergic to septrim (rash)- Also to eggs & shellfish4- Questions on the previous history- Presenting symptoms- Radiography to request- Medications- Mechanism of action of carbimazole- Name given to thyrotoxicosis with exophthalmos- Any other medical problems- Allergies- Smoking?- How many units of Alcohol?- Complications of thyroidectomy5- X-ray C-spine for a patient with long standing Rheumatoid arthritis6- Anaesthetic machine check- Was terrible, cubicle is dark, machine that I haven’t seen before.- Examiner is not happy- No pipelines- Anyway, went through usual routine check but wasn’t very smooth- Couldn’t find where is the power switch to start with- Oxygen & Nitrous cylinders were full- Blanking plug was available- Flowmeters working- Hypoxic guard working- Vaporiser is empty- Oxygen analyser wasn’t connected- I turned off the O2 cylinder to try to activate the O2 failure alarm, but it didn’twork, even though I heard it working few times.- I believe all candidate were not happy with that station7 – Picture of Entonox cylinder- Identify- What is the content- Pressure8

University Hospitals Coventry & Warwickshire NHS trust- Examiner told me the definition of the pseudocritical temp. & asked for theword itself.- What’s the pseudocritical temp. of the mixture (Numerical Value)- Definition of critical temp.- Asked about the name of the 2 nd stage valve- How is the patient affected if the mixture is cooled below the pseudocriticaltemp.- Who else can give entonox apart from medical profession8 – Diathermy- Showed me a neutral plate to identify it- Showed me a smaller one & asked if we can you use it on an adult & why not.- I had to explain about current density- Showed 2 diagrams of different circuits & asked which will be safer to use &why? (One with a floating circuit)- Another picture of a patient touching a drip stand. Asked me about the risks &why?- Why AC & not DC- What current is used- Pictures of mono & bi polar & what is the difference9 – Cross section of a spinal cord- What are the contents of the grey matter- What’s the dorsal root ganglion- Pain pathway starting from dorsal horn cell to the sensory cortex- Identify the lat spinothalamic tract on the diagram- What’s transmitted through the anterior spinothalamic tract- Asked me about the post. Column- Asked to identify another tract, I wasn’t sure if it is ascending or descending, Iwent for spinocerebellar tract10 – Communication skills: 82 male taken to the theatre for emergency AAA. U are asked tomeet his daughter & explain about the implications of that surgery.11 – Examination + History + investigations u need to assess a pregnant lady for either spinalor GA LSCS (didn’t say emergency or elective)- It was a bit random, and disorganised- I asked if it was her first pregnancy- I did a quick general examination- Asked for BP which was 140/105- Checked for ankle oedema (Told me ankles are swollen (forgot to check forsacral oedema)- Asked about few other symptoms of pre-eclampsia- Asked about the foetus- Asked about back problems (didn’t actually examined the back, but mentionedI would)- Asked for FBC, platelets were 82- No protein in the urine9

University Hospitals Coventry & Warwickshire NHS trust- LFTs were normal- Assessed the airway- I wasn’t sure what else should I do or ask for12- PEA post cholecystectomy on the ward- No manikins or patients, just a chat with the examiner- Had to diagnose PEA (ECG sinus rhythm, but pt. has no pulse)- What would u do- Went through ALS Algorithm- Had to mention all the reversible causes- What do u think is the most possible cause- CO is back, what would u do now?- Was straight forward13 – Defibrillation station- CPR in progress on a manikin (one ventilating the pt, another doing chestcompression + resuscitation officer for the defib + the examiner)- LMA insitu- Monitor showing VF (Asked me to identify it)- Asked me what do u think about the CPR (compressions were slow & notproperly on the sternum)- What would u do now (I said connect the defib & shock the pt.)- They attached the leads for me and asked why we place them like that i.e.across the heart.- Then I had to switch on the defib & shock the pt. myself- I made sure no one is touching the table; I left the oxygen as it was connectedto the LMA, which was in place.- Then asked what next- When would u reassess, how often u give adrenaline- Finally he’s back to sinus rhythm with a cardiac output.14 – History taking from an elderly pt. coming for a cataract operation15- Fast bleeped by the ITU nurses. Pt deeply sedated on a tracheostomy. Trache tube fell offwhilst transferring him. Pt. known difficult to intubate- I went in, the nurse was panicking- Monitors on SPO2 dropping- Called for help- Other parameters were Ok, but I didn’t comment- Trolley with an laryngoscope, ETT, Guedal, Tracheostomy tube and LMA- Tried to bag & mask him while the nurse was occluding the hole, no luck- Tried to pass another another trache tube, false track- I thought to see if I can intubate, laryngoscope hasn’t got light (I think it wassilly for me to try this anyway knowing that he’s difficult to intubate)- Inserted a Guedal airway & went for 2 hands technique, whilst occluding thehole, started to get some air entry- Inserted LMA, ventilation was much better & they stopped me there.10

University Hospitals Coventry & Warwickshire NHS trust- Asked me how else can u sort out his airway. I said we could do anothercricothyroidotomy.- I am not sure why I didn’t go for the LMA from the start.16 – CT head with an extradural hge- Straight forward questions17- Checking an invasive arterial BP monitoring- 18 G venflon- Long compliant tubing- Air bubbles- 5% glucose- Not pressurised- Asked what is the effect of each of these faults- How to zero the transducer- How to calibrate it to higher pressure- Showed me a picture of over damped arterial wave form & asked how wouldit affect the readings18 – Intraosseous injection- Demonstration on the manikin- Indications- 2 sites for insertion- 3 Complications- How would u give fluid through this route- How to estimate the weight of a child- How much fluid bolus- Maintenance fluid in a 10 Kg childSOE 8/10/2008Clinical ScenarioMiddle aged female with long standing crohn’s disease coming for pan-proctocolectomy.Recent abdominal pain, diarrhea and pyrexia. She is on Prednisolone 7.5 mg as well asSulphasalazine & Azathioprine.- What are ur concerns about this lady.- Patho-physiology of crohn’s- Is it familial?- Relevant problems (I mentioned about obstruction, perforation, electrolytedisturbance, sepsis, side effects of drugs)- Asked about side effects of steroids i.e. didn’t ask about Sulpha orAzathioprine, Thank God.- Then asked how would u anaesthetise her?- What monitoring (I said the basic staff + A-line + Urinary catheter), forgot tomention the temp.11

University Hospitals Coventry & Warwickshire NHS trustPhysics:1 – Defibrillator- What position she would be in during surgery.- What are the causes of postop oliguria (Pre-renal, renal & postrenal)- What’s olguria- What drugs we give that can affect the renal function- The nurse called you because the epidural is not working. What would u do?- Large volume low conc. Vs small volume high conc. Bupivacaine- What is a capacitor, how does it work?- What factors influence the capacitance?- Difference between AC & DC- Definition of Coulomb- Asked to draw the defib. Circuit.- Showed me graphs of the current flowing in the circuit versus time2- LASER- Safety measures- Components of laser- How does it work- Types of Laser- Indications3 – Supraglottic devices- Different types of LMAs- Sizes & weight range for each size- Advantages- Disadvantages- What airway devices u can use for difficult intubation (Bell rang)Physiology1- Blood Gases: PH 7.1 , Pco2 12 , Po2 15.5- What’s wrong with these gases- What’s the normal range for each- Why is the Po2 high- What’s the H ion conc. at that PH- What are the compensatory mechanisms?- How is that pt. clinically?2- Autonomic nervous system- Compare between symp. & parasymp.- I started with anatomical differences- Asked to compare receptors & neurotransmitters- Then effects on different systems- Mainly CVS & GIT12

University Hospitals Coventry & Warwickshire NHS trust3- Total Body Fluid- Started with distribution of TBF- Electrolytes- Movement of electrolytes- Osmotic effect- What happens if we transfuse 2 L of Normal Saline- Had to mention also about barorecptors, atrial receptors & ANPPharmacology1- IV Anaesthetic agents- Different classes- What is the difference between different barbiturates- Mechanism of action of Thiopentone- Had to explain about GABA receptors- Mechanism of action of Ketamine- Had to explain about NMDA receptors- Why do anaesthetist prefer propofol over Thiopentone2 – Pharmacokinetics- Plasma conc. vs time curve after IV injection- Equation- Had to explain about exponential function- Logarithmic scale- 1 st & zero order kinetics- ½ life & time constant3 – ColloidsSet 8SOE 1:PHYSIOLOGY- Different types- Molecular weight- Mechanism of action- Which one stays long in the IV compartment, starch or Gelatin? & Why?- Side effects- How do they interfere with coagulation?1) Compliance,13

University Hospitals Coventry & Warwickshire NHS trust· define, types, static vs dynamic, Which pressure increases, definitions of all thepressures involved eg transpulmonary, intrapleural,· compliance curve, draw, what will happen in restrictive and obstructive diseases tothis crve.· Work of breathing, why is expiratory work less, why hysteresis.2)Adrenal Gland,· anatomical layers and· secretions layers wise· control of all those hormones by drawing the axis and explaining along with that.3)Body water distribution….· Normal distribution in detail with percentages and volumes· difference in neonate,· 1 L of water orally, ...physiological effects· 1L of Normal Saline intravenously, effects.Wanted to hear what eill happen to ADH and baroreceptors in each case.PHARMACOLOGY:1)Non depolarizinfg Musclerelaxants,· Classify,· What effects the onset of action of Non depolarizing Muscle relaxants.· What effects the offset of action of Non deporalizing Muscle relaxants.· Can you name some other drugs which can act as a mucle relaxant.2)Routes of drug administration,· Name all the roués f drug administration you are aware of· What is the purpose of all these routes,· Factors effecting Oral Route,Bioavailability definition,Curve.3)Drugs sed in Asthma,14

University Hospitals Coventry & Warwickshire NHS trust· Classify.· How does Salbutamol Work.(wanted all the Gs protien mechanism)· Tell me about the side effects of Phosphodiestrase inhibitors.SOE 2:Clinical:Scdenario: an 18 year old fell off the bike,presenting with a rigid abdomen, how will youproceed.1) Surgeons want to take him to theatre immediately, how will you assess his blood loss.· All THE CLINICAL PARAMETERS, WHAT WILL HAPEN TO THEM IF HEHAS LOST 20 % of his circulating volume.· How will you manage this case Anaesthetically.· Go through the steps of Rapid Sequence Induction.· How will you resuscitate him.· How will you improve his oxygen carrying ability?Blood transfusion· Defin Massive Blod Tranfusion· what are the complications associated with massive blod transfusion.· Enumerate each, asked more about infective complications.Critical incident: ABO incompatibilty reaction, what will you do,How do you perform the checks when tranfusing blood to some one.Postoperative management of this case.Pain Relief Options for this case.PHYSICS:1)ELECTRICITY15

University Hospitals Coventry & Warwickshire NHS trust· All the electrical symbols(i.e all cmmon one which we see in books).· Few definitions: resistance, Ohms law with equations,.... Relate through an equationrelation between power, resistance and current.· Define Capacitence, capacitor.ive an example of device whih uses capacitor.· What does Diode do.(was not satisfied with my definition that converts AC into DCcurrent)· Define AC and DC current.· Draw and AC waveform, and superimpose on it a DC wave form.2)LOW Flow Anaesthesia:· define,· what are the advantages,· what are the disadvantages.· Components of a Circle System.3)Questions related to heat:· Define boiling point,· define freezing point.· Q: a graph was shown in which ice was melting into water and then boiling intovapour, at the state of change of phase temprature was remaining constant, wanted meto explain the definitions of Latent heat of vaporization and fusion at this stage.· Define triple point of water.· Shown 3 graphs of N2O cylinder emptying, one in which pressure remainingcostant, another in which pressure dropping with time....didnt get tho this thirt one...asbell rang.OSCE:1)History: 33 year female, for varicose vein surgery, has got asthma.2)SIMMAN: cant intubate cant ventilate scenario in a RSI.3)Radiology: enlarged heart and Q related to that16

University Hospitals Coventry & Warwickshire NHS trust4)Radiology Lateral Chest Xray showing hiatus herna, and questins related to that5)ANATOMY: Rib, and first rib, questions on chest drain, insertin site, demonstratehow will you do needle decompression in a tension oneumothorax.6)ANATOMY: Orbit, Structures passing through supra and infra orp fissure, and opticcanal., and cribriform plate, Facial Fracturesclasification(three tyes).Direction of needle in a peribulbar eye block.Complications of eye block.7)Machine Check8)PH electrode and every thing about that ( labelling of everything on the diagram withquestions related to that)9)Skills: Epidural insertion10)History11)History Follow on : Young Patient who had Porphyria. In History follow on most ofthe station consisted of proper viva type questions with all the aspects of porphyria.very little was asked specifically related to the history of patient.12)Resuscitation: young lady with a PEA Arrrest folloing ruptured ectopic pregnancy.13) Resuscitation: Tachycardia, unstable, stable…almost 90 % of the algorithm wasasked.14) Pulsoximeter: various questions and graphs related to that(seemed quite straightforward)15) Needle stick injury , all the questions related to that egwhat will you do following a needle stick inj,who will you report at what time,what will you do with the patient,what will happen to your bloods,sero conversion,incidence of HIV after needlestick injury from a high risk patient.What is the difference in incidence if you get a prophylaxisDrugs used for prophylaxis16) Communication: Patient postponed for surgery.17) Airway management: various views of laryngoscopy on cards. Various capnographytraces. Laryngoscopes, various blades and indications.17

University Hospitals Coventry & Warwickshire NHS trust18) JVP measurement:actual method,demonstare hepato jugular reflex.What heppnes at a wave, and v wave.Conditions with increased JVPConditions with large a waves, Large v W#SET 9Clinical - 60 yr old lady for emergency retinal detachment surgery. PMH asthma onsalbutamol and steroids. Viva went on assessment of asthma on history, then investigationsand anaesthetic management and effects of steroids. Fisnished in 10 min. So he asked aboutPONV. Causes and management.Physics - Measurement of Dead space. Specifically asked about how do we measure volumeon the graph of N2 conc versus volume graph and to mark exact percentage of N2 on Y axis.Next he showed 2 LMA in a bag and asked which on I was happy to use. One had thestripedautoclave indicator strip. Then the Viva went on decontamination, disinfectants, sterilisationasked about percentages of chlorhexidine and about pasteaurisation.Third question was on blood warmers and what properties would you like the giving set tohave.Pharma - local anaesthetics - about differences of amides and esters, mechanism of action,toxicity of bupivacaine and lignocaine. factors causing variability in drug response.physiological and genetics their effects on pharmacokinetics from there. about sux apnea. lastquestion was antacids. types and mechanism of action.Physio - control of breathing straight forward. showed the box concept of receptors,modulators and effectors.adrenergic receptors. all about them. and last was nausea and vomitting. again asked to drawthe box concept.OSCE - X-ray of pulmonary angiogram -Xray 2 was LVH I think anyways.History follow on for lt hemicolectomy and was on warfarin.history 2 was Afrocarribean for TAH. Came to his country 5 yrs back and hadrheumatic fever in childhood. and no sickle cell trait.Equipment was temp monitor and Epidural set.Anatomy of Arm. mainly ACF and wrist and al the blocks.Examination of Airway.Technical skills Management of airway.Sim man - MH and New onset AF.resus station ALS rpotocol.surface anatomy of axillary block.CVP line, waves and last question was 4 clinical ways of knowing that tip is in thecorrect position. I said about Xray, CT. but He said clinical. Don't know what he expected.cant remember the last two stations.18

University Hospitals Coventry & Warwickshire NHS trustSet 10Primary FRCA 8 th Oct 2008 VivasClinical27-year-old man has an eye injury following a fight outside a nightclub, questions aboutmanagement, assessment, etcAnaphylaxis on inductionDusky colour, decreased sats in recovery - how would you deal with if you hadn'tanaesthetised the patient, failure to breathe, inadequate reversal, etcPhysicsBlood pressure management on a ward - Oscillotonometer, DINAMAPColligative properties, osmotic pressure, osmolarity, osmolality, why we measureCylinders - testing, nitrous oxide cylinder picture (incl PIN index), pressure curve fornitrous oxide cylinderPhysiologyLV pressure/volume, Starling's lawBlood - constituents, types of WBC, structure of RBC, functionsCentral chemoreceptors, alveolar gas, Arterial pO2 if you go up a mountainPharmacologyWhat is MAC, why is it useful, what does it do, Meyer overtonTell me about diazepam and it's metabolism. Where in body are drugs metabolised?wasn't satisfied with liver, kidney, plasma?? Cyp450, isoenzymesHeparin - everything, LMW vs unfractionated. Then onto when do you give heparin intheatre, etc, DVT etc.OSCE1 Communication - PDPH headache in pregnant lady2 Clinical: Examination - Arterial pulses, praecordium and heart sounds, with a fewquestions3 Clinical: Cricoid - demonstrate on model, discuss how you would tell ODP to do it,amount of pressure to use, when to apply, when not to.4 Anatomy: Brachial plexus questions5 Clinical: pictures of different positions (arm extended, neck extended,trendellenberg), picture of brachial plexus, pick the nerve that would be damaged witheach.6 Resus - Cardioversion of Pulsed VT7 Equipment - Vapourisers: rubbish drawing of Plenum vapouriser, talking about SVP,in/out of circle, concentrations, if you go up a mountain, etc, advantages/disadvantagesover Boyle's bottle, etc8 Resus - just an ECG rhythm strip of sinus brady then talk through9 History taking -man for TURP10 Sim-man: aspirated in theatre, called by ITU F1 because decreased sats - tube was intoo far11 Radiology - CXR - questions12 History - young man for CT head under GA (claustrophobia) - asthmatic13 Recounting history - they ask questions: what is he having CT head for, what sx, whyGA, asthma, GA hx, drugs allergies, Peak flow that day, etc19

University Hospitals Coventry & Warwickshire NHS trust14 Foetal circulation: name parts on bad diagram, then answer questions, incl adultremnant of Ductus arteriosus15 Clinical - assess airway of actress, then questions incl photo of a tongue to giveMalampatti to, c-spine x-ray to look at and comment on16 Radiology - CXR with pacemaker and questions17 Equipment - Magills, laryngoscope blades plastic vs metal, curved vs straight18 Equipment - line diagrams of Clark electrode, fuel cell and paramagnetic O2 analyserthen questionsSet 11Pharmacology/ PhysiologyFent & AlfentWhen would you use each of them?What factors determine their onset of action and elimination ie pKa; protein binding; lipidsolubility.What is the link between pKa & degree if ionisation.Could you define volume of distribution.What factors determine it?Could you define Context sensitive half time.Could you draw me a graph indicating how the half lives of fent; alfent and Remi vary withthe duration of infusion.Could you me about the renal elimination of drugs.I divided this into filtration and secretion.What factor determine whether a drug is filtered or secreted. ie MW, protein binding, chargeand lipid solubility.Could you classify Anti – convultants.Tell me about GabapentinUses; Mechanism of action; Doses!!Phenytoin- Tell me about its elimination kinetics.PhysiologyGiven a set of gases showingPh of 7.3 and Pa CO2 OF 4.0Asked to explain the possible causes of this. What would you expect the HCO3 results toshow in an acute situation.What factors determine alveolar ventilation.Could you draw me a graph showing the link between alveolar Pa CO2 and minuteventilation.What is the blood flow to the kidney/min.What is the GRF/min and URINE output/min.What factor determine Renal perfusion.How does the kidney auto- regulate its perfusion.ie Myogenic and Neural control.Asked to draw juxta-glomerular apparatus and explain physiological role of macula densa.20

University Hospitals Coventry & Warwickshire NHS trustSet12Clinical Scenario75y Male.Known COPDDue for Urgent HaemorrhoidectomyNo other notes or info availableHow would you manage himPre – op assessmentHow would you assess severity of COPDBed side tests.Other IxWhat would you expect his gases to show.Talked about possibility of Regional / GA anaesthesiaWhat potential complications could arise in a COPD pt with invasive ventilationIn Recovery area post extubation the patient goes into larygospasm.How would you manage this.How you manage pain relief in a patient.How do you assess pain relief in a patient.What different methods providing op analgesia are you aware of. Tell me about the risks/benefits of each.PhysicsDefine SVP.What factors determine it?Could you draw me a graph showing the correlation between SVP and temp.What is the SVP of SEVO, ISO & DESShown a TEC 5 vaporiser. Asked to explain its mechanism of action.Talked about temp compensating mechanisms, wicks, splitting ratio and then specificfeatures of TEC5.Shown TEC 6 vaporiser. Asked why DES couldn’t be used in a TEC 5 vaporiser.Asked about specific features of TEC 6 ie differential pressure transducer and pressurereducing valve.Tell me about the ways of reducing theatre pollution.Briefly talked about regional anaesthesia; TIVA & circle system.Then asked about scavenging.Active and passiveAsked about Cardiff aldsorber.Features of active scavenging systems.Tell me about ultrasoundUses. How the waves are produced.Do you know the eqn for Doppler/ultrasound.21

University Hospitals Coventry & Warwickshire NHS trustWhat is the Doppler effect. How can we use this to determine CO.Could you tell me about trans- oesophageal echocardiography.-------------------------------------------------------------------------------------------------------OSCE.1.) SIM Man - M.H. scenario2.) Hx taking station from a young female due for a laparoscopy for lower abdominal pain.She had an illness as a child which left her with a heart murmur. She recently emigratedfrom Africa. She c/o increasing SOB on exertion over the past two months.3.) Shown uss image of RIJ. Asked about CVP waveform and CVP cannulation.4.) Resus scenario – AF with fast Vent response requiring electrical cardioversion.5.) Airway station – asked to assess airway of a man in pre-op scenario. Then asked toreview his lateral c-spine6.) Shown ETT used in LASER surgery. Key features ie double cuff filled with salineand metalAsked about uses of laser therapy. Briefly about mechanism of laser generation.Safety precautions during use for both patients and operating staff.Shown a clear set of goggles and asked if they would provide protection against co2 lasertherapy.7.)Anatomy Station. Para & Symp nervous system. Receptors, neurotransmitters and nerveroots.8.) Axillary Nerve block. Technique.Then shown a picture of arm and asked to point out certain dermatome levels.9.) Temp. Asked about nasopharngeal temp probe. Principle behind it.Asked for definition of CORE body temp; Triple point of water; Kelvin andscale. Heat loss in surgery and methods of preventing it.celcius10.) Epidural station. Risks. Check equipment and explain purpose of each.11.) X-Ray showing cardiomegaly.12 & 13.) Hx and presentation of a case.55yr Male due for hemi-colectomy. MI 5 YRS ago. AF. Failed DC cardioversion.Further MI 6 weeks ago.IHD. OA both knees.On Warfarin.14.) Anatomy of antecubital fossa – nightmare station. Location of biceps tendon, ulna nerve.Allens test and details. Names of muscles around ulna nerve.22

University Hospitals Coventry & Warwickshire NHS trust15.) Airway management station. Shown a dummy. Asked how I would optimise the airwayfor facemask ventilation. Airway optimisation for a child.Shown nasopharyngeal airway and asked about uses risk and C.I.16.) X-ray taken post contrast injection into the pulmonary vasculature in a patient with aP.E.Asked a few questions concerning management of P.E.Set 13October 2008OSCE1. Anatomy of the Rib and Relations of the first rib.Surface anatomy of trachea on chestHow perform intercostal block and complications2. Lateral CXR: Hx cough, SOB. Planned surgery of empyema.- I think it was collapse/ consolidation with a prominent breast shadow- questions related to management and whether fit for surgery3. Machine check - no blanking plug, no second oxygen cylinder, no battery in oxygenanalyser, leak in back bar4. ABG Electrodes - classic severinghaus electrode picture from Parbrook and then picture ofall three electrodes in ABG machine from Parbrook but altered slightly - bit confusing buteveryone found hard. Once worked out what it was, a fairly standard question5. Resus : Ectopic. Initial management, PEA arrest, definitive management of taking totheatre.6. Communication: Patient cancelled due to emergency - apologise etc.7. Needle Stick injury-- What to do in the event – who you contact- Risk of HIV-Name a drug used in PEP- by how much does PEP reduce your risk and who else would you contact - apparentlyanswer health and safety8. Epidural - anatomy and insertion9. Pulse Oximeter - straight from book10. CXR - globular heart in patient. Hx Rheumatic Fever11. History - Patient with Porphyria. You had to specifically ask about skin and liverproblems or the actor did not declare them. Even if asked how it affects him or what type ofPorphyria he has.23

University Hospitals Coventry & Warwickshire NHS trust12. History - Varicose vein surgery in an asthmatic13. Examination - JVP, describe JVP waveform and what happens, abnormalities etc14. SimMan - difficult intubation - cannot intubate, cannot ventilate scenario15. Discuss difficult intubation manoeuvres - blades, positioning etcShown different capnography traces - asked when would occurHow can you confirm oesophageal intubation? Clinically as well as CO2 etc related16. Skull - ethmoid, SOF and Orbital canalPeriorbital block and complicationsVIVA:PHYSIO/PHARM1. VolatilesDesflurane + Sevoflurane - What type of compounds + draw structureTalk about properties - blood/gas, oil/gas/ MAC/Metabolism and what they represent2. PharmoacokineticsConcentration-Time curve - exponential equationClearance/Volume of distribution + equation linking themHow can you use graph to calculate themTime constant/ Co/ Zero order and first order kinetics - what are and how graph represents+ examples of drugs3. Resus drugs - Adrenalin/Atropine/Amiodarone/MagnesiumHow adrenalin worksWhen do you use drugs in algorithmWhat is the evidence behind their use4. Starling Forces - Net filtration - how varies between blood/Pulmonary/Renal circulation5. Thyroid hormone - Synthesis, Receptor action. How thyroxine worksCalcitonin and mechanism of action6. V/Q Ratios - units/Shunt/dead space- Fowler Method- Bohr equationClinical/ Physics68 year old smoker, XS ETOH with Burns to chest, face and arms. Fallen in blaze.How would you assessUse of suxamethonium and burnsDifficult intubation incidentEffects of smoking and liver problems on anaesthesia24

University Hospitals Coventry & Warwickshire NHS trustPhysics1. Venturi and Coanda effectExamplesExtraction ratioGiven figures to calculate2. Humidity - why is it importantways of measuringShown picture of regnaults hygrometer - how does it workWays of humidifying - HME/Nebuliser/Water Bath + how workProblems associated with humidification3. Measurement of volatiles- IR --> how does it work/what interferes with measurement- How does mass spectrometry work- How does Raman scattering workSet14viva PhYSICS AND CLINICALS1. What is a capacitor , Define farad. Defibrillator Diagram Uses . How is the chargeincreased . What is the use of inductor ?2. Does Inductor allow AC/ DC current to pass through ? Why3. What is impedence ?,can a capacitor allow an AC current to pass through4.Laser definition, Uses Principles , Hazards . Prevention,5 Differnce between LMA and ETT what is the advantages in using LMA over ETT ? whatare the different type LMAClinicalsA 34 yr old female booked for an emergency panproctocolectomy for known crohns diseaseand is pyrexial and is having diarrohea . She is on treatment with prednisolone 7.5mg/day ,sulphasalazine, and methotrexte .What are the problems you encounter in this patientWhat type of anaesthesia do you chooseWhat other differnt organs that the disease affectwhat are the effect of steroids associated with the problemshow will resuscitate the patients intraoperativelyassuming the patient having and epidural and working in effectively , How do you managethe problemPost op managementViva -Physiolgy25

University Hospitals Coventry & Warwickshire NHS trust1. ph -7.1, po2 15.5 kpa, pco2 12kpa, What is the diagnosis ?Do you need any other parameters to diagnose ?Explain acid base balance in the bodyHow is the normal values of acid and base derived2. Explain the ANS ,Differnce between sympathetic and para sympathetic nervous system and its effects onvarious organs of the body3. If you infuse 2 l of Normal saline tell me about the physiolgy that affect . tell me aboutTBW, ECF and ICF volumesViva- Pharm1.Draw the structure of thipentone and explain how the substitution with various atom changethier characteristics?2. Tell me about propfol ,ketamine and etomidate3How is thipentone distributed in the body draw the exponential graph4.Draw the Plasma conc versus time for the thipentone what order kinetics does it followWhat are the differnt types of kinetics do you know , explain with example and graphExplain the first compartmental model, second and third compartment model, explain thecantenary and mamilary model and equation for the second and third compartmental model5.What type of colloid do use ?tell me about the gelatin, hetrastarch, dextran, osmolality, PH, Metaboilism and effect on thebodyWhat are the other means of carrying haemoglaobin explain?Set15I am pleased to inform you that I have passed the Primary FRCA exam successfully.The following are the set of questions /stations for the osce held on 9th october:Station 1: Rhythm strip of asystole ...Questions related to resuscitationStation 2: History taking 25 year old lady for laproscopy , day case surgery, had a heartmurmur, not had any tests done.Had sore throat in childhood and had stiff joints and nodulesthen.Station 3: Simulation station :Patient given propofol 200 mg i.v , followed by 8mgvecuronium and presently being ventilated with O2:N2O and sevofluraneHigh etco2 , Malignant hyperthermia.Station 4:xray : pulmonary embolism.Station 5:history taking & follow on 65 year old gentleman for right hemicolectomyfollowing bleeding p.r26

University Hospitals Coventry & Warwickshire NHS trustHe was on warfarin for atrial fibrillation, frusemide, digoxin , nsaids for arthritis .he had a MI1 MTH back & has had sync cardioversion for fast AF 5 YEARS back.They asked about family history -2 brothers died of MI, and pharmacological interactions.Station 6: Xray : Straight left heart border, 70 year old lady with chest pain & breathlessnessfor a hip replacement .she also has a murmur.Station 7:Epidural kit and questionsStation 8 : Temperature measurement , graphs shown.Station 9:Antecubital fossa ( anatomy ) on live patientStation 9:Axillary block ( anatomy & technique ) -live patientStation10:ANatomy -Sympathetic & parasympathetic nervous systemStation 11:AIRWAY examinationStation12: Laser tubes & safety questions,principle of laserStation 13: bag mask ventilation on manikinquestions related to airway managementStation 14:cvp trace & ultrasound questionsStation 15:Safe defibrillation for fast Atrial fibrillationSet 16OSCE: (tricky)1a History: Porphria / Allergy penicillin. For elective surgery Take history anddocument1b History: follow on – details about patient case / what is porphyria? / symptoms ofporphyria. What enzyme defects? Name anaesthetic drugs that are contraindicated.Can this man have co-amoxiclav3 Xray – lateral chest. ?fit for theatre. Smoker / wheeze /4 Anaesthetic machine check – check the machine only. No banking plug on CO2.Definite leak in system5 Blood gas analysis: two diagrams of pH and severinghaus electrode. Obscurequestioning. Label parts of machine. Name solutions.6 Discuss how you would place an epidural / what level for knee replacement/where isC7 on this actor/ where would you go in / talk through epidural kit /how long tuohyneedle / LOR to saline/ how much do you leave of catheter in epidural space /namelayers you would go through/ 3 complications of epidural7 ECG: SVT / unstable / adenosine sync shock what energies / use of amiodarone8 Discuss measurement of JVP clinically on patient/ what gives a and v wave?What gives a large a wave, large v wave, no a wave?27

University Hospitals Coventry & Warwickshire NHS trust9 Resus: Ruptured ectopic / PEA / only lma available / fluids / ALS / output returnedon giving lots of blood / where take – theatre then ITU10 Pulse oximetry / oxyhaemoglobin curve / discuss actual PaO2 numbers at differentsats / how does pulse oxeter work /what are wavelengths used / when is pulseoximetry inaccurate / what is the difference of pulse oximetry to lab oximeter11 Simman – CICV following RSI / needle cricothyroidotomy12 Xray – MVR globular heart / pul htn / need prophylactic ABX13 Eye – skull anatomy / contents of cribriform plate/superior orbital fissure/optic canal /how long optic nerve / innervation to eyeball / show how would do a peribulbar block14 History – counsel man whos op is cancelled due to emergency list15 History – take a history – woman elective ENT op / asthmatic / 1 st GA / mum hadPONV scared this will occur16 Difficult intubation discussion / who intubate and confirm intubation / discuss nervesupply to larynx / talk through difficult intubation techniques / what grade is thisphoto / grade 3/17 Needle stick injury and management18 Rib and 1 st rib muscle attachments-vessels-brachial plexus/chest clinical landmarks /apex beat / decompression of pneumothorax / chest drainVIVAS:SOE1: Pharm/Physio• Sevo and desflurane differences (what group/halogenated ethers/drewstructures/svp/og/bg/mac)• Blood gas coefficient /draw diagram• Differences in SVP and vaporisers/plenum vs tec6• Drugs used in cardiac arrest: discuss adrenaline/vasopressin/ Amiodarone/• Pharmacokinetics / exponential/dose time graph/log dose time/ measurement vd, C0/Equation for the line / what is T1/2 / what is time constant/ what is e / howmeasurement clearance /• Starlings forces in capillary / lung /kidney• Hormones produced by thyroid gland/calcitonin/T3 and T4 production• Ventilation and perfusion / areas of lung / diagram /• Dead space / fowlers method /bohr equationSOE2: Clin/physics• Burns / management of burns airway/effects of smoke inhalation/effects ofsmoking/effects of alcohol on body and in anaesthetics / effects of CO and hyperbarico2 /• Can’t intubate / can’t ventilate what would do• Describe grading system• Venturi masks/how work/explain bernouilli principle and coanda effect/clinicalsituations of coanda (ventilators/MI) / entrainment / entrainment ratio• Humidity; definitions of absolute and relative/importance/ways of measuring/describewet and dry bulb hygrometer/hair hygrometer/HME filter how work• PZ electric crystals and USS• Discuss mass spectrometer / IR analysis of conc of gases /28

University Hospitals Coventry & Warwickshire NHS trust• Response and Rise time for CO2 analyserSet 17OSCE1)follow on history taking - partial thyroidectomy.Mechanism of action of carbimazole. what would her T4/TSHbe?2)Lateral C-spine xray - questions on rheumatoid drugs.should this patient have a soft collar or be x3immobilsed?3)coronary angiogram - identify vessels. what are sinusesof valsalve. blood supply/position of SA & AV nodes4)machine check5)entonox cylinder - pseudocritical temp (definition andvalue). poynting. uses. valves6)IO needle - indications, contraindications, carry outprocedure, complications7)examination of pregnant woman to decide if regional orGA for LSCS (not really sure what they wanted - I ended uptaking a history after looking at airway & back, andinvestigations)8) resus - VF9)resus - PEA (talk through algorithm10)history for nervous woman having cataracts11)misplaced trache tube - unable to intubate, hard toventilate12)lumbar epidural - do procedure, complications, how muchadrenaline do you add to 20mls to make 1:200,000concentration?13)CT head - extradural14)diathermy - current density, complicationsabout all I can recall for thatVIVA PHARMLocal anaesthetics - what effects speed of onset.Henderson hasselbach. What can be added to localanaesthetics. signs and management of toxicity.Receptors - classify and give examples of things acting ateach. then concentrated on g-protein oupledAnit muscarinics - anaesthetic & non-anaesthetic uses.compare glyc, atropine, hyoscine.29

University Hospitals Coventry & Warwickshire NHS trustVIVA PHYSIOLOGYSodium balance - daily requirement. Homeostasis. starlingsforces. RAAS. ADH. osmoreceptors, barorceptors.Cardia cycle - drawVIVA CLINICAL22 YO female. RIF pain. Tachycardic hypotensive (just likeyour course!)VIVA PHYSICSBiological signals. HZ/volts. amplifiersECG - components, safety featuresVapourisers - mainly concentrating on des. SVP BP ofanaesthetic agentstemperature measurementSet18OSCES:1. Demonstrate anatomy of antecubital fossa and wrist onan actor. Talk about peripheral nerve blocks at wrist andelbow.2. History taking - 1. history for AP resection in a chapwho had had a recent significant PR bleed, requiredtransfusion, had an MI. Follow-up questions about lengthof time post-MI that an elective anaesthetic should beoffered, and which study first identified this. 2- Historyfor a gynae op, in a young african woman with chroniccough.3. X rays - 1. Globular heart, questions about mitralstenosis. 2. Pulmonary venogram showing large PE in apost-op orthopedic patient.4. Equipment - show how you would go about checking anepidural set before using. Warning - they have an unopenedpack that has a rip in the back!5. Temperature measurement devices, including anoesophageal thermometer prop, diagrams on changes inresistance with temperature of different devices30

University Hospitals Coventry & Warwickshire NHS trust(thermistor, thermocouple, resistance wire), methods ofheat loss.6. Resuscitation stations x 2 - one was a dummy with AFthat needed DC cardioversion, the other a Q&A station thatbegins with a rhythm strip showing either asystole or anagonal rhythm - I wasn't sure which.7. Q&A station about the autonomic nervous system -anatomy of ganglia inc. the stellate ganglionspecifically, neutrotransmitters used, spinal cord levels.8. Q&A station about CVP measurement, and waveforms.9. Critical incident - this was the simman station,incident was malignant hyperthermia. Fairlystraightforward - walk in, monitors immediately showingtachycardia, low sats, rising CO2. Questions about what todo next (remember to ask for temp, because it's not shownon the monitor).10. Bag-mask ventilation - demonstrate on a mannequin,talk about differences when the patient is a child.11. Show how to do an axillary nerve block on an actor,and talk about this and other brachial plexus blocks.12. Laser tubes - handed a tube and asked to talk aboutpertinent features. Then questions on lasers themselves(what it stands for, different types, different surgicaluses, safety precautions).13. Communications skills - pain relief options for a ladyundergoing abdominal hysterectomy.VIVAPhysiology:1. physiological effects of being turned prone. Follow-upquestions on how ventilation and perfusion varies acrossthe lungs.2. PEEP and its effects.3. oxygen flux - inc. the effects of PEEP on oxygen flux4. cerebral blood flow, with graphs.31

University Hospitals Coventry & Warwickshire NHS trustPharmacology1. ketamine etc.- they really went to town on this,wanting to know in particular about structure of the NMDAreceptor and agonist, its molecular effects, ion channelopening, downstream second-messanger effects.2. ways in which drugs may have different effects ondifferent populations.ClinicalScenario was a chap with IDDM, scheduled for emergencyBKA, with temperatures, high BMs. Questions on what couldbe going on, how to plan the anaesthetic, what kind ofanaesthetic would be preferable (they seemed to want torule out spinal because of potential sepsis). He laterstarted fitting post-op, and they wanted to know reasons,and how to manage fitting.Physics1. Ventilators - ways of classifying, advs and disadvs ofeach flow-generators vs pressure-generators.2. pressure-regulating valves.3. "what is a vaccuum" "how can we make use of it"4. Physics behind neuromuscular monitors.5. body plethysmography and underlying principles.32

University Hospitals Coventry & Warwickshire NHS trustSet 18Clinical case: 60 year old Asthmatic for retinal detachment surgery.Longterm steroid use.We discussed Markers of severity in asthma/ Pain/Analgesia options/PONV/Oculocardiacreflex/Critical incident: Failure to breath in recoveryThird question was on criteria for who you decide to give prophylaxis for PONV.Riskstratification for PONV.Physics was more physiology:Measurement of dead space/Bohr equation/Shown graph for FowlerKs method axes notlabelled/ asked to explain how it all works.Decontamination/disinfection/Sterilisation.They asked pretty much everything including howto sterilise a flexible bronchoscope.Blood warmers,types and principles ehind how they work.Shown picture and asked to explainhow that particular type operated.Asked to explain how countercurrent flow mechanismworks.Pharmacology:Local anaesthetics I everything you can think of including relating structure to function .Wasasked to draw the structure of an amide as well as that of an ester and to name examples.Wasasked about Henderson Hasselach equation and was asked to write it down in refernce to LA.Acid production.Receptors and transmitters involved.Why we need to control acid secretion/which patient etc.Explain how you would manage a pregnant patient and explain your choiceof drugs for this patient.Asked why we cannot use anticholinergic drugs to reduce acidproduction and which type of Ach receptors are involved in acid productionInter-patient variability to drug response.Give examples by organ system.Asked aboutcodeine and sux.Also asked about how pregnancy changes response to drugs.Physiology:Control of respiration.Asked to draw diagrams showing the structures involved and theafferent and efferent pathways.Asked to draw graphs for RR vs PaCO2 and PaO2.Vomiting reflex.Receptors,mediators.triggers the works.Asked about antiemetics that do not work via theCTZ (Dex,propofol)Draw graphs for infusion of Adrenaline/Noradrenaline. HOUR vs Time and MAP vsTime.Discussed baroreceptors etc.Set 1933

University Hospitals Coventry & Warwickshire NHS trustClinical:30 yrs lady 34 weeks pregnant with long standing Foetal Bradycardia. She has refused anepidural and you are called to assess her for an Emergency section.Physics:Draw an arterial trace. What information can you derive from it.Whats the difference between swing in A-line trace in HF and Hypovolaemia.What are the ways in which Oxygen can be measured?Explain principal, components and working of a Oxygen Paramagnetic analyserAmbu bag. Components. Draw the of its valve. How do you test it for its working.Physiology:Define the modes in which heat is lost from the body.What causes the heat to be produced in the body.Thermoregulation in infants. Mechanism of heat production from Brown fat.Glucose metabolism. Pathways, ATP generation in each etc.What governs flow of fluids in capillaries.Starlings forces. Explain, draw diagram with values.Pharmacology:Classify IV induction agents.Tell me about Etomidate.Draw structures of- Thiopentone, Methohexitone, Propofol.Anti-HT in use in theaters.Tell me about Vasodialtors in use in theater.Nitrates : MOA, Indications, S/eMethods of drug administration.Oral route : governing principals, benefits, fall backsBioavailabilityOSCE:1> Epidural : for TKR – Level you will aim to achieve, Risks, Benefits, structures passedthrough by the epidural needle, show on patient : landmarks, corresponding spine level.2> Orbit : Identify and tell the structures passing through Optic canal & Superior orbitalfissure.Eyes blocks : Different types. Explain Retrobulbar block : Landmarks, Indications,Complications.3> ECG : SVT-Causes, treatment, indications for Cardioversion, anticoagulation.4> JVP : Show how you would measure it on a patient. Different waves and troughs,causes for the same. Causes for increased A and V waves (one cause for each), complications34

University Hospitals Coventry & Warwickshire NHS trustof central line.5> Resus: Pregnant lady with ? ectopic collapsed ----- Bradycardic6> Simulation: Failed intubation ---- Failed ventilation, method of needle cricothyrotomy.7> Anatomy: Rib. Relationship of neurovascular bundle and various muscle and nerverelations8> Communication: Postponed Inguinal Hernia Repair9> Hx taking with follow on questions: Wisdom teeth removal in a pt with PCT10> Hx taking: Asthmatic for Varicose vein surgery.11> CXR : MS with cardiomegaly12> CXR : Lateral CXR with lobar pneumonia13> Machine check: Just the machine, Rotameters, Vapouriser and the CO2 absorber14> H-electrode and Severinghaus electrode, components, label diagram. EtCO2 trace in –Rebreathing, Oseophageal intubation and COPDSet 20OSCE October 20081. SIM MAN – RSI, can’t open mouth after given sux (masseter spasm), can’t ventilate.Crico-thyroid puncture2. Resus – PEA in ectopic pregnancy woman.3. Resus – Talk through management of SVT. Straight forward questions about drugsused, energy levels, biphasic principle etc.4. CXR – mitral stenosis, pulmonary hypertension & related questions5. Lat CXR – Think it was right middle lope collapse. Not sure6. Machine check - no blanking plug/leak at vaporiser/o2 analyser not working./O2cylinder almost empty7. Anatomy – given a normal rib and first rib. Asked to explain structures crossing etc.Got it all wrong if couldn’t orientate rib ant-posteriorly. Asked to point out surfaceanatomy on actor of tracheal bifurcation, dermatome of T4, position of intercostalnerve block, rib relations of the spleen.8. Anatomy – skull. Asked to identify cribriform plate, optic foramen, superior orbitalfissure – structures passing through? What is the somatosensory supply of eyeball.What is length of socket. What structures are damaged in frontal fracture, how do youclassify, what are the signs? Demonstrate a peribulbar nerve block.9. Equipment – Tracheal intubation – 3 clinical signs of correct placement, 3 pieces ofequipment to confirm. Identify capnograph trace of Bain and Circle when 1 stconnected. Talk through management of grade 3 view.10. Equipment – Shown 2 electrode pictures – which is the pH system. Questions onelectrodes used, electrolyte, what else can be measured, what is the principle.11. Equipment – Pulse oximeter, O2 dissocation curve. Identify myoglobin curve. What isthe isobestic point, what parameter does it represent. What wavelengths are used.12. History – asthmatic, straight forward13. History follow-on – Dental extraction with history of porphyria cutanea tarda. Marksfor knowing which systems affected, enzyme abnormality involved, who wascollecting him from hospital.14. Communication – angry patient, operation cancelled due to another emergency caseslotted in.15. Examination – JVP on an actor. Questions on trace and abnormalities – causes ofraised JVP, large and absent a waves, large v waves.35

University Hospitals Coventry & Warwickshire NHS trust16. Procedure –Lumbar epidural. Demonstate where you perform on an actor. Questionson technique, complications, appropriate level for total knee replacement.Demonstrate how to connect end of catheter to filter hub and what to check.17. Safety – needlesticks – what do you do when it occurs, who do you tell, what do youtell patient, consenting for blood tests, incidence of HIV infection after needlestick,what is the reduction if PEP given.Clinical12 year old boy, black, with painful testis. Surgeon wants to operate straight away.Discussion about RSI, sickle testing, precautions, post op pain management. Criticalincident – laryngospasm after extubation.Physics1. How do you calculate time of oxygen left in cylinder for transfers. Explain gaslaws, critical temp etc. Talk through isotherm graph for N2O2. ECG as a biological signal, voltage levels. Role of amplifiers, how to filterinterference, isolating capacitors, impedance of capacitors3. Types of needles, Hagen-poiseuille and flow, advantages of pencil point spinalneedlePhysiology1. CO2 dissociation curve. Label arterial and venous lines and appropriate values in bothaxis, How is CO2 carried in body. Haldane effect. Carbonic anhydrase.2. Name eg of genetic polymorphism in physiology. Sickle cell discussion. Explaingenotype and phenotype, alleles, autosomal recessive inheritance3. Starling curve and cardiac cycle.Pharmacology1. Reversal agents. Classification and mechanism of anticholinesterases, side effects.Why given with anti-muscarinics. Sugmmadex and role, side effects and how to giveetc.2. Effect of liver disease on drug pharmacokinetics. Discussion and egs of drugs affectedby change in protein binding, metabolism and volume of distribution.3. Classify anti-arrhythmics and more detail about amiodarone and side effects.36