primary frca exam january 2010 - · pdf fileprimary frca exam january 2010 5 osce caudal block...

Primary FRCA exam January 2010

1

VIVA

Pharmacology

- Opiods and opiod receptors - where they are in the

body and how they work, side effects etc

- Beta Blockers - How they lower the blood pressure,

different characteristics, etc

- Metabolism - Phase 1 and Phase 2, differences and

purpose of metabolism, cytochrome P450

Physiology

- Cardiac cycle, LV pressure and volume curves

- Iron metabolism - storage, heamoglobin, absorption etc

- Water balance - "If you drink a litre of water what

will happen...", osmopreceptors, ADH

Physics

- Capnography, methods that can be used, different

capnography traces

- Infusion Pumps - Errors with them, safety features

- Fluid flow, pressure difference across tubes, laminar

and turbulent - somehow this lead onto cardiac output

measurement with doppler!

Clinical

40 year old in an RTA with a closed femoral fracture.

Questions on haemorrhage, further trauma management,

complications of blood transfusion, finally fat embolism

intra-operatively

OSCE

1 - Axillary nerve block - show position on an actor

2 - Anatomy of coronary arteries

3 - Communication - Consent a Jehovah's witness -

discuss options other than blood products

4 - Nerve injury - Stupid station - 6 different pictures

of positions on the operating table that can damage the

brachial plexus and 7 different parts of the plexus that

could be damaged - match them up. Went on to the


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consequences of radial and ulnar nerve injury.

5 - Defibrillator - had to defbrillate simman who had

gone into fast AF intraoperatively

6 - Checking A-line set

7 - CVS examination

8 - x-ray of neck with C2/3 fracture

9 - Resus scenario - just talking through asystolic

arrest

10 - History taking - Man for TURP, history of chronic

bronchitis

11 - Simman - Desaturating due to ETT in right main

bronchus

12 - Anatomy of trigeminal nerve

13 - Change of tracheostomy tube

14 - History taking - young woman with history of

rheumatic fever

15 - History follow on station

16 - x-ray - lateral chest x-ray

17 - Check a Bain circuit - few questions about fresh gas

flow

18 - Humidity - measurement, equipment and graphs

Set 2

OSCE

XR- upper lobe consolidation

How to insert LMA and contraindications

Hx for wisdom tooth extraction who has prev # nose and penicillin allergy

Picture of Fischer Paykel hot water humidifier

Severinghaus electrode

Caudal block

Anatomy of ribs and intercostal block

Comm skills - pt for arthroscopy who has URTI

Cross section anatomy at C6

Sim man- pulsed VT

Examination (on sim man) CVS- AS

Bradycardia in recovery (talk through) (evil examiner!)

Hx for Lap Steri (IVDU and suggestive of TB)

3D reconstruction of CT facial views (very random)

Examine peripheral pulses and take BP and measure CVP


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US images for IJV cannulation then questions on CVP waveform (didn't want you to draw it

though)

Vivas

Pharm

Factors affecting speed of onset of local anaesthetics

Receptors (focused on GPCRs)

Antibiotics- mainly penicillins then a bit on aminoglycosides

Physio

V:Q matching, west zones and effects of anaesthesia

Compare cardiac myocyte and pacemaker action potential

Compnents of blood then went on to ask about buffers (but other people got asked about

immunoglobulins)

Clinical

22year old with penetrating eye injury whilst drunk- discussion around sux and IOP

Critical incident- anaphylaxis after RSI

Then another critical incident re hypoventilation in recovery (differential diagnosis)

Physics

Isotherms for nitrous then oxygen, critical temp etc

Biological potentials, amplifiers, interference, CMRR, gain etc

Work, power, energy, force etc

Set 3

Pharmacology SOE

1. Name some classes of intravenous induction agent. Discuss the structure of thiopentone

and how it contributes to its action. Tell me about methohexitone (....aaargh!). Compare the

pharmacokinetics of Thiopentone with Propofol.

2. Pharmacokinetics. Tell me about steady state. What factors influence steady state. Context

sensitive half life.

3. Digoxin

Physiology SOE

1. CO2 dissociation curve, carriage, haldane effect. ODC.

2. Receptors: ion-channel linked, kinase-linked, G-protein linked, intracellular. Examples.

3. Stress response (focussed on neuroendocrine response).

Clinical SOE

54yo elective hernia repair, obese, HTN

-How would you assess this patient pre-operatively

-What are the risks?


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-Critical incident: high spinal - tube, cancel the surgery, go to ITU (was what they wanted to

hear!)

Physics SOE

1. Blood pressure measurement (focussed on non-invasive)

2. Lasers

3. Fibreoptic scope

OSCE

1. Humidification (wet/dry bulb hydrometer: MoA, definitions, dangers of

overhumidification)

2. Central line: internal jugular anatomy and landmarks, discuss technique and complications

3. Electrical safety. Symbols. Circuit diagram, asked to comment on (difficult station!)

4. Communication skills. Needle phobia, consent for sickle screen.

5. Resus 1: tracheostomy change

6. Resus 2: obstetric emergency: local anaesthetic toxicity

7. Spinal cord anatomy

8. History: TAH (fibroids), anaemia, previous PE/PONV

9. History: Lap chole, GORD, FHx sux apnoea

10. Cranial nerves III-XII

11. CXR - inhalation of foreign body

12. C-spine - patient for appendicectomy, looked like Ank Spond, questions about heart block

and aortic regurgitation

13. Giving set/Flow: flow rates through various cannulae, how to improve flow etc.

14. Airway anatomy/difficult intubation: how to improve a Grade III view, laryngeal nerve

supply, methods to detected oesophageal intubation

15. SVT

16. Capnography (abnormal traces, calibration)

17. Ankle block: distribution of nerve supply, demonstrated on model

Set 4

Phys/pharm

CO2 dissociation curve

Stress response to surgery

Receptors and neuromuscular transmission

Physics/ clinical

Non invasive BP measurement- how does DINAMAP work?

Picture of Bronchoscope- what parts, how does it work? How do you clean it?

Safety and Lasers


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OSCE

Caudal block

Anatomy C6 level

Broad complex tachy and defib

Anatomy of thorax and ribs

Humidification

CO2 electrode

Chest drains- what the different bits are for

Bradycardia and management

Set 5

SOE Pharmacology/Physiology

PHARM

1)IV Inductions agents, list what we use, structure of thio and differences between oxy and

thio barbiturates, keto/enol transformation, side effects of thio,

2)Pharmacokinetics of IV infusions, time to reach steady state, distribution half lives, context

sensitive half times, talked about remi Vs propofol

3)Digoxin, mechanism of action, negative chronotropy vs positive ionotropy, uses in AFib,

narrow therapeutic index ED50:LD50, treatment of overdose

PHYS

1)CO2 carriage in the blood, draw the graph (everyone else got given the graph to label, I had

to draw but did it VERY badly), draw the red cell, carbamino compounds, haldane effect and

chloride shift

2)Surgical stress response, neuroendocrine, hypothalamo-pituitary axis, glucagons and

insulin, nitrogen balance

3)Neuromuscular junction, Ach nicotinic receptor, draw it, other receptors, G protein with

examples of each type, intracellular steroid receptors, how they work, gene regulation

SOE Clinical/Physics

CLINICAL

54 year old obese man with hypertension on diuretics for inguinal hernia repair. BP

165/105mmHg on admission. Night before operation. Called to ward by nurse because of BP.


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1)What is obesity, BMI, Problems with obesity, physiological, cardio, resp, GI, metabolic,

type 2 dm causing gastric stasis, what is OSA and why is it a problem, post op with opiates

etc

2)would you take this BP at face value? No, need to repeat, check cuff size etc. BP now

150/90. Would you anaesthetise? Probably, not set rules RE BP and this may represent good

control for him

3)How would you anaesthetise, wanted spinal, then short of breath on table DD of this high

spinal, cardiac and resp causes. Causes of high spinal excess volume, excess dose AND put in

too high!

Then gets really short of breath so end up having to tube, where would you send him after?

When would you wake up? Wanted a specific time frame I said when cardiovasc stable and

controlled environment I said 6 hours.

PHYSICS

1)Non-invasive BP measurement, how they work, what is measured and what is derived, how

to calculate MAP, cuff sizes, when are they inaccurate, what complications can they cause,

wanted petechial haems, nerve damage, poor blood supply to distal extremities, pressure

sores

2)Fibreoptic bronchoscope, what is it used for, why do ENT surgeons use them pre-op,

wanted things like airway swelling in burns, epiglottitis etc, showed a picture, what each part

was (pointed to them for me), how is it cleaned and sterilised, what methods of sterilisation

do you know

3)Lasers, what precautions are taken in theatre, why, what does laser stand for and how does

it work, showed a picture of a lasing medium and asked how it produces the beam, where is

laser surgery used in hospital medicine, wanted general surgery/ENT and ophthalmology

OSCE

1)History taking watched by an examiner. Lady for lap chole. Cousin with anaesthetic

problem ?what. nothing else particularly different. Quite straight forward.

2)Resus sim man. Patient on ICU with perc trache done 48 hrs ago known to be a difficult

intubation. Tracheostomy just fallen out. Sats low 70s. Cant put trache back in. Can ventilate

with guedel and mask only when nurse puts finger over trache hole! Cant intubate cant see

anything. LM A didn’t work for me. Sats never came above 70 but not sure if they were

meant to. One person got sats of 95%! Help is coming.

3)Radiology Cxray. 2y old child SOB from a party. Complete whiteout left lung. 10 T/F

questions some were

Left haemothorax

Left collapse

Anaphylaxis

Inhaled foreign body


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Heimlich manoeuvre dangerous

Bronchoscopy indicated

Chest drain indicated

4)Cross section of spinal cord. Very hard. Knew id got some wrong as told later what they

were! Whats blood supply to the cord. Where does ant spinal artery arise. What happens in

ant spinal artery occlusion.

5)Given grade 3 layngoscopy picture. How could you improve the view. Clinical ways to

know of oesophageal intubation NOT capnography. Capnography traces from bain/circle and

rebeathing.

6) and 7)History from 42 y old with menorrhagia for TAH. Had previous GA as a child. Also

GA Csection with post op DVT and PE 12 yrs ago. Also had migraines and took aspirin

PRN. Taking iron tablets. Smoker. Cap to front tooth. No allergies. On the follow on station

was asked why she was having TAH and menorrhagia was not the answer! So i don’t know

because she told me it was for heavy periods. Also asked what else she did for migraines???

8)IV cannulae and maximal rates of flow. Differences between pink and grey. Not the colour.

Wanted 4 differences. IV giving sets how to improve the flow.can you entrain air through the

giving port?

9)Humidity. Different pictures of humifiers. What can achieve 100% humidity in the trachea.

What is humidity absolute/relative.

10)IJ cannulation landmark technique. Seldinger technique. Angle you go in

at.complications. post op care i.e., chest xray.

11)ankle block. Anantomy of nerves. How to block each nerve and doses of LA.course of

saphenous nerve in the leg.

12)cranial nerve exam excluding optic nerve.nothing difficult here

13)electricity (very hard!!) picture of patient attached to lots of monitoring in theatre and

questions about equipotential earths and mains frequency etc I just didn’t understand really.

Then asked to pick 2 electrical symbols from about 30 on a laminated sheet and say what

they were which was fine.

14)Resus SIMman. Obstetric PEA arrest. Just had epidural top up now unresponsive. DD

high spinal and IV LA. Was IV LA. ALS algorithm then asked questions on intralipid. Also

what else can be given???

15)SVT management. Rhythm strip given of SVT. Drugs. Vagal manoeuvres. Joules used for

cardioversion and how many times.then what other drugs?? I had already said amiodarone so

Im not sure if this is what she wanted again?

16)capnography. How does it work. What clinical info does it give you (3 things). Signs of

cardiac arrest, disconnection, COPD. Very straightforward.

17)radiology. Lateral C spine. Think it was ank spond. 10 TF questions

All cervical intervertebral disc spaces visible (C7 T1 was there so I said yes)

Obvious osteophyte formation

Signs of fusion

Cricoid pressure may fracture this neck


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Patient will have severely restricted mouth opening

Patient may have aortic regurg

Rare complication is cardiac conducting defects

Patient will have preserved VC

Patient likely to have chest wall involvement

Set 6

Pharmacology:

Tell me about isoflurane.

Tell me specifically about its effect on CVS.

Compare CVS effects with sevo, halothane, desflurane.

Tell me about routes of administration. What factors make it desirable to administer drugs by

S/L and transdermal routes? What drugs can be given by these routes?

Tell me about heparin. How does it work? Unfractionated vs LMWH.

Physiology:

Tell me about West's zones. Blood flow in each area.

Tell me about PVR. What factors affect it?

Tell me about temperature control and how body responds to low temperatures. Neural

pathways etc.

Tell me about a nerve cell membrane and what property allows conduction of electrical

activity. Nernst potential & Goldman-Field.

Physics:

What factors determine flow in a cannula? What are the desirable properties of an arterial

cannula & why? Pictures of art lines, IV lines, Tuohy, Stimuplex. Describe features. Quincke

vs pencilpoint for SAB. French gauge & SWG.

Defib - circuit, features. Factors influencing charge on capacitor. Factors influencing

discharge.

CPEX. What is it? How does it work? What does it measure? What info does it give?

Clinical:

37yr old lady with bad Crohn's, on steroids, sulphasalazine, azathioprine. Needs pan-


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proctocolectomy. Has had diarrhoea, abdo pain, pyrexia. What would your plan be for

preparation, anaesthesia & post-op? Epidural stops working - what do you do? Stops peeing -

what do you do? Pre-renal/renal/post-renal etc.

SET 7

Pharmacology

Local anaesthetics

- Structures including drawing

- Factors affecting speed of onset/potency/duration/venoconstriction

- Whether LA useful in infected tissue

- Henderson Hasselbach equation

Penicillins

- Structure

- Mechanism of action

- Spectrum of cover

- Resistance mechanisms

- Synergism with gentamicin

Sorry can’t remember the 3rd

topic!

Physiology

Functions of the blood

- Components and proportions

- Clotting cascade

- Red blood cells

- Hb structure, cooperativity etc

VQ

- Definitions

- Diagram

- FRC

- Factors affecting VQ


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Cardiac action potentials

- Pacemaker vs ventricular AP’s

Physics

Gas laws

- Cylinder pressures

- Bourdon gauge

- Measuring contents of N20/O2 etc

Biological potentials

- Compare and contrast ECG/EEG/EMG

- Black box concept

- Common mode rejection

Lots of definitions – Force etc and their applications to anaesthesia

Clinical

22 yr old man who had sustained a penetrating eye injury outside a nightclub

- Pre-op assessment

- Method of induction

- Critical incident – anaphylaxis

- Then discussed a pt in recover who has resp depression and possible causes and

how to approach management

OSCE

1. C6 transverse anatomy

2. Facial CT reconstruction – Frontal and maxillary fractures.

3. History station – young male for wisdom tooth extraction. Day case. Lives

alone and had driven to the hospital. Allergies.

4. Questions about 3

5. Humidifiers – why used, different types and problems associated with them

6. Severinghaus electrode – labelling parts (very odd diagram!) and talking about

the mechanism. Other methods of CO2 analysis

7. Demonstrate a caudal, calculate safe LA doses, mx of LA toxicity and it’s

recognition


11

8. Rib anatomy – 1st rib and a thoracic rib. Demonstrate where subclavian a, v,

& brachial plexus cross. Neurovasc bundle. To demonstrate how you would

do a IC block. On a real person, show site of carina, needle decompression &

IC chest drain insertion

9. Peripheral arterial and venous examination, BP,

10. Sim man – Broad complex tachycardia with pulse. Compromised therefore

defib. Amiodarone.

11. Rhythm strip – sinus brady – management, risks of asystole

12. History taking (observed) – lap steri … pretty standard, not entirely sure what

I was meant to discover!

13. Explaining to a patient with a URTI for a knee op that he should be postponed

14. Sim man – Assess CVS system and take BP. Comment on likely diagnosis

and investigations. Why regional may be inappropriate

15. CXR – RUL collapse

16. LMA insertion and questions about appropriateness

Set 8

OSCE 11/1/10

1. History – 35 year old lady for lap. Sterilisation. Recent hx night sweats and weight

loss.

2. Simman – feel pulses, NIBP, auscultate heart – systolic murmur, questions on aortic

stenosis

3. Xray – postop cxr collapse RUL questions on management postop.(someone else

thought it was aspiration)

4. LMA – check equipment, insert on manikin, questions about contraindications and

safety

5. Anatomy – cross section of neck at C6, label diagram, route of EJV

6. History taking and follow-on –young fit man for dental extraction, broken nose so one

nostril patent only, allergy to penicillin, fhx anaesthetic problems

7. Radiology – CT 3D reconstruction of trauma to head and face. Questions on

management of head injury.

8. Equipment – humidifiers. Picture of hot water bath humidifiers, pros cons other types

of humidifier.

9. CO2 electrode – picture with labels, ways of measuring CO2 how is it transported in

the blood.

10. Caudal block in child – sacral anatomy, max dose local, show technique, what criteria

for going home.

11. Communication – patient for day case op with bad cold, cough and fever. Discuss

plan, pt having trouble getting time off work. Didn’t shout, actually quite compliant.

12. Chest drains – 2 underwater seal chest drain bottles, what are the parts, where do they

connect, how full, what height from pt, problems with transport.

13. Resus – pulsed VT but low BP, already intubated. Better after 1 shock synch.

14. Exam – Assess pts pulses, BP and JVP.

15. CVP line insertion – pictures of ultrasound views, questions of how deep, how to

know in correct place, where is correct place, why head down


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16. Resus – sinus brady requiring atropine, general run through of brady algorithm

17. Anatomy – 1st rib, other rib where is neurovasc bundle, where would you do

intercostals block, which attachments and grooves.

Set 9

PRIMARY FRCA EXAM QUESTIONS JAN 2010

OSCE STATIONS:

1. Simulation scenarios:

Anaphylaxis post induction

Can’t intubate can’t ventilate.

2. Resucitation stations (Actors as patient)

RTA with haemothrax pt in A&E(Q about initial assessment / chest

drain insertion/GCS).

ITU pt on vent with tension pnemothorax(Q about examination and

needle insertion and definitive treatment)

3. Resuscitation stations with manikin:

Cardiac arrest/?AAA rupture

VF arrest : algorithm

Bag & Mask ventilation/NP airway,FRC

4. Mono oral Stethoscope

5. Skin temp probe: define Kelvin,triple point water?,core temp?

6. Laryngeal blades+ Magill’s:

Compare disposable blade & straight blade

light bulb adv/disadv over FO light

reasons for brady cardia with straight blade

7. Anatomy trachea/Lung/Diaphragm

8. Anatomy orbit

9. Anatomy Laryngeal inlet

10. Anaesthetic machine with modified Jackson-Rees circuit;


13

Q on efficiency/What happens if bag is completely torn?

What happens if reservoir tube length is doubled

Minimal gas flow in 25 kg

11. Labour Epidural skill demo

12. History stations:

Lady for Vaginal hysterectomy with significant PMH pre-eclamp/renal

failure /PPH in previous pregnancy

Pregnant lady with Ankylosing spondylitis

Diabetic /IHD pt for cataract surgery

20 yr old for tonsillectomy-peanut allergy/crown

13. Dynamap.

SOE:

Pharmacology:

Benzodiazepines

Route of adm of drugs/Bioavilability

Phenothiazines/antiemetics

Physiology:

Cardiac pacemaker cell AP

What are Hormones/classification

ABG (resp alkalosis) analysis

Clinical:

72 yr old with Rh Arthritis for Hemiarthroplasty hip.

About RA

CI : High spinal

Post-op analgesia

Physics:

Transport ventilator

Arterial trace and CO calc

Draw over vaperizors


14

Set 10

Osces

1. Needlestick injury - what to do after needle stick, incidence of getting HIV (%), incidence

of HIV if take antiretroviral medications, who to report to, who do they report to, what do

they do after. do you take consent from the victim to take his blood.

2. Take BP of this lady - select the right cuff, why select that cuff, what sounds listen for

(diastolic and systolic), do men and women have same BP.

3. Eye - peribulbar block and how to do it on a skull, what is the sensory supply of the eye,

what is the motor supply, length of eye ball. complications of peribulbar block.

4. exam this mans pulse, precordium, and heart sounds. explain what you do as you do it.

5. resuscitation - 24 year old lady with ectopic pregnancy in pea - steps. who do you call.

6. History from lady for hysterectomy. she had an ITU experience which wasnt good before.

7. History and follow on - Young IDDM for tonsillectomy. last bout of tonsillitis 2 weeks

ago. cant open mouth wide with tonsillitis. lots of holiday due to recurrent bouts.

8. Temperature. Picture of thermistor, then graphs and which one corresponds to the picture -

and the other graphs are representing what device. why do kids loose temperature quicker.

how do you stop it.

9. Two laryngoscope blades - straight and curved. one plastic and one metal. advantages of

plastic. pressor response to laryngoscopy and why get bradycardia sometimes. what nerve

responsible. The showed magills forceps - what used for.

10. Resuscianni - what head position for ventilation. give the manikin 5 breaths.

disadvantages of nasopharygeal airway.

11. Resuscitation - MH.

12. Picture of stethescope and earpeice (hearing aid) attached to it. what used for. advantages.

for kids or adults. when use it. what respiratory and cvs sounds can you hear with it that you

want to.

13.

14.

15.

16.

17.

Physiology/ Pharmacology viva

- ODC. draw it and mark on points. what shifts it to left/ right. why is this useful. how

measure oxygen content blood.

- calcium - use in body. why get tetany and explain it in terms of calcium.

- muscarinic receptors in body. where, what type. draw receptor. what acts on it. name

muscarinic agonist.

- colloids - what are they. why use.


15

Physics/ Clinical

- clinical was 24 year old 38 weeks pregnant with severe fetal bradycardia. management -

catagory of c section. explain anaesthetic technique. is regional CI. say you anaesthetise -

then CICV. mx.

physics - what is a vacuum. where do we use them. draw scavenging system. explain why

high flow low pressure. where is low flow high pressure used in anaesthetics. draw a graph of

temperature decline with anaesthetised patient. what do we do to stop decline. how efficient

is it.

Set11

Physics

- Mapleson circuits, efficiency during controlled and SV and why this is the case (inspiration,

expiration, expiratory pauses etc.)

- Oxygen measurement - different types, explain in detail galvanic fuel cell electrode

including equations at both anode and cathode, explain the mechanism of paramagnetic

analyzer

- Symbols on anaesthetic equipment. Very small print stuff - symbols for manufacture date,

symbol for expiry date, symbols for different types of sterilisation. Didn't know a single one

of them but the examiner was very patient and guided me through (e.g. what does this look

like? an egg timer, oh it's probably expiry date then)

Clinical

Young motorcycle RTC victim, compound tib fib no other injuries but may be hepatitis

positive.

- First question mostly regarding preop assessment and how you would anaesthetise him

- Second question - develops high airway pressures and hypotensiobn. Differentials.

Treatment of anaphylaxis

- Third question - talk me through what you would do following a needlestick injury from

this patient

Pharmacology

- Draw a dose response curve, semi log plot, definitions of agonists and antagonists and their

dose response curves

- Volatiles - compare sevo and des in terms of physical properties and how this affects their

action

- Drugs acting on platelet function - I asked and was allowed to eat up some time by

describing steps in platelet plug formation. Spoke about aspirin and NSAIDs. I couldn't recall

how clopidogrel worked and couldn't recall a name for a GIIb/IIIa inhibitor (tirofiban was

what I was after).


16

Physiology

- What is an enzyme, Michaelis Menten kinetics, which enzyme systems are we interested in

as anaesthetists, talk about acetylcholinesterase and pharmacogenetic variability

- Physiology of ascent to altitude, control of respiration, alveolar gas equation

- Pressure volume loops in the left ventricle in minute detail, demonstrating stroke volume,

myocardial work, changes in contractility, changes in afterload

OSCE

13. Anatomy - spinal cord - LA volumes to block one level in epidural, total CSF volume,

name the tracts on the diagram (which confusingly had ascending and descending all on the

same side rather than how it is normally illustrated). Which tracts do which, blood supply to

cord, affect of anterior artery ischaemia.

14 History taking - woman for TAH. Elicited hx of awareness during GA section, traumatic

gas induction plus all the usual bits including a cap on tooth.

15 Follow on station - questions I couldnt answer there: what is the patients Hb on the blood

test GP did, when was the patient's PE which she didn't have the courtesy to disclose

16 C-spine X-ray from patient with history of severe arthritis. Looked arthritic. Questions

including is the patients FVC likely to be reduced, is mouth opening likely to be impaired, do

they need an echo to rule out AR.

17 Fluid flow. Appalling station, absolutely godawful. Given a pink venflon and a grey

venflon - name 4 differences (not including the coloured cap), what is the flow rate for each.

Shown a blood giving set - what happens to flow when diameter doubled, why doesn't it

actually achieve this 16x increase. What is the ball valve in the giving set for. What fluid is

used to calibrate flow rates in venflons (???)

18 Hazards - humidity - absolute vs relative, identify types of hygrometer from pcitures. Why

is the wet thermometer at lower temperature. How is humidity read from a wet and dry bulb

hygrometer. What is humidity maintained at in theatre, two reasons why this is beneficial.

Name 3 types of humidifier that allow 100% humidification in a breathing circuit.

1 Technical. CVP insertion. Landmarks for IJ, contents of sheath, talk through the procedure

with equipment on table, post procedure management, 5 common or serious complications

2 Anatomy/ technical - ankle block on an actor. Nerves supplying ankle joint, how would you

block deep peroneal and tibial. Describe course of saphenous nerve. Point out area supplied

by saphenous, area supplied by tibial

3. Examination - cranial nerves III-XII inc Rinne and Weber tests

4 Communication station - young man for elective arthroscopy. Afro-Carribean and refusing

sickle cell testing as needle phobic.

5 Resus - called to labour suite after SHO has given 20mls marcain down epidural. Pt

arrested, PEA on monitor. Got BLS started, wedged, called for help. Practical side stopped

then asked questions - what are two most likely causes (total spinal, intravenous), what would

you do now that BLS has been started (doses of adrenaline and atropine, when they are


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repeated, doses of intralipid, need for section). All straightforward - other candidates said that

examiner didn't hide his disappointment well when they didn't know the dose of intralipid,

apparnetly asked one if he'd every administered local anaesthetics!)

6 Hazards - electrical safety showing very confusing diagram of patient connected to CVP

line and ECG monitoring, types of earth, differences in earth potentials. Really hard to follow

what was wanted. Finished with a grid of about 20 symbols and asked to pick two and name

them.

7 Equpiment - capnography - information provided, what happens at each stage in a

capnograph trace, causes of abnormal traces

8 Critical incident - managing a narrow complex tachycardia, doses of adenosine, action if

adenosine fails, energy used for cardioversion, doses of adrenaline,

9 History taking - patient for interval lap chole.

10 Resus - recently inserted trache falls out on AICU, nurse bagging without O2. difficult to

bag, better with two person technique, sats not improving markedly, reinsertion fails, unable

to intubate from top. Options now.

11 Radiology - Child sudden breathless at birthday paty. X ray shows almost complete

whiteout on left with mediastinal shift to left (i.e. collapse). Straightforward questions the

theme being is it aspiration or foreign body and collapse

12 Difficult intubation - identify this laryngoscopic grade, techniques to improve it, clinical

and objective signs of oesophageal vs tracheal intubation. Identify 3 capnograph traces from

choice of 4 - oseophageal intubation, tracheal intubation in a Bain and in a circle.

Set 12

SOE Pharmacology and physiology

Pharmacology

1. Antibiotics; Fluclocaxillin and other penicillins difference and indications for use, moved

onto gentamicin with reference to indications for use and therapeutic index and finished up

with antibiotic resistance and penicillins

Receptors- classification and types and moved on to g protein coupled receptors

Local anaesthetics- what affects speed of onset of local anaesthetics pka, lipid solubility and

protein binding, moved onto pKa of lignocaine, bupivicaine and toxicity and treatment and

IVRa and why prilocaine is used.

Physiology

Shunt and V/q mismatch and V/q ratio of upper lung to lower lung west zones and how

anaesthesia affects V/Q

Components of blood and the pH of blood, HB WCC platelets - speaking to other candidates

they moved on to buffers which I did not


18

Action potentials- cardiac VS pacemaker potentials, differences and why, things that affect

the pacemaker cell potential and why

Physics

Cylinders and the differences between oxygen and nitrous cylinder and why is this

Isotherms and N20

Biological potentialsECG interference and Common mode rejection, amplifiers and gain

Clinical

22 year old male post penetrating eye injury, was standing outside a night club and how

would you assess this patient- ABCDE trauma could he have drugs as well as alcohol on

board

what other investigations would you request and how would you anaesthetise this patient- i.e

RSI but Sux would increase IOP, what else could you do to reduce IOP?

Turned into critical incident about anaphylaxis but what other differentials could there be

how would you manage this situation

Another clinical incident about some one desaturating post op and opioids and residual

Neuromuscular blockade

OSCE stations:

Electrical Hazards- symbols safety and earth

Communication station- sickle cell anaemia and needle phobia

Landmark technique for Internal jugular vein cannulation

Ankle block nerves and areas supplied as well as veins that run with the nerves

History taking - TAH menorrhagia, reduced haemoglobin and migraines

Fluids and giving set - cannula sizes and how could you increase the speed of the infusion

SVT ECG and management

Capnography traces and principles

Pregnant lady - cardiac arrest post epidural top up

History taking lap chole with Reflux

Critical incident tracy fallen out COPD with difficult intubation

X rays- collapse lung after inhaled foreign body in a child

C spine x ray in arthritic

Spinal cord anatomy and tracts

Airway mallampati scoring and Laryngoscopy grades and what could you do to improve the

view in a difficult intubation

Humidification - definitions measurement and types

Examination of cranial nerves 3-12

Set 13

Primary Viva Jan 2010


19

Pharmacology

1) Tell me how NSAIDS work?

Drew diagram of pathway. Effects. Uses. Side effects. Why does aspirin’s antiplatelet

effect last 7 days?

2) What are Ach receptors? What types. Where are they found.?

Discussed nicotinic Ach Rs in the autonomic ganglia and NMJ, and muscarinic Ach Rs

in the PNS. How do they work (Ligand gated ion channels/ GPCRs). Different ligands- eg

atropine. Ipratropium. Uses and effects.

3) What are the characteristics of the ideal colloid? Colloids vs crystalloids. Starches vs

gelatins.

Physiology

1) Given a drawing of the Oxygen dissociation curve. Mark on 3 points- arterial blood

(with normal pKa range), mixed venous blood and p50. What is the purpose of the

p50 value. What causes right shift? Had to calculate O2 content of blood and O2

delivery. What is huffners constant? To calculate dissolved O2 in blood, why do we

multiply PaO2 by 0.0225? What happens to O2 content at altitude? What happens in

hyperbaric situation eg 10m below sea level.

2) What is the role of Ca2+ in the body? How is it regulated? Vitamin, PTH

3) How is blood pressure controlled? What is the body’s response to losing 15%

circulating volume blood

Clinical scenario

25 year old primigravida 39/40. Sudden foetal distress. Had not required epidural up until

then. Discussed management options. How would I anaesthetise this pt for emergency

LSCS. Physiological changes in pregnancy/special considerations. Critical incident:

difficult intubation. Sats drop afterwards- possible causes. Management of aspiration.

Physics


20

1) What is suction/Vacuum? What are the features of medical suction? What pressures?

What flow rates? (vs scavenging) How is the vacuum created? What are the

complications of suctioning?

2) Types of heat loss under anaesthesia. Ways of minimising heat loss by radiation.

What are the 3 phases of heat loss during a 3 hr operation? (I didn’t know this- graph

of temp vs time)

3) Dead space- what is it? Fowlers method. Derive the Bohr equation.

Primary FRCA OSCE 13th

January 2010

1) Equipment: shown a monoauricular stethoscope- what is this? Uses.

2) Base of skull anatomy (name foramen) and orbit anatomy- discuss peri bulbar eye

block. Whats special about the needle. Complications.

3) History station. See elderly obese with obstructive sleep apnoea man in preop

assessement who wants hernia repair next week as day case. You need to advise him

to stay in overnight- he gets angry. Concerned about leaving his wife alone.

4) Resus SIM MAN- called to A and E. Lady with ectopic pregnancy- unresponsive.

BLS- ALS. PEA arrest- lead scenario.

5) History station- See a 39 yo lady pre op assessment for hysterectomy.

6) Examination- examine a patient’s cardiovascular system. Peripheral pulses.

Praecordium- ?aortic stenosis

7) Resus- talk through. Cardiac arrest on medical ward. Shown a rhythm strip with fine

VF. ALS

8) Theatre SIM MAN. Fit well young man just been given drugs for RSI for

appendicectomy. Drugs given, you walk in and take over. Anaphalaxis- CICV

scenario (swollen tongue- unable to open mouth). Desaturates- emergency needle

cricothyrotomy.

9) Xray station- CXR ?coarctation- rib notching

10) Talk through anatomy of thorax, hilum, diaphragm

11) Paeds- 2 yo to bag-mask ventilate. Optimum positioning.

12) Xray- barium swallow with pharyngeal pouch. Management

13) History with follow on station- young man type 1 diabetes pre tonsillectomy.

14) Equipment: plastic MacCoy blade vs metal straight blade. Innervation of larynx

15) Equipment: Axillary thermometer. How does it work? Name graphs (resistance vs

time) for platinum resistance wire, thermocouple and thermistor.


21

16) BP measurement- actually measure BP using sphyg. Cuff size. What is MAP? What

happens to BP as get older. Male vs female.

Set14

Pharmacology

Neuromuscular blockers

o Structure of vecuronium

o Structure of the nAChR and vecuronium binding site

o Compare and contrast vec and roc

o Why is roc faster acting?

o What are the non-NMJ actions of rocuronium

Statistics

o How do we design a study?

o What types of error do you know?

o How do we minimise the risk of type I errors?

o How do we calculate power?

Vasodilators

o Pt in theatre has a BP of 230/120. What would you do?

o Draw a table of drugs the reduce BP

o How do beta-blockers work?

o What alpha-blocker do you know?

Physiology

Preoxygenation

o What are the physiological principles of preoxygenation?

o How does [N2] change in the lungs?

o Draw the oxyhaemaglobin dissociation curve

o What is the blood content of oxygen?

o How can we increase the oxygen content?

Autonomic nervous system

o Compare and contrast the sympathetic and parasympathetic nervous system

(anatomy, chemistry, functions)

Capillary dynamics

o What properties of blood determine flow?

o Describe the movement of fluid across the capilliary wall

o What are the functions of lymph?

Clinical


22

You are asked to anaesthetise a 13yo afro-caribean male who presented with a painful

testicle.

o Lots of discussion about sickle cell – his Hb is 11 when you ask for it.

o How do you test for sickle cell disease?

o Anaesthetic management for RSI

o Particular focus on pain management

Post-op analgesia regime including drug doses

Regional anaesthesia

Critical incident: severe laryngospasm on extubation

Physics

Humidification

o Humidity definitions

o Measuring relative and absolute humidity, concentrating on wet and dry bulb

hygrometer and its limitations

o Methods of humidification in anaesthesia

Pressure

o Definitions of force and pressure

o Measuring atmospheric pressure

o Torricellian vacuum

Monitoring

o What are the AAGBI standards?

o How would you detect disconnection?

o Awareness – who’s at risk, prevention


23

OSCE

MONITORING

o Assemble this Bain circuit

o Talk about examples of EtCO2 traces, eg obstructed, rebreathing

ALS

o Pt with stable VT in recovery – focus on management

o VT is refractory to amiodarone and cardioversion – what do you do?

HISTORY

o Pregnant patient with ankylosing spondyllitis.

SimMan

o Anaphylaxis

EQUIMENT AND PROCEDURES

o Epidural technique, landmarks, LA dose, epidural adrenaline dose

ANATOMY

o Spinal cord blood supply, spinal tracts + functions, CSF volume, CSF specific

gravity

RADIOLOGY

o CXR – sarcoidosis (probably....!)

o Steroid replacement

HISTORY + FOLLOW ON

o Elderly woman for phaeco with angina and diabetes

o End organ damage in diabetes

EQUIPMENT

o Mapleson F – test the circuit – the reservoir bag had a leak

o What are the minimum gas flows for 20kg kid if spontaneously / mechanically

ventilating.

o What is the maximum weight for use?

RADIOLOGY

o Cardiomegaly and PPM

o Questoions about PPM modes and implication for anaesthesia

EQUIPMENT

o DYNAMAP

o Graph of cuff pressure vs oscillations. How are sBP, MAP and dBP

calculated?

COMMUNICATION

o Explain MH to this trainee ODP, who saw a case today and felt out of his

depth. What can he do to help in a crisis?

EXAMINATION / PROCEDURE


24

o Diagnosis of tension pneumothorax and insertion of needle thoracostomy and

ICD.

o Complications of ICD insertion

EXAMINATION AND MANAGEMENT

o ATLS scenario

o Pt has a haemothorax and is hypovalaemic

ANATOMY

o Structure, muscles and innervations of the larynx

CRITICAL INCIDENT

o Lead a VF arrest

o Perform BLS correctly

o Defibrillate safely

o ALS drug doses

Set 15

Viva -

Physiology - 1. ABG trace with pH 7.0, pCO2 1.3 kPa, pO2

17 kPa - questions were about dignosis and compensation

including role of CSF, chemoreceptors in compensation. 2.

effects of 1000 ml NS infusion rapidly. 3. CSF -

formation, absorption and differences with plasma. Monroe-

Kelly doctrine and questions on ICP.

Pharmacology - 1. LA- mechanism of action, pKa, lipid

solubility and protein binding principles and d/d between

ester and amide and then lignocaine and bupivacaine. 2.

Liver in drug metabolism- phase 1 & 2 reactions and

examples of each of them with details of P450. 3.

Pharmacogenetics - sux apnoea, MH.

Physics - 1.freezing point, boiling point, SVP and

colligative property. 2. N2O SVP and cylinder pressure,

latent heat of evaporation, fusion, specific heat. 3 temp

time graph, differences between laminar and turbulant

flow, Hagen- Poisell. equation, reynold's no. Zeroeing &

calibration, 2point & 3 point calibration & application.

Damping & resonance.

Clinical - 68 year old insulin dependent DM for emergency

below knee amputation, temp 38.5, BM 27 mmols. DM and its

complications, GA, regional advantages & disadvantages,

pain relief, Post-op seizures in recovery, d/d & mx.

OSCE -

1. Diagram showing ECG leads, CVP line and questions on


25

leakage current, potentials, equipotential and identify

two from the diagram.

2. Ankle block - all five nerves and their supply in

details.

3. IV canuula - d/d between 16 & 20 gauge and d/d between

IV and arterial cannula. Giving set, fature flow rate and

funtion of 3-way tap.

4.Sim man- dislodgement of tracheostomy tube and

management.

5. Resuscitation- Cardiac arrest in pregnant patient, LA

toxicity and dose of intralipid.

6.Equipment - Humidity and identification of hair, dry&

wet & Regnault's Hygrometers.

7. Capnograph traces and questions.

8.IJV cannulation.

9.History taking - For Hysterectomy.

10. History follow-on- For elective Lap-cholecystectomy.

11.Communication- Afro-Caribbean for Blood test for Sickle

cell disease.

12.ECG - Narrow complex tachycardia, SVT.

13. X-ray -a. Collapse lung, b.

14.Section of spinal cord- different tracts(very confusing

diagram, all tracts on one side).

15.endotracheal intubation- Diagram showing Cormack-L

classification 3.

16.

Set 16

Pharmacology

Classify induction agents

Draw barbituric acid

What are the different physicochemical properties of thiopentone and

propofol?

What classes of drugs affect gut motility?

What are the differences between metoclpramide and domperidone and

droperidol?

Draw a concentration time curve for an IV drug

What is meant by bioavailability?

How can we relate clearance, Vd and T1/2?

Physiology

What is the body's response to 500ml blood loss?

Can you draw a nerve action potential?

Why are there gaps in the myelin sheath?


26

What determines the resting membrane potential?

How does the kidney produce a concentrated urine?

Explain the countercurrent mutiplier mechanism

Clinical

6 year old girl for squint surgery. What would you like to discuss

with the mother?

Critical incident: MH and its management

Physics

Pick one from 6 logarithmic graphs. What is its equation? Give a

clinical example?

How can you work out the exact angle between the x axis and a straight

line?

What is a time constant? What is a rate constant?

How do vaporisers work?

How is a desflurane vaporiser different?

OSCE

Sacral anatomy and caudal epidural talk-through

Pre-op history from a really miserable woman

History of young man due for wisdom tooth extraction and follow-on

station with an examiner

Sim-Man: patient on table with VT and BP <90 mmHg. You are called to

assist a junior colleague.

Sim-Man: CVS examination including manual BP and ECG interpreation.

Obvious murmur. What other investigations would you request?

ECG interpretation: sinus bradycardia and management

Anatomy: cross section of neck at C6 (drawing)

Anatomy: shown ribs (1st and 12th) asked to identify groove for NV

bundle. What is the order of vein, artery and nerve? What are the

structures attaching and crossing over 1st rib and where? Asked to

demonstrate on actor where to insert chest drain and needle

thoracocentesis.

CXR: RUL collapse and Spo2 of 89% T/F questions on management e.g

bronchoscopy? antibiotics? Unmanned.

Examine "peripheral arterial pressure and venous pressure". Also

peripheral pulses

Discuss chest drains. Purpose of water in bottle. How much? Any

problem if overfilled? How high above bottle should patient be?

Discuss humidification. Shown hot water bath humidifier. Purpose.

Other methods.

LMA placement and confirmation of correct position

3D skull reconstruction. Frontal view. Vertical fracture through

frontal sinus, orbit and maxilla. T/F questions. Unmanned.

Management plan for man with high temperature and cough due for knee


27

arthroscopy. Unwilling to have op postponed. Convince him!

PHARMACOLOGY:

They started all the vivas gently but they got harder as

the 15 minutes went on and the pace was really fast so if

you said you didnt know something they moved on. I did

feel that the questions were repeated rather than asked in

a different way.

1. They asked me to talk about the mechanism of action of

NSAID. They wanted the pathways drawn from arachidonic

acid and all the end products and enzymes involved.

What is the difference between COX1 and COX2 when do they

act?

Why do we want selective inhibitors? What problems were

found in their use?

What does each product of the COX reaction so and where?

Asked about types of prostaglandins and the side effects

of their production being inhibited.

2. Cholinergic receptors and their agonists. What

muscarinic receptor types exist and where are they

present? What agonists do you know? What antagonists do

you know? When are they used in anaesthesia? What

effects do they have? we talked about teritary and

quaternary structures and the BBB.

Otheres were asked to draw the muscarinic receptor. I

was asked about organophosphates and then briefly about

their action and effects.

3. Colloids, what are they and what types exist and why

are they useful? Which ones are in my hospital and what

types they are. I was then asked to compare gelatin

colloids from starch colloids. Where and how each are

metabolised. Why do colloids stay in the intravascular

space. What happens when they are infused. Describe the

ideal colloid or intravenous fluid. What are the side

efffects or complications of their use.


28

PHYSIOLOGY

1. Draw the oxygen haemoglobin dissociation curve. Why

is it that shape? What is the significance of the 50%,

75% and 100% saturation points? What is the oxygen content

of blood? What the value per 100ml of blood for venous

and arterial blood and they expected me to do a bit of

mental arithmetic from the equation to work it out, but

in the heat of the viva I found that quite difficult and

he was happy with the normal values written in the

equation and as a result. What would happen in altitude

and draw this on the graph.

2. Tell me about BP response. We discussed baroreceptors

and the Renin angiotensin aldosterone system. I described

the process with high and low BP and the effects. He

asked where the hormones were produced. What would happen

in I litre of saline was rapidly infused. What is the

Bainbridge reflex and why does BP sometimes go up and

sometimes down with tachycardia?

We also talked about osmoreceptors and hypothalamus. He

was very encouraging and corrected little mistakes eg

missing out the factor of 10 in the oxygen content

equation or mentioning the bainbridge reflex. When I said

I did not know he said thats fine and moved on.

3. Tell me about calcium. He let me talk and appeared

satisfied with the direction it was going. He asked why

it was important and where present and how controlled.

Which organs and which hormones are important and what are

their effect. What happens when you hyperventilate? Why

does tetany occur? We talked about alkalosis causing

increased unionized calcium and making the cells more

excitable and that alkalosis causes increased in the

binding affinity to albumin.

CLINICAL

We all started together in a room and were given a

laminated sheet with a description of a case. A 25 year

old primigravida 39/40 fit and well with severe fetal

distress. Prolonged bradycardia on CTG. What do you do?


29

He seemed uninterested and huffed and puffed a bit and

was frustrated when I skirted around any issues by saying

I would discuss with a senior anaesthetist in repsonse to

some of his question yet still gave me a good mark at the

end!

He wanted a description of each category of section and

when I was not clear enough made me clarify what the

difference was between 2 and 3. I said I would discuss

with tsurgeon but that this was a category 1 section and

therefore would need a RSI. He wanted to know what

equipment I would need and then what clinical changes

occur in pregnancy eg difficult intubation. What is the

incidence of difficult intubation in the pregnant

population compared to non pregnant and why I thought this

may be. What I could do about this and different

larynogscope blades and handles. He wanted percentages

when discussing changes eg FRC and blood volumes. We

discussed aortocaval compression and left sided tilt and

as I took a while to remember this he hinted and was fine

when I mentioned it.

When the RSI occurred it is was a grade 4 view and he

wanted to know what I would do. We went throught the DAS

and he then basically wanted me to make a decision whether

to wake the patient up or continue.

PHYSICS

1. What is dead space? How can it be measured and I

explained and drew Fowlers method/ graph and then they

wanted me to derive the Bohr equation. Why is it

important in clinical practice.

2. Define a vacuum? Why is it important in clinical

practice? What is the difference between suction and

scavenging? What are the components? They wanted values

too. Could I draw the components?

3. Heat loss in theatre. what is important. they showed me

a diagram of a person lying on a table with arrows for

radiation, conduction, evaporation and respiration and

convection.


30

What percentages do they contribute to overall heat loss.

What can be done to prevent each loss? what is

hypothermia? Why is it problematic? Warming methods.

OSCE

1. Anatomy of the larynx. yes/ no and true/ false of

diagrams I had not seen but were similar to the A-Z

pictures. muscles, nerve, blood supply and lymph drainage

2. Resuscitation station ALS algorithm and shock patietns

3. history taking for elective CS

4. critical incident anaphylaxis on sim man.

5. put together a coaxial D circuit and name. How long is

it and the diameters of the tubing. how to check it

6. epidural technique on mannequin and LOR and then

calculate adrenaline and lignocaine doses and how to make

up solutions. anatomy of epidural space

7. histoy taking an then questions on this. Diabetic.

8. Diathermy frequency and recognition of diagrams eg

blending.

9. tension pneumothorax and management and placement of

chest drain.

10. cross section of spinal cord and description of tracts

and their function.

11. dinamap, what is the principle. what values are

calculated and which are measured and what they would

correlate with on their diagram of oscillations

12. X ray station of PCP

13. X ray station of sail sign

14. X ray staion of C spine fracture

15. Mapleson F circuit check would I use it? small hole in

balloon. what is the minimum FGF for 3 year old?

16. explain to trainee ODP about Malignant hyperthermia

and treatment and what they should know.

My questions for the OSCE were: (and apologies for scanty

details, it all goes by in such a flash):

1) 2 chest drains differently filled - complications of

overfilling, how far should the tube go into the water,


31

how far below the pt, if lifted what would happen - I said

it would flow back into pt but they seemed to want more??

2) 2 photos of neck as if looking through US probe -

?side, ?vessels, ?causes of increased/decreased size of

vessels or intrathoracic/cerebral volume.

3) Explained to pt unwell with fever decisions re elective

arthroscopy - I went down line of not in best interests,

but identified that he would lose his job soon if couldn't

go to work. Said could consider WCC/CXR and if ok consider

proceeding under spinal as long as pt acknowledged risk

and discussed with consultant/surgeon.

4) Simman - feel pulse, manual BP, auscultate heart,

identify AS, describe implications.

5) Hx for lap chole.

6) Hot water bath picture - asked what %relative humidity

it would provide, advantages and disadvantages, few more

details.

7&8) Hx for wisdom teeth & follow on - general things in

fit young man but lost points as didn't know his job, he

had had previous GAs with no probs but his sister ahd had

a reaction which I didn't have time to go into and they

wanted more details on despite him being a bit evasive?

Last question they wanted to know what could obstruct his

airway after? I just listed stuff and clearly wasn't

saying what she wanted - I wonder if it was throat pack??

I had said bld, foreign bodies, collpased airway etc etc.

9) 2x xrays - one looked ok?? One generally abit shadowy,

nothing obvious. Details were that pt was post-op for

colitis and had lower than normal sats during ob but was

now fine. Asked if he should have antibiotics and whether

he had aspirated but there was nothing in the history to

say there was any periop problems so I just guessed that

it was some CXR finding that happens with people with

colitis and answered accordingly, no idea.

10) 3D facial #'s - questions whether should go straight

to neuro unit, is ICP 'invaluable', what #'s they were - I

think it was through one of the orbits.

11) Fake sacrum - question re anatomy, how to go about

caudal block & demonstrate, how far to go into space.

12) Pick size of LMA for mannikin, demonstrate insertion,

balloon, hom many mls it needs etc. Talk about


32

complications other than pregnancy/full stomach.

13) 2 pictures - pick one that can we use to measure

gases. I picked what I recognised as the CO2 electrode

(speaking to someone after he thought one was CO2

electrode and the other was all O2, CO2 and pH as part of

ABG machine so both were ok as long as you could answer

questions on whichever you chose). Question: what does the

2 electrodes with the electrolyte in between form? What

other methods can we use to measure CO2?

14) Pick 1st rib out of selection on table, answer 1st rib

anatomy but they asked about all the bits that are not the

labelled bits in my book. Also anatomy of it and where you

would find bifurc of trachea and aorta on an actor on the

bed and some other related question that I can't remember.

15) Simman - pt on table by your junior colleague, walk

in, pt goes into VT - compromised, they seemed to want us

to ignore A&B, went straight for DC cardioversion and he

stabilised, then reassessed. What tests would you do

after?

16) Bradycardia post op - many questions on causes,

management, wanted adrenaline infusion with doses.

17) Asked to examine periph pulses on an actor then do

manual BP, asked about Korotkoffs sounds and which to take

as diastolic BP.

18) ? - sorry.

Vivas:

Pharmacology:

Asked how NDMRs work.

Isomers: was fairly standard other than they wanted me to

talk more about thio in that context.

Anti-emetics: again was ok but wanted to know more about

where each receptor was and about their crossover ie.

cyclizine being H1 and muscarinic antagonist.

Physiology:

Starlings forces/CO/add L atrium trace and aortic trace to

LV trace on cardiac cycle.


33

Control of UO - I started with kidney itself, talked about

ADH & other hormones.

Buffers - what is one? How can we classify - I talked

about open & closed systems, we then talked about

different ones and so they suggested that I reclassify

what I said into intracellular & extracellular based on

what I said. Finally they moved onto 'what are buffer

titration curves' and I think we may have been heading

towards drawing one but I was saved by the bell.

FRCA Primary OSCE/VIVA Exam Sitting January 2010

VIVA

Pharmacology:

Comapare cardiovascular effects of isoflurane and enflurane

Heparins

Transdermal drugs

Physiology:

V/Q and West Zones

Cell membrane structure, membrane potentials, Nernst Equation, transport

mechanisms.

Pulmonary vascular resistance

Clinical:

Inflammatory bowel patient with current illness for panproctocolectomy.

o Discussion re: anaesthetic considerations, RSI, steroids (role), analgesia,

immunosuppressant medications.

o Epidural – assessment, management, top-up.

o IV resuscitation post-op.

Physics:

Different needles


34

o 16g Tuohy

o 14g intravenous needle (discussion french gauge vs wire gauge)

o 20g abocath (discussion re damping etc.)

o Peripheral nerve stimulator

CPEX testing

Defibrillator


35

OSCE

1. Technical Skills 1

a. Trauma patient

i. Discussion re: surgical chest drain insertion

2. Anatomy 1

a. Larynx

3. Communication

a. Explain malignant hyperthermia to a trainee ODP

4. Anaesthetic Hazards

a. Electrical safety

i. In operating theatre

ii. Diathermy

5. Physical Exam

a. Head injury patient

i. reduced GCS patient

ii. Haemothorax

6. Interactive Resuscitation 1

a. Defibrilation and ALS algorithm

i. Safe defibrillation of patient

7. Monitoring Equipment

a. Capngraphy

i. Side stream bain circuit

8. Resuscitation Skills 2

a. Tachyarrythmia algorithm

9. History-taking

a. Communication skills – history taking

i. Ank spond

ii. Previous difficult airway + PONV

10. Simulation

a. SIMMAN

i. Anaphylaxis

11. Radiology 1

a. CXR – Cystic fibrosis

12. Technical skills 2

a. Epidural

i. Insertion, Safe practice, Analgesia

13. Anatomy 2

a. Anatomy

i. Spinal cord anatomy (Asc + desc tracts)

ii. Cord lesions

14. Radiology 2

a. CXR – indwelling pacemaker

15. Anaesthetic equipment


36

a. Mapelson F

i. Check system and identify problem

16. Measurement

a. DINAMAP

i. BP measurement, Calculated vs observed readings, Cuff sizing

Not included in mark scheme:

17. Hx from patient

a. Eye operation

i. Local anaesthetic options

ii. CVS/RS co-morbidities

18. Report history taking to Consultant

Physics:

Asked all sorts of facts about cylinders, what is the

range of sizes, the colours of all the different gases,

the volume of cylinders of different sizes containing this

gas/that gas and the pressures etc etc. Other

distinguising features. I only knew abit about nitrous and

oxygen in size E and they wanted much more than this.

Pressure: wanted all different units of measurement and

what they all are when equivalent to 1 bar. What is a

Newton, how could it be calculated from cubic metres etc??

Cardiac output monitoring: just got started and classified

into invasive/semi-invasive/non-invasive and we ran out of

time.

Clinical:

Given paragraph about 15yr old with known asthma, needing

appendicectomy, questions relating to optimisation,

questions need to ask and why. Difficulty ventilating

peri-op, differentials, what to do? Thought i was ok but

they looked very quizzical when I said that we could give

nebulised salb via the catheter mount which is something

I'd just read so I don't know why and I also mentioned IV

so? Then we moved onto management of anaphylaxis.


37

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