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All the posts from this blog have been added over there, and recategorised (look in the right sidebar).

To understand how the site works, visit the About link in the top right hand corner!

New Site....

Image by Indian Boy via FlickrWell, the new site is coming along nicely, and hopefully we'll have some interesting content to go with the blog as well!

Do come back to see when it's up, which should be very shortly!

Potential questions?

One of the hot topics at the moment in hospitals is something called the "Saving Lives Campaign", basically all about reducing HAI (hospital acquired infections). If you don't know anything about it, don't worry too much, BUT you should be aware that there are several potential questions for the SAQ and the viva brewing as a result of it.

One of the two main drives is about cannulation and insertion of intravenous lines, and how to reduce infection as a result of careful use of skin cleansing for both peripheral AND central lines (Not sure there's a huge amount of evidence for that as far as peripheral lines are concerned - Ed.) Also, insertion of urinary catheters has been targeted, use of enteral feeding systems, and how to do it properly, and the prevention of spread of infection by hand washing, safe sharps disposal, good aseptic technique and use of PPE (Personal Protective Equipment). (See this page at www.clean-safe-care.nhs.uk (!! When will the Vieux Boulogne come to an end? - Ed.))

I would just like to bring to your attention this quote from the RCOA Commentary on the April SAQ

The SAQ paper was set on February 28th 2008. At this meeting the members of the SAQ group noted
that some of the repeat questions continued to be poorly answered, and that questions relating to
issues of public interest and patient safety were poorly done. Although matters relating to patient
safety are not textbook knowledge, they will continue to be part of the syllabus and candidates can
expect that the examiners will emphasise this important aspect of the College’s work.

What this means is that you definitely need to be aware of stuff coming out of the NPSA and NICE as related to anaesthesia and medicine in general, and we will bring you some more information on those kinds of things when the new website goes live at the beginning of next week! More on that in another post...

MCQ Answers

1. The following are associated with a decrease in muscle strength/power:
A. Eaton-Lambert syndrome - TRUE
Myasthaenic syndrome is associated with a decreased release of Acetylcholine from the nerve terminal, and therefore patients will have decreased strength.

B. Fallot’s Tetralogy - FALSE
Sorry, we just made that up. You can find out all about the Tetralogy of Fallot by looking at this link (http://www.emedicine.com/med/topic3579.htm)

C. Treacher-Collins syndrome - FALSE
This one too. Treacher-Collins is a syndrome known by several other names. As a hater of eponyms (and I would hate to inflict my name on future students of medicine for some little known group of signs or symptoms), I would rather people just called it mandibulofacial dysostosis. Read about, and see photos of patients with it, here (http://www.treachercollins.net/syndrome.html). Once you have seen the gallery of photos, you will not forget it. It is important to anaesthetists because of the associated airway problems that may arise.

D. Guillain-Barrè syndrome - TRUE
Need we say more?

E. Kawasaki disease - FALSE
Nope. This is an acute febrile vasculitic syndrome of early childhood. There is increasing evidence for an infective cause. The vasculitis is most can occur in veins, capillaries, small arterioles, and arteries. characterized by fever, rash, conjunctival injection, cervical lymphadenitis, inflammation of the lips and oral cavity, and erythema and edema of the hands and feet.

2. Tetanus
A. is caused by the Gram-positive bacillus Tetanus botulinum - FALSE
Um, no. It’s a Gram-positive rod-shaped anaerobic bacterium called Clostridium tetani.

B. has an incubation period from 1 to 36 days - FALSE
The incubation period is 3-21 days.

C. is fatal >50% of the time - FALSE
Mortality in untreated patients is apparently up to 45% (66% in neonates), with treatment <10%, the rate in those who have received 1-2 doses of vaccine previously being approximately half that of the unvaccinated. (http://www.patient.co.uk/showdoc/40000432/)

D. is associated with myocardial infarction - FALSE
Nope.

E. can be prevented by vaccination with inactivated tetanus toxoid which should be boosted every 3 years. - FALSE
Vaccination is a core tenet of the childhood vaccination program. Its normally given as part of “triple vaccine”, followed by boosters at school entry and leaving. It is thought that 5 doses likely to confer lifelong immunity. Additional boosters may be given to travellers to areas where medical attention may be unavailable,(and likely to sustain at-risk injury) if last dose >10yrs ago, even if completed 5 dose schedule.

EXCITING NEWS....(and a less exciting few MCQ)

As a part of a drive to bring you better intelligence we are developing a new website. This will be up and running very very shortly. We're just learning how to operate the more sophisticated parts of our webhost, which is a stunning machine based in the US, with ridiculous amounts of bandwidth, power and storage, so keep checking back.

In the meantime, for a little fun, we thought you might like to see some MCQs, which are definitely different from the ones you'll have seen elsewhere:

Some of them will be at the same level, some will be harder, some will be easier, and some of them will be plain ridiculous (and therefore tagged as work distraction).

So:

1. The following are associated with a decrease in muscle strength/power:
A. Eaton-Lambert syndrome
B. Fallot’s Tetralogy
C. Treacher-Collins syndrome
D. Guillain-Barrè syndrome
E. Kawasaki disease

2. Tetanus
A. is caused by the Gram-positive bacillus Tetanus botulinum
B. has an incubation period from 1 to 36 days
C. is fatal >50% of the time
D. is associated with myocardial infarction
E. can be prevented by vaccination with inactivated tetanus toxoid which should be boosted every 3 years.

Critical and Pseudocritical Temperature

Image via Wikipedia Critical Temperature is the temperature above which, no matter how much pressure you apply, you cannot force a gas to become a liquid. Interestingly enough, though, if you apply sufficiently high pressures, you can form a solid. Essentially, distinct liquid and solid phases of a substance no longer exist.

If you measure the vapour pressure of a substance at the critical temperature, that pressure is called the critical pressure. Alternatively it could be defined as the pressure which is required to liquefy a vapour at its critical temperature.

A substance is a vapour when it is in equilibrium with the substance in another phase, and a gas when there is no liquid or solid present. Therefore, by definition, except at the extremely high pressures mentioned above, any substance above its critical temperature, is a gas. A liquid does not have to boil, nor a solid to sublime (change state directly from solid to vapour/gas-Ed.) to form a vapour. You can draw a serious of lines, plotted on a graph where the x-axis shows volume, and the y-axis shows pressure, which correspond to different temperatures and called isotherms, which demonstrate what will happen to a substance as you increase temperature with a given volume (or pressure). The one with most relevance of course is nitrous oxide...(see here).

Pseudo-critical temperature is the critical temperature of a mixture of gases. In anaesthesia it is commonly used to describe the temperature at which a 50:50 mixture of oxygen and nitrous oxide separates (laminates) forming liquid nitrous oxide and gaseous oxygen, which occurs at (depending on the pressure) temperatures in the range -7 to -5.5 degrees Celsius in cylinders, and lower temperatures in a pipeline (due to lower pressures) at around -20 degrees Celsius.

Book Review: Final FRCA Short answer questions by Nikells et al

FINAL FRCA Short answer questions by James Nickells, Maan Hasan, Vino Ramachandra and Neville Robinson (ISBN: 0-7279-1289-5; Publisher: BMJ Books)


Published way back in 1998, this book is looking a bit dated now, and that's not just in terms of it's cover, but also it's typeface (better known as font, nowadays). The layout is in the form of nine exam papers which are the same format as the current paper, and include some old favourites, such as writing notes on statistical tests, describing the anatomy of the trachea, stress ulcers in ICU and anaesthetising in an MRI. From this point of view it gives you the opportunity to set a timer, and sit down and do "a practice paper under exam conditions".

The model answers are simply laid out with bullet points and subheadings given to show a suggested framework, and the explanations are generally short and sweet. The questions chosen for inclusion were quite cleverly chosen for the principles of management and principles of answering, and answers are still applicable today. However, because the book is from 1998 some of the answers can be out of date and/or dated. For example magnets are no longer recommended for routine use (Anaesthesia 2006) with pacemakers. After a prolonged re-read, however, no massive glaring problems were discovered, and any issues there are with answers are fairly obvious, on the whole, and should only cause a minor irritation to the reader.

Less wordy than some other SAQ books in its answers, this proved a useful revision aid for it's simle layout and simple answers. There are no "for extra bonus points" points, instead the authors stuck to the KISS principle. (Keep it simple, silly - Ed.)

Would we recommend it? Difficult one. Questions in this book are covered in other books which also cover more topics. I preferred the style and layout of the answers in this to some of the other books, but not everyone will do. Overall, it wouldn't be top of the list, because other books have slightly more to offer, but it's a useful adjunct to revision.

Another Hot Topic

If like us you are a member of the AAGBI then you will recently have received a copy of their latest glossy on Red Cell Transfusion. Sadly they don't appear to have put it up on their website yer, and we've not had time to review it, but we will try to keep an eye on the website and put up a link as soon as we can.

Keep an eye on the site as we get closer to the closing date for entry and we will put up a list of what we consider are likely to be the hot topics from the previous 12 months. Also, watch James Shorthouse's blog over at Passing the Final, as he keeps a good update going, which often includes the hot topics.

Random Factoid: Perlite

Image via WikipediaEver wondered what Perlite is?

It's the stuff that goes in between the two layers of steel in a Vacuum Insulated Evaporator (VIE) which is used for storing about 10 days worth of oxygen on hospital grounds.

It's a form of volcanic glass, which when heated expands from being a glass to being about 10-15 times the original volume. This means that it becomes very low density, and also acts as a good insulator.

It is also used in plaster (as in for walls) and in hydroponics because it's very good at holding water.

Needle-stick injuries; and consent

We're back!

EI has been on holiday in sunny sunny Spain (y Viva España...), although we didn't take a plane to the Costa Brava or anything like that. In fact, we were in one of the highest villages on the Iberian Peninsula, so look out for an altitude physiology article to follow.

In the meantime, a question regarding needlestick injuries has come in, i.e. are there any definitive guidelines. The answer is that there are several documents which have various aspects about what to do when suffering a needlestick injury. We have tried to bring you the ones we consider the most important and most relevant. Also, every trust will have its own set of guidelines, and these should be available from your Microbiology department, A&E (or Emergency Medicine) department or on your hospital intranet.

Take a look at the following links:

DoH Guidance for Clinical Health Care Workers: Protection Against Infection with Blood-borne Viruses (see section 5.12 onwards) (which could be considered definitive)
DoH guidance on Post-Exposure Prophylaxis for HIV
Patient Plus report on Needlestick Injury

Consent

Whilst were on this, and as a result of the fact that there were references to consent for testing for blood-borne viruses, the GMC has published new guidance: Consent: patients and doctors making decisions together.

Bearing in mind that the new Mental Capacity Act 2005 (MCA2005) has now come into force, I would keep a look out for Consent as a hot topic. The AAGBI published guidelines in 2006: Consent for Anaesthesia. Also, the BMA has published guidance on the Mental Capacity Act here.

Consent for anaesthesia has always been a debated topic. Should we take written consent? What risks should we explain? Should we explain nothing at all if the patient tells us just to do what we think is best?

Intensive Care is the area which brings up more issues on consent and capacity, however, as the new Act directly impacts on what will happen. In one trust we are aware that the Consultant in ICU have requested an Independent Mental Capacity Advocate (IMCA) be present at all Multi-disciplinary rounds in order to ensure that they are complying with the Act...

If you want to find out more about the MCA2005, take a look at this link, which explains it all in very simple terms. For something more substantial, try the links on this page.

Adiabatic change

EI has been asked about this concept, and spent some time trying to explain it. However, although EI understood the concept, it actually became quite difficult to explain. So we’ve thought about it some more, and here is our attempt at trying to explain it.

Firstly, an adiabatic change is one in which NO HEAT is TRANSFERRED TO or FROM a fluid (gas/liquid) doing work, or having work done on it. Normally this occurs when there is a change in pressure in a gas.

In other words, as a gas is compressed, it’s temperature will increase. Have you ever pumped up your bicycle tyre, and the nozzle or barrel of the pump has got really hot, almost too hot to touch by the time you’ve finished pumping the last bit of air in? That’s because of adiabatic HEATING. Diesel engines work on the same process of compression generating enough heat to cause ignition. There is no external source of heat, but the temperature has still increased. This must all have come from the act of pumping, i.e. pressurising, the air. The energy of the pumping has been converted to heat energy (internal energy) of the compressed gas.

Conversely, if a gas is suddenly allowed to expand, it will cool. A CO2 fire extinguisher (They used to be solid black, didn’t they? Now we’ve just got those EU compliant red things with different labels on. How the hell are you supposed to recognise the difference in a hurry now?? – Ed.)…when it is used, or any gas cylinder opened and allowed to vent suddenly will rapidly cool. In fact, if you are using a CO2 extinguisher, don’t put your hand on the funnel, because it might freeze to it. Why does this happen? As the gas expands, it does work on the surrounding air, pushing it out of the way. Since energy cannot be created or destroyed, merely converted from one form to another, the energy has to come from somewhere, and it comes from the internal energy of the gas doing the expanding, which we conveniently refer to as temperature.

So, as a gas is compressed or expands rapidly, it’s temperature changes, but no HEAT energy has been transferred into or out of the system. If heat is added to or lost from the surroundings, this is NOT a-diabatic. So for example a gas expanding as a result of being heated is not adiabatic, and a gas contracting as a result of being cooled is not adiabatic either. These processes involve a transfer of heat energy.

Eventually, after the sudden compression or expansion, there will be a transfer of heat energy, but at the time of the expansion or compression, there is not.

And that, in a nutshell, is adiabatic changes.

(It also happens with magnets, apparently, and they’re not fluids…- Ed.) Okay, yes it does happen with magnets, but don’t try and complicate the issue. (If you want to know more, see Adiabatic Demagnetisation on Wikipedia, but make sure you have your maths head on. You have been warned!)

Usually drink, usually dance, usually bubble

EI has relations with a Street Style blog over at Stitsh.com, and recently a little vid caught our attention over there. Click here and scroll down to 28.06.08.

It reminded us of a little law that the examiners sometimes like to question, that is Henry's Law:

At a constant temperature, the amount of a given gas dissolved in a given type and volume of liquid is directly proportional to the partial pressure of that gas in equilibrium with that liquid.

Okay, so what does that mean.

Most of the time we refer to Henry's law by the formula p=kc (that's one way of looking at it - Ed).

Another way is to say:

where:

is approximately 2.718, the base of the natural logarithm

is the partial pressure of the solute (the gas being dissolved) above the liquid in which is being dissolved.

is the concentration of the solute in the solution

is the Henry's Law constant, which has units such as L·atm/mol, atm/(mol fraction) or Pa·m³/mol (this is so that the dimensions all work out correctly - the funny thing about constants is that they usually can be expressed in many different units, depending on what units the rest of the equation is being calculated in....more on that another time).

(In other words, most of the time, we take the natural logarithms of both sides).

The pressure above a solution dictates how many collisions occur between the gas and the liquid. So if you increase the pressure above the solution, the partial pressure of the gas increases, the number of collisions increases, and more gas is dissolved. What will then happen is that an equillibrium will be achieved, where the number of molecules of gas crashing into the surface of the liquid will be the same as the number of molecules leaving the surface of the liquid.

The more observant amongst you will have realised that temperature hasn't been mentioned yet except in the definition....

So what effect does temperature have?

Well, think of a can of "fizzy pop" (you're showing your age there - Ed). When it comes out of the fridge, it's not that fizzy, is it? However, the longer you leave it standing around, the closer it's temperature comes to room temperature, and then when you go back to the can, first it will seem quite gassy, and then eventually it will go flat. This is because the gas in the drink is coming out of solution. The gas solubility relationship with temperature is very similar to the reason that vapor pressure increases with temperature. (This is Gay-Lussac's Law: The pressure of a given number of moles (given amount) of gas, is directly proportional to its temperature in Kelvin (absolute temperature scale), when the volume is kept constant. Better known as P/T=k).

Increased temperature causes an increase in kinetic energy, which in a gas causes either expansion or an increase in pressure, or in this instance, more movement of the molecules, which break free of the surface of the solution! (The surface could be the gas side of a small bubble of gas trapped within the solution, which is one reason we get bubbles!)

If you want to see another demonstration of Henry's law in action, look at a pan of water. As you warm the pan, small bubbles start to form, well before the pan reaches 100°C (373K). Those bubbles are air coming out of solution.

So why do the examiners like this concept: the Bends.

Decompression Sickness occurs when gas (specifically nitrogen) is breathed at higher than atmospheric pressure, and the diver then returns to atmospheric pressure without allowing the gas to come out of solution slowly, resulting in gas bubble formation, and hence, "the bends" (gas in the joints) and "the staggers" (gas bubbles in the brain causing confusion and ataxia) and "the chokes" (probably PE).

It is also a concept that comes into play when talking about Ostwald and Bunsen coefficients....(more on that another time).



(Equations courtesy of Wikipedia)

Lurking in the background? Lurk no more....

To all those readers out there who are lurking....we know you're there....see that little counter at the bottom?

Please help EI improve. Leave a comment, an email, a request. If you have a problem, if no one else can help, maybe we can.

And you can bet that there are others out there struggling as we did...

We've become skilled at seeking out the information and presenting it to each other in a simple understandable manner, and have accumulated notes over some considerable period of time to draw on. So if you're struggling with something, let us know! We'll learn something too!

Don't know much about history....

Did you know that cyclopropane was discovered in 1881 by August Freund?

It's chemical structure can be represented in standard molecular shorthand by a simple equilateral triangle, because each Carbon has 2 bonds to other carbons, and is bound to 2 hydrogen atoms as well.

It's mixture with oxygen is highly explosive, because it breaks down to form linear propane, which is itself a potentially explosive reaction, and there is a reaction with the oxygen as well!

And we used to use this as an anaesthetic gas....

Course Study

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

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

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

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

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

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

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

Del.Icio.Us link fixed

Many apologies for the broken link, which we've only just got around to fixing.

The bookmarks can be found at del.icio.us

The Last Day...

This is the final day of Final FRCA vivas, and EI hopes
many people have passed the exam. For those of you who
have yet to sit the exam this coming Autumn, all the best
of luck.

The last question we can tell you about, as intelligence
received has run thin in the last 24 hours, was a
pharmacology question which came up about the use of
NSAIDs, including the pathway and enzymes they act on and
the implications of their use and the controversy of COX-2
selective inhibitors and why increased cardiovascular
deaths occurred.

EI is going to take a (quite frankly well deserved) break
for a few days, before starting to home in on further
tips, tricks and techniques for studying, learning,
remembering and most importantly passing the Final
Examination.

Please keep visiting, as there is something new on the
horizon which is going to be developed behind the scenes,
and will initially be released in bits and pieces before
coming together in one fell swoop.

Congratulations to all those who passed, and our
comiserations for those of you that didn't. Stick with EI
and we will try to bring you information to maximise your
chances of success.

A little further Viva intelligence

EI has heard about some more exam questions that have come up in the vivas this week, so here we go:

-Describe the pathophysiology of ARDS
-Describe your management of a patient with ARDS
-How do you optimise PEEP?
-How do you optimise PEEP if you don't have fancy ventilators(!)?

-Draw a saggital section of the eye.
-Describe the anatomy.
-Mark the insertion of the conjunctiva into the sclera.
-Why is the anatomy of the eye important to anaesthetists?

A physics/measurement question on CPX and examining a CPX test result came up.

Future Sounds...
Keep an eye on this blog for some well researched answers to the questions that have come up in this last Final FRCA Exam.
Also, as the next sitting approaches, EI will bring together more resources, and simplified explanations of topics that might come up. Hopefully we can help others achieve the same success we have, by sharing some of our revision tips and tricks, and some of the cunning ploys we adopted.
We welcome any suggestions and questions, please feel free to comment or contact EI on the email link in the right-hand column.

If you have a topic you struggle with, ask us, and we will try to help.

If you are still waiting to take your viva tomorrow: GOOD LUCK!

Question some more?

Firstly, E.I. hears that the questions today included THAT
kyphoscoliotic lady for cholecystectomy, a head injured
child with fractured tib and fib, a question about
categorisation of Emergency LSCS, and a question about
heart blocks. More detailed information than that has not
really yet come this way.

Secondly, for those doing the Final FRCA in the
future....the grapevine has told us that The Clinical
Anaesthesia Viva book is going to reach us in a second
incarnation sometime soon, so keep your eyes peeled for
that one....

If you have any information you want to share, please pass
it on to examintelligence"AT"googlemail.com .

Good luck to anyone still awaiting their viva!

Apologies and further info

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

Just to cover the further questions...

The remaining question in the morning was about epidural
abscess:

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

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

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

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

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

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

Watch this space for developments.

NB: IF YOU ARE TAKING THE FINAL IN THE FUTURE, WATCH THIS
BLOG FOR MORE EXAM INTELLIGENCE RELATED ARTICLES!

Questions, questions...

First things first, I PASSED SUCCESSFULLY.

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

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

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

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

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

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

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

Questions

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

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

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

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

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

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

Exam Intelligence @ Del.icio.us

Exam Intelligence now has a bookmarks database at del.icio.us.

If you're unfamiliar with delicious....ooops, I mean del.icio.us, according to them: "the primary use of del.icio.us is to store your bookmarks online, which allows you to access the same bookmarks from any computer and add bookmarks from anywhere, too."

If we come across anything interesting and worthy, it will get added here.

If you think there's anything worth adding, email me, and I'll take a look.

Only the things considered most useful, topical or interesting will be added, and I reserve the right of veto!

Good luck!

Instant Feedback

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

EXAM DAY!

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

24 hours to go....

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

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

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

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

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

Calorie Count

Okay, so far we have been doing viva practice for 7 hours.

We have consumed:

• 1 tub of M&S chocolate cornflake crispy things.
• 1 pack of M&S percy pigs
• 1 tub humous
• 1 pack carrot batons
• 1 pack of grapes
• 6 beef burgers made into cheeseburgers with cheese singles, a salsa sauce (all natural ingredients), mayonnaise, ketchup and sesame seed bun.
• 2 litres diet coke
• 3 double double espressos (with double cream and sugar)
• 1 pack Fire Roasted Chilli Flavoured Tortilla Chips
• 1 pack reduced fat ready salted crisps

And that's between 3 of us.

We have done 6 long cases, at least 8 short cases, 6 science vivas and argued about various things that have been thrown up as a result of the vivas. We also argued about the (old) Final FRCA Guide question on management of Guillain-Barre. Where was the protein in CSF????

Update:It's just been pointed out to us that we've had 2 of our "5-a-day".

Stats suck (updated Saturday)

Everybody loves statistics, right? Right.

There's a reason that Benjamin Disraeli (or Mark Twain, take your pick, "That's a controversial issue....") said there are "Lies, Damn Lies and Statistics".

The number of ways of manipulating data and testing it to come up with a "statistically significant result" is huge.

So here is a very very simplified explanation of some of the things I've learned in the last 24 hours.

Mean: the sum of the observations divided by the number of observations.
Mode: the observation value that occurs the most often.
Median: the number separating the higher half of a sample from the lower half (in a list of numbers sorted in ascending order, it is the middle one, and if you have an even number of values then you take the mean of the two middle ones).

Normal distribution: the bell shaped curve, whose mean, median and mode are the same.
Skewed distribution: any curve which is not bell shaped.

Standard deviation: the square root of the variance. It is the root-mean-square (RMS) deviation of the values from their mean.

Variance: sum of the squares of the differences between each of the values and the mean of the values, divided by n-1 (where n is the number of values) (There is another formula for calculating variance, but this give the UNBIASED estimate - see here for a better explanation, but only if you've got your maths head on, otherwise just take it as read). It is a description of the amount of spread about the mean (a measure of central tendency).

In a normal distribution, 95.45% of values lie within 2 standard deviations of the mean.

Quantitative variables: Usually have a true zero (i.e. there is none of what we are counting).

• Continuous variable/data: can have any value within a given range (e.g. height, BMI)
• Discrete variable/data: can only have certain values (e.g. number of children (No 0.4 kids round here - Ed))

Qualitative variable/data: (as opposed to quantitative variable)

• Categorical variables/data: values are different classes or groups
  
• Nominal: no order (eye colour, race)
• Ordinal: ordered (first, second, third for example, or pain scores)

Interval variable/data: there is no true zero. Good example is temperature measured in degrees Celsius or Fahrenheit. Being 0°C does not mean there is an absence of temperature (or heat energy).
Ratio varaible/data: there is a true zero, for example temperature measured in Kelvin.

The distinction between the above two is this:
If I measure temperature in degrees celsius and then the temperature in degrees celsius doubles, then the temperature in Kelvin and degrees Fahrenheit does NOT double. Degrees Celsius is an interval variable, as is Fahrenheit, whereas Kelvin is a ratio variable.
Another example of a ratio variable is weight in kg and pounds. If you double your weight in stones and pounds, you double your weight in kg.
Yet another example: pH is NOT a ratio variable, because doubling your pH does NOT double your H⁺.

Range: difference between highest and lowest
Interquartile range: difference between values below which 25% lie, and above which 25% lie (so the range of the middle 50%).
Confidence interval: see here. (Also explains some of the other concepts!)


Okay, so now what about statistical tests:

Parametric tests: assumptions are made about the distribution (i.e. that it is normal and has constant variability, i.e. the variances of the two samples (or the standard deviations) are the same.
Non-parametric tests: make no assumptions.
Ordinal data or nominal data: Chi-squared

Normally distributed data (non-ordinal, non-nominal), two data sets: Student's t-test (paired or unpaired)
Normally distributed data (non-ordinal, non-nominal), more than two data sets: Analysis of variance (ANOVA) (paired or unpaired)

Non-normally distributed (non-ordinal, non-nominal), two data sets: Mann-Whitney U (or Wilcoxon Signed Rank if paired data (replaces paired Student's t-test)

Non-normally distributed (non-ordinal, non-nominal), more than two data sets, paired: Friedman's (don't ask, and don't look. The link is for completeness. You have been warned.)
Non-normally distributed (non-ordinal, non-nominal), more than two data sets, unpaired: Kruskal-Wallis (no, really, really don't ask, unless you have a real maths head. It is probably enough to know it is an extension of the Mann-Whitney U test).

Non-Normally distributed: "Oh Mann, I can't use the t-test" (Mann-Whitney U test) (Thanks to SR for this little "mnemonic")

Oh, and one last thing, if we take a number of samples from a population, and then we calculate the mean for each sample, plot this on a graph, we get a curve (with normal distribution) which has a standard deviation. This standard deviation is called the standard error of the mean. The smaller the standard error of the mean, the more closely the sample mean estimates the true population mean. Simple really!

Okay? So, that's it.

I'm not sure how much more I will write before the exam, but do keep coming back anyway, if you're a regular reader. If I pass, I'll pass on my knowledge, and if I fail, well, I'll be revising, so I'll pass on any other things I learn along the way! Feel free to leave suggestions or questions?!

Meaner and meaner

One of the most disconcerting things about going to a viva is that (apart from having no clue about what you might be asked), is the possibility of coming across an examiner who is a complete, erm,...is very mean.

There are several ways you might choose to cope with this.

• Pray you don't get one before you get to the exam.
• Like the Beautiful South, Carry on Regardless.
• Imagine them sitting naked in the chair in front of you with nothing but socks on, although this may make you feel slightly queasy (unless Jessica Alba was your examiner (substitute celebrity of choice) - Ed).
  
• Simply remember that you have worked very hard for the exam, know a lot (even if you think you don't) and probably know more than the examiner what you are talking about.
• Practice before the exam with someone who you feel intimidated by, respect a great deal, or get one of your friends to be annoying and act all disinterested. Get them to interrupt, ask you "Oh really", "Are you sure?", "Do you want to start again?" and so on. Have them change tack rapidly and switch topics without warning.

We have been trying this technique in preparation for Monday/Wednesday. It can be quite disconcerting having a good friend turn into a "bad cop". Sometimes though, if taken to extremes, it's impossible not to laugh....

69 hours to go....

"In a place of safety with standard monitoring attached...."

I am now so bored of repeating this phrase after 10 solid hours of viva practice today, that I think I will have to try saying it in different languages, just to be different.

On the upside, however, it just trips off the tongue....

Only 4 days to go....

Vivas Up

Past Vivas are now up online, thanks to my ISPs...timely...intervention.

Click here to get the link.

Practice makes perfect

Do you waffle when telling stories?
Does your partner tell you to get to the point when you're explaining about something that happened at work?
Do your family hold their heads and groan when you start off by saying "A funny thing happened the other day....", or something similar?

Then you may be a waffler, and I'm not talking about someone who bakes light crisp battercakes in a waffle iron, rather, I mean the other type of waffler, who speaks or writes in a vague and wordy manner (The Free Dictionary).

You may not even realise you are doing it, unless some particularly harsh person in your vicinity tells you about it, or you do one of the things I will come to shortly.

To realise you waffle will take some getting used to. There will have to be acceptance on your part that you are using empty "filler" words as previously discussed, which simply waste your time, as you are not scoring points. Remember back to the SAQ. The key was to transmit as much information as possible in the most succinct, legible manner possible (A remarkable achievement you got a viva then - Ed.) Yes, thanks, I know my handwriting is terrible... Anyway, BACK TO THE POINT: in the viva, you have to do the same, but in the spoken word, so to speak (ahem).

To help you on your way out of denial, try doing one of the following:
1. Pop down to your nearest Lidl and buy yourself a £15 dictaphone with 15minute blank tape, or failing that, blow all your money on one of these dinky gadgets, and practice talking about, say, "What are the changes in physiology in a runner's body from 30 minutes prior a marathon race, until some time after the race?"
2. Better yet, borrow a video camera and do the same.
3. Sit down with two really harsh consultants from your department and practice being viva'd by them on the above topic, whilst recording the whole thing with one of the above devices, or just get them to feed back to you whether you waffle or not.

If it is the case that you harp on without going anywhere, then you only have a few days in which to hone your technique to eliminate waffling. Nil desperandum, as they say. It is all perfectly feasible.

The key is in practicing with yourself, in front of a mirror, with your wife/husband/boyfriend/girlfriend, with a dictaphone or video camera, or in front of pairs of consultants (or even one will do, at a pinch) in your department.

• Try using the Five Word Viva Game to cut out absolutely everything extraneous, then flesh out your answers a little bit to build up to a sensible answer.
• Don't repeat yourself: "The main concerns are residual nerve block, excess opioid and residual narcotisation, incomplete recovery of neuromuscular function, hypoxia and metabolic/endocrine derangement, are the main concerns."
• Try to cut out saying "Er, um, ar, ah, aer" etc. Try a pause instead.
• Elongate vowels in starts of sentences slightly "Weeelll", "Theeeere aaaarre" and "Iiiiii wooouuullld" for example (you get the idea, I hope?).
• Be confident about your knowledge when you are sure about it, and make the examiners feel you are confident. Remember that you are not about to become a consultant (this isn't an exit exam, as one of my consultants put it), but they are looking for someone who is a good Registrar (Specialist, Specialty or otherwise) to whom they could entrust a case in the middle of the night whilst they cosy up back to sleep, and not worry about it (unless worrying is really necessary, in which case they'll probably come in anyway).

Keep at it: one way or another it'll all be over bar the drinking in a 10 days time...

Consider this....

The statement:
"I believe this patient has rhabdomyolysis because they have raised CK, raised K+, renal failure, leg weakness"

versus:

"This is a classic case of rhabdomyolysis, with leg weakness as a result, demonstrating raised CK, raised K+ and renal failure".

Cardiac Risk

No-one is sure how to accurately predict the chances of someone having an MI or sudden cardiac death whilst they are having an anaesthetic. We can make an estimation (for example that 56% I mentioned) based on complex scoring systems (Goldman Cardiac Risk Index for example), but can’t say for certain that one person will have problems, whilst another definitely will not.

So how many scoring systems/assessment methods are there? I can’t tell you. Too many. The most common one is the Goldman Cardiac Risk Index, but there are others such as the Detsky system (a calculator may be found here), Lee’s Revised Cardiac Risk Index and more!

And then the AHA/ACC go and publish another document!

Final Vivas of the Past

Unfortunately, my ISP has managed to cut me off from my web-server, meaning I can't upload anything at the moment. However, some readers have expressed interest in some Past Viva papers I discovered in my filing cabinet at home, as mentioned in a previous post. If you are interested in seeing them, please email me. Eventually I will be able to upload them, but I don't hold high hopes of that happening before the middle of next week!

I KNOW you will all have seen this, but it's classic....

Classic.

Congratulations!

Congratulations to all those who passed the Primary MCQ, results of which came out on Thursday!

As anyone who has done this exam will be aware, it is a bugger, but only the first step on the way to becoming FRCA.

Next up is the OSCE and viva, which are also a bugger in a different way. If you want a useful book for this (it has many little tidbits and lots of diagrams you could be expected to reproduce in the exam) consider this one The Anaesthesia Viva: Volume 1, Physiology and Pharmacology and this one: The Anaesthesia Viva: Volume 2, Physics, Clinical Measurement, Safety and Clinical Anaesthesia. Although not perfect, they have helped many people in their preparation for the exam, and I've even looked back at it in revising for the Final (though there are better books for this).

For the OSCE examinations, the most popular book is probably this one: Anaesthesia OSCE. I am not sure that there is actually anything else out there at the moment.

Other books I bought and used to revise for the Primary Structured Orals, and useful for the Finals as well were The Clinical Anaesthesia Viva Book and The Anaesthesia Science Viva Book. The latter is probably more use going into Primary, to be honest, and contains a reasonable amount of detail. I didn't come to these until very late in the day, but I reckon that if you can reproduce some of the stuff in the Science Viva book in the Primary, you'll be well away.

Anyhow, best of luck!

Genius?

Another work avoidance tactic led me to find a little website that tells me:

TV Reviews

I find this rather worrying, especially since I don't feel like a genius what with everything I don't know at the moment...

Five Word Viva Game

Critical thinking and prioritisation is paramount in our
daily anaesthetic lives, and is one of the things that is
being tested when we are invited for viva voce exams. It
is, of course, also tested in the SAQ and to a certain
extent the MCQ as well. Our answers should be prioritised
to present those things which are most important, most
common or most life-threatening first. No zebras outside
the windows when we hear hoofbeats!

One way of practicing critical thinking and prioritisation
is to try and answer viva questions with only five
critical words (key words). You can try doing this for
either a big topic or a subsection of a question when you
are practicing. Obviously you will need a friend, and an
ideal answer or example of a very good answer laid out in
front of you.

By practicing this Five Word Viva Game, when it comes to
the real thing you will have an advantage. It will help
your exam technique in several ways.

Firstly, when you practice it will make you think very
carefully about anything you DO know about the topic, and
you will formulate an answer which at least gives an
overview. One of the most difficult things to do in the
exam is to get away from waffle. You start answering a
question and then end up using lots of filler words, which
take up time, but don't go anywhere near answering the
question. Suddenly the bell goes, and ooops... By
summarising down to five important key words you have
automatically got the main points in your head, you are
more likely to say those than waffle, and you can get away
with using filler words a bit more (but should still try
and avoid anything which is not relevant).

Secondly, if you don't know anything about the topic when
your...friend...asks you the really difficult question
about immunoglobulins, when you go off and read about it,
and then try and figure out "What are my five key points I
need to get across for answering a viva question on this?"
then you have to process the information you have read.
This makes your brain form associations using that
information. You "intra-integrate", so to speak, the
information within itself, and you also "extra-integrate"
with information you already know and have thought about.
This means that you are more likely to remember it at
another time, and will actually allow you to trigger off
more information at another time.

An example of five words:

Q:Tell me a little bit about the immune system.

A:Innate, acquired, lymphocytes, antibodies, complement.

Q:Tell me a little bit about the innate immune system.

A:Barrier (skin/secretions), non-specific, phagocytosis,
cytotoxic, cytokines

Q:Tell me a little bit about acquired immunity.

A:(Previous) exposure, lymphocytes (B&T), antibodies
(ADGEM), specific, T-helper

So hopefully you see what I mean.

Now obviously it doesn't have to be five words, it could
three or seven, but five is a nice number, and three is
really too few for some of the topics. The point is, that
you aim to slim down to key words. Better yet if you can
associate those key words with key images, but I'll talk
about that another time.

Viewing Banned Blogspot Blogs

Are you having issues viewing blogspot blogs because of
firewalling?
Have a look at this article, as it may help you.
Written by Lorelle on Wordpress, who has been blogging for
some 14-15 years in various guises, including writing for
the Blog Herald, Lorelle has some
useful tips and tricks to share.

Do you have any useful tips/tricks/comments to make about
passing Primary or Final FRCA? If so please contact me by
using the comments page.

How To Arrange Your Thoughts (or Classify or Die Part 2)

Time is running away fast now, with 12 days until viva week, so I need some help brushing up my skills as well as my knowledge.

When giving an oral presentation or answering a viva voce question, it's important to appear organised with your thoughts. (See Classify Or Die part 1)
To that end, here are some suggestions as to how one should organise these thoughts:

• At medical school we are taught: History of Presenting Complaint, Past Medical History, Drug History, Social History, Examination, Investigations. It still applies that we do them in that order (well, obviously we know that's not always true, but you should do First Things First).

• Pre-/peri-/post-operative management (includes history taking and examination)

• "The problems of anaesthetising/associated with disease x can be divided into patient factors, surgical factors and anaesthetic factors (order these by which ones you want to talk about first, or which ones are the most important)

• "Complications of performing procedure y can be divided into immediate, early and late"

• When presenting an answer to "How would you anaesthetise this 63y old obese patient with a BMI of 44 and a history of aortic stenosis for a total knee replacement?", talk about the underlying principles (maintain SVR, maintain preload, avoid rhythm disturbances etc... ). The same is true for any of the other questions which could come up. It is important that they know what you are worried about. It's important that you know what you are worried about too...

• Be concise and try to be precise. If you mean a vasopressor, don't say "inotrope".

• Remember:

• Blood Pressure = Cardiac Output x SVR
  
• Cardiac Output = Stroke Volume x Heart Rate
• Therefore Blood Pressure = SV x HR x SVR
• Stroke Volume is dependent on contractility, preload and afterload
• Heart rate is a function of rhythm.

James has some other tips.

A story about family...

Eaton Lambert is a funny guy. He's got plenty of mates to play with, but he just can't throw the ball fast enough.
Why's that? When he was young his dad (Igor) stopped him from drinking his milk like every good little boy should. Now he doesn't have the strength. His skinny upper arms mean he can't whip the ball far enough to reach his mates.
He does get noticeably better the more he practices though, and if he drinks his special "power up" (Guanidine) he's much better at it. He's tried his sister's Regonol*, but that just didn't do it for him.
He's still a sensitive boy though, and whenever Tracria (his latest crush) comes near him, he goes very weak at the knees (too much of a good thing, apparently).

His sister, Myasthenia is a troublesome young minx, who goes around causing all sorts of problems. She seems to get on well with the little old men in the retirement home (they like her cakes), and spends lots of time in the company of other young troublemakers for example with weight problems, depression and dry hair and skin. She hates Igor too, who hangs around 90% of the time at home, and 10% in the pub. (He says he's 3/4 Thymic). Unlike Eaton, whenever she starts to try and play with her friends she ends up tiring herself out, gets blurry vision, slurs her words and can't drink her Regonol*. If she gets a cold (or Igor is nearby) things just get worse. (God forbid if she ever got pregnant!) The first time she got ill she got really weak, and they gave her some disgusting stuff they called "Deltacortil*", but it made her much worse before she got better. The second time they hooked her up to a machine with lots of tubes and spinning pumps, which made her feel better in no time. Now she just drinks the Regonol instead. Sometimes she overdoes it though, and starts drooling like Homer Simpson, and has real problems seeing if someone turns out the lights. When that happens she needs to make sure she stays in the vicinity of the nearest ladies.
Like Eaton she goes weak at the knees whenever Tracria is around...for similar reasons (hey, it's the 21st Century, you know!). One of the boys in her class, a guy called Scoline Anectine (nickname Sux, poor guy), has a real crush on her, but hasn't got the message that he doesn't have any effect on her, even though after every approach she blanks him.
Most of time she wishes that Igor would disappear back to Thymus, but since it disappeared (after a vicious, but surgically executed coup during which many people were gassed; and following which there were more than a few breathless moments), he can't.


Their second cousin Dystrophia (a very unusual name, only 1 in 20,000! Her parents thought she was going to be a boy...it was a 50:50 chance I suppose) goes to a school just around the corner, because the teachers there can spend more time with her. She's quite weak, and has problems controlling her movements. Sometimes when she shakes hands with people she can't let go, a situation that always seems worse in winter. She has a poor constitution, and has been told she's got a weak heart. She certainly gets a few chesty coughs.
She's been told that her eyesight will almost certainly deteriorate as she gets older, and she's not going to be able to eat much apart from soup. Her father has started going bald at a young age, and her mother is worried that she will too (D, that is, not mum!) She hates Tracria and Sux equally because they always seem to be hanging around, and she just can't seem to catch her breath when they're nearby.

*Regonol is a trade name for pyridostigmine, and deltacortil is a trade name for prednisolone tablets.


Hopefully this will serve me as an aide memoir for the Final FRCA Viva....

Auscultation Points ™

I finally found a way of remembering which area of auscultation is which. Normally I spend ages working it out from first principles...

Only at exam time....

Work Avoidance Par Excellence

I got turned onto this by MissBliss over at Frolicking Through Life. I have no idea who they are, but it's quite cool....

Studying again...

In one of my better work-avoidance moments, I was reading
that we waste a lot of our time when studying (rather than
avoiding studying, like I'm doing).

I mentioned earlier that I like to try and sit down and
decide what I intend to learn from a particular study
session. What I hadn't thought about was that I should
define a period of time I am going to spend on doing the
learning. There appear to be a couple of reasons that
make setting a goal and a time limit a good idea.

Firstly, if we decide on what it is we are intending to
learn, we avoid meandering around a lot and ending up
becoming distracted by concepts or ideas that are not
central or essential to what we want or need to learn. If
you read an article and don't understand a concept, you
can usually read to the end of the article without
understanding the concept, and grasp the central tenet of
the article anyway. If each time you didn't understand
something you went off and looked it up, several things
would happen. You would waste time looking it up, and you
would get distracted from your main theme.

Secondly, there is something called the serial position
effect.
When asked to repeat back a list of things they have just
been told, people will usually (not always) start with the
last thing they were told (called the recency effect),
then more than likely some of the first few things they
were told (the primacy effect) and then those things in
the middle are least well remembered. By working
continuously without interruption for lengthy periods of
time, we don't give ourselves beginnings and endings
(primacy and recency) to recall from, and if we don't set
ourselves a time limit or a "learning limit" or "learning
goal", we are less likely to stop work. (This appears to
me to be a special application of Parkinson's Law, where
work will simply expand to fill the time available, and by
giving ourselves an indefinite time to finish, we could
give ourselves and indefinite and infinite amount of
work).

Thirdly, there is always the "fear of the unknown".
Imaging you want to learn the contents of e.g.
Fundamentals (Pinnock et al) or Miller's Anaesthesia, or
(my favourite) Hutton. How many pages are there in each
of those books? (963, 3376 and 1072, in case you were
wondering). A lot. Imagine sitting down and starting to
read at page ONE, only to read all the way through? Every
time you stop and come back, you still have "1072 pages
less whatever I read so far" to go. Or are you a glass
half-full kind of chap/chapess and think "I've read this
many pages, fantastic"? And how long is it going to take
to read (well you could work it out, I suppose)? This
uncertainty of the amount of time it will take is almost
certainly going to be a millstone around your neck.

So what am I trying to say here?
Well, basically it boils down to: when studying, set
yourself a goal, and set yourself a (realistic) time in
which to achieve that goal. Take a break when you've got
to the end of that goal to allow primacy and recency a
chance to exert their power, and then come back to your
studying. Which is where I'm going now.

Anatomical Intelligence

I was never any good at anatomy when I was at medical
school, though I learned and remembered enough of it to
pass the exams. When I actually started working, that's
when I learned clinically relevant anatomy to what I was
doing, and much more in depth at the same time.
For example as an orthopaedic SHO it's quite useful to
know the anatomy of the rotator cuff, which tendons and
nerves are likely to be severed if someone flies with arm
outstretched through a sheet of plate glass, and which
ones you can use to replace Tendo Achilles if necessary.
As an anaesthetist there are certain areas which one
needs to pay attention to as well. Actually, seeing as we
are (as someone put it on a forum recently), the "last
true generalists" we probably need to know most anatomy,
but that's beside the point for the purposes of this blog.

The areas of particular interest are cranial nerves,
sympathetic and parasympathetic nervous system, triangles
of the neck, epidural and spinal anatomy, paravertebral,
costal/intercostal/diaphragmatic anatomy, anatomy of the
airway including lungs, femoral triangle, cervical, lumbar
and sacral nerve plexi (or should that be plexuses?),
anywhere where a nerve runs that we can stick a needle,
and of course vascular anatomy...

Erm...quite a lot then.

Quite frankly I personally can't be bothered to go back to
the anatomy books to start from scratch about learning all
this stuff, but we have discovered a former urology
surgeon who now teaches anatomy at Cambridge has
co-authored a book which some of you may have seen at
college. Instant anatomy is a fantastic little book, full of simple
diagrams and lists. Even better than this, though, is the
website, which is cheaper (read free), but also provides
the opportunity to buy a CD-ROM, a snip at £17.99. Full of diagrams, podcasts
and PowerPoint presentations, we've found it an invaluable
aid in our...revision (ahem). Simply pop it in your
computer, get out your popcorn/pizza/wild boar and venison
sausages and chianti/Tamatar Dal (that's Dal with
tomatoes, apparently best done with Urad Dal, which I
haven't tried) and salad, click, sit back and relax as you
absorb the information in your own personal lecture.

PS: Sadly I get no commission for encouraging anyone to
buy it, but it really is a good CD...

Brain Pain

Neuroanaesthesia is not by way of being my forte, having
not done any lengthy period of it.

I did, however, find this, which seems to be a fairly straightforward, as long as you
recognise that a "tuberculin syringe" (or TB syringe) is
very very similar to what we might call an "insulin
syringe" (see here), that "anode tubes" are reinforced ET tubes, and
remember that Pentothal is the trade name for Sodium
Thiopental.

Another little resource is the SNACC website (Society for
Neurosurgical Anesthesia (sic) and Critical Care), which
has this little guide on it.

In all honesty I think, however, that the questions are
more likely to be asked on principles, such as ICP (and
management) and Cerebral Blood Flow (and that nice graph
with the three lines for MAP, PaCO2 and PaO2 on it plus
effects of anaesthetic drugs). There might be a mention
of air embolism and management in a sitting neuro case...

Looking at ECGs

For a little light revision regarding ElectroCardioGraphy (or EKGs if you're from the USA) this link to the University of Utah's ECG image library may be useful.

Another link is this one to the ECG Library, created by the authors of ECG by Example.

Long Case Tip

My friend Tash showed me a neat little trick. Some of you probably do this anyway...

Take a sheet of A4, and divide it up into sections for History and Examination, Investigations, Bloods, Drugs, Main Problems and Implications, and if you have time add information about your possible anaesthetic technique.

Use this when going through any practice long case viva, so that you get used to the layout, and it becomes a bit like the Mersey technique for SAQs, where you do it the same way often enough you don't get frightened of it.

When Tash showed me this I remarked that it seemed to be remarkably similar to the front side of the anaesthetic charts where I work...

For an example (obviously created in Paint):



Why do this? Well, it keeps everything neat and organised, and means you can easily refer back to your information "at a glance".

Moles etc....

Please click on the picture in the profile section (top right).
Tell me what you think....

A little study tip time...

I'm afraid I don't have any magic answers on how to succeed in the exam, other than, "Study Hard", "Practice Often" and "Study Some More".

The thing is, that "Studying" is one of those ill-defined things that I say "I'm going to study", but actually I'm not sure what I mean, and that's what's held me back, I think, from getting on with some proper work.

Now I hate "drawing up a studying plan" (or "study plan", if you like), and I've never done that. What I do, however, is decide what it is I hope to learn by the end of my session of "studying", whatever length of time that may be.

This morning I decided I was going to learn about principles of anaesthetising patients with cardiovascular disease, including hypertension, abnormal ECGs, valve disease, and congenital heart disease. That sounds like a big topic, and it is in some ways. However, by grouping it all together under the "Cardiovascular Diseases" heading, and not spreading them out over a few days, I felt I was better able to integrate the information. Whether it's gone in for good or not is another question!

Let me explain a bit more: because I had in my mind to learn about CVS disease and the impact on anaesthesia/anaesthetic technique, I had a peg to hang things on. If I then read about some CVS, some renal, some hepatic, and then came back tomorrow to read about some more CVS, it would be kind of jumbled up. Comprende? Instead, because I read all about it in one go, I was able to take ideas from one bit and integrate them with another bit and it all makes (more) sense.

Anyway, that's what I mostly do, try and have an idea of what it is I want to learn by the end of the session, rather than generically "learning something, anything!"

I did spend about one and a half hours with one of my friends doing some viva voce practice, but I can't say I felt very positive at the end of it. I would like to excuse myself by saying I have just finished 5 nights, but that doesn't really make me feel much better.....

Work Distractions (Part Deux)

Oh boy...this guy's got a lot to say....
And he doesn't hold back, either.


Oops, back to work....

Work Distractions

I think I must be the past master at work distractions, ranging from watching this, to browsing this (some amazing photography), to reading this, to writing this blog, which admittedly doesn't normally take very long. However, having now finished 5 nights in a row in Obstetric on call, I'm back to reading again, and so Prof Hutton's tome drags me back.

Obstetric Nights...

An invaluable resource came to light in my filing cabinet last night, of a collection of previous viva details from previous candidates of both the Primary and the Final FRCA, and even some FFA Part II and Part III vivas. I was trying to read through them, as they include questions and the answers given by candidates, and they give some valuable insight

If anyone is interested in them, drop me a line.

Also, I have decided that I am bored of re-reading Simon Bricker's FRCA Viva books and nothing going in, so I have adopted a new approach (at least temporarily) of reading through Prof Hutton's Book: Anaesthesia. They neatly divide assessment of a patient up into chapters such as "The Patient with an abnormal ECG", "The patient with poor pulmonary function" and "The patient with an acute abdomen". I orignally bought it for the Primary, but didn't read these bits very carefully, so maybe now is the time to get my money's worth from it?

3 weeks to go.....

I FINALLY GOT IT!

Sensitivity and Specificity....I got the matrix!
Here's how. And you don't even have to read the whole article!

Things never stand still

Just to prove a point, new BTS Asthma Guidelines were published this May.
And here they are. (Well, the quick reference, anyway).

And, if like me, you had a really hard time understanding Flow-Volume loops, see this article (which has a nice downloadable PDF of loops part way down) at Merck.

Work Distraction

Since the other website is down I was searching for other FRCA related content, and came across this rather humorous blog about Anesthesia and Flying Planes.

Exam, lack of locums and hassle

There appears to be a fundamental lack of locums to cover study leave and annual leave at the moment.
This is mildly to moderately annoying when you want to go on a course, especially when you want to go on holiday very shortly after the exam...

Unfortunately the Anaesthesia UK website (www.frca.co.uk) has been down since last night.
It appears to be built on .NET functionality...

Good Grief?!!

Well, I didn't post anything for a while, because I felt it was unfair to do so when I might not even have passed the written Final FRCA part.
But I did.
Now all I have to do is pass the viva voce exam and I'll be done....hahahaha! Oh how I laugh.
All uphill from here then.
My friend Tasha N. pointed out that having found out you passed the SAQ/MCQ gave you an extra confidence boost that might make you feel "Oh well, I can coast it from here on in".

NOT the case at all.

I have just spent a few hours sitting with a clinical viva book and going "Yes, but I would anaesthetise him, because I've anaesthetised patients like that in real life" and then finding that, actually, the book says "No you jolly well don't". Ah. Okay.

Anyway, I think as fellow blogger James S. points out over at Passing the Final, the most important thing is probably to talk lots.

By the way, if you want a nice sieve for differential diagnoses, try this one "VINDICATE".

Happy revising....