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...

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.

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)

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....

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!

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...

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!

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.

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".