The Gabe Files

The Gabe Files - Appendix I : Recollections of Finals Vivas

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September 2001 Anaes Finals Viva

"The following are my memory of the vivas I sat for in the second sitting of the Part II exams in 2001. I was in the second group – Saturday Sunday – and the second lot of the second group! You can’t get later than that, folks"

"These memories are for information of anyone who wants them, and while they are the best of my memory, I can’t guarantee that every syllable or value is 100% accurate. Anyhow, they may be of use."

VIVA 1 – the one with the medical vivas.
Basic Topic – Retrieval of Severe Burns.

Scenario: Woman 40yo distant location local doctor present; sever burns. 90 minutes to get her by retrieval, 90 minutes back. You are rung and asked for advice as to what the local doctor should do.

Issues discussed in the following order roughly:
                IV access. Assessing ability of LMO - constraints imposed.
                Resuscitation and Fluid Management. Formula would help to be known in detail.
                Pain Relief
                Indications and concerns for special burns, eg respiratory. Use of bronch.
                Intubation. Use of sux? Mechanism of intubation. Securing tube. ? Cervical Spine.
                Other injuries assessment and management.
After transport.
In ICU. OT debridement requested.
                If around face how to secure tube.
                Requirements for grafting - setting up the OT - OT requirements
                Therapy needed during grafting. E.g. blood, FFP, platelets.

VIVAS 2-5 First session next day
VIVA 2 : Basic Topic - Obstetric
Scenario: 30yo G3P2 at 32/40. IDDM. Admitted at 32/40 with premature labour.

What are the signs of autonomic neuropathy in diabetes. Effect of pregnancy on these.
What bedside tests can be used to demonstrate autonomic neuropathy.
Long term control assessment.

Placed on tocolytic infusion. IV salbutamol infusion.
*What are the consequences of salbutamol infusions.
* What to monitor with salbutamol.
* What are the effects of salbutamol - interaction with diabetes.
* Labour is stopped initially - what other treatment should be given in interim.
* What effects of this.

Obstetricians advise tocolysis has failed and there is foetal distress and desire to perform LSCS.
What anaesthesia would you use.
Foetal Distress is in fact very urgent.
What anaesthesia would you use?

Obstetricians want uterine relaxation after incision of uterus.
* How would you do it?
* What are the risks?

What other tocolytics are available?

VIVA 3 : Basic Topic - PONV in a child.
Scenario: A 7yr old male booked for Open Nissen Fundoplication. Parents advise past history of severe PONV and concern in this operation

How would you approach the problem of PONV.
     Method of anaesthesia in step by step detail.
     Premed in a child.
     IV vs Gas Induction
     IF IV, Rapid sequence? Pros and Cons of sux. Alternatives to sux.Which muscle relaxant?
     If NGT used - why, how, how to prepare child.
     Surgical implications of NGT
    As I considered Remi and TIVA, discussion of TIVA in children.

Final unusual question - you don’t have to name them, but are there unlicensed (for children) drugs used in children? (Not “do you use them?” but “are there any used?”)

VIVA 4 : Chronic Pain
Scenario: A 60yo lady under a neurologist for 12/12 said to have trigeminal neuralgia, treated without success. Referred for opinion because of failure to control.

How would you confirm the diagnosis.
What are the features of trigeminal neuralgia. What is it’s history.
How would you investigate this person to assist the diagnosis.

What is the anatomy of the trigeminal nerve, centrally, then the mandibular component. What are the central relations.

What causes trigeminal neuralgia.
What are the analgesic options. Why? How do they work?
Gabapentin is not available. What else can you use? (Carbemazepine) What are the problems with carbemazepine.
What are the surgical options (seeing I’d mentioned surgically oriented causes) and what is surgical cure’s risks.
I was surprised that when I mentioned antidepressants, social assessment, adjunctive psychological treatment, etc., that this wasn’t pursued, or really acknowledged.

What are the neuroablative options. How are they prepared. How is the patient prepared. Advice for the patient.

VIVA 5 : Acute Pain and Drug Abuse
Scenario: A 140kg 24yo man admitted in last 36 hours with peri-anal abscess. Booked for surgery in 24 hours. You are called to provide pain reflief, as he is in severe pain, and quite agitated and panicky.

Describe your approach to pain relief options
Brief discussion of regional analgesia as I was less happy in the presence of sepsis.
History unfolded as I asked for history of pain, nature of pain, and any recent analgesic intake. Man is drug addict on methadone 80mg daily. Has no illicit intake.

Effect of this information, in assessment of pain.

Further history - examiner said “he got these yesterday” and gave a bottle of Pethidine tablets 100mg. 30 prescribed, and 3 left.

How does this influence your assessment of this man.
Signs of drug withdrawal.
Causes for agitation.
                Management of agitation in this man.
                Your analgesic plan - and prescription of dose regimen in detail.

For operation, what are the considerations for anaesthesia.
Would you use a regional, and what are the problems.
                What are the problems with a GA.
Review respiratory physiology in obesity.
                Discuss OSA

VIVA 6 : Difficult Airway
Scenario: 60yo man for BKA due to PVD. Working epidural in place. 15' into procedure you are called back to the operating theatre where the man has collapsed and is unrousable. Resident is struggling with bag and mask to ventilate without success.
Sats 88%, Pulse rate 40/min, BP unrecordable, ETCO2 flat.

What is your first approach.
                (ABC - first and discussion turned to airway first)
                First manouvres
                Difficult Airway algorithm.
Took me as far as TTJV.
                Whose help can you enlist.

Diagnosis and management of the collapse.
                Disposal after end of surgery.

One day later epidural is in place and pain relief/paraesthesiae is patchy.
                Assessment.
                Suppose concerned for spinal cord complication, how to assess and investigate
                Logistics of investigation.

VIVA 7 : Introperative Complications
Scenario: A 30yo lady having C2C3 spinal fusion. Is prone and intubated with head 20 degree up. After 1 hour, ETCO2 drops over a short, but not instant, interval from 36 down to 25 mmHg

Assessment (DD) and management.
Management of air embolus (only since it was mentioned)
Equipment causes. Immediate actions for anaesthetist.
Cause ultimately found to be deflated cuff.
Options for dealing with deflated cuff in prone position.

In recovery patient will not breathe.
Causes?
(Ultimately cause found to be surgical)
You noted at time of ETCO2 drop, that SaO2 also dropped to 80% for max 2 min and only at lowest fleetingly.
How would you document the events regarding the cuff, CO2 and O2. Where would you document it and in what form?
Relatives are aware of the ongoing breathing problems and become aware of the CO2 and O2 problem intraoperatively. They request to speak to you.
What is your approach to the relatives?

VIVA 8 : TURP / Haematology
Scenario: A 70yo booked for electrocautery TURP for benign obstruction. 3 days prior admitted for leg pain and was heparinised. Repeated investigations showed no DVT, and heparin ceased over 24 hours ago.

Pre-op (from memory) Hb 14.1, WCC 8, Plat 145,000 (on admission 220,000), Na 138, K 4.1, Cl 98, LFT normal, Coags normal, ABG normal.

Approach to anaesthesia.
Regional in this context?

Comment on the platelet count.
What are the causes of this platelet count
Could HITS be a cause.
                Describe the HITS syndrome
                Mechanism of HITS. Progression of HITS.
Treatment of HITS.
Ultimately it’s not HITS.

Surgeon is proceeding, and encounters severe bleeding from a venous plexus.

How do you estimate the blood loss?
His Hb is now 7.1 and Plats are 50,000. Fibrinogen now <0.5
How can you assist control the bleeding.
(When I suggested hypotension, questions on degree allowable, and how it would work for venous bleeding.)
Mentioning transfusion, FFP, and Platelet administration, criteria were asked for for FFP and platelets.
What does the fibrinogen make you think of.
                Could you use EACA.

                Is DVT prophyllaxis important. (This actually came out of order earlier)
                How would you do it.

VIVA 9 : ICU Transport

Scenario: You are called to ICU to look at a patient for whom ICU requests an open lung biopsy.

32yo man admitted with a presumptive chest infection though never proven. Has worsened despite continuous antibiotic cover with ceftriaxone and doxycycline. He is ventilated prone and worsening. Lung biopsy requested for diagnosis.

On Noradrenaline, Ceftriaxone and Doxycycline. Ventilated FiO2 0.6, RR 15, TV 400, PEEP 10, Prone. PaO2 65, PaCO2 48, BP 100/60, PR 110. IAL in place, ETT in place.

What crosses your mind as you go to ICU?
What are the considerations here?
* Will you agree to anaesthetise for the biopsy?
* How will you do it?

You agree, and need to transport the patient to the OT which is 1 floor down in the lift.
How do you do the transport.
Staff, Equipment, Monitoring, medication, backup drugs, tubes, etc.
You are offered a Mapleson C circuit for backup. Is this acceptable.
(In case you’ve forgotten, here is a picture of a Mapleson C circuit!)

You are in transport, and the BP drops in the lift to 60/40.
Likely causes and treatment.

You arrive in OT, and the surgeon can do it via a thoracoscopy incision.
In progress, the surgeon asks for you to drop the lung and do OLV.
Do you agree or not? Why?

END OF VIVAS

COMMENTS
"Just a few comments on the above. Probably a good set of vivas, but with perhaps a disproportionate number of pain topics. Especially with a Pain Faculty in the College. Nonetheless they were relevant to anaesthesia mostly."

"The TURP question was more haematology, and HITS was strongly pushed. I didn’t know much about it! I felt it was overdone, and when a candidate says that he doesn’t know an answer or a topic it is fine to penalise him for that, but not to continue plugging the same topic."

"I was really annoyed with myself. I like obstetric anaesthesia, and felt I did poorly in the obstetric viva - perhaps panicked a bit and got flustered. Keep cool, as there are generally no trick questions. If you’ve done it, and can show it, you’re in good shape. Don’t let nerves get in the way of showing it!"

"The importance of placing one viva behind and concentrating on the next cannot be overemphasised. There is an almighty scurry between stations and only two minutes to move and read a scenario - often detailed. Make sure you know the layout, and move quickly between stations. A quick polite “thank you” to the examiner on the bell, and then move quickly is about all you have time for."

"All in all I felt the examiners were friendly and helpful and encouraging. Smiling helps, encouragement is a huge benefit to the candidate, and poker faced frowns from examiners don’t help. But the latter were rare (probably 3 out of 12 vivas)."

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Last updated Thursday, 23 June 2005 11:01 AM EST