Examiner musings on candidacy Pt I

Extracts from a messaging app conversation between some examiners…

How much time did you spend studying? I started a year before, but spent the first three months falling asleep at night trying to read Guyton’s chapter on cellular physiology. After this, I gave up and read West instead…

A couple of things I did which were effective. A few months out I decided to do 6 hours effective study per day on the weekend, and then go out. I made 24 checkboxes, and ticked each one off after I did 15mins of effective study. It is a lot easier to keep yourself focused for 15mins than 6 hours…

The other really useful thing was compiling a list of every viva opening question. I ranked them in order of frequency, and wrote a card on each one—the answer to the opening question, and what I thought the followup would be…  (The opening questions aren’t published anymore but there is a large bank of them to be found on older exam reports. WW.)

I think once you have read things once, re-reading isn’t very effective. You need to do something else to ensure you retain and understand the knowledge…

having to teach others is a good technique…

In my first run through the material, I was draconian about what I learned. If I came across something that I decided wasn’t core material, I discarded it. The stuff that was left, I made sure I knew backwards. Then on my second run through, I attached a bit more depth to the “core”. It worked for me, and was actually the first time I’ve studied this way. But I’d never recommend it to anyone else. It just might not work for everyone, and if you misjudge what is “core” you could come very badly unstuck…

The thing that made the biggest difference for me was working with anaesthetists who understood the material, and made it come to life in the operating theatre by using basic sciences to inform their decision making. This not only made the information ‘stick’ it also motivated me to study!

2017.1 : SAQ 6

Discuss the potential adverse effects of suxamethonium

BT_GS 1.38

This is a drug with a cornucopia of adverse effects, know them so you know when not to use the drug, and what to be alert for every time you do use it.

Hyperkalaemia is more likely with a repeat dose  TRUE/FALSE

Bradycardia is more likely with a repeat dose  TRUE/FALSE

Prolonged paralysis is more common in South East Asians than Caucasians  TRUE/FALSE

Myalgia is more likely in a patient who has a spinal cord injury  TRUE/FALSE

Masseter spasm can be an early sign of MH  TRUE/FALSE

2017.1 : SAQ 5

Describe the advantages and disadvantages of using nitrous oxide as part of a general anaesthetic (well, this wasn’t exactly the question, I have corrected the spelling error that was on the paper :P)

BT_GS 1.27

This was a commonly used component of anaesthesia up until the late 90s. Can you sum up why it was used almost universally then, why many anaesthetists don’t use it routinely now, and where you think it should fit into your anaesthetic practice?

Nitrous oxide is more soluble in blood than desflurane   TRUE/FALSE

Nitrous oxide is more soluble in blood than nitrogen  TRUE/FALSE

Nitrous oxide undergoes approximately 10% hepatic metabolism  TRUE/FALSE

Nitrous oxide increases plasma homocysteine levels  TRUE/FALSE

Nitrous oxide is an analgesic agent  TRUE/FALSE

 

ANZAC Day

ANZAC day is an opportunity for us to reflect on how fortunate we are to live in a peaceful, democratic country like Australia or New Zealand. It’s also the one day when most of us stop to think about and appreciate our armed forces.

Many of the advances in resuscitation, anaesthesia and surgery have developed through the tragedies of war.

Today I want to pay tribute to Dr Arthur Guedel (1883-1956), an American anesthesiologist who served with the US Army during World War I, in France.

guedel_1 Dr Arthur Guedel

Faced with thousands of wounded, he devised a method of training nurses and medics to give simple open ether anesthesia. Guedel’s four stages of anaesthesia, and the associated breathing patterns, eye signs etc. are still referred to today. A fascinating training film (made in 1945) on the stages of anaesthesia can be viewed here.

guedel_4Guedel’s Stages of Anaesthesia

Guedel is best remembered for his eponymous oropharyngeal airway. Originally made of black rubber, it improved upon earlier metal airways, and instantly became an essential tool for airway management.

guedel_3 Guedel airway

Guedel was also involved with the development of cuffed endotracheal tubes. To prove that the cuff would prevent aspiration, he anaesthetised his own dog, inserted a cuffed tube, and then submerged him under water in a fish tank. One hour later, the dog was woken up, with perfectly dry lungs. The trivia buffs out there would already know that Guedel’s dog was named “Airway”.

guedel_3“Airway”

Thanks to all the military anaesthetists, past and present, who have made so many advances to our specialty.

2017.1 : SAQ 4

Outline the genetic variations in the cytochrome P450 2D6 enzyme and discuss the clinical relevance for drugs used in the perioperative period.

BT_GS 1.20

This enzyme is responsible for much of the variation in efficacy and toxicity of some commonly used drugs.

This enzyme metabolises tramadol into a more active metabolite   TRUE/FALSE

Ondansetron may be ineffective with poor metabolisers  TRUE/FALSE

Patients from the middle east are more likely to be ultrarapid metabolisers  TRUE/FALSE

Approximately 90% of caucasians are poor metabolisers  TRUE/FALSE

This enzyme metabolises codeine into a more active metabolite  TRUE/FALSE

 

Wood vs trees

BT_PO 1.3 Describe the adverse effects of antimicrobial agents

BT_PO 1.130 Outline the pharmacology of antimicrobial drugs and their interactions with other drugs used during the perioperative period.

BT_PO 1.131 Explain the principles of antibiotic prophylaxis

Antibiotic Coverage

The mechanism of action of antimicrobials is examinable, but don’t overlook the more important points such as activity, dosing regimen and side effects.

2017.1 : SAQ 3

Propofol and remifentanil target controlled infusions are often given together as a total intravenous anaesthesia technique. Discuss pharmacological reasons why this is a useful combination.

BT_GS 1.59    BT_GS 1.53    BT_GS 1.41

A practical pharmacology question on a common drug combination. Before setting out to write a model answer try asking yourself first what are the clinical reasons you use this combination.

There are significant pharmacokinetic interactions between these drugs  TRUE/FALSE

There are significant pharmacodynamic interactions between these drugs  TRUE/FALSE

Both drugs have a rapid offset  TRUE/FALSE

Adding remifentanil to propofol can lead to more stable haemodynamics  TRUE/FALSE

Can be used in patients susceptible to malignant hyperthermia  TRUE/FALSE

 

 

2017.1 : SAQ 2

Compare and contrast oxygen delivery via nasal cannulae (nasal prongs/specs), simple face mask (eg Hudson or CIG mask) and Venturi mask.

BT_SQ 1.14

A very practical question, understanding the physics of oxygen delivery by these different means will aid you in appropriate use.

 

Having an end-expiratory pause will affect the performance of the Hudson mask   TRUE/FALSE

Having a high peak inspiratory flow will affect the performance of nasal cannulae   TRUE/FALSE

Low flow rates may lead to an increased inspired pCO2 with the Hudson mask TRUE/FALSE

The Bernoulli effect is relevant for Venturi mask function   TRUE/FALSE

With nasal cannulae the nasopharynx acts as an oxygen reservoir   TRUE/FALSE

 

 

2017.1 : SAQ 1

Previously examined SAQs are a useful study tool. We’ll work through the February 2017 paper for the next couple of weeks.

Question 1 was quite a visual question asking about the anatomy relevant to LIJ line placement.

BT_GS 1.72   BT_RT 1.20

The vagus nerve is in the carotid sheath   TRUE/FALSE

The glossopharyngeal nerve is in the carotid sheath  TRUE/FALSE

Pneumothorax is more likely with LIJ placement than RIJ  TRUE/FALSE

The carotid pulse is lateral to the LIJ  TRUE/FALSE

The LIJ has a greater calibre than the right  TRUE/FALSE

Preparing for the Primary

“You must read Nunn.” “You must belong to a study group.” “It takes 1000 hours of study.” “You must go to the Brisbane and Christchurch course.” “Just one course is plenty”………..

……… and so on and so on. A trainee preparing for the primary is inundated with advice – usually dogmatic, ranging from the erudite to the nonsensical and always (hopefully) well meaning. In more than twenty years of observing success and otherwise in the primary exam, I have come to realise there are nearly as many valid ways of tackling this exam as there are candidates. My advice below has no more validity than anyone else’s. But I have yet to regret dispensing it. Here goes.

  1. Listen to all the advice. It’s a gift. Listen, but by no means should you take it. Evaluate where every piece of advice fits into your own world view, and decide based on your knowledge and experience of yourself whether you’ll accept it. You know yourself and what works for you better than anyone else on the planet. There are no rules.
  2. Be honest about yourself. Although this is probably the toughest academic hurdle you’ve faced; you won’t change in anticipation of it. The way you’ve always *actually* worked (not how you’d *like* to have worked) all through Medical School will be how you work for this exam. If you’ve always been a relatively distractible, not terribly focused studier; that ain’t going to change. You’re just going to have to put more hours in. And if two hours at a desk was your limit at age 20, it’s likely it will still be. You’re simply going to have to come up with a preparation framework that accommodates this.
  3. Commit to a date and stick to it. Being non-committal about when you’re going to do the exam is a huge negative predictor.
  4. No big blocks of time off. When in official study mode (for most of us about a year) you will still have plenty of nights off and down time. But what you shouldn’t have, in my opinion, is big blocks (more than about a week) of time where the exam is right out of your consciousness – because if you’re not going forwards; you’re going backwards. Try to avoid major life events during prep time (easier said than done, of course).
  5. Some peer contact is essential. It doesn’t have to be a “formal” study group if that isn’t your style; but some kind of collegial relationship with at least one other person who is sitting the exam with you is hugely beneficial. Establishing this isn’t easy for some people; but this is the one area where I would urge you to push past any barriers and get yourself out there.

It’s worth it. It’s a fantastic career.