Evolution of a viva- Part 1

Before you get your hopes up I will not be revealing the intimate details of a viva but I will attempt to convey some of the thought processes that are employed in the creation of a viva. I can only speak for myself here but I suspect my colleague examiners do similar things.

It begins with an idea (as do most things) which is often formed during the actual viva exams. I think to myself, “Gee the candidates don’t know much about basic propofol pharmacokinetics.” Often this thought is engendered as I watch a colleague examine on a particular topic. I like to examine on topics that satisfy a few criteria:

  • I think anaesthetists should know this stuff
  • The topic is clinically relevant (hopefully these two aren’t mutually exclusive)
  • I have seen a knowledge deficit about the topic in my trainees (if they already know it then someone else can ask them that!)
  • The ‘answers’ or responses I want need to be in the set texts (this can be quite difficult and has scuppered a few viva ideas along the way)
  • Another person with a FANZCA would at least understand most of what the viva was getting at
  • The nature of the topic lends itself to being asked in a viva format

Once I have the idea I write down what the main points I want candidates to demonstrate an understanding of are. (I also need to make sure there is a learning objective pertaining to the viva!!) Each viva topic is only five minutes long so the path to pass responses needs to be direct and hopefully short. Next I hit the books and confirm that the topic is adequately covered. Occasionally I discover that my understanding of the topic is at odds with what the books say! Not uncommonly I may have to look at six different books and it is frustrating for all of us if they say six slightly different things. Next I need to formulate the questions to get the information I want. Each viva should ideally start with a simple and brief question to allow the candidate to answer the opening question correctly and begin in a good frame of mind. So, for a propofol PK viva I might ask “What is the induction dose of propofol for a healthy unpremedicated 20 year old?” Subsequent questions need to flow on naturally from the opening question. I like a diagram or two in a viva but it needs to be simple and easily drawn. Sometimes it may be better to provide a diagram. It may be deliberately incomplete. Lastly I run through the viva myself a few times to check the timing and make sure the flow of the viva is alright. Then the real hard work starts. Part 2 will elaborate.

BT GS 1.36 Describe the PK of neuromuscular blocking agents

IMG_3494

Regarding rocuronium:

It is a more potent agent than vecuronium   T/F

If you drank it, it would paralyse you eventually         T/F

Its duration of action is dependent on what time of the day you administer it    T/F

It commonly causes stinging when injected*    T/F

It is presented as a racemic mixture                 T/F

 

*Read this paper for a description of what it feels like to have rocuronium and suxamethonium injected when you are wide awake.  Response of the bispectral index to neuromuscular block in awake volunteers. P Schuller et al. British Journal of Anaesthesia 2015; 115(Supp 1): i95-103.

Reading any clinical paper about rocuronium should allow you to answer the third question. Unfortunately, reading any of the recommended texts for the exam won’t be enlightening about this particular property of rocuronium.

BTGS 1.30 and 1.31 Describe and compare the PK/PD of sedative/ induction agents

IMG_3500

Regarding midazolam:

It can sting on administration because it has a high pKa   T/F

It has very poor bioavailability   T/F

It can induce anaesthesia when used as a sole agent    T/F

It tastes nice hence its popularity as a paediatric premed   T/F

It has an active metabolite   T/F

Despite what the practice of many trainees may suggest, the t1/2 keo of midazolam is significantly more than about thirty seconds.

BT GS 1.29 Describe the physical properties of sedative/ hypnotic agents

7787914-1x1-700x700

Regarding a propofol ampoule:

It contains egg products so shouldn’t be given to patients with an egg allergy   T/F

The contents are white because it contains soya bean oil$       T/F

It costs more than an ampoule of thiopentone               T/F

It contains antimicrobial preservative                            T/F

If you drank a 100ml ampoule it would make you quite sleepy*     T/F

$ Ask yourself what colour most oils are and what colour mayonnaise is and why they aren’t the same…

*In the trial of Michael Jackson’s cardiologist come ‘anesthesiologist’, Conrad Murray, an expert witness for the defence suggested that Jackson swigged a whole lot of propofol. This hypothesis was strongly refuted by the expert witness for the prosecution who happened to be none other than Steve Shafer. Who was correct?

Phew – well done!

FullSizeRender 15

 

A big congratulations to all of you who sat the exam today – it is quite a feat of physical and mental endurance!

Now time for a bit of a break. Give yourselves a chance to recuperate and participate in normal life – can you remember it😉 –  for the next week or so. Read a novel, take your partner out for dinner or enjoy dinner with friends, permit yourself an extra hour at the gym ( only if that won’t be torture), go to the beach or the bush, binge watch your favourite TV show….

For those of you who like cooking, and who are not too health obsessed, I could recommend making this recipe, pictured above, touted by my favourite podcast.

It is quite normal to feel a bit down in the dumps after a big effort such as today’s. Here is my post from after the written exam in February. We seem to be programmed to remember and dwell on the things we have done wrong, or that upset or scare us, rather than those we have done right. Perhaps this has an evolutionary advantage to stop us getting ourselves into dangerous situations. In the coming days you are likely to mull over those things that you forgot to write down in the exam. It’s Ok. No one can possibly write all there is to know about a topic, under pressure, in 10 minutes…

I like the advice at the end of this article. We can overcome those negative thoughts by creating a bank of good ones. So have a go now, whilst the day is fresh in your mind, and think of 5 or 10 things that went well today ( making it through the exam definitely counts as one). In the coming days, if misery sets in, look back at your list and encourage yourself – well done!

Mineraloglucoaldosticosteroids

BT_PO 1.90

Describe the pharmacology of * insulin preparations *oral hypoglycaemic *corticosteroid drugs.

Intravenous dexamethasone has a slow onset of action. TRUE/FALSE

Prednisone and dexamethasone are synthetic corticosteroids with predominantly mineralocorticoid effects. TRUE/FALSE

The anti-inflammatory response of corticosteroids is a mineralocorticoid effect. TRUE/FALSE

Mineralocorticoid effects of synthetic corticosteroids are less than the natural hormones. TRUE/FALSE

Dexamethasone lacks mineralocorticoid effects. TRUE/FALSE

 

 

Stress

 

drkrishnans-stress-management-7-638

Stress: A state of mental or emotional strain or tension resulting from adverse or demanding circumstances.

Is it a bad thing?

I recently attended a management course that concentrated on resilience in the workplace. Learning how to identify stress in your life and identify it in others is at the crux of this course. The above slide was put up and my mind immediately travelled to performance in the primary examinations. Examinations are stressful, but is this a bad thing?

The above graph looks different for everyone but displays some important points. The yellow section is where people perform best. It is called the “optimum stress” area and is where you want to be when you sit the vivas. You are tense yet motivated, your senses are heightened and you are prepared for the challenge ahead.

At the Olympics, what separates good athletes from extraordinary athletes is often their ability to perform in high stress situations. Most of the athletes are very similar in their fitness and physique, and it comes down to performance on the day. Two people with very similar skills and training can perform drastically different when faced with high-pressure situations.

Everyone has warning signs about when they are moving into the overload category, and when fatigue is becoming exhaustion. In this overload area, we tend to do less of our normal, healthy coping mechanisms (e.g. exercise) and our performance starts to decline. This overload of stress has been linked to impaired performance in military and in civilian populations.

Resilience: The capacity to recover quickly from difficulties; toughness.

The good news is that you can get better at identifying and managing the stress you inevitably feel when facing difficult and uncertain situations. Identification and management of stress, and building of resilience, is possible. The trick is to manage your stress and keep it within optimal levels in order to perform on the day. If you don’t have the tools in place to keep your stress in check, you’ll under perform on the day of the exam.

The key thing to understanding this is that you are indeed facing uncertainty—the outcome of your future has not been decided. It’s up to you to develop the beliefs and mental toughness that will get you through the next few weeks, and perform well on the day of the viva.

 

8 minutes….

With the exam rapidly approaching, I thought this would be a good time to address the 8 minute reading time. This is a time where you can read the questions and start planning your attack. You cannot write anything during this time, but you can have an internalised plan.

Easy things first…There are 15 questions to read during this time, read them well. There will be some repeat questions. Do not spend your 8 minutes thinking about the repeat questions. There may be questions that you think are repeats if you don’t read them properly so read them well!  There will be other new questions.  Some of these will be hard and one or two of them may seem impossible during the first read. Use your reading time to think about these new questions.

The things to ask yourself during this time are things such as “what are the key words in this question?” “WHY are the examiners asking me this question?” “WHAT about this topic is important?”. Vomiting an answer onto the page, without a plan or structure, does not fill the examiner with a feeling that you understand the topic. Whereas, if you have a structure to the question then the important points will hopefully follow. The better answers are often shorter than many of the other answers as they are efficient, and demonstrate that the candidate knows the topic well enough to know what is important.

When answering new questions, remember that this is an exam to enter anaesthetic training (more or less). Placing a whole bunch of random facts onto the paper will get you a few marks, but it won’t score you high marks. Stay calm, think about the question and have trust in yourself and the work you have done. Use the eight minutes to your advantage and think “structure, structure, structure (and handwriting!)”.

Good luck and stay strong!

Bleedy McBleedster

BT_PO 1.121

Describe methods to reverse the effect of warfarin

BT_PO 1.120

Describe the pharmacology of warfarin and other anticoagulant drugs

The metabolic clearance of warfarin is inhibited by amiodarone. TRUE/FALSE

Third generation cephalosporins reduce the anticoagulant effect of warfarin. TRUE/FALSE

Intravenous vitamin K should return the prothrombin time to a normal range within 1 hour. TRUE/FALSE

Skin necrosis is a side effect of warfarin therapy. TRUE/FALSE

Warfarin can be reversed with recombinant factor VIIa TRUE/FALSE

Big Owie

BT_PO 1.120

Describe the pharmacology of warfarin and other anticoagulant drugs

Warfarin has a mild effect on platelet function. TRUE/FALSE

Peak concentration of warfarin occurs at 36 hours. TRUE/FALSE.

Despite its low protein binding, warfarin has a long elimination half time after oral administration. TRUE/FALSE

Warfarin crosses the placenta and is found in significant levels in breast milk. TRUE/FALSE

The elimination half time of warfarin may be prolonged by volatile anaesthetic agents. TRUE/FALSE