Study Tips: “I keep six honest serving men (they taught me all I knew); Their names are What and Why and When And How And Where and Who.” – Rudyard Kipling, The Elephant’s Child

The vivas are over for another year, which means that it is less than six months until the next written exam.

For those of you planning to sit the first exam in 2018 it is probably time to revisit your study plan to see how you are tracking.

For those aiming for the second sitting next year, it is time to put pen to paper and make a study plan and timetable.

Here is a list of  the types of resources you could include:

  • ANZCA Curriculum (Learning outcomes mapped to the primary examination) – here is great site
  • Online MCQ collections (a previous study tips post covered the Black Bank and also applies to newer collections)
  • Past SAQ papers (including examiner reports)
  • Operating theatre teaching – Rudyard Kipling can help with this one
  • Primary LO of the Day (a bit of recursive promotion)

  • Other internet resources (try googling ‘anaesthesia exam technique resources’)
  • Study notes from past trainees – bear in mind that the real benefit of study notes comes from creation not consumption
  • Exam technique resources
  • Psychology support – managing exam anxiety

If there are others you know about feel free to leave a comment below.

Aviation 2 – Duel in the Stratosphere

To add to the interest, we will be following the fortunes of two remarkable pilots from World War Two.

Flying Officer’s Emmanuel Galitzine and G.W.H. Reynolds were Spitfire pilots who, in 1942, came up against German Junkers 86 (Ju86) high altitude bombers in two different theatres of war: Galitzine over England and Reynolds over North Africa.

To understand the incredible feats of these pilots it is important to know that some high altitude duels happened at over 40,000 ft and that the Ju-86’s had pressurised cabins but the Spitfire’s cockpit did not.

BT_PO 1.22 Describe the composition of ideal alveolar and mixed expired gases

Using the alveolar gas equation, calculate the alveolar oxygen tension at each of the following altitudes.

Altitude      Atmospheric pressure

18,000 ft     380 mmHg (Mt Everest Base camp)

33,000 ft     190 mmHg

40,000 ft     142 mmHg

45,000 ft     111 mmHg

50,000 ft     87 mmHg

Did you allow for changes in carbon dioxide tension caused by the response to hypoxaemia?

Our Spitfire pilots had face masks and regulators that allowed delivery of up to 100% oxygen.

Re-calculate the alveolar oxygen tensions at the altitudes above assuming 100% oxygen was being administered.

Do you think 100% oxygen would have allowed our pilots to function at these altitudes?

What else could be done to improve oxygenation in this situation?

How might the effective atmospheric pressure be increased?

Aviation 1 – Introduction

Today we start a periodic series of posts with an aviation theme.

I am sure you have heard tropes comparing aviation and anaesthesia: human factors, crisis management, check lists, take off, cruise and landing to name a few.

You may not be aware that many physiological principles relevant to anaesthesia are also relevant in aviation and space travel.

The environmental stressors experienced by pilots and astronauts are similar to those experienced by patients, but magnitude of these stressors and the physiological effects can be more extreme.

Thinking about these effects can test and hopefully extend your understanding of the underlying principles.

There is only one primary exam learning outcome (BT_PO 1.37) that specifically mentions altitude and this has been the subject of previous posts.  There is also one in the final exam curriculum (SS_IC 1.102).

However there are many others that have relevance to aviation physiology.

BT_SQ 1.6 Describe the methods of measurement applicable to anaesthesia, including clinical utility, complications and sources of error in particular: 

  • SI units 
  • Measurement of volumes, flows, and pressures, including transducers

Pressure is measured in different ways throughout anaesthesia and a working knowledge of conversion factors between various units is important.

TRUE/FALSE  1 atmosphere (ATM) = 760 mmHg

TRUE/FALSE  29 psi = 200 kPa

TRUE/FALSE  30 cmH2O = 22 mmHg

TRUE/FALSE  5 kPa = 40 mmHg

Some harder ones:

TRUE/FALSE In aviation, altitude is measured in feet not metres

TRUE/FALSE There is an exponential decline in pressure with increasing altitude

TRUE/FALSE There is a linear decline in temperature with increasing altitude

BT_RT 1.39 Interpret blood gas analysis in respiratory failure

TRUE/FALSE  When breathing room air, an arterial PO2 of less than 20 mmHg is not compatible with life.

TRUE/FALSE  Respiratory failure is ruled out if blood gas analysis shows an arterial PCO2 of 27 mmHg.

TRUE/FALSE  Generally, arterial PO2 gives a better indication of respiratory failure in comparison to arterial PCO2.

TRUE/FALSE  Arterial PCO2 in excess of 85 mmHg is usually never due to iatrogenic causes.

TRUE/FALSE  It takes only 30 seconds to develop hypoxaemia with acute hypoventilation in room air.

BT_SQ 1.19 Describe the principles of surgical lasers, their safe use and the potential hazards

TRUE/FALSE  CO2 lasers may cause retinal damage if protective eyewear is not worn

TRUE/FALSE  Nd-YAG lasers cause injury confined to the cornea if eye protection is not worn

TRUE/FALSE  A laser may ignite material under a drape without igniting the drape

TRUE/FALSE  “Laser” stands for light amplification by stimulated electron radiation

TRUE/FALSE  Laser hazards include atmospheric contamination

Remember the Primary Exam does not define you

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The viva component of the exam is almost upon us again. I sincerely hope that all of you sitting over the next few days, leave the exam with a sense of calm, knowing that you have done everything you can…

Last exam sitting, I posted  The primary exam does not define you. The sentiments of the post hold true and I would encourage those of you sitting to read it.

Today, as the examiners finalise and double check their questions, I hope that you are able to spend some time doing something which brings you joy…

 

Dress for Success

As an examiner I’m often asked how a candidate should dress for the Viva. The answer is simple. Dress in the same way as everyone else – perhaps sharper and neater if you really want to make the best impression – but not “different”.

Why should this be so? Surely the examiners should be professional enough so as to render what is on the “outside” completely irrelevant? This is true to an extent – and we do try – but examiners are only human. Impressions count. You want to make a statement with your knowledge, not through any need to express yourself as someone who rejects professional norms through a highly individualised dress sense.

So what does this actually mean? For men, dark suit and tie, neatly worn. Borrowed is generally a bad idea. Wear the tie like you don’t completely resent its very presence. Similarly for women – dark coloured professional attire is what most of your candidate and examiner colleagues will be wearing. If you front up wearing fluorescent orange (yes, it has happened) the examiners’ cortices will try and get over it – but their amygdalae won’t. And that’s just not a conflict that you want to trigger.

In a nutshell, come groomed as though you’re attending a job interview – which in a sense, is what it is.

And for those of you sitting next week – we sincerely acknowledge how you’re feeling, and wish you all the very best.

SS_OB 1.11 Describe the pharmacology of tocolytic agents with particular reference to beta 2 agonists, calcium antagonists, magnesium, inhalational anaesthetics, nitrates and NSAIDS

TRUE/FALSE  Sublingual GTN spray can be used as a uterine relaxant during Caesarean section

TRUE/FALSE  The emergency management of eclamptic seizures includes the administration 4g of Magnesium sulphate by intravenous (bolus) injection

TRUE/FALSE  Exposure to NSAIDs after 30 weeks’ gestation is associated with an reduced risk of premature closure of the fetal ductus arteriosus and oligohydramnios

TRUE/FALSE  Nifedipine is contraindicated in pregnant women with pre-existing cardiac disease

TRUE/FALSE  Calcium channel blockers are associated with a higher incidence of neonatal respiratory distress syndrome than other tocolytic drugs

SS_OB 1.7

SS_OB 1.7 Describe the changes in the anatomy of the maternal vertebral column, the spinal cord and meninges relevant to the performance of a central neuraxial block including epidural, spinal and combined spinal-epidural, with appropriate surface markings

 

TRUE/FALSE  The risk of inadvertent venous puncture, with epidural placement in pregnant women, is the same as in the non-pregnant population

TRUE/FALSE  The line joining the iliac crests (Tuffier’s line) may transverse the body of L5 in late pregnancy

TRUE/FALSE  Epidural space pressure may be positive during labour

TRUE/FALSE  Epidural veins are engorged in late pregnancy

TRUE/FALSE   The ligamentum flavum softens during pregancy

SS_PA 1.80 Describe the maximum safe doses of local anaesthetic agents in different age groups

TRUE/FALSE  Neonates are more prone to develop methaemogolbinaemia with prilocaine administration due to the presence of foetal haemoglobin

TRUE/FALSE  Transfer of local anaesthetics across the placenta is inversely proportional to drug lipophilicity

TRUE/FALSE  Methaemoglobin reductase requres NADH as an electron donor

TRUE/FALSE  Methaemoglobin reductase is functionally deficient in the neonate

TRUE/FALSE  Children are more prone to cocaine toxicity due to reduced cholinesterase activity