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 itūüėȬ†– ¬†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!

Study tip: Answering SAQs – make the most of your unconscious brain, but don’t let it fool you….

Ok, that title is a little cryptic, but bear with me….

We have probably all had experiences when we are asked to recall something which we are sure that we know (for me this is often a person’s name), but seems impossible to drag up from the depths of our brain. We give up and then the answer just pops into our consciousness. Perhaps this is your unconscious brain at work.

How can you use unconscious brain to your advantage during the SAQs? As soon as you read the questions your brain will start working on them. Make sure that you read all of the questions carefully in the first 10 minutes. Spend a bit of time carefully checking to see exactly what the question is asking, as you want to set your brain off on the right track. I will assume that you have studied well and have a good knowledge base. In spite of this, some questions may initially seem tricky: perhaps the information doesn’t spring to mind; you may not be sure how to structure the answer. That’s ok – don’t panic! Panic is shocking for your memory. Send these questions to the unconscious mind and get on with answering the questions you feel more confident with. When the time comes to answer the questions that you have set aside, hopefully your mind will have worked on them in the background and that knowledge will be easier to access.

Now for your second part – don’t let the unconscious brain fool you. This part applies to your SAQ practice. I suspect, and hope, that all of you are practising past SAQs. How do you do this? Here are some options:

  1. Do you select 6 questions at the start of your study session to write at the end?
  2. Do you choose some questions the day before to attack the following day?
  3. Have you put a whole lot of individual past SAQs in a box, from which you randomly pick a selection to look at and answer straight away?
  4. Do you have a friend/colleague put a set of questions in a sealed envelope to open and answer under exam conditions?

If you picked 3 or 4 – perfect! You are receiving a true reflection of how you could answer that question in the exam. The results may be confronting, but it will show your where a brush up is needed.

If you picked 1 or 2, I would contend that you are giving yourself an advantage that you will not have in the exam. You are giving your brain extra time to work on these questions even if you consciously try not to think about them.

There are still a couple of weeks until the next written exam. It’s not too late to give yourself some good quality SAQ practise. Any holes that you find in your knowledge should be easier to learn as this information is likely to have meaning for you.

Good luck everyone!! I am not sure that I will be back on the blog until after the written, but I wish you all of the best…..

….and just to finish, I couldn’t leave you photo free.


“Brain” jellyfish, Mljet, Croatia

BT_PO 1.36 Discuss the physiological effects of hypoxaemia

Keeping with a similar theme….

I have to admit I was feeling a bit low on inspiration as I was writing this post and was wondering which LOs would be of specific interest to you, the reader.

If you have any LOs which you would  like to see a post on, please leave a comment and I will write on them at a future date. A full list of the more than 300 options can be found here

I have updated the¬†Oxygen Cascade¬†post to include quite a nice little article from BJA education…

…and here is another photo from the Plitvice Lakes….


BT_PO 1.36 Discuss the physiological effects of hypoxaemia, hyper and hypocapnia, and carbon monoxide poisoning

Hypoxaemia causes activation of the sympathetic nervous system  TRUE/FALSE

Hypoxaemia causes vasodilation in all tissue beds    TRUE/FALSE

Hb concentration rises acutely with hypoxia due to auto transfusion from the spleen TRUE/FALSE

Alveolar ventilation increases linearly as PaO2 falls below normal levels    TRUE/FALSE

In response to significant hypoxia, neuronal tissue initially becomes hyperpolarised TRUE/FALSE

BT_PO 1.41 Nitric Oxide

Staying on a vaguely respiratory topic….

This little molecule is actually mentioned in two LOs, so double bang for your buck today.


But perhaps Nitric Oxide itself will give you the most bang!!

BT_PO 1.41 Outline the pharmacology of drugs used to treat pulmonary hypertension including nitric oxide

BT_PO 1.58 Describe the pharmacology of anti-hypertensive agents and their clinical application, including the following agents:

  • nitric oxide
  • plus lots of others….


Nitric oxide is synthesised from l -arginine                                   TRUE/FALSE

Nitric oxide for inhalation is stored in cylinders diluted with nitrogen   TRUE/FALSE

Nitric oxide inhibits platelet activation                                           TRUE/FALSE

Inhaled nitric oxide improves oxygenation by reducing V/Q mismatch   TRUE/FALSE

Effects of NO on the immune system are beneficial                     TRUE/FALSE


BT_SQ 1.6 Oximetry

There have been a couple of posts on this topic before, but as we were talking about oxygen, I thought it might be worth revisiting.

Here is a comprehensive review of the sources of error with pulse oximetry, following a discussion of the principles. See the link to the CinderHK page below for more information on good references.


Slightly off topic, ¬†though I think fascinating, here is a picture of the absorption spectrum of different contaminants of glass. The glass used in long distance telecommunication fibre optic cables is ultra pure. The signal is transmitted in the IR spectrum, at about 1.5őľm, such that the attenuation of the signal is only 0.2dB per km! I took this photo at the Hong Kong Science Museum.

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

  • Oximetry
  • Plus heaps of others ūüėČ


Pulsatile venous flow may cause an over estimation of SpO2                              TRUE/FALSE

The red:IR absorption modulation ratio (R) equals 1 at SpO2 85%                      TRUE/FALSE

Intravenous injection of indocyanine green causes a transient reduction in SpO2   TRUE/FALSE

The accuracy of SpO2 in humans has not been calibrated below 70%               TRUE/FALSE

Red nail polish is likely to cause inaccurate SpO2 readings                                  TRUE/FALSE

BT_PO 1.23 Oxygen Cascade


This may seem like a pretty easy topic and, I agree, it is easy to memorise the step wise decreases in oxygen tension as you move from the atmosphere to the the tissue.

Why to these changes occur? Have you thought about the implications, on the oxygen cascade, of environmental and patient factors and how they may exacerbate the natural fall in oxygen partial pressure? Ask yourself these questions and, if you have a patient who is hypoxaemic, look to the oxygen cascade to give you an answer…

There is an great diagram, and accompanying text, in Ch 10¬†Nunn’s Applied Respiratory Physiology¬†which will help you with your exploration of this topic.¬†This¬†article from BJA Education also contains some good information.


The most amazing cascades I have seen, even in the pouring rain, ¬†–¬†Plitvice Lakes National Park, Croatia….

BT_PO 1.23  Describe the oxygen cascade

Increasing alveolar ventilation will generally increase PAO2     TRUE/FALSE

The effect of a low inspired oxygen concentration can be offset by increased alveolar ventilation TRUE/FALSE

Hypoxaemia caused by increased shunt can be overcome by increasing FiO2  TRUE/FALSE

A sudden reduction in cardiac output will cause an immediate decrease in PAO2 TRUE/FALSE

Diffusion capacity limits oxygen uptake at the the pulmonary capillary in the healthy subject at rest   TRUE/FALSE

BT_PO 1.132 Antiseptics and disinfectants, clinical uses and risks

This is perhaps not one of the most obvious topics to study, but when you think about it, every patient having surgery, and hence being looked after by us, will be exposed to one of these creatures. Probably a good idea to know something about them, especially their hazards….

There is a reasonable section on this topic in both ¬†Katzung¬†Ch50 and¬†Stoelting’s book¬†Ch41 (until recently unavailable on the ANZCA site – but it is there now, yay!)

For some “clean” is a highly overrated concept….


BT_PO 1.132 Outline the pharmacology of antiseptics and disinfectants, their clinical use and associated risks

Chlorhexidine can cause sensorineural hearing loss if instilled in the middle ear TRUE/FALSE

Povidone-iodine 10% aqueous solution is the only antiseptic which is non toxic to the cornea  TRUE/FALSE

Antiseptics are disinfectants which are safe to use on skin, wounds and mucous membranes    TRUE/FALSE

Providone-iodine is more likely to cause hypersensitivity than tincture of iodine TRUE/FALSE

It is essential to allow chlorhexidine skin preparation to dry before performing spinal anaesthesia   TRUE/FALSE

Study tip: Remember information more effectively 

Why is it that some things stick in our minds forever and others we have to work so hard to retain?

The Ebbinghaus forgetting curve shows that new information is lost exponentially without revision. It looks terrifying….

The Ebbinghaus experiments were done on himself, trying to remember short sequences of unrelated letters – most of us would find that hard. It has no context and is not meaningful for most people ( except if you like remembering strings of random letters!)

We have seen previously on this blog, that one way to help with retention of information is to revise the information regularly. This is important and to be most effective must use  active recall

There are other ways that you can give yourself the best chance of remembering the information you are learning in the longer term.

  1. Add the new information to a frame of knowledge that you already have – try to build your new knowledge on to well established memories. This is not always easy to do if learning totally new concepts. This technique could be used to layer information into your brain. It is a technique used by at least one previous part one candidate (see the 5th comment)
  2. Make the information you are learning meaningful. This one should be easier to achieve. We remember things that we think are important much more easily than things we don’t (which may explain why Ebbinghaus’s curve looks so pessimistic). Find relevance in what you plan to study. Build up a list of questions during your day at work – why did the blood pressure drop on induction? what might have caused that dodgy sats reading? – and study to find the answers when you get home.  This technique has also been used with success (see comment 6 in the above link). You will be using the knowledge gained through studying for the Primary Exam throughout your whole career – it’s your job.
  3. Look after yourself. Good nutrition, regular exercise, plenty of sleep and some time to relax, will all help your brain to function at it’s best. Do not under estimate the importance of this

As promised  the flying frigate bird – it’s a bit hard to photograph a moving target, but I did my best!


IT_GS 1.8 Physiological changes associated with pneumoperitoneum and their implications for anaesthesia

Another practical LO for today. Miller’s Anaesthesia used to have a chapter devoted to this topic, but unfortunately it has vanished from the current edition. There is however a quite nice little section at the end of Chapter 21

Here is another brief overview of anaesthesia for laparoscopy. In the middle there is a section on the physiological changes. It is worth remembering that a number of the effects are worsened as the intra-abdominal pressure generated increases (one of the reasons for the alarm on the gas insufflation machine).

This chap (a male frigate bird) doesn’t have a pneumoperitoneum, but rather an inflated gular pouch – apparently irresistible if you are a female frigate bird. They can fly with that pouch inflated (I’ll show you a photo of that tomorrow)


IT_1.8  Outline the physiological changes that occur with and the implications for anaesthetic management of pneumoperitoneum

Harking back to¬†yesterday’s post¬†what do you think the effect of pneumoperitoneum is likely to be on renal function?

A pneumoperitoneum causes activation of the sympathetic nervous system TRUE/FALSE

Release of a pneumoperitoneum may be associated the ischaemia-reperfusion injury TRUE/FALSE

Pneumoperitoneum may be associated with abdominal compartment syndrome TRUE/FALSE

Trendelenberg positioning can reverse some of the haemodynamic effects of pneumoperitoneum  TRUE/FALSE (what effect will it have on the respiratory consequences?)

Pnemoperitoneum reduces respiratory system compliance TRUE/FALSE

BT_PO 1.71 Explain the effects on anaesthesia on renal function

I didn’t realise that this LO existed – found it when I was looking for a renal topic to post on, as there seem to be a dearth of renal posts on this site.

This is actually an important topic as relatively minor reductions in renal function are associated with worse peri-operative outcome.

I don’t have any kidney photos. Below is the best I could do for the genitourinary system. There are a whole series of these (some much more X rated) on view at MONA


BT_PO 1.71  Explain the effects on anaesthesia on renal function

Any anaesthetic agent which results in a reduction of blood pressure is likely to reduce GFR   TRUE/FALSE

Attenuation of the stress response to surgery is renal protective   TRUE/FALSE

Volatile anaesthetic agents may provide protection against ischaemia- reperfusion injury of the kidney TRUE/FALSE

IPPV improves renal blood flow TRUE/FALSE

Metabolic acidosis increases the kidneys’ vulnerability to nephrotoxins TRUE/FALSE