AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS

EXAMINATION REPORT

FINAL FELLOWSHIP EXAMINATION

APRIL 2000

THIS REPORT IS PREPARED TO PROVIDE CANDIDATES, TEACHERS AND

SUPERVISORS OF TRAINING WITH INFORMATION ABOUT THE RECENT
EXAMINATION AND TO ASSIST WITH PREPARATION FOR FUTURE EXAMINATIONS.

MULTIPLE CHOICE PAPER

Overall, 75% of candidates passed the MCQ paper. The table below outlines the average subject
performance in each subject category (noting that an individual question may have more than one
topic). The proportion of topics varies from exam to exam, partly as a reflection of subjects covered in
other sections of the exam. Of note, questions on neuromuscular disorders, regional anaesthesia and
obstetrics were answered poorly.

When sitting the multiple choice paper, candidates should be mindful that marks are not deducted for
mistakes and so every question should be attempted.

Description Number of Questions % Correct

neurosurgical anaesthesia 4 85.34
equipment 8 79.83
pain 7 79.59
cardiovascular disease 7 76.44
critical care 7 74.21
paediatric anaesthesia 8 74.19
shock resuscitation 6 71.86
cardiac investigations 4 70.45
medicine 10 70.24
liver disease 5 69.61
endocrine disease 4 66.88
haematological disorder 7 64.75
applied pharmacology 27 64.71
miscellaneous complications 6 64.50
pre-operative clinical assessment 7 64.19
monitoring 5 61.50
applied anatomy 10 61.25
applied physiology 10 58.05
neuromuscular skeletal 5 55.52
statistics 5 54.81
regional anaesthesia 9 40.40
neuropathy 5 35.06
pregnancy obstetrics 4 29.22
 2

SHORT ANSWER QUESTION PAPER

Overall, 66% of candidates passed the short answer section of the examination. For examples of the
style of responses considered acceptable, please refer to previous exam reports.

Candidates are reminded to carefully read each question and to answer only what is asked. Marks are
not awarded for ‘extra’ information which is not relevant to the question.

Question SAQ subject Pass

1 Abdominal Aortic Aneurysm - TOE vs ECG 75%
2 Abdominal Aortic Aneurysm - ATN prevention 65%
3 Abdominal Aortic Aneurysm - hypertension control 43%
4 Labour - Twins epidural technique 62%
5 Labour - Twins perineal analgesia 44%
6 Labour - epidural consent 84%
7 Alcohol on surgeon's breath 61%
8 Chronically impaired colleague 65%
9 Signs of alcohol abuse 73%
10 3 y.o. BSM - innocent murmur 64%
11 3 y.o. BSM - management VSD 60%
12 3 y.o. BSM - paracetamol pharmacokinetics 71%
13 Fresh gas flow - sevoflurane 74%
14 Diabetes insipidus 79%
15 Ankle block anatomy 71%

A patient is to have surgery for resection of an abdominal aortic aneurysm.

Question 1. What advantages does trans-oesophageal echocardiography have over ECG

monitoring for intra-operative myocardial ischaemia?

This question was generally well answered with most candidates recognising the different
sensitivity and specificity of the monitoring techniques. Candidates should have included
mention of the different time courses for changes in ECG and TOE findings and the limitations
of ECG monitoring.

Question 2. Justify the measures you would use to minimise the risk of acute tubular
necrosis if the surgeon is to clamp the supra-renal aorta.

Most responses included information about pharmacological as well as physiological methods.

An explanation of the reasons for choosing particular strategies was required, including both
before clamping and after cross clamp removal.

Question 3. What are the relative merits of sodium nitroprusside versus glyceryl trinitrate
for the control of hypertension when the aorta is cross-clamped?

Candidates had the most difficulty with this question in the group. An understanding of the
pharmacology related to clinical use of the drugs was required. The question asked for
relative merits and not a discussion of side effects not related to this application.
 3

You are asked to provide pain relief for a woman in labour. She is a primigravida, has twins and
is 5 cm dilated.

Question 4. You provide epidural analgesia. Describe and give reasons for your choice and
method of delivery of drug(s).

Many candidates simply gave recipe answers without explaining the reasons for their choice of
drugs and most failed to adequately give reasons for the method of drug delivery

Question 5. This patient is now ready for vaginal delivery, but perineal analgesia is
inadequate. Discuss the method you would recommend to remedy this.

Many candidates supported the use of paracervical block in this situation, which was
inappropriate. Again, recipe answers scored poorly as the question clearly asks candidates to
discuss their method of providing analgesia for delivery.

Question 6. Indicate elements you consider important when obtaining consent for epidural
analgesia in labour.

This question was the best answered in this section. Most gave an account of the consenting
process and in addition specific risks. However many candidates failed to describe the
problems encountered in active labour. In addition, many gave answers which were impossible
in practice.

You are asked to provide anaesthesia for an appendicectomy late at night. When you arrive, you
smell alcohol on the surgeon’s breath.

Question 7. How would you respond to this situation?

A number of candidates did not attempt to distinguish between the smell of alcohol and
impairment of surgical performance. Many failed to seek assistance from an anaesthetic or
surgical colleague in resolving the matter. A few candidates did not discuss the issue with the
surgeon

Question 8. What are your obligations if you suspect a colleague may be chronically impaired?

A number of candidates had no plan for coordinated intervention and only planned to discuss
the matter with the colleague themselves.

In answering this, consideration should include :

♦ Collection of factual evidence of chronic impairment and documenting such evidence
♦ The risk of suicide when an impaired colleague is confronted by the evidence
 4

Question 9. What are the signs of alcohol abuse in a colleague

This was the best answered part of the question. Common omissions were failure to mention
the possibility of observing physical signs of alcohol abuse and impairment of professional
performance.

A three year old child is being assessed for insertion of middle ear drainage tubes. On
examination you discover that the child has a precordial murmur.

Question 10. What information would you be seeking in your assessment of this child to decide
if the murmur is innocent?

Evaluation of a heart murmur appeared to be a new task for many candidates.

Question 11. If the child is found to have a ventricular septal defect, but is otherwise well, how
will this influence your anaesthetic management?

Many candidates overstated the physiological significance of an asymptomatic VSD and its
impact on anaesthesia

Question 12. Describe the pharmacokinetics and dosing schedule of paracetamol for post
operative analgesia.

There was generally good familiarity with the pharmacokinetics of paracetamol. Although the
question related to a paediatric case, a number of candidates gave broader answers.

Question 13. What are the considerations in setting the fresh gas flow rate when anaesthetising
an adult with sevoflurane in nitrous oxide/oxygen being administered using a
circle absorber system?

Many candidates focused on toxic compounds only, completely leaving out other areas such as
changing anaesthetic depth, dynamics of wash-in and wash-out, pollution and cost
considerations.

Question 14 Describe the pathophysiology and diagnosis of diabetes insipidus following head
injury

A number of candidates confused Diabetes Insipidus with the Syndrome of Inappropriate ADH.
 5

Question 15 Describe the anatomy relevant to providing an ankle block for amputation of the
great toe

Candidates are encouraged to use diagrams where appropriate – such as with an anatomy
question like this. Knowledge of the nerve supply to the foot was poorly understood by a
number of candidates. This question asked for anatomy relevant to ankle block – details of
drug choice and dose, toxicity etc. were not appropriate.

MEDICAL CLINICAL VIVAS

84% of candidates passed this section.

Points that candidates should note :

♦ Listen to what the patients say.

♦ ECGs were not interpreted uniformly well.
♦ Angina is not always manifested as pain but may present as other forms of discomfort.
♦ Functional assessment by history was often poorly done.

ANAESTHESIA VIVAS

84% of candidates passed this section.

The initial scenarios for the vivas are reproduced below.

You are called to assist the on-call registrar in intubating a patient with a neck haematoma
following a cervical fusion earlier in the day. The patient is a 66 year old male, Type II
Diabetic on Metformin and diet, with cervical myelopathy (Right C5,6) and has had an anterior
cervical fusion with iliac bone graft. He was noted as Grade II on earlier intubation, however,
after preoxygenation, Thiopentone and Rocuronium, the registrar is now unable to intubate.

A 24 year old 80 kg male motor accident victim has been admitted to the intensive care unit
following surgery for abdominal trauma. His condition is stable, but due to closed chest
injuries he remains intubated and ventilated. You are asked to review him in 36 hours
postoperatively because he has developed tachycardia and a temperature of 39.0 degrees.

A 7 year old falls from a bicycle at 7.00 pm and sustains a compound fracture of the skull near
the hairline anteriorly with a 3cm stone embedded in the wound. After transportation to your
hospital by air, she requires surgery at 5.00 am to repair the wound. Her history is remarkable
only for asthma, for which she takes occasional medication. She appears tired, wanting to
sleep, but is co-operative. The CT scan shows about half the stone lodged in the fracture and
pushing against the dura.
 6

An 85 year old woman is added to the emergency list for a laparotomy for suspected perforated
diverticulum and peritonitis. She is taking unknown medication for “heart problems”. On
examination she is in considerable pain and is peripherally shut down. Her heart rate is 90 per
minute, in atrial fibrillation with a blood pressure 105/80 mmHg and she has a 2.6 ejection
systolic murmur over her percordium radiating to both her carotids. There are no beds
available in your intensive care unit.

You are asked to assess a 60 year old man for a possible laparotomy for a small bowel
obstruction. He also has symptoms of double vision, dysphagia, dysarthria and generalised
muscle weakness. He has a 30 pack year history of smoking but has not smoked for 2 years.

A 45 year old patient presents for endometrial resection of a submucous fibroid. She has had a
heavy menstrual blood loss for several months and complains of increasing tiredness,
exertional dyspnoea, cough and palpitations. She has a past history of rheumatic fever and has
been told she has a mitral heart murmur. Her only treatment is iron replacement.

You are the consultant on call. The registrar phones you on Saturday at 3.00 pm to say that the
recipient for the renal transplant has arrived. The operation is scheduled to start at 5.00 pm.

You are the anaesthetist on a retrieval term sent to a remote farm where a building accident has
occurred 8 hours ago. A 40 year old labourer is trapped under a collapsed wall. He is prone
and is pinned by masonry lying on his legs. You are unable to access his head. On your arrival
the initial observations are mild confusion, PR 120, BP 100/80 and a respiratory rate of 32/min.

A healthy 25 year old multiparous woman had an uncomplicated vaginal delivery three hours
ago, but since then has had vaginal bleeding for which the surgeon now plans to perform an
examination under anaesthesia and uterine curettage. The student nurse reports the patient has
lost about 500ml of blood since delivery.

A 30 year old, 130 kg primaparous woman with a breech presentation presents at term for
elective caesarean section. Otherwise the pregnancy has been uneventful. She requests
regional anaesthesia for the procedure.

A 60 year old woman with a long history of rheumatoid arthritis presents with increasing
headache two weeks after a fall and minor head injury. A CT scan shows that she has a
subdural collection with requires surgery.

A 75 year old 85kg female presents for revision total hip replacement. Her relevant past
history includes osteoarthritis, high serum cholesterol, a single episode of classical angina two
years ago and an uneventful general anaesthetic one year ago for carpal tunnel release. General
anaesthesia for primary hip replacement was uneventful. Her activities are very limited by hip
and knee pain and she has experienced significant weight gain. Her only medications are
paracetamol and cholestyramine.

You are working in a large rural base hospital and are called to the emergency room where a 7
year old boy has been brought in by ambulance following a house fire.

A 65 year old male presents for trans urethral resection of his prostate gland. He is a
paraplegic following thoraco-abdominal aortic aneurysm repair.

There is a 4 year old boy with a history of nocturnal snoring on your day surgery ENT list for
adenotonsillectomy.
 7

You are asked to transport a 40 year old patient from the Intensive Care Ward (ICU) to the
Radiology Department and to manage the patient for a head CAT (Computerised Axial
Tomography) Scan. The patient is not intubated, breathing supplemental oxygen, slightly
confused but conscious. There is an underwater chest drain in place.

A 54 year old woman who is a recovered alcoholic presents for her fourth resection of recurrent
benign laryngeal papillomata. She is very hoarse and develops stridor when trying to breathe
quickly or deeply.

You are an anaesthetist accompanying a surgical team to procure the heart, liver and kidneys
from a donor in a large provincial town. On arrival in the Unit, the donor’s distraught spouse
states that the right foot moved in response to rubbing the heel. You are asked to certify the
presence of Brain death

CHAIRMAN
FINAL EXAMINATION

DISTRIBUTION College Council Supervisors of Training

Regional Education Officers Panel of Examiners
Registered Trainees