The Hong Kong College of Anaesthesiologists

Final Fellowship Examination July/September 2007

Examiners Report
Dates and Venues of Examination
Written: 20th July 2007, Hong Kong Academy of Medicine Building.
Viva: 7th September 2007; 2nd Floor, Hong Kong Academy of Medicine Building.
OSCE: 8th September 2007; K11 Operating Theatre, Queen Mary Hospital.

External Examiner:
Dr. Patrick Farrell, ANZCA (Australia).
The external examiner took an active role in each section of the examination.

Internal Examiners:
Written : YF Chow, SK Ng, Theresa Hui, JC Lawmin, Edward Ho, Cindy Lai, Serena Fung,
PT Chui
Viva : YF Chow, SK Ng, Theresa Hui, Anthony Ho, Anne Kwan.
OSCE : CK Koo, Douglas Fok, WM Chan, WH Kwok, Bassanio Law, SK Ng, WS Chan,
Karl Young, Michael Poon, Matthew Chan, MK Yuen, Theresa Li, Serena Fung, Monica
Lee, KF Ng, Edward Ho, JC Lawmin, CH Koo, Anthony Ho.

OVERALL RESULTS
Eleven candidates presented for the examination and five candidates passed. The
overall examination pass rate was 45%.

WRITTEN EXAMINATION
The written examination consisted of two papers. Overall 4 out of 11 candidates
passed this section.

PAPER 1 – SCENARIO QUESTIONS

Scenario A
A 69 years old male has an implantable cardioverter-defibrillator (ICD) located in his
chest wall, below his left clavicle, to treat recurrent ventricular tachycardia. He presents
for arthroplasty of his right shoulder under general anaesthesia.
1. How would you evaluate his cardiovascular status preoperatively? (9/11 passed)
This question was reasonably well managed. However, many candidates did not know
all ICD had inbuilt pacemaker function. It was important to know whether the patient
was pacemaker dependent during the preoperative assessment. Only one candidate
would check magnesium level, in addition to potassium, of the patient preoperatively.

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2. What special precautions need to be taken intraoperatively to avoid problems related to
his ICD? (5/11 passed)
It was evident many candidates had not previously considered the issues of patients
with ICD for surgery under general anaesthesia. It was important to arrange for a
technician to disable the ICD in a monitored environment with a defibrillator readily
available. If monopolar diathermy was to be used, return pad should be placed such that
circuit would not pass through the ICD heart circuit, not simply away from the ICD. It
was surprising that most candidates would insert an arterial line. Only a few would
check appropriate filtering on the ECG monitor.

3. You decide to perform an interscalene block for post-operative pain relief. Describe the
anatomy relevant to this block and briefly outline your technique. (10/11passed)
In general, candidates handled this question well. A diagram was acceptable to provide
the information required. Better candidate would mention the anatomy of the three
trunks in relation to major blood vessels and nerves and their close proximity would
increase the risk of complication.

Scenario B
You are required to provide general anaesthesia for a 10-year-old boy with idiopathic
scoliosis for corrective surgery using a posterior approach.
4. Outline your pre-operative assessment. (5/11 passed)
This is a straightforward question. Most candidates focused on the cardiorespiratory
system and the potential problems of restrictive lung disease, pulmonary hypertension
and right heart failure. Routine investigations would include a full blood count, type
and screen, arterial blood gas, ECG, CXR, lung function test and if indicated an
echocardiogram. Better candidates went into a more detailed discussion of the criteria
for post-operative ventilation and other issues such as blood transfusion and the wake
up test.

5. Discuss the potential problems associated with the prone position in this patient. (8/11
passed)
This question was generally well answered with the candidates required to mention
about how to protect the eyes, the cervical spine, the brachial plexus and other
peripheral nerves, how to properly fix and secure the endotracheal tube and proper
chest and abdominal positioning on a frame. Only a few candidates mentioned about
abdominal malposition causing engorged epidural veins and increased bleeding and the
potential problem of venous air embolism.

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6. During the course of the surgery, SSEP monitoring suddenly indicates a serious
neurological problem. You are required by the surgeon to perform a wake-up test.
Describe how you would do this. (5/11 passed)
This question was generally poorly answered with many candidates obviously never
having seen or done such a test. The sequence of events is critical
• Stop the muscle relaxant infusion but maintain anaesthesia until 4 sustained
twitches are apparent on the train of four monitoring
• Stop the propofol infusion or turn off the volatile agent and reduce the opiate
infusion e.g. Remifentail to < 0.1 µg / kg /min
• Two observers are required, one at the head end and one observes the feet. Once
awake, then his feet. If able to do so, he is then reanaesthetised.

Scenario C
An 80 year-old woman has early dementia, but is otherwise healthy. She is scheduled for
cataract extraction of the left eye under general anaesthesia.
7. Outline the assessment and preparation of this patient before anaesthesia. (8/11passed)
Some candidates only gave an outline of a routine pre-anaesthetic assessment, covering
past anaesthetic history, drug allergies and co-morbidities. Better candidates were able
to cover the specific issues, including the causes, complications, and treatment of
dementia. An assessment of the patient’s preoperative cognitive function would
facilitate perioperative management, including anaesthetic consent, and other aspects
requiring comprehension and cooperativeness with health care workers. Few candidates
mentioned continuation of usual medications including sedatives, anti-depressant and
major tranquillizer. No candidate mentioned the potential interaction of central acetyl
cholinesterase inhibitor with neuromuscular blockers.

8. What cognitive disturbances are likely in this patient in the postoperative period?
Outline how these can be minimized in your anaesthetic management. (7/11 passed)
Most candidates recognized postoperative delirium as a possible postoperative
cognitive disturbance, but only a few mentioned postoperative cognitive dysfunction.
Even fewer candidates described their clinical features. Delirium refers to disturbances
in consciousness and cognition that tend to be acute in onset and fluctuate throughout
the day. Postoperative cognitive dysfunction refers to deterioration in intellectual
function, with impaired memory, concentration, language comprehension, and social
integration that lasts for months postoperatively. Candidates were expected to have
understanding of anaesthetic techniques that might minimize these complications in the
high risk patients. Candidates were better on the general supportive care, such as

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 normal oxygen, and carbon dioxide tension, body temperature and arterial pressure.
Few candidates discussed the importance of avoiding overdose of volatile anaesthetics
and drugs such as atropine, benzodiazepine, ketamine and pethidine. No candidates
mentioned that IV and volatile anaesthetics dosage requirements were reduced in the
elderly.

9. The patient became restless and agitated in the recovery room. Outline your
management. (10/11passed)
Most candidates discussed the initial crisis management of a patient who became
restless and agitated in the recovery room without considering the clinical context. The
initial crisis management, such as COVER ABCD, was an integral aspect. However, a
better answer should also cover the broader issues. In this patient, candidates should
consider emergence reaction of general anaesthesia, which would be transient and
self-limiting. The causes of acute delirium might include life-threatening causes such as
hypoglycaemia, hypoxia, and electrolyte disturbances. Simple causes included bladder
distension, unfamiliar environment, and visual and hearing problems. Treatment
included supportive and preventing harms, non-pharmacologic (e.g. minimizing
disturbances, lighting, and noise, and repeated explanation and reassurance), and
pharmacologic (e.g. haloperidol 0.5 mg IM or IV every hour as required).

PAPER 2 – SHORT ANSWER QUESTIONS

1. Discuss the important issues in the management of the anaesthetic for a 35-year-old
patient having debridement of extensive (30%) neck, chest and leg burns 3 days after
the injury. The patient has been managed unintubated in intensive care. (3/11 passed)
This is a straightforward question. It is expected that candidates should discuss the
anaesthetic management, rather than simply outline the problems, of a patient three
days after burn injury. However, quite a number of candidates failed to read the
question carefully and described in detail the initial management of this patient as seen
in the Accident and Emergency Department. The Parkland Formula for acute volume
resuscitation was also commonly mentioned in the answers. These irrelevant answers
will score no mark and will also mislead the candidate to continue to write irrelevant
answers. Potential difficult airway management, either due to airway oedema or neck
scarring, was not mentioned in half of the answers. One candidate wrote illogical
statement like “…rapid sequence induction, but make sure can ventilate patient before
rocuronium”. Vague statement like “pain can be difficult” but did not elaborate on
how he/she would manage the situation was not going to impress the examiner.

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2. Discuss the options to anaesthetise a 67 years old woman with Ca trachea for rigid
bronchoscopy and stent insertion. (0/11 passed)
This question was poorly answered. All candidates described their anaesthetic
management down to minor details without any discussion, which is what the
examiner asked for. Most of the answers wrote a lot of details to describe
preoperative assessment, most of which were routine and did not deserve lengthy
discussion. This would leave inadequate time for the candidate to DISCUSS
intraoperative and post-operative management. The examiner urges future
candidates to spend some effort to read the question, plan the answer and have better
time management. Some of the points expected in the discussion are:
• Assessment of severity of obstruction and optimization of co-morbidities.
• Importance of having surgeons and equipment ready before induction
• Pros and cons of inhalational vs. intravenous induction and maintenance
• Pros and cons of using muscle relaxants
• Pros and cons of various options of ventilation with muscle paralysis
• Management of intraoperative desaturation
• Risk of stent dislodgement and airway obstruction post-operatively.

3. You are to anaesthetise a 42 years old woman with Hunt-Hess Grade II subarachnoid
haemorrhage for endovascular GDC occlusion. What are the anaesthetic concerns?
(2/11 passed)
This is again a straightforward question. Many candidates just presented general
principles on neuro-anaesthesia but showed little understanding of the neurological
X-ray intervention procedure. Good answers will include preoperative optimization,
problems related to X-ray suite, the need for motionless patient, intraoperative
complications and pre-arrangements for urgent transfer in case of urgent craniotomy.
The importance of reading the question carefully is illustrated by an answer which
incorrectly pointed out that this conscious, oriented but drowsy patient had a GCS of
8/15. This translated (wrongly) into an urgent need for intubation as well as a consent
problem. The obvious outcome was precious time being wasted in writing an
inappropriate answer.

4. “Pressure control ventilation is better than volume control ventilation for intermittent
positive pressure ventilation in infants”. Discuss this statement. (0/11 passed)
The candidates were expected to provide a short description of pressure control and
volume control ventilation, compare the differences between the two modes, and then
how the differences might apply in ventilation of infants. A lot of the candidates
answered this question poorly with poor understanding of the physiology between the

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 two modes and mixed up the advantages of the two modes of ventilation when applied
to infants.

5. Describe the effects on a patient of a core temperature of 34° C at the end of surgery
and anaesthesia. (7/11 passed)
The answer to this question is straightforward and most candidates score well and
were able to provide a comprehensive list of effects. Some candidates did not do so
well with poorly organized answer and missing important points. One candidate
wasted time by describing how the temperature could be maintained during surgery.

6. Describe the major classes of anti-platelet drugs and their mechanism of action.
Comment on their safe use in conjunction with spinal anaesthesia. (8/11 passed)
Most candidates were able to give satisfactory answers to the first part of the question.
The candidates were expected to describe the major groups of antiplatelet drugs
including, cyclooxygenase inhibitors, the thenopyridenes ADP receptor inhibitors,
Glycoprotiein IIB/IIIA antagonists, and a brief descriptions of their mechanism of
action. Most candidates stated that Aspirin and COX inhibitors were safe with spinal
anaesthesia and that there were increased risks with the newer group of agents but
could not provide a length of time that the other drugs should be stopped before safe
spinal anaesthesia.

7. Discuss the prevention and treatment of maternal hypotension during spinal

anaesthesia for caesarean section. (2/11 passed)
Most candidates gave a technical answer and described how to conduct a spinal
anaesthetic. Candidates did not discuss the implication of maternal hypotension and
why it was important to maintain a normal maternal blood pressure. There was a lack
of discussion on the choice of fluids, vasopressors, dose of local anaesthetic and the
use of adjuvants in the spinal anaesthetic. Some candidates wasted time in crisis
management of a high spinal.

8. A 74-year-old female with no significant medical history is admitted for elective

laparoscopic cholecystectomy. Halfway through the operation she develops a
bradycardia of 40 bpm and you noted T wave inversion and ST depression on her
ECG monitor. Describe your management of this patient. (1/11 passed)
This question is asking intraoperative management of myocardial ischaemia and most
candidates gave a generic answer of crisis management without considering the likely
diagnoses and failed to prioritize their management.

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9. A 30-year-old woman is scheduled for laparoscopic examination for primary
infertility. She finds the statement “awareness whilst under general anaesthesia” in
the written consent form unacceptable and demands your explanation. She wants you
to promise her not having such horrible experience. Outline your management. (2/11
passed)
Most candidates did not write legibly. Many chose to answer the questions in
note/point form. There were too many abbreviations without explanation. Regarding
to the content of answer, most candidates listed out what they would do to minimize
the chance of awareness without further discussion on the rationale behind. Some
candidates wrote short notes on awareness instead of discussing the specific scenario.

VIVA EXAMINATION
The viva examination consisted of three vivas. Overall 5 out of 11 candidates passed this
section.

1 A 3 year-old presents for bilateral ureteric reimplantation, she weighs 16 kg and is

otherwise well. Her parents are very anxious about pain post operatively.
• The parents ask you to explain what options there are to manage their daughter’s
post-operative pain; briefly explain each technique/option, explain the risks and
benefits, and indicate your preferred technique.
• Following your discussion the parents request a single shot caudal. Describe how
you would perform the block including drugs and dosages.
• During injection you notice a decrease in heart rate, and a change in the T waves;
what do you do,
• You have decided to use desflurane as your general anaesthetic agent; what is the
MAC of Desflurane in this age group?
• Explain how you would use a circle system in this age group.
• The child develops acute spasms of lower abdominal pain post operatively, what
might this be and how would you treat it?

2. A 16 years old boy with Downs’s syndrome presents for MRI for investigation of
recent onset of epilepsy as a day stay patient. He weighs 85 kg with a BMI of 29 and is
generally well; he is treated with sodium valproate. He requires a general anaesthetic
because he is unlikely to cooperate and lie still, long enough for the scan.
• What are the major issues for general anaesthesia in the MRI suite?
• What are the major issues with this boy?
• How would you investigate his neck stability? What are you looking for?
• Outline your preferred anaesthetic technique for this boy?

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 • Half way through the procedure you lose the capnography trace what will you do?
• The patient is light, has coughed and is breath holding SaO2 = 93%. What will you
do now?

3. A 34 years old woman, G2P1, at 31 weeks gestation presents with mild vaginal
bleeding. She has one previous caesarean section. Her last pregnancy was complicated by
hypertension and she stopped smoking 5 months ago on the advice of her obstetrician.
• What are the common causes of antepartum haemorrhage?
• 24 hours later, obstetrician decides to proceed to caesarean section for placental
abruption. What anaesthetic technique will you use and why?
• A mildly depressed but otherwise healthy baby is delivered but there is significant
bleeding. What will you do now?
• There is still ongoing blood loss and you have already given 25 units RBC, 15 units
FFP, 6 units of platelets and 6 units of crypoprecipate. The obstetrician decides to
proceed to hysterectomy and ask you to do something to help to stop the bleeding.
What other medical treatment can be used?
• Bleeding decreases after activated Factor VII but there is pink frothy fluid coming
out of the endotracheal tube. PIP rises to 35 cmH2O and SpO2 drops to low 80’s
with 100% O2. What do you think is happening to the patient?
• How can TRALI be reduced?

4. A 35 years old woman G2P1 with a 35 weeks singleton presents with regular uterine
contractions. Her height is 157cm and body weight 125kg that gives a BMI of 50. Her
cervix is 3 cm dilated. The obstetrician asks you to evaluate her for labour analgesia.
• What are the medical / pregnancy-related complications of morbidly obese
parturient?
• How will you provide labor analgesia?
• Six hours later, obstetrician decides to proceed to caesarean section for failure to
progress. How do you manage anaesthesia of this patient?
• How do you manage anaesthesia if epidural catheter was dislodged on transfer of
patient to OT table?
• Fetal heart rate drops to 90 and obstetrician insists can’t wait for you to establish
regional anaesthesia. Describe how you administer GA in this morbidly obese
parturient.
• Operation was uneventful and a 4.5 kg infant was delivered. How should the
mother be managed post-operatively?

5. A 53 years old man with acromegaly presents for transphenoidal excision of his

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pituitary tumour.
• How would acromegaly affect your pre-operative assessment?
• How would you manage this patient’s airway for the operation?
• What anaesthetic technique would you choose?
• The surgeon tells you that the pituitary tumour is difficult to access surgically.
He asks you if you could perform any manoeuvre to optimize the surgical
exposure
• What complications would you expect for this operation?
• What special precaution would you take during emergence?
• Post-op Issues

6. You are to anaesthetize a 65 years old woman with a cerebellar haemangioblastoma in

the prone position.
• What would you look for during your preoperative assessment?
• What are the problems associated with prone position?
• She worries about postoperative blindness. How would you explain to her?
• Discuss the role of electrophysiological monitoring in this patient.
• During the operation, the surgeon has problem in achieving haemostasis and
complains of marked brain swelling. Describe how your management.
• Surgery was postponed and she develops high ICP postoperatively in the ICU
despite maximal support. She then develops fixed dilated pupils.
Describe the conditions and tests that would confirm brain stem death and
specify which cranial nerves are tested.
• Discuss the important issues in anaesthesia for a brain dead patient for organ
procurement.

7. A 75 years old man who had MI 2 months ago required emergency surgery for small
bowel obstruction. He had long history of NIDDM, HT, IHD and smoker. Medications: Oral
hypoglycaemics, Propanolol, Natrilix, Aspirin, TNG, Frusemide, KCl
• What are your anaesthetic concerns?
• What is your plan of anaesthetic management?
• Pre-op assessment and optimization
• Anesthetic technique and pain management
• Monitoring
• Post-op care
• How to minimize the risk of reinfarction?

8. You are called to the emergency room to assist in obtaining a head CT scan on a

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 24-year old uncooperative, disoriented male following a motorcycle accident.
• How do you proceed? (Initial vitals: BP 95/50; HR 112; SpO2 95%, RR 32)
• Why tachypnoeic and hypoxic?
• What is your anaesthetic technique?
• You decide to use general anesthesia. How to proceed?
• Would you use Sux? Adverse effects of sux?
• Would you apply PEEP for aspiration?
• What monitors would you use?
• What are the concerns in CT suite?
• During the CT scan, BP 60/40; HR 40. What would you do?
• Would you give steroid for cervical spine cord trauma?

9. A 70-yr-old man presents for a left total knee replacement. The operation was
scheduled 8 months ago. He had a paclitaxel-eluting stent placed 4 months ago in the LAD
and circumflex artery for angina. He has been angina free since. He has a history of DM,
obesity, smoking, and hypertension. Current medications are: metformin, adalat, aspirin,
clopidogrel. Physical exam reveals obesity and history of very difficult intubation
(confirmed by a past GA record) but otherwise is unremarkable. ECG and Chest XRay are
normal.
• How would you manage the patient?
• If the DES was inserted 13 months ago, how would you manage the patient?
• How long does the hypercoagulable state last after major surgery?
• How soon should one restart clopidogrel?
• What if the same patient is to undergo removal of a pin and plate from his ankle
put in 12 months ago, how would you manage the case?
• Would you do a spinal if both aspirin and clopidogrel are continued?
• How soon can one have elective surgery after bare metal stent placement?
• Explain the difference between bare metal and drug eluting stents and the
implications on perioperative management.
• If a patient is in need of surgery within a few weeks but has unstable angina
despite optimum medical therapy, what kind of stent would you recommend
before surgery?
• What kind(s) of surgery would you recommend cessation of dual antiplatelet
therapy in spite of the risk of stent thrombosis?
• What is the perioperative hypercoagulable state mainly due to? How would you
measure it?

10. A 70-kg-man has been admitted for left total hip replacement 5 days later. He has a

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bi-leaflet mechanical mitral valve placed 8 years ago. He has chronic atrial fibrillation with
a ventricular rate of 85/min. He is on warfarin and INR is 3. Examination reveals an obese
patient with a potentially difficult airway (history documented on previous GA). How
would you manage this patient?
• Discuss bridging therapy:
• Discuss choice of anesthesia – regional or GA
• If regional, spinal or epidural catheterization
• Discuss postoperative pain management

11. 65 year old man scheduled for elective right extended hepatectomy next week.
• Preoperative assessment.
• What is the difference between right and left hepatectomy?
• Describe Child’s classification in detail.
• Estimation of his postoperative liver function?
• Liver surgery may involve massive haemorrhage. What are anaesthestic
techniques that are available to minimize his blood loss?
• Patient with liver disease is more prone to renal failure. How can it be
prevented?
• What are the other frequently encountered problems with this type of
operation?

12. 68 year old man scheduled for laryngectomy next week.

• How you are going to access him?
• He seems to have difficult airway, how are you going to deal with this
problem?
• He has an almost obstructed airway, surgeon suggests tracheostomy under LA.
What are the associated problems? How are you going to anaesthetize him?
• What are the airway devices available for this type of operation?
• What are the advantages of different types of tubes?
• Half way through, you cannot ventilate, what are the differential diagnoses?
• How are you going to deal with this crisis?
• What are the other frequently encountered problems with this type of
operation?

OSCE EXAMINATION
The OSCE consisted of 10 stations. 6 out of 11 candidates passed this section.

Station 1: Communication. (8/11 passed)

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In this station, candidates adopted the role of a consultant anaesthetist and he had to
conduct an interview with his trainee to explain a medication error/incident to a relative of
whom her father had received double dose of the intended amount of epidural morphine for
post-op pain relief.
Candidates were tested on the following areas:
1. Communication skills - gesture, language, attitude
2. Ability to report the incident clearly without non factual / cover up comments
3. Professionalism - able to discuss the indication/ efficacy of epidural analgesia as
compared with other modes of post-op pain relief, expected effects of large dose of
neuraxial morphine, sound management plan with "overdosing" the epidural morphine in
this particular case.
Overall, the candidates were well-mannered. However, it was surprising when a couple of
the candidates tried to avoid admitting that double dose of morphine was given which had
contributed to the ICU admission. Most seemed to have trouble elucidating the technical
steps in placing an epidural catheter, which was what anaesthetists do during the pre-op
assessment everyday. Some candidates did not explain the advantage and thus the reason of
choosing epidural analgesia for this patient. Most candidates were able to give reassurance
to the relative but failed to discuss proactively the management plan after the incident. In
general, the candidates were nervous when confronted by the aggressive relative. Perhaps
more practice to speak in public, news breaking/ debriefing situations should be useful both
for examination and daily anaesthetic work.

Station 2 : Physical Examination (7/11 passed)

The patient was a middle-aged man with small ventricular septal defect with unambiguous
physical signs. Candidates were not required to pinpoint the exact anatomical diagnosis.
Rather, a proper cardiovascular examination followed by a logical deduction of the
differential diagnosis was expected. On the whole, the examinations were well done. But
many candidates focused on the murmur without describing the character of the heart
sound; which in this patient might help to distinguish between the various possible
diagnoses.

Station 3 : Physical Examination (8/11 passed)

The patient was a young lady with extensive bronchiectasis involving both lungs.
Candidates were, in general, able to perform the respiratory examination with reasonably
good technique. They were able to give clear instructions to the patient and motivate them
to perform appropriate maneuvers to facilitate their examination.
Candidates are advised to place more weight on proper examination techniques and correct
interpretation of signs rather than obtaining very exact and subtle clinical signs. It is also

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worthwhile to put more emphasis in correlating the physical findings with discussion of
other relevant investigations, such as blood gases or spirometry. When the Chest
Radiograph was shown to the candidates after the clinical examination, very few were able
to describe the typical ring like shadows or tramlines of bronchiectasis. Most of the terms
used to describe the radiograph, such as infiltrates or shadows, were too non-specific. This
reflected a lack of astuteness in reading chest radiographs.

Station 4 : ACLS/ATLS (7/11 passed)

The scenario was about a patient who sustained smoke inhalation, upper body burn, and
long bone fracture after a fire and explosion in an enclosed area. Candidates were asked to
provide resuscitation and initial managements of the patient without any hands-on
procedure on the manikin. They were expected to recognize the urgency of the situation,
give 100% oxygen and prepare for possible difficult intubation. After tracheal intubation,
candidates were expected to ventilate the patient with 100% oxygen due to possible carbon
monoxide poisoning, start circulatory support, calculate the area of burn, discuss amount of
fluid needed taking into account the extensiveness of the burn as well as the long bone
fracture. They were then asked about appropriate monitoring, investigations, managements
and possible differential diagnosis when patient developed CXR picture of early ARDS.
Most candidates managed the situation well. Those candidates who did not do so well were
slow to intubate the patient, needed prompting before mentioning smoke inhalation and
carbon monoxide poisoning, and underestimated the fluid requirement.

Station 5 : X-rays (1/11 passed)

The x-ray section comprised of 9 CXR's that were preceded by a brief clinical history that
gave the candidate good clues on what to look for. This is in keeping with real life where
one knows the history of each patient. The conditions included lobar pneumonia,
organising pneumonia with abscess cavities, chest trauma, old pulmonary TB, and lobar
collapse.
Suggestions for candidates:
• Make use of any opportunity during their training to review and report x-rays with
guidance from seniors and radiologists. These may be in the forms of X-ray rounds
in ICU, tutorials by radiologists, physicians or intensivists.
• Develop a systematic approach in assessing and reporting medical images
• Develop a vocabulary of precise radiological terminology such as "alveolar",
"airspace", "interstitial", "air bronchogram", "consolidation", "silhouette sign", etc.
to describe the nature or pattern of the abnormal lung field shadows instead of
"haziness", "opacity", and "shadow" that gave no indication as to the anatomical
position or nature of the abnormality.

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 • Listen carefully to the examiners instructions and information offered. E.g. Do not
waste time in saying such things as "this is a chest x-ray", "it is erect", "the film is
well-centered", etc when the examiners indicate that marks will be gained for
positive findings only.

Station 6 : Procedures (6/11 passed)

This station examined candidates on the selection of appropriate size double lumen tube for
a patient requiring one-lung ventilation for right thoracotomy.
Most candidates selected the correct side and size Bronchocath DLT based on the sex and
height of the patient. Fewer candidates knew how and where to measure the diameter of the
trachea and left main bronchus on the CXR and CT scan of the thorax. Candidates were not
familiar with making measurements on CXR and CT scan using the scale on the side of the
film. It was argued that candidates were not usually taught the method of selecting the
appropriate size DLT using measurement from X-ray films. However, it was felt that
specialist should be familiar with this method. Most candidates answered the question on
the Arndt’s connector well. Candidates who did well were also asked about the method of
one lung ventilation in infants and small children and most answered quite well.

Station 7 : Anatomy and Regional Anaesthesia (11/11 passed)

This station asked for the regional analgesia options for a child undergoing inguinal hernia
repair as a day case. Candidates were expected to discuss ilioinguinal/ iliohypogastric nerve
block and caudal analgesia. Overall the candidates' performance in this station was
satisfactory. However, not many candidates scored high marks. While all candidates had a
good working knowledge of the blocks involved, and could demonstrate the performance
of the blocks, as well as discussed the side effects/ potential complications of the blocks
satisfactorily, there were a number of common inadequacies. For instance, the knowledge
of using ultrasound guidance in performing ilioinguinal/ iliohypogastric block was
generally poor. Most candidates also failed to describe in detail the relevant anatomy with
respect to the blocks. A lot of candidates did not describe the procedures satisfactorily,
although they were not penalised if they were seen to perform the procedure correctly.
Some candiates apparently did not consider the "caudal" space as part of the epidural space.

Station 8 : Equipment (7/11 passed)

This station comprised of 3 parts :
1. Assemble and check the Laerdal/Ambu manual resuscitator
• Most candidates had difficulties in assembling the components together in a timely
manner, let alone checking the equipment. Assembling by trial and error could be

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 successful but time was wasted and little time was left for follow-up questions
which were aimed to test the candidates’ deeper knowledge of the equipment
2. Candidates were presented with a case of “difficult intubation and ventilation” during
ward consultation for intubation and were asked to assemble a “workable” needle
cricothyroidotomy set, using only available items in the ward.
• When given the choice, some did not choose the largest available IV cannula and
chose 16G instead of 14G.
• Most candidates were able to assemble a set that allowed oxygen insufflation
(when connected to a manual resuscitator) but failed to assemble one that could
provide adequate ventilation through the connection to a Manujet.
• A few candidates failed to appreciate that one could not ventilate a patient at all
when connecting the needle cricothyroidotomy set to the manual resuscitator
3. Identify circuits according to Mapleson’s classification
• Candidates are expected to know their circuits, despite some circuits might have
become historical interest. Most candidates were fair in their performance

Station 9 : Investigations (5/11 passed)

This station comprised of 6 questions that included ECG, electrolytes, blood gas and
acid-base, lung function test, haemodynamic data and polysomnography. This was a
non-interactive station and each question carried equal marks. Candidates would perform
better if they read the questions carefully before answering and spent more effort in time
management and planning.
• The importance of defibrillation instead of synchronized cardioversion in pulseless
wide complex tachycardia was not recognized by some candidates.
• Most candidates failed to distinguish syndrome of inappropriate ADH secretion
from cerebral salt wasting syndrome by noting the patient’s volume status and
urine output.
• With blood gas analysis, a number of candidates got the PAO2 correct but failed to
subtract the arterial PaO2 from PAO2 to give the A-a gradient, which was the
required answer.
• Many candidates had problems recognizing the spirometry pattern of variable
extrathoracic airway obstruction.
• Very few candidates could recognize equalization of cardiac chamber pressures
and made a diagnosis of cardiac tamponade from the haemodynamic data obtained
from pulmonary catheter.
• Most candidates did not know how to assess the severity of obstructive sleep
apnoea syndrome.

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Station 10 : Crisis Management (9/11 passed)
Majority of candidates did well in the crisis station. The scenario consisted of a critically ill
lady presented for emergency laparotomy. The pilot balloon of the tracheal tube was cut by
a trainee during suturing of left internal jugular venous catheter. Lung ventilation was
ineffective necessitating a change of the endotracheal tube immediately. The lady also had
pneumothorax and sepsis due to faecal peritonitis.
Candidates were expected to obtain a background history of the lady, in particular related
to airway management and demonstrate a technique to change the tracheal tube safely.
They had to identify clinical pneumothorax and sepsis. Appropriate management was
rewarded accordingly. Candidates were also expected to maintain a good communication
between the trainee and surgeon.

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