The Hong Kong College of Anaesthesiologists

Final Fellowship Examination March/May 2006

Examiners Report
Written examination 17th March 2006
Viva examination 19-20th May 2006
OSCE examination 21st May 2006

External Examiners:
Dr Glenda Rudkin, ANZCA (Australia)
Dr Mark Heining, RCA (UK)
The external examiners took an active role in each section of the examination.

Internal Examiners:
Written: CT Hung, YF Chow, Theresa Hui, PT Chui, CK Chan, Edward Ho, SL Tsui
Vivas: Simon Chan, Edward Ho, CT Hung, Andrea O’Regan
OSCE: Matthew Chan, Simon Chan, WM Chan, PW Cheung, Amy Cho, YF Chow,
Serena Fung, Edward Ho, CK Koo, WH Kwok, Cindy Lai, TW Lee, SK Ng, Andrea
O’Regan, Peggy Tan, Steven Wong, BH Yong, Karl Young

OVERALL RESULTS
Twenty candidates presented for the examination and twelve were successful. The
overall examination pass rate was 60%.

WRITTEN EXAMINATION
The written examination consisted of two papers. Overall, 13 candidates passed this
section. Candidates are reminded to pay attention to key words in the questions. For
instance, in Question 9 of Written paper II, candidates, being asked to “justify” a
technique, would be expected to “show reasons for decisions or conclusion”.
Candidates would have failed for limiting the discussion to reasons against the
technique. In addition, candidates should not waste time in providing irrelevant
information that is not required by the question (see Q6 Written Paper II). In general,
understanding and awareness of everyday practice, clinical and institutional, often
will provide useful clues to answering questions (see Q7 Written Paper II).

PAPER 1 – SCENARIO QUESTIONS

1) A 29-year-old woman presents with acute cholecystitis for laparoscopic
cholecystectomy. A gangrenous gall bladder is suspected. She is 22 weeks pregnant
and the surgeon requests you to provide anaesthesia for essential surgery.

a) In your preoperative assessment of this woman, what are you going to explain to
her regarding risks to her and her foetus?

Eleven candidates passed this question. Most candidates covered both surgical and
general risks, without specific reference to anaesthesia risks. Better candidates had
more organized and structured approach in answering the question. Some answers
were not risk-directed, and overlapped with perioperative management in the other

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part of the question. Few candidates discussed the significance of the mentioned risks.
Reassurance to the mother during the explanation was often missed.

b) Outline the principles of your anaesthetic management for this woman and foetus.

Fifteen candidates passed this question. Poor candidates spent excessive description
on specific steps of management while omitting a complete outline of the principles.
Some candidates concentrated mainly on assessment which was only part of the
whole management. Significant number of candidates did not mention preoxygenation
and limiting penumoperitoneum.

c) Outline your postoperative care of this patient and her foetus in the first 24 hours.

Eleven candidates passed this question. Answers were in general too brief. Better
candidates discussed monitoring of foetal heart rate and uterine activity, including
aggressive management of perterm labour if necessary. The mother should be
managed with adequate anaglesia and antiemetics, allowing early mobilization to
prevent thromboembolic complications. The major omissions included postoperative
management of the patient in the setting of HDU with obstetric involvement, and
management to maintain foetal perfusion, such as oxygen supplement, and lateral
uterine tilt.

2) A 56-year-old woman with insulin dependant diabetes is scheduled for elective

craniotomy and resection of left cerebellar pontine angle tumour

a) The surgeon is planning to monitor cortical somatosensory evoked potentials

(SSEP), lower cranial nerves electromyography (EMG), and brainstem auditory
evoked response (BAER). State how the use of these monitors might affect your
choice of anaesthetic technique and which technique you would choose.

Only eight candidates passed this question. Most candidates were just able to give an
account of using TIVA, opiates and avoiding muscle relaxant for this procedure. Few
candidates knew about the anaesthetic effect of nitrous oxide, volatile agent , opiates
and temperature on SSEP and BAER. Candidates were not expected to have practical
experience in the monitoring of SSEP, BAER and EMG. However, candidates were
expected to have knowledge of the effects of anaesthetics on these electrophysiologic
monitors, which should be attained during rotation to the neuroanaestheisa module.

b) Discuss the peri-operative management of this patient’s diabetes mellitus.

Fourteen candidates passed this question. Most candidates realized that tight control
of blood sugar was very important in preventing complications such as wound
infection, and exacerbation of ischaemic injuries. However few actually knew the
desired level of blood sugar that should be maintained. Common omissions included
the discussion that steroid and perioperative stress would cause blood sugar to be
markedly increased, necessitating prompt treatment. Some condidates also failed to
discuss that frequent monitoring of blood glucose and constant re-adjustment of
insulin dosage would be the cornerstone of ensuring tight control of blood sugar.

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c) Following an uneventful 8 hours procedure the patient is transferred to recovery
room extubated, awake and obeys commands. Her cardio-respiratory parameters
are stable. After 20 minutes the recovery nurse informs you that the patient’s GCS
has dropped to 7. State how you will manage this, highlighting the possible causes.

Fourteen candidates passed this question. Most candidate answered this question quite
well. After acute airway management and correcting the metabolic factors, emergency
head CT scan would be mandatory. The management should be co-ordinated with
surgeons making plans for the possibility of re exploration, and booking and transfer
to the operating room.

3) A 30-year-old man is scheduled for video-assisted thoracoscopic pleurodesis for a

left pneumothorax which he developed during his latest attack of acute severe
asthma. He has had chronic asthma requiring frequent hospital admissions since
childhood. He was discharged from the intensive care unit 4 days ago. His current
medications are salbutamol and beclomethasone inhalers prednisolone 30 mg
daily.

a) Discuss assessment and preparation of this patient before anaesthesia and surgery.

Thirteen candidates passed this question. The candidates were expected to summarize
the potential problems in an asthmatic patient who had a recent attack of
pneumothorax and required one lung ventilation. The assessment of the patient
should target the concerns and potential problems of this patient. The preparations
should mention optimizing the condition of the patient with medications, steroid, and
chest physiotherapy, liaison with surgeon, and the use of premedications.
Most candidates covered the major points required to pass but some of the answers
were poorly organized and presented. Many candidates wasted time by putting in
general and non-specific points, or giving a list of investigations without mentioning
how they would be applied to this patient.

b) Twenty minutes after instituting one lung ventilation, the patient’s pulse oximetry
reading decreases from 97% to 88%. List the differential diagnosis. How would
you manage this situation?

Seventeen candidates passed this question. The question was relatively straight
forward. Most candidates appreciated the urgent situation and gave an appropriate list
of differential diagnosis and management. The better candidates were those that came
up with a systematic approach to the whole process and therefore not missing any
important diagnosis and management.

c) Seven days after the operation, the patient complains of persistent hoarseness. You
are asked to review him. Outline the likely causes and your management.

Fifteen candidates passed this question. Candidates were expected to provide possible
causes due to local damages by the cuff and the tube, damage to nerve and arytenoids,
and other causes unrelated to the anaesthesia. The management would include
assessment of the patient, referral to ENT service for a diagnosis, and management of

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the problem. Those candidates who failed could not provide a satisfactory list of the
differential diagnosis and the appropriate management.

PAPER 2 – SHORT ANSWER QUESTIONS

1) A 50-year-old ex-drug addict is scheduled for debridement and secondary suture of
a left thigh ulcer. He is currently on methadone maintenance of 30 mg per day.
Discuss your anaesthetic and pain management for this patient.

Sixteen candidates passed this question. Candidates performed well overall in this
question. The concerns for this opioid-dependent patient included balancing the
requirements for adequate pain relief and avoidance of withdrawal, with risks of
prescription opioid abuse behaviours. Poor candidates failed to discuss the central and
peripheral regional anaesthetic technique, oral and IV opioid conversion, use of non-
opioid modalities and iv PCA. The risks of opioid agonist-antagonists, such tramadol,
were in general not appreciated. Candidates can refer to the review article: Peng PW,
Tumber PS, Gourlay D. Review article: perioperative pain management of patients on
methadone therapy. Can J Anaesth. 2005;52:513-23.

2) A 50-year-old man presents for inguinal hernia repair. He is known to have

acromegaly. Highlight the specific anaesthetic problems which may arise from this
condition.

Eleven candidates passed this question. On the whole, candidates did well with the
co-existing medical problems of acromegaly, such as hypertension, diabetes mellitus,
and cardiomegaly. However, only better candidates were able to discuss more
practical anaesthetic problems such as difficult venous access because of soft tissue
hypertrophy, thickening of laryngeal soft tissues requiring smaller-sized tracheal tube,
and musculo-skeletal problems resulting in difficult surgical positioning. A few
candidates failed to discuss the potential of obstructive sleep apnoea and its
anaesthetic implications.

3) Describe the patterns of peripheral nerve stimulation that can be used to monitor
non-depolarising neuromuscular blockade during anaesthesia. How is each used
in clinical practice?

Nineteen candidates passed this question. In general, candidates did well overall with
this straight forward question. Nearly all candidates were able to describe the train-of-
four and the post-tetanic count. However, a few candidates omitted the single twitch
and tetanic stimulation. Even these are not used commonly, candidates were expected
to describe these modes, and their clinical limitations. A few candidates also showed
mis-understanding of the double burst compared with the train-of-four.

4) List the possible causes of non-surgical postoperative visual loss and outline its
prevention.

Twelve candidates passed this question. This question was generally well answered.
Good answers would classify the causes, identify both procedure-dependent and
patient-dependent risk factors and outline manoeuvres to lessen the risks accordingly.
Candidates are reminded to explain their abbreviations.

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5) Evaluate the clinical benefits of sevoflurane and desflurane in paediatric
anaesthesia. (Cost-benefit analysis NOT required)

Ten candidates passed this question. Most candidates were able to give an overview
of the advantages of both sevoflurane and desflurane in clinical practice like faster
induction and emergence from anaesthesia due to their low blood gas partition
coefficients. Only a few candidates mentioned the problem of emergence delirium or
agitation in paediatric patients. MAC values of both agents in children, when given,
were incorrect. It was disappointing when candidates provided answer like ‘both
desflurane and sevoflurane do not cause respiratory depression’!

6) A 90-year-old man presents with a fungating mass on the vertex of his head that
requires excision and a local rotational flap. Describe the sensory innervations of
the scalp and outline the nerves block you will perform to completely anaesthetize
the scalp.

Eight candidates passed this question. This was a straight forward question.
Candidates who did not score well obviously lack knowledge of the anatomy of the
scalp region. A few candidates mentioned sedation, monitoring, and consent which
were not asked in the question.

7) Write an account of the factors, with examples, that lead to the occurrence of
mishap during clinical anaesthesia.

Four candidates passed this question. This question was poorly answered. It is
disappointing that so many candidates failed this question, which could have been
answered well with common sense. Most candidates did mention some of the
essential points, but only a few organized these points systemically to cover all the
important aspects. The answer shall include: patient factors (e.g. poor risk, difficult
airway) and surgical factors; anaesthesiologist factors like inadequate vigilance
(fatigue) and/or experience; environmental factor like unfamiliar locations outside
operating theatre and lack of suitable assistants; institutional factors like provision of
up-to-standard equipment, drugs and departmental protocols in routine checking of
machines, handover of cases, coverage of junior staffs, as well as clinical audit to
identify underlying risk factors before mishap occurs.

8) Outline the advantages, disadvantages and risks on the use of transdermal fentanyl
patch in cancer pain management.

Eleven candidates passed this question. This question was not well answered. It could
be due the candidates’ lack of experience and clinical exposure to cancer pain control.
Many candidates failed to point out the special adavantage of fentanyl patch like
bypassing the enteral route, as many cancer patients had gastrointestinal problems
(emesis, obstruction or fistula formation). Transdermal fentanyl patch allow a non-
enteral but non-invasive route (in contrast to injections) for potent opioid
administration. Other advantages include a constant long analgesic action lasting for
72 hours. The latter can also lead to the potential risk of relative overdose due to the
changing condition of the patient. The fentanyl skin depot will take a long time to be

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cleared (T1/2 about 17hours). Also the risks of accelerated absorption due to local
warming or through an open wound were seldom mentioned.

9) A healthy 19-year-old man undergoes general anaesthesia for reduction of a

fractured nose. Justify the use of a laryngeal mask airway for this surgery.

Fourteen candidates passed this question. This question is well answered overall.
Most candidate gave an adequate discussion on the advantages over alternative
techniques like intubation, and limitations of LMA (e.g. failure to protect airway from
aspiration). However, a few candidates only discussed reasons for not using a
laryngeal mask for the surgery, and did not answer the question. To “justify” is to
“show reasons for decisions or conclusions”. Candidates are reminded to pay attention
to key words in the questions.

VIVA EXAMINATION
The viva examination consisted of three vivas. Overall, 9 out of 20 candidates passed
this section. As this is a qualifying examination for the specialist, candidates should
be prepared to state their decision or diagnosis. They should never appear reluctant to
do so. Answers given should be specific and concise. They should not hope that by
saying a lot of things, the examiners wound extract the correct material and gave them
good marks. This is especially true when answering scenario questions where some
candidates tended to wandered off to talk about more general patients. Also about
medical consultation, the problem will not be solved by just referring a patient to the
physician, and the specialist is also expected to know the general principles of some
medical assessment or management of complications.

SCENARIO BASED QUESTIONS:

45 yo woman with Cushing’s Disease is scheduled for transsphenoidal resection of
pituitary macroadenoma. Periop management plan , intraop ST depression and
hypertension, polyuria in recovery.
3 yo with cerebellar tumour. Anaesthetic management of posterior fossa surgery,
cerebral physiology of 3 yo, intraop high airway pressure alarm, and major blood loss
3 yo suspected brain tumour. Sedation in your hospital’s newly opened MRI suite.
45 yo woman with severe depression. Assessment of patients for ECT-/contra-
indications/ assessment of ‘room readiness’/physiological changes with ECT
50 yo woman with a huge goitre and thyrotoxicosis for subtotal thyroidectomy. Preop
assessment, airway management, controlled hypotension, venous air embolism,
postop airway compromise.
9 yo boy post-tonsillectomy bleeding for emergency haemostasis. Peop assessment,
possible causes for the bleeding, management of anaesthesia and postop care.
50 yo man with bilateral nasal polyps for FESS. Preoperative assessment, intraop
bleeding, induced hypotension, prolonged unconsciousness postop.
65 yo man with controlled cardiac failure for elective TUR-P. Intraop monitoring, SA,
failed spinal, and postop TURP syndrome, and rapid AF
35 yo man with Crohn’s disease, on long term oral steroid and opioid, for elective
laparotomy. Preop assessment, anaesthetic management and postop analgesia.
30 yo woman for Caesarean section under epidural anaesthesia. Sudden collapse after
delivery. Management, resuscitation, and differential diagnosis.

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4 yo boy for tonsillectomy and adenoidectomy. Assessment for day surgery, postop
analgesia, and bleeding.
4 mo full-term infant for inguinal hernia repair in a day surgery centre. Assessment
for possible family history of malignant hyperpyrexia, management of MH
susceptible patient, and conduct of paediatric spinal anaesthesia.
12 mo boy with suspected foreign body aspiration. Differential diagnosis,
investigations, emergency management, and anaesthesia for rigid bronchoscopy.
Patient with Obstructive Sleep Apnoea for elective Total Hip Replacement. Pre-
operative assessment, operative management and postoperative analgesia.
Patient for elective Total Knee Replacement. Choice of postoperative analgesia
Patient with severe longstanding rheumatoid arthritis presenting for elective major
joint surgery. Preop assessment and periop management.
45 yo man admitted after a Road Traffic Accident with fracture femur, tender
abdomen. Hypotensive. Assessment of intra-vascular volume and blood loss, fluid
resuscitation: crystalloid or colloid, coagulopathy.
A patient with ARDS in ICU after RTA and abdominal trauma, requiring re-
exploration of abdomen. Ventilation strategies in ARDS, intraop hypotension, fluid
replacement, pulmonary artery catheter.
Patient with burn to the upper torso and face. Assessment of airway and severity of
burn, fluid resuscitation, and periop management of burns patient requiring repeated
anaesthesia.

STAND-ALONE SHORT VIVA QUESTIONS:

Patient with SAH for endovascular coiling of intracerebral aneurysm. Oxygen mains
failure
SAH for craniotomy and aneurysm clipping. Implications of nimodipine infusion-
Neuraxial blockade for lower limb surgery in the Day Case Unit?
Advantages and disadvantages of the use of tourniquets for surgical procedures
Postoperative analgesia following forefoot surgery (e.g. bunion surgery)
Best opioid to use in epidural analgesia
Complications of interscalene brachial plexus blockade
Epidural abscess following epidural analgesia: cause, diagnosis, prevention, and
management
Pharmacological agents to reduce neurological damage after head injury
Implication of chronic alcoholism and anaesthesia
Emergency management of suspected regurgitation and aspiration in emergency
anaesthesia
Management of raise intra-cranial pressure after head injury
Hypertonic saline in trauma patients
Use of nitrous oxide in trauma patients

OSCE EXAMINATION
The OSCE consisted of 10 stations. Overall, 13 out of 20 candidates passed this
section.

STATION 1. COMMUNICATION (17/20 PASSED)

The scenario of this communication station was constructed in order to assess the
candidates’ skill on handling complication related to anaesthesia: awareness during
Caesarean section. Candidates who passed this station could demonstrate good

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communication skills including verbal and non-verbal techniques. Most candidates
were able to demonstrate their knowledge on the key components of awareness:
psychological sequelae, possible explanation of awareness, reassurance on low
probability of recurrence, and remedial action on future anaesthesia and surgery.
However, it was also surprising that a few candidates failed to handle this infrequent
but yet well-known complication related to anaesthesia.

STATION 2. PHYSICAL EXAMINATION (13/20 PASSED)

Morning session: cardiovascular examination of 71 yo female with severe mitral
stenosis and atrial fibrillation.
Afternoon session: examination of respiratory system of 65 yo female with
bronchiectasis of the right lower lobe and clubbing of fingers.

STATION 3. PHYSICAL EXAMINATION (14/20 PASSED)

Morning session: neurologic examination of a 39 yo male with mixed sensori-motor
peripheral neuropathy.
Afternoon session: cardiovascular examination of 41 yo female with severe mitral
stenosis and atrial fibrillation.
Candidates were, in general, able to perform the cardiovascular, respiratory and
neurological examination with reasonably good techniques. They were able to give
clear instructions and motivate the patients to perform appropriate manoeuvres to
facilitate their examination. Neurological examination of the lower limbs is supposed
to be an uncommon examination topic. It was good to note that many candidates
performed this fairly well. This is largely a clinical art that remains useful in daily
clinical practice with relevance to anaesthetic practice.

STATION 4. ACLS/ATLS (14/20 PASSED)

The candidates were presented with a patient with injury to the left chest and kidney,
fractures of left femur and ankle, and signs of shock. The candidates were expected
to diagnose that the patient was in shock, and started resuscitation. They then should
suggest that bleeding was likely from the fractures and a retroperitoneal or intra-
abdominal source, and recommended appropriate management. During the process
the patient developed cardio-respiratory distress from a tension pneumothorax and the
candidates were expected to use systematic assessment to identify and manage the
problem appropriately. Candidates should be hands-on with the resuscitation as in
real life. The examiner could not offer any clinical findings to the candidates unless
they were actually looked for. Therefore candidates who just said to the examiner: “I
would look for intra-abdominal bleeding” without further actions should not expect
the examiners to help them to find the answer or score any points.

STATION 5. X-RAYS (15/20 PASSED)

The radiology station comprised a series of films including chest radiographs of the
following: cardiogenic pulmonary edema with PAFC and IABP in situ, but with a
gastric tube too short with tip in esophagus; multiple fractured ribs; chronic
obstructive airways disease; burns patient with ARDS also complicated by
endobronchial intubation and L lower lobe collapse; pneumothorax from kinked chest
drain after patient has elective lung biopsy, and plain CT brain showing pineal gland
tumour with hydrocephalus despite presence of a ventricular drain. Some written
clinical information were provided for each film and prompting was standardised to
all candidates.

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The overall standard was reasonable. Some candidates did well and were quick to
note radiological findings and make diagnoses, with fluent and smooth delivery.
However it was disappointing to note a few candidates made guesses or were not sure
of basics including whether the chest film showed rotation, whether the endotrachel
tube was endobronchial or not, or the specific radiological signs of lung collapse,
consolidation and heart failure.

STATION 6. PROCEDURES (17/20 PASSED)

This station tested the knowledge of using a biphasic defibrillator for synchronized
cardioversion of unstable broad-complex tachycardia, then defibrillation of VF and
finally transcutaneous pacing of complete heart block. As this station tested
knowledge and application of generally accepted ACLS protocols candidates tended
to fall into two groups- those who knew and had 'practised' the protocols and those
who obviously had not.
The candidates who scored high marks were those who 'role played’, treating the
simulation as the real thing rather than saying eg 'I would...' or ' Is the patient
breathing..............’ This station required the candidate to take action and follow the
protocols. Common errors and omissions by the candidates were: (1) not activating
“synchronization” when performing synchronized cardioversion, (2) not switching off
“synchronization” when performing defibrillation, (3) attempting to discharge the
energy without first charging.

STATION 7. ANATOMY AND REGIONAL ANAESTHESIA (15/20 PASSED)

The scenario was designed to examine the candidates’ knowledge and skill on
brachial plexus block for a patient undergoing surgery to medial epicondyle of right
humerus and a tourniquet was required to facilitate the surgery. Candidates were
expected to discuss their choice on various approaches of brachial plexus block based
on knowledge on dermatomal and cutaneous innervation of the arm. Although 75%
candidates passed this station and most of them had demonstrated good knowledge on
anatomy of brachial plexus and the first rib, a significant proportion failed to apply
the knowledge to justify their choice of brachial plexus block. In addition, a small but
significant proportion of candidates failed to appreciate the surface anatomy, for
example lateral end of clavicle or the coracoid process, despite a sound knowledge on
anatomy of brachial plexus. This probably reflects the lack of clinical exposure and
further training on regional anaesthesia is recommended.

STATION 8. EQUIPMENT (10/20 PASSED)

Candidates were asked to assemble a three-bottle under-water chest drainage system.
They were required to show understanding of safety features of underwater seal and
application of suction pressure. Poor candidates were unable to work from first
principle to assemble the 3 bottle system of chest drainage and troubleshoot common
problems of chest drainage.

STATION 9. INVESTIGATIONS (13/20 PASSED)

Candidates were asked to interpret a series of blood results and a set of
electrocardiograms. Whilst most candidates could point out the obvious
abnormalities, only the better candidates were able to explain the underlying
mechanisms for the deranged blood results. The performance on ECG interpretation
was disappointing. Candidates could recognize ECG rhythms but were unable to point
out features on the ECGs to support their diagnoses.

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STATION 10. CRISIS MANAGEMENT (19/20 PASSED)
This station tested candidates’ performance in dealing with hypoxia, laryngospasm
and lung collapse in the recovery of a five year old boy undergoing open herniotomy.
Candidates were expected to demonstrate the use of T-piece and other equipments for
the application of PEEP. Many candidates attempted to use a “small” does of
succinylcholine to treat the laryngospasm, but the dosages were often incorrect. All
candidates were able to secure a patent airway with tracheal intubation in a reasonable
amount of time. Most candidates were able to confirm collapse of the lung and
provide appropriate treatment afterwards. Additional marks were given to candidates
who could plan ahead the management after stabilization of the patient.

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