Hong Kong College of Anaesthesiologists

Final Fellowship Examination March/May 2007

Examiners Report

Dates and Venues of Examination

Written examination 23rd March 2007, Hong Kong Academy of Medicine Building
Viva examination 11th May 2007, 2nd Floor, Hong Kong Academy of Medicine Building
OSCE examination 12th May 2007, Operating Theatre, 4/F, Block D, Queen Elizabeth Hospital

External Examiners:
Dr Jeremy Langton, RCA (UK)
The external examiner took an active role in each section of the examination.

Internal Examiners:
Written: Simon Chan, YF Chow, PT Chui, Serena Fung, Theresa Hui, Anne Kwan, Cindy Lai, Steven
Wong
Vivas: Simon Chan, PT Chui, Theresa Hui, Anne Kwan, Steven Wong
OSCE: KW Au Yeung, Matthew Chan, Simon Chan, YF Chow, Douglas Fok, Anthony Ho, CK Koo,
Anne Kwan, KY Lai, Bassanio Law, Monica Lee, SK Ng, Judith Shen, Steven Wong, Florence Yap,
Victor Yeo, BH Yong, SC Yu

OVERALL RESULTS
Fifteen candidates presented for the examination but one withdrew from the examination before the
viva and OSCE examination. Out of the 14 candidates, 8 were successful. The overall examination pass
rate is 57%.

WRITTEN EXAMINATION
The written examination consisted of two papers. Only 3 out of 14 candidates passed this section.

PAPER 1 – SCENARIO QUESTIONS

Scenario A
A 74-year-old lady presents for right carotid endarterectomy under regional
anaesthesia.

1. Describe the performance of the regional anaesthetic technique required for this
procedure and outline the complications and contraindications.
(12/14 passed)
Although not a commonly performed regional block, this block has a number of peculiar features
relevant to regional anaesthesia. Some candidates failed to understand that both superficial and
deep block need to be done for CEA. Very few candidates can clearly describe the technique of
the blocks. Some candidates missed out complications specific to this block, namely the intra-
vertebral arterial injection, phrenic nerve block, as well as intrathecal and epidural injections.

2. Outline the intra- and post-operative management of this patient.

(9/14 passed)
The answers to this question showed that most candidates did not have much clinical experience
with regional anesthesia for CEA. Most candidates could give a good account of the management,
but few could show a good understanding of the rationale behind. Few candidates could explain
the rationale behind intraoperative monitoring of cerebral perfusion after clamping. Few
candidates could explain the mechanisms of hyperperfusion syndrome, and the unstable
postoperative hemodynamics.

3. Briefly explain the physiological changes that may occur with carotid cross
 clamping.
(5/14 passed)
This question was poorly answered, indicating a lack of understanding of the physiological
changes during clamping. Most candidates mentioned about the decrease in ipsilateral cerebral
flow and dependence on collateral flow via the Circle of Willis. However, few mentioned about
the resultant vasodilatation in the ipsilateral brain and the subsequent hyperperfusion. Few
candidates could explain the effect of clamping on the hemodynamics.

Scenario B
A 32-year-old healthy man requires a posterior fossa exploration for an acoustic
neuroma. Surgery will be performed in the sitting position.

4. What anaesthetic technique would you choose for this patient? Justify your
choice.
(10/14 passed)
The question asked for justification of a chosen anaesthetic technique. Better candidates were able
to discuss the reasons for an anaesthetic technique such as TIVA with propofol and remifentanil.
They explained the beneficial effects of propofol such as decrease in CMRO2 and cerebral blood
flow, and those of remifentanil such as titratability and rapid emergence. Better candidates also
explained that avoidance of NMB and volatile anaesthetics would facilitate monitoring of MEPs
and SEEPs respectively. Some candidates wasted time on discussing preoperative and
postoperative management. Also, some candidates only provided a detailed description of the
anaesthetic techniques without justifying the choices. Awake craniotomy was clearly not a
feasible technique. Similarly, few marks were rewarded for discussion of general anaesthetic
techniques, such as IPPV, tracheal intubation, haemodynamic stability, and normocarbia. These
showed a lack of comprehension of the specific anaesthetic requirements and problems.

5. What specific problems could arise during this type of surgery and how would
you monitor for them?
(11/14 passed)
Better candidates were able to list the specific problems, and explained the monitors for such
problems, including venous air embolism, cardio-respiratory complications of brain stem
manipulation, cranial nerve injuries, upper airway oedema from positioning, bleeding and
inadequate cerebral perfusion pressure. More common omissions included intra- and post-
operative brain stem dysfunctions and calibration of the cerebral perfusion pressure taking into
account of the hydrostatic gradient between heart and brain in the sitting position. Again, a few
candidates wasted time discussing non-specific anaesthetic problems such as anaphylaxis, sputum
retention, and myocardial ischaemia.

6. During removal of the tumour, the patient’s pulse oximeter reading (SpO2) drops
to 78% and end-tidal carbon dioxide (ETCO2) drops to 20 mmHg. His heart rate
is 70 per minute and the blood pressure 106/63 mmHg. What will be your
immediate treatment?
(12/14 passed)
Most of the candidates were able to recognize the clinical picture compatible with venous air
embolism, and discussed immediate treatment including ABC and 100% O2, asking surgeon to
flood surgical site with saline, reducing gradient between surgical site and RA, aspirating RA
catheter, and I.V. fluids. Candidates were awarded marks for adopting a systematic approach to
the crisis, such as calling for help, and simultaneous evaluation and management of problems.
However, poor candidates did not discuss appropriate approaches to the crisis situation in context
of the clinical scenario. Placement of appropriate monitors such as intra-arterial line would have
been performed before surgery. Turning the patient to the lateral position would be unwarranted at
that stage given the relative stable haemodynamics. Candidates would also score poorly for
omitting essential steps such as asking surgeon to flood surgical field with saline, and manual
ventilation with 100% O2.
Scenario C
A 68-year-old male with no significant past medical history was found to have
carcinoma of oesophagus and is scheduled for Ivor-Lewis oesophagectomy
(involving two-stages laparotomy and right thoracotomy).

7. Outline the pre-operative and post-operative factors that may contribute to the
post-operative respiratory complication for patient undergoing Ivor-Lewis
oesophagectomy.
(8/14 passed)
Most candidates did well for patient and anaesthetics factors, but omitted the disease (oesophageal
cancer and the related morbidity) and the surgical factors. Ivor-Lewis oesophagectomy is
associated with significant mortality and morbidity with mortality rate reportedly 3-10%. The
incidence of post-operative respiratory complications, included pneumonia, respiratory failure,
atelectasis, pleural effusion, chylothorax and pulmonary embolism, is up to 30% and is closely
associated with mortality.

8. You notice in your pre-operative assessment that the patient has features
suggestive of difficult intubation. List the options of lung isolation techniques and
justify your choice for this patient.
(11/14 passed)
The options for lung isolation technique include – double lumen tube, endobronchial intubation
with endobronchial tube, endobronchial blockers such as Univent tube, Arndt’s blocker. This
patient would have airway secured before anaesthesia with single lumen endotracheal tube using
awake bronchoscopic technique. The subsequent management would either be a bronchial blocker
or change to a double lumen tube with an aid of tube exchanger.

9. In the operating suite, the surgeon suggests to restrict the use of intra-operative
intravenous fluid. What would be your considerations? Discuss your strategy of
intra-operative fluid management.
(8/14 passed)
Although majority of candidates passed this question, there is no good answer. Most candidates
failed to appreciate the advantages of intra-operative fluid restriction, as there is increasing
evidence that intra-operative fluid restriction can improve the outcome for patients undergoing
oesophagectomy probably by reducing third space fluid shift into pulmonary and gastrointestinal
tissue with resultant tissue oedema, and avoidance of haemo-dilution.

PAPER 2 – SHORT ANSWER QUESTIONS

1. Discuss how you would obtain informed consent from a primigravida, who is
otherwise well, in established labour (cervix 4 cm dilated) in moderate distress
requesting epidural analgesia.
(4/14 passed)
Most candidates concentrated on risks disclosure without discussing the issues they face when
obtaining informed consent from a labouring patient. Candidates are advised to review the
following article for a detailed discussion on this topic: Journal of Clinical Anaesthesia 2003;
Vol.15, Issue8: 587-600.

2. You are consulted to provide monitored anaesthesia care for a 70-year-old man
with obstructive jaundice scheduled for Endoscopic Retrograde Cholangio
Pancreatography (ERCP). Outline your plan of management.
(6/14 passed)
Most candidates presented an anaesthetic management of a procedure performed in remote area. A
few candidates wrote a summary of preoperative assessment non-specific to patient with
obstructive jaundice. All candidates assumed the patient was very sick when anaesthetist was
 involved in such a procedure. Most candidates discussed crisis management during the procedure.
No candidates discussed on the appropriate level of sedation for the procedure and very few
candidates mentioned pain control during papillotomy. (Reference: Gastrointest Endosc 2004; 60:
361-6)

3. Write short notes on “Propofol Infusion Syndrome”.

(4/14 passed)
For a straightforward question on a drug that is so commonly used by anaesthetists, the candidates’
lack of knowledge in this area is disappointing. (References: Intensive Care Med 2003; 29(9):
1417-25; Current Opinion of Anesthesiology 2006; 19: 4)

4. List the extra-articular manifestations of rheumatoid arthritis and explain how they
may be relevant to anaesthesia.
(9/14 passed)
In general, most candidates demonstrated a good understanding of rheumatoid arthritis and its
relevance to anaesthesia. Candidates are again reminded to read the question carefully. Although
knowledge of cervical involvement is of particular importance in airway management by
anaesthetists, this was not asked in the question.

5. Discuss the role of laryngeal mask airway in management of the difficult airway.
(6/14 passed)
Laryngeal mask is an airway device commonly used by the anesthetists and candidates are
expected to have a thorough knowledge of its application. Many candidates listed the pros and
cons of the device with little relevance to the difficult airway. It was surprising that no candidate
mentioned the obvious condition which precluded its use - where access to the oral pharynx is
denied.

6. Discuss the strategies for blood conservation in major orthopaedic surgery.

(11/14 passed)
This question is well handled by most candidates.

7. Outline the issues to be considered in the provision of anaesthesia services in a

new Magnetic Resonance Imaging (MRI) suite.
(3/14 passed)
This question is poorly answered. Provision of anesthesia services in a new MRI suite is different
from management of anaesthetic problems in the MRI suite. However, most candidates focused on
individual patient care rather than tackling it from the anaesthetic service perspective. Some
answers are brief and unorganized. Good answers should include environmental, equipment,
personnel, health and safety issues, as well as risk management.

8. Discuss the strategies to minimize neurological complication after

cardiopulmonary bypass.
(2/14 passed)
It is disappointing that candidates showed poor concept of complications of CPB. Most answers
were focused on physiological and monitoring perspectives, rather than the global problems of
CPB related to neurological complications. Few mentioned the technical issue of filter bubbles
and pH management of CPB.

9. Outline the methods to prevent electrocution in the operating theatre.

(4/14 passed)
Most answers were superficial and general. Satisfactory answers should provide concepts of
electrical safety in operating theatre in relation to environment and equipment design,
eqipotentiality and procedural precaution. Some answers did not provide information on
macroshock and microshock.
VIVA EXAMINATION
Overall, 11 out of 14 candidates passed this section. The viva examination consisted of three vivas. At
the beginning of each viva, the candidates were given a clinical scenario with an introductory question
printed on a sheet of paper. The viva was structured with further follow-on questions.

Viva questions:
1. 70 year old male presenting for elective abdominal aortic aneursym repair. Known to have
ischaemic heart disease and insulin dependant diabetes mellitus.
- Discuss the pre-operative assessment of this patient.
- How would you anaesthetise this patient ?
- How would you manage / prevent myocardial ischaemia intraoperatively ?
- What are the common post operative problems encountered ?

2. 83 yr female presenting for emergency laparotomy due to intra abdominal sepsis

- How would you assess this patient preoperatively ?
- What are the common problems posed by these patients ?
- How would you monitor the patient intra operatively and how would you treat intra op
and post operative hypotension ?
- Discuss the options for pain relief in this patient

3. A 35 year-old woman at 34th week of pregnancy is admitted because of small amount of vaginal
bleeding. She had two previous caesarean sections.
- What are the problems with this woman?
- What is placenta previa and how is it classified?
- The obstetrician wants to perform emergency section because of increased vaginal
bleeding. What would you do?
- While the baby is being delivered, you notice that the blood pressure drops to
80mmHg. What would you do?

4. 30 year-old primigravida at 36th week of pregnancy is admitted for induction of labour. She was
found to have increased blood pressure during the third trimester. You are consulted to provide
epidural analgesia.
- What are the problems with this woman?
- What is preclampsia and how to assess its severity?
- What are the treatments of preeclampsia and what are their mechanisms?
- What are your concerns in providing epidural analgesia?
- The obstetrician requests emergency section. What would you do?

5. A 72 year old woman fractured her right hip during a fall at home last night. She has long standing
hypertension being treated with nifedipine SR 20 mg twice daily. She has no other major illness.
On admission to hospital, her BP was 190/95 and heart rate 88 /min.
- Discuss how you will assess her before anaesthesia.
- Further management of HT
- Discuss issues of pain control in elderly patient with fracture hip.
a. Assessment of pain
b. Pros and cons of various analgesic modalities.
- No evidence of end-organ complications. Preop Ix all normal. When will you take the
patient to surgery?
- What is your anaesthetic technique? Why?
- On arrival to OT, initial BP 210/105 HR 90/min. What will you do?

6. A 22 year-old woman injured her left knee during a soccer game. She is scheduled for left knee
arthroscopy and repair of menisci as a day case. She smoke 10-20 cigarettes daily, but is otherwise
healthy.
- Discuss the considerations in your anaesthetic management.
- What is your anaesthetic technique? Why?
- Patient keen to have SA because she wants to watch surgery. Pros and cons of SA in
day surgery.
 - Tell me how you will perform SA in this patient. What drugs? Lignocaine?

7. 68 years old man with a vocal cord mass for laser excision. He gave a history of hypertension and
chronic heavy smoking. He took atenolol for control of his blood pressure.
- What are the hazards of laser (light amplification of the simulated emission radiation)
surgery of the airway?
- Hazards associate with laser surgery of the airway.
- Measures to minimize hazards?
- Discuss the different anaesthetic techniques and their pros and cons.
- Differential diagnosis and systematic approach to managing a patient who fails to
regain consciousness in recovery.

8. 68 years old man with history of allergic rhinitis, hypertension, diabetes and ischaemic heart
disease for sinus surgery of nasal polyps under general anaesthesia. His medication included
metoprolol, diltiazem, metformin, glibenclimide and aspirin.
- How do you ascertain his diabetes is under good control?
- Discuss the assessment of patient with IHD and diabetes for elective surgery.
- Discuss the intraoperative management of a patient for sinus surgery.
- Discuss the causes and management of laryngeal injury from endotracheal intubation
/LMA.

9. A 7 year old boy coming to see you at the Pre-admission Clinic for tonsillectomy to be performed
in 2 weeks.
- He is recovering from a cold, can you explain the risk of general anaesthesia to him.
- You discover from his clinical notes that he had antibodies in his blood, how are you
going to prepare him for his operation.
- His mother tells you that he had some sort of reaction to the muscle relaxant the last
time he had his inguinal herniotomy, how are you going to deal this problem?
- You further discover that he may have sleep apnoea syndrome. What is the screening
and confirmation tests for this condition.
- Please outline the anaesthetic implications of OSAS.

10. A 68 year old man with carcinoma of pancreas presenting for operation but unfortunately found
inoperable.
- Please comment on immediate post-operative pain management.
- The patient wants to have celiac plexus block, can you give him advice on the
procedure.
- If one uses alcohol for permanent nerve block, there may be a risk of systemic alcohol
toxicity, please outline the signs and symptoms and treatment of this condition.
- What are the alternatives for the long term pain relief?

11. You were asked to assist in the Emergency Department. A 45 years-old male pedestrian was hit by
a medium-speed vehicle while he was crossing the road. On arrival to the Emergency Department,
his vital signs were noted as: HR 110/min, BP 100/50, respiratory rate 16/min and oxygen
saturation 99% with oxygen supplement. He opened his eye on commend but reacted
inappropriately and only localized to pain. He was also noted to have obvious deformity of right
leg and smell of alcohol.
- What is your initial management?
- His haemodynamic was stabilized after initial resuscitation. The cerebral / abdominal
CT scan was unremarkable and the injuries sustained – fracture right femur and tibia.
When he recovered from the intoxication 6 hours later, he was found to be a drug
addict and you are consulted for his pain control.
- The patient was scheduled for opened reduction and internal fixation of his fracture 48
hours after the injury. While he is in the Operating Theatre, you note that the patient is
drowsy but arousable and he has tachypnoea and tachycardia with saturation 91% on
room air. What will be your differential diagnosis and action?
- The patient is diagnosed to have fat embolism syndrome and the patient’s clinical
condition remains the same 12 hours later. The orthropaedic surgeon would like to
discuss with you the plan of management on when/how the surgery to be conducted.
12. You were asked to assist in the Emergency Department for a trauma call. A 45 years-old male
driver was involved in a medium-speed head on collision. His vital signs: HR 95/min, BP 110/65,
SaO2 99% on oxygen supplement. His eyes opened on command but react inappropriately and
localized to pain. Bruise was noted over his left chest wall.
- What is your initial management?
- On subsequent investigations, he was found to have sustained injuries: small traumatic
subarahnoid haemorrhage, fracture left 5-9th ribs without pneumohaemothorax, and he
is being observed in ICU. You are consulted for pain control in order to avoid
intubation.
- 48 hours after the initial injury while the patient is still in ICU for observation, he
complains of abdominal pain and became hypotensive and tachycardic with BP 90/50
and HR 125/min. What is your differential diagnosis and management?
- Delayed splenic rupture was diagnosed and the patient is rushed for emergency
laparotomy. How would you anaesthetize the patient?
- 5 minute after the surgery started, the patient becomes profoundly hypotensive with
BP 65/40 and HR 140/min. What is your management?

OSCE EXAMINATION
The OSCE consisted of 10 stations. Overall, 10 out of 14 candidates passed this section.

Station 1. Communication (11/14 passed)

The scenario of this station was an elderly man who suffered from brief cardiac arrest resulting in
hemiparesis after spinal anaesthesia for fracture femur operation. The candidate was to play the role of
the consultant in-charge. The principles of supporting the anaesthetic trainee who gave the anaesthetic
were tested. The candidate was also asked to help the trainee to conduct an interview with the patient’s
daughter after the incident.

Overall most candidates scored a fair performance. This station tested the candidates’ skill of
communication rather than the ability to regurgitate facts and figures. Good candidates showed care,
concern and empathy. Developing rapport with family member could enhance trust and soothe the pain
caused by such calamity. Some candidates forgot to introduce themselves to the patient’s daughter; one
failed to introduce him/herself even when patient’s daughter directly asked who he/she was. Some
candidates failed to show empathy and just regurgitate some facts with a blank, expressionless ‘robotic’
face and verbal tone. One candidate was commented to be “rude” by the daughter.

Candidates can refer to the following articles for reference in techniques of breaking bad news:
1) Catastrophes in anaesthetic practice - dealing with aftermath (2005). Publication of The
Association of Anaesthetists of Great Britain and Ireland.
2) Manser T, Staender S. Aftermath of an adverse event: supporting health care professionals to
meet patient expectations through open disclosure. Acta Anaesthesiol Scand 2005; 49(6): 728-
34.
3) Aitkenhead AR. Anaesthetic disasters: handling the aftermath. Anaesthesia 1997; 52(5): 477-
82.

Station 2. Physical Examination (11/14 passed)

The examination case was a patient with inguinal hernia, lymphadenopathy and splenomegaly. The
overall performance of the candidates was satisfactory. Most of the candidates spotted the
splenomegaly, but only 3 candidate discovered the hernia. Detail examination of hernia is NOT
required. Candidates are expected to note their presence. Another weak area was that many candidates
did not define the upper border of the liver before commenting on the size of the liver.

Station 3. Physical Examination (13/14 passed)

Cases examined included upper lobe pneumonia or ankylosing spondylitis with pneumonia. Overall
examination of the respiratory system was disappointing with many candidates requiring significant
prompting. Important deficiencies included inadequate exposure for examination, upper lobe clinical
examination, and general observation of ankylosing spondylitis.
Station 4. ACLS/ATLS (12/14 passed)
The scenario was a motorcyclist who collided with a lamp-post and sustained a closed chest injury.
Candidates were expected to diagnose a haemothorax, differentiate it from other causes of hypotension,
look for other causes of occult bleeding, recognize a transient responder to fluid resuscitation,
appreciate that hypoxia and hypotension can lead to a drop in GCS, and know the indications for
thoracotomy (in OT) for haemorrhage control. The injury was straightforward with no “tricks” and
candidates who had a systematic approach to assessment and resuscitation did well.

Station 5. X-rays (12/14 passed)

In this examination, candidates were instructed (by instruction sheet posted before the entrance of the
station) to go through 10 films. They were instructed to only identify the abnormities and list the
differential diagnoses, rather than to systematically describe each film. For those candidates who
finished the 10 films before 10 minutes, there were extra ‘bonus’ films, the marks of which will be
considered in the total marking. The examiner should try to get the candidates to go through the 10
mandatory films

Overall the standard was quite good. The shortcomings were the following:

1) Most failed to identify bilateral upper lobe bullae in a chronic smokers.

2) Most candidates could not differentiate lung consolidation from collapse.
3) All the candidates could not differentiate the enlarged pulmonary trunk from the left
atrium in pulmonary arterial hypertension.
4) No candidate could identify gastric volvulus in a patient with history of acute left chest
and abdominal pain with shock, although most candidates scored marks in identifying the
retrocardiac fluid levels. A differential diagnosis of hiatus hernia would also score some
marks.

Station 6. Procedures (11/14 passed)

In this station, candidates were required to demonstrate how to turn an intubated manikin from supine
to prone position with special attention paid to:
1) Preparation before turning included checking the patient’s status, securing ETT position, checking
all monitoring & intravascular lines, manpower & cushion supports.
2) Leadership
3) Actual turning with emphasis on patient & staff safety
4) After turning, checking patient status, pressure points, neurovascular adequacy, all monitoring &
intravascular lines
Most candidates were able to fulfil the above expectations. One candidate achieved full marks. The
decision in turning patient back to the supine position to secure the ETT is vital; candidates who
loosened or cut the fixative tie to re-fix the ETT whilst in the prone position was considered a
dangerous practice & would fail that part of the station.

Station 7. Anatomy and Regional Anaesthesia (13/14 passed)

In the first part of the examination, candidates were expected to demonstrate on a live model the
technique of brachial plexus block using the interscalene approach. In the second part, they were asked
to identify anatomic structures while the examiner performed ultrasound on the live model. The overall
performance was good although some candidates mixed up the technique with the supraclavicular
approach. Basic anatomical knowledge was weak. Although ultrasound techniques could be unfamiliar
to some, good candidates could derive their answer through sound basic anatomical knowledge.

Station 8. Equipment (8/14 passed)

A nerve stimulator was used at the equipment station to test the knowledge of the candidates.
Considering nerve stimulator is used routinely at our operating theatres, it is slightly disappointing to
see this passing rate.

Station 9. Investigations (12/14 passed)

Six questions were set; 3 on electrolytes/blood gas, 2 ECG’s and 1 rhythm strip. Most of their
candidates managed their time well. A few did not score well on individual questions and few managed
to spot the more difficult abnormalities. In general, however, most candidates showed adequate
competency in analyzing the blood results and ECG’s. As a group, they performed reasonably well
considering the amount of anxiety shown by some of them.

Station 10. Crisis Management (10/14 passed)

This station tested candidates’ performance in dealing with aspiration following oesophageal intubation
in a six year old boy after severe head injury. The scenario used a high fidelity simulator that will
respond to physiologic challenge. Tubing must be connected properly before oxygen can be delivered
to the (simulated) patient. Similarly, the mannequin must receive lung ventilation to prevent
hypercarbia and hypoxia. Therefore, candidates are reminded that running commentary is not sufficient
and they need to carry out the tasks in order to keep the patient alive.

Candidates were expected to spot the oesophageal intubation early in the course and were required to
reintubate the trachea. Candidates should also detect widespread bronchospasm after securing the
airway and establishment of lung ventilation. They should propose a reasonable list of differential
diagnoses (like aspiration and anaphylaxis) and initiate some form of treatment (like inhaled
bronchodilator). Some candidates have trouble in assessing the clinical situation in a systematic
approach and have resulted in chaos during management. Additional marks were given to candidates
who could carry out the primary survey after initial treatment of hypoxia.