The Hong Kong College of Anaesthesiologists

Final Fellowship Examination Apr / Jun 2022

Examiners’ report

Background
The Final Fellowship Examination, which was originally scheduled on Mar/May 2022, was
postponed to Apr/Jun 2022 due to the COVID-19 pandemic, and completed with a fully online
format. With the change in format announcement, candidates who were newly applying the
exam were allowed to either proceed with the online exam or to be refunded. For candidates
carrying forwarded from previous passed written exams, they were allowed to either proceed
with the online VIVA/OSCE exam, or skip the exam with one attempt exempted. Candidates
proceeded with the online exam completed under proctoring system surveillance according to
college administrative instructions.

Date and Venues of Examination

Written: 25th April 2022; online using proctoring system
VIVA: 17th June 2022; online using Zoom platform
OSCE: 19th June 2022; online using Zoom platform

Examiners:
(External examiner and advisor) Prof Sophia CHEW (NUS, Singapore)
(Advisory) Dr SK NG (Written and VIVA), Dr Anna LEE (OSCE)
(Coordinator) Dr Frances LUI
Written: Prof Sophia CHEW, Dr Matthew CHAN, Dr Gordon JAN, Dr Patricia KAN, Dr Linda
LAI, Dr Frances LUI, Dr Anna LEE, Dr Wai Tat WONG
VIVA: Prof Sophia CHEW, Dr Timmy CHAN, Dr Gordon JAN, Dr Patricia KAN, Dr Linda
LAI, Dr Anna LEE
OSCE: Prof Sophia CHEW, Dr Albert CHAN, Dr Victor CHEUNG, Dr Mandy CHU, Dr
Douglas FOK, Dr Danny IP, Dr Gordon JAN, Dr Vincent KONG, Dr May LEUNG, Dr
KC LUI, Dr Henry WONG, Dr Wendy WONG, Dr KS WONG, Dr Leo WAT

Overall results

21 candidates sit the written examination with 5 candidates passed (23.8%).

17 (5+12) candidates were invited to the VIVA and OSCE examination. 8 passed the VIVA exam
(47%), 15 passed the OSCE exam (88.2%). Overall 7 candidates passed the whole examination.

Written examination

The written examination consists of two papers. Paper I consists of scenario-based questions
and short answer questions. 5 candidates passed paper I (23.8%). Paper II consists of questions
on critical appraisal, radiology, and investigations. 5 candidates passed paper II (23.8 %). The
Written section is considered pass if the sum up marks of both papers passed. Overall 5

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candidates passed the Written examination (23.8%). Candidates are required to pass the Written
section to be invited to VIVA/OSCE sections.

Candidates are advised to have better formatting or indentation when typing their answers, and
answer to the clinical contexts as in the scenarios. Some answers included brief listed points
without correlation with other points. Answers in a systematic and legible way score higher
marks. The comments from examiners in specific questions are quoted as below.

Paper I

Candidates are advised to have better formatting or indentation when typing their answers, and
answer to the clinical contexts as in the scenarios. Some answers included brief listed points
without correlation with other points. Answers in a systematic and legible way score higher
marks. The comments from examiners in specific questions are quoted as below.

Scenario A for answering questions 1-3

A 60-year-old lady with left breast cancer is scheduled for elective left mastectomy. She has a
deep brain stimulator (DBS) placed for advanced Parkinson’s disease three years ago. The
implantable pulse generator (IPG) is located under her right clavicle.

1. What are the anaesthetic implications associated with Parkinson’s disease?

76.2% candidates passed this question (16/21 passed)

Most candidates were able to describe the pathological changes in multiple systems associated
with Parkinson’s disease. However, there was a lack of explanation on how these changes affect
anaesthetic management. To get a pass, candidates were also expected to provide a reasonable
coverage on potential drug interactions and perioperative management of anti-Parkinsonian
medication in the answer.

2. What perioperative precautions are required in relation to deep brain stimulator?

47.6% candidates passed this question (10/21 passed)

Most candidates were able to mention appropriate preoperative evaluation of deep brain
stimulator. However, some candidates failed to mention the intraoperative strategies to
minimize electromagnetic interference and precautions with electrocautery. Good candidates
mentioned postoperative management including neurological examination to rule out adverse
events related to device interaction and DBS device check by device representative or DBS
physician.

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The patient was given general anaesthesia and was intubated for the surgery. The surgery went
uneventful and lasted for 2 hours. However, 30 minutes after the end of anaesthesia, the
patient remained unarousable and could not be extubated.

3. Describe the possible causes and outline your management.

52.4% candidates passed this question (11/21 passed)

Most candidates could provide a reasonable list of possible causes of delayed emergence from
anaesethesia and outline the basic and essential steps of management. Good candidates
considered causes related to Parkinson’s disease and DBS.

4. A 55-year-old healthy man with cervical stenosis and myelopathy is electively scheduled
for posterior fusion of cervical C4 to C6. Outline your considerations throughout the
perioperative period to facilitate intraoperative neuro monitoring and extubation at the
end of the operation.

38.1% candidates passed this question (8/21 passed)

Many candidates wrote on “Anaesthesia for a spine surgery” rather than focus their answers to
the context. Most recognized the importance of balanced anaesthesia with meticulous control
of physiological parameters and avoided neuromuscular blockade during MEP measurements.
Wake up tests were mentioned. Volatile agents are not “absolutely contraindicated” but a
propofol based TIVA is preferred especially if extensive numbness in myelopathy. Few candidates
however, described how to manage if unfavourable IOM parameters.

The discussion on safe extubation was inadequate and occasionally omitted by some.
Preoperative airway assessment was not routinely mentioned. Many candidates chose awake
fiberoptic intubation. The use of video laryngoscopy without further precaution for
immobilization may not be enough in extensive myelopathy. No candidate mentioned stable
IOM parameters intraop is also a factor to be considered before safe extubation.

Some candidates checked for adequate reversal despite neuromuscular blocking agents not
administered. Some of them tested by asking patient for sustained head up, after a cervical spine
fusion.

Undue delay in extubation had been shown to be associated with more respiratory events and
complications. If extubation is delayed electively, airway plan and neurological monitoring
endpoints must be pre-defined. No candidate discussed the use of neck collar or even halo vest
by orthopaedic surgeons.

Scenario B for answering questions 5-7

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A 70-year-old woman who lives alone presenting with a 5-day history of fever, abdominal pain,
nausea and vomiting. The abdominal X ray reveals gas under the diaphragm. She is listed for
an emergency laparotomy for suspected perforated colonic carcinoma. The patient has a
history of severe aortic stenosis and her effort tolerance has been getting progressively worse
of late.

5. What are your major anaesthetic concerns?

76.2% candidates passed this question (16/21 passed)

Main points expected for a pass

The candidate is expected to give a comprehensive preoperative assessment that would
include not just the severe aortic stenosis but also in relation to the surgical pathology.
The candidate should recognize the urgency of the surgery and the limited time for
optimization in this patient who is obviously at high risk of major adverse cardiac events
and mortality. As such, informed consent and postoperative care must be considered and
discussed with the patient or next of kin.
Additional Points which attracted higher marks

Better candidates could relate the worsening cardiac symptoms to possible complications
from the surgical pathology e.g. anaemia, sepsis. Other consideration which very few
candidates mentioned is to further elucidate the recent deterioration in effort tolerance,
such as development of concomitant ischaemic heart disease.
Good candidates gave a holistic approach to the preoperative assessment of the patient
including discussion with the surgeon, expected complications, and reiterating an
important care plan in this elderly patient who lives alone.
Common mistakes or omission
Candidates just listed the cardiac assessment without applying to this scenario and very
few attempted to elucidate the cause for worsening of cardiac function. Many also failed
to emphasise the need for informed consent particularly for such a high- risk case and to
plan for postoperative care and disposal.

6. What is the pathophysiology of severe aortic stenosis and its relation to the development
of symptoms in patients? (60%) How do these symptoms correlate with echocardiography
findings? (40%)

47.6% candidates passed this question (10/21 passed)

Main points expected for a pass

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 In order to pass, the candidate must demonstrate understanding of the etiology and the
different phases of the natural history of an aortic stenosis. The candidate is expected to
show understanding of the echocardiography measurements in relation to assessment of
the aortic stenosis which would include the valve area, peak velocity, and mean gradient.
Additional Points which attracted higher marks

Candidates that correlated pathophysiology with clinical symptoms and progression of

symptoms did well. Candidates who demonstrated understanding to consider other
pathologies such as IHD when the echo and clinical symptoms are disparate did
exceptionally well.

Common mistakes or omission

Candidates failed to demonstrate understanding of the progressive nature of severe aortic
stenosis and how the ejection fraction may be relatively preserved till late in the course of
the disease and how these relate to development of symptoms as the valve becomes
progressively smaller. Many candidates also fail to appreciate that if the symptoms,
echocardiography findings are disparate, then it is also important to evaluate for other
conditions, such as coronary artery disease.

7. Discuss your anaesthetic plan including postoperative care.

66.7% candidates passed this question (14/21 passed)

Main points expected for a pass

The candidate is expected to devise a comprehensive plan including preoperative

optimization and demonstrate understanding of essential monitoring and the
haemodynamic goals for this patient as well as the postoperative management.

Additional Points which attracted higher marks

Candidates that demonstrated understanding of how the aortic stenosis can impact the
conduct of anaesthesia in the setting of intrabdominal sepsis and surgery did well.
Exceptional candidates could devise care plans that considered the stress of induction
versus the need for securing the airway in an unfasted patient with intrabdominal sepsis,
haemodynamic instability, and possible problems post induction.

Common mistakes or omission

Many candidates simply listed an anaesthetic plan that is for a major abdominal surgery
but failed to relate it to this particular patient with severe aortic stenosis and poor social
support. Many candidates perhaps hoped by giving a laundry list, some of the

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 components would answer the question but they fail to justify with any reasons why they
chose a particular course of actions.

8. Discuss the factors favouring monitored anaesthesia care (MAC) as the choice of
anaesthesia for endovascular aortic repair (EVAR).

28.6% candidates passed this question (6/21 passed)

Candidates performed poorly in this question. A significant number of them misinterpreted the
question and only focused on describing the pros and cons of MAC for EVAR. Those that passed
were able to mention the basic requirements for patients to undergo EVAR under MAC for
example (a) simple infrarenal AAA that will not take long; (b) cooperate patients that can remain
still during the operation and (c) surgeons that can tolerate minor movements of patients. Better
candidates can show their understanding of the requirements the possibilities of patients to
stopping breathing for some time during juxtarenal AAA or discuss on why MAC is not a good
choice for long procedures in view of possible re-perfusion syndrome, to name a few.

9. Describe the pharmacology (25%), benefits (25%) and possible limitations (25%) of
perioperative tranexamic acid administration. Discuss the use of tranexamic acid in
primary postpartum haemorrhage. (25%)

42.9% candidates passed this question (9/21 passed)

This is a straightforward question on tranexamic acid, which is an anti-fibrinolytic agent of which

its early use is advocated in trauma and postpartum hemorrhage. While candidate might not
need to quote the trial, it is crucial to know its clinical application as well as possible adverse
effects such as increasing risk of thromboemobolism and seizure. Despite its widely use, some
candidates however have no knowledge of its mechanism of action or misbelieve its use should
be guided by ROTEM or as a last resort when other treatment failed.

10. A 5-year-old child is scheduled for tonsillectomy as day surgery. He was born at 29 weeks
and has a cold two weeks ago. Outline the areas of concern during your anaesthetic
assessment.

61.9% candidates passed this question (13/21 passed)

The question is about anaesthetic assessment of a child with recent cold scheduled for
tonsillectomy. A good answer should cover the following areas: (1) long term complication of
prematurity including respiratory and neurodevelopment impairment (2) indication for the
surgery, of which sleep apnoea as the most frequently encountered reason must be considered
(3) assessment of the recent upper respiratory tract infections in the context of previous
prematurity. While the question is on assessment only, some candidates also include a detailed
anaesthetic plan including a discussion on the use of LMA vs tracheal intubation. Please note that
no extra marks will be given to irrelevant answers, indeed It is important to keep your answer
specific and context sensitive during an examination.

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11. As the Safety Officer for the Department, you were informed that a patient with a known
drug allergy to Penicillin was given Ampicillin during anaesthesia. Describe what steps you
will take to investigate the incident (60%) and recommend any organisational strategies
that will help to minimize these errors (40%).

61.9% candidates passed this question (13/21 passed)

The overall performance was fair. Obviously most of the candidates were not familiar with the
processes of incident investigation. Common omissions include description of the essential steps
in root cause analysis, human factors in drug errors and the preventability of the event. Besides,
the question was asking your role as department safety officer investigating this drug incident,
not the role of the attending anaesthetist. Therefore no mark would be given for those answers
covering the intraoperative resuscitation and postoperative anaphylaxis investigation.
Many candidates just gave brief and general answers in organizational strategies. The suggested
strategies should be relevant to the root causes of the event, including human factors,
organization factors, team factors and etc, and how the system changes can eliminate those
errors, from a department perspective. Candidates who only focused on measures limiting to
intraoperative anaesthetic practice would score less.
Incident investigation is an important quality and safety exercise in anaesthesia and we expect
candidates should have some degree of exposure+/- experience gained from their own or
rotational anaesthetic departments, through incident reporting, attending department M&M
meeting or reading newsletter from their cluster Q&S office.

12. You were called by a post-anaesthesia-care-unit (PACU) nurse to assess a patient with
difficulty of breathing after extubation. He is a 70-year-old man, BMI 35 with baseline
creatinine 200mmol/L and was operated for emergency laparotomy for intestinal
obstruction. Justify your method to exclude residual neuromuscular blockade (20%).
Discuss the perioperative clinical strategies to minimize residual neuromuscular blockade
in this scenario. (80%).

47.6% candidates passes this question (10/21 passed)

The performance of this question was surprising unsatisfactory, giving the fact that the clinical
scenario asked in the question was so common in the usual practice. The first part of the question
was generally answered better than the second part. Candidates who passed this question were
able to correlate their answers with the context, and state the rationale of their strategies. Most
of the candidates wrote non-specific answers like maintaining normal physiology or ensure
electrolyte balance, use of neuromuscular monitor without further elaboration, etc. This kind of
answering technique may reflect some degree on knowledge gap and deficiency in the ability to
formulate an individualized anaesthetic care for a particular clinical problem.
Candidates are advised to interpret the question carefully and structure the answer according to
what is asked. The second part of this question asks about strategies to minimize residual
neuromuscular blockade, not how to detect the complication from residual block. So answers
like postoperative SpO2 monitoring, use of CPAP or postoperative ICU care will score no mark.

Paper II

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1. Critical Appraisal
100% candidates passed this question (21/21 passed)

Questions based on the article:

Sleep disorders among French anesthesiologists and intensivists working in public hospitals. A
self-reported electronic survey. Eur J Anaesthesiol 2015; 32:132-137. Elisa Richter, Valery
Blasco, Francois Antonini, Marc Rey, Laurent Reydellet, Karim Harti, Cyril Nafati, Jacques Albanese
and Marc Leone, for the AzuRea Network.

Candidates were given 30 minutes reading time for the article then answer 10 True or False
questions in 10 minutes. Questions covered the nature of the study, the recruitment, sampling,
different biases, methods to reduce biases, statistics, confounding, and external validity in
True/False format. Some candidates have trouble to interpret figures presented in the article
and mistaken that vacation improves sleep. Some confused about the difference between
severity and prevalence, and prevalence with incidence. All candidates assumed that the study
would have different results if performed in private hospitals or if participants have been on night
shifts – this is not known as it is elaborating study results to outside domains. Overall
performance was good.

2. Investigation
19.1% candidates passed this question (4/21 passed)

Many candidates cannot pick up the ECG abnormalities caused by digoxin effect and extreme
hyperkalaemia. A large proportion of candidates cannot use the formula to calculate corrected
sodium (affected by hyperglycaemia) and calcium level (affected by hypoalbuminaemia).

3. Radiology
38.1% candidates passed this question (8/21 passed)

X rays and CT films were presented. Candidates were asked to identify radiological features and
diagnoses, such as retained guidewire, pneumothorax, interstitial infiltrates, hydrocephalus,
cerebral hematomas, pacemaker leads and their locations etc.

VIVA examination

47% candidates passed (8/17 passed)

The viva examination consists of three tables. At each table, candidates were given two clinical
scenarios. The introductory scenarios and questions are listed as follows.

1. A 30-year-old mother presented to your anaesthetic clinic for assessment for labour
epidural analgesia. She is in her 39th week of pregnancy and plan for labour induction

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 next week. She has GDM and her usual medications include Aspirin 100mg daily and
Protaphane 10u sc bd.

The first part of the question was about assessment of gestational DM and insulin management
during labour induction. Common mistakes included mixing up complications of GDM and DM,
inappropriately started fasting during the latent phrase of labour when patient should allow for
oral intake. The second part centred on epidural analgesia, how to manage a unilateral block and
the options of having an inadequately functioning epidural catheter for LSCS. When time is
allowed, regional anaesthesia is always preferable. The options include replacing the epidural
and top it up or performing a combined spinal epidural anaesthesia.

2. 64-year-old male has severe chronic obstructive pulmonary disease (COPD), peripheral
vascular disease and hypertension. He is a current smoker with a 50 pack-year history.
He had history of myocardial infarction. Recently, his right foot has become necrotic
and infected, and it has been decided that an urgent below-the-knee amputation is
needed. He also has chest pain and acute coronary syndrome. How do you assess this
patient? And what investigations do you want to order ?

Preoperative assessment for patients with multiple comorbidities was assessed. Regional
anaesthesia for lower limb surgery was assessed. Although there are workshops on USG guided
regional anaesthesia are easily available, the performance of candidates was quite disappointing,
reflecting knowledge deficit. Postamputation pain syndrome was also examined with good
performance.

3. A 40-year-old mother presented to your anaesthetic clinic. She is in her 37 th week of

pregnancy and scheduled for elective LSCS next week. What other important issues you
would like to know about this patient?

The question centred on initial assessment of a parturient of advanced maternal age, possible
indications for LSCS, followed by investigation and management of possible gestational
hypertension. The second part was on provision of a safe general anaesthesia and postoperative
monitoring. Candidates are expected to have good knowledge in the use of antihypertensive
medication and special considerations in giving a GA including use of arterial line, vasopressors,
uterotonic medications, muscle relaxants and intravenous fluid.

4. 76-year-old male is scheduled for left primary total hip arthroplasty. He has chronic
obstructive pulmonary disease (COPD), hypertension, congestive heart failure with an
ejection fraction of 20-30%, coronary artery disease status post coronary artery bypass
grafting (CABG x4), ischemic cardiomyopathy with an automated implantable
cardioverter defibrillator (AICD) in place, atrial fibrillation, and peripheral vascular
disease with moderate left internal carotid artery stenosis. How do you assess this
patient?

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Areas to be examined were similar to morning session. Preoperative assessment for patients with
multiple comorbidities was assessed. Regional anaesthesia for lower limb surgery was assessed.
Although there are workshops on USG guided regional anaesthesia are easily available, the
performance of candidates was quite disappointing, reflecting knowledge deficit.

5. A 78 year old man with background of diabetes mellitus and hypertension had a
myocardial infarction 1 month ago. A drug eluting stent was placed in the left anterior
descending artery. He now presents with right lower limb ischaemic pain and a big toe
gangrene. He is listed for an urgent femoral-popliteal bypass in your list. What are your
major anaesthetic concerns and how would you evaluate these concerns?

Main points expected for a pass

The candidate is expected to give a targeted preoperative assessment of the patient’s cardiac
function, the implications of a recent myocardial infarction and the placement of a drug eluting
stent. Most candidates understood the need for double antiplatelet therapy and its implication
in the choice of anaesthesia. Candidates were expected to understand the risks of stent
thrombosis versus that of bleeding related to surgery. In addition, a through cardiovascular
evaluation for any active cardiac condition is expected. Candidates should also conduct a
thorough evaluation of the vascular problem, gangrene and related issues including sepsis. The
urgency of the surgery should also be considered in tandem with surgical input so that an
informed consent taking can be obtained from the patient.

The arrhythmia should be correctly diagnosed and the cause of stent thrombosis must be
entertained in view of the history. Correct treatment should be instituted including the need for
cardiologist input for urgent re-stenting.

Subsequent pain management should include a comprehensive list of possible diagnoses and the
systematic approach to them. Candidates are also expected to know the pharmacological
treatment options of neuropathic pain and the specifics of gabapentin and pregabalin.

Additional points which attracted higher marks

Candidates who did well had good understanding of the high cardiovascular risks of this patient,
the implications of the drug eluting stent, the continued need for DAPT versus risk of stent
thrombosis. The need to have a multidisciplinary approach including performing this case in an
institution with capability to perform emergency re-stenting must be considered. Candidates
who did well in the crisis came up with the most likely diagnosis and acted in an appropriate
manner to call in the interventional cardiologist and consider stent thrombosis and need for
revascularization.

Candidates who did well also considered the different causes of lower leg pain and how to
differentiate between the various causes as well the treatment plan.

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Only few candidates managed to discuss the difference between GABA analogues and their
advantages and disadvantages.

Common mistakes or omissions

Candidates gave a scripted reply of managing a patient with cardiovascular risks but were unable
to articulate the specific cardiovascular risks of this patient. Most did not appreciate the risk of
stent thrombosis, appropriate management of DAPT and were vague about the specific risks
related to this patient.

Although most candidates easily identified the myocardial ischaemia and ventricular tachycardia,
most could not prioritise the diagnosis and thus the treatment plan.

Again, it is obvious that candidates did not think of various causes of lower limb pain and have to
be prompted to think about this on the spot. Candidates should do well to acquaint themselves
of the various painful conditions and have some basic knowledge of these in relation to the
presentation, the dermatological regions and how to differentiate between ischaemic ,
neuropathic conditions etc.

6. 50-year-old man with laryngeal papilloma is scheduled for laser excision.

How are you going to assess the patient?

Most candidates demonstrated good understanding on the various options of airway

management regarding ENT laser surgery and managed to discuss their pros and cons. The safety
concerns and precautions associated with the use of lasers were also well answered. Some
candidates were unfamiliar with the tubeless technique and failed to describe the appropriate
oxygenation method.

7. A 45 year old man with alcoholic liver cirrhosis and a past history of intravenous drug
abuse has repeated episodes of bleeding from oesophageal varices is now listed for
transjugular intrahepatic portosystemic shunt (TIPS) procedure in the interventional
radiology suite. What are your major concerns in this case?

Main points expected for a pass

The candidate is expected to give a comprehensive and targeted preoperative assessment of the
patient’s liver function, drug abuse history and issues of anaesthesia in a remote location. Most
candidates were able to discuss the Child Pugh classification and the different components of the
score. Candidates were expected to discuss rationale for platelet transfusion and also formulate
a reasonable anaesthetic plan. Candidates should be able to respond correctly to a crisis and
think on their feet how to react in a dynamic situation. The common causes of agitation in the

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PACU should be prioritized with respect to this particular patients and candidates should not just
give a laundry list of causes of agitation in general.

Additional points which attracted higher marks

Candidates who did well had better in depth knowledge of the problems of liver cirrhosis and
could use the Child Pugh classification to risk stratify patients. They could systematically work
through the various issues and formulate an appropriate anaesthetic plan. Candidates that
performed exceptionally well respond to the crisis calmly and systematically and could change
course in an appropriate fashion.

The better candidate was able to discuss diagnoses in a manner related to this particular patient
and thus formulate a treatment plan.

Common mistakes or omissions

Candidates gave a scripted reply but were unable to demonstrate that they could apply the
knowledge to the scenario posed. Although most candidates knew the Child classification, few
knew how to apply it in risk stratification. Candidates often could not justify the reasons for their
choice of anaesthesia and were not systematic in working out the crisis scenario.

8. A one-day-old neonate was scheduled for right thoracotomy and tracheoesophageal

fistula repair. He was born at 36 weeks of gestation with birth weight 2.6 kg. How are
you going to assess the patient?

Most candidates could give a reasonable preoperative preoperative assessment of a

neonate with tracheoesophageal fistula. Some candidates were confused about how the
presence of fistula could affect airway management. Good candidates could mention the
methods of isolation of fistula and appropriate ventilation strategy with justifications.
Most candidates provided good counselling to parents regarding the effect of anaesthesia
on developing brain.

9. You are going to provide anaesthesia to a 50 year old lady for robotic laparoscopic
vaginal hysterectomy for uterine prolapse next week and you are seeing her in the pre-
op assessment clinic. How are you going to assess this lady?

The scenario was about a middle aged lady for robotic laparoscopy vaginal hysterectomy for
uterine prolapse.
Candidates found no difficulties on the pre-op assessment of the patient and could all list the
anaesthetic concerns for robotic surgery as a whole. Most candidates were able to deal with
intraoperative situations such as hypercapnia and surgical emphysema although some forgot
that it may be difficult to assess and perform physical examinations on patients who is covered
up during robotic surgeries.

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10. You are seeing a 78 year-old man at pre-admission anaesthetic clinic, scheduled for
video assisted thoracoscopic right upper lobectomy for resection of a right upper lobe
carcinoma within 2 to 4 week times. He has been smoking for 40 years, hypertensive
and BW 50kg (BMI 19). Pulmonary function test was done in last week. Please interpret
this pulmonary function test.

The overall performance was satisfactory. To achieve a pass, candidates should:

• acknowledge this patient is high risk for postoperative pulmonary complications, and
further testing is beneficial for better risk stratification
• be able to point out what essential components for preoperative anaesthetic
optimization and the timing required
• effectively communicate with the surgical team and patient on the risk and plan
• demonstrate a systematic approach for the diagnosis and management of persistent
hypoxemia after lung resection
Better marking would be for those who were able to correlate the answers with
patient’s clinical context and with details.
Common deficiencies in this question include unable to interpret a pulmonary function
test and lack of systematic approach in the management of common intraoperative
problems.

11. You are the Anaesthesia Specialist on call of a small suburban hospital. During your call
day you are informed by the Accident and Emergency Department that they have just
admitted a young female being thrown out of a car and picked up by an ambulance. She
had cardiac arrest in the ambulance and the ambulance men decided to take the patient
to the nearest hospital (your hospital) for resuscitation. Just before arriving at your
hospital, ROSC occurred after CPR and fluid resuscitation. She is now fully awake. How
would you assess the patient when you arrive at the AED?

The patient was a traffic accident victim who had a cardiac arrest and was easily
resuscitated.
Almost all candidates can demonstrate organized assessment of trauma patients
according to ATLS guidelines and were able to exclude the life-threatening conditions. A
number of candidates made fatal mistakes by saying VF or pulseless VT are easily
reversible rhythms. Some candidates showed hesitation in intubating a deteriorating
patient while a few found difficulties in the preparation of inter-hospital transfer of a
trauma patient.

12. The urology team refers a 80 year old man to you, scheduled for robotic assisted radical
cystectomy+ ileal conduit +/- open in 4-week time, for preoperative anaesthetic
consultation. He has long standing history of chronic obstructive lung disease due to
smoking, old TB, hypertension and atypical chest pain refused coronary angiogram.

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 His current medication includes: aspirin, lisinopril, Ventolin puff prn, spiolto 2puff daily
and prn Panadol. Preoperative lung function test as follows. Tell me your major
preoperative concerns of this patient when you see him during the consultation.

The overall performance was fair. To achieve a pass, candidates are expected to demonstrate:
• the main concerns of this patient for minimally invasive robotic surgery, with respect to his
medical background and the proposed operation
• professional judgement on team decision to proceed with MIS
• the essential knowledge on the multimodal analgesia approach in relation to this patient’s
clinical context
• basic knowledg on epidural analgesia for robotic/ open cystectomy
Better candidates were able to provide comprehensive and structured answers, rationalize the
clinical decision or judgement with the clinical context.
Common deficiencies include general and non-specific answers and the lack of knowledge of the
somatic/dermatome levels to be blocked for cystectomy and laparotomy.

OSCE

The OSCE consists of 7 examining stations. Each station lasted 10 minutes. Candidates were
given 2 minutes before the station started to read background information and task instructions.
Overall 15 out of 17 candidates passed the OSCE (88.2%). In the crisis and ACLS stations,
candidates were presented with a simulated environment and a monitor panel on Zoom platform
to instruct a surrogate to perform tasks. In the medical case stations, candidates were instructed
to take history from a standardized patient in roughly 5 minutes, and present their findings and
interacted with examiners. In the communication station, candidates were asked to interview
an actor on Zoom platform. In the regional anaesthesia and anatomy station and equipment
station, candidates were given photos and interacted with examiners.

A. Equipment (Dr Wendy Wong, Dr Gordon Jan)

64.7% candidates passed this question (11/17 passed)

This station asked about needles to perform neuraxial blockade. Three kinds of needles in
particular were asked, the cutting point vs. pencil point spinal needle and the Touhy
needle. Questions include the differences in the design of these needles , the advantages and
disadvantages resulting from the design and the safety precautions to note using these
needles. Most candidates were able to recognise the differences between the needles. Many
candidates were not aware that epidural catheter should not be withdrawn through the Touhy
needle once it had been threaded beyond the bevel as that can transect the catheter. Both the
needle and the catheter should be removed in unison.

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Management of post dural puncture headache was also discussed. This part was generally
covered well by most candidates. Many candidates only mentioned the use of caffeine, either
orally or intravenously, after prompting.

B. ACLS (Prof Sophia Chew, Dr Albert Chan)

70.6% candidates passed this question (12/17 passed)

Scenario
You are called in to aid with resuscitation in the labour ward during your night shift.
Ms Becky Lee, is a 40 year old woman, who just delivered a baby in the labour ward. She was
at 38 weeks gestation, G2P1 and antenatal history was otherwise uneventful. She suffered
from asymptomatic COVID-19 infection 3 weeks ago but has since recovered and latest serial
RAT and PCR tests are negative.
The day time anaesthetist inserted an epidural for her 6 hours ago – it was a smooth
uncomplicated insertion and analgesia worked perfectly. The epidural infusion ran all the time
up until delivery.
Ms Lee delivered the baby 10 minutes ago through instrumental delivery for prolonged 2nd
stage, with blood loss around 100 mL. Initially the blood pressure was at 110/70 mmHg but Ms
Lee becomes progressively distressed and tachycardic. The latest blood pressure is 80/40
mmHg. The obstetrician calls you in to assist in resuscitation.
Please take up the leadership role and coordinate the team to perform resuscitation for this
patient, the examiners will act as your staff in the labour ward to assist in the resuscitation. As
the staff are unfamiliar with resuscitation, please give clear instructions to the team in the
steps of resuscitation.

Main Points needed for a pass

The candidate is expected to take on a leadership role in this crisis situation and demonstrate
effective communication and professionalism throughout. They were expected to identify the
various arrhythmias that occurred and act decisively in treating these conditions including the
use of synchronized cardioversion for unstable atrial fibrillation and unsynchronized defibrillation
for ventricular fibrillation. Details on placement of pads and how to turn on the defibrillator were
expected.
While most candidates demonstrated proficiency in Adult Cardiac Life Support algorithms in
managing ventricular fibrillation, they did less well with recognition of atrial fibrillation and its
management.
While most candidates could name causes of cardiac arrest for post-delivery parturient in the
labour ward, none made the possible link between the recent COVID infection and
thromboembolism.

Additional Points which attracted higher marks

Understandably, the OSCE station was conducted virtually via ZOOM, yet candidates who could
direct the resuscitation through verbal communication and give detailed instructions to the
“staff” did well. Future candidates are advised to learn the skills of proper communication and

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how to give explicit instructions to other staff who may not be well versed in ACLS. Those who
gave a logical approach to the treatment of atrial fibrillation including detailed dosages of drugs
fared better. The exceptional candidates also mentioned PPE precautions and worked through
differential diagnoses while simultaneously resuscitating the patient. Candidates who did well
formulated the post resuscitation care and transfer of a critically ill patient.

Common mistakes or omissions

A number of candidates failed to recognize atrial fibrillation even when prompted. Several
candidates had to be reminded on the proper use of the “synchronize” button and a number did
not follow the ACLS algorithm for cardiac arrest and the timing of giving adrenaline was incorrect.

C. Regional anaesthesia and Anatomy (Dr KS Wong, Dr Victor Cheung)

100% candidates passed this question (17/17 passed)

The innervation in shoulder area is not simple: it receives contribution from cervical plexus and
brachial plexus. The regional anaesthesia technique is modified by the widespread use of
ultrasound and this approach has several benefits: higher successful rate, fewer side effects/
complications and new approach to target individual nerves.
All the candidates were able to get pass mark in the anatomy/ regional anaesthesia station.
Better candidates had good knowledge in anatomy, optimal use of ultrasound machine and
different phrenic sparing methods with interscalene brachial plexus block.

D. Communication (Dr Louis Lui, Dr May Leung)

76.5% candidates passed this question (13/17 passed)

This station examined the communication skills of candidates to a patient who suffered from
positioning-related brachial plexus injury of his right arm after a robotic assisted operation. Most
candidates performed satisfactorily and passed. In addition to admitting responsibility and did
not shifted responsibility to the junior trainee, candidates who demonstrated sincere attitude,
empathy and professionalism, listened actively to the patient’s concerns, explained clearly the
possible diagnosis and progress, as well as provided a concrete management plan scored well.

E. Medical case (A) (Dr Vincent Kong, Dr Leo Wat)

88.2% candidates passed this question (15/17 passed)

Question
Ms Chan, 62-year-old lady, presented two days ago with abdominal pain and repeated vomiting.
CT showed partially obstructing carcinoma of colon without metastasis. She is scheduled for open
hemi-colectomy tomorrow. She has past history of renal failure, diabetes, hypertension and
hyperlipidaemia. Please take a history from the patient for the pre-operative assessment.

Examiners’ comments
Candidates performed well in this station. Most candidates were able to obtain essential
information from the history relevant to the patient’s poorly controlled chronic illness.

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Candidates who failed this station were unable to demonstrate solid knowledge on the
implications of the chronic diseases in relation to the planned anaesthesia.

F. Medical case (B) (Dr Douglas Fok, Dr Danny Ip)

88.2% candidates passed this question (15/17 passed)

In this station, candidates were asked to spend 5-minutes to perform a preoperative assessment
in a Pre-Anaesthetic Clinic setting (via zoom) on a hypothetical young patient with known
moderate to severe mitral stenosis scheduled for an elective ovarian cystectomy; followed by 5-
minutes of presentation and case discussion.

Candidates were expected to take a general anaesthetic history as well as a focused history
related to her cardiac condition, they were asked to describe in detail how they would perform
a cardiovascular physical examination, their expected physical findings and their relevant
investigations for her in this scenario.

Overall, their performances were satisfactory. A few candidates only focused on taking history
on her cardiovascular system and completely omitted on the general anaesthetic history which
would cost them dearly. A little less than half of the candidates dived directly into precordial
examination when asked to describe in detail how they would conduct their cardiovascular
system examination, which may reflect on their lack of practices in performing system
examination under exam condition over the past few years. Discussion was well-handled by most
while a few struggled with their anticipated physical findings in a patient with significant mitral
stenosis. It was gratifying to see almost all candidates would only proceed to this non time-
sensitive surgery after further proper cardiac workup.

G. Crisis (Dr Mandy Chu, Dr Henry Wong)

100% candidates passed this question (17/17 passed)

This station examined candidates on their management of hypoxia and raised airway pressure.
Similar clinical condition happened twice in the scenario with different diagnoses, endobronchial
intubation and pneumothorax respectively. Alertness to the change in clinical conditions, the
ability of systematic management for reaching diagnosis were assessed for the candidates’
competency. Bonuses were awarded on knowledge related to chest drain bottle system. Most of
the candidates were able to handle the situation systematically and reached the correct
diagnoses. However, a few candidates “called for help” too early in the scenario while it was only
a simple, mild desaturation without hemodynamic changes. Marks were deducted for the
inappropriate clinical judgement and response. We would expect a specialist to handle and
troubleshoot a simple desaturation without much difficulty. Some candidates jumped into
conclusion of tension pneumothorax while it was still a stable pneumothorax. Needle
thoracotomy is not indicated for simple pneumothorax but it would be essential to minimize the
positive ventilatory pressure before the pneumothorax is drained. While some candidates were

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rather fixated and excited on needle thoracotomy during tension pneumothorax, they forgot to
declare crisis in this real crisis situation.
It was challenging to “manage” a crisis virtually. The candidates were also expected to describe
certain procedures including shifting of endotracheal tube and chest drain insertion in detail.
Most of the candidates however performed well and demonstrated adequate knowledge. One
candidate mentioned to clamp the endotracheal tube during repositioning. It was considered
unnecessary. Quite a number of candidates forgot to do sputum suction and ask about the fasting
schedule before deflation of the cuff. These are considered important to minimize the risk of
aspiration.

The examination team would express deep gratitude to thank all the devoted examiners, college
staff and helpers in organizing and completion of our professional examination during the
pandemic. Special thanks to Prof Chew to her invaluable opinion and enthusiasm as the external
examiner and supported all the components of our professional examination.

END

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