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 The Final

FRCa
Structured Oral examination – a Complete Guide

BOBBy KRiShnaCheTTy

and

DaRShinDeR SeThi

Bobby Krishnachetty_Book.indb 1 27/04/16 5:50 PM

 CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2016 by Bobby Krishnachetty and Darshinder Sethi

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

Version Date: 20150710

International Standard Book Number-13: 978-1-909368-25-5

This book contains information obtained from authentic and highly regarded sources. While all reasonable
efforts have been made to publish reliable data and information, neither the author[s] nor the publisher
can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers
wish to make clear that any views or opinions expressed in this book by individual editors, authors or
contributors are personal to them and do not necessarily reflect the views/opinions of the publishers.
The information or guidance contained in this book is intended for use by medical, scientific or health-
care professionals and is provided strictly as a supplement to the medical or other professional’s own
judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the
appropriate best practice guidelines. Because of the rapid advances in medical science, any information
or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly
urged to consult the relevant national drug formulary and the drug companies’ and device or material
manufacturers’ printed instructions, and their websites, before administering or utilizing any of the
drugs, devices or materials mentioned in this book. This book does not indicate whether a particular
treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the
medical professional to make his or her own professional judgements, so as to advise and treat patients
appropriately. The authors and publishers have also attempted to trace the copyright holders of all material
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Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are
used only for identification and explanation without intent to infringe.

Visit the Taylor & Francis Web site at

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and the CRC Press Web site at

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Bobby Krishnachetty_Book.indb 2 27/04/16 5:50 PM

 CoNTENTS
FoREWoRD vii
PREFACE ix
LIST oF CoNTRIBUToRS xi
ACKNoWLEDGEMENT xii
INTRoDUCTIoN xiii

section 01

clinical Viva 1
01.1 Long case: Epilepsy and learning difficulties 2
01.2 Short case: Complete heart block 7
01.3 Short case: Nutrition in ICU 11
01.4 Short case: Electroconvulsive therapy 14

Basic science Viva 19

01.5 Anatomy: Liver and spleen 20
01.6 Physiology: Brainstem death 26
01.7 Pharmacology: Anaesthesia in Parkinson’s disease 30
01.8 Physics: Magnetic resonance imaging 33

section 02

clinical Viva 37
02.1 Long case: Foreign body aspiration in a child 38
02.2 Short case: Anaesthesia for lung resection 42
02.3 Short case: Amniotic fluid embolism 45
02.4 Short case: Postoperative eye pain 47

Basic science Viva 51

02.5 Anatomy: Spinal cord blood supply 52
02.6 Physiology: Pneumoperitoneum 56
02.7 Pharmacology: Drugs used in malignancy 58
02.8 Physics: Sodalime 61

section 03

clinical Viva 65
03.1 Long case: Pregnant woman with diabetic ketoacidosis 66
03.2 Short case: ICU weakness 72
03.3 Short case: Consent issues 75
03.4 Short case: WPW syndrome 78

iii

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 CONTENTS

Basic science Viva 81

03.5 Anatomy: Cranial nerve monitoring 82
03.6 Physiology: Apnoea physiology 85
03.7 Pharmacology: Comparing volatile agents 87
03.8 Physics: Intracranial pressure monitoring 89

section 04

clinical Viva 93
04.1 Long case: Guillain Barre syndrome 94
04.2 Short case: Intrauterine fetal death 99
04.3 Short case: Eisenmenger’s syndrome 101
04.4 Short case: Myotonic dystrophy 104

Basic science Viva 107

04.5 Anatomy: Mediastinum 108
04.6 Physiology: Cerebral circulation 110
04.7 Pharmacology: Serotonin 112
04.8 Physics: Monitoring in scoliosis surgery 115

section 05

clinical Viva 119

05.1 Long case: Abdominal aortic aneurysm for EVAR 120
05.2 Short case: Fracture mandible 127
05.3 Short case: Rheumatoid arthritis 130
05.4 Short case: Inadvertent dural puncture 134

Basic science Viva 137

05.5 Anatomy: Caudal block 138
05.6 Physiology: Preeclampsia 142
05.7 Pharmacology: Tricyclic antidepressants 147
05.8 Physics: osmolarity 149

section 06

clinical Viva 151

06.1 Long case: Pregnant woman with aortic stenosis 152
06.2 Short case: Hoarseness and microlaryngoscopy 161
06.3 Short case: Head injury 164
06.4 Short case: Chronic obstructive pulmonary disease 168

Basic science Viva 171

06.5 Anatomy: Coronary circulation 172
06.6 Physiology: Liver disease 177
06.7 Pharmacology: Drugs used for secondary prevention 180
06.8 Physics: Scavenging 182

iv

Bobby Krishnachetty_Book.indb 4 27/04/16 5:50 PM

 CONTENTS

section 07

clinical Viva 185

07.1 Long case: Child for fundoplication 186
07.2 Short case: Epidural abscess 192
07.3 Short case: Cardiomyopathy 194
07.4 Short case: Autonomic dysreflexia 200

Basic science Viva 203

07.5 Anatomy: Pleura 204
07.6 Physiology: Denervated heart 209
07.7 Pharmacology: Hypotensive drugs 213
07.8 Physics: Renal replacement therapy 217

section 08

clinical Viva 221

08.1 Long case: Patient with valve replacements for urgent surgery 222
08.2 Short case: Supraventricular tachycardia 230
08.3 Short case: Cystic fibrosis 233
08.4 Short case: Pneumothorax 236

Basic science Viva 239

08.5 Anatomy: Pituitary 240
08.6 Physiology: Ventilator associated pneumonia 247
08.7 Pharmacology: Anticholinesterase 250
08.8 Physics: Humidity/temperature 253

section 09

clinical Viva 257

09.1 Long case: Acute cervical spine subluxation 258
09.2 Short case: Diseases of red cell morphology 264
09.3 Short case: Permanent pacemaker 269
09.4 Short case: Bleeding tonsil 271

Basic science Viva 275

09.5 Anatomy: Paravertebral block 276
09.6 Physiology: Pulmonary hypertension 282
09.7 Pharmacology: Target controlled infusion 285
09.8 Physics: Cardiac output monitoring 289

section 10

clinical Viva 293

10.1 Long case: Mediastinal mass 294
10.2 Short case: Preoperative anaemia 301
10.3 Short case: Cholesteatoma 304
10.4 Short case: Cardiac risk stratification 306

Bobby Krishnachetty_Book.indb 5 27/04/16 5:50 PM

 CONTENTS

Basic science Viva 309

10.5 Anatomy: Intraosseous anatomy 310
10.6 Physiology: Chronic regional pain syndrome 314
10.7 Pharmacology: Anticoagulants and bridging 317
10.8 Physics: Peripheral nerve monitoring 319

Appendix 1 323
Appendix 2 345
Appendix 3 373
Appendix 4 379
Appendix 5 383
Appendix 6 391

index 399

vi

Bobby Krishnachetty_Book.indb 6 27/04/16 5:50 PM

 FoREWoRD
The Structured oral Examination (SoE) has undergone considerable development since
it was introduced more than a decade ago. It is intended to test an understanding of safe
practice of anaesthesia. This component of the FRCA examination process combines a vast
curriculum of clinical anaesthesia with the clinical application of basic sciences. Add the
daunting task of facing unknown examiners in the viva, and this proves to certainly be the
biggest professional challenge that any aspiring anaesthetist would have been confronted
with, up to that stage in their career.
Good preparation for the examination is crucial to a successful outcome. Answering
intimidating questions while thinking on one’s feet, does not come naturally for any
candidate, and has to be practiced. This exam preparation book, The Final FRCA Structured
Oral Exam – a Complete Guide, is exactly what its name says. This is an excellent guide to
polish the candidate who has successfully passed their written exams.
The editors of this book, Bobby Krishnachetty and Darshinder Sethi, are both College
Tutors for the Royal College of Anaesthetists, and are well-experienced leaders in trainee
education and preparation of candidates for FRCA Exams. In addition, the other contributors
to the book are all young anaesthetists who have recently been exposed to the challenge
of the FRCA SoE. This group is therefore perfectly equipped to share their important
examination preparation experience.
Together they have compiled this book comprising ten sections, over a wide range of
possible examination topics. Each section starts with a long clinical case followed by three
different short scenarios. A viva section then follows, with four topics covering applied
anatomy, physiology, pharmacology, and physics/monitoring. The case scenarios as well
as the viva topics are problem-based and supported by evidence. All the section topics
are presented with numerous possible examination questions, accompanied by well-
prepared answers. Plenty of basic diagrams and special investigations are included, which if
reproduced during the real exam, will definitely impress any examiner.
A real valuable resource is the six appendices covering such important areas like ECG
interpretation, patient risk scoring systems, as well as risk stratification indices, and blood
result interpretation. In addition there is one appendix with a list and short explanation of
recent important clinical trials, which when quoted during the exam, will definitely have a
positive influence on examiner judgment!
The SoE arrives rapidly after the FRCA written examination and time to revise the full
syllabus is limited. I believe that the educational material in this book is up-to-date, and
presented in such a way that it will identify gaps in areas of clinical knowledge. It provides the
candidate with the important practice of answering appropriate, but uncomfortable questions.
I can strongly recommend this book to both teacher and candidate preparing for the FCA SoE.

Justiaan swanevelder
Professor and Head of Department of Anaesthesia
Health Sciences Faculty
University of Cape Town
South Africa
Previous Examiner for Royal College of Anaesthesia Primary and
Final Examinations – 2003–2012
Present Examiner for the Faculty of Anaesthesia,
College of Medicine of South Africa – 2012–present

vii

Bobby Krishnachetty_Book.indb 7 27/04/16 5:50 PM

 PREFACE
We have conducted the Darent Final FRCA course in Kent for 3 years, and it was during this
period that we felt motivated to write this book as a way of contributing to a wider audience
preparing for the exam. We have collected a vast database of questions from our trainees
who sit the exam, and the book reflects a variety of commonly asked themes.
The style of questions mimics the exam, and we have added tutorials for ECG
interpretation and radiology, which will benefit trainees immensely in their preparation.
We have spent several months researching the subject material in an effort to make it as
evidence-based and the references as up-to-date as possible. We would like to express
our gratitude and appreciation to our colleagues who have contributed to the publication of
this book.
We sincerely hope this book will be a valuable addition to the FRCA exam preparation and
that anaesthetic trainees will find the book highly useful.
BK
DSS

ix

Bobby Krishnachetty_Book.indb 9 27/04/16 5:50 PM

 LIST oF
CoNTRIBUToRS
Oliver Blightman Sidath Liyanage
Specialist Registrar in Anaesthetics Consultant Radiologist
South East School of Anaesthesia Southend University Hospital

Oliver Boney Queenie Lo

Specialist Registrar in Anaesthetics Specialist Registrar in Anaesthetics
Barts and the London School of Anaesthesia Barts and the London School of Anaesthesia

Parminder S Chaggar Sanjay Parmar

Senior Registrar in Cardiology Consultant Anaesthetist
University Hospital of South Manchester Darent Valley Hospital

Dinesh Das Jenny Townsend

Specialist Registrar in Anaesthetics Specialist Registrar in Anaesthetics
Central London School of Anaesthesia Barts and the London School of Anaesthesia

Geetha Gunaratnam Ali Zaman

Specialist Registrar in Anaesthetics Specialist Registrar in Radiology
Barts and the London School of Anaesthesia Southend University Hospital

Francoise Iossifidis
Consultant Anaesthetist
Darent Valley Hospital

xi

Bobby Krishnachetty_Book.indb 11 27/04/16 5:50 PM

 ACKNoWLEDGEMENT
Dr Mike Cadogan of Life in the FASTLANE
Lifeinthefastlane.com
For permitting the use of important X-rays and ECG from their collection

Dr William Herring of Learning Radiology

learningradiology.com
For permitting the use of X-rays from their collection

xii

Bobby Krishnachetty_Book.indb 12 27/04/16 5:50 PM

 INTRoDUCTIoN
confucius (c. 551 – c. 479 BC)
There’s a place in the brain for knowing what cannot be remembered.

clinical Long case

The 10-min preparation time is usually short for getting things ready. Use it wisely!

First part of the question will be about summarising and discussing the investigation
results. Write down your punchy summary so you have a confident start. Find the abnormal
investigations, think why they are abnormal, derive possible reasons etc. Anaemia is one
such example… almost always expect them to ask you the causes of anaemia if the patient
is anaemic.

Second part would be the anaesthetic management of the patient. Prepare your answers
with the possible headings in mind.

Preoperative
• Is it emergency or urgent… have you got time for preoptimisation?
• Further history and examination
• Investigations
• Preoperative risk stratification and optimisation
• Premedication

Intraoperative
• Preparation
• Senior help
• Monitoring – invasive
• Emergency drugs and equipment
• Induction
• Maintenance
• Emergence
• Analgesia – regional technique
• Antiemesis
• Fluids
• Temperature
• Positioning

Postoperative
• Destination HDU/ITU
• oxygen
• Analgesia
• Antiemesis
• Fluids
• DVT prophylaxis
Third section of the clinical long case viva is about a critical incident whilst in theatre or
recovery – hypoxia, confusion, agitation etc.

xiii

Bobby Krishnachetty_Book.indb 13 27/04/16 5:50 PM

 INTRODUCTION

short cases
A mix of obstetric, general, intensive care, and chronic pain cases for just over
20 minutes… and you are done with the clinical viva!

Anatomy
In a 7-minute anatomy viva, 2-3 minutes are given to pure anatomy questions… remember
this is Final FRCA, hence what is important is the application and implications related to
anaesthesia.
The chosen strategy for being successful on applied anatomy is to learn it, one topic a day
and to recite it the next day to someone who will listen.
‘It does not matter how slowly you go so long as you do not stop’

Have a set format to answer some kinds of question. For example – factors affecting blood
flow of any organ the following classification always works.
• Factors inherent to the circulation
• Pressure or myogenic autoregulation
• Chemical/metabolic factors
• Neural factors
• Humoral factors
• others
Determinants of cerebral blood flow are
1. Autoregulation by the myogenic mechanism
2. Chemical/metabolic – o2 and Co2 and local metabolites like prostanoids
3. Neurohumoral – ineffective
4. others – blood viscosity and temperature

I have jotted down the anatomy questions in the order of recurrence. It is wise to look at the
rarities too as ‘the cautious seldom err’.

Most common/regular questions

Circulation
Coronary circulation and myocardial ischaemia/ECG changes
Spinal cord circulation and aortic cross clamping
Spinal cord anatomy and central neuraxial blockade
Cerebral circulation and head injury management
Blood supply of the hand and arterial line placement
Femoral triangle – CVC insertion/femoral nerve blocks
Structures
Trachea – trauma to neck and AFoI
Larynx and nerve damage
Diaphragm and hernia
Sacrum – caudal
Eye – blocks and periop injury to eye
Pleura – pressures and injury
Nerves
Cranial nerves –5, 7, and 10
Sympathetic – stellate and coeliac plexus
Intercostal block and VATS surgery
Phrenic nerve
Brachial plexus and injury/blocks
Femoral nerve
Ankle block
Sciatic nerve

xiv

Bobby Krishnachetty_Book.indb 14 27/04/16 5:50 PM

 INTRODUCTION

Fairly common
Pituitary – hormonal/pressure effects and transsphenoidal surgery
Cervical plexus
Paravertebral space
Liver anatomy – blood supply
Bowel circulation and abdominal compartment syndrome

occasional popups
Bone – for Io circulation
Foetal circulation
Spleen
T10 cross section
Mediastinum
Coeliac plexus

Physiology, Pharmacology, Physics, and clinical Measurement

Same principles apply in answering these questions too. Try and classify to make your
answer interesting and complete. You should have a general idea about every topic so you
have a good start.
It is better to ask a question than to remain ignorant. So if you did not understand please
request the examiner to rephrase it.

Behind every successful candidate there is a lot of hard work.

I hear and I forget. I see and I remember. I do and I understand….
So Practice! Practice! Practice!

xv

Bobby Krishnachetty_Book.indb 15 27/04/16 5:50 PM

 section 01
CliniCal
VIVA

Bobby Krishnachetty_Book.indb 1 27/04/16 5:50 PM

 01 CLINICAL VIVA

01.1 LonG cAse:

ePiLePsY AnD LeARninG
DiFFicULties
HistoRY You have been asked to review a 36-year-old man who has fallen
against a radiator and sustained a penetrating injury to his right eye.

He has a past medical history of learning difficulties and poorly controlled

epilepsy with one to two fits per week, on average. He has also recently been
referred to a sleep studies clinic.

He is conscious in A&E and responding to questions appropriately, despite being

clearly distressed. The caregiver who is with him did not witness the fall but says
that other than his eye injury, he appears to be otherwise acting normally.

stePs KeY Points

current medication Carbamazepine 600 mg tds

Levetiracetam 1.5 g bd
Vigabatrin 1g bd
Quetiapine 300 mg od
Lorazepam 2–4 mg PRN

clinical examination Weight 135 kg

Height 175 cm
BMI 44 kg/m2
Heart rate 80/min
Respiratory rate 16/min
BP 165/90 mmHg
Temperature 36.5 °C
He is overweight with a large jaw and thick beard. Airway examination
reveals poor dentition, a large tongue, and a Mallampati score of 3.

Blood investigations Awaited

Bobby Krishnachetty_Book.indb 2 27/04/16 5:50 PM

 LONG CASE: EPILEPSY AND LEARNING DIFFICULTIES

stePs KeY Points

Arterial blood gas pH 7.38

po2 8.69 kPa
pCo2 6.98 kPa
BE +4.8
HCo3 32 mmol/L
Hb 17 g/dl

chest X-ray
done two months ago

Fig. 1.1

sleep studies
done two months ago
The polysomnogram demonstrated an apnoea-hypopnoea index (AHI)
of 15 events/hr and a nadir oxygen saturation of 78%; supine AHI was
44 events/hr. Definitive obstructive events were not observed in the non-
supine position. The total sleep time was 337 minutes, with a sleep time
in the supine position of 113 minutes. A 2-minute epoch from the patient’s
polysomnogram is shown in Figure 1.2.

Fig. 1.2

Bobby Krishnachetty_Book.indb 3 27/04/16 5:50 PM

 01 CLINICAL VIVA
stePs
summarise the case.
comment on the chest X-ray.
How does a vagal nerve
stimulator work?
What are the anaesthetic
implications for patients
with epilepsy?
correlate and comment on the
ABG and sleep studies result.
What is AHi? How can you
classify the severity of osA?
What symptoms suggest a
diagnosis of osA?
What scoring systems are used
for screening for osA?
Bobby Krishnachetty_Book.indb 4
KeY Points
• 36-year-old man with penetrating eye injury
• Poorly controlled epilepsy and learning difficulties
• Untreated obstructive sleep apnea (OSA)
• Obese with potentially difficult airway
• Potential liver and renal function impairment due to antiepileptic drugs
obvious abnormality is the presence of a vagal nerve stimulator
• Reduced lung volumes
• Lung fields otherwise clear except haziness in left lower border
• Normal heart borders, borderline cardio thoracic ratio
• Pulse generator/stimulator that sends regular, mild electrical stimuli to the
vagus nerve
• Used in drug-resistant epilepsy, particularly partial seizures and
treatment-resistant depression
• Often not immediately effective and rarely prevents seizures entirely
• Battery-powered so requires changing every 5–10 years
• Increased incidence of seizures perioperatively—multifactorial
• Continue anti-epileptic drugs (AEDs) with minimal fasting period (or use
parenteral alternative)
• Caution regarding AEDs—hepatic enzyme metabolism and other drug
interactions
• Hypoxaemia, hypercapnia, and polycythemia, related to OSA
• Metabolic compensation (chronic disease)
• Apnea/hypopnea index indicates severe OSA
AHi
AHI is the number of apneas or hypopneas recorded during the study per
hour of sleep. It is generally expressed as the number of events per hour.
Based on the AHI, the severity of oSA is classified as follows:
• None: < 5 per hour
• Mild: 5–14 per hour
• Moderate: 15–29 per hour
• Severe: ≥ 30 per hour
oxygen Desaturation
Desaturations are recorded during polysomnography. Although there are
no generally accepted classifications for severity of oxygen desaturation,
reductions to not less than 90% usually are considered mild. Dips into the
80%–89% range can be considered moderate, and those below 80% are
severe.
• Snoring
• Daytime somnolence
• Early morning headaches
• Dry or sore throat upon waking
• Poor concentration and irritability
stoP BAnG questionnaire
• Snoring
• Tired—daytime tiredness or fatigue
• Observed apnoea during sleep
• Pressure (blood)—treatment for hypertension
• BMI more than 35 kg/m2
• age over 50 years
• neck circumference greater than 40 cm
• Gender—high prevalence in male gender
27/04/16 5:50 PM

stePs
What are the risk factors
for osA?
What are the complications
or associations of osA?
What are the anaesthetic
implications for patients with
osA?
Bobby Krishnachetty_Book.indb 5
LONG CASE: EPILEPSY AND LEARNING DIFFICULTIES
KeY Points
epworth sleepiness scale
• The questionnaire looks at the chance of falling asleep on a scale of
increasing probability from 0 to 3 for eight regular activities during their
daily lives.
• The scores for the eight questions are added together to obtain a single
number.
• Normal: 0–9; mild to moderate sleep apnea: 11–15; severe sleep
apnea: 16 and above
Berlin questionnaire
• Patients can be classified into high or low risk based on their responses
to similar questions.
• Obesity
• Male gender
• Age > 40 years
• Neck circumference > 17 inches
• Family history of OSA
cardiac
• Treatment-resistant hypertension
• Congestive heart failure
• Ischaemic heart disease
• Atrial fibrillation
• Dysrhythmias
Respiratory
• Asthma
• Pulmonary hypertension
Gi
• Gastro-oesophageal reflux
neurological
• Stroke
Metabolic
• Type II Diabetes Mellitus
• Hypothyroidism
• Morbid obesity
sedative premedication
• Avoid sedating premedication
• Alpha-2 adrenergic agonist (clonidine, dexmedetomidine) may reduce
intraoperative anaesthetic requirements and have an opioid-sparing effect
Difficult airway
• Ramp from scapula to head as patient is obese
• Adequate preoxygenation
• Associated gastro-oesophageal reflux disease—consider proton pump
inhibitors, antacids, rapid sequence induction with cricoid pressure
Analgesia
• Minimise use of opioids for the fear of respiratory depression
• Use short-acting agents (remifentanil)
• Regional and multimodal analgesia (NSAIDs, acetaminophen, tramadol,
ketamine, gabapentin, pregabalin, dexamethasone)
27/04/16 5:50 PM
 01 CLINICAL VIVA
stePs
What are your concerns of
anaesthetising this patient now?
What would be your induction
technique and airway
management plan for
this patient?
What are the possible causes
and how might you manage
them?
What is your approach to
deep vein thrombosis (DVt)
prophylaxis in this patient?
Bobby Krishnachetty_Book.indb 6
KeY Points
Anaesthetic technique
• Carry-over sedation effects from longer-acting intravenous sedatives and
inhaled anaesthetic agents
• Use propofol/remifentanil for maintenance of anaesthesia
• Use insoluble potent anaesthetic agents (desflurane, sevoflurane)
• Use regional blocks as a sole anaesthetic technique (not in this case!)
Monitoring
• Use intraoperative capnography for monitoring of respiration (mandatory
anyway!)
• Arterial line if OSA associated with cardiac dysfunction
Postoperative period
• Verification of full reversal of neuromuscular blockade
• Ensure patient fully conscious and cooperative prior to extubation
• Non-supine posture for extubation and recovery
• Resume use of positive airway pressure device with close monitoring
post-operatively
• May require HDU/ITU admission
• Newly diagnosed hypertension
• Urgency of surgery—discuss with surgeons but likely to be urgent rather
than an emergency
• Exclude other trauma, especially neck and intracranial
• Anaesthetic technique in view of potentially difficult airway
• Control of intraocular pressure
• Post-operative care—will need HDU/ITU bed
• Ideally get help—two anaesthetists present
• Awake fibreoptic intubation unlikely to be suitable (coughing, distressed,
learning difficulties)
• Allow for adequate starvation time if possible
• Preoxygenate in ramped position
• Modified rapid sequence induction with rocuronium (ensuring
sugammadex available) may be most appropriate
• Use of video laryngoscopy may be ideal
The patient is now extubated and in recovery. You are called to review him
because he is agitated.
• Pain: analgesia
• Inadequate reversal of muscle relaxant: check the TOF count and use
reversal
• Drug-induced, e.g. atropine, opioids: review anaesthetic chart
• Hypercapnia: treatment of sedative/opioid toxicity, airway manoeuvres,
and adjuncts if obstructed
• Hypoxia: O2, airway manoeuvres, and adjuncts if obstructed
• CPAP likely to be contra-indicated due to eye injury
• High risk for DVT—obese, polycythaemic
• Mechanical prophylaxis
• Early mobilisation
• Balance risk versus benefit of anticoagulation in eye trauma—get
specialist help regarding the plan
27/04/16 5:50 PM
 SHORT CASE: COMPLETE HEART BLOCK

01.2 sHoRt cAse:

coMPLete HeARt BLocK
HistoRY An 80-year-old male patient presents to pre-assessment clinic for
SCC removal on his forehead. He complains of dizzy spells. The pre-assessment
nurse wants to know what to do. See Figure 1.3.

Fig. 1.3

Bobby Krishnachetty_Book.indb 7 27/04/16 5:50 PM

 01 CLINICAL VIVA
stePs
What does the ecG show?
What are the causes of
complete heart block?
Would you anaesthetise
him now?
How would you manage this if
it occurred intraoperatively?
Bobby Krishnachetty_Book.indb 8
KeY Points
• Regular P waves and QRS complexes are seen but are unrelated to
each other
• No QRS widening
• Voltage criteria for LVH
• No obvious features of coronary ischaemia
The ECG shows third-degree AV block, with a ventricular rate of 34/min.
Congenital
• With maternal antibodies to SS-A (Ro) and SS-B (La)
Acquired
• Drugs: quinidine, procainamide, disopyramide, amiodarone, β blockers
• Infection: Lyme disease, rheumatic fever, Chagas disease
• Connective tissue disease: ankylosing spondylitis, rheumatoid arthritis,
scleroderma
• Infiltrative disease: amyloidosis, sarcoidosis
• Neuromuscular disorders: muscular dystrophy
• Ischaemia: e.g. AV block associated with inferior wall MI
Iatrogenic
• AV block may be associated with aortic valve surgery, PCI
No. Patient is at high risk of severe peri-operative bradycardia leading to
cardiac decompensation, or even cardiac arrest.
• He requires referral to a cardiologist, and probably electrical pacing,
ideally with a permanent pacemaker.
• Further cardiac investigations to determine the cause (e.g. angiogram)
and to establish his baseline cardiac function (e.g. echocardiogram)
would also be helpful.
• If the surgery is deemed too urgent to wait for further investigation and
PPM implantation, other options include a temporary pacing wire, or
pharmacological chronotropy via an isoprenaline infusion.
Ask surgeons to stop, check correct attachment of monitoring, and feel for
a pulse.
If there is no pulse palpable, start CPR and then treat the underlying
problem.
Pharmacological options
• Trial of antimuscarinic drugs (e.g. atropine or glycopyrollate)
• Carefully titrated adrenaline boluses (10–100 mcg)
• Isoprenaline infusion (β-agonist): 0.02–0.2 mcg/kg/min
Electrical/mechanical options
• Percussion pacing using a clenched fist (rarely achieves electrical
capture)
• Transcutaneous external pacing via defibrillator pads; increase current
until electrical capture achieved. Set rate at 70–80 bpm
• If pharmacological measures fail to restore an adequate heart rate,
a temporary pacing wire (inserted via a central line) will probably be
necessary, but this takes time to organise (and should be done under
aseptic conditions by an appropriately trained cardiologist under X-ray
guidance)
• Transoesophageal pacing is also possible but similarly requires specialist
equipment and expertise to set up
27/04/16 5:50 PM

stePs
What are the indications for
insertion of a permanent
pacemaker?
… And for temporary pacing?
What features are associated
with a high risk of asystole?
What do you want to know
before anaesthetising a
patient with a PPM?
Bobby Krishnachetty_Book.indb 9
SHORT CASE: COMPLETE HEART BLOCK
KeY Points
As for all emergencies, management would also require simultaneous rapid
assessment/management of airway and breathing/ventilation
- Is airway patent? Give 100% o2, check ETT/LMA position
- Is oxygenation/ventilation intact? Manually ventilate patient, check for
bilateral chest rise, air entry on auscultation, EtCo2, misting of ETT, and
saturation
- Remember to maintain anaesthesia while you sort out the new-onset
complete heart block!
• Any symptomatic bradycardia (i.e. causing collapse/syncope/presyncope)
• Complete heart block
• Mobitz type II block
• Sick sinus syndrome
• Hypersensitive carotid sinus syndrome
• Symptomatic bradycardia in transplanted heart
• Severe heart failure (cardiac resynchronisation therapy)
• Some patients with dilated or hypertrophic cardiomyopathy
All of the above indications for permanent pacemaker insertion are also
indications for temporary pacing in an emergency situation (or if a permanent
pacemaker is unavailable/contraindicated (e.g. systemic sepsis).
• Acute myocardial infarction causing asystole/bradyarrhythmia that entails
haemodynamic compromise
• Drug overdose (e.g. β-blockers, calcium channel blockers, digoxin)
• Surgery/general anaesthesia for patients with stable heart block not
causing haemodynamic compromise but potentially at risk of worsening
bradycardia/asystole
• Following cardiac surgery (usually involves placement of epicardial
pacing wires, rather than transvenous pacing wire, at end of surgery by
surgeons)
• Pauses of >3 seconds
• Previous asystolic episodes
• Complete heart block with wide QRS complexes
Preoperative assessment should be aimed at finding answers to the
following questions:
• Indication of pacemaker insertion
• Check date (Does it need checking again before theatre?)
• Is the patient pacing dependent?
• Type of PPM (unipolar/bipolar, number of leads, biventricular/
univentricular, etc)
• Programmed mode
Investigations/preparation
• All patients should have CXR (to show PPM position and number
of leads)
• ECG: look for pacing spikes before each QRS to determine whether
pacing-dependent
• Correction of any electrolyte abnormalities (which may cause loss of
capture)
• Switched to fixed rate mode if necessary
• PPM check if any doubts re: function/battery life/failure of capture, etc.
• May need to arrange cardiac-monitored bed post-op (plus another
PPM check)
27/04/16 5:50 PM
 01 CLINICAL VIVA
stePs KeY Points

What hazards arise in theatre
in patients with a PPM?
• Electromagnetic interference (mainly from monopolar diathermy) may
reprogram the PPM (usually into a fixed rate back-up mode) or inhibit
pacing inappropriately. To reduce the risk of PPM malfunction, use
bipolar diathermy. If monopolar diathermy is unavoidable, the pad should
be placed as far as possible from PPM; diathermy current should flow
perpendicular to PPM current.
• Patient shivering, fasciculations following suxamethonium, and sources
of vibration may cause inappropriate ‘sensing,’ which will inhibit pacing or
rate modulation (if not previously switched to fixed rate mode).
• PPM may be dislodged during patient positioning or CVP line insertion.
• Theoretical risk of microshock via PPM lead, which may induce
arrhythmia.
• All PPM-dependent patients are at risk of asystole or bradyarrhythmias if
the PPM fails for any reason. Emergency drugs and pacing facilities (as
discussed above) should therefore be readily available.

nAPse/BPeG* ReViseD cLAssiFicAtion oF PAceMAKeRs (2002)

I II III IV V
(chamber (chamber (response to (rate (multisite
paced) paced) sensing) modulation) pacing)

0 = none 0 = none 0 = none 0 = none 0 = none

A = atrium A = atrium T = triggered A = atrium

R = rate modulation
V = ventricle V = ventricle I = inhibited V = ventricle

D = dual D = dual D = dual D = dual

* North American Society of Pacing and Electrophysiology/British Pacing and

Electrophysiology Group

other potential questions for Physiology of cardiac conduction

this case: Hazards associated with diathermy
ICD and anaesthesia—NPSA guideline

10

Bobby Krishnachetty_Book.indb 10 27/04/16 5:50 PM

 SHORT CASE: NUTRITION IN ICU

01.3 sHoRt cAse:

nUtRition in icU
HistoRY Figure 1.4 shows the CXR of an ITU patient.

Fig. 1.4

stePs KeY Points

comment on the most obvious Nasogastric tube is above the diaphragm and follows the course of the right
finding in the film. lower lobe bronchus.

Would you authorise the tube No.

for enteral feeding?

How can the tube position national Patient safety Agency alert/nice guideline
be confirmed? • Use pH paper.
° pH < 5.5 indicates gastric placement.

° If > 5.5, or no aspirate, change patient position and check in an hour.

• X-ray is recommended only if the pH test fails.

The position of all nasogastric tubes should be confirmed after placement
and before each use by aspiration and pH graded paper (with X–ray if
necessary) according to the NPSA guideline.

11

Bobby Krishnachetty_Book.indb 11 27/04/16 5:50 PM

 01 CLINICAL VIVA
stePs
What are the normal nutrition
requirements for a healthy
person?
Define malnutrition.
What is he at risk of?
What are the complications
of enteral nutrition?
12
Bobby Krishnachetty_Book.indb 12
KeY Points
Measuring energy use requires sophisticated equipment, so nutrition
requirements are estimated using formulae.
The Harris Benedict Equation estimates basal metabolic rate (BMR) in kcal/day.
In men: BMR = 13.75 × weight (kg) + 5 × height (cm) − 6.78 × age (years)
+ 66
For women: BMR = 9.56 × weight (kg) + 1.85 × height (cm) − 4.68 × age
(years) + 655
For an afebrile healthy individual, this is around 25 kcal/kg/day.
Conditions such as fever, sepsis, surgery, and burns increase the
requirements.
european society of Parenteral and enteral nutrition (esPen)
The total energy requirements of critically ill patients are given in recent
guidelines issued by the ESPEN in 2006.
• Acute initial phase of critical illness: 20–25 kcal/kg/day
• Recovery/anabolic phase: 25–30 kcal/kg/day
• Protein around 1.5 g/kg/day (2g/kg/day in severely catabolic patients).
• lipid should be limited to 40% of total calories.
• Carbohydrate makes up the remaining calorie requirements.
Glutamine, arginine, fish oils, and ribonucleotides; antioxidants including
Vitamins C and E; selenium and other trace elements are considered useful
for immunonutrition.
Sodium 1.0–2.0 mmol/kg/day
Potassium 0.7–1.0 mmol/kg/day
Calcium 0.1 mmol/kg/day
Magnesium 0.1 mmol/kg/day
Chloride 1–2 mmol/kg/day
Phosphate 0.4 mmol/kg/day
Malnutrition is the condition that develops when the body does not get the
right amount of vitamins, minerals, and other nutrients it needs to maintain
healthy tissues and organ function.
Patient has been on ITU for 5 days and has not been fed.
Malnutrition is associated with increased morbidity and mortality.
• Increased risk of infection and pulmonary oedema
• Reduced ventilatory drive
• Impaired production of surfactant
• Prolonged weaning due to muscle fatigue
• Impaired wound healing
• Delayed mobilisation resulting from weak muscles
Mechanical
• Obstruction, discomfort
• Ulceration
Metabolic
• Dehydration or overhydration
• Hyperglycaemia
• Electrolyte imbalance
Gastrointestinal
• Gastric stasis/retention, nausea, vomiting, diarrhoea, bloating
• Aspiration pneumonia due to gastro-oesophageal reflux
27/04/16 5:50 PM
Another random document with
no related content on Scribd:
Susan felt inclined to say, “And were you?” but her courage failed
her. Bella could never see a joke! She had no recollection of Bella’s
beauty—Bella’s complexion, as long as she could remember it, had
been the colour of mutton fat—but Bella was twenty-five years her
senior—and no doubt her bloom had withered early.
“The girl looks to me—as if—as if——”
“Bertie Woolcock had proposed!” supplemented Bella. “Yes, I
shouldn’t wonder.”
“No—not that.”
“Then what?” snapped her sister. “As if—and you stop; it’s a dreadful
habit not to be able to finish a sentence—it shows a weak intellect.”
“Well, since you must have it, Bella—as if she were in love.”
“So she is—with young Woolcock.”
“Nonsense,” repeated Susan, with unusual decision.
“Susan, don’t you dare to say ‘nonsense’ when I say a thing is so;
you forget yourself. Aurea will be married to Herbert Woolcock
before Christmas—that is pretty well settled. And now you may lock
up the silver; I am going to bed.”

As Miss Morven was proceeding homewards, and, as usual,

unattended (in spite of her Aunt Bella’s repeated remonstrances),
she passed the Drum, and noticed a motor in waiting, and also a
light in a conspicuous part of the premises—the little, bulging, front
sitting-room. Here two figures were sharply outlined on the yellow
blind. As Aurea looked, she saw a man and woman standing face to
face; the man put his hands on the woman’s shoulders and stooped
and kissed her. She recognised his profile in that instant—it was the
profile of Owen Wynyard!
Although brother and sister had taken leave of one another, when
they reached the car Wynyard looked up at the sky and said—
“It’s a splendid night; I believe I’ll go on with you to Brodfield, and
walk back.”
The motor overtook Miss Morven as she reached the Rectory gate;
here she stood for a moment in the shadow of the beech trees, and
as the car and its occupants swung into the full light of the last lamp
(oil) in Ottinge, she had a view of the back of the woman’s head—a
woman talking eagerly to her companion, who faced her in an easy
attitude, cigar in hand. The man was her aunts’ chauffeur. As the car
glided by, he laughed an involuntary, appreciative, and familiar laugh
that spoke of years of intimacy—a laugh that pierced the heart of its
unseen listener with the force and agony of a two-edged sword.
For a moment the girl felt stunned; then she began to experience the
shock of wounded pride, of insulted love, of intolerable humiliation.
So the dark-haired lady was “the Obstacle!” That impassioned
declaration on Yampton Hill had been—what? Mr. Wynyard was
merely experimenting on her credulity; he wished to discover how far
he might go, how much she would believe? A gay Hussar, who had
got into such trouble that he was compelled to hide his whereabouts
and name, until he could return to the world after a decent interval of
obscurity and repentance! Meanwhile, he played the mysterious
adorer, and amused himself with “a country heart,” pour passer le
temps.
And yet—and yet—when she recalled his steadfast eyes, the
tremulous ardour of his bearing in the garden, and, on the hillside, he
had looked in desperate earnest.
“Yes,” jeered another voice, “and in deadly earnest in the Drum
window!”
And she? She had actually believed that he was hopelessly in love;
and she, who had been ready to stand by him against all her
kindred, who had blushed and trembled before his eyes and voice,
had kissed her own glove where his lips had pressed it! As these
memories raced through her brain an awful sensation of sinking
down into the solid earth possessed her. Aurea groped blindly for the
gate and rested her head upon it. It seemed to her as if, under the
shade of those beeches, a something not of this world, some terrible
and relentless force, had fought and wrested from her, her
unacknowledged hopes, and her happy youth.
Half an hour later she toiled up the drive with dragging, unsteady
steps. Prayers were over when she entered the library—a white
ghost of herself, and, with a mumbled apology, she went over and
bade her father good-night, and touched his cheek with lips that
were dry and feverish. He, simple, blind man, absorbed in proofs,
barely lifted his head, and said—
“Good-night, my child, sleep well!”
And his child, evading Norris with a gesture of dismissal, hurried to
the seclusion of her own apartment, and locked the door.
Three days later, Miss Morven left home somewhat unexpectedly;
but it was conceded even by her Aunt Bella that the shock of Captain
Ramsay’s death had upset the girl. She wanted a change, and a
lively place and lively society would divert her mind.
Wynyard had not once seen her since their never-to-be-forgotten
walk, and the news of her departure came as a shock—although his
outward composure was admirable—when he was informed that
Miss Morven had left home, to be followed by her father. The Rector
would return in three weeks, but Ottinge was not likely to see his
daughter for a considerable time. Miss Davis had taken over the
surplices, Miss Jones the girls’ sewing-class, and Miss Norris the
altar flowers.
Wynyard put artful and carefully guarded inquiries, respecting her
niece, to his friend, Miss Susan, who was never reticent, and talked
as long as she found a sympathetic and intelligent listener.
“Well, indeed, Owen, I must confess Miss Morven’s going was a
great surprise,” she volunteered, in a burst of confidence, as she
swiftly snipped off dead leaves. “I’d no idea of it till she came to me
on Wednesday, and asked me to help her pack, and take over some
of her parish accounts. She looked pale and not a bit like herself;
though she said she was all right, I didn’t believe her. It struck me
she had had some sort of shock, she looked as if she hadn’t slept,
but she wouldn’t see the doctor, and was quite vexed at the idea. Dr.
Boas told me it was really the reaction of the dreadful tragedy that
she and I witnessed. So I’m glad she’s gone, though I miss her
terribly!”
And what was her loss to his? Wynyard had believed he was on the
point of establishing a firm if inarticulate understanding—at least he
had shown his colours, and she had said “Perhaps.” This morsel of
comfort was all that remained to him; and oh, the many, many things
that he could and should have said during that memorable walk!
These unspoken sentences tormented him with cruel persistency.
Had he wasted the opportunity of a lifetime?
 CHAPTER XXVII
SCANDAL ABOUT MISS SUSAN

Before Aurea had departed—and her departure was, as we know,

in the nature of a flight—she had paid the necessary visit of
ceremony to her Aunt Bella, who imagined herself to be busy making
plum jam, but was really obstructing the operations and straining the
forbearance of the new cook to a dangerous limit. The old lady
trotted into the drawing-room with sticky outstretched fingers, and
announced—
“Susan is out laying the croquet ground—the old bowling-green; you
may go and find her.”
“If you don’t mind sending for her, Aunt Bella.”
“Oh, I know you like giving your orders! Then ring the bell. Well, and
so you are off to-morrow?”
“Yes, father will come up later; he has a good deal of work in hand,
and he wants to go over to Hillminster once or twice.”
“I know; I’m lending him my car on Friday.”
“Aunt Bella, I do wish you’d sell it!” said Aurea, speaking on an
irrepressible impulse; “do get rid of it.”
“Rid of it! you silly, excitable girl, certainly not. I’m more likely to get
rid of the chauffeur; he does not know his place, and he does other
people’s jobs, too, in my time. He exercised Katie’s dogs, and
attended the Hanns’ sick pony, and, when the carrier lost his horse, I
believe he doctored it and probably killed it—and they sent round for
subscriptions for another, I gave ten shillings—handsome, I call it!—
and what do you think I saw in the list afterwards? ‘J. O., One
Guinea.’ My own servant giving double—such unheard of
impertinence! But Susan has spoiled him; I blame her. She talks to
him as if he were an equal; I declare, if she were a girl, I’d be in a
fine fright.”
Aurea maintained a pale silence.
“Yes; and Mrs. Riggs and others have remarked to me that they
really thought it was dangerous to have such a good-looking young
man about the place, though I don’t think him good-looking—a
conceited, dressed-up puppy. Oh, here’s Susan. Susan,”—raising
her voice—“you see, Aurea sends for you now!”
“And welcome! Now, my dear child, come along; I want to show you
my—I mean—the new croquet ground; it’s going to be splendid!
Won’t you come out and have a look at it?”
“No, thank you, Susan. It will be something to see when I come
back. Let me get your hat, and we will stroll up together to the
Rectory.”
“Oh, very well, my dear; but I’d like you to see the croquet lawn.
Owen has made it. He really is worth half a dozen of Tom Hogben—
and it’s as level as a billiard-table.”
But nothing would induce Aurea to change her mind.

Miss Susan accompanied her brother-in-law over to Hillminster,

where he was due at a Diocesan meeting; it was thirty miles off, and
he had suggested the train, but Miss Susan assured him, with
eloquence, that “it was ten times better to motor, and to go through
nice, out-of-the-way parts of the country, and see dear old villages
and churches, instead of kicking your heels in odd little waiting-
rooms, trying to catch one’s cross-country slow coach, and catching
a cold instead.” It happened that Mr. Morven had arranged to spend
the night with friends in the Cathedral Close, but Susan Parrett was
bound to be home before sunset; only on these conditions was she
suffered to undertake this unusually long expedition with the
precious car.
“Yes, Bella, I’ll be back without fail,” she declared; “though I’d like to
stay for the three o’clock service in the Cathedral,” and she gazed at
her tyrant appealingly.
“Not to be thought of,” was the inflexible reply; “you will be here at
six.—Remember the motor must be washed and put away, and the
evenings are already shortening.”
The run was made without any mishap, and accomplished under
three hours. It happened to be market day in Hillminster, the main
street was crowded with vehicles, and Miss Susan could not but
admire the neat and ready manner in which their driver steered
amongst carts, wagons, gigs, and carriages, with practised dexterity.
Presently they drove into the yard of the Rose Inn, and there
alighted. Mr. Morven and his sister-in-law were lunching with the
Dean in the Close, and Miss Susan notified to Owen, ere she left
him, that she proposed to start at half-past two sharp, adding—
“For, if we are late, Miss Parrett is so nervous, you know.”
The drive home began propitiously; but after a while, and in the
mean way so peculiar to motors, the car, when they were about ten
miles out of Hillminster, and a long distance from any little village or
even farmhouse, began to exhibit signs of fatigue. For some time
Wynyard coaxed and petted her; he got out of the machine several
times and crawled underneath, and they staggered along for yet
another mile, when there was a dead halt of over an hour. Here Miss
Susan sat on the bank, talking with the fluency of a perennial
fountain, and offering encouragement and advice.
Once more they set out, and, before they had gone far, met a boy on
a bicycle, and asked him the way to the nearest forge?
With surprising volubility and civility, this boy told them to go ahead
till they came to a certain finger-post, not to mind the finger-post, but
to turn down a lane, and in a quarter of a mile they would come to
the finest forge in the country! The misguided pair duly arrived at the
finger-post, turned to the left as directed, and descended a steep
lane—so narrow that the motor brushed the branches on either side,
and Miss Susan wondered what would become of them if they met a
cart? They crept on and on till they found themselves in some
woods, with long grass drives or rides diverging on either side—
undoubtedly they were now on the borders of some large property!
The lane continued to get worse and worse—in fact, it became like
the stony bed of a river, and the motor, which had long been crawling
like some sick insect, finally collapsed, and, so to speak, gave up the
ghost! The axle had broken; there it lay upon its side with an air of
aggravating helplessness! and it was after six o’clock by Miss
Susan’s watch!
“Now,” she inquired, with wide-open eyes, “what is to be done?”
“We must go and look for some farmhouse; I’m afraid you will have
to pass the night there, Miss Susan, unless they can raise a trap of
some sort!”
“Oh, but I’m bound to get home,” she protested, “if I have to walk the
whole way. How far should you say we were from Ottinge?”
“Well, I’m not very sure—I don’t know this part of the country—but I
should think about fifteen miles. You might manage to send a
telegram to Miss Parrett,—in fact, I wouldn’t mind walking there
myself, but of course I must stick by the car.”
“See!” she exclaimed, “there are chimneys in the hollow—red
chimneys—among those trees.” And she was right.
As they descended the hill, in a cosy nook at the foot they
discovered, hiding itself after the manner of old houses, an ancient
dwelling with imposing chimney-stacks, and immense black out-
buildings. Here Miss Susan volubly told her story to a respectable
elderly woman, who, judging by her pail and hands, had evidently
just been feeding the calves.
“I don’t know as how I can help you much,” she said; “this is Lord
Lambourne’s property as you’ve got into somehow. Whatever
brought you down off the high road, ma’am?”
“We were told to come this way by a boy on a bicycle. We asked him
to direct us to a forge.”
“The young limb was just a-making game of you, he was! There ain’t
a forge nearer than five miles, and my master took the horses in
there this afternoon; he’s not back yet.”
“I suppose,” said Miss Susan, “that you have no way of sending me
in to Ottinge—no cart or pony you could hire me?”
“I’m afraid not, ma’am. Where be Ottinge?”
Here was ignorance, or was it envy?
“Then I don’t know what I’m to do,” said Miss Susan helplessly. “My
sister will be terribly anxious, and I’m sure the motor won’t be fit to
travel for quite a long time. What do you think, Owen?”
“I think that the motor is about done!” he answered, with emphatic
decision. “To-morrow morning I must get a couple of horses
somewhere, and cart her home. I wonder if this good woman could
put you up for the night? This lady and I,” he explained, “went to
Hillminster from Ottinge to-day, and were on our way home when the
motor broke down; and I don’t think there’s any chance of our getting
to Ottinge to-night.”
“Oh yes, I can put the two of you up,” she said, addressing Miss
Susan, “both you and your son.”
Miss Susan became crimson.
“I am Miss Parrett of Ottinge,” she announced, with tremulous
dignity; “that is to say, Miss Susan Parrett.”
“I’m sure I beg your pardon, Miss Parrett; I can find you a bed for the
night. This is a rare big house—it were once a Manor—and we have
several empty bedrooms—our family being large, and some of the
boys out in the world. Mayhap you’d like something to eat?”
“I should—very much,” replied Miss Susan, whose face had cooled,
“tea or milk or anything!”
At this moment a respectable-looking, elderly man rode up, leading
another horse.
“Hullo, Hetty,” he said to his wife, “I see you ha’ company, and
there’s a sort of motor thing all smashed up, a-lyin’ there in the Blue
Gate Lane.”
“It’s my motor,” explained Miss Susan, “and we have walked down
here just to see what you and your wife could do for us.”
“Our best, you may be sure, ma’am,” rejoined the farmer, and
descended heavily from his horse, then led the pair towards the
stables, where he was followed by Wynyard, who gave him a hand
with them and borrowed their services for the morrow.
A meal was served in the very tidy little sitting-room, where Miss
Susan found that places had been laid for Owen and herself; it was
evident that the farmer’s wife considered him—if not her son—her
equal! To this arrangement she assented, and, in spite of his
apologies, Miss Susan and her chauffeur for once had supper
together without any mutual embarrassment.
Afterwards, he went out to a neighbouring farm to see if he could
hire a pony-trap for the following day, and although Miss Susan was
painfully nervous about her sister, she was secretly delighted with a
sense of freedom and adventure, and slept soundly in the middle of
a high feather-bed—in a big four-poster—into which it was
necessary to ascend by steps.
Owing to vexatious delays in securing a trap, driver, and harness, it
was tea-time the next afternoon when Miss Susan drove sedately up
to the hall door at the Manor.
Miss Parrett was prostrate, and in the hands of the doctor! The
telegram, dispatched at an early hour from the nearest office to
Moppington, was—on a principle that occasionally prevails in out-of-
the-way places—delivered hours after Miss Susan had set the minds
of her little world at rest! There had been an exciting rumour in the
village—emanating from the Drum—that “Miss Susan had eloped
with the good-looking shover,” at any rate no one could deny that
they had gone to Hillminster the day before, had probably been
married at the registry office, and subsequently fled! The Drum was
crowded with impassioned talkers, Mrs. Hogben was besieged, and
the whole of Ottinge was pervaded by a general air of pleasurable
anticipation. One fact was certain, that, up till three o’clock of this,
the following afternoon, neither of the runaways had returned!
However, just as it had gone four, here was Miss Susan—bringing to
some a distinct feeling of disappointment—seated erect in a little
basket carriage, drawn by an immense cart-horse, driven at a foot
pace by a boy; and a couple of hours later she was followed by the
motor, this time on a lorry, and, undoubtedly, also, on what is called
“its last legs.”
When everything had been exhaustively explained to Miss Parrett,
she, having solemnly inspected the remains of her beautiful green
car and heard what its repairs were likely to cost, heard also the
price which she would be offered for it—fifteen pounds—broke into a
furious passion and declared, with much vehemence and in her
shrillest pipe, that never, never more would she again own a motor!
And, since the motor had ceased to be required, there was no further
use for a chauffeur, and once more Owen Wynyard was looking for a
situation.
 CHAPTER XXVIII
A NEW SITUATION

The venerable green motor, whose value by an expert had been so

brutally assessed, was not considered worth repair, yet Miss Bella
Parrett could not endure to part with a possession which had cost
five hundred pounds, for fifteen sovereigns; so it was thrust into a
coach-house, shut in the dark with cobwebs and rats, and
abandoned to its fate.
Miss Susan, who enjoyed motoring and liked the chauffeur, was
exceedingly anxious that Bella should purchase another car, but of
course she was powerless, being next to penniless herself; indeed,
at the outside, her income amounted to one hundred a year—less
income tax. The mere word motor seemed now to operate upon her
wealthy sister as a red rag to a bull; for the loss of five hundred
pounds rankled in her heart like a poisoned arrow.
The old lady had decided for a brougham, a middle-aged driver, and
a steady horse. (It may here be added that the animal, which was
coal-black and had a flowing tail, came out of the stables of an
undertaker, and was as sedate and slow as any funeral procession
could desire.)
As for Wynyard, his fate was sealed! A chauffeur without a car is as
a swan upon a turnpike road. He had had visions of proposing
himself as coachman—for he did not wish to leave the village, and
the vicinity of Aurea Morven—but Miss Parrett had other plans. In
her opinion Owen, the chauffeur, was too good-looking to remain
about the place—on account of the maids—and indeed her sister
Susan treated him with most shocking familiarity, and spoke to him
almost as if he were her equal. Her quick little eyes had also noticed
in church that, during her brother-in-law’s most eloquent sermon, the
chauffeur’s attention was concentrated upon her niece Aurea; and
so, without any preamble, she called him into the library and handed
him his pay, a month in advance, promised a first-rate reference, and
waved him from her presence.
And Wynyard’s occupation was gone! There would be no more
expeditions in the ramshackle old motor, no more potting of
geraniums for Miss Susan, no more clipping of hedges, or singing in
the choir. He must depart.
Departures, to be effective, should be abrupt; possibly Wynyard was
unconscious of this, but the following day he left for London; his
yellow tin box went over in a cart to Catsfield, whilst he walked to the
station across the fields by the same road as he had come. His
absence caused an unexpected blank in the little community; the
Hogbens regretted him sorely, he was such a cheery inmate, and
gave no trouble. His absence was deplored at the Drum; the village
dogs looked for him in vain; his voice was missed in the choir; other
people missed him who shall be nameless; and Joss howled for a
week.
Wynyard had written to his sister to inform her that, owing to the
breakdown of the dilapidated old car, he was once more out of a job,
and found, in reply, that she was on the eve of sailing for America.
He went round to see her in Mount Street, two days before she
started.
“You are looking remarkably fit, Owen,” she said, “and the Parretts
can’t say too much for you; indeed, in Susan’s letter I observe a tone
of actual distress! Six months of the time have passed. I suppose
you have saved a little money?”
“I have twenty pounds in the bank, and a couple of sovereigns to go
on with. Of course I must look out for another billet at once.”
“And on this occasion you will take with you a really well-earned
character. You have no debts and no matrimonial entanglements—
eh? What about Miss Morven?”
“I’ve never laid eyes on her since I saw you.”
“How is that?”
“She’s been in London.”
“And now you are here—ah!”
“I didn’t follow her, as you seem to suppose. I wasn’t likely to get
another billet in Ottinge, and anyway, I was a bit tired of having Miss
Parrett’s heel on my neck.”
“Tired of ‘ordering yourself humbly and lowly to all your betters,’ poor
boy! But to return to the young lady; are you still thinking of her?”
Was he not always thinking of her? But he merely nodded.
“You haven’t written?”
“No; I’m not such a sweep as all that!”
“But, Owen, didn’t you wring a sort of half promise from the
unfortunate girl? I know it was only ‘perhaps,’ but château qui parle
—femme qui écoute.”
“I think it will be all right.”
“And that her ‘perhaps’ is as good as another’s solemn vow! I must
say you show extraordinary confidence in yourself and in her, and
yet you scarcely know one another.”
“No, not in the usual dancing, dining-out, race-going style; I give in to
that, or, indeed, in the ordinary way at all. She only saw me driving or
washing the motor, or doing a bit of gardening.”
“And you think you were so admirable in these occupations that you
captured her heart! Owen, I’m seeing you in quite a new light, and I
think you are deceiving yourself. I expect the young woman has
forgotten you by this time. London has—attractions.”
“Time will tell; anyhow, she’s refused the great Bertie Woolcock.”
“No!” incredulously, “who told you? When did you hear it?”
“It was all over Ottinge a week ago, and I heard it at the Drum. I was
also given to understand that Miss Parrett was fit to be tied!”
“If she had an inkling of her late chauffeur’s pretensions, a strait
waistcoat would hardly meet the occasion. How I wish we could take
you with us to America; but it’s not in the bond. Martin has a great
deal of capital invested out there; he is not very strong, and after we
have put all his business through, we are going to spend the winter
in Florida. We shall not be back before April, and then I will keep my
promise. I am so sorry, dear old boy, that I shall be out of the country
while you are ‘dreeing your weird’ and not able to help you; but of
course Uncle Dick’s great object is for you to learn absolute
independence. I will give you my permanent address and a code-
book, and if anything happens for good or bad, you must cable. We
have let this house for six months—to friends. We may as well have
it aired, and have the good rent! Every one lets now—even dukes
and duchesses! I wonder what your next billet will be? You had
better advertise.”
“What shall I say?” he asked.
“Let me think.” After a moment she rose and went to her writing-
table, scribbled for a few moments, and brought him the following:
‘As chauffeur, smart young man, experienced, aged 26, steady, well
recommended, wants situation. Apply—— Office of this paper.’ “Just
send this to the Car, the Morning Post, the Field, Country Life; it will
cost you altogether about twenty-five shillings, and I’ll pay for it.”
“No, no, Sis,” he protested, “that’s not in the bond. And, as it is, you
are keeping up my club subscription.”
“Pooh!” she exclaimed, “what’s that? I hope this time you will get into
a nice rich family who have a good car, and that you will be able to
have a little more variety than in your last place, and no young
ladies. You will be sure and write to me every week?”
At this moment the door opened and Sir Martin Kesters entered, and
paused in the doorway.
“Hullo, Owen, glad to see you,” holding out his hand; “so you are
back?”
“Only temporarily—for a day or two.”
“You’ve done six months, and the worst is over.”
“Well, I hope so; but one never can tell.”
“Upon my word, I don’t know how you stood it. Leila described the
place. I’m not a gay young fellow of six-and-twenty, and a week
would have seen me out of it; but six months——” and he gazed at
him in blank astonishment.
“Oh, well,” apologetically, “I’ve learnt all sorts of things. I’m quite a
fair gardener, and can clip a hedge too; I know how to physic dogs,
and fasten up the back of a blouse.”
“Owen!” exclaimed his sister, “I am present!”
“It was only Mrs. Hogben; she had no woman in the house, and
Tom’s hands were generally dirty, and she said she looked upon me
as her other son. She is a rare good old soul, and I’d do more for her
than that.”
“You must feel as if you’d been underground, and come up for a
breather,” said his brother-in-law.
“My breather must be short; but I’m not going to take any situation
with ladies.”
“Why so proud and particular? They won’t all be Miss Parretts!”
“Oh, you women are so irregular, unpunctual, and undecided—yes,
and nervous. Even Miss Susan clawed me by the arm when we took
a sharp turn.”
“I hope the next year will fly,” said Sir Martin; “I tried my hand on your
uncle, you know—did Leila tell you? I have got him to make it
eighteen months hard labour—and eighteen months it is.”
“No! I say—that is splendid news! How awfully good of you!”
“I fancy he’s a little bit indulgent now; he finds that you can stick it,
and have brought such a magnificent character.”
“Profound regrets,” supplemented Leila, “if not tears. Ah, here is
dinner! I don’t suppose you’ve dined since you were here in April;
come along, Owen, we are quite alone, and let us drink your health.”
Two days later Wynyard saw his sister and her husband off from
Euston by the White Star Express, and felt that his holiday—his
breathing time, was over. He must get into harness at once. His one
hope, as he wandered about the streets, was that he might catch
sight of Aurea. By all accounts, she was staying in Eaton Place;
more than once he walked over there, and strolled up and down on
the opposite side, and gazed at No. 303 as if he would see through
the walls. But it was no use—telepathy sometimes fails; Aurea never
appeared, and, had she done so—though he was not aware of the
sad fact—she would not have vouchsafed the smallest notice of her
aunts’ former employé.
The daily post brought several replies to Owen’s advertisements.
When he had looked through and sorted them, he found that, after
all, the most tempting was from a woman—a certain Mrs. Cavendish
Foote, whose address was Rockingham Mansions, S.W.
The lady announced that she required a really smart, experienced
chauffeur for town—she had a new Renault car; he would have to
live out, and she offered him four guineas a week, and to find himself
in clothes and minor repairs. She wrote from Manchester. He replied,
forwarding his references, and she engaged him by telegram, saying
she would be back in London the following day, when he was to
enter her service, and call to interview her.
It seemed to him that this was good enough! He would rather like a
job in town for a change—the more particularly as Aurea and her
father were staying with General Morven in Eaton Place, and now
and then he might obtain a glimpse of her! He glanced through the
other letters before finally making up his mind; one was from a
nobleman in the north of Scotland, who lived thirty miles from a
railway station. He thought of the bitter Scotch winters, and how he
would be cut off from all society but that of the servants’ hall; no, that
was no good. Another was from a lady who was going on tour to the
south of France and Italy. The terms she offered were low, and she
preferred as chauffeur, a married man. There were several others,
but on the whole the situation in London seemed to be the best. He
debated as to whether he should put on his chauffeur clothes or not,
but decided against it, and, hailing a taxi-cab, found himself at
Rockingham Mansions in ten minutes.
These were a fine set of flats, with carpeted stairs, imposing hall,
and gorgeously liveried attendants. He asked to be shown to Mrs.
Cavendish Foote’s address. It was No. 20 on the third floor. The door
was opened by a smart maid with a very small cap, an immensely
frizzled head, and sallow cheeks.
“To see Mrs. Cavendish Foote on business?” she repeated, and
ushered him into the tiny hall, which was decorated with a curious
assortment of pictures, stuffed heads, arms, and looking-glasses.
“Oh, bring him in here,” commanded a shrill treble voice, and
Wynyard found himself entering a large sitting-room, where he was
saluted by an overwhelming perfume of scent, and the angry barking
of a tiny black Pom. with a pink bow in his hair.
The apartment had been recently decorated; the prevailing colours
were white and pink—white walls, into which large mirrors had been
introduced—pink curtains, pink carpets, pink and white chintz. Two
or three half-dead bouquets stood in vases, an opera cloak and a
feather boa encumbered one chair, a motor coat another, several
papers and letters were strewn upon the floor, and on a long lounge
under the windows, a lady—white and pink to match her room—lay
extended at full length, her shapely legs crossed, and a cigarette in
her mouth. She wore a loose pink negligé—the wide sleeves
exhibiting her arms bare to the shoulder.
“Hullo!” she exclaimed, when she caught sight of Wynyard, as he
emerged from behind the screen.
“Mrs. Cavendish Foote, I presume?” he inquired.
“Right-o!” she answered, suddenly assuming a sitting posture; “and
who may you be?”
“I’ve come about the situation as chauffeur.”
“The chauffeur!” she screamed. “Good Lord! why, I’m blessed if you
ain’t a toff!”
“Is that a drawback?” he asked gravely.
“Well, no—I suppose, rather an advantage! I thought you were my
manager, or I wouldn’t have let you in,” and she pulled down her
sleeves, and threw the stump of her cigarette into the fireplace. “You
see, though I’m Mrs. Cavendish Foote, my professional name is
Tottie Toye. I dare say, you have seen me on the boards?”
“Yes, I have had the pleasure,” he answered politely.
“Oh my!” she ejaculated. “Well, anyhow, you’ve got pretty manners.
Can you drive?”
“Yes.”
“I mean in London traffic. I don’t want to get smashed up, you know;
if I break a leg, where am I? How long were you in your last place?”
“Six months.”
“And your reason for leaving?”
“They gave up keeping a motor.”
“Idiots!” she exclaimed. “I couldn’t live without mine! Your job will be
to take me to the shop, and fetch me back at night, and to run me
about London in the daytime, and out into the country on Sundays—
home on Monday night. Do you think you can manage all that?”
“I think so.”
“The car is in the garage close to this. I dare say you would like to
take her out for a run and try her? I shall want you this evening at
seven o’clock.”
“Very well,” he agreed.
“I suppose you’re one of these gentlemen that have come down in
the world, and, of course, a chauffeur has a ripping good time. I like
your looks. By the way, what’s your name?”
“Owen.”
“And I suspect you are at this game, because you are owing money
—eh?” and she burst into a shriek of laughter at her own joke. “Well,
life has its ups and downs! If it was all just flat, I should be bored stiff.
I’ve had some queer old turns myself.”
At this moment the door opened, and a stout, prosperous-looking
gentleman made his appearance—red-faced, blue-chinned,
wonderfully got up, with shining hair, and shining boots.
“Hullo, Tottie!” he exclaimed; “who have we got here?” glancing
suspiciously at Owen. “A new Johnny—eh—you naughty girl?”
“No, no, dear old man,” she protested; “and do you know, that you
are twenty minutes late? so I have given him your precious time.
This”—waving her hand at Owen—“is Mr. Cloake, my manager. Mr.
Cloake, let me present you to my new chauffeur.”