Exam Question Types
There are several different types of questions. This section highlights how they differ, approaches and techniques for answering.
It is commonly stated that trauma oral exam questions are the easiest to answer because they follow a common approach, Advanced Trauma Life Support or ATLS. Typically the response follows the primary survey followed by the secondary survey if required. Candidates tend to use a 'trauma blurb' or a memorized script that covers about 90% of the required actions for a trauma scenario.
There are a few things I believe are helpful when using or constructing your own 'blurb'. First, identify the main anesthetic consideration and possible conflicts for the describe scenario. Second, assure that during your blurb, the description should include the application of the standard CAS monitors and trauma work-up. Mentally 'link' certain actions to one another. For example, when placing 2 large bore IV's, link it to obtaining blood work and fluid resuscitation.
Once you are comfortable with your trauma blurb, learn to become fluid with it. How do you adjust your blurb for unusual situations?
Trauma 'Blurb' Example
This is just an example of a typical trauma blurb. It is meant to give candidates an idea of an approach. It is only my opinion.
Question: A 30 year old man is brought the ER after begin hit by a car at an intersection. The vehicle was travelling at 40km/hr. The patient was thrown 20 feet and landing on asphalt. There is an open left Tib/Fib fracture, left humeral fracture and and he complains of pain with breathing. On arrival, his BP is 90/40, HR 120, RR 24 and SaO2 of 90% with FiO2 of 50%. Discuss your approach to this patient.
Response: This is a potentially life-threatening situation. From the description provided, I am concerned about thoracic injury such as flail chest, pneumothorax or hemothorax. There is a high risk of a C-spine injury, occult injuries as well as hypovolemia and other significant MSK injury.
On arrival, I would immediately begin my assessment and resuscitation. First I would assess the airway for patency and easy of intubation. I would assure that supplemental oxygen was applied via a high flow non-rebreather mask. I would check the quality of air exchange examining the patients color and respiratory effort, listening on both sides for air entry and extra sounds and by applying SaO2 probe. I would then assess the patients CV status by palpating the pulse, and examining the JVP and cardiac sounds and by looking for any obvious bleeding. I would ask for blood pressure and rate every 5 minute and have the patient monitored by ECG as well as request a 12-lead ECG. I would start 2 large bore IV’s sending blood for CBC, lytes, coag, ABG and stat X-match for 8 units. I would run Ringers (Saline) wide open through both IV until the patient has received 2 liters. Finally, I would assess the patients level of consciousness by verbal or painful stimuli and check the pupil’s size, equality and reactivity.
While resuscitating, I would do a history limited by the emergency of the situation. I would attempt to get an AMPLE history specifically allergies, medications, past medical history, last meal and events surrounding the accident doing as much as possible simultaneously.
Standard Assessment Question
A common oral exam question is the assessment. You will be given a scenario and the examiner will ask "How will you assess this patient?" This type of question is meant for a candidate to demonstrate their knowledge about uncommon but important disease entities. It is usually in the context of a surgical or medical emergency that creates conflicts in management. A commonly use acronym is HELPPP. History. Exam. Labs (investigations). Preop Consults (are any required), Preop Medications and Preop Optimization.
History: You must cover the standard anesthesia Hx (prev Sx, anesthetic Hx, Allergies, Medications, and Cardiovascular/Respiratory/Neurological review of systems as would seem appropriate). Then there is the history of the primary complicating condition (when did it start, how severe, sequalae, impact on exertional capacity etc) and the surgical condition (onset, severity, planned surgical approach, etc).
Exam: A-airway, assess for ease of intubation is adequate (unless there is suspect difficult airway), B-breathing or respiratory exam (does the condition have physical finding that would be important on exam such as wheeze, cyanosis, clubbing etc) C-cardiovascular (any specific CV finding such as a murmur or differences in BP laying vs sitting). Additional exam inquiries would be directed by the situation. You would not do a neurological exam in all patients but if they had neurological deficits, these should be assessed.
Labs: is any bloodwork required? Cross-match? Review any imaging that may have already been obtained or order as needed.
Pre-op Consults: consider the situation, does your patient need further workup or additional optimization preoperatively?
Pre-meds: primarily a reminder to give preop medication such as aspiration prophylaxis, combivent nebule etc.
Pre-op optimization: There may not be time or the need to consult another physician for optimization. Does the patient need anything to improve safety prior to the OR.
Once this information has been sought by the candidate, typically the exam will proceed. It is very likely you will be prompted for more information or to clarify a specific point. Prompting does NOT mean you are doing poorly as the examiner is just trying to get the best answer they can from you.
Question: a 56 year old woman is presenting for a Video Assisted Thoracoscopic resection of a right upper lobe tumor. She has a 22 year history of cutaneous scleroderma which limits her activities of daily living secondary to shortness of breath. How will you assess this lady for the proposed operative procedure?