Oral Exam Techniques

There are many different strategies that can be useful while answering oral exam questions. I will cover different concepts to help improve your responses.

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Anesthetic Considerations

Anesthetic considerations (AC) are medical concerns that have to be addressed when planning an anesthetic. They are not a summary of a patients medical history. An allergy to peanuts can be very important to a patient but has no impact on how I would provide an anesthetic. A history of asthma would have an impact as I would want to avoid triggers of bronchospasm. 

An AC can be singular such as having a full stomach and also has a singular goal of minimizing the risk of aspiration on induction. A more complex AC can have several components which may need to be addressed. An acute abdomen has three issues or AC's that have to be addressed, full stomach, hypovolemia and possible sepsis.

Some disease entities can be very complex with many possible considerations. It is important to demonstrate the understanding of the complexity but not to the detriment of wasting time discussing issues the patient might have. Rheumatoid arthritis is a good example. It is a multiple system disease primarily of MSK, but there are a number of important possible extra-articular manifestations that can impact the manner of providing an anesthetic. The AC of an RA patient would include management with immunosuppressants and/or steroids', atlantoaxial instability, arytenoiditis, cardiomyopathy, dysrhythmia, aortic regurgitation, pericardial effusion, pleural effusion, pulmonary fibrosis, pulmonary nodules, etc, etc. It is a long list of issues the patient likely does not have but should not be missed.

It doesn't take many medical and surgical issues to generate a large number of anesthetic considerations. It is important to be succinct when listing your AC's. Think of it as a list of bullet points that need to be listed in a short period of time. Don't waste effort justifying why you have included something on your list. Don't go down the rabbit hole of multiple branching AC's. RA (above) is a good example. It is important to mention the possibility of a cardiomyopathy but not all the AC's that the presence of a cardiomyopathy require. Specific, to the point, list of concerns.

 

Generating an Anesthetic Management Plan

STANDARD QUESTION

It is common to be asked what your anesthetic management plan will be for a question. It is not adequate to simply state 'a general anesthetic'. The discussion of your plan is key as it should demonstrate your understanding of the situation. More importantly, it is your decision making that is also being assessed. Many questions do not have a 'correct' answer, but instead, have a number of poor options. I refer to this as painting a candidate into a corner. There is no good way out so you must choose a course of action and explain why this is the best approach in your hands. Not just your plan but why is it your plan.

Anesthetic considerations (AC) typically results in modifying a standard management plan to obtain a certain goal.  A full stomach will change a standard plan as you don't want the patient to aspirate. So the goal associated with a full stomach is minimize the risk of aspiration. The anesthetic plan should attempt to meet this goal and conducting a 'rapid sequence induction (RSI)' would satisfy this requirement. Keep in mind that there other approaches that would also fulfil this goal such as an awake fiberoptic intubation. This would not be the first choice as it is very unpleasant for the patient (and takes more time). 

A potentially difficult airway is another common AC. The goal is a little more complex as you can either avoid securing the airway (regional anesthesia or LMA use) or secure the airway in a safe manner. There are many approaches that would be acceptable such as an 'awake look' or an awake fiberoptic intubation.

Let say we have a patient with a full stomach and a potentially difficult airway. They have different goals but have common possible management plans. A regional anesthetic would be acceptable for both AC's as the airway is not instrumented and the patient is able to protect their airway from aspiration.

Now we will add one more AC, acute appendicitis for a lap appe. A regional anesthetic would not be appropriate as the manipulation of the bowel would not be covered. A general anesthetic is required (there are many more AC with lap appe but will not be covered here). 


Taking all three sets of goals and finding a common management plan helps define your approach. The goals for a full stomach and a difficult airway for a lap appe can all be satisfied with an awake fiberoptic intubation followed by GA. 

Assess your AC for specific goals and find common management strategies to generate an appropriate plan.

 

Providing an Anesthetic

HOW TO PULL THE 'TRIGGER'.

Frequently, you will be asked to 'provide an anesthetic' or 'how will you induce'. The knee jerk reaction is to just blurt out an answer but in reality we don't just slam a person to sleep. We always prepare resources and tailor the anesthetic to the situation. The challenge is how to put your actions into words. I advocate the use of 2 acronyms, SIMER and DAMship.

SIMER stands for Setup, Induction, Maintenance, Emergence and Recovery. The 'setup' is everything you have ready before your induction. This would include checking your machine, lines etc. There are numerous steps that need to be addressed so the Setup has it's own acronym, DAMship.

Prior to starting any case, you will have your standard emergency drugs available. The bare basics would be a vasopressor and a paralytic. By stating you would have your 'standard emergency drugs ready' would only cover the basics. Use the 'D' as an aid to think about other emergency drug or equipment you may need for the case. For example, vasodilators for controlled hypotension, magnet for pacer/ICD etc.

'A' stands for airway. If there is no concern with the airway, one could just state that they would have their standard airway equipment ready. One thing an anesthesiologist should never do is be inadequately prepared for an airway. The 'A' is meant to prompt you for additional airway preparation.

'M' stands for machine and monitors. Typically would would have your standard CAS monitors in place prior to induction. Again, it is meant to be a cognitive aid for you to consider the placement of additional monitors for the case. In the acronym, DAM are capitalized as they are required prior to any induction. If you forget to have emergency drugs ready, a proper airway plan or appropriate monitors in place for induction, it is hard to do well on any question.

The 'ship' in DAMship are small case as they are meant to be considered for each case but not actually verbalized unless needed. 's' is for suction (eg double suction for blood in airway), 'h' is for heat (eg increase heat for premie, deliberate hypothermia...), 'i' is for IV's (eg 2 large bore, lower limb line with SVC syndrome...) and finally 'p' is for position (eg- sitting craniotomy, prone).

Once you have completed the Setup (DAMship), you move onto 'I' for the induction. Discuss your induction in keeping with the anesthetic considerations and goals discussed earlier. 'M' is for maintenance or your intraoperative plan/goals. Some situations are better served with TIVA vs a GA. Maybe you may need to use a carefully titrated epidural with judicious sedation. 'E' is for emergence. Is there are specific issue that should be mentioned such as avoiding coughing or a clear emergence to assess neurological status. 'R' is for recovery or what is the disposition plan.

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