Malaysia Anesthesia Parallel Pathway Post FCAI Assessment, Part 4 of 6, Clinical Review

Station 1:
Elective AAA preop assessment
Scoring
Relationship with smoking
Physics relationship as regards to rupture
Indications for op
Access and monitoring
Physiology of cross-clamping and release
Management of the above
Renal protection
Spinal cord ischemia, monitoring/prevention
Lumbar drain physiology
Anterior cord syndrome & anatomical basis

Station 2:
Assessment of patient with TBI, possible maxillofacial injury
Ideal preparation for airway management
Emergency intubation management
MILS
Interpretation of CT: EDH, gross cerebral edema. Cervical X-ray: cervical retrolisthesis
Anticipated neurological deficit
Anesthetic management for neurosurgery
BTF targets - Gases, hemodynamics
Mannitol
DI and management

Station 3:
Classification of CDH, embryology
Pathophysiology
Timing of surgery
Assessment and optimization
iNO in respiratory failure
Decision on proceeding with surgery
Ventilatory management (protective ventilation strategy)
Fluid management
Airway management for child not already intubated
Prevention of hypothermia
Concerns post reduction (atelectasis, abdominal compartment syndrome)
Tension pneumothorax

Station 4:
Perforated gastric ulcer with septic shock
Surviving sepsis campaign (SSC) definition of septic shock
Hemodynamic recommendations (fluids, vasopressors)
Physiologic basis for MAP vs SBP
Recommendations on vasopressor, inotropic choice
CO monitoring
PiCCO
Interpretation of values (supranormal CO, normal GEDVI, low SVRI, normal EVLW)
Choice of induction agent choices (etomidate, ketamine)
Choice of volatile mixture (air, nitrous) - hemodynamic, surgical implications
Refractory hypotension
Fluid challenge
Steroids - recommendations, physiology

Yeah, I passed, but I’m burned out preparing for repeated assessments while the COVID epidemic rages on. While living away from the wife and kids (and currently an inability to travel) for almost 5 years now. I felt I prepared better the last time around (despite less than ideal circumstances). This time around the “study week” (thank you roster makers) was spent more recuperating and weaning from stimulant, ehem caffeine, abuse and trying to slow down my personal struggle versus frailty (with the closure, and lack of time when it was open anyways, of the gym) as compared to studying. This is proven by the relative lack of notes written for this exam season.

Going to the exam 2 days after my second COVID vaccine jab probably didn’t help, but I don’t think it affected my handling of the exam at the end of the day.

But then again, every healthcare worker is burned out. There is no solution. Just survive it before it kills you, then medicine becomes more of a venous ooze versus arterial cut. I wonder how was the suicide rate among Western healthcare workers the past 1 year… The fuck (while looking this up):

“...residents are used “as cheap labor,” making on average $61,000 a year for working 80+ hours a week.”

I’d rather not talk about how much we earn here in comparison. But enough sad shit. Have you heard of Crossy Road Castle?

Malaysia Anesthesia Parallel Pathway Post FCAI Assessment, Part 3 of 6, Clinical Review

What a lengthy title….

Anyways, I passed this with distinction despite the odds: Broken computer a few months back, lack of any time in another month, and lastly my son is down with bronchiolitis, currently being taken care by my non-doctor wife at home. He’s improving, but I barely studied anything 3 days prior to the exam and drove to KL from Melaka only when “happy enough” the morning of the exam with little sleep. But that’s beside the point. I want to share the topics discussed that you, the reader, can reference for your own study topics.

Examiner 1:
Preggy elective breech ppm sick sinus syndrome
All about obs preoperative review, ppm classification n management
ECG review; pacemaker (ventricular pacing) dependence
Anesthetic technique (decided for CSE), needs during LSCS
Blood on aspirating epidural
Tachyarrhythmia post buzzing

Examiner 2:
Cardiac assessment non cardiac surgery
RCRI
Non invasive tests
Elective BKA for patient on warfarin
Bridging & Chads2vasc
Fast AF intraop; stable tachyarrhythmia algorithm
Guillain barre syndrome coming for tracheostomy
What is GBS and anesthetic concerns
Airway emergency post tracheostomy
Concerns with new tracheostomy

Examiner 3:
Neonatal vs preterm definitions
CVS changes of infants vs adults
Common surgical procedures in the age groups
Preparation for neonate/preterm surgery
2 week post 35 weeks premmie for herniotomy; concerns
Anesthetic technique in full
Postop considerations

Examiner 4:
SAH presentation
CT scan interpretation
SAH classification and implications
Myocardial injury post sah
Differentiation with MI?
Deferral of op?
Anesthetic aims, technique, TIVA vs inhalational
Monitoring (considerations for neuromonitoring/CO monitoring)
Temporary clipping n complications
Transmural pressure and implications
Management of rupture (burst suppression, flow arrest)

Many of the topics here were not specifically covered during my preparations. Probably around 30%-50% of the topics have been made into notes the past, but I only reread a minimal amount of them. Personally I wasn’t happy with my performance during the 2nd and 4th sessions. Will probably have to go deeper into these topics next time. If you followed this blog, you’d know that none of my new notes actually made it into this particular exam.

Based on my own personal review, I don’t think I need to drastically change my approach to studying yet. Don’t fix what is not broken.

Ideas on Studying Moving Forward

And so I passed the recent FCAI Written Exam on the 28th of February. So now I can start planning on how to approach the Final Clinical/SOE. So far I haven’t decided on when to sit for it. There will be 2 available dates: 1 in May and another in November. I’m leaning towards November as I need a mental vacation. It might also be difficult to do the exams in May as I’m in the GICU rotation that month. Just going on cruise control for a while is probably the best choice. Besides, short of winning some gambling games, I don’t see me having enough money to sit for the exam and associated travel (they only host it in Dublin).

I think that I should try to break up my notes into smaller, more quickly finished topics. One thing I noticed during the written exams was that there was a lot of low-hanging fruit which I didn’t cover with focus. Most of the topics were all ones of the “I’ve read this once upon a time” variety and were quite frankly relatively simple.  But if you’ve never read them anyway and thought of your daily work in an academic manner how would you be able to put it in writing?

With the way I do notes at the moment, I’ve been trying to cover fully the topics I’m making notes on, whether the issues are common or relatively obscure with the same level of attention. This is especially difficult when trying to continue making notes on another day, trying to recover the train of thought from the previous note making session (which can sometimes be a few days in between). By breaking them up into smaller subtopics and focus on what is the likely hot key points, I can quickly move on to another major topic, while not hindering the ability to work on another subtopic at another time without messing up the flow. The more obscure points will be covered by reading alone without writing. This is partly inspired by OpenAnesthesia’s Key to the Cart podcasts: just a few minutes talking based on a few key words. This seems to be the best way to approach the way the CAI has been in my experience: a broad base of topics, with only some topics discussed deeply and many others relatively superficially.

As for sources of topics to cover in day-to-day studying, in addition to the usual "stuff that I encounter" and "stuff on Wednesday teaching sessions", I'll go back to my usual email AnaesthesiaUK newsletter of past FRCA questions (different format but similar breadth of topics I'd assume) to look for things to cover.

Examples of question from the AnaesthesiaUK newsletter

The priority will be given to reading for all "stuff that I encounter" and "Wednesday tutorials" first. Whatever free time is left will be spent on note-making on a variety of topics, with the priority on (Addendum: questions that came out in the written exam and) sample questions from AnaesthesiaUK, while looking at the CAI website and ensuring that I have a healthy balance between the different major topics. Since it's a structured oral exam, the key will be getting the important keywords and not go too lengthy (and take away time that should be spent a wider base of topics). But notes must be made: the process of processing information into a "final form" that is readily accessible has been the key so far to efficiency and efficacy.

Not so much a revolution, but more of a fine-tune to the approach that I've used since 2013, that has given me slow but steady success.