Hong Kong College of Anaesthesiologists
Final Fellowship Examination April/May 2008
Examiners Report
Dates and Venues of Examination
Written examination 3rd April 2008, Hong Kong Academy of Medicine Building
Viva examination 23rd May 2008, 2nd Floor, Hong Kong Academy of Medicine Building
OSCE examination 24th May 2008, Operating Theatre, 4/F, Block D, Queen Elizabeth Hospital
External Examiners:
Dr Paul Clyburn, RCA (UK)
The external examiner took an active role in each section of the examination.
Internal Examiners:
Written: Simon Chan, Serena Fung, Anthony Ho, Michael Irwin, Cindy Lai, Steven Wong
Vivas: Simon Chan, YF Chow, PT Chui, Anthony Ho, Michael Irwin, Steven Wong
OSCE: KW Au Yeung, Matthew Chan, WS Chan, YF Chow, MC Chu, Douglas Fok, CH Koo, CK
Koo, WH Kwok, KY Lai, Bassanio Law, Monica Lee, Theresa Li, SK Ng, Michael Poon, Nora Soon,
Steven Wong, Victor Yeo
OVERALL RESULTS
Out of seventeen candidates presented for the examination, 14 were successful. The overall
examination pass rate was 82%.
WRITTEN EXAMINATION
The written examination consisted of two papers. Thirteen out of 17 candidates passed this section.
PAPER 1 – SCENARIO QUESTIONS
Scenario A
A 50-year-old woman is scheduled for elective total thyroidectomy for long-
standing multi-nodular goitre.
1. How would you assess and manage this patient preoperatively?
(10/17 passed)
Most candidates were able to assess the thyroid status of the patient and to look
for pressure symptoms including stridor, SVC obstruction and possible
retrosternal extension. Preoperative management should include optimization of
thyroid function and preparation for difficult airway,
2. Discuss your anaesthesia technique for total thyroidectomy in this patient (pre-
and post-operative management NOT required).
(5/17 passed)
Most candidates only focus on airway management and failed to appreciate that
any problem was most likely to be infraglottic and that laryngoscopy was not
usually a problem. Other aspects of anaesthesia for thyroid surgery should include
positioning, isolated/shared airway, possibility of blood loss, and the importance
of smooth extubation to minimise the risk of post operative bleeding.
3. Three hours postoperatively, the patient complains that “she can’t breathe” and
insists on sitting up. SpO2 is 94% on oxygen. What are the likely causes and how
would you manage her?
(12/17 passed)
This question was meant to test the candidate’s ability to manage acute upper
airway obstruction. Most candidates could score well with this question if they
could recognize and declare it as a crisis situation and formulate a plan based on
the differential diagnoses. The most likely cause of this obstruction was local
haemorrhage causing compressive venous congestion and oedema of the larynx.
Scenario B
A 32-year-old healthy woman undergoes laparoscopic cholecystectomy. She has
no known allergies. Her father died of myocardial infarction at age 60. On
arrival in the operating theatre her pulse was 100/min and her blood pressure
was 120/60 mmHg. Anaesthesia was induced with fentanyl, propofol and
rocuronium. She has had morphine 5 mg and end-tidal isoflurane is 1.1% in
70% nitrous oxide. Twenty minutes after incision, her blood pressure suddenly
rises to 250/115 mmHg, and her heart rate increases to 150/min.
1. What are the potential causes for the haemodynamic changes?
(10/17 passed)
Most candidates were able to list out the potential causes, which should include
severe pain or inadequate anaesthesia, thyroid crisis, malignant hyperthermia,
malignant neuroleptic syndrome, and phaeochromocytoma.
2. How would you manage this patient? Explain your reasons.
(12/17 passed)
Most candidates could score well in this question provided that they managed
according to some algorithms based on the possible differential diagnoses.
3. The blood pressure decreases to 165/102 mmHg and the heart rate is 100/min
with frequent ventricular extrasystoles. All other physiologic parameters are
normal. What would you advise the surgeon now? How would you manage her?
(8/17 passed)
Most candidates did not recognize that the most likely situation here was
undiagnosed phaeochromocytoma or malignant hyperpyrexia. Thyroid crisis,
severe pain and malignant neuroleptic syndrome were also less likely
differentials. Some candidates fixated on myocardial infarction which was
implausible in a relatively young woman. As a result they “missed the plot” and
scored poorly.
Scenario C
A 73-years-old male with infra-renal abdominal aortic aneurysm is scheduled for
endovascular stenting which will take approximately 4 hours at the radiology
suite. His significant past medical history includes: diabetes mellitus and chronic
obstructive pulmonary disease with mild cor pulmonale which are well
controlled. The notable results of his recent investigations: hyper-inflated lung
on chest x-ray, FEV1/FVC = 0.85/1.38 (50% predicated), mildly dilated right
ventricle on echocardiography, and serum creatinine 120 µmol/L. His functional
status is about 4 METs and his medications include: bronchodilators, ramipril
and metformin.
1. What is your choice of anaesthesia for this patient? Justify your choice.
(10/17 passed)
Various anaesthetic techniques have been described for endovascular stenting:
general anaesthesia, spinal anaesthesia, epidural anaesthesia, combined spinal-
epidural anaesthesia and local anaesthetics with sedation. Candidates are expected
to understand the pros and cons of different techniques, and factors that would
have to be taken into account on deciding the choice. It was evident that some
candidates had a poor understanding of endovascular procedures and confused it
with more invasive surgery.
2. Discuss the strategy of renal protection for this patient.
(9/17 passed)
Because of the pre-existing diabetes and renal impairment, this patient is at risk of
developing contrast-induced nephropathy. General measures included: pre-
operative assessment of GFR and to consult nephrologist if GFR <
60ml/min/1.73m2 and avoidance of nephrotoxic drugs such as NSAID in the peri-
operative period. Specific approaches in prevention of contrast-induced
nephropathy should included hydration, choice and quantity of contrast,
pharmacological renal protection, and post-procedural monitoring. (Reference:
McCullough PA, Berman AD, Percutaneous coronary interventions in the high-
risk renal patient: Strategies for renal protection and vascular protection.
Cardiol Clin 2005;23:299-310.)
3. Discuss the role of Swan-Ganz Catheter (pulmonary artery catheter) as part of
the monitoring for this particular case.
(9/17 passed)
Most candidates failed to take into the context of this particular scenario and just
listed out the indication of pulmonary artery catheter. The use of a Swan Ganz
catheter in this situation is controversial and the candidate was expected to
discuss the relevant pros and cons of its use. These should include pre-existing
cor pulmonale making CVP reading less reliable, technical difficulty and patient
acceptance of TEE if under regional anaesthesia, the need for postoperative
monitoring and the potential complications.
PAPER 2 – SHORT ANSWER QUESTIONS
1. A 75-year-old man is scheduled for cataract surgery. He is a heavy smoker and
has chronic obstructive airway disease with frequent cough. The eye surgeon
would like you to provide Monitored Anaesthesia Care (MAC) for him. Outline
your anaesthetic plan.
(16/17 passed)
A heavy smoker with frequent cough isn’t really suitable for eye surgery under
local anaesthesia. Conscious sedation wouldn’t help the situation as the patient
would still have a tendency to cough and potentially disrupt surgery. Many
candidates didn’t appreciate this and instead described their technique of MAC.
This approach prevented the candidate scoring highly. The sensible solution
would be to discuss with the surgeon the benefits of general anaesthesia instead of
the surgeon’s suggestion of local anaesthesia with MAC.
2. How can you assess at the bedside whether tracheal intubation will be difficult?
Comment on the usefulness of these assessments.
(13/17 passed)
This question was intended not only to find out whether the candidate knew how
to assess the airway but also whether they understood the limitation of these tests
and appreciated their sensitivity and specificity. An appreciation of how
combining tests was more useful and that positive predictive value is a more
helpful way of expressing the usefulness of the techniques and their combinations
attracted higher marks. Candidates generally did this question well.
3. A 60-year-old man is scheduled for transurethral resection of prostate. He has a
coronary stent in place and is taking aspirin and clopidogrel as antiplatelet
therapy. How would you assess his platelet function?
(1/17 passed)
This question required more than just a list of available tests but an appreciation
of how commonly used antiplatelet therapy affects platelet function and how the
available tests assisted in the evaluation of the altered platelet function. In
practice, tests are of limited value in assessing any bleeding tendency and
additional marks were given that this was appreciated by the candidate and that
there is a need to prepare for excessive bleeding. Candidates performed poorly
with this question.
4. How would you recognise a type 1 anaphylactic reaction occurring during
anaesthesia and how would you manage and subsequently investigate the patient
after the acute event?
(16/17 passed)
This is a straight-forward question and most candidates could handle it well.
5. Name five conditions in a patient with major trauma in which positive pressure
ventilation could precipitate acute circulatory collapse. Explain the
pathophysiology of each.
(16/17 passed)
Most candidates could get three out of five conditions. These included cardiac
tamponade, tension pneumothorax and hypovolaemia. Few candidates mentioned
haemothorax, though it is similar to tension pneumothorax, and none mentioned
pulmonary venous-bronchiole fistula, where positive pressure ventilation drives
gas into the fistula from whence it travels via the pulmonary vein to the heart and
coronary arteries.
6. How would you assess the risk of postoperative nausea and vomiting in a patient
for elective gynaecological day surgery? How would you manage a patient for
diagnostic laparoscopy if she has a high risk of postoperative nausea and
vomiting?
(16/17 passed)
This question was well handled by most candidates.
7. An 80-year-old woman was undergoing a transurethral resection of a lateral
bladder wall tumour under spinal anaesthesia when violent jerk interrupted
surgery. Describe the relevant anatomy of the nerve that causes the above
phenomenon and briefly describe how it can be selectively blocked to allow
surgery to proceed.
(8/17 passed)
Candidates were expected to cover the relevant anatomy include the origin of this
nerve, its course, emphasizing that the nerve lies close to the lateral bladder wall
and is prone to direct electrical stimulation by the resectoscope during bladder
tumour resection. In describing how to block the nerve in a patient under spinal
anaesthesia, candidates were expected to describe the extra equipment required,
the relevant landmarks and how to determine if the nerve block was successful.
Some candidates wasted time on information like establishing intravenous access,
putting on monitors and using an anaesthetically safe environment.
8. Outline your management for a parturient who developed headache the next day
following a normal vaginal delivery under epidural analgesia.
(15/17 passed)
Candidates were expected to propose the likely diagnosis (post dural pucture
headache) and give a list of differential diagnoses based on distinguishing
features obtained from history and physical examination. Management issues to
cover include relevant investigations and both general and specific measures for
the treatment of post-dural puncture headache. Extra points were awarded to those
who gave relevant information on the use of epidural blood patch.
9. You have been delegated the responsibility of helping the dental department set
up a procedure room to provide sedation for day stay dental patients. This dental
clinic is within 10 minutes walking distance away from the main hospital
premise. Briefly outline your recommendations for how the facility should be
setup.
(6/17 passed)
Candidates were expected to cover areas including site layout, equipment and
staffing requirement and patient selection and care (including pre, intra and post-
operative care). Those who scored well organized their answer and did not just
regurgitate “college guidelines”.
VIVA EXAMINATION
Overall, 12 out of 17 candidates passed this section. The viva examination consisted of three vivas. At
the beginning of each viva, the candidates were given a clinical scenario with an introductory question
printed on a sheet of paper. The viva was structured with further follow-on questions.
Viva questions: scenario and an introductory question:
1. A 75-year-old woman with a past history of CVA and reduced mobility has been admitted with a
three day history of right sided abdominal pain, loss of appetite and vomiting. The surgeons wish
to perform a diagnostic laparoscopy.
- How would you prepare this patient for theatre?
2. An 80 year old female who has a history of rheumatoid arthritis, has suffered from progressive leg
weakness and paraesthesia of her hands and is scheduled for elective decompression of her
cervical spine between the levels of C3 and C5.
- How would you assess her suitability for surgery and anaesthesia?
3. You are the specialist anaesthesiologist working in a small peripheral hospital. A 4- year-old boy,
25 kg in weight, is scheduled for examination under anaesthesia for investigation of his
hoarseness.
- What are the main concerns in your pre-operative assessment?
4. A 15-month-old male infant with good past health, is scheduled for cleft palate repair. The infant
and his parents arrived this afternoon from Mainland China for the surgery tomorrow.
- On your pre-operative assessment, you noted that the infant has recovered from a ‘cold’ 5
days ago and there is mild residual runny nose. What will be your plan of anaesthesia?
5. A 65-year-old man with carotid stenosis is scheduled for a right carotid endarterectomy. He has
stable angina, controlled hypertension and non-insulin dependent diabetes mellitus.
- How would you assess this patient preoperatively?
6. A 32 year old healthy man requires a posterior fossa exploration for an acoustic neuroma. Surgery
will be performed in the sitting position.
- What anaesthetic technique would you choose for this patient. Justify your choice.
7. A 57-yr-old man has been scheduled for thymectomy using a right-sided Video-Assisted
Thoracoscopic approach. He is 165 cm tall and weighs 60 kg. He has had myasthenia gravis for 8
years and is currently taking pyridostigmine 300 mg q4h. He is otherwise healthy. On
examination, he has no ptosis and have 4-5/5 power in all four limbs.
- What ancillary tests would you request preoperatively?
8. A 65-year-old man has been admitted with right hip fracture. He suffered a stroke 4 weeks ago
with right sided weakness. He also has hypertension for 10 years. His current medications include
nifedipine SR, and aspirin. The patient has been scheduled for gamma nail of the right hip.
- What are your major concerns in preoperative assessment and preparation of this patient?
9. A 50-year-old man with long standing ankylosing spondylitis and “bamboo spine” is scheduled for
revision right total hip replacement.
- What are your major concerns in preoperative assessment and preparation of this patient?
10. A 30-year-old primigravida at 36 weeks of gestation was admitted for onset of labour. Her blood
pressure on admission was 140/90mmHg. The obstetrician requests you to give her epidural
analgesia.
- The patient enquires about the risks of epidural. What would you tell her?
11. A 60 year-old healthy woman who had recent minor subarachnoid haemorrhage with good
recovery. She is scheduled for embolization of cerebral aneurysm as a semi-emergency operation
the next morning.
- What are your major concerns?
OSCE EXAMINATION
The OSCE consisted of 10 stations. Overall, 14 out of 17 candidates passed this section.
Station 1. Communication (12/17 passed)
The scenario was an elderly man who underwent gastrectomy but suffered cardiac arrest after a
difficult intubation. He was successfully resuscitated and transferred to the intensive care unit. The
candidate was to play the role of the specialist in-charge and was asked to interview the daughter of the
patient. Most candidates were able to break the bad news by stating the facts, allowing questions and
ventilation of feelings while expressing continuing support and sympathy.
Station 2. Physical Examination (11/17 passed)
The candidates are expected to do a complete physical examination of the system concerned. The
accurate anatomical diagnosis is not expected. The emphasis is on meticulous examination, accurate
observation and logical deduction of the diagnosis.
Station 3. Physical Examination (15/17 passed)
Station 4. ACLS/ATLS (16/17 passed)
In this station, the candidates were presented with a young female trauma victim who presented to
A&E after being hit by a bus and sustained probable head, cervical spine & abdominal injuries.
Candidates were expected to take up a leading role & have a systematic approach to the early
management of trauma victims (primary survey & adjuncts, secondary survey). Extra scores were
awarded to accurate neurological assessment, ability to demonstrate the correct techniques in cervical
spine & airway protection and the prioritization of investigations and surgical interventions. A
substantial portion of the total marks was assigned to cricoid pressure application and immobilization
of the cervical spine during endotracheal intubation. Overall, the candidates had demonstrated that they
were familiar with the ATLS or EMST recommendations for initial assessment and management of
trauma victims.
Station 6. Procedures (13/17 passed)
In this station, the candidate is asked to “instruct” and “supervise” a first year trainee (role-played by
one of the examiner) to do the internal jugular vein central venous cannulation (IJV CVC). The
examiners are looking for the ability of the candidate to teach a safe technique to the trainee, while it is
understood that various techniques have been described in the literature. Ultrasound technique on
locating the internal jugular vein was also tested.
Followings are some areas that trainers need to be aware during their teaching, as those points did not
score well for the candidates:
1. Several candidates are unable to explain to the trainee explicitly the technique of IJV CVC
using verbal English instruction.
2. Several candidates have tendency to touch the aseptic field without wearing a sterile glove
while teaching.
3. Many candidates used imprecise terminology to name the different components of the CVC
sets. For example, the world “trocar” may be used to name the needle or the dilator. Similarly,
the world “introducer” may be used to name the needle, guidewire introducer or the dilator.
4. One candidate inaccurately thought that a 20 cm triple lumen catheter is too short for an adult
patient.
5. Several candidates pay insufficient emphasis on asking the trainees to differentiate arterial
from venous blood before threading in the guidewire. Colour is considered as an inaccurate
way. A better way is to disconnect the syringe from the introducer needle and look for
“pulsatile” arterial blood.
6. Several candidates asked the trainee to thread the guidewire through the side-hole of the
introducer needle without disconnecting the syringe. This is considered as a less safe
technique for the reason that we cannot be sure if the needle is in the artery or not.
7. When there is resistance to pass the guidewire, although gentle manipulations of the needle or
guidewire are acceptable, the safest way is to remove the guidewire and the needle as a whole
complex. Some candidates just ask the trainee to remove the guidewire from the needle
without considering any risk of fracturing the guide wire fracture. Some candidates try to
rotate the needle with the guide wire in situ which is at risk of fracturing the guide wire
8. Two candidates inaccurately thought that the dilator should be inserted in full length.
9. Most candidates cannot explain clearly the meaning of different colour when they use colour
Doppler mode to scan the neck.
It is worthwhile mentioning some good points:
All candidates asked the trainees to hold on the end of the guidewire while threading in the
triple lumen catheter.
All candidates remembered to remove the guidewire.
One candidate makes sure the tip of the guidewire was intact after removal.
Most candidates could locate the IJV using ultrasound (US) and differentiate the artery from
the vein on US.
Station 7. Anatomy and Regional Anaesthesia (14/17 passed)
The questions began with a scenario that calls for the stellate ganglion block. Marks were given to
correct answers on relevant anatomy, description of the procedure (including demonstration of the
landmarks) and complications. As pain management is an integral part of anaesthesia training,
candidates were expected to have a working knowledge of common interventional procedures.
In general the questions were well answered. Candidates who have observed or performed the block
tend to do well and gained marks related to the technical details. Most candidates were able to relate
the anatomy questions with technical aspects. It is disappointing that some candidates could not
identify the cricoid cartilage correctly.
Station 8. Equipment (14/17 passed)
The scenario was a young woman requiring general anaesthesia for a 5-hour long hand surgery. The
question tested the knowledge and skills of the candidates on the use of endotracheal tube (ETT),
classic laryngeal mask airway (CLMA) and Proseal laryngeal mask airway (PLMA) as airway devices.
Overall the questions were well answered. Most candidates had good concept of a supra-glottic versus
an infra-glottic device. The relative advantages of the three devices were well understood. During
insertion of the PLMA, some candidates had problems with using the cuff-flattener, mounting the
introducer and proper placement of the device. Candidates were not very familiar with the use of gum
elastic bougie as an insertion aid in difficult situations, as well as the use of the drain tube of the PLMA
to test for the proper position of the PLMA after insertion. All candidates preferred the gauze roll to the
Guedel airway as bite block when using classic LMA. However, a few candidates failed to recognize
that the gauge roll should be placed over the molars instead of the incisors.
Station 9. Investigations (14/17 passed)
Most candidates knew the basics. However, a few lacked confidence and were not specific enough in
their answers. More specifically, a few failed to recognize problems associated with paralysis without
sedation/anaesthesia and mechanisms of modern ICU treatment in modifying the disease processes.
Station 10. Crisis Management (17/17 passed)
The crisis station tested the performance of candidates in managing brady- and tachyarrhythmias.
Candidates demonstrated a systematic approach to the problem scored better. Most candidates could
effectively utilize resources available to them, taking the role as a leader and call for additional help
(like consulting a cardiologists or intensivist) at the appropriate time. It is also important for the
candidates to draw the attention and communicate effectively with all the team members (including the
trainee, theatre assistants and the surgeon). The scenario ended with a series of questions testing
whether the candidates can plan ahead to diagnose and manage the patient after the crisis. It is
however, somewhat puzzling to see candidates using phenylephrine as their first choice of drug in
treating symptomatic bradycardia. It is also worrying to see candidates doing cardioversion in patient
with sinus tachycardia or tachyarrhythmia with stable hemodynamics.
