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Primary OSCE 75

Created: 4/7/2014
1. Anatomy
- Describe the anatomy of the spinal cord.
- Describe how you would perform epidural plexus block. What dose of local anaesthetic would you use per segment?
- At what level of the cord does the block terminate in adults?
- You are shown a schematic diagram of a cross-section of the spinal cord, and are asked to name the different tracts and their functions.
- Describe the blood supply to the spinal cord and its origins.
- What are the effects of a loss of blood supply to the anterior two-thirds of the spinal cord?

2. Anatomy
- Describe the anatomy of the larynx.
- At what level of the spinal cord is the larynx?
- You are shown a lateral view diagram of the larynx and asked to name the structures labelled.
- What does the superior laryngeal nerve supply?
- Name and describe the function of the muscles around the larynx.
- You are shown a diagram of the view of the larynx at laryngoscopy; name the labelled structures.
- What structures lie posterior to the larynx?

3. Simulator manikin
You are brought in to help an ST1 trainee after induction of a young man for an appendicectomy. You are shown a list of the drugs (with doses) being administered to the patient (thiopentone, suxamethonium, atracurium, fentanyl, morphine, ceftriaxone), and the patient is receiving an intravenous (IV) infusion of Hartmann’s solution. On starting the scenario, the ST1 states “I’m not sure what is happening but the patient is desaturating”.
- Demonstrate the airway, breathing, circulation, disability, exposure (ABCDE) approach and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) anaphylaxis drill.
- The patient has anaphylaxis and responds to IV adrenaline (100 g) and Hartmann’s fluid challenge (500 ml IV); what secondary therapy would you administer?
- What further medication would you give postoperatively in the intensive care unit and what follow-up investigations would you perform?

4. Communication
You are an anaesthetic SHO called to see a 37/40 pregnant patient who wishes to discuss options for pain relief in labour. Discuss the safety of different analgesia options - including her past obstetric history, history of current pregnancy (signs of preeclampsia), eliciting any contraindications for regional anaesthesia.

5. History taking
Take a history from a patient listed for ophthalmic surgery. She has type 2 diabetes and angina. The patient has become housebound over the past year because of poor vision. You are given an operating list with a number of patients, with this patient highlighted. You are asked the following questions about her:
- What operation is the patient listed for? (Left phacoemulsification and intraocular lens).
- Does the patient have any evidence of diabetic complications?
- Describe the signs of autonomic neuropathy.
- How does the patient monitor her diabetes?
- How good is the patient’s control of her diabetes?
- What is the frequency of her angina episodes? Why have they improved in the past year?
- Does the patient have evidence of heart failure?

6. Examination/skills
Demonstrate the relevant anatomy and technique for a lumbar epidural in obstetrics.
- Describe the anatomical landmarks for this technique.
- Assuming that the patient has had a full anaesthetic history taken, has had the procedure explained, and is fully prepared with IV access, preparation and drapes, demonstrate how you would insert an epidural on this patient.
- What is the volume of cerebrospinal fluid in an adult?
- What changes are seen in the spine in pregnancy?
- What length of catheter would you insert?

7. Examination/skills
How would you assess a ventilated patient with a suspected pneumothorax?
- Name two respiratory signs you would see on this patient.
- Demonstrate how you would examine the patient and describe your findings.
- How would you manage a pneumothorax? Describe/demonstrate needle decompression.
- What do you do once you have inserted the cannula?
- Demonstrate how you would insert a surgical drain. Describe how you would secure the drain and what you would connect it to.
- What are the complications of surgical chest drains?
- Give two reasons why a chest drain may stop swinging.

8. Anaesthetic machine check
You are asked to identify a breathing circuit.
- Demonstrate how you would check this circuit. Describe any faults that you find and assess its suitability to be used.
- What body weight is this circuit suitable for?
- What fresh gas flow would you use for spontaneous ventilation and intermittent positive pressure ventilation in a 20 kg child?
- What is the effect of not including a reservoir bag on the circuit?

9. Examination/skills
You are called to A&E to assess a trauma patient. The patient was a pedestrian hit by a car, with little recollection of the event. His eyes are closed and he only opens them when requested and appears to be well orientated at present.
- Carry out an ABCDE assessment, discuss your diagnosis and management, and carry out a full set of observations.
- How would you manage the patient’s C spine?
- What percentage blood loss has this patient suffered?

10. Equipment
You are shown an adult and paediatric diathermy return plate and asked to identify each.
- Would you use a paediatric plate on an adult patient? If not, why not? What principle is this based on?
- You are shown two diagrams of diathermy circuits; one has an isolating transformer, the other does not. Each diagram has a point marked on it; identify which of the two points you could touch without being electrocuted and why.
- You are shown four diagrams of waveforms; which graph represents coagulation and which represents cutting?
- You are shown a picture of a patient with his elbow resting on a metal bed rail; what likely complication will this patient develop and why?

11. Anaesthetic monitoring & measuring equipment
- You are shown a picture of a DINAMAP machine. On what principle does this machine work?
- What values are measured and what values are calculated?
- Is 170/150 mmHg likely to be a true measurement? If not, why not? What is the physiological reason for this?
- You are shown a diagram of oscillations versus time with blood pressure (BP; identify systolic BP/mean arterial pressure/diastolic BP).

12. Resuscitation
You are part of a crash team; demonstrate safe defibrillation.
- What rhythm is this patient in?
- Is the CPR in progress adequate? What should be changed?
- What energy settings would you use?
- What energy settings would you use in a paediatric case?
- What would you do after the first shock?

13. Scans
You are shown an ECG and told that the patient has a pulse and is alert.
- Identify the ECG rhythm.
- How would you assess the patient?
- Discuss the management of a stable patient. What would you do if the patient does not respond?
- Discuss the management of an unstable patient.

14. Scans
You are shown a chest X-ray on a light box and given an optical marking sheet to record your answers. The patient is a young male patient with a 2-year history of shortness of breath on exercise, with recent worsening, who is listed for appendicectomy. The X-ray shows signs consistent with pulmonary fibrosis.
- Does this patient need erythromycin?
- Does this patient need postural drainage postoperatively?
- Will this patient’s lungs be more compliant?
- Does this patient have cystic fibrosis?
- You are asked further questions related to other potential differential diagnoses - i.e. infection, fluid overload etc.

15. Scans
You are shown a chest X-ray on a light box and given an optical marking sheet to record your answers. The patient has a pacemaker, and a single pacing wire is visible. Answer the following questions:
- Is the pacemaker dual chamber?
- Has it got implantable cardioverter-defibrillator (ICD) capabilities?
- Is antibiotic prophylaxis needed for pacemaker insertion?
- Is a magnet needed for this patient?
- You are asked further questions relating to pacemaker safety.

16. Communication skills
Explain malignant hyperthermia to a trainee operating department practitioner. He has been in post for 6 months and so has some experience in post.
- Discuss the use of dantrolene and the practical implications of managing such a patient.
- Discuss postoperative management.

17. Equipment
You are given coaxial tubing, a heat moisture exchanger filter (HMEF), sidestream capnography tubing, a reservoir bag and an adjustable pressure limiting (APL) valve and are asked to assemble a Bain circuit.
- Why is the sample port for the capnograph downstream of the HMEF?
- What would be the effect of including the capnograph on the patient’s side of the HMEF?
- Two different capnograph tube sizes are available; why would you not select the thicker tubing?
- You are given different capnograph traces and asked to identify and explain any abnormalities.

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