MEDICINE

The Primary FRCA

The Primary FRCA Structured Oral Examintion Study Guide 1 • Second Edition
Structured Oral
Examination
Study Guide 1
Second Edition
Packed with new guidelines and current hot topics, this book and its companion
The Primary FRCA Structured Oral Examination Study Guide 2 are the
definitive revision aids to the Primary FRCA structured oral examination. This
second edition is revised and updated in line with the new Royal College of
Anaesthetists guide, with eight new sections to reflect changes to the RCA’s

The Primary FRCA

model questions and a major revision of six of the existing sections.

Features
•
•
Comprehensive resource to prepare for the SOE
Aligned to the Royal College of Anaesthetists Guide Structured Oral
Examination Study Guide 1
• Summary diagrams and flowcharts effectively distil the key points

Authors Kate McCombe and Lara Wijayasiri wrote the first edition when they
were trainees, after failing to find a good resource to prepare for the SOE
component of the FRCA Primary exam. They wanted a book that contained
Second Edition
model answers to the RCA’s published model questions – this book provided,
and continues to provide, just that.
Wijayasiri & McCombe
Lara Wijayasiri and Kate McCombe
About the Authors
Lara Wijayasiri and Kate McCombe are both Consultant Anaesthetists at
Frimley Health NHS Trust Illustrations by Paul Hatton • Foreword by David Bogod

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 The Primary FRCA
Structured Oral
Examination Study Guide 1
Second Edition

Lara Wijayasiri and Kate McCombe

Illustrations by Paul Hatton • Foreword by David Bogod

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business

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CRC Press
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 contents
Foreword v
Preface vii
Contributors ix
Acknowledgement xi

PART 01

PHYSIOLOGY 1
1. Red blood cells and haemoglobin 2
2. Oxygen–haemoglobin dissociation curve 4
3. Hypoxia 7
4. Oxygen transport 12
5. Carbon dioxide transport 15
6. Alveolar gas equation . . 18
7. Ventilation–perfusion (V /Q ) mismatch and shunt 20
8. Respiratory dead space 25
9. Lung volumes 28
10. Lung compliance 31
11. Control of respiration 34
12. Altitude and diving 39
13. Lung function measurement 44
14. Effects of anaesthesia on lung function 48
15. Baroreceptors and control of blood pressure 50
16. Cardiac cycle 53
17. Coronary circulation 54
18. Exercise 56
19. Carbohydrate metabolism 58
20. Starvation 63
21. Nausea and vomiting 66
22. Liver physiology 68
23. Gastric regulation 72
24. Total parenteral nutrition 75
25. Acid–base balance 78
26. Buffers 81
27. Renal blood flow 85
28. Glomerular filtration rate 87
29. Renal handling of glucose, sodium and inulin 91
30. Fluid compartments 93
31. Osmoregulation 97
32. Action potentials 99
33. Cerebral blood flow 102
34. Cerebrospinal fluid 106
35. Autonomic nervous system 109
36. Child versus adult 112
37. Pregnancy 114

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 CONTENTS

38. Placental transfer 116

39. Fetal circulation 118
40. Ageing 120
41. Adrenal gland 122
42. Thyroid gland 124
43. Eye 126
44. Endothelium 127
45. Portal circulations 129
46. Immune mechanisms 131
47. Pain pathways 134
48. Muscle electrophysiology 140
49. Reflexes 142

PART 02

PHYSICS 145
50. Definitions 146
51. Standard international units 150
52. Principles of measurement 152
53. Gas laws 157
54. Supply of medical gases 160
55. General aspects of pressure 164
56. Pressure regulators 166
57. Flow 169
58. Electrical components 172
59. Defibrillators 175
60. Electrical safety 177
61. Diathermy 180
62. States of matter, heat capacity and latent heat 182
63. Temperature measurement 189
64. Pollution and scavenging 193
65. Oxygen measurement 196
66. pH measurement 200
67. Carbon dioxide measurement 202
68. Blood pressure measurement 204
69. Arterial pressure waveform 207
70. Cardiac output monitoring 210
71. Depth of anaesthesia monitoring 217
72. Safety features of the anaesthetic machine 220
73. Disconnection monitors 223
74. Breathing systems 225
75. Resuscitation bags and valves 230
76. Ventilators 234
77. Vaporisers 237
78. Neuromuscular blockade monitoring 244
79. Lasers 251
80. Ultrasound and Doppler 254
81. CT and MRI 257
82. Pulse oximetry 260

Index 263

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 Foreword
Much has happened since I wrote the Foreword to the first edition of this invaluable guide
to the Primary FRCA Structured Oral Examination in 2010. Of the three original authors, two
have married (each other) and produced a baby girl. One of these two has had to relinquish
the authorship of this new edition, since his promotion to the ranks of Primary Examiner
unsurprisingly bars him from writing a book on how to pass the Primary exam. The two
remaining authors have both moved up the ranks and been appointed as consultants,
one with an interest in obstetrics, ethics and law, and the other specialising in vascular
anaesthesia and the difficult airway. The first edition, meanwhile, has rapidly become the
best-selling textbook on the Primary SOE. If a soap opera was ever to be based around the
publication of a guide to passing post-graduate anaesthetic exams – admittedly an unlikely
proposition – the story of McCombe and Wijayasiri would surely rival ‘EastEnders’ for
intrigue and plot development.

In this new edition, as well as updating existing topics, the authors have included substantial
additions to what was already a very comprehensive book, in line with changes made by
the Royal College to the Primary syllabus. The section on ‘special patient groups’ now
includes paediatrics and the elderly, the latter of increasingly personal interest to this writer.
The section on physics – often a stumbling block for the Primary candidate – has been
extensively revised and now covers those perennial favourites of the examiners, arterial
waveforms and vaporisers; as one reads these, there are frequent ‘aha!’ moments, not
least with respect to critical damping, the pumping effect and the influence of altitude on
performance. Mindful of the old adage that ‘a picture paints a thousand words’, the authors
have enhanced the number and quality of diagrams and figures, helping to clarify areas such
as fetal circulation and the Kreb’s cycle.

Some aspects of these books remain, thankfully, unchanged, in particular the resolutely
pragmatic approach that McCombe and Wijayasiri take to help readers through the tangled
thickets of the Primary. Here are the questions the examiners like to ask, the authors
seem to say, and this is how to answer them. It is, perhaps, a tribute to the exam syllabus
itself that this approach results in a textbook that is not only very readable but also highly
educational.

In short, if you are not lucky enough to be working in the same hospital as the authors, and
you cannot approach them for viva practice (or even if you can), then the new edition of this
book is an essential companion and a true vade mecum. Look it up – a bit of Latin can still
impress the examiners!

David Bogod
Consultant Anaesthetist and Ex-Editor-in-Chief of Anaesthesia
Nottingham

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 PREFACE
During our revision for the primary exam we were advised that the best way to ensure
success in the structured oral examination (SOE) was to prepare answers to all of the
questions in the back of The Royal College of Anaesthetists Guide to the FRCA Examination,
The Primary. Undoubtedly, this was excellent advice but it proved an enormous task and
one we simply did not have time to complete before our own exams. However, once they
were over, we began to answer all those questions in the hope that this might help others to
prepare for the Primary, or for the basic science component of the Final FRCA. Finally, then,
here is the result: the book we wish we’d had.

The Primary FRCA Structured Oral Examination Study Guide provides answers to the
questions regularly posed by the examiners. We have not attempted to write the next
great anaesthetic textbook, but rather to collate information and deliver it in a relevant and
userfriendly layout to make your exam preparation a little easier.

In the SOE itself, each topic will be examined for approximately five minutes. Many of
these answers contain much more information than could reasonably be expected of you
in that time; however, we have tried to cover several angles of questioning.

We have included the usual chapters on physiology, physics (Study Guide 1) and
pharmacology (Study Guide 2) and, in addition, have written a section on patients who
present the anaesthetist with unique problems, ‘special patient groups’ (Study Guide 2).
These patients tend to appear in the clinical SOE before some terrible ‘critical incident’
befalls them. Again, we have included a section addressing the ‘critical incidents’ beloved of
the examiner, with advice as to how to approach them in the SOE (Study Guide 2).

There is a unique pharmacology section including information on drugs commonly examined

presented in a spider diagram layout. These extremely visual learning aids allowed us to
revise the drugs in the necessary detail, and helped us to recall the information even under
the acute stress of the exam. We hope you find them just as useful.

We wish you every success in what is undoubtedly a rigorous exam. We believe the key to
this success is to practise presenting the knowledge that you already have, logically and
concisely. The only way to do this is to practise speaking, even though the possibility of
exposing any ignorance is daunting. The more you talk, the more you will cover, and every
question is so much easier to answer in the exam if you have already had a dress rehearsal.
We hope this book will help you in your preparations.

Good luck!
Lara Wijayasiri
Kate McCombe
December 2015

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 To Andrew, who makes me believe anything is possible.
Kate McCombe

To Amish, my husband and best friend- thank you for giving me the time to complete this
book. And to Maya, my beautiful daughter- thank you for giving me a greater focus in life
other than this book.
Lara Wijayasiri

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 Contributors
Paul Hatton B.Tec
Illustrations
Dr Barbara Lattuca MBBCh MRCP FRCA
Locum Consultant Anaesthetist, St George’s NHS Healthcare Trust
Physiology
> Acid-base balance
> Buffers
> Renal blood flow
> Glomerular filtration rate
> Renal handling of glucose, sodium, inulin
> Fluid Compartments
> Osmoregulation
> Baroreceptors
> Immune mechanisms
> Pain pathways

Lt Col Mark Wyldbore MBBS BSc(Hons) FRCA RAMC

Consultant Anaesthetist, Queen Victoria Hospital NHS Foundation Trust
Physiology
> Reflexes

Physics
> General aspects of pressure
> Pressure regulators
> Electrical components
> Defibrillators
> Electrical safety
> Diathermy

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 Acknowledgement
Dr Tim Case MBBChir MPhil MA(Cantab)
Our sincerest thanks go to Tim for his eagle eyes and enviable grasp of physics. The book is
better for his meticulous reading and attention to detail!

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