Osce

1) History: young man for wisdom teeth extraction, sister had a previous problem with
GA ? relted to sux, patient reveals he is afraid of being awake, and has a needle
phobia.

2) ECG station: Sinus Bradycardia on ECG, direct questions and treatment of sinus
bradycardia in line with resus guidelines.

3) X-ray station: lateral CXR, history of upper abdominal pain, surgeons want to take
patient for laparotomy. Asked about fluid levels on x-ray, would you cancel the
operation, what is the diagnosis.

4) Abdominal x-ray: Hx of patient on rifampicin, isoniazid, B12, and a few other

medications. Patient listed for lithotripsy, asked what side renal calculus is on, Hb is
8 would you transfuse pre-op, something about renal replacement therapy I think.

5) Simulator: Patient on ICU with a head injury, you are called by CT1 to review patient
who is deteriorating-Cushing response, asked about initial management, further
investigations, mannitol dose, what else would you do?

6) Clinical skill: Assessment of tension pneumothorax, how to identify tension pneumo,

how to treat, demonstrate on volunteer. Then chest drain insertion, demonstrate on
a volunteer where you would place it, what the landmarks are, demonstrate and
describe surgical chest drain insertion.

7) Equipment: shown pictures of analysers, asked to identify Co2 measurement device

correctly, then asked questions about Co2 analysers. Asked to state 5 different Co2
measurement devices (I could only think of 4)

8) History station: 69yr old male for hernia repair I think it was. History of previous heart
attack and current angina which hasn’t been fully investigated or treated. Anxious
that procedure won’t be cancelled.

9) Equipment: Machine check, check Ayres T-piece, then asked questions about T-
 piece, when used, flow rates with spontaneous and controlled ventilation, what
happens if circuit expiratory limb is too long, or a crack is found in inspiratory limb.

10) Resus scenario: Asked to identify rhythm on monitor, how you would treat if it was VF,
asked questions about treatment of VF following ALS guidelines. Also had to instruct
paramedic on how to do chest compressions correctly.

11) Clinical skill: Asked to demonstrate how you would do a spinal on a volunteer. Then
asked to talk through spinal technique, and specifically medical contraindications to
doing a spinal.

12) Anatomy: Asked to identify 5 nerves supplying the foot, then demonstrate how to
position patient for nerve blocks, then talk through how you would do blocks.

13) Anatomy: Shown a picture of sympathetic/parasympathetic nervous system, asked

about innervation of each, cardiac innervation from what level, what each releases
pre/post synaptically, and where sympathetic NS releases ACH post-synaptically.

14) Explain awake fibre optic to an anxious patient.

15) (? test station) Equipment: Asked about sterilisation and chlorhexidine, how to prevent
line sepsis, national guidelines on what to do to prevent line associated sepsis or
something like that. Shown picture of CVP line and asked what is on the line to
prevent infection (2 things).

16) Clinical examination: Check arterial and venous pulses and measure BP.

17) Equipment: Ultrasound image of neck veins, identify which side the image is of, asked
about ultrasound frequencies, resolution and about neck lines.

OSCE
Station 1 Technical skill
Perform an interscalene block
Demonstrate on this patient the relevant anatomy and where you would perform the
block
What manoeuvre can be used to highlight the sternocleidomastoid muscle?
What is being blocked in an interscalene block?
Why is an interscalene block done?
What structures can be damaged during an interscalene block?
What makes up the brachial plexus?
If you use a nerve stimulator, what happens if you are too anterior?
If you use a nerve stimulator what happens if you are too posterior?
Which nerve is frequently missed?
What can assist in locating the correct position?
Picture of dermatomes of arm – what nerve root supplies this dermatome?

Station 2 ALS
Pregnant patient for category 2 section. Just given epidural top-up of 20ml
0.5% bupivacaine by CT2. Now unresponsive. Epidural was sited only a few
minutes ago for labour analgesia (not stated whether tested or not). You have a
student midwife to assist you.
Confirm cardiac arrest
Call for help (midwife comes back very quickly)
Teach midwife how to do CPR – thereby telling everyone you know the rate of CPR,
ratio of compressions to breaths etc
Pulse and rhythm check twice (neither shockable)
ROSC once patient intubated and 1mg adrenalin given
What symptoms would patient have experienced prior to this happening (still not sure
if this was a total spinal or IV LA! – on balance group decided it was total spinal)

Station 3 Anatomy
Larynx again!!!!
Saggital CT of larynx
What is 1, 2, 3, 4 – epiglottis, hyoid, thyroid, cricoid
What elevates the larynx?
What depresses the larynx?
Motor and sensory supply of the larynx?
What abducts the vocal cords?
What is the motor supply to this muscle?
What is the sensory supply of the tongue?
Very strange picture of superior vocal cords
What is this and this – think it was vocal cords and aryepiglottic fold but very strange,
almost oblique view

Station 4 communication
50yr old lady for some day case surgery (cannot remember what, maybe
gynae). Daughter recently had awareness during emergency C/S. Discuss this with
her as she is scared this may happen to her. In addition she has a history of motion
sickness. She is worried about vomiting post-operatively especially on the way home.
There was not enough time to discuss everything with this lady, but standard
discussion, nothing unexpected. Actor was nice and understanding once this
explained to her. Very basic understanding to start with, but came out with more
informed questions as station progressed.

Station 5 Safety
Discussing equipment used during paediatric ENT and safety features
Picture of re-inforced ETT, nasal north-facing RAE and oral south-facing RAE
Child for adenotonsillectomy
What symptoms might this child have (listed what felt like millions – wanted frequent
infections!)
Which of these tubes would you use? (Don’t think there was a preference, just a
discussion)
Would you use a supraglottic device?
Why not (discussed trusting surgeons not to move it, need to keep airway clean and
dry)
What do the surgeons insert to keep mouth open (wanted name of the gag, which I
still don’t remember even after he told me!)
What problems can this give the anaesthetist? (think this was about – extubation,
endobrochial intubation and obstruction of the tube)
What would you look at to exclude these problems (forgot to mention capnography –
which he specifically wanted despite doing a full AB assessment, checking airway
pressures and tidal volumes)

Station 6 Physical exam

Examine the radial arterial pulse, precordium and listen for murmurs or
additional sounds. Do not attempt to examine any other part of the CVS

Station 7 Monitoring equipment

Capnography
Shown picture of monitor – capnograph trace – what is this?
What three numerical pieces of information does it give you?
What is the principle that this monitoring equipment works on?
What infrared wavelength is used?
Three pictures of capnograph traces – what is occurring here?
Rebreathing – what may be the cause (2)?
Rapid decline in EtCO2 – what may be the cause (2)?
EtCO2 abruptly ceases – what is the cause (2)?

Station 8 History
Patient for hysterectomy, take a history. This is not a communication station.
Menorrhagia. Has anaemia despite iron supplementation. Recent history of GA for
emergency C/S with history of awareness. Post-operative severe nausea and
vomiting. Developed DVT and PE with extended hospital stay, warfarin stopped 6
months ago.

Station 9 Resuscitation station

Shown ECG of SVT
What does this ECG show?
What would you look for to determine if the patient is stable?
Patient is stable. What manoeuvres can you attempt to treat this?
If this doesn’t work, what medication can you try?
If this doesn’t work what other medications can be used?
If the patient is unstable what should you do?
What energy level do you use for synchronised cardioversion?
If electrical cardioversion doesn’t work what do you do?
Station 10 Xray
Elderly gentleman, post hip replacement, from rehabilitation after 3 days in
hospital, severe SOB, chest pain. ?tachycardia
Xray showed pulmonary arteriogram with cut-off of right pulmonary artery.
True / false
This is a pulmonary venogram
It shows complete occlusion of the right pulmonary artery
This patient should be blue-lighted to the nearest cardiothoracic centre immediately
This patient is liable to collapse at any moment
(I can’t remember the other questions)

Station 11 CT scan
Middle aged man, head injury (can’t remember mechanism) unconscious, lucid
interval, now becoming increasingly confused. On arrival moving to command
but confused.
Two CT scans – bone and tissue phase. Shows left extradural
True / false
This shows a left subdural
There is air in the frontal sinus
There is a right temporal bone fracture
There is evidence of raised ICP
He needed intubation on admission
He will have bilateral fixed, dilated pupils
He should be ventilated to pCO2 of less than 3kPa for 24hrs
(I can’t remember rest)

Station 12 SIM station

45yr old male (possible bicycle versus lorry?) with right femoral fracture. CT2
has induced patient, now intubated an on table. Surgeons scrubbing. Please
take over.
Initially on taking over patient has normal vital signs, very quickly becomes
tachycardic as assessing. When asked, BP is 80/40ish. Seemed to be management
of hypotension d/t bleeding into thigh.
Called for assistance, turned down sevo (no MAC on monitoring but dialled to 4%,
wanted to know what MAC I was aiming for – titrate to effect seemed to satisfy)
Gave IV fluid bolus (how much), metaraminol (how much) in 0.5-1mg boluses to
effect. Another large cannula (only had one) and urgent crossmatch of blood.
Told surgeons what had happened and asked to apply tourniquet but not open until
stable.
While treating and managing with an ABC approach I ruled out pneumothorax and
haemothorax, anaphylaxis and inter-abdominal bleeding.
BP came up on second re-assessment and they stopped the station with 1min30 to
go!

Station 13 Cricoid pressure

In this station you will be teaching a CT1 to apply cricoid pressure
(Although actually you just answer the questions the examiner asks, not like a
teaching station in other exams)
Which situations is cricoid pressure used in?
How much pressure should be applied once the patient is asleep?
What are contra-indications to cricoid pressure? (two was enough)
On model demonstrate relevant surface anatomy
Why is the cricoid used?
How would you explain what 30N is?
When should cricoid pressure be applied? (I think asking when the ODP knows when
to start pressing – talked about 10N while awake, increase to 30N as anaesthetist
loses contact with patient, but essentially when anaesthetist asks for it)
When should cricoid pressure be released after patient is intubated?
How might cricoid pressure cause problems?
In which situations should cricoid pressure be released despite patient not being
intubated?
(Active vomiting, hindering intubation, in CICV when attempting to ventilate or insert
LMA – moved on once all of these mentioned)

Station 14 Measurement of humidity

Three diagrams – which is a hair hygrometer, which is a wet & dry, which measures
the dew point?
Does hair hygrometer measure absolute or relative humidity?
How does the Regnault’s work?
What is relative humidity?
What is absolute humidity?
What are the units of absolute humidity?
What should the humidity in theatre be?
Why not higher?
Why not lower?

Station 15 History taking

Ms Ndebele (young female) coming for laparoscopy tomorrow. Please take a
relevant history.
Laparoscopy for endometriosis, didn’t seem to have history of menorrhagia or
anaemia. Sickle cell negative. Had 6 month history of dry cough and increasing SOB,
just able to make 2 flights of stairs. Had CXR yesterday but no other investigations,
no results yet. Prior to moving to UK as young child was told she had a heart murmur
– no further history, investigations or treatment.

Station 16 Anatomy
Model and picture of external structures in neck – anatomy of larynx
What are 1, 2 and 3 – hyoid bone, thyroid cartilage, cricoid cartilage
How does cricoid differ from thyroid?
Blood supply to larynx
Motor and sensory supply to larynx
What does cricothyroid do?
What abducts vocal cords?
What nerve supplies this muscle?

Station 17 Equipment
This is a standard O2 cylinder found on an anaesthetic machine, what is it made of?
(picture of E-type cylinder)
Can it be used in MRI?
What is this? (Gives you a bodok seal)
What is its function?
What is the pressure in this cylinder?
What is the pressure of pipeline N20?
What size is the internal and external diameter of connectors in breathing circuits?

OSCE Stations
1) History taking stations (x2)

• 64 year old male – for Right inguinal hernia repair, on Warfarin,

Digoxin, Furosemide, PRN GTN, PMHx – MI 10 years ago (no
intervention)

• 30 year old female – for rhinoplasty. Hx of polytrauma one year ago

following RTC – required splenectomy, post-op ICU stay, anaphylaxis
to Suxamethonium

2) Communication

• Please speak to the daughter of an 82 year old male currently in theatre

having a ruptured AAA repair. Explain likely prognosis etc.

3) Anatomy (x2)

• C6 vertebra – label all the structures in a cross-section diagram

• Spinal cord – ascending and descending tracts, blood supply and

origins of blood supply, what volume of LA is needed to block each
segment when doing an epidural?, contents of grey matter, Sx of
anterior cord syndrome

4) Resus (x2)

• PEA – ruptured ectopic

• Broad-complex tachycardia- discussion session, as per ALS guidelines

5) Simulation

• You’ve been handed over a patient with severe asthma who’s been
intubated and ventilated in ICU. Please take over – ABCDE
 assessment, progression to tension pneumothorax and details of chest
drain insertion.

6) Neuromuscular monitoring

• Placement of electrodes

• Graphs of DMR vs NMDR blockade

7) Temperature

• Measurement – photos of nasal thermistor probe and tympanometer

• Definition of core temperature

• 4 ways to reduce heat loss due to CONDUCTION

8) Technical skills

• Shown photo a Grade 3 view – methods of trying to improve this view

• Anatomy of larynx

9) Equipment

• Bain circuit check

10) Radiology (x2)

• CXR – bilateral multiple cavitating lesions in a 45 year old female

smoker, fevers and recent travel abroad. ?miliary TB

• CXR – Single lead pacemaker, cardiomegaly, sternotomy clips.

Questions of possible type of pacemaker

11) Diathermy

• Photos of monopolar and bipolar – asked which one is which

• Mechanism of action

• Safety features

• Coagulation and cutting waveforms

 12) Vaporisers

• Broad classification

• Advantages of plenum over draw-over

• Effects of altitude

• Methods of flow and temperature compensation

OSCE
1) Coronary circulation, specifically venous drainage with angiogram picture
2) Anaesthetics Hazards in Operating Theatre - microshock and symbol
recognition
3) Cranial Nerves
4) Monoaural Stethoscope
5) Communication - Awareness
6) Resus - Narrow Complex Tachycardia
7) XRay - Young Cardiomegaly
8) CT Recon - Lumbar Spine Fracture with Spinal Cord Involvement
9) Simulation - Peri-op Ischamic Changes
10) History 1 - Pre-op TAH, asian, FH Thalassaemia
11) History 2 - Tonsils, T1DM
12) Intraosseous Needle and insertion on dummy
13) DINAMAP
14) Equipment check RSI - bulb did not work, blue tack in elbow extension, tube
did not inflate
15) Epidural Anatomy and placement
16) Resus Scenario - drowning and VF

OSCE
1. Communication to mother of child with sux apnoea picked up during
appendicectomy.
2. History- woman coming in for THR. Known murmur Orthopnea, decreased ET
3. Equipment- suction. MOA.
4. Equipment- filters- HME/ Blood giving set/ epidural. Size of pores etc
5. Equipment- capnography. Identify different traces
6. Defib station. Patient on operating table, develops bradycardia and hypotension-
which drugs do you use? doses? switches into sinus tachy, compromised. operate
defib machine.
7. Sim- patient with hypertension. Picked up inadequate plane of anaesthesia.
Increased flows/ AA; hypertension improved. developed tachy. questions re: tachy
algorithm.
8. lateral CXR.
9. ALS- talk through management for patient in asystole. When would you use
sodium bicarb?
10. Anatomy- trigeminal nerve. id base of skull foramen. qs on pathway of nerves
11. Anatomy- shown model of spine. id: odontoid peg/ atlas/ axis/ differentiate
pedicles/ lamina. where can an epidural be sited? levels of spinal cord ending in
infants/ adults.
12. epidural in knee surgery. Id insertion point on patient- describe preparation. what
structures will you pass through.

OSCE
1. Communication. Lady for elective shoulder replacement aware of surgery and
pain, talk to her.
2. Electricity. Horrible diagram with patient, intracardiac device and multiple earths,
questions about the earths that mainly I didn't understand! identify 2 electrical
symbols, few questions about microshock.
3. Rythm strip, looked like AF, questions about management, drugs and defib.
4. Monoauricular stethoscope, questions about use e.g. paeds/air embolus,
placement to listen. Could you use it to confirm endotracheal intubation? and some
questions about this in general.
5. Angiogram and questions re anatomy of coronary arteries where they arise etc
what supplies AV node in most people, breif question on venous drainage.
6. X-ray, globular heart and upper lobe diversion hx rheumatic feaver and SOBOE ?
mitral regurg, questions re mumur, ? needs antibiotics prior to op.
7. Reconstructed Lumbar spine CT # L1 body ? can see only lumbar veterbrae (had
one with rib), will cord be damaged at what level etc, will the anterior spinal ligament
be intact? patient paralysed, tachy and hypotensive with other injuruies is he
hypotensive due to spinal shock?
8. Sim-man, ST depression, got better with GTN then hypotensive got better with
decreased MAC, decreased GTN and metaraminol, gave me unlabelled syringe of
metaraminol not sure if this a test or not. What other test would you want next.
9. IO Acess tibia on model, what ther sites how give drugs etc, when would you use.
10. Anatomy of larynx side view and view on laryngoscopy name labeled structures,
questions on blood supply and innervation and muscles.
11. RSI equipment check it what else would you want? Cuff on tube broken, blue
tack in connector, suction too small, Magills stuck together, questions on failed
intubation.
12. History 35 lady for hysterectomy hx thalassemia on iron.
13. History 21 year old for tonsillectomy hx of insulin contolled diabetes, alchohol and
hypos.
14. Drowning 15 year old boy in VT brought to ED no crash team, person doing chest
compressions badly, initially I thought member of ED staff but was member of public
so should have confirmed what he was happy to do etc. Shock patient, questions on
hypothermia and when to shock.
15. Cranial nerve examination 3-12
16. Obstetric epidural on model and questions about Tuffiers line and dermatomes of
pain 1st stage labour, what level spinal cord ends.
17. Can't remember sorry!
OSCE
Simulation- called to see 35 y/o involved in RTC earlier in the day. Now
intubated on ITU. C spine cleared.
Assessed him A-D. Bradycardic, hypertensive. Fixed pupils. Asked what the
main problem his.
Showed an ABG with pO2 22, pCO2 6.5. What is your next step?
Asked Q's re head injury management, inc mannitol dosage.

Technical skill- tension pneumothorax. Discussed how to confirm tension

pneumothorax. Anatomy and technique of drain insertion.

History- 68 year old for inguinal hernia. Hx of MI. exertional SOB.

Equipment- shown diagrams and asked which is CO2 electrode. Q's re. The
different components.

Technical skill- ankle block. Demonstrate where you would block each nerve.
Volumes of LA. positioning. asked to map territory supplied by sural and
superficial plantar nerves.

Equipment- check T-piece circuit with a bag. Hole in the bag. Subsequent Q's
about mapleson classification and FGF needed.

Equipment- shown picture of CVC. What is this coated in to minimise infection

risk. Q's about minimising infection from peripheral lines. Uses of
chlorhexidine.

Technical skill- CVC insertion. 2 pictures of US image of neck. Asked to explain

the differences. Eg. Head down, volume state.

Technical skill- demonstrate spinal technique on actor. Select needle and why.
Level needed for TURP.

defibrillation technique. Q's re management of VF including drugs and

dosages.

Anatomy- diagram of autonomic nervous system. Q's re sympathetic ganglia.

Cranial nerves with parasympathetic supply.
Communication- lady for lap chole. Previous difficult intubation. Discuss AFOI.

Showed rhythm strip. Bradycardia. Q's based on ALS bradycardia algorithm.

History taking- 22 y/o student for dental extraction. Needle phobia. Sister had
'aches' after previous GA for same op. apparently he had previously broken his
nose, I didn't get this from him.

Radiology- lateral CXR of patient with gallbladder empyema. Looked like R

middle lobe collapse. Q's mostly related to management of patient. Eg delay
op, abx, bronchoscopy.

Radiology- IVU of patient for lithotripsy. On anti tuberculous therapy and OCP.
Is the right kidney working? Is it a urate stone? Is there increased risk of
pregnancy?