Sunday, June 22, 2008

This is it.....

Well, nearly seven months have passed, and it all comes down to eighty minutes or so tomorrow. I've reached the stage today where I am not really able to do much more. Shortly, I'll be heading off to London to stare at the hotel walls for a few hours and follow the usual pre-exam routine of trying to read stuff but not really achieving much.

I've usually found that having done the exam, everything I've read would have made no difference anyway, but I'm still holding onto my earlier piece of advice re: keep reading.

Best of luck to everyone taking the exam this week - I'd like to think that if we've put the work in and done the viva practice, we deserve to pass this marathon! Thanks to all who've left messages of support on this blog: nice to know that there are others sharing the pain. Looking forward to a pint or two tomorrow afternoon in the Square Pig - come and find me, I'm easy to spot: tall with red hair!!

Friday, June 20, 2008

Stir Crazy

Does the below sound familiar?

-Frantically trying to read a whole textbook in one day?
-Random A-Z hopping?
-Reading the same sentence six times and then wondering what you have just read?
-Panicking because of failure to retain the new clotting cascade?

Enough is enough and, whilst going completely mad on my own in the house trying to achieve the above may seem like the only way forward, I have to try and preserve some sort of sanity and order. So, here is the well-meaning plan for the next two and a half days:

-Concentrate on some clinical viva stuff for the rest of today and part of tomorrow. To break it up, I will do some "light-hearted" revision of ECGs and X-Rays/scans.

-Tomorrow, I will look at topical stuff: this includes guidelines (found earlier in the blog), resuscitation algorithms (you never know - would be embarassing to stumble here!), and a quick scan at the Bricker SAQ book. I will break this up with some more "light-hearted" diagram drawing practice from both the A-Z and my notes.

-This leaves Sunday free: I will go through the RCOA guide (both old and new - received two days ago by post), as colleagues have had vivas straight from this guide in the past. I will also re-re-re-re-re-revise some anatomy and probably try and learn how to draw inhalational agents, including their SVPs etc. I'll probably read through this blog as well just for good measure!

Tuesday, June 17, 2008

The Final Countdown

We're nearly there! Anyone done any A-Z chasing (see previous posting re: flipping through the holy book of Anaesthesia from topic to topic? - Guilty as charged!! My rollercoaster week continues - some days I feel I am going to nail this exam. I'm going to walk in and from the start be confident, articulate, and present my text-book knowledge in a concise, yet structured manner. Other times, I look blankly at my viverer, my mouth dry, and my brain even drier - a feeling of hopelessness overwhelming. I have discovered a new phrase: "The £680 answer - an answer so disorganised or dangerous that it will precipitate a return to the College when the leaves are brown!!

I've been pretty lucky and had a lot of viva practice. I've also had a lot of excellent advice from both Consultants and Registrars alike:

There is a famous quote:

"The harder I work, the luckier I get" by Samuel Goldwyn (or Gary Player!).

You often hear of people coming out of an exam, complaining about being asked 'xyz'. There are also people who when dissecting the exam, reveal some extraordinary questions asked, but having answered them without breaking a sweat: "Amazing, I read it just two days ago!"

The moral of this story (and one of the best pieces of advice given to me this week) is: keep reading and reading right to the bitter end. A random topic may come up for you!

Another phrase which keeps repeating itself is: "You already have the knowledge to pass this section" How many people have said that to you? Really irritating isn't it when you have forgotten the Alveolar Gas Equation for the fifth time!? A large proportion of your answer is structure. The temptation when answering a question that you know something about, is to spew forth everything at once. Another piece of excellent advice I was given, is to imagine that the structure of your answer is analogous to a tree. Do not aim for the fruit immediately - start with the trunk (or definition) and a few main branches thereafter (classify). The examiner will guide you towards which piece of fruit to pick and digest upon!!

E.g. Propofol is an anaesthetic agent which is used for induction of anaesthesia, causing a drop in blood pressure and decreased pharyngeal reflexes.......etc.


Propofol is an intravenous agent used for induction and maintenance of anaesthesia, sedation in ICU, and for the control of status epilepticus. It's chemical name is........

Exaggerated example I know, but it illustrates the point.

This week is all about keeping the mental attitude and trying to stay sane - to pass this exam, you do not need to know every little detail. You need to be strong and structured on the basics, and you need to be clinically safe: when asked during a clinical scenario, say what YOU would do because it's probably what you do most days without thinking.

Saturday, June 7, 2008

Annual Leave

I have one more shift on ICU between now and the D-day of Monday 23rd June. My now familiar hotel booking at the Park Inn Hotel (see previous posting for link) in Russell Square has been made!

I've deliberately combined post-nights time-off, study leave, and annual leave to give me this block of flexibility. My plans are to try and keep to a routine of some catch-up reading in the mornings, travel to the hospital at lunchtime and hunt down consultants/SRs for viva practice followed by our formal viva practice for 90 minutes in the early evening.

More tips:
-No wild gesticulations - hands clasped under the table - don't fiddle with the pencil.
-Don't dig a hole - if you don't know, say so.
-Don't mention something you can't talk about.
-Don't say: "You would intubate....etc" It apparantly annoys examiners -they will not be doing anything apart from marking. Say: "I would intubate..." or "The patient requires intubation"
-Don't use abbreviations or colloquialisms. You need to sound professional.
-Be able to draw all line diagrams from the A to Z.

Wednesday, May 28, 2008


We had a tutorial on paediatric fluid prescribing/administration the other day which was extremely useful, but it reminded me of how I'd managed to miss out on providing the guidelines pre-SAQ paper that were issued by the NPSA on fluid management of paediatric patients. I thought I'd covered all of them in a previous entry, and it was typical that the one that escaped came up in the SAQ paper. So, apologies for the tardiness but here they are:

Reducing the risk of hyponatraemia when administering intravenous infusions to children NPSA March 2007

-Since 2000, there have been four child deaths following neurological injury from hospital-acquired hyponatraemia reported in the UK.

-Remove 0.18% NaCl with glucose 4% from stocks & general use in areas treating children.
-Produce local clinical guidelines for the fluid management of paediatric patients.
-Provide adequate supervision and training for all staff involced in the prescribing, monitoring, and administering of IV fluids for children.
-Review & improve design of existing drug prescription/fluid balance charts.
-Promote reporting of hospital-acquired hyponatraemia incidents

Resuscitation: intravascular volume depletion should be managed with 0.9% NaCl boluses
Deficit: estimate fluid deficit & replace as 0.9% NaCl with 5% dextrose or 0.9% NaCl over a minimum of 24hrs
Maintenance: do not use 0.18% NaCl with glucose 4%

The majority of children may be managed with 0.45% NaCl with 5% glucose (or 2.5% glucose)

So there - I've outed my demon!

There are also some new relevant NICE guidelines:

-April 2008: Management of Inadvertent Perioperative Hypothermia
-March 2008: Prophylaxis against Infective Endocarditis

Saturday, May 24, 2008

The Home Straight

Well, the last month has been agonizing. So difficult to motivate one's self to get viva practice with the unthinkeable potential that it might all be in vain. I am pleased to say that so far my extremely public humiliation has not occurred and that I passed the written SAQ/MCQ paper. I'm absolutely delighted and it has given me the emphasis and boost to keep going for these last couple of weeks.
Congratulations to everyone who has passed (including my esteemed colleagues whom I work with - all eight of us passed).

So, the hard work begins again. Our hospital very kindly runs a nightly viva session for 90 minutes, where consultants and senior registrars put us through our paces in true exam style. It has been intimidating (five seconds of silence can stretch to eternity!), frustrating (I really did know the Alveolar Gas Equation but could not reproduce it), and sometimes just hilarious (yesterday I tried to convince a cardiothoracic anaesthetist that I would perform a fibreoptic intubation somehow combined with RSI - thanks to my guru Dr B who suggested I would attempt it nasally as well!!). The eight of us have formed an excellent bond and friendship during preparation for this exam which has been most welcome.

It's time to talk......and talk. You need to pester consultants and senior registrars and get them to viva you - at least twice a day. You need to be selfish with your time and if your list is not fruitful then excuse yourself and find somewhere that is.

Practice your technique of talking about drugs; I use the setup from Sasada & Smith:

-Main Action
-Mode of Action
-Routes of Administration/Dose
-Effects (CVS, Resp etc)
-Toxicity/Side Effects
-Kinetics (ADME)

You need to be adept at reading and presenting ECGs (a notable area of weakness by candidates in recent exams as stated by the College itself). You need to be able to identify common problems on X-rays and CT scans e.g. CT head.

Similar to the SAQs, you need to be uptodate with current topics and guidelines (see previous postings).
Additions include:
-Recent advances in thoughts about IHD in non-cardiac surgery including dual antiplatelet therapy and stents
-POISE Beta-Blocker RCT ( May 2008)
-Updated Surviving Sepsis Campaign (Intensive Care Medicine 2008 34:17-60)

Also, keep up to date with BJA/Anaesthesia Review Articles and, of course, the beloved CEACCP articles.


Friday, May 2, 2008


Many thanks to one of my consultants this week for providing me with a beautiful structure to answer any clinical question. I'm sure he won't mind me sharing it:

-Investigations (Observations, Bloods, ABGs, ECG, CXR, Other X-rays, Echo, PFTs etc)

-Check (machine/equipment, patient)
-Monitoring (AAGBI minimum standards)
-Venous Access
-Emergency Drugs/Equipment
-Skilled Assistance
-Resuscitation equipment


-Disposal (Recovery, HDU/ITU, ward)
-IV Fluids
-DVT prophylaxis

The beauty is that you could know nothing about the actual surgery, but by mentioning all of the above in the correct order, you'll probably pass!

Verbal Diarrhoea

I really thought I knew about U/S and the Doppler Effect - I could have written a short answer question on it. But when someone said to me this week: "Tell me about the Doppler effect", odd words and incomplete sentences came out of my mouth in the wrong order. Then I confused myself and then my brain-to-mouth interface stopped working altogether.

This precisely demonstrates the need to practice speaking and being viva'd. You may know a subject inside out, but it is the ability to convey this information clearly and succinctly in an ordered manner to the examiners which is a lot harder than it would appear.

My aim this week has been to get a viva a day from the consultant I have been working with. I've not done badly, especially on Wednesday when I was doing plastics (8hr TRAM flap) - I got three vivas! You need the consultants (or registrars) to be harsh on you - to really push you - and that's what they did. At times I felt like a real amateur (not like someone ready to be admitted as a Fellow to the RCOA) - I was nervous, I forgot basic knowledge and my clinical answers were unstructured. But I learnt a lot!

The topics I have been viva'd on this week include:
-Haemorrhage / Hypovolaemia
-Emergency cricothyroidotomy
-Nausea & Vomiting
-Temperature Management
-Subarachnoid Haemorrhage / Anaesthesia in Angio Suite
-Alveolar Gas Equation / ABGs from severe asthmatic
-Doppler / U/S
-SI Units
-PDPH/Epidural Blood Patch

Monday, April 28, 2008


I've deliberately not written anything for about a week to try and forget about the written exam last week.
It was an exhausting day, but I'm really glad it's done for now. I thought that with a couple of exceptions, the SAQ paper was reasonable - it could have been a lot worse. The MCQ paper was an absolute nightmare - more about that later.

1) Thoracic paravertebral space: either you know it or you don't. Despite having performed a couple of these blocks in early SHO-days, I couldn't recall the anatomy as I hadn't revised it - simple as that. I tried to make it up as best I could. The indications and complications were fairly generic answers for all nerve blocks.

2) CEMACH - one of my predicted questions came up, so the risk factors and causes of death were hopefully recalled verbatim. The next bit about Early Warning Scoring Systems was the usual lists of stuff making up PAR scoring/APACHE or whichever system is used.

3) Air Embolism - standard question seen before in similar guise in Bricker. I think there was a review article in Anaesthesiology about this subject.

4) 4yo appendicitis, dehydrated - fluid management. This question was about paediatric fluid management with specific reference, I think, to NPSA guidelines on avoiding hyponatraemia in children post-operatively. I thought that the NPSA website was a bit of a nightmare to navigate around, and had not found these guidelines pre-written paper. So, consequently had not read them, so probably missed out some quite important points - typical the only bloody guideline I do miss comes up!!

5) Pre-oxygenation. The lucky people who went on the Booker Course and did this question almost verbatim up there will be happy with this one

6) Complex Regional Pain Syndrome. As for 5) I'm afraid - congrats to Dr Booker!

7) Rocuronium - the 'topical' question. Fortunately I used to have a boss who was fascinated with Sugammadex, so was at least able to give a basic description of this. Unfortunately, I had a complete blank about neostigmine and was only able to write some pretty basic stuff about it - c'est la vie.

8) Asthma/Acute Bronchospasm - waffling plus some standard clinical emergency management.

9) Elective paeds - child not cooperating. The first part of the question about decreasing pre-op anxiety was a chance to be very touchy-feely etc. The second part was much less structured, and perhaps was touching upon consent in paediatric patients ?Gillick competency. I don't think I answered the second bit very well, but hopefully did enough on the first bit.

10) AAA - emergency. So much to write, too little time. A recent CEACCP article on exactly this topic.

11) Needlestick injuries. Very unusually for the College they have repeated a question from just six months ago - I assume it was done fairly badly last time out.

12) Acute Pancreatitis - again repeated from six months ago. So much to write, too little time.

I honestly don't know what to say about the MCQ section. I normally go through the paper fairly quickly to start with, just answering the stems that I definitely know. By the time I got to Q.45 and a lot of stems were unanswered, I started to get that feeling of desperation. You know, six months of hard work, thousands of practice MCQs - utterly pointless in trying to do this exam!!
I recognised a few questions from the college book. There were also a few questions from Elfituri & Arthurs MCQs (which incidentally I would have tried to do more questions from had there not been so many dreadful errors in it). But the rest of them......

There were obviously quite a few new questions, as the exam had to be halted numerous times to make corrections for the paper.

The only consolation was the fact that everyone else found it exactly the same!

So, onto viva practice - A senior registrar has grilled me today on the exam he got. Subjects include: phaeochromocytoma, pacemakers, N2O cylinders, tetanus, foetal circulation, and adverse drug reactions.

Monday, April 21, 2008

Last minute

Well, I'm off to London shortly to spend an uncomfortable 18 hours or so waiting to get this little test out of the way!
I hate the weekend before the exam - there is a lot of frantic reading done, which is completely pointless as I'm sure none of it goes in. My gastrointestinal autonomic system is doing its usual pre-exam malfunction and I can never eat properly! I hope I echo many other people's thoughts out there.
The problem is that you tend to concentrate on all the stuff you think you don't know or have forgotten, rather than the considerable bulk of material that you have managed to assimilate into your completely overloaded brain!

My advice, for what it's worth at this late stage, is:

-Try not to panic - part of this exam is keeping a cool head. Remember what you need to pass - usually 12/20 on each question (sometimes lower, sometimes higher) to get a '2', and minimum 6 1+'s and 6 2's to pass the SAQ paper.
-Get nice pens, plus a spare or two
-Arrive early & bring photo ID as told.
-Read the questions (properly).
-Write nicely and space answers out - make it easy for the examiner! 10% of marks can be gained here!
-Don't overrun on questions
-Eat and sleep well tonight!
-Look through RCOA MCQs
-Look through some guidelines/protocols/past papers.

-Have some luck !

All the best

Thursday, April 17, 2008

Psychological imbalance

Is it psychologically acceptable to swear at a computer screen?
During QBase I reckon it is. I am ploughing my way through QBase 2 at present on the computer - it feels marginally less like doing work if you're clicking a mouse every so often. But the MCQs can be so frustrating. They contradict answers in different MCQ books and unfortunately a small proportion of questions are out of date. But, the standard is reasonably high and the more the merrier etc etc. I've been getting between 42-49% on QBase 2 - which allowing for stupid errors (often!) and not reading the question/stems properly (occasionally!), I think, is OK. I'm sure some of you will be feeling smug on reading this if you're getting higher marks - so this portion was to make you feel better!!!

Well, I've just come off two of the most hideous night shifts on Neuro ITU ever. That'll learn me for taking in books to read/MCQs to do. It reminds me of a week of nights as a surgery house officer where our first three nights were so quiet. So, on the third night my SHO at the time decided to bring in his Playstation for the mess......the rest is history - Tits Up!!!!

Four and a half days to go - so how best to make use of the time?
-I'm still trying to get through as many MCQs as I can - in fact I wish I'd spent more time on them earlier as I may not finish all the books I have. I generally try and do at least two papers a day (usually take about 2 hours to do each), one first thing in the morning and then one later when I'm really tired, exactly like the real thing!!
-Today, I'm concentrating on sexy topics, review articles, guidelines etc, and hopefully if there's time, to finish going through some physics.
-I think the time has come to stop trying to learn new things now, so over the next few days I shall be rereading all the SAQs I have done from the Mersey Course, College papers, and SAQ textbooks (especially Bricker and Dashfield & Murphy).
-Over the past few months, I have been transferring some of my Basic Science notes from Primary into the Bricker Basic Science Viva Book, hopefuly leaving myself with one definitive but concise Basic Science text for both this written part and any future vivas (fingers crossed). I'll also try and go through as much of that as I can in the next few days.

I'm going to buy some really nice pens that are comfortable to write with - preferably ones that I don't have to press too hard onto the paper with. Hand cramp 90 minutes into the SAQs would not be desirable.

I have pledged not to take part in the dangerous pre-exam sport that is A-Z word-chasing. This involves reading a topic in A-Z, then seeing a bold word highlighted in the text that you have forgotten about, and going to that entry, and so on. It wastes a lot of time, and induces sphincter-loosening panic (?sympathetic or parasympathetic).

I am taking the exam in Central London but live about half an hour outside. Rush hour trains or traffic i.e. M4 are not conducive to good mental preparation. Therefore, a four star hotel overnight and a good breakfast, for me, is a prerequisite. So I've booked a nice room at the Park Inn Hotel on Southampton Row about ten minutes walk from the Exam hotel.


Saturday, April 12, 2008


I've just returned back from the European City of Culture 2008 where I attended the Booker course. I am shattered!
It was really encouraging to speak to a number of people who actually read this blog - thanks for your support and please leave comments and your advice/tips etc.

About the course:
I still reiterate that I think these courses are so valuable in preparing you for this type of exam. I found it pretty tough-going, but it has completely fulfilled it's purpose i.e. enforced writing of a range of SAQs under time pressure (I think we did 44 SAQs altogether including one full 12 question paper), some even more time-pressured MCQs (not easy standard either). The standard of candidate on the course was really high, and I found it quite daunting at the beginning of the week, but as the week progressed there were encouraging signs.
My MCQ marks gradually got better!

My SAQ technique i.e. timing, layout, and handwriting has really improved - mostly thanks to the 'Mersey Method' (unfortunately I don't think it would be fair to divulge it on the www!). There was a couple of sessions where we marked other candidates' SAQ answers - eye-opening the difference between handwriting and layout.

My tips at this point would be:

-MCQs MCQs MCQs (do the college book again the day before!)

-Hone your SAQ technique: make sure you have written a full 12 question paper in 3 hours a) to get your timing right, b) to practice handwriting/layout, c) for stamina!!

-Think of some sexy topics (the exam was set at the beginning of March!)

-Don't forget anatomy (it comes up in all parts of the exam!)

Thursday, April 3, 2008

With a little help from my tutor!

Continuing on the spotter theme.....
I mentioned in a previous entry about the SAQ tutorials I have been attending with some friends, which are run by a consultant we have worked with previously. I cannot understate the value of enforced MCQ practice and group discussion about the answers. At this week's session, we ventured briefly onto the subject of question spotting and our tutor raised a highly valuable point regarding a potential question.
I'm sure he won't mind me passing on his advice: a question on pain in some form or another. Two potential reasons: one, there hasn't been a pain question recently in the SAQs, and secondly (and most importantly), the setting up of the Faculty of Pain Medicine in April 2007 may lead to a request for pain representation within the SAQ questions.

Sunday, March 30, 2008

Quick link

Check out this blog site for more thoughts on how to pass the Final FRCA - glad to see people sharing the pain!!

Friday, March 28, 2008

What next?

4 weeks to go.... it's difficult to know at this stage where to focus revision. I've got one more week at work, then I go off to Liverpool for the Booker course and have annual leave etc, two night shifts at work, then more annual leave and then the exam. So, I do have a fair bit of study time available, but what's the best way to utilise it? I need to 'cane it' with MCQs - literally try and do hundreds (maybe into the thousands if possible) - it's the only way, and it's worked before for me. The good thing about MCQs is that they can be done anywhere: in the bath, on public transport on the way to work, even (dare I say it, although couldn't possibly condone it) at work!!

SAQs: I've nearly finished working my way through the Past Papers on the College web-site. Incidentally, the majority of the questions from 1996-2000 can be found in the SAQ textbooks by Bricker, and Dashfield & Murphy, taken verbatim. There are many more SAQs to be answered from the AnaesthesiaUK website (also see one of my previous posts where I categorised all of them).

The RCOA kindly publishes a report on the previous SAQ paper which has some interesting content. Firstly, it would appear that recently, questions done poorly in one year are repeated the following year (but not six months later). Also, they emphasise the inclusion of hot topics. I have taken the liberty of "guestimating" my very own hot topics for the forthcoming exam!!

- CEMACH 2003-2005 - it's just too good an opportunity to miss, surely?

- Obesity in pregnancy was a hot enough topic to make the national news headlines.

- Amniotic Fluid Embolism deaths shot up in this triennium - a lovely little question!!

- POISE (Perioperative Ischaemic Evaluation) study: looks at beta-blocker use in non-cardiac surgery

- CEPEX testing: here and here

- Awareness - trendy topical subject. Has been in the headlines in past couple of months + ironically a Hollywood film is about to be released in the UK.

- Mental Capacity Act - has come into force in late 2007

- Association of Anaesthetists Guidelines in 2007
-LA toxicity +/- Intralipid use
-Malignant Hyperthermia treatment (already used in a question and answered well, so unlikely to come up)
-Perioperative Management of the Morbidly Obese Patient - THIS IS FAIR GAME FOR THIS YEAR!!
-Standards of monitoring during anaesthesia & recovery

- NICE Guidelines (2007-8)
-Venous Thromboembolism: April 2007
-Acutely Ill patients in hospital: July 2007
-Head Injury: September 2007
-Intrapartum Care: September 2007
-Ultrasound Guidance in locating the Epidural Space: January 2008

-New Ideas
-Advances on clotting pathways
-Sickle cell anaemia

I also think that it is prudent to read through review article from the big journals for the last year i.e Jan 2007 - Feb 2008. Bold highlighted articles are those which lend themselves to SAQs!

BJA: here & here

Jan Fentanyl patch vs post-op pain

Feb Statins in sepsis

Mar Neuromuscular monitoring

Apr Blood flow & ventilation in the lung / percussion pacing

May CA stents in non-cardiac surgery

Jun Diastolic heart failure

Jul Neuro ++! The whole post-grad issue is neuroanaesthesia/NICU reviews

Aug Carotid endarterectomy

Sept Perioperative platelet Rx

Oct Sciatica & epidural injections / contrast-induced nephropathy

Nov Cardioprotection with remote ischaemic preconditioning

Dec Gabapentin

Jan Sedation & Regional anaesthesia

Feb Prone position / epidural analgesia vs periph NB for knee surgery


Feb Simulators

Mar Temp. epicardial pacing part 1

Apr Temp. epicardial pacing part 2

May Systemic complications post-head injury

Jul Propofol-infusion syndrome

Oct Interpleural block part 1

Nov Interpleural block part 2 / new thrombotic agents & neuraxial anaesthesia for major orthopaedic surgery

Dec Remifentanil

Jan Oesophageal Doppler in abdominal surgery / Statins for non-cardiac surgery part1

Feb Statins for non-cardiac surgery part 2 / cardiac output monitoring

Happy Reading!!