AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS

ABN 82 055 042 852

EXAMINATION REPORT

FINAL FELLOWSHIP EXAMINATION

May 2015

GENERAL COMMENTS

Candidates should be aware that whilst the exam is not held at the absolute end of their
training, the standard expected across all aspects of the exam is that of someone ready to
commence independent specialist practice; it functionally is an exit exam.
As all aspects of the curriculum are examinable, trainees are advised their best chance of
success is to sit the exam when their clinical experience matches their theoretical knowledge.
All sections of the exam are referenced to the curriculum so candidates are advised to be
familiar with this document.
Candidates and trainees are also reminded that memorising questions from the exam, in
particular the MCQ paper, and posting them on the “black bank” would be a breach of their
training agreement with the College and of ANZCA intellectual policy.

The mark allocation for the examination is as follows:

SECTION FANZCA Performance Vivas only

assessment
MCQ 20
SAQ 20 20 (25%)
Medical Clinical 12 12 (15%) 12 (20%)
Anaesthesia vivas 48 48 (60%) 48 (80%)
TOTAL 100 80 (100%) 60 (100%)

The pass rates for candidates presenting for the Final Fellowship in March /May 2015 are
presented below:

CATEGORY MCQ SAQ Medical Viva Overall Pass

ANZCA Trainees No. sitting 184 184 184 171 150
Pass rate 73.9% 75% 72.3% 90.6% 81.5%

IMGS – Full FFE No. sitting 4 4 4 4 3

Pass 100% 75% 0% 100% 75%

IMGS – No. sitting 5 5 5 2

Performance
Assessment
Pass rate 40% 40% 40% 40%

IMGS – No written No. sitting 6 6 1

Pass rate 50% 16.7% 16.7%

Total No. sitting 188 193 199 186 156

Pass rate 74.5% 71.9% 69.3% 87.1% 78.4%
MEDICAL CLINICAL VIVAS

Overall pass rate 69.3%

The medical viva tests the ability of a candidate to identify and assess the severity and
stability of a specified medical condition. It is not a pre-anaesthetic assessment.

Candidates are expected to take a focused history, elicit relevant physical signs and from
these, determine the functional status of the system to which they are directed. They are
expected to be able to interpret ECG's, CXR's, blood results, Pulmonary Function Tests and
other investigations, which are relevant to the progress of the condition or its complications.

An understanding of the management of acute aspects of the medical condition is expected

and candidates should also be able to discuss medical optimisation.

Criteria for assessment include

- professionalism in dealing with patients
- an appropriate history which explores risk factors, degree of severity, progression, response
to therapy and long-term management (where appropriate) for a disease state
- physical examination that elicits key signs in an efficient, logical sequence
- an organised presentation of findings which interprets and integrates history, examination
and investigations

Candidates should be mindful that they are interacting with patients. Difficulties may well arise
in the course of the exam and candidates need to demonstrate some flexibility in their
approach to the patient.

Candidates who score well

- demonstrate respect for the patient
- elicit a comprehensive history relevant to the system
- evaluate the functional impact of the condition
- perform a fluent and accurate physical examination
- integrate the information into a reliable and succinct summary
- prioritise and correctly interpret relevant investigations

The following is a list of some of the primary medical conditions of patients used for this
exam.

Cardiovascular system
- Valvular heart disease
- Post cardiac transplantation
- Heart failure
- Atrial fibrillation/flutter
- Ischaemic heart disease
- Pulmonary hypertension
- Marfan’s Syndrome
- Congenital heart disease
- Hypertrophic obstructive cardiomyopathy
- Other cardiomyopathy

Respiratory system
- Chronic obstructive pulmonary disease
- Asthma
- Pulmonary fibrosis
- Fibrosing alveolitis
- Post lung transplantation
- Bronchiectasis
- Obstructive sleep apnoea
- Cystic Fibrosis
Nervous Sytem / Musculoskeletal
- Peripheral neuropathy
- Guillain-Barre
- Spinal cord AV malformation with neuropathic pain
- Ankylosing spondylitis
- Rheumatoid arthritis
- Acromegaly
- Myotonic dystrophy
- Systemic sclerosis
- Myasthenia
- Cranial nerve pathology

Other
- Liver cirrhosis
- Chronic renal failure
- Haemochromatosis
- Diabetes and its complications
MULTIPLE CHOICE QUESTION PAPER

74.5% of the candidates who sat this section passed

Each question is of the one best answer type; no marks are deducted for incorrect answers.

The table below outlines the number of questions in each subject category (noting that an
individual question may have more than one subject). Only subjects represented in four or
more questions are listed. The subject spread in the MCQ paper varies from exam to exam,
as it is partly determined by the content of the short answer and viva sections of the exam, to
ensure that an appropriately wide range of subjects is covered by the whole examination

Topic Number Of Questions Percentage (%)

PA Paediatrics 16 10.67
GS Pharmacology 13 8.67
OB Obstetrics 12 8
PO Cardiovascular 11 7.33
disorders
AM Airway Management 10 6.67
PO Haematol/ oncology, 9 6
anticoa
SQ Equipment 9 6
PO Metabolic & Endocrine 7 4.67
RA Regional anaesthesia 7 4.67
PO Perioperative 6 4
Investigation
CS Cardiac surgery 5 3.33
PO Neurological, 5 3.33
Neuromuscular
RA Regional Anatomy 5 3.33
RT Periop Crises 5 3.33
RT Shock/Haemorrhage 5 3.33
RT Trauma 5 3.33
GS Monitoring 4 2.67
NS Neurosurgery 4 2.67
OP Eyes 4 2.67
PO Aspiration 4 2.67
PO Immunology 4 2.67
PO Respiratory disorders 4 2.67
RA Regional Complications 4 2.67
SQ Safety 4 2.67
SQ Scientific Enquiry 4 2.67
SHORT ANSWER QUESTION PAPER

71.9% of candidates who sat passed this section.

All questions are worth equal marks. The SAQ section tests a combination of knowledge and
reasoning skills, above that tested by the MCQ section. The material covered is mapped to
the curriculum.

It is recognised that preparation and performance for this section is demanding. Candidates
are advised that practicing answering SAQ questions under exam conditions is a valuable
method of preparation for this section.

Responses that answer the specific question asked require less time to write and material
around the question, but not related to the answer, receive no marks.

Writing must be legible and abbreviations should be avoided unless explained in the body of
an answer.

Logical, well-organised, clearly expressed answers that reflect safe practice, defensible
judgment and evidence-based practice attract higher marks.

The examiners acknowledge that there is often a great deal that the candidates can offer in
response to some of the short answer questions. Part of the challenge of this section is to
manage time and rank information that is included.

Question 1

Pass rate 66.3%

Describe the anatomy relevant to performing a thoracic paravertebral block. (50%)

List the advantages and complications of performing this block for a patient undergoing
radical mastectomy. (50%)

Candidates were expected to include the following

A. Provide an adequate description / labelled diagram of boundaries and contents of the

paravertebral space, including relevant surface anatomy.
Some mention of relation of needle placement relative to anatomy (i.e. lateral enough
to avoid epidural, medial enough to avoid pneumothorax)
The question does NOT ask for ultrasound information, however, anatomical
information provided may possibly enhance a candidate's answer.
The question also does NOT ask for details on how to actually perform the block.
Again, however, relevant anatomy details may come to light with a detailed block
explanation.

B. The list should include:

Advantages: unilateral analgesia OR anaesthesia suitable for mastectomy.

Complications expected include spinal, pneumothorax, local anaesthetic toxicity.
Question 2

Pass rate 58.5%

List the risk factors for postoperative nausea and vomiting (PONV) (30%)

Evaluate methods to minimise PONV (70%)

Candidates needed to include the following points

A. List most of the risk factors that have positive overall evidence .If items that are
disproved are listed candidates performance was marked down

B. Understand role of risk stratification to minimise PONV (choosing appropriate

methods) and considers/evaluate more than just antiemetics.

Question 3

Pass rate 82.9%

A patient who is 6 weeks post cardiac surgery has a pericardial effusion requiring treatment.

Outline the symptoms and signs of this condition. (70%)

Which of these features would trigger an urgent intervention? (30%)

Key responses to pass this question included

A. Demonstrates an understanding of the range of severity of presentation (not just the

classic acute signs).

B Recognises the symptoms and signs of acute / severe tamponade

Question 4

Pass rate 38.3%

A 40-year-old 100 kg patient presents with septicaemia of unknown cause. After receiving two
litres of 0.9% NaCl (Normal Saline) as initial resuscitation the patient has the following
observations:

HR 126 bpm

BP 80/40 mmHg

Outline your initial resuscitation goals. (30%)


Evaluate options for ongoing fluid resuscitation at this time. (70%)

Candidates were expected to include the following in their answers

A. Mention at least three resuscitation goals

B. Produce a reasonable discussion / evaluation regarding crystalloids versus colloids.

Question 5

Pass rate 98.4%

You are planning a trial to evaluate the efficacy of a new drug on reducing post-laparotomy
pain.

Describe potential sources of bias and indicate how these can be minimised.

Key components required of candidates were

1. An adequate definition of bias indicating that they understand the difference between
bias (systematic error) and imprecision. This is key to understanding why we do
randomised controlled trials.

2. The need to mention at least 3 types of bias and matching solutions or methods of
minimisation

Question 6

Pass rate 71.5%

You are called to see a 30-year-old woman who has collapsed 2 hours post normal vaginal
delivery.

What is the differential diagnosis? (30%)

Outline the clinical features and investigations that would support a diagnosis of postpartum
haemorrhage. (70%)

Candidates were expected to mention the following

A. The potential Obstetric and non-obstetric causes of collapse

B. History,examination and investigations consistent with PPH.

Question 7

Pass rate 74.6%

An elderly patient is scheduled for total hip replacement and has been taking oxycodone
40mg twice daily in the last six months for severe hip pain.

What issues do you anticipate with regard to her oxycodone use? (50%)

How do these issues influence your postoperative management? (50%)

Candidates were expected to mention the following

A. Recognise the issues of chronic high dose opioid use including tolerance,
dependence, addiction and side effects

B. Mention the need for an increased opioid requirement, monitoring and weaning of
opioid therapy and identify problems associated with opioid tolerance and
withdrawal.
Question 8

Pass rate 56.5%

A thirty-year-old man has sustained a penetrating eye injury requiring surgery.

What are the key anaesthetic issues? (30%)

Outline your plan of perioperative management and justify your choices. (70%)

Candidates were expected to mention the following

A. Recognise this is an acute case and problems associated with that / often
can wait Considers potential for loss of contents of eye and strategies
to manage that and considers mechanism of injury and its implications

B. Should demonstrate that they are making an attempt to minimise the risk of
increasing IOP, particularly at induction and emergence - but also intra-
operatively. Candidates should demonstrate due regard for the potentially
non fasted patient Note that the question asks them to justify their
anaesthetic technique so purely describing a GA is inadequate.

Question 9

Pass rate 83.4%

Forty minutes after a laparoscopic appendicectomy has been completed, a 55 year old patient
has failed to regain consciousness.

List the potential causes. (30%)

Describe your management (70%)

Candidates were expected to at least mention the following

A. Residual neuromuscular blockade, anaesthetic / opioid overdose and other

common causes of gross CNS depression e.g. hypoglycaemia, stroke,
hypothermia

B. Management should include prioritising safety, systematicly hunting and

managing causes; drugs, metabolic and pathological
Question 10

Pass rate 69.9%

A 68 year-old male with severe Parkinson's Disease presents for elective right
hemicolectomy. Current medications include levodopa/benserazide and selegiline
(monoamine oxidase inhibitor).

What clinical features of Parkinson ’s disease affect anaesthesia? (50%)

Justify your perioperative drug management plan. (50%)

Candidates were expected to mention

A. The significance of airway issues and one other significant clinical feature
and show appropriate understanding that this patient has severe disease
affecting anaesthetic management.

B. Avoidance of antidopaminergic drugs (i.e. needs to mention dopamine) and

describe a reasonable plan to administer routine medication pre-operatively,
justifying their thinking. Should also mention significance of MAOI's
(particularly with opioids)

Question 11

Pass rate 77.%

List the essential equipment currently recommended to manage a difficult airway in an adult
patient. (50%)

Justify supplementary items you would recommend. (50%)

Candidates were expected to mention

A. Range of Guedels/NP airways

Laryngosopes/macintosh blades plus alternative/2 handles incl short
Introducer/stylets/Airway exchange catheter
ETTs-selection of specialized (mlt,RAE,etc)
LMAs-classic and intubating with ancillary equip
Non-standard laryngoscopes-mccoy,glidescope etc
Emerg cricothyroid puncture/cricothyroidotomy kit/kink resistant cannula and
HPV system
Oesophgael detector (bulb or syringe)
CO2 detector

B. Fibreoptics within 5 mins, including videolaryngoscopes

Combitube
Non-standard laryngoscopes-direct (mccoy)/indirect(cmach,glidescope)
Light wand
Retrograde intubation kit
Rigid ventilating bronchoscopes
Question 12

Pass rate 83.4%

In preadmission clinic you are assessing a patient who is concerned about the risk of
developing venous thromboembolism (VTE) perioperatively.

Outline the patient factors that increase the risk of VTE. (50%)
Describe measures that may reduce the risk of perioperative VTE (50%)

Candidates were expected to at least mention

A. Previous history/family, obesity, cancer and oestrogen containing pills

B. Measures would include minimising the preop, intraop and postoperative

risks

Question 13

Pass rate 78.8%

An elderly patient has collapsed with a bleed into a known brain tumour and is unable to
communicate. An advance health directive has been produced stating she would not wish to
receive treatment if the most likely outcome was a significant permanent neurological deficit.

Define advance health directive, including its scope and legal status (50%)
How would this advance health directive influence decision making
around treatment options. (50%)

Candidates were expected to mention

A. Advance health directives were

 Legal binding
 Made by (a competent) patient
 Outlines treatment choices when no longer competent

B. Decision making may be affected by

 risk of permanent neurological injury affects treatment choices e.g.
may not proceed with surgery
 candidates should recognise / clarify what "treatment" entails
Question 14

Pass rate 34.7%

A 40 year old requires a laparotomy ten days after an isolated traumatic spinal cord
transection at C6.

Outline the key anaesthetic issues. (50%)

How would these influence your anaesthetic management? (50%)

Candidates were expected to mention

A. Key issues including unstable c spine, neurogenic shock and acute laparotomy

B. Anaesthetic management would be expected to include a sensible airway

plan, managing the neurogenic shock and dealing with an unfasted, unwell
patient for laparotomy

Question 15

Pass rate 83.4%

Describe the physiological principles underlying preoxygenation prior to the induction of

anaesthesia. (50%)

Discuss the advantages and disadvantages of using a high inspired oxygen concentration
(>80%) during maintenance of anaesthesia. (50%)

Candidates were expected to at least mention

A. FRC, the O2 concentration within FRC, prolonged apnoea time and

denitrogenation

B. Advantages: avoidance of hypoxia

Disadvantages: Mention of atelectasis and toxicity
ANAESTHESIA VIVAS

87.1% of candidates passed this section

VIVA 1

Pass rate 82%

You are the on-call consultant anaesthetist on Sunday morning at a district general hospital.

You receive a telephone call from the emergency department registrar, who says:

“We have a man down here with an injury to his face from an angle grinder. We’re worried
about his airway. He’s bleeding profusely and we need you straight away.”

You are currently anaesthetising an ASA physical status 3 patient for laparotomy, with a first
year trainee anaesthetic registrar.

What will you do?

VIVA 2

Pass rate 77%

You are the anaesthetist for the emergency list. The gastroenterology registrar has contacted
you to book a patient for endoscopic retrograde cholangiopancreatography.

The patient is a 38-yr-old pregnant woman at 35 weeks' gestation, who has presented to the
emergency department with acute ascending cholangitis.

Her vital signs are:

Blood pressure 83/49 mmHg

Heart rate 115 /minute
Respiratory rate 24 /minute
SpO2 95% (on room air)
Temperature 39.1°C
Her full blood count shows: (reference range)

Haemoglobin 126 g/l (110–165)

9
White cell count 31 x 10 /l (3.5–11.0)
9
Platelets 224 x 10 /l (140–400)

What other condition may have a similar clinical presentation in this patient and how would
you exclude this?
VIVA 3

Pass rate 80%

You are the senior duty anaesthetist in a major metropolitan hospital.

You receive a call from the emergency department regarding a four-year-old girl, who has
presented with post-tonsillectomy haemorrhage.
Her initial surgery was performed in a private hospital seven days earlier.

Her vital signs are:

Blood pressure 110/70 mmHg
Heart rate 110 /minute
Respiratory rate 30 /minute
SpO2 99% (on room air)
Temperature 37.3°C

Describe your initial assessment and management in the emergency department.

VIVA 4

Pass rate 84%

An 86-year-old woman is admitted for repair of a fractured neck of femur following a fall.

Her surgery has been postponed for several days because of lack of theatre time.

You are seeing the patient for the first time in the holding bay of theatre.

She has a past history of hypertension and congestive cardiac failure.

Her regular medications are metoprolol 25 mg daily and frusemide 40 mg daily.

How will you proceed?

VIVA 5

Pass rate 89%

You are in the pre-anaesthesia assessment clinic.

This 54-year-old truck driver is scheduled for excision of a posterior fossa meningioma in a
few weeks' time.

His height is 175 cm and weight 140 kg (body mass index 46).
His comorbidities include type 2 diabetes, hypertension and chronic back pain.
His current medications are: metformin 1 g tds
quinapril 20 mg bd
oxycodone (sustained release) 20 mg bd
paracetamol 1 g qid

His observations are:

Blood pressure 145/85 mmHg

Heart rate 90 /minute (sinus rhythm)

SpO2 95% (on room air)

What are the important preoperative issues in this man?

VIVA 6

Pass rate 83%

It is 0900 hours on Saturday morning; you are working in a large regional hospital and
respond to a trauma call to the emergency department.

A young man has sustained injuries from an accident when his motorbike hit a tree. He was
initially found confused at the scene by a passing motorist.

On arrival in the emergency department he is uncooperative and smells of alcohol. He has

obvious large lacerations to his head and lower limbs.

His observations are:

Blood pressure 90/50 mmHg
Heart rate 120 /minute
Respiratory rate 22 /minute
SpO2 95%
Temperature 35.3°C

How will you approach this uncooperative patient?

VIVA 7

Pass rate 77%

You arrive in the emergency department to assist with the management of an acutely unwell
76-year-old man, who has re-presented to hospital a week after thoracoscopy and talc
pleurodesis for a non-resolving left-sided malignant pleural effusion.

Two years ago he was diagnosed with lung cancer, which was treated with chemotherapy
and radiotherapy. Twelve months ago he developed atrial fibrillation and also suffered a mild
left cerebrovascular accident, with no residual deficit.

He has more recently been referred to the Palliative Care team who have commenced him on
pregabalin and tramadol because he is intolerant to morphine, fentanyl and oxycodone.

His current medications are: digoxin 0.125 mg daily

warfarin 4 mg daily
pregabalin 150 mg bd
tramadol (sustained release) 150 mg bd

His vital signs are:

Blood pressure 83/41 mmHg

Heart rate 125 /minute

Respiratory rate 26 /minute

SpO2 93% (O2 6 l/minute via Hudson mask)

Temperature 36.1°C

Please comment on his chest X-ray and how it will influence your initial management.

VIVA 8

Pass rate 79%

You are called by the emergency department registrar to help with the management of a 33-
year-old man who has just presented, shouting about extreme pain in his left hand.

He is on the methadone maintenance program and has accidently injected a solution made
with crushed oxycodone tablets into his brachial artery.

His hand is pale with mottled fingertips.

He is restless, agitated, and behaving in a threatening manner to the staff, who have been
unable to perform any interventions.

Describe how you would approach this patient, and your thoughts on initial pain management.
VIVA 9

Pass rate 72.1%

It is 1100 hours on Saturday morning and you are working in a large metropolitan hospital.
You have just finished a case when you are phoned by the registrar in the high dependency
unit.

An 84-year-old man who underwent neck dissection for melanoma two days ago is now in
respiratory distress. A large right-sided neck swelling has developed over the last two hours.

His SpO2 is 97% on 15 l/minute of oxygen; his blood pressure is

140/80 mmHg and his heart rate is 95 /minute.

He has a background history of atrial fibrillation and transient ischaemic attacks, for which he
takes dabigatran, 110 mg twice daily, as his only medication.

Dabigatran was ceased two days preoperatively and recommenced orally three hours ago.
He was bridged with enoxaparin; the last dose of enoxaparin 1.5 mg/kg was 12 hours ago.

You have two minutes to consider the case as you proceed to the high dependency unit.

What further key information do you want to obtain once you get to the bedside?

VIVA 10

Pass rate 81.4%

A pregnant woman at 36 weeks' gestation presents in respiratory distress to the emergency

department of your hospital.

The obstetrician asks you to review the patient as her condition is rapidly deteriorating and he
wants to deliver the baby.

How will you assess this patient?

VIVA 11

Pass rate 70.9%

It is 1100 hours on Monday morning, and you are the anaesthetist for the emergency list at a
large regional hospital.

The paediatric surgical registrar has booked a 12-year-old boy for drainage of a large pleural
effusion. He thinks the effusion is secondary to pneumonia and tells you that the child looks
unwell.

The interventional radiologist will insert the chest drain, under ultrasound guidance, in the
radiology suite.

You send your anaesthetic registrar to the emergency department to assess the child.

You are able to view the child’s chest X-ray on the radiology information system.

Having seen this chest X-ray, what information will you require from the anaesthetic registrar?

VIVA 12

Pass rate 79.1%

A 56-year-old woman with a body mass index of 45 and known metastatic ovarian cancer has
presented to the emergency department of a peripheral hospital with severe pain in her right
thigh following a seemingly trivial injury.

You have been asked to assist with her pain management.

The X-ray of her lower limb is shown.

Her usual medications are: morphine (sustained release) 60 mg tds
tramadol 100 mg qid
morphine syrup 30 mg q4h prn
(for breakthrough pain)

How will you manage this patient?

VIVA 13

Pass rate 89.5%

After taking your patient to the post-anaesthesia care unit (PACU), you are asked by nursing
staff to review another patient.

He is a 28-year-old man who has had a left craniotomy for excision of a tumour. The nurse
has been unable to contact the anaesthetist who was involved with the case.

The patient has been in the PACU for one hour. In the last ten minutes he has become
increasingly restless, agitated, and hypertensive.

His blood pressure, measured from a radial arterial line, is 200/100 mmHg.

Outline your initial assessment and treatment in the PACU.

VIVA 14

Pass rate 82.6%

You are the anaesthetist on trauma call at a tertiary hospital.

The retrieval service has just brought a 26-year-old man to the emergency department
following an industrial blast injury.

He has sustained burns to his anterior chest, abdomen, and legs.

He is already intubated.

His vital signs are:

Blood pressure 80/45 mmHg

Heart rate 110 /minute
SpO2 80% (FiO2 1.0)
Temperature 36.5°C

Describe your initial management of this patient.

VIVA 15

Pass rate 73.3%

You are the on-call consultant anaesthetist in a tertiary referral hospital and are called to the
emergency department.

A previously fit and well 70 kg 16-year-old girl has presented with acute shortness of breath.
She has been generally unwell for three months, with a cough, increasing breathlessness,
and occasional fevers.

She takes no regular medication.

Her observations are:

Blood pressure 100/70 mmHg

Heart rate 140 /minute
SpO2 92% (room air)
Respiratory rate 40 /minute

On entering the emergency department you see her chest X-ray on the viewing screen.

What does the chest X-ray show, and how will you assess this patient?
VIVA 16

Pass rate 75.6%

You are in the pre-anaesthesia assessment clinic.

A 72-year-old man is scheduled for excision of a dorsal right forearm squamous cell
carcinoma with a large rotation flap closure.
It is expected to take two to three hours, and is planned for next week.

His past history includes severe chronic obstructive pulmonary disease, asthma, and chronic
renal impairment.

The patient does not speak English and an interpreter is present.

Please comment on his chest X-ray, shown here.

Thanks

Dr Chris Cokis