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SBAs for the Final FRCA
SBAs for the Final FRCA
Caroline Whymark
Consultant in Anaesthesia and Pain Medicine,
University Hospital Crosshouse,
NHS Ayrshire and Arran, UK
Ross Junkin
Consultant in Anaesthesia,
University Hospital Crosshouse,
Judith Ramsey
Consultant in Anaesthesia and Intensive Care Medicine,
University Hospital Ayr,
1
3
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 209
The moral rights of the author have been asserted
First Edition published in 209
Impression: 
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
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above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
98 Madison Avenue, New York, NY 006, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 208966985
ISBN 978–0–9–880329–4
Printed and bound by
CPI Group (UK) Ltd, Croydon, CR0 4YY
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-pregnant
adult who is not breast-feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
PREFACE
Good preparation is vital for success in the Final FRCA examination. Many candidates report that
the SBA questions are the most difficult part of the exam in which to score well. Not only do they
test advanced clinical decision making, but these questions are relatively new to postgraduate
exams in Anaesthesia and therefore there are very few accurate examples available to inform exam
preparation.
This book is designed to address that need and is written primarily as a formative tool to direct
study. Candidates can be assured that the questions in this book reflect the breadth of the syllabus
including subspecialties of which they may have limited experience. We include a mock exam
chapter for completeness.
All questions in this book are original, and many are based on real scenarios we have encountered
in our day-to-day practice, thus ensuring their clinical relevance. Each is fully explained and
referenced. The book is closely linked to Intermediate Training under the 200 Curriculum. Each
chapter is dedicated to a specific unit of anaesthetic training. The book can therefore be used
to consolidate studying on specific topics and identify knowledge gaps. The explanations and
references direct the candidate to further learning resources.
We have a shared interest in medical education and are committed to delivering training of the
highest standard. Together we developed and deliver a successful Final FRCA preparation course
in the West of Scotland. Delegates consistently exceeded the national pass rates for this part of
the exam.
We have used this experience and feedback from delegates to guide the creation of this book.
Caroline Whymark
Judith Ramsey
Ross Junkin
CONTENTS
List of abbreviations ix
 Introduction 
2 Perioperative medicine
Questions 5
Answers 2
3 Trauma and orthopaedics

Questions 9
Answers 27
4 Resuscitation and transfer

Questions 35
Answers 43
5 ENT, maxillofacial, and ophthalmology

Questions 49
Answers 56
6 Vascular and general

Questions 63
Answers 70
viii Contents
7 Day surgery, preoperative assessment, gynaecology,

urology, and plastics
Questions 77
Answers 84
8 Cardiothoracics
Questions 93
Answers 98
9 Neurosurgery
Questions 05
Answers 
0 Paediatrics
Questions 7
Answers 23
 Obstetrics
Questions 29
Answers 35
2 Intensive care
Questions 43
Answers 49
3 Chronic pain
Questions 55
Answers 60
4 Mock exam
Questions 67
Answers 75
Index 85
ABBREVIATIONS
ADP adenosine diphosphate

ALS advanced life support
ASA aspirin
AV atrioventricular
BMI body mass index
BMS bare metal stent
CABG coronary artery bypass graft
CBG capillary blood glucose
CEA carotid endarterectomy
COPD chronic obstructive pulmonary disease
CPET cardiopulmonary exercise testing
CPR cardiopulmonary resuscitation
CT computed tomography
CVS central venous catheter
DES drug-eluting stent
DKA diabetic ketoacidosis
DLCO diffusing capacity of the lungs for carbon monoxide
ECG electrocardiogram
EEG electroencephalogram
ET endotracheal
FBC full blood count
FEV forced expiratory volume in  second
FVC forced vital capacity
GCS Glasgow Coma Scale
GTN glyceryl trinitrate
Hb haemoglobin
IABP intra-aortic balloon pump
ICU intensive care unit
IPPV intermittent positive pressure ventilation
IV intravenously
LMA laryngeal mask airway
x Abbreviations
MAC minimum alveolar concentration

MAP mean arterial pressure
MCH mean corpuscular haemoglobin
MCV mean corpuscular volume
MI myocardial infarction
OIH opioid-induced hyperalgesia
ORIF open reduction and internal fixation
OSA obstructive sleep apnoea
PBF pulmonary blood flow
PCA patient-controlled analgesia
PEA pulseless electrical activity
PEEP positive end-expiratory pressure
PEF peak expiratory flow
PONV postoperative nausea and vomiting
PTCA percutaneous transluminal coronary angioplasty
PTE pulmonary thromboembolism
PVR pulmonary vascular resistance
RSI rapid sequence induction
SAH subarachnoid haemorrhage
SIADH syndrome of inappropriate antidiuretic hormone secretion
ST stent thrombosis
SVR systemic vascular resistance
TAP transabdominal plane
TIVA total intravenous anaesthesia
TURP transurethral resection of prostate
U&E urea and electrolytes
CHAPTER INTRODUCTION

To pass the written part of the FRCA, candidates must achieve the pass mark for the SAQs and
the MCQ/SBA papers combined. Therefore, doing particularly well in one paper, or one area, can
compensate for another in which you have scored poorly.
The 30 SBA questions is an area that candidates commonly find difficult. There is a feeling these
questions are unjust and that it is impossible to second guess the examiners and choose the correct
option. They feel further punished that four marks are awarded for each correct answer or lost
for an incorrect choice. While this reflects the fact that four answers have been eliminated in the
course of choosing the best answer, candidates often state it is an unfair ‘all or nothing’ way to
mark these questions. They can commonly narrow the choice down to a final two options but
report finding it difficult to then choose between them. They receive no credit having successfully
eliminated three of the options and cite the SBA element as being the reason they failed the
examination.
These comments however are not supported by examination success data published by the RCoA.
The pass rate for this paper was consistent at around 70% before and after the introduction of the
SBA component in September 20.
We believe the concepts behind the SBAs are misunderstood by many. When asked to write a
SBA question, candidates inevitably produce a five-part A to E multiple choice question but with
only one correct answer. The finer points of SBA questions are lost among quickly written revision
aids containing what the authors believe to be examination standard questions, when often they
are not. Further, because SBAs are a relatively new element to the FRCA there is a limited bank of
questions, and a highly restricted number in the public domain. Both these factors make practice of
these questions difficult.
Part of exam success is practice of the technique and question type in advance. We believe the
practice of SBAs is an area to which candidates do not give enough attention.
In our experience, candidates practice SBA questions as a mock exam, attempting 30 questions
covering an array of topics in the curriculum. This is evidenced by the many books that are written
in this way. Candidates cannot wait to ditch the books and studying proper to try the mock exam
and find out their score. As they mark their own paper, they try to learn from their mistakes and
end up with a list of random facts that have popped up from the explanations.
Since 204, the subject matter of the final FRCA SBA questions have changed from consisting of
5 questions from general training and 5 from specialty units of training to now closely follow
and reflect the key units of training of the intermediate curriculum. All questions can be mapped
to specific competences and all areas of the curriculum can be sampled. The result is less of an
emphasis on general anaesthesia and more pointed inclusion of the other key units of training.
Learning is much more effective when achieved within context. It makes sense to practice questions
which reflect the studying you have most recently done and with this book you can do this. The
2 Introduction
questions in each chapter pertain to one or two key units of training enabling candidates to study
one area of the curriculum and then test their knowledge by attempting themed SBAs on that same
unit of training. This makes practice questions much more of a formative tool as the explanations
can highlight areas where specific knowledge is required and any additional points learned can be
incorporated into that which was recently studied. This is much more effective way to test the
quality of studying and retention of knowledge. Visiting a topic again in a different format such
as this, reinforces learning and is much more useful than the traditional mixture of practice exam
questions and summative scores.
Another reason for poor performance in the SBA section is the questions. That is not as silly as it
sounds. Many candidates fall into the trap of immediately ‘recognizing’ the question. They assume
it is identical to one they have seen before and do not bother to finish reading it accurately. Instead
they go straight to the answers and choose the option they remember being correct the time
before. Often it is not.
As well as questions published by the RCoA, there are many other ‘remembered’
questions: transcripts from peers who have already taken the exam. This practice is fraught with
error and inaccuracies. The substitution of only a few words in the question can change the thrust
of the question entirely. Questions can and do change in subtle ways and peers sitting the exam are
not primarily focused on remembering the small print for someone else. It boils down to the simple
fact of reading the question accurately and answering the question that is being asked, not the
question you think is being asked or the one that was asked in a previous exam.
When new questions are constructed for the SBA paper, a great deal of attention and discussion
takes place around the specific wording, to improve the clarity of the question and avoid ambiguity.
No words are chosen by accident; each has been closely considered and discussed so the candidate
must pay close attention to the words used, their meaning, and the reason for their use. There
will be a specific reason that the patient is 69 years old (not 70) and had a myocardial infarction
two months ago (not three) and needs an emergency operation (not an elective one). Usually a
question is testing one piece of knowledge. Think about what that is from the detail provided in the
question.
We have followed this practice when compiling this book of questions. No questions in this book
are remembered from any exam, taken from websites, or indeed existed in the past. We have
written de novo questions following the required structure and format. We have peer reviewed
each question and have referenced our correct answers to justify them and have often added
additional references which discuss the reasons other answers are less correct. In the nature of
SBA’s, a judgement must be made in providing a correct answer. Clearly there will be instances
of differing opinion amongst readers given the often encountered clinical contention and we, the
authors, are fully accepting of this fact. Hence we have simply provided what we believe is a “best
answer” given the clinical scenario described. Any debate which this provokes will only add to the
candidates ability to assess, scrutinise, balance and ultimately judge the information provided.
SBA technique
Questions for the examination itself are written to exacting standards and follow a set format.
Rather than testing simple factual knowledge, SBAs test deduction, critical appraisal, and balancing
of risks in an often complex clinical setting. Their aim is to assess application of knowledge within
a specific clinical context, rather than to recall isolated facts. They focus on important concepts or
significant clinical events. The SBAs are written very precisely to a template containing many rules.
The stem, or introduction, consists of a vignette of clinical or laboratory information which can be
Introduction 3
up to 60 words in length. This will be followed by a short lead in to which the best answer must
be chosen. The lead in should be a simple, direct question answerable by applying knowledge and
information presented in the stem.
The five options are succinct and should each relate to a defined concept only. There should be no
double options; ‘Do X because of Y’, instead it should be ‘Do X’.
In SBA questions all five answers will be plausible. Several may also be possible. More than one
or two answers may be correct or acceptable. But one option will be better than the others, and
this is the answer. It is often the case that three options can be clearly eliminated and it is difficult
to decide between the remaining two. There may be debate around the ‘best’ answers: some
having a degree of subjectivity, and others reflecting true variations between the varied practice of
different clinicians. At times, not all the examiners will agree on what the best answer ought to be.
This makes it difficult for trainers and candidates to predict what specifically makes the best answer
better than the others. The Royal College of Anaesthetists look for the answer they would expect
to receive from a competent trainee anaesthetist transitioning into higher training. That is, one at
the beginning of ST5 who is practising safely and who errs on the side of caution. Notably, the best
answer is not that given by a Consultant with a niche role in the particular clinical area. It is also not
the answer given by a very experienced Consultant who may know ‘What works for me’ and will
draw on lengthy experience to aid clinical decision making.
When two correct options remain, candidates should choose the simplest one, the least invasive
one, the one with the lowest risk to the patient. The safest one.
The first rule of answering these questions is to find your correct answer within the list of five
options. To do so it is important not to colour your judgement by what you see listed there,
because all the options may sound reasonable. Our advice is to firstly cover over all five options to
the question. Next read the stem, and the lead in. Then STOP. Do not look at the options yet. Stop
and think about the question, note the specific wording, decide what it is asking, and think about
what you would actually do in your clinical practice when faced with this scenario. SBA questions
are often written subsequent to real-life clinical dilemmas. If you do not know what you would
do, think who you would ask to help you and what kind of help you require. Do you need help
to decide between two options? Do you need help with a specific skill only? Or do you need help
with the decision making? In case of the last one, try to imagine what your senior colleague would
advise you to do if you telephoned them with this scenario. What if they were a Final examiner?
What would they suggest you do? Once you have formulated what you believe to be the answer,
only then uncover the options. If the answer you have arrived at is there, excellent! This is the one
to select. Do not be tempted to change your mind to any of the distractors (incorrect answers).
Congratulate yourself on having the self-discipline to cover the answers while you stop and think,
because this is difficult to do.
If your answer is not listed then you have to use a different strategy. Try to eliminate as many
wrong answers as you can. If you can eliminate four then that is fantastic. If, however, you can only
eliminate three, you must apply the best guess strategy to the remaining two answers. When left
with two options there is a 50% chance that any one person would guess correctly. Assuming you
have some degree of knowledge relative to the question, your chances will be much closer to 00%
than to 50%. You will not always choose correctly, nor will you agree that the correct answer is in
fact the best one. That is the nature of these questions and there will always be some conflict of
opinion. If you have prepared well and practised your technique, such guesses will be few and far
between.
Remember to use this approach by thinking of the patient safety initiative, introduced to prevent
inadvertent wrong-sided placement of peripheral nerve blocks: ‘Stop Before You Block’. This asks
4 Introduction
you to stop and re-check the side, needle poised, immediately prior to its insertion into the skin.
Apply the same technique in this paper. Immediately before reading the question, stop and cover
the answers. You must Stop Before You (Mentally) Block.
Summary
We hope this book will be a helpful adjunct to studying for the FRCA, that it will help ensure the
candidate covers the whole intermediate curriculum during their preparation, and provide a marker
of the effectiveness of that studying. Importantly it will provide many opportunities for candidates
to practice critical, accurate, and active question reading. We have provided suggested best answers
which will no doubt provoke healthy debate amongst candidates around areas of established clinical
contention and which will stand them in good stead when they take the real exam.
CHAPTER PERIOPERATIVE MEDICINE
2 QUESTIONS
. Which of the options is most characteristic of a perioperative

myocardial infarction?
A. Occurs intraoperatively
B. Is associated with ST elevation
C. The patient complains of shortness of breath and chest pain
D. Has a mortality of up to 25%
E. Occurs secondary to mismatched oxygen supply and demand
2. Regarding the minimum standards of monitoring during anaesthesia

and recovery, which of the following statements best reflects the most
recent guidance?
A. The minimum standard of monitoring recommended varies with the seniority of the
anaesthetist
B. A processed electroencephalography (EEG) monitor is recommended when total
intravenous anaesthesia (TIVA) with neuromuscular blockade is employed
C. Temperature must be monitored during all cases
D. The minimum standard of monitoring recommended varies depending on the clinical area
E. If the minimum standards of monitoring cannot be met then anaesthesia should be
postponed or cancelled
3. A 78-year-old woman is listed for emergency laparotomy. She has

presented with acute upper abdominal pain and a pneumoperitoneum
is evident on chest X-ray. Her medical history includes early Alzheimer’s
disease and osteoarthritis. Drug history includes galantamine and
diclofenac. The best plan regarding muscle relaxant use is:
A. Atracurium and wait for spontaneous inactivation
B. Atracurium and neostigmine
C. Rocuronium and sugammadex
D. Rocuronium and neostigmine
E. Suxamethonium
6 Perioperative medicine | QUESTIONS
4. A 65-year-old man presents to preoperative assessment before elective

inguinal hernia repair. He has no medical history and good exercise
capacity. You are asked to review his electrocardiogram (ECG), which
shows progressive prolongation of the PR interval culminating in a non-
conducted P-wave on a repeating four-beat cycle. The most correct
action now is:
A. 24-hour ECG
B. Echocardiography
C. Check electrolytes
D. Cardiopulmonary exercise testing
E. No further investigation required
5. You are asked to review a postoperative patient in recovery. He is

complaining of severe central crushing chest pain radiating down his left
arm. He appears grey and clammy and is very distressed. Bedside ECG
reveals 4-mm horizontal ST segment depression in leads V–V3, upright
T-waves, and a dominant R wave in V2. The coronary artery most likely
to be implicated is:
A. Posterior descending artery
B. Right marginal artery
C. Circumflex artery
D. Left anterior descending
E. Left marginal artery
6. You have used a bronchoscope during a difficult intubation. The best

means of reprocessing the bronchoscope for use in another patient is:
A. Pasteurization
B. Chemical disinfection
C. Decontamination
D. Steam sterilization
E. Chemical sterilization
7. You assess a 60-year-old man for umbilical hernia repair as a day

case. His wife volunteers that he snores a lot during sleep. The most
discriminating sole predictor of obstructive sleep apnoea (OSA) is:
A. BMI >35
B. Age >50
C. Neck circumference ≥43 cm (7 inches)
D. Hypertension
E. Smoking
Perioperative medicine | QUESTIONS 7
8. A 75-year-old man presents for elective total knee replacement. He

has well-controlled atrial fibrillation and is stable on rivaroxaban.
His U&E are normal. He experienced significant postoperative
nausea and vomiting after his last general anaesthetic and requests
regional anaesthesia. What is the best course of action regarding his
anticoagulation?
A. Continue rivaroxaban and proceed with general anaesthesia
B. Stop rivaroxaban seven days before surgery
C. Stop rivaroxaban the day before allowing 24 hours before spinal is performed
D. Allow 36 hours between last rivaroxaban dose and performance of spinal anaesthesia
E. Continue rivaroxaban and proceed with spinal anaesthesia
9. A 36-year-old man requires laparoscopic colectomy for ulcerative

colitis. He is to be managed in accordance with local enhanced recovery
practices. The best way to provide postoperative analgesia to enhance
recovery for this patient is:
A. Patient-controlled analgesia (PCA) morphine
B. Thoracic epidural (local anaesthetic and fentanyl)
C. Spinal (local anaesthetic and diamorphine)
D. Wound catheter with lidocaine infusion
E. Bilateral transabdominal plane (TAP) blocks
0. A 60-year-old man presents for a right total hip replacement. He has
Parkinson’s disease for which he takes levodopa and ropinirole. Which of
the following would be the best management plan perioperatively?
A. Stop his ropinirole but continue levodopa
B. Continue both his medications until induction and recommence as soon as possible
C. Withhold both his medications before surgery
D. Convert oral regimen to a subcutaneous apomorphine infusion prior to surgery
E. Convert oral regimen to transdermal rotigoline prior to surgery
. A 64-year-old man presents for renal stone fragmentation surgery

under general anaesthesia. He has a pacemaker in situ for sick sinus
syndrome. Which statement is the most accurate regarding pacemaker
management perioperatively?
A. Lithotripsy is contraindicated
B. Peripheral nerve stimulation should be avoided
C. A magnet should be placed over the pacemaker during surgery
D. Monopolar diathermy should be used in preference to bipolar diathermy
E. Rate modulator function should be deactivated prior to surgery
2. A 55-year-old man is day 2 post operation following repair of a large

epigastric hernia. He is a smoker, has type 2 diabetes and chronic renal
failure stage 3. He is using a morphine PCA and has good pain relief but
complains of severe nausea. You decide to stop his morphine PCA and
replace it with oral oxycodone. When compared with oral morphine,
the benefit of oral oxycodone in this patient is:
A. It has more affinity for central mu receptors than peripheral
B. It is safer in renal failure
C. It does not require metabolism by cytochrome p450 CYP2D6
D. It has a second mechanism of action by increasing noradrenaline (norepinephrine) and
serotonin
E. It is more potent than morphine
3. A 60-year-old woman presents with a carcinoid tumour in her terminal

ileum. She has been experiencing weight loss, flushing, sweating, and
hypertension in the last six months. She is to have the tumour surgically
removed. What would be the best medication to treat her symptoms
preoperatively?
A. Phenoxybenzamine
B. Doxazosin
C. Methysergide
D. Octreotide
E. Aprotinin
4. You assess a 7-year-old lady requiring a primary total hip replacement.
She has a past medical history of hypertension. On examination you
hear a loud ejection systolic murmur and arrange further investigation.
What echocardiogram finding is most suggestive of severe aortic
stenosis?
A. Mean gradient across aortic valve of 35 mmHg
B. Peak gradient across aortic valve of 60 mmHg
C. Aortic jet velocity of 3 m/s
D. Valve area of 0.9 cm2
E. Presence of bicuspid aortic valve
5. A 65-year-old lady presents for a total knee replacement. She has
polymyalgia rheumatica and has been on 5 mg of prednisolone for
the last nine months. What is the most appropriate perioperative
management of her steroid use?
A. Continue usual oral dose of 5 mg daily
B. Withhold oral dose and give 25 mg hydrocortisone intravenously (IV) at induction
C. Give usual oral dose and 25 mg IV hydrocortisone at induction
D. Give usual oral dose with 25 mg IV hydrocortisone at induction and continue 25 mg IV
once daily for 48 hours postoperatively
E. Give usual oral dose with 25 mg IV hydrocortisone at induction with 25 mg IV three to
four times daily for 48 hours postoperatively
6. An 89-year-old man is scheduled for laparoscopic sigmoid colectomy in

two days’ time. He has no cardiovascular or respiratory comorbidities.
He does not smoke and denies drinking any alcohol. He weighs 54 kg,
lives alone, and walks with the assistance of a stick. The best way to
minimize the risk of postoperative delirium is:
A. Ensuring that his hearing and visual aids are worn at all times
B. Sedation on the intensive treatment unit (ITU) postoperatively
C. Haloperidol 0.5– mg intramuscularly (IM) as required
D. Starting diazepam 2 mg orally as required preoperatively
E. Encourage naps during the day as required
7. A 48-year-old man with a body mass index (BMI) of 5 is having bariatric
surgery. You elected to perform an awake fibreoptic intubation. At
the end of the procedure he is fully reversed using sugammadex with
good tidal volumes and you have pre-oxygenated with 00% oxygen.
He is cardiovascularly stable. What is the most appropriate plan for
extubation?
A. Deep extubation
B. Elective tracheostomy
C. Delay extubation and take to ICU for prolonged recovery
D. Awake extubation once obeying commands
E. Place an airway exchange catheter before extubating
8. A 64-year-old man with chronic liver disease requires a right

hemicolectomy for adenocarcinoma. Which is the best test to assess the
synthetic function of his liver?
A. Serum albumin
B. Serum bilirubin
C. Prothrombin time
D. Aspartate aminotransferase (AST)
E. Alanine aminotransferase (ALT)
9. Which option best describes the information available on the label of
packaged sterilized devices?
A. Date of sterilization, sterilizer used, and identification of person who carried out
sterilization
B. Date instruments used, cycle or load number (from sterilizer), expiration date of
sterilization
C. Location of sterilizing service, sterilizer used, identification of person who carried out
sterilization
D. Type of device, date of sterilization, log of number of times sterilized
E. Sterilizer used, cycle or load number (from sterilizer), date of sterilization
20. The Cochrane Collaboration provides guidance on the evidence base for
medical practices. Which of the following best describes their approach
to assessment of published research?
A. A six-point scale is used
B. Level  evidence is the least acceptable level of evidence
C. Case reports count as Level 5 evidence
D. The strongest evidence requires a published review of many well-designed randomized
controlled trials
E. Opinions of respected authorities are Level 4 evidence
2. Which of the following is the most likely to result in persistent

contamination of a medical device following attempted sterilization?
A. The use of steam as the method of sterilization
B. The use of low-temperature sterilization
C. Device being made of plastic
D. Poor decontamination of device
E. Poor disinfection of device
22. You review a 68-year-old man with weight loss and dyspnoea. You note
he has a sodium level of 9 mmol/L. His medications are aspirin and
amlodipine. He has no peripheral oedema. The results of his tests are
as follows: potassium 4.3 mml/L, Urea 6.7 mmol/L, creatinine 74 µmol/
L, serum osmolality 26 mOsmol/kg, urinary sodium 43 mmol/L, urine
osmolality 230 mOsmol/kg. The most likely diagnosis is:
A. Severe dehydration
B. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
C. Renal failure
D. Water overload
E. Heart failure
23. You anaesthetize a 56-year-old woman for rigid oesophagoscopy. She has
no significant medical history. You extubate her awake and then notice
that her upper front incisor has been completely avulsed. She has good
dentition, no gum disease, and otherwise good oral hygiene. The best
initial response is:
A. Push the tooth back into the socket and hold for several minutes
B. Discard the tooth
C. Discuss with dentist
D. Place the avulsed tooth in milk
E. Place the avulsed tooth in sterile saline
24. A 68-year-old man is scheduled for laparoscopic upper gastrointestinal

surgery for carcinoma in two weeks time. His haemoglobin is 0
g/L and his ferritin is 25 µg/L. The best means of preoperative
optimization is:
A. Give oral iron therapy
B. Give intravenous iron
C. Give two units of allogenic blood the night before surgery
D. Give erythropoietin (EPO)
E. Arrange pre-donation of autologous blood
25. A 20-year-old male on an opioid substitution programme requires acute

appendicectomy. He currently takes 30 mg of methadone each day. The
best way to manage his acute pain in the perioperative period would be:
A. Continue usual 30 mg of methadone and give only non-opioid analgesics adjuncts
B. Continue usual 30 mg of methadone and give additional short-acting parenteral opioids
and non-opioid adjuncts
C. Continue usual 30 mg of methadone and give PCA morphine postoperatively
D. Stop methadone on day of surgery and give PCA morphine with background infusion
postoperatively
E. Stop methadone and convert to equivalent dose of MST, give sevredol in addition for
acute pain
Chapter PERIOPERATIVE MEDICINE
2 ANSWERS
. D
Perioperative myocardial infarction (MI) can be difficult to diagnose as it usually presents without
the typical symptoms associated with myocardial ischaemia. Further, the abnormal physiological
signs are common and can occur non-specifically in the perioperative setting.
Two types of MI can occur. Type  is due to rupture or fissuring of plaques in response to
tachycardia and hypertension and is compounded by the surgery-conferred pro-coagulant pro-
thrombotic state. Type 2 is associated with oxygen demand outstripping supply and pathological
changes associated with both types are commonly found at post-mortem. Less than 2% of
perioperative MIs are associated with ST elevation. The vast majority are preceded by a period of
ST depression. Early mortality is high (as high as 25%) partly as there is no certainty over the best
treatment in the perioperative phase. Beta-blockers are known to further increase mortality and
the risks of antiplatelet and antithrombotic therapies are greater at this time. Proceeding to PCI is a
complex decision in this period due to the requirement of dual antiplatelet therapy afterwards.
Reed-Poysden C, Gupta KJ. Acute coronary syndromes. BJA Education 205; 5 (6): 286–293.
2. B
The guidelines published by the AAGBI in December 205 state that the minimum standards of
monitoring apply whenever and wherever general anaesthesia, regional anaesthesia, or sedation
is given. If any required element is not available, it is up to the anaesthetist in charge to decide
whether to proceed without it. If so, they must document why it was not available for use.
Temperature should be monitored in cases lasting more than 30 min. It is recommended that the
processed EEG should be used alongside TIVA and neuromuscular blockade. Data derived from
it provide an additional source of information about the patient’s condition but their efficacy in
predicting awareness or predicting an adequate level of anaesthesia remains inconsistent and much
debated.
Checketts MR, Alladi R, Ferguson K, et al. Recommendations for Standards of Monitoring During
Anaesthesia and Recovery. London: Association of Anaesthetists of Great Britain and Ireland, 205.
Available at: http://onlinelibrary.wiley.com/doi/0./anae.336/full
3. C
Alzheimer’s disease is associated with a loss of cholinergic neurons resulting in profound memory
disturbances and irreversible impairment of cognitive function. Specific dementia treatment largely
comprises the use of acetylcholinesterase inhibitors. Galantamine is one such drug. The anaesthetist
should therefore be aware of the potential for interactions and consider avoiding neuromuscular
blocking agents altogether. However, if muscle relaxation is required it should be noted that
suxamethonium paralysis may be prolonged. Larger doses of non-depolarizing neuromuscular
blocking agents may be required to achieve sufficient paralysis. Neostigmine may be relatively
Perioperative medicine | ANSWERS 13
ineffective (due to already present cholinesterase inhibition). Larger doses of rocuronium can be
given safely in the knowledge that reversal can be achieved predictably with sugammadex.
Alcorn S, Foo I. Perioperative management of patients with dementia. BJA Education 207; 7 (3): 94–98.
4. E
The ECG finding is second-degree atrioventricular (AV) block, Mobitz type  (Wenckebach
phenomenon). A serial lengthening of the PR interval occurs with consecutive beats culminating
in a P-wave without a subsequent QRS before the cycle repeats itself. Mobitz type I is usually a
benign rhythm, causing minimal haemodynamic disturbance and with low risk of progression to
third degree (or complete) heart block. Asymptomatic patients with Mobitz type  rarely require
treatment. Symptomatic patients usually respond to atropine. Permanent pacing is rarely required.
The patient reports no specific cardiac symptoms and is having peripheral surgery. They can
progress to surgery without delay for further investigation which is likely to be of low yield.
Mobitz type 2 is another form of second degree AV block which is at risk of deterioration to
complete heart block. It describes intermittent non-conducted P-waves without progressive
prolongation of the PR interval.
Hutchins D. Peri-operative cardiac arrhythmias: ventricular dysrhythmias. Anaesthesia Tutorial of the
Week 203; 285. Available at: https://www.aagbi.org/sites/default/files/285%20Perioperative%20
Cardiac%20Dysrhythmias%20-%20Part%202%20v2[]‌.pdf
5. A
The clinical presentation and ECG findings are consistent with a posterior myocardial infarction. The
posterior wall is usually supplied by the posterior descending artery, a branch of the right coronary
artery in 80% of individuals. The ECG findings provide a mirror/opposite of an anterior wall MI
pattern. Thus, the lack of ST elevation in this condition means the diagnosis is often missed as ST
elevation becomes ST depression, Q waves become R waves, and T waves remain upright. The
posterior MI ECG is often held up to a light by the observer with the sheet turned back to front
and upside down to reveal a classic ST elevation pattern through the paper, almost as if the ECG
electrodes had been placed on the posterior chest.
Ramanathan T, Skinner H. Coronary blood flow: continuing education in anaesthesia. Critical Care &
Pain 2005; 5 (2): 6–64.
6. B
Decontamination is removal of contaminants prior to disinfection or sterilization. Pasteurization
uses hot water at 77 degrees for 30 min to achieve intermediate level disinfection. Sterilization
processes render an object completely free of all microbial life but is a harsh enough process to
damage various reusable medical equipment such as bronchoscopes. Chemical disinfection with 2%
glutaraldehyde is commonly used to disinfect scopes after decontamination.
Sabir N, RamachandraV. Decontamination of anaesthetic equipment. Continuing Education in
Anaesthesia, Critical Care & Pain 2004; 4. (4).
7. C
All the answers represent criteria often assessed during obstructive sleep apnoea (OSA) risk scoring
such as in the STOP-BANG criteria. This is a mixture of patient questions and demographics as
follows:
· Snoring?—do you snore loudly, e.g. to be heard through closed doors?
· Tired?—do you often feel tired or sleepy during daytime?
14 Perioperative medicine | ANSWERS
· Observed—has anyone observed you stopping breathing, choking, or gasping during sleep?
· Pressure—do you have high blood pressure?
· BMI >35
· Age >50 years
· Neck circumference >43 cm (male) or >4 cm (female)
· Gender = male?
Copyright © 204 University Health Network, Toronto, Canada. This tool is presented for
educational purposes and not to be used for screening patients.
Each question scores a point and grades risk of OSA as low (0–2), intermediate (3–4), or high (5–
8). Increased scoring during STOP-BANG should prompt consideration of further screening tools
such as the Epworth Sleepiness Scale (ESS) or indeed investigation with sleep studies. While the
most common risk factor for OSA is obesity, the OSA tendency correlates best with increased neck
circumference.
Williams JM, Hanning CD. Obstructive sleep apnoea. British Journal of Anaesthesia CEPD Reviews 2003;
3 (3): 69–74.
8. C
Rivaroxaban inhibits platelet aggregation induced by Factor Xa. It is used alone and in combination
with other drugs to prevent thrombus formation in those at risk of embolic stroke and as treatment
for VTE. There is no reversal agent available. Such newer anticoagulants have led to adjustments in
the interval between discontinuation of the drugs and performance of neuraxial procedures, based
on the degree of risk of thrombosis. Research has focussed on the pharmacokinetics of the drug
and its effect on anticoagulant parameters by laboratory monitoring. It is recommended that waiting
for at least two half-lives to elapse is an adequate balance between the coagulation risks of stopping
treatment and the bleeding risk of developing a spinal haematoma. Half-life is commonly prolonged
in the elderly and for rivaroxaban is 7– hours so double would be 22 hours. Platelet count is
unchanged with this drug and coagulation studies may not be helpful. Risk is further minimized by
avoiding multiple injection attempts, avoiding epidural catheter placement, and waiting for a period
of one half-life minus time to peak plasma concentration before restarting treatment.
Benzon HT, Avram MJ, Green D, Bonow RO. New anti-coagulants and regional anaesthesia. British
Journal of Anaesthesia 203;  (suppl ): i96–i3.
9. C
Enhanced recovery after surgery (ERAS) is a multidisciplinary and multimodal treatment package
delivered in the perioperative period to reduce postoperative morbidity and length of stay in
hospital by expediting return to normal physiology and function. One aspect of this is providing
effective analgesia with minimal detrimental effects. Systemic opioids should be minimised where
possible as this slows return of gut function and necessitates the patient being connected to an
intravenous line. Epidural analgesia, particularly thoracic, is the preferred analgesia regimen for
open abdominal surgery but the risk/benefit ratio for laparoscopic surgery is different and epidural
analgesia is generally not required. Wound catheters work well in open surgery but their role is
limited in laparoscopic surgery. TAP blocks are useful adjuncts but will not attenuate the stress
response intraoperatively and are unlikely to provide sufficient analgesia alone.
Boulind CE, Ewings P, Bulley SH, et al. Feasibility study of analgesia via epidural versus continuous
wound infusion after laparoscopic colorectal surgery. British Journal of Surgery 203; 00: 395–402.
Jones NL, Edmonds L, Ghosh S, et al. A review of enhanced recovery for thoracic anaesthesia surgery.
British Journal of Anaesthesia 203; 68 (2): 79–89.
Levy BF, Scott MJ, Fawcett W, et al. Randomised clinical trial of epidural, spinal or PCA for patients
undergoing laparoscopic colorectal surgery. British Journal of Surgery 20; 98: 068–078.
0. B
Although antiparkinsonian medications can interfere with many anaesthetic drugs their
withdrawal can result in severe relapse of symptoms therefore it is very important that the usual
antiparkinsonian medications continue with minimum disruption. This patient should have all their
usual preoperative doses and should be able to eat and drink very soon after surgery. There would
be no need to add in anything else. They should be able to resume their oral regimen quickly so
careful assessment and management of postoperative nausea and vomiting is recommended.
Avoidance of dopamine antagonist antiemetic drugs (e.g. metoclopramide) is of paramount
importance given the directly opposing action on the dopamine agonist Parkinsonian treatments.
For patients who may not be able to manage anything orally or via the nasogastric route, e.g. if
requiring emergency intra-abdominal surgery, conversion to apomorphine or rotigotine may be
considered.
Chambers DJ, Sebastian J, Ahearn DJ. Parkinson’s disease. BJA Education 207; 7 (4): 45–49.
. E
If a pacemaker has a rate modulator function this should be deactivated prior to surgery. Lithotripsy
is safe provided the lithotripter is >6 inches away from the pacemaker device. Peripheral nerve
stimulators are again considered safe provided they are used a safe distance from the pacemaker
and not in a parallel axis with the pacemaker. A magnet should not now be placed over a pacemaker
during surgery. They have unpredictable effects on the programming in modern pacemakers.
Bipolar is the preferred diathermy used.
Diprose P, Pierce JMT. Anaesthesia for patients with pacemakers and similar devices. Continuing
Education in Anaesthesia, Critical Care & Pain 200;  (6): 66–70.
2. B
Oxycodone is a semi synthetic opioid that is commonly used in the postoperative period due to its
superior side effect profile when compared with morphine. It has a potency twice that of morphine
and hence increased affinity for all receptors. This is relevant when converting from one to the
other and to be aware that the potential for addiction to opioid drugs is greater with those of
higher potency and faster onset. Hence answer E is true but does not confer any benefit as pain is
well controlled, so it is not the best answer. There is no central versus peripheral preference to its
receptor binding but in the central nervous system (CNS) its action is greatest at supraspinal levels;
hence oxycodone is not suited to intrathecal or epidural use.
Oxycodone works only at opioid receptors mu, kappa, and delta. It does not influence
noradrenergic or seretonergic pathways. This is a feature of tramadol and tapentadol.
When taken orally its absorption and distribution kinetics are similar to morphine however the
bioavailability is almost double: 70–80% compared with 30%. It is metabolized by hepatic enzymes,
and phase  metabolism is dependent upon the cytochrome p450 pathway. The main enzyme
responsible for metabolism of oxycodone is cytochrome P450 3A4. This enzyme is inhibited
by many drugs including other opioids but is not subject to the pharmacogenetic variability of
CYP2D6. This enzyme is important in the metabolism and conversion of code in to its active form,
norcodeine.
The metabolites of oxycodone have only a fraction of the activity of the parent compound and do
not accumulate in renal failure as is a significant risk with morphine and its metabolite M6G.
Holmquist GL. Opioid metabolism and effects of cytochrome p450. Pain Medicine 2009
(suppl ) 0: S-2009. Available at: https://nam0.safelinks.protection.outlook.com/
?url=https%3A%2F%2Facademic.oup.com%2Fpainmedicine%2Farticle-abstract%2F0%2Fsuppl_%2F
S20%2F94905&data=02%7C0%7C%7Cbb97b7cd640842e5608d5a69b885c%7C84df9e7fe9f
640afb435aaaaaaaaaaaa%7C%7C0%7C6365980929930468&sdata=LWAuuL4lC6mNCqeLFMUT
SN%2F4S%2BfOvd72RVpuwLVhYw%3D&reserved=0
3. D
Carcinoid syndrome, although rare, can create serious problems to the anaesthetist, both by
the nature and variability of clinical manifestations and by the complications that can occur
perioperatively. Carcinoid tumours are rare, slow-growing neoplasms of neuroendocrine tissues.
The classification of carcinoid tumours is based on the histological characteristics and site of
origin which includes lung, stomach, and small and large intestine. As a group, carcinoid tumours
represent a wide spectrum of neuroendocrine cell types including enterochromaffin or Kulchitsky
cells, which have the potential to metastasize. The cells typically contain numerous membrane-
bound neurosecretory granules composed of hormones and amines. The most familiar of these
is serotonin, which is metabolized from its precursor, 5-hydroxytryptophan by a decarboxylase
enzyme. The mediators released from these tumours when bypassing the hepatic metabolism, can
lead to the possible development of carcinoid syndrome. This is a life-threatening complication
potentially seen as a carcinoid crisis, which can lead to profound haemodynamic instability, flushing,
and bronchospasm especially in a perioperative period. The use of octreotide, a synthetic analogue
of somatostatin, has significantly reduced the perioperative morbidity and mortality. All these agents
in the question answer are potential treatments but octreotide is considered the first-line agent.
Powell B, Al Mukhtar A, Mills GH. Carcinoidː the disease and its implications for anaesthesia.
Continuing Education in Anaesthesia, Critical Care & Pain 20; (): 9–3.
4. D
The presence of a bicuspid valve is not one of the criteria included in grading of aortic stenosis.
All the other measurements indicate moderate aortic stenosis except for a valve area of 0.9 cm
squared. Peak gradient across the valve would be >65 mmHg, and mean gradient would be
>40 mmHg in severe stenosis. Guidance on echocardiography-based quantification of aortic
stenosis can be found in the ACA/AHA guidelines (and Bonow et al.).
Bonow R, Carabello B, Chatterjee K. American College of Cardiology/American Heart Association
(ACC/AHA). 2006 guidelines for the management of patients with valvular heart disease. Circulation
2006; 4: e84–e23.
Bonow RO, Carabello BA, Chatterjee K, et al. Focused update practice incorporated into the ACC/
AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation 2008; 8: e523–66.
Chacko M, Weinberg L. Aortic valve stenosis: perioperative anaesthetic implications of surgical
replacement and minimally invasive interventions. Continuing Education in Anaesthesia, Critical Care &
Pain 202; 2 (6): 295–30.
5. E
Most hospitals and trusts have guidelines for supplementation with hydrocortisone for patients
on long-term corticosteroid therapy based on whether surgery is minor, moderate, or major. If
the patient has been on more than 0 mg of prednisolone a day for more than three months they
require their usual dose plus 00 mg/day for two to three days after major surgery.
Nicholson G, Burrin JM, Hall GM. Peri-operative steroid supplementation. Anaesthesia 998;
53: 09–04.
6. A
Good basic care is the most important way to reduce the incidence of postoperative delirium.
This includes glasses being worn, hearing aids being worn and working, being orientated to
surroundings, visits from friends and family. Ensuring a regular diurnal sleep–wake pattern to allow
a long, uninterrupted nocturnal sleep is preferable and short daytime naps should be avoided. Long
hospital stays and admission to ITU worsen the condition. Haloperidol is seen as a last resort for
rescue rather than prevention. Diazepam may be indicated if regular alcohol excess is suspected but
should not be used routinely.
Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. British Journal of Anaesthesia
2009; 03 (): i4–i46.
7. D
All are possible extubation plans, but D is the most appropriate as the patient is fully reversed,
stable, and pre-oxygenated.
Popat M, Dravid R, Patel A, et al; Difficult Airway Society Extubation Guidelines Group. Difficult
airway society for the management of tracheal extubation. Anaesthesia 202; 67 (3): 38–340.
8. C
Synthetic liver function is best assessed by prothrombin time and it is used as a prognostic indicator
in acute liver failure and after surgery in patients with chronic liver disease. The prothrombin time
produced is a result of the appropriate synthesis of multiple clotting factors by the liver at different
levels of the coagulation cascade. Albumin levels can also be a useful indicator in addition to the
prothrombin time. Bilirubin levels are often elevated and the pattern of AST and ALT enzyme rise
varies with the aetiology.
Vaja R, McNicol L, Sisley I. Anaesthesia for patients with liver disease. Continuing Education in
Anaesthesia, Critical Care & Pain 200; 0 (): 5–9.
9. E
The sterilizer and load number is important in case a problem is detected and other potentially
contaminated items need to be identified. The date the instruments were used is not relevant. Only
some pieces of equipment have an expiry date on their sterilization status.
Ref e-LA Module 07d: core training basic sciences equipment.
20. D
A five-point scale with Levels I–V is used where I is the strongest evidence and V is the weakest
level of evidence considered. This includes reports from expert committees and opinions of
respected authorities. Case reports are not robust enough to enter the assessment process.
Cochrane. Available at: http://www.cochrane.org
2. D
Decontamination is the initial process required to remove the particulate matter from any device.
Failure to do so prevents the sterilizing method making contact with the whole of the instrument
and therefore cannot be sterilized entirely.
Ref e-LA Module 07d: core training basic sciences equipment.
22. B
SIADH fits the biochemical and clinical picture. Criteria for diagnosing SIADH include clinical
euvolaemia, serum osmolality <275 mOmol/L, urine osmolality >00 mOsmol/L, urinary sodium
>30 mmol/L, normal thyroid and adrenal function, and no recent diuretic use. In this case, the
symptoms suggest SIADH secondary to bronchial carcinoma.
Hirst C, Allahabadiah A, Cosgrove J. The adult patient with hyponatraemia. BJA Education 204; 5
(5): 248–252.
23. A
The root surfaces should not be touched before pushing it back into the socket. It should be
expedited so that the dental ligament does not become dehydrated. Only replace an adult tooth
from a healthy mouth, in a patient who is not immunocompromised. Risks and benefits of replacing
a loose tooth in an asleep anaesthetized patient should be considered, as it could potentially behave
as a foreign body in the airway. This patient is awake however. The injury should then be referred
to a dentist for splinting. If the anaesthetist does not feel comfortable replacing the tooth, it can be
stored in saline or milk pending dental review.
Paolinelis G, Renton T, Djemal S, et al. Dental trauma during anaesthesia. Safe Anaesthesia Liaison
Group. 202, National Patient Safety Agency. Available at: https://www.rcoa.ac.uk/system/files/CSQ-
DentalTrauma.pdf.
24. B
Haemoglobin levels below 30 g/L in a man, or 20 g/L in a women (WHO 968), should be
improved preoperatively. A ferritin of <30 µg/L indicates severe iron deficiency. Oral iron is
indicated if the surgery is non-urgent but treatment of gastric carcinoma should not be delayed for
this reason. Intravenous iron is indicated to increase haemoglobin in the short term and reduce the
risk of perioperative allogenic transfusion and the associated poorer outcomes in cancer surgery.
Kotze A, Harris A, Maker C, et al. British Committee for Standards in Haematology Guidelines on
the identification and management of pre-operative anaemia. British Journal of Haematology 205; 7
(3): 322–33.
25. B
Patients on daily doses of methadone can present a challenge when managing their acute pain
in the perioperative period. They have tolerance to opioids and are relatively resistant to them
meaning they may require seemingly large doses to achieve any effect. Their dependence on these
drugs mean they are frightened and anxious about the continued supply of their methadone while
in hospital. Some fear having additional opioid analgesia will rekindle their addictive tendency
and cause them to default from their substitution therapy programme. Further, there can be a
reluctance by medical and nursing staff to provide additional opioid analgesia. Best practice is to
continue the usual dose of methadone throughout the perioperative period (assuming the gut is
working) and to treat acute pain with fast acting, short duration parenteral opioids as required.
Paracetamol and non-steroidal analgesics should be prescribed regularly.
Quinlan J, Cox F. Acute pain management in patients with drug dependence syndrome. International
Association for the Study of Pain (IASP). Pain Clinical Update 207; XXV: –8.
CHAPTER TRAUMA AND ORTHOPAEDICS
3 QUESTIONS
. You see a patient two days following left total knee replacement. He
complains of right foot drop since surgery. He had a spinal anaesthetic
and wonders if this was the cause, although no complications were
reported at the time. He is otherwise well and clinical examination
confirms weak dorsiflexion of his right foot. What is the most
likely cause?
A. Cerebrovascular accident
B. Poor intraoperative positioning and padding
C. Spinal abscess
D. Spinal haematoma
E. Spinal nerve root injury
2. A frail 86-year-old female requires neck of femur fixation surgery.

Her BMI is 8. Her core temperature is 36.°C prior to induction of
anaesthesia. Which process will be responsible for the largest amount of
heat loss during anaesthesia and surgery?
A. Radiation
B. Convection
C. Respiration
D. Evaporation
E. Conduction
3. A 67-year-old man completed a 2-unit blood transfusion during his

revision hip arthroplasty 8 hours ago. He has developed a fever, urticarial
rash, and back pain. His heart rate is 32, BP 95/50, respiratory rate is
32. He has passed 30 mL of very dark urine since surgery. His post-
transfusion blood results show a haemoglobin level of 75 g/L. What is
the most likely explanation for his deterioration?
A. Transfusion-related acute lung injury
B. Transfusion-associated circulatory overload
C. Transfusion-associated graft versus host disease
D. Transfusion-related bacterial infection
E. Acute haemolytic transfusion reaction
20 Trauma and orthopaedics | QUESTIONS
4. A 28-year-old woman presents with a trimalleolar fracture of her left

ankle. She is haemodynamically stable. She is 27 weeks pregnant. She
has had an uneventful pregnancy so far and has no other past medical
history. What would be the most appropriate anaesthetic management?
A. Recommend conservative management of the fracture until 3rd trimester
B. General anaesthesia with a laryngeal mask airway (LMA) in situ
C. General anaesthesia and intubation without a rapid sequence induction
D. General anaesthesia and intubation with a rapid sequence induction
E. Spinal anaesthesia
5. A 59-year-old woman had an elective total knee replacement earlier

today under spinal block which included 0.2 mg of preservative-free
morphine. She is now complaining of severe itch around her neck
and chest. She is otherwise well. What would be the most effective
treatment for her symptoms?
A. Chlorpheniramine
B. Diclofenac
C. Hydrocortisone
D. Naltrexone
E. Ondansetron
6. A 72-year-old man is listed for an elective total hip replacement. Which

of the following is the strongest indication for the use of perioperative
cell salvage?
A. Preoperative haemoglobin level of 3 g/dL
B. Preoperative ferritin level of 50 ng/L
C. Von Willebrand’s disease type 3
D. 75 mg of aspirin stopped five days ago
E. Anticipated blood loss of 500 mL
7. A 79-year-old female who sustained a fractured neck of femur the

previous day is scheduled for operative fixation with a dynamic hip
screw. She has a past medical history of type 2 diabetes mellitus on
metformin. She denies any history of chest pain, breathlessness, or
syncope. Which of the following is most likely to result in postponement
of surgery?
A. A loud ejection systolic murmur on auscultation
B. Blood tests show urea 8.0 mmol/L and creatinine 58 mmol/L
C. Fasting blood glucose this morning was 6 mmol/L
D. ECG (electrocardiogram) shows atrial fibrillation with rate of 92 bpm
E. SpO2 96% on 2 L/min oxygen, RR 8 breaths/min. Apyrexial
Trauma and orthopaedics | QUESTIONS 21
8. You anaesthetize a 34-year-old man for an open reduction and internal

fixation (ORIF) of scaphoid fracture under general anaesthesia. You
perform an ultrasound-guided radial nerve block above the elbow as
part of your analgesia plan. Which is the most accurate statement
regarding the performance of this block using ultrasound?
A. A high-frequency curvilinear probe provides the best images
B. A reduced concentration of local anaesthetic is likely to be needed compared with the
landmark technique
C. The radial nerve appears hypo-echoic
D. The probe should be orientated to show the nerve in the short axis
E. Use of ultrasound removes risk of intravascular injection of local anaesthetic
9. A 70-year-old lady is listed for a left dynamic hip screw for fixation of her
fractured neck of femur. Her medical history includes hypothyroidism,
hypertension, and depression. Her medication includes levothyroxine,
bendroflumethazide, amlodipine, and phenelzine. You administer
a spinal anaesthetic and 5 min later her heart rate decreases to 57
bpm and her blood pressure drops to 85/46 mmHg despite 500 mL of
Hartmann’s solution. What is the most appropriate drug to improve her
cardiovascular status?
A. Phenylephrine
B. Metaraminol
C. Adrenaline (epinephrine)
D. Noradrenaline (norepinephrine)
E. Ephedrine
0. A 48-year-old woman presents with severe pain, swelling, and erythema
of her left forearm. The only history of trauma is of a small scratch while
gardening a week ago. Her C-reactive protein (CRP) is 98, her white
cell count (WCC) is 28, and her creatinine level is 80 µg/L. What is
the gold standard method to confirm/refute necrotizing fasciitis as the
diagnosis?
A. Blood cultures
B. Computed tomography scan
C. Percutaneous needle aspiration
D. Surgical exploration and tissue biopsy
E. Creatinine kinase level
. A 76-year-old lady is on the trauma list this morning for a femoral
nailing. Her past medical history includes severe dementia, stable
angina, and hypothyroidism. Her haemoglobin is 98 g/L. You notice
in the orthopaedic a single sentence stating the patient is a Jehovah’s
witness. What is the best way to proceed?
A. Postpone operation until you can speak to her next of kin to see what blood products they
will permit
B. Proceed with a general anaesthetic and femoral nerve block. Give tranexamic acid and
avoid transfusion of blood products even if life-threatening haemorrhage
C. Proceed with a general anaesthetic and femoral nerve block. Give tranexamic acid but use
blood products if required to save her life as an Adults with Incapacity form is signed
D. Postpone operation until you speak to relatives and verify what her wishes would be in the
event of life-threatening haemorrhage
E. Continue with spinal anaesthesia and femoral nerve block. Give tranexamic acid and avoid
blood products even in life-threatening haemorrhage
2. A 68-year-old man has sustained a hip fracture. He is listed for

hemiarthroplasty. There are no other injuries apparent. He has stable
angina and no other significant medical history. His resting ECG is
normal. His full blood count reveals a haemoglobin of 0.9 g/dL. The
most appropriate management is:
A. Preoperative transfusion  unit packed red cells
B. Preoperative transfusion 2 units packed red cells
C. Crossmatch 2 units packed red cells and proceed
D. Crossmatch 4 units packed red cells and proceed
E. Grouped sample and proceed
3. A 68-year-old man presents to hospital two weeks after elective right
primary total hip replacement performed under uncomplicated spinal
anaesthesia. He had complained of left thigh pain during his hospital
admission but was reassured and sent home. He now reports left-sided
reduced sensation in his lateral thigh skin with an unpleasant burning
sensation. Neurological examination is otherwise normal. The most
likely cause is:
A. Meralgia paraesthetica
B. Soft tissue thigh injury
C. Conus injection
D. Compartment syndrome
E. Epidural haematoma
4. A 68-year-old man presents to the Emergency Department having

fallen. A chest X-ray shows three fractured ribs on his left side. He is
Glasgow Coma Scale 5 with no other injury. He has well-controlled
hypertension and mild angina. His pain has been controlled after
titration of 0. mg/kg intravenous morphine and  g of paracetamol.
His dynamic pain score is now . What would be the most appropriate
initial pain management plan?
A. Regular paracetamol
B. Insert a thoracic epidural
C. Insert a left paravertebral catheter
D. Morphine sulphate slow-release tablets twice a day with oramorph for breakthrough and
regular paracetamol
E. An intravenous morphine patient-controlled anaesthesia with regular paracetamol
5. When considering risk of systemic local anaesthetic toxicity, which site
for a regional block carries the highest risk?
A. Brachial plexus
B. Intercostal
C. Caudal
D. Epidural
E. Femoral
6. You assess a 77-year-old man for excision of palmar Dupuytren’s

contracture. He is breathless at rest and uses home oxygen. His
operation is necessary to allow him to use a zimmer frame to
mobilize around his home. The best regional block to perform for the
procedure is:
A. Median and ulnar nerve blocks at the wrist
B. Median and ulnar nerve blocks at the antecubital fossa
C. Axillary plexus block
D. Supraclavicular block
E. Interscalene block
7. A 24-year-old male presents for a right knee arthroscopy and medial
meniscectomy under general anaesthetic in day surgery. He is otherwise
fit and well. What would be the best regional technique to use in
addition to the general anaesthetic?
A. Psoas compartment block
B. Adductor canal block
C. Femoral block
D. Sciatic nerve block
E. Wound infiltration by the surgeon
8. An 80-year-old woman is booked on the trauma list having fallen 24

hours previously causing a fracture of her neck of femur. She remains
in significant pain. She gives a history of blackouts preceded by light-
headedness over the last three months. Past medical history includes
hypertension treated with lisinopril and bisoprolol. Heart sounds are
normal and chest is clear. ECG today reveals normal sinus rhythm, rate
75 and normal axis. The most appropriate course of action is:
A. Postpone the operation pending investigation of blackouts
B. Cancel the operation and advise conservative management of fracture
C. Proceed to operation and plan for general anaesthesia
D. Proceed to operation and plan for spinal anaesthesia
E. Withhold bisoprolol, proceed to operation and plan for general anaesthesia
9. A 74-year-old male is having a cemented hip hemiarthroplasty under

spinal block. He has stable angina and chronic obstructive pulmonary
disease. Two minutes after insertion of the prosthesis his oxygen
saturations drop to 80% on 4 L of oxygen via a Hudson mask. He loses
consciousness and his blood pressure is now 60/32 mmHg having
previously been stable. Which of the following best describes the initial
physiological cause of this clinical syndrome?
A. Decreased pulmonary artery pressure
B. Increased systemic vascular resistance
C. Increased central venous pressure
D. Increased pulmonary vascular resistance
E. Deceased systemic vascular resistance
20. You anaesthetize a 63-year-old woman for manipulation of distal

radial fracture. She is spontaneously ventilating on a laryngeal mask
airway (LMA), breathing oxygen/air/sevoflurane to a minimum alveolar
concentration (MAC) value of .0. On manipulation of the forearm she
develops noisy breathing on inspiration. What is the most appropriate
immediate action?
A. Increase sevoflurane to 8%
B. 00% oxygen
C. IV propofol
D. IV rocuronium
E. Remove LMA
2. A 28-year-old professional rugby player has undergone rotator cuff

repair. You administer general anaesthesia including 0 mg of morphine
and an interscalene block. In recovery he reports a sensation of difficulty
breathing. His respiratory rate is 8, oxygen saturation 97% on 4 L via a
Hudson mask, and nerve stimulation shows he has four twitches with no
detectable fade. The most likely cause of his breathing difficulty is:
A. Inadequate reversal
B. Relative overdose of morphine
C. Covert use of anabolic steroids
D. Phrenic nerve palsy
E. Anxiety
22. An 84-year-old woman presents to the emergency department with

a suspected fractured neck of femur. She had a simple fall on the way
to the bathroom in her nursing home and it is 4 am. She has had 0
mg of morphine IM by the paramedics and a further 0 mg titrated
IV since she arrived. She reports an ongoing pain score of 0/0 and
the orthopaedic doctor has asked for your pain advice. The best
management of her analgesia is:
A. Take to theatre for operative fixation
B. Continue to titrate IV opioid
C. Offer N2O/O2
D. Administer oral ibuprofen and paracetamol
E. Perform a femoral nerve block
23. A 25-year-old man is admitted with a right compound mid-shaft tibial

and fibular fracture following a simple fall. He is planned for operative
fixation the next morning. He has a past medical history of deep venous
thrombosis (DVT) five years ago following a hernia repair. He is on no
regular medication. Overnight, he complains of severe right-sided leg
pain and tingling. On examination, his leg is warm, tender, and swollen.
The pedal pulse is faint. The wound dressing is dry. On examination,
HR 05 bpm, regular, BP 0/65, RR 20, SaO2 94% on 2 L of O2 and
temperature is 37.4°C. The most likely diagnosis is:
A. Deep vein thrombosis
B. Compartment syndrome
C. Cellulitis
D. Necrotizing fasciitis
E. Acute limb ischaemia
24. A 68-year-old female with rheumatoid arthritis presents for a left

shoulder hemiarthroplasty. She takes etoricoxib and methotrexate
as treatment. You notice an abnormality on her cervical spine X-ray.
What is the most common cervical spine abnormality associated with
rheumatoid arthritis?
A. Atlanto-axial dislocation
B. Anterior atlanto-axial subluxation
C. Lateral atlanto-axial subluxation
D. Sub-axial dislocation
E. Sub-axial subluxation
25. A 54-year-old presents for an ORIF of a fractured wrist. He has no major

comorbidities. However, he is a heavy smoker with a chronic productive
cough. He is being sent home to come in fasted for his operation
tomorrow. You advise him on smoking cessation as part of your pre-
assessment. What effect would be most likely if he stops smoking for
24 hours?
A. No effect
B. Increased oxygen carriage by the blood
C. Less reactive airways
D. Reduced sputum production
E. Reduced likelihood of postoperative respiratory failure
chapter TRAUMA AND ORTHOPAEDICS
3 ANSWERS
. B
Postoperative complications may result from surgical, anaesthetic, or non-medical factors including
patient positioning. Intraoperative positioning and padding may lead to prolonged pressure on the
common peroneal nerve during anaesthesia which is a well-documented cause of postoperative
foot drop. One must ensure adequate padding around the fibular head when positioning patients
under general or regional anaesthesia for long periods of time. A central neurological cause is
unlikely to cause such well-defined peripheral nerve lesions and in any case is very rare. Treatment
is conservative and the transient neuropraxia will usually pass. However, the patient should also be
counselled of the possibility that this may be a permanent injury.
Sawyer RJ, Richmond MN, Hickey JD, Jarrratt J. Peripheral nerve injuries associated with anaesthesia.
Anaesthesia 2000; 55: 980–99.
2. A
These five mechanisms all contribute to heat loss from the body. Around 40% is estimated to be by
radiation which is the largest.
Sullivan F, Edmondson C. Heat and temperature. Continuing Education in Anaesthesia Critical Care &
Pain 2008; 8 (3): 04–07.
3. E
Acute haemolytic transfusion reactions present within 24 hours after a transfusion of ABO-
incompatible red blood cells. Antigens on the donor red cells react with antibodies in the recipient’s
plasma leading to degranulation of mast cells, inflammation, increased vascular permeability, and
hypotension. Intravascular haemolysis can occur leading to disseminated intravascular coagulation
(DIC), renal failure, and death. The treatment is supportive.
Inadvertent transfusion of ABO-incompatible blood components resulting in serious harm or death
is classified as a Never Event by the Department of Health. All the others are possible consequences
of blood transfusion but the symptoms, signs, and timescale support E as the correct answer.
Clevenger B, Kelleher A. Hazards of blood transfusion in adults and children. Continuing Education in
Anaesthesia Critical Care & Pain 204; 4 (3): 2–8.
4. E
A trimalleolar fracture cannot be managed conservatively. In general, the second trimester is
preferred for semi-elective procedures that can’t be deferred until after the baby is delivered.
There is no benefit in delaying until the third trimester. Elective surgery should be postponed if
possible until at least six weeks post-partum. Lower oesophageal sphincter tone is reduced from
early gestation and intra-abdominal pressure increases during the second trimester so an LMA is
not recommended. If a general anaesthetic is necessary, it should be a rapid sequence induction
28 Trauma and orthopaedics | ANSWERS
(RSI) with cricoid pressure from the second trimester. Regional anaesthesia is highly desirable as
airway management can be more difficult in pregnant patients. The patient would thus maintain her
own airway and the spinal would also minimize fetal drug exposure and give good postoperative
analgesia. A spinal anaesthetic would therefore be the preferred choice in this patient.
Nejdlova M, Johnson T. Anaesthesia for non-obstetric procedures during pregnancy. Continuing
Education in Anaesthesia Critical Care & Pain 202; 2 (4): 203–206.
5. D
Itch is a common side effect of intrathecal opiates. Its mechanism is not fully understood. Opioid
itching is not thought to be secondary to histamine release so chlorpheniramine is unlikely to
be effective. Prostaglandins are known to modulate c fibre transmission and seem to have a
role in opioid induced itch but studies have shown only limited effect form anti-inflammatories
like diclofenac. Steroids such as hydrocortisone have no place in the treatment of itch. Opioid
antagonists such as naloxone and naltrexone are associated with the greatest success. Low dose is
required so as not to reverse the analgesic benefits. Use of ondansetron for pruritis is not first line
and evidence for its use is lacking except perhaps in obstetrics.
Hindle A. Intrathecal opioids in the management of acute postoperative pain. Continuing Education in
Anaesthesia Critical Care & Pain 2008; 8 (3): 8–85.
6. C
The general indications for cell salvage are:
• Surgery where there is expected blood loss > L or >20% blood volume, e.g. revision hip
replacement
• Preoperative anaemia or major risk factors for bleeding such as Von Willebrand’s disease.
The WHO classifies anaemia as <3 g/dL in males (<2 g/dL in females)
• Iron deficiency anaemia is common. Normal ferritin levels are 4–400 µg/L
• Patients with rare blood group or antibodies
• Patients who refuse conventional blood transfusion, e.g. Jehovah’s Witnesses
Aspirin treatment alone is not a strong indication.
Kuppurao L, Wee M. Perioperative cell salvage, Continuing Education in Anaesthesia Critical Care & Pain
200; 0 (4): 04–08.
7. C
Surgery should be postponed only when there is clear clinical benefit to doing so. Many of the
population have an ejection systolic murmur and in the elderly it is often due to aortic sclerosis.
Should echocardiography confirm aortic stenosis, there is no reasonable acute treatment to reduce
the risk of anaesthesia and hip surgery. Thus there should be no delay awaiting echocardiography.
Mild derangement of urea and electrolytes is seen in 40% of patients presenting with a hip fracture.
There is commonly a period of dehydration followed by intravenous fluids in hospital. This is not
an indication to delay surgery. The patient remains clinically well and respiratory parameters are
close to normal for this patient’s age with a low oxygen requirement. Atrial fibrillation needs no
specific treatment here in the absence of tachycardia. Uncontrolled diabetes with a blood sugar of
6 mmol/L should be controlled acutely prior to surgery. This is well above the normal limit and
will become further deranged during surgery. A high glucose will predispose to wound infection.
Prosthesis infection is a severe complication when metal is implanted in orthopaedics.
Membership of the Working Party, Griffiths R, Alper J, Beckingsale A, et al. Management of proximal
femoral fractures. Anaesthesia 20; 67: 85–98.
Trauma and orthopaedics | ANSWERS 29
8. D
A high-frequency linear probe would provide the best images. A reduced volume of local anaesthetic
is likely to be sufficient rather than reduced concentration. The radial nerve will look hyper-echoic.
The probe can trace the nerve in the long axis but this block is best performed in the short axis to
give a good view of surrounding structures. Use of ultrasound should reduce the risk of intravascular
injection but does not remove it and careful aspiration before injection of local anaesthetic is
required.
Capek A, Dolan J. Ultrasound-guided peripheral nerve blocks of the upper limb, Continuing Education
in Anaesthesia Critical Care & Pain 205; 5 (3): 60–65.
9. A
The cardiovascular compromise is most likely due to the sympathectomy caused by the spinal
anaesthetic. Phenelzine is a non-selective irreversible mono-amine oxidase inhibitor. Administration
of indirectly acting sympathomimetic agents such as ephedrine or metaraminol may precipitate
a severe hypertensive reaction. The next best choice to treat her blood pressure drop
secondary to probable vasodilation is phenylephrine. Adrenaline (epinephrine) and noradrenaline
(norepinephrine) would be safe to use; however, due to their potency they would not be
considered a first line choice.
Bromhead H, Feeney A. Anaesthesia and psychiatric drugs part —Antidepressants and anaesthesia.
Anaesthesia Tutorial of the Week 64. Available at: http://www.frca.co.uk/Documents/64%20
Anaesthesia%20&%20psychiatric%20drugs%20part%20%20-%20antidepressants.pdf
0. D
Blood cultures may be useful to guide antibiotic treatment but can take 48–72 hours to become
positive. There is a laboratory result-based risk indicator scoring system for necrotizing fasciitis
which gives scores for CRP, WCC, haemoglobin, creatinine level, sodium, and glucose levels.
This can help differentiate between cellulitis and necrotizing fasciitis. However, the diagnosis of
necrotizing fasciitis is essentially clinical, and D is the gold standard to confirm. Percutaneous
needle aspiration may be useful and can be sent for gram stain and culture but tissue biopsy is the
investigation of choice. Imaging such as computed tomography or magnetic resonance imaging may
be useful but should not delay surgery.
Davoudian P, Flint NJ. Necrotizing fasciitis. Continuing Education in Anaesthesia Critical Care & Pain 202;
2 (5): 245–250.
. D
This is a question about consent. The operation is urgent rather than emergency so it is reasonable
to postpone to allow the patient’s wishes to be verified preferably with an advance directive already
in place. The family can provide information but ultimately cannot accept nor refuse treatments on
behalf of the patient.
AAGBI, Members of the Working Party, Ward ME, Dick J, Greenwell S, et al. Management of
Anaesthesia for Jehovah’s Witnesses, 2nd Edition. AAGBI, 2005, available at: https://www.aagbi.org/sites/
default/files/Jehovah’s%20Witnesses_0.pdf
2. C
Preoperative anaemia occurs in around 40% of hip fracture patients. It is multifactorial resulting
from fracture site bleeding, haemodilution, pre-existing anaemia, or chronic disease. Haemorrhage
and haemodilution may result in a fall of around 2.5 g/dL. Anaemic patients are therefore at risk of
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Ostiaks and Samoyedes, settle disputes, and deal out justice
generally; the Russian merchants are on the outlook for buyers and
sellers, the dishonest ones among them, and the swindling Syryani,
for thoughtless drunkards, and the clergy for heathen to be
converted. Among the Ostiaks and Samoyedes all sorts of
agreements are made, weddings arranged, enemies reconciled,
friends gained, compacts with the Russians formed, debts paid and
new ones contracted. From all sides appear long trains of sledges
drawn by reindeer, and one tshum after another grows up beside the
market-place, each tshum surrounded by heavily-laden sledges
containing the saleable acquisitions of the year. Every morning the
owner, with his favourite wife in gala attire, proceeds to the booths to
sell his skins and buy other commodities. They bargain, haggle, and
attempt to cheat, and Mercury, as powerful as of yore, shows his
might not only as the god of merchants but of thieves. Alcohol,
though its retail sale is forbidden by the government, is to be had not
only at every merchant’s, but in almost every house in Obdorsk, and
it blunts the senses and dulls the intelligence of Ostiak and
Samoyede, and impoverishes them even more than the much-
dreaded reindeer plague. Brandy rouses all the passions in the
ordinarily calm, good-tempered, inoffensive Ostiak, and transforms
the peaceable, friendly, honest fellows into raging, senseless
animals. Man and wife alike long for brandy; the father pours it down
his boy’s throat, the mother forces it on her daughter, should they
begin by rebelling against the destructive poison. For brandy the
Ostiak squanders his laboriously-gained treasures, his whole
possessions; for it he binds himself as a slave, or at least as a
servant; for it he sells his soul, and denies the faith of his fathers.
Brandy is an indispensable accompaniment to the conclusion of
every business, even to conversion to the orthodox church. With the
help of brandy a dishonest merchant can get possession of all an
Ostiak’s skins, and without these, with empty purse and confused
head, the man who arrived in Obdorsk full of hope and pride, returns
to his tshum cheated, not to say plundered. He repents his folly and
weakness, makes the best of resolutions, becomes tranquil in doing
so, and soon remembers nothing except that he enjoyed himself
excellently with his fellow tribesmen. First they had drunk together;
then men and women had kissed each other, then the men had
beaten their wives, had tried their strength on each other, had even
drawn their sharp knives, and, with flashing eyes, had threatened
each other with death; but no blood had been shed; there had been
a reconciliation; the women who had fallen on the ground, stupefied
with blows and brandy, were lifted up tenderly, and were tended by
other women; to celebrate the reconciliation an important compact
had been made, a bridegroom was sought for the daughter, a little
bride for the son; even a widow had been married, and they drank
again to the occasion; in short, they had had a splendid time. That
the government officials had shut up all those who were dead drunk,
that all, all their money had gone the way of things perishable, had
certainly been disagreeable, very disagreeable. However, the prison
had opened again; after a time, the loss of the money had been got
over, and only the golden recollection, over which they could gloat
for a whole year, and the betrothal, so satisfactory to all parties,
remained as permanent gain from the delightful festival.
The bridegroom and bride had also been at the fair, had drunk with
the rest, and thus made each other’s acquaintance, and the
bridegroom had agreed with his parents to choose the maiden as his
wife, or rather had agreed to receive her. For it is the parents’
decision, not the consent of the couple themselves, that concludes a
marriage among the Ostiaks. They may perhaps have some regard
for the bridegroom’s wishes, may allow him to cast his affections on
one or other of the daughters of his people, but they only send an
agent to treat with the girl’s father if their own circumstances
correspond with his. The maiden herself is not consulted, perhaps
because, at the time of her betrothal, she is much too young to be
able to decide upon her own future with discretion. Even the future
husband has not reached his fifteenth year when the agent begins to
treat for the twelve-year-old bride. In this case the general
exhilaration of fair-time had considerably hastened the course of
proceedings. The matrimonial agent had gained an immediate
consent; the negotiations, often very protracted, had been at once
begun, and thanks to brandy, which usually proves an evil demon,
but in this case expedited matters, they were brought to a speedy
conclusion. It had been agreed that Sandor, the young bridegroom,
should pay for his little bride, Malla, sixty reindeer, twenty skins of
the white and ten of the red fox, a piece of coloured cloth, and
various trifles such as rings, buttons, glass beads, head-dresses,
and the like. That was little, much less than the district governor,
Mamru, who was scarcely better off, had to give for his wife; for his
payment consisted of a hundred and fifty reindeer, sixty skins of the
Arctic and twenty of the red fox, a large piece of stuff for clothes,
several head-dresses, and the customary trifles. But times were
better then, and Mamru might well pay what was equivalent to more
than a thousand silver roubles for his wife, who was stately, rich, and
of good family.
The amount agreed on is paid; the nuptials of the young couple are
celebrated. The relatives of the bride’s family come to her father’s
tent to bring presents and to receive others from the bridegroom’s
gift, which is laid out for everyone to see. The bride is arrayed in
festive garments, and she and her friends prepare for the drive to the
tshum of the bridegroom or of his father. Beforehand they have
eaten abundantly of the flesh of a reindeer, fresh killed, according to
custom. Only a few fish caught under the ice have been cooked to-
day; the flesh of the reindeer was eaten raw, and when one began to
grow cold a second was slaughtered. The bride weeps, as becomes
departing brides, and refuses to leave the tshum in which she was
brought up, but she is consoled and coaxed by all, and at last she is
ready. A prayer before the domestic idol solicits the blessing of the
heavenly Ohrt, whose sign, the divine fire Sornidud—in our eyes
only the flaming northern light—had shone blood-red in the sky the
evening before. The daughter is accompanied by her mother, who
keeps close by her side, and even remains near her during the night.
Mother and daughter mount one sledge, the rest of the invited
kinsfolk mount theirs, and, in festive pomp, to the sound of the bells
which all the reindeer wear on their harness, the wedding procession
sets forth.
In his father’s tent the bridegroom awaits the bride, who modestly
veils her face with her head-dress in the presence of her future
father and brothers-in-law. This she continues to do after the
marriage is consummated. A new banquet begins, and the guests,
who have been joined by the bridegroom’s relatives, do not disperse
till late at night. But the next day the mother brings the young wife
back to her father’s tent. A day later all the bridegroom’s relatives
appear to demand her back again for him. Once more the low hut is
filled with festive sounds; then the bride leaves it for ever, and is
again conducted with pomp to the tshum which she is thenceforward
to share with her husband, or with him and his father and brothers
and sisters, or later on with another wife.
The sons of poor people pay at most ten reindeer for their brides;
those of the fisher-folk only the most necessary furnishings of the
tshum, and even these are often shared among several families; but
their weddings, too, are made the occasion of a joyful festival, and
there is as much banqueting as circumstances will allow.
The poorer Ostiaks marry only one wife, but the rich look upon it as
one of the rights of their position to have two or more. But the first
wife always retains her privileges, and the others appear to be rather
her servants than her equals. It is otherwise, however, if she should
have no children; for childlessness is a disgrace to the man, and a
childless wife in the tshum, as elsewhere, is much to be pitied.
The parents are proud of their children, and treat them with great
tenderness. It is with unmistakable happiness in look and gesture
that the young mother lays her first-born in her bosom, or on the soft
moss in the neat birch-bark cradle with its lining of mouldered willow-
wood and shavings; carefully she fastens the cover to both sides of
the cradle, and envelops the head-end of the little bed with the
mosquito curtain; but her ideal of cleanliness leaves much to be
desired. As long as the baby is small and helpless she washes and
cleanses it when she thinks it absolutely necessary. But when it
grows bigger she only washes its face and hands once a day, using
a handful of fine willow fibres as sponge, and a dry handful as towel,
and afterwards looks on quite complacently when the little creature,
who finds many opportunities for soiling itself, goes about in a state
of dirt, to us almost inconceivable. This state of things comes
gradually to an end when the young Ostiak is able to take care of
himself; but even then, hardly anyone considers it necessary to wash
after every meal, even should it have left stains of blood. The
children are as much attached, and as faithful to their parents as
these are to them, and their obedience and submission is worthy of
mention. To reverence parents is the first and chief commandment
among the Ostiaks, to reverence their god is only the second. When
we advised Mamru, the district governor already mentioned, to have
his children taught the Russian language and writing, he replied that
he saw the advantage of such knowledge, but feared that his
children might forget the respect due to their father and mother, and
thus break the most important commandment of their religion. This
may be the reason why no Ostiak, who clings to the faith of his
fathers, learns to do more than make his mark, a sort of scrawl
binding on him and others, drawn upon paper, or cut in wood or
reindeer-skin. Yet the Ostiak is capable and dexterous, able to learn
whatever he is taught so quickly and easily that, at the early age at
which he marries, he understands everything connected with the
establishment and maintenance of his household. It is only in
religious matters that he seems unwilling to trust to his own
judgment, and on this account he, in most cases, shows unmerited
respect for the shamans,[85] who profess to know more about
religion than he does.
For our part, we regard the shaman, who claims the status of a priest
among the Ostiaks as among the other Mongolian peoples of
Siberia, as nothing short of an impostor. The sole member of the
precious brotherhood with whom we came in contact, a baptized
Samoyede, bore the sign of Christianity on his breast; according to
report he had even been a deacon in the orthodox church, and yet
he did duty as a shaman among the heathen Ostiaks. I learned later,
on good authority, that he was no exception to the general rule; for
all the shamans met with by my informant, Herr von Middendorf,
during years of travel in Siberia, were Christians. I have already
mentioned in the report of my travels that the shaman whom we met
took us also for believers; but I have reserved my account of his
performances and prophecies for to-day, as this description seems
to me a fitting frame for such a picture.
To begin with, he demanded brandy as a fee, but was satisfied with
the promise of a gift, and retired into a tent, saying that he would let
us know when his preparations were finished. Among these
preparations, apparently, was the muffled beating of a drum which
we heard after a considerable time; of other arrangements we
discovered nothing. On a given signal we entered the tshum.
The whole space within the birch-bark hut was filled with people,
who sat round in a circle pressing closely against the walls. Among
the Ostiaks and Samoyedes, who were there with wives and
children, there were also Russians with their families. On a raised
seat to the left of the entrance sat the shaman Vidli; at his right,
crouching on the floor, was an Ostiak, the master’s disciple at the
time. Vidli wore a brown upper garment, and over it a kind of robe,
originally white, but soiled and shabbily trimmed with gold braid; in
his left hand he held a little tambour-like drum, in such a way that it
shaded his face; in his right hand was a drum-stick; his head was
uncovered, his tonsured hair freshly oiled. In the middle of the tshum
a fire was burning, and now and again it blazed up and shed bright
light on the motley throng, in the midst of which we sat down in the
places reserved for us. A thrice-repeated, long-drawn cry, like a song
from many voices, preluded by beating of the drum, greeted our
entrance, and marked the beginning of the proceedings.
“That you may see that I am a man of truth,” said the master’s voice,
“I shall now adjure the messenger of the heavenly will, who is at my
behest, to appear among us and communicate to me what the gods
have determined concerning your future. Later, you yourselves will
be able to determine whether I have told you the truth or not.”
After this introduction, which was translated to us by two interpreters,
the favourite of the gods struck the calf-skin, or rather reindeer-skin
of his drum, with quick strokes which followed one another at equal
intervals, but were indefinitely grouped, and accompanied his
drumming with a song which, in the usual Samoyede fashion, was
half-spoken, or rather muttered, and half-sung, and was faithfully
repeated by the youth, whom we may call the clerk. The master held
the drum so as to keep his face in shadow, and he also shut his eyes
that nothing might distract his inward vision; the clerk, on the other
hand, smoked even while he sang, and spat from time to time, just
as he had been doing before. Three slow, decided strokes brought
the drumming and the song to an end.
“I have now,” said the master with dignity, “adjured Yamaul, the
heavenly messenger, to appear among us, but I cannot say how
much time must pass before he arrives, for he may be far off.”
And again he beat his drum and sang his incantation, concluding
both song and accompaniment as before.
“I see two emperors before me; they will send you a writing,” spoke
the messenger of the gods through his lips.
So Yamaul had been kind enough to appear in the tshum to oblige
his favourite. Then the individual sentences of the heavenly
message, with the invariable prelude of drumming and song, were
uttered as follows:—
“Once again, next summer, you will traverse the same route as this
year.”
“Then you will visit the summit of the Ural, where the rivers Ussa,
Bodarata, and Shtchutshya begin their course.”
“On this journey something will befall you, whether good or evil I
cannot tell.”
“Nothing is to be achieved at the Bodarata, for wood and pasture are
lacking; here something might be accomplished.”
“You will have to render an account to your superiors; they will
examine you and will be satisfied.”
“You will also have to answer to the three elders of your tribe; they
also will examine your writings, and then come to a decision about
the new journey.”
“The course of your journey will henceforward be happy and without
accident; and you will find your loved ones at home in the best of
health.”
“If the statements of the Russians who are still at Bodarata
corroborate yours, two emperors will reward you.”
“I see no other face.”
The performance was at an end. On the Ural Mountains lay the last
glow of midnight. Everyone left the tent, the faces of the Russians
showing the same credulity as those of the Ostiaks and Samoyedes.
But we invited the shaman to accompany us to our boat, loosened
his tongue and that of his disciple with brandy, and plied him with all
manner of cross-questions, some of them of the subtlest kind. He
answered them all, without exception, without ever getting into a
difficulty, without hesitation, without even reflection; he answered
them full of conviction, and convincingly, clearly, definitely, tersely,
and to the point, so that we recognized more clearly than before the
extreme craftiness of the man with whom we had to deal.
He described to us how, even in his boyhood, the spirit had come
upon him and had tortured him till he became the disciple of a
shaman; how he had become more and more intimate with Yamaul,
the messenger of the gods, who appears to him as a friendly man,
riding on a swift horse, and carrying a staff in his hand; how Yamaul
hastened to his help, and even, if need were, called down aid from
heaven when he, the shaman, was struggling with evil spirits often
for several days at a time; how the messenger of the gods must
always communicate the message to him just as he received it, for
that otherwise he felt every drum-beat as a painful stroke; how
Yamaul, even to-day, though visible to him only, sat behind him in the
tshum and whispered the words in his ear. He also informed us that,
by his own art, or by the grace bestowed upon him, which even his
conversion to Christianity could not weaken, he could reveal what
was hidden, find what was stolen, recognize diseases, prophesy the
death or recovery of the sick, see and banish the ghosts of the dead,
work much evil, and prevent much evil, but that he did nothing but
good, because he feared the gods; he gave us a clear and detailed,
if not quite correct picture of the religion of the Ostiaks and
Samoyedes; he assured us that all his people, as well as the
Ostiaks, came to him in their troubles to ask advice, or to have the
future unveiled, and that they did not doubt, but trusted in him and
believed him.
The last statement is not correct. The great mass of the people may
regard the shaman as a wise man, perhaps even as an intermediary
between men and the gods, and possibly as the possessor of
mysterious power; but many believe his words and works as little as
other races do those of their priests. The real faith of the people is
simpler and more child-like than the shaman approves of. It is here
as elsewhere; the priest, or whoever acts as such, peoples heaven
with gods, and councillors and servants of the gods, but the people
know nothing of this celestial court.
According to the belief of the people there is enthroned in heaven
Ohrt, whose name signifies “the end of the world”. He is an all-
powerful spirit, who rules over everything but Death, and he is
benevolently inclined towards men. He is the giver of all good, the
bestower of reindeer, fish, and furred animals, the preventer of evil,
and the avenger of lies, severe only when promises made to him are
not fulfilled. Feasts are held in his honour, sacrifices and prayers are
offered to him; the suppliant who prostrates himself before a sacred
symbol thinks of him. The symbol, called a longch, may be of carved
wood, a bundle of cloth, a stone, a skin, or anything else: it
possesses no powers, affords no protection, it is in no sense a fetish!
People assemble before a longch, place it in front of the tshum, lay
dishes of fish, reindeer flesh, or other offering before it, place
valuables before it, or even pack them inside it; but they always look
up to heaven, and both their offerings and their prayers are intended
for their god. Evil spirits dwell in heaven as on earth; but Ohrt is
more powerful than they all; only Death is mightier than he. There is
no everlasting life after death, and no resurrection; but the dead still
wander as ghosts over the face of the earth, and have still power to
do good or evil.
Fig. 65.—The Burial of an Ostiak.
When an Ostiak dies his spirit-life begins at once; so his friends

proceed immediately to arrange for his burial. They had all
assembled before his death, and as soon as life is extinct they kindle
a fire in the tshum in which the body lies, and keep it burning until
they set out for the burial-place. A shaman is called to ask the dead
where he wishes to lie. This is done by naming a place, and
attempting to raise the head of the corpse. If the dead man approves
he lets his head be raised; if he does not, three men cannot move it.
Then the question must be repeated until the man gives his consent.
Skilled persons are despatched to the chosen spot to prepare the
grave, for this work often requires several days.
The burial-places are always in the tundra, on elevated spots,
usually on a long ridge; the coffins are more or less artistically
wrought chests, which are placed above the ground. Failing solid
planks to construct the coffin, a boat is cut up and the corpse is laid
in that; only the very poor people dig in the ground a shallow hollow
in which to bury their dead.
The corpse is not washed, but is arrayed in festive garments, the
hair anointed, and the face covered with a cloth. All the rest of the
deceased’s clothing is given to the poor. The Ostiaks never touch the
dead body of a stranger with their hands, but they do not hesitate to
touch a loved relative, and even to kiss his cold face with tears in
their eyes. The corpse is brought to the burial-place on a sledge, or
in a boat, and is accompanied by all the relatives and friends. A
reindeer-skin, on which the dead is to rest, is laid in the chest or
coffin. At the head and sides are placed tobacco, pipes, and all
manner of implements which the dead man was wont to use in his
lifetime. Then the corpse is lifted with cords, carried to the chest, and
laid on the bed thus prepared; the face is covered for the last time, a
piece of birch-bark is spread over the open top of the chest, which, if
the family be a rich one, is perhaps first covered with costly skins
and cloths, the lid of the chest is put on above the sheet of bark, or
at least heavy branches are laid close together upon it. Around and
under the chest are laid such implements as could not be placed
within it, but they are first broken up and thus rendered useless for
the living, or, according to Ostiak ideas, made the ghosts of what
they were.
Meanwhile, a fire has been kindled in the neighbourhood of the
grave, and one or more reindeer slaughtered, and now the flesh is
eaten, raw or cooked, by the funeral company. After the meal, the
skulls of the slaughtered reindeer are fixed upon a pole, their
harness is hung on the pole or on a tree, the bells they have worn on
this, as on all solemn occasions, are hung on the top of the coffin
itself, the sledge is broken to pieces and thrown beside the grave as
its last ornament. Then the company travels homewards. Mourning
is now silenced, and the daily round of life begins again.
But in the shades of night the ghost of the dead, equipped with his
ghostly tools, begins his mysterious spirit-life. What he did while he
walked among the living, he continues to do. Invisible to all he leads
his reindeer to pasture, guides his boat through the waves, buckles
on his snow-shoes, draws his bow, spreads his net, shoots the
ghosts of former game, catches the ghosts of former fishes. During
night he visits the tshum of his wife and children, causing them joy or
sorrow. His reward is to be able to show beneficence to his own flesh
and blood; his punishment, to be obliged continually to do them
injury.
Such in outline is the religion of the Ostiaks, whom the Greek
Catholics despise as heathen. But a just estimate of these honest
people, with their child-like nature, inclines us rather to wish that they
may ever remain heathen, or at least may never be other than they
are.
THE NOMAD HERDSMEN AND
HERDS OF THE
STEPPES.
Though the steppe of Central Asia is really rich, and may even seem
gay to one who visits it in spring, and though it contains much fruitful
land, it is nevertheless only its most favoured portions which admit of
a settled life, of a continued residence on any one particular spot.
Constant wandering, coming and going, appearing and
disappearing, is the lot of all the children of the steppe, men and
animals alike. Certain portions submit to the labours of the
husbandman; in others, towns and villages may be established, but
the steppe as a whole must for ever remain the possession of the
nomadic herdsman, who knows how to adapt himself to all its
conditions of life.
Among these nomadic herdsmen the Kirghiz take the first rank, by
virtue both of numbers and of civilization. Their domain extends from
the Don and the Volga to the mountains of Thianshan, and from the
middle Irtish to south of the Balkhash Lake, indeed, almost to Khiva
and Bokhara; they are divided into tribes and hordes, into steppe
and mountain herdsmen, but they are one in descent, in language
and religion, in manners and customs, however much the various
tribes may appear to differ. The smallest or youngest horde wanders
throughout the steppe of Orenburg; a branch of the same, calling
itself the Buka tribe, traverses the steppe between the Volga and
Ural rivers, especially in the governments of Turgai and Ural; the
middle or elder horde inhabits the steppes and mountains of the
Irtish and Balkhash regions; and finally, extending from beyond the
river Ili towards Khiva and Bokhara are to be found the ever-
changing dwelling-places of the mountain Kirghiz, who describe
themselves as the great, or eldest horde. No branch of these people
applies the name Kirgis or Kirghiz to itself, for that is a term of infamy
equivalent to “freebooters”. The proper designation of our people is
Kaisak, Kasak, or, as we should read it, Cossack, although even the
Russians apply the name Cossack to a people quite distinct from the
inhabitants of the steppe.
The Kirghiz, as I shall call them nevertheless, are a Turkish people,
about whose racial affinities different opinions are held. Many, if not
most, travellers look upon them as true Mongolians, while others
regard them, probably more correctly, as a mixed race, suggestive of
the Mongolians in some particulars, but, on the whole, exhibiting the
characteristics of Indo-Germans, and especially resembling the
Turkomans. All the Kirghiz I saw belonged to the middle horde, and
were well-built people, small, or of medium height, with faces, not
beautiful indeed, but not of the caricature-like Mongolian type, neat
hands and feet, clear or transparent light-brown or yellowish
complexions, brown eyes, and black hair. The cheek-bones are
seldom so prominent, or the chin so pointed, as to give an angular or
cat-faced appearance; the eye, of medium size, is usually most
arched centrally, and drawn out horizontally at the outer angle; it is
thus almond-shaped, but not obliquely set; the nose is usually
straight, more rarely hooked; the mouth moderate in size and sharply
cut, the beard thin, without being actually scanty. True Mongolian
features are certainly to be met with also, more especially among the
women and children of the poorer class; but, though I have seen
very few really beautiful Kirghiz women, I have met with quite as few
of the grotesque faces so common among other undoubted
Mongols. The characteristics are unmistakably more suggestive of a
mixed race than of any one sharply defined stock. I have seen men
whom I should unhesitatingly have pronounced to belong to the
nobler Indo-Germans if I had known nothing of their kinship, and I
have become acquainted with others about the Mongolian cut of
whose faces there could be no possible doubt. The members of the
older families usually possess all the essential marks of the Indo-
Germans, while men of lower descent and meaner extraction often
remind one of the Mongols in many details, and may sometimes
resemble them completely. The power of Islam, which permits to
slaves who have become converts all the rights of the tribe, may in
the course of time have made Kirghiz out of many heathen Mongols,
and thus not only have influenced, but actually destroyed the racial
characteristics of the Kirghiz.
Although the chief features of the Kirghiz dress are Turkish, it is, as a
whole, by no means suited for displaying their figure to advantage. In
winter the fur cap, fur coat, and thick-legged boots hide all the details
of the figure, and even in summer these do not come into
prominence. The poorer Kirghiz, in addition to his fur coat and the
inevitable fur cap, wears a shirt, kaftan, and wide trousers; the higher
class rich man, on the other hand, wears a great many articles of
dress one above the other, like the Oriental; but he stuffs all those
which envelop the lower part of his body, with the exception of his fur
coat, into his wide trousers, so that he may not be impeded in riding.
Consequently, the more richly attired he is the more grotesque he
looks. They prefer dark colours to light or bright ones, though they do
not despise these, and they are fond of decorations of gay
embroideries or braiding. Nearly every Kirghiz wears at his girdle a
dainty little pocket, richly decorated with iron or silver mountings, and
a similarly ornamented knife; beyond these, and the indispensable
signet-ring, he wears no decoration unless the Emperor has
bestowed one upon him, in the shape of a commemorative medal.
Of the dress of the women I can say little, first, because modesty
forbade me to ask about more than I could see, and secondly,
because I did not see the women of the upper class at all, and never
saw the others in their gala attire. In addition to the fur coat, boots
and shoes, which are exactly like those of the men, the women wear
trousers which differ very slightly, a shift, and over it a robe-like
upper garment, falling below the knee and clasped in the middle; on
the head they wear either a cloth wound in turban-fashion, or a nun-
like hood which covers head, neck, shoulders, and breast.
The clothing of both sexes is coarse, except the riding-boots and
shoes, which are always well made. Very characteristic, and
obviously adapted to the climatic conditions, are the extraordinarily
long sleeves which both men and women wear on their upper
garment; these fall far beyond the hands, and cover them almost
completely.
Fig. 66.—The Home of a Wealthy Kirghiz.
The roving life to which the Kirghiz are compelled by the necessity of
finding sufficient pasturage for their numerous herds, involves a style
of dwelling which is easily constructed, can be taken down at one
spot and erected again at another without special difficulty, and
which must yet afford a sufficient protection against the hardness
and inclemency of the climate. These requirements are fulfilled more
thoroughly by the yurt than by any other movable dwelling, and it is
not too much to say that this is the most perfect of all tents.
Thousands of years of experience has made the yurt what it is—a
home for the nomadic herdsman, or any other wanderer,—which, in
its own way, cannot be surpassed. Light and easily moved, readily
closed against storms, or thrown open to admit air and sunshine,
comfortable and commodious, simple, yet admitting of rich
decoration without and within, it unites in itself so many excellent
qualities that one appreciates it ever more highly as time goes on,
and finds it more and more habitable the longer one lives in it. It
consists of a movable lattice-work which can be extended or
contracted, and which forms the lower upright circular walls of the
framework, a coupling ring which forms the arch at the top, spars
inserted into both these, and a door in the lattice-work; light mats of
tschi-grass, and large wads or sheets of felt, cut to shape, and most
ingeniously laid on, compose the outer covering of the whole
framework, and thick carpets of felt cover the floor. With the
exception of the door-frames, which are mortised together, and of
the spars, the upper ends of which are inserted into holes in the
coupling-ring, the whole structure is held together simply by means
of cords and bands; and it is thus easily taken to pieces, while its
form—circular in cross section, and cupola-like longitudinally—
renders it capable of great resistance to violent storms and bad
weather of all sorts. The work of putting it up scarcely requires more
than half an hour, that of taking it down even less; the strength of a
single camel conveys it from place to place, but its construction and
decoration take up much of the time and all the ingenuity of the
housewife, to whose share falls the chief work of making it, and the
whole labour of setting it up.
The yurt forms an important part of the movable property of a
Kirghiz. A rich man owns six or eight, but he spends money rather on
the decoration of a few than on the construction of many, for he is
assessed and taxed not according to the size of his herds but the
number of his yurts. The high-class Kirghiz certainly shows his
wealth through his yurt, by fitting it up as richly as possible, making it
out of the most valuable felt, and decorating it without and within with
coloured pieces of cloth; but he sets store rather by the possession
of costly rugs, and beautifully sewn and embroidered silken
coverlets, with which he decorates the interior of the living-room on
festive occasions. Such rugs are handed down from father to son,
and the possession of them ranks scarcely below that of uncoined
silver.
The real wealth of the nomadic herdsman cannot, however, be
estimated by such secondary things; it must be calculated by his
herds. Even the poorest owner of a yurt must possess numerous
beasts to enable him to live, or survive in the struggle for existence;
for the herds he tends form the one indispensable condition of life;
they alone stand between him and ruin. The rich man’s herds may
number thousands upon thousands, those of the poor man at least
hundreds; but the richest may become poor, if disease breaks out
among his herds, and the poor man may starve if death visits his
beasts. Wide-spreading murrain reduces whole tribes to destitution,
causes thousands of human beings literally to die of starvation. Little
wonder, then, that every thought and aspiration of the Kirghiz is
bound up with his herds, that his manners and customs correspond
to this intimate connection between man and beast, that the man is,
in short, dependent on the animal.
Not the most useful, but the noblest and the most highly prized of all
the domesticated animals of the Kirghiz is the horse, which in the
eyes of its owner represents the sum and essence of domestication,
and the climax of all beauty; it is a standard by which to reckon,
according to which wealth or poverty is determined. He does not call
it a horse, but simply the domestic animal; instead of the words “left
and right” he uses the expressions, “the side on which one mounts a
horse”, and “the side on which one carries the knout”. The horse is
the pride of youth and maiden, of man and woman, whether young
or old; to praise or find fault with a horse is to praise or blame its
rider, a blow given to a horse one is not riding is aimed not at the
horse but at its owner.
A large number of the Kirghiz songs refer to the horse; it is used as a
standard of comparison to give an estimate of the worth of men and
women, or to describe human beauty.
“Little bride, little bride,
Dear foal of the dark brood-mare!”
the singer calls to the bride who is being led into the bridegroom’s
yurt;
“Say where is the play of the white locks
And where the play of the foals,
For kind as is the new father,
He is not the old father to me,”
the bride answers to the youths who sing the “Jarjar”, the song of
consolation to the departing bride, referring by the words “Foal-play”
to the time of her first love.
The wealth of a man is expressed in the number of horses he
possesses; payment for a bride is made in the value of so many
horses; the maiden who is offered as a prize to the winner in a race
is held as being worth a hundred mares; horses are given as mutual
presents; with horses atonement is made for assassination or
murder, limbs broken in a struggle, an eye knocked out, or for any
crime or misdemeanour; one hundred horses release from ban and
outlawry the assassin or murderer of a man, fifty, of a woman, thirty,
of a child. The fine imposed by the tribe for injuring any one’s person
or property is paid in horses; for the sake of a horse even a
respectable man becomes a thief. The horse carries the lover to his
loved one, the bridegroom to the bride, the hero to battle, the saddle
and clothing of the dead from one camping-place to another; the
horse carries man and woman from yurt to yurt, the aged man as
well as the child firmly bound to his saddle, or the youthful rider who
sits for the first time free. The rich man estimates his herds as
equivalent to so many horses; without a horse a Kirghiz is what a
man without a home is among us; without a horse he deems himself
the poorest under the sun.
The Kirghiz has thoroughly studied the horse, he knows all its habits,
its merits and defects, its virtues and vices, knows what benefits and
what injures it; sometimes, indeed, he expects an incredible amount
from it, but he never exacts it unless necessity compels him. He
does not treat it with the affectionate care of the Arab, but neither
does he ever show the want of consideration of many other peoples.
One does not see anything of that careful and intelligent breeding of
horses which is practised by Arabs and Persians, English and
Germans, but he does constantly endeavour to secure the
improvement of his favourite breeds by only placing the best stallions
with the mares, and castrating the rest. Unfortunately his choice of
breeding-horses is determined solely by form, and does not take
colour into consideration at all, the consequence being that many of
his horses are exceedingly ugly, because their colouring is so
irregular and unequal. The training of the horse leaves much to be
desired; our wandering herdsman is much too rich in horses for this
to be otherwise.
We found the Kirghiz horse a pleasant and good-natured creature,
although it by no means fulfilled our ideal of beauty in all respects. It
is of medium size and slender build, with a head not ugly though
rather large, decidedly ram-nosed, and noticeably thickened by the
prominent lower jaw-bones, a moderately long and powerful neck, a
long body, fine limbs, and soft hair. Its eyes are large and fiery, its
ears somewhat large, but well-shaped. Mane and tail have fine, long
hair, always abundant, the hair of the tail growing so luxuriantly that it
sweeps the ground; the legs are well formed, but rather slim, the
hoofs are upright, but often rather too high. Light colours prevail and
very ugly piebalds often offend the eye. The commonest colours are
brown, light-brown, fox-coloured, dun, and bay, more rare are dark-
brown and black, and one only occasionally sees a gray. The mane
and tail greatly increase the beauty of all the light-coloured horses,
because they are either black or much lighter than the body hairs.
The temper of the animal is worthy of all praise. The Kirghiz horse is
fiery, yet extremely good-natured, courageous in the presence of all
known dangers, and only nervous, skittish, and timid when it is
bewildered for a moment by something unusual; it is spirited and
eager in its work, obedient, docile, willing, energetic, and very
enduring, but it is chiefly valuable for riding, and requires long
breaking-in to make it of use as a draught animal, in which capacity it
is much less valuable than as a riding-horse.

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4. A 28-​year-​old woman presents with a trimalleolar fracture of her left

5. A 59-​year-​old woman had an elective total knee replacement earlier

6. A 72-​year-​old man is listed for an elective total hip replacement. Which

7. A 79-​year-​old female who sustained a fractured neck of femur the

8. You anaesthetize a 34-​year-​old man for an open reduction and internal

2. A 68-​year-​old man has sustained a hip fracture. He is listed for

4. A 68-​year-​old man presents to the Emergency Department having

6. You assess a 77-​year-​old man for excision of palmar Dupuytren’s

8. An 80-​year-​old woman is booked on the trauma list having fallen 24

9. A 74-​year-​old male is having a cemented hip hemiarthroplasty under

20. You anaesthetize a 63-​year-​old woman for manipulation of distal

2. A 28-​year-​old professional rugby player has undergone rotator cuff

22. An 84-​year-​old woman presents to the emergency department with

23. A 25-​year-​old man is admitted with a right compound mid-​shaft tibial

24. A 68-​year-​old female with rheumatoid arthritis presents for a left

25. A 54-​year-​old presents for an ORIF of a fractured wrist. He has no major

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3. A 78-year-old woman is listed for emergency laparotomy. She has

4. A 65-year-old man presents to preoperative assessment before elective

7. You assess a 60-year-old man for umbilical hernia repair as a day

8. A 75-year-old man presents for elective total knee replacement. He

9. A 36-year-old man requires laparoscopic colectomy for ulcerative

. A 64-year-old man presents for renal stone fragmentation surgery

2. A 55-year-old man is day 2 post operation following repair of a large

3. A 60-year-old woman presents with a carcinoid tumour in her terminal

6. An 89-year-old man is scheduled for laparoscopic sigmoid colectomy in

8. A 64-year-old man with chronic liver disease requires a right

24. A 68-year-old man is scheduled for laparoscopic upper gastrointestinal

25. A 20-year-old male on an opioid substitution programme requires acute

2. A frail 86-year-old female requires neck of femur fixation surgery.

3. A 67-year-old man completed a 2-unit blood transfusion during his

4. A 28-year-old woman presents with a trimalleolar fracture of her left

5. A 59-year-old woman had an elective total knee replacement earlier

6. A 72-year-old man is listed for an elective total hip replacement. Which

7. A 79-year-old female who sustained a fractured neck of femur the

8. You anaesthetize a 34-year-old man for an open reduction and internal

2. A 68-year-old man has sustained a hip fracture. He is listed for

4. A 68-year-old man presents to the Emergency Department having

6. You assess a 77-year-old man for excision of palmar Dupuytren’s

8. An 80-year-old woman is booked on the trauma list having fallen 24

9. A 74-year-old male is having a cemented hip hemiarthroplasty under

20. You anaesthetize a 63-year-old woman for manipulation of distal

2. A 28-year-old professional rugby player has undergone rotator cuff

22. An 84-year-old woman presents to the emergency department with

23. A 25-year-old man is admitted with a right compound mid-shaft tibial

24. A 68-year-old female with rheumatoid arthritis presents for a left

25. A 54-year-old presents for an ORIF of a fractured wrist. He has no major