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An Authentic Mock Oral Exam with Suzanne Bennett and Steve Summers · Style Points

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Hello anesthesia enthusiasts, and welcome to a special episode of Style Points.
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The most difficult test that I ever took was the oral board exam for anesthesiology.
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This test is taken after successful completion of residency, and has two 35-minute sessions
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that assess your judgment, adaptability to unexpected clinical changes, organization,
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and presentation of information.
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One of the most difficult parts of the exam was how to study.
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Personally, I really appreciate examples.
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However, really good examples of an oral board exam are hard to find.
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With the permission of the ABA, I've taken one of their example board stems, as well
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as an official oral board examiner, Dr. Suzanne Bennett, to present the highest fidelity example
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of what the oral board is really like.
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One of my colleagues who recently passed the exam, Dr. Steve Summers, graciously agreed
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to play the role of the examinee.
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Without further ado, the mock oral exam.
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Steve Summers is an assistant professor of anesthesiology at the University of Cincinnati
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and a good friend of mine.
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In addition to being a clinically excellent anesthesiologist, he has two beautiful daughters
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and is quite skilled at smoking meats.
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He successfully passed his oral boards in October of 2022.
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Steve, welcome to the program.
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Thanks for having me.
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Suzanne Bennett is a professor of anesthesiology at the University of Cincinnati, where she
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wears many hats, including being medical director of the CBICU and the ECMO program at UC Health
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and director of the critical care division at UC Health as well.
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In her spare time, she administers the ABA oral board exam.
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Suzanne, thanks for joining us.
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Thank you for having me.
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When I was studying for my oral boards about five years ago, one thing that I always thought
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was difficult to find was an example of what the oral boards might actually be like.
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Today, with a real board examiner and the permission of the ABA, we present what the
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oral board exam is like, followed by some debriefing.
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One last thing before we start, I do want to mention that Steve is post-call, having
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worked overnight before we recorded this this morning, which is the equivalent of doing
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this with one hand tied behind his back.
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I'll start by reading the short stem aloud.
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A link to the stem will be in the show notes.
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A 38-year-old, 50-kilogram woman is scheduled for excision of an occipital glioma while
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in the sitting position.
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You are first to note a late systolic murmur, loudest at left sternal border.
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She has mild controlled hypertension.
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Medications include hydrochlorothiazide for five years and dexamethasone for five days,
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bolsus 74, blood pressure is 135 over 80, respiratory rate is 16, temperature is 37
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degrees Celsius, hemoglobin is 13 grams per deciliter, sodium is 140 mEq per liter, and
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potassium is 2.9 mEq per liter.
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Okay Steve, thank you for coming.
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We want to make sure that we have the same exam as described in the introduction, a 38-year-old,
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50-kilogram woman going for a excision of an occipital glioma.
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That's what I have in front of me here, yep, thank you.
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Perfect.
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We'll get started with the preoperative evaluation.
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The neurosurgeon asks, what cardiac evaluation is needed for this patient?
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What would you say?
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Well given her murmur, I think I certainly want some more information on the nature of
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any valvulopathy that she might have, especially given the sitting cranny and the higher risk
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of the position for that procedure.
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What do you mean the higher risk of that sitting position for that procedure?
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How does that affect your cardiac evaluation?
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Well as opposed to most patients who are supine and the profusion of the brain is at the level
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of the heart, there's going to be a discrepancy between what the heart is seeing and what
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it's delivering to the brain.
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So I would certainly want to make sure that there isn't some depression and ventricular
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function or other severe valvular abnormality that I would have to adjust my treatment and
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monitoring of.
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What is your concern with this late systolic murmur heard at the left sternal border?
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So it could certainly be aortic stenosis, it could be pulmonic valstenosis such as pulmonic
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stenosis, it could also be some other intracardiac defect.
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And what studies did you want?
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Specifically for her I would order an echocardiogram.
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Would you delay the surgery to get the echo?
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I would.
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Given the nature of the positioning, I think it could have a significant impact on how
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I manage the patient.
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Anything else you could get from her history that might reassure you with proceeding without
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the echo?
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Well certainly, I think that aortic stenosis is probably the most likely thing I would
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be asking about any chest pain, shortness of breath, edema, syncope, presyncope, and
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just other general questions for patients who may or may not be in heart failure.
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What about mitral valve prolapse?
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Could that be what's going on here?
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Mitral valve prolapse doesn't tend to have like a late peaking murmur.
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I think there's more of an opening snap and some regurgitant type of murmur.
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So I am less likely that that's the case for her.
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But the echo would help delineate that as well.
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So if you got an echo and it does in fact show she has aortic stenosis, would you cancel
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the case?
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No, not necessarily.
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It sounds like it's a surgery that needs to happen.
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Certainly if it was like critical aortic stenosis, if there were other abnormalities, then we
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would certainly have to have a discussion with the neurosurgeon as well as the cardiac
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team to devise the best strategy.
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But if it weren't that serious, it may just key me into changing how I monitor the patient
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and proceed.
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What if there were no intracardiac defect?
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How would that affect your management of this patient?
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Well she's still at risk for hypoperfusing her brain, giving the sitting nature.
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So even without any obvious cardiac dysfunction, I still would need to plan to make sure she
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has the appropriate access and monitoring to ensure she has a good cerebral perfusion
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during the case.
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Speaking of the cerebral perfusion, how do you determine, let's say, if the intracranial
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pressure was increased currently, like preoperatively?
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So clinically, there are a number of things you can look for.
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So patients often have a depressed sensorium or altered mental status.
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They often have a headache.
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They often have some nausea and vomiting.
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They can have blurry vision.
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And as it progresses in severity, you can get cranial nerve deficits as well.
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What would be important to assess this before surgery?
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Because it can impact not only my anesthetic plan as far as improving blood flow to the
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brain, but the surgeons are also going to want an ideal operating environment, including
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brain relaxation.
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So if there were things that could be done preoperatively to set us up in a better position,
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then certainly we'd do some of those things.
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If you do suspect that the intracranial pressure is elevated, what could you do preoperatively
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to intervene?
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So the patient is already on dexamethasone, which can help with some vasogenic edema.
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You can also do things such as osmotic diuresis, whether that included hypertonic saline or
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mannitol.
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Which would you choose?
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I would probably do mannitol, but either of those would be fine options.
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Why did you choose mannitol over hypertonic saline?
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I have used it more, just personally speaking, in the operating room, so maybe have a little
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bit more of a comfort level with that.
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How does this hypokalemia, the potassium of 2.9, play into your decision?
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Well, she already has some hypokalemia, and certainly giving mannitol could make that
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worse.
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It could dump more potassium into her urine, so that's definitely something to consider.
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Would you want to treat that before you went to the operating room?
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I would, ideally.
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I would talk to the surgeon, if it didn't sound like it's something that had to go
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immediately, I would talk about delaying the case to get it to at least a low normal level.
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One anticipating that if I were giving an osmotic diuretic, that that would drop her
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potassium even more.
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Also, I may be hyperventilating the patient during the case to help with brain relaxation
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and reduction in ICP, and so that could further drive potassium lower.
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The nurse surgeon's like, why do we even care about this low potassium?
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What impact does that have on the patient?
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I would explain to him what I just mentioned to you.
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Also, I think the heart in general is at a higher risk during this case, and if there
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was hypotension, if there was any air that entered into the heart, I think if she was
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more likely to have arrhythmias already at baseline, then that could potentially just
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further aggravate things.
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Would you delay surgery?
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I would.
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To what end point?
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When would it be okay to go to the operating room?
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I would shoot for low normal, which would be roughly 3.5.
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What if she was 3.4?
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If it was 3.4, we would probably proceed, and I could also give her more potassium during
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the case as well.
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How would you manage the potassium if you had the increased ICP and you had to do the
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hyperventilation and the diuresis, as you mentioned?
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Yeah.
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Well, there's a couple things that I could do.
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Certainly, you can give potassium faster if you have a central line, so I could give it
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about twice the rate as compared to a peripheral IV.
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I could also potentially have, allow some permissive acidemia.
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Also, I wouldn't go crazy with that, but there was slight metabolic acidosis that would allow
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the potassium to drift a little higher as well.
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What are the implications of hypertension to your anesthetic management?
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I think one of the major tenants of neurosurgery is maintaining an adequate oxygen delivery
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blood flow to the brain, and there can be problems with both hypertension and hypotension
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in the setting of a brain tumor.
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It looks like her baseline blood pressure is 135 over 80, so I would certainly want
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to make sure that we were close to that level or making sure that she was taking her medications
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leading up to surgery.
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What if the blood pressure was 180 over 115 preoperatively?
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How would that affect your decision?
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I would first try to get a sense of, one, if she was having a lot of pain, if she was
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anxious about going back to the operating room.
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She had recently taken her hydrochlorothiazide.
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I would also want to reassure myself that she wasn't having some sort of cushing reflex
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that-
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Would you treat it?
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Again, if her baseline was what it is in the stem, and I thought that this was more so
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anxiety driven, I would be less likely to treat it to get it right back down to a baseline
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knowing that if I treated it preoperatively, I potentially could overshoot when I induce
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anesthesia and then have hypotension that I would have to-
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Let's say she didn't take her medications this morning and this blood pressure is 180
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over 115.
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Would you treat it prior to going to the operating room to bring it back down?
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Some practitioners would.
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I would not.
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I certainly wouldn't give her her hydrochlorothiazide.
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That can make her more hypovolemic and hypochalemic.
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I would bring her back to the operating room and I would slowly induce anesthesia to make
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sure that we were keeping a close eye on her blood pressure and getting closer to her baseline.
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We're going to move from the preoperative evaluation into the interoperative management
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part of the case.
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What type of IV access would you use?
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I would definitely want large bore IV access for this patient to be able to give fluids
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quickly.
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I'm not sure if I would place a central line or not, but it would also depend on if she
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had any abnormalities on her echo preoperatively as well.
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Does the sitting position impact your decision as to whether or not to place only peripheral
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IVs or to proceed with some central access?
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I know then a lot of textbooks that talks about placing central lines for these cases.
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I don't think that the literature is clear cut that there's obvious benefit for that.
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I think if there was possibility that there would be benefit to placing that and the risk
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was low enough to placing, then I would probably place a central line.
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Let's say she does have terrible IV access.
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You are unable to get the peripheral IVs that you thought were needed for the anesthetic
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and you have to proceed with the central access.
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Would you go with the standard central venous catheter?
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Would you use a pulmonary artery catheter?
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What would you choose?
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I would use a multi-orphous central venous catheter that one, not only had the ability
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to give certain medications and fluids safely, but also would give me the best shot at being
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able to aspirate any air should there be a venous air embolism during the case.
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What would you choose?
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The multi-orphous central venous catheter.
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For this particular patient, wouldn't place a PA catheter.
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You are in the operating room and you're proceeding with the right internal jugular cannulation
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for the central catheter that you mentioned.
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As you're doing that, the patient coughs and becomes dyspneic.
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What's your differential?
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My main concern would be that the needle was close to the pleura and that I may have caused
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the pneumothorax.
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It's possible that she could also have had injury to the phrenic nerve or be anxious,
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but obviously would want to roll out a pneumothorax in this situation.
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So how would you do that?
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How would you roll out or roll in a pneumothorax?
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I think the fastest way would be to have someone bring an ultrasound in the room and I would
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scan the chest to roll that out.
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What are you looking for?
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Specifically I'd be looking for absence of B-lines, absence of lung sliding and lung
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pulse.
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If I did not have those, then I'd be looking for a lung point to pathognomonically confirm
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a pneumothorax.
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I would also call the x-ray tech to get a chest x-ray as well.
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If the x-ray hasn't arrived and you're confident based on your ultrasound exam that this is
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a pneumothorax, would you treat that prior to the x-ray?
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It depends on the hemodynamic circumstances.
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If everything was kind of stable and status quo, then I wouldn't immediately need to treat
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it if there was hemodynamic compromise.
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Actually the blood pressure is dropping precipitously.
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What would you do?
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In that case, I would need to do a needle decompression.
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How would you do that?
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I would use a 16 gauge angiocath placed roughly between the second and third intercostal space
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on the side that the pneumothorax was on to allow a decompression of the air.
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I would also be calling for trauma surgeon or whatever surgeon I had in-house to assist
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with placing a chest tube after that.
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What do you think happened there?
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Why did the blood pressure drop?
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I think enough air accumulated in a pleural space that led to a reduction in the venous
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return and therefore decreasing cardiac output.
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How do you plan to induce this patient?
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Let's say you fixed the whole pneumothorax or maybe the patient never even had one.
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How would you plan to induce the patient?
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My main goals are to maintain perfusion pressure to the brain.
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I would do, assuming that she didn't have terrible reflux or some other reason that
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I needed to do an RSI, I would slowly induce the patient, I would have an arterial line
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in place to begin with and I would monitor the blood pressure closely.
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I would plan on using propofol.
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I would also have agents such as Esmolol and fentanyl before laryngoscopy just to ensure
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that I blunted any laryngoscopic reflexes.
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Why did you choose propofol?
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Propofol is reliable, it's predictable, it blunts reflexes to a certain degree, I think
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better than say, a Tomidate would.
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Even though it can cause some reduction in blood pressure, it also tends to decrease
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the cerebral metabolic rate for oxygen.
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What about lidocaine?
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What role do you have for lidocaine in this induction?
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I know most people give lidocaine, I think that would be fine to give.
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I don't know that it is particularly effective.
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If my goal is to avoid sudden tachycardia and hypertension on induction with this patient,
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I think I would rely more heavily on things such as Esmolol and fentanyl.
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What about blunting the laryngeal reflexes?
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Is there a role for lidocaine in that?
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I'm not clear cut on the evidence there.
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I think there's some suggesting that it's beneficial and others suggesting that it's
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not so much.
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I do routinely use it, but if I have a real reason that I really wanted to avoid the hypertension
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and tachycardia like in this case, then I wouldn't solely rely on it.
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What about an opioid?
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Would you administer an opioid with this induction?
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Yeah, I would give a small dose of fentanyl.
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Again, I would be monitoring the blood pressure the whole time with the sympathectomy that
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it can cause just to ensure that I wasn't dropping too much.
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What about midazolam?
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Is there any value of midazolam administration in this patient?
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There could be, but I would be very cautious about giving it.
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If there were concerns about increased ICP, then giving midazolam that could cause respiratory
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depression, one could cause hypercarbia, potentially hypoxia that could make the situation worse,
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and then also just certain tenants of neuroanesthesia would be to, if at all possible, avoid medications
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that could confound a neurologic exam.
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What about the maintenance?
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What's your plans for maintenance of anesthesia?
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Let's speak with a neurosurgeon just to make sure that there weren't plans for neuromonitoring.
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I don't believe that occipital tumor sections are, at least from what I'm aware, typically
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use neuromonitoring that would necessitate a TIVA.
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If that were the case that they didn't need neuromonitoring, then I would plan on using
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a volatile agent such as seboflurine and paralytic.
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What about nitrous?
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I don't think nitrous would be a great choice here.
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Is it contraindicated?
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It's probably more or less absolutely contraindicated.
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A couple of reasons.
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I think number one would be sitting crannies, I think are ubiquitously associated with some
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degree of venous air embolism, whether that's very small amounts or potentially even larger
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amounts.
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And then pneumocephalus is another concern for this type of surgery in this position
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that nitrous would just make either situation worse.
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You mentioned TIVA for neuromonitoring.
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What neuromonitoring would be in play that you would not use the volatile anesthetic
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but you'd use TIVA?
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So specifically in the occipital lobe, you have the optic radiation.
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So if there was a chance that the tumor was pressing on part of that pathway, then visual
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evoke potentials could have a role.
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I know that they are very sensitive to the effects of volatile anesthetics.
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So if the surgeon did have a plan on monitoring for the integrity of those tracks, then I
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could use a TIVA for that.
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But otherwise...
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Does this surgery require relaxation with neuromuscular blockers?
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It doesn't require it.
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It certainly requires a still field.
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So if I didn't use neuromuscular blocker, I would need to use something else such as
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remifatinol to keep the patient still.
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What would you use?
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I would use a neuromuscular blocking drug such as rockeronium if there was no other
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neuromonitoring going on.
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Why did you choose rockeronium?
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It's predictable.
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It's relatively short acting.
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They're proceeding with surgery now.
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You've induced...
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You've got the patient comfortably and safely anesthetized and the surgeon complains that
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the dura is taut.
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What would be your response?
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How would you treat this?
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A couple of things I could do.
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So probably the fastest thing that I could do to help with a situation would be to hyperventilate
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the patient to a certain degree.
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You could also make sure that there aren't excessive levels of peep that could cause
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increased CBP and therefore some venous congestion.
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Some things that would take a little bit longer would be administration of mannitol, but I'd
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be talking to the surgeon about all those things.
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How much hyperventilation is enough?
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How do you know you've done enough?
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I think low normal is appropriate, so probably be shooting for a PA CO2 in the low 30s.
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I think that will help with vasoconstriction and reducing the cerebral blood volume and
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therefore ICP.
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Any beyond that, any more hyperventilation is likely only going to potentially lead to
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cerebral ischemia and not have any further effects.
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How does it lead to cerebral ischemia?
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It's a vasoconstriction response.
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Could you deepen the anesthetic?
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Would that help?
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I could, but if I was mainly relying on volatile agents such as sevoflurane, increasing the
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anesthetic depth there would likely only lead to uncoupling of cerebral blood flow.
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It can actually cause excessive vasodilation, so I could actually make the situation worse.
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You mentioned osmotic diuresis for mannitol.
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How much would you give?
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I am familiar with giving doses in the half a gram per kilogram range for patients.
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I would obviously discuss with the surgeon if they had a preference on how much to give,
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but it would be somewhere in that ballpark.
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Is there a maximum dose where you would just not give anymore?
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I don't know that there is an actual maximum dose.
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I think theoretically if you kept giving it, then you would run into issues with hypovolemia
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and electrolyte derangements.
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What about deliberate hypotension?
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Would that be beneficial to decrease the intracranial pressure?
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Probably it could help decrease the intracranial pressure.
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However, it would be highly likely that I could be inducing ischemia to the brain, either
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globally or to the area of interest that the tumor where they're working on.
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I would be very hesitant to deliberately induce hypotension.
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I could decrease the blood pressure within a certain range compared to the patient's
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baseline.
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How far would you go?
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How low would you go?
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Assuming that her blood pressure, her baseline was what it is in the stem, you could drop
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it 15, 20 percent.
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How would you do that?
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Well, assuming that I had an appropriate depth of anesthetic, I would use... There's a
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couple different options.
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There's direct vasodilators.
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Nacardipine would be a good option for something short acting and predictable.
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That's probably what I would reach for first.
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There's a sudden blood pressure decrease.
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It drops to like 50 over 35.
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What do you think could be going on?
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There's a number of things.
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My main concern would be that there could be a venous aromalysm.
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If we had caused pneumothorax earlier with central line placement, that there could be
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a kind of a delayed presentation in tension physiology there.
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You could have excessive anesthetic on board or accidental administration of a vasodilator.
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But certainly, we want to rule out venous aromalysm in the first place.
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How does that work?
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How does this venous aromalysm create hypotension?
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When air entrains and enters into the right heart, it goes through the pulmonary tree.
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If there is enough air, it can actually cause an obstructive shock type of picture in the
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right ventricle and the right ventricular outflow tract.
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How could you establish the diagnosis of a venous aromalysm?
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I know this wasn't brought up, but I would, for this case, probably would have placed
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a TEE probe to monitor for that.
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That would be the fastest and probably the most sensitive way to detect air entering
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the heart.
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If I didn't have that, I could call for a precordial Doppler to get that in the room.
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But I would also be looking for other signs such as a decrease in the end-tidal CO2.
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Obviously, the patient's hypotensive.
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You could be hypoxic at some point since you're not delivering blood flow through the pulmonary
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tree.
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How would you...
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Let's assume it is an aromalysm.
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Your suspicion is quite high.
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How would you manage it?
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I would first notify the surgeon, make sure that they had flooded the field with saline
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to stop any further air entry.
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I would be treating the blood pressure with one fluids and then inotropes.
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I think epinephrine would be a great choice in this case, not only to help raise the blood
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pressure, but also to support the right ventricle.
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If I had that central venous catheter in place, I would be attempting to aspirate air from
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that.
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Then I would also be talking to the surgeon if it would be appropriate to drop the head
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of the bed, place them in more of a left side down just to try to move air away from the
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RVOT.
28:47
This patient you suspect has a venous aromalysm.
28:51
Why with this particular surgery?
28:54
Is there a greater risk in cranial operations as opposed to other surgeries that are prone?
29:02
Prone surgery.
29:04
There are cerebral venous sinuses that can be quite large, that are fairly non-compressible
29:13
compared to other sites.
29:15
There can be multiple of them.
29:17
That's kind of my understanding of why it can be particularly problematic for these
29:22
type of surgeries.
29:23
What type of fluid would you be using for the anesthetic?
29:28
I would probably use normal saline, given that I wouldn't be administering large amounts
29:34
that could cause a metabolic acidosis, but the relatively hypertonic nature of it would
29:43
possibly have some benefit of decreasing brain water content during the case compared to
29:49
say lactated ringers or something else that would be hypotonic.
29:54
Is there any value of dextrose to be added to the IV fluids?
29:59
Not that I know of.
30:00
I certainly would want to avoid, well obviously hypoglycemia, but hyperglycemia is also detrimental
30:09
in general, but definitely in neurosurgery as well.
30:13
I would not use dextrose unless the patient were hypoglycemic.
30:17
Why is hyperglycemia particularly concerning in neurosurgical procedures?
30:23
I think it exacerbates the metabolic milieu whenever there is ischemia, retraction, injury
30:33
to the brain.
30:36
Hyperglycemia is known to make the metabolic situation worse there in the brain.
30:41
How would you know how much fluid to give the patient?
30:46
There's a number of things that I would be looking for, certainly vital signs, heart
30:50
rate, blood pressure, I'd be looking at urine output, skin turgor, mucous membranes, and
30:57
then there's a number of lab indicators that I would look at such as the hemoglobin hematocrit,
31:03
lactate, base deficit, all those kind of clumy end.
31:07
So you have that data, what would tell you you are adequately resuscitated from those
31:14
findings?
31:16
Just numbers that all kind of correlate with what I would expect for that case at that
31:22
particular point in time.
31:23
I'm not sure if more specifically beyond that.
31:27
We're going to stop there.
31:28
That's the end of that case.
31:29
Take a deep breath, drink of water.
31:31
We're going to move on to totally different cases now, so just forget that case.
31:36
You went home, came back the next day.
31:38
Perfect.
31:39
All right.
31:40
First one is you have a 34-week gestation newborn, 2.5 newborn, who shows up for a TE
31:51
fistula repair.
31:53
What are the major anesthetic risks for a patient with a TE fistula?
32:00
So aspiration is a big concern.
32:07
Also difficulty with placing the ET tube and getting it in the correct location.
32:14
Those are some of the bigger concerns.
32:17
I know that patients with TE fistula also tend to have a fairly high incidence of congenital
32:24
cardiac abnormalities, so I'm looking into that as well.
32:28
Does the type of fistula alter your approach to management?
32:36
There may be some nuances in what I would do differently.
32:40
I think the tenants are mostly the same.
32:47
Let's say this child actually has the H-type fistula.
32:51
What does that mean for you and your anesthetic management?
32:55
So the H-type is both a proximal and distal TE fistula.
33:03
Again, there's risk of one, aspiration of any secretions that were in the esophagus
33:11
or stomach and causing pneumonia.
33:17
There's also the risk, and this goes for most TE fistulas, would be air entering the
33:25
stomach through the lungs and causing difficulty with ventilation.
33:30
Does this type of fistula impact your pre-anesthetic plan?
33:39
I'm not sure.
33:40
Beyond the cardiac workup and ensuring that there wasn't a pre-existing pneumonia that
33:49
needed to be treated before heading to the operating room, I'm not sure.
33:53
What kind of orthopedic workup would you want?
33:56
I would get an echocardiogram for this patient just to make sure that there weren't any cardiac
34:02
defects that needed to be addressed prior to heading to the OR.
34:05
How would you induce anesthesia for this patient?
34:10
Assuming that I had a working IV, since the patient's already going to be an inpatient,
34:15
I imagine, I would plan on doing an RSI for this patient.
34:23
I could do an inhaled induction, but I'd probably choose an RSI for this patient.
34:27
Why would you choose RSI?
34:30
The risk of aspiration is fairly high.
34:32
I certainly would ensure that the patient had an NG tube, or I guess a tube into the
34:39
enteric pouch, the esophageal pouch there, just to decrease the risk of aspiration.
34:46
But nonetheless, there's still a risk of aspiration.
34:49
So assuming that the airway weren't planned on being difficult, I would want to get the
34:54
breathing tube in as soon as possible.
34:56
What would you use for induction?
34:59
I would use, assuming stable hemodynamics, I would use propofol and rocuronium.
35:08
Would a circle system be appropriate?
35:12
Circle system, I believe, is what most modern anesthesiast breathing circuits are, as opposed
35:21
to some of the more open-air ones.
35:24
So yeah, I think a circle system would be appropriate for this patient.
35:27
Would you plan to extubate this patient at the conclusion of surgery?
35:31
It would be a discussion between us and the surgical team, given the nature of a more
35:41
delicate operation with fixing the fistula.
35:46
It may be wise to take the patient back to the operating room and have a more controlled
35:51
environment for slowly waking the patient up.
35:56
Which would you do?
35:58
Right immediately post-operatively or delay that and come back for extubation in the operating
36:05
room another day?
36:08
If the surgeons were happy with how they ligated the fistula and didn't have any other major
36:15
concerns as far as a delicate anastomosis, and if the patient were appropriate otherwise
36:24
from a blood gas and hemodynamic and metabolic standpoint, I would probably elect to extubate
36:30
the patient in the operating room, knowing that leaving a breathing tube in for a prolonged
36:35
period of time can further compromise lungs that may already be compromised.
36:40
We're going to move from that patient to a new patient, and it's a healthy 25-year-old
36:43
man who requested an epidural anesthetic for repair of the inguinal hernia.
36:49
This is an outpatient procedure.
36:50
Would you agree with the plan?
36:53
Not immediately.
36:54
I would first want to ascertain why he had a preference for that, see if he had particular
37:00
objections to doing, say, general anesthesia, which is what I would most likely choose for
37:07
a healthy 25-year-old having that type of surgery.
37:09
What are your concerns about the epidural anesthetic versus the general anesthetic?
37:14
One would be that there could be an inadequate surgical level of blockade to do the surgery
37:24
itself that might necessitate converting to general anesthesia.
37:29
Also, there's fairly minimal risks, but there's always a risk of post-dural puncture
37:38
headache or, I'm sorry, just a dural puncture, and then also, it's not likely, but there's
37:43
at least some degree of risk of causing some neurologic damage from, say, a hematoma formation.
37:49
If you choose the epidural, what drugs would you use for it, assuming it's used for your
37:54
surgical anesthesia?
37:59
I would probably do, essentially would just rely on a local anesthetic, such as ropivacaine
38:07
or bupivacaine.
38:10
I would put a small dose of fentanyl in there, but I wouldn't use anything long-acting like
38:15
morphine that could cause delayed respiratory depression.
38:19
What did you choose for ropivacaine?
38:21
Could you use bupivacaine?
38:25
I could.
38:26
I think either would be fine.
38:27
Are there any reasons to choose lidocaine, let's say, over ropivacaine?
38:35
Lidocaine would have a faster onset.
38:38
It would be shorter duration, but yeah, I mean, it could lead to a surgical block faster
38:45
than ropivacaine, so that may be advantageous as well.
38:49
Assuming you did do the epidural for your anesthetic, what would be the criteria for
38:52
discharge home?
38:55
I would want to make sure that the level had regressed, that the patient had return of
39:02
electric function and had the ability to avoid, and beyond that, it would just be kind of
39:08
the standard things I'd be looking for for discharging a patient from the setting.
39:13
Let's assume the patient had a dural puncture that you witnessed when you did the epidural.
39:20
You were confident you got a CSF.
39:23
How would you manage that in that scenario?
39:26
If he was a straightforward placement, I would probably go to a different level and attempt
39:34
epidural placement again.
39:36
If it was a particularly challenging placement, then I may thread the catheter and just carefully
39:44
dose as an intrathecal catheter.
39:47
Would you admit the patient?
39:49
No.
39:50
No, I don't think so.
39:51
I would counsel and educate the patient on the possibility of postural puncture headache,
39:59
give him instructions about adequate hydration, maybe some over-the-counter things, and also
40:05
give him a phone number to follow up.
40:07
What if any value would there be to a prophylactic blood patch?
40:12
I don't think that's something that is generally done.
40:18
I would probably go the more conservative route and give him a number to call back and
40:23
follow up should he have a classic headache that would be amenable to a blood patch a
40:28
couple days later.
40:30
What would be the problem with doing a blood patch prophylactically?
40:33
What are the risks?
40:36
There's risks that there could be contamination.
40:39
So you sterilely draw the patient's own blood and then inject it into the epidural space.
40:46
So infection would certainly be a risk.
40:49
We're going to stop there and move to the next patient.
40:51
You're called urgently to radiology where you find a 25-year-old woman undergoing an
40:55
arteriogram for upper extremity ischemia.
40:59
She's hypotensive with urticaria, stridor, and sternal retractions.
41:03
What would you do?
41:06
So it sounds like she may be having an anaphylactic reaction, most likely due to the contrast
41:14
dye.
41:15
So first, ABCs, of course, I would want to ensure airway patency.
41:20
Things I could do to help with that would be epinephrine is fast acting.
41:26
I would also, once I had ensured that she had airway patency, would be giving her bronchodilators
41:34
as well.
41:35
If she had any hemodynamic changes, hypotension and whatnot, I'd be treating that with fluids.
41:42
And obviously, the epinephrine would help with that as well.
41:45
What if the patient proceeded to have a cardiac arrest, what would you do?
41:50
In that situation, I'd be following standard ACLS protocol.
41:57
In that situation, I would want to secure the airway.
42:00
That way I could control ventilation.
42:04
And yeah, I would be obviously calling for help and initiating chest compressions, having
42:10
the crash cart in the room.
42:12
We'll stop there.
42:13
We're at the conclusion of the exam.
42:16
All right.
42:18
Excellent job, Steve.
42:20
Was it?
42:21
Okay.
42:22
I'm glad you think so.
42:23
I think so.
42:24
I chose you to help out with this because when we were practicing together for your real
42:30
oral exam, I was always really impressed with your composure and the way that you delivered
42:35
things.
42:36
But my opinion doesn't really matter here.
42:38
I'm not a oral board examiner.
42:39
Suzanne, what do you think?
42:41
I think, well, first, whenever I'm doing practice exams with people, I often ask them how they
42:48
think they did.
42:49
So how do you feel?
42:52
I feel like there were a lot of ums in there.
42:56
I don't think that I made the best eye contact that I could have the whole time.
43:00
I think I had overall pretty good answers, but it didn't come out as fluid as I would
43:09
have hoped.
43:10
I feel like if I was betting whether I would have passed or failed, I think I got enough
43:16
of the important information that you were hopefully seeking.
43:19
Yeah.
43:20
I mean, I agree with everything you just said.
43:25
When we go through the exam with candidates, we're looking for people to show that they
43:32
are, it's kind of, we go through and check each section as we're going through questions
43:38
just to see how they covered all of the questions and if they did it adequately.
43:45
And then after we go through each of the sections noting, you know, did they hit every question
43:53
fairly on point and make appropriate safe decisions, after we review all that, then
44:01
we go and assess the, whether the candidate had the appropriate application, adaptability,
44:09
judgment, and organizational presentation style when they're going through their responses
44:16
to the questions that we're doing.
44:19
This is probably the most important aspect of it.
44:23
It's not really a knowledge-based test.
44:26
It's a test that we're looking to make sure that the candidate will be able to function
44:32
safely and practically in the clinical arena doing anesthesia.
44:40
And the components that I just mentioned, again, I'll say them again, application, adaptability,
44:44
judgment, and then how did you organize and present yourself during the exam is kind of
44:51
the major components that we're looking to see that the candidate's hitting effectively.
44:56
And by application, we're talking about, you know, how did they analyze the clinical
45:02
scenario, synthesizing factual knowledge, adaptability, we're looking at how do you
45:09
apply the information that I've given you to the patient that we're speaking to, and
45:16
then when the scenario changes, how are you adapting to those changes?
45:21
And of course, judgment.
45:22
Judgment is judgment, right?
45:26
Did you display safe approaches to the questions that we're asking related to the patient,
45:34
and did you choose the appropriate managements?
45:37
And then finally, important but maybe not as important for the practice of anesthesia,
45:45
but important in that was the presentation clear, organized?
45:53
Did you provide adequate information?
45:56
What I mean by that, it's hard to grade someone who doesn't have the answers to the questions.
46:02
So if I ask a question and there's a difference or an I don't know and we continue through
46:07
the exam like that, I'm unable to grade the three other prior things adequately.
46:16
So that's definitely a challenge.
46:20
The areas that, you know, I thought you did well is that you were able to change, you
46:25
were able to adapt to the different scenarios that I presented.
46:31
Even when I'm examining, I may choose if I notice that a candidate is unable, is struggling
46:40
with a topic, I try to change my approach to guide the candidate into the right way.
46:45
Sometimes it could be how I'm asking the question versus and how the candidate's interpreting
46:51
it, versus does the candidate just simply not know?
46:55
And our goal is to really elicit the maximum knowledge that we can get out of you.
47:01
We are assuming you have it.
47:03
And we want to make sure that we're testing you on what we think you know so that you
47:12
can practice safely.
47:14
That all makes sense.
47:16
Do you have any particular feedback about one section or another questions that you
47:22
think I didn't navigate particularly well?
47:26
You know, let's just go through it.
47:28
So from the preoperative evaluation section, you know, we jumped into cardiac and increased
47:33
central cranial pressure and hypokalemia and hypertension.
47:37
I think we, I think, you know, you hit all of it appropriately.
47:41
I think if I provided feedback as to maybe areas that you could have probably swung the
47:50
bat a little bit harder, let's say, is the discussion of blood pressure when we went
47:57
through the hypertension component.
47:59
I think providing just a very deliberate answer as opposed to kind of working around the answers.
48:05
And that's one of the struggles that I think candidates have is when we're asking questions,
48:10
we want the answer and then provide the support for that.
48:16
The trick though for the candidate is that if you're providing the support for it, it
48:20
opens the door for me to ask questions about that.
48:24
Why you ask that?
48:26
We will, you will find we will ask why multiple times because we really want to understand
48:33
why you're choosing that.
48:35
You know, why is that important?
48:36
We really want to know what you know.
48:40
Going to the next section, I think perhaps a little, a little more deep or deeper discussion
48:48
on how the sitting position and the risk of air embolism plays into this.
48:55
And you had mentioned you'd place a TEE for the, once we got down to air embolism, noting
49:03
that in advance, of course, I would have probably challenged you a little bit on that because
49:07
it's a cranny and a TEE and you all at the head of the bed may be challenging.
49:14
I think perhaps maybe speaking a little bit more to focus and what opportunities that
49:19
provides to us now in the operating room for air embolism could have been another way to
49:24
divert that.
49:26
And that's probably what I would have done if you would have introduced to EEs sooner.
49:32
It's interesting when I was preparing for my oral boards a couple years ago, all the
49:37
things that you really want to focus on, like not dancing around the question, getting the
49:43
answer out, displaying that you have made your decision, then when you get to the real
49:51
thing and you hear the words that are coming out of your mouth, sometimes you immediately
49:58
know that that wasn't exactly how you wish you would have said it, but you can't take
50:02
those words back and all you can do is hope that it leads you to the right place and then
50:06
see where the examiner is going to go with that.
50:11
And there were a couple situations where I think with the mannitol and the hypokalemia,
50:17
when you kind of brought that up, I was like, ooh, did I make the wrong decision?
50:21
Should I have chosen hypertonic saline?
50:23
Because it may not lead to further exacerbation in hypokalemia, but I can't take it back and
50:29
all I can do now is just adapt and move forward and have a short memory and go with it.
50:35
It's, candidates need to know that we want them to pass, like we want you to pass, we
50:42
want you to be successful.
50:45
And so we, I call it a dance and it's a dance.
50:49
As I'm seeing the candidate going in one direction or the other, I will try to navigate how I'm
50:55
asking questions to either, if I think it's a comfort level, I'll try to change and adapt
51:01
to increase the comfort of the candidate because what we really want to know is we don't want
51:07
to know how good you are at exams, right?
51:10
We want to know that you're going to be able to practice anesthesia safely.
51:15
And the only way to do that is for us to adjust as you're, we're seeing how you're navigating
51:19
the exam.
51:20
And that's what we do.
51:21
We'll kind of swing a little bit one way or the other, recognizing, and I could feel in
51:25
times during the exam when you were heading down a path and I would stop questioning much
51:32
further on that because I didn't want to get you in a brain lock situation where you're
51:37
unable to answer further questions.
51:39
It's very kind of you.
51:41
Well, again, I think it's the goal of us is, is we want to get through this exam.
51:46
We need to get through the each, all of the questions that we have available to us.
51:50
We only have 35 minutes to do it.
51:51
And it's a hard, it's a hard stop, 35 minutes.
51:55
And each section, you know, the first section is 10, the second section is 15, and the last
52:00
section is 10.
52:01
And we have to, you know, to administer a fair exam for each candidate that comes in,
52:06
we need to be able to get through each of those questions or conceptually the content
52:11
or in the, the intent behind the questions.
52:17
And so we don't want you, the candidate to get, you know, I call it brain locked where
52:23
you freeze up and, and now you're, you can't move forward because you're so stuck and maybe
52:31
a mistake you made.
52:33
Right.
52:34
And so our goal is to try to get you moving forward and give you some other questions
52:37
to kind of boost that confidence back up and then kind of circle back just to ensure that
52:41
we're you're able to answer the question appropriately.
52:46
Makes sense.
52:47
As a candidate, if you feel that your answer was not correct and you really want to change
52:56
that, you can.
52:59
You can change that.
53:00
We're going to ask why there'll be a lot of whys, but it's, there's, it's not a game of
53:07
no take back.
53:08
You know, there's take back until the final buzzer goes off until the final buzzer goes
53:13
off.
53:14
Right.
53:15
One of the things that I think really struck me preparing for my oral boards is how stark
53:21
of a contrast it is compared to almost every other test we've ever taken before going through
53:27
medical education.
53:28
Almost every single test is multiple choice written tests staring at a computer screen.
53:35
Here I'm staring across at someone who is sort of in a way deciding my future.
53:40
There's the immediacy of they ask a question and I have to give that feedback right now
53:44
and I have to get it out in a succinct, efficient, organized manner.
53:50
I can't come back to question two after I've done question a hundred.
53:55
And there's just, there's other things at play that really are different than the written
54:01
exam.
54:02
So in this situation, it's almost advantageous to make assumptions such as if the airway,
54:09
assuming that the airway were not intended to be difficult, yes, I would proceed with
54:13
an RSI, whereas in written tests, you can only take the information that's presented
54:18
to you and you should not make assumptions.
54:21
So there's just key differences that you really have to kind of forget the written multiple
54:27
choice test and just gear up for in person, in the moment.
54:38
And that's why you have to practice, practice in your mind with your responses.
54:43
How many practice exams do you think you did prior to your oral board exam?
54:49
I officially with different attendings in our department, I did eight.
54:54
One was with you.
54:56
And that's one of the only reasons I agreed to do this today is because I knew that you
54:59
wouldn't kill me.
55:01
But I did some more informal practice ones with another co-resident of mine from residency.
55:09
But I would say, you know, each and every one of those mocks, I learned something different.
55:16
And Dr. Crowe, I did one with you almost forgot that as well.
55:20
Everyone's style of questioning is different, their pace, the way that they look at you,
55:27
and the level of comfort that you feel in their room.
55:30
So I think every single one of those is beneficial.
55:35
And everyone else told me, you need to practice, practice, practice.
55:39
In my head, I was like, but can I just go through the book, the prep book and answer
55:45
questions in my head and I'll be good.
55:47
And I would say, yes, you need to do that.
55:49
But it's invaluable to have that in person.
55:54
Sure you can do it over, you know, Skype or FaceTime if you really wanted to or needed
55:58
to.
55:59
But I think in person practice with multiple different people, in my mind anyways, is the
56:05
key to feeling more comfortable and prepared for the real thing.
56:09
Yeah, you know, practicing with people you know, places you in a vulnerable position.
56:16
Because in that was that would say I would say that other than time, I think vulnerability
56:22
to colleagues or peers for fear that your lack of knowledge or your response is not
56:28
what it should be, probably limits people from practicing as much as they would.
56:33
I can see that.
56:34
And, and I, you know, if people can get past that and just look at some practical things
56:39
like you've paid a lot of money.
56:40
Yeah, and you spent a lot of years in training.
56:45
This is probably that one time just to throw your vulnerability out the window and expose
56:49
yourself because the more failures you have prior to the exam, set you up for your success
56:55
during the exam because we learn so much from our failures, right.
56:59
And when you're failing in a comfortable place with peers and colleagues, you know, it's
57:05
like it's like a hug, right?
57:07
When you fail at the boards, you walk out, you've lost all the money and you've got
57:11
your months or a year before you can take it again.
57:14
And so time and money and are really important.
57:19
And while vulnerability is important as well in this scenario, I would just say to people
57:24
to let go of that just a bit.
57:27
And fail, you know, fail, fail, fail over and over again, because your greatest success
57:32
will come from those failures.
57:36
The other thing that I think is important for people to know is that when I took my
57:40
oral boards, we were still in hotels, we don't have to go back to years and dates.
57:45
I don't actually feel old.
57:48
But as I speak, it seems so.
57:50
And I left I was doing my critical care fellowship.
57:54
I took it on a Friday morning at 7am and left there had a hoodie on.
58:01
Sat I was in New York, sat at the airport and not at my gate where my plane was going
58:06
to take off.
58:08
Other people were celebrating, you know, having drinks at the bar.
58:11
I'm at the airport taking the earliest flight home.
58:15
And I've got my hoodie up.
58:16
I'm crying because I knew I failed.
58:20
And then, you know, got got off the plane in Cincinnati, drove straight to the ICU and
58:30
did afternoon rounds with Dr. Friedrich, who is my attending in the unit.
58:35
And Dr. Mecklen was my resident and and Dr. Pino was also as well.
58:43
And did my afternoon round so I could take call all weekend.
58:46
It was really super awesome.
58:47
You know, Dr. Friedrich said, oh, you did fine, buddy.
58:51
And then just congrats, you're done.
58:53
And then we made rounds.
58:55
And what was really super cool is my team had created a little little welcome gift that
59:00
was really comical upon my arrival, which I still keep on my desk in my office.
59:07
And you passed.
59:08
And I passed.
59:09
Yeah.
59:10
OK.
59:11
I thought you were going to leave that piece of information out.
59:12
Yeah, I was like, oh, my gosh, I passed.
59:13
But yes, I think it's common.
59:15
Yes, the point of the story here is it's common for everybody to feel anyway, but even as
59:21
worse as you failed.
59:23
Because you will start cycling through.
59:26
Oh, man, I should answer this.
59:27
Oh, man, I should answer that.
59:29
I still remember personally several examples of questions that they asked me.
59:34
It really is a situation where their questions and your responses get locked in your brain
59:41
sort of permanently.
59:42
Yes.
59:43
Yes, they do.
59:44
I mean, I remember exactly that even today, like the am I examiners actually.
59:50
So am I stems?
59:52
Yes.
59:53
So well, any more specific feedback that you have for Steve on the stem there was no anything
59:59
that.
1:00:00
No, I think, you know, in all exams, there's areas that people won't know everything.
1:00:11
They just won't.
1:00:12
But as long as you are practicing safely, that's important.
1:00:15
And when you look at, you know, if we go through the last three topics, you know, sometimes
1:00:21
we can identify whether someone's a pediatric anesthesia trained person or if they're a
1:00:28
pain person or if they're critical care, it seems to kind of bubble up as we're examining
1:00:32
people.
1:00:33
And yeah, no, I think I think overall, I think you did really well.
1:00:40
Well, thank you.
1:00:42
All right, Steve, Suzanne, thank you so much for joining us.
1:00:45
Thank you.
1:00:46
Thanks for having us, John.
1:00:47
Absolutely.
1:00:48
Thanks for joining us for our special mock oral exam podcast.
1:00:54
If this was helpful to your oral board studying, please drop me a line.
1:00:58
You can find me at stylepointspodcast at gmail.com or feel free to leave a rating or a review.
1:01:05
As always, thanks for listening.
1:01:07
Take a deep breath.
1:01:08
Open your eyes.
1:01:09
We're all done.
1:01:10
And then we'll see you again soon.