your boss make a decision i'll probably get a lot of nods if i ask this question has anyone told you
an examiner a colleague say do not say the phrase i could do do not say my options are and it's it's
it's something that i was told constantly through my training um because when you when you're first
in your first two years of training it's all about the options your first part is all about giving
all the different categorizations of hypoxemia or hypovalemia or whatever it is and then going into
some detail but this exam is about knowing those options and definitively choosing one of them so
again this exam is about knowing all those options but you don't have to talk through them this is
about decision making and judgment calls so let's run through some decision making for this exercise
what would you do in this situation so i want you all to think about this 30 year old g2p1 female
for an elective caesar at 39 weeks it's a known grade 4 airway by a consultant no mention of bag
mask or lma five years ago and has gained 30 kilos since let's say this patient is now 110 kilos
with a bmi of let's say 40 43 or something like that what do you do so what would i do i would
probably put in a i would put in a cse on this patient i would have a c-max and digital airway
something new as well as i'm flexible i'm going to stop you there you rightly said csc that i think
that's what most people would like to do knowing what's about to happen here you're unable to place
the cse what would you do use an ultrasound to image the back to see if i can improve my view
and increase my ability to place a neuraxial you try you do that and you reattempt the cse and you
still can't find the space for whatever reason and note that i i'm just being annoying right
but i really want to push you towards something so um keep going sure so if uh if i cannot perform a
csa i will have one final attempt at performing a straight spinal anesthetic if i'm unable to do
this i'm going to plan to do an intubation let's say you can definitely do the spinal stage but
then on further history you find out the spinal wore off as they were closing the skin in the
delivery of the last last baby which is a seizure as well does that change what you do i would so
this is a risk benefit discussion and i would have this discussion with the patient as well as with
the obstetrician fantastic and i'd be wanting to know some more information about their previous
uh um caesar so whether that was performed by a training whether it was particularly long caesar
and what kind of dose they put in the spinal anaesthetic right and that would help me make a
decision as to what i'm gonna do next sounds good uh let's say they put a standard dose let's say
2.2 mils of heavy 0.5 percent b pivot can plus 15 mics of fentanyl it was done by a consultant
uh obstetrician and the seizure was completed in a reasonable time let's say let's say an hour
so in that case i think considering that last time all of the factors were probably uh were optimized
in terms of the length of the block and the speed of the surgery i think in this case the safest
approach is going to be to electively intubate this patient after having a discussion with the
surgeon and the patient about the reasons why how would you go about interpreting the patient
carefully um so i would sure that i have a skilled assistant and a skilled anesthetic nurse and
i would optimize my positioning for intubation just to clarify you're you're not you're not
doing i have a video in the scope and i have a flexible bronchoscope nearby as well as all
my airway adjuncts so just to clarify you're not doing a weight fiber optic you're doing a general
anesthetic okay um can i just get a show of hands with anyone doing a weight fiber optic considering
the situation we're in now okay good and who would go ahead with a just an induction and by the way
i'm not saying that any answer is right i'm just getting you to a pointy end of a decision which no
one on the planet is comfortable with right um you know weight fiber optics are you know rare
enough and it just feels a bit irksome to do that in this situation personally given that situation
i'd probably do an away fiber optic because that feels like the right right thing to do in such a
such a high risk environment but you're not wrong in saying what you did because what i'd suggest
people to do is to go to each consultant that they work with and they trust and say what would you
do in this situation anyway next part here let's say you were about to do an induction and then um
the patient says they really really really really want to be awake for delivery does that change
your plan i don't think it's going to change my plan um i think it just means that i need to
have further discussion with the patients so that they understand the complexity of the situation
and i need to acknowledge their desire to be awake for the delivery and that there's a completely
reasonable things want to do for the birth of your baby but for the safety of the patient
um that this is what we need to do to keep her safe yeah sounds good so i think the take home
message here is that you're gonna you can make any situation a very very difficult situation where
you are damned either way and i think it's really the most important part of that is being able to
make a decision because trust me in the survivor you will get you know occasionally get this kind
of crazy situation one of my colleagues before me had a situation of a wake fiber optic in a known
grade four or impossible airway who's allergic to all uh allergic to all local anesthetics obviously
a really tough situation and this exam isn't one where you can reasonably postpone things
because again this exam if someone could postpone as an answer as a general rule it it doesn't
it doesn't differentiate between candidates this exam is generally speaking one that requires you
to proceed with something and mitigate risks that said let's go through this example so uh what i've
what i've just done there is a particular technique that i think is really worthwhile
uh you can supersize any scenario to make it difficult like that initially wasn't that
difficult but we just added on complexity after complexity so imagine that you do maybe 500 cases
a year and maybe a few of them will be really difficult um but when you do your viper practice
you you want to be training that muscle constantly so add complexity to your scenario when you're
training with your colleagues when you're doing vibrant practice with your colleagues to just help
work that decision-making muscle so let's start with this one eight-year-old male cataract surgery
in just a small private hospital stable nyha 3 heart failure cardio extent 10 years ago
on clopidogrel which wasn't c so clippity goals continued diabetic hypertensive cholesterol like
smoker exercise tolerance the surgeon requests a parry bubble block for cosmetic reasons which is
quite common in private what do you do so for this patient on clopidogrel um i wouldn't be
comfortable to do a peri bulba block and and so i would have that conversation with the surgeon
about other options which would be um for me to do your sub tenons block or alternatively
for um sort of a topical local anesthetic drops only or um the surgeons or the ophthalmologists
to place intracamara local anesthetic using their microscope um i guess as we've discussed it's all
risk benefit but cosmetic reasons wouldn't be enough for me to justify doing this yeah good
and having a firm stance on that in difficult situations is is almost easier in the viver than
actually in private in in your private career in the future but absolutely knowing all the
different options they are and you may get to a point where the surgeon goes nah nah nah or the
examiner goes nope you must do a perivalva i think it's i think there's many different angles you can
take and i like the example that you took that cosmetic reasons are really not a valid reason
in in our culture in our medical climate to do anything but that said you could also ask a panel
of your the consultants around you and say who would do a peri-balba clopidogrel and there is
evidence that the increase of you know bleeding doesn't you know does rise but the fact that
there are plenty of people doing doing parabolas on clopidogrel and anticoagulation and the fact
that the absolute increasing risk is still very small so again you could probably go ahead with a
peri-balba based on what i know of you know common practice in melbourne uh but again you could i
feel like you could talk through this either way and it's about being able to talk through that
decision to sound you know sound smart sound like a consultant that allows you to get through this
because often there isn't a right or wrong answer and there's quite a massive variance of practice