um so what i really want to go through is how to flag the critical issues and how do you cover all
the usual points without wasting time as well so we're going to go through all of that in the next
few exercises so i want you to have a go at this um what do you want to know when assessing this
patient imagine this 50 year old patient with rib fractures supposed to fall past history of copd
i've tried to make it simple by saying there's no other traumatic injury just the rib fractures
just to get across my point prolonged intubation icu will require tracheostomy in theater and the
examiner asks you what do you want to know in your assessment so i want everyone to have a go
at thinking what would they what would they want to know on this patient's assessment before i go
to someone just to realize that you know this is obviously a very complicated assessment any
icu patient has so much you need to talk about on top of what the anesthetic history might be
but just have a go at finding out what those critical issues are
so as part of my pre-anaesthetic consultation um i'd like to start with what was his initial
said he's intubated i'd like to know what was his initial airway grade yes with any concerns over
the airway um i'd like to know what intervention he's had thus far and what are his ventilation
settings has he had any issues with developing ards or any other ventilatory associated issues
um i'd like to consult with my ent surgeon and discuss our plan particularly around the city of
the tracheostomy and airway management i'd also like to know of any other issues he's had in icu
uh that would potentially uh impact my anesthetic management that's great essentially i think you've
picked up on a lot of the really important points so just the first bit of that i think it's great
what you did was you you went straight to what i would want to know most about in this assessment
but sometimes you're not really sure what exactly the examiner is asking and so you know we're here
to try to make sure that we are getting gradual points and just making sure we're very thorough
what we say so i i know that going through a full history is time consuming so what can i say to hit
the critical issues i i say something along the lines of look in addition to my usual assessment
because you know that any you know bty can or even any resident can do a normal assessment that can't
be a point of discrimination between you and the other candidates so i make make note of that make
mention of that but then i'd specifically want to know what are these points of difference so level
of respiratory support and you mentioned exactly very rightly um you know the parameters that you
might want to know fio2 especially if they're using um diathermy in the airway um you know
pressure support peep levels if they've got aids is this patient a difficult airway i've just added
their fasting status and coagulation profile because that often makes a difference for me
about how how i'll proceed and i remember getting asked this question by one of my examiners and um
prior to the actual exam and just going through every single little bit of an assessment that
i would do and it was very thorough but i could just see the disappointment on her face
as i was going through this in excruciating detail when really all she wanted to know was was the
stuff that really differentiated this case from every single other case just to talk back about
uh you know varying the phrasing examiners are human and they hear so many of the same statements
so to be able to say something slightly different and just vary your language i think is useful um
you know obviously it's not the most important thing your content and your presentation of the
facts is most important but you know i might say words as well as my usual assessment on top of
my usual assessment further too in addition to aside from besides whatever it is you can vary
your phrasing in whatever setting to make it a bit more interesting let's go through the actual cases
now so uh talk through this case in addition to your usual assessment what do you want to know
about a 50 year old female for total thyroidectomy for a large goiter what do you want to know an
assessment so this is a 50 year old female for thyroid surgery the large goiter and in addition
to my usual assessment i would like to assess the critical airway issues specifically functional so
i would like to know about current dyspnea stridor and any positional changes i'd like to also review
imaging to assess uh current airway diameter and any metabolic components of her thyroid disease
when i think of this case obviously there's a mass there and the mass can affect very very
important structures especially when it's in the neck or retrosternly so i i globally talk
about respiratory compromise and then i would go through exactly what you said with the recipes you
compromised then think about vascular compromise and all the low pressure structures around that
area and what they would do in all the you know history factors investigation factors
but the first level of that is knowing what is the you know the end point of the problem of mass
effect um i also really care that the patient is euthyroid and you know that's one of those things
i'll always check there's a thyroid storm would be a very very you know tragic event or crisis in the
in the operation and then over the last few years i've noticed that whether it's malignant or not
it's really made a big difference to what my you know what my stress levels are for this
case whether there's going to be a mass that i can push past with a tube or a mass that might cause
tracheomalacia later so those are really the things that i want to i want to look for in this
case think about this case a piezoton selected me five-year-old for tonsillectomy what do you
want to know an assessment um and just with this the fact that it's a peds case is obviously peds
is niche enough that you would probably talk about your full assessment but um in in real
life and in the exam it seems to be that it seems to me that peds cases are often you know i guess
coincidental with a few other things so talk to talk to your partner now what do you want to know
on assessment after your general general pediatric pediatric assessment my usual pediatric assessment
i'd be specifically looking at symptoms related to the tonsils for any obstructive sleep apnea
any snoring any other respiratory symptoms or limitation of their daily activities
i would be looking at any previous anesthetics that they've had um any difficulty with
intubations due to extreme tonsils i'd do a thorough assessment of the airway looking at the
size of the tonsils and likelihood of difficulty um ventilating the patient and also the compliance
with the child and any need for pre-meds yeah sounds good and again everyone will
have a slightly different angle on this and that's completely fine because really what you're trying
to do is make it make your best guess at what you believe this is is most likely in this situation
i've just made it broad here so often these kids will be coming in with os osa repeated respiratory
infections and in a viva there's always some kind of congenital issue to make it a bit more
complex for you as well but everything you said was completely valid next case cesarean section