(2)Station 1 - Rater: Please circle your score

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Informed Consent Case-Stem

Mrs. Colleen Wing, a 67 y/o female is scheduled for an exploratory laparotomy/ tumor debulking surgery with possible lymph node dissection, possible bowel resection and possible cystoscopy and stenting. Her pertinent past medical history includes obesity (BMI 33), HTN, CAD s/p stent with reassuring cardiac functional status (stress ECHO: EF 60%, no new WMA), and rheumatoid arthritis. Her only past surgeries include 2 C- sections and a right knee replacement all under neuroaxial anesthesia without any complications. Of note, she is a Jehovah’s Witness.

Allergies: None

Meds: Prednisone 5 mg qd, metoprolol 25 mg BID, ASA 81 mg qd Labs: BMP and CBC WNL except for HCT of 34, INR 1.2

Vitals: Pulse 59, BP 120/72, RR 14

Exam: Obese female with reassuring airway exam Task Statement

During this scenario, your goal is to discuss blood product options, risks and benefits of discussed options and identify patient’s wishes for blood product utilization. Assume that verbal consent for blood product utilization is sufficient. You should NOT repeat the physical examination.

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Station 1 - Rater: Please circle your score.

Analytic Scoring Scoring Elements

1. Introduces self and establishes role Yes No 2. Explains what a blood transfusion is and why a blood

transfusion may be needed. Yes No

3. Explains benefits of a blood transfusion (at least two) Yes No 4. Explains risks of blood transfusion (at least two) Yes No 5. Discusses all three alternatives to blood transfusion. Yes No 6. Elicits and allow time for questions Yes No 7. Demonstrate responsiveness to questions Yes No 8. Elicits affirmative consent without coercion Yes No 9. Demonstrates understanding of and concern for the

situation of the patient. Yes No

Holistic Scoring Overall Score

Fail Borderline Pass

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Treatment options

Case-Stem

Mrs. Karen Smith, 59 y/o is scheduled for L total hip replacement. She is in the holding area waiting for your pre-operative evaluation.

PMHx: HTN, tobacco use (15 pack-years), chronic left hip pain Allergies: Tetracycline- hives

Meds: Atenolol, lisinopril, ASA, tylenol, ibuprofen ECG: NSR

TTE: overall normal, EF 65%, mod LVH

Pre-op labs: WNL, specifically INR 1.1 and no coagulation abnormalities Vitals: 62, 140/84, 5’6”, 92 kg

Airway: Mal 1, normal ROM Task Statement

Your goal is to analyze a clinical scenario, formulate appropriate anesthetic plan options, and discuss these options (general anesthesia vs neuroaxial) with a patient. Suggest and explain spinal as recommended treatment. Assume that verbal consent for the

procedure is sufficient. You should NOT repeat the physical examination.

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1. Introduce self and establish role Yes No

2. Describe the procedure itself in clear, simple language Yes No 3. Explain the benefits of the spinal for the procedure (at least

two) Yes No

4. Explain the risks of the spinal for the procedure (at least

two) Yes No

5. Describe alternatives to the procedure Yes No

6. Elicit and allow time for questions Yes No

7. Demonstrate responsiveness to questions Yes No 8. Make sure patient understood the information Yes No

9. Elicit affirmative consent Yes No

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Peri-procedural complication.

Case-Stem

Mr. Thomas Kane, 72-year-old patient underwent robotic assisted laparoscopic prostatectomy for prostate cancer the day before. The patient now complains of numbness and weakness in his left leg and foot and is waiting for your evaluation. The patient had an uneventful general anesthetic and operative course.

PMH: HTN, tobacco use (30 pack-years) Meds: HCTZ, captopril

Allergy: NKDA

Vitals: HR 70, BP 138/70, Wt 109 kg, Ht 6’2’’, BMI 31 Pre-op labs: WNL, ECG: NSR, TTE: WNL

Anesthetic record: 18G IV placed in left hand, A-line in left radial artery, Easy mask and intubation (direct laryngoscopy 1st attempt, grade I view with Mac blade 3), Lithotomy

& Trendelenburg position, No apparent complications in OR and PACU, Anesthesia time: 3:30

Task Statement

Your specific task is to evaluate and develop a plan for the management of this potential complication.

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1. Introduces self and establishes role Yes No 2. Queries for history of prior neurologic problems with the

leg

Yes No

3. Elicit current symptoms, both motor and sensory Yes No 4. Performs focused physical evaluation of the leg Yes No 5. Discusses potential causes including pressure under the

knee

Yes No

6. Discusses potential outcomes, including the potential for permanent sensory loss

Yes No

7. Presents plan for further evaluation and/or treatment, including neurology consultation

Yes No

8. Elicits questions and responds appropriately in lay terms Yes No 9. Demonstrates understanding of and concern for the

situation of the patient

Yes No

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Ethical Issues Case-Stem

You are at an ambulatory surgical center in Redwood City.

You are providing sedation and monitored anesthesia care (MAC) to a 22-year-old healthy female for ankle hardware removal. She has anxiety and no other significant past medical history. She is accompanied today by her mother.

The patient had an open reduction and internal fixation (ORIF) of left ankle fracture last year and had post-operative nausea and vomiting (PONV). Today she is in the operating room for left ankle hardware removal. Preoperatively, she received single shot local anesthetic blocks to the saphenous and popliteal nerves. You start a propofol infusion, vital signs are stable, the procedure is underway, and your colleague relieves you for a lunch break.

Task Statement

At the end of your lunch break, you receive a text from the break attending (Dr. Shirley Cohn), “Case is finished. Meet me in PACU bed 6.”

You will be presented with an ethical scenario.

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1. Elicit disclosure of medication error. Yes No 2. Communicates professionally with break attending Yes No 3. Plans to be truthful and disclose error to patient and family Yes No 4. Plans to follow up with patient and family Yes No 5. Plans to communicate event with attending surgeon Yes No 6. Plans to advise primary team to admit patient for

neurologic and cardiovascular workup Yes No

7. Plans to seek guidance from risk management Yes No 8. Plans to report event for internal review Yes No Holistic Scoring Overall Score

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Case Notes and Script:

Frame and discuss appropriate plans to address common ethical dilemmas in clinical care settings.

The ASA Guideline for the Ethical Practice of Anesthesiology provides guidance into ethical issues facing anesthesiologists. The successful candidate will demonstrate behaviors consistent with application of the principles articulated in these guidelines, including the principles of patient autonomy, beneficence, and non-maleficence.

+++++

When the examinee enters the room, they will meet their examiner, who is playing the role of break attending.

I have bad news. I think I made a medical error. At the end of the case, I gave zofran. On the way to the PACU, the patient started complaining of a headache, chest tightness and pressure, and belly pain. I thought it was anxiety. It took us a few extra minutes to get the patient onto the PACU monitors because the nurses were still cleaning the monitors when we arrived. The first blood pressure reading we got was 198/94, but I thought it was artifact or anxiety, so I gave her 50mcg of fentanyl. After ten minutes, her blood pressure gradually came down to 122/68, and she said that her headache, chest tightness, and belly pain had resolved. Then I was worried that I made a medication error. I went back to the operating room and found an empty vial of phenylephrine and no empty vial of

ondansetron in the kidney basin, so I am afraid that gave 10mg of phenylephrine instead of 4mg of zofran.

The patient says she’s feeling fine now. Since she’s healthy and is feeling okay now, can she just go home? Do we have to tell her that we made a medication error? I’m afraid that I’ll get fired or sued. What should we do now?

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Communication with other professionals Case-Stem

65 y/o obese male presents for elective right total knee replacement. His known past medical history is hypertension and hyperlipidemia, but notes rarely visiting a primary care doctor. His social history is significant for smoking and sedentary lifestyle, which the patient attributes to his knee pain. He is currently scheduled for the first of four cases with surgeon Dr. Adam Smith, of note the second patient of the day has already arrived in the facility.

You receive a call from the pre-op nurse stating the patient complains of new onset shortness of breath, mild non-radiating chest pain, and new lower extremity peripheral edema.

Vital signs: BP 165/95, HR 98, RR 24, RA sat 93%.

Height 5’ 10” Weight 113 kg, On exam is slightly diaphoretic

EKG shows LBBB, age indeterminate, as he does not have one to compare to.

Task Statement

Your specific task is to present your clinical concerns and to recommend postponing the surgery to Dr. Smith (who does not know you well). You will offer to arrange additional work-up (rule out current active process, and arrange for future testing for

optimization). The discussion is taking place in a consultation room shortly prior to the scheduled start of the case.

You will NOT have any interaction with patient as part of this scenario.

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1. Introduces self and role in a professional manner Yes No 2. Articulates specific risks of proceeding with surgery at this

time Yes No

3. Articulates specific benefits of postponing surgery and

optimizing patient condition Yes No

4. Demonstrate understanding of the concerns and perspectives of other health care professional through active listening

Yes No

5. Recognizes the potential of conflict and initiates conflict

resolution as appropriate Yes No

6. Formulates collaborative plan of action including criteria

fro proceeding in the future Yes No

7. Offers to be part of discussion with patient Yes No 8. Maintains decision to postpone the surgery Yes No 9. Maintains professional demeanor and communication

throughout conversation Yes No

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Practice-based Learning and Improvement

In this station you will be presented with two separate case scenarios.

Case-Stem 1

You’ve been called in as a replacement for the other resident who had to leave because of a family issue. Handover with following information:

Patients name: Bob Jones, 68 y/o, scheduled for redo right total hip replacement.

Medical information:

BMI 28

Hypertension

DM 2 under oral agents

Allergy to Ceclor (rash, tongue swelling, difficulties with breathing) NO other relevant findings in his chart

Uneventful induction: Smooth mask ventilation, intubation Cormack & Lehane I°.

The patient has been prepped, and draped and the team is ready for time out.

Task Statement 1

You are the anesthesia provider responsible for the patient. The focus of this scenario is not on the patient’s vital signs but on your proactive participation in the team time-out.

Case Stem 2

In many hospitals, the World Health Organization Safe Surgery Checklist (team time-out) is poorly implemented. You are chosen to be part of a local Quality Improvement

Committee to address this issue.

Task statement 2

Which QI-framework would you use to improve this situation?

What concrete examples of QI-activities would you like to plan for this project?

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Station 6 - Rater:

Please circle your score

Analytic Scoring

Scoring Elements Case 1

1. Introduces self to surgeon and rest of the team Yes No

2. Reduce distraction (at least one) Yes No

3. Reduce physical barriers (at least one) Yes No 4. Address Quality of communication (at least one) Yes No 5. Address Omissions in TO (at least one) Yes No Analytic Scoring

1. Present a framework (at least one e.g PDSA) Yes No 2. Present at least two concrete Examples Yes No

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Interpretation of Monitors

In this station you will be presented with three separate scenarios.

Each scenario will begin with a short case description. A recording of simulated hemodynamic and respiratory monitors will then be shown. In each scenario, changes will occur in the monitor recording.

These changes may occur while the recording is playing, or you will be shown two separate recordings, one before and one after changes have occurred. After you watch the recordings, you will be asked questions about the scenario by an examiner. This will include the likely causes of changes in the monitors, and what features of the monitors support your answer. Each scenario is separate and has no connection with the preceding or subsequent scenario. You will NOT have the opportunity to ask questions related to the scenario.

Case-Stem 1

70 y/o 5’6” 80kg man for laparoscopic cholecystectomy, ASA 3. After uneventful intubation (Grade 1 v, ETT 23 lips) and establishing maintenance with desflurane, fentanyl, rocuronium the patients vital signs are stable with no twitches.

PMH: HTN, DLP, COPD, CAD s/p DES 1 year prior with global EF 40%

Medications: Lisinopril, simvastatin, albuterol/ipratropium

Task Statement 1

There will be two sets of two separate 10-second intervals recordings of monitors to interpret. This is a not a memory test - You may review none, either, or both of these videos per request at any time. Please state when you are ready to view the first video.

Case-Stem 2

81y/o 5’10” 70kg man for pancreaticoduodenectomy ASA 3. A preinduction T6-7 epidural is placed with positive sensory change over T7-8 and hydromorphone is given prior to incision. Currently two hours into maintenance with desflurane, fentanyl, rocuronium the monitors display the following.

PMH: HTN, DLP, COPD, CAD prior MI with global EF 45%, Chronic renal insufficiency baseline Cr 1.7, Depression, PTSD

Medications: ASA, metoprolol, isorobide mononitrate, simvastatin, venlafaxine, quetiapine Task Statement 2

There will be two sets of two separate 10-second interval recordings of monitors to interpret. This is a not a memory test - You may review none, either, or both of these loops per request at any time. Please state when you are ready to view the first video.

Case-Stem 3

There is an overhead call for help into the Vascular Hybrid Operating Room for help.

On arrival, the anesthesiologist provides the following information;

Situation – Help called due transient hypotension poorly responsive to phenylephrine.

Background – 63 y/o 6” 83kg man for EVAAR. Induction with Lidocaine, Fentanyl, Ketamine, and Rocuronium, easy airway complicated by hypotension into MAPs 50’s for <2minutes. Stable afterwards, during triple lumen placement, and on maintenance for 2 hours on desflurane, fentanyl, rocuronium requiring phenylephrine 50mcg/min for MAPs 85-95. Past medical history of CAD, EF 35%, HTN. EVAAR stent just deployed, followed by hypotension MAP 50’s not responsive to phenylephrine 200mcg. Took Asa, metoprolol, Lisinopril this morning.

Task Statement 3

There will be one recording 20 seconds of monitors to interpret. You may review these loops per request at any time

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Analytic Scoring

1. List differential diagnosis (At least one) Yes No 2. List constellation of monitor findings with diagnosis. (At

least one) Yes No

3. List Diagnostic maneuvers (At least one) Yes No 4. List Management options (At least one) Yes No Analytic Scoring

1. List the clinical concern (At least one) Yes No 2. List differential diagnosis (At least one) Yes No 3. List constellation of monitor findings with diagnosis. (At

least one) Yes No

4. List Diagnostic maneuvers (At least one) Yes No

5. List Management options (At least one) ^Yes ^No

6. How would you manage this patient’s Afib (At least one) Yes No 7. What are the indications for DCCV of Afib (At least one) Yes No

Analytic Scoring

1. List the clinical concern (At least one) Yes No 2. List differential diagnosis (At least one) Yes No 3. List constellation of monitor findings with diagnosis. (At

least one) Yes No

4. List Diagnostic maneuvers (At least one) Yes No

5. What type of heart block is this and why did it likely occur Yes No

6. How will you manage this heart block Yes No

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Interpretation of echocardiograms.

In this station you will be presented with two separate case scenarios.

Case-Stem 1

80 year-old male with history of HTN, DM, Hyperlipidemia, and prostate CA in OR for R iliofemoral bypass. One hour into the case, patient becomes progressively more hypotensive, 70s/40s, responding minimally to phenylephrine boluses. ECG shows maybe some ST depressions. You are called to perform transesophageal

echocardiography to assess the patient’s hypotension.

Task Statement 1

Please perform a basic TEE exam to assess hypotension. You should be able to make the diagnosis with 3-4 TEE views from the list below. Please name the view you have

obtained and the important structures in the view. Please also name any pathology that you are able to diagnose and the treatment plan for this patient.

Case-Stem 2

You are in the Cardiothoracic ICU and you have just received a transfer patient from an outside hospital. Per report, the patient is a 75M with history of poorly controlled hypertension, diabetes, and COPD who is transferred for suspected type A aortic

dissection. He was combative and disoriented at the outside hospital and was intubated for airway protection. The nurses are calling you urgently to the patient’s bedside for worsening hypotension. The surgeons request an urgent transesophageal

echocardiography.

Task Statement 2

Please perform a basic TEE exam to assess for aortic dissection. Please name the view you have obtained from the list below and the important structures in the view. Please also name any pathology that you are able to diagnose.

Each scenario is separate and has no connection with the preceding or subsequent scenario. You will provide all answers verbally to an examiner who will be in the room.

The examiner will NOT provide additional information about the cases or the images.

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Basic Perioperative Tranesophageal Echocardiography Views

a.Midesophageal Four Chamber b. Midesophageal Two Chamber c. Midesophageal Long Axis

d. Midesophageal Ascending Aortic Long Axis e. Midesophageal Ascending Aortic Short Axis f. Midesophageal Aortic Valve Short Axis

g. Midesophageal Right Ventricular Inflow-Outflow h. Midesophageal Bicaval

i. Transgastric Midpapillary Short Axis j. Descending Aortic Short Axis

k. Descending Aortic Long Axis

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Station 8 - Rater:

Please circle your score.

Analytic Scoring

1. Obtain the mid-esophageal 4 chamber view Yes No 2. Name the R and L atria and ventricles Yes No 3. Obtain the mid-esophageal 2 chamber view and/or long axis Yes No 4. Name the mitral valve and aortic valve Yes No 5. Obtain the transgastric midpapillary short axis view Yes No 6. Name the walls of the left ventricle Yes No 7. State which coronary artery had a lesion Yes No 8. Offer the correct treatment plan for the patient (O2,

epinephrine, cardiology consult) Yes No

Analytic Scoring

1. Obtain the mid-esophageal 4 chamber view Yes No

2. Diagnose a pericardial effusion Yes No

3. Obtain the mid-esophageal long axis view Yes No 4. Obtain the ascending aorta long axis view Yes No 5. Obtain the ascending aorta short axis view Yes No

6. Diagnose an aortic dissection Yes No

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Application of Ultrasound

In this station you will be asked to complete three tasks related to the use of ultrasound for vascular access or nerve blocks.

For each task, you will be required to produce an ultrasound image using an ultrasound probe on a standardized patient. You can instruct the standard patient to position him or herself as appropriate. The patient should remain supine for all vascular access.

The examiner will operate the ultrasound machine, and you may request that the examiner adjust the depth or gain. For each task, you will generate an image that would support the conduct of a specified vascular access or nerve block procedure.

Once you are satisfied with the image, you will ask the examiner to freeze the image. You will then be asked to identify at one or more structure(s) in the image, as directed by the examiner, and use a cursor to indicate this structure.

For nerve blocks, you will also be asked to identify the optimal location for the needle tip to deposit the local anesthetic, again using a cursor.

You have no more than 2 minutes and 30 seconds to complete each task.

Your three tasks are to produce images to facilitate the following procedures, including identification of the appropriate structures.

1. Adductor Canal Block

a. Identify the Femoral Artery b. Identify the Sartorius

c. Identify the Saphenous Vein

d. Where would you place your needle to perform a single injection 2. Infraclavicular Block

a. Identify the subclavian artery b. Identify the Pectoralis Minor c. Identify the Pleura

d. Where would you place your needle to perform a single injection 3. Right Internal Jugular Cannulation

a. Identify the Carotid Artery b. Identify the Internal Jugular Vein

c. Confirm patency of the Internal Jugular Vein

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1. Identify the Femoral Artery Yes No

2. Identify the Sartorius Yes No

3. Identify the Saphenous Vein Yes No

4. Where would you place your needle to perform a single injection Yes No

5. Identify the subclavian artery Yes No

6. Identify the Pectoralis Minor Yes No

7. Identify the Pleura Yes No

8. Where would you place your needle to perform a single injection Yes No

9. Identify the Carotid Artery Yes No

10. Identify the Internal Jugular Vein Yes No

11. Confirm patency of the Internal Jugular Vein Yes No