OSCE

Question 1

How would you devise a quality improvement project?

Answer 1

1. Measure current outcomes and benchmarks if applicable
2. Identify stakeholders and devise changes with their collaboration
3. Educate and train clinicians regarding the change
4. Implement changes
5. Measure outcomes after the change in practice

Question 2

What TEE view can evaluate for left atrial appendage thrombus?

Answer 2

ME 2 Chamber

Question 3

What TEE view can evaluate for SAM?

Answer 3

ME Long Axis View

Remember right coronary cusp near RVOT

Question 4

What TEE view can evaluate for ascending aortic aneurysms?

How about dissections?

Answer 4

ME ascending aortic long axis view
ME LAX

Dissection seen in both

Question 5

What TEE view can evaluate for a PE?

Answer 5

ME ascending aortic short axis
ME bicaval
ME RV inflow-outflow

May see large RV in ME 4C

Question 6

What is the best view for visualizing PA catheter placement?

Answer 6

ME right ventricular inflow-outflow

Pulmonic valve on right of screen

Question 7

What is a good view to visualizing central line or femoral line placement?

How about IABP, femoral catheters or dissection?

Answer 7

ME Bicaval view - SVC on right

Descending aortic short or long axis

Question 8

What views can you assess for ASD?

Answer 8

ME 4C

ME Bicaval

Question 9

Best view to asses volume status and response to volume therapy?

Answer 9

TG MP SAX

Question 10

What views best asses for aortic valve lesions?

Answer 10

ME AV SAX

ME LAX - esp AI

Question 11

Which views assess mitral valve lesions?

Answer 11

ME 4C
ME 2C
ME LAX

Question 12

Which views best visualize for pericardial effusion?

Answer 12

ME 4C

TG MP SAX

Question 13

What are the elements of informed consent?

Answer 13

Description of procedure
Indication for procedure
Associated risks, benefits and alternatives
Discuss strategies for minimizing risks
Eliciting questions
Confirm final decision for consent

Question 14

What are some ways to optimize a JW pre-operatively for possible bloody case, esp if they a minor?

Answer 14

If a minor - obtain a court order for transfusion if highly likely to be needed

EPO
Iron therapy
DDAVP
Delaying elective case until minor can fully participate in making decisions

Question 15

Is the patient able to give consent after receiving pain medications?

Answer 15

When administered in reasonable amounts in order to relieve pain while avoiding sedation it may serve to facilitate consent by mitigating distracting pain.

Question 16

How would you obtain consent in an emergency situation?

Answer 16

Obtaining consent is deal but in an emergent situation where there is imminent threat to life I would proceed in the best interests of the patient while obtaining whatever history I can and explain how I will care for the patient

Question 17

Explain cancelling a case for a URI to a mother

Answer 17

After examining your son, I believe that to proceed with anesthesia today would place him at an unacceptable risk.

He appears to have significant cold symptoms - cough, fever that place him at risk for having low oxygen levels, bronchospasm where his lungs get very tight and laryngospasm which blocks his breathing.

Therefore I would recommend delaying surgery for 6-8 weeks following the resolution of his symptoms which would allow his lungs to recover and make surgery safer.

Question 18

Explain to a patient (after their insistence/demanding to proceed) that you must still cancel their procedure.

Answer 18

I understand that it is extremely inconvenient to delay surgery, especially after having taken time off of work and travelled a great distance.

However, given the current condition, it places you (or child) at significant risk for harm and I can not agree to provide anesthesia.

Please know that while we disagree I am doing this with your best interests in mind. I would be happy to bring in the surgeon to discuss with him as well.

I will also do everything I can to help reschedule when it is safe to do so and amenable to your work schedule..

Question 19

How do you approach a minor who is refusing surgery?

Answer 19

1. Ask why they don’t want to have surgery
2. Suggest all going into a consultation room with the surgeon to talk about why surgery is need and what is it like to sleep with anesthesia.
3. Discuss indication for surgery
4. Go through process of anesthesia, risks, benefits, alternatives and steps to mitigate risks

Avoid just giving anxiolytic to help cooperation in a minor, if minor is old enough explain that she likely has ability to understand risks and benefits and they should be taken into consideration (esp if not emergent)

Question 20

How would you approach a surgeon or colleague pressuring you into a certain mode of treatment (block), avoid discussing certain complications etc?

Answer 20

I understand your concern and after reviewing the history I (agree/disagree) however it would violate informed consent to avoid discussing (complication) with her.

Withholding information (therapeutic privilege) when believed information would

• impair rational decision making
• cause psychological or physical harm
• inhibit needed therapy

Reiterate that you may agree with the surgeon but there are alternatives and I will discuss both the risks and benefits with her, does that sound reasonable to you?

Question 21

How would you approach a patient who keeps refusing a treatment like an a-line and refuses to hear about the complications?

Answer 21

I respect your request not to hear about the complications but if you change your mind at any point please let me know.

Eventhough I may disagree, I will certainly respect your decision in this matter. However, I do want you to be sure that you fully understand the risks of proceeding without …

Question 22

Patient got pre-op sedation for elective procedure, now too sleepy to obtain consent, surgeon is pressuring you to go, what will you do?

What if the husband is there to provide consent?

Answer 22

Unfortunately the patient received some pre-op sedation that has significantly impacted her capacity to give consent. We will have to wait until her sedation resolves before obtaining adequate consent.

Since this procedure is non-emergent it would be inappropriate to obtain consent from a surrogate decision maker. I am very sorry for the delay, can we move up your next case in the meantime?

Question 23

How would you discuss a dental injury?

Answer 23

I would apologize and say i feel badly for injuring her tooth. Unfortunately unintentional dental injuries do occur and I want to reassure you that we will help you with the problem.

We have a dental injury policy that will help you get the proper dental care and make it look as normal as possible and will pay for any related expenses.

Question 24

How would you assess persistent numbness after an epidural in a labor patient?

Answer 24

I understand that this numbness can be distressing and there are several potential causes and i think it is unlikely to be related to the epidural but I would like to perform an exam if you don’t mind?

Neuro and motor exam

Lateral cutaneous? - should not cause any motor symptoms and likely not from the epidural. Usually caused by stretching during pushing when legs are elevated. Fortunately the vast majority resolve in a matter of days to weeks.

Offer contact information, neurologist only if they want but not need at this time.

Question 25

How would you evaluate a PDPH for OSCE?

Answer 25

Ask about symptoms - type of headache, positional, N/V, neck stiffness, visual symptoms, sensitivity to light or sound Ask about other symptoms - fever, chills, weakness Perform PE - cranial nerves, EOM, neck, peripheral sensory and motor, examine spinal site Wait 48-72 hours for blood patch as performing too early can fail

Question 26

How would you address post-op memory issues?

Answer 26

1. Ask about any medications (benadryl/anticholinergics) 2. Ask about sleep, mood 3. Perform exam - neuro exam, A&O x3, motor and sensory 4. Describe delirium vs. POCD POCD - can last from days to weeks, rarely up to a year - inflammation from surgery - risks include >60, hx memory problems - only prevention is not having surgery - mention to future anesthesiologists - discuss with PCP and or neurologist if it persists to exclude any other causes

Question 27

How would you address DNR with a patient?

Answer 27

1. Understand wishes and goals in relation to the surgery 2. Differences b/w routine care and resuscitative measures in the OR 3. Risks and benefits of resuscitative measures 4. Interventions you deem as appropriate Routine care - intubation, ventilation, medications for cardiovascular system Resuscitative - chest compressions, defibrillation Concern with ventilation, intubation - usually acute and reversible with a better prognosis than in other venues

Question 28

JW without capacity but advanced directive refusing blood products. Surrogate says they would agree to cell-saver but child says otherwise. Who can decide?

Answer 28

Durable power of attorney - after reiterating that it is his responsibility to make decisions consistent with her wishes See guidance from legal/risk management

Question 29

How is death determined?

Answer 29

1. Cessation of circulatory and respiratory functions 2. Irreversible cessation of brain function - confirm with absence of cortical and brainstem activity (pupillary response, pain, cough/gag, apnea) - no confounding factors (sedation, hypothermia, hypotension)

Question 30

Would you administer any additional medications for organ procurement/declaring death?

Answer 30

May be used to minimize pain and distress but NOT to hasten death. Timing of procurement should have no bearing on administration of sedative for dying process. Therefore muscle relaxants would be inappropriate as it would hasten death and not reduce pain or distress.

Question 31

When to reintubate after declaring death?

Answer 31

Each institution should have a policy, usually between 2 and 5 minutes after cessation of neurologic function to avoid experiencing any pain as well as avoid hypoxia to organs

Question 32

How would you discuss obtaining a pregnancy test with parents present and refusing?

Answer 32

1. Explain reason for test - exposure to anesthesia may pose risks to developing baby like birth defects, loss and brain development 2. Insufficient evidence to confirm risks, also lacking evidence to assure that baby is protected 3. If you decide to undergo testing there is a small false negative rate and false positive Options: proceed without testing understanding the risks, take the test with small risk of false result, or delay proceed until after menses

Question 33

How would you respond to a positive pregnancy test in a minor with her parents present?

Answer 33

Ask nurse to bring patient, nurse and surgeon to private room for discussion - obligation for confidentiality

Question 34

What situations require protecting minors privacy?

Answer 34

1. treatment of STDs 2. Provision of contraceptive services 3. Prenatal care 4. Mental health and substance abuse treatment

Question 35

What TEE views asses biventricular function and wall motion?

Answer 35

#1 = TG MP SAX ME 4C ME 2C ME LAX

Question 36

What TEE views asses for RV function?

Answer 36

ME 4C | ME RV Inflow-outflow

Question 37

Your TG MP SAX view shows a dilated LV and little ventricular movement. What is your diagnosis and plan for management?

Answer 37

Acute systolic HF Add an ionotrope ? Any WMA - get EKG for signs of ischemia Consider cardiac consultation

Question 38

What is the EKG pattern for RV strain?

Answer 38

ST depression in V1-4

Question 39

What are the phases of a PDSA cycle?

Answer 39

Plan - make a plan to test a change and make predictions Do - test change on a small scale Study - complete analysis, compare data to predictions - use gathered data to build new knowledge and make predictions * **develop easily entered and accessible documentation in the EMR like a documentation template*** Act - Adopt change - Repeat cycles as needed

Question 40

What is the 6-sigma process and what are the steps?

Answer 40

Systematic quality improvement framework that provides a stepwise approach to developing and implementing a quality improvement project. It looks at both process and outcome measures DMAIC 1. Define 1. Define the goals 2. Obtain support and resources and put together a team 2. Measure 1. Measure baseline metrics/performance (eg. clinical survey) 3. Analyze 1. Examine system for areas of improvement 4. Improve 1. Improve through implementation of ideas and statistically validate improvements 5. Control 1. Institutionalize improvement and monitor stability over time

Question 41

What are "Runs" or "times series" charts?

Answer 41

Graphic display of quality improvement data that allows for observations of trends over time - Did improvement strategy have an effect Variable being studied on Y (vertical axis)- Time on X (horizontal axis ) 12 data points for baseline and 25 to detect a trend (5+ points all increasing or decreasing)

Question 42

What is a "control" chart?

Answer 42

An extension of a run chart Help differentiate between random and specific types of variation Random - always present, no known cause Specific - occurs as a result of known factors - accounted for when removed from the system Stable process = specific variations no longer present Variable being studied on Y (vertical axis)- Time on X (horizontal axis ) Centerline = Mean Upper and lower control limits = +/- 3 sigma from mean Stable process = all data points are between control limits

Question 43

What quality improvement strategy would you employ for this project?

Answer 43

I would use the Model for Improvement and then a PDSA cycle It starts by asking: What are we trying to accomplish? How will we measure at the change? What changes can we make that will result in improvement? Plan - make a plan to test a change and make predictions Do - test change on a small scale Study - complete analysis, compare data to predictions - use gathered data to build new knowledge and make predictions Act - Adopt change - Repeat cycles as needed