FCAI Clinical Exam Spring 2019 at Dublin Ireland: The Clinical Review

This is part 2 of my review of the overall exam, where the first part is about the trip and this will be about the “academic” aspects: what came out, how I fared. There will be an avalanche of topics posted (probably as an addendum post) so be prepared.

I won’t be wearing this any time soon

The exam was run in 2 separate days. In each day there were 4 groups, of which 2 would get the same set of short case questions. For simplicity’s sake, my exam was on the second day, with I’d guess the first set of questions.

Day 1 Long Case:
52yo/ obese, hpt, breast ca on adjuvant chemotherapy complicated by axillary dvt, came for MAC & Mammoplasty.

Asked on obesity, problems with obesity, THRIVE, HPT definition, cut off point for cases, antihypertensive. Asked on Rivaroxaban. Choice of anaesthesia. Explain Pec block, LA toxicity and treatment

Day 2 Long Case (mine):
A diabetic smoker with diabetes, hypertension, IHD, obesity, presenting with acute severe headache.

Asked on SAH, initial assessment and resuscitation. Grading.
Issues regarding sedation for CT in such a patient (or nothing at all...)
Monro-Kellie doctrine definition & ICP pressure volume curve
Obesity and OSA, airway concerns
Double antiplatelets on DES in periop period
BP management pre, induction and intraop
SGLT-1 inhibitors and other OHA's
NSM (neurogenic stunned myocardium) and effect on intervention
The ISAT study
Issues regarding interhospital transfer
Medical management of intracranial hypertension
Hyponatremia - CSW vs SIADH
Mortality of rupture
BP management in the OT

Day 1 Short Cases:
SOE 1 (both of 1 group)
House burn, draw ODC, oxy alveolar equation, A-a gradient and causes. Hemoglobinopathies
Tracheostomy, indication, advantages, complication, compare percut vs surgical
HIV, cerebral toxoplasmosis and treatment antiviral and complication.

SOE 2
Trauma - cxr on pneumothorax, hemothorax, approach
Acromegaly, symptoms, transphenoidal approach, problem post op - they wanted to talk about hypertension post op
Preeclampsia, hellp syndrome, treatment
Arthroscopy, explain femoral and sciatic block

Day 2 Short Cases:
Group 1 questions, combined (my group):
HPAA axis, RAA axis, the JGA
Malnutrition and complications in the critically ill, assessment, biochem markers, replacement strategies, Harris-Benedict equation, indirect calorimetry, immunonutrition
Pulse oximetry, odc curve, cyanide toxicity, methaemoglobina, CO toxicity
Esophageal doppler, limitation, contraindication, interpretation of eosophageal doppler
Ultrasound, principle, doppler effect, equation
Interscalene block & sonoanatomy of neck
Obesity, osa
Trigeminal neuralgia
Pheochromocytoma
Serotonin syndrome vs neuroleptic malignant syndrome
Posterior pituitary hormones and their production, perioperative steroid use, angiotensin II
Maternal hemorrhage - diagnosis, labs, management, MTP, hemostatic procedures, WOMAN trial

Group 2 questions, combined:
Failed back syndrome, management
Bronchiolitis, pathophysiology, diagnosis
Pregnancy with tetralogy of fallot (corrective surgery done in childhood) explain physiology, anaesthetic management
Myasthenia gravis going for upper limb surgery, question on ms relaxant and reversal. Anaesthetic management
Lower limb surgery post op pain management. Ankle block, LA toxicity
Foot drop. Which nerves are affected, Risk factor, causes, investigation and management
Trauma patient road traffic accident with hypotension and tachycardia differential diagnosis. Blood result: coagulopathy, differential diagnosis, management
Stroke patient from nursing home admitted icu for pneumonia. BP crashed. What are the likely pathogens, choice of antibiotics, antibiotic classification
Brainstem death testing. Ancillary testing
Guillian barre syndrome, differential diagnosis, treatment
Defibrillator, principle. AED vs conventional defibrillator

Personally, how did I do? Well one thing I knew was that there was a lot I didn’t know (but didn’t have the time to revise), and many things that I’ve already revised but forgotten. Some areas that I really effed up:
1) Grading of SAH. Mortality rates
2) Classification of oral antidiabetic agents (I really had an embarrasing brain freeze on this)
3) The name ISAT trial (I remembered the take-away)
4) The term JGA
5) Serotonin syndrome versus NMS (despite reading multiple times)
6) Particular frequency ranges of various USG probes

My score? I got a 3/3/2. So it wasn’t a great score by any means; another 2 (borderline) and I’d have failed. But considering that I probably only really started studying on December, I can’t complain! A pass is a pass in the end. So what was my strategy then?

I generally kept being consistent in how I approach my studying to prepare for the exams. There was literally no major changes when compared with how I studied for the FCAI Written (or from my first exam, the MCAI MCQ’s for that matter). There was only minor tweaks in how I focus and allocate time for things. I always try to revise the topic of the day (in the cases and scenarios I encounter) regardless of whether I had those notes or not. When at home, my aim would be to make notes, with the aim of “short bursts” on a topic; this would allow me to switch to another topic. If I needed to return to that topic, I’d then continue to do so. This allowed my notes to cover a broader number of topics (but with the notes relatively “incomplete” compared to my previous notes). I tried to focus my notes on conceptual aspects and those that would involve comparisons and diagrams, but I didn’t necessarily succeed in ensuring the needed focus to only do notes where there is a good payoff versus the effort needed to make such notes.

So now what’s next? There’s a lot to do still, and it’s likely much harder. Now, instead of being purely focusing on academic pursuits alone, I also have to deal with:
DOPS (Directly observed procedural skills)
Case-based discussions
Research
6 monthly assessments that consist of viva (they said it’s not an exam, just an assessment; whatever, they’re the same)

Before this I had to take time off for various reasons, and could afford to as the interval between exams was up to me. There won’t be any opportunity for time off now. Which means I really need to settle my main problems looking forward: my problems with fatigue, maintaining lifting performance, both of which is needed for my mental wellbeing. Without solving the equation above, I will not be able to manage all of the above stuff and maintaining to study.

Damn.

FCAI Clinical Exam Spring 2019 at Dublin, Ireland

I will divide this topic into 2: one on the experience and another on the academic aspect (topics). So yeah, I passed this exam, making it 4 passes out of 4 attempts but taking 5 years, which is much longer than desired (but the way the journey had to be due to various circumstances).

I flew with Emirates. My process was to initially screen the flights available via Expedia (for available times and general price range), then I individually booked the flights and hotel separately via their respective websites (to get the best discount). Being someone who lifts weights, not sitting in the aisle was not an option (to give me the best sitting space for comfort). I spent some extra money ensuring I’d get those seats, and I did not regret it. The food was definitely good.

From a colleague’s recommendation, I decided to stay at Kildare Street Hotel, which was definitely the right choice. The price was cheap, the room has WiFi, and close to the important places (Dublin Bus Airlink bus stop, exam venue, college, and shops).

To get to Dublin from the airport, I rode the previously mentioned Airlink bus by Dublin Bus. By buying the ticket online, I was able to get a € 1 discount on the € 12 2 way ticket.

I tried to survive without turning on roaming and succeeded. With WiFi being ubiquitous for the most part (airports, some restaurants, and even on a couple of the flights), there was no need for cellular data. For navigation, I’d turn it on before leaving the hotel (to load the needed directions and locations of additional  nearby places) , then allow the phone’s GPS to handle the rest.

The main place where I would have my meals was The Cedar Tree, with it’s fulfilling portions, WiFi and nice ambience. On my final day in Dublin, they even served some Baklava and Turkish coffee, on the house. I’d highly recommend this place. In between, I’d have yogurt and milk to minimize hunger and focus on last minute studying. 

At the Cedar Tree

The exam itself was held at the Chartered Accountants of Ireland building, which was around a 10 minute walk at most and near the College. The place itself didn’t have free WiFi, but it wasn’t needed. 

I brought my pre-ground coffee and cold brew bottle, but in the end it was not needed. Coffee is everywhere in Dublin, including the hotel, in more than enough supply. The coffee wasn’t weak unlike the standard stuff in Malaysia. Even during the exam, there was free flowing coffee, tea, and milk. In the end, I had to “force” myself to finish my cold brew coffee before going back.

You don’t need a fridge here to make cold brew coffee

Waiting for the bus back to the airport

There was a major problem on the flight back: there would be only a small gap in between the flights from Dublin and Dubai. This gap became non-existent when the former flight departed late. On arrival a group of Emirates’ staff was already ready to hand us new tickets for the connecting flights; the problem was that the flight would be delayed by 12 hours.

To solve that, the new tickets also included a stay at their airport hotel with free meals. By the time we got there via the shuttling coach it would be around 11 am Dubai time, with an eight hour gap before the shuttle back to the airport. Lunch and dinner buffets were available on the house, and thoroughly enjoyed.

“Among” the foods I ate. When a trip gets delayed, the airline had better pay me well. And pay me well they did.

In general, typical of me, this was a “business trip”; study, exams, rest, go back. No sight-seeing/any meaningful shopping. Like the inspirational Snakes and Bosses: get in, destroy the objectives, get out (except with Hideo Kojima there’s a lot of drama that comes along with that).

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A face of relief

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Random Thoughts (4/4/18)

1) I've had no time to make notes so far in my POT posting. It's been all out "studying stuff that I encounter" mode, as I see and do things I've never did before, along with the relatively later times of going home, and fitting in time to go to the gym. Needing to sleep earlier also did not help (see below) any efforts to invest time in making notes. 

2) I really need to get my sleep deprivation and stimulant-laden life in check. The other day, I had a cup of coffee and 2 cups of green tea by 11 am. My heart rate? 70. And of course I was sleepy. And so there was a dilemma along with being a powerlifter: what are the differentials when I've a headache? Is it sleep deprivation/caffeine withdrawal/caffeine overload/viral illness/some other causes? How about bodyache: was it DOMS or viral illness (a bit weird to have back muscle ache after a bench session? And both symptoms together? In the end, sleep was what gave me the most relief. And 2 tablets of paracetamol of course.

3) Being the Malaysian Tony Roma's Ribs Eating Champion 2 years in a row, of course I'd like to win again. But if I plan to sit for the Final FCAI viva in November, it could potentially clash with the plans. The first competition was held on a Saturday, while the more recent one was held on a Sunday. The exams will be either on Tuesday/Wednesday Dublin time (going back timezones). Either I should fly on a Sunday night, or skip the exam for another few months: the voucher prize has been invaluable to save money on family treats outside.

4) After my bench press accident, I've started learning to bench in a power rack after looking up how to bench press safely alone (as I don't trust non-powerlifting spotters). So far so good, but I wonder if the bench will always be available when I do come to the gym to use it over at the power rack. 

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