OB Case

[pjl]

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Good to know, but I had to ask since my oral boards book had me convinced to do an AFOI or at least a sedated FOI, and at first I thought it was strange answer, but it did have an appeal in terms of...can't go wrong with securing an airway. It might be ( a little) complicated but also very safe. I think the jury is still out.

I had an OB question, and was all set for them to start asking about the airway stuff. I just did a spinal, and it was never mentioned again. Not even a followup about why spinal over GA. There were "other issues" they wanted to get to in the case.
Obviously on boards just answer with what you would do in real life, and have justification. As long as you arent doing something stupid daily, you are fine.

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[twoliter]

Think about what you're saying. Urgent C-section, otherwise uncomplicated, and you've put yourself down a garden path of AFOI, KETAMINE and PRECEDEX. Wtf?! How much more complicated can you make it?

I brought this up in a roundabout way during my oral boards. I mentioned something about doing a spinal assuming she had a normal airway. They asked what the airway had to do with it. I said I would rather deal with a difficult airway (i.e., intubate) than at some point emergently during the case (e.g., after a high spinal with aspiration). I may have gotten dinged for that answer, who knows. But I passed overall, so I don't really care. It may not be the way you'd do if. It may not even be the way I'd do it in real life. But it's certainly a reasonable option.

 

[chrisv]

I brought this up in a roundabout way during my oral boards. I mentioned something about doing a spinal assuming she had a normal airway. They asked what the airway had to do with it. I said I would rather deal with a difficult airway (i.e., intubate) than at some point emergently during the case (e.g., after a high spinal with aspiration). I may have gotten dinged for that answer, who knows. But I passed overall, so I don't really care. It may not be the way you'd do if. It may not even be the way I'd do it in real life. But it's certainly a reasonable option.

Thanks for the advice. It seems like the reasonable way of handling this is to just say you'll do a spinal and if they come back at you with "what if it's a difficult airway?" then you go down that route, explain your reasoning and move on. And a high spinal isn't all that rare if the patient has a failed epidural with multiple top offs and a narrowed intrathecal space, but that's a whole another can of worms LOL

 

[deleted162650]

There's no "right" answer on the orals. There are usually many "right" answers and only a few "wrong" answers. Do what you would normally and be able to effectively communicate why that's what you'd do. Then be prepared with potential pitfalls and have plans b, c, and d ready to go. That's what they are looking for.

They also don't have the time or desire to chase you down every potential rabbit hole. They have a script they need to follow and they want to get through as much of it as possible.

 

[deleted171991]

Not to prolong this exhaustive thread on the benefits of spinal over GA but if I may ask one more question...

What if this was an elective c-section and the patient ate a hearty breakfast on the way to the hospital? Would you delay the case? Or assume her stomach is full regardless and proceed with the spinal.


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Elective + not NPO (i.e. not optimized) = postpone surgery.

 

[deleted171991]

Thanks for the advice. It seems like the reasonable way of handling this is to just say you'll do a spinal and if they come back at you with "what if it's a difficult airway?" then you go down that route, explain your reasoning and move on. And a high spinal isn't all that rare if the patient has a failed epidural with multiple top offs and a narrowed intrathecal space, but that's a whole another can of worms LOL

For every question in their script, they (used to) grade you on a scale like Strongly agree/Agree/Disagree/Strongly disagree. You need(ed) a passing score from 3 examiners out of the 4.

The scoring is based on their expert opinion (this is why it's adjusted to the examiner, based on his/her history). It's all relative to how they think a reasonable and safe consulting anesthesiologist should approach the problem.

 

[IlDestriero]

You have to remember that, as noted above, there's a lot of right ways to do a case. The oral examiners want to know that you're going to do it one of the safe ways and can explain why you chose that method.
However, if you've reviewed cases before for peer review or litigation, you'll know that there's a lot of obviously wrong ways to do a case, and people are absolutely doing them that way. The difference is that I don't think they think their anesthetic through at all and just do plan a for everyone, if they thought about it for 2 seconds they'd realize that what they're doing is stupid.


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Il Destriero