Mastering your fellowship

The series, ‘Mastering your Fellowship’, provides examples of the question format encountered in the written and clinical examinations, Part A of the Fellowship of the College of Family Physicians of South Africa (FCFP [SA]) examination. The series is aimed at helping family medicine registrars prepare for this examination. Model answers are available online.

acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and presents with mild to moderate illness in 80% of patients, severe illness in 15% of patients and critical illness in 5% of patients. The reproduction ratio of the disease and the series interval are alarming and have already had devastating effects on healthcare systems around the world. The anticipated surge in cases in South Africa in the coming months is expected to stress the healthcare system. The management of limited resources, such as intensive care unit beds, is expected to come under severe strain, and plans are in place to improve the capacity at lower levels of care to deal with severely ill patients presenting with severe respiratory distress.
Our knowledge of COVID-19 is evolving, almost daily, and as new knowledge becomes available, practice guidelines are amended. Recently published material on the pathophysiology of acute respiratory distress in  suggests that lung compliance is initially preserved, despite poor oxygenation. A ground glass appearance on computed tomography (CT) scans suggests interstitial rather than alveolar oedema. These patients are referred to as the 'L-type' patient (low elastance, high compliance). Some of these patients progress to the 'H-type' (high elastance, low compliance), which is the typical acute respiratory distress syndrome (ARDS) associated with a high mortality rate.
The South African clinical guidelines provide the following guidance: Aim for an initial tidal volume of 4-6 ml/kg. Higher tidal volume up to 8 ml/kg predicted body weight may be needed if minute ventilation requirements are not met in a patient with good lung compliance. Strive to achieve the lowest plateau pressure possible. Plateau pressures above 30 cm H 2 O are associated with an increased risk of pulmonary injury.
An increased peak pressure and a difference of peak to plateau pressure of greater than 5 cm H 2 O usually implies airway resistance such as bronchospasm, secretions or mucus plugs. An increased plateau pressure and a smaller difference between peak and plateau pressures usually imply decreased compliance and this may be associated with acute respiratory distress syndrome, pneumonia or pneumothorax. In the case above, the tidal volume was initially set at 6 mL/kg, so it was acceptable to increase it to 8 mL/kg and continue to monitor the plateau pressures, as a rise in the plateau pressure may signify a loss in lung compliance and alternate strategies would then need to be considered. It is always prudent to consult an intensivist when decisions about ventilation are being made.
Acute respiratory distress syndrome is characterised by noncardiogenic pulmonary oedema, hypoxaemia, and reduced aerated lung size and low lung compliance. In such circumstances, the aim is to increase lung size by recruiting previously collapsed alveoli by using higher levels of peak end-expiratory pressure and prone positioning. High transpulmonary pressures are poorly tolerated in acute respiratory distress syndrome, hence low tidal volumes with permissive hypercapnia help to prevent ventilator-induced lung injury. Strenuous spontaneous inspiratory efforts may also contribute to lung damage by increasing transpulmonary pressures, hence there may be a need to sedate the patient to prevent patient-induced lung injury.
Understanding lung physiology and the pathophysiology of SARS-CoV-2-induced lung injury is critical to ventilator use in the primary care setting. Family physicians may be called on to use these skills in the coming months. Resources to improve competencies are listed below. You decide to prepare for intubation as the patient is becoming more hypoxic, confused and hypotensive. Which principles should you keep in mind for intubation and ventilation, with specific reference to the technical steps of the procedure as well as personal protective equipment? (5 marks) Here, it is essential to apply the recommended principles, such as those of the South African Association of Anaesthesiologists (SASA). The principles of managing this patient's airway (a suspected COVID-19 case with progressive respiratory distress or failure) should be considered from three aspects, namely before, during and after intubation. During each step it is essential to remain mindful of the need to prevent staff contamination.

Before intubation
Start with focusing on staff protection: Ensure hand hygiene, full protective gear, minimise the number of staff members present during aerosol-generating procedures (as is the case of intubation), and aim to perform the intubation and ventilation in a dedicated area prepared for airborne infection isolation.
Preparation should now focus on the procedure itself: Ensure the early protection of drugs and equipment needed for intubation and emergency ventilation; perform airway assessment (anticipate a difficult airway); formulate a plan early in conjunction with the team in the emergency centre (and your referral institution); and, if time allows, use a closed suctioning system and connect the appropriate filter to the ventilator's circuit and manual ventilator, such as an Artificial Manual Breathing Unit.
Whilst preparing, ensure that the patient has an intravenous access, receives oxygen via nasal oxygen and/or face mask, and receives other supportive treatment as needed (antibiotics, inotropes, diuretics, etc.). Remember to avoid giving nebulised treatment (an aerosol-generating procedure); rather give beta-agonists via an inhaler and spacer.

During intubation
Again, first focus on preparation: Ensure that there is clear delineation of roles (the SASA guidelines refer to 'hot' and 'non-hot' roles, to ensure minimise the number of staff exposed during this aerosol-generating procedures); other key aspects of team dynamics should include clear communication of the airway plan (such as escalation when encountering a difficult airway), closed loop communication throughout, and cross-monitoring by all team members for potential contamination.
Technical aspects to highlight, aimed at shortening the risk of staff contamination, include: performing airway management by the most experienced practitioner, use a tight-fitting mask with two hand grips to minimise leak, ensure paralysis to prevent coughing, using the lowest gas flows possible to maintain oxygenation, pre-oxygenating with 100% oxygen for 5 min, using rapid-sequence induction instead of prolonged bag-mask ventilation, and initiating positive pressure ventilation only after the endotracheal tube's cuff is inflated.

After intubation
The need to prevent staff contamination should be ensured.
Avoid unnecessary circuit disconnection (should this occur or be needed, wear PPE and consider clamping the endotracheal tube), maintain strict adherence to proper degowning ('doffing') steps and hand hygiene habits, and dispose of contaminated airway equipment appropriately. A team debriefing post-intubation is recommended, to review the treatment plan and support team members.
As your junior colleague is helping to prepare the equipment described above, you contact your referral hospital.

Discuss the ethical principles behind the South African triage guidelines used for all patients requiring intensive care during the COVID-19 pandemic. (2 marks)
The Critical Care Society of Sourthern Africa (CCSSA) provides guidance on triaging scare resources. The ethical guidelines of the South African Medical Association -SAMA (https://www.samedical.org/cmsuploader/viewArticle/ 1139) -also refer to the CCSSA triage guidance.
In the introduction to the document, the following text is provided (a model answer will capture these key elements): The purpose of the CCSSA guideline is to provide guidance for the triage of critically ill patients in the event that a public health emergency creates demand for critical care resources (e.g. ventilators, critical care beds) that outstrips the supply.
These triage recommendations will be enacted only if: • critical care capacity is, or will shortly be, overwhelmed despite taking all appropriate steps to increase the surge capacity to care for critically ill patients; and • His Excellency, the President of South Africa, has declared a public health emergency.
This allocation framework is grounded in ethical obligations that include: • duty to care, • duty to steward resources to optimise population health, • distributive and procedural justice, and • transparency.
It is consistent with existing recommendations for how to allocate scarce critical care resources during a public health emergency.
With reference to the triage guidelines, the consultant from the referral hospital recommends a palliative approach for your patient. How would you communicate the decision of providing palliative care to the patient's wife and son, who have just arrived? (The patient has become confused.) (4 marks) The PALPRAC guidelines describe approaches to various scenarios one may encounter during the COVID-19 pandemic and describe key aspects of communication in these scenarios. The guidelines highlight the unique challenges presented by the COVID-19 pandemic, especially the issues of staff safety and the potential absence of family at the bedside. Once the decision has been made by the clinical team to withdraw or withhold ventilatory support, this decision should be documented in the clinical notes. Guidelines for family communication are provided and this conversation should also be captured in the clinical notes. Skilled and compassionate communication should include the following steps from page 15 of the PALPRAC guidelines (a model answer will include elements of these steps): Always start by checking the patient/family member's understanding of the situation and ask what they have been told before. There are often clues for you to use in order to take the conversation forward.
• Give information in small, digestible chunks, avoiding medical jargon. • Use silence -this allows people to absorb what was said and show emotion. • Acknowledge emotion: NURSE acronym ß Name emotion: 'You seem to be upset/worried?' ß Understanding: 'Given what is going on, I can understand your concern'. ß Respecting: 'You have been really patient under difficult circumstances'. ß Supporting: 'I understand that this is very hard. We will be here to help'. 1. Comment on the scientific and social value of this study (2 marks) 2. What were the aims of the study? (1 mark) 3. Comment critically on the dates of the references as well as the appropriateness of references 1 and 2. (3 marks) 4. Comment critically on the study population. (5 marks) 5. What was/were the definitions of a failed spinal?
(3 marks) 6. In light of the limitations mentioned, would you have confidence that the definitions were consistently applied? Substantiate your answer. (2 marks) 7. From Table 2, can you work out how many women needed a general anaesthetic? Substantiate your answer.
(2 marks) 8. Calculate and comment on the risk ratio of a failed spinal anaesthetic for an emergency caesarian section versus an elective caesarian section. (3 marks) 9. Were there any significant complications presented which were not discussed in this article? (4 marks) 10. In the discussion, the authors comment on the association between a bloody tap and a failed spinal (see extract below).
Bloody CSF from an initial attempt was significantly associated with FSA in our study. This finding has significant clinical and academic implications; there is a greater likelihood of inaccurate placement of the spinal needle into a vessel and, hence, higher FSA and other complications following intravascular injection of bupivacaine.
Comment critically on both the clinical and academic implications to which the authors allude. (2 marks) 11. Do the data presented in Table 3 support the conclusions that anaesthetic training amongst junior doctors should be prioritised? (2 marks) 12. What is your take-home message from this article?

Model answers
Comment on the scientific and social value of this study.

Comment critically on the dates of the references as well as the appropriateness of references 1 and 2.
18/25 (64%) of the references are more than 5 years old. Ideally > 80% -85% of references in a manuscript should be less than 5 years old.
Reference 1 is the reference given for increasing CS rate globally and spinal anaesthetic as the anaesthetic of choice for this procedure. However, reference 1 (Páez JJ, Navarro JR. Anestesia regional versus general para partopor cesárea. Rev Colomb Anestesiol. 2012;40:203-206) is not a meta-analysis of global trends or a World Health Organization report on global trends, but an article in Spanish from Colombia which does not seem to be an appropriate reference. (The abstract from the article states: 'Methods: Article for reflection. A nonsystematic search of the literature on the topic was performed in the Medline/Pubmed, Embase, Cochrane and Lilacs databases, using the following Mesh terms: Cesaerean section, General anesthesia, Spinal anesthesia, Epidural anesthesia. Results: Although the rates for cesarean sections have been constant, the use of general anesthesia has decreased progressively. Maternal mortality associated to general anesthesia during cesarean section has dropped to practically the same level as regional anesthesia: 1.7 (95% confidence interval [CI]: 0.6-4.6). Mortality is lower with regional anesthesia: less bleeding, lower risk of surgical site infection, less post-operative pain. The neonatal outcomes are practically the same.') The abstract contradicts the statement, which is that there is an increasing CS rate globally. In addition, the data were collected in 2013 and only published in 2017, making the data old and out of date.

Reference 2 is a thesis from the University of the
(1 mark)

What was/were the definitions of a failed spinal? (3 marks)
• Women experiencing pain after 10 min of administering spinal anaesthesia. • Women who experienced pain during the procedure whose pain persisted after being given pethidine. • Women without any sensory block (see discussion).

In light of the limitations mentioned, would you have confidence that the definitions were consistently applied? Substantiate your answer. (2 marks)
The limitations state that: (1) the time of failure of spinal anaesthesia was not documented in the study and (2) it is possible that a number of spinals were repeated as they state 'We also do not have data on the number of FSAs which were repeated'. (Surely this should have been recorded in the notes if comprehensive records are being kept, as suggested by the quantity of data being collected.) It is by no means clear that the definitions were consistently applied. If no one has recorded the time the anaesthetic started, it makes it difficult to know whether 10 min was used to assess whether or not the spinal anaesthetic had failed or not.
In addition, as no record of whether or not an additional spinal was given if the initial spinal failed, it is impossible to know whether or not the findings (and complications) are based on one or more attempts and what the implications of repeat spinals are.

From Table 2, can you work out how many women needed a general anaesthetic? Substantiate your answer. (2 marks)
No - Table 2 needs to be read in conjunction with the discussion if one is to work out how many women needed a general anaesthetic.
The discussion states: A failure rate of 14.2% (of 169 = 24 patients) and 10.5% (of 21 = 2 patients) was observed with use of L3-L4 and L4-L5. Total of 26 patients, not 23 patients, with failed spinal anaesthetic.
Results should be presented in the results section and should be able to stand alone. The discussion should discuss the results and not provide additional results.

Calculate and comment on the risk ratio of a failed spinal anaesthetic for an emergency caesarian section versus an elective caesarian section. (3 marks)
This suggests that there is a 1.4 times greater chance of having a failed spinal during an emergency CS than during an elective CS. However, the 95% confidence crosses '1', which makes this not significant, and the p-value is high, which also indicates that this is not a significant finding. (Table 1) (1 mark) Were there any significant complications presented which were not discussed in this article? (4 marks) The authors state that a significant number of women developed complications -hypotension 39%, shivering 16%, vomiting 6.9%, mortality 4.3%, pain 2.9% and headache 2.9%.
(1 mark) While the focus of the article is on failed spinal and the reasons for this, significant adverse events such as hypotension and shivering, as well as a mortality rate of 4.3% (9/197 patients died) are very significant and should have been commented on and discussed. Shivering is touched on but no mention is made of the hypotension or the mortality. In addition, it is difficult to understand the reported pain of 2.9%. (2 marks) Is this women who experienced pain during the procedure (they should have been converted to a general anaesthesia) or is this pain at the injection site? In what way would this be considered a complication of spinal anaesthesia? (1 mark)

In the discussion, the authors comment on the association between a bloody tap and a failed spinal (see extract below).
Bloody CSF from an initial attempt was significantly associated with FSA in our study. This finding has significant clinical and academic implications; there is a greater likelihood of inaccurate placement of the spinal needle into a vessel and, hence, higher FSA and other complications following intravascular injection of bupivacaine.

Comment critically on both the clinical and academic implications to which they allude. (2 marks)
It is difficult to understand what the authors are referring to in this paragraph and what the academic and clinical implications are. No clear definition is given about what would be considered to be a bloody tap. The understanding of a bloody tap is that there is a small amount of blood in the CSF as it flows back through the spinal needle, suggesting that one is in the correct space but has injured a vessel when doing the spinal. Usually, one would allow the blood to clear and then inject the bupivacaine. If it does not clear but blood continues to flow, one would conclude that one is in a vessel and would remove the spinal needle and NOT inject the bupivacaine. In the article, there is no evidence from the study or from the literature of complications following intravascular injection of bupivacaine.
The academic and clinical implications may be the need to correctly teach students and clinicians how to do a spinal anaesthetic using appropriate landmarks and to understand the implications of a bloody tap -when experiencing a bloody tap, to allow the blood to clear prior to injecting bupivacaine and to ensure free flow of CSF, and not to the inject bupivacaine if there is only blood draining from the CSF needle, but rather to remove the spinal needle and redo the spinal. Table 3

support the conclusions that anaesthetic training amongst junior doctors should be prioritised? (2 marks)
In Table 3, years of experience is reported as being significantly associated with the increased chance of a failed spinal and seems to support the conclusion that anaesthetic training amongst junior doctors should be prioritised. However, although this may be true, no details are given regarding the experience of those giving the anaesthetic other than to mention how many of the 197 anaesthetics were given by each category of staff (FP -19, registrars -80, medical officers -90, community service officers -8) and experience is probably a more important indicator than years of service. It is also unfortunate that this was presented as a binary < or > 1 year, as there might also be a falloff in competencies of more senior staff who are no longer routinely involved in giving anaesthetics.

Objectives of station
This station tests the candidate's ability to: • Conduct a pre-operative consultation for an elective caesarean section, including a risk assessment. • Manage a high-risk patient appropriately.

Type of station
Integrated consultation.
• Chest x-ray of a mitral stenosis patient. • Electrocardiogram of a mitral stenosis patient.

Instructions for candidate History/context
You are the family physician working in a rural district hospital. A 26-year-old woman with a history of shortness of breath for 1 week, at 37 weeks of gestation, was reviewed in the antenatal clinic and referred to you. The attending clinician commented, 'high risk pregnancy with cardiac condition' and advised to book for elective caesarean section. The patient's basic workup has been done.

Your task
• Do a pre-operative anaesthetic fitness consultation. • Negotiate a management plan appropriate to your assessment.
N.B.: You do not need to do an examination on this patient. All examination findings will be provided on request.

Instructions for the examiner Objectives
This station tests the candidate's ability to: • Conduct a pre-operative consultation for an elective caesarean section, including a risk assessment. • Manage a high-risk patient appropriately. This is an integrated consultation station in which the candidate has 14 min. Familiarise yourself with the Assessor guidelines ( Figure 3) which detail the required responses expected from the candidate.
No marks are allocated. In the mark sheet, tick off one of the three responses for each of the competencies listed. Make sure you are clear on what the criteria are for judging a candidate's competence in each area. Provide the following information to the candidate when requested:

Examination findings
Electrocardiogram and chest x-ray -candidate to interpret. Please switch off your cell phone. Please do not prompt the student. Please ensure that the station remains tidy and is reset between candidates. This station is 15 min long. The candidate has 14 min, then you have 1 min between candidates to complete the mark sheet and prepare the station.

Gathering informaƟon: History
The competent candidate gathers sufficient informaƟon about past medical history, risk factors, current symptoms and paƟent experience. The good candidate gathers all relevant informaƟon in an efficient, paƟent-centred manner.

Gathering informaƟon: Physical examinaƟon
The competent candidate requests all specific examinaƟon findings that uncover the underlying pathology (soŌ diastolic murmur of mitral stenosis, with signs of cardiac failure). The good candidate is guided by the history, and requests specific examinaƟon findings in a methodical manner.

Gathering informaƟon: InvesƟgaƟons
The competent candidate idenƟfies P-wave abnormaliƟes on ECG and pulmonary congesƟon on CXR.
The good candidate provides a specific descripƟon of p-mitrale in affected leads, and a detailed descripƟon of CXR abnormaliƟes.

Clinical reasoning
The competent candidate idenƟfies the possible diagnosis (thoughit may not be exact) of a cardiac lesion, with underlying cardiac decompensaƟon, and consequent high risk, needing referral to a regional hospital for an elecƟve CS. The good candidate makes a specific diagnosis of mitral stenosis with cardiac decompensaƟon, recognises the need for referral, and elicits the paƟent's perspecƟve and understanding of the situaƟon. Figure 2 are relevant clinical competencies extracted for the OCSE station from the mini CEX (mini clinical evaluation exercise). This is a validated examination tool that is used in the registrars portfolio of learning. The aim is to establish that the candidate is able to safely and effectively identify that this patient is too high a risk for a district hospital and needs to be transferred to a regional hospital.

Competencies
Competent: The task is completed safely and effectively.
Good: In addition to displaying competence, the task is completed efficiently and in an empathic, patient-centred manner (acknowledges the patient's ideas, beliefs, expectations, concerns and fears).

Role play -Instructions for actor Appearance (including dress) and behaviour (emotions and actions)
Pregnant woman in her 20s'. Some difficulty breathing with minimal activity. Anxious about the condition and future of own and baby's health.
Opening statement: (Responds to doctor) 'Dr, I'm worriedwhy did the other doctor say I must come see you. Is the baby OK?'

History Open responses: Freely tell the doctor if asked …
This is your first pregnancy. Everything was fine at all your check-ups so far.
In the last 3 weeks, you developed swelling in your legs. At first you thought it is normal to be tired and for your legs to get swollen in pregnancy. But now it seems that it is getting worse. Since last week, you also developed difficulty breathing.

Closed responses: Only tell the doctor if s/he brings this up
You know that the other doctor in maternity suspects that you might have a heart condition. No one in your family has ever had anything like this.
You planned this pregnancy. You are married, and your husband is at work.
You don't drink or smoke. You have never really been involved in exercise or sports. You don't have any medical problems, and apart from the vitamins for pregnancy, you don't take any other medications.
You have never been in hospital before, and you work as a receptionist at a local dentist.

Ideas, concerns and expectations
You are worried that your baby may be affected, and that you will have a long-term problem. What does all this mean?
The doctor must do whatever must be done to ensure that the baby will be fine.