IAC Module 4v2

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@@.whitetext; !!!Virtual Anaesthetics_4 Welcome the fourth in a series of interactive scenarios to support learning during the IAC. You can find out more on using this scenario ''[[here|howtoguide]]''. ''Disclaimer: Virtual Anaesthetics is not responsible for your use of the information contained in or linked from this site. All users should act within their own competence and according to local and national guidelines and policies. All treatment information contained herein is provided as a general example only and you should always check drug doses in an appropriate formulary. Any descriptions of procedures or techniques is intended as an example only and as a supplement formal training. Individuals should only perform procedures or techniques they have been formally trained in and are competent to perform.'' @@ ''[[Next|Introduction]]'' [[I'm a clinical supervisor or trainer|trainers_area]] @@.whitetext; If you are ''not'' a health care professional please read our brief message first [[here|message]]@@

/* <<countdownTimer>> Widget - Start */ <<widget "countdownTimer">> <<set _seconds = $args[0]>> <<set _minutes = Math.floor(_seconds / 60)>> <<set _replacementPassage = $args[1]>> <div id="timer" class="timergreen">Time remaining _minutes:<<= (_seconds - (_minutes * 60)).toString().padStart(2, '0')>></div><<script>> if (!recall("countdown", undefined)) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } else { setup.countdown = recall("countdown"); if (setup.countdown.passage !== passage()) { setup.countdown = { startTime: new Date(), lastStr: "", passage: passage() }; memorize("countdown", setup.countdown); } } setup.countdown.intervalID = setInterval(function () { if (setup.countdown.passage !== passage()) { clearInterval(setup.countdown.intervalID); forget("countdown"); setup.countdown.passage = ""; } else { var curtime = new Date(), str, seconds = State.temporary.seconds; var diff = Math.floor(seconds - ((curtime - setup.countdown.startTime) / 1000)), min = Math.floor(diff / 60); if ((diff >= 0) && (diff < seconds)) { if ($("#timer").length) { str = "Time remaining " + min + ":" + (diff - (min * 60)).toString().padStart(2, '0'); if (str != setup.countdown.lastStr) { $("#timer").empty().wiki(str); setup.countdown.lastStr = str; } if (diff <= 10) { if (!$("#timer").hasClass("timerred")) { $("#timer").removeClass("timeramber").addClass("timerred"); } } else if (diff <= 20) { if (!$("#timer").hasClass("timeramber")) { $("#timer").removeClass("timergreen").addClass("timeramber"); } } } } if (diff < 0) { clearInterval(setup.countdown.intervalID); forget("countdown"); $("#passages div.passage").empty().wiki('<<include "' + State.temporary.replacementPassage + '">>'); delete setup.countdown.passage; } } }, 200); <</script>> <</widget>> /* <<countdownTimer>> Widget - End */

@@.whitetext; !!!Virtual Anaestheics_4: Preoprative assessment part II Enter your first name: <<textbox "$firstname" "">> Enter your surname: <<textbox "$surname" "">> <<set $role = ["-", "Stage 1 Anaesthetist in Training", "Stage 2 Anaesthetist in Training", "Stage 3 Anaesthetist in Training", "Consultant Anaesthetist", "Associate Specialist Anaesthetist", "Speciality Doctor Anaesthetist", "Foundation Doctor", "Doctor (Other)", "Medical Student", "Other health care professional", "Role outside healthcare"]>>''Select your professional role:'' <<listbox "$role">> <<optionsfrom $role>> <</listbox>> <<set $randomid to random(10000000,99999999)>> <<nobr>><span id="ReplaceMe"> <<link "''Next''">> <<script>> Dialog.setup("Analytics"); Dialog.wiki("Users' privacy and data protection are our priorities. Virtual Anaesthetics uses analytics and collects anonymised data to improve your service and provide academic governance including passage function, anonymised scores, playtime, and any feedback comments you provide. This anonymised data may also be used in part or in its entirety for research and publication. For more information on our privacy policy please see ''[[here|https://www.virtualanaesthetics.com/privacy-policy/]]''. Please also be aware that this information is temporarily stored in your local internet browser cache. If using a public or shared computer you can avoid this by clearing your internet history and website data on competition of the scenario."); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[Next|Core clinical learning objectives]]''<br> <</replace>> <</link>></span><</nobr>>

<<cacheaudio "text" "audio/text.mp3">> <<cacheaudio "bell" "audio/bell.mp3">> <<cacheaudio "bell2" "audio/bell2.mp3">> <<cacheaudio "dalby" "audio/dalby.mp3">> <<set $history to []>> <<set $started to 0>>

!!!@@.greentext; Scenario learning objectives:@@ * Apply the knowlege gained in previous scenarios in decision making * Preassess a virtual emergency patient * Know some commonly used risk assessment tools and have used these to risk stratify an virtual emergency patient * Be able to describe the ASA-PS classes and give examples of these * Know the NCEPOD classification of urgency of intervention * The principles of shared decision making and discussing risk with patients * Use the information gained throughout the module to formulate an anaesthetic plan for a high-risk patient undergoing emergency surgery [[Next|exam1]] [[Show me the EPA for IAC mapped to this scenario|epa]] [[Show me the stage 1 curriculum|stage1]]

The OSCE you did for medical school finals feels a lifetime ago as you nervously wait with the other candidates. You watch the exams officer going round the room checking IDs and giving out name lables. It's your turn 'Dr $firstname $surname'. The exams officer hands you a label with your name on it and does a photo ID check. "Right everyone" they say to the room. "Has everyone put their phones and electronic devices away? No phones allowed on the exam floor." A few guilty shuffles as phones are silenced and put away. "Excellent. We will get you through to the OSCE stations. If you'd all like to follow me. Good luck everyone." They finish brightly. You take a deep breath, [[and follow them out of the room...|exam1b]]

<center> @@.whitetext; ''Audio will play automatically''@@ <<audio dalby play>> [[Transcript->transcript1]]   [[Next->audiopost1]] <img src="images/dalby.jpg" style="max-width: 100%;"/> </center>

<p style="text-align:justify"> @@.typing;''Jonus Dalby:'' "Thought I had a bug, ate something I shouldn’t, took myself off to bed with a bucket, couldn’t really see what all the fuss was about. Now some surgeon is here telling me I have to have a big operation because my innards are blocked. Can’t really understand it. I’m fit as a fiddle me." ''Molly Dalby:'' "Tell them what's really been happening Jonus. He’s been really poorly, not well, for two weeks at least, not been keeping anything down, not done number two for all that time, he’s too light headed to stand up even, and not quiet right for months before that, a bit pale and sluggish. Loosing weight, he’s not one to be off his food." ''Jonus:'' "Don’t fuss Mol. I can tell the doctor. It is true I’ve been tired a lot lately, sleeping more. I’ve got an allotment and it’s been hard work recently. I’ve still been going on my bike but half an hour with a spade and I’m fair done in, last season I’d spend the day there and stop off for a game of darts on the way home. Not now! The last week I’ve not even left my bed, it’s not surprising though, I haven’t eaten anything for days." ''Molly:'' "It’s not like him. He doesn’t bother the doctor for anything usually. Wouldn’t set foot in a hospital if he could help it. Just gets his blood pressure checked once a year with the nurse. He’s taken ramipril for donkeys years, never missed a day, and that’s it." ''Jonus:'' "I had my tonsils out as a child, didn’t have any problems but it was enough to put me off. I don’t understand this all. I feel like I’ve done my bit, gave up smoking forty years ago when I met my Mol. Just a couple of halves of bitter when I’m playing darts, otherwise I don’t drink. I like my dinners, but who doesn’t?" ''Molly:'' "He’s not even allergic to anything." ''Jonus:'' "No, nothing. All my own teeth too, dentist says I’ve got the teeth of a man half my age. One filling and all the rest sound as a bell. Not that their going to do me any good now. But once I’ve had this operation I’ll be back to the allotment in no time." @@ </p> <center> [[Play audio|audio1]]    [[Next|audiopost1]] </center> <<audio dalby pause>>

<center> @@.whitetext; ''With thanks to everyone who helped make this scenario happen!'' Our actors: Gareth Evans and JulieAnn Caulfield Dollard Our photographers: Calvin Westwell and Richard Wassall Our tech support: Charlie Hargood and Louis Rose Our logistical support: Patrick Wainwright Our editorial team: Fiona Martin and Oliver Pratt Our creative director and lead programmer: Kate Wainwright !!!Well done for completing Virtual Anaesthetics_4 <<nobr>><span id="ReplaceMe"> <<link "''certificate''">> <<script>> Dialog.setup("Tell us"); Dialog.wiki("<center> <h3>@@.greentext;You can make Virtual Anaesthetics better. <br><br>Tell us what you think of this scenario [[here|https://forms.gle/QjzbkPQPd5vttkBS7]]. It should take less than a minute. <br><br>Thanks!@@</h3> </center>"); Dialog.open(); <</script>> <<replace "#ReplaceMe">> ''[[certificate]]''<br> <</replace>> <</link>></span><</nobr>> @@ </center>

What key points did you get from the history? If you have the opportunity you could discuss the case with a clinical supervisor? You may have identified some of these [[points|surg10]] <<audio dalby pause>>

"Hello, I'm Dr Adams your examiner today. This is your History Station. In a moment I’d like you to undertake a preoperative assessment on Mrs Doors, who is having an abdominal hysterectomy today." Somewhere a bell rings. "Ah, time to get started" says Dr Adams. [[Next->exam3]] <<audio "bell" play>>

<br> You take a deep breath. Competing questions are running through your mind, what do you say first? [[What operation are you having today?|exam3b][$three = "incorrect"]] [[Introduce yourself and confirm you have the right patient.|exam3a][$three = "Good"]] [[Are you in any pain?|exam3b][$three = "incorrect"]] [[Why do you need the operation?|exam3b][$three = "incorrect"]] [[Have you been seen by the surgeon yet?|exam3b][$three = "incorrect"]] <<timed 59s>> <<goto exam3b>> <</timed>> <<countdownTimer 60 "exam3b">> <<set $result to 0>> <<audio "bell" pause>>

<br> Dr Adams keeps his poker face on as 'Mrs Doors' answers. So what next... [[Can you tell me what operation you are having done today?|exam4a][$threeb = "Good"]] [[Can you tell me what drugs you take?|exam4b][$threeb = "incorrect"]] [[Are you allergic to anything?|exam4b][$threeb = "incorrect"]] [[Do you smoke?|exam4b][$threeb = "incorrect"]] <<timed 59s>> <<goto exam4b>> <</timed>> <<countdownTimer 60 "exam4b">>

<br> Dr Adams keeps his poker face on but you think you see him make a tick on the mark sheet. 'Mrs Doors' confirms her name and date of birth. So what next... [[Can you tell me what operation you are having done today?|exam4a][$threeb = "Good"]] [[Can you tell me what drugs you take?|exam4b][$threeb = "incorrect"]] [[Are you allergic to anything?|exam4b][$threeb = "incorrect"]] [[Do you smoke?|exam4b][$threeb = "incorrect"]] <<timed 59s>> <<goto exam4b>> <</timed>> <<countdownTimer 60 "exam4b">> <<set $result to $result + 1>>

<br> You don't feel confident in that last question but plough on. What question do you follow with? [[Can you tell me whether you take any recreational drugs?|exam4c][$four = "incorrect"]] [[Can you tell me in your own words why you need a hysterectomy?|exam4d][$four = "Good"]] [[What's your job?|exam4c][$four = "incorrect"]] [[Who do you live with?|exam4c][$four = "incorrect"]] [[Have you signed a consent form?|exam4c][$four = "incorrect"]] <<timed 59s>> <<goto exam4c>> <</timed>> <<countdownTimer 60 "exam4c">>

<br> Mrs Doors confirms she's having a hysterectomy. What question do you follow with? [[Can you tell me whether you take any recreational drugs?|exam4c][$four = "incorrect"]] [[Can you tell me in your own words why you need that done?|exam4d][$four = "Good"]] [[What's your job?|exam4c][$four = "incorrect"]] [[Who do you live with?|exam4c][$four = "incorrect"]] [[Have you signed a consent form?|exam4c][$four = "incorrect"]] <<timed 59s>> <<goto exam4c>> <</timed>> <<countdownTimer 60 "exam4c">> <<set $result to $result + 1>>

<br> 'Mrs Doors' tells you she's never had an anaesthetic. "Has anyone in the family... [[...got suxamethonium apnoea?|exam7b][$six = "incorrect"]] [[...got malignant hyperthermia?|exam7b][$six = "incorrect"]] [[...had problems with anaesthetics?|exam7a][$six = "Good"]] [[...had an allergy to volatiles|exam7b][$six = "incorrect"]] [[...had dental damage during an anaesthetic?|exam7b][$six = "incorrect"]] <<timed 59s>> <<goto exam&b>> <</timed>> <<countdownTimer 60 "exam7b">> <<set $result to $result + 1>>

<br> "No." 'Mrs Doors' replies "I'm in good health generally." "Has anyone in the family... [[...got suxamethonium apnoea?|exam7b][$six = "incorrect"]] [[...got malignant hyperthermia?|exam7b][$six = "incorrect"]] [[...had problems with anaesthetics?|exam7a][$six = "Good"]] [[...had an allergy to volatiles|exam7b][$six = "incorrect"]] [[...had dental damage during an anaesthetic?|exam7b][$six = "incorrect"]] <<timed 59s>> <<goto exam7b>> <</timed>> <<countdownTimer 60 "exam7b">>

<br> "I'm adopted so I have no idea and I don't know what that is anyway." Ok, time's getting on. What's your next question? "Do you have... [[...hearing problems?|exam8b][$seven = "incorrect"]] [[...loose teeth?|exam8b][$seven = "incorrect"]] [[...COPD?|exam8b][$seven = "incorrect"]] [[...thyroid problems?|exam8b][$seven = "incorrect"]] [[...any medical conditions or things you see a Dr about?|exam8a][$seven = "Good"]] <<timed 59s>> <<goto exam8b>> <</timed>> <<countdownTimer 60 "exam8b">>

<br> "I'm adopted and I have no idea." Ok, you think it's going alright. Time's getting on though. What's your next question? "Do you have... [[...hearing problems?|exam8b][$seven = "incorrect"]] [[...loose teeth?|exam8b][$seven = "incorrect"]] [[...COPD?|exam8b][$seven = "incorrect"]] [[...thyroid problems?|exam8b][$seven = "incorrect"]] [[...any medical conditions or things you see a Dr about?|exam8a][$seven = "Good"]] <<timed 59s>> <<goto exam8b>> <</timed>> <<countdownTimer 60 "exam8b">> <<set $result to $result + 1>>

<br> "I'm generally in good health." You follow up with... [[...do you drink much alcohol?|exam9b][$eight = "incorrect"]] [[...do you take any medications?|exam9a][$eight = "Good"]] [[...are you ok with NSAIDs?|exam9b][$eight = "incorrect"]] [[...any chance you could be pregnant?|exam9b][$eight = "incorrect"]] [[...do you need a sick note?|exam9b][$eight = "incorrect"]] <<timed 59s>> <<goto exam9b>> <</timed>> <<countdownTimer 60 "exam8b">>

Just over 24 hours later you are in CEPOD theatre's anaesthetic room taking the on-call bleep from an outgoing colleague. "Anything to handover?” "Oh hi $firstname. We'd cleared the board but the surgical F1 has just booked a patient who needs a laparotomy tonight." "Oh, OK. Do you know who the boss is tonight?" "I think it’s Dr Franklin?" You take the bleep and... [[track down a booking form for this case|surg1]]

<p style="text-align:left"><img src="images/examlogo.jpg" style="max-width: 175px;"/></p> <p style="text-align:right">Virtual Anaesthetics The internet St Elsewhere HE11 0U <<set $CurDate = new Date(Date.now())>> <<= $CurDate.toLocaleString("en-UK", { day: "numeric", month: "numeric", year: "numeric" } )>></p> Dear Dr $firstname $surname <u> ''EXAMINATION <<set $CurDate = new Date(Date.now())>> <<= $CurDate.toLocaleString("en-US", { month: "long", year: "numeric" } )>>'' </u> Following your recent Objective Structured Clinical Examination please find your results as follows: ''OSCE station 1:''<<if $result > 7>> ''PASS'' <<else>> ''FAIL'' <</if>> ''OSCE station 2:''<<if $result2 > 7>> ''PASS'' <<else>> ''FAIL'' <</if>> ''OSCE station 3-14: Results to follow'' Please refer to the enclosed report for a break down of these results. We wish you every success in your future endeavours. Yours sincerely !!!@@.writing; //S Boyle//@@ Exams department [[Exam Report]] [[Next->finally]]

The exams officer leads you up a flight of stairs to the exam floor where a room has been divided off into fourteen smaller areas with partitions. They gesture to you to enter the first. An examiner sits discreetly in the corner of the cubicle holding a black clipboard. The rest of the space is taken up by two chairs. One occupied by someone you assume is a mock patient, and a vacant seat that the examiner gestures is for you. [[Next|exam2]] <<audio "bell" pause>> <<set $three = "no answer given">> <<set $threeb = "no answer given">> <<set $four = "no answer given">> <<set $five = "no answer given">> <<set $six = "no answer given">> <<set $seven = "no answer given">> <<set $eight = "no answer given">> <<set $nine = "no answer given">> <<set $ten = "no answer given">> <<set $eleven = "no answer given">> <<set $twelve = "no answer given">> <<set $twelve2 = "no answer given">> <<set $thirteen = "no answer given">> <<set $fourteen = "no answer given">> <<set $fifteen = "no answer given">> <<set $sixteen = "no answer given">> <<set $seventeen = "no answer given">> <<set $eighteen = "no answer given">> <<set $nineteen = "no answer given">> <<set $twenty = "no answer given">> <<set $twentyone = "no answer given">> <<set $twentytwo = "no answer given">> <<set $twentythree = "no answer given">> <<set $rhythm = "no answer given">>

<br> 'Mrs Doors' looks a bit flustered but answers. "Thank you, I need to ask you some questions about your general health and previous anaesthetic experiences if that's ok?" She nods. [[Have you got diabetes?|exam6b][$five = "correct"]] [[Have you got any cardiac problems?|exam6b][$five = "incorrect"]] [[Have you had an operation or anaesthetic before?|exam6a][$five = "Good"]] [[Do you go to the gym?|exam6b][$five = "incorrect"]] [[Has anyone in the family got epilepsy?|exam6b][$five = "incorrect"]] <<timed 59s>> <<goto exam6b>> <</timed>> <<countdownTimer 60 "exam6b">>

<br> 'Mrs Doors' explains she has big fibroids and has been anaemic for a long while. "Thank you, I need to ask you some questions about your general health and previous anaesthetic experiences if that's ok?" She nods. [[Have you got diabetes?|exam6b][$five = "correct"]] [[Have you got any cardiac problems?|exam6b][$five = "incorrect"]] [[Have you had an operation or anaesthetic before?|exam6a][$five = "Good"]] [[Do you go to the gym?|exam6b][$five = "incorrect"]] [[Has anyone in the family got epilepsy?|exam6b][$five = "incorrect"]] <<timed 59s>> <<goto exam6b>> <</timed>> <<countdownTimer 60 "exam6b">> <<set $result to $result + 1>>

<br> "Errr, no. They told me to bring this to my appointment." She offers you a repeat prescription slip: <center> <img src="images/doors.jpg" style="max-width: 400px;"/> </center> [[Ask her what she takes these for?|exam10a][$nine = "Good"]] [[Move on time's running out.|exam10b][$nine = "incorrect"]] <<timed 59s>> <<goto exam10b>> <</timed>> <<countdownTimer 60 "exam10b">>

<br> In reply she offers you a repeat prescription slip: <center> <img src="images/doors.jpg" style="max-width: 400px;"/> </center> [[Ask her what she takes these for?|exam10a][$nine = "Good"]] [[Move on time's running out|exam10b][$nine = "incorrect"]] <<timed 59s>> <<goto exam10b>> <</timed>> <<countdownTimer 60 "exam10b">> <<set $result to $result + 1>>

<br> You quickly read through her meds and then carry on with taking her history. "Do you have... [[...someone to pick you up?|exam10d][$ten = "incorrect"]] [[...any allergies?|exam10c][$ten = "Good"]] [[...a next of kin?|exam10d][$ten = "incorrect"]] [[...any pets at home?|exam10d][$ten = "incorrect"]] [[...any mental health problems?|exam10d][$ten = "incorrect"]] <<timed 59s>> <<goto exam10d>> <</timed>> <<countdownTimer 60 "exam10d">>

<br> "I take the prednisolone for rheumatoid arthritis. It mainly affects my hands, I was diagnosed in my mid 20s. I take the inhalers for very mild asthma, I’ve never needed other treatment for it." "Do you have... [[...someone to pick you up?|exam10d][$ten = "incorrect"]] [[...any allergies?|exam10c][$ten = "Good"]] [[...a next of kin?|exam10d][$ten = "incorrect"]] [[...any pets at home?|exam10d][$ten = "incorrect"]] [[...any mental health problems?|exam10d][$ten = "incorrect"]] <<timed 59s>> <<goto exam10d>> <</timed>> <<countdownTimer 60 "exam10d">> <<set $result to $result + 1>> <<audio "bell2" pause>>

Dr Adams raises his hand slightly just as you finish your sentence. "Time's up." You try to read his expression, but he's giving you nothing. Nor is Mrs Doors. [[On to the next station|exam14]] or [[Leave the exam and go home|gohome]] <<audio text pause>> <<set $result to $result + 1>>

The first thing you do when you get off the exam floor is retrieve your bag and turn your phone back on. There’s 47 unread emails and a [[text->text2]]. <<audio text play>> <<set $result2 to 0>>

<center><img src="images/matt.jpg" style="max-width: 100%;"/> @@.greytext; ''Today'' 13:08@@ </center> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> how'd it go????</p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; i'm bailing, not up for the rest @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> pub?? </p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; nights tomorrow, need an early night, sorry @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> <img src="images/sademoji.jpg" style="max-width: 25%;"/> </p> </div> </div> </p> [[time to get going->home]] <<audio text pause>>

There's a laminated sheet pinned to the wall outside the station that you read quickly: <div class="white2">You have been asked to attend the emergency department where a 69 year old man has been bought in by paramedics following a collapse at home. He has been intubated at the scene and CPR is ongoing. Please note, this scenario will be marked according to the Resuscitation Council UK 2021 Advanced Life Support guidelines.</div> [[Next|exam14a]]

<br> "Err..." 'Mrs Doors' frown deepens, she looks a bit flustered. "Right." No time to expand on that so your crack on. "Do you... [[...smoke cigarettes or drink much alcohol?|exam10e][$eleven = "Good"]] [[...understand the operation you are having?|exam10f][$eleven = "incorrect"]] [[...want a premed?|exam10f][$eleven = "incorrect"]] [[...know the risks of having an anaesthetic?|exam10f][$eleven = "incorrect"]] [[...want further information about pain relief?|exam10f][$eleven = "incorrect"]] <<timed 59s>> <<goto exam10f>> <</timed>> <<countdownTimer 60 "exam10f">>

<br> "I get a bit of a rash when I have penicillin." "OK. Great. Do you... [[...smoke cigarettes or drink much alcohol?|exam10e][$eleven = "Good"]] [[...understand the operation you are having?|exam10f][$eleven = "incorrect"]] [[...want a premed?|exam10f][$eleven = "incorrect"]] [[...know the risks of having an anaesthetic?|exam10f][$eleven = "incorrect"]] [[...want further information about pain relief?|exam10f][$eleven = "incorrect"]] <<timed 59s>> <<goto exam10f>> <</timed>> <<countdownTimer 60 "exam10f">> <<set $result to $result + 1>>

<br> You spot a defib on a trolley to the side. There's that bell again. Dr Smith continues “What rhythm is this?” <center> <img src="images/vfcompressions.jpg" style="max-width: 500px;"/> </center> [[VT|exam15b][$thirteen = "incorrect"]] [[VF|exam15b][$thirteen = "incorrect"]] [[SVT|exam15b][$thirteen = "incorrect"]] [[Polymorphic VT|exam15b][$thirteen = "incorrect"]] [[Stop the chest compressions|exam15a][$thirteen = "Good"]] <<timed 59s>> <<goto exam15b>> <</timed>> <<countdownTimer 60 "exam15b">> <<audio "bell2" play>>

<br> You kick yourself, you need to pause chest compressions because of artifact. "Actually, sorry, could you please pause the chest compressions?" Keith stops for a moment. <center> <img src="images/vf.jpg" style="max-width: 500px;"/> </center> "OK, thats... [[VT|exam16b][$fourteen = "incorrect"]] [[VF|exam16a][$fourteen = "Good"]] [[SVT|exam16b][$fourteen = "incorrect"]] [[Polymorphic VT|exam16b][$fourteen = "incorrect"]] <<timed 59s>> <<goto exam16b>> <</timed>> <<countdownTimer 60 "exam16b">> <<set $result2 to 0>> <<audio "bell2" pause>>

<br> "Could you please pause the chest compressions?" Keith stops for a moment. <center> <img src="images/vf.jpg" style="max-width: 500px;"/> </center> "OK, thats... [[VT|exam16b][$fourteen = "incorrect"]] [[VF|exam16a][$fourteen = "Good"]] [[SVT|exam16b][$fourteen = "incorrect"]] [[Polymorphic VT|exam16b][$fourteen = "incorrect"]] <<timed 59s>> <<goto exam16b>> <</timed>> <<countdownTimer 60 "exam16b">> <<set $result2 to $result2 + 1>> <<audio "bell2" pause>>

<br> "No, never smoked, rarely drink." Perhaps time for a final couple of quick questions? "When did you... [[...last use your inhaler?|exam10h][$twelve = "incorrect"]] [[...arrive this morning?|exam10h][$twelve = "incorrect"]] [[...last have food or drink?|exam10g][$twelve = "Good"]] [[...have your pre-op clinic appointment?|exam10h][$twelve = "incorrect"]] <<timed 59s>> <<goto exam10h>> <</timed>> <<countdownTimer 60 "exam10h">> <<set $result to $result + 1>>

<br> "Yes, I do." She doesn't look happy. Perhaps time for a final couple of quick questions? "When did you... [[...last use your inhaler?|exam10h][$twelve = "incorrect"]] [[...arrive this morning?|exam10h][$twelve = "incorrect"]] [[...last have food or drink?|exam10g][$twelve = "Good"]] [[...have your pre-op clinic appointment?|exam10h][$twelve = "incorrect"]] <<timed 59s>> <<goto exam11b>> <</timed>> <<countdownTimer 60 "exam11b">>

<br> The rhythm on the monitor changes. <center> <img src="images/vt.jpg" style="max-width: 500px;"/> </center> "And what rhythm is this?" asks Dr Smith You take a long look before replying... [[VT|exam16c][$rhythm = "Good"]] [[VF|exam16d][$rhythm = "incorrect"]] [[SVT|exam16d][$rhythm = "incorrect"]] [[Polymorphic VT|exam16d][$rhythm = "incorrect"]] <<timed 59s>> <<goto exam16d>> <</timed>> <<countdownTimer 60 "exam16d">>

<br> Your fingers reach to sim man's neck. "There is no pulse." Dr Smith glances at the mark sheet. "What rate of ventilation to chest compressions would you use?" Keith has obligingly got back on the chest. "I would do... [[15:2|exam17d][$sixteen = "incorrect"]] [[2:15|exam17d][$sixteen = "incorrect"]] [[30:2|exam17d][$sixteen = "incorrect"]] [[2:30|exam17d][$sixteen = "incorrect"]] [[continuous chest compressions|exam17c][$sixteen = "Good"]] <<timed 59s>> <<goto exam17d>> <</timed>> <<countdownTimer 60 "exam17d">> <<set $result2 to $result2 + 1>>

<br> Dr Smith glances at the mark sheet. "What rate of ventilation to chest compressions would you use?" Keith has obligingly got back on the chest. "I would do... [[15:2|exam17d][$sixteen = "incorrect"]] [[2:15|exam17d][$sixteen = "incorrect"]] [[30:2|exam17d][$sixteen = "incorrect"]] [[2:30|exam17d][$sixteen = "incorrect"]] [[continuous chest compressions|exam17c][$sixteen = "Good"]] <<timed 59s>> <<goto exam17d>> <</timed>> <<countdownTimer 60 "exam17d">>

<br> You deliver a shock. "We no longer need you to interact with the mannequin. I am going to ask you some more questions related to the scenario. When should the adrenaline be given?" [[As soon as venous access is secured|exam19b][$eighteen = "incorrect"]] [[Before the second shock|exam19b][$eighteen = "incorrect"]] [[After the second shock|exam19b][$eighteen = "incorrect"]] [[Before the third shock|exam19b][$eighteen = "incorrect"]] [[After the third shock|exam19a][$eighteen = "Good"]] <<timed 59s>> <<goto exam19b>> <</timed>> <<countdownTimer 60 "exam19b">>

<br> "When should amiodarone be given and what dose?" [[After the second shock, 150 mg|exam20b][$nineteen = "incorrect"]] [[After the second shock, 300 mg|exam20b][$nineteen = "incorrect"]] [[After the third shock, 150 mg|exam20b][$nineteen = "incorrect"]] [[After the third shock, 300 mg|exam20a][$nineteen = "Good"]] [[Amiodarone isn't given for VT|exam20b][$nineteen = "incorrect"]] <<timed 59s>> <<goto exam20b>> <</timed>> <<countdownTimer 60 "exam20b">>

<br> "Would you please go ahead and defibrillate the patient?" What order do you perform this action? [[everyone clear, select energy, charge, shock, rhythm check|exam18b][$seventeen = "incorrect"]] [[continue compressions, everyone else clear, select energy, charge, off the chest, shock, rhythm check|exam18b][$seventeen = "incorrect"]] [[continue compressions, everyone else clear, select energy, charge, off the chest, shock, continue compressions|exam18a][$seventeen = "Good"]] [[continue compressions, everyone else clear, charge, select energy, off the chest, shock, continue compressions|exam18b][$seventeen = "incorrect"]] [[everyone clear, charge, select energy, off the chest, shock, rhythm check|exam18b][$seventeen = "incorrect"]] <<timed 59s>> <<goto exam18b>> <</timed>> <<countdownTimer 60 "exam18b">>

<br> "If the VT persists and amiodarone has been given when would you repeat the amiodarone and what dose?" [[Before the fourth shock, 300 mg|exam21b][$twenty = "incorrect"]] [[After the fourth shock, 150 mg|exam21b][$twenty = "incorrect"]] [[Before the fifth shock, 300 mg|exam21b][$twenty = "incorrect"]] [[After the fifth shock, 150 mg|exam21a][$twenty = "Good"]] [[Amiodarone isn't given for VT|exam21b][$twenty = "incorrect"]] <<timed 59s>> <<goto exam21b>> <</timed>> <<countdownTimer 60 "exam21b">>

<br> "Pauses in chest compressions should be no longer than...?" [[As long as it takes to charge the defibrilator|exam22b][$twentyone = "incorrect"]] [[3 seconds|exam22b][$twentyone = "incorrect"]] [[5 seconds|exam22a][$twentyone = "Good"]] [[8 seconds|exam22b][$twentyone = "incorrect"]] [[10 seconds|exam22b][$twentyone = "incorrect"]] <<timed 59s>> <<goto exam22b>> <</timed>> <<countdownTimer 60 "exam22b">>

<br> "What is the role of waveform capnography during advanced life support?" You think for a second, you are sure you know this and time is running out. [[Ensuring ETT placement is in the trachea|exam23b][$twentytwo = "incorrect"]] [[Monitoring ventilation rate during CPR|exam23b][$twentytwo = "incorrect"]] [[Monitoring the quality of chest compressions|exam23b][$twentytwo = "incorrect"]] [[Identifying return of spontaneous circulation during CPR|exam23b][$twentytwo = "incorrect"]] [[Prognostication during CPR|exam23b][$twentytwo = "incorrect"]] [[All of the above|exam23a][$twentytwo = "Good"]] <<timed 59s>> <<goto exam23b>> <</timed>> <<countdownTimer 60 "exam23b">>

And there's the bell. Time's up. You thank Keith, Dr Smith and Dr Hurst. You go round the rest of the OSCE circuit and the remaining 14 stations. Finally the exam is over, the relief is almost palpable. [[Time to escape->finished]] <<audio text pause>>

And there's the bell. Time's up. You thank Dr Smith, Dr Hurst and Keith. You go round the rest of the OSCE circuit and the remaining 14 stations. Finally the exam is over, the relief is almost palpable. [[Time to escape|finished]] <<set $result2 to $result2 + 1>> <<audio text pause>>

The first thing you do when you get off the exam floor is retrieve your bag and turn your phone back on. There’s 47 unread emails and a [[text->text3]]. <<audio text play>>

<center><img src="images/matt.jpg" style="max-width: 100%;"/> @@.greytext; ''Today'' 18:08@@ </center> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> done????</p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; yep @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> pub?? </p> </div> </div> </p> <p style="text-align:right"> <div class="talk-bubble2 tri-right round right-in"> <div class="talktext"> <p> @@.whitetext; nights tomorrow, need an early night, sorry @@ </p> </div> </div> </p> <p style="text-align:left"> <div class="talk-bubble1 tri-right round left-in"> <div class="talktext"> <p> <img src="images/sademoji.jpg" style="max-width: 25%;"/> </p> </div> </div> </p> [[time to get going->home]] <<audio text pause>>

Finally you get a seat on the train heading for home. You get your laptop out and carry on with the journal club summary you've been doing for next week's session. <a data-passage="next weeks journal club 2" class="link-internal link-image"> <img src="images/journalclub.jpg" style="max-height: 175px"> </a>

@@.typing;''From:'' Sally Fenton ''Sent:'' Today ''To:'' $firstname $surname and 18 others ''Subject:'' next week's journal club Hi Everyone I've attached the summary for next week's teaching. It's about emergency surgery and assessment of the high-risk perioperative patient. And of course there's some NELA in there! See you all next week. Cheers Sally @@ <a data-passage="next weeks journal club 2" class="link-internal link-image"> <img src="images/bja.jpg" style="max-height: 175px"> </a> Sent from my iPad [[I'll skip that thanks->night1]]

<center> !!@@.typing; Managing risk @@ <img src="images/risk.jpg" style="max-width: 100%;"/> </center> <div class="notes">''National Emergency Laparotomy Audit''</div> Emergency laparotomies in England and Wales^^1^^: * 25,000 in 2018-19^^1^^ * 9% mortality * 84% had preoperative assessment of risk * 46% assessed as high-risk with a predicted mortality ≥ 5% * 94% of high-risk patients seen pre-op by anaesthetic consultant * Almost 1 in 4 high-risk patients dead at 90d //''Recommendation 1.1:'' Clinical teams must assess all patients' risk of death and morbidity, using validated tools, ensuring other factors such as frailty, nutritional status, are recognised.// <div class="notes">''Tools^^2^^''</div> <center> !!!@@.greentext;No risk score methodology is perfect They should be used within an overall clinical decision making process@@ </center> ''ASA physical status score (ASA-PS):'' * Population based mortality from retrospective review of hospital records in 1941 * +++ revised, last update 2014 for BMI, alcohol and smoking * Predictor of both mortality and post-op complications after non-cardiac surgery * Subjective |@@.greentext; ''ASA class'' @@|@@.greentext; ''Patient description...'' @@|@@.greentext; ''e.g'' @@|@@.greentext; ''% mortality'' @@| |''1''|Normal, healthy|Non-smoker; minimal alcohol; healthy|0.1| |''2''|Mild systemic disease|No substantive functional limitations; smoker; social alcohol use; BMI 30-39; well controlled hypertension, asthma or diabetes|0.7| |''3''|Severe systemic disease|Substantive functional limitations; one or more moderate-to-severe diseases; poorly controlled hypertension, asthma or diabetes; BMI ≥40; alcohol dependence; dialysis; history of CVA, TIA, MI or PPM >3mth ago|3.5| |''4''|Severe disease that is a constant threat to life|History of CVA, TIA, MI or PPM <3mth ago; severe valve dysfunction; ongoing cardiac ischaemia; end-stage renal disease not on regular dialysis|18.3| |''5''|Moribund, unlikley to survive without the operation|ruptured AAA; massive trauma; ischaemic bowel with significant cardiac or multiple organ/system dysfucntion; intracranial bleed with mass effect|93.3| |''6''|Declared brain-dead patient for organ donation||| ''POSSUM:'' * Risk prediction model * ''P''hysiological and ''O''perative ''S''everity ''S''core for the en''U''meration of ''M''ortality and ''Morbidity'' (there is also a Portsmouth variation P-POSSUM) * Both tools: 12 physiological + 6 surgical variables to predict 30d mortality * POSSUM also morbidity prediction <center> |@@.greentext; ''Physiological variables'' @@|@@.greentext; ''Surgical variables'' @@| |Age; cardiac signs; resp history or CXR findings; systolic BP; HR; GCS; Hb; WCC; urea; Na^^+^^; K^^+^^; ECG|Operative severity; multiple procedures; total blood loss; peritoneal soiling; malignancy; urgency of surgery| </center> ''NELA calculator:'' * 30d mortality after bowel surgery * P-POSSUM <u>overestimates</u> laparotomy mortality for some patients so NELA calculator developed * No morbidity component * NELA calculator available [[here|https://data.nela.org.uk/riskcalculator/]] ''SORT:'' * Surgical outcome risk tool developed after 2011 NCEPOD 'Knowing the Risk' report, //'mortality risk should be made explicit to patients and documented on the consent form'// * Non-neuro, non-cardiac, non-obstetric * 30d mortality * Six variables: ASA-PS; urgency of surgery; severity of surgery; surgical speciality; cancer; age * Simple, using preoperative data ''ACS NSQIP:'' * American College of Surgeons national surgical quality improvement project * Available [[here|https://riskcalculator.facs.org/RiskCalculator/]] <center> <img src="images/acsnsqip.jpg" style="max-width: 100%;"/> </center> <div class="notes">''So they're high-risk...''</div> High-risk patients: * 12.5% of the surgical population * 80% of perioperative deaths * 30d mortality 6% after elective surgery, 30% after emergency surgery <div class="notes">''What do they need?''</div> <center> !!!@@.greentext;Experienced surgical and anaesthetic personnel Patient should be informed of the risk(s) and involved in decision making@@ </center> As part of the preassessment process consider how to optimise the patient in front of you: * What is their <<link [[functional capacity?|next weeks journal club 2]]>> <<set Dialog.setup("Functional capacity")>> <<set Dialog.wiki("Functional capacity is the ability to increase and sustain tissue oxygen delivery and consumption. Patients with diminished functional capacity are at increased risk of adverse postoperative outcomes. Not being able to get up a flight of stairs prior to admission is a poor prognostic sign")>> <<set Dialog.open ()>> <</link>> * Are they haemodynamically stable? * Are they hypovolaemic or septic? Will they tolerate fluid shifts? * Have they got an AKI? * Where do they need to go after? * Blood tests? How will these change my management? * Do they need a G&S or cross match? * Do they need a arterial or venous blood gas? (if they are sick - yes) * Pregnancy test? * ECG? ECHO? CXR? Other investigations? How will these change my management? @@.greentext;''When planning perioperative care ask: how will pre-existing comorbidities and the surgical pathology, influence the choice of anaesthetic agents, monitoring, and perioperative management?''@@ <div class="notes">''How long have we got??^^3^^''</div> <center> !!!@@.greentext;Surgical urgency is usually an explicit part of booking emergency and trauma cases, if not find out@@ </center> ''Immediate'' * Life or limb threatening pathology * Theatre within 2h of decision to operate (often within minutes, * resuscitate on the operating table) * Examples: ruptured AAA, major haemorrhage, fracture with neurovascular deficit, compartment syndrome * When?: Next available theatre day and night ''Urgent'' * Risk of deterioration to life-threatening conditions, treatment of distressing symptoms * Theatre within 6h * Examples: perforated large bowel, fixation of compound fractures, penetrating eye injuries * When?: emergency list(s), day and night ''Expediated'' * Early treatment of condition that isn’t an immediate threat to life, limb or organ survival, stable patient * Theatre within days * Example: stable, non-septic patients with acute surgical pathologies * When?: elective lists with spare capacity, emergency list(s) during the day ''Elective'' * Routine booking * Examples: resection for non-obstructing carcinoma, joint replacements, laparoscopic cholecystectomy * When?: elective lists There is an equivalent system <<link [[equivalent system|next weeks journal club 2]]>> <<set Dialog.setup("Categorising the urgency of caesarean section")>> <<set Dialog.wiki("''Cat 1:'' theatre and delivery within 30 minutes for life-threatening maternal or fetal compromise; ''cat 2:'' theatre and delivery within 90 minutes for non-life-threatening maternal or fetal compromise; ''cat 3:'' expediated with no maternal or fetal compromise; ''cat 4:'' elective")>> <<set Dialog.open ()>> <</link>> used in obstetrics !!!<p style="text-align:justify"> @@.typing;The bottom line: Assess risk using risk assessment tools and clinical evaluation. Document it. Act on it. What can you do to optimise the patient in front of you? High risk patients should have a consultant anaesthetist and surgeon in theatre.@@</p> [[Next->night1]] [[Show me the evidence->ref1]] <A HREF="javascript:window.print()">Click to Print This Page</A>

# NELA Project Team. Sixth Patient Report of the National Emergency Laparotomy Audit. RCoA London 2020. Available [[here|file:///C:/Users/Kate/Downloads/The%20Sixth%20Patient%20Report%20of%20the%20NELA%202020%20-%20Executive%20Summary%20November%202020.pdf]] # Stones J, Yates D. Clinical risk assessment tools in anaesthesia. //BJA Ed//. 2019; 19(2):47-53 # Ilyas C, Jones J, Fortey S. Management of the patient presenting for emergency laparotomy. //BJA Ed//. 2019; 19(4):113-118 # NCEPOD. Classification of Intervention. Available [[here|https://www.ncepod.org.uk/classification.html]] # Minto G, Biccard B. ''Assessment of the high-risk perioperative patient''. //CEACCP//. 2014; 14(1):12-17 [[Back->next weeks journal club 2]]

!!Objective Structured Clinical Examination 1: History taking <p style="text-align:justify">Overall candidates who asked all the routine questions, in a logical fashion, avoided medical jargon and did not overwhelm the patient with multiple closed questions or too much information scored highly on this station. Borderline/underperforming candidates used erratic or closed questions or questions phrased in medical language. They did not develop on questions and lost marks from not identifying pertinent information.</p> @@.pinktext;''Q1 Expected level of performance:'' Forms rapport, introduces self and confirms the patient identity.@@ ''Your performance:'' <<print $three>> <p style="text-align:justify">''Candidate feedback:'' Candidates should always introduce themselves including their role in the patient's care, and confirm they have the correct patient before undertaking any further questions.</p> @@.pinktext;''Q2 Expected level of performance:'' Checks understanding of procedure/operation the patient is expecting.@@ ''Your performance:'' <<print $threeb>> <p style="text-align:justify">''Candidate feedback:'' It is important to establish the procedure the patient is expecting and whether this agrees with the consent form, theatre list and other pertinent documentation.</p> @@.pinktext;''Q3 Expected level of performance:'' Uses open questions to establish reason for procedure/operation @@ ''Your performance:'' <<print $four>> <p style="text-align:justify">''Candidate feedback:'' In an attempt to get as many marks as possible many candidates rushed this stage of the history taking process and asked closed questions, missing relevant information and losing marks in the process.</p> @@.pinktext;''Q4 Expected level of performance:'' Uses open questions to establish whether patient has had previous operations or anaesthetics.@@ ''Your performance:'' <<print $five>> <p style="text-align:justify">''Candidate feedback:'' Good candidates used open questions in a logical fashion without rushing the patient, picking up the salient points and gaining marks.</p> @@.pinktext;''Q5 Expected level of performance:'' Uses open questions to establish whether the patient or anyone in their family has had problems with anaesthetics.@@ ''Your performance:'' <<print $six>> <p style="text-align:justify">''Candidate feedback:'' Good candidates continued to use open questions while more borderline/underperforming candidates used medical jargon, confusing the patient and missing out on important information.</p> @@.pinktext;''Q6 Expected level of performance:'' Uses open questions to establish whether the patient has any relavent medical history.@@ ''Your performance:'' <<print $seven>> <p style="text-align:justify">''Candidate feedback:'' Good candidates continued to use open questions in a logical fashion to explore the patient's medical history while borderline/underperforming candidates used a more scattergun approach in their questioning, confusing the patient further and again missing out on key information.</p> @@.pinktext;''Q7 Expected level of performance:'' Uses open question to establish whether the patient takes any medications.@@ ''Your performance:'' <<print $eight>> <p style="text-align:justify">''Candidate feedback:'' Good candidates continued to use open questions in a logical fashion to find out what medication the patient was taking. Borderline/underperforming candidates used closed questions that would not illicit a comprehensive drug history.</p> @@.pinktext;''Q8 Expected level of performance:'' Uses targeted questions to explore conditions that become apparent from the history taking.@@ ''Your performance:'' <<print $nine>> <p style="text-align:justify">''Candidate feedback:'' Good candidates used targeted questions relevant to anaesthesia to expand on answers given by the patient. Borderline/underperforming candidates did not adapt their history taking based on the answers given and did not obtain further valuable information.</p> @@.pinktext;''Q9 Expected level of performance:'' Confirms allergies and types of reactions. @@ ''Your performance:'' <<print $ten>> <p style="text-align:justify">''Candidate feedback:'' Good candidates asked logical questions with relevance to anaesthesia. Borderline/underperforming candidates lost valuable time asking unnecessary questions or questions using medical language that the patient did not understand.</p> @@.pinktext;''Q10 Expected level of performance:'' Confirms smoking history and alcohol use.@@ ''Your performance:'' <<print $eleven>> <p style="text-align:justify">''Candidate feedback:'' Good candidates asked logical questions with relevance to anaesthesia. Borderline/underperforming candidates lost valuable time asking unnecessary questions or questions using medical language that the patient did not understand.</p> @@.pinktext;''Q11 Expected level of performance:'' Confirms when patient last ate and drank@@ ''Your performance:'' <<print $twelve>> <p style="text-align:justify">''Candidate feedback:'' Good candidates asked logical questions with relevance to anaesthesia. Borderline/underperforming candidates lost valuable time asking unnecessary questions or questions using medical language that the patient did not understand.</p> @@.pinktext;''Q12 Expected level of performance:'' Allocates time to summarise and confirm the history.@@ ''Your performance:'' Good <p style="text-align:justify">''Candidate feedback:'' Good candidates were able to summarise the history in a logical and coherent way and check that this was correct by sharing with the patient. Borderline/underperforming candidates either omitted this important aspect of the history, had a poor structure to their summary or did not confirm the history with the patient.</p> @@.pinktext;''Q13 Expected level of performance:'' Offers the patient the opportunity to ask questions.@@ ''Your performance:'' <<print $twelve2>> <p style="text-align:justify">''Candidate feedback:'' Good candidates gave the patient an opportunity to ask questions. Borderline/underperforming candidates either omitted this important aspect or had not allocated enough time.</p> !!Objective Structured Clinical Examination 2: Interactive resuscitation <p style="text-align:justify">Pre-station information: You have been asked to attend the emergency department where a 69 year old man has been bought in by paramedics following a collapse at home. He has been intubated at the scene and CPR is ongoing.</p> @@.pinktext;''Q1 The candidate correctly stops CPR to avoid artifact causing misinterpretation of the patient's rhythm''@@ ''Your performance:'' <<print $thirteen>> <p style="text-align:justify">''Candidate feedback:'' Borderline/underperforming candidates omitted to stop chest compressions.</p> @@.pinktext;''Q2 The candidate correctly identifies ventricular fibrillation''@@ ''Your performance:'' <<print $fourteen>> <p style="text-align:justify">''Candidate feedback:'' Good candidates were able to correctly identify the rhythm as ventricular fibrillation. Borderline/underperforming candidates did not correctly identify the rhthym. This was frequently due to artifact caused by ongoing chest compressions.</p> @@.pinktext;''Q3 The candidate correctly identifies ventricular tachycardia''@@ ''Your performance:'' <<print $rhythm>> <p style="text-align:justify">''Candidate feedback:'' Good candidates were able to correctly identify the rhythm as ventricular tachycardia. Borderline/underperforming candidates did not correctly identify the rhthym. This was frequently due to artifact caused by ongoing chest compressions.</p> @@.pinktext;''Q4 The candidate correctly identifies that ventricular tachycardia can be associated with a pulse''@@ ''Your performance:'' <<print $fifteen>> <p style="text-align:justify">''Candidate feedback:'' Good candidates confirmed the patient was in cardiac arrest. Borderline/underperforming candidates did not confirm cardiac arrest and/or did not manage the scenario according to recognised national guidance.</p> @@.pinktext;''Q5 Candidate correctly identifies that an advanced airway is in place and chest compressions can be performed continuously''@@ ''Your performance:'' <<print $sixteen>> <p style="text-align:justify">''Candidate feedback:'' Borderline/underperforming candidates did not perform continuous chest compressions. Some candidates performed compressions at ratios other than 30:2 for an <u>unsecured airway</u> as advised within the 2021 ALS guidelines.</p> @@.pinktext;''Q6 Performs defibrillation safely, according to the 2021 ALS guidelines while minimising interruptions to chest compressions.''@@ ''Your performance:'' <<print $seventeen>> <p style="text-align:justify">''Candidate feedback:'' Good candidates performed safe defibrillation, at the correct energy while minimising interuptions to chest compressions. Borderline/underperforming candidates had prolonged interruptions to chest compressions while charging the defibrilator and/or while performing a rhythm check after the shock was delivered.</p> @@.pinktext;''Q7 Candidate correctly gives 10 ml of 1:10,000 adrenaline after the third shock''@@ ''Your performance:'' <<print $eighteen>> <p style="text-align:justify">''Candidate feedback:'' The majority of candidates correctly gave adrenaline at the correct dose after the third shock.</p> @@.pinktext;''Q8 Candidate correctly gives 300 mg of amiodarone after third shock''@@ ''Your performance:'' <<print $nineteen>> <p style="text-align:justify">''Candidate feedback:'' Good candidates correctly gave 300 mg of amiodarone diluted to 20 ml in 5% dextrose during the interval between the third and fourth shocks. Borderline/underperforming candidates either omitted amiodarone or administered amiodarone at times/doses other than those recommended in the 2021 ALS guidlines.</p> @@.pinktext;''Q9 Candidate correctly identifies that amiodarone can be repeated after the fifth shock at a dose of 150 mg''@@ ''Your performance:'' <<print $twenty>> <p style="text-align:justify">''Candidate feedback:'' Borderline/underperforming candidates either omitted a second dose of amiodarone or administered amiodarone at times/doses other than those recommended in the 2021 ALS guidlines.</p> @@.pinktext;''Q10 Candidate minimises interruptions to chest compressions and ensures they are no more than 5 seconds''@@ ''Your performance:'' <<print $twentyone>> @@.pinktext;''Q11 Candidate correctly identifies the role of waveform capnography during advanced life support''@@ ''Your performance:'' <<print $twentytwo>> ''Candidate feedback:'' Good candidates recognised the role of waveform capnography during advanced life support: * Ensuring ETT placement is in the trachea * Monitoring ventilation rate during CPR * Monitoring the quality of chest compressions * Identifying return of spontaneous circulation during CPR * Prognostication during CPR [[Back->resultletter]] <A HREF="javascript:window.print()">Click to Print This Page</A>

<<if $result > 7 & $result2 > 7>> Well done you! Time to treat yourself to a takeway and open a bottle of fizz to celebrate. <<elseif $result < 8 & $result2 < 8>> Bad luck. That's just how it goes on the day sometimes. Time to order that takeaway you promised yourself and plan when to tackle it again. <<else>> It could be worse, you could have failed the lot. Time to order that takeaway you promised yourself and plan when to tackle it again. <</if>> [[End->exit2]]

<center> <img src="images/letter.jpg" style="max-width: 50%;"/> </center> @@.whitetext; A couple of weeks later you arrive home after a regular day shift to find a tonne of junk mail, and an official looking envelope waiting for you on the doormat. Better [[open it->resultletter]]

!!!@@.greentext;Scenario learning objectives:@@ * Apply the knowlege gained in previous IAC modules in decision making * Preassess a virtual emergency patient * Know some commonly used risk assessment tools and have used these to risk stratify an virtual emergency patient * Be able to describe the ASA-PS classes and give examples of these * Know the NCEPOD classification of urgency of intervention * The principles of shared decision making and discussing risk with patients * Use the information gained throughout the module to formulate an anaesthetic plan for a high-risk patient undergoing emergency surgery ''Printable evidence for the LLP'' ''[[here|https://www.virtualanaesthetics.com/IACModule%204/IACmodule4mapped.pdf]]'' [[Next|credits]] <<set $historyOutput to "">> <<nobr>> <<set _last to $started>> <<for _event range $history>> <<set $historyOutput to $historyOutput + "<br>Passage: " + _event.passage + ", Seconds: " + setup.toSeconds(_last, _event.time)>> <<set _last to _event.time>> <</for>> <</nobr>> <<nobr>> <<set $passagetimes to $historyOutput>> <<set $id to "VA4IAC">> <<set $result1 to $result>> <<set $playtimehr to playTime('hours')>> <<set $playtimemin to playTime('minutes')>> <<set _data = {randomid: $randomid, role: $role, id: $id, playtimehr: $playtimehr, playtimemin: $playtimemin, result1: $result1, result2: $result2, passagetimes: $passagetimes }>> <<run sendData4(_data)>> <</nobr>>

<p style="text-align:justify">We are absolutely thrilled that you have found us and shown an interest in our learning platform. We wanted to give you the heads up before you get any deeper into the scenario, that like the best medical dramas, bad things may happen. This is to support learning and clinical decision making. It is ''REALLY RARE'' for things like this to happen to otherwise well people undergoing anaesthetics. The Royal Collage of Anaesthetists has some really helpful information explaining the risks of having an anaesthetic if you want further information, available [[here|https://rcoa.ac.uk/patient-information/patient-information-resources/anaesthesia-risk]]. When you are ready, welcome to our virtual world...</p> [[Start|Introduction]]

<br> "I last ate yesterday and had a drink of water at 6am." "Is there anything else I haven't asked that you think is important for me to know?" You ask. "No I don't think so." She replies. You quickly summarise what's been discused. "Just to finish off, do you... [[...still want the surgery?|exam11b][$twelve2 = "incorrect"]] [[...want a spinal or a GA?|exam11b][$twelve2 = "incorrect"]] [[...know where to get changed?|exam11b][$twelve2 = "incorrect"]] [[...have any questions?|exam11a][$twelve2 = "Good"]] <<timed 59s>> <<goto exam11b>> <</timed>> <<countdownTimer 60 "exam11b">> <<set $result to $result + 1>>

<br> "I can't remember exactly. Is it that important?" "No, don't worry. Is there anything else I haven't asked that you think is important for me to know?" You ask. "No I don't think so." She replies. You quickly summarise what's been discused. "Just to finish off, do you... [[...still want the surgery?|exam11b][$twelve2 = "incorrect"]] [[...want a spinal or a GA?|exam11b][$twelve2 = "incorrect"]] [[...know where to get changed?|exam11b][$twelve2 = "incorrect"]] [[...have any questions?|exam11a][$twelve2 = "Good"]] <<timed 59s>> <<goto exam11b>> <</timed>> <<countdownTimer 60 "exam11b">> <<set $result to $result + 1>>

A different examiner greets you as you enter. “Hello, I’m Dr Smith. I will be examining you during this station. My colleague Dr Hurst is in the corner there and this is Keith, who will be assisting you.” The uniformed RTO is doing chest compressions on a mannequin who is lying on a trolley in the centre of the cubical. [[Next|exam14b]] <<audio "bell2" pause>> <<set $result2 to 0>>

After seeing the booking form what are your first thoughts... I need to... [[...call the boss|surg3][$action = "Not quite"]] [[...see the patient|surg3][$action = "Not quite"]] [[...know their lactate|surg3][$action = "Not quite"]] [[...workout their POSSUM/NELA score|surg3][$action = "Not quite"]] [[...get an ECG|surg3][$action = "not quite"]] [[...talk to the surgeons|surg3][$action = "Not quite"]] [[...do all of these things|surg3][$action = "Correct"]]

<<print $action>> Initial management of this patient includes further assessment including the use of risk assessment tools, targeted investigations, and involvement of senior clinicians. The phone in the anaesthetic room rings, you pick up. "CEPOD theatre." "Hi, sorry, it's the surgical F1, I've just dropped off a booking form." "Yes, I've got it here." "I've got the rest of the infromation for the form." You grab a pen. "OK go for it." You note down the data as they relay it. "By the way Mr Timmins is in the hospital and ready to team brief as soon as you are ready." The F1 throws in at the end of the call. As soon as they are off the line you open the NELA calculator, input the data and press...[[ENTER|surg4]]

What do you think of the NELA estimated mortality? Your patient is... [[...high risk|surg6][$nela = "Correct"]] [[...moderate risk|surg6][$nela = "Not quite"]] [[...low risk|surg6][$nela = "Not quite"]]

<<print $nela>> Mr Dalby has a NELA estimated mortality of ≥5% and is ''high-risk''. He should have active consultant involvement in the diagnostic, surgical, anaesthetic and critical care elements of his pathway. You pick up the handset again and dial 0. "Operator." "Hi, can I have Dr Franklin on his mobile please? Anaesthetic consultant on call." "Sure, just one moment." There's some crackles and then the line rings. "Franklin." A familiar voice answers. "Hi Dr Franklin, its $firstname. The surgeons have booked a laparotomy." You quickly run through the information you have. There's a pause. "OK, on my way. Go and see the patient. I'll be with you in ten minutes." He rings off. [[Go see the patient|surg7]]

You grab a [[blank anaesthetic chart|https://www.virtualanaesthetics.com/IACModule%201/blank.pdf]] to take with you, knowing full well they will be skilfully hidden on SAU. A helpful staff nurse on SAU points you in the right direction of Mr Dalby's bedspace. He's in the corner of a four bedded bay. You have a quick flick through the surgical admission. No new information there from what you have already been told and his old notes don't seem to have arrived yet. You go over to [[see him|surg8]]

Mr Dalby is lying, eyes half closed, in bed. Even under a blanket you can see his abdomen is distended. He looks grey and drawn. An NG tube is snaking its way from his nose down to a bag of green-brown fluid that is clipped to his top. He is hugging a paper bowl to his chest. A women of similar age is sat in the chair beside the bed. She gives you a weary smile as you approach. "Mr Dalby?" He nods. "Can I just check your full name and date of birth?" He obliges. "And this is?" "I'm Molly Dalby, Jonus's wife." "Is it ok if I ask a few questions about what's been happening and your general health?" They nod in unison. [[Next|surg9]]

Fortunately Mr Dalby is about to volunteer a decent history for your anaesthetic pre-assessment. Have the blank proforma ready, and fill it out as he tells you what you need to know. Once that’s ready click [[here->audio1]] to listen to what he says. Alternatively a written transcript is available [[here->transcript1]]. <<audio dalby pause>>

Did you get these key points from the history: * Short history of acute pathology with good functional status preceding these events * Long history of hypertension, avoids attending the GP so this may be suboptimally managed and he may have undiagnosed secondary complications such as hypertensive heart disease and chronic kidney disease * Has been taking ramipril during acute illness * Some red flags for underlying malignancy * No previous anaesthetic problems * No recent surgery, no previous abdominal surgery * Historic ex-smoker * Has strong wish to proceed with surgery and for things to ‘return to normal’ * Doesn’t have insight into the risks and impact of major surgery [[Next|surg11]] <<set $risk to "No answer given">>

As part of the anaesthetic consent process you decide to warn him about the risk of memory problems following a GA. How are you going to present that information? [[1 in 10 people your age having an anaesthetic will have some temporary memory loss|surg12][$risk = "Correct"]] [[Post-operative cognitive dysfunction is very common in people undergoing anaesthesia|surg12][$risk = "Not quite"]]

<<print $risk>> Helping Mr Dalby understand the risk of the surgery and anaesthetic is a collaborative process involving the surgical and anaesthetic team and the patient. Giving him information in a format he can understand allows him to make informed decisions. Avoid medical jargon, ambiguous statements and complex numbers which are hard for people to understand especially when they are in pain, are tired or have already been given lots of information. The RCoA have this visual guide in numbers that are easy for people to understand: <center> <img src="images/rcoa.jpg" style="max-width: 100%;"/> </center> NICE has also recently published NG 197 //Shared decision making// available [[here|https://www.nice.org.uk/guidance/ng197/resources/shared-decision-making-pdf-66142087186885]] [[Next|surg13]] <<set $plan to "No answer given">>

In terms of the anaesthetic what else does Mr Dalby need to know about? That he will need... [[...one or more peripheral cannula|surg14][$plan = "Not quite"]] [[...an arterial line|surg14][$plan = "Not quite"]] [[...an RSI|surg14][$plan = "Not quite"]] [[...a central line|surg14][$plan = "Not quite"]] [[...pain relief which could be via PCA, wound catheters or a neuraxial technique|surg14][$plan = "Not quite"]] [[...to go to intensive care afterwards|surg14][$plan = "Not quite"]] [[...to be aware that he may be woken at the end of the surgery or more slowly on ICU depending on how he tolerates surgery|surg14][$plan = "Not quite"]] [[...further discussion depends on him|surg14][$plan = "Correct"]]

<<print $plan>> You tailor the rest of the discussion to Mr Dalby. Avoiding medical jargon and using easy to understand language, you explain about the central, arterial, and peripheral lines he will need. You talk about the methods of pain control that will be used to keep him as comfortable as possible, and that he may need to go to ICU after the surgery, either awake or asleep depending on how well he has tolerated the surgery and how long the operation takes. You make sure he understands and try to allay the fears he has. You tell him what will happen when he arrives in the anaesthetic room and give him a chance to ask questions. "No questions. I trust you doc, I know I’m in safe hands." [[Next|surg15a]]

Dave gets a pen and a scrap of paper out of his pocket. "Go on then, what do you want?" Have a think about what you need for this anaesthetic and then click [[here|surg16]] to see Dave's list.

@@.writing;''Big drip Art line - awake Central line - asleep RSI with Rocuronium Size 8.5 ETT Emergency drugs Oesophageal temp probe Warming blanket Fluid warmer BIS monitor Cardiac OP monitor US guided rectus sheath catheters at the end (unless surgeon places under direct vision) ICU bed +/- PCA if wake up at the end of case +/- pumps for propofol/opioid/inotropes if goes to ICU asleep Transfer monitor/kit''@@ [[Next|surg17]] [[Tell me more about my plan|plan]]

Dave goes off to get kit from the stock room. You glance at another booking form that's been left on the side. Maybe they spoke to Dr Franklin about it? It's going to be a long night, that's for sure. [[To be continued...|exit1]]

<div class="notes">''"A big drip..."''</div> <p style="text-align:right"><img src="images/drip.jpg" style="max-width: 100%;" alt="pink cannula"/> <img src="images/arrow.jpg" style="max-width: 20px;"/> ''≥ 15 min to infuse 1 L of crystaloid.'' </p> !@@.typing;CO = HR x SV@@ ~~Cardiac output       Heart rate           Stroke volume~~     ^^ml/min              beat/min             ml/beat^^ !!!For our patient... !@@.typing;CO ≈ 4,900 ~~ml/min~~@@ <p style="text-align:justify">So in the event of a major vascular injury during surgery, Mr Dalby could loose his entire blood volume in just over a minute. In reality the surgeons would identify a problem and press on the hole/put on a clamp/occlude the artery above the injury/pack the area, to prevent exsanguination. BUT being able to give rapid resuscitative fluid (especially blood and blood products) is lifesaving.</p> <img src="images/chart.jpg" style="max-width: 100%;" alt="chart showing cannula size and flow rate"/> ^^*^^Pressure from pressure bag at 300 mmHg or Level 1^^®^^ infuser <p style="text-align:justify">Flow rates for canula are generally for a crystalloid run under gravity. The length of the tube, viscosity of the fluid and the pressure gradient make a difference (<<link [[there’s an equation for this|plan]]>> <<set Dialog.setup("Hagen-Poiseuille Equation")>> <<set Dialog.wiki("@@.greentext;''Q = πPr^^4^^/8ηl''@@ where: Q = flow; π = pie; P is the pressure gradient in pascals; r = radius; η = viscosity; l = length. This will come up time and time again in exams")>> <<set Dialog.open ()>> <</link>>). In practice, blood flows slower than saline, a pressure bag will speed up delivery, and the shortest, smallest gauge cannula in the most proximal vessel is best. Standard adult central venous catheters are usually a 16 G with a two or more 18 G lumens and are 15 or 20 cm long so are not ideal.</p> <div class="notes">''And the rest...?''</div> |''Art line, central line, cardiac OP monitor'' <img src="images/artline.jpg" style="max-width: 100%;" alt="flowswitch arterial cannula"/>||In addition to minimum monitoring standards high-risk patients benefit from more advanced haemodynamic monitoring. Central venous access also allows the administration of inotropic drugs and potentially TPN if needed at a later stage. Arterial access provides beat-to-beat blood pressure monitoring, avoids the repeated compression of a non-invasive cuff during a long case, and gives vital information on ventilation, gas exchange and acid-base and electrolyte status| |@@.whitetext;filler here@@|@@.whitetext;XXX@@|| |''RSI, rocuronium, size 8.5 ETT, emergency drugs'' <img src="images/emerg.jpg" style="max-width: 100%;" alt="green tray with emergency drugs"/>||The patient is obstructed and vomiting, they have a high risk of aspiration mandating an RSI. They are dehydrated with a sympathetically mediated increased SVR maintaining their BP. They are at risk of instability on induction. Emergency drugs are always an essential part of preparations| |@@.whitetext;filler here@@||| |''Oesophageal temp probe, warming blanket, fluid warmer'' <img src="images/warmer.jpg" style="max-width: 100%;" alt="fluid warmer"/>||The amount of evaporative heat loss via an open abdomen can be considerable. Even modest hypothermia leads to pharmacokinetic alterations (e.g. prolonged action of neuromuscular blocking drugs), sympathetic activation, coagulopathy, cardiac morbidity and higher wound infection rates| |@@.whitetext;filler here@@||| |''BIS monitor'' <img src="images/bis.jpg" style="max-width: 100%;" alt="BIS monitor"/>||We have already anticipated a degree of perioperative cardiovascular instability and emergency patients are known to be at greater risk of accidental awareness under GA. BIS monitoring can assist in ensuring an adequate but not excessive depth of anaesthesia when used in addition to usual clinical assessment practices| |@@.whitetext;filler here@@||| |''Ultrasound guided rectus sheath catheters at the end, PCA if woken up at the end of case'' <img src="images/pca.jpg" style="max-width: 100%;" alt="PCA pump"/>||This patient will need adequate pain relief postoperatively which should have been discussed during the preoperative assessment| |@@.whitetext;filler here@@||| |''ICU bed, pumps for propofol/opioid/inotropes if goes to ICU asleep, transfer monitor/kit'' <img src="images/pump.jpg" style="max-width: 100%;" alt="pump for drugs"/>||The equipment, including beds and pumps, used in ICU may not be standard throughout theatres or the rest of the hospital, follow local practice as to sourcing the correct equipment to send with a patient to ICU (the OPD will know)| !!!<p style="text-align:justify"> @@.typing;The bottom line: Perioperative resuscitation aims to optimise cardiac output and prevent tissue hypoxia so a patient can survive the insult of surgery and recover from their illness. Historically, and in exams, the ‘gold standard’ uses a pulmonary artery catheter and thermodilution. In practice CO can be estimated non-invasively using either aortic blood flow with an oesophageal doppler, or arterial flow with systems LiDCO^^TM^^ or the Nexfin monitor. NELA advises the use of non-invasive CO monitoring in these patients where it’s all about incremental gains to improve outcomes.@@ </p> [[Back|surg16]] [[Show me the evidence|ref2]] <A HREF="javascript:window.print()">Click to Print This Page</A>

# NCEPOD: //Knowing the Risk// A review of the peri-operative care of surgical patients. 2011. Available [[here|https://www.ncepod.org.uk/2011report2/downloads/POC_fullreport.pdf]] # Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? //EMJ//. 2011;28(3):201-202 # Pasley J, Miller CHT, DuBose JJ, et al. Intraosseous infusion rates under high pressure. //J Tra Acute Care Surg//. 2015;78(2):295-299. # Brown NJ, Duttchen KM, Caveno JW. An evaluation of flow rates of normal saline through peripheral and central venous catheters [abstract]. //Anesthesiology//. 2008;109:A1484. # Drummond K, Murphy E. Minimally invasive cardiac output monitors. //CCEACCP//. 2012;12(1):5-10. [[Back|plan]]

!!!@@.greentext;EPA 1: Performing an Anaesthetic Preoperative Assessment@@ EPA for this scenario in ''bold'' * ''Take a focused history, perform appropriate physical examination and interpret relevant investigations'' * ''Understand how a patient’s past medical, surgical and anaesthetic history influences the safe conduct of anaesthesia'' * ''Identify patients with an increased ‘perioperative risk’ and raise concerns appropriately'' * ''Communicate the anaesthetic plan to patients in an understandable way, including counselling on commonly occurring risks and addressing patient concerns'' * ''Understand limitations and scope of practice of a novice anaesthetist'' !!!@@.greentext;EPA 2: General Anaesthesia for an ASA I/II patient having uncomplicated surgery@@ * ''Understand your scope of practice as an inexperienced practitioner and seek help appropriately'' * Plan and deliver general anaesthesia to appropriate patients including the following techniques: airway management with supraglottic devices and endotracheal intubation; spontaneous and controlled ventilation; rapid sequence induction * Prepare and check emergency drugs and equipment commonly used in anaesthetic practice * Independently check and use a standard anaesthetic machine * Manage tracheal extubation, including common complications occurring during emergence from anaesthesia; eg, laryngeal spasm * Manage acute postoperative pain including the use of rescue opioids in recovery and patient controlled analgesia * ''Demonstrate understanding and capability in Anaesthetic Non-technical Skills'' * Initiate management of common anaesthetic emergencies, including unanticipated difficult airway management, and call for senior help [[Back|Core clinical learning objectives]]

!!@@.greentext; 2021 Curriculum learning syllabus stage 1@@ !!!@@.greentext;Perioperative medicine and health promotion learning outcomes:@@ @@.greentext;''//Identifies clinical and social challenges that increase risk for patients undergoing surgery Appreciates the principles of sustainability in clinical practice//''@@ !!!@@.greentext; ''Key capabilities''@@ * Explains the patient, anaesthetic and surgical factors influencing patient outcomes * Applies a structured approach to preoperative anaesthetic assessment of ASA 1-3 patients prior to surgery and recognises when further assessment and optimisation is required * Explains the effect that co-existing disease, subsequent treatment and surgical procedure may have on the conduct of anaesthesia and plans perioperative management accordingly * Explains individualised options and risks of anaesthesia and pain management to patients * Considers patient informed preference when obtaining consent for anaesthetic procedures !!!@@.greentext;General anaesthesia learning outcome:@@ @@.greentext;''//Provides safe and effective general anaesthesia with distant supervision for patients undergoing non-complex elective and emergency surgery within a general hospital setting//''@@ !!!@@.greentext;Key capabilities@@ * Conducts comprehensive pre-anaesthetic and pre-operative checks * Safely manages induction and maintenance of anaesthesia by inhalational and intravenous techniques, extubation and emergence from anaesthesia * Plans recovery care, and manages recovery from anaesthesia utilising safe discharge criteria * Diagnoses and manages common perioperative complications These scenarios are ''not'' designed for exam revision. They are to support your leaning during the IAC and ultimately help you make good decisions at 2am. [[Back|Core clinical learning objectives]]

<br> "And what should your next step be if you saw this rhythm?" "My next step would be... [[Defibrilation at 70-100 J|exam17b][$fifteen = "incorrect"]] [[Defibrilation at 150-360 J|exam17b][$fifteen = "incorrect"]] [[Give 300 mg amiodarone|exam17b][$fifteen = "incorrect"]] [[Give 1 mg adrenaline|exam17b][$fifteen = "incorrect"]] [[Check for a pulse|exam17a][$fifteen = "Good"]] <<timed 59s>> <<goto exam17b>> <</timed>> <<countdownTimer 60 "exam17b">> <<set $result2 to $result2 + 1>>

You finish up on SAU. Dr Franklin is in the anaesthetic room when you get there with Dave the OPD. You run through the history, covering all the salient points. "Nice history $firstname. I'm going to go down and cast an eye over Mr Dalby. While I'm gone let Dave know your plan and what we need?" [[Next|surg15]]

<center> !!!BETA Virtual Anaesthetics_4 <<link [[What is Beta Testing?|beta]]>> <<set Dialog.setup("What is Beta Testing?")>> <<set Dialog.wiki("@@.greentext;Beta testing is an opportunity for real users to use a product in a production environment to uncover any bugs or issues before a general release. Beta testing is the final round of testing before releasing a product to a wide audience. The objective is to uncover as many bugs or usability issues as possible in this controlled setting.@@")>> <<set Dialog.open ()>> <</link>> !!![[Start scenario|Intro 1]] </center>

<img src="images/wing.png" style="max-width: 30px" alt="small wing"/>@@.name; Virtual Anaesthetics_4@@

''>'' On each page there are clickable links within the text. ''>'' Navigate using the links in the scenario or the forward and back arrows in the left menu bar NOT the forward and back arrows on your internet browser. ''>'' Each scenario should take around an hour. ''>'' Your time spent accessing the scenario is recorded on your completion certificate. ''>'' If you access the scenario several times the certificate will only show the duration of the most recent access. ''>'' For the best platform experience access from a larger screen device such as a tablet ''>'' ''Check you're not on mute''. ''>'' When printing your certificate from a mobile device turn to portrait orientation. [[Back|Intro 1]]

<<set _answer to "">> !!!@@.greentext; Welcome to the trainers area of this scenario@@ Please input the password to continue: <<textbox "_answer" "">> <<button "Check Password">> <<if _answer is "">> <<script>>UI.alert("You did not supply a password");<</script>> <<else>> <<set _answer to _answer.trim().toLowerCase()>> <<if _answer is "vatrainersarea">> <<goto "trainers_area2">> <<else>> <<script>>UI.alert("Incorrect password");<</script>> <<goto "trainers_area">> <</if>> <</if>> <</button>>

Trainer guide for this scenario available ''[[here|https://www.virtualanaesthetics.com/trainerguides/IACmodule4.pdf]]'' [[Back|Introduction]]

/* Update the time of the previous history record if there is one. */ <<if $history.length gt 0>> <<set $history.last().time to Date.now()>> <<else>> /* Record the time the first passage was shown. */ <<set $started to Date.now()>> <</if>> /* Add current passage's history record to the array, unless it has a 'no-history' passage tag. */ <<if not tags().includes('no-history')>> <<set $history.push({ "passage": passage(), "time": 0 })>> <</if>>