DOH Operation Theatre Technologist oral exam prep

Knowledge: The Difficult Airway Society guideline organises unanticipated difficult intubation into Plan A (tracheal intubation), Plan B (supraglottic airway rescue), Plan C (face mask ventilation) and Plan D (emergency front-of-neck access). The 2025 update keeps this structure and stresses continuous oxygenation, first-pass success, early videolaryngoscopy, waveform capnography, and moving on without repeated attempts. A falling saturation after failed intubation means the priority is oxygenation, not the tube. If oxygenation fails with a supraglottic airway and a face mask with two-person technique, the situation is 'cannot intubate, cannot oxygenate' and front-of-neck access must happen without delay.

Management: I would call for senior help and the difficult airway trolley, and say the time and saturation out loud. I would hand the bougie, a different blade or a smaller tube as asked, and help with external laryngeal manipulation if directed. When the anaesthetist declares failed intubation, I would hand over a second-generation supraglottic airway of the right size, already checked, and connect the capnograph. If that fails, I would help with two-person face mask ventilation using an oropharyngeal airway. If the anaesthetist declares 'cannot intubate, cannot oxygenate', I would open the front-of-neck access kit used in the department, typically a scalpel, bougie and small cuffed tube, extend the neck with a shoulder roll and confirm placement with capnography.

Ethics and communication: I work under the anaesthetist's direction, but I must speak up if I see the saturation falling or repeated attempts going on too long, using clear words. I would document the sequence, times and equipment used, and take part in the debrief and incident report. The patient should be told afterwards that he had a difficult airway and given an alert letter or record, so future teams are prepared.

Reference: Ahmad I et al, Difficult Airway Society 2025 guidelines for management of unanticipated difficult tracheal intubation in adults (Br J Anaesth 2025)

Knowledge: A falling inspired oxygen concentration with a normal pipeline pressure, which worsens as oxygen flow is increased, means the pipeline is not delivering oxygen. This suggests a crossover with another gas, such as nitrous oxide or air, or contamination after maintenance. Because the pipeline pressure is normal, the machine will keep drawing from the pipeline, not the reserve cylinder, even if the cylinder is open. The oxygen analyser is therefore a vital monitor and must be calibrated and checked during the machine check. The Association of Anaesthetists guideline describes the daily checks, including the oxygen analyser and the reserve cylinder.

Management: I would tell the anaesthetist immediately what I see, and give the patient oxygen from an independent source: a self-inflating bag connected to a separate oxygen cylinder. I would open the machine's reserve oxygen cylinder and disconnect the oxygen pipeline hose from the wall, so the machine draws from the cylinder, and confirm that the inspired oxygen rises. The anaesthetist may switch to total intravenous anaesthesia. I would inform the theatre coordinator and engineering at once, so other theatres using the same pipeline are warned, and fetch extra cylinders. I would tag the outlet as faulty and not reconnect it until the engineers have tested and released it.

Ethics and communication: This is a serious incident that could affect many patients, so I would report it immediately and through the facility system. I would document the readings, times and actions. The patient should be told about the event and its effect by the anaesthetist. If the pre-use check had been skipped, I would be honest about it, as the review is about preventing harm, not blame.

Reference: Association of Anaesthetists, Checking Anaesthetic Equipment (2019)

Knowledge: A surgical fire needs three things: an oxidiser (oxygen or nitrous oxide), an ignition source (diathermy, laser, light cable) and fuel (drapes, alcohol prep, hair, gauze). Open oxygen under drapes near the face in a high-risk procedure creates an oxygen-enriched space, and alcohol prep that has not fully dried is highly flammable. The ASA practice advisory recommends a fire risk assessment at the time-out, letting alcohol preps dry fully, using the lowest oxygen needed, and avoiding open oxygen near ignition sources where possible. Burns to the face and airway are severe and can be life-threatening.

Management: I would shout 'fire' and the anaesthetist stops the oxygen flow at once. The surgeon stops the diathermy. The burning drapes are removed from the patient and smothered or put out with saline or water. I would check the patient for burns and breathing, and assess the airway and face. If the fire continues, I would use the carbon dioxide extinguisher in theatre and follow the facility fire plan. Once safe, the anaesthetist resumes oxygen when no fire remains, and I would keep the drapes and materials for the investigation. The patient may need airway assessment and burns care. I would make sure the fire alarm and theatre manager are informed as policy requires.

Ethics and communication: The patient must be told honestly what happened and what injury occurred, usually by the surgeon and anaesthetist. I would document the event, report it through the incident system, and contribute to the review, which should look at oxygen use, prep drying and the time-out risk assessment rather than at individual blame.

Reference: ASA Practice Advisory for the Prevention and Management of Operating Room Fires (Anesthesiology 2013); AORN Guidelines for Perioperative Practice

Knowledge: Retained surgical items are a preventable never-event type of harm, and abdominal swabs are the most common item retained. They lead to infection, abscess, fistula and repeat surgery. Risk is highest in emergency surgery, unplanned changes in procedure, high body mass index and long operations. Counts are done at set stages, by two people, aloud, and recorded. When a count is wrong, the AORN guideline and the WHO surgical safety approach require the surgeon to be told, a search of the field and room, and imaging if the item is not found, before the patient leaves the theatre where possible.

Management: I would tell the surgeon clearly, 'The swab count is incorrect, one abdominal swab is missing', and ask for the closure to pause while the surgeon explores the wound. I would recount the swabs with the circulating staff, and search the drapes, floor, bins, bags and instrument trays. If the swab is not found, I would ask for an X-ray in theatre before the patient leaves, as the facility policy requires, and inform the theatre lead. I would document the count, the search and the outcome in the record. If the surgeon refuses to pause, I would escalate to the senior surgeon and theatre lead immediately.

Ethics and communication: Speaking up is my professional duty, even when a senior surgeon disagrees. A missing item must never be recorded as 'count correct'. I would report through the incident system, and the patient should be told about any retained item or the imaging done. Honest disclosure is supported by the principle of openness underpinning Federal Decree-Law No. 4 of 2016 on Medical Liability.

Reference: AORN Guidelines for Perioperative Practice; WHO Guidelines for Safe Surgery (2009); Federal Decree-Law No. 4 of 2016 on Medical Liability (UAE)

Knowledge: Wrong-site surgery is a never event, and the WHO Surgical Safety Checklist and the Joint Commission Universal Protocol were designed to prevent it. They require confirmation of the patient's identity, procedure and site with the patient, the consent form, the list, imaging and the site marking, in a pre-procedure verification, site marking, and a time-out. Any discrepancy must be resolved before the patient enters theatre or before anaesthesia. Language barriers, late running lists and team pressure are known contributors to error. The patient's own statement is a key part of verification, but only if it is obtained clearly in a language he understands.

Management: I would stop the process and tell the surgeon and anaesthetist that the site does not match. The patient stays in the anaesthetic room and no anaesthetic or block is given. I would ask for an interpreter, or a qualified staff member who speaks his language, to confirm his complaint. The surgeon must review the notes, imaging and clinic letter, re-examine the patient and confirm the correct side with him. The wrong mark should be removed and the correct site re-marked by the surgeon, and the consent form corrected or re-done. Only then does the time-out take place with all team members.

Ethics and communication: Consent must be informed and must name the correct procedure; Cabinet Resolution No. 40 of 2019 requires informed consent before treatment, except in emergencies. Every team member has a right and duty to stop the line, whatever their grade. I would document the discrepancy and report it as a near miss so the booking and marking process can be reviewed. The patient deserves an honest explanation of why there was a delay.

Reference: WHO Guidelines for Safe Surgery (2009); The Joint Commission Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery

Knowledge: Implants are high-risk items because any contamination can lead to a deep prosthetic joint infection, which may need revision surgery. ANSI/AAMI ST79 discourages immediate-use steam sterilisation (formerly flash sterilisation) for implants, and allows it only in a documented emergency when no other option exists, with full monitoring including a biological indicator and traceability to the patient. A dropped item must not be used without proper reprocessing. Hiding the event would also remove the record needed to trace an infection later. Safe alternatives include asking the supplier or another hospital for a sterile implant, or using a different size or system the surgeon accepts.

Management: I would tell the surgeon calmly that I cannot agree to hide the event and that we need to find a safe option. I would contact the implant company representative and the sterile services department, and check for another hospital nearby, and inform the theatre lead and the anaesthetist, who may need to adjust the anaesthetic for a delay. If the surgeon and team decide that immediate-use sterilisation is the only option, it must follow the manufacturer's instructions, with chemical and biological monitoring, and it must be documented and traceable to the patient. The drop is recorded in the theatre record regardless.

Ethics and communication: Honesty is a basic duty, and a request to cover up an event conflicts with patient safety and with my professional obligations. I would report the event through the incident system and inform the theatre lead. The surgeon should explain the delay and the issue to the patient afterwards, consistent with informed consent principles in Cabinet Resolution No. 40 of 2019. I would avoid a public conflict in theatre and raise concerns professionally.

Reference: ANSI/AAMI ST79:2017 Comprehensive guide to steam sterilization and sterility assurance in health care facilities (with 2020 amendments); AORN Guidelines for Perioperative Practice