my name is Max Feinstein and I'm an anesthesiologist in New York City and in this video I strap a camera to my forehead and show you everything that's involved with inducing general anesthesia for a patient who came to get his hernia repaired Dr Le hello hello Mr patient how are you sir we're going to go ahead and get started shortly just need to check a few things [Music] [Music] sir I just want to make sure you have all your monitors on your blood pressure cuff EKG stickers and pulse oximeter on the same arm as your IV you're going to feel a tight squeeze on that blood pressure cuff starting right now all right sir how you feeling a little nervous it's normal to feel that way I've got some nice relaxing medication I'm going to give you through your IV in just a moment this takes about 10 seconds 15 seconds to kick in starting to feel a little better all right sir I've got some oxygen for you to breathe here just oxygen nothing else I want you to take nice deep breaths all the way in and out [Music] you're doing a great job just like that got a little bit more relaxing medication that's going to go in right now keep taking those nice deep breaths and in just a minute we'll give you the medication to go off to sleep all right we're going to have you go off to sleep right now you may feel some warmth in your IV and the next thing you know you're going to be waking up in the recovery [Music] room for [Music] [Music] for when I was a medical student and I was interested in anesthesiology and trying to learn more about the field one of my biggest challenges was trying to get inside the head of the attending anesthesiologist to really understand what they're thinking about as they're working in the operating room if you're strictly observing an anesthesiologist it might look like there's not very much going on or not very much that they're thinking about but once you really get an understanding of the thought processes behind what they're doing that's when it starts to get a lot more interesting so in this video I'll take you through step by step everything that I thought about as I induced general anesthesia for this simulated patient before we get started a big shout out to mount siai Hospital's Department of anesthesiology for letting me use this High Fidelity simulation equipment and also a big thank you to Dr Mike Le who you see running the simulator in this video whose idea it was to make this video in the first place Dr Le has an excellent Channel on YouTube and you can check it out right here without further Ado let's break things down step by step Dr Le hello hello of course this is just a simulation but in reality it's really important to have Rapport and collegiality amongst everyone who's working in the operating room because having good communication amongst everyone can be really critical when there's a patient safety issue that's at stake now before I even get to the anesthesia machine I have situational awareness about what equipment is and is not available in the operating room and as you can see right here there's emergency resuscitative equipment so this is a defibrillator and then this is a bag valve mask so in the event of an emergency this is equipment that I would resort to using Mr patient how are you sir we're going to go ahead and get started shortly just need to check a few things now generally before before we even get into the operating room with the patient I've gone through my typical Ms Maids pneumonic which I'm about to show you here to make sure that I've got everything that I need to safely induce anesthesia but even when I've done that prior to the patient coming into the operating room I still go through that same checklist while the patient's in the operating room just before we get started [Music] [Music] the first part of the pneumonic is M for machine and at this point I'm getting all of the ventilator settings in place to make sure that the machine is ready to go once anesthesia has been induced and in this case I can program in the patient age as well as their body weight which facilitates calculating ideal ventilatory settings for this patient as well as dialing in the exact amount of inhaled anesthetic gas if that's what I'm going to deliver next is s which stands for suction that doesn't sound like it's such a critical piece of equipment but having working suction can actually be the difference between life and death for a patient because if something like vomit or blood gets into a patient's mouth after anesthesia has been induced then the only thing that's going to allow you to remove that contents from the mouth is a suction so this is a critical piece of equipment sir I just want to make sure you have all your monitors on your blood pressure cuff EKG stickers and pulse oximeter on the same arm as your IV the next m in the pneumonic stands for monitors and it's extremely important to make sure that you have monitors attached to your patient and that you also look at what those monitors are outputting before you induce any sort of anesthesia you're going to feel a tight squeeze on that blood pressure cuff starting right now so right now I'm starting to cycle the patient's blood pressure cuff to get a baseline reading here in the operating room and I'm actually looking at the EKG Rhythm strip to make sure that everything looks as I'd expect it to look I've actually been in a situation before where a patient came into the operating room we attached all of the monitors and realized that there was a new regular heart rhythm which warranted further work up prior to proceeding with surgery so it's really important to actually look at the monitors before giving any anesthesia you'll notice in this situation that the patient has a faster than expected heart rate for a 35-year-old male there are a number of different things that can lead to a fast heart rate commonly anxiety will do it so that's why it's really important to be communicating with your patient in this period to understand how they're feeling because if anxiet is the reason that they have a fast heart rate then that's something you can try and treat with music or calming words or relaxing medication like maasam but if there is a more nefarious cause of a fast heart rate then that might require further work up before proceeding with surgery and of course I'm paying attention to what the patient's oxygen saturation is which in this case is 99% the a in the pneumonic stands for Airway so I'm just checking that I have all of my air Airway equipment and then it functions as I need it to which in this case means having a working light on my lingos scope here I'm checking the Integrity of the cuff that's at the end of the endot tral tube so that cuff is what inflates inside of the trachea and creates a sealed system between the ventilator and the patient's lungs if you rewind and listen for that very subtle beeping sound that is the sound that all anesthesiologists are trained to hear which is the sound of a blood pressure cuff cycling an important part about becoming an anesthesiologist is making all of the audio cues from the ventilator become second nature so that if I'm focusing for example on placing an IV or an arterial line but I hear the blood pressure cuff go off I should look at it because it might be a reading that I need to do something about and interrupt my arterial line so that I can give some medications in addition to the blood pressure cuff there are all sorts of sounds that the anesthesia machine makes that are important to be aware of including of course the patient's heart rate which you can hear in the background as well as the pitch of the heart rate which corresponds with the patient's oxygen saturation so without even looking at the screen I know that if the pitch is going down on the heart rate then they're desaturating and I need to act on that the other Airway equipment I'm double-checking is making sure I've got oral fing Airways and in this case I've got a couple different sizes so these are pieces of plastic with a hole in the middle that can go into the patient's mouth after they're under anesthesia to try and maintain a patent Airway so that I can move oxygen using a mask because sometimes when patients go under anesthesia the soft tissue in the mouth collapses not too unlike snoring and makes it hard for air to move back and for it so the oral Fingal Airway helps prop things open the i in the pneumonic stands for IV so in this case I'm just double checking that the patient's IV which was placed prior to coming into the operating room actually works the D in the pneumonic stands for drugs so right now I'm double-checking that I have all of the medications available that I intend to administer to the patient for induction of anesthesia I'll explain more about what those specific medications are once we get to that point in the video and like I mentioned before it's important to have an understanding of where any sort of resuscitative Emergency Equipment is it's not always in the operating room sometimes it might be in a hallway next to the operating room all right sir how you feeling a little nervous it's normal to feel that way I've got some nice relaxing medication I'm going to give you through your IV in just a moment I think this patient's just nervous about being on camera but don't worry he signed a consent I'm not violating Hippa by doing this the medication I'm ad ministering here is a benzo dipene called maalam which is short acting and is frequently used in the operating room setting to help patients feel relaxed and in addition to feeling relaxed patients often don't remember much after they've gotten aasal Lam so that can be helpful particularly if a patient's nervous and doesn't have any interest in making these memories this takes about 10 seconds 15 seconds to kick in one of the aspects of anesthesiology that I love is how quickly you can go from making a diagnosis which in this case is anxiety to administering a treatment which was mazam to then seeing the effects of those treatment which you can see is the slowing of the patient's heart rate starting to feel a little better now I'm getting the next medications ready to administer and I'm trying to make it easier to do that because I anticipate that my left hand is going to be occupied by holding the oxygen mask over the patient's face all right sir I've got some oxygen for you to breathe here just oxygen nothing else I want you to take nice deep breaths all the way in and out this process is called preoxygenation or denitrogenation which entails filling up patient lungs with 100% oxygen the air that we're breathing is approximately 21% oxygen and the rest of it is mostly nitrogen but in order to increase our margin of safety after we induce anesthesia meaning increasing the amount of time that the patient can safely spend without breathing then we have to administer 100% oxygen to replace all of the nitrogen in the patient's lungs this typically takes a minute or two depending on how much the patient is breathing you might have noticed that the blood pressure cup just cycled again so I'm looking at that and you can appreciate in this video that it's actually not always so straightforward to create a good seal of the Mask over a patient's face I don't like to be too aggressive by doing this because this can be really claustrophobic for a lot of patients but it is important to make sure that we get as much oxygen into a patient lungs as possible you're doing a great job just like that got a little bit more relaxing medication that's going to go in right now now I'm administering an opioid called fentanyl which is very frequently used in the surgical setting because it's excellent at relieving pain right now this patient is not expected to be in any amount of pain but in just a minute I'm going to be intubating the patient and while this patient won't be conscious while they're being intubated because of the propol that I'm about to administer the body can still react to painful stimulus which could be reflected by an increased blood pressure or an increased heart rate or both so administering fentanyl can help reduce the response that a patient has to the intubation process you'll notice that I'm taking a close look at the syringes as I'm injecting because I'm always double-checking that the medication I'm administering is the medication and the concentration and the amount that I want to deliver to my patient you'd be surprised how easy it can be to have an oversight and make drug errors which is why it's especially important to double and triple check many of the things that are done in the operating room one of the effects of administering opioids and especially opioids in combination with benzodiazapine so in this case the Fentanyl and medlam that the patient got is respiratory suppression and you can see right here that the patient's respiratory rate has gone down down to seven which is approximately half of what I would expect it to be normally keep taking those nice deep breaths and in just a minute we'll give you the medication to go off to sleep now I'm getting ready to put rocuronium which is a paralyzing agent on the IV line to administer after I've given propofol and the patient has gone under anesthesia again I'm double-checking what medication and concentration I have that I'm putting on the line you can see with this green number right here that the volume that the patient is breathing this is called the tidal volume is quite low for an adult patient in reality I wouldn't induce anesthesia for a patient who wasn't taking better title volumes than this but because it's a simulator and I was having difficulty getting a good mask fit over the patient I decided to go ahead and induce so just suspend a little bit of disbelief for the simulator all right we're going to have you go off to sleep right now you may feel some warmth in your IV and the next thing you know you're going to be waking up in the recovery room so you can see the patient's eyes closed as I was administering the propol and you'll notice that I described feeling some warmth in the IV in reality propofol can actually be quite uncomfortable for patients but there's some evidence to suggest that if I let patients know that they'll experience something warm instead of something painful then the expectation that I've set might reduce the amount of pain that they experience when the propools injected having said that in many cases it's possible to inject lidocaine or use other Tech techniques to reduce the amount of discomfort from propofol being injected because it really can be quite unpleasant immediately following induction of anesthesia with propofol I go ahead and administer a paralyzing agent which is rocuronium the propal typically takes effect in a pretty short period of time like 10 or 20 seconds whereas the rocuronium that I'm administering takes longer up to 2 or 3 minutes for full effect depending on the dose that's given and here you can see that the patient is no longer breathing on there own it's very important to protect a patient's eyes from corneal abrasions which is just a fancy way of saying scratches on the surface of the eye which in the worst case can actually lead to blindness so I always look for the first safe opportunity for me to apply eye protection to the patient before I embark on Airway management where when I'm leaning over the patient there's a possibility that I could accidentally scratch their eye with a stethoscope that's hanging off my neck or some of the airway equipment that I'm [Music] using so now I've connected the patient to the ventilator which is Switched Off off and is just in bag mode which allows me to bag mask ventilate the patient meaning that when I squeeze the bag in my right hand it should move the air mixture into the patient's lungs and in this case the air mixture is 100% oxygen if you look really closely you can actually see the patient's chest Rising every time I squeeze the bag and this is what I do in real life the best indicator to make sure you're actually moving air is simply looking at your patient as you're doing bag mask ventilation to ensure that there is adequate chest rise another place to ensure that I'm ventilating the patient is looking at the monitor where you can see not only the flows which are adequate in this case over 400 milliliters for every breath that I'm delivering but you can also see the tracing of CO2 that the patient is exhaling so the end title CO2 is a really important monitor that anesthesiologists have to make sure the patients are breathing adequately and I'm always looking back at the vital signs to make sure that they're in an appropriate range I mentioned that rock uronium can take up to 3 minutes to exert its full effect and so right now I'm just biing my time by bag mask ventilating the patient making sure that I'm continuing to keep their lungs filled with 100% oxygen and that their Vital Signs look stable the reason why I'm giving a paralytic in this case is twofold one is because it relaxes the vocal cords so it allows me to pass a breathing tube through the vocal cords and the other reason I'd administer paralytic in a case like this is because the surgeon actually needs the patient to be completely relaxed to do laparoscopic [Music] surgery now that I'm satisfied with the vital signs and enough time has passed for the rock uronium to take effect I'll go ahead and start performing laryngoscopy which which is using the lingos scope in my left hand to manipulate the mouth so that I can see the vocal cords and pass the breathing tube through the vocal cords into the wind pipe unfortunately due to the position of the camera you can't actually see what I was seeing directly with my eye which was the vocal cords being opened so I knew where to pass the tube the flexible metal device that I just removed from the endot tral tube is called a stylet and it actually just helps the endot trical tube keep a firm shape as I'm intubating a patient and then I remove that stylet once I've intubated the patient it is possible to intubate without a stylet sometimes it can be a little more difficult so for the most part anesthesiologist do use stylets but not always now I just injected air into the cuff of the endot tral tube so that there's no air that can leak around the endot tral tube it all has to go through the endot tral tube and now I connect the tube to the Circuit that's attached to the ventilator so I can go ahead and continue delivering a gas mixture to the patient's lungs I'm holding on tight with my left hand because at this point Point there's nothing keeping the endot trial tube in place I'll tape that eventually so again I'm looking at the patient's Vital Signs and I'm looking for confirmation that I'm actually successfully bag mask ventilating the patient which you can see here with the title volume tracing as well as the intitle CO2 tracing that switch turns the ventilator on and recall that I had pre-programmed in the settings at the beginning of this video and with my right hand I just turned on an inhaled volatile anesthetic called cof Florine which is very commonly used as the maintenance agent for general anesthesia I just made some adjust ments to the ventilator settings now that we've successfully intubated the patient and I'll go ahead and secure the endot tral tube with tape that I have ready to go in reality I'm quite a bit more OCD about the way that I apply tape to the endot tral tube but for the sake of this video I didn't want to bore for you by going through my typical tape routine if you enjoyed this video you might want to check out this video that I made where I take you inside a real operating room with a real patient on the table and show you what cardiac anesthesiology looks like thanks very much for watching I'll see you next time [Music]