In this video, anesthesiology resident Max Feinstein, MD, walks us through a simulation of general anesthesia induction.
Following is a transcript of the video; note that errors are possible.
Feinstein: My name is Max Feinstein and I'm an anesthesiologist in New York City. 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."
Michael Minh Le, MD: "Hello. Hello."
Feinstein: "Mr. Patient, how are you, sir? We're going to go ahead and get started shortly. We just need to check a few things. Sir, I just want to make sure you have all of your monitors on, your blood pressure cuff, EKG stickers, and pulse oximeter on the same arm as your IV. You are going to feel a tight squeeze on that blood pressure cuff starting right now."
"All right, sir, how are you feeling? A little nervous? It's normal to feel that way. I have 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 have got some oxygen for you to breathe here. It's just oxygen, nothing else. I want you to take nice deep breaths all the way in and out."
"You're doing a great job, just like that. I have 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 room."
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 are thinking about as they're working in the operating room.
If you're strictly observing an anesthesiologist, it might look like there is 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 are doing, that's when it starts to get a lot more interesting. 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 Sinai 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."
Le: "Hello. Hello."
Feinstein: Of course, this is just a simulation, but in reality it's really important to have rapport and collegiality amongst everyone who is working in the operating room because having good communication amongst everyone can be really critical when there is 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. As you can see right here, there is emergency resuscitative equipment. 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. I just need to check a few things."
Now, generally, before we even get into the operating room with the patient, I have gone through my typical MSMAIDS mnemonic, 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 have done that prior to the patient coming into the operating room, I still go through that same checklist while the patient is in the operating room just before we get started.
The first part of the mnemonic 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. In this case, I can program in the patient's 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 content 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."
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 would expect it to look. I have 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 workup prior to proceeding with surgery. It's really important to actually look at the monitors before giving any anesthesia.
Max Feinstein, MD, is a PGY-4 anesthesiology resident at Mount Sinai Hospital in New York City, where he is also chief resident of teaching. His YouTube channel focuses on perioperative medicine, especially the role of the anesthesiologist.