what's up everybody my name's max feinstein and i'm an anesthesia resident at the mount
sinai hospital in new york city. in this video i'm going to be reacting
to an "anesthesia challenge" video and pointing out all the things I do,
but mostly don't like about what I'm seeing. if you find this video interesting or helpful
i'd really appreciate it if you liked it and subscribe to the channel. let's dive in
to be honest i think these types of "reaction videos" -- that are usually characterized by
thumbnails on youtube of people with their mouth open and their hands on their head and they're
looking shocked-- i think they're pretty dumb. but then i found a video that was magnitudes dumber.
so i sat down and did what any mediocre medfluencer does in this situation:
i took a picture of myself looking disappointed, and recorded the following commentary picking
apart this video piece by piece. anyways this video popped up in my feed and i
wasn't really interested in watching it, but then i saw the description which read:
"this is just a cool video someone sent to me if you [I guess] know who it is or want it taken down
let me know" [lollll ok??] and also it has over 2 million views
and initially i didn't think too much of it. it's just a
guy laying down on an operating room table, anesthesiologist is putting on some monitors,
this is a non-invasive blood pressure cuff that's going on the patient's right arm.
and this appears to be a pulse oximeter which measures oxygen saturation in the
blood. i will just point out the anesthesiologist is putting it on the patient's index finger which
i typically try to avoid because when people wake up from anesthesia and are a little disinhibited
sometimes they'll reach for their face, and of course the first finger that they use to try to
scratch their eye is their index finger. so i do try to put the pulse oximeter on the patient's
ring finger if at all possible with the hopes of reducing the likelihood of corneal abrasion
wait a second now the anesthesiologist is reaching for what is clearly propofol and getting ready
to push it-- hold on i don't think that this guy has even cycled the blood pressure cuff.
are there EKG leads on!? has the anesthesiologist looked at the pulse oximeter reading?!!!
i'm going to just use this opportunity to stop here and point out that while adhering to the
American Society of Anesthesiologists standards for monitoring under anesthesia, it's extremely
important to establish baseline vital signs for patients before you induce anesthesia.
even for a really healthy looking patient like this guy, you never know what sort of underlying
abnormalities may exist. anyways i just bring this up because if you are doing anesthesia,
an extremely important principle for being able to take safe care of a patient is to look
at all of their vital signs before you give any anesthesia. the patient's now inducing anesthesia
but i want to point out something really critical besides the vital sign issue,
which is: this patient has not been pre-oxygenated at all
let's talk about pre-oxygenation for a second. ordinarily
if you're at sea level and you're breathing room air, that room air is composed of 21%
oxygen. we can use the alveolar gas equation to determine that the oxygen content in the
alveoli at 21% oxygen, aka room air, is about 100 mmHg. For an otherwise healthy person like this
patient who has just received an induction dose of general anesthesia and been rendered apneic,
that means they'll probably be able to last a minute, maybe a couple minutes,
before they start desaturating. one important goal for anesthesiologists who are inducing anesthesia
is to extend that amount of time where a patient won't desaturate while they're apneic.
this is essentially a safety mechanism that anesthesiologists have to maximize the amount of
time to troubleshoot any sort of unanticipated difficulties that may arise, particularly as
it pertains to the airway assuming a patient's been adequately pre-oxygenated with 100% oxygen,
which is routine for pretty much any general anesthetic. then we can expect that their alveolar
gas is going to contain about 660 mmHg of oxygen. and converting that to a useful clinical measure,
an otherwise healthy patient would probably not desaturate after being apneic for eight or nine
minutes. that's a lot of time that you have to troubleshoot any issues that may come up
if you pre-oxygenate, but as we can see in this video, that's not what happened
moving right along
i don't really know what's going on with the camera. is there some anesthetic gas
that the cameraman is inhaling? i don't know
that's... that's a little entertaining
okay so i think if you listen closely you can actually start to hear the tone of the
pulse oximeter going down, which means this patient is already beginning to desaturate.
not a huge surprise but come on dude. okay i'm starting to get dizzy watching this video.
okay now leaning over the patient and getting ready to insert a laryngeal
mask airway and the patient's eyes are not protected-- this is an extremely easy way
to cause a corneal abrasion which can lead to permanent eye damage, and happens to be
one of the leading causes of malpractice suits against anesthesiologists
where are your gloves?! this guy is sticking his hand in the patient's mouth with no gloves on
okay now the patient is definitely starting to desaturate if you listen
closely to the tone of the pulse oximeter. ah there's our blood pressure cuff again,
and has this even gone off at any point? i have no idea what this patient's blood pressure is.
is that an oxygen saturation in the 80s?? that's... that, yes!
oh yeah and you can see this is where the blood pressure reading is supposed to be and there's
no reading we literally have zero idea what this guy's blood pressure was before anesthesia was
given and now we definitely have no idea what it is after the anesthesia was given,
and as you know propofol is one of the biggest vasodilators of any of
the anesthetics that we give so who knows how far this patient's blood pressure has dropped
now he's reaching for the EKG leads, they're literally not even on! look i just want to
point out that if this patient had come in and not ever had anesthesia before and had never been to a
doctor and was getting whatever surgery is done, and he happened to have a condition called "long
QT syndrome" that could definitely be picked up by looking at an EKG before inducing anesthesia,
which i will point out can be extremely dangerous in patients who have long QT syndrome
and needs extra special consideration. we have no idea what this guy's EKG tracing looks like and,
hold on- i'm going to just back up for a second and point out that even if you can't see exactly
what the pulse oximeter is reading, you can see that there's a yellow box that is now around the
number, which means that it has fallen into alarm territory. and by default on most ventilators that
means an oxygen saturation that's somewhere in the 80s. so here's a healthy guy who, if he'd been
adequately pre-oxygenated, probably wouldn't start desaturating for eight minutes, nine minutes,
and here already he's starting to desaturate to a level that would cause a ventilator to alarm
okay so before i develop a cerebral aneurysm that explodes, let's just go through a few take away
points that might actually be useful for your understanding if you are providing anesthesia.
number one: always look at the vital signs before you induce anesthesia so you have a
baseline to compare any changes that may crop up later. number two: pre-oxygenate your patient
before you induce general anesthesia. this is anesthesia 101. number three: use gloves,
particularly when you're manipulating a patient's airway. and of course this video
came out before a covid but especially now it's extremely important to protect
yourself by wearing a mask like an n95 when you're working with any patients and doing
any aerosolizing procedures. while anesthesiology does have its moments of being entertaining,
the number one priority above all else is patient safety. to learn more about the specific monitors
that are used in anesthesiology, check out this video that i made where i go through each one
and put them on myself. thanks very much for watching i'll see you next time