what's up everybody my name is Max
Feinstein and i'm an anesthesia resident
at the Mount Sinai Hospital in New York
City
i was recently on an off-site rotation
giving anesthesia for a surgery at a
non-Mount Sinai Hospital
everything was going very well, no issues
at all--
was a couple hours in the case and then
all of a sudden
my monitoring equipment and my computer
screen go completely
Black. in this video, i'm giving you an
in-depth look into a scary,
actual power loss event that happened to
me during a surgery.
if you find this video interesting or
helpful, i'd really appreciate it if you
liked it and subscribed to the channel.
let's dive into what happened!
the reason that i wanted to make this
video is not to scare you about
potentially major problems that can come
up during surgery, but actually quite the
Opposite-- i wanted to give you insight
into how an anesthesiologist’s training
provides the skills needed to navigate
patients safely through catastrophic
events
and i'm not talking about problems that
come up very frequently,
if ever. in fact, anesthesiologists get
trained on navigating catastrophic
problems that they
may never see in their entire career, but
in the event that an anesthesiologist
ever does encounter a problem like this
it's essential that they know what to do
in order to get the patient safely
through surgery.
there's a natural tendency to think that
problems in the operating room come up
either directly related to the surgery
or to the patient themselves,
but it's important to step back and
consider that there are problems that
can come up that affect the equipment
and things that are going on
in the operating room. before you can
understand how serious a power loss in
the operating room is,
you have to understand what pieces of
equipment require power
obviously we're not actually in the
operating room right now. this is Mount
Sinai's department of anesthesiology
simulation lab
which the department has been great
about letting me use- they've been very
supportive with this channel, and if
you'd like to find more information
about Mount Sinai Anesthesiology
you can click the links in the
description below. i'm going to use the
simulation lab to walk you through
exactly what monitoring equipment we
have
this isn't anything official, but
categorically the way i think about how
power gets to all of this equipment
is broken down into two different
Categories: so one is the ventilator
itself
and the ventilators actually have backup
power supplies
that last about a half an hour, and you
can actually dial into the ventilator
settings and see how much of a charge is
left on it
then besides the ventilator the other
category of equipment is the monitoring
Equipment.
so two of the three screens that you see
here are monitoring equipment,
then the third screen is actually the
ventilator screen which includes some
information about monitoring,
but not everything. there are four
different aspects of a patient's
physiology
that we are required to monitor during
Surgery. those aspects
Are: 1) oxygenation, which is how much oxygen
goes into the patient's blood
2) ventilation, which is how much carbon
dioxide comes out of the patient's blood
3) circulation which describes the heart's
ability to move blood around the body
and then 4) temperature. there are many
different ways to monitor all of these
aspects of a patient's physiology
and as far as oxygen monitoring goes
there are two required ways
so the first is looking at the amount of
inspired and expired oxygen which we can
see
on this monitor right here
the second aspect of oxygenation is
monitoring what percentage of hemoglobin
molecules are carrying oxygen
and we can see that right here. it's
actually routine for us to be able to
listen to that information about
oxygenation status which is when you
hear the typical beeping sound that's
just like this
so this beeping sound tells us how fast
a patient's heart rate is going,
which is part of circulation, and then
also the pitch that it's making
tells us about what percentage of
hemoglobin molecules are saturated with
Oxygen. so as the pitch goes down
that tells us that oxygen saturation is
going down, and that typically
is not a good thing. next up is carbon
Dioxide, and we actually measure how much
carbon dioxide is being blown off of a
patient's lungs which is what this
tracing is
right here. There are some very important
physiologic consequences of having too
much or too little carbon dioxide,
and also the shape of this carbon
dioxide curve, which is called
Capnography, can tell us a lot of
information about someone's heart
and lungs. the other aspect of
ventilation that we monitor is for any
circuit leak or disconnect
so if there's a circuit leak or
disconnect then these monitors will let
us know with an audible sound
the third aspect of a patient's
physiology that we monitor during
surgery is circulation
and that includes at least three
required components. the first is an EKG
which is an electrocardiogram which we
have continuously going, which you can
see right here.
that gives us detailed information about
the electrical activity inside the heart
itself
the next part of circulation is blood
pressure and we have a lot of different
ways of monitoring blood pressure and
i'd say probably the most routine way
is just putting a blood pressure cuff on
a patient's arm and monitoring that
at least once every five minutes, if not
more frequently, and we see that readout
right here on the machine
the third component of circulatory
measuring is monitoring a patient's
Pulse,
which we can either get from an EKG or
we can get it from our pulse oximeter
which is the instrument that gives us
the oxygen saturation level and also
gives us a pulse.
that's the one that made that nice sound
that i like to hear, just like this--
the last aspect of patient physiology
that's constantly monitored
is temperature which we can see right
Here. so just to summarize,
this is all of our vital monitoring
equipment that we have which is separate
from the ventilator and has its own
power supply.
then shifting down to our ventilator
screen right here we get
several pieces of information about
patient physiology, but mostly we're
getting information about the ventilator
settings itself.
obviously this is extremely important
but it's not everything that we need to
know about the patient.
the last screen here that has a power
supply is the computer that essentially
takes all of the information from both
the monitors and the ventilator and
aggregates it into one screen
the computer keeps a historical record
of everything that's gone on during the
case and also allows me to input what
medications i've given and at what time.
so it's a really important part of
keeping track of everything that's going
on during the surgery.
this screenshot is actually just
something i found on google image search
but it looks just like the electronic
health records that we use
which shows how you can plot every piece
of information that you get during a
surgery
over time on a computer so that you can
look back on it at any point for
reference
now that you've gotten a sense of all of
the important things that an
anesthesiologist measures on their
monitors
you can understand how big of a problem
it is if all of those measurements
disappear when the monitors turn off.
so going back to the surgery which was,
like i said, a general abdominal surgery-
it wasn't urgent, the patient was very
stable the entire way through, and we
were about a couple hours into the
Surgery,
all of a sudden my screen with all of my
information about my patient monitors
went black
my computer screen went black and i
rushed to press the power button
but nothing turned on. it may sound
surprising but nobody else in the room
immediately knew that there was any
problem at all
and even if they did, nobody else who was
in the room at that time had
any training on anesthesia equipment let
alone how to diagnose or fix
any problems with it. to set the scene a
little more for you, here's a quick
overview of who was in the room and what
exactly their jobs are:
in this extremely rough sketch of the
operating room that i made, you can see
in the middle
there's the operating table with the
patient that was on it,
laying on their back, under general
Anesthesia,
intubated with the abdomen partially
open
because they were being operated on by
the surgery attending
you can see here, and the surgery
resident on the other side of the table.
keep in mind that this big red box with
the anesthesia machine here
has monitors that face me and don't face
the surgery attending,
or the surgery resident, or the other two
people in the room
who were the circulating nurse, which is
a nurse who is not sterily scrubbed
and is able to assist with all sorts of
things in the operating room,
including picking up the phone which, as
i'll get to soon, is very important.
and then there's the scrub nurse who is
scrubbed in sterily
and is able to assist with handing
instruments to the surgeon
and other tasks that are directly
related to surgery.
and then of course there's me over here
behind the drapes
so really i was very by myself in the
room
with an attending anesthesiologist who
is nearby. so there i was,
standing next to my anesthesia machine
and i saw the monitors went black.
i tried to turn them on and immediately
realized that they weren't going to turn
on
so the very first thing that i did was
point to the circulating
nurse say their name and tell them call
this phone number and ask for help.
what i gave the nurse was a five digit
phone number to call the anesthesia
coordinator on call,
and if they get a call saying that
there's a problem and somebody needs
help in an operating room,
that coordinator will get all of the
free anesthesiologists and send them
directly into that room
Immediately. so you better believe that
within 45 seconds
the room flooded with anesthesia
attendings
the second thing i did immediately after
calling for help was i told the surgeon
to stop operating
because of course if i'm unable to
assess the patient's vital signs it's
not safe for the surgeon to continue
operating because we don't know exactly
how the patient's doing under anesthesia.
the third thing that i did was try to
get together portable monitors so that i
could at least make up for some of the
monitoring equipment that i'd lost.
i've mentioned in a previous video that
i always carry with me a portable pulse
oximeter which i had with me, and i put
on the patient's finger so that i could
get their oxygen saturation as well as
their pulse
next i asked the circulating nurse to go
try to find a portable blood pressure
cuff and portable EKG leads so that i
could have that equipment as well.
by the time i did all this and assessed
the patient's vital signs and made sure
that everything was fine on the
Ventilator,
the attending physicians who were in the
room had already diagnosed the problem
as a blown fuse and were able to change
the outlets
that my monitoring equipment was going
to and turn it back on.
within about 10 minutes we had
electricians that came into the room
confirmed the problem and were able to
fix the blown fuse.
as it turned out, some of the surgical
equipment had been plugged into the same
circuit as the anesthesia equipment
which overloaded the fuse and caused a
short circuit.
it's important to point out here that
while hospitals have backup power
through generators
that isn't going to work if a fuse is
blown within a specific circuit.
while that fact may sound trivial, it's
actually something that gets tested on
anesthesia board certification exams.
so how does an anesthesiologist learn to
deal with problems like this?
i can tell you that in my first couple
months of residency, we had a specific
lecture with our program director
Dr. Adam Levine.
he sat down with a ventilator in front
of us and we walked through every
possible scenario
of losing power to monitors, losing power
to the ventilator,
losing backup power to the ventilator,
and how we would deal with every one of
those problems as it came up.
Additionally, in my first couple months
of residency i was doing twice weekly
simulations in that sim lab
that i was showing you, where we went
through all different types of problems
including mix-ups of gases, loss of gas
in the operating room
and all different sorts of scenarios
that we will probably never see in real
Life, but if we do see,
we do have the training to be able to
navigate those problems. and beyond that,
when i'm in the operating room with my
preceptor Dr. Marc Sherwin and also other
anesthesia attendings,
we commonly talk through what kinds of
problems could come up
even if they're not actually happening,
and then work through what we would do
to diagnose the problem and then try and
fix it.
definitely one of the challenges in
training to become an anesthesiologist
is learning how to feel comfortable with
problems that come up very rarely,
that's why it's really important to have
a good simulation curriculum
and it's also really important to have
preceptors who are thinking about these
sorts of problems and teaching you what
you might do in the event that you
encounter them
i think that sometimes there's a
misconception that anesthesiologists
just
sit around in an operating room while
surgery is going on and
don't really do very much, but in reality,
anesthesiologists have to be
anticipating problems that could come up
and what they would do to fix them,
that especially includes issues related
to airway, breathing,
IV access, hemodynamic instability,
factors directly related to the surgery
Itself, and then of course the equipment
in the operating room. these are some of
the aspects of anesthesiology that
really appeal to me
and why i thought it would make the
perfect career choice. well that's all
for this video, i hope you found it
interesting
thank you very much for watching and
i'll see you next time