what's up everybody my name is 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 walking you through a day in the life
of an anesthesia resident on cardiac anesthesia rotation. 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 in
a typical day for any rotation in residency actually starts the night before
when i look up my cases for the next day and then i get on the phone with my attending,
present my plan, and then they give me any feedback that they want so the next day when
i show up at the hospital i'll know exactly how to set up for every case. tomorrow i actually
just have one case and it's anticipated to be a pretty long case, and once it finishes,
then since i'm on call, i'll either get put into a different operating room or if there are any
emergency cases then i'll help staff those cases and i'll be on call until 7am the next morning
so at this point i've actually already gone through my patients' medical records,
gone through and read about the pathology that the patient has that i'll be taking care of tomorrow,
and come up with a plan and texted my attending, let them know that i'm ready to talk,
and they said i can call whenever so we'll go ahead and call right now
right so we have one case tomorrow and this is for an [patient age/sex] with a past medical history
of [muted] and the case that we're doing is repair of [muted]. it doesn't seem like they've ever had
any anesthetics before, it doesn't seem like they've had surgery, and i wasn't able to find
any indication that anybody in the family has ever had problems with anesthesia before. so my plan
for this case is: i would propose that we do a gas induction with a mask. we can use sevoflurane and
then once the patient is under general anesthesia we can go ahead and place a peripheral IV, and
then i'll have a 4.0 and a 4.5 internal diameter tube ready. and then once the patient's intubated
i propose that we'd go ahead and do a right-sided arterial line in the radial artery. and then we
can also do a right-sided internal jugular central line, and i'll use an ultrasound for
the central line. medications that i'll have drawn up will include glycopyrrolate, succinylcholine,
and epinephrine. that's all i've got for the case. everything sounds good so i'll have everything all
ready to go and we'll go ahead and start the case at 7:15. okay sounds good, see you in the morning
as you heard this is a 7:15 start which is on the earlier side. typically cardiac cases start early,
and my day is going to start extra early because it takes me a while to do not just
a cardiac setup, but this is also a pediatric case so there are some special considerations that i'll
show you as i'm setting the case up tomorrow that will take a little bit of extra time so
i'm going to go ahead and set an alarm for 4:15 and i'll see you bright and early in the morning
oh and of course the other part of preparing for the day is figuring out what scrub cap i'm going
to wear to best represent my personality. is it going to be the heart scrub cap to represent that
i'm on cardiac anesthesia? or is it going to be the zebra scrub cap to represent the rarity of
the illness that my patient has tomorrow? i don't think this is a decision my attending
can help me make. i probably should just sleep on it and we'll see what happens in the morning
i would say that waking up early is definitely one of the downsides of anesthesiology. i am
not a morning person and i've never been a morning person but overall thought that the
benefits of a career in anesthesiology definitely outweigh the cons. but this is one of the cons
i still haven't come up with an answer to the question about the scrub caps so
i'm gonna just pop into my bedroom real quick and get some assistance in
making this decision. it's a little early but pretty sure i'll be able to get some help
thanks for the help buddy, you can go back to sleep
before you give me too much pity for getting up this early to come in
i will say that i actually did request to do these peds cardiac anesthesia cases
because i'm currently applying for a fellowship in pediatric anesthesia
to get everything set up for the day i'm actually going to start by just using the
normal mnemonic that i always use, "MSMAIDS," as a framework for getting everything ready.
but then there are a lot of complexities that go into this case above and beyond
a typical case so there's a reference sheet that has been provided by the
department of anesthesiology for all the special considerations and i'm going to get that pulled up
and it'll take me a little bit more than an hour to get everything all ready
while being careful to de-air IVs is an important part of taking care of any patient,
it's of paramount importance when taking care of pediatric patients, especially those with known
cardiac lesions because of the risk for air to travel from the venous side of the circulation
to the arterial side of circulation where it could travel to the brain and cause a stroke. for that
reason what i'm doing right now is making sure that there are absolutely no micro air bubbles
inside of the injection ports for all of the IV tubing that i plan to use for this case
here i'm filling up the gas vaporizer which takes anesthetic that comes in liquid form such as this
sevoflurane and vaporizes it into gaseous form which is breathed in by the patient who will
then be under general anesthesia in a pretty short period of time. now i'm inflating the
pressure bag that's connected to transducers that allow me to get a blood pressure reading off the
arterial line as well as a central venous pressure reading off of the central line.
this is the echocardiography machine that is complete with a pediatric-sized probe,
and this is the catheter that i'll use to place a radial arterial line
it's now nine o'clock in the morning case is off to an excellent start. we induced
anesthesia with a mask, placed a peripheral IV, placed an arterial line, placed a central line,
placed an echo probe and now surgeons are starting to do their thing. one of the major benefits of
doing anesthesiology, which has been appropriately made fun of by the likes of Glaucomflecken,
includes taking breaks. and so right now i'm on a morning break which i'm
using as an opportunity to eat the breakfast that I brought
alright it is the middle of the afternoon and i just dropped off my first patient in the
peds cardiac ICU. generally speaking any sort of invasive cardiac case is going to require
ICU level of care afterwards and for that reason it's important to transport the patient on a bed
that includes monitors for our heart rate, EKG, arterial line, central venous pressure, and make
sure that we have all the medications with us that we would need, and also intubating equipment
in case there were any sort of issue that came up between the operating room and the ICU
i just took a look at the operative schedule right now and the ORs are actually
pretty light and i haven't gotten a page with my next assignment, so for the time being i'm
going to just be waiting around, do some studying and see where i get assigned next
for better for worse there are a lot of tests that we take as anesthesiology residents and so
it's pretty much a given that at any point there's always something to study for. so
whenever i get a longer break like the one that i have right now, i like to sit down with some of my
study resources and just refresh some material or go through a question bank or try and read about
an upcoming case. i'll share with you some of the resources i'm using right now, and because i'm
on cardiac anesthesiology i'm going through one of the more popular textbooks which is kaplan's
cardiac anesthesia, and there's also a question bank that's very commonly used not just for
cardiac anesthesiology but for pretty much everything that we get tested on in residency,
and that's the True Learn question bank. another resource that i find very helpful for training in
general and especially their videos on cardiac anesthesiology is a youtube channel from the
university of kentucky. i always do make it a habit to write down any information that i
read that i'm not familiar with so i can easily go back and review it later. i like to do that
in the form of a spreadsheet this has served me very well not only in medical school but
also in residency. and i have a recurring to-do list task every day that reminds me to try to
get at least one fact into this spreadsheet so that i've constantly got some impetus to study
one of the other ways that i have to study and especially while i'm on my cardiac rotation
is by using this high fidelity mannequin that is an echo simulator not only for
transthoracic echocardiography, which means putting an echo probe on the chest,
but also trans esophageal echocardiography which as this mannequin shows is having an echo probe
that goes through the mouth and then all the way down into the esophagus and also into the stomach.
the views that we get on echocardiography are actually tested as part of the anesthesiology
boards so this is a really great way for me not only to review for the boards
but also to practice what it is that i'm doing inside the operating room, because while i'm
working with cardiac anesthesiologists and also our liver transplant anesthesiologist,
they have me use intraoperative echo and try to get a bunch of different views of the patient's
heart. the view that i have pulled up right now is what's called a mid-esophageal four-chamber view
which is when the probe is inside of the esophagus and it's looking at a cross-section of the heart
that allows us to see the left atrium, the left ventricle, the right atrium,
and the right ventricle. and so when i'm looking on my screen right here, which simulates what i
would see in the operating room: i've got my view of the left atrium, the left ventricle,
the right atrium, and the right ventricle. and here i can see my tricuspid valve and also
the mitral valve. there are a lot of different views that i can get on the simulator and so
being able to come in here and practice on it is a really nice thing for my learning
well my break was unfortunately short-lived. got a little bit of studying done but mostly i
was just redoing takes of this video because it takes me like seven tries to get any one shot,
but now i'm going to relieve another resident in one of the other operating rooms. on my way
over i did get a little something to drink. i'm not sponsored by Naked but if I were, i would
say something like "Naked Juice-- an overpriced and mediocre drink for the middle of the day"
just dropped off in ICU, it is about 10 o'clock i'm heading back to the operating
room to return the Alaris rack that i came up to the ICU with and i think that is the end of
the ongoing cases for now, but let me check in with the coordinator and see what's coming up
i'm happy to say cases are done and i can go home.. but there's a catch: the call that i'm
on is a special type of home call where once cases are done, like now, then i go home but i have to
have my pager on me and if there's an emergency case that comes up overnight, then i come in and
staff that case. and it's my responsibility to do that until seven o'clock in the morning
i have to say, it does make me think back to the first day of my third year of medical school,
which represented of course the beginning of clinical rotations. and to start that experience i
was given a pager. now i don't know what i thought i would be able to do as a first day third year
medical student, or why anybody would be paging me for any reason but i can tell you that the
excitement that i once had to carry a pager has dissipated. not to say that i don't love my job,
because i absolutely love doing anesthesiology, but one of the major benefits is that for the
most part, once i go home, i'm done with work. the only exception to that is this occasional type of
home call that i do which admittedly is pretty infrequent. but when i am on home call, and i'm
really hoping that my pager doesn't go off, i do sometimes cast a spell on it. you start with,
of course, the pager, and then you grab whatever magic stick you happen to have nearby,
which for me right now is this 20cc syringe full of propofol so i'll wave it over the pager
and see what happens!
i'm just kidding, i'm not superstitious or anything,
there's obviously no way that this would work... but there's no harm in doing it
definitely one of the biggest highlights of coming home is-- wait for it...
kobe!!
good boy
it's time for me to go to sleep, so i'm gonna take this pager and i'm gonna set it
right here next to me and this beautiful photo of my wife, who's on the other side of the room being
concerned about the way that i'm treating my pager right now. but hopefully the pager's just quiet
all night and i'll wake up after seven o'clock in the morning without having heard anything from it
i'm happy to say i didn't end up getting called in overnight, so i got a full night of sleep and
i still have the rest of today off which i plan to spend watching old glaucomflecken videos with my
dog kobe. i hope you found this video interesting and helpful. thanks very much for watching!