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 sharing with you what i tell my patients as
i'm getting ready to give them general anesthesia for surgery if you find this video interesting or
helpful i'd really appreciate it if you liked it and subscribe to the channel let's get started
before we get too far let me give you a sense of what the patient actually goes through
before getting anesthesia for surgery the very first thing that will happen as far as
the anesthesiologist is concerned is that i'll go ahead and place an IV typically in the hand
or in the arm. sometimes this is done by a nurse or another healthcare professional but at a major
academic teaching center in the united states it's pretty common for an anesthesia resident
to be the one placing the IV before surgery. once the IV is placed and the nursing staff
and anesthesia and surgery has all spoken with the patient then we go back into the operating room,
and typically i'll disconnect an IV for transport and then i reconnect it when i
get back to the operating room and i just want to make sure that it works so that's the first
thing that i test when we get back into the operating room. "all right mr. patient first
thing we're going to do is get that IV tubing reconnected and make sure that still works"
"yeah sure thing doc make sure that IV still works so you don't have to do that again"
"great, running beautifully, so next up i'm gonna get some monitors put on you"
this next part is nothing official but at least in my own head i break down the pre-anesthesia
components into three categories: so the first one is putting on monitors, the second one is called
pre-oxygenation, and the third part is called induction. for every procedure that has anesthesia
with it, i always place at a minimum the following monitors: starting with a blood pressure cuff
which goes anywhere between once every three minutes and once every five minutes. i place EKG
leads, at a minimum three but typically i place five of them, then this device which is called a
pulse oximeter which allows me to see oxygenation in the patient's blood and also gives me their
heart rate. another monitor that i place is a thermometer which can be placed in a variety of
areas on the body and i usually put that on after the patient's already gone to sleep. the other
monitor that doesn't exactly get connected to the patient per se is a co2 monitor which is connected
to whatever type of breathing device that i'm using. once i've got all my monitors placed and i
made sure that they're working well, i move along to pre-oxygenation. pre-oxygenation is a really
important process of essentially filling up the patient's lungs with a hundred percent oxygen. so
you may know that the air that we're breathing is actually mostly nitrogen- it's about 78% nitrogen,
so another term for the process of pre-oxygenation is called denitrogenation which means removing all
the nitrogen from the patient's lungs and having the patient's lungs be filled as close as possible
to 100% oxygen. so if i can get to 90% oxygen in the patient's lungs that's an excellent level for
getting ready to start general anesthesia. after i've completed pre-oxygenation which typically
takes anywhere from two to three minutes then i'll go ahead and induce general anesthesia. so
the induction of anesthesia is an extremely important time where we're giving a very
carefully calculated mix of medications in order to safely get the patient to sleep.
the kinds of things that i'm thinking about as i'm inducing general anesthesia include the patient's
heart rate their blood pressure because often the anesthetic agents that we use can decrease
a patient's blood pressure so we have to be very mindful of that i want to make sure that their
oxygen levels are adequate i want to make sure there aren't any concerning changes on the EKG
and i want to make sure that there aren't any sorts of indications of an adverse drug reaction-
that could be changes in skin color, that could be changes in some of the settings that i'm seeing on
my ventilator- so all of these things i'm being mindful of as i'm inducing general anesthesia.
what the patient experiences is typically, maybe some relaxation if i've decided to give a drug
called versed or midazolam to relax a patient several minutes before giving general anesthesia.
to induce general anesthesia there are a number of different medications that
we can use but the one that i'd say is by far the most common is called propofol, and propofol is a
medication that usually kicks in within about 10 seconds and patient will have the experience of
losing consciousness and the next thing they know they're waking up, the surgery is all done,
and they're probably not going to start forming new memories until they're in the recovery room
although patients are usually awake and responsive once we have stopped the anesthesia and woken them
up in the operating room themselves but typically that's not something that people even remember
after surgery. anyways so at this point i'm about five months into my training and i've administered
roughly 250 anesthetics of which approximately 200 of those have been general anesthesia.
now there are different levels of anesthesia but for the most part when people think about going
under for anesthesia they think about general anesthesia which means not being conscious,
not making memories, not being aware of any pain from surgery, so this is the type of anesthesia
that i'm focusing on in this video. so i'd say out of those 200 general anesthetics that i've given,
probably about 90% of them fall into what i call the "usual category" and the usual category is a
patient who may be a little bit nervous- it's very normal to be nervous before surgery-
but they're not overwhelmingly nervous, they're maybe talkative, not overly talkative but we have
conversation and i like to chat about all sorts of stuff before surgery and especially if that
helps them get their mind off surgery. anyways for the usual patient we get into the operating room,
we connect the IV, put on all the monitors, do the pre-oxygenation with the mask and then
induce general anesthesia and it's not really anything for me to write home about although
i can definitely appreciate that it can be a very nerve-wracking experience for patients.
next up is the "funny patient" encounter and that might be because the patient's cracking
jokes. occasionally i'll have a patient who's just hilarious and making jokes all the time
or sometimes i think i'm funny so i try to crack jokes, anyways one time i had a patient who wanted
to count backwards and that's not something that i instruct patients to do but this patient was
really excited about it so i let them go ahead and do that. "doc is this a point where you
tell me to count backwards?" oh well that's not actually something that we ask patients
to do sorry to disappoint "oh well can i just count backwards anyways like they do on tv?"
uh sure yeah you can go ahead and count backwards from ten, you probably won't make it to five
honestly but uh yeah go ahead you can knock yourself out "oh yeah well i got a liver of steel
i bet i can count backwards from 10 twice before i fall asleep" uh sure thing go ahead and try "10 9
8 7 six five four three two one ten nine eight seven six five four three two one" i'm impressed!
but definitely the funniest part of this experience was actually in the recovery
room after the surgery happened because i told the patient that they counted backwards from 10
twice and they didn't believe me. and not only did they not believe me,
they aggressively did not believe me. they went so far as to accuse
me of being a liar and it was getting a little intense in the recovery room
"you're a liar man i don't believe you you are full of it you are lying to your patient man"
anyways once i made sure the patient was feeling well and i signed out to the nurse in the recovery
room i went ahead and left without trying to fully convince the patient of what had happened
the other thing that i used to think was funny was telling patients to just let me know when they're
asleep once i started inducing general anesthesia. i thought that was really clever and sometimes a
nurse in the operating room might laugh a little bit but then i had this one patient who was
actually a pediatric patient "alrighty buddy why don't you let me know when you're asleep"
"i bet that's not the first time you've used that joke" uh you're right but it's probably the last
yeah so that was fairly shameful after that i stopped using that joke.
sometimes i get patients who are just really talkative they might be really
talkative because that's just how they are normally or maybe they're really
nervous about surgery so that makes them talkative these patients do not
care what i'm doing to them or whether i'm listening to them they just keep talking
"...yeah sometimes i like to watch videos on youtube but i
haven't really seen any good videos on youtube especially in the medical
profession aren't really people who are releasing good videos on youtube"
yeah okay all right we're gonna go ahead and connect that IV
"...about it but i couldn't find anybody who was good with anesthesia so i don't know..."
but especially once i give this relaxing medication midazolam the talkers
really start talking
"...and i love mount sinai hospital and i've been feeling so good especially since giving
me that a couple minutes ago i wonder if i can get more medication like that
what's inside the medication i just love being inside and outside..."
right yeah that's nice um yeah can you go ahead and start breathing this oxygen for me
and to be honest that's totally fine because as long as they're safe and they're comfortable
then i'm happy and they can talk all they want until the general anesthesia kicks in
okay time to sleep now
next up is the extremely nervous patient and i can totally empathize with this. i have had
anesthesia myself- it was a concerning experience to me although everything went very well and so
i can completely understand if somebody is very nervous about their experience with anesthesia.
one of the wonderful things about being an anesthesia resident is that i can do
something to help out with that nervousness. so one of the ways that i can help patients
is pharmacologically either with midazolam or some other medications that help patients relax.
and the other way that i like to help someone relax is to just turn on music and i usually
carry a speaker with me so i can have music in the operating room either before or during surgery
so when i can i do like to ask patients what they'd like to listen to as they're
getting ready to undergo anesthesia and their surgery. "hey mr patient you feeling okay?"
"yeah doc i'm real nervous right now"
sure that's completely understandable and normal to feel that way right now.
would it be helpful if i put on some music for you?
"sure yeah some music would be great"
yeah here let me just go ahead and pull up some music
and uh what kind of stuff would you like to listen to right now?
"yeah i mean the music that always calms me down
the most is underground european rave music from the late 90s"
oh yeah i uh i think i can dig some of that up...
the only thing about this technique is that once the surgeon walks in after anesthesia has been
induced and they hear this music playing over the speaker i do get some funny looks sometimes
depending on what the patient picked out. i do put on a lot of reggaeton in my operating
rooms and nobody's ever told me to turn it off so i'm just going to keep doing that
the last type of patient that i actually haven't encountered that much of is a pediatric patient.
so we have formal pediatric rotations throughout residency. i have not done mine yet-
i have done some cases with pediatric patients but just a handful at this point and i have to
say that with kids and especially with young kids i really have no idea how their brain
works and what i can do to help them feel relaxed and at ease and let them
know everything that's going on during the process. i don't want to be that stuffy
non-fun doctor behind a mask so i usually try to find ways to make pediatric patients feel
at least a little more comfortable. i have no idea what kids actually find funny or comforting so
my approach has been to pretty much just dissociate reality and try and
come up with things that may be entertaining somehow and i found that it actually works
"okay now i'm gonna put this clippy on your finger that all the cool kids are using and
if you put it on just right it'll light up a red light and then make the beeps go beep beep beep"
"whoa do you smell that it smells like bubble gum?"
one of the best things that i've seen to keep a kid's mind occupied especially as we're
getting ready to do the pre-oxygenation and a mask is going over their mouth
is they make this special concentrated bubble gum flavor
that you can just drop onto the mask so the mask smells like bubble gum
"i love bubble gum do you want to smell the bubble gum? the bubble gum smells great"
maybe i'll just start bringing bubble gum flavor concentrate into the operating room
for all surgeries because who wouldn't like that?
well that wraps up this video and if you have any feedback and especially any ideas for funny
things i can tell patients before i induce general anesthesia i'd really appreciate it
if you left it in a comment below thanks very much for watching and i'll see you next time