what's up everybody my name is max feinstein and i'm an anesthesia resident at the mount sinai
hospital in new york city today i'm going to show you how i set up my operating room to get ready to
start a case i'm going to be using the standard ms maids mnemonic which i'll go ahead and narrate for
you so you can follow along if you find this video interesting or helpful really appreciate it if you
like it and subscribe to the channel got about 20 minutes here so let's go ahead and get started
i don't exactly have a bunch of pro audio and video recording equipment but i do have this handy
iv pole so i'll go ahead and get my camera set up here so you can see everything that i'm doing
and the first part of getting ready for my case is going with the m in the ms maids
mnemonic which stands for machine and so the first thing that i'm going to do with
my machine is actually go around to the back and i'm going to open up the oxygen tank so
this isn't actually where the oxygen normally comes from from the machine this is a backup
tank but in the event that there's any sort of issue with the oxygen coming off of the wall
then i'll have this tank as a backup that's available and it's important to make sure
at the beginning of each day that there's an adequate amount of oxygen in the tank and then
once that's open i can walk around the front of the machine and i can pull up and see what the
gauge pressure is on that tank and this tank when full of oxygen is about 2100 or 2200 psi
i can see this is 1649 and i want it to be more than half so that should be fine the next part of
making sure that my machine is ready to go is doing a machine test so i'm going to go ahead
and start a full test which requires that i'm on vent mode and that i've got my y pipe disconnected
and so that test is gonna run
with the rest of my machine check which is gonna include looking at gases to make sure that my
volatile cartridges are full and then i also need to get to the back of the machine again
and turn my o2 tank off because if i don't do that there's a possibility that it may actually
leak throughout the course of the day and become empty when i actually need it next up is s for
suction which is a simple and quick part of the setup but definitely not to be overlooked
they say that the two most important things to save somebody's life are suction and an ambu bag
which i'll get to soon and the suction works so we'll move along to the next letter which is m
again and this time it's for monitors so i'm going to get my american society of anesthesiologists
standard monitor setup here i've got an ekg lead i'm going to have five ekg leads set up
next is a temperature probe this one is a stick on temperature probe
but i can also take the sticker off to insert for example in somebody's nostril
next is a blood pressure cuff and i don't show it here but also capnography for end
tidal co2 monitoring i'm also not showing it here but we have pulse
ox imagery that's bundled in with all the rest of these cables next to my ekg leads
and this is personal preference here but i do like to get my ekg stickers attached to the
cables so that i can quickly attach them once a patient comes into the room but watch out because
once these stickers are attached to the cables they can very quickly become tangled next up
is a for airway so i'll start with a mac 3 blade which you'll choose your blade size depending on
your patient's height and weight and gender and also an endotracheal tube this is a 7.0 internal
diameter tube also dependent on patient's height weight and gender and then i've got a stylet which
is not necessary but depending on your preference may make intubation easier and then a 10cc syringe
which i'm going to fill with air so that i can inflate the cuff in my endotracheal tube
and an oral airway is essential for both the beginning and end of the case
and eye tape and tape for the endotracheal tube it's also important to go ahead and open up your
endotracheal tube and test the cuff to make sure that there aren't any leaks because that could be
a huge problem if there was a leak from the manufacturer and you didn't discover it
until the middle of the case this one's good i'll go ahead and deflate the cuff
and since personally i like to use a stylet to intubate i'll go ahead and get my stylet
placed and then i'll make the classic hockey stick shape which is what i've gotten used to intubating
patients with i always like to have my eye tape ready to go i tape a patient's eyes closed
pretty much immediately after induction and then i get my oral airway open so it's ready for use
the last part of my airway check is i make sure my ambu bag works
like i said this can be an essential part of saving someone's life next up on the list is i
for iv so i'm going to start with this bag of crystalloid in this case i'm using plasmalite
i like to keep a couple stopcocks in between my iv tubing so that i can easily add new lines or
inject medication or disconnect and reconnect the tubing really easily so i'm just being extra
careful to not touch any part of the tubing that will touch any medication that will go into the
patient now i'll go ahead and spike this iv which is important because i want to run fluid through
the iv tubing so that i don't have any air by the time that i connect it to the patient the next
part of the iv setup is i like to put together little iv kits so i'll start with some 4x4 gauze
and get three of these laid out for three different iv kits i've got rubber bands
that i use for tourniquets as well as tape to tape down my ivs i'll also get out alcohol pads
and tegaderms which in addition to the tape will keep the iv nice and secure i like to go
ahead and get all of this laid out then i'll go ahead and get out two 20 gauge needles
for each iv kit bundle everything up put some tape on top and then rubber banded all together
at your institution you may have pre-made iv kits or different equipment or other people may do your
ivs for you so this is really just a matter of personal preference but either way you need to
make sure that you've got adequate iv equipment in order to take care of your patient next is drugs
which for me begins with getting out all of my syringes so as i'm getting all this out i've got
in mind exactly what medications i'm going to want to have drawn again it's important
to maintain sterility here which means either wearing gloves or making sure not to touch the
part of the syringe or the needle that it will come into contact with any substance that will
come into contact with the patient for the case i'm doing today i want to start with rocuronium
a non-depolarizing muscular blocker i'd also like to have succinylcholine drawn up which is
a depolarizing neuromuscular blocker i'd like to have reversal agents so i'll start with
glycopyrrolate and then a little later on i'll also get some neostigmine yellow sticker here
for propofol which will be part of my induction i also typically drop some fentanyl which is
helpful for pain control and reducing the amount of anesthetic gas that i need to give a patient
next is midazolam also known as versed which we typically use for anxiolysis just before induction
and here's neostigmine which will be part of my reversal of neuromuscular blockade next
is dexamethasone which is a helpful antiemetic that i give at the beginning of cases generally
next is ondansetron or zofran which is also an antiemetic but i tend to give that at the end
of the case when i give it and here's a label for some lidocaine which can be helpful for
reducing the amount of discomfort that's caused by propofol and then in this particular card i've
got pre-made syringes of phenylephrine and ephedrine which i like to get out
and now i'm going to go ahead and pull out all the vials of the drugs that i'm about to draw up
when i draw up drugs i always triple check everything that i'm drawing up
so i start by comparing the labeled syringe with the labeled vial and make sure they're the same
and so with that i'll go ahead and draw it up and as i'm drawing it up
i'm again checking the labeled syringe against the vial to make sure that it's the same
and then i always do a third check right here at the end just making sure that both labels pair up
i realize that this is extremely redundant but i would much rather spend a little bit of extra time
to make sure that i've got the right medication because this is a place
where medication errors can happen extremely easily here's my rocuranium
here's my glycopyrrolate and also if you're interested in learning more details about the
medications that are stocked in this cart you can check out this video narrated by dr erica fagelman
one of the former chief residents and current liver transplant anesthesia fellows at mount
sinai hospital next up is neostigmine here i've got dexamethasone more dexamethasone
here's my ondansetron or zofran this is two percent lidocaine i'm going to draw five
milliliters of it now i'll go ahead and put all my drugs in a lock box and some controlled substances
i'll need to drop later once the pharmacy opens and the last part of the mnemonic is s for special
which really entails any special equipment that's going to be needed for the case and in this case
i'm grabbing an ultrasound because i'm going to be doing a transversus abdominis plane block now
that i've got the ultrasound in the room i want to make sure that i've got my cleaning solution
syringes needles stopcock and then i'll also have to go ahead and grab my local anesthetic
from the room next door alright well that's everything that i need to get started with this
case i use the ms maids mnemonic every day and most of my colleagues do the same thing it's an
essential part of the anesthesiologist toolbox thanks for watching and i'll see you next time