Congratulations! You have the best anesthesia channel I’ve seen so far. It’s great to see our specialty being explained with such clarity for the lay and yet keeping the technicalities that make it enjoyable for the med students. It’s great that you have the support from Mount Sinai to make your videos. There are not that many institutions willing to do the same.
My daughter is an Integrative bio major at Berkeley and she mentioned anesthesiology as a possible career path. I found your channel and shared it with her. Very nice work!!!
Max, thanks for the Miller vs. the Mac blade video! Been waiting for this for a long time. As a retired Advanced EMT, I always fell back on the Mac blade, it just naturally came to me versus the Miller blade. Glad you seriously emphasized the absolute rule of looking for the pearly white cords. If you don't see them, don't tube that patient was always my baseline field rule. One other 'safety rule' I used in the field was as soon as I took the mask off to begin the ET process, I held my breath, so If I needed to take a breath, my patient needed to be bagged and to back off placing the ET. Good stuff Max, keep it coming.
Hey Dan, good safety rule on holding your breath. On the OR, when we don't perform rapid sequence intubation and can "preoxygenate" the patient prior to intubation, this safety rule won't apply given the patient has a reserve of oxygen in their lungs. For example, after induction a healthy 70k male patient will consume 1 MET of oxygen equal to 3.5cc of O2/kg/min. If the patient weighs 70kg they will consume 245cc of oxygen per minute. At rest (after induction) the patient's lung volume will be at functional residual capacity, FRC, which is equal to about 2.5L. This FRC decreases by 20% under muscle relaxation/paralysis after induction of anesthesia. This FRC ends up being 2L. If we preoxygenate a patient prior to intubation with an end tidal oxygen measuring 90%, this means that 1.8L of the 2L lung volume is filled up with oxygen (90% of 2L). If you have 1.8L of oxygen in your lungs and consume 245cc oxygen/minute then that means you have approximately 7.35 minutes of time to intubate the patient. This is close to ideal situations. The average patient ends not being healthy which further affect FRC and oxygen consumption levels, thus in reality, "safe intubation time" ends up around 2-3 min.
@@sovereign775 can you preoxygenate a patient before intubation who is laying unconconsious or worse has his heartbeat stopped due to sudden heart attack?
Your videos have been a great tool for me. I am having surgery at the end of January and I get comfort from knowing what will happen before it happens. I have had many surgeries in the past but have been particularly nervous for this one. Thank you for all of your educational videos!!
Amazing video as always! Might be a little biased to pediatrics (and this might be a little nerdy for the non med student) but would love to see a video on pediatric anesthesia considerations broken down by age groups and the important milestone changes in physiology. Either that or explaining the stages of induction would be a really cool concept to explain to people :)
I’ve intubated about only 6 people now but my last one just had vomit non stop no matter how much I suctioned. Once I had got the tube in, my tube had vomit in it as well and even though I was able to suction with a French cath I wasn’t confident despite my capnography reading . I’ve been a medic for 6 months and love to keep learning new things and/or advice . Thank you.
Very informative. I have a stomp kit (we are preppers) with an intubation kit. I don't have a straight blade, but do have 3 different sizes for adults and kids. They are a hard plastic. I have practiced on a dummy and have gotten pretty good at it. I've learned to stitch and also have staples. I have spent over a thousand in medical supplies for my kit and adding my own things as well. Antibiotics, ammonia inhalants, coagulant granules, Albuterol, pain medication, etc. Everybody should have a serious med kit at home. Mine has already been so useful.
Applying firm, steady upward pressure at a 45-degree angle, the curved laryngoscope is used to lift the epiglottis and expose the vocal cords. Once the glottis is visualized, the operator will ask the respiratory assistant to place the endotracheal tube with the malleable stylet on the operator's right hand
I was always amazed that enough O2 can be supplied to patient via a small tube. When you compare the diameter of throat versus diameter of tube, throat is bigger. Of course when patient's diaphragm also goes to sleep, he needs mechanical means to supply air to the lungs. Does the respirator only supply a positive pulse of air or does it also provide a vacuum to pull air out?
Have you considered a video on intubating patient's who have challenges such as A.S. and long cervical fusions? I know fiberoptics can be used. As a former R.T. and now a patient with said conditions, I would be interested to know how it's done and when you would try alternative measures. I am surgically fused from C2-T3 but also had some auto fusion from the A.S. before my last surgery (#3) on my neck. Also, thanks for doing such a great job of explaining things, using visuals and having a sense of humor which is a must IMHO when you work in the medical field.
Hi Denise, thanks for the suggestion! The short answer is that asleep fiberoptic intubation is typically a good choice for patients with limited neck extension, for example after cervical spine fusion. I will see about making a video like that one day!
@@MaxFeinsteinMD Hi Max Thanks for replying. In general, I think a video that deals with difficult airway management regardless of etiology would be of benefit to those who are following or considering following in your footsteps. i.e. trauma, tumors, fusion, etc. Keep up the good work! I look forward to watching new videos as they arrive.
Sir I wish I grew up to be a third as clever as you, wow the thing needed to look after us, much respect and love to a wonderfull man such as your self❤️👍❤️
Great video man! I always learn a lot! You rock! I can’t wait to start Donating to the Anesthesiologist Foundation since It was hard for me to go to college after I graduated high school in 08 to be a Anesthesiologist because of my cerebral palsy
I was told by one teacher today to use Miller just as you explained but today I was told to push IN the epiglottis with the straight blade it worked with maniquin. But I've seen more video of pick it up. So yea everyone teaches it differently lol
I got cut off. The operation is on my ureter. I was very interested in the breathing tube. All my procedures before I just got a cannula. I asked for a second opinion because this one will be robotic surgery. I am being sent to UT Dallas for this surgery. Thanks so much for all the information you have given me. Anesthesiology is so interesting!!!
I like how u explain everything in such detail. I would think at 1st it would be nerve racking haveing someone standing over your shoulders. So is it a anatomical issue when u see the tongue all cut up or improper technigue?
This was soooo interesting and so educational. Thank you so much for this. I’ve always shuddered at the thought of being intubated (still kinda do, lol) but I really appreciate having some insight into the procedure. Thanks again!
I’ve had multiple surgeries over the years and I’ve never had a consultation with an anaesthetist prior. Are there circumstances which would make the aforementioned unnecessary?
If I am able to intubate with a previously unknown tumor in place, I will go ahead and do that. If I have difficulty, I go through what’s called the difficult airway algorithm (you can Google it). If there’s a known tumor and intubation is necessary, we have options for numbing the mouth/throat and intubating while awake.
Does the type of breathing tube really matter if the person has sleep apnea like with the laryngeal mask not be advised because of the patient's airway is patient's airway with the possibility of closing due to the apnea
Retired paramedic and ED/Trauma nurse here....I always preferred the Miller Blade when I had the option...cardiac arrest usually, but so often couldn't use it because the patient was elderly and you really couldn't extend the neck enough to visualize the cords...or it was a trauma patient...those were always fun...🙄 intubate upside-down on a highway while firefighters try to get them out...our medical directors didn't trust us with RSI...🤦♂️ do you guys train new medics in the OR? That's what they did with my class...anesthesiologists and CRNAs supervised us intubating in the OR with ASA 1s and occasionally 2s...
Hello Sir, I believe it is still part of the national registry of Paramedics to require 10 live intubations and 5 live LMA insertions. Or any other Suerglottic airway.
@@marksmadhousemetaphysicalm2938 for sure! There is no manikin as real as an actual human and for me personally, that knowledge from anesthesia was so valuable. At the service where I work we have hospital privileges and are able to schedule OR time whenever we want. And it’s required for medics that don’t get at least 2 tubes a year.
@@rkgs2782 I started before the NREMT-P was even a thing...but we were allowed to hit the OR when certain procedures and docs/CRNAs were scheduled...they didn't want us doing ASA 3 or 4 cases and we didn't need to go in if we got 5 or more tubes...of course since it was a teaching hospital...docs and CRNAs and RTs and specialist RNs got dibs...🤷♂️ then new paramedics in the training program and finally us...in order of sign up...🤦♂️
I strongly suspect that selecting you for their program was an easy decision. I do take some exception to one statement and would emphasize the importance of actually seeing the tube pass between the cords. As a med. student, the first time I intubated a pt. I took my eye off the tip of the tube for only a fraction of a second. It was almost in contact with the cords but somehow it actually advanced into the esophagus. It was immediately apparent and repositioned. But I had made the mistake and I never forgot it. I also never missed again even in difficult cases...codes with head and neck trauma, etc.
I once had a complication that made it really difficult for me to speak and eat 3-4 months after surgery. I think it was called hypoglossal nerve palsy. I was told that the anesthesiologist struggled with intubation. Now, I wonder if I'm more difficult to inturbate than other patients due to anatomy and would like to know if there's anything I can do to avoid such a complication in potential future operations or if there's something the anesthesiologist can do different if they know something
Great video! You're going to replace "anesthesia for the totally uninterested" (got me through an elective early on in medicine - bad to have as a resident!) So, here is the million dollar question: "How long do residents cut suture?"
It's generally safest to have an IV in place before delivering any anesthesia. However, since kids typically don't tolerate having IVs placed, they often go to sleep with inhaled anesthesia and have an IV placed immediately upon being under general anesthesia.
Have you done an intubation through the nose? I have many facial surgeries, specifically osteomyelitis of the jaw, where the have went in through my mouth. Every time they stated they have intubated through the nose. I must say this is painful for me after the surgery, nose bleed and bad throat pain. I would like to see that done. Cause I have more surgeries coming up. But not sure if I will go I got he surgery like I did before finding your page. I didn’t realize so many medications were used. Just scary. My last surgery I woke up with nurses screaming I was in tachycardia I was straight up panicking. Screaming back don’t let me heart blow up. Put me back to sleep. Not sure if they’re ere really panicking and they probably didn’t realize I know what that words means. However my fear was real.
Amazing Video Max! I had a question about airways, why would you use an ETT over a supraglottic airway such as an I-gel? Assuming proper ventilation can be provided.
Laparoscopic surgeries require ETTs in order to deliver positive pressure ventilation. Also any surgery lasting an extended period of time, generally better to avoid LMAs as they can lead to nerve damage in the mouth over a long case. Many reasons certain cases would require ETT over LMA but these are just a couple that come to mind.
Uncontrolled Gerd and full stomach can cause aspiration. ET tubes protect the airway better. Also if I have to position a patient prone (face down) I personally always use a tube. It’s a better airway and one of the last things you want is a patient that’s face down with an airway/ventilation problem. There are ways to fix it safely but you’ll look like an idiot and the surgeon isn’t going to like you. A lot of these prone cases tend to be long anyway. If you’re doing anesthesia for lung surgery you’ll have to be able to ventilate one lung and not the other so you’ll need a special ET tube. You could theoretically do it with an LMA and a bronchial blocker but it’s not standard of practice. There are lots of reasons but it boils down to what’s going on with the patient and the proposed surgery.
Thanks for the great video. Now I can visualize the difference between the Mac and Miller blades. As an ENT patient your videos often provide me with "insight" that makes my surgeries less stressful. How about a video on endotrachial tubes - hunsaker for instance?
When in the or what if the surgeon or the leader imposes the ga and the patient has ask for a spinal who decides? Who has the last word ? And should the patient be informed before I order to give clear open consent? Which is not done in France. Thank you for your openness. Can you break a tooth when you put the tube in? And do tell the patient?
The patient has the last word. The decision about what kind of anesthesia to deliver is based on a conversation between the anesthesiologist, surgeon, and patient. I can’t speak for other countries, but in the US a surgery/anesthetic can only proceed when the patient has given informed consent, unless it’s an emergency. Yes, it is possible to break a tooth during intubation, and yes the patient should be told but of course they’d also figure it out on their own 🦷
Your videos are both enjoyable and informative. Thank you for sharing them! Do all patients get intubated during surgery? If not, what is the deciding factor to do so?
hey doc! i think i saw you outside the mount sinai on 58th and 10th about a month ago during midday (1pm maybe?). was just gonna say hi and that you made great videos but i wasn't 100% sure it was you
@GSimm: Funny comment on what I think we’ll agree is a fascinating vid. As a retired paramedic, learning to intubate (and becoming “comfortable” doing so) was one of my steepest and longest learning curves, and I was wondering if your experience during training was similar? I was always absolutely terrified of breaking or chipping or just hitting teeth with the scope. Fortunately my class trained hands-on with attending anesthesiologists, and their presence and (mostly) patient and calm teaching really helped me and I know a lot of my fellow classmates develop skill and confidence over time. Best wishes and stay safe if you’re still out there in the field practicing.
@@andycraddock7677 I’m still out here brother. Almost finished after 35 years. Intubation was definitely a tough skill. Especially for us being in such unstable situations. But what used to rack my nerves was that I had someone’s breath in my hands. Knowing that made me really practice all the time and really get it perfected over the years.
Hello Dr max ! I like your video.I have plan to join anesthesia!I am studying for step 1 and 2 currently! Keep up doing doing such invaluable video.I wish if could join your Hospital in future!
Hi Max. I hope you are all right. At this point of my career all I want is to become an intensive care physician. I understand that the way to do that is by completing the ICU fellowship. Recently some doctors close to me and my family told me that i can do the anesthesiology specialty and work as an ICU attendant and that my life would be "easier and better" (they said). What do you think about thay?
I think you can do regular critical care as an anesthesiologist but if you want to do pulmonary/critical care I think you have to go the internal medicine route. I could be wrong on that though. Personally, I think ICU is stressful and depressing. I love anesthesia and I’d rather see my patients get better and go home. I’m perfectly happy doing bread and butter cases all day long.
Assalamu alaikum. I have recently subscribed to your channel and found it really helpful, interesting and creative! I also wanna apply anesthesiology residency in the upcoming years, so your contents help me to get more knowledge and skills for future practice. Keep improving! 💪💪💪💪
It’s not common. Getting teeth broken (especially the two upper front teeth) is from improper technique. I’ve been doing anesthesia for a couple years on my own after training and have never broken a tooth in training or after training. As he mentioned in the video, the correct motion with the laryngoscope is more forward and up. If you do it wrong and crank back like if you’re trying to pull a nail out of a board with a hammer, then there is a lot of pressure and leverage on the teeth and they can easily break. I will also say though that the technology for placing breathing tubes has advanced significantly in the last 15 years. The proper technique described in the video should be known by anyone who does anesthesia but there are more tools available now to help ensure the safety of our patients.
My last surgery was for a cervical fusion that failed and was unstable. So I was intubated while awake after breathing in this numbing medicine for a few minutes and then he gave me a shot in my voicebox. It was really weird lol. Once it was in the anesthesiologist kept saying, "K, goodnight" and I was just looking around thinking this is weird for about 15-20sec. It was like suddenly I couldn't take a breath in but I wasn't panicky about it. Which I think was his biggest fear lol.
Hello! I am a big fan of your channel. I was just wondering if you have ever seen someone place an LMA using a tongue depressor blade? I just did on to TicTok by a CRNA. The patient was completely sedated and paralyzed,so it seemed. Just wondering if intubations are ever performed using the tongue depressor method? Lol!
I’ve seen some people use tongue depressors for LMAs but I find it unnecessary. I just pop the mouth open with my left hand and put the LMA in with my right hand. Works every time. You don’t ever see the vocal cords with an LMA. When intubating you usually need to see the cords so a tongue depressor wouldn’t work.
The laryngoscope blade goes into your throat and can cause some soreness, and the tube passes through your vocal cords which causes irritation and inflammation, causing short term voice issues. If you have concerns I would speak to your medical provider as there could be other causes.
You may have a problem with vocal cord movement causing the hoarseness. Sometimes pressure from the breathing tube through the trachea onto the laryngeal nerves stuns or paralyzes them. Other times it can cause inflammation or scarring of the tiny joints (arytenoids) that the cords pivot on. You should see an ent to have them check your cords. FYI 2 weeks is pushing the outer limit of where “inflammation” is an acceptable answer for hoarseness of any cause, without having ENT look to make sure it isn’t anything else.
September 2021 I was going into anaphylactic shock which I needed to be intubated the nurse anesthetist try to intubate me while I was awake it did not go well because I punched her in the face. What do you think about intubating a patient while they were awake? Every doctor I have spoken to said it was incorrect and you never should intubate anybody fully awake. I like to know your comments about this.
Yes I was completely awake nobody had given me any drugs and at first she said she was measuring to see what size intubation tube she needed she put the speculum in my throat and I gave her one chance to try to intubate me awake as the doctors were yelling at her this is not our protocol she was an agency nurse anesthetist that was filling in in the ICU and did not work for that hospital. The second time she said she was going to try I told her no that I needed to be put asleep while she grabbed my face tilted it back and put the speculum in and I took my left arm up and I punched her in the face so she would stop and it took three doctors to walk over and remove her from me that was all that I remembered because the next time I woke up I had intubation tube in and my hands tied down. They had me on a fentanyl drip to keep me sedated but I could wake up now and again to communicate. So yes the nurse did try to intubate me while I was fully awake.
Question: With the emergence of other healthcare professionals that can perform RSIs (such as paramedics) and even full anaesthetics (such as CRNAs), do you think that the role of the anaesthesiologist might become redundant in the future? Also perhaps a video idea: what’s the difference between anaesthetists/anaesthesiologists and CRNAs and Paramedics/CCPs especially focusing on differences when it comes to anaesthetics. Awesome videos by the way!!
My question is how do u intubate a patient that is awake. I am sure there are situations in which this is true. What do u do? Do u bother giving any anesthetic so the patient doesn't feel the intubation happening? How can u make the patient more comfortable.
I'll stick with my McGrath video laryngoscopy, with a boogie added when needed.... Technically. a Mac blade I suppose, but nothing beats the addition of video!
@@bettysmith4527 not sure how much a bougie helps when the airway is full of blood and clot (I’d rather see the glottis, personally) but whatever keeps your patients alive…
@@khyrand The whole point of using a boogie is for when you cannot see the glottic opening! It uses tactile instead of visual cues that your in the trachea!
@@bettysmith4527 again, not optimal to blindly shove a hundred cc of clot or carcinoma into the lungs when a different instrument could obviate aspiration, pneumonitis, icu, etc. Bougies are appropriately used when there's an ANATOMIC cause for poor visualization. In a bleeding or tumor filled airway, it isn't among my top choices. I guess we just think differently about optimal patient care.
Both, as well as what is the safest for a patient given their medical history. For example, I would not intubate the majority of patients coming in for relatively non-invasive anorectal procedures under moderate sedation, but any patient getting laparoscopic surgery would need to be intubated. I hope that helps!
one of the most causes of difficult intubation is the shape of the teeth , some have long front teeth some as in Geriatrics have few teeth that neither support your intubation and make it easy nor with someone has nothing teeth at all as in a dentures and you can use a pad as a type of support to do intubation more easier and also those with small oral cavity that restricted or limited your view or have a big tongue that even laryngoscope can not to hold it completely by its blade and as much you got experience still sometimes you are facing a problem of difficult intubation that makes you to feel after years of working as anesthesiologist you feel that this is the first day in your job especially when all those around you looking for you with some doubt ..................................................
And what happens if a patient is having a heart attack and u need to give them epinephrine. But they are on beta blockers. In an emergency is there time to check for drug interactions? Does the computer tell u there is an interaction? How do u prevent drug interactions in emergency situations. I assume that having an updated medicine list is the best way. I guess ur shooting in the dark if u get someone who comes in with no perscription history. How can u prepare yourself so if a medical emergency happens to yourself, u are ready. I mean we hope it doesn't happen. But it does. Would be good to know how to be better prepared as a person to increase the possibility of surviving
Congratulations! You have the best anesthesia channel I’ve seen so far. It’s great to see our specialty being explained with such clarity for the lay and yet keeping the technicalities that make it enjoyable for the med students. It’s great that you have the support from Mount Sinai to make your videos. There are not that many institutions willing to do the same.
Thanks! Yes I’ve been very fortunate to have strong support from the department and hospital.
My daughter is an Integrative bio major at Berkeley and she mentioned anesthesiology as a possible career path. I found your channel and shared it with her. Very nice work!!!
Max, thanks for the Miller vs. the Mac blade video! Been waiting for this for a long time. As a retired Advanced EMT, I always fell back on the Mac blade, it just naturally came to me versus the Miller blade. Glad you seriously emphasized the absolute rule of looking for the pearly white cords. If you don't see them, don't tube that patient was always my baseline field rule. One other 'safety rule' I used in the field was as soon as I took the mask off to begin the ET process, I held my breath, so If I needed to take a breath, my patient needed to be bagged and to back off placing the ET. Good stuff Max, keep it coming.
Mac 4 baby!
Hey Dan, good safety rule on holding your breath. On the OR, when we don't perform rapid sequence intubation and can "preoxygenate" the patient prior to intubation, this safety rule won't apply given the patient has a reserve of oxygen in their lungs. For example, after induction a healthy 70k male patient will consume 1 MET of oxygen equal to 3.5cc of O2/kg/min. If the patient weighs 70kg they will consume 245cc of oxygen per minute. At rest (after induction) the patient's lung volume will be at functional residual capacity, FRC, which is equal to about 2.5L. This FRC decreases by 20% under muscle relaxation/paralysis after induction of anesthesia. This FRC ends up being 2L. If we preoxygenate a patient prior to intubation with an end tidal oxygen measuring 90%, this means that 1.8L of the 2L lung volume is filled up with oxygen (90% of 2L). If you have 1.8L of oxygen in your lungs and consume 245cc oxygen/minute then that means you have approximately 7.35 minutes of time to intubate the patient. This is close to ideal situations. The average patient ends not being healthy which further affect FRC and oxygen consumption levels, thus in reality, "safe intubation time" ends up around 2-3 min.
@@sovereign775 can you preoxygenate a patient before intubation who is laying unconconsious or worse has his heartbeat stopped due to sudden heart attack?
Amazing. Very informative. I’m not even in medical field and just find it fascinating how things are done with an Anesthesiologist
same! Love this stuff
Rejoice that Max shares his knowledge (with his outstanding medical school's blessing) to other medical students or prospective medical students!
Your videos have been a great tool for me. I am having surgery at the end of January and I get comfort from knowing what will happen before it happens. I have had many surgeries in the past but have been particularly nervous for this one. Thank you for all of your educational videos!!
Amazing video as always! Might be a little biased to pediatrics (and this might be a little nerdy for the non med student) but would love to see a video on pediatric anesthesia considerations broken down by age groups and the important milestone changes in physiology. Either that or explaining the stages of induction would be a really cool concept to explain to people :)
A comment from @ND MD himself! These are great ideas, as I get further into pediatric anesthesiology I will make videos along these lines.
Yooo ND MD ! Stay safe !
I’ve intubated about only 6 people now but my last one just had vomit non stop no matter how much I suctioned. Once I had got the tube in, my tube had vomit in it as well and even though I was able to suction with a French cath I wasn’t confident despite my capnography reading . I’ve been a medic for 6 months and love to keep learning new things and/or advice . Thank you.
I don’t plan to ever follow these instructions, but did find them interesting. Well done video.
I love your videos. I learn a lot about anesthesia. I have spent a lot of time in hospitals with at least 20 surgeries.
Very informative. I have a stomp kit (we are preppers) with an intubation kit. I don't have a straight blade, but do have 3 different sizes for adults and kids. They are a hard plastic. I have practiced on a dummy and have gotten pretty good at it. I've learned to stitch and also have staples. I have spent over a thousand in medical supplies for my kit and adding my own things as well. Antibiotics, ammonia inhalants, coagulant granules, Albuterol, pain medication, etc. Everybody should have a serious med kit at home. Mine has already been so useful.
Applying firm, steady upward pressure at a 45-degree angle, the curved laryngoscope is used to lift the epiglottis and expose the vocal cords. Once the glottis is visualized, the operator will ask the respiratory assistant to place the endotracheal tube with the malleable stylet on the operator's right hand
Max always putting out the fire content
I really appreciate your tenderness and passionate explanations cos am enlightened already. I can't wait to see you face to face.
I have a lot of respect for you guys really amazing work. and also Hello from Australia :)
I was always amazed that enough O2 can be supplied to patient via a small tube. When you compare the diameter of throat versus diameter of tube, throat is bigger. Of course when patient's diaphragm also goes to sleep, he needs mechanical means to supply air to the lungs.
Does the respirator only supply a positive pulse of air or does it also provide a vacuum to pull air out?
Have you considered a video on intubating patient's who have challenges such as A.S. and long cervical fusions? I know fiberoptics can be used. As a former R.T. and now a patient with said conditions, I would be interested to know how it's done and when you would try alternative measures. I am surgically fused from C2-T3 but also had some auto fusion from the A.S. before my last surgery (#3) on my neck.
Also, thanks for doing such a great job of explaining things, using visuals and having a sense of humor which is a must IMHO when you work in the medical field.
Hi Denise, thanks for the suggestion! The short answer is that asleep fiberoptic intubation is typically a good choice for patients with limited neck extension, for example after cervical spine fusion. I will see about making a video like that one day!
@@MaxFeinsteinMD
Hi Max
Thanks for replying. In general, I think a video that deals with difficult airway management regardless of etiology would be of benefit to those who are following or considering following in your footsteps. i.e. trauma, tumors, fusion, etc.
Keep up the good work! I look forward to watching new videos as they arrive.
Breathtaking, just like the hospital cafeteria food that I am snacking on. And yes, you do look cooler using the Miller.
thank you so much for your videos . i just started my residency in anesthesiology and it is so helpful !
Sir I wish I grew up to be a third as clever as you, wow the thing needed to look after us, much respect and love to a wonderfull man such as your self❤️👍❤️
Great video man! I always learn a lot! You rock! I can’t wait to start Donating to the Anesthesiologist Foundation since It was hard for me to go to college after I graduated high school in 08 to be a Anesthesiologist because of my cerebral palsy
who knew they had to know and do all of this. unbelievable
I was told by one teacher today to use Miller just as you explained but today I was told to push IN the epiglottis with the straight blade it worked with maniquin. But I've seen more video of pick it up. So yea everyone teaches it differently lol
Advancing a straight blade into the epiglottis directly is often taught for intubating very small patients like neonates.
Thanks Dr Max! Very interesting…I am getting ready for another operation on my right uttered. This will be my fourth…each time I get a breathing tube
I got cut off. The operation is on my ureter. I was very interested in the breathing tube. All my procedures before I just got a cannula. I asked for a second opinion because this one will be robotic surgery. I am being sent to UT Dallas for this surgery. Thanks so much for all the information you have given me. Anesthesiology is so interesting!!!
@@davidadams9391 you mean UT Southwestern. I’m a UT Dallas student. We don’t have a hospital facility.
@@MaulinAgrawal1217 thanks 😊
@@davidadams9391 you’re welcome. Good luck for your next surgery.
I like how u explain everything in such detail. I would think at 1st it would be nerve racking haveing someone standing over your shoulders. So is it a anatomical issue when u see the tongue all cut up or improper technigue?
Great video! Also love the zebra scrub cap!
This was soooo interesting and so educational. Thank you so much for this. I’ve always shuddered at the thought of being intubated (still kinda do, lol) but I really appreciate having some insight into the procedure. Thanks again!
I’ve had multiple surgeries over the years and I’ve never had a consultation with an anaesthetist prior. Are there circumstances which would make the aforementioned unnecessary?
AMIGO! ER DOC Here ! Cool video keep it up ! STAY SAFE Everyone !
max should be an instructor for colleges! Really great videos!
I already know i want to use a miller, probably atleast 5 years before i will ever touch one. Benefit of this video!
What if you see a tumor or mass in their throat while trying to intubate? How how do things move forward or do they not temporarily?
If I am able to intubate with a previously unknown tumor in place, I will go ahead and do that. If I have difficulty, I go through what’s called the difficult airway algorithm (you can Google it). If there’s a known tumor and intubation is necessary, we have options for numbing the mouth/throat and intubating while awake.
Can you please please please make a video on ergonomics in the OR? Specifically tangled wires
Man I cannot wait to get to do these on actual patients.
Stay focus !!!
Does the type of breathing tube really matter if the person has sleep apnea like with the laryngeal mask not be advised because of the patient's airway is patient's airway with the possibility of closing due to the apnea
Retired paramedic and ED/Trauma nurse here....I always preferred the Miller Blade when I had the option...cardiac arrest usually, but so often couldn't use it because the patient was elderly and you really couldn't extend the neck enough to visualize the cords...or it was a trauma patient...those were always fun...🙄 intubate upside-down on a highway while firefighters try to get them out...our medical directors didn't trust us with RSI...🤦♂️ do you guys train new medics in the OR? That's what they did with my class...anesthesiologists and CRNAs supervised us intubating in the OR with ASA 1s and occasionally 2s...
Hello Sir, I believe it is still part of the national registry of Paramedics to require 10 live intubations and 5 live LMA insertions. Or any other Suerglottic airway.
@@rkgs2782 glad to hear that...
@@marksmadhousemetaphysicalm2938 for sure! There is no manikin as real as an actual human and for me personally, that knowledge from anesthesia was so valuable. At the service where I work we have hospital privileges and are able to schedule OR time whenever we want. And it’s required for medics that don’t get at least 2 tubes a year.
@@rkgs2782 I started before the NREMT-P was even a thing...but we were allowed to hit the OR when certain procedures and docs/CRNAs were scheduled...they didn't want us doing ASA 3 or 4 cases and we didn't need to go in if we got 5 or more tubes...of course since it was a teaching hospital...docs and CRNAs and RTs and specialist RNs got dibs...🤷♂️ then new paramedics in the training program and finally us...in order of sign up...🤦♂️
I strongly suspect that selecting you for their program was an easy decision. I do take some exception to one statement and would emphasize the importance of actually seeing the tube pass between the cords. As a med. student, the first time I intubated a pt. I took my eye off the tip of the tube for only a fraction of a second. It was almost in contact with the cords but somehow it actually advanced into the esophagus. It was immediately apparent and repositioned. But I had made the mistake and I never forgot it. I also never missed again even in difficult cases...codes with head and neck trauma, etc.
I once had a complication that made it really difficult for me to speak and eat 3-4 months after surgery. I think it was called hypoglossal nerve palsy. I was told that the anesthesiologist struggled with intubation. Now, I wonder if I'm more difficult to inturbate than other patients due to anatomy and would like to know if there's anything I can do to avoid such a complication in potential future operations or if there's something the anesthesiologist can do different if they know something
Great video can you intubate someone that has a tracheal tube if it’s needed?
Hello, I want a speciality where I have médecine knowledge, hand procedures and also mediactions. Do you think anesthésiology is good for me?
In 2017 I had to be intubated because I got Norovirus and got so extremely dehydrated that I quit breathing. It was scary but thankfully I’m ok now!
Great video! You're going to replace "anesthesia for the totally uninterested" (got me through an elective early on in medicine - bad to have as a resident!) So, here is the million dollar question: "How long do residents cut suture?"
Thanks just a regular guy but it definitely gets the day started🧠🙏
After the intubation and surgery notice cut in the glossopalate arch is that normal after full anesthesia what time take to heal ?
Great video! Would you considering doing a video about performing an airway exam? Thanks!
Nice. Thanks so much! Enjoyed the video
if someone accidentally insert ryles tube instead oesophageous how we can detect
this is so fire. from an EM resident PGY-1 thanks
SRNA here; thank you for the great videos!
I was a kid they used sleep gas when I got older they said they can’t do it anymore I wonder why I had no issues with the nasty smelling gas
It's generally safest to have an IV in place before delivering any anesthesia. However, since kids typically don't tolerate having IVs placed, they often go to sleep with inhaled anesthesia and have an IV placed immediately upon being under general anesthesia.
Have you done an intubation through the nose? I have many facial surgeries, specifically osteomyelitis of the jaw, where the have went in through my mouth. Every time they stated they have intubated through the nose. I must say this is painful for me after the surgery, nose bleed and bad throat pain. I would like to see that done. Cause I have more surgeries coming up. But not sure if I will go I got he surgery like I did before finding your page. I didn’t realize so many medications were used. Just scary. My last surgery I woke up with nurses screaming I was in tachycardia I was straight up panicking. Screaming back don’t let me heart blow up. Put me back to sleep. Not sure if they’re ere really panicking and they probably didn’t realize I know what that words means. However my fear was real.
You need to make a video about extubation and waking from anesthesia
Amazing Video Max! I had a question about airways, why would you use an ETT over a supraglottic airway such as an I-gel? Assuming proper ventilation can be provided.
Laparoscopic surgeries require ETTs in order to deliver positive pressure ventilation. Also any surgery lasting an extended period of time, generally better to avoid LMAs as they can lead to nerve damage in the mouth over a long case. Many reasons certain cases would require ETT over LMA but these are just a couple that come to mind.
Uncontrolled Gerd and full stomach can cause aspiration. ET tubes protect the airway better. Also if I have to position a patient prone (face down) I personally always use a tube. It’s a better airway and one of the last things you want is a patient that’s face down with an airway/ventilation problem. There are ways to fix it safely but you’ll look like an idiot and the surgeon isn’t going to like you. A lot of these prone cases tend to be long anyway. If you’re doing anesthesia for lung surgery you’ll have to be able to ventilate one lung and not the other so you’ll need a special ET tube. You could theoretically do it with an LMA and a bronchial blocker but it’s not standard of practice. There are lots of reasons but it boils down to what’s going on with the patient and the proposed surgery.
Wow, I never realised just how brutal intubation is on the vocal chords! Scraping a tube past it like that must do terrible damange!
The patient is paralyzed so the vocal cords are open. The tube is placed right between them. They might have a little sore throat but are fine.
Thanks for the great video. Now I can visualize the difference between the Mac and Miller blades. As an ENT patient your videos often provide me with "insight" that makes my surgeries less stressful. How about a video on endotrachial tubes - hunsaker for instance?
When in the or what if the surgeon or the leader imposes the ga and the patient has ask for a spinal who decides? Who has the last word ? And should the patient be informed before I order to give clear open consent? Which is not done in France. Thank you for your openness. Can you break a tooth when you put the tube in? And do tell the patient?
The patient has the last word. The decision about what kind of anesthesia to deliver is based on a conversation between the anesthesiologist, surgeon, and patient. I can’t speak for other countries, but in the US a surgery/anesthetic can only proceed when the patient has given informed consent, unless it’s an emergency. Yes, it is possible to break a tooth during intubation, and yes the patient should be told but of course they’d also figure it out on their own 🦷
Your videos are both enjoyable and informative. Thank you for sharing them! Do all patients get intubated during surgery? If not, what is the deciding factor to do so?
hey doc! i think i saw you outside the mount sinai on 58th and 10th about a month ago during midday (1pm maybe?). was just gonna say hi and that you made great videos but i wasn't 100% sure it was you
As a paramedic I approve this video, LOL.
@GSimm: Funny comment on what I think we’ll agree is a fascinating vid. As a retired paramedic, learning to intubate (and becoming “comfortable” doing so) was one of my steepest and longest learning curves, and I was wondering if your experience during training was similar? I was always absolutely terrified of breaking or chipping or just hitting teeth with the scope. Fortunately my class trained hands-on with attending anesthesiologists, and their presence and (mostly) patient and calm teaching really helped me and I know a lot of my fellow classmates develop skill and confidence over time. Best wishes and stay safe if you’re still out there in the field practicing.
@@andycraddock7677 I’m still out here brother. Almost finished after 35 years. Intubation was definitely a tough skill. Especially for us being in such unstable situations. But what used to rack my nerves was that I had someone’s breath in my hands. Knowing that made me really practice all the time and really get it perfected over the years.
Gary, so glad we have video laryngoscopy now in the field, makes life so much easier, add a boogie and never miss a tube!
@@bettysmith4527 no video here in NYC. LOL
@@garyjsimm cheap scapes!! We have ventilators too, makes extrication and transport MUCH easier!!
Dr. Feinstein, what is your perspective regarding video laryngoscope such as the McGrath?
Why do we have to advance the blade on the right side of the mouth, when it can obstruct our vision while putting in the ET 🤔?
The blade actually allows you to have a view because it move the tongue out of the way. The ET tube just passes underneath the blade.
Hello Dr max ! I like your video.I have plan to join anesthesia!I am studying for step 1 and 2 currently! Keep up doing doing such invaluable video.I wish if could join your Hospital in future!
He is a beautiful and amazing human 💪🏻🧡
It's true 👍
Hi Max. I hope you are all right. At this point of my career all I want is to become an intensive care physician. I understand that the way to do that is by completing the ICU fellowship. Recently some doctors close to me and my family told me that i can do the anesthesiology specialty and work as an ICU attendant and that my life would be "easier and better" (they said). What do you think about thay?
I think you can do regular critical care as an anesthesiologist but if you want to do pulmonary/critical care I think you have to go the internal medicine route. I could be wrong on that though. Personally, I think ICU is stressful and depressing. I love anesthesia and I’d rather see my patients get better and go home. I’m perfectly happy doing bread and butter cases all day long.
Are there no nurses in US ORs to assist you with intubation?
Hey Doc! Any quick tips or clinical pearls for a paramedic student performing RSI in the prehospital, uncontrolled setting?
Assalamu alaikum. I have recently subscribed to your channel and found it really helpful, interesting and creative! I also wanna apply anesthesiology residency in the upcoming years, so your contents help me to get more knowledge and skills for future practice. Keep improving! 💪💪💪💪
Thanks for the continued education !!👍
During surgery about 15 years ago I got two front teeth broken. I suspect this is quite common
It’s not common. Getting teeth broken (especially the two upper front teeth) is from improper technique. I’ve been doing anesthesia for a couple years on my own after training and have never broken a tooth in training or after training. As he mentioned in the video, the correct motion with the laryngoscope is more forward and up. If you do it wrong and crank back like if you’re trying to pull a nail out of a board with a hammer, then there is a lot of pressure and leverage on the teeth and they can easily break. I will also say though that the technology for placing breathing tubes has advanced significantly in the last 15 years. The proper technique described in the video should be known by anyone who does anesthesia but there are more tools available now to help ensure the safety of our patients.
I want to do that for a living so bad this this is so interesting
Miss you Max!
My last surgery was for a cervical fusion that failed and was unstable. So I was intubated while awake after breathing in this numbing medicine for a few minutes and then he gave me a shot in my voicebox. It was really weird lol. Once it was in the anesthesiologist kept saying, "K, goodnight" and I was just looking around thinking this is weird for about 15-20sec. It was like suddenly I couldn't take a breath in but I wasn't panicky about it. Which I think was his biggest fear lol.
Nyc Paramedic here. Yep im a weirdo i love the miller. Many look at me like i have 10 heads when i ask for it.......but hey to each is own.
I'm watching this as I am currently on my Anesthesiology AI haha
On my last anesthetic they used a video scope to put the tube in as I have a high palate narrow Airways I am an adult but they use kids tubes on me
I can’t wait to try this on my brother
Hello! I am a big fan of your channel. I was just wondering if you have ever seen someone place an LMA using a tongue depressor blade? I just did on to TicTok by a CRNA. The patient was completely sedated and paralyzed,so it seemed. Just wondering if intubations are ever performed using the tongue depressor method? Lol!
I’ve seen some people use tongue depressors for LMAs but I find it unnecessary. I just pop the mouth open with my left hand and put the LMA in with my right hand. Works every time. You don’t ever see the vocal cords with an LMA. When intubating you usually need to see the cords so a tongue depressor wouldn’t work.
What causes sore throat from anesthesia?
Same question for almost full loss of voice for almost 2 weeks????
Thank you, your Videos are AWESOME!
The laryngoscope blade goes into your throat and can cause some soreness, and the tube passes through your vocal cords which causes irritation and inflammation, causing short term voice issues. If you have concerns I would speak to your medical provider as there could be other causes.
You may have a problem with vocal cord movement causing the hoarseness. Sometimes pressure from the breathing tube through the trachea onto the laryngeal nerves stuns or paralyzes them. Other times it can cause inflammation or scarring of the tiny joints (arytenoids) that the cords pivot on. You should see an ent to have them check your cords. FYI 2 weeks is pushing the outer limit of where “inflammation” is an acceptable answer for hoarseness of any cause, without having ENT look to make sure it isn’t anything else.
Love this video! Thanks
September 2021 I was going into anaphylactic shock which I needed to be intubated the nurse anesthetist try to intubate me while I was awake it did not go well because I punched her in the face. What do you think about intubating a patient while they were awake? Every doctor I have spoken to said it was incorrect and you never should intubate anybody fully awake. I like to know your comments about this.
Yes I was completely awake nobody had given me any drugs and at first she said she was measuring to see what size intubation tube she needed she put the speculum in my throat and I gave her one chance to try to intubate me awake as the doctors were yelling at her this is not our protocol she was an agency nurse anesthetist that was filling in in the ICU and did not work for that hospital. The second time she said she was going to try I told her no that I needed to be put asleep while she grabbed my face tilted it back and put the speculum in and I took my left arm up and I punched her in the face so she would stop and it took three doctors to walk over and remove her from me that was all that I remembered because the next time I woke up I had intubation tube in and my hands tied down. They had me on a fentanyl drip to keep me sedated but I could wake up now and again to communicate. So yes the nurse did try to intubate me while I was fully awake.
Thank you
Which books you are reading about anesthesia
Question:
With the emergence of other healthcare professionals that can perform RSIs (such as paramedics) and even full anaesthetics (such as CRNAs), do you think that the role of the anaesthesiologist might become redundant in the future?
Also perhaps a video idea: what’s the difference between anaesthetists/anaesthesiologists and CRNAs and Paramedics/CCPs especially focusing on differences when it comes to anaesthetics.
Awesome videos by the way!!
My question is how do u intubate a patient that is awake. I am sure there are situations in which this is true. What do u do? Do u bother giving any anesthetic so the patient doesn't feel the intubation happening? How can u make the patient more comfortable.
I'll stick with my McGrath video laryngoscopy, with a boogie added when needed.... Technically. a Mac blade I suppose, but nothing beats the addition of video!
Video scopes are great unless there is bleeding in the upper airway. Once that lens gets smeared, patient is SOL
@@khyrand sense the fact that I said "...with a boogie when needed".
@@bettysmith4527 not sure how much a bougie helps when the airway is full of blood and clot (I’d rather see the glottis, personally) but whatever keeps your patients alive…
@@khyrand The whole point of using a boogie is for when you cannot see the glottic opening! It uses tactile instead of visual cues that your in the trachea!
@@bettysmith4527 again, not optimal to blindly shove a hundred cc of clot or carcinoma into the lungs when a different instrument could obviate aspiration, pneumonitis, icu, etc. Bougies are appropriately used when there's an ANATOMIC cause for poor visualization. In a bleeding or tumor filled airway, it isn't among my top choices. I guess we just think differently about optimal patient care.
Great education thanks
Brilliant, thank you so much.
Tnx so much❤❤
Lifeguards upon Beaches must know how to use the tool now
Wow! It is so interesting to know.😊
Hello sir i need some information...
Большое спасибо from Russia)
Dang, noticed the ring, Max is married. Was hoping to get some digits....LOL
Are most patients intubated?
It really just depends on the type of surgery.
@@MaxFeinsteinMD The type of surgery, or the ammount of time the surgery will take?
@@shayleegoss1460 yes!
Both, as well as what is the safest for a patient given their medical history. For example, I would not intubate the majority of patients coming in for relatively non-invasive anorectal procedures under moderate sedation, but any patient getting laparoscopic surgery would need to be intubated. I hope that helps!
one of the most causes of difficult intubation is the shape of the teeth , some have long front teeth some as in Geriatrics have few teeth that neither support your intubation and make it easy nor with someone has nothing teeth at all as in a dentures and you can use a pad as a type of support to do intubation more easier and also those with small oral cavity that restricted or limited your view or have a big tongue that even laryngoscope can not to hold it completely by its blade and as much you got experience still sometimes you are facing a problem of difficult intubation that makes you to feel after years of working as anesthesiologist you feel that this is the first day in your job especially when all those around you looking for you with some doubt ..................................................
Why is a miller preferred for paediatric patients?
And what happens if a patient is having a heart attack and u need to give them epinephrine. But they are on beta blockers. In an emergency is there time to check for drug interactions? Does the computer tell u there is an interaction? How do u prevent drug interactions in emergency situations. I assume that having an updated medicine list is the best way. I guess ur shooting in the dark if u get someone who comes in with no perscription history. How can u prepare yourself so if a medical emergency happens to yourself, u are ready. I mean we hope it doesn't happen. But it does. Would be good to know how to be better prepared as a person to increase the possibility of surviving
I was trained by a doc who was trained by Sir Robert Macintosh… the guy that invented the damn thing
I 💗 Intubation
This video made my throat hurt
Never intubated in the back of an ambulance during a trauma