We are discouraged from doing that from an infection control point of view. I will pop the packets open from the ‘non critical’ ends if I do do that. You don’t want to be dragging the torn packaging across the ‘critical’ area of the syringe or needle before use and thereby possibly introduce infective agents into the syringe or needle.
Never in my life I realised you can peel off the packaging... I always stabbed it through the packaging. But it doesn't work for the 10nk syringes we have here because for some reason, they come attached to a needle. They break if you try to stab them through...
I've had 40+ surgeries in the past 21 years. Had cancer in my mouth , neck and jaw. I have had many anesthesiologists over the years , never had a bad experience ever.. THANK YOU FOR YOUR TIME AND SERVICE
I've had 20+ operations, and I've loved watching your videos because they have really helped me become more comfortable with "being put under." It used to absolutely *terrify* me. Now that I understand the medications used, and the safety measures taken to ensure my safety, my pre-surgery anxiety has been cut in half.
I absolutely love your videos, I’m a surgical ICU nurse in Germany. The thing that surprises me though, is that you guys recap your needles. We’re not allowed to do that, we throw away the needle and put a stopper on the syringe, to prevent needle injuries.
@@tommythetank212 Grab it at the bottom at the plastic part, or use the tool that’s inside the lid of the needle bin if you don’t want to touch it at all.
As a medical student who is now attending an anesthesiology internship I find all your videos very useful, I LOVE them! With your advice I can learn a lot and they can help me not to give a bad impression when they let me prepare the drugs Greetings from Italy!!
I often inject the air *above* the fluid level in the vial, then bring the needle tip *below* the fluid level to let it fill. This avoids creating bubbles, particularly for things that froth like propofol (or antibiotics - similar technique when diluting powders).
Same here! I think he has a lot of us nursing students and RN's as viewers. Although anesthesiologists are much more advanced, we share a lot of common overlapping tasks. I've learned a lot about med safety from his channel. TBH, that nurse in TN who just got convicted, would have benefited from learning more about paralytic agents like Max works with.....
@@petemiller2598 that case is more complex than you carelessly indicated.....there’s plenty of medication errors in the anesthesia/OR every single day that goes unreported- I’ve been there.... your comments reinforces the misperception that only nurses make mistakes, rather than the environment in which they are subjugated to perform in.
You and me both. As a side note if I know I'm having a surgery with say my plastic surgeon to have a revision procedure I remember the name of the anesthesiologist I had during a surgery in 2020. I will for sure ask my surgeon if he can request "Dr. Somal" (my actual anesthesiologist). I'm sure surgeons who have more seniority at a particular facility can request a certain Anesthesiologist/CRNA
Graduating and starting an anaesthesia residency very soon, this has been the subject of my nightmares for some time now :D Thanks for the video, I'm sure it'll help me later! :)
I'm so impressed with your informative videos! I am understanding so much more about this part of surgery. I wondered why the CCU nurses were so concerned after my open heart surgery when I developed a fever in the recovery room. I remember dreaming then that I was in the hot sun, so thirsty and my body was drying up in the heat. It was the fever and the nurses were very quick to contact the doctor who ordered antibiotics. I am glad that doctors in your field have such high standards of care. - Beki Anderson, Jim's wife.
Hey Max, your videos have really inspired me. I didn't know what I wanted to be after graduating from college but I am going to pursue medical school and try to become a anesthesiologist one day. Love the videos!
Sure, there are long days and nights, but when you love what you do, it's not work. Agree to always packing snacks, very few bathroom breaks, cold food/left overs, but big rewards. You really get to know your co-workers during the long cases.
I watched all of your videos. Had surgery yesterday under general anesthesia. Your videos made me much less stressed and anxious. Thank you so very very much. These are outstanding videos - educational and easy to understand. Great job. ❤
I’m a new-ish nurse and appreciate your pop open the packaging demo. I spend way too much time trying to perfectly peel those things open. Can’t wait to try this! Thank you!
You can pop syringes through the package UNLESS you're placing them on a sterile field. Drawing up meds safely on an anesthesia cart is a clean procedure. But, when it is a spinal anesthetic, everything anesthesia touches will be sterile.
I’m in my second semester of nursing school and those tricks are going to be so helpful and they look cool. I’m going to try this on my Thursday clinical rotation this week. Thank you :)))
The caps on vials have been described as “dust caps” that do not maintain any sterility of the vial so it is recommended that one cleans the top of the vial with an alcohol wipe prior to withdrawing the medication. There are quite a bit of research based articles and suggestions from organizations like the CDC and WHO if anyone is interested in further information/guidance. If you are a nursing student, you will be taught the rights of medication administration and how to properly clean the vial prior to accessing it.
@@leslielafferty4448 yup I was and that’s why I carry alcohol pads with me :) I get to try this new skill tomorrow which is nice. Hopefully it goes well.
I just did my IVF egg retrieval and I have to say, I tried the cap popping thing with my IVF meds after seeing another professional do it (with the exact same meds) on TH-cam. It didn't work for me and I ended up having to do it the old-fashioned way anyway. Also, on a fun note, I actually found your channel because of my egg retrieval. I wanted to figure out what moderate sedation actually was with respect to other types of anesthesia, because that's what they used on me.
THANK you for mentioning the warning on the paralytic- I was going to to a whole project on safety features like this- how you can miss the label is beyond me
If the room is dark, if you are doing too many things at once, if you are in an unfamiliar area, using a new, unfamiliar med dispensing machine, if you have been "taught" by whomever to override the system temporarily, if you're expected to be doing the job of 2 or 3 people....but, yes, all paralytic agents have warnings. Do other meds have similar colored caps-yes. Do you have sound-alike/look-alike vials? Yes. Etc. Etc. Always rely on what you know to be correct, ethical, safe, etc. Do your safety project and stress that many times there are 100 things trying to compete for your attention. Stick to what you know and proper protocol ALWAYS! Just my thoughts and not nursing advice.
I just love your videos! Yes it's always important to triple check omg I laughed when u showed the quick way of getting a syringe and needle out of the package. I must admit during my 20 + yrs of nursing I never thought of that. I always slowly would have to find the corners and peel. Yes I did pop off the lid of vial. This is a very good time for this video. Again your pts are so blessed to have u as there anesthesiologist!
In my hospital (I'm a pharmacy tech so I'm the one refilling those trays), we have a lot of these (most notably succinylcholine, phenylephrine, ephedrine, and a couple others) already drawn up by us in the pharmacy so there is not need for those in the operating room to do it themselves especially in emergency situations. Cool to see how you guys do it though!
I've been watching a lot your videos and found them all very informative and interesting. Pharmacist here and through out the past few years of administering covid vaccinations, I have never ever thought of popping the syringe and needle out of the packaging like that. Genius! Will definitely be doing this from now on!
You are a very contientious doc by reminding others to throw away the garbage they created. Nothing is more irritating than picking up after grown-ups!! Triple check always. If distracted, start your safety checks over. I noticed you didn't state expiration dates or times drawn up. We, nurses, we're made to initial syringes, date & time. Not easy to get all that info on. We also had to wipe syringe top with alcohol swab, yes, even if it was covered. I always kept my med vials for each case & pt. Toss them when pt out of the room. That way, if there were any questions. Your stressing of safe practice is great to hear for anyone watching. We had a locked med cart for all meds; only exception was the crash cart or MH cart.
Hi,Max, im getting ready to take my nursing TEAS exam on monday and have been finding your video's have helped me understand a lot more, medically, thank you 😊.
Great video. Thank you. You have done a day in the life I do believe, however, I can always get into a video that features workflow throughout a working day. In the absence of being able to shadow its the best way to see what each specialty looks and feels like. So I vote for more workflow videos! Thanks again!
@@MaxFeinsteinMD 🤗👋🙋🏼♀️ could you give us your opinion on pump-head.. any new research on it....what really causes it ECT,,,,and why it happens and who is most prone to get it...??? My husband is going in for triple bypass surgery..on pump...in nov
Wait...I have a huge question that has bugged me in our medical device development. When you draw air into the syringe and inject it into the vial - which I understand - are you not introducing an infection risk here? I realise this is a youtube video but in reality how is this risk controlled? Thanks!
I really appreciate seeing this, I have anxiety and would love to eventually have skin removal surgery but I have been too nervous about the potential complications/errors to actually pull the trigger yet and your videos help tremendously with easing my fears about the entire process! (The only “surgery” I’ve ever had was wisdom teeth removal, and I had stitches to reattach my nose that I cut on a stamp box when I tripped as a toddler, so aside from other family members surgeries I’m sort of a newbie personally which adds to my anxiety).
Thank you for the late night laugh. When you talked about accidentally sticking yourself with a paralytic I had a flash back to the dentist skit on the Carol Burnett show, Tim Conway played the dentist and Harvey Korman the patient. Tim accidentally sticks himself twice with the Novocain and numbs his hand making it worthless. It was the perfect skit for your story.
Great tips man! It’s always good to be safe doing Anesthesiologist! I can’t wait to start Donating to the anesthesiologist Foundation since It was hard for me to go to college to be a anesthesiologist after I graduated high school in 08 because of my cerebral palsy, I have had 14 surgeries because of my cerebral palsy I’m 32 from Memphis
It's pretty sad that you post this EXACT comment on every one of Max's videos. It's almost like you desperately need his attention for something...sad.
One thing I would like to add. Please use an alcohol swab on the rubber seal before drawing up the medication. Just because the cap was still attached DOES NOT mean it's sterile.
I have no idea why youtube presented your channel to me, but here we are. Now I know more about anesthesiology than anyone else in my circle of humans. So…thanks for giving me knowledge of a field that I didn’t know I kind of am now curious about…I know that doesn’t make sense. Whatever. Thanks, dude.
I love watching you. I have been doing this a while. One other thing I do is save my vials for a case until the end of a case. I always double check. This is my triple check especially if some one relieves me. That I have charted everything I have given in case Just in case I got really busy during the case. One thing maybe to talk about.. when hanging a presser drip always use the closest port to pt. Also, if u have ports on the line to those pressers. Tape them off and label the roller so no one that relieves you pushes drugs threw ur presser line instead of your ns line. Or opens the wrong roller aka the presser verses the ns line.
I am a perfusion assistant and I can’t tell you the amount of times I yell at residents for leaving a mess lol all out of love I know they are still learning
You should try drawing up meds in the back of a moving ambulance! I totally do the medication vial top flip with my thumb. 100% of the time it lands on the floor of the ambulance but I always make sure to pick it up after the call. A messy ambulance is a sad ambulance.
Cool video Dr Max! I have always passed out at the site of a needle (lol). But I am currently giving myself shots of Lovenox twice a day!!! My syringes are preloaded so I don’t have to draw it up. Air always scares me but I don’t need to worry about it giving my shots in the stomach. I love learning and I love your videos! Have a great day!
How common is Malignant Hyperthermia and how does it manifest itself during a surgery. Then what do you do as an anesthesiologist and how critical is it? Love your videos. It has given me lots of talking points for reference when I meet pre-operatively with an Anesthesiologist
Thanks for sharing your knowledge and intelligence with us max!! I'll be starting an Anasthesiology Tech degree path in the fall. My short term/6 yr plan is to become a CAA. I would love to shadow you in the O.R. some day soon.
During a tonsillectomy my daughter had a reaction to Anectine. That was 45 years ago and she still has anxiety because she remembers being awake but paralyzed.
I’ve always done the ‘poke through the paper’ technique in my lab. And I teach it to everyone. They think I’m genius, I thank the cell biologist who taught me that during my masters year
Good vid. Off topic question: My X had a situation where paralytic took effect but he felt the entire surgery. My question is this: this procedure was at a world renowned medical center that is a teaching hospital. Is it ever possible that the doc in charge - you - leaves the room so that only a junior level resident is administering and does it incorrectly? I know there are times anesthesia just failsl - but more wondering the safety checks on physicians not correctly monitoring things in a teaching situation.
A big thank you to all anesthesiologists, have had 4 major surgeries and each time I go ‘out’ and wake up it feels like seconds. Prior to surgery the anesthesiologist would come in talk calmly to me about what’s going to happen on their end and ask me if I have any questions and I’m good to go.
Thank you, I use hypodermic needles to refill computer printer cartridges and the ink comes in vials with rubber tops just like the drugs. Never knew about injecting air into the bottle. The needles and syringes are OTC and legal to possess here in Thailand.
A few comments if I may. Some excellent tips. But just 2 infection control tips… 1. don’t ‘pop’ the packets open at the ‘critical’ end of the syringe or needle thus possibly introducing infective agents into those ‘critical’ areas. Pop the non critical ends to get the syringe or needle out quickly. 2. Tops of vials should be swabbed with an alcohol swab and allowed to dry before accessing with a needle. Those tops are not sterile under those caps. This is especially important if accessing propofol via a sealed topped vial. Propofol is an excellent medium for growth of infective agents. We had a few cases of patients getting pseudomonas blood infections that was found to be from the tops of vials of propofol not being swabbed before accessing, as staff presumed the tops were sterile under the covers you pop off.
@@MaxFeinsteinMD I guess our OR practice differs then. From the pharmacy where I work and from the infection controll unit we are mandated to do it because we can't be certain that we did not contaminate the top, or that it's not contaminated before arriving at the OR (not all caps are air-tight). It's just a precaution, f.ex. when one considers how good of a growth medium the lipid solution in Propofol is!
@@Veritias while different places have different policies, this is what I’ve been taught/practice too. Most of the time the caps are really just serving as “dust caps” to keep the vial top “clean”, but it’s not actually sterile - hence the need to clean with alcohol. I really wish the FDA or NIH or whoever would do a study to establish a national standard policy, instead of the current mixed practices.
@@MaxFeinsteinMD just from a friendly hospital pharmacist - The 2015 ISMP safe practice guidelines for adult IV medications states that many practitioners may be unaware that the caps function as a dust cover and are not designed or intended to maintain sterility of the vial diaphragm or access point - thus necessitating cleaning of the critical site. Just something to think about. Of course in some instances, where the medication is given immediately in an urgent situation, the amount of bacterial growth that can happen is negligible. Very interesting video
I also open my syringes and needles that way (so much faster!), but you have to keep in mind that you are actually breaking the sterility by doing so. And at least theoretically there is a risk of contamination of the luer-part of the needle from any debris on the outside of the package. Probably not a real risk in most situations, but if drawing medications for storage or for sensitive uses I will open the needle package correctly.
This was very interesting to see. Most of us wouldn’t ever see this but thanks to TH-cam we can. How fast would a paralytic if someone accidentally poked themselves go into effect? Or would it not really do anything? I get tb tests for work and one nurse broke off the needle 💉 in my arm. She had the syringe in her hand while the needle was stuck in my arm. She said I had tough skin and that’s why it broke off. I was like what in the world? Thanks for the video Doc! 🏥
This is a really interesting question. There was a study in Korea that showed subcutaneous injection of succinylcholine at 1mg/kg will produce full paralyzing effects, but onset of paralytic took 7min instead of 1min or less. However, that means you have to inject almost an entire 5cc syringe depending on weight of the person. If you stab yourself, its likely 1cc or less, or maybe even a drop. The ED50 of succinylcholine is 0.14mg/kg, which is 0.5cc. If you were using a 10cc syringe, it is absolutely possible you could have injected close to that amount into subcutaneous tissue. You would definitely need another anesthesia provider to take over your case, and you need to be closely monitored with direct medical care immediately to protect your airway and provide ventilation ASAP. You would need an other anesthesia provider to start watching you within minutes, as you would likely never make it to the ER if you actually had an effective dose of SQ succinylcholine.
I've had 5 major surgeries plus many procedures requiring some sort of anesthesia. I will admit, I kind of secretly get a crush on my anesthesiologists. If it's a male , of course . I think it's because they basically have my life in their hands. I get kind of awestruck because of the work they do. And I admire the work they do
This would be a good video for insulin-dependent diabetics. I remember when my daughter was 5 and developed Type 1 diabetes. As a parent of a Type 1 kid, we struggled with this.
I actually poked myself with a needle when as a child by curiosity I removed a cap, and then tried to put it back on. Since then I am afraid of needles, but at least I can manage the fear by being careful with needles. I learned to but back the cap the way you showed already as a kid and do that way every time I have to inject medication to my animals. No paralytics or opioids though :)
I always feel like this is a dumb question, but this seems like the most appropriate video to ask on. Is there no concern about contamination with pulling the rooms air into the syringe, then bubbling it through the medication to pressurise the vial. Even at the research lab I used to work in where the air was replaced with clean air 10-12 times a minute we still had some issues with contamination in cultures and such. Where I shadowed a surgeon, he said the air was replaced about 5 times a minute.
Great question, I’ve never thought of that. I’ve never heard anybody bringing this up as a concern, even in environments where patients are particularly susceptible to infection, for example immuno suppressed transplant patients. I’ll look into it
The operating room air is changed 20 times an hour. Also, the surgical equipment sit out in room air often for hours. If this was such a concern, there would be even more surgical infractions.
As you can see by the other replies the OR air is changed often. Also at least where I work it's a hyperbar airflow pushing air from the OR out the doors if they are open, avoiding air from the doors to flow in.
@@MaxFeinsteinMD where I work drawing up air first is 'forbidden' (especially in high infection risk agents like propofol). Not because of the air going in, but because when you pull the syringe, you touch (and possibly contaminate) the plunger with your hands, which you then insert back into the syringe. For vials with a rubber membrane, we use a second needle to let air into the vial to avoid having to let the plunger pass the inside of the syringe multiple times. There are some really interesting studies on this topic (plunger-syringe contamination).
Hi thankyou for your interesting, informative post. I wondered how anesthetic is given to emergency patients who have already eaten ? Hope I'm not wasting your time, just curious to know the procedure.
Hi! In case of an emergency patient that's not fasting, has bowel obstruction, reflux-syndrome, severe pain etc. it's common practice to do a rapid sequence induction. We give Natriumcitrate 30ml to neutralize the stomach acid. Then we preoxygenate the patient until expired O2 of around 90%. You do not ventilate these kind of patients, as air going into the stomach increases the risk of aspiration. Then you give medication in rapid succession, depending on the patient. As opioid you usually use a rapid-effect-opioid like Alfentanil or Fentanyl. Then you give Propofol or any other sedativa like Thiopental or Etomidate. Then give a muscle relaxant. Before it was common to use Succinylcholine, but in my practice it's more common to use Roccuronium. The advantage Succinylcholine is the rapid onset, and patient is ready to intubate after fasciculations. In Roccuronium you're just a few seconds slower. There are many reasons to choose one over the other, so it will be up to the anesteshiologist to choose. Succhinylcholine is prone to malignant hyperthermia, allergies and arythmias if patient has a high K+ as it releases a large dose of K from intracellular to extracellular. Roccuronium can be reversed with Sugammadex which is considered expensive, but has fewer side-effects than Succhinylcholine. After the musclerelaxant is working we intubate the patient, usually with a mandreng inserted to make the tube have a more correct angle. In some patients it's common to put a tube down into their stomachs ahead of anesthesia and drain their stomach contents. Or you can awake-intubate with a flexible scope if you are afraid of losing the airway because the patients airway is that difficult.
with greater risk and difficulty 😅 the anesthetic drugs aren't the greatest problem with sedating patients who have eaten it's when the food decided it doesn't want to chill there anymore 👀🤮
I know I'm late to the conversation, but I've seen nasogastric tubes used to clear out as much as possible from the stomach depending on the urgency of getting to the OR.
3:01 in the background the orange label is glowing..... neonorange... you can not overlook this color..... 3:39 you should open the needle and syringe in the first way because if you open the package like in the second way you can contaminate the syringe because the sterile item can touch the unsteril outside of the package....
Good for novices, for sure. I suggest you use "milliliters" (mL) not "cc," which the Joint Commission banned for the risk of medical error when it was written in a chart. ("cc" written quickly can look like the "u" in units). Now with electronic orders, mL is the standard, but using the safe jargon, especially for nurses who are the ones drawing up and administering 99% of meds outside the OR, it's an important point.
A couple of pointers: -You should alcohol swab the top of the rubber stopper before putting the blunt needle in the vial. Those are just dust caps that you flick off; it's not sterile under the dust cap. There are studies you can look up regarding this.. -You should try not to label the syringe prior to putting the medication in the syringe. Medication goes in the syringe, label goes on. -Opening the packages like you do saves time, but can contaminate the top of the syringe and the opening of the needle. The outside of the wrapper/package isn't sterile; this brushes against the top of the syringe as you open it like you to to 'save time'.
Been a nurse for 26 years and never thought to crack the syringe and needle package like that. I’ve been doing it wrong for years! Made my day!
Some people think outside of the box. You are never too experienced to do it also
We are discouraged from doing that from an infection control point of view. I will pop the packets open from the ‘non critical’ ends if I do do that. You don’t want to be dragging the torn packaging across the ‘critical’ area of the syringe or needle before use and thereby possibly introduce infective agents into the syringe or needle.
Lol, you're a joke
Never in my life I realised you can peel off the packaging...
I always stabbed it through the packaging.
But it doesn't work for the 10nk syringes we have here because for some reason, they come attached to a needle. They break if you try to stab them through...
I've had 40+ surgeries in the past 21 years.
Had cancer in my mouth , neck and jaw. I have had many anesthesiologists over the years , never had a bad experience ever..
THANK YOU FOR YOUR TIME AND SERVICE
I've had 20+ operations, and I've loved watching your videos because they have really helped me become more comfortable with "being put under." It used to absolutely *terrify* me. Now that I understand the medications used, and the safety measures taken to ensure my safety, my pre-surgery anxiety has been cut in half.
All those safety measures and you could still just die.
Super phobic of anesthesia too
I absolutely love your videos, I’m a surgical ICU nurse in Germany. The thing that surprises me though, is that you guys recap your needles. We’re not allowed to do that, we throw away the needle and put a stopper on the syringe, to prevent needle injuries.
we recap if it hasnt been inserted into a patient yet, after insertion it goes into sharps bin immediately
How do you remove the needle from the syringe without recapping it first?
@@tommythetank212 Grab it at the bottom at the plastic part, or use the tool that’s inside the lid of the needle bin if you don’t want to touch it at all.
I work in the US. I prefer to use sterile caps & stoppers when possible.
If you put a "stopper" on the needle, isn't that basically the same as recapping a needle?
As a medical student who is now attending an anesthesiology internship I find all your videos very useful, I LOVE them!
With your advice I can learn a lot and they can help me not to give a bad impression when they let me prepare the drugs
Greetings from Italy!!
I often inject the air *above* the fluid level in the vial, then bring the needle tip *below* the fluid level to let it fill. This avoids creating bubbles, particularly for things that froth like propofol (or antibiotics - similar technique when diluting powders).
IV tech here, same
As a nursing student I absolutely LOVE your videos. I graduate in May and appreciate all the tips I can get 😁
Same here! I think he has a lot of us nursing students and RN's as viewers. Although anesthesiologists are much more advanced, we share a lot of common overlapping tasks. I've learned a lot about med safety from his channel. TBH, that nurse in TN who just got convicted, would have benefited from learning more about paralytic agents like Max works with.....
@@petemiller2598 that case is more complex than you carelessly indicated.....there’s plenty of medication errors in the anesthesia/OR every single day that goes unreported- I’ve been there.... your comments reinforces the misperception that only nurses make mistakes, rather than the environment in which they are subjugated to perform in.
Hope that you have a fantastic and interesting career. 👍🏻
@@urielromero5069 Thanks for this uriel!
I’m getting a major procedure done In August at mount Sainai. I wish I could choose my anesthesiologist. I would definitely choose you.
Maybe you can ask. I’d love to have him.
@@mrsNetty34 they don’t give us options to chose our anesthesiologist. They just show up randomly.
@@CalmIrregular true
If you dont ask, you are sure it will not happen!
You and me both. As a side note if I know I'm having a surgery with say my plastic surgeon to have a revision procedure I remember the name of the anesthesiologist I had during a surgery in 2020. I will for sure ask my surgeon if he can request "Dr. Somal" (my actual anesthesiologist). I'm sure surgeons who have more seniority at a particular facility can request a certain Anesthesiologist/CRNA
Popping open the package is the *only way* to go 😂
I appreciate the triple checks, and have done this myself as a medic since day 1.
Graduating and starting an anaesthesia residency very soon, this has been the subject of my nightmares for some time now :D Thanks for the video, I'm sure it'll help me later! :)
Congratulations on matching, enjoy the process!
Congrats, but I sure hope you’re getting some in-person instruction. 😳
Always remember- when in doubt THROW IT OUT
@@Toni_Snark She'll get thousands of hours of in-person instruction. :)
wow congrats
I'm so impressed with your informative videos! I am understanding so much more about this part of surgery. I wondered why the CCU nurses were so concerned after my open heart surgery when I developed a fever in the recovery room. I remember dreaming then that I was in the hot sun, so thirsty and my body was drying up in the heat. It was the fever and the nurses were very quick to contact the doctor who ordered antibiotics. I am glad that doctors in your field have such high standards of care. - Beki Anderson, Jim's wife.
And with that scrub cap, you never run out of medication labels! Thanks for the tips. Way to keep it safe & fun.
Hey Max, your videos have really inspired me. I didn't know what I wanted to be after graduating from college but I am going to pursue medical school and try to become a anesthesiologist one day. Love the videos!
Cool! Get ready to work 24-7 and no sleep and learn to pack snacks 🙃
Sure, there are long days and nights, but when you love what you do, it's not work. Agree to always packing snacks, very few bathroom breaks, cold food/left overs, but big rewards. You really get to know your co-workers during the long cases.
I watched all of your videos. Had surgery yesterday under general anesthesia. Your videos made me much less stressed and anxious. Thank you so very very much. These are outstanding videos - educational and easy to understand. Great job. ❤
As an RN, I appreciate your videos...safety is #1.
Same here. The nurse in Tennessee with the Versed/Vercuronium mistake probably could have benefited from this channel...
I’m a new-ish nurse and appreciate your pop open the packaging demo. I spend way too much time trying to perfectly peel those things open. Can’t wait to try this! Thank you!
You can pop syringes through the package UNLESS you're placing them on a sterile field. Drawing up meds safely on an anesthesia cart is a clean procedure. But, when it is a spinal anesthetic, everything anesthesia touches will be sterile.
Thank you , starting my anesthesia rotation tomorrow, I might surprise my attending with these tricks :)
Howd it go?
wowowow congrats
Max, I love your videos! I love having someone explain to me the importance of things rather than just telling me to blindly do them.
Love the videos man. I like that you make vids about practical skills like this
I’m in my second semester of nursing school and those tricks are going to be so helpful and they look cool. I’m going to try this on my Thursday clinical rotation this week. Thank you :)))
The caps on vials have been described as “dust caps” that do not maintain any sterility of the vial so it is recommended that one cleans the top of the vial with an alcohol wipe prior to withdrawing the medication. There are quite a bit of research based articles and suggestions from organizations like the CDC and WHO if anyone is interested in further information/guidance. If you are a nursing student, you will be taught the rights of medication administration and how to properly clean the vial prior to accessing it.
@@leslielafferty4448 yup I was and that’s why I carry alcohol pads with me :) I get to try this new skill tomorrow which is nice. Hopefully it goes well.
Be careful with the vile flick-off, I hit my clinical supervisor in the head when an errant cap flew in the wrong direction.
I just did my IVF egg retrieval and I have to say, I tried the cap popping thing with my IVF meds after seeing another professional do it (with the exact same meds) on TH-cam. It didn't work for me and I ended up having to do it the old-fashioned way anyway. Also, on a fun note, I actually found your channel because of my egg retrieval. I wanted to figure out what moderate sedation actually was with respect to other types of anesthesia, because that's what they used on me.
THANK you for mentioning the warning on the paralytic- I was going to to a whole project on safety features like this- how you can miss the label is beyond me
If the room is dark, if you are doing too many things at once, if you are in an unfamiliar area, using a new, unfamiliar med dispensing machine, if you have been "taught" by whomever to override the system temporarily, if you're expected to be doing the job of 2 or 3 people....but, yes, all paralytic agents have warnings. Do other meds have similar colored caps-yes. Do you have sound-alike/look-alike vials? Yes. Etc. Etc. Always rely on what you know to be correct, ethical, safe, etc. Do your safety project and stress that many times there are 100 things trying to compete for your attention. Stick to what you know and proper protocol ALWAYS! Just my thoughts and not nursing advice.
Thank you Dr., I appreciate how you explain the techniques and show that safety is a priority.
God bless
please keep this same passion for the field and patients even when you're years in the field. many drs lose that
I just love your videos! Yes it's always important to triple check omg I laughed when u showed the quick way of getting a syringe and needle out of the package. I must admit during my 20 + yrs of nursing I never thought of that. I always slowly would have to find the corners and peel. Yes I did pop off the lid of vial. This is a very good time for this video. Again your pts are so blessed to have u as there anesthesiologist!
In my hospital (I'm a pharmacy tech so I'm the one refilling those trays), we have a lot of these (most notably succinylcholine, phenylephrine, ephedrine, and a couple others) already drawn up by us in the pharmacy so there is not need for those in the operating room to do it themselves especially in emergency situations. Cool to see how you guys do it though!
I've been watching a lot your videos and found them all very informative and interesting.
Pharmacist here and through out the past few years of administering covid vaccinations, I have never ever thought of popping the syringe and needle out of the packaging like that. Genius!
Will definitely be doing this from now on!
7:40 when you do the code dose epi- wow that was fast! So impressive. Love your work.
You are a very contientious doc by reminding others to throw away the garbage they created. Nothing is more irritating than picking up after grown-ups!! Triple check always. If distracted, start your safety checks over. I noticed you didn't state expiration dates or times drawn up. We, nurses, we're made to initial syringes, date & time. Not easy to get all that info on. We also had to wipe syringe top with alcohol swab, yes, even if it was covered. I always kept my med vials for each case & pt. Toss them when pt out of the room. That way, if there were any questions. Your stressing of safe practice is great to hear for anyone watching. We had a locked med cart for all meds; only exception was the crash cart or MH cart.
Hi,Max, im getting ready to take my nursing TEAS exam on monday and have been finding your video's have helped me understand a lot more, medically, thank you 😊.
Great video. Thank you. You have done a day in the life I do believe, however, I can always get into a video that features workflow throughout a working day. In the absence of being able to shadow its the best way to see what each specialty looks and feels like. So I vote for more workflow videos! Thanks again!
Glad you enjoyed it!
@@MaxFeinsteinMD 🤗👋🙋🏼♀️ could you give us your opinion on pump-head.. any new research on it....what really causes it ECT,,,,and why it happens and who is most prone to get it...???
My husband is going in for triple bypass surgery..on pump...in nov
You made my whole experience way better! Thank you Max, keep making these great videos!
Wait...I have a huge question that has bugged me in our medical device development. When you draw air into the syringe and inject it into the vial - which I understand - are you not introducing an infection risk here? I realise this is a youtube video but in reality how is this risk controlled? Thanks!
I really appreciate seeing this, I have anxiety and would love to eventually have skin removal surgery but I have been too nervous about the potential complications/errors to actually pull the trigger yet and your videos help tremendously with easing my fears about the entire process! (The only “surgery” I’ve ever had was wisdom teeth removal, and I had stitches to reattach my nose that I cut on a stamp box when I tripped as a toddler, so aside from other family members surgeries I’m sort of a newbie personally which adds to my anxiety).
I have huge anesthesia phobia, though in my case it's less about mistakes and more about terror of the anesthesia
As a commercial aviation student, I have no reason to be here but for some reason I love your videos.
I am not a med student but I came to learn and the laughs. ❤😂 I cant help but giggle at least 1 time during any of your videos.
Thank you for the late night laugh. When you talked about accidentally sticking yourself with a paralytic I had a flash back to the dentist skit on the Carol Burnett show, Tim Conway played the dentist and Harvey Korman the patient. Tim accidentally sticks himself twice with the Novocain and numbs his hand making it worthless. It was the perfect skit for your story.
Very interesting and educational videos I like all your videos thank you
Great tips man! It’s always good to be safe doing Anesthesiologist! I can’t wait to start Donating to the anesthesiologist Foundation since It was hard for me to go to college to be a anesthesiologist after I graduated high school in 08 because of my cerebral palsy, I have had 14 surgeries because of my cerebral palsy I’m 32 from Memphis
٨ج٩
It's pretty sad that you post this EXACT comment on every one of Max's videos. It's almost like you desperately need his attention for something...sad.
@@DominicNJ73 maybe don't comment on someone elses life.
This is great Dr. F thank you so much.
One thing I would like to add. Please use an alcohol swab on the rubber seal before drawing up the medication. Just because the cap was still attached DOES NOT mean it's sterile.
I have no idea why youtube presented your channel to me, but here we are. Now I know more about anesthesiology than anyone else in my circle of humans.
So…thanks for giving me knowledge of a field that I didn’t know I kind of am now curious about…I know that doesn’t make sense. Whatever. Thanks, dude.
I love watching you. I have been doing this a while. One other thing I do is save my vials for a case until the end of a case. I always double check. This is my triple check especially if some one relieves me. That I have charted everything I have given in case Just in case I got really busy during the case. One thing maybe to talk about.. when hanging a presser drip always use the closest port to pt. Also, if u have ports on the line to those pressers. Tape them off and label the roller so no one that relieves you pushes drugs threw ur presser line instead of your ns line. Or opens the wrong roller aka the presser verses the ns line.
You're doing great work, sir thank you❤🙏
I am a perfusion assistant and I can’t tell you the amount of times I yell at residents for leaving a mess lol all out of love I know they are still learning
Thank you, Max.
Its really helpful lesson 💓💓
You should try drawing up meds in the back of a moving ambulance! I totally do the medication vial top flip with my thumb. 100% of the time it lands on the floor of the ambulance but I always make sure to pick it up after the call. A messy ambulance is a sad ambulance.
Love your videos, always very educational!
Cool video Dr Max! I have always passed out at the site of a needle (lol). But I am currently giving myself shots of Lovenox twice a day!!! My syringes are preloaded so I don’t have to draw it up. Air always scares me but I don’t need to worry about it giving my shots in the stomach. I love learning and I love your videos!
Have a great day!
I take insulin which is a pen.
HEY AMIGO !!! Nice to see you again. Hope all is well. Keep up this great videos. Hope residency is going well. Stay safe pls !
Hola Facundo thanks for continuing to follow along my friend!
@@MaxFeinsteinMD Hey ! Hola, un placer. We should make that video at some point ! :) Before I leave NY in like 2 moths :(.
As a high school drop out and a drug lord your videos are helpful.
How common is Malignant Hyperthermia and how does it manifest itself during a surgery. Then what do you do as an anesthesiologist and how critical is it? Love your videos. It has given me lots of talking points for reference when I meet pre-operatively with an Anesthesiologist
Thanks for sharing your knowledge and intelligence with us max!! I'll be starting an Anasthesiology Tech degree path in the fall. My short term/6 yr plan is to become a CAA. I would love to shadow you in the O.R. some day soon.
Definitely is going to help me during my rotations in CRNA school
During a tonsillectomy my daughter had a reaction to Anectine. That was 45 years ago and she still has anxiety because she remembers being awake but paralyzed.
I’ve always done the ‘poke through the paper’ technique in my lab. And I teach it to everyone. They think I’m genius, I thank the cell biologist who taught me that during my masters year
Max so easy to listen to and learn from
Good vid. Off topic question: My X had a situation where paralytic took effect but he felt the entire surgery. My question is this: this procedure was at a world renowned medical center that is a teaching hospital. Is it ever possible that the doc in charge - you - leaves the room so that only a junior level resident is administering and does it incorrectly? I know there are times anesthesia just failsl - but more wondering the safety checks on physicians not correctly monitoring things in a teaching situation.
Great work
A big thank you to all anesthesiologists, have had 4 major surgeries and each time I go ‘out’ and wake up it feels like seconds. Prior to surgery the anesthesiologist would come in talk calmly to me about what’s going to happen on their end and ask me if I have any questions and I’m good to go.
Thank you, I use hypodermic needles to refill computer printer cartridges and the ink comes in vials with rubber tops just like the drugs. Never knew about injecting air into the bottle. The needles and syringes are OTC and legal to possess here in Thailand.
In the beginning he shows an operating room with a bright red garbage can. Are the things that go in that can the things I 'm thinking of?
Great video Max.
A few comments if I may. Some excellent tips.
But just 2 infection control tips…
1. don’t ‘pop’ the packets open at the ‘critical’ end of the syringe or needle thus possibly introducing infective agents into those ‘critical’ areas. Pop the non critical ends to get the syringe or needle out quickly.
2. Tops of vials should be swabbed with an alcohol swab and allowed to dry before accessing with a needle. Those tops are not sterile under those caps. This is especially important if accessing propofol via a sealed topped vial. Propofol is an excellent medium for growth of infective agents. We had a few cases of patients getting pseudomonas blood infections that was found to be from the tops of vials of propofol not being swabbed before accessing, as staff presumed the tops were sterile under the covers you pop off.
Love your videos 🙏 having surgery on December 23 👌 from! Y'all have a Merry Christmas
thank you very much for this show!!
Great video, and REALLY great cap! Where did you find that? Thanks for all your great videos, man.
Thanks Stephen! The cap is from a company called TACK, I love their products.
Love your channel, I was always fascinated about your trade but don't have the intelligence or money to do it. Thanks for a peak into this world
Great explanation, helps us understand a scary time!
Great video! You should have included the part where you disinfect the vial after removing the cap with a isopropyl alcohol swab or the like :)
This is not common practice in the OR. If the cap removed from a vial without contaminating the top, then there is no need to sterilize anything.
@@MaxFeinsteinMD I guess our OR practice differs then. From the pharmacy where I work and from the infection controll unit we are mandated to do it because we can't be certain that we did not contaminate the top, or that it's not contaminated before arriving at the OR (not all caps are air-tight). It's just a precaution, f.ex. when one considers how good of a growth medium the lipid solution in Propofol is!
@@Veritias while different places have different policies, this is what I’ve been taught/practice too. Most of the time the caps are really just serving as “dust caps” to keep the vial top “clean”, but it’s not actually sterile - hence the need to clean with alcohol. I really wish the FDA or NIH or whoever would do a study to establish a national standard policy, instead of the current mixed practices.
@@MaxFeinsteinMD just from a friendly hospital pharmacist - The 2015 ISMP safe practice guidelines for adult IV medications states that many practitioners may be unaware that the caps function as a dust cover and are not designed or intended to maintain sterility of the vial diaphragm or access point - thus necessitating cleaning of the critical site. Just something to think about. Of course in some instances, where the medication is given immediately in an urgent situation, the amount of bacterial growth that can happen is negligible. Very interesting video
Thank you for the tips on opening the syringe, I've been having a hard time doing it quickly while assisting the anesthesia team as a med student 😅
Love your videos, great info. Keep going!👍
As a paramedic in a busy system I draw drug very often and we do rsi in the field.
Ever thought about having the cap color the same as the needle sheath? Just a thought
I also open my syringes and
needles that way (so much faster!), but you have to keep in mind that you are actually breaking the sterility by doing so. And at least theoretically there is a risk of contamination of the luer-part of the needle from any debris on the outside of the package. Probably not a real risk in most situations, but if drawing medications for storage or for sensitive uses I will open the needle package correctly.
Very useful! Thank you
This was very interesting to see. Most of us wouldn’t ever see this but thanks to TH-cam we can. How fast would a paralytic if someone accidentally poked themselves go into effect? Or would it not really do anything? I get tb tests for work and one nurse broke off the needle 💉 in my arm. She had the syringe in her hand while the needle was stuck in my arm. She said I had tough skin and that’s why it broke off. I was like what in the world? Thanks for the video Doc! 🏥
This is a really interesting question. There was a study in Korea that showed subcutaneous injection of succinylcholine at 1mg/kg will produce full paralyzing effects, but onset of paralytic took 7min instead of 1min or less. However, that means you have to inject almost an entire 5cc syringe depending on weight of the person.
If you stab yourself, its likely 1cc or less, or maybe even a drop. The ED50 of succinylcholine is 0.14mg/kg, which is 0.5cc. If you were using a 10cc syringe, it is absolutely possible you could have injected close to that amount into subcutaneous tissue.
You would definitely need another anesthesia provider to take over your case, and you need to be closely monitored with direct medical care immediately to protect your airway and provide ventilation ASAP. You would need an other anesthesia provider to start watching you within minutes, as you would likely never make it to the ER if you actually had an effective dose of SQ succinylcholine.
As someone not it medical school or the hospital workforce this video slaps 🔥🔥🔥
Thanks Dr. The videos you make are right on the spot.
Best Regards!
Quick Question, Can you Do a video on inhalatory anesthetics??
Hello from Uganda, you have very interesting videos.
What about replacing the blunt needle with the injection needle? When do you do that?
These are all injected through IV ports, so no needles needed.
I've had 5 major surgeries plus many procedures requiring some sort of anesthesia. I will admit, I kind of secretly get a crush on my anesthesiologists. If it's a male , of course . I think it's because they basically have my life in their hands. I get kind of awestruck because of the work they do. And I admire the work they do
Interestingly, I learned how to open the syringes and needles like that while I worked in the lab and not in nursing school.
This would be a good video for insulin-dependent diabetics. I remember when my daughter was 5 and developed Type 1 diabetes. As a parent of a Type 1 kid, we struggled with this.
Great video! You should do a video on inhalational anesthetics
I actually poked myself with a needle when as a child by curiosity I removed a cap, and then tried to put it back on. Since then I am afraid of needles, but at least I can manage the fear by being careful with needles. I learned to but back the cap the way you showed already as a kid and do that way every time I have to inject medication to my animals. No paralytics or opioids though :)
Med student here !!! I LOVE your videos as well and your OR head cap - where did you get it??
I just subscribed you. Thank you so much for making these videos
When do you check the expiration date of the drugs to be drawn up?
Popping caps always makes me think of the title sequence of EMERGENCY! With popping the bi-carb amp caps.
Thanks for educating everyone, including the "general population"... nice head covering by the way! Did Kobe chose it for you this time too? :)
Ha ha no, I picked this one out all by myself because this hat seemed like the obvious choice for this video 😂
@@MaxFeinsteinMD it was indeed. Thanks for taking the time to answer and chag sameach for the upcomming days...
I always feel like this is a dumb question, but this seems like the most appropriate video to ask on.
Is there no concern about contamination with pulling the rooms air into the syringe, then bubbling it through the medication to pressurise the vial.
Even at the research lab I used to work in where the air was replaced with clean air 10-12 times a minute we still had some issues with contamination in cultures and such. Where I shadowed a surgeon, he said the air was replaced about 5 times a minute.
Great question, I’ve never thought of that. I’ve never heard anybody bringing this up as a concern, even in environments where patients are particularly susceptible to infection, for example immuno suppressed transplant patients. I’ll look into it
The operating room air is changed 20 times an hour. Also, the surgical equipment sit out in room air often for hours. If this was such a concern, there would be even more surgical infractions.
As you can see by the other replies the OR air is changed often. Also at least where I work it's a hyperbar airflow pushing air from the OR out the doors if they are open, avoiding air from the doors to flow in.
@@MaxFeinsteinMD where I work drawing up air first is 'forbidden' (especially in high infection risk agents like propofol).
Not because of the air going in, but because when you pull the syringe, you touch (and possibly contaminate) the plunger with your hands, which you then insert back into the syringe.
For vials with a rubber membrane, we use a second needle to let air into the vial to avoid having to let the plunger pass the inside of the syringe multiple times.
There are some really interesting studies on this topic (plunger-syringe contamination).
I've heard this argument before and thought Dr. F. Would not draw up the air first. I suspect many of these habits are more legendary than real.
I love your surgical cap… where did you got it? Awesome tips btw
Thanks! It’s from a company called Tack.
Hi thankyou for your interesting, informative post.
I wondered how anesthetic is given to emergency patients who have already eaten ?
Hope I'm not wasting your time, just curious to know the procedure.
Hi! In case of an emergency patient that's not fasting, has bowel obstruction, reflux-syndrome, severe pain etc. it's common practice to do a rapid sequence induction. We give Natriumcitrate 30ml to neutralize the stomach acid. Then we preoxygenate the patient until expired O2 of around 90%. You do not ventilate these kind of patients, as air going into the stomach increases the risk of aspiration. Then you give medication in rapid succession, depending on the patient. As opioid you usually use a rapid-effect-opioid like Alfentanil or Fentanyl. Then you give Propofol or any other sedativa like Thiopental or Etomidate. Then give a muscle relaxant. Before it was common to use Succinylcholine, but in my practice it's more common to use Roccuronium. The advantage Succinylcholine is the rapid onset, and patient is ready to intubate after fasciculations. In Roccuronium you're just a few seconds slower. There are many reasons to choose one over the other, so it will be up to the anesteshiologist to choose. Succhinylcholine is prone to malignant hyperthermia, allergies and arythmias if patient has a high K+ as it releases a large dose of K from intracellular to extracellular. Roccuronium can be reversed with Sugammadex which is considered expensive, but has fewer side-effects than Succhinylcholine.
After the musclerelaxant is working we intubate the patient, usually with a mandreng inserted to make the tube have a more correct angle.
In some patients it's common to put a tube down into their stomachs ahead of anesthesia and drain their stomach contents. Or you can awake-intubate with a flexible scope if you are afraid of losing the airway because the patients airway is that difficult.
with greater risk and difficulty 😅 the anesthetic drugs aren't the greatest problem with sedating patients who have eaten it's when the food decided it doesn't want to chill there anymore 👀🤮
Yes l thought as much ! !
Thankyou.
I know I'm late to the conversation, but I've seen nasogastric tubes used to clear out as much as possible from the stomach depending on the urgency of getting to the OR.
3:01 in the background the orange label is glowing..... neonorange... you can not overlook this color.....
3:39 you should open the needle and syringe in the first way because if you open the package like in the second way you can contaminate the syringe because the sterile item can touch the unsteril outside of the package....
Good for novices, for sure. I suggest you use "milliliters" (mL) not "cc," which the Joint Commission banned for the risk of medical error when it was written in a chart. ("cc" written quickly can look like the "u" in units). Now with electronic orders, mL is the standard, but using the safe jargon, especially for nurses who are the ones drawing up and administering 99% of meds outside the OR, it's an important point.
Dr Feinstein is the color code for the medications international? Specific per hospital ? Per country ?
My understanding is that you must still scrub the rubber top of the vial prior to needle insertion even after a fresh cap removal
A couple of pointers:
-You should alcohol swab the top of the rubber stopper before putting the blunt needle in the vial. Those are just dust caps that you flick off; it's not sterile under the dust cap. There are studies you can look up regarding this..
-You should try not to label the syringe prior to putting the medication in the syringe. Medication goes in the syringe, label goes on.
-Opening the packages like you do saves time, but can contaminate the top of the syringe and the opening of the needle. The outside of the wrapper/package isn't sterile; this brushes against the top of the syringe as you open it like you to to 'save time'.
Can you do a series on Ketamine, while not new it seems to be used more and more in the OR