I saw a potential aspiration hazard in the OR today. How many times a day do we routinely peel plastic wrappers off of airway equipment? If I’m at the surgicenter, I might need 7 face masks, a variety of LMAs and endotracheal tubes and an oral airway or two.

Take a look at the typical plastic wrapped mask here in this photo. We unwrap these sorts of objects dozens of times a day.

Typical plastic wrapped disposable mask.

Here is the same mask unwrapped. Do you see the hazard I found?

Same unwrapped mask with an almost invisible aspiration hazard inside.

Here it is, a tiny piece of torn plastic that was stuck to the inside of the mask. It’s almost invisible unless you look for it.

Aspiration hazard: a bit of plastic wrap stuck inside the mask

Look back at the wrapped mask. Do you see it now?

Arrow points at aspiration hazard inside the mask

Aspirating something like this could have serious consequences. In anesthesia, or any field of medicine, the devil is in the details. You cannot be too compulsive about safety. Check and recheck everything. Every little bit counts.

May The Force Be With You

Christine Whitten MD