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Hey, everyone. It's uh Doctor G. It's 4 O2. Welcome. Um Make yourselves at home uh at 404. We'll go ahead and start. So for the time being just come on in and relax. All right, everyone. It is 404, Jan. Are you ready? All righty. How many are we up to at the moment? 15 but trickling in 15, but we got Deborah and Abdul RR Man. So we're going to go to Deborah. Are you in the States or are you in South America? Deborah, can you hear me? Yes. OK. Got it. Thank you, Deborah. And um uh got it. Oh, you can't see me. Oh, let me turn on the camera. Sorry. Boom, Deborah. Can you see me now? Let me know if you guys can see me. Sorry for that. Um Janie, can you see me? Yes, perfect. All right. So let's go ahead and um we can perfect Abdulrahman. Where are you coming from? Remind me again. Where are you at the moment? Still in Jersey? Great faith. Good to see you. Faith. Oh You're getting so much, Doctor G time today. All right. So today we're gonna go over um building up. So for those who um if this is your first time, please go back and review some of the lectures, Deanie, is there one that we've labeled like entered like, like, like there is a um a document called like introduction or review document and there's also a video labeled the same. So you guys should definitely take a look at that if it's your first. Perfect. The other thing to say um if you have a moment, watch last time's video. Uh So we've only done two videos in 2024. Watch the first one cause the first one we talked about an anomaly in the pleural space today, we're gonna build off of that a little bit uh different pers. Um So a little bit of a different intervention, I'll lean that all home and near the end of the class. Um But uh so for those of you who, it's your first time to sit back and relax and enjoy this with us. Um For those of you who have come before, great. It should be a lot of fun uh to review these slides and I am going to call Deborah and a uh Abdulrahman. Do you guys, do you two wanna come to the stage and uh read a chest X ray with me? Do you need, do you want, do you want to go ahead and invite them? Hopefully they'll accept? Yeah, sounds good. Uh And they both said. Yes, perfect. All right, let's invite him to the stage. You guys will read the first x-ray, I'll read the second and the third, but let's do it together. Ok, Deborah, how are you? My friend. I'm good. How about you? All right. And while we're waiting for Abdul Rahman to join us, Deborah, put on, on the spot. Do you mind to sharing with the group? How many of these, uh you can have a ballpark? Like maybe I've done a dozen. But how many uh have you been here and tell the group if you feel comfortable reading a chest X ray? OK. I have been here one year and a half. I have feeling more comfortable. But of course, if doctor, you would feel more comfortable than in medical school or in the hospital. Excellent. Thank you, my friend and Abd Rahman. My, you've been here since uh what for like six months? Is that something? Is that actually I've been here before we switched to me as well? All right. II wasn't as active and then I talked a little bit more and then recently I've been throwing up. Yeah, this is great. And same question to you. Do you feel like, hey, you're, you're getting a little bit more comfortable with this 100%. In fact, I went to like uh the hack and sack internship and there was a radiologist there as well. So when I saw, he saw like some chest x-rays. And I was like, I remember doctor G taught me this, I got this. So for those of you who, it's your first time, the intention with the shadowing is for you guys to walk away with the ability to feel confident that you could probably point something out on the chest X ray cause I want you guys to do the same thing that Deborah and Abdul Raman just said, hey, if you're around other people, you can kind of wow them a little bit. That's it. I want, I want you guys to wow other human beings because you know this uh already from a background. So that's the goal of this. We'll talk about some science and physiology and all that jazz. So Deborah and Abdulrahman, I'm gonna call you guys out on different parts to read an X ray. But the first thing I'm gonna ask you guys, when I pull up the slides after a while, after a while of doing this, every physician gets the immediate instinct when they see some uh you see an x-ray that blows up in their mind normal or not normal. That's when you know you've seen a ton. That's when you know you've gone through thousands of x-rays where instinctively you see it and you're like, oh there's something abnormal there. But even if there's an abnormal thing, I told you guys, you still stay diligent, right? It's like get grabbing a book. Hey, it look cool. It looks like a cool book, but you're still gonna read it. Page one to the, the last page, not skipping over everything. So you're diligent with it. And so, and thorough. Same thing here. So, the first thing I'm gonna ask you, I want your instinct to kick in. I'll call in Abdul Rahman first and I'll have to see if Deborah agrees. Do you guys think this is normal or abnormal? Don't tell me what's abnormal about it? Just tell me what your spider senses say. That's the goal of a great physician over time. You've seen enough normal from physical exam to data to know what is abnormal. Once you know something's abnormal, then you begin chasing it down. Right? That's what we do as doctors, we've come through millions of cases of normal and when something deviates from that, that's what sets us off. Like something's not right. That clinical intuition is what we're trying to sharpen here with an X ray. All right, with that in mind. Let me go ahead and share the screen. So I'll, I'll lean with the teaching lessons at the end about how this ties in from the last case as well. All right. Share my screen now. It's a matter of finding. All right. I think this is it Abdulrahman. Can you see this? Yep. I can I, what's your spider sense is telling you the first instinct, normal or not normal, not normal, not normal, Deborah normal or not normal, not normal. All right, perfect. So let's go through this to try to understand what is not normal about this. All right. So as I said, we're always diligent. So the first thing we're gonna do is make sure the technician took the patient and appropriately positioned them. So they are not rotated. And for those of you who are new here, the way we do that is if you take your left hand, it could be your right hand if you don't have a left hand and just feel the back of your neck when you are saying, oh yeah, I'm feeling my spine that's called a spinal process. And this is what it looks like on an X ray. If the patient's perfectly positioned, it should almost look like a tear drop. So Deborah does the patient rotated or not rotated. We, we can't see the x-ray anymore. Oh You can't see the x-ray anymore. Oh, goodness, that was not intentional. That was not like a dramatic effect. All right. Uh Share my screen. All right. Let me go back here. Why is he not letting me hold on? All right. Wait, hold on. Technical difficulties have been driving me crazy. So if you need, I can also pull it up and share it if you can't get it to work on your, I appreciate you, Deanie. That's why you're here. You're my backup. Let me see if this. All right. Can you see it now? Yes. All right, perfect. I know what, what happened. I hit, I hit high. OK. Can you still see it? Can you still see it? Yes. Yes. Uh Deborah. All right. Let me ask you, my friend is the patient rotated or not rotated as I draw out the spinal snot, not rotating. Good. All right. Next, we're gonna look. So when we look at a chest X ray, there are two anatomical spaces. We are gonna look at that before we ever get into the lungs. We're gonna look at the mediastinum and we're gonna look at the pleural space. The mediastinum is the space between the right and left lung. That space is very important for living. That's where your trachea, your windpipe ends. That's where the aorta does its nice little arch in order to send blood to the rest of the body. That's where the esophagus goes by. And it's also where mm the heart is, right? The second most important organ of the body. There's other things, the lymphatic system is there. The thymus is there, create, it's good space to kind of know if the mediastinum is normal, right? Or somewhat. I would call it different unremarkable. We find an anatomical landmark called the carina to see the crna. Well, because there's air in it and that's gonna mean there's gonna be a play on white and gray shadows to see it. Well, you lean back when you lean back, you begin to see the Crna pretty darn well as it comes into light and I'm drawing that out for everyone here, especially if you're new. So, the carina again, I'm gonna put ac right here. It's where the trachea bifurcates into the right bronchi, right airway and left bronchi, left airway. All right. So when I find the Crna, I'm looking for two things, I'm looking to see if it falls within the boundaries of the vertebrae of the spine. If it does that, then I will make the case. Hey, doesn't it? It's probably there's nothing in it that's shifting it around or, or the lungs aren't pushing it around. So with that in mind, hold on, let me just make sure I drew the boundaries appropriate. And the last thing that I'll look at is is the Crna plate spl is our fancy term for saying is it is the angle of the Crna less than 90 degrees a an acute angle that's normal. A splayed. Crna means it's more of an obtuse angle, more than 90 degrees. And that means something is either under it or pushing. All right, with that in mind, Abdulrahman, what do you think is the cry of where kinda I drew these boundaries? Does it look like it's somewhat staying in the center or what it, what's your first impression? I think it's like slightly shifted towards the left lung. It's mostly in the center, but just one part of it is getting pulled in that direction. OK. And there's another way you can tell something's happening because of the angle it's splayed. Would you not agree to that? Yeah, it's pretty. It looks produce. Yeah. All right, perfect. So you're telling me, hey, something's up with the media. ST I'm right off the bat. Love it. Good. And by the way, for our new beginners, our radiologists think the rest of the doctors are not that smart. So the l if you're wondering what it stands for, stands for left. All right, perfect. We got the Mediastinum. So if I read this, I'd say as Deb said, the patient is not rotated. So now there's no confounding in regards to the positioning of the patient. Let me dive into the x-ray. I have located the cr up. I agree with Abdulrahman seems somewhat shifted, leaning more towards uh favoring the left side and it, the uh cri appears to be splayed. When you say splayed, it implies as a to angle. The other way of interpreting that is if it's not splayed, you say that the cry uh appears to be in the center, not shifted and it does not appear to be splayed. That's it. That's the entire medias. Next, we're gonna talk about the pleural space. The pleural space is the space between the left uh between the lungs and the chest wall. Every mammal has a pleural space except one mammal and I think I discussed it last time, but we'll discuss it again this time. That's the elephant. And I'll tell you why. At the end, again, in the pleural space for humans, there is some fluid, about 3 mL acting kind of a lubricant allowing the lungs to slide very nicely. With each deep breath that you take. Now, in the pleural space, you can get excess fluid from pneumonias, from heart failure, from cancers. And you can also get air, a pneumothorax and air producing bacteria or someone unfortunately stabbed the patient and air got in from the outside world to the inside. So, since fluids are rather dense, they'll be at the base the way you look for fluids. As you look to see if this costophrenic angle that I'm drawing is present. If it is present, there's no significant amount of fluid there. It should look like a vampire's fans. It's called a pasto for ribs. Phrenic for diaphragm angle. Deborah. Do you agree that there's two evident costophrenic angles on both sides? Yes, I agree. Perfect jab. Do you remember how much fluid you need in order 300 mL, 100? Love it. Oh, my friend. You were doing great good Deborah. You're, you're gonna be our pleural space individual since Abdulrahman did our mediastinum. Next, let's go to the apex, the apex of the lungs is the top portion, the apex of the lungs is up here. This is where I'm drawing the a it's right above the clavicle. Now, what I'm looking for here is, is there air, is, this air is not as dense and it'll go up. Let's look at the left side first, we're gonna look at the left side and decide if there's air, the way air will appear in the lung is a darker black, not as black as where I'm drawing this circle here. Right? That's pitch black, right? Because it's air inside the body still, it's just not inside the lungs. So it might come across a little bit more grayish but air that's not outside the lungs that's in the lungs should show lungs where the markings go up and it's relatively a grayish white. Do you agree, Deborah, that there's no air in the apex of the left lung? Yes, I agree. Deborah. Yes, I agree. Yeah. Oh, no, no, I know. Yeah. Sorry. So, my next question to you, my friend. What about the right lung? Do you think there's air there? I think. Yes. Yes. Perfect. Excellent. Next we now begin to tiptoe into the lungs. And the next part we will look at is the hyaline. The high LM I can tell you is not evident in this x-ray. So we're not gonna go through it. The hilum in a normal x-ray will be present on the right side. It kinda looks like a nice kidney binging shaped like this. And on the left side it just pops out over the left atrium. The high LM is where the lymph nodes, the airways and the blood vessels all first begin and then they take off into the lungs, right? They, they spread out like this and they get more diffuse, et cetera, et cetera. They're not present. So I won't, have you read them? They're not present because we're gonna lean the case in a little bit of what this all represents. But next we're gonna talk, we're gonna actually now go back into the Mediastinum to look at the heart. Abdul Rahman tackling you to do the uh Mediastinum again with the heart. Are you right? All right. So when we evaluate the heart, there's only one comment we can say about the heart. Is it big or not big? That's it. A chest X ray will tell you if there's cardiomegaly, megaly implying big. The way you will flush that out is by two weeks, one does the apex of the heart, which is the left ventricle, that's the apex of the heart right here. Touch the chest wall. Now, Abdulrahman don't overthink this just answer my question. Does it look like this heart is about to touch or at least bordering the chest wall? Yep. Yeah, it does. So if you were my intern, you would say that you'd say, hey, there's no space between the left ventricle and the chest wall. But before you dive into saying there could be cardiomegaly, you will be reminded that earlier, you said that the mediastinum has shifted. So because the Mediastinum has shifted Abdulrahman that rule of thumb that I told you that space is out the window. You don't know it. Now, does that make sense? Yup. So what Abdul Rahman said earlier is that the Mediastinum something is shifting. It, the Kina is no longer at the center and because of that, everything like the heart gets shifted. So, in reality, for this heart, I can't really comment on cardiomegaly. Now, if you've come to this class before you have probably said, well, Doctor J, there's another way you've taught us and that's a two slope rule. That one still is alive and well, and I'll point it out right now. Poop. Poop. There you go. So here's the left atrium right here. And then that's the left ventricle. A two slope rule implies that the left atrium's pressure is not too excessive, which is normal. So I do recommend you appreciate the true slope rule. Yup, I appreciate it. It's a nice little. Yeah. Well, this part right here. This is all the hilum that's just being pushed with the heart. Does that make sense? Yup. Ok. Deborah. Yes, we're gonna read, we're gonna read the lungs. Now, we're finally getting into the lungs. Ok. Getting into the lungs means what doctor he always does is you zigzag within the lungs. Poop. Poop. We will zig zag and then we'll zigzag across that. What you're looking for is uniformity, the top of the lung and the bottom of the lung should relatively match the left lung and the right lung should look relatively the same. But Deborah, why let me erase? Sorry, Deborah. I'm not doing dramatic pauses for you. I'm so sorry, Deborah. While Dr G just said, hey, there should be uniformity you recognize and understand, um, that there should also be the, the markings within the lungs. These markings that you guys can see here. These markings, these are called interstitial markings. These are just the blood vessels. Yeah, maybe to some extent the lymphatics, that's these little lines, these little lines should be more prominent up until about the mid clavicle and should be a lot more prominent at the base. Why at the bases, Deborah, why, why are more blood vessels at the bottom parts of the lung? Um Gravity? Right. Ok. Right. Yeah. The same reason why the fluid uh pleural fusions, fluid in the pleural space happen at the bottom. So gravity pools a lot more of the blood to the bottom parts of the lungs. So with that in mind, when you read an X ray, you should see some markings somewhat come up to the top and all of them should at some point disappear by midway. Does that make sense? Yes, Deborah. Perfect. All right. So Deborah, let's go into the right part, the uh left lung first. Ok. Mhm. Do you appreciate some good lung markings up? Uh Do you appreciate lung markings for the most part. Yes. At the top. I do. Awesome. Let me ask you this though. Do you appreciate that? The lung markings? Actually, they're extending pretty far out. Not, they're past way past what Doctor ZG said? It should be the middle of the clavicle, right? This is the middle part of the clavicle. These lung markings are pretty prominent going past that. Would you not agree? Yes. Perfect. And Deborah, would you agree that the right lung has absolutely no lung markings? Yes. 00. All right. Excellent. Um Deborah and Abdulrahman, stay one. You guys did a fantastic job. This patient has a pneumothorax, pneumo implying air thorax, meaning there's air in the chest wall. Now, if I was reading this, Deborah and Abdulrahman, you guys did a fantastic job. What I would do, what I would say is, as you guys have been saying, um I always start out by pointing out the spinal processes they're located, they're identified, the patient does not appear to be rotated. Next. Let me go into the Mediastinum. I've identified the carina. It appears split and it appears to be shifted, favoring the left. Now, when I say shifted, there's one of two reasons a mediastinum is gonna be shifted to the left or the right, either something is pushing on it to go into the other side or that same side is pulling it. Does that make sense? Um Abdul Rahman and Deborah, if something shifted, you gotta make a decision is it shifted because something on the right side is pushing it into the left or something on the left side is pulling it in. Does that make sense? Deb and Abdulrahman, what does perfect. So all I can see right now is Mediastinum has shifted, favoring the left side and it appears to be displayed, um going into the pleural space, costophrenic angles are present bilaterally. However, the left lung apex, uh clear markings to the top, but on the right seems a lot more darker gray, implying that there's air. Next, I can't see the hilum. They are not evident in this x-ray. In regards to the heart, the left ventricle seems to be bordering the chest wall cavity, but I cannot imply that there's any level of cardiomegaly from that rule of thumb simply because there's a shift in the mediastinum. So it's gonna throw off that space. However, there's a two, the left atrium and the left ventricle seem to have two unique slopes implying that there isn't at least elevated pressures in the left atrium. Next. Uh I'm gonna go actually into the lung spaces. The left lung has lung markings that are pretty uniform from top to bottom. However, they seem to be extending all the way to the chest wall implying that there's increased interstitial markings. The right lung has absolutely no lung markings. Uh uh Actually the right lung is right here. This is the right lung guys right there. That's it, it is massively collapsed. Um Last thing for those of you who are new and you guys are wondering, whoa doctor G, I'm seeing these lines right here. What are they? These are EKG lines. These are for the telemetry in order to capture the cardiac rhythm of the patient, these are outside of the body. These are right in the chest. So this is a pneumothorax. Let me tell you about the case. This was a 24 year old who began to use cigarettes when he was about 16 and then uh began vaping about two years ago and he was in his room, took in a do deep Vape heard a pop and then couldn't breathe and gets rushed to the hospital. Uh Sure enough, they snap an X ray on him and he is his lu his right lung is completely down. Let me stop sharing for a second cause I wanna talk to you guys so you guys can see me. That's not what I'm looking for. Uh Hold on one second. Let me go here. Oh Let me go here, stop sharing for a second and let me go here. All right. So last time we were together, we talked about a pneumothorax as well. That patient you saw had a little bit of air right above the apex and you guys knew in our case conversation it happened right after I did a biopsy on his lung and a little bit of air escaped and the way we manage that, do you guys remember the way that patient was managed? I took oxygen, right? You and I Abdul Raman Deborah Danny, you and I as we breathe that air is composed of 21% oxygen. That's it for patients with that small of a pneumothorax that you guys saw in the prior case. And everyone here is like, oh, I gotta go watch that. Yes, please do. Um All we do for those patients is we give him a face mask and we ask them breathe it to 100% oxygen. So what that's gonna do is displace all the nitrogen that you're breathing in the air. The nitrogen has a higher partial pressure by removing it. You drop the pressure in the pleural space, allowing them the lung to expand, right? Greater pressures will expand against lower pressure systems. That's it. It does that when you have a pneumothorax that you're confident it is coming because of the air going into the lungs is escaping. It means something has injured the lung. There's a hole in the lung. I can't go grab a bandaid and fix that hole. That's not what we do. What you do is you try to get the lung to reexpand by one of two ways either the way I just said, if it's a small enough pneumothorax, if it's a small enough pneumothorax, you go ahead, give him 100% oxygen and you do yours. That what makes a small pneumothorax? X ray shows exactly what it, last time he did. It's a little bit of a sliver and the patient's doing fine. Actually, if I put a pulse oximeter on that patient, his SATS are fine. He's 100 per, he's satting at 100% oxygen, right? He's breathing is fine. He's like, look, I'm good. Can I just go home? Well, you guys making too big of a deal versus this patient? This is a large pneumothorax, right? The entire right side of the lung, you can't see any lung markings. He's des setting, right? I'm actually giving him here. If we go back to sharing the screen, I'm actually giving him oxygen just to maintain his saturations, right? He is not doing well. So this little uh calf, uh this kind of um coiling up here that's nasal cannula. Um And at the same time, the mediastinum is impacted, right? What we heard Abdulrahman say is the mediastinum has shifted. So right off the bat, this is concerning me because if I leave this go, if the medias dyn is shifted by a pneumothorax, what do you Deborah or Abdulrahman, what other organ now am I worried about being impacted? It's in that same space. Don't overthink this. It's the second most hard, hard. So why am I concerned about that is because this patient can form a tampon node? A what's called a tension pneumothorax, meaning the right lung will push against the heart so much, especially the right side of the heart. That's very weakened pressure, right? If you guys have ever gotten your BP taken, you know, that number, the Doppler report back is about 120 millimeters of mercury. Over 80 millimeters of mercury. That's the BP of the body, the BP of the heart, I'm sorry of the lungs is about 20 millimeters of mercury. Over 10 millimeters of mercury. It's a low pressure system. So the right side of the heart is very flimsy. So yeah, I'll, I'll send out some blood casually. So that right lung is, is comp like all cause all that air that's going into that space has nowhere to go. So it just sits there, pushing and pushing and pushing the lung and that eventually that lung will push against the right ventricle and the right atrium, stopping any blood from entering the right side of the heart and stopping any blood from leaving the right side of the heart. And that is called attention pneumothorax. That is a medical emergency. Or else this patient will die. The patient that we have here, this 24 year old is not there yet, but the fact the media is standing on him has shifted, he is going to get there. So we got to act. So what do I do? What do I do to help this patient not die? So I stab him in the back. Sounds cruel. I know. But I promise you there is a method to this madness. This is what I do. Let me take that away. Let me get back to the pen. Let me go. Abdul Rahman. What do you notice now is in the chest. This nice little curved tube. It's a nice little curve to Deborah. What animal, what animal, what mammal has a tail but it's currently don't overthink this. It's on a farm. You eat it too. Well, we may eat it. Many people do eat it. What mammal that lives on a farm has a curly tail. I don't know. You get bacon from it. A pig. You get a, did you say pig? Yes. Yes. So this catheter is called a pigtail catheter for that very reason because it coils. Does that make sense? Yes. Look us lung doctors. We are not good at anything. Someone saw this catheter. I kid you not. And it's like, hey, it curls like a pig's tail. Pigtail catheter. So Deborah stick to you. Do you also appreciate that? All right. Look, let's go back to this slide. Look at this space right here. It's nice and white and bright. That's soft tissue. That's skin muscle, maybe a little bit of fat here. Do you appreciate that? There's a little bit of air there now? Yes. Yeah. So what we do is I take a needle. It's about 14 to 15 inches long and I stabbed the patient in the back. Right. And with that needle, I go into the space. Oh my gosh. Once I like, take off the syringe, you feel the air blowing out. Now, actually you can see even some air going up to the space a little bit here. Once I have that needle in, then I drop a wire and that wire coils up like this. It's a very long wire. Then I take the needle out and then I slide the pigtail catheter in and I remove the wire and I leave the pigtail catheter there. When I leave the pigtail catheter, II attach it to a kind of a device that allows the air to flow out and flow out and flow out. So this patient got a pigtail catheter but Deborah did the lung. Don't overthink this did the lung reinflate. Is it back up? Is the entire lung back up? Yes, we know the entire Yes. No, it's not. You're right. You can say, well, look, it got a little bit bigger, right? It got a little bit bigger here. It is compared to this. Yes. By the way, guys, the reason why the left side's interstitial markings are more prominent ra because the left lung is getting squished a little bit because the right lung is really pushing it. And b all the blood flow now is going to the left side of the lung. The the lungs are really smart. The lungs know I can't oxygenate the right lung anymore. So these lung markings are a you appropriate compensation for this patient. That's why you're seeing them more prominent. Anyway, this patient's right lung is not coming up. We place a chest tube, it's not coming up. He's still deat So this is now where I call my thoracic surgeons. And I asked them to do a talc procedure in this picture of the same patient caught, you know, the spinal processes are normal. So patients not rotated, you see the costophrenic angles here? Oh, why is this not drawing? Yeah. And here. So no fluid in the pleural space you can actually see now the hilum right here. You can see the other hilum here. Perfect. You can see his heart. Hey, Abdulrahman, how normal does his heart look? Right? Great. Yeah, for 24 this is normal heart. You can see a little bit more, less marking up. Oh, would you say Deborah? No, after how long time you called the thoracic surgery? Oh I, if I place a chest tube and it doesn't come up within moments. II will say this. I place a chest tube, I see air coming out of it. I get an x-ray within 15 minutes. If the lung is not up, I'm calling thoracic surgery. I'm gonna repeat an x-ray in an hour. But I know my thoracic surgical colleagues, I need them to be involved sooner than later because if the lung is still not coming up, it's gonna pose a potential still threat to the patient. Not from a death perspective, but it's gonna pose a concern that this patient, I gotta figure out a more permanent way of him getting home. So, if I place a chest too and it snap an x-ray in 15 minutes and he is not reinflating. I'm calling thoracic surgery. Does that make sense? Yes, Deborah. Yes. So, my thoracic surgeons did here is they made, ok. They're so good. You can't even see it. They made some incision at one of the rib spaces. They put a camera in and they made another incision, uh another rib space and they put a device in that sprayed the patient with TALC essentially baby powder. I don't know if who's ever held baby powder before, but you know, I'm gonna stop sharing. But you know, if you've held baby powder before, if it gets wet, it gets very sticky. That's what they did. They just sprayed the entire chest wall with talc. The patient is in surgery right now, right? So the sur the anesthesiologists are blowing just enough air into the lung to help with the inflation. Some of it is coming still out and as it does that it's gonna stick, stick, stick, stick, um to the chalk. So that's what happens to this patient. This patient essentially has pleural space. Some of it, not all of it has become like an elephant. Elephants don't have that pleural space, the entire space of an elephant's pleural space is all connective tissue. The re did I go over Debbra and Abdulrahman last time? Why that is for the elephant getting a know good. The re the reason why elephants are the only mammals that don't have a pleural space. It because they, they're only in animals that in their living moment experience two unique atmospheric pressures at the same time. It's because elephants were the only animals that can actually snorkel. We can, but we don't go that far deep, right? We stay a little bit superficial. We got maybe like six inches out out of the water. Elephants with their trunk can go about 10 ft deep. So meaning the water pressure around that lung space is going to at some point be up against the atmospheric pressure that their trunk is breeding in. And those pressure differences, if the elephant had a normal, I had not had a pleural space like us, their lungs would collapse with each breath that they take, right? Because the atmosphere pressure will um the pressure of the water will crush the atmospheric pressure. It just brought in pressure differences. Remember, high pressure systems will crush low pressure systems so it can take a deep breath. And the fact that it's lungs are glued to the chest wall that never happens to an elephant. It's good to go for humans doing this procedure. I can tell you to this 24 year old is not done easily. So, while I call my friends, Deborah, the reason why I call my thoracic friends is because I got to convince them this is the right move and it's the only move. The first thing they're gonna ask me and this whether we relate to this 24 year old they are. Do you have any medical conditions? Turns out he was somewhat of a premature baby. So when we got a CT Scan, there's parts of his lungs that aren't like at 100% because he was born premature. Why we do this? Why we got dive into a very thorough conversation with this patient about his lungs is because if he identified a disease, like say Abdulrahman say you were talking to this patient, his lungs are collapsed, az cystic fibrosis. This patient has cystic fibrosis, Deborah and Abdulrahman. He will never get that t procedure. That patient will likely sit in my hospital for probably 6 to 8 weeks, two months of his or her life waiting for the lungs to slowly reinflate. It is snail's pace. I've seen those patients. It sucks and it's really hard to entertain them. Why do you think? And if you don't know, just say, look, doctor just answered the question, I'm gonna, you know what I'm gonna answer the question. But I want you to think why I can't do that procedure to a patient with cystic fibrosis. The answer is these are patients that may need lung transplants. At some point. If you ever need a lung transplant, I better be able to grab those lungs, pull them out really easily. If I've glued them to the chest wall, I can't pull them out, they're stuck permanently there. Does that make sense? So, when my thoracic surgeons come and I wanna tell them, I wanna do a top procedure on a patient. The first question is, is this a patient who has any underlying lung condition that you, you may need to consider lung transplantation on because the second I talk him or her, that lungs out of the question of ever getting transplanted. And there are some diseases that you can do just fine, which is a one lung transplant. CO PD is one of them interstitial lung uh diseases or another. Meaning I can t that lung and I can get him a new lung on the other side. If I need to cystic fibrosis is not one of them, no diseases that have excessive issues with infections, they need bilateral. Because if that lung gets infected, all those germs are gonna go into the new lung and it's gonna waste it. So this kid is 24. When that is all the challenge I got over the next 90 minutes. Once my thoracic surgical colleagues, they came to look, look, start setting up the or we can cancel it very easily, but you got to do your homework. And convince us this patient will never need a lung transplant. So I'm talking to him, I get act scan. I'm like, all right. He told me he was a preemie. I can make sense. Things are like that. And I dive in, I'm like, look, how are you like any breathing issues? He's like, no, I've never seen doctors. I've seen pediatricians. I have to make sure that his premature lungs won't result in him. And as an adult ever needing a new set of lungs and I have to make those decisions in 90 minutes. Felt pretty confident he's my patient. Now, I see him. He's a good guy. Um, but that's the case. You guys have seen two types of pneumo thoracis one earlier and for those who didn't see it, please watch and the way it was small, it's a nice little sliver. It's cool to catch the way we treat that 100% oxygen reinflates. Not because it got healed, but because we can kinda knock out the nitrogen, drop, the pleural pressure even more, allow the lung to expand. And once it does that, it kind of like starts connecting again. This one, we place a chest tube depending on the patient, depending on the circumstance. That's probably enough lung reexperience and they're usually in the hospital for about 3 to 4 days until their lung heals for patients. That, that, that doesn't happen immediately. Like Deborah has amazing question. That's what my interns ask, hey, when am I calling thoracic surgery? You're calling them the second that lung doesn't re expand chest tube should be enough to re expand the lung. By the way, last thing, I'll tell you guys and then we'll close off if this converted into attention pneumothorax. The way we know that is I take his BP and it's low. It's like 90/60. Then it's like, cause what ends up happening in attention. Pneumothorax, the top number and the bottom number begin to equal 50/50 plus. The patient's also like unconscious at some point cause blood's not flowing. How I fix that is one of the coolest things. I think it's cool and I've done that several. I've done that probably about 10 times in my career. The most memorable time is I did it in the hospital's elevator because we were in that moment of an emergency. So you take a needle about an 18 gauge, a little bit big in the hole. You find the second the, you know what you do is you go under the clavicle and above the nipple line probably halfway and you stab the patient right there and you unscrew it and you just watch the air flow out because that's what's causing the tension. It's air just pushing. Once you got it to flow out, life is good. Not that the lung may re expand, but that air is no longer causing attention pneumothorax in that patient. I've done that moments later, the patient wakes up the, the elevator scene was by far one of the craziest things that even was remotely relatable to like a Grey's anatomy episode. The nurse gives it to me. I stab and she's like, but I thought that was cool. And today that's still my only time I've ever done that. The nurse is like, this is like the fourth or fifth time I had to do a attention pneumothorax and an elevator to which I said your bad luck never getting in an elevator with you. But it's by far one of the uh most rewarding fast imme uh immediate things you can do to save a patient's life. So we'll stop there. Our next session. Dne will happen the our next two sessions, one on Valentine's day also at four inperson meeting also at four o'clock and uh February 14th Valentine's day four o'clock and then February 28th also at actually February 28th. Yeah, we'll do it at four o'clock. OK. Sounds good. I'll add those events soon too. So you guys should be able to see it on the M GG um site of metal. Awesome guys. Thank you so much Abdul Rahman and Deborah. Did you guys have fun or was this a fun kid? Yeah, it was, it was pretty fun. All right. And if I can ever get you guys in person shadowing me, especially if I'm in the ICU if we ever get a chest tube to place, it's fun to watch it. What I love about it is like, every patient like this guy was like, oh man, I'm tough. Then I showed them the needle and he like, somehow became unconscious to which I was like, oh my gosh, did you get any attention? You know, he was just stressed. So everyone faints when they see the size of the needle. It's pretty, it's pretty interesting. Are good people. You guys are awesome. Go and enjoy yourselves and go be amazing. Human. Everyone take care that you.