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Thank you. Hey, everyone. Happy 2024. Uh to those who are joining us today, uh Hopefully you guys are all doing well. Um This is uh uh Panicky Scio, I'm a physician uh at Johns Hopkins, a lung and critical care doctor. Um If this is your first time joining us by all means, please watch the prior videos. Um We tend to just continue diving in uh to the lessons on how to read a chest X ray. Um If you've come here before then today, we're gonna invite people to the stage and hopefully you'll be brave enough to join us. Remember you're amongst friends here. There's no wrong answers just come in and uh we'll have fun together. Um So from that standpoint, um it looks like many of you have already been here before. Um drop your uh drop a quick Happy New Year into the chat box just so I can see a few of the names of people here at the moment. Oh, maybe if I had people. Oh, good. I just figured out how to maneuver this. This is fantastic, Deborah. Good to see you. Oh, good. Oh, this is great. And thank you guys for accommodating. We switched the times for an hour earlier uh today than what we've usually done. But um yeah, just trying to accommodate my schedule. Uh I was just telling, uh de and we'll be back end of January. We'll try to hold two of these a month. Um And uh thank you, Aila all the way from the UK. Thank you. Um Yeah, I think this time works really well for a lot of our international friends, but the next one will be on the 31st, the time to be decided. So with that in mind, we have a fun case today. I think it's fun. It's lungs, chest, X rays. Does anyone any brave soul wanna read an X the x-ray with me? And we're gonna talk about that case a little bit. So I'm not gonna tell you anything about the case. We're just gonna dive in and read the x-ray. Anyone want to join us on stage? I'm looking for one or two volunteers, you know, and if you want to just drop in the chat by saying I, I'll jump on. No. Again, you're with family, your friends. We my call my, my friend Debor. Debor. Do you wanna, do you wanna give it a go? So, and I have the card that I need to pay for it. Yes, a few more minutes or seconds. Yes. All right, Deborah. We got Deborah and Abdullah. All right, Deanie will stop with them too. Invite Deborah and Abdullah to the state. So of those, let me know if that's if you're ok. Yes, I just invited both of you to the stage. Perfect. I'll wait for them to pop up as we wait for those of you who have done x-ray readings with me before you understand that I go through kind of a, a systematic approach towards this. I go, I read a chest X ray like I would read a book, right? You start with page one and you move on. You realize the book has a lot to offer, but you go through it systematically. So you can take it all in same thing with reading an X ray. It's a lot of information. Hi, Deborah, it's a lot of information. So to not overwhelm yourselves, you dive into this systematically. I'm gonna help Abdullah and Deborah go through this x-ray reading and then talk about why you think this case is awesome with that in mind. How are we x-rays is first? I just make sure the patient is well positioned. We identify that with the spinal process, right? That piece of the vertebrae that sticks out, making sure it looks nice and tear shaped if it does that. And then you can make the comment, the patient isn't rotated next, you dive into the mediastinum, you identify the cri making sure it's not shifted and you make sure it's not splayed. So it's an acute angle where the right and left bronchi split, meaning nothing, pathological is happening to the media. It's not shifted and there isn't a mass underneath that's pushing up. Then you go to the plural space and you look to see if there's fluid or water fluid in the bottom. Walk at the top. Next you go to the hilum. Yeah, anatomical part where the lymphatics, the airways and the blood all come out of. And what you're looking for is just the size, right? There's a little kidney shaped beam shaped on the right side and somewhat transparent. And on the left side, you're just looking for that kind of bit of a lobe popping out because the heart's covering the rest. Then you look at the heart, you look at the size by saying, hey, is there a space between the left ventricle and the chest wall and does the left atrium and the left ventricle kind of create this two slope system. If that's the case, then you say the heart is not enlarged, then you're going into the lungs. You zigzag zigzag zigzag, you zigzag zigzag zigzag and then you zig zag all across take into account, recognizing that the bottom part of the lung will be uh Abdullah's good to go. So whenever uh de if we can get him to the stage, that'll be great. My, I have invited um Abdullah to the stage so you can expect whenever you're ready. Excellent, Abdullah, thank you for joining us. Um, and so with the lungs and we will demonstrate this, what you're looking for is just making sure it looks uniform from top to bottom and from left to right. But the uniformity will be recognizing that the um, interstitial markings, meaning the blood vessels. Yes, they're gonna be much more prominent at the base versus the top and same thing. Uh, in regards to you're gonna be much more prominent, the closer they are to the heart. So as long as we all agree to that, we'll be fine as we wait, Abdullah, just go ahead and accept. Hopefully you're finding where to accept. Deborah. Remind us. Where are you coming from today? Hi, everyone. Um I'm Deborah. Um I'm, I'm from Brazil. I was living in Argentina and now I am in North Carolina, Charlotte and yeah, happy to participate today. It's been a while. Uh Deborah. I know I was trying to, I was in Charlotte too, visiting my sister. Uh Next time, maybe our stars will line. I'll be back there in March, but good to know you were there, my friend Abdullah, if you're having trouble. No worries, my friend. Um Honestly, we, there'll be plenty of times. Danny does. It just seem like a challenge with accepting the uh invitation? Yeah, there might be a challenge if you're having any trouble, feel free to put it in the chat. Yeah, that's it. You can just comment in the chat. Uh Bulla, let us know if you hear us and you can always write in the chat. So Deborah, it'll be us. Is that OK? My friend? All right, let me put this in presenter mode. Let me, so Deborah, I'm not giving you any insight about this case. I'm just gonna read the chest X ray. By the way, you would never do this to your radiologist. You will let him know what you're looking for in an X ray. All right, let me go ahead and share my screen. All right, Deborah unmute and just tell me that you can see this chest X ray, I can see. All right, Deborah, we're gonna walk through this together. Are you ready? Let's do it. All right, my friend. I love it. OK? So first things first, I'll be calling these out and you just tell me what you're seeing. All right, the spinal processes are here. You tell me is the patient rotated or not, not rotated? Perfect. Next, we're gonna go down, tell me when to stop. When you see the carina. I think uh you, you pass it a little bit up. Perfect. So I'm gonna outline it right here. Remember to visualize it. You can always lean back a little bit. Um So the carina is that anatomical landmark where the trachea ends and the right and left bronchi branch out. So I use it as a an anatomical landmark to look to see if the mediastinum, the mediastinum is that anatomical space between the lungs. It's where the esophagus, aorta and heart are located, for instance. And a few other organs I look at the vertebrae boundaries. Sorry, sometimes it slips that I'm drawing. If the media, if ther stays kind of within those boundaries, it's reasonable to say it's not shifted. What do you think depo is it within the boundaries? It is, it is perfect. So the mediastinum doesn't appear shifted. Next, you look at the angle of the rima this angle right here. Would you say this is an acute angle or an obtuse angle? Deborah? Oh Good question. Can you repeat? Yeah. So an acute angle is less than 90 degrees, right? So an acute angle looks like this versus an obtuse angle that looks big and wide. Does the angle right here look like an acute angle? Mm I think so. Yes, I agree with you. So if the, if the angle comes down and looks acute, that's normal. If the angle looks larger, like an obtuse angle, usually that means something is pushing up against it oftentimes the heart, but it could be a mass, the thymus could be doing that or a really large lymph node. Um If it is wide, an obtuse angle, you call that a splayed chin. So right off the bat, w using the cr as the anatomical landmark, what Deborah is telling you is it's not shifted and it's not displayed doesn't mean overall, the mediastinum is free of disease, but it's, it's free from a disease that you could pick up on an X ray. Cause. If there's a disease impacting the mediastinum, it will shift the carina, it's pretty sensitive to position. There's not a lot of space uh in the mediastinum. So it's gonna shift it or it will get splayed, right. It will the angle uh that it branches out, uh gets bigger next. You ready? Yes, we're gonna go to the pleural space. The pleural space is the space between the chest wall and the lung. It acts for various different purposes and we'll discuss that, but it provides a nice lubrication in order to allow the lungs to slide with each inhalation to make sure there's no fluid that we can see on a chest X ray. We look right here at what are called the costophrenic angles, the costophrenic angles or where the bones of the ribs meet the diaphragm. And I tell kind of comically it should look like vampire fangs. So what do you think Debra, do you think these look nice and sharp, like a vampire thing? Yes, it's normal. Perfect. So the way we would say this is no uh identifiable pleural effusion, effusion implies there's fluid in an area that shouldn't have that much fluid, right? Cause we already said the pleural space should have fluid. It's about 3 mL, costophrenic angles by the way to be lost in an X Ray Deborah. Do you remember how much you need in order to lose the angle? 303 100. 0, Deborah, you are becoming a lung doctor. I know that might not be what you wanna do. But I'm telling you you should, uh, I'm biased because I want, I want more and more. Next, we're gonna look at the apex, right? And the apex is the top part of the lungs, the top part of the lungs and you can usually look above the clavicle to some extent. And what you're looking for is are there lung markings that kind of go all the way to the top? What do you think, Deborah? What do you think you told me? Ok, I think, uh, it looks normal. We said that the top of the lungs should look like gray. Yeah, because of the air like so, yeah, so we're looking for air. All right, my friend. Next, we're gonna look at the hilum. So this is the right side of the hilum, right? Looks nice and kidney shaped and yes, it should look nice and dense in the center but everywhere else you can. So you should be able to sort of see through it. So it's some level of transparency. And on the left side, you do have kind of a nub in that pops out by the way, if you're wondering, oh my gosh. But there's this like circle right here, oftentimes around the hilum that happens because it's literally a cylinder that's coming straight at you um three dimensionally. But when a two dimensional slice, which is a chest X ray, it just looks like a circle. Um On the right side. Do you agree? Looks nice and kidney shaped and somewhat transparent. Yes, perfect. And on the left side, somewhat similar, you can see this numbing and looks OK. Yeah, perfect. All right. Next we go to the heart left atrium will give it a bit of slack here. 00, that's a horrible looking drawing. I apologize. Um But for the heart, what we look for is it's kind of two slope approach and it's, it's the slightest of angles there and then there's a space between the left ventricle apex. The apex is the tip of the left side of the heart and the chest wall being right here. So Deborah heart enlarged or not enlarged, not enlarged. Perfect. My friend. So this is great. Right? Reading a chest X ray before we even look at the lungs, you have looked everywhere else. Now, I'm gonna ask you one more question that has nothing to do with the lungs. This is the liver and this is the stomach. What is this? Do you know Deborah if you don't know? I don't know if it's uh a small bowel maybe. Oh, it's, it's just a gastric bubble. It's just gas in the stomach. That's ok. Gas in the stomach any time you see gas on the left side that's contained, right. It shouldn't touch the diaphragm. That's gas in the stomach. That's perfectly acceptable. Now, if you saw this on the right side, oh, you call your surgeon that's an emergency. So, gas in the stomach, it's allowed, it shouldn't touch the diaphragm. You're good to go. All right. Zigzag with the lungs. I'll kind of draw to the audience. What that means. You're gonna zigzag like this and then you're gonna zigzag to the left and then you're gonna zigzag back and forth, back and forth, back and forth. And what you're looking for is assurance that the, um, from the top to the bottom looks the same, you're gonna allow the bottom of the lung to have more prominent interstitial markings that really should fade away by halfway. Like the, like, look how prominent the markings look here, but they lose that prominence by the time you reach the tip of the lungs, just cause the diameter drops so small, right? Your blood supply, um, blood vessels, their diameter are large, they're large, closer to the heart and they, they branch out considerably by the time you get to the chest wall. So you can't, in theory really see them. So lungs normal or not normal. All right, my friend. All right, Deborah, you are awesome. So, the reason why I wanted you to do this case is, oh, let me see if I can hit, stop sharing. Let me see. Hold on one second. I'm gonna go to here. Oh, so how I can do that? Hold on. Bear with me. Stop sharing. Ok. The reason why we do this case, Deborah, the way you read the X ray is the way an intern would have read it, the way a second year would have read it the way a third year would have read it and potentially. Oh, Abdullah Nice Ti syndrome. Yes. That's when you have, it's a very, I'll try to find one. It's a great finding of looks like free air under the right side of the diaphragm, but it's technically just small out that's stuck there. So this x-ray Deborah, you right now read it like any medical resident, maybe even surgical or surgical residents probably would have done the same thing. I mean, this because ii use this countless times, like, tell me there is, there is an abnormality in it and this is not meant to be a trick. This is meant to, you know, when I teach you all, there isn't a aha moment or a gotcha moment. There's no such thing. For instance, if we were in a math class every week, we build to more and more complex theoretical math equations. It's meant to take the knowledge you guys have and build on it and build on it and build on it. If you have followed me, Deborah, you followed me for like a year plus plus your heart and you're still here with me? Um I expect you guys to be a you I Deborah II have the confidence Deborah can read an X ray as good as my fellows, my pulmonary fellows. I don't doubt that one bit. At the same time. I know I can build you guys a little bit more with more little subtle nuances. There is a subtle nuance here. So I'm gonna tell you about this patient. He is 52 years of age. He was gonna get a knee surgery and with a knee doctor, he was like old school. So he's like, hey, I want a preop clearance, go get an X ray gets an X ray. And there was the slightest little nodule that a radiologist read. I can't even find it on here. So I II spare you guys with it. Long story short. He got a CT Scan and sure enough three millimeter nodule, the challenge weight so tiny. But it looked concerning enough that we sent to my colleagues to do a potential biopsy of it. So this picture of an x-ray is oh doctor uh Soraya from Nigeria. Welcome this x-ray. Now watch this right. This is after what's called a transbronchial biopsy. Meaning put him to sleep. We went in with a bronchoscope and I sent down these alligator clips to try to get to this nodule. We weren't successful, but we did biopsy his nod, his lymph nodes. It actually did show a little bit of cancer. So, nonetheless, but let me show you something more here. As I said, Deborah, you read this as I would expect any resident to read, right? So when I point this out, I don't want you to be like, oh, no, you did. Great. My friend. That's exactly what I expected. All right, let me show you the nuance here. So Deborah turn your attention with me to the left side of the lung. OK? The left side of the lung, right, the apex. Look at here and now look at here and what I want you train your eyes to look for what I'm about to show you this liver here. Now I'm gonna make it go away and look at it one more time. Do you appreciate that sliver? Yes. So that's the liver, right, right off the bat. It like abruptly stops the lungs from underneath it, right? You can see these interstitial markings coming up right to it and then stopping and then there's nothing above it, but that's stopping. That demarcation is actually black first before it becomes all gray after that. Do you appreciate that? Yes. OK. This patient here and you, you'll probably appreciate it more here. Do you appreciate it there? A lot more? Yes, much more. Yeah, everybody look at this. This is the lung right here and then this is just the pleural space well exposed and look at this. Look at the lung markings. Look at the lung markings that come out and stop Deborah. Do you know what this is called? Um would be some. So there is known as pneumo and it's in the thorax. So, do you put those two together? It's a pneumothorax, pneumothorax, my friend. Yes. So this patient has a pneumothorax. We cause it. So let me dive into. Yes, Janta. And actually you don't need to specify its ap air has a low density. It'll always travel to the apex, right? So like if I say pleural fusion, everyone will know that water is gonna be at the base. I will only tell them it's somewhere else. If it's somewhere else, not at the base and water being anywhere else, usually something funky is going on the pneumothorax, it's always the air is gonna travel out. So let me actually let's discuss this real quick. Why isn't air in the pleural space to begin with? Why don't we just have like we have fluid, why not air? Why doesn't air ever go into the plural space? Normally, the reason for that is first, let's know what's the atmospheric pressure that exists? So we're gonna turn a little bit of physics. Let's have fun with this real quick. The reason why I want you guys to have fun with this part is because I wanna teach you guys how we fix this. OK. Now, atmospheric pressure, 716 millimeters of mercury, that's what exists out there. OK. In our bodies we have four types of gasses that live in us constantly, you may say. All right, I know it's oxygen. I know oxygen is in there. Yeah, you're correct. Oxygen is in there. CO2 is in there. You're right. CO2 is in there. So it was water. And you're like, well, water is a liquid. It is a liquid. But guess what? It's also a gas too. There's components of water that are in their gas form and then there's one last gas that we breathe in and it really doesn't do much anyone. A ed with the last gas we breathe in nitrogen to ha Yes, my friend, nitrogen, the most abundant gas in our, in our atmosphere. So what does this all mean? Ok. The space, the pressure of the pleural space, no way, shape or form should, should be 100 760 millimeters of mercury shouldn't be right? Because if it is then uh it's not gonna allow the lung to really expand, right? Cause think of pressure, right? Low pressure systems allow high pressure systems to go into it. Ok? Not just nitrogen, nitrogen. Uh So with that in mind, the pleural spaces pressure is minus three millimeters. So 757 millimeters of mercury, so minus three millimeters of mercury compared to the atmospheric pressure. OK. That's it. So it's thus allow the lungs to expand. So what what the remember the question that opposed you guys, the question that opposed is, why doesn't air naturally just go into the lungs? Well, let's go over the four gasses. All of them exert a pressure. Right. So, what's called a partial pressure? Oxygen is 40 mg waters. Oh, where did my computer go? Water is, I'm typing. So sorry about that. Water's partial pressure is 47 co two's partial pressure is 46 and then nitrogens partial pressure that's, uh exhibited in us is 573. If you calculate that real quick, about 706. Why is that a big deal? But that pressure is less than the 757 right? So it won't be able to actually get into that space unless you knock the uh the pressure of the right cause you can't get a low pressure system, you go into a high pressure system that, that it doesn't work backwards. So if you want air in the pleural space, naturally, you gotta go somewhere where the barometric pressure drops considerably. That won't happen here. So there's only three reasons you will ever have air in the pleural space. Only three reasons Deborah, in this case, what the reason is iatrogenic, what we call this, meaning the alveoli is damaged and has a direct connection with the pleural space. So alveoli pleural space connection, that's one way to get gas into the plural space, right? And I did that the integrity of the lung, we damaged it, the air I breathe in. Leave the lung gets into the plural space. The second part is a thoracic pleural space connection. What does that mean? It? And I'm trying to be violent. Someone stabs you opens that up. Hey, suddenly air can get from the air into your pleural space. Yeah. More like a surgeon operating when you're cracking open your chest air got in. Anyone wanna take a guess on the third way air can get into the plural space. I'll give it 10 seconds. The bronchopleural connection part is what we said about the alveoli. So same concept, the lung integrity is broken. Uh deep sea diving. Keep see diving if your lungs do collapse because of that. It's the integrity of the lung tissue infection. Lupus. Yes. Gas forming microorganisms. A microorganism got in there cause kind of like an empyema. You're forming gas. Those are the three ways you get gas air into the plural space. OK. So, meaning you gotta know the audience. Look, if someone's chest is cut open, it's gonna be pretty obvious. A gas forming infection. You'll have an empyema. The patient is doing very bad this, this is a patient. He's doing great. He's sitting in the chair. He's like, oh, the X ray is done. Am I done? Can I go home? And we're like, 00000 dear goodness. You have a pneumothorax. We caused it. So, how do we fix this patient? How do we fix this? I told you guys this is a bronchopleural or an alveolar pleural connection. The lung is damaged. There's a hole in the lung. How do we fix this? Anyone wanna take a guess? How do we get the lung to re expend? You can. All right, let's pause. Zero. Paas wrote chest tube. So when to do a chest tube and when to not? Ok. This is a great question. This is a great question. So, what does the chest tube mean? It means I'm gonna put a chest tube into the plural space to let the air out. Do we do that? We do? However, who do we do that for? Deborah? Looked at this X ray and Deborah, you told me the mediastinum is not shifted, correct if the mediastinum was shifted, right? If the mediastinum was being pushed to the left side because remember the pneumothorax was on the right side and if that air is escaping into the lungs at such a rate and it's causing the lung to collapse, that lung will push the mediastinum into the left side. Deborah will tell me the mediastinum has shifted. There's a pneumothorax. This patient just bought himself a chest tube. OK. I place in chest tubes for mediastinal shifts caused by pneumothorax. That's what place it for. For the most part. Obviously, there's a little wiggle room there. This patient's mediastinum has not shifted. He's not having a tampon nod, right attention. Pneumothorax is what it's called. That's not the case here. So while a chest tube is a reasonable answer, that's not this patient. He's sitting there being like, I feel fine, like I wanna go home. How big is the pneumothorax? Yeah. So it's not just also size, let's go back to it. Hold on. It's not also just size. It's also physiologically. What is the pneumothorax doing? Oh How do I let me go back to sharing my screen. Here we go. So look at the pneumothorax here. All right. It's just a sliver. But nonetheless, even if it was larger, say it's down here, right? Say, say the pneumothorax came all the way down here. If it's not shifting the mediastinum, if it's not having a physiological issue to the patient and the patient's standing fine, they're not in respiratory distress, you know, yeah, larger the pneumothorax, the more consideration, but it still falls into kind of the odd window of do I put a chest tube in a chest tube be put in if there's a tension pneumothorax or patients des setting or the patients having physiological consequences right there to keep respiratory rates driving. But even if it's large, they're fine, you can still have some wiggle room and say maybe I don't need to be invasive. So the other answer and many of you are dropping this in there is oxygen. Give this patient 100% oxygen. Why is oxygen is oxygen about to close the hole? Is oxygen closing the hole? You can watch and wait, you, you can do that too. Is oxygen closing the hole put that in there, right. We're not going in there and putting a bandaid on the lungs. The answer to why oxygen is in the chat box. All right. Let's go through this again. Partial pressure of h2o. What did we say? It was 47 partial pressure of oxygen is what, what did we say? That was 40 partial pressure of CO2 is what? 46 partial pressure of nitrogen is 573. Yeah, that causes the, the gasses himself to contribute some level of a pressure to the patient and they're breathing in. Ok. We know that the air that the patient will breathe in. Some of it is gonna go into that pleural space. Ok. Some of them it is gonna go into the pleural space. What if we can make that pleural spaces pressure? We already said the plural plate. The pleural pressure, pressure is 757 706 of it is contributed by those gasses that can't get in there but kind of contribute to it. What if I can make the pleural spaces pressure? Lower all those four gasses? Which one should I remove? Ok. Nitrogen don't ever think this nitrogen, nitrogen is contributing the most. 573 573 millimeters of mercury is contributed by nitrogen. So am I gonna have the patient breathe 100% CO2 No, that will kill him or her. Am I gonna have the patient breathe 100% h2o. No. Yeah, it'll kill him or her. So get the patient to breathe 100% oxygen by breathing in 100% oxygen. You're gonna make the partial pressure exhibited only by the gasses to be about 40 millimeters of mercury. Cause it's just gonna be the oxygen, right? You put on this nasal cannula and let them breathe that in every breath they take is no longer filled with nitrogen or CO2 or water. It is just filled with oxygen. So, meaning the gas that gets into the lungs and into the pleural space is about 40 millimeters of mercury. You're gonna drop the pleural pressure, the pleural spaces pressure significantly. So the way the lung ends up re expanding is not because you've healed a hole, right? You haven't, the lung could just stretch again because it doesn't have that much pressure to compete with. It's like, oh, this is good. I'm expanding myself. That's why you're giving 100% oxygen. So, for these patients, could you watch what you could and hope it re expands because once it re expands, the lung can kind of reattach to expedite this without just watching and waiting is this is why you give 100% oxygen. If you've ever wondered, this patient's lung has collapsed. We're not doing anything invasive. We're just giving him oxygen or her oxygen. If you've ever wondered why this is why it's all physics. If you know the partial pressure of these gasses, then you know why we give 100% oxygen? No, we, we definitely give 100% CO2 or H2O because that will kill the patient. That's all they're breathing. But the whole intention is someone wrote this kind of washing out the nitrogen and you wash it out. But why if you ask your, if you've ever asked yourself why it's this, you're gonna try to get the gas in the pleural space to match oxygen's partial pressure, which is significantly less and allows the lung to reexpand. This patient spent 12 hours in the hospital, lung re expanded that evening. He went home. That's it, Deborah, my friend. Uh Hopefully you didn't feel bad. You, you didn't miss anything. I would have expected this by everyone. Um But was this a good case guys? Did you guys like this case? And did you, do you guys understand the physiology behind this? Thank you, Deborah. So, yes, perfect. So what I, what I want you guys to take away this right? The whole purpose of becoming strong clinicians, doctors, nurses and everything else is having a physiological understanding of why I had plenty of my med students because they all were gonna get 100% oxygen. And many of you did. I love that. Why. But now you can. Yes Bianca, this is all recorded and the slides are all yours. And by the way, the numbers I told you I have them on the slide. So if we go back to sharing my screen, you'll get them too. All right, you guys will get them right. We'll, we'll see them here and then you'll form. Why is there no gas and space right there? There's only three ways and then we go over this as well. So let me stop sharing. Um But I want you guys to understand the physics of it. Well, all right, last question and then we will stop for today's lesson. We'll be back January 31st, the time to be decided by mid January. Um question to you guys. What animal, what mammal? What mammal does not have a plural space? Anyone want to take a guess what mammal has no plural space. This is not stuff you learn in med school and you shouldn't. But why it doesn't have a pleural space is really fascinating. Anyone wanna guess why? Why anyone want gets an animal whale? We got whales. Who elements? Paras elephant is the answer. Whales have plural spaces. Elephants don't remember whales when they go deep into the water, they're not breathing right? Remember whales have to come to the surface to breathe. So whales have a nice plural space. Elephants are amazing swimmers, amazing swimmers. And what's fascinating that elephants is they're breathing their entire time. They're swimming because of their trunks, right? Their trunks are out above water, but their bodies can be massively below water where the atmospheric pressure drops considerably. There's no other animal that does that. None. We snorkel, but I don't snorkel. You know, they got a little tube like six inches outside the water. Elephants don't. Elephants can be h you know, their size under the water. So if the elephants had a plural space, like we humans do that atmosphere, right? Because you're gonna have create a pressure difference, right? They're breathing in air, still flowing in and that they're bringing it, meaning they're bringing in the low atmospheric pressure in to a high atmospheric pressure system, their lungs will collapse on, on one another, they'll crash. So elephants don't have a plural space. Instead, their plural space is just filled with connective tissue or if you stab an elephant, you're not getting that far because it's like this thickened tissue, right? Cause that thickened tissue allows, right? It's kind of like a spider web, it's holding on to the lungs so they can breed like this. This is where we think elephants are descended of some mammal that predominantly was Seaborne and then they just made their way out. But that's how they, that's, yeah, and elephants don't have a pleural space, but that's why now you guys know right, because they're constantly breathing. If they weren't breathing, they would have a pleural space no different than a, than a whale. The whales when they're underwater aren't breathing, right. They gotta come up with a blow hole to take in a breath, then they go back down, not elephants crazy. All right, you guys are awesome. If you wanna become a vet now you learn about elephants too. So you guys are great, great lesson and we will be back in four weeks. This gives me time. The reason why for the time discrepancy is I wanna try to see if I can bring a colleague for many of my colleagues, four o'clock is hard. So let's see if we can bring someone in but watch this again if you guys want. Now you guys understand a little bit of physics as well. And thank you guys so much, Deborah. Thank you for being a great soul today. Are good people. Take care. Bye. Ok.