 I'm a big fan of what's about to happen. Not for the patient. This is like my specialty. That doesn't sound right. What is going on everybody? Welcome back to my channel. For those of you who are new around here, my name is Michael, aka Dr. Chalini and I am in my final and sixth year of training in interventional radiology. And on today's video, we are going to be going over Linux Hill. I guess it's like a TV show documentary kind of thing. But Linux Hill holds a special place in my part. And I'll tell you why and we'll go through this entire first episode right now. So first and foremost, Linux Hill Hospital holds a very special place in my heart because before starting your diagnostic radiology residency, you have to do it your first year in either internal medicine or surgery. I chose surgery and it shows to do it in New York City at Linux Hill Hospital. And secondly, it happens to be where I met my lovely wife. She was working there at the time I did my internship. When I first saw this video series come up on Netflix, obviously I was intrigued. Let's go ahead and jump into it and we'll see how it is. So I'm just going to play this right here and I'll jump through or fast forward some of the slow parts because who likes to watch slow parts? Should I fast forward this? I know that guy. I used to see him in the neuro ICU because the surgical ICU and the neuro ICU was essentially the same floor or the same area. So we used to take care of some of their patients overnight and whatnot. So we would see him Dr. Langer. Give me a squeeze, Hannah. Give me a left hand squeeze. She's there. She's slow to come around. She'll be fine. So he's a neurosurgeon. I assume this young lady had neurosurgery as well. And the most important part about having neurosurgery, I mean, I don't perform neurosurgery, but it's when they wake up because you want to see if there's any neurological deficit for you to tell if there was a successful surgery. Is she fully right now? I hope she's fully. I think when she says fully, I mean fully dilated or your cervix is dilated up to 10 centimeters. Good job! Yay! If only it happens within two seconds in real life, she's walked in and delivered a baby in two seconds. Never happens that way. I don't think you have any care. It's so fast! So easy! Maybe it wasn't fast. Two pushes, good for her. I definitely was thinking about trying to start a department. I underestimated what that meant. No one knew how to take care of a neurosurgery patient. They didn't know what a neurological deficit looked like. Hey, Hannah. How are you feeling? You there? Now we're saving people. Your eyes? It's all done, okay? The lack of legacy and the lack of anything and nothingness of this place. Do this left foot? Is what allowed it to become everything. Everything went great. See, so now that patient is awake, she's moving her feet, which means she's neurologically intact for what we see. And that's what he was testing postoperatively and now he's happy with the results. Okay, got the whole thing out. But it's not just me, it's the whole group. That kind of special chemistry is what allowed us to be able to compete against the biggest neurosurgery departments in the city and in the world. You got radiation here? I did. Yes, you did? Yes, that's what my hair fell off. Well, your hair looks great, so that's why I was asking. Scalp exploration, resection of mass. That's my initials. Oh, good. We're gonna go in and open her scalp. I did a brain surgery on her for metastasis to the brain, which she's doing terrific from. She had radiation and has been disease free for over a year. Interestingly, about three weeks ago, she developed real pain in the scalp area. And so in a patient who's had a history of cancer, we worried about metastasis. Fixation system of the skull back onto her natural skull. And that may be a plate that's come loose or is irritating the scalp. And keep our fingers crossed that it's not cancer and you go home, see inside. Nothing to worry about. So basically, he's taken her back. She's already had surgery before had a plate in her skull as well. They are trying to see if it's cancer, if it's irritation from the plate itself, or if it's some sort of infection as well. So the only way to really tell that is to go in there and investigate. A lot of imaging won't really tell you what's causing it. So MRI, there'd be a lot of artifact from the metal plate and same with CT. So sometimes you just have to get direct visualization to see what it is. To me, my job's not a job. That's my life. It's about loving to operate and loving to do good cases and ultimately loving to help people. All right. All right. You say it. Daddy. You have to. This year, I have to. I'm sensing some strong Southern accents. Reminds me of Georgia where I was born and raised. The patient's a 41-year-old female police officer from Tennessee. Tennessee, Georgia. It's about the same. Living with his tumor in her skull base and neck for about 10 years. What she has here is a big tumor in her neck. This is the oldest white thing, is the tumor. And this is the coronary going right through it. All right. So she has, so basically this, so the coronary is this black vessel going through it and it's completely encased by this large contrast enhancing white tumor, which is probably a carotid body tumor or a pyridine dolema or something of that nature. It's hard to really tell based off this one image, but that's the most common kind of tumor in that area. We'll see what it is. The problem is we don't think we can take it out safely without sacrificing the carotid artery. And even if we get into it, it could bleed. So we'd rather control the whole thing ahead of time before we go and access the tumor. In her case, the vast majority of the blood supply that's coming is making up for that carotid is actually in the neck also, the external carotid artery. And that has us less to go to. So we're going to do it at stages. So what we'll do is, well, we're going to close our internal carotid today and then we may decide to take the external carotid down tomorrow. And then there are all these other decisions that have to be made about other aspects of the surgery that are all really important. That's why having guys like Ortiz here and me and together were able to really consider all the options and really do all the things necessary to keep these people safe. So essentially she has this entire tumor encasing her left internal carotid artery and they're trying to go ahead and knock out that internal carotid artery. But the only way to do so is if she has appropriate blood flow from the right side that can supply blood to the left side of her brain. So what I mean by that is there's something in the brain called the circle of Willis and it's a complete circle or ring that connects the left hemisphere to the right hemisphere of the brain. So the blood supply to the brain is by two vessels in the neck on each side, two internal carotid arteries and two vertebral arteries. They kind of meet in a network in the middle and can supply brain to the other side if for some reason blood shuts off. It's kind of like a generator or a backup source of blood in case something goes wrong. That's the best way to think of it. It's all just plumbing. So they wanna go ahead and knock out her left internal carotid artery and the only way they could do that is if she had a full ring or circle of Willis in her brain that would allow blood to flow from the right neck up into the brain and also communicate with the left side of the head because if they didn't do that and they knocked out the left internal carotid artery essentially she would lose blood flow to her entire left cerebral hemisphere and have a devastating or catastrophic stroke which would leave her neurologically devastated for the rest of her life. So I'm sure they did a whole bunch of planning leading up to this surgery. It sounds like a pretty extensive surgery. I don't do this, I've never done this before but I'd imagine it takes quite a bit of planning to do this so let's go ahead and watch and see what they do. We think you'll be fine. The biggest risk is the other vessel you really need to. That's gonna give your brain the blood it needs temporarily. So by the time we take that one the bypass will be in and the bypass will take over all the blood flow that you need. So I think what he's saying is the external carotid artery is also supplying some of the tumor and or supplying some of the brain. So I think what they plan on doing is taking out the left internal carotid artery and then creating a bypass. I don't really know that part. It's hard to decipher that but we'll see what they do. And this isn't working. You could have a stroke, you know that's the risk. Look we're here with you the whole time it's not gonna leave you and if there's a problem we'll just attack it and fix it if it has to be done. It doesn't mean it's gonna be easy. There could be some tough moments you have a great family and if you trust me and you trust us then we're good. I do wanna touch on one topic here because I think that a lot of people aren't really sure what a stroke is. You always hear about that and you hear old people get it and I didn't know what it was until I went to medical school honestly. So a stroke most of the time is caused from ischemia or lack of blood flow to a portion of the brain. It could be from a piece of clot that breaks off in the neck from plaque over years and years and years and it goes up to some smaller vessel blotches off the blood flow and when that portion of the brain doesn't get blood flow essentially it dies after a certain amount of time. Some of the literature saying six hours plus now and after that it's irreversible. So this is why we always say time is brain because if you recognize a stroke early you can reverse it but if you don't it can leave you with irreversible brain tissue loss essentially for the rest of your life. Check yourself in the mirror make sure your hair is covered, ears are covered. But you notice all of those, the blue coats and the head coverings they used to wear? So during my intern year, five years ago or whatnot they started making us wear those in the OR and there wasn't any data behind it at all. It was like the only OR in the country I feel that would have to wear this stuff or we would have to wear a jacket we'd also have to wear a head covering that covers essentially our whole head and our beard all in one unless we were clean shame in that day. I don't know where these rules came from nobody knew there was no data behind it but I guess they still do it five years later for some reason. You're about to see what greatness is all about. Students come in here don't touch anything blue. You have to make sure the med students know not to touch anything everything blue is sterile. For some reason med students always want to like touch things especially in the OR. So as you can see it's already been previously resected here and here and this is the same person they were talking about who had a possible metastatic lesion to that stole. Guess they're going on the right side right here. They look like a boomerang. Did they take it? Question is this massive cancer or not? A lot of times when you're in the OR you can pretty much identify if something looks cancerous or not. It just doesn't look normal. Sometimes it's either black or necrotic. The best way I can describe it is it just looks like cancer. When you see it you know it. You see this looks like cancer you can see this is normal scar tissue. This is what I was hoping we'd find. This looks like cancer it's purple and it's bloody. Let's go to pathology and look at the frozen. Well this is a woman who is 70-something one with scar tissue and then one look like cancer. Take a look. This is all cancer right? It's all cancer. So what are you gonna do? You stop or do you keep going? I would just take it out of there. Always good to have the courage of your convictions. Yeah so this is surprising. She's gonna be unhappy because she thinks it's just a plate that's being removed. So the frozen section is basically they take a piece or a sample of the tumor they walk to the pathologist they freeze it, look at it under the microscope and then they can tell if it's cancer or not then they go back to the OR while the patient's still under anesthesia they can either resect more or stop the procedure or proceed however they see fit. Sorry. See you in a little bit. Ah. ACT 257. So the anesthesiologist is putting that blade down her throat about to intubate her so they do preoperatively. And also they're in the cath lab or the endovascular suite. As you can see by this nice X-ray machine here this is where I do all my work. So obviously I'm a big fan of what's about to happen. Not for the patient but this is like my specialty. That doesn't sound right. So he's using steam right there to kind of bend or form his catheter or wire into the specific shape he wants it to kind of match the shape of the blood vessel on the patient's anatomy. I never do this but I think a lot of neurosurgeons who do this kind of endovascular stuff do this. It weighs on you. Putting wires in catheters. This is all I do. Her friend's in. Her friend should thank you. Everything we all do here are all of us. It's ultimately for the patient. It's only for them. What the? So that orange device he's using there is basically a detachable coil device. So I guess they're embolizing the or blocking off the blood flow to the internal carotid artery with coils and they're using detachable coils. Once you get the coils deployed in the right spot to block off the blood flow, you put this little battery pack on the end, press a few buttons and it deploys. It's a good way to safely deploy exactly where you want your coils. It's a good device. Now let's go six for, six for 10. So six for 10, that's what we always say when we're about to do a power injection of contrast to get a good crisp image. So six for 10, he's probably in like the internal carotid artery. He wants to do six CCs a second for 10 CCs total in volume. And then he also mentioned, what's the ACT or when's the recent ACT? And the ACT is activated clotting time. And that's our way of assessing how anti-coagulated or how thin a patient's blood is while we're doing this procedure. And that's especially important when you're working in neuro because you don't want any clots to form while you're doing these procedures because as we mentioned prior, that can be very devastating. But you usually check it about every 30 minutes or so during these procedures. Mitzi, hi, can you tell me your name? Mitzi, how old are you? How old are you, Mitzi? Okay, good, okay. Again, just like we talked about earlier, the most important thing is to assess the patient, they've assessed their neurological function after the case. That's a good sign. Thank you so much for your time. Hang in there, okay, all right. Okay. All right, I think we're gonna stop there. This is an hour-long episode. If you want me to do more of these or see the other part of this case or the other cases as well, I think they track these over the next few episodes or whatnot. So if you want me to do another episode, let me know in the comments below. If you liked it, let me know as well. If you hated it, don't leave a comment. Anyways, make sure you smash, like, subscribe button, comment and Instagram if you're not already, and I'll see you all on the next video.