 It's time to go to the gym. Good morning. So as you may know by now, I just finished my workout and every time I do that workout, I'm like, why did I do that to myself? I mean, why do I wake up so early? Why do I work so hard? Why do I get this sweaty? And then it dawns on me when I finish because I feel so good after I finish. And I know I talked about all this on my 430am workout routine, all that stuff. But there's just nothing that makes you feel as good as working out in the morning and just starting your day. I don't know if it's because I'm a morning person. I don't know what, but I love it. And I will say I've never worked out this hard since probably college sports, like when I swam in college for those of you who don't know. And that was probably the last time I actually worked this hard. I've been working out consistently for probably 10 years now and I have never worked out this hard before. Which is good because bust my butt back in shape because I need it after the pandemic. After all this stuff, where I wasn't working out and eating, drinking, all this stuff. So I gained like 10 pounds, which no bueno, trying to get back into it. But nonetheless, today is Sunday. I failed to mention that. It's about like nine o'clock or so. I had my coffee. And by the way, I'm on call this whole weekend. I got called about three times so far this weekend, which is crazy for my hospital. It's a smaller community hospital and we hardly ever even get phone calls when we're on call. Much less three times over the weekend. But apparently the ER has been crazy busy today and yesterday. So I could tell when the ER doc called me that they were super busy. They didn't really have time to like tell me what was going on. They're just like, just don't figure it out. So today I'm going to probably go replace a nephrostomy tube that fell out over the weekend. When that happens, sometimes you can get back in the track if the patient has had it for a very long time. This is a well formed nephrostomy tube track. Otherwise, I'll just have to do a direct stick into the kidney. And then I think I just might drain some fluid around the lung or thoracentesis while I'm there. We'll see. But what I probably want to do during this vlog is just bring you around. You know, this is just my weekend on call or whatever, but I'll show you the procedures. Well, probably not the factual procedure, but I'll explain to you in depth what exactly I'm doing in the procedure. So you have a pretty good understanding what I'm talking about. So first things first, I'm obviously very sweaty. I need to go take a shower and let's get this day started. Well, continue this day, I should say. All right, so we are back at the hospital. Who would have thought? It's Sunday, like I said earlier, and about to go replace this neph tube because it fell out, which is a very, very common problem with any tube that we place that can always fall out, like for any reason. Sometimes the patient rolls over, sometimes the patient's spouse pulls it out on accident, sometimes they pull it out on accident. Rather than keeping the patient here for two nights for no reason, I'll just come in, even though it's Sunday and replace it, it's not emergent, but it could get emergent because the kidney could become infected if the tube isn't draining the urine properly. So it's better to be proactive instead of reactive. So I think what I'm going to do is draw out exactly what I'm doing, because a lot of people don't really understand what the heck I'm talking about. So I'm going to basically like draw it out, so you know exactly what I'm talking about right now. All right, I have no idea what happened to the top of this notebook, but what can you do? So my patient had a nephrostomy tube, sometimes also called a percutaneous nephrostomy tube, also called PCN for short. So what is a nephrostomy tube? So this is a kidney, you have a collecting system, this is a terrible drawing, but you have blood coming into the kidney, it filters out all the blood and then urine is drained into the collecting system here and goes down here and into your bladder. Once it's in your bladder, you can then urinate it out. What happens is some people that have say cancer somewhere in their pelvis, they can actually obstruct this ureter causing back pressure to build up in the kidney, causing this kidney to be dilated to look like this. So you see how the collecting system here is nice and small, but here, since there is an obstruction down low before it gets to the bladder, the back pressure leads to dilation or dilatation of the actual collecting system. When this happens, the only way to relieve that pressure is to put a percutaneous nephrostomy tube in to relieve some of that urine to drain out of the patient's back and into a bag versus going anti-grade like it normally does. So what I do under ultrasound is I will access the lower pole calyx right here, I'll put a wire in and then through that wire, I'll advance a pigtail catheter into the patient and then it drains to a bag external to the patient. So the patient actually drains their kidney as the kidney produces urine, it drains into the bag outside of the patient. That way it does not have to go down to the bladder, it goes this way instead. Think of it as a bladder outside of the patient that they can just open up and drain the bag whenever they need to. So what happened with my patient? My patient was flushing their tube at home and what happened was they actually pulled out the tube so there was no tube anymore. So when this happens, we have to go in and replace it. Sometimes we can go in through the existing tract or we can just start over fresh with a new stick with a new needle. So what I did on this patient was try to find and navigate the tract that the patient already had in order to get the tube into that position. I didn't feel like accessing with a new needle this time because there's obviously a risk of bleeding every time you access the kidney with another stick or another needle. So if I could go through the existing tract with a wire and catheter and get into the collecting system, I could put a drain in quickly. So if you think of, let's see how we can draw this. So this is going to be a patient looking at them from the toes to the head. This is how we read radiology studies. So this is the spine. You have a kidney over here and a kidney over here and it drains into the collecting system. What happens is when we access back here, there's a tract that forms between the scan. This is a scan by the way, liver, stomach, spleen. This tract right here that our tube is going through. When that tube is removed either on purpose or not on purpose is this tract between the collecting system and the kidney and the skin will eventually close up. Think of it as like an earring. So if you have your ears pierced and you take the earring out of the actual ear lobe, you notice how that tract or the hole in the ear will slowly close up over a few days. Same thing happens with nephrostomy tubes. If it closes up, I can't get back in and I have to do a direct stick with a new needle. So I was fortunate enough to put a catheter in here through the skin, get a wire up into the collecting system and place a new catheter. When that place the new catheter into the collecting system, you leave it like right here, patient drains out fluid out of their back again and all things are good. That's what I did for that patient. This is what it looked like before he got obstructed down low. Over time, you begin to dilate your kidney. You have to put in a nephrostomy tube because there's no way for urine to come down distally into the bladder and to urinate out. Put in a nephrostomy tube drains out into a bad external to the patient. If that tube dislodges, you can get back in the tract. If it's in 24, 48 hours or so, you can place a new tube and the kidney is happy again. And that's pretty much it. All right. So everything with that nephrostomy tube went really easy. I was able to get in the tract like I mentioned in my drawing there. Went perfect. My house is a complete disaster right now because I've just been on call this weekend, filming some content, all that stuff. Haven't really done much of the whole cleaning thing. So Andrade is getting home later tonight. And it's about time for me to tidy this place up before I get yelled at by married folks know what I'm talking about. All right. That officially concludes this video. Thank you all for joining me for my call weekend extravaganza. Hopefully you all learned something from those little diagrams that I drew and all that stuff. Tend to like draw stuff out. I draw it out for patients. I draw it out for the PAs I work with. I draw it out for med students, any other residents I'm working with, all that kind of stuff. I feel like for what I do, you have to draw it out. Otherwise, nobody really understands it. Basically, to sum up, got that neph tube back in. Everything went smoothly. And the best thing is, so one thing about working in private practice is procedures like that aren't really emergent and most people won't come in on the weekend for myself included. I just did it because I don't know. I didn't want that patient to stay in the hospital another day. But I will say it helps you look so much better to other physicians in the hospital. If you do something like that, I already got like two or three phone calls from the admitting physician, the urologist, all that stuff. All thanking me for coming in on a Sunday to do that. And they were like surprised that I would do that. Which, I don't know. I feel like the patient needs it and you don't want to waste resources with the patient in the hospital. Don't want the patient to be in the hospital. You should do it. If it's pending discharge, you should probably do it. Even if it's not an emergency. So, hopefully you all enjoyed it. Let me know if you have any questions in the comments below. And I guess I'll see you all in the next one. Make sure you smash the like, subscribe button, follow me on Instagram, and TikTok if you're not ready. And I'll see you all on the next video. Bye.