 As a doctor, one of the coolest things that we get to use is to use our hands as well as some time and practice to be able to better care for our patient. And so in today's episode, I want to share with you some of my favorite procedures that I do as an internal medicine physician. Let's get into it. Hey friends, welcome back to the channel. In case you're new here, my name is Lakshman, internal medicine physician. Wrong side. There we go. Hey friends, welcome back to the channel. In case you're new here, my name is Lakshman, internal medicine physician. And here on the MD journey, we make videos and content to help people like you succeed on whatever journey you're on, but doing it with less stress. Today I wanted to go over a fun topic where I talk about my favorite procedures that I do as an internal medicine doctor, because let's be honest, I see a lot of surgeons, interventional radiologist, and so on who are on YouTube sharing their cool things. I want to do the same. So hopefully if you're interested in internal medicine, you can see what kind of procedures you may be doing. And you can see the ones that I like and the ones that I don't. So starting with the list of my favorite procedures, number one has to be an arterial line. Now, if you're not familiar with an arterial line or an A line for short, think of it as an IV inside specifically your artery. Usually we do the right deal. And the main reasons we get two things out of it. One, you can essentially monitor somebody's blood pressure 24 seven. Usually in the hospital, somebody will have a cuff of blood pressure cuff on, but that will cycle anywhere from two to five to 10 to 30 minutes. And it doesn't give you an accurate measurement of what that patient's blood pressure is all of the time. And especially if you have somebody that's really sick, like a patient who needs to be in ICU for low blood pressure, they're not the most accurate. So often when I'm working in ICU, I have to put an arterial line for anyone who I'm concerned that has a low blood pressure. So to walk you through quickly how an arterial line works, usually you're going to go for an artery in somebody's wrist. So the first thing that we do is we go ahead and position the patient to where their wrist is on the side of the bed. And it's usually kind of cocked back a little bit because it makes the arteries come to the front. And usually we'll go for an artery on the radial side instead of the ulnar. So usually on the side of the thumb. And you can either do it by feel or you can do it my favorite way, which is via ultrasound. This video is going to show by feel. So this person has a finger on the radial artery. They're feeling for the pulse. And then they're going to go ahead and insert their needle at the direction to where they feel their pulse until they get some level of blood draw. And as soon as they do, then they're going to go ahead and guide a wire. So if you watch, they're going to go ahead and essentially insert this wire. And what that does with this animation, you can see that this part essentially represents the needle. And as you push the wire through, now you're essentially able to have that wire go to the length of the artery that you need. So then you can actually insert the catheter that you want in the artery without the needle being there. This is called the Seldinger technique. So essentially you would guide the wire through. And once the wire is through, then you can take your needle that you put out. And then go ahead. And now that you have your wire all the way down the radial artery, you can essentially say, okay, well, there's a wire there. I'm just going to cover that up with the catheter that I want it to be. And then they're going to go ahead and nicely place it over. And then once you have your catheter set up, essentially you can grab an apparatus that your nurse should be setting up for you at the same time. And then you'll be able to connect and measure the patient's blood pressure 24 seven. It's also useful for being able to draw blood from the patient. If you need to draw an ABG or any kind of labs, you can draw from there 24 seven without that patient getting stuck over and over again. Now the reason that this is one of my favorite procedures is that doing it under ultrasound, you're essentially playing a fancy video game. So I'll link down this video right here by Adam Collins on how to do an ultrasound guided arterial line. But essentially you would be looking at your artery, which I believe is in this case for this patient. Boom. I'm correct. And you'd essentially be following your needle to almost like a video game and playing target practice. So you would make sure that you start at where the artery would be above their skin and then you would slowly go and advance your ultrasound probe until you keep seeing the tip get closer and closer and closer to the actual area. So as you can see, he's about to insert into this vessel and then boom, usually as soon as he does, he should be able to get blood flow. Now, because this is an artery compared to a vein, there is muscles in the wall of the arteries that are very strong and don't necessarily compress to pressure. So if I'm pushing on this person's arm, the artery should be still easy for me to see compared to a vein. As soon as I really do anything to the skin, it pushes off and that makes it a little bit harder to putting an IV or some of the other procedures that we'll talk about. Now, while we talked about putting an arterial line in somebody's wrist, which is the most common place that I put it, I've also put in somebody's upper arm, especially if they don't have really good targets in their arm. I've also had to do it in some interesting places like a femoral artery. Usually this happens if a patient already has a lot of IV lines and access or if they lose a pulse and they immediately need somebody to say, I need you to put an arterial line so I can measure their blood pressure consistently. I can't depend on this cuff going every two minutes. A patient who may have lost their pulse, needed CPR and now has a heartbeat, you want to make sure you have their blood pressure 24-7. While putting an arterial line in somebody's groin may seem unique, probably the most interesting place I've put an arterial line in actually happens to be the top of somebody's foot in their dorsalis pedis. This is a patient who had a long history of kidney disease, which usually disrupts how well your arteries are. They've kind of become pretty nasty and useless in terms of putting in lines. Only really good one I could find was the top of her foot, put it in, use a smaller catheter, draw it in, and sure enough, we had a blood pressure and were able to drop blood from her. And by far in my three years of internal medicine, probably the coolest place I've put an arterial line. Now, similar to an arterial line, the second procedure I really enjoy doing has to be a central line. This is pretty quintessential for any internal medicine resident. You don't necessarily do it when you're in attending, unless you're very big in ICU or cardiology or procedures that require us getting access. But a central line is essentially an IV, just like the ones we typically have seen in people's arms, but typically in a bigger vein. So usually in your internal jugular, so in your neck, your subclavian, so right by your clavicle, as well as the femoral, which we just talked about for an arterial line. And some of the reasons that you may have to put a central line in for a patient also includes that if their blood pressure is low, you may want to make sure they're getting those medications that they need immediately to their heart. So these lines, instead of an IV, which are pretty short, so you can imagine if it's in my arm, it's going to take a while for the medication to go and ultimately get to my heart and then pump to the rest of the body. Compare it to a line that may be anywhere from 15 to 20 centimeters if I put it in somebody's neck. It's going to be sitting pretty much right next to their heart. And so if I push any medications, any fluids, it's going to get there relatively quickly. And on a similar note, often the ICU have a patient who has really low blood pressure. Usually I learn that after I put in the arterial line and I'm like, oh man, that patient needs meds really quickly. Often some of the medications that we use in ICU are pressers, which basically constrict the arteries. But you can imagine if you try to use those medications peripherally or close to somebody's hands, it starts to also constrict some of those small vessels that they have in their hands and have some risk for ischemia, especially if you're using really high doses. So if somebody has really resistant low blood pressure because they have a really bad infection, they've lost a lot of blood or et cetera, then having a bigger IV that is closer to the heart so you can get the medication as well as minimizing the risk for ischemia is preferred. Now, usually almost all of these procedures are performed using ultrasound. In those crazy crash situations, I've had to put some in without really being able to see where I was going. You just kind of go with feel and experience. But usually you'll have a kit like this where you'll have your wire, your catheter, some syringes, and essentially just like before, you're going to ultrasound, but now you're going to look for their internal jugular. Usually we'll go in the neck and the difference between their internal jugular and the carotid artery. Although they're closed, the vein usually will collapse to pressure as I was talking about. And one of the things that we have to keep in mind while doing this procedure is that the vein and the carotid artery are very close to each other. Hit the vein, not a big problem. That was your goal. Hit the artery, that can be a big problem, especially in the next few steps. So the first way that we know that we're going to go into the right place, which is an internal jugular vein in this setting, is that we want to give it a little bit pressure. Remember, veins don't have too much muscle around them, so giving some pressure, if it collapses that is a good sign, you'll likely look at the vein and the artery usually will pulse it because that's where the pulses come from. So if you look at this example, and I'll link all these videos down below, they're gonna essentially give this patient some pressure and you can start to see that that vein is collapsing and the artery is roughly staying the same. So I know that that's my target. So when I come in, usually I'll start a little bit away from the artery. That way I have more than enough margin of error to make sure I go to my right target. Once I know where I'm going, I'm gonna go ahead and grab my needle until I get blood flow, just like I did with our tear line. So they just got in the vein. You'll start to see a little shot of blood go in. That means you're in the right place. And I think they show a really nice animation where essentially it looks like this is the vein I'm trying to go into and you're gonna have to put a little bit of pressure. And then as soon as you beat that pressure, boom, you're usually right there and then your needle is gonna be in the nice vein. Once you're able to get a nice pull of blood flow, that means you're actually in the vein. You didn't actually go through it or beyond it. A lot of times especially when we're doing it for the first time, some of us have really shaky hands and you can imagine the needle moving a centimeter, a little bit too far or a centimeter too back can really mess up if you're in the vein or not. So we always check to see, okay, am I getting blood flow? That's a good sign you're actually in your right target. Now, once you actually get blood flow, just like before, you're gonna put a wire through it to essentially go to the duration of the vein and now you have a placeholder. But the difference between arterial line that we just talked about before and this one is that your catheter is gonna be much bigger in terms of your diameter. So it won't be able to easily go to the skin unless you open it up and dilate it. So you can see that that's what they're doing now. They're essentially taking the wire they already have in place and they're gonna put a dilator. This is not gonna stay in the patient by any means, but essentially it's gonna be able to break through any sub-q, any muscle and parts of the vein. That way when you put the catheter in, it's the same size as a dilator and so then the catheter will be able to nicely flow through. This is the part where you sometimes have to kind of go through their sub-q and their tissue to just kind of give yourself a very clean path to go. But if you do it correctly, everything else becomes so much easier. And then once you get your dilator in place, you take it out and you replace it for the catheter you actually wanna put and you go ahead and just essentially hub it to the size of the neck, especially if the patient is of normal size. Now that the line is in, the most important thing you have to do before you actually use it, before you give the nurses permission to use it is you wanna make sure it's in the right place. Yes, you saw the vein, you're really almost 99% confident but the worst thing you wanna do is realize later that you actually went into the artery. So the first thing that we do is we order an X-ray that usually will come in within 10 to 15 minutes and we'll take a picture like this and this is the heart. Essentially you want this line, again they went on the right side of this patient's neck to be a little bit right sitting at their SBC which is their super vein of Kiva. That's the big vein going into the right side of their heart. This is usually good as long as the line doesn't look like it's going into arterial system. So over here or over there or if it's too far in the right ventricle you're usually good and sometimes the radiologist will tell you it looks perfect or you need to pull it back a centimeter or two before you start using it. Now to finish off central lines another reason I may have to do a procedure like that is if somebody has to start dialysis either temporary or if they're about to become a permanent person that's on dialysis you may have to put a central line in with a bigger, wider dialysis catheter so you have to even dilate even more and more often but it's essentially the same principle we call those dialysis or quintines but essentially it's like putting in a central line in terms of the procedure. The line that you use is just a little bit different for the purposes of what the patient needs. Now that we talked about arterial lines and central lines probably my most favorite especially as a brand new doctor has to be a thoracentesis. Now imagine seeing an X-ray like this you can see that this patient right here would definitely have trouble breathing because on one side they're along and they have a lot of fluid. Now this is very classic if somebody has an infection or if they have recurring cancer that is just not able to be controlled. They'll continue to form pleural fusions over and over again and so sometimes the best thing you can do is just drain it out for the patient and take anywhere from a liter, a liter and a half and really will make the patient feel amazing. You can see how a patient will quickly feel better when they go from X-ray like this to this one where clearly the fluid comes down significantly. And the quick and dirty way of how this works is essentially you will find a good place between their rib spaces and their back and you'll use a kit like this that's called a safety synthesis kit. Essentially you can think of it as a needle but the top of the needle is actually blunt. So take for example my pen right here. I'm gonna go ahead and put the tip out. Now one, it's going through somebody's skin. It's going to try to do what it's supposed to which is actually break through it. But as soon as it gets to the other side so you can imagine that there's fluid on one side of somebody's body and then this is their outside of their environment it's gonna break through and break through but as soon as it stops hitting any skin or muscle it's gonna just go ahead and let the tip go and it's gonna be a blunt tip. So nice thing about a safety synthesis kit is that because it gives the tip away as soon as you're in an open space like fluid you have low risk of hitting other organs like if the lung was there or the diaphragm or the liver. And so if I know that I have a good enough pocket I can go into, I can go in there with pretty good confidence as long as I'm able to kind of get through their muscles and their sub-q then as soon as I get into the fluid everything will go away and the fluid will nicely flush in to the rest of the catheter. So as a quick demonstration this patient right here is gonna go ahead and get that same thing they're gonna go first put some lidocaine because this process is not very nice in terms of pain you wanna make sure that it's comfortable for the patient. And in this video they're not using a safety synthesis kit but the idea would essentially be the same as soon as the needle gets into their space in their lungs where the fluid is the tip would essentially go away and the syringe would be able to pull back on fluid. And so they're gonna go and go and go until they get fluid and they draw it back and then you can essentially keep drawing until you get about a liter, a liter and a half or if the patient starts telling you that they can start feeling the catheter. Now the reason this is probably arguably one of my favorite procedures is the patient just feels significantly better as soon as you're done. They're able to sit up, go down, lay down the next day they're like, oh, I feel amazing. And sometimes we do have patients where we have to do this pretty often especially on some of our cancer patients that develop fluid unfortunately in their lungs quite often because their cancer isn't controlled and sometimes we may have to do the procedure once and then just leave a catheter and that they can then essentially just drain like a water fountain when they feel like they have a lot of fluid once or twice a day. Now that we've talked about some of my favorite procedures that I get to do as an internal medicine physician, let's talk about things that are probably lower on my list. Number one has to be by far a paracentesis. So just like a thoracentesis is essentially poking somebody's chest to get fluid out, a paracentesis is essentially poking somebody's belly to do the same. And one of the most common reasons that we have to take fluid out of somebody's belly happens to be cirrhosis or liver disease. And a lot of these patients that I see will just be accumulating fluid because their livers just don't do a good enough job of holding onto protein so their fluid essentially goes everywhere except their vessels and they start to accumulate and accumulate and they look like a balloon that's about to pop. And as you can imagine, that's very uncomfortable when a patient can't function in their day-to-day life. In addition, a lot of these patients, particularly liver patients, have a high propensity for things like infections. So if we do find fluid, the first thing we want to make sure is, is that the source of where their fever and their infection may coming from? So getting a sample and then sending it to the lab is also very helpful. Now just like a thoracentesis, we also use the Safety Synthesis Kit. So just like before, I'm trying to go through their muscles and their fat and their belly and I'm going to basically be using an ultrasound like this one and essentially be able to say, oh, all this black stuff is fluid or asides and as long as I have a big enough pocket, usually I'll go anywhere from two to three centimeters, that means I can comfortably put a needle in there and no, I'm not going to hit their bowels or their liver. Now the reason this happens to be one of my least favorite procedures is that once, often the patients who get them are often very sick. So a liver patient also has a high propensity of being very confused. So you're trying to take fluid out of somebody to make sure they don't have an infection or at least make them feel better, but often they can't sit still and if you're poking somebody with a needle, it's not comfortable, I know, I probably wouldn't sit still. So having somebody who's very anxious or very confused sits still, not the greatest thing. Now the second reason I don't like it is compared to a thoracic entices where everything is very just firm in place, your ribs are in place, your muscles, your sub-queue, it's very easy to know when you're going forward because things don't bounce. Compared to the belly that does bounce, it does feel like you're kind of pushing into a balloon and just hoping that your catheter or your needle eventually breaks through, but then there is like a, in the back of your mind, am I pushing too hard or am I eventually going to hit the bowel? Remember, you have a safety centesis kit so you're not going to, but it's still this weird pushing feeling that you're trying to get through. You really hope you don't hit anything and it's not comfortable to the patient who already has a lot of pressure. So there is like this balloon effect that you're trying to push against, which is much harder in my opinion compared to just trying to break through the muscles and the sub-queue in somebody's back. Go ahead and actually comment down below if you're watching this on YouTube, how many milliliters CCs or liters if you think it's that much, I take out of a typical liver patient. Now, if you put your guests down below, the most I've ever had to take out, somebody is 12 to 15 liters and the most I've seen on somebody's chart is 26 liters of fluid in somebody's belly. Now, that is a lot. So taking it out takes a lot of time. There's really only two ways you can do this. One is manually pulling on the syringe and pushing it out the other way. That's a three-way stop clock, so it's going to take out fluid from the belly. It's going to draw it into the syringe and then when you push on the syringe, it's going to go out into a bag. Or the third way is that you hook it up to a vacuum and you have it go through canisters. The unfortunate part is that most of the canisters that we have in the hospital only are about a liter big. So if somebody has 12 liters need to be taken out, I first have to find 12 bottles and then every time I'm putting the fluid through, once the first one is done, which does take a while, it's not just doesn't spurt out, I like drips. You just have to wait for it to fall. Then I go to the next one, and the next one, the next one, you do it 12 times. I've done the manual process where I've had to pull and push hundreds of times to get an adequate amount of fluid and I've had to do the canister. Regardless of how you do it, it still takes 20, 30, 40, 50 minutes of being in the room with this patient just doing that. It's very mundane and it's very boring. Thankfully as an upper level resident, I usually don't do these procedures as much as I supervise them now as new doctors are learning to do them for the first time. But still, when I had to do them, I would definitely get those arm cramps. Now we do this internal medicine a lot for a few things. One, if we're concerned if somebody has an infection like meningitis or encephalitis, or if we think somebody has a lot of pressure or fluid in their brain and we need to train some of that fluid out to get rid of headaches. And finally, if we're concerned that somebody may have cancer that has spread to their brain, sometimes we have to go ahead and get a sample of their spinal fluid. Now essentially what a lumbar puncture involves is that you go ahead and position your patient to where they're gonna go ahead and be either laying on their side or sitting up front, depending on how with it they are. So a patient with meningitis, probably just best that they just lay down and try to make sure they don't move. Compared to a patient who's very with it, you'll just kind of have them lean against a table and just kind of wait for you to finish your procedure. Now the trickiest part of a lumbar puncture is that you have to get your anatomy right. As you can imagine throughout your back, you have your spinal cord with a bunch of nerves that you do not wanna hit with the needle. And so to do a lumbar puncture, you have to go to some of the lowest areas where you know the spinal cord has finished and then you have a few vertebrates of safety just in case. And essentially the way you do a lumbar puncture is you will feel for somebody's top of their hip bone and essentially it will tell you where they're L4, L5 spaces and that is a target that you are okay to go to if need be. Now while this seems simple in practice that I can just find the top of the hip bone and move to the middle and say, cool, that's my target, it's very different from patient to patient. One, if you have a really big patient, it can be hard to say, okay, first of all, where are your hip bones? And then hopefully that you're aligning yourself to the middle, especially if you can't feel their vertebrates as well because they have a lot of sub-q. And second, if a patient has any type of curvature in their back, yes, you may feel where their target is but their back may curved but their spine may actually be still central. So even though you may actually be going to space your target and to be able to get the spinal fluid may be a little bit off to the left or the right. Compared to some of the procedures that we talked about, you don't really do this one through ultrasound. I have done in the past just to be able to find my landmarks but you won't be able to actually see your needle go into the right place to get your spinal fluid. So as you can see in this video, they're feeling for the top of the iliac crest and they're gonna go ahead and just line their thumbs until they find the right vertebral space to go to and usually we'll mark it or sometimes what I'll do is I'll grab the syringe and I'll kind of suction out because then that little bit of suction will stay on their skin. Now once you have them cleaned up, you're essentially going to be using a needle with the stylet at the end and going in the direction of where you think your spinal fluid will be. Now this is going to be a big kind of by feel kind of procedure which is why it's so difficult. And again, I haven't done as many of them compared to the first few procedures I talked about. And essentially where you're gonna be doing is you're gonna be going through the different layers of the spine or the back until you go ahead and feel a pop. And then once you're there, then eventually you know you'll be right nicely in the subarachnoid space be able to grab some of the fluid. Now usually we're taught that once you feel the pop that you're usually on the second to last layer and you'll be able to get right nicely into the subarachnoid space to get that fluid off but it's not as nicely or easy as it's spelled out to be. Maybe some people make it look very easy. And again, if you're off a little bit to the left or right or up or down, you won't be able to do anything. I've had a lot of times where I'm just hitting what feels like bone and don't even know which way I'm going anymore. And in those situations, I need help from somebody who's clearly done this procedures more than I have. But if this is gonna be a procedure you're gonna essentially be doing a lot in your future and neurologist or if you're going into oncology you'll be doing this a lot with some of your leukemia lymphoma patients. Once you go ahead and think that you have fluid you pull the stylet out and you essentially see this fluid flow off nicely just like you're saying here there's some drops of fluid and then you start collecting it in your samples. In addition to actually collecting the samples you can actually measure the pressure that is representative of how much pressure is in the head by getting an opening pressure. Essentially you'll get a fancy little chemistry set going on and you essentially will see where does the fluid top out of that is essentially your opening pressure. There's usually a set of normal and if a patient has extraordinary high that usually will confirm a diagnosis like pseudo tumor. Now there's other procedures that I've done here and there including solar injections, knee injections for things like steroids especially if somebody has very chronic pain for things like osteoarthritis, rheumatoid arthritis but those aren't things that have done enough in residency and unless you're going into those specific fields or if you're gonna go into a very outpatient heavy medicine kind of setting you won't really do those. And on the same note every single subspecialty with internal medicine also has their own unique procedures. For example if you're going to GI things like colonoscopy, endoscopy where you're looking through or things like an ERCP where you essentially go through the biliary system to be able to take out a stone be able to make diagnosis like pancreatic cancer and things of that sort. If you're going to cardiology going into somebody's carotid system and being able to find out that a heart attack remove blockages, place stents, remove and exchange vows lots of cool and different things there as well as electrophysiology if somebody has an arrhythmia and you want to essentially burn it off so then their heart can function there's some cool stuff. If you're going into hematology or oncology you may want a sample from somebody's bone marrow and usually the way they do that is essentially drill through somebody's hip to be able to get a nice little core of their marrow and then be able to send it for studies and you can do that for your cancer patients to see is their cancer responding to your treatment. If you're going into pulmonary one of the procedures you may end up doing very often includes intubation as well as bronchoscopy where you're essentially using a camera to go into somebody's pulmonary system look at their lungs and their airways could draw samples as well as break up any blockages that may be causing a patient to fever or have shortness of breath. And then finally if you're going into nephrology or interested in the kidney you may be doing procedures like renal biopsy as well as some of the procedures that we already talked about in today's episode. So bottom line internal medicine is freaking cool. If you're considering it definitely check out this episode right here on the main reasons that I love internal medicine after doing the job for two to three years. If you have any questions make sure you drop in the comment section down below. If you did get any value out of this you're like that was actually very helpful. All I ask in return is you hit the like and subscribe button if you haven't done so already as well as hitting that notification bell to be notified when new videos go out like this one. And if you're listening to this on a podcast and audio form hopefully you enjoy the content definitely consider hitting that follow or subscribe on your favorite listening platform. But with that my friends hopefully you guys enjoyed this video. Again if you did enjoy this one check out this video right here on the main reasons that I love internal medicine as well as this video right here on all the different ways that I use to actually learn medicine as a full-time doctor. Thanks as always for being a part of my journey. Hopefully I was a little helped to you guys on yours. I'll see you guys in the next one. Peace.