 The Good Doctor. I really am not familiar with this show. I know a little bit about it, but I feel like today's show is going to be a little interesting. Welcome back to the channel, everybody. For those of you who are new around here, my name is Michael, aka Dr. Chalini, and I'm a board-certified, diagnostic and interventional radiologist. And that last part is going to come into play in this video. So just this week, one of my coworkers that does all of my outpatient scheduling, shout out Lisa, told me that they mentioned interventional radiology on the show Good Doctor. And when I heard that, I went back to Google, typed in Good Doctor New Season, season six, episode one, the first episode this past week, and I opened it up. But before I did that, I decided to turn on the camera, record it because if they're mentioning interventional radiology, I want to watch it for the first time with you all and critique it, because that's my favorite thing to do. And before I get into this part, by the way, this is like an hour-long video, and I'm not going to make this an hour long, so I'm going to fast-forward to the part where it looks like there's going to be interventional radiology based on what I'm seeing on the little scroll caption. So let's fast-forward to, like, a quarter of the way through this first episode. Dr. Glassman says Dr. Lemoners Villanueva may be hurt on the fifth floor. So I don't know who Dr. Lil Nova. I'm not even saying that right, but I don't know who this person is, because I don't watch the show, but hopefully something will come together here. Is anyone here? I'm really sick. I'm not going to be the shooter or a sick guy. There's a shooter in here? I must have fast-forwarded. I'm only like a couple of minutes into the episode here. Let's throw it on. We can 3D-coded pulse. I love how he used his ear instead of a little thing called a stethoscope, old scroll. Let's throw it on some. So I actually don't know who they're operating on here, but I think maybe I don't know what's going to happen. Lessor races for the pulmonary hyalum. Left ventricles nicked. This will cause the tamponade. So basically when he stuck the needle in the peritardium, there was blood around the heart or cardiac tamponade. Stuck the needle around the heart into the peritardium, sucked out all the blood. Then when they went into the OR, I think this is the same patient. Well, that's what I'm gathering here. There was a laceration of the pulmonary hyalum or the main kind of branch point of the pulmonary vessels and also a laceration to the actual peritardium or the heart. I don't know which one yet, but that's what caused the blood to accumulate around the heart. And when the blood accumulates around the heart, the heart isn't able to expand and pump like it should. And therefore, the blood does not pump to the rest of your body, which is why it is an emergency to relieve that pressure or relieve the blood around the heart. As a grade four liver laceration with active bleeding into the peritardium. So grade four liver laceration, it's a high-grade liver laceration, usually caused by trauma. We see it a lot in patients who are in a bad car accident, usually from blunt force trauma, but I think this person was stabbed maybe, can also obviously be from that. I've seen it be caused by many different things, like a couch falling on someone and causing a very bad liver laceration. So maybe that's what they're going to repair because that's not really an easy repair in the operating room, but it's a lot easier sometimes to get from an interventional approach or a vascular approach, which is what I would do. We can do an NGO embolization instead. And if that goes south, you need a major transfusion That can't happen, we're in a lockdown. A hematectomy would decrease her life expectancy by 10 years. Life expectancy, Sean? She has 20 minutes, maybe, unless we can stop this hemorrhage. So basically they're going through the options of what you can do if someone has a bad liver laceration. He says a hemohepatectomy or resecting a piece of the liver, which he's saying gives her a low probability at a long life, but in the setting of an emergency, if you can give someone five, 10, whatever, many years, it's better than nothing. You are being short-sighted. He's very short-sighted. I wanna keep her alive. Dr. Glassman, Dr. Andrews needs your help with Villanueva. Dr. Gull is showing up. Sean, you are going to cut out and damage low, do you understand? So I don't know if Sean is a resident or not, but it sounds like that older guy is the attending and he's like making him do the hepatectomy even though he doesn't want to. Which, you know, he, all he's gotta do is go down to IR, which I hope is what they're going to do. She's unconscious. There's no way to test the collateral circulation to see if there's enough to perfuse her right. She's young. I'm willing to take that bet. You're willing to risk a massive stroke as opposed to letting her bleed to death? Yeah. These are actually all good scenarios here. These are the things that a lot of surgeons, physicians, interventional radiologists, we're thinking about all these scenarios in our head very quickly about what we can do, especially in an emergency situation, to save someone's life and what's the best option for that patient, given all the circumstances. And this is a lot to think about, but a lot of people don't realize is we do it very, very quickly and you have to come up with a plan fast or else we know what can happen. Do not need to take half a lever. We can do the angioembolization safely. What you told Dr. Glassman you were going to do the hemipatectomy. For others have changed. The angioembolization is the proper choice. Should someone let Dr. Gossman know? Inform him if you like. It is the proper choice in this case. I will say I agree with him here, even though I don't really like know the case. And basically what I'm trying to say is you would at least try to do the angioedram and embolization first. And if that fails, then you may go through with the hemipatectomy, but you should always start with the conservative minimally evasive approach, especially if the patient is stable like they are now. Now, one thing I will say though, is this guy is a surgeon. He is not an interventional radiologist. So a surgeon or a general surgeon or a hepatobiliary surgeon or a trauma surgeon don't know how to do interventional radiology procedures. So they would need a board certified interventional radiologist to do this. So I'm hoping that he's not the one that's doing this and they call on someone like me. Shawn, did you change the surgical plan? The parameters, it was based on changed. I adjusted accordingly. Well, now he's getting the flak. This is what happens. I mean, if he is a resident, which I don't know if he is or not, and he changed the attending's plan without telling him, woo, not only is that dangerous, but he may not finish residency if you do something like that. Also, I guess he's now an interventional radiologist, but that's neither he or nor there. And ignored my instructions in favor of what you wanted to do? Yes. How far into this are we? I located the site of contrast extravasation and the catheter is in position. Okay. When we're talking about extravasation, that means when we inject contrast within the artery and we see it going outside of the vessel, it's extravasating into the belly. So that's the site of bleeding. So when we say there's contrast extravasation, that means there's an area of acute hemorrhage because the contrast is just doing what the blood usually does because we're injecting it in the vessel. That's a scream. We're locked in. Give me a coil. So the interesting thing is on that angiogram, there actually are coils. So somebody, either him or whoever, already embolized something, but they just didn't show us. And what he just said right there was, give me a coil. That's a little platinum coil. It's literally a coil, very tiny, that we insert into the vessel and block off the vessel that's bleeding. And that's known as an embolization. One area of extravasation remaining. Deploying my coil. Let's go back to that picture. Let's study that for a second. So a couple of things going on here. One, that screen is so far away from where they're working. So I don't know how they see that. But nonetheless, basically they have a catheter up into some artery. It looks like a hepatic artery and there's already a big coil packed centrally, which you see all those little squiggly lines. And then there's one random coil that's up north, which maybe that just like flew out of there. Who knows? But that's basically what they're doing. They're coiling the area of bleeding so that it stops off and clots off and no more bleeding. Herry 168, big drop in BP. Coils are flying, we're still bleeding. I don't know if he said the coils are flying, which means they're not going where they're supposed to or there's another side of bleeding. Large collateral vessel must be damaged. We can inject gel foam particles for distal embolization. Okay, that's partly true. Gel foam particles aren't really a thing. There are a couple kinds of embolic or embolic agents that use temporary and permanent. Gel foam is a temporary agent, which is more of like a styrofoam type material that when you mix with saline turns into like a slushy or what we call a gel foam slurry. It's a temporary embolic. It usually stops the bleeding for one week, two weeks, four weeks. Different studies show different lengths of time that it stops for but that's considered a temporary agent. Permanent agents are something like a coil which stays in your body forever. It blocks off the vessel and it'll always be blocked off forever. Particles are separate from gel foam. They're teeny, teeny tiny particles like 200, 300, 400, 800 microns size each and we inject them to go distally into the very, very, very tiny capillary vessels to block off smaller vessels that are bleeding. You don't inject particles and gel foam at the same time. That's not really a thing. Don't touch her. I'm injecting contrast. I am removing the packing, Sean. I see how to stop the bleed injecting particles. And you wouldn't use particles in this case for someone who is actively hemorrhaging. The particles are way too small and they wouldn't block off the blood vessel. Complete embolization with the residual bleeding. So basically he blocked off the blood flow to the second site of bleeding with the particles even though you and I both know that's not how you do it. I would have probably used glue. Yeah, glue, like super glue, or I would use more coils or you could also use gel foam in there, but particles are the last and only embolic that I wouldn't use here. Nonetheless though, you will see a dramatic drop in heart rate or increase in pressure in someone who's bleeding after you embolize them. It's actually a pretty rapid response. Okay, let's close her up. So it looks like he did the right thing after all. Once again, interventional radiology saves the day. At least he's humble about it, huh? So I don't think there's any more interventional radiology in this specific episode, but hopefully you got a little taste there. I don't wanna drag this out too long, so we'll end it there. Hopefully you all enjoyed this video. If you have any questions about interventional radiology or this procedure or anything like that, leave them in the comments below. As always, make sure you smash like, subscribe button, follow me on Instagram and TikTok if you don't already and check out Chilini Rounds podcast. I'll put a link up here and in the description below. You need to watch our podcast that I do with my two brothers. I promise you, you'll laugh, you'll love it. If you like medicine, if you like laughing, you'll like this podcast. So go check that out and I guess as always, I'll see you on the next one. Bye.