 What is up, YouTube? Today, we are going to be looking at the expectations versus realities in radiology as they pertain to chest x-rays. So hopefully you guys enjoy and let's get to it. All right, guys. So this first chest x-ray is the expectation x-ray when most people have when they go into radiology or when you're presented with cases as clinicians or physicians and other specialties. You look at a chest x-ray, you're able to pick out all of the anatomy. It's a nice young patient, probably mid-20s, standing up straight, not sick at all, just a routine outpatient chest x-ray. Everyone's able to look at this, know it's normal, have a nice lateral view to compare. You see this, you know it's normal, you move on to the next one. However, let's check out the reality in radiology. I like to call these kind of studies insta-close studies because usually if you're a first-year radiology resident, as soon as you open one of these studies, you close out of the study immediately. You insta-close the study. That way your poor upper level or senior resident or attending has to suffer through this kind of study. But eventually you feel comfortable reading this kind of difficult study and you don't close it instantly. You end up just reading everything that comes across your cue and that's what makes you a good radiologist. But let's get back into it. Okay, so this is the reality of radiology. Most of your patients are going to look like this when they are imaged in the hospital or in a hospital setting, especially if you have an ICU. We get a ton of x-rays like this per day and they can be very complicated and very daunting to look at to a beginner. However, search pattern is key. And if you don't have a search pattern, you can go watch my previous video. I'll put a link up here. And you can check out that search pattern. Go watch that one and then come back to this video. Okay, so my search pattern is a little different when I read ICU or portable radiographs than it is when I do a normal outpatient x-ray. Okay, so the very first thing I do is look at the lines and tubes. When you have a ton of tubes and a ton of layering EKG leads and everything like this, like this patient has, it's very easy to miss a line or miss a malposition line or tube and cause the patient harm. So that is my number one priority in these in these x-rays. So the first thing I notice here is a right subplavian approach impella device. Let's see if I can window in right there. So as you can see, this is the impella device coming from the right subplavian artery. Since I'm on the right already, I'll keep working my way from the right. So the next thing I see is a right IJ approach swan gans catheter, which I'll try to follow this one down for you. So here it is coming in the neck right here, coming down, it loops around through the right ventricle, right ventricular outflow tract, into the main pulmonary artery. And they can advance these things and push them into the right pulmonary artery as well, but this one's in kind of the neutral position. All right, next I'm working my way to the left. We have a left central line. So this is a left IJ approach central venus catheter coming down. It's very difficult to follow down through here. It ends in the right atrium. Next, we notice this inferior approach ECMO cannula, which I presume is a right femoral approach ECMO cannula, and it is overlying the right atrium as well. So next I look at the airway and esophagus. So right here we have an endotracheal tube. Let's see if I can zoom in on this. It's terminating right here. This is this long radiophage line coming down. It's terminating right just above the clavicular heads. Next, you can sort of see a nasogastro tube coming down. You can kind of follow it down. Let me see if I can zoom in here. You can see it coursing down the esophagus through the GE junction, which you can't really see distally, so you won't be able to comment on its location within the stomach. All right, so now we got the lions out of the way and the airway and esophagus. Let's go to the lungs. Over on the right hemothorax we have not one, not two, but three chest tubes. As you can see right here, one, two, three with their respective side ports. This side port and this side port. On the left, you'll notice the left pleural pigtail catheter as well. And I think that about concludes all the lines and tubes in this patient. Okay, once I got all the lines and tubes out of the way and I know that they're in correct position, I moved to the actual lung field. So what I do is I will zoom up just like I did on the prior X-ray example. I will make sure there's no pneumothorax. I can switch to inverted windows if I need to. Now, this patient does have chest tubes in here. So if I saw a pneumothorax, it would possibly mean that the chest tube, that the chest tubes are not working properly, but I don't see one in this case. And oftentimes it's very difficult to see a pneumothorax in these patients because they're hunched over and not seeming upright. So the next thing I do after really not a pneumothorax is look at the actual lungs. So this patient has really low lung volumes or hypo-inflated lungs. You can tell by the elevated diaphragms, almost obscuring part of the heart. Next, I will check out the left lung field, which looks pretty clear. Honestly, I see no obvious pleural fusion down here. Moving to the right, you can see that there is a nice tracking opacity along the right lateral pleura and into the crostophenic angle down here. That likely represents a pleural fusion tracking along the pleura. There's also a more focal opacity along the right minor fissure. This could just be a loculated portion of fluid or a loculated pleural fusion in this fissure. Or it could be an underlying mass or infection. There are a lot of scattered, diffuse opacities throughout this lung as well that could be secondary to the pleural fluid tracking the lung, making the lung wet. There's also probably a nice component of atalaxis, giving the low lung volume in this area. However, underlying infection is also a possibility, and that depends on how the patient is doing clinically. All right, so once we got the lines and tubes and lungs out of the way, the next thing I do is look at the mediastinum. So I want to make sure there's no pericardial effusion or obvious enlargement of the cardiac silhouette. Make sure there's no pneumomediastinum or pneumopericardium. The next thing I do is look at the bones and soft tissues. The soft tissues look good. I kind of glance around the chest wall and the neck. You'll be able to see some soft tissue gas tracking along the chest wall. If one of the chest tubes is now positioned next, you want to make sure there's no obvious osteosabnormality. So these soft tissues and bones look good in this patient. All right, guys. So that concludes this session of expectations versus reality in radiology. I plan on doing this with a few other modalities in radiology as well. So if you like it, make sure you smash that like and subscribe button. Leave a comment below. If I like it, I'll respond to it. Otherwise, I will see you guys on the next video.