Emergent IR cases? On-call lifestyle questions, etc.

[PJB1018]

I've heard that doing IR is basically like committing yourself to a surgical lifestyle, or at least somewhere in between the ENT/Ophtho lifestyle and the GenSurg lifestyle. However, I don't really have a good understanding of what sorts of procedures IR does that are emergent, and actually require coming in at 3am. During a call night for an IR doc, do they ever have the option of going back to bed and saying "I'll see them first thing in the morning" a la some of those "cushier" surgical subspecialties?

Sorry, this is my first-post, so if it's in the wrong place or breaking some type of forum rules, just let me know.

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[badasshairday]

I've heard that doing IR is basically like committing yourself to a surgical lifestyle, or at least somewhere in between the ENT/Ophtho lifestyle and the GenSurg lifestyle. However, I don't really have a good understanding of what sorts of procedures IR does that are emergent, and actually require coming in at 3am. During a call night for an IR doc, do they ever have the option of going back to bed and saying "I'll see them first thing in the morning" a la some of those "cushier" surgical subspecialties?

Sorry, this is my first-post, so if it's in the wrong place or breaking some type of forum rules, just let me know.

I think diagnostic radiology is between general surgeon and ENT/Ophtho lifestyle in private practice. Interventional radiology is probably much closer to a general surgeons lifestyle.

-GI bleeds that need embolization are nortorious for occuring after hours.
-Percutaneous nephrostomies always become an IR emergency after 5pm on a Friday.
-Critical limb ishemia at 3am becomes your problem even if you aren't doing much elective angioplasty in the day time.

Just to name a few. It is a cool field, but definitely a tough lifestyle.

 

[tco]

It seems that bleeds, bleeds, bleeds are the main reason that IR gets consulted at 2 AM. Bleeds that can be embolized to fix the problem, and bleeds that cause problems for surgery to see the problem and fix it. Also, as mentioned, limb ischaemia is an emergent condition that requires the attending to roll out of bed and get to the hospital. PEs causing severe right heart strain can also be treated by IR... Those never happen at 10 AM on Tuesday.

 

[shark2000]

It seems that bleeds, bleeds, bleeds are the main reason that IR gets consulted at 2 AM. Bleeds that can be embolized to fix the problem, and bleeds that cause problems for surgery to see the problem and fix it. Also, as mentioned, limb ischaemia is an emergent condition that requires the attending to roll out of bed and get to the hospital. PEs causing severe right heart strain can also be treated by IR... Those never happen at 10 AM on Tuesday.

This is what happens.

The patient comes to the hospital at 10 am with lower GI Bleeding. He is stable. He is admitted to hospitalist service at around 11 am. They start IV fluids and put a GI consult at 1 am. GI is busy doing screening colonosocpies and since the patient is stable, they do the scope at 6-7 pm. They can't find the spot. They plan to do another scope tomorrow AM. Later at 9 pm the hospitalist checks another set of Labs and the Hb is 3 units less than am number. He immediately calls IR and asks for emergent procedure. By the time you get to the hospital and call in the techs, it is 11 pm. A visceral angiogram may take up to 3 hours.

 

[badasshairday]

This is what happens.

The patient comes to the hospital at 10 am with lower GI Bleeding. He is stable. He is admitted to hospitalist service at around 11 am. They start IV fluids and put a GI consult at 1 am. GI is busy doing screening colonosocpies and since the patient is stable, they do the scope at 6-7 pm. They can't find the spot. They plan to do another scope tomorrow AM. Later at 9 pm the hospitalist checks another set of Labs and the Hb is 3 units less than am number. He immediately calls IR and asks for emergent procedure. By the time you get to the hospital and call in the techs, it is 11 pm. A visceral angiogram may take up to 3 hours.

Exactly.

I remember a massive variceal bleeder who coded in the ED at 11am. Needed 25 units PRBC's. The GI guys ordered a Minnesota tube (google it) to tampenade the bleed. They scoped or planned for scope, I forgot the details. But anyways finally around 6 or 7 pm they consult IR for an emergent TIPS.

 

[Gute]

In real life these things aren't happening every single night. When I was a medical student I thought critical limb ischemia would be common, but we see it infrequently (we don't even see too many CTA of the legs in patients with limb pain on diagnostic call). Despite bring at a very busy trauma center, our IR attendings come in about once or twice per week at night to do a case. Their lifestyle is no where near as bad as a general surgery.

 

[fun8stuff]

In real life these things aren't happening every single night. When I was a medical student I thought critical limb ischemia would be common, but we see it infrequently (we don't even see too many CTA of the legs in patients with limb pain on diagnostic call). Despite bring at a very busy trauma center, our IR attendings come in about once or twice per week at night to do a case. Their lifestyle is no where near as bad as a general surgery.

coming in 1-2x/week at night is not that bad of a lifestyle?? 😱

 

[shark2000]

In real life these things aren't happening every single night. When I was a medical student I thought critical limb ischemia would be common, but we see it infrequently (we don't even see too many CTA of the legs in patients with limb pain on diagnostic call). Despite bring at a very busy trauma center, our IR attendings come in about once or twice per week at night to do a case. Their lifestyle is no where near as bad as a general surgery.

It is not about how common is limb ischemia. The key is how often do you get called for a consult at night.

In today's environment, if you want to do high end cases in IR, you have to act like a clinical service. You have to get consults and you have to admit the cases in your service.

Limb ischemia may happen once a week, but you get 10 calls a week to assess a patient with questionable limb ischemia. The patient comes to ED with leg pain. It may not be a limb ischemia at all, but the ED doctor asks for a consult to rule out limb ischemia. You can do it or may let vascular surgeons do it.

For a procedural field, you have to do 5-6 consults to get one case. This is how it works. Surgeons don't go to OR in 2 am more than once or twice a week, but they constantly get called in the middle of the night to assess the patient.

Long story short, if you want to do just lines, ports and biopsies that is the different story. If you want to do high end cases, the life style is similar to general surgery.
And what happens in a big academic center is not a good sample of community practice.

 

[tco]

This is what happens.

The patient comes to the hospital at 10 am with lower GI Bleeding. He is stable. He is admitted to hospitalist service at around 11 am. They start IV fluids and put a GI consult at 1 am. GI is busy doing screening colonosocpies and since the patient is stable, they do the scope at 6-7 pm. They can't find the spot. They plan to do another scope tomorrow AM. Later at 9 pm the hospitalist checks another set of Labs and the Hb is 3 units less than am number. He immediately calls IR and asks for emergent procedure. By the time you get to the hospital and call in the techs, it is 11 pm. A visceral angiogram may take up to 3 hours.

Shark tells the truth here.

I'm currently on an away in IR. In the past month, I've stayed numerous times until 7 or 8 PM to put in a drain on a patient that has had signs of infection and the primary service tried "everything else" before draining the puddle in the patient's abdomen. It's not about the treatment or when it comes in, it's about when you get consulted for it. In those cases, the puddle became an "emergency" at around 5 - 5:15 PM.

 

[deleted525628]

Exactly.

I remember a massive variceal bleeder who coded in the ED at 11am. Needed 25 units PRBC's. The GI guys ordered a Minnesota tube (google it) to tampenade the bleed. They scoped or planned for scope, I forgot the details. But anyways finally around 6 or 7 pm they consult IR for an emergent TIPS.

Holy crap, practically the exact same scenario happened where I work except this was on a kid...

 

[PJB1018]

Given that emergent cases are often high-risk cases, what's the malpractice risk like with IR? Is it much worse than with DR?