Interventional Radiology and Critical Care

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Anyone have any experience with interventional radiologists pursuing further training to staff the ICU? Recently heard about Khanant Desai at Brigham who appears to have done both IR residency and a critical care fellowship. It seems intriguing.

 

[gro2001]

Have not heard of IR docs do this.

It's fairly common in the Interventional Neuro-radiology world. For neurologists going into INR, either a stroke or a neurocritical care fellowship are prerequisites for an INR fellowship. So this neurology -> neurocritical care -> interventional neuroradiology is a fairly common path. Most folks who go down that pathway don't do much if any ICU time though. It's a significant pay cut to spend any time on service in the ICU in lieu of endovascular, makes the endovascular call schedule harder to arrange, and they are already fairly involved with their ICU cases anyway.

I imagine the DR -> IR -> CCM pathway to be quite challenging as I'd think it doesn't provide much exposure to general medicine, resus/physiology, or non-IR procedures.

 

[CCM-MD]

I saw PM&R to critical care a few weeks ago, now radiology to critical care.

We are living in a reality which is disconnected from logic and common sense.

 

[SurfingDoctor]

Nope.

Why would they want to do that?

 

[sloh]

I saw PM&R to critical care a few weeks ago, now radiology to critical care.

We are living in a reality which is disconnected from logic and common sense.

I cant decide between PM&R and Neurology. Looking for advice

I cant decide between PM&R and Neurology. Looking for advice

I am a crossroads regarding what I want to go into between Neuro and PM&R. Hoping someone could shed some light on suggestions as there are benefits to both specialties and reasons I like them each. Neuro: I enjoy like neuro trauma and the acute care aspect of it. Deciphering the diagnosis and...

forums.studentdoctor.net

Nuts indeed. Read the post I linked about PM&R —> CCM

 

[Radetzky]

Why would anyone do that?

 

[Clean7795]

I have never seen nor heard of this. The purpose of someone doing radiology is to get away from ward care and spend all day reading images or doing procedures.

Theoretically could a radiologist learn to work in that environment? Sure. If you did a medical internship you probably have more general medical training than some... But really, the point of radiology training is to form someone who can interpret images, do some procedures, and run the radiology department... most of your training goes to waste in the CC setting.

 

[irwarrior]

For DR physicians may not have much of a role.

For VIR physicians it makes more and more sense to have some ICU experience. ICU training is a requirement of the current integrated VIR training program as well as ESIR. The patients that come down to the Endovascular suites are often quite ill . HFrEF (EF 30 pct) ; Critical AS; ESRD; Bleeding patients (GI bleed/trauma patients/ hemoptysis/epistaxis/ solid organ bleeds/ vatical bleeds) so mass transfusion protocols and correction of coagulopathy helpful. DVT/PE patients and RV dysfunction and knowing how to navigate the RV at stress is helpful as is dealing with the countless septic patients (biliary/ cholecystitis/ necrotizing pancreatitis with abscess/ pyonephrosis etc) and how quickly they decompensate. There is often no anesthesia support and so the management has to often be initially provided by the VIR physician.

Many of the ESRD patients are quite sick and are likely to code at some point in the VIR suites. A VIR physician should be comfortable as the first responder in initiating ACLS . Now with the growth of OBL/ASC it will require more and more comfort in handling these near code or code situations.

Some interventions we do in the adrenal gland/ thyroid gland etc can result in difficult to control hypertension and having some comfort with iv anti hypertensives is of benefit .

 

[Doc Doc Doc Goose]

For DR physicians may not have much of a role.

For VIR physicians it makes more and more sense to have some ICU experience. ICU training is a requirement of the current integrated VIR training program as well as ESIR. The patients that come down to the Endovascular suites are often quite ill . HFrEF (EF 30 pct) ; Critical AS; ESRD; Bleeding patients (GI bleed/trauma patients/ hemoptysis/epistaxis/ solid organ bleeds/ vatical bleeds) so mass transfusion protocols and correction of coagulopathy helpful. DVT/PE patients and RV dysfunction and knowing how to navigate the RV at stress is helpful as is dealing with the countless septic patients (biliary/ cholecystitis/ necrotizing pancreatitis with abscess/ pyonephrosis etc) and how quickly they decompensate. There is often no anesthesia support and so the management has to often be initially provided by the VIR physician.

Many of the ESRD patients are quite sick and are likely to code at some point in the VIR suites. A VIR physician should be comfortable as the first responder in initiating ACLS . Now with the growth of OBL/ASC it will require more and more comfort in handling these near code or code situations.

Some interventions we do in the adrenal gland/ thyroid gland etc can result in difficult to control hypertension and having some comfort with iv anti hypertensives is of benefit .

Isn’t that why anesthesia I present for these critically ill patients ?
So you aren’t relying on someone with a few months of medicine/ICU exposure?

 

[passiveobserver1979]

How about the reverse i.e a critical care board certified doc doing a IR fellowship. That way there would be no need to have IR on call at night. A critical care doc could take care of everything on his own.

 

[irwarrior]

How about the reverse i.e a critical care board certified doc doing a IR fellowship. That way there would be no need to have IR on call at night. A critical care doc could take care of everything on his own.

Interesting idea. There was Dr. Michael Dake, who developed thoracic aortic interventions. He was pulmonary critical care trained at UCSF and then did radiology and VIR training at UCSF and was an amazing interventionalist.

 

[irwarrior]

Isn’t that why anesthesia I present for these critically ill patients ?
So you aren’t relying on someone with a few months of medicine/ICU exposure?

It is quite hard to get anesthesia at many places given the scarcity of anesthesia in some centers. So, often we have to make due without them. As you deal with more and more of these bleeding and septic patients you start to get your algorithms for management down.

 

[Doc Doc Doc Goose]

Interesting idea. There was Dr. Michael Dake, who developed thoracic aortic interventions. He was pulmonary critical care trained at UCSF and then did radiology and VIR training at UCSF and was an amazing interventionalist.

You mean intenseventionalist

 

[Doc Doc Doc Goose]

It is quite hard to get anesthesia at many places given the scarcity of anesthesia in some centers. So, often we have to make do without them. As you deal with more and more of these bleeding and septic patients you start to get your algorithms for management down.

My point is … that is a huge problem and an issue with the hospital / system. No offense to the amazing things the IR ppl learn and do. But it’s simple: they didn’t spent years learning to manage critical ill pts / learn acute resuscitation. so anesthesia should be present for these procedures on pts with the morbidities and pathologies you describe.

 

[irwarrior]

As VIR physicians are being asked to do more and more on sicker and sicker patients, more and more critical care rotations and training are being incorporated into their rotation schedule at more an more programs. It would be nice to have anesthesia support but as more and more services are vying for anesthesia it is getting harder and harder to have them available. Many of our inpatients have comorbid illnesses and are quite ill and are on the verge of shock.

 

[CopaceticOne]

As VIR physicians are being asked to do more and more on sicker and sicker patients, more and more critical care rotations and training are being incorporated into their rotation schedule at more a more programs. It would be nice to have anesthesia support but as more and more services are vying for anesthesia it is getting harder and harder to have them available. Many of our inpatients have comorbid illnesses and are quite ill and are on the verge of shock.

I think this is the critical point with respect to patient safety. When a patient is in a clinically tenuous state the individual performing the invasive procedure can not devote their complete attention to both 1) doing the intervention and 2) managing the minutia of the hemodynamic changes. Sometimes a slight change in HR is enough to warrant an intervention. Sometimes a NIBP result in the “normal” range actually requires intervention based on trends.

Trying to multitask critical activities only puts people at risk. People being the patient clinically & the proceduralist medico-legally.

The proper solution is to have the hospital appropriately staff personnel for the clinical needs of the patient population.

 

[irwarrior]

This would be ideal. Many of the interventional procedures are getting more and more complex and longer duration and on sicker patients and some can be quite painful and needs deeper sedation than moderate sedation.