Why is CT Surgery considered dying even though it has the thoracic (lung) domain?

[LebronManning]

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So many physicians I speak with all say CT Surgery is a dying field and that Interventional Cardiology is taking a huge and growing portion of the heart domain. Obviously, there's a lot of truth to this, but there will always be some heart things only a surgeon can fix. It's worrisome though that this eventually becomes so small that the demand for CT Surgeons will become shockingly low.

My question is why is CT dying when they can theoretically always fall back upon lung surgery? I'd assume most of these are cancer related surgeries so are they usually in the domain of CT Surgeons or does one also need a surgical oncology fellowship for this at most institutions? Or do these surgeries belong to the Thoracic only surgeons?

 

[ThoracicGuy]

So many physicians I speak with all say CT Surgery is a dying field and that Interventional Cardiology is taking a huge and growing portion of the heart domain. Obviously, there's a lot of truth to this, but there will always be some heart things only a surgeon can fix. It's worrisome though that this eventually becomes so small that the demand for CT Surgeons will become shockingly low.

My question is why is CT dying when they can theoretically always fall back upon lung surgery? I'd assume most of these are cancer related surgeries so are they usually in the domain of CT Surgeons or does one also need a surgical oncology fellowship for this at most institutions? Or do these surgeries belong to the Thoracic only surgeons?

Most thoracic surgeons do either cardiac or thoracic. There's not all that many that do both. Sure you'll find some cardiac surgeons that do lungs on the side, but they rarely do them all that well compared to a general thoracic surgeon.

The field isn't dying. People have been calling for its death for years, yet it keeps on going.

 

[Medstart108]

So many physicians I speak with all say CT Surgery is a dying field and that Interventional Cardiology is taking a huge and growing portion of the heart domain. Obviously, there's a lot of truth to this, but there will always be some heart things only a surgeon can fix. It's worrisome though that this eventually becomes so small that the demand for CT Surgeons will become shockingly low.

My question is why is CT dying when they can theoretically always fall back upon lung surgery? I'd assume most of these are cancer related surgeries so are they usually in the domain of CT Surgeons or does one also need a surgical oncology fellowship for this at most institutions? Or do these surgeries belong to the Thoracic only surgeons?

Thoracics is not dying, Cardiac isn't either. The field may shrink in the coming years. The primary issue for CT surgeons is that technology is on cardiology's side. As long as any new technology is as good as open surgery and it is doable percutaneously, surgery is out, especially because cardiology controls the patient. The biggest mistake that cardiac specifically made was they let interventional go to cardiology and they let cardiology take over the clinic. Other surgical specialties have all learned from the mistakes cardiac has made. Thoracics works up primary lung tumours, general surgeons often work up and follow their own cancer patients. The only thing cardiac follows is aortic aneurysms.

In the CABG domain, surgeons have won a reprieve with a few of the latest studies showing CABG is still superior in several areas. CV is investigating specifically total arterial revascularization in more earnest as well. There will always be CABGs for patients who have unfavourable coronary anatomy. Hybrid-CABG aka bypassing the LIMA-LAD in a minimally invasive manner and then stenting the other vessels is experimental.

The valve domain is the one in the largest flux. Aortic valves have traditionally been around 25% of the caseload and most predict that between 50-90% of aortic valves will go to TAVR in the future. Surgeons are fighting to do these procedures but cardiologists invented TAVR and likely have the upper hand in this area. Currently the heart team approach is in place due to funding structures, but as the procedure becomes less invasive and safer, it could settle in the hands of cardiology, although many CT surgeons are interested and many perform them as well. I can see it ending up similar to endoscopy where surgeons and GI do them varying by center and individual expertise. No question though that a certain percentage of valves will be lost to cardiology.

The next big domain is mitral valves. These comprise maybe 10-15% of the caseload and currently there is Mitraclip, but it isn't as good as a surgical mitral valve repair and mainly used in inoperable patients. However, total mitral valve replacements are currently being developed and implemented. Due to the complex nature of mitral anatomy, surgeons are more involved in TMVR and will likely maintain a significant role in TMVR in the future. The issue is, will technology get good enough that a mitral can be done safely and fully percutaneously? Probably, but not sure when.

Heart failure seems to be in the hands of CV for now. However, short term devices and pVADs are in development and could potentially see interventional entering the field in the coming 10 or so years. With that being said, the big long term destination therapy VADs like Heartmate III are still going to be surgery only for the forseeable future. In terms of stem cells, it is nascent, but the reality and probability is that interventional cardiology would have this field. A mesh or an injection would be easily done interventionally.

Transplant is obviously a CT only thing and will remain so. However, we are a long way off of mass produced transplantable organs, by the time they come most of us will probably be retired or close to it.

Will volumes drop? Probably. Volumes are currently stable because the population is aging and hitting the 60-80 peak of having open heart surgery. Once the boomers jump past 80, volumes will drop unless some new technology allowing safe and routine surgery in 90-100 yr olds comes. Then again, volumes have never been high for many surgical fields like Thoracics, which is why there traditionally have been more cardiac than thoracic surgeons at most institutions, in the next 15-20 years the ratio of cardiac:thoracic may drop, but cardiac will always be there. There will always be cases that are open heart only.

 

[LebronManning]

Thoracics is not dying, Cardiac isn't either. The field may shrink in the coming years. The primary issue for CT surgeons is that technology is on cardiology's side. As long as any new technology is as good as open surgery and it is doable percutaneously, surgery is out, especially because cardiology controls the patient. The biggest mistake that cardiac specifically made was they let interventional go to cardiology and they let cardiology take over the clinic. Other surgical specialties have all learned from the mistakes cardiac has made. Thoracics works up primary lung tumours, general surgeons often work up and follow their own cancer patients. The only thing cardiac follows is aortic aneurysms.

In the CABG domain, surgeons have won a reprieve with a few of the latest studies showing CABG is still superior in several areas. CV is investigating specifically total arterial revascularization in more earnest as well. There will always be CABGs for patients who have unfavourable coronary anatomy. Hybrid-CABG aka bypassing the LIMA-LAD in a minimally invasive manner and then stenting the other vessels is experimental.

The valve domain is the one in the largest flux. Aortic valves have traditionally been around 25% of the caseload and most predict that between 50-90% of aortic valves will go to TAVR in the future. Surgeons are fighting to do these procedures but cardiologists invented TAVR and likely have the upper hand in this area. Currently the heart team approach is in place due to funding structures, but as the procedure becomes less invasive and safer, it could settle in the hands of cardiology, although many CT surgeons are interested and many perform them as well. I can see it ending up similar to endoscopy where surgeons and GI do them varying by center and individual expertise. No question though that a certain percentage of valves will be lost to cardiology.

The next big domain is mitral valves. These comprise maybe 10-15% of the caseload and currently there is Mitraclip, but it isn't as good as a surgical mitral valve repair and mainly used in inoperable patients. However, total mitral valve replacements are currently being developed and implemented. Due to the complex nature of mitral anatomy, surgeons are more involved in TMVR and will likely maintain a significant role in TMVR in the future. The issue is, will technology get good enough that a mitral can be done safely and fully percutaneously? Probably, but not sure when.

Heart failure seems to be in the hands of CV for now. However, short term devices and pVADs are in development and could potentially see interventional entering the field in the coming 10 or so years. With that being said, the big long term destination therapy VADs like Heartmate III are still going to be surgery only for the forseeable future. In terms of stem cells, it is nascent, but the reality and probability is that interventional cardiology would be have this field. A mesh or an injection would be easily done interventionally.

Transplant is obviously a CT only thing and will remain so. However, we are a long way off of mass produced transplantable organs, by the time they come most of us will probably be retired or close to it.

Will volumes drop? Probably. Volumes are currently stable because the population is aging and hitting the 60-80 peak of having open heart surgery. Once the boomers jump past 80, volumes will drop unless some new technology allowing safe and routine surgery in 90-100 yr olds comes. Then again, volumes have never been high for many surgical fields like Thoracics, which is why there traditionally have been more cardiac than thoracic surgeons at most institutions, in the next 15-20 years the ratio of cardiac:thoracic may drop, but cardiac will always be there. There will always be cases that are open heart only.

Thank you for your reply and expertise. I agree open surgery can never die but I think even you are echoing that volumes will continue to drop because of the technology on the side of the cardiologists. That and the fact that the referral network is owned by the cardiologists doesn’t put the surgeons at a good spot strategically at all. Hypothetically, which would you recommend someone choose?

 

[Psai]

One is surgical and one is medical. They are pretty different. Also, there have been several well publicised trials about the lack of efficacy of stents. These studies have gotten a lot of press in places like the new york times.

 

[LebronManning]

One is surgical and one is medical. They are pretty different. Also, there have been several well publicised trials about the lack of efficacy of stents. These studies have gotten a lot of press in places like the new york times.

In talking to some interventional cardiologists, I was told the vast majority of those trials were with first generation stents and that the 2nd gen one would fare much better.

I think the real risk comes with structural work though. The Cards guys are who created TAVR and I think they won’t be falling back in structural work and innovation.

 

[Medstart108]

Thank you for your reply and expertise. I agree open surgery can never die but I think even you are echoing that volumes will continue to drop because of the technology on the side of the cardiologists. That and the fact that the referral network is owned by the cardiologists doesn’t put the surgeons at a good spot strategically at all. Hypothetically, which would you recommend someone choose?

I recommend someone choose CT surgery if they love it. You have to love 70 hr work weeks as staff, you have to love 4-8 hr surgeries. If you want to do transplant you have to love operations starting at 1am. If you want to do CT at an academic site you have to love research as well. The volumes will drop but there will be a need. It is up to you if you want to do it or not. If you aren't super sure but you like general surgery, do that first.

Understand though that CT is not the field of the 1980s when people were making 5 grand a CABG, it was an ultra competitive specialty and surgeons were awash in so much money they didn't know what to do with it. No one really wonders now then why CT let Cardiology take pacemakers, angioplasty and clinic away when they were making insane amounts doing CABG only.

I would recommend someone choose Interventional Cardiology if they love it. You have to love 70 hr work weeks as staff, you have to love waking up at 2am to rush to the hospital to do PCI even when you are 50. You have to love research unless you do community. Honestly, they are similar and yet different. Unlike many commentators who repeat the mantra that surgery and medicine are diabolically different fields, they just simply aren't. Both act as MRP, both now do procedures of some sort, clinic of some sort and both can lead to careers in the ICU. Both have horrible working hours. The reality of course with IC is that you need to like IM at least to some degree and you definitely should like Cardiology. If you don't, you won't have a good time at all for 6 years and you may not even match to IC ultimately. Conversely, if for whatever reason you decide you don't want to not have a life at any point, you can always practice general Cardiology or even pursue different training pathways. This is a big strength of IC as I see it.

 

[VA Hopeful Dr]

In talking to some interventional cardiologists, I was told the vast majority of those trials were with first generation stents and that the 2nd gen one would fare much better.

I think the real risk comes with structural work though. The Cards guys are who created TAVR and I think they won’t be falling back in structural work and innovation.

Heh, yeah I'm sure they think that

 

[heraclez]

On one of my rotations, a Cardiothoracic surgeon was telling us he got out of CT surgery and decided to do... I want to say Vascular Surgery. Maybe I'm wrong about that last part.

But what stuck with me during his lecture, was him saying how much he loved CT surgery, but reimbursement (in California) has gotten so bad that he decided it wasn't worth his time. 🙁

 

[dynx]

1. It’s not a dying field. It’s growing right now. We can’t keep up with the demand. That’s likely temporary. For those that saw that stents were a temporary fix and people are going to die from cancer or cardiac disease eventually they are riding a wave that was created by pushing these patients back a couple of decades. That wave is going to crash, and the current plethora of patients is probably only likely to last a decade or so. That’s my guess...but I was right the first time.
2. “This study showed CABG was better but now we have THIS stent and it will be better...oh wait, that wasn’t better but now we have THIS stent and it will be better...damn! But now we have THIS stent...” you get the point.
3. TAVR. Here’s how I see it going down if we’re smart. “We’re not available for backup”. The end of Cardiology doing TAVR alone. That’s how we’ve handled it. The end. “We’ll bring in a CT surgeon to back us up!” Okay, he’s on his own. Vacation? Take backs? Weekends? Good luck. You can feed him business go ahead...see how long he lasts Q1.

Overall it’s a good field. If you got in when it was down you’re doing far better than expected. I’m not sure id expect the same results 10 years from now so I’d approach with caution but if you love it the opportunity will be there to do well. If you don’t love it don’t do it regardless. The end.

 

[dynx]

On one of my rotations, a Cardiothoracic surgeon was telling us he got out of CT surgery and decided to do... I want to say Vascular Surgery. Maybe I'm wrong about that last part.

But what stuck with me during his lecture, was him saying how much he loved CT surgery, but reimbursement (in California) has gotten so bad that he decided it wasn't worth his time. 🙁

Payment in Cali SUCKS. It’s a strange situation. People are either their and established and make bank or new and make nothing. People make bank for 10-20 years then are willing to take a huge cut just to be back home I think. It is/was terrible market. Southern by the grace of god is where you want to be.

 

[LebronManning]

Update: Anyone else kept up with the recent American College of Cardiology conference? Based on twitter, the interventionalists are making a firm push to now allow low to moderate risk patients to also have TAVR instead of surgical AVR.

 

[doc05]

Update: Anyone else kept up with the recent American College of Cardiology conference? Based on twitter, the interventionalists are making a firm push to now allow low to moderate risk patients to also have TAVR instead of surgical AVR.

Of course they are. Doesn't make it right. Cardiologists...have a different way of looking at things.

 

[VA Hopeful Dr]

Of course they are. Doesn't make it right. Cardiologists...have a different way of looking at things.

 

[ThoracicGuy]

Reminds me of the old joke...

How do you hide $100 from a cardiologist?

Spoiler

You can't.

 

[TypeADissection]

I don't want to sidetrack this thread, but I was at a conference a few weeks ago and during the aortic aneurysm session, the usual luminaries in vascular surgery were up there talking about up to date research stuff. Right in the middle of the 10-lecture panel, 2 different cardiologists presented something along the lines of "how to start an EVAR program as an IC" and "what skillset is required of an IC to do EVARs."

Cardiology is the proverbial 800-pound gorilla. There are a lot of them and they're very well connected and influential politically. There are maybe 3500 vascular surgeons in the entire country and in the current workforce, IC and IR are putting out way more grads per year than vascular surgery. I'd imagine CTS is in a similar boat. I write this to only bring up the fact that IC is not going to go anywhere except wherever they damn well please.

 

[Jolie South]

I don't want to sidetrack this thread, but I was at a conference a few weeks ago and during the aortic aneurysm session, the usual luminaries in vascular surgery were up there talking about up to date research stuff. Right in the middle of the 10-lecture panel, 2 different cardiologists presented something along the lines of "how to start an EVAR program as an IC" and "what skillset is required of an IC to do EVARs."

Cardiology is the proverbial 800-pound gorilla. There are a lot of them and they're very well connected and influential politically. There are maybe 3500 vascular surgeons in the entire country and in the current workforce, IC and IR are putting out way more grads per year than vascular surgery. I'd imagine CTS is in a similar boat. I write this to only bring up the fact that IC is not going to go anywhere except wherever they damn well please.

I am tired of taking care of complications from procedures that are actually within their scope of practice, let alone ones of procedures they shouldn’t be doing. Some of the worst cases I have done explanting an infected endograft and a type 1a endoleak with rupture from placement by cardiologist.

We need to publish data to show that it is criminal for them to do endografts, and we need to expand our residencies and fellowships.

 

[Psai]

I don't want to sidetrack this thread, but I was at a conference a few weeks ago and during the aortic aneurysm session, the usual luminaries in vascular surgery were up there talking about up to date research stuff. Right in the middle of the 10-lecture panel, 2 different cardiologists presented something along the lines of "how to start an EVAR program as an IC" and "what skillset is required of an IC to do EVARs."

Cardiology is the proverbial 800-pound gorilla. There are a lot of them and they're very well connected and influential politically. There are maybe 3500 vascular surgeons in the entire country and in the current workforce, IC and IR are putting out way more grads per year than vascular surgery. I'd imagine CTS is in a similar boat. I write this to only bring up the fact that IC is not going to go anywhere except wherever they damn well please.

Man **** THAT

Cardiologists are always stealing procedures. They're terrible at owning their patients and complications. I would never work with them in the OR, surgeons only for me thanks.

 

[LebronManning]

Even with all the animosity towards Interventional Cards, it doesn't seem like anyone can or will stop them...Owning the cardiology patient is huge.

 

[Man o War]

1. It’s not a dying field. It’s growing right now. We can’t keep up with the demand. That’s likely temporary. For those that saw that stents were a temporary fix and people are going to die from cancer or cardiac disease eventually they are riding a wave that was created by pushing these patients back a couple of decades. That wave is going to crash, and the current plethora of patients is probably only likely to last a decade or so. That’s my guess...but I was right the first time.
2. “This study showed CABG was better but now we have THIS stent and it will be better...oh wait, that wasn’t better but now we have THIS stent and it will be better...damn! But now we have THIS stent...” you get the point.
3. TAVR. Here’s how I see it going down if we’re smart. “We’re not available for backup”. The end of Cardiology doing TAVR alone. That’s how we’ve handled it. The end. “We’ll bring in a CT surgeon to back us up!” Okay, he’s on his own. Vacation? Take backs? Weekends? Good luck. You can feed him business go ahead...see how long he lasts Q1.

Overall it’s a good field. If you got in when it was down you’re doing far better than expected. I’m not sure id expect the same results 10 years from now so I’d approach with caution but if you love it the opportunity will be there to do well. If you don’t love it don’t do it regardless. The end.

Cardiac anesthesiologist here.
Our surgeons have drawn a line in the sand on this, and the hospital is backing them. We have one cardiologist that hardly ever has a complication, he gets special treatment.
The rest tread lightly.

 

[Dares Dareson]

I'm naive to a lot of this as a student, but I don't get why CTS can't do all the endovascular stuff. Vascular surgery does surgery and endovascular procedures. Is it just because CTS has enough volume with CABGs and valves that they don't need to learn caths or endovascular valve repair? Or is there something about cardiology that makes it mores suited to endovascular domain?

 

[doc05]

I'm naive to a lot of this as a student, but I don't get why CTS can't do all the endovascular stuff. Vascular surgery does surgery and endovascular procedures. Is it just because CTS has enough volume with CABGs and valves that they don't need to learn caths or endovascular valve repair? Or is there something about cardiology that makes it mores suited to endovascular domain?

Because there's no point. A patient never finds their way to a cardiac surgeon without seeing a cardiologist first... who will just do the cath themselves anyway

 

[nlax30]

I certainly don't think CTS is "dying". Coming from the Cardio side of things I guess I've been fortunate in that the places I've trained (residency/fellowships) we've had good relationships with the CT surgeons and for the most part I haven't seen some of the IC vs CTS animosity. That said our IC guys had no interest in things like EVAR and our TAVR program thus far was a combined Cards/CTS program. I guess theoretically once reimbursement changes for that and goes to mainstream single operator then more a turf war could ensure.

In EP same thing, we've had a good relationship with CTS as we get folks from them for post valve/MAZE arrhythmias and devices and we also rely on them for epicardial leads, combined approach albations, MAZEs/valves, etc..

 

[Medstart108]

Update: Anyone else kept up with the recent American College of Cardiology conference? Based on twitter, the interventionalists are making a firm push to now allow low to moderate risk patients to also have TAVR instead of surgical AVR.

I think low to moderate risk patients having TAVR instead of SAVR is inevitable. As TAVR gets safer and safer, it will become equivalent to SAVR and the only patients who will get an isolated surgical aortic valve will be those who want/need a mechanical valve or those who are not eligible for TAVR.

I think that future surgeons need to get on the catheter train asap as the next valve will be the mitral valve.

 

[LebronManning]

I think low to moderate risk patients having TAVR instead of SAVR is inevitable. As TAVR gets safer and safer, it will become equivalent to SAVR and the only patients who will get an isolated surgical aortic valve will be those who want/need a mechanical valve or those who are not eligible for TAVR.

I think that future surgeons need to get on the catheter train asap as the next valve will be the mitral valve.

I think future CT Surgeons would LOVE to be on the catheter train but it seems like IC controls their destiny in this regard. As transcatheter procedures get safer IC will obviously try to cut out CT Surgeons as much as possible. Maybe it will end up like GI and Surgery with endoscopy but GI is winning that battle handily likely due to referral patterns. Cards referral is stronger if anything plus as another poster mentioned they are very strong politically.

 

[DarknightX]

Because there's no point. A patient never finds their way to a cardiac surgeon without seeing a cardiologist first... who will just do the cath themselves anyway

Exactly. It's a little bit different for vascular surgery, as primary care physicians will send their patients with claudication symptoms straight to a vascular surgeon to be evaluated. They will also send patients with AAA's straight to a vascular surgeon.

A patient with chest pain or angina will be referred to a cardiologist, who will then work them up perform whatever procedures they deem fit. Nobody is referring that same patient to a CT surgeon right off the bat.

 

[Medstart108]

I think future CT Surgeons would LOVE to be on the catheter train but it seems like IC controls their destiny in this regard. As transcatheter procedures get safer IC will obviously try to cut out CT Surgeons as much as possible. Maybe it will end up like GI and Surgery with endoscopy but GI is winning that battle handily likely due to referral patterns. Cards referral is stronger if anything plus as another poster mentioned they are very strong politically.

That is true, i think ultimately it is up to the trainees to get training in this area and learn this area from cardiologists and surgeons who already do this procedure who are willing to teach. It is a challenge no question, but I see the future is going to be more and more catheter based. Eventually something is going to have to give, but I believe that CT cannot just stick with open. A lot of other specialties have their own turf wars, but I think CT needs to draw a line in the sand and start insisting on their trainees being given access to train and practice endovascularly or else they will be consequences. This kind of discussion is being had at the national surgical conferences which is a good sign.

CT does need to venture outside of the surgical only domain. It is probably the least medical of surgical specialties in terms of their involvement in diagnosis, investigations etc. I wonder if there is room for cardiac surgeons to start following their own patients post-operatively and it would be interesting to know how valuable that actually is for patients.

 

[LebronManning]

That is true, i think ultimately it is up to the trainees to get training in this area and learn this area from cardiologists and surgeons who already do this procedure who are willing to teach. It is a challenge no question, but I see the future is going to be more and more catheter based. Eventually something is going to have to give, but I believe that CT cannot just stick with open. A lot of other specialties have their own turf wars, but I think CT needs to draw a line in the sand and start insisting on their trainees being given access to train and practice endovascularly or else they will be consequences. This kind of discussion is being had at the national surgical conferences which is a good sign.

CT does need to venture outside of the surgical only domain. It is probably the least medical of surgical specialties in terms of their involvement in diagnosis, investigations etc. I wonder if there is room for cardiac surgeons to start following their own patients post-operatively and it would be interesting to know how valuable that actually is for patients.

Agreed. I think now is the time, if ever, for the CT surgeons to make some ground on this. 10 years from now when IC's are doing TAVRs and god knows what else by themselves will be too late! Additionally you bring up a great point about the medical management of cardiac patients. My true belief is that the future of cardiology is medical management at least for CAD. Current data already shows that stents aren't very useful. Maybe they'll make much better stents but they've been saying that for a decade. Surely there's a chance medical management takes over much more and in this case.. forget CT Surgeons, even IC will struggle to find procedural volume. Nice thing with IC though is they can always fall back on practicing general cards.

 

[_Rod_of_Asclepius_]

Kinda hijsckjng this thread and doing so kind of late...what are the advantages of the I6 vs 5+2 vs 4+3 programs??? I’ve had the incredible opportunity to shadow and speak with some older Congenital Surgeons who all went 5+2 (obviously) but claimed they “truly learned to be surgeons” there. I’m only going to be starting med school next year (DO too) but really trying to sample out as many specialties as possible.

Btw I know an I6 for DO is next to impossible

 

[deleted547339]

I don't want to sidetrack this thread, but I was at a conference a few weeks ago and during the aortic aneurysm session, the usual luminaries in vascular surgery were up there talking about up to date research stuff. Right in the middle of the 10-lecture panel, 2 different cardiologists presented something along the lines of "how to start an EVAR program as an IC" and "what skillset is required of an IC to do EVARs."

Cardiology is the proverbial 800-pound gorilla. There are a lot of them and they're very well connected and influential politically. There are maybe 3500 vascular surgeons in the entire country and in the current workforce, IC and IR are putting out way more grads per year than vascular surgery. I'd imagine CTS is in a similar boat. I write this to only bring up the fact that IC is not going to go anywhere except wherever they damn well please.

If IR is graduating so many fellows, why can I never get them to do anything between their rounds of golf!? I swear, these folks are afraid of the hospital outside of bankers hours.

 

[badasshairday]

If IR is graduating so many fellows, why can I never get them to do anything between their rounds of golf!? I swear, these folks are afraid of the hospital outside of bankers hours.

What are you trying to get them to do? Paracentesis and LP? Maybe that's why? We come in after hours for acute limb ischemia, trauma bleeders, gi bleeders. Not tunneled HD lines and chest tubes or fluid collection drainage. Sorry. 🙂

 

[deleted547339]

What are you trying to get them to do? Paracentesis and LP? Maybe that's why? We come in after hours for acute limb ischemia, trauma bleeders, gi bleeders. Not tunneled HD lines and chest tubes or fluid collection drainage. Sorry. 🙂

I literally didn’t know IR does paras.....the number of times I ask IR to do an LP because I fail is on the order of 1/10-1/20 attempts - I don’t care if they’re 500 lbs, I’ll pull out the US and the harpoon and give it a go. And I’ve literally never asked them to place a non-tunneled line - that’s my job. And if I can’t get a CVL, I’m fairly certain no one will.

How about “this patient is having active extrav on CTA from her L colic artery and has brady’ed down 3 times and gone apneic. Her hgb is 4. She is bleeding to death” - Response: “well, it’s pretty high risk, you should medically manage”

Or “this woman has massive hemoptysis, you wouldn’t embolize her early today with her sentinel bleed because she had half a cup of coffee....I just had to intubate her after she vomited up a couple of units and became profoundly hypoxemic”. Response: yah, we get in around 8....

If I get told to check another hemoglobin by an IR fellow in a patient in hemorrhagic shock and blood pouring out of their rectum, I am going to beat a radiologist to death with their computer screen.

 

[irwarrior]

This is truly unfortunate and you should have the IR, at the least come in and write a note in the chart and do a formal consult and talk to the patient or patient's family and explain their rationale. The interventionalist , if covering call for that hospital may be liable if they do not come in and document an assessment and rationale for not intervening.

Also, I would consider doing a patient assessment and bring all parties on board ie ICU, hospitalists, surgery, IR, and GI to discuss an algorithmic approach/guidelines to GI bleeders (Upper/lower) as well as for hemoptysis (IR/thoracic surgery/pulmonary/ICU). When it comes to hemoptysis, and bronchial embolization we do wait until it is larger volume as the adverse event is a spinal cord infarct and paralysis.

 

[badasshairday]

I literally didn’t know IR does paras.....the number of times I ask IR to do an LP because I fail is on the order of 1/10-1/20 attempts - I don’t care if they’re 500 lbs, I’ll pull out the US and the harpoon and give it a go. And I’ve literally never asked them to place a non-tunneled line - that’s my job. And if I can’t get a CVL, I’m fairly certain no one will.

How about “this patient is having active extrav on CTA from her L colic artery and has brady’ed down 3 times and gone apneic. Her hgb is 4. She is bleeding to death” - Response: “well, it’s pretty high risk, you should medically manage”

Or “this woman has massive hemoptysis, you wouldn’t embolize her early today with her sentinel bleed because she had half a cup of coffee....I just had to intubate her after she vomited up a couple of units and became profoundly hypoxemic”. Response: yah, we get in around 8....

If I get told to check another hemoglobin by an IR fellow in a patient in hemorrhagic shock and blood pouring out of their rectum, I am going to beat a radiologist to death with their computer screen.

Well, that is pretty crummy. Sorry you have such crap IR. Def would not happen at my place or any of the places I've trained at.

 

[AdmiralChz]

I literally didn’t know IR does paras.....the number of times I ask IR to do an LP because I fail is on the order of 1/10-1/20 attempts - I don’t care if they’re 500 lbs, I’ll pull out the US and the harpoon and give it a go. And I’ve literally never asked them to place a non-tunneled line - that’s my job. And if I can’t get a CVL, I’m fairly certain no one will.

How about “this patient is having active extrav on CTA from her L colic artery and has brady’ed down 3 times and gone apneic. Her hgb is 4. She is bleeding to death” - Response: “well, it’s pretty high risk, you should medically manage”

Or “this woman has massive hemoptysis, you wouldn’t embolize her early today with her sentinel bleed because she had half a cup of coffee....I just had to intubate her after she vomited up a couple of units and became profoundly hypoxemic”. Response: yah, we get in around 8....

If I get told to check another hemoglobin by an IR fellow in a patient in hemorrhagic shock and blood pouring out of their rectum, I am going to beat a radiologist to death with their computer screen.

I've worked at 6-7 institutions in 3 states and this is 100% par for the course with my experience with IR.

 

[deleted547339]

Well, that is pretty crummy. Sorry you have such crap IR. Def would not happen at my place or any of the places I've trained at.

Without outing myself, both of the hospitals I’ve worked at are tertiary care centers with highly rated radiology departments.

 

[deleted547339]

This is truly unfortunate and you should have the IR, at the least come in and write a note in the chart and do a formal consult and talk to the patient or patient's family and explain their rationale. The interventionalist , if covering call for that hospital may be liable if they do not come in and document an assessment and rationale for not intervening.

Also, I would consider doing a patient assessment and bring all parties on board ie ICU, hospitalists, surgery, IR, and GI to discuss an algorithmic approach/guidelines to GI bleeders (Upper/lower) as well as for hemoptysis (IR/thoracic surgery/pulmonary/ICU). When it comes to hemoptysis, and bronchial embolization we do wait until it is larger volume as the adverse event is a spinal cord infarct and paralysis.

I’ve never heard of IR writing a note or evaluating a patient they don’t do a procedure on.

 

[badasshairday]

I’ve never heard of IR writing a note or evaluating a patient they don’t do a procedure on.

I do. So now you heard it. 🙂

 

[badasshairday]

Without outing myself, both of the hospitals I’ve worked at are tertiary care centers with highly rated radiology departments.

Great diagnostic radiology department doesn't always go hand in hand with great IR. Clearly Bad interventional radiology department.

 

[badasshairday]

I've worked at 6-7 institutions in 3 states and this is 100% par for the course with my experience with IR.

So these patients bleed to death ie. Trauma / gi bleed / variceal bleed or go into septic shock ie. Stone urosepsis?

I have worked in 6 different hospitals in 2 different stages. 100% not my experience.

My experience has been other specialists do what is convenient for them then dump on IR. Ie. Stone with sepsis. After 5 PMor weekend goes to IR. Before that goes to urology. Gi bleed, scope all day, oops can't stop the bleed now call IR at 10 PM even though we knew about bleed since 8 am.

 

[AdmiralChz]

So these patients bleed to death ie. Trauma / gi bleed / variceal bleed or go into septic shock ie. Stone urosepsis?

Might look at it if before 3 Monday-Friday.

After hours? If you’re lucky, the answer is “consult surgery / GI / Urology for surgical evaluation” and written in the chart. Greater than 50% you’ll get hemming and hawing on the phone and demanding to know “is it REALLY and emergency and have you called a surgical consult”

I’m thrilled I don’t have to call consults to them anymore.

 

[deleted547339]

Great diagnostic radiology department doesn't always go hand in hand with great IR. Clearly Bad interventional radiology department.

You wouldn’t call either of the programs bad based on IR reputation. I’ll leave it at that.

 

[Winged Scapula]

So these patients bleed to death ie. Trauma / gi bleed / variceal bleed or go into septic shock ie. Stone urosepsis?

I have worked in 6 different hospitals in 2 different stages. 100% not my experience.

My experience has been other specialists do what is convenient for them then dump on IR. Ie. Stone with sepsis. After 5 PMor weekend goes to IR. Before that goes to urology. Gi bleed, scope all day, oops can't stop the bleed now call IR at 10 PM even though we knew about bleed since 8 am.

You're not going to get a lot of sympathy from general surgeons here on the topic of dumping patients.