Day In The Life: Interventional Radiologist

I’m just a resident, but I plan on doing an IR fellowship. Despite what others will tell you, if you’re on call for IR you can expect to be extremely busy, at least at my institution. We usually only get a few days a month to swim in our money vaults, scrooge mcduck style.

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Types of cases

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IR is going to vary in scope from hospital to hospital. While it’s true that essentially every percutaneous intervention was initially done by radiologists (cardiac cath, intracerebral arterial work, angioplasty/stenting), much of that work has been stolen adopted by other services (cards, neurosurgery, vascular). You’ll still see IR do angios, and even perform angioplasty and stenting, but this is often on relatively trivial things like fistulas for dialysis access. The larger cases, like coiling intracerebral aneurysms, removing clots in embolic stroke, and treating AAAs with EVAR have all been largely taken by the aforementioned services. If you’re in a smaller hospital without access to vascular surgery, though, IR may very well still be the big dog for intra-arterial work.

On the other side of the vasculature, we have much more of a presence. IV access, especially for tunneled lines and ports, is absolutely the wheelhouse of IR. Our outcomes are substantially better than surgery for the placement of such lines. The other big thing we do is IVC filter placement and retrieval (just as an aside to my clinical colleagues, make sure you get those taken out when you no longer need them. They actually increase the incidence of DVT after being in for a few years). Another huge area for IR is in lysis of intravenous clots with things like an angiojet or EKOS. We also do ablations for varicose veins, which is nice because it’s both a cosmetic procedure and a treatment for venous stasis ulcers.

Our other big area of specialization is in what I’d classify as Interventional Oncology. We do a lot of TACE and Y-90 embolization for HCC or metastatic liver CA. This is in addition to all the percutaneous interventions we do for ablations with RFA or microwaves as well.

IR also has a large presence in the placement of percutaneous nephrostomy tubes under ultrasound guidance and placement of percutaneous biliary drains, particularly the type that are both internal and external, so you can cap off the external drain if necessary, making it essentially a percutaneously placed biliary stent. There are a ton of advanced procedures that I haven’t even discussed, either, like TIPS or thoracic duct embolization or uterine fibroid embolization or a number of other things we can do.

On the “IR lite” side of things, most general radiologists will feel relatively comfortable performing basic procedures too, such as CT/US guided percutaneous biopsy, drain placement, chest tube placement, or lumbar punctures under fluoro. I feel very comfortable doing all of the “IR lite” procedures as this point, and I can generally place tunneled lines without too much difficulty after about 2 months of body IR and 2 months of vascular IR. The more advanced procedures require a fellowship to master.

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Typical Day

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I’m going to give you the attending’s perspective on this and then talk a bit about residency, so here it goes. A typical day on IR starts around 7 AM. You consent your patients for the cases and typically will do about 8-10 lines when on that service, or maybe 2-3 “larger” cases like a TIPS or a TACE with a few vascular access lines between the big ones. In addition to that, you’re constantly getting new consults for cases so you have to review the imaging and chart and determine whether or not it’s a good idea to do the case, and whether or not it’s technically feasible. For instance, ID loves to ask us to drain every single fluid collection they see, but often it’s either not a good idea (because it’s a hematoma, say) or not technically possible due to bowel or organs being in the way. VIR also reads all of the CTAs of for AAAs, thoracic aortic aneurysm cases, and CTA for a run-off, and all of the MRAs of the lower extremities. Our volume of cross-sectional studies is low enough that we don’t need a dedicated cross-sectional guy, but it’s close and we’re almost always behind on the list. In private practice, you would be expected to do both IR and DR throughout the day. Pure IR jobs are rare except in tertiary referral centers or very large hospitals. When you’re not on call, you can expect to leave around 5 or 6.

As a resident, you do all of the above with more work and fewer cases. Consents? Get your ass in there resident! CTs? Better draft them all before the attending reviews them with you! New consult? Better look up all the important stuff and get that note ready! Patient on your service on the floor? Better write that progress note! Etc. Fellows have it a bit easier in terms of the mundane floor crap, but they’re basically bouncing from room to room doing case after case (which sounds glorious to me!)

When you’re on call, it’s usually home call because it’s not that common to get called in at night. You basically finish up any of the late consults that are urgent or emergent, and then go home and hold the pager. The things IR has to come in for at night are pelvic trauma (need to do angios of the pelvic vessels and coil/embolize the bleeders) and lower GI bleeding, or upper GI bleeding refractory to endoscopy. “Luckily,” must LGIBs need to be medically managed first, and often need a tagged RBC scan prior to going to angio. They tend to be hemodynamically stable and can tanked up over night, so we don’t often come in for GIBs. If the patient is hemodynamically unstable, they’re a surgery player anyway.

Pelvic trauma is really the one thing that I see us coming in the middle of the night for (IMO, maybe other IR docs can speak more intelligently about this than I). Right now, though, at our hospital, volume is so high that we basically operate 7 days a week to keep up with everything. Being “on call” for that weekend means you’re going to be there all day Saturday and Sunday, but you’ll probably also sleep at night, so it’s not the worst call we take. Diagnostic call is far more stressful.

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