03 October 2011

Living in the future

My father in law, now deceased, was a nephrologist. I met him while I was in medical school. He was a reserved guy, not prone to butt into what he saw as others' business. So I still remember that while I was considering what sort of residency to pursue, he took a surprisingly strong stance that I should go into interventional radiology. His reasoning was simple: they have a great lifestyle, they make bags and bags and bags of money, and they get to play with all the coolest gadgets.

It was tempting, I admit. As anyone who knows me can attest, I am ALL about the gadgets. I'm not averse to bags of money either. But I never gave it much consideration, mostly because I am just not real good at radiology, though for an ER doc I do OK. (A low bar, it is true.)

I sometimes regret that decision. For example, I wrote the other day about a gentleman who presented with a ruptured abdominal aortic aneurysm. We had some heroic fun in the ER resuscitating him and getting him to the OR. After the fact, I had to wonder whether it was all in vain -- the mortality on ruptured AAAs used to be upwards of 75% even if they made it to the OR. It's a huge surgery with tons and tons of blood loss, and the only people with AAAs are old vasculopaths with bad hearts and bad brains and even if they survive the surgery they stroke out or die of kidney failure or ARDS or what have you. Bad juju.

So it was with pleasure that I logged into the computer the other day and checked on my "interesting patient" list to see that he was still alive and not even in the ICU. I'm not sure which fact was more surprising. I pulled up the dictations and read the op notes and was stunned to realize that when this guy's fricking aorta exploded, the vascular surgeons/interventionalists are such badasses they didn't even open his abdomen. They fixed it all through his groin. Through his groin.

I knew endovascular grafts were around -- they're not exactly new. But I did not know they could be used in the setting of acute aortic rupture. How cool is this? They get to the OR, access the femoral artery, then throw in a balloon catheter and occlude the aorta above the level of the aneurysm:


This stops the bleeding and increases perfusion to the brain, which is good. Then they do a nice leisurely series of angios to measure things and pick the right graft to apply, hook in the contralateral iliac limb, and you are good to go: one functional artificial aorta, estimated blood loss 50 cc. (Not counting the six units in the peritoneum.)


What an amazing thing these guys have accomplished with this technology. If we can get you to the OR alive, they can fix the gnarliest vascular catastrophe standing on their heads. I have got to say, I love living in the future. This sort of coolness almost -- almost, mind you, but not quite -- makes up for not having hovercars and personal jet packs. Which we were promised.

Had I known what sort of awesomeness the future held in the world of interventional radiology, this might well be a very different blog. And I would have bags of money. And the coolest fricking gadgets on earth. (Sigh.) If you'll excuse me now, there's a ninety-year-old dizzy patient I need to go see.


  1. If you were a nurse you would have been fired for violating hipaa for accessing the chart of a patient you are no longer directly caring for. Heck, I was counseled for going "too far back" in the chart of a patient I WAS directly caring for.

    Very cool, though.

  2. Good thing he is the boss, then!

  3. Christine, that is absolutely not true. He has provided no patient identifiers, and it is impossible for us to effectively improve the care we deliver if we don't follow up on our patients' outcomes.

  4. Amazing. That is pretty damn cool. Also I'm so happy for your patient and his family.

    My sweetie has Marfan syndrome, so I'm a lot more concerned about aortic mishaps than I used to be. They're pretty terrifying.

  5. Those vascular surgeons are surely the "Pros from Dover".
    A good team to have on your side.

  6. I recently completed the latest round of HIPAA compliance training and a case very similar to what is described here-a physician curious about the outcome of a patient who was no longer on his service- was presented as a HIPAA violation and the physician was suspended. Whether or not personal identifiers were divulged has nothing to with it. I know it doesn't make any sense, but the anally petrified compliance people could care less about what makes sense, only that the hospital doesn't get dinged by the Feds.
    This is the medical world we live in today.

  7. At where I went to medical school they did them like this too. They even took it a bit farther. They said that one of the biggest contributors of mortality was the induction of the anesthesia, so they used to do the acute EVARs under local and MAC! I don't know if that's common place at all, but I thought that that was far out.

  8. We were just talking about this at work the other day, I came from the ICU in the day that the stable AAA patients came to the ICU a day or two pre-op, got a Swan-Ganz catheter and then got pumped up with fluid pre-op. They looked like Jabba the Hut post op and never did very well, shocking.

  9. Annon- not a hipaa violation for posting- a violation for lookig at a chart of a patient he isn't directy involved in. HIPAA is a federal law and as such doesn't really care who the boss is.

  10. I'm a 4th year med student and was really interested in doing Interventional Radiology throughout my first two years... that was until I found you had to do a 5 year residency in Diagnostic Radiology *sigh

  11. Well, you have a robot in the ER, that's a fairly cool gadget. Maybe not quite as cool as cool, but still pretty good.

    I am glad the badass interventional radiologists are out there, but I still wand my effing hovercar.

  12. Oh, the HIPAA thing. I think Dr. Shadowfax's access of the information falls under "Health Care Operations". Pretty sure that all 6 of the things listed under that heading are part of his job.


    I must be pretty bored this morning to have looked that up.

  13. If my doc helped save my life like that, he could look up whatever he damned well pleased in my medical file and I'd happily cover his ass with the HIPAA crap! It's not a violation if the patient consents - and the Feds don't have to know it was after the fact.

  14. This is one of the most cool things I have ever seen. Thanks for posting it.

  15. thnx for the wonderful post~ your post have always been an amusement, especially when I am dying of stress:)


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