In this episode, Dr. Aaron Fritts interviews Dr. Christopher Beck about gastrostomy tubes, including the evolution of his method, tips for patients who pull their tubes out, and why g-tubes are such a controversial topic in IR.

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We begin by discussing indications and contraindications for gastrostomy tubes. Frequent indications are stroke patients, head and neck cancer patients, and trauma patients. Contraindications include uncorrectable coagulopathy, ascites, peritoneal carcinomatosis, or something interposed between the abdominal wall and the stomach, such as liver or bowel. Dr. Beck prefers having imaging to review, which most patients have. If no prior imaging is available, he will get a non-contrast CT abdomen the day of the procedure. He likes all his patients to drink barium for visualization of bowel during the procedure, but will not cancel the procedure if they didn’t drink it, as the insufflation should move bowel out of the way and there should be enough bowel gas to identify and avoid the bowel.

Next, Dr. Beck reviews the details of his method. He likes to use monitored anesthesia care (MAC), because frequently he has patients with bad Mallampati scores. Additionally, anesthesia is very helpful with NG placement. Furthermore, it makes the procedure much more comfortable for the patient. He always checks liver margins with ultrasound prior to starting the procedure. He always gives 1 mg glucagon before insufflation and antibiotics per the SIR Guidelines App. As for equipment, he uses t-fasteners from Avanos, a dilator set, and a 20Fr G-tube. He used to start with 16Fr but found he frequently had to size up to a 20Fr. He uses a 24Fr peel away sheath. For the procedure, he insufflates, marks his entry point with a hemostat, and then numbs in all 3 spots where he will place his gastropexies. He uses 1/2 syringe of contrast for his gastropexy placement. He uses 2 t-tags, and prefers the C-arm in RAO rather than AP during this step. For G-tube placement, he aims 20 degrees toward the pylorus, and always makes sure he sees wire touching two walls of the stomach to ensure he is intraluminal. He uses sterile water to inflate the balloon rather than saline or contrast. Lastly, he always makes sure to get a good final image to confirm placement in the stomach.

For post-care, on inpatients he rounds the next morning, checking that the tube flushes and then clears it for use. For outpatients, he recommends no feeding (via G or NG) for three hours and a consult with a dietician before discharge. After this, the patient can receive nutrition via NG. If the patient has no peritoneal signs, the G-tube can be used the next day. For tube management, he exchanges the tube every 6 months or sooner if there is an issue, such as the tube being pulled out or becoming clogged beyond the point of a bedside fix.

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RESOURCES

BackTable YouTube Gastrostomy Tube Demo:

https://www.youtube.com/watch?v=17ep0AEkKqs

Early Initiation of Enteral Feeding:

https://pubmed.ncbi.nlm.nih.gov/24674218/

SIR Guidelines App:

https://apps.apple.com/us/app/sir-guidelines/id1552455529

In this episode, Dr. Ally Baheti interviews interventional radiologist Dr. Judy Gichoya about her recent paper on artificial intelligence (AI) and the use of a deep learning model to recognize patients’ self-described racial identity, based on radiology images.

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SHOW NOTES

Dr. Gichoya had started by tackling the original problem of bias in diagnoses for chest X-rays, since it has always been difficult to tell whether something is a real diagnosis, or simply just a finding. Her team built a deep learning model; however, they saw that it did not work well for black patients. With further investigation, they discovered that their model had learned signals that correlated with self-identified race.

Intrigued by this finding, Dr. Gichoya and her team sought to identify the factors that the model used when making its race determination. Because AI is black box in nature, the methods by which the algorithm learns remains largely unknown. When tested in other imaging modalities (mammogram, chest CT, spine imaging), the model still showed high accuracy. Additionally, the model retained accuracy when different information was eliminated from the images (ex. age, disease distributions, bone densities). The model was also able to predict race in healthy patients, showing that it did not rely on patterns of disease prevalence in specific ethnic groups.

Next, we spoke about the implications of this research in developing risk scores. Deep learning models are able to look at factors that humans are not trained or able to see. Dr. Gichoya highlights the model’s potential effectiveness in predicting osteoarthritis risk in black patients. We also look at applications in opportunistic screening and information about social determinants of health. For example, most patients presenting with chest pain often get chest CTs. Dr. Gichoya thinks that these images can be used by the model to learn about patients’ environmental exposures, like pollution.

We finish the episode with a discussion on the changing landscape of IR and how AI can be used as an assistive technology. Interventional cardiologists are already using AI to dictate their procedural reports in real-time. In the interventional oncology space, AI could help integrate imaging and pathology findings to determine personalized treatment courses. All of these applications depend on researchers’ ability to market their findings to peers and the public, Dr. Gichoya gives tips on how to do this.

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RESOURCES

AI recognition of patient race in medical imaging: a modelling study:

https://www.thelancet.com/journals/landig/article/PIIS2589-7500(22)00063-2/fulltext

In this episode, Dr. Vishal Kumar interviews Dr. Mark Wilson, vice chair and professor of radiology and biomedical imaging at UCSF, and chief of diagnostic and interventional radiology at the Zuckerberg San Francisco General Hospital and Trauma Center about the evolution of trauma care in interventional radiology, translational research, and the impact of mentorship and student outreach.

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SHOW NOTES

We begin by discussing how Dr. Wilson discovered radiology, and how he has come to be a leader in IR. He started out with an interest in psychiatry, and became involved in research on psychiatric brain imaging. As he delved deeper into biomedical imaging, his fascination grew. With help from his mentor, he began publishing, which motivated him to further pursue his passion for research. He learned about IR, and then got into UCSF for his radiology residency.

Being at the frontier of innovations, Dr. Wilson has been involved in research on MR guided interventions, remote navigation, and percutaneous venous chemo filters. He says these projects have reinforced that radiology and research isn’t done in a vacuum. He depends on his collaborators in material science, chemistry, and other fields to successfully innovate. One thing he loves about the research lab is the student involvement, and getting to see high school and college students get their name on a paper. This is one area of student outreach that has an incredible impact and shapes future leaders in radiology and medicine.

Finally, we discuss how Dr. Wilson spearheaded the role of radiology within the hospital infrastructure when they created the new SF General Hospital, the Zuckerberg San Francisco General Hospital and Trauma Center. He collaborated with hospital leadership and architects, as well as emergency medicine, surgery, anesthesia and nursing to build a state of the art trauma care center to serve the people of San Francisco. It fulfills its goal of bringing the services to the patient to deliver better and more efficient care. From CT scanners in the ED, to a hybrid trauma OR, this new center is one of the leading IR and trauma centers in the world.

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RESOURCES

The History of the Zuckerberg San Francisco General Hospital and Trauma Center:

https://zuckerbergsanfranciscogeneral.org/about-us/our-history/

In this episode, BackTable is on location in Barcelona for CIRSE 2022! Dr. Aaron Fritts conducts a live video interview with interventional radiologist Dr. Lorenzo Patrone. They discuss their experiences with balancing clinical, academic, and family responsibilities, as well as differences in the American and European physician work environments and the use of social media in medicine.

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SHOW NOTES

Dr. Patrone recounts his entry into the European IR speaking circuit. Through networking, he continues to meet speakers, learn from their experiences, and gain effective communication and presentation skills. He speaks about normalizing the feeling of imposter syndrome, especially when being invited to speak among IR founders and luminaries. He emphasizes personal growth and identifying where your passion and talent overlaps with lecture content.

Dr. Patrone highlights the fact that the field of IR revolves around three different aspects: First, the pioneering phase to innovate new procedures, then the research/evidence phase to demonstrate reproducible results, and finally, the education phase to disseminate knowledge and inspire new generations of IRs. It is common for IRs to feel overwhelmed when trying to commit to all of these fields. Instead of trying to master all aspects of the job, Dr. Patrone recommends that clinicians find different angles of their jobs and hone in the aspects that make them enthusiastic to come to work. Personally, he prioritizes clinical care and teaching. We discuss how time is the ultimate luxury, and how to avoid over-commitment and burnout. We also consider societal gender roles and talk about unjust extra pressures faced by female physicians.

Then, we look at some key differences between a physician career in the US, versus one in Europe. Dr. Patrone comments on the pay gap, training pathway, and overall philosophy of the Italian and British healthcare systems.

Finally, we discuss benefits and misuses of social media within the medical community. Dr. Patrone emphasizes that social media should be used as a tool to teach and inspire, rather than a platform to criticize individuals or specialties. Regarding case-based posts and feedback, he highlights the point that every clinician could have a different but valid approach to each case, based on the practice setting and operator skill. He also encourages other posters to talk about case complications, which can provide enormous educational value for learners.

In this episode, Dr. Aaron Fritts interviews Dr. Peder Horner about the impact of staff culture on patient care, how to manage bad players, and how to maintain an active role in shaping a healthy work culture.

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We begin by discussing why staff culture is important. In IR, many people are coming out of a toxic training program and are now expected to be department leaders. We take after our mentors, and we pick up both good and bad habits. So where does healthy staff culture start? Dr. Horner explains that it starts from the top. You have to play an active role in molding the culture, otherwise it will remain toxic or simply be uninspiring.

Next, we ask Dr. Horner how he inspires his staff. He shares many values as a parent and a leader. If he is tired and as a result doesn’t smile while at work, it can set the mood for a case, similarly to how it can add up and impact a home relationship on a day to day basis. When employees have negative feelings at work, this results in worse patient care.

Lastly, we talk about how to maintain culture once you have a good team onboard. Dr. Horner believes in checking in frequently by asking his techs and nurses how they are doing. He prioritizes their career growth and mobility, which he says may lose him employees over time, but in turn makes people enjoy coming to work because they feel like they are improving and advancing. He says you must be selfless as a leader. If you expect everything to stay static, you’re doing your staff and patients a disservice. Even a great team, if left static, will not go far. He encourages personal and professional development among his staff which is a huge part of the culture of growth he believes in.

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RESOURCES

Harvard Business Review:

https://hbr.org

Paper on Work Culture and Patient Care:

https://asqblog.com/2015/02/25/barsade-oneill-2014-whats-love-got-to-do-with-it-a-longitudinal-study-of-the-culture-of-companionate-love-and-employee-and-client-outcomes-in-a-long-term-care-setting/

In this episode, Dr. Vishal Kumar interviews trauma surgeon Dr. Andre Campbell about his career path and policy interests, including gun safety, nationwide access to trauma care, and diversity and inclusion within surgical subspecialties.

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Dr. Campbell starts the conversation by explaining how he was exposed to early mentorship, which guided him towards pursuing his interest in medicine. He outlines his journey, including his childhood in the Bronx, medical school at UCSF, and residency training. Dr. Andre emphasizes the importance of mentorship at all stages of one’s career. He personally became interested in medicine due to a sixth-grade teacher who sparked his interest in science.

Next, we discuss his journey of choosing trauma surgery as a specialty. He found it difficult to decide between medicine and surgery, so he first completed a medicine residency, and then applied to match into surgery afterwards. Dr. Campbell found himself gravitating towards ICU and trauma care, which led him to specialize in trauma surgery. He currently performs trauma, acute care, and elective surgery.

Dr. Campbell also talks about the importance of allowing himself to feel the pain of trauma patients and their families, instead of keeping a distance. With every patient loss, he steps back and thinks about lessons that he could learn and how he could do better next time.

Then, we shift to a conversation on gun violence, a health emergency in 2022. The incidence of gun violence has rebounded to a higher level than it was before the COVID-19 pandemic started. Dr. Campbell has served as an advocate for gun control, and he highlights the fact that shootings happen every day, but it is only high profile mass shootings that get media attention. He emphasizes that as healthcare providers “staying in our lane” means taking a stance on firearm laws, since our jobs are centered around taking care of injured people. He also talks about respecting gun owners and the complex role that guns play in American culture and symbolism. Dr. Campbell highlights recent progress being made with laws requiring stricter background checks, allocating more funds for hospital based violence intervention programs and psychiatric care, and continuing efforts for gun safety research. We look at the role of Level One trauma centers in providing care for the US population, including people who live in “trauma deserts” with no easy access to a trauma center. Dr. Campbell speaks about the benefits of implementing a nationwide trauma system.

Finally, Dr. Campbell shares his observations about increasing diversity within surgical subspecialties. Again, he notes that mentorship is a large factor, as well as intentional initiatives to build supportive environments for underrepresented minorities.

In this episode, guest host Dr. Jacob Fleming interviews Dr. Jason Cox about musculoskeletal interventions and how he uses ultrasound for diagnosis and intervention in his full spectrum musculoskeletal practice.

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We begin by discussing Dr. Cox’s path to MSK intervention. During his interventional training at University of Missouri, the musculoskeletal radiology program was rebuilt, and ultrasound was incorporated heavily. He used his ultrasound skills from vascular intervention in IR to learn musculoskeletal anatomy on ultrasound. He was drawn to MSK radiology due to the mechanical aspect of MSK work and the integration of visual spatial awareness and hand eye coordination involved in MSK ultrasound.

He started out by learning steroid injections for sports injuries, commonly rotator cuff injuries. He now does around 20 diagnostic or interventional ultrasound procedures each day in his clinic. He opened his clinic with a partner, and did it slowly while still working at his prior job. He started working at his new clinic on his vacation days until he could build up the clientele to leave his prior job. One of the biggest challenges in opening his MSK radiology clinic was finding a sonographer able to do the complex MSK cases he was doing.

The most common procedure Dr. Cox does at his clinic is ultrasound guided carpal tunnel release. He also does tendon barbotage for hydroxyapatite deposition disease for the rotator cuff tendons. His practice has grown largely due to the number of patients that are referred because they cannot get an MRI. He reads his ultrasound exams like an MRI report, with a high level of detail, differential diagnosis and recommendations.

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RESOURCES

Institute for Advanced Medical Education:

https://www.iame.com

Linked In:

https://www.linkedin.com/in/jasoncoxmd

Ultrasound First Clinic:

https://ultrasound-first.com

European Society of Musculoskeletal Radiology:

https://www.essr.org

In this episode, host Dr. Ally Baheti interviews Dr. Jayson Brower about building a Y90 service line in his outpatient based lab (OBL).

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SHOW NOTES

First, Dr. Brower describes the IR/DR makeup of his practice and partnerships with surrounding hospitals. Inland Imaging’s collaboration with the Providence healthcare system was formed to provide quality outpatient imaging and avoid duplication and competition of services. Over time, they added interventional services, including interventional oncology procedures, to their joint venture.

The decision to move Y90 from the hospital to the outpatient setting was spurred by the need in the community, availability of more modern imaging equipment, and patient convenience. In 2019, it was not very common to perform Y90 in an OBL. Dr. Brower outlines the steps he took to move these services, starting with building consensus within the group. Next, he explained the benefits of the OBL to the hospital administration, which include freeing up time in the hospital for true emergencies and providing care for patients who prefer the OBL setting. Then, the group proactively reached out to payers and secured written agreements that they would provide coverage. After securing these agreements, they drafted pro formas, searched for adequate sites, and contacted vendors.

Since each state has different regulations for “hot labs” that use radioactive materials, Dr. Brower recommends working with your radiation safety officer to help walk you through the regulations. His OBL has a “mini hot lab” that allows him to draw up the Sirtex dose that he prescribes. Nuclear medicine technicians assist in transporting the radioactive material. Patients have pre-Y90 SPECT mapping close by, at another center.

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RESOURCES

Inland Imaging Interventional Radiology:

https://interventional.inlandimaging.com/

OEIS:

https://oeisweb.com/

Radioactive Material (RAM) License:

https://dpbh.nv.gov/Reg/RAM/dta/Licensing/Radioactive_Material_Program_(RAM)_-_Licensing/

In this episode, host Dr. Aaron Fritts interviews Dr. Ali Alikhani about his solo outpatient IR practice, how he leveraged his sales background in the OBL setting, and marketing advice for IRs in an outpatient practice.

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SHOW NOTES

Dr. Alikhani started working at an OBL three years out of fellowship. He became the solo practitioner at an outpatient center that had recently lost its physician to retirement. The practice is OBL based, and had a medical director and staff that flew him around to get trained for his first role. This OBL was part of a company that owns around 70 labs around the country. He primarily does embolization; his favorite procedures include uterine fibroid, prostatic artery, and genicular artery embolization. He works as a W2 employee, but there are 1099 locums IRs who are able to cover him for vacation.

Due to his background in marketing, he had a strong interest in building up this OBL and diversifying its services. He works with a marketing team including one employee who has worked at this company for 10 years and is very comfortable going to marketing meetings on her own. She helps plan which meetings he needs to attend, and gives Dr. Alikhani weekly reports on who she has met with during the past week. Together, they are building up the practice. Despite this strong marketing team, Dr. Alikhani still only works 60% at this OBL and has to work 40% at a separate OBL due to lack of patients. It takes time to build relationships with referring providers and build a large patient base.

Dr. Alikhani speaks on the responsibilities of being a solo IR at an OBL. It is a great responsibility that requires planning, teamwork and a willingness to make mistakes and learn. It is a stressful adjustment from hospital work, but it can also be a very rewarding shift with the right team in place. He recommends early career IRs to start out at an established OBL that knows how to run the business. Learn from this, and then open your own center if this is something you find yourself capable of and willing to do.

In this episode, our hosts Drs. Michael Barraza and Aaron Fritts interview Dr. John Pavlus about his methods of drain placement, monitoring, and removal, as well as his vision to design an ideal drainage system.

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In this episode, our hosts Drs. Michael Barraza and Aaron Fritts interview Dr. John Pavlus about his methods of drain placement, monitoring, and removal, as well as his vision to design an ideal drainage system.

Dr. Pavlus became interested in abscess drains when he noticed that across different institutions had very different indications, types, and methods of putting in drains. Dr. Pavlus prefers to place drains under ultrasound guidance, and he will also obtain a CT image afterwards to ensure the drain is in place. The doctors discuss their favorite guidewires to use: Dr. Pavlus prefers the Coons wire and Dr. Barraza prefers the Amplatz wire.

For deep pelvic cul-de-sac abscesses, Dr. Pavlus describes how he obtains transgluteal access and uses a Hawkins needle. Liver abscesses can be challenging, due to their variety of drainage contents (hematoma, bile, necrotic material), and increased time of drainage. We also discuss the debate between suction bulbs and gravity drainage bags, noting that research studies and personal experiences have not shown significant differences in the rate of fistula formation with either method. One exception is post-operative spinal drainage, where using suction could confer the risk of removing CSF.

To assess when a drain needs to be removed, Dr. Pavlus monitors the output and obtains a CT. He prefers to take ownership of drain care and remove drains that he originally placed, but if needed, he also collaborates with trauma surgeons to ensure that drains and sutures are removed properly. Dr. Pavlus also recognizes the need to standardize follow up care for drains. Dr. Barraza describes a workflow for drain checks at his fellowship site, which included daily rounds and a standardized checklist for each patient.

Finally, Dr. Pavlus speaks about his ongoing mission to design an ideal drainage system for various dwell times, viscosity of contents, and catheter sizes.