Interventional radiology‰Ûªs role in extreme situations

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It takes more than just the normal dose of expertise to practise in the midst of war, a natural disaster or a place where there is extreme poverty and no infrastructure. But many interventional radiologists, those recognised experts in image interpretation and cessation of blood flow, feel that it is in these and other such extreme situations that the adaptability and ingenuity of the subspecialty comes alive. IRs are typically a hands-on lot, “prepared to turn their hands to almost anything”.

“One of the things we often forget while we get bogged down in current procedural terminology (CPT) codes and all that we do, is how fortunate we are to practise in places that are safe to live in, with wonderful sterile equipment, stable electrical supplies, and use equipment that has not been used before. Many SIR members practise in very tough environments, in emergency situations, and many live in these places. In this session, you will get some sense of the diversity of the environments in which we have to practise,” said Murphy.

 

Commander Stephen Ferrara, from the US Navy, who had just returned from Afghanistan where he had been involved in setting up the first interventional radiology service, spoke on interventional radiology in Indonesia, following the Asian tsunami. His talk was titled “Radiology Afloat: Experience from the USNS Mercy in Tsunami relief and beyond”.

 

Ferrara said, “Performing interventional radiology in an austere environment exemplifies the inherent ingenuity and adaptability within this field.”

 

Ferrara made a critical distinction between “humanitarian assistance” and “disaster relief”.  The former type of medical mission involves primary care work with a heavy emphasis on diagnostic imaging and, in general, “simple” scheduled surgery. All of which usually take place in some form of infrastructure, he said. On the other hand, in “disaster relief, the infrastructure is completely obliterated, and there is much trauma and critical care. However, imaging is still important, as are image-guided procedures,” explained Ferrara.

 

He created a vivid picture of the striking armageddon-like atmosphere left behind by the tsunami, and working in an angiosuite with heavy seas, rocking and rolling, where image monitors were strapped down for stability. “You encounter interesting challenges which are different from land-based hospitals,” said Ferrara.

 

He also said there was a huge role for IVC filters in Afghanistan where there was a lot of polytrauma, spine, neurological injury and long-bone trauma. “As these patients cannot get long-term coagulation, we felt the best thing to do for them in order to prevent potentially fatal pulmonary embolisms, was to put filters in them,” he said.

 

In situations like this, Ferrara told delegates: “Be prepared to function a lot outside of your traditional role and comfort zone and to do a lot of women and child care.” He described a case involving an infant with pneumothorax at a time when there was no paediatric intensivist or anaesthesiologist present.“I was the only one willing to put a chest tube in the baby, no-one else felt comfortable, so this is where you will find that interventional radiologists will usually do pretty much anything,” he said.

Then, Matthew S Johnson, Indiana University School of Medicine, USA, spoke about the long journey which took interventional radiology to the Moi Teaching and Referral Hospital in Eldoret, Kenya.  “When I first went there in 2003, I realised there was no need for IR, because there was no radiology. The chest X-rays were the property of the patients, who had paid for them, and they were kept under the mattresses, or with them. There were no radiologists to read them; the doctors read them at the bedside through the windows.”

 

Johnson pointed out that there were as few as 70–90 radiologists in the entire country. More than 50% of those are in Nairobi, the capital, and fewer than 45 in the rest of Kenya.

 

“There are many challenges to IR in Kenya. There are very few radiologists, there is lack of clinical training in radiology, very little equipment, and frequently when it is there, it does not function. There is also very little money, so a CT scan which could cost up to 80 dollars is clinically irrelevant. There is also inadequate record keeping, in that, once a radiologist read an image, they would write on a piece of tissue paper that got thrown away.”

 

Johnson then spoke about the  people he worked with, and their difficult journey together, which has led to the setting up of a Picture Archiving and Communication system (PACS) system, where outside clinics now send X-rays,  getting a new multislice CT scanner and other equipment in the hospital.

 

He talked about cases where without IR, patients would have died, such as the 26-year-old woman with HIV, and ascites which was attributed to liver failure. That diagnosis prevented treatment of her HIV. However, when liver function tests came back normal, ultrasound showed massive ascites.  Johnson and team placed a percutaneous peritoneal drain where 25 litres of pus drained in just 16 hours. Sonosite suggested an intraloop tubercular abscess and the patient went to the operating room to drain the abscess and was then released on highly active antiretroviral treatment.

 

Johnson spoke of how over the course of time, he has seen Kenyan radiologists such as Livingstone Wanene become committed to the cause of interventional radiology. “He is now the “go-to” guy in Kenya for biopsies and nephrostomies, and is involved in training people,” he said. Johnson also spoke about the donated equipment which is “re-used and re-used till it breaks”.

 

Johnson told delegates about the high incidence of cancer, and gave an example, of young women with cervical cancer and ureteral obstruction which precluded chemotherapy. “We did nephrostomies using only ultrasound guidance. It can be done and is so important, because now those young ladies are getting nephrostomy tubes, and then chemotherapy.  They would otherwise have been sent home to die,” he said.

 

SIR attendees learned that “There is a lot of promise, but then there are several problems, including the possibility of the hospital going bankrupt.”

 

Johnson’s last slide was a copy of an email he received from Livingstone Wanene telling him about his pride and humility in performing three percutanous nephrostomies. It read, “[…] your faith in the fact that one day interventional radiology will be a medical aspect for Eldoret is not for naught. Eight years has been a long incubation period, but we are now good to go. So what next?”

SIR delegates then listened to a recorded session by Aghiad Al-Kutoubi of the American University of Beirut Medical Center, Lebanon, on the Lebanese experience who began by acknowledging the contribution of all the staff who risked their lives.

 

Al-Kutoubi shared that Lebanon went through several difficulties in the last 50 years —the 15-year Civil War (1975–1990), the Israeli invasion of Lebanon and Beirut (1982) and the Israeli war against Lebanon (2006). He told delegates, “We had to handle variable injuries relating to type of battle and type of weapons used. Frequently, there were problems with victim transportation which was hampered by ongoing hostile activities.‰ÛöWe also faced direct pressure from families and comrades to intervene, even in hopeless cases, sometimes with a weapon pointed to our heads.”

 

In the Civil War period, said Al-Kutoubi, the weapons used were machine guns and grenades which resulted in heavy artillery injuries. The victims brought for treatment had manageable injuries and it was seen that vascular, intracranial and abdominal sites of injury were suitable for imaging and intervention. So there was a major role for interventional radiology to play.”

 

On the other hand, said Al-Kutoubi, in the Israeli wars on Lebanon, the weapons used were heavy rockets, bombs, heavy artillery bombardment from tanks, ships and airplanes, and landmines. These resulted in  massive injuries, with the victims frequently being unrescuable. “As such there was a limited role for IR and imaging, except for victims on the periphery of the area of damage,” said Al-Kutoubi.

 

He said the most important aspect for the team was agreeing triage and management protocols, staff issues, safety issues, equipment and devices, safety of patients during transport, and rapid and focussed imaging/intervention.

 

The hospital had to ensure that staff had transportation, accommodation, contact with their families, and protection during the hostilities outside. The team also had to ensure that equipment, power supply, and access were maintained.

 

“When it came to supplies and devices, we used to store and hoard as much as possible. We had “black market” contacts for supplies and had to use our existing resources like coils and tubes with creativity.  We made our own catheters from tubing, and re-used them maybe 30 or 40 times, and used pieces of guide wires instead of readymade coils.

 

 “In addition, we had to do our regular duties, maintain diagnostic imaging, consultations, consider modern imaging requirements, train residents, keep up-to-date  and,” Kutoubi continued, “through it all live for the moment and look for the light at the end of the tunnel.”