Trash IR

Before everyone brands me as an oversensitive snowflake, let me explain why “trash IR” is an offensive term. “Trash IR” procedures are roughly defined as, but not limited to, paracentesis, thoracentesis, central venous access, drains, and G tubes. Often associated with inpatient hospital work, these procedures are the opposite of sexy; “real” IRs won’t clamor to do this work, and often complain about it since they’d much prefer to involved in meatier, cooler, more technically and intellectually challenging cases like PVR TIPS, PAE, or GAE. Who wants to be bothered with a Mast Cell Activation syndrome patient who needs yet another PICC with burned out arms and you have to wait for anesthesia who won’t be available until 7:30 PM? Waiting around until then is bad enough but the dogfight is just beginning- just wait until you try to find a non-spasming vein in two burned out arms that have had several PICCs while listening for the inevitable stridor. My blood pressure goes up just thinking about it.

But here’s the really obvious thing: that patient needs us just as much if not more than the patient who suffers from a chronically indwelling foley catheter, or the ESLD patient with portal vein occlusion. A patient who is dying of lung cancer laboring for every breath needs us to drain their pleural effusion so they can speak comfortably with their loved ones. The mom with ovarian cancer can’t get comfortable enough to play with her kids- she needs us to drain her ascites. Say what you want but these are real scenarios; I’m not dramatizing this to any extent.

Go ahead and use the term “trash IR” if you want. Heck, I am guilty of it as well. In my younger, stupider, and more cynical days, I laughed at the use of “dumpster IR.” I understood what it stood for as it relates to our practice of IR. What I did NOT laugh at were the needs of the patients that I had conveniently (and pejoratively) labelled. When the time came to take care of these patients, I took it seriously and I always will.

I’m sure I’ve exceeded the “1000 paracenteses performed” milestone and I’m guessing I may eventually pass the 2000 mark. How do I keep performing a procedure that is so common? How do I NOT become jaded and cynical about the 1,654th paracentesis I will eventually perform? Lindsay Machan and I were discussing this and we have the exact same answer (and anytime I have the same answer as LM, I know I’m doing something profoundly right): we both focus on trying to perform the procedure without the patient ever knowing we did anything. Can I infuse lidocaine without the patient noticing? Can I insert the Yueh needle without them feeling anything? Can we drain 3L of ascites and all the patient says is “I feel better! I didn’t even know you had done the procedure!”

That’s also the reason why we can’t pawn the “trash IR” cases off to other services: because we are the best at performing them. There is no question in my mind that IR is the best at minimally invasive procedures. All you have to do is ask a repeat thoracentesis patient who has had both IR and floor MDs perform them. When the patient says, “hey doc, what’s your name again? I want to make sure to ask for you next time,” that’s all you need to hear.

“Clinical IR” (a weird term that Eric Keller and I laugh about- I mean, does that mean there’s a “non-clinical IR” entity out there?) isn’t defined by big, cool, sexy IR cases. It means taking care of patients and doing so in a compassionate, competent, and comprehensive manner. We don’t necessarily get to choose- people get sick in all kinds of ways. We have the privilege of building trust with patients who allow us to care for them. To overlay any kind of value judgment onto a patient’s specific need is inappropriate.

I think outpatient-cased labs (OBL) are a critical feature of our specialty- we need to embrace OBL practice for both new trainees and practices as well as existing ones. The obstructionist Radiology groups and hospital credentialing entities are an enormous threat to our independent future. This must be mitigated by all means necessary. But what is important for me to convey here is that this is not an Either/Or proposition. I think that the perfect practice is having both an inpatient practice and and OBL practice. That being said, referring to “trash IR” doesn’t make OBL operators sound awesome or make a better case for their chosen practice setting. All it does is denigrate the important work that inpatient-focused IRs do.

So let’s agree to stop using that term. I think “inpatient IR” (as opposed to “outpatient IR”) is a suitable term that conveys the same idea. Let’s continue to focus on every patient and what they need in their worst moment and not judge them for it. Let’s be grateful for the privilege of caring for patients and earning their trust every day. Let's recognize that it doesn't matter whether we care for these patients in a hospital or in an OBL; what does matter is that we CAN care for them.