Interventional Radiology in the 21st Century Whose Responsibility is it? Tony Watkinson Professor of Interventional Radiology Royal Devon and Exeter Hospital and Peninsula Medical School

Ideal Provision of IR (2009) Elective and Emergency work 24/7 delivery of high quality IR service Clear recommendations to NHS trusts, departments and individuals

26 year old Motorbicycle accident RTA am CT pm Angio13.13 pm Completed embolisation pm-avoided open surgery and has had the spleen preserved

74 year with 17 unit bleed post sphincterotomy for CBD stones

Angiography and coil embolisation of SMA branch 30 min procedure via small groin incision Avoid major surgery

Responsibility of Individual Adhere to good practise as defined by GMC Maintain skill base and only perform procedures that normally perform in hours Recognise that ad-hoc rotas are not in best interest of patient Report any concerns to clinical governance committee

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Current Provision of IR RCR Survey Only 10% of Trusts 24/7 availability IR 90% nil or traditional “good-will” ad hoc –Consultant surgeon/physician tries to find IR -if can find/sober persuade to do emergency procedure on an individual case basis Pressure for delivery of service from clinical colleagues IR on call can be very challenging technically and medically Why no on call –? on call nurse or radiographer on a rota –Lack of support from trust-not properly resourced –? Lack of willing from IR to provide service due to other pressures ie frequency of rota (1 in 3 or less), already part of diagnostic radiology on call

What Should Happen to Ensure “Interventional Radiology Services Fit for the 21st Century” 24/7 IR is in many instances best for patients 24/7 IR is essential in the provision of modern medical care It must be properly resourced Local solutions to decide what/what cannot be provided Discussions with SHA, PCT and other trusts to ensure 24/7 cover to all patients in the region Ensure care is not post code specific

4 /52 ago 8.10 am received call from hospital 100 km away with no IR cover

81 year old Female Retained stones in common bile duct following cholecystectomy Benign condition Patient previously fit and well, independent and living alone Failed Endoscopic removal of stone via ERCP Had a combined procedure with a percutaneous approach through the liver via PTC which was successful Patient discharged following day

Combined PTC/ERCP for CBD stone

5 days later After 2-3 days intermittent RUQ pain Sudden collapse at 6 am Called ambulance and taken to A/E Clinical signs of ongoing haemorrhage 11 unit transfusion CT scan-active bleed from liver capsule Patient deemed unfit for surgery No IR cover-called me although no formal agreement exists between our hospitals Patient deemed unfit to transfer

8.20 am WebPACS CT Active haemorrhage from liver capsule I was asked to travel to stop the bleeding using IR techniques- Angiography and embolisation

Angiography and Coil Embolisation-15 mins Took me 1 ½ hours to drive-arrived am

Patient stabilised immediately-10 days on ITU- Haemodynamically stable and passing urine but had suffered a severe neurological event Whose responsibility was it? Individual doctor…..hospital….trust If you cannot deal with complications should you be doing case….. No agreed pathway of care or arrangements within the hospital or with adjacent trusts if IR was required Should patients be told during the consent process that if complications occur the most effective treatment modality to deal with them will not be available?

How would your trust have dealt with this clinical scenario? Do you have IR 24/7? Thankyou for your attention