Adaptation: An Interventional Radiology Residency Response to COVID-19.

As New York City became the worldwide epicenter of the coronavirus disease 2019 (COVID-19) pandemic, every physician has been forced to adapt to a constantly evolving situation. In April of 2020, the demands on our institution required immediate redeployment of residents across all specialties to meet the unprecedented demand on the health system. On March 25, the institution declared the Accreditation Council for Graduate Medical Education (ACGME) Stage 3: “Pandemic Emergency Status” (1). Our Interventional Radiology (IR) residency has been able to leverage our unique skill set to contribute in numerous front-line areas while continuing to meet the needs of our primary patients.

Interventional Radiology/Diagnostic Radiology residents (IR/DR) and Diagnostic Radiology residents participating in the Early Specialization in Interventional Radiology (ESIR) curriculum in our institution have been actively mobilized outside the radiology department to provide clinical patient care. These postgraduate year (PGY) II, III, and IV residents have worked side-by-side with redeployed cardiology, anesthesia, and pediatrics trainees in the intensive care units and on the rapid response teams. At the peak of the COVID-19 pandemic, these departments have had to expand up to 5-fold to handle the intensive care needs of the hospital. The critical care department has expressed gratitude for the redeployed trainees from different departments and their ability to leverage their respective unique skill sets. All trainees throughout the hospital, including those from the radiology department, were given appropriate personal protective equipment to safely treat these patients. In addition to being the primary clinical provider for the patients and assisting in the clinical throughput of the units, our re-assigned IR and ESIR residents perform bedside procedures, diagnostic ultrasounds, interpret imaging studies, and coordinate logistical issues that arise in transporting these critically ill patients for cross-sectional imaging and radiologic procedures.

The unique skill set of our IR residents was put on display when a young COVID-19 patient, whose hospital course was further complicated by stroke, myocardial infarction, and renal failure, developed bacteremia and acute hepatic insufficiency. The IR resident assigned to the unit ensured rapid placement of arterial and central lines for monitoring and resuscitation, and performed a bedside ultrasound to assess the liver parenchyma and vascularity, and determine the patient's volume status. Having an imaging expert available to document and interpret pertinent radiological findings in this critically ill patient allowed the intensivists to focus on this patient's clinical deterioration with a clearer differential diagnosis.

Another example where IR was invaluable to the critical care team was in a decompensating COVID-19 patient with back pain, who had received therapeutic anticoagulation. The patient's hemoglobin had dropped significantly, to 3.4 g/dL, raising concern for bleeding. The critical care team wanted to take this patient for computed tomography angiogram to assess for a potential site of bleeding and possible abdominal aortic aneurysm, but was somewhat reluctant to give intravenous contrast as the patient was in acute renal failure. Given there were no clinical signs of gastrointestinal bleeding (melena or bright red blood per rectum) and the patient had stabilized after rapid transfusion, the IR resident volunteered to perform a comprehensive bedside ultrasound of the abdomen, which revealed a normal-sized aorta and no evidence of complex fluid in the abdomen to suggest bleeding. The presence of an imaging expert, able to confidently convey these findings allowed the team to feel comfortable continuing to monitor the patient without further imaging, preventing worsening renal failure risks of instability during transport. Another IR resident was able to clinically identify an active bleed in a hemodynamically unstable patient, place the appropriate resuscitation central venous catheter, and ensure appropriate stabilization prior to IR consultation for transarterial embolization.

Our PGY V and VI integrated IR/DR residents and fellows have remained on IR at our six different hospital sites. While the case mix of our IR service has shifted towards more emergent and inpatient centered care, including interventional oncology cases, gastrostomy tube and hemo- and peritoneal dialysis catheter placements, the IR service has continued to remain fairly busy. In addition, our senior trainees have joined the vascular access team throughout the hospital, placing bedside dialysis catheters, arterial lines, and central lines in order to ease the clinical burdens of frontline providers. This approach has been implemented across multiple other specialties and institutions with great success (2).

Despite the new intensity of the new demands, resident supervision and continued training remained intact. The junior residents redeployed to the ICUs were overseen by the critical care attending staff for patient care and procedural supervision, while radiology attendings remained available to provide remote assistance for imaging challenges. The senior residents participating in the vascular access service had an IR attending designated each day to supervise bedside procedures on an as-needed basis.

The COVID-19 pandemic has severely impacted resident training at all levels and specialties, and IR is no different (3). ACGME has allowed for flexibility for traditional graduate requirements and rotations based on institutional outbreak severity. Additionally, the ESIR residents will receive credit for their ICU time in order to fulfill their ESIR intensive care unit requirement, and IR/DR residents are expected to receive credit towards their graduation requirements. Additionally, the case requirement for ESIR residents has been relaxed such that residents can complete PGY-5 with fewer than 500 cases, though they will still require 1000 cases prior to completing an independent IR residency.

Unfortunately, junior IR/DR residents that are fulfilling their ICU requirements early, are losing valuable time to hone their diagnostic radiology skills and fulfill necessary responsibilities within the diagnostic radiology department. This pandemic and its associated hospital changes will likely continue to impact their completion of diagnostic rotations and may affect their diagnostic radiology skillset and performance on board examinations in the future. Residencies across the country must devise unique solutions to ensure that their trainees receive proper training in all aspects of radiology. Our institution has continued daily IR and DR lectures via online video conferences, allowing residents and fellows the ability to view these lectures remotely. In addition, these lectures are recorded so those who cannot participate in the live lecture due to clinical responsibilities can view them at a later time. Furthermore, with changes in the board exam schedule caused by the COVID-19 pandemic, schedules have had to be adjusted for the next academic year. If closures related to COVID-19 continue beyond the current time or recur, this could have a deleterious impact on trainees for years to come with regards to scheduling these necessary exams.

The past 6 weeks in the epicenter of the pandemic have left us frightened, inspired, exhausted, and humbled. It can be uncomfortable stepping out of our traditional role, however the added responsibilities for IR trainees will strengthen our training. Overall, it has been incredible to work with faculty and trainees across many different specialties who are collaborating as a healthcare community to fight one enemy. We have come together across disciplines, titles, and levels of training, with common goals; to care for our patients and each other. These relationships will last a lifetime (Fig 1 ).

Figure 1.

Images showing our redeployed interventional radiology trainees working in the COVID-19 intensive care units.

Disclosures

Dr. Aaron Fischman reports personal fees from Terumo, personal fees from Adient Medical, personal fees from Boston Scientific, personal fees from Embolx, personal fees from Perikinetics, outside the submitted work.

All authors wrote and edited this opinion piece.

The authors had no source of support for this opinion piece.

The authors declare that they had full access to all of the data in this study and the authors take complete responsibility for the integrity of this opinion piece.