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Yeah. Yeah. OK. You're welcome. OK, welcome back. I hope you guys enjoy all the sessions in the workshops room. And then you have now convinced this is one and only career you are going to go in and then before you go all, we have to, we always keep the best lecture last so that you have to come back. So II, you know, it's a real pleasure to introduce all of you, you know, to doctor Georgia PNA. Um she's actually an intervention radiologist from Newcastle. She's gonna give you a tour on the IR training program and um and her journey here as a female intervention radiologist. So without further ado Georgia. Thank you. Yeah, I just, I'm sorry. Yes, that should be the one. OK. Hello. Excellent. So anyone that we want you to get any one of us that you know, I on my back, there you go. Lovely. Perfect. And I'll just, hi, I'm I'm George. I'm one of the intervention radiology consultants and I work in Newcastle. Uh I'm I'm resting thing and my presentation is pain. You're hoping to, to hear about the secrets of how to get into interventional radiology. I've gone a little bit more fluffy. We'll talk a little bit about how to get into interventional radiology. But, um, at your stage, what I found really difficult to put my head around was the soft aspects of the jaw that you've heard. A lot of facts and, uh, being enthused about things and seeing different oncology and M SK IR and pediatric ir. Uh, but I'll just be a little bit more general. Um, Surprisingly, my talk will probably, uh somewhat we've already talked about all day. Uh, but we'll, we'll see how we get on. So I work in Newcastle, I work at the Freeman Hospital, which is a transplant center. All right. Um So interventional radiology, pathway career life advice, generally, all that will be me for you today. So what we're gonna go through, um, what is interventional radiology? Uh you should know by now. Um I hope so. Who can do it and how do we get there? Challenges and ways to overcome them and retirement plan? So you haven't even started your career and I'm talking to you about retirement plan. Uh Well, actually time flies. So what is interventional radiology public? Doesn't know, media doesn't know any doctors don't know. My mom definitely doesn't understand what I do. I can tell you this. I don't understand to your non medics relatives, what you do? Impossible. So, a bit of CT, a little bit of ultrasound, a little bit of imaging, a little bit of that. A little bit of this. Is it the procedure? Is it surgery, is it minimally invasive? Is it pinhole? Is it pinhole? So it's a rapidly evolving specialty provides lots of ways to treat lots of different things with less mortality and morbidity. And it doesn't matter what age the patient is, what size the patient is, will completely get from everywhere, anywhere in the body. And that what su intervention, radiology. And there are many specialties that can say that and you just have to hold that thought. You don't deal with 11 thing, you don't intervene on one thing, you intervene on absolutely everything and anything. So you've heard about S Seldinger. The thing you probably don't know is that he invented his Seldinger technique when he was 32 years old. OK. And that's what we base our life doing on, on an idea that the medical student had Charles daughter. Crazy Charles realized that he can treat endovascularly. Um uh you can treat vessels uh by using guide wire. So that was the first time we came across therapy in intervention radiology. He was actually trying to do a autom from a groin, uh passed his wire through a stenosis and then that looked better afterwards and then said, oh, then we can do something about that. How cool is that? So what happened within the last 16 years? Imaging has made lips and bounds move forward a lot. You have CT that can tell you exactly what you need to do. This is an infrarenal aortic aneurysm that traditionally would be done with an open operation. But now we can do it from two little tiny cuts from the groin and someone that had symptoms of a stroke, we can immediately know what's wrong with them by doing an MRI of their carotids. Ultrasound, can give us functional results and can tell us if um, a vessel is narrowed significantly and then we can plan treatment. And most importantly, all this imaging assists us in doing lots of really exciting stuff. And this is a very nicely placed needle in a tiny little ve vein in somebody's arm, but the with the big lining, ok. Um And as simple as that you make a difference from very early on skills that are transferable probably to most specialties and things that you could theoretically take for granted to make a huge difference to, to to patient care. Um This is a DSA, this is an angiogram of an aorta. Uh someone that might need an aortic stent or might have an injury. This is a mesenteric angiography of someone that might be bleeding who can go and stop the bleeding from the colon that the surgeons won't be able to find or get to. And not only we can use contrast dye to find problems, we can now do something like this of that place. Mm No. Oh. Oh, wow. It doesn't rotate I'm sorry about that. But this is con beam CT. So we can plan intervention can inject contrast in the arteries of the liver and very specifically find the humoral supply of the liver tumor and navigate our catheters exactly to the one vessel that supplies that liver tumor and provide treatments. This is a little rotational CT scan that we have in our IR suites that help us navigate through different things. Oh, now it's turning just need the one more click. So super cool staff, but it's not only the imaging is the advantages within the industry and the changes that we've we've encountered. So this little guy here called the Swift Ninja surprisingly is the name of a catheter is not a joke. It is called Swift Ninja because it goes right, it goes left, it takes different shapes. It helps us going into places that without these advancements, we wouldn't be able to get to. We have different stents, different type of drugs to embolize and help us to see things better. So when we're doing our case procedures, we can put beads that stain the tumors and we can see them if we've missed a little bit promote good technique. So ir in a nutshell and blocks blocked things by arteries, veins, bile ducts, kidneys. Um This is one example of an artery in your leg that the leg of some of that had a limb ischemia that has been treated and looks much better. If that doesn't work with simple balloon angioplasty, you can use stents and the stents can use if they're covered, we can use them to stop hemorrhage. So we unblock things that are blocked and we block things that leak or things that are not really good to sustain life because of hemorrhage. So this one is a nice VC occlusion. So you probably have heard of SVCO people with lung cancer get stenosis or, or venous stenosis of uh of their upper body vessels, veins and and they get very puffy, they can't breathe. This is the same woman before and after procedure. It's not a myth. It changes life and is as simple as an intervention, radiologist open in a blocked vein from there to there and from that to that so covered stent, as I said to stop bleeding, this is a gout, gunshot wound. So someone's been shot in their arm artery, went ahead, put a covered stent and beautiful, save another life. It's not only that what it used to be like open cut surgery, 10 hours straight is now tiny, little bit of surgery within half an hour, all done. So, time effort, better response for the patients less anesthetic time. This is an IOP transection. This is trauma that has been treated acutely. This is the little area where the pseudoaneurysm of of the the shearing forces of the trauma occurs and that has been covered nicely with the thoracic aortic stent and we have many applications you've heard throughout the day about oncology, case chemotherapy in the liver tumor. So this is the dynasty I was talking to you about Little Beam City intraoperatively finding out the tumor put in the beads that illuminate the tumor and run deliver chemotherapy to the tumor. Complete response that quite chunky tumor around six centimeter tumor has been treated within one go or radiotherapy third treatments as part of the interventional oncology, very large tumors when you have two large tumors, chemotherapy ca cases. So chemo embolization can cause quite a bit of pain and quite ss quite a bit of systemic response. Ct is slightly more gentle and doesn't cause the embolization syndrome that, that the case would cause for large tumors and again, smaller glass microspheres loaded with um uh radiation delivered very precisely within the liver tumor. And you have tumors that from that size, this is inoperable. This patient, if it wasn't for our uh for intervention, if he was to be put in on medical treatment, he will probably have six months to live. You're taking someone from there with a tumor that big and a liver eminent that small. You deliver ct that hypertrophies, the good bit of the liver and shrinks the one that you targeted with radiation, you take it from there to that beat with a large hypertrophic liver, you bridge them through resection. That patient has been cancer free since 2016 is still alive. You would have been long gone. So you do make a difference. There are no lost cases to our mind. We always try to do the right thing that we go to extreme. And that's what interventional oncology is about these helping fellow surgeons when they removing metastatic, um they're doing uh orthopedic operations or a, a renal RCC helping them not to, to have vascular bed of tumors, embolize them preoperatively or for interventional oncology, you can use a little needle to go into very targeted small lesions, treat them and they're gone and have as good as results as you would have with surgery. And in patients with cirrhosis ablation is probably the first port of call. You wouldn't get resection these days for small under three centimeter liver masses. So we have moved on a lot. We we can do extra anatomical bypasses, create connections in the body to treat um refractory ascitis or bleeding through tips. And ok, I've gone through lots and lots of things. But who can do Ir who do you think can do ir like? Is it a specific breed of people that can do ir so different pencils? So all different colors. Um you have to want to walk on sunshine because it's a wonderful specialty and you, you have to, to be positive about things, especially if you do oncology, you have to look at the bright side of things and drive for some treatment and although we're all different colors as long as you have the right shape and you're, as long as you've been trained, right. You can all do it. There's nothing clever about it. There's nothing special about it. And don't, don't tell, let every, anyone tell you differently. So I take me here. All right. I am not priv, privately educated. I'm coming from Greece. I finished in the University of Athens medical School. I graduated in 2007. Now. Anyone knows what that place is. Liverpool? Yes, I did my foundation training in Liverpool. So from Greece didn't understand the accent very well back then. Wouldn't, didn't speak very good English either still. But it's all right. A bit better now. And then I went to that place, which is Wales and did core surgical training. And then I got my number, my radiology training number up in Aberdeen who I've been a lot quite a bit, taking a long time to do that. Don't have to, to go directly through to radiology. You can wonder about it. Worked for me and I picked up different accents. Kept mine. Sorry, I've, I've, I've ended up in, in Newcastle where I had my baby. I got my IR training. They gave me a job and I'm very happy and you have the other end of the spectrum where you have very significant careers, but you'll have to start from somewhere. Doesn't matter as long as you want to do something you can do it. Despite all this, II have to mention that a little bit because I see a lot of women here, probably more women than I see men. That's probably reflecting the fact that in medical school, there are more women that there are men in medicine in general. 40% in radiology, 40% of the workforce is women yet only 10% of the consultant body are IRS you know what that means? If we don't improve on that, IR recruits from half of the trainee pool, that's not good enough. There are various reasons why this happening. And despite our great efforts there, there's still misconceptions around radiology and ir too much radiation, not enough patient contact, not good work-life balance. You can do whatever you want, you can work part time, you can work full time. You can be as, as involved as you want. There is space for everyone and the culture is changing. So I encourage you all to look into your careers and don't choose based on convenience, choose based on passion. How do you get there? How do you, how do you decide to do Ir how how do can you do Ir So days like these are perfect. So early interest get involved in research. The world needs to know that these treatments are as good as open surgery. So it is your responsibility to get involved in research, early build your CV like that at the same time, read college guidelines. Ok. So go on the RCR website and read the guidelines that they have of how, what boxes do you need to do to take, to take, do you need to take to, to do IR or do radiology? And the only way to get started is quit talking and begin doing. Apparently this is Walt Disney. That's how pink I am today. All right. I'm quoting Walt Disney and ask, listen, get inspired. Don't be shy. Now, a little bit about the curriculum, the curriculum has changed very recently, the IR curriculum. So for your average cohort, you'll finish in a few years' time, you do your foundation training and after that, you will be in the position to apply for radiology training. Now, November time, normally you apply for your radiology um uh interviews and then January you will do your test. There is a national test that tests you and ranks you and that is taken into consideration and then you, you see for your interviews. If you were to be successful. Since last year, you can either choose to do diagnostic radiology or IRI R is a little bit more competitive and the IR bit guarantees you if providing that you progress properly, you will get an IR six-year training program and you will be at the end of your career, at the end of your training, diagnostic radiology with Supe SU SU Subspecialty CCT and IR which is the only Subspecialty in clinical radiology um you need to tick your boxes, you need to do your audits and whatever else you need to do. What you need to remember is actually there is room for everyone. Even if you don't get the IR training and you decide you, you go through radiology at ST three, you could still be selected to do IR as a as a subspecialty, the number of IR training posts are only small. The rest of the posts will be filled after that. OK? So don't shy about no, everyone has challenges. Well, you need to overcome your challenges will be an inspirational team behind you. Ok? As you go through training, you can have personal challenges navigating through training. You have to remember. It's not only about papers and audits and working hard and going home very late is about when you do all that you probably fall in love, get married, have kids, move about if you get married to medics. Good luck with that terrible story you move about, you have no stability, no one tells you this. No one signs you up for this either and you suddenly are in a position where you have to compromise again, please. If you have to do the compromise, do it in a way where it's constructive for you, make sure when you go to work, you're always happy. You love your job. Don't compromise on your passion. All right, I've been very fortunate. So I've been inspired by these women, I would, I look up to them. I, and I don't say that because prof is here. I do look up to them. They have helped me. They have given me a purpose. That's why I'm standing here today. I wouldn't do it. Otherwise this guy, you probably know him. He's the president of BSI R of our society. Been very fortunate. I've been mentored by him. I've been trained by him and uh it's privileged to call him my colleague. You probably a recognize also this guy. So this is Doctor Haslem. This is Doctor Ler. These are now my colleagues and I call them friends. And you have, you can have that, you can have success stories, you can have happiness. The system is not perfect and the NHS is not perfect. You can always impact with your ability to work and your working interest and make changes around you. And hopefully things will follow my retirement plan. I know what is important to me. I'm telling you from now before you even start start thinking what is important to you. Respect to others, kindness to others training, juniors training registrars are one of my most important joys in life. All right. I'm very proud of my family. I'm very proud of my work. I'm two years in, as a consultant. I haven't done much, but I do feel fortunate and I think as long as you, you keep true to yourself, you will have a wonderful career. And as I say, start them early. That's why we're here to start you early guys. You'll be the few too. Thank you. Does anyone have any questions for Doctor Prion? Oh, no, no. Thank you, Georgia. That was a very inspiring talk. And um so life is a journey. You will start yours today and then where it leads you in some way, I might do that. And um if you guys have a note system, I always say this to, to, to them and I will say it to all of you. If you can find out who you are, then you are winning your life journey. So the authentic version itself is our strength. So if you can discover that version of you, you're on the winning journey. It took me many, many decades to discover who I am. So this is the wisdom that if you can, you know, if I can leave anything for all of you, discover that version of yourself and then play out in that strength because you'll be most optimal or powerful from that place. So that authentic version on you and I'm going to then pass on to the next uh uh group of uh speakers, uh quiz answer and case highlights. But uh troops of um um you um no, no happening guys. Um So we're not necessarily gonna go. So what we're gonna do is we're gonna use some of the questions as kind of a bit of a springboard into just some general kind of background. I information. Um later on, we'll be sending individual feedback and there will be a winner who is gonna get a prize, but Helen's gonna sort that after today. Uh So the first question we had, which I think everyone should have got. Right. Cos Costa said it right. This holidays, if you're listening, you'd have known this. So a sheath, what a sheath used for. And the answer to that is that a sheath is used to maintain access to a vessel. So I don't know enough about my history. But what I didn't realize until this morning chatting to Omar was that before sheets were invented, you would do a direct puncture and then you'd put your wire in and a catheter in and you wouldn't have a sheath. So you wouldn't have kind of secure access. So if you wanted to change your way, you'd have to be pressing on the groin whilst you take out your, your catheter to exchange for a new one. Whilst now we have a sheath that gives you, you know, so the way it's made up is that you have, um So basically the bit at the end, the dark green bit that is a dilator and the white bit itself is a sheath and the back, you have a hemostatic valve with a side arm for which you can inject materials or you can also draw blood back from but it means that once you have access to a vessel, if you wanna take your wires, your catheters out, you've still got access to this vessel. So you can change your wires, you can change your system from a high profile wire to a low profile wire. So it's a really simple looking piece of kit, but it's been fundamental in changing ir and actually increasing the number of procedures you can do. And so kind of. So normally you puncture the vessel wire. So then you put your wire through, put your sheet over the top and you've got secure access and your procedure can begin. And so the di are a six French sheath. So as you can see in this picture, that kind of explains the different parts of the, the sheath and the diam of a a sheath is approximately two millimeters. Now, it's useful to know cos you need to know the size of a hole you're making in the vessel because that has implications of when you're trying to close it. And so the franchise is a system used. But basically, if you can remember that your sheath size, if you divide it by about three, that will give you the approximate size of your vessel. It's important to know because sometimes you use sheets which are 18 French, 20 French, 22 French. So if suddenly someone says, you know, you've got 22 French sheets, you, they think, ok, I've got round about a seven millimeter hole in, in my vessel. And then that makes you think about if you're gonna close it, the type of options you have, whether it have to be surgical, using closure devices, preclosure, post closure. So it's really important to understand the equipment you're using the size equipment you're using cos you'll have implications later on in your case. And then we ask, what does 0.035 refer to in regards to wires. So wires have lots and lots of different, there's lots of information about them. So you can have different wire lengths, different wire diameters, you can have different shape tips, you can have different weights, you can have different properties and so on the patching of a wire, you often get lots of information. So as you can see here, this one says it's angled, uh it says 0.035 which is the diameter. You can get 0.0140 0.018 and you get different lengths. You can get 80 centimeters, you can get 150 you can get 2 m wires, you can get 3 m wires and depending on where your access site is and where you're trying to achieve your treatment. That can determine what you're which wire you're going to use. Having a straight tip or having a slightly curved tip can help you trying to navigate through tortuous vessels and then you can have wires which are stiff, you can have wires which are hydrophilic, they like water. So some things are better for crossing a lumen. Whilst other things are better for giving you stability. So this was the question just to show you that, you know, wires aren't like not all wires are the same and that the way they work has a big influence and gives you a really wide range of procedures you can do. OK. So I put in a few um questions not so related to the everyday practice of IR but a bit more about the wider field of radiology. So I asked um about uh the radioactivity of bananas and how that relates to um CT scans. So uh you probably don't think about this each time you eat a banana or take a flight and get high up in the atmosphere and you're less shielded by in the atmosphere closer to the radiation sun, but you get radiation in everything you uh do or eat. Um And actually one CT scan is about 70,000 bananas. Um So you can uh consent your patients for that with that sort of metric um for your procedures. And um he's a very handy child which oh in the next slide um which shows uh bananas there in the top uh left corner as a small um proportion relating to um a tiny bit next to that green square which is a chest X ray. And then that's just a, a fraction of the dose you get with the act or um for example, going to the exclusion zone. And um then another question I put in was about uh blunt trauma and you can either have um a massive arterial bleed, which is um your classic uh spurting, bright, bright red blood sort of leaking out from your neck or the same sort of thing uh inside the body. But if you have blunt trauma to an organ, you can have um a different sort of bruising effect on the tissue and you can have small set of aneurysms. Now, when you do an angiogram, when you put a catheter in and inject contrast eye and take an X ray picture, you see lots of little small dots and um who's uh and that's named after uh a certain painter with a certain uh pointer style and um a bit like that actually with tiny little brush rates and dots and that's the sac spleen. So this is what it looks like. There's um that little white streak in the vessel is um the catheter black is the x-rayed eye and that spleen has a lot of little mottled brush strokes through it. Um And then on the other picture number B that's after embolization. So the blood flow has been slightly reduced but not completely blocked off to the spleen. And you can see a lot less of that blush. A lot less of the pseudoaneurysms going on. And yeah, so I thought I'd add some uh clinical questions because you guys will be in the wards shortly. And if you know the answers to these questions that might save you from a job from phoning the IR consultant and asking for a procedure if the patient has taken the Warfarin, if they have taken Apixaban. So if you know the, if they've got high in R and somebody asked you to phone IR for a procedure basket procedure, you will know the answer. So acceptable iron in R result depends on the procedure. There are low risk procedures and high risk procedures. So for, for the vascular procedures, most of them, it's 1.5. So the cut off the, yeah, but for the venous stuff, some people accept higher than that. So procedures are split between low risk, moderate and high risk. So the vascular stuff or the arterial stuff is moderate and high risk as well, all the vascular stuff. So you'll find that the inr target is less than 1.5. So here and there, if it's penis, some people might accept to by find that most of the consultants would ask for less than 1.5 for every procedure. So that's a good thing to know. So next, if you've got a patient on Apixaban again, and somebody asks you to call Ir for a procedure, how long do you need to stop it beforehand? For Apixaban? It is two days. Again, there's a big table for every single doac warfarin Heparin that tells you when to stop what? So with the Warfarin, it's normally five days with the towa, it's two days and Heparin is less than around one day, just a bit a dose. So Aaban is normally for low risk is 24 hours, moderate and high risk procedures is 48 hours, two days. Something else that you might face on the wards for patients who might have had embolization, especially for the fibroid and the taste. The chemo embolization for liver cancers, they might get post embolization syndrome. And what is? So, I combined these two questions together. The treatment for post embolization syndrome is primarily supportive, just analgesia and IV fluids. So what is post embolization syndrome? It's bay and fever, nausea and vomiting. That might happen in around 40% of people after embolization because we cause tissue necrosis and infarction. And that might initiate some inflammatory reaction and cause a lot of pain, fever, nausea and vomiting. So we shouldn't jump into giving them antibiotics or doing CTS or just jumping into conclusions really quickly is expected and we do consent patients for it. So they will be aware about it. If you get called about patients who have had some sort of embolization beforehand, you just reassure the patient, reassure the nurse and the referring team. It is not a self limiting, but it overlaps with infection. But the treatment is supportive. That's it. Thank you very much. Any other questions about, to be honest, the question just I always thought if you have a two millimeter, she that will. So two, sorry, a two millimeter catheter cos that, that's why it's really nice. It, it, it's like the sheath size is about what you put through it, which, but because obviously you've also got the sheath, then you need to add on a little bit, but it's probably gonna be a fraction of a millimeter. Right? Yeah. So technically, I would, I would, it would be over two, wouldn't it? But it might not be three. Yeah, it's, it's a but yeah, I see what you mean. But I guess if you, if you've got like a 600 you know, to be about, it'd be close to two. That's been really a anyone else. I think we would like to thank everybody who showed up in person on a Saturday for an IR conference. That's a great effort. So I would hope everybody and just to let let you know guys that Ir is great. Yeah, from fellows in here trainees. I've been enjoying my training every day. Looking forward to going to work every day. So the advice would be to get involved as early as you can go and knock doors, speak to consultants. It's really easy to get a publication, a case report of also in radiology because you do not have to go through all the notes to see the patient do examination. Most of the information that you need would be on packs. So just sit on a computer in an afternoon, get all the information, do a case report and that's it. Or you need to get on really early on, on that note, if you're looking to get involved in ir research, to know more about the specialty uh network with like minded people, you don't have the mentors who live in the hospital without um I presence. Um I'd recommend getting involved with IR juniors, which is a group of trainees and junior doctors doing educational initiatives. Just in the past few months, we finished up um uh a range of events online in person and the applications to radiology. Uh Last event was um interview practice. Uh We're taking a bit of a pause and then in uh April, we'll have uh an in person student conference in Edinburgh that's coming up. And then the next event after that will be end of September in Manchester. So if you uh have a project or now you have the motivation to um find a mentor, start a project, do an audit. Uh There might be places you you want to present, especially if the larger national conferences for which might be aimed more consult to seem a bit in. These are also mostly for trainees and junior doctors like today. Yeah. And one thing that the BSI R offers every year is an award. So there's a, an essay scholarship award and it's not difficult to do. So look it up. It's 300 lbs towards accommodation and transportation and then free conference registration. It's just writing. They give you a title and then you look it up, you do some research and write an essay. So that's uh that's an easier word to put in the, into the, the CV before the interview. Thank you. Thank you. Thank you to Helen. I know committee because you all made a really, really good day. Uh Yeah, so we are coming to the na uh which is a little bit on kind of the, the winners of the poster presentations. I'm not sure if you are aware, there was a present poster presentation. Um Our lovely training committee has um marked them um and the winner actually, er in the scientific research category. He was here earlier this um today, but he had other child minding business, I think. Um So he had to go early. I've already presented him with his certificate and we'll be sending out some prizes shortly and um the other um person is a virtual participant, so I'd just like to congratulate them here um and give them a virtual round of applause for the recording if that's alright. Um And there's not much else from me. So if you have registered on me, um you will receive a, er, feedback form, er, after today, er, which if you fill in, er, it will automatically give you ate of attendance afterwards. Um, and obviously we would love to have your feedback about the day about how we can improve so we can do it better next year. Um, and I'll leave some closing remarks to prof so thank you, Helen and thank you all the student committee for making, this is such a success and everyone taking part. In fact, you know, all of us have take part and contributed, especially faculty travel from everywhere. I mean, this is Saturday, right? I'm not sure that uh um how much trouble I'm gonna get with your, some of your family member, so enjoy the rest of the evening. And then there is um uh we will hopefully see you guys next year. So give yourself a round hope. Thank you and um to show you this. So, oh wait, it was just, this starts which Nick mentioned about our juniors. It was shown during the breaks, but I don't think many of you were here during the break. So I'm just gonna quickly kind of share it. Well, it will load, you can have a read and you can pack up and um as we come to the end of the conference, if that's OK. If anyone have any burning questions, we've still got some, some of our amazing speakers here. So ask them now or forever, hold your peace. All right. Thank you everyone for coming. So Good. I Yeah. Yeah. Yeah. Yeah. Yes, thank you very much. Thank you very much on the other side. Um So the other was.