Goodbye Dotter - Thursday August 12th to Saturday August 14th

Well that's it. It's Saturday morning, I'm packed and ready to head for the airport. Loads more intervention and teaching at the institute over the last couple of days (including participation in a west coast webinar) but I won't bore you with any more IR nerdiness.

I've had a fantastic couple of weeks which have more than met my initial expectations. I have no idea if anyone has been reading this blog but if you have then I hope you have enjoyed it.

The Dotter institute certainly deserves it's reputation as a centre of clinical excellence - I've been lucky enough to observe some very talented interventional radiologists perform advanced and innovative techniques. The IRs at the unit are also particularly adept at working within their financial constraints and this is a useful lesson for anyone working in a cash-strapped NHS.

This has also been an interventional radiology pilgrimage of sorts. Charles Dotter is often described as the father of interventional radiology and the Dotter Institute can fairly be considered the birth place of our specialty. The best IRs in the world have gravitated to the institute and some of them have never left. When I spent the afternoon in the research lab with Fred Keller, several elderly men came into the room to watch and advise as I struggled with the TIPS (in my defence pigs have rather different anatomy from humans). I gratefully received all advice offered but it was only later that I realised that my audience included Josef Rösch - the first person ever to perform a TIPS. (Looking through my blog I've realised that I unforgivably cropped a photo from the Dotter website for inclusion in an earlier blog entry. The victim of my cropping was none other than Josef Rösch - please see the original photo below.)

Kaufman, Keller and Rösch restored!

A humbling experience and a great opportunity for an interventional radiologist at the start of his career. Thank you Charles Dotter.

Charles Dotter

Innovation and Improvisation - Wednesday August 11th

A busy day in the Dotter intervention rooms where I got to see two types of intervention that I had never seen before. I won't bore you all with the details but the cases, both performed by Fred Keller, nicely summed up the Dotter ethos.

Adrenal vein sampling is a notoriously fiddly procedure which requires insertion of catheters directly into the (tiny) veins which drain the adrenal glands. FK is an expert at this and, as previously described, shapes his own catheters over a boiling flask rather than using expensive pre-shaped catheters.

A selection of pre-shaped vascular catheters

Afterwards he performed a Balloon-occluded Retrograde Transvenous Obliteration (BRTO) - a rare and complex procedure for abnormal bleeding vessels in the stomach - something that I am unlikely to ever see again (until I'm asked to do one!)

The Dotter Research Lab - Tuesday August 10th

The Dotter institute was founded in 1990 with a mission statement to develop a multidisciplinary program in interventional radiology with emphasis on research, education and patient care. In addition to the creation of the Dotter Institute itself (essentially a rebranding of the interventional radiology department of OHSU) a research lab was created to allow for the development of new IR techniques.

The Dotter Research Lab

The lab was originally housed in a small disused fire station at the edge of the OHSU campus site. In the last 20 years countless new IR technologies and techniques have been imagined and developed here. The original lab has been extensively expanded and redesigned and now incorporates the animal research lab, a conference centre and museum in a pretty chalet style building.

Visiting fellows can opt to spend a supervised afternoon in the lab practicing any IR techniques they choose. So after a quick visit to the museum I arrived in the lab with Fred Keller where my patient (lets call her "Bacon") was under general anaesthetic and ready to go.

I spent the afternoon performing a TIPS procedure and practicing caval filter deployment and retrieval techniques on Bacon under the supervision of one of the best interventional radiologists in the world. Which seemed to be time well spent.

Afterwards Bacon was sent to live on a farm...

The VA - Monday August 9th

Monday August 9th

Not much happening in the main OHSU interventional labs today so I crossed the 660ft skybridge (the longest suspended pedestrian skybridge in North America no less) to spend the day at the neighboring veterans association hospital or "VA".

The VA is an organisation which provides a range of benefits and medical care for US military veterans and their families - clearly a huge benefit of military service in a nation with no civilian state health care. It is the second largest department of the US government (after the department of defence obviously) and employs nearly 300,000 staff.

Most VA hospitals operate entirely independently from civilian hospitals but the VA in Portland takes advantage of the local sub specialist expertise by sharing OHSU staff including IRs.

Everything on the other side of the skybridge is slightly different. The walls are covered in military promotional material with the VA "honouring our promise" slogan everywhere. There are signs too reminding patients not to bring firearms into clinical consultations. The patients themselves are a different breed - routinely refusing any sedation or analgesia during procedure and often refusing to remove the baseball cap with the logo of their army unit/ship. A slice of pure Americana.

Road Trip - Sunday August 8th

Favourite things that have been said to me:

1. "Yes"
When I asked Kate to marry me.

2. "It's a boy"
When George was born. Actually I'd have been just as happy if it had been a girl but you know what I mean.

3. "For an extra twenty dollars would you like to upgrade to a convertible mustang sir?"

I love you Hertz car hire man and I always will.

My hire car. Seriously.

So in my subtle, understated 3.7L V6 convertible I headed out into rural Oregon. Most visitors do "the loop" which is a 150 mile route along the Columbia river gorge and then around mount hood park before finishing with a hike in the foothills of mount Hood.

Far too beautiful to describe but I've stuck a few iPhone photos in below. Enjoy.

Columbia River Gorge viewed from Vista House

Multnomah Falls

Bridal Falls

Mount Hood viewed from the end of the Pacific Crest Trail

The Timberline Lodge - Famous for being the exterior location for one of my favourite films "The Shining"

Attempted self portrait at the end of the Pacific Crest Trail

Saturday Market - Saturday August 7th

I know that my heavily pregnant wife, currently single parenting whilst I galavant in the Pacific North West will not have much sympathy for this, but it's been a truly exhausting week here so I've been looking forward to some R&R. I've spent the week polling all the Docs and Techs for suggestions and have settled on spending today exploring Portland downtown and hiring a car to explore further afield tomorrow.

Saturday is market day in downtown Portland and the freaks (sorry, "counter-culturalists") are out in force. The area under the Burnside bridge is filled with hundreds of stalls with artists selling their own work. Good for a browse with a few gems amongst the tut. Of more interest to me, there are loads of food stalls - I broadened my gastronomical horizons with Philly Cheese Steak, Burrito salad and Cheesecake on a stick.

Arlene Schnitzer Concert Hall - 'The Schnitz'

After hanging around the market and listening to the bands that play there I wandered back to the hotel via the cultural district. Tomorrow - road trip!

Rob Barton and the Second Ammendment - Friday August 6th

Apologies for the gap in blog entries. A busy few days here.


One interesting aspect of the time I've spent here has been the opportunity to meet people from different parts of the USA. On my previous trips to the states I've visited huge multicultural cities like Chicago and New York but spent most of my time in the company of fellow Brits. Not so here. Whilst the majority of the rad techs and nurses are native Portlanders, the IR fellows and attending physicians (equivalent of UK consultants) have been recruited from throughout America and have their own regional accents and traits.

Keller and Kaufman are from Birmingham (Alabama not the midlands) and Boston respectively. My favourite though is Rob Barton, a stereotypical Texan:

Rob Barton

Time spent with Rob is particularly enjoyable because, as well as being a superb and vastly experienced interventionalist (probably the best practical interventional radiologist here as he tends to avoid academic roles in favour of hands on teaching) he also completely lacks any political correctness.

 As soon as he got wind of my (vaguely) left wing political tendencies he started to test my convictions with a few choice digs. He is a typical republican; pro Bush, anti-immigration, anti-health reform, anti-gun control etc etc. His particularly favoured political philosophy is the 'Tytler cycle' - an interesting and initially persuasive argument against democracy if you've never heard it before (which I hadn't).

A passionate defender of the second amendment  (the right to keep and bear arms) he is a fully card-carrying member of the NRA and has an extensive collection of handguns, hunting and assault rifles. He also has a license to carry a concealed handgun (which I think he brings to work with him) so I'm not tempted to push him too far in any of our heated political debates.

A nice guy - he's lent me a bunch of maps for hiking this weekend - but I'm quietly glad that he lives 4900 miles away.