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.

Doing more with less - Thursday August 5th

What I'm starting to really like about the Dotter institute is the 'can do' attitude of the staff. My perception of medical healthcare in the states before my visit was that it was exceptionally well funded and that insured patients routinely received the gold standard of diagnostic tests and treatments.

The reality that I've seen is quite different. Medical insurance companies demand value for money and in the context of a rapidly evolving specialty like interventional radiology this often means that the latest equipment and technologies simply aren't funded. The Dotter institute is particularly good at adapting to these constraints. "We do more with less" is an unofficial motto here.

One of the interventional rooms at the Dotter. Note the vending machine style equipment lockers.

A nice example of this is the set up of the interventional labs themselves. Rather than shelves of equipment on the walls, all the wires, catheters and other kit are kept in computer controlled storage lockers, similar vending machines. Rather than just taking a different catheter of the shelf when it is needed, the rad techs have to request the kit via the computer to ensure that everything is billed to the insurance company.

In the UK if we are unable to access a vessel with a particular shaped catheter we will open a new catheter (at about £100 a go). Here, to avoid opening unneccesary kit and incurring additional expense, a large flask is kept boiling on the side and catheters are held in the steam until malleable and then reshaped.

A constantly boiling flask kept on a hot plate to reshape catheters.

Keep Portland Weird! - Wednesday August 4th

The working day at the Dotter finished a bit earlier yesterday, and my jetlag is beginning to wear off a little, so after work I got on the free street car and headed north into downtown Portland.

The Portland streetcar

Portland is fairly compact as American cities go and once you're downtown it's easy to get around on foot. I walked through the old town and Chinatown where I had Thai food "a-la-cart" at one of the numerous food carts which fill any empty parking lot. Then I walked into the  cultural district where I watched a bit of live jazz in the street outside the art museum.

Eating "a la cart" in Portland - a massive Thai meal for $5

Shopping in Portland is fairly quirky. I was looking for a big music and video shop to buy a couple of DVDs but instead I found off-the-wall art shops, second hand book shops and little independent coffee shops, restaurants and micro-brewery bars.

Portland also has it's fair share of random weirdness boasting several small museums including the hat and vacuum cleaner museums. I saw lots of cars with the "Keep Portland Weird" bumper sticker, and this pretty well sums ups this side of Portland life.

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Leather bindings and scary politics - Tuesday August 3rd

Attended my first American MDT meeting today, known in local parlance as "tumor board". For the uninitiated, an MDT or multi-diciplinary-team meeting is a forum for discussion of patients with cancer, which allows doctors from a range of specialties to discuss and (hopefully) agree on an appropriate treatment strategy. These days interventional radiologists play a fairly central role in both the diagnosis and treatment of many different tumours so I will spend a lot of my working life in these meetings.

The format for the meeting was very similar to the UK, although the coffee was much better, but what I was really struck by was the setting for the meeting - a vast wood paneled library shelved floor to ceiling in leather bound books and journals. The staff doctors all sat in huge leather chairs and quoted "the latest research" at one another.

There seems to be a real fondness here for old fashioned academia and all the associated paraphernalia. I've noticed that at European meetings you are simply awarded a distinction for your presentation/poster but in America you are awarded Magna Cum Laude or some similar tripe. Similarly, American students have endless formal graduations and join college fraternities and sororities with Latin names. It all seems to be an odd contradiction from a country that usually wants to distance itself from its European roots.

On the subject of which, I spent most of today watching cases from the control room because the interventionists were doing radio-embolisation and the hospital radiation control officer wouldn't let me in the room. As a result I got chatting to the "rad techs" (radiographers) who are all friendly guys but politically just a little bit right wing. They started with a bit of Obama-bashing, then a rant on illegal immigration but after their grievances on British Petroleum and Libyan (alleged) bombers we were soon on to the perceived state of the UK. "Is it true that Britain is being taken over by Muslims?"

Scary stuff.

I might cancel that canoeing trip this weekend.

"Is it true that Britain is being taken over by Muslims?"

Welcome to the Dotter - Monday August 2nd

Learned yesterday’s lesson and started what I think must be my favourite ever daily commute on the Portland Aerial Tram (cable car). The “sky tram” is initially very impressive but any mention of it is greeted with scorn by OHSU staff. A favourite local white elephant it cost $57 million to build after initial estimates of $15 million and 85% of the bill was footed by OHSU.

The Portland Aerial Tram

My fellow passengers were all like minor characters from Grey’s anatomy, commuting to work in their fitted scrubs and flirting over their morning lattes. The tram passes over a large supporting tower halfway up the hill. The attendant has to warn the passengers that the tram may swing a little and this is the cue for all the nurses to grab the arm of an attractive man. All very entertaining.

The day at the Dotter institute starts at 07:30 with the morning conference lead by Dr Fred Keller and Dr John Kaufmann. The two fellows (who have to “pre-round” all the patients at 6am) present the cases for the day while Drs Keller and Kaufman hold court and skewer the poor fellows with pertinent questions.

John Kaufman (left) and Fred Keller (right)

Keller and Kaufman are a brilliantly contrasting double act. Keller is short, still, sardonic and probably never says anything that doesn’t need to be said. John Kaufman is tall, lanky and nervously energetic in a Woody Allen sort of a way.

After the conference I spent most of the day watching a series of IR cases with the opportunity to discuss the cases with the staff doctors (equivalent to consultants I think) and fellows. I had expected the cases to be complex, the equipment to be cutting edge and the department to function very efficiently and I wasn’t disappointed in any respect but more than anything else I was struck by just how similar the whole setup is to the NHS and I felt a little pang of pride for the little old nash. It says something that our cash strapped health service can provide something (very nearly) equivalent to the most famous IR centre in the world, which clearly has enough dosh to make Solomon blush.

Lost in Portland - Sunday August 1st

Woke up at 5am (thank you jetlag) and took in my surroundings. The hotel receptionist apologized endlessly last night that my room was on the ground floor but it's lovely to be virtually on the river, so after unpacking and a a few cups of coffee I set off for a run along the river path.

iPhone snap from my balcony

My hotel is about a mile south of downtown Portland and a mile southeast of the OHSU hospital. It backs directly onto the river and I can pretty much run straight off my balcony onto a few miles of riverside running track. Portlanders are famous for their outdoorsiness so even at 6am there were plenty of runners, cyclists and rowers out.

After breakfast I decided that my main mission for the day was to find the hospital so, armed with simple directions courtesy of Google maps I set off. I was a little surprised that Google suggested that the mile walk would take 45 minutes but I assumed that this was aimed at tubby Americans so I anticipated a 10 or 15 minute stroll.

Wiggly route to hospital

When I arrived at the hospital, and hour and a half later and dripping with sweat I realized that I had forgotten two things:

1. American cities (even "compact, accessible, pseudo-European cities") are never designed for pedestrians. Sidewalks lead you into 6 lanes of traffic then entirely disappear and there seem to be no footbridges or tunnels so the Google instructions are entirely unusable!
2. Portland is built on a volcanic plain surrounded by volcanoes so there is some serious elevation. The climb to the hospital is fairly punishing but the view from the top is spectacular.

Panorama from the OHSU balcony. Mt St Helens and Mt Hood visible in the background. Downtown to the left, my hotel behind the wooded area to the right.

 The hospital itself is truly spectacular and stands fifteen stories high on stilts to counter the steep hillside. The main OHSU is accessed (by all sane people) by a cable car which runs between a riverside tram stop and the hospital pavilion. The main building is then joined to the veterans hospital by a long sky-bridge. It is all fairly breathtaking and more than lives up to Nigel Hacking's claim that this might be the most beautiful IR lab in the world.

I found the Dotter Institute on the 11th floor with a plaque outside the institute proclaiming "At this site on January 16th, 1964, Charles T Dotter MD performed the world's first percutaneous transluminal angioplasty". This might seem unexciting to non IRs but for me this is tantamount to visiting Mecca. It's also incredibly intimidating and I just hope I don't make a complete fool of myself when I start tomorrow. Wish me luck!

Plaque outside the Dotter Institute

Hampshire To Oregon - Saturday July 31st

After getting spectacularly lost on my way from home to the Heathrow Holiday Inn, I only managed two and a half hours of sleep before getting up to catch the 04:40 transfer bus to the airport. Predictably I arrived with loads of time to spare so I sat outside and drank a pint of strong black coffee and enjoyed my last view of drizzly London for a few weeks.

I forgot to pack a book for the journey so while I was in the departure lounge I bought paperback copies of Bill Bryson's A Short History of Nearly Everything and Richard Dawkins' The God Delusion.

When we boarded I found myself sitting next to a sweet American called Gracie who was on her way home after a few weeks in England. She noticed that I was tall and volunteered to swap seats so that I could stretch my legs out in the aisle. We chatted for a few minutes while the plane taxied and she told me a little about herself. She was originally from the east coast but moved to Oregon when she got married. There is, as she sees it, a distinct cultural and political divide between the coastal west and inland east of Oregon. Portland is in west Oregon and is typically considered to be 'liberal' (virtually a swear word for most Americans) and secular. In contrast rural east Oregon is conservative and populated by good god-fearing types. Like Gracie.

Needless to say, things got a little frosty when I pulled out the Richard Dawkins...