A Day in the Life

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Nicholas Oravetz, PA-C

Nick Oravetz works in interventional radiology for Mecklenburg Radiology Associates in Charlotte, North Carolina. He has indicated no relationships to disclose relating to the content of this article.

As a PA student, I aspired to a high-intensity career in emergency medicine or surgery. I thought that working in one of these areas would let me use all my new knowledge and expend all the energy and enthusiasm I had accumulated over 2 years in PA school. Once I graduated, though, I learned that new PAs with no experience have trouble landing jobs of this type. Fortunately, I also learned about interventional radiology (IR) around this time. I discovered what PAs working in IR at my hospital were doing and how they were utilized. As a new PA, I had never considered IR and didn’t even know that PAs practiced in this field. Luckily, I was offered an excellent opportunity in IR, and to this day I can’t imagine working in a different field of medicine.

8:30 AM

I arrive at the hospital and am greeted by the usual chaos of patients, staff, and visitors all racing to their destinations. Once in radiology, I meet with the five other PAs I work with to go over our daily assignments. Most of my work involves doing procedures, so I make my rounds through special procedures, fluoroscopy, ultrasound, and CT. Because our schedule contains a mix of outpatients and inpatients, we coordinate our inpatients around our outpatient schedule. I visit my first patient in our holding area, an elderly man who needs vascular access in order to begin dialysis. Before the procedure, I review the chart, recent labs, medical history, and orders. I talk with the patient about the procedure, and I obtain informed consent.

Before starting my first procedure, I check on a few inpatients from the previous day, and I write any necessary orders and a quick progress note for each. This particular day, I have only two patients to follow up on, so I finish with enough time to make a quick trip to the medical staff lounge to grab a quick bite for breakfast.

9:15 AM

I’m back in radiology, and the dialysis patient is prepped and draped. After conscious sedation is administered, I begin the procedure. I typically use the right internal jugular vein for a dialysis catheter, given the anatomy and access to the superior vena cava and right atrium, where the tip of the catheter will be placed. The procedure itself takes about 30 minutes, and the patient is transferred immediately to the dialysis unit in good condition.

I move to another room to place a peripherally-inserted central catheter (PICC) line, which is a very common procedure for us in IR. I would be lying if I didn’t say that placing PICC lines can become mundane, considering the volume of them we do, but the steps are fundamental to almost all the other procedures we do in IR.

9:45 AM

By now the day is in full gear, and an outpatient has just arrived for a CT-guided biopsy of periaortic lymphadenopathy found on a prior CT scan. The radiology nurse draws the blood for the necessary lab work (prothrombin time, partial thromboplastin time, and international normalized ratio). Once the results are back, I discuss the case with the radiologist, and we talk over options for the biopsy. The patient is placed on the scanner and I perform the biopsy, taking special care not to disrupt any vascular or visceral structures, especially the aorta and inferior vena cava. The biopsy sample is obtained, and the specimen is sent to pathology. I write orders for the patient, who recovers in our holding area before going home.

I find it amazing that we can perform such intricate biopsies with such accuracy, but current technology allows us to perform many biopsies that used to require a risky surgical procedure as a relatively safe outpatient procedure.

10:45 AM

As I walk back to the office from the CT department, I find myself thinking about the biopsy patient, wondering what the results of the biopsy will be and how they will affect him and his family. I think my work for this reason is meaningful and important. Whether the results are good or bad, patients get some answers about their ailment and can begin the healing process, whichever road that may be. This feeling is common in IR—after all, we PAs are responsible for performing the majority of all biopsies that are done in our radiology department. I am reminded daily of how different patients are from one another and how uniquely their own their problems are, but they all have the same human desire to persevere. Beep, beep, beep … I hear the all too familiar sound of my pager going off, and my thoughts take another direction. I have two more PICC-line patients waiting for me.

11:30 AM

We finish early with our morning patients, and I and the other PAs meet back in our office for lunch. During lunch, a patient who had a lumbar puncture a few days ago calls to say he is having severe headaches. I reassure him, saying he is probably suffering from a lumbar puncture-induced headache. I tell him these are an occasional side effect from having this procedure. I phone the anesthesia department and schedule him for a blood patch, which will alleviate his headaches.

The lunch hour gives me and the other PAs a chance to catch up on any developing cases for the afternoon and discuss any interesting patients from the morning. We also go over our inpatient list and review any patients who need lab work before they come down for procedures this afternoon.

1:00 PM

The afternoon schedule begins to fill up quickly. A nephrologist tells us about an inpatient who has an occluded arteriovenous dialysis graft. He asks if we can perform a thrombectomy to clear the occlusion so the patient can receive dialysis. I inform the technologists and nurses, and we begin the workup before the patient’s arrival. I check the records in our computer system and see that we have done similar procedures on this patient in the past. This information will help us manage this patient’s problems today. The patient arrives, we obtain informed consent, and we prep the patient for the procedure. Using fluoroscopic guidance, I gain access into the graft; using different catheters, guide wires, and a special thrombectomy device, we are able to remove the occlusion. Before the patient leaves the table, I go over my images with the radiologist and we discuss the case and the outcome. Once we agree that everything looks good, the patient is discharged from our department.

2:30 PM

I make my way to the fluoroscopy department and to an outpatient there for a lumbar puncture. I first review prior head studies (MRI, CT) to make sure the patient has no anatomical variants such as masses that could result in adverse outcomes. Once again, after obtaining informed consent and using fluoroscopic guidance, I perform the lumbar puncture. This patient has a history of weakness and changes in her vision. Her MRI suggested a demyelinating process such as multiple sclerosis. During procedures, I often visit with patients, attempting to ease their anxiety and distract them from what’s going on. X-ray guidance has dramatically decreased the time and overall difficulty of a lumbar puncture, but I think pretty much everyone, myself included, still appreciates a few comforting words during this type of procedure.

3:20 PM

I hurry back to the special procedures department to handle a couple more PICC lines. After this, I have a few minutes to catch up on dictating the procedures performed earlier in the day and to get a little midday fuel in the form of black coffee. I’m sure many readers can relate to the importance of that!

I have just a bit of paperwork to finish and a few more PICC lines to complete on patients admitted from the emergency department. To prepare for tomorrow, I go over the schedule; I present the cases to the radiologist, and we review the appropriate previous radiologic studies.

4:30 PM

The work day is complete, and I finish a few last minute details before heading out the door at 5 PM. This is just one day in IR, and every day is different. Some are hectic and chaotic, but others are quieter. I never know until I get to work what kind of day it will be.

I am fortunate to have found a niche in IR—especially one that allows me a great deal of autonomy but also gives me excellent supervising radiologists who are always willing to help. My experience in IR has proven to be challenging, rewarding, and ever-changing. The need for PAs in radiology appears to be growing; as medicine changes and PAs are introduced into more subspecialty practices, this trend will continue. For now, I head out of the parking garage with only one thing on my mind: enjoying a beautiful Carolina summer evening before I go back tomorrow and do it all over again.