Interventional radiologist loves solving problems

Close-up of Mitchell Karmel, MD, performing a nephrostomy tube check, a procedure to evaluate whether a kidney remains obstructed and to evaluate the position of the tube. (photo by Susan Kahn)

Close-up of Mitchell Karmel, MD, performing a nephrostomy tube check, a procedure to evaluate whether a kidney remains obstructed and to evaluate the position of the tube. (photo by Susan Kahn)

BY AMBER SMITH

In a typical day, Mitchell Karmel, MD, may take a biopsy of a liver tumor in one patient, install a port, so another patient can receive chemotherapy, and drain an abscess from deep within the abdomen of another.

He may treat a woman’s uterine fibroids using particle embolization, an alternative to hysterectomy, and then treat a liver tumor with radiation particles before caring for a baby who needs long-term intravenous access.

Karmel is an interventional radiologist (see explanatory note at the end of this story).

He chose the specialty, he says, “because I liked that it was very goal-directed and problem-solving.” Many patients arrive in the interventional radiology department because other doctors need assistance in making a diagnosis or because they need intravenous access installed in the form of a port or a PICC line. That’s medical parlance for peripherally inserted central catheter, a way to provide long-term venous access, for patients who require repeated intravenous medications or blood draws.

Karmel reviews a CT scan of a chest to evaluate whether fluid around the lung needs to be drained. (photo by Richard Whelsky)

Karmel reviews a CT scan of a chest to evaluate whether fluid around the lung needs to be drained. (photo by Richard Whelsky)

After medical school, Karmel completed a yearlong internship and four years of residency training at Cornell University Cooperating Hospitals, plus an additional year of fellowship training at Harvard Medical School. Today, as an associate professor of radiology at Upstate, he is director of vascular and interventional radiology.

He and his colleagues staff Upstate University Hospital around the clock.

They provide minimally invasive, image-guided diagnosis and treatment of a broad range of diseases and conditions, for a broad range of patients. Most of the procedures they offer are alternatives to open surgeries, with generally less risk, quicker recovery time and lower cost than open surgeries.

Interventional radiologists are sometimes summoned for emergencies. It was an interventional radiologist who stopped the bleeding and stabilized U.S. Rep. Steve Scalise, R-La., so that a surgeon could repair the damage the congressman suffered in June 2017 when he was shot in the hip during practice for a charity baseball game near Washington, D.C.

Venous access

One of the most common procedures interventional radiologists perform is the insertion of a PICC line when other services have failed, or in pediatric patients.

On a recent weekday, Karmel walks into a hospital room to talk with a mother who cradles her baby girl. The 10-month-old was not growing properly. He explains how he would install a line in the big vein of her neck that would help with her therapy.

A short time later, the interventional radiology team assembles in an operating room, the baby looking like a small doll on a vast operating-room table. She wears a tiny blood pressure cuff, and a tiny mask covers her nose and mouth. Nurses roll a baby blanket, position it beneath her neck and turn her head to the left.

Karmel places a nephrostomy tube in a patient with blocked drainage of the kidney while a fourth-year medical student observes. (photo by Susan Kahn)

Karmel places a nephrostomy tube in a patient with blocked drainage of the kidney while a fourth-year medical student observes. (photo by Susan Kahn)

It would be Karmel’s job to insert a central catheter into the baby’s jugular vein, a big vessel on either side of the neck that carries blood from the head and face to the lungs. Not all interventional radiologists are comfortable inserting a PICC line on a child, especially one this little.

The secret, Karmel discloses, is to use ultrasound guidance to find and puncture the vein, a technique interventional radiologists are comfortable with. Using his left hand, Karmel presses a probe along the baby’s neck. Images of her vessels appear on a television screen on the opposite side of the table.

Karmel’s right hand wields a tiny needle, destined for the jugular. Not only are baby vessels small, they are rubbery and difficult to puncture. After Karmel makes his insertion, it’s time for an X-ray.

“Has everyone got lead on?” he asks the room. Nurses, technicians and the anesthesiologist check to make sure they’re wearing protective gear. A machine shaped in a giant C is rolled near the bed and arcs around the patient. The X-ray it produces confirms that Karmel has placed the line correctly.

His most challenging case in 35 years was a 26-week-old premature infant who needed long-term vascular access — just like this 10-month-old, but even smaller.

Performing image-guided biopsy

Biopsies are another typical procedure done by interventional radiology. That’s where ultrasound, computerized tomography or fluoroscopy provide image guidance while the physician places small needles into areas of abnormality. Tissue samples or cells can be removed for analysis, often to help diagnose cancer or rule it out.

His white hair now keeps most patients from asking Karmel, “So, how many of these biopsies have you done?” But one patient asked him recently.

Karmel had to stop and think. He has done so many that he has lost count: more than 4,000, probably closer to 5,000.

What is an interventional radiologist?

Interventional radiologists diagnose and treat a variety of benign and cancerous conditions of the thorax, abdomen, pelvis and extremities. In caring for patients, they use imaging to guide minimally invasive techniques that help open blood vessels, stop bleeding, obtain tissue for biopsy, and other varied procedures.

Upstate Health magazine summer 2018 issueBoard-certified interventional radiologists at Upstate University Hospital see patients at both the downtown and Community campuses and can be reached at 315-464-5189. This article appears in the summer 2018 issue of Upstate Health magazine.

 

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