See One, Do One, Teach One
Synopsis
Interventional Radiologist Bobby Chiong's patient codes on the table during a procedure, prompting a frantic but successful resuscitation. Afterward, Dr. Chiong reflects on the high-stakes nature of his job and the intimidating responsibility of being entrusted with patients' care.
Listen
Storyteller
Bobby Chiong is an Interventional Radiologist as well as the Radiology Department Chairman at SBH Health System in the Bronx, NY.
Credits
Hosted by Emily Silverman.
Produced by Emily Silverman and Jon Oliver.
Edited and mixed by Jon Oliver.
Original theme music by Yosef Munro. Additional music by Blue Dot Sessions.
Illustrations by Ashley Floréal.
Story coached by Jennifer Hyde and performed at The Nocturnists’ show on the theme of “Learning” at Housing Works Bookstore Cafe, New York in December 2019.
Emily’s interview with Dr. Chiong was recorded in October 2021.
The Nocturnists is made possible by the California Medical Association, the Patrick J. McGovern Foundation, and people like you who have donated through our website and Patreon page.
This episode of The Nocturnists is sponsored by Pattern.
Transcript
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The Nocturnists: Stories from the World of Medicine
Season 4 Episode 2: "See One, Do One, Teach One"
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
Being trusted—that's what we want as doctors: for our patients to feel safe, like they're in good hands with us. But sometimes, the trust of our patients is overwhelming, and even scary. This is The Nocturnists: Stories from the World of Medicine. I'm Emily Silverman.
Today, I speak with Bobby Chiong, an interventional radiologist and Chair of Radiology at the St. Barnabas Hospital Health System in the Bronx. He's a native of Southern California but has long since acclimated to the New York City way of life. When not being a doctor, Bobby is usually out dancing, riding his motorcycle, or practicing jiu jitsu. Before we chat with Bobby, we're going to hear the story that he told live at The Nocturnists in New York City, all the way back in December 2019. Here's Bobby:
Bobby Chiong
“See one, do one, teach one”—that's the time-honored way that medical procedures are taught. And this is how I had to do all three on the same day.
My patient was Mr. Jones. Mr. Jones had lung cancer and he was starting to notice his face was swelling. His veins were popping up on his neck and he was starting to have trouble breathing. He was having trouble eating and lying down. So he came into the hospital. And he was diagnosed with SVC syndrome.
So, the SVC—the superior vena cava—that's the major vein that drains the blood from the head and the arms—and his was blocked by the cancer. So his doctors called on me to see if there's anything I could do to help. So the first step is I would go and I meet the patient. And I explained to him the risks and the benefits of a procedure I could do. I could do a venogram, and I could possibly get through that obstructed vein and open a channel and put in a stent. And, of course, there's risks and benefits. And I explained to him the risks and benefits of the procedure. And he signed the consent, said he understood. And he said, "Do what you got to do, Doc."
So, we set up the procedure for the next day. He came to the radiology department—and my patients are generally awake for our procedures. They get a little bit of sedation—and I explain, "Okay, we're going to clean your neck, and we're going to prep, drape the area. You'll feel a stick and a burn—this local numbing. And put a needle into the vein, put a wire through that needle, put a catheter over the wire." And I'm in the jugular vein. So now I can get to work trying to get through the SVC, add a Glidewire." And the Glidewire is a very slippery wire. That's kind of a workhorse for this, and I'm working with the Glidewire.
I feel a little pop, a little give. "Mr. Jones, all right. I think, I think we're through this obstruction. I have to put up a balloon now, and you know, you may feel a little discomfort. Just let me know." Put up the balloon, he does fine. Take down the balloon. And Mr. Jones says, "I don't feel so good." He says, "I can't breathe." And then—I haven't seen this often—but then I see him die. So he's limp, the life goes from his face. I look at the monitors: his EKG activity still—still going on. I feel his neck. He's got no pulse. "Shah, you call team one!" Team one is the highest call for help in my hospital.
So, first step at a code: check your own pulse. Go back to the basics. Okay. ABCs: airway, breathing, circulation. He's not breathing. He’s got no circulation. I start chest compressions. Finally, the code team shows up. Dr. Smith is there—he's the new ICU attending—and they take over compressions. They start giving medications, and I'm numb.
So, what happened? All right, there's electrical activity. He's got no pulse. He’s pulseless and electrical activity is PEA arrest. Okay. I know PEA arrest. The Hs and Ts. What are the Hs and Ts? H—hypovolemia? He didn't lose blood all of a sudden. Hypokalemia—his electrolytes didn't change. Hypothermia—he's not cold. Ts. What are the Ts? Tension—tension pneumothorax. I just had a fluoroscopy on his chest. His lungs are up. Tamponade... could this be tamponade? I grabbed the ultrasound machine. I put it on his chest. I see his heart struggling to beat. There's an echogenic room around the heart. It's tamponade, and I know the treatment for tamponade—it's a pericardial drain. Only, I've never done a pericardial drain… This seems like a bad time to say that out loud.
So, instead, I say, "Dr. Smith. Pericardial tamponade. We need to do a pericardial drain. Can help me with this procedure?" Dr. Smith says, "Okay." We gather up the needle, the wire, the catheter, splash some Betadine on Mr. Jones' chest. I put the ultrasound on his heart. I land that needle right to that pericardial fluid. "Dr. Smith, can you feed this wire through the needle for me? Thank you.” Take off this needle. Safety it. “Can you just load this 10 French pigtail?" He loads the drain onto the wire. I feed the drain off. Perfect loop. And I've done my pericardial drain… only, nothing's draining. So, now I have to troubleshoot.
It's blood. Could it be clotted? And I know that—I know how to treat blood clots. "Shahji, mix me alteplase, please. Eight milligrams." Alteplase is what we give for clots in the lungs, clots in the legs, clots in catheters. This should work. Shahji mixes the alteplase; I put it through the drain. And, nothing. I kind of irrigate back and forth. And I feel give. And dark, melted blood clots start coming out. I connect it to a drainage bag. The drain's draining. "Pulse check!" So, they check his pulse—pulse is back. He has a breathing tube at this point. He's on a ventilator, he's got his airway, he's got his breathing, he's got circulation. And… and he's stable enough to go back to the ICU. So the code team takes him up. And it's just me and Dr. Smith.
And after a code like that, it's sort of a wreck, you know? It's boxes from medications that they've been given, wrappers from the catheters, blood, Betadine, gowns, gloves. And Dr. Smith says, "That was really smooth! You must have placed a lot of pericardial drains." "That was my first one." And he gives me a look and a pat on the back, and he goes up to the ICU to take care of the ICU and take care of Mr. Jones.
The next day, they extubate him. They take out his breathing tube. Day after that, they take the pericardial drain. And he still has the blocked SVC, still has a swollen face. He has veins on his neck that shouldn't be there. He still can't lie flat. And I still need to do my procedure. And as the first part of my procedure, I need to go and get informed consent. So I go up, and now he's all too aware of the risks. But I tell him the risks and the benefits anyways, and he still trusts me. And he still signs the consent, and… and at this point, what I want to say is, "I'm sorry. I'm sorry the procedure didn't work the first time. I'm sorry you're in this ICU now. I'm sorry you have SVC syndrome. I'm sorry you have lung cancer." And I can't say that.
So, I set up the procedure for the next day. And he comes to the radiology department. We prep and drape the neck. Lidocaine. Feel a stick and a burn. Needle. Wire. Catheter. I feel my Glidewire get through. Put up the balloon slowly. Take down the balloon slowly. Blood’s flowing to where it needs to go. Here's a slightly bigger balloon. Put in the stent. This time, procedure goes like clockwork, and he leaves the radiology department doing great. Goes home after a couple of days, and I don't see him until he comes back to my clinic in a couple of weeks.
So, he's in my clinic and I see his face. I see he’s better. And I see my procedure worked. And it scared me—the fact that he trusted me just because I'm the doctor. And he trusted me twice. But seeing his face, seeing that he was himself again—he could eat, he could breathe, he could lay down flat. I had to believe that I was in that room with Mr. Jones for a reason—that I deserved to be there. Even if I don't know how to do every procedure, I needed to trust myself that I could take care of my patients. And that's how I learned how to place a pericardial drain.
APPLAUSE
MUSIC
Emily Silverman
I am sitting here with Bobby Chiong. Bobby, thank you for being with me today.
Bobby Chiong
Thank you for having me.
Emily Silverman
So, the last time I saw you in person, we were in a packed room in New York City in December 2019. And since then, a lot has happened. I know COVID hit your community really, really hard. So, I just wanted to ask, how are you doing now?
Bobby Chiong
It's definitely not what it was in March and April of 2020. That time was… it was hard to think about. And it's some of the time that… I tried to, you know, give it a place, and I don't want to completely bury it—it happened. It's hard to believe that it actually happened. You know, the cases are down. I think we have less than 15 cases in the hospital right now. It's a far cry from when every inch of this hospital—the waiting rooms, the clinic rooms—were ICUs. I know we're still in a pandemic, but you know, there's levels of pandemic and, and that March-April of 2020, in New York City, I'm glad that part's over.
Emily Silverman
And I'm wondering, as you think back to the story that you told all those months ago… I guess now, years ago? Is there anything about the pandemic or COVID that changed the way you think about that story or affected it?
Bobby Chiong
I think the part I think about the most from that story is trusting myself to do the right thing. During the pandemic, it was a lot of… do what you have to do. We were just making really difficult decisions without a lot of resources. And just to be able to trust myself that I may not like it, but I am actually the guy who knows how to triage these things that I need to do. And I'm just gonna have to do it. And that's what it is.
Emily Silverman
Yeah, you talk a lot about self-trust toward the end of the story. And I imagine that these experiences before COVID during medical "peacetime" might have in some way prepared you for the uncertainty of the pandemic and having to trust yourself in those moments where it was unclear what should be done. How do you summon that feeling of self-trust in a time of chaos?
Bobby Chiong
My favorite movie is As Good as It Gets with Jack Nicholson and Helen Hunt. And there's a line in that movie I really like and I think about. And the line is, "There's nothing that makes you feel at home like having no choice." It's those times that you just don't have a choice. And you have to pick a direction and this is the direction you're going in. And you may find out that we have to change it a little bit. But you have to trust your best instinct. So, it's great when you can look to a playbook or you can look to someone who's been there before. But, in the situation of my story, I was the guy in the room that knew the best how to do what needed to be done. And during the pandemic, I was the guy in the room that knew best what needed to be done because it was a completely novel pandemic. So, kind of, no choice forces me to be brave.
Emily Silverman
I want to talk a little bit about your craft—interventional radiology. I am an internal medicine doctor, and I never really liked procedures. I'm much more comfortable, like, in my mind. And for me, doing procedures on patients—breaking skin, using needles—it always made me uncomfortable. I never felt confident with it. But interventional radiology is very much a field of doing and it's very tactile. And so I'm wondering if you could talk a little bit about the process of becoming an interventional radiologist and, and how you learn that craft—how you develop it and build it.
Bobby Chiong
I think you've touched on something I'm very passionate and ready to talk about because I love interventional radiology. And it's such a shame that nobody knows what it is. And it's such a shame that it's even hard to explain.
Manual dexterity is very important. I tell people all the time that it's almost like I play video games for a living: I look at a screen, I have something in my hands. And based on very precise movements I have to do with those hands, it changes the outcome of what happens on the screen. It just happens to be very, very high stakes. So I always tell people that want to be good at procedures to develop your left hand. Sometimes I tell them to write the infinity sign with their left hand. I can write with both hands. I play drums, play video games. I used to do a lot of close up magic. So I'm just always kind of doing things with my hands, which is a very important part of interventional radiology.
And then the other thing I love about interventional radiology is—again, I kind of always feel strange about saying this out loud—but so little of what we do, you can learn in a book. And so little of what we do is evidence-based. And so much of what we do can't really be studied because every interventional radiologist does things their own way. And I remember I was at SIR, the Society for Interventional Radiology conference. And I remember somebody said that if you do a procedure the same way twice, that's a waste. You always have to get better. You always have to refine.
And, I remember, I was doing a PICC line on a patient, and he was so impressed just with the way I moved and the way everything flowed. He said, "Oh man, you're like one of those pizza guys—like Di Fara’s in Brooklyn.” There's just these guys that just make pizzas all day, every day, and they just refine their technique. It seems like the same thing over and over again. But, in actuality, you're just getting a little bit better every day—a little bit better every day. And so much of interventional radiology, it's like, “Needle, wire, catheter.” Like in my story, it is needle, wire, catheter. But you can do so much with a needle, a wire, and a catheter. It's… it's amazing. Or it's like Taco Bell, you know how Taco Bell keeps coming up with new stuff, but it's all the same 10 ingredients? You know, it's like we have needles, wires, catheters, we got some balloons, we got some stents, but we can do amazing, amazing things.
And the other thing about interventional radiology is so much is off-label. We may have the stent that is a tracheal-biliary stent, but we put it in a vein. Or it's an angioplasty balloon—you can use that to open a tract for a gastrostomy balloon. It's just… I just feel it's such a great place for just being able to make up these new techniques. And like I said, you can't learn it in books. During the pandemic, I was so sad that the local Angio Clubs were shut down, because that's one of my favorite things is—we go, and we meet with the local IR guys, and we trade all these techniques. And it's amazing. I love the field very much, I don’t know if you can tell.
Emily Silverman
No, I love it. I love to hear your enthusiasm. And I'm also just fascinated by these gatherings you're describing where you're all sitting around swapping stories. I mean, can you bring us into that a little bit? What's an example of a story that somebody might share at a gathering?
Bobby Chiong
When you get dialysis, you can have an AV fistula or an AV graft. When there's a stenosis upstream from where you puncture the fistula, if that gets stenotic, you can have persistent bleeding, and these bleeds can be pretty bad. So, a lot of times, you can put in a suture. But the problem is: a suture, if you tie it down, it'll be hard to dig the knot out later. And someone discovered that you can take a flow switch, which is a switch that goes on a catheter and that has a little click—you can click it on or off. You can cinch that down on the suture and use that until you get hemostasis, until the bleeding stops, and then you can undo that. And I was like, "Wow! How did you think to put a flow switch on the suture?" So, that's the one I heard recently that kind of blew my mind.
Emily Silverman
And you talk about how there isn't a lot of evidence behind these things. And I'm wondering, is this how the knowledge is passed down? Is it much more like an apprenticeship? Or like a guild where, like you said, there's these sort of backdoor gatherings where people are swapping stories? Or do people… do they publish on this? Is there, like, paper in the Journal of Interventional Radiology about using the flow switch on the suture? Or is there, like, an online hub where people can throw up their suggestions? Or… how does this knowledge get passed down?
Bobby Chiong
SIR has a yearly meeting where we get to learn a lot, and they have something called "Extreme IR" where they show—I hate to use the word “cowboy”—but cowboy-ish cases. And then, now, post-pandemic the SIR has an online Angio Club. I still enjoy more the gathering with actual people. Twitter, I learned a ton from, you know. Shout out to the Twitter group chat. I don't know if it's a secret, but if it is, then forget what I said. So, there are definitely basics that you have to learn in IR: put in a port, put in a pic, do a biopsy, do embolization. But then, there are kind of more fancy ways to solve problems.
MUSIC
Emily Silverman
In your story, what your patient needs is a pericardial drain, and you've never placed a pericardial drain before. And so I remember sitting in the audience and thinking to myself, like, "Oh, my God, I can't believe that this is going to be his first time—like, he's going to do this procedure for the first time under these life-threatening circumstances, and that's so stressful." But now, hearing you talk about the Taco Bell analogy, I'm wondering like, "Huh! I mean, it definitely still sounds like a scary thing. But is placing a pericardial drain actually that different from placing a drain, say, in another part of the body?" Or like, how different was it?
Bobby Chiong
Yeah, the technique is the same. It's like—it's needle, wire, catheter. So, like doing nephrostomy for an obstructed kidney, doing a cholecystostomy for cholecystitis, doing just a periappendiceal or diverticular abscess drain. The drain actually wasn't working at first. So, what I did was, I put tPA into the drain… Is that just gonna make him bleed out into his mediastinum? But no, I tPA'd the drain, and I got to take the pericardial blood out. I've actually never heard of that before. Since, I showed that at my Angio Club. They applauded after I presented that case, because it was so insane.
Emily Silverman
Later in the story, the patient who you call Mr. Jones, is in the ICU. And he still has this problem of the SVC syndrome. And he still needs the procedure. And, just to clarify, it sounds like the bleeding into the pericardium, that was a complication of the procedure you were doing. Is that correct?
Bobby Chiong
Correct. So, what happened was, the wire I was using, it's a Glidewire—and Glidewire is very slippery, and it's good for getting through obstructions. But it's also well known for going outside of a blood vessel—going extra-luminal. And, especially in a patient with cancer, the tissue planes are often not normal. So that's something that can happen. And it took me a long time and I talked about it with a lot of people. And I remembered, at Angio Club one of the people there said that his partner did the same thing—and the patient died in the room—where his wire went outside the vessel, and then he ballooned. And then when you put in the balloon, the balloon expands the channel where that wire went through, and blood must have tracked through into, around the heart. So, I'm glad I recognized it. I'm not sure if the other people that had this happen, recognized it or tried what I tried. Complications are going to happen. And anyone that trains with me, I always say, "Complications, mistakes. They happen. Just recognize them, fix them." And we're lucky that I recognized and fixed the problem on Mr. Jones.
Emily Silverman
But the story doesn't end there. You have to go back and consent him again for your second try. And he gives consent. And there's a line in your story that really stood out to me, which was, you said, "After everything that happened, he still trusted me. And it scared me. The fact that he trusted me, and trusted me twice." Can you tell me a little bit more about that feeling of being scared when he trusted you again?
Bobby Chiong
People talk about imposter syndrome a lot. And… I live in my body. So, I know how I feel. And all the time, I think to myself, “I can't believe that they let me be an attending,” you know? So, I'm so still in that medical student-intern-resident mentality, and I've been an attending for over seven years now. I'm the chairman of this department. But, somewhere inside of me, I'm like, “I'm just learning this. I'm just trying to figure this out.” And I have to balance that with the fact that I have done all these things. And I do have all this knowledge. But there's still so much more.
You know, that was a case early in my career. And it's something that did help me build the trust in myself. But I don't think I'm ever going to feel like I know enough to do this job—even though I do I know enough to do this job. I kind of hate saying this stuff out loud, because I don't know that sounds like something you want in your doctor...
Emily Silverman
It's the truth. And I think it's important to talk about these things, which is why your story, in my opinion, was so powerful—one of the most powerful of the night—because of the intensity of it and the vulnerability of it, and just really laying it out there for the audience. Like, what is it like to be in this business? What is it like to have your job be this high-stakes video game? And I don't think most people could do that job. I couldn't do that job.
Bobby Chiong
I was a little bit scared of what people would say to me afterwards, especially a lot of non-doctors in that room. And all the non-doctors were really appreciative of the honesty of my saying that I don't know everything, and sometimes we're just making it up.
Emily Silverman
Well, I just wanted to say thank you for telling the story at The Nocturnists. Thanks for talking to me today. And, I'm sure there are people listening who are interested in procedures and who are interested in interventional radiology, or adjacent specialties like interventional pulmonology, interventional cardiology, other procedure-based careers. If you could shout out a message to those people, what would you say to them?
Bobby Chiong
I would say that interventional radiology is fantastic. And I love it. And find me, and ask me about it. As you can tell, I'm always happy to talk about interventional radiology.
Emily Silverman
Awesome. Well, I will let you go because, for the listeners, before this conversation, Bobby was telling us about all these cases that he's dealing with. So, we stole him away from his clinical work for a little while, but we'll let you get back to it—to the good work you do and the hard work you do. And thank you for the work that you do. And thanks again for being here.
Bobby Chiong
Thank you.