Chapter Outline
How do Practitioners in a Surgical Practice Approach the Patient?
What do Physician Assistants in Surgery Typically do on a Daily Basis?
What will I be Expected to do During the Surgery Rotation?
Which Clinical Environments may I Work in During the Surgery Rotation?
Operating Room and Recovery Team
Postanesthesia Care Unit or Recovery Room Nurse
Circulating Nurse (Circulator)
Scrub Nurse or Registered Nurse First Assist
Which Special Populations of Patients may I See on the Surgery Rotation?
What are the Special Challenges of Surgery?
What are the Special Rewards of Surgery?
Scrubbing and Gowning and Gloving
How do Practitioners in a Surgical Practice Approach the Patient?
Whenever a surgical practitioner approaches a patient, the questions in the back of his or her mind include “Will this patient benefit from surgery?” “Is surgery the most appropriate next step?” “Is this patient a surgical candidate?” These questions are answered after a history and physical examination have been performed. Even though the practitioner may have a large amount of information on the patient because he or she has been consulted by a primary care provider or other specialist, it is always necessary for the surgeon to perform his or her own history and physical examination. The last thing the practitioner wants is to find out that the information he or she has been provided by someone else is incorrect. This could lead to the cancellation of surgery or an increased risk of surgical complications.
Will this Patient Benefit from Surgery?
Surgery is not always a guaranteed cure or help; sometimes a surgery can leave a patient in worse pain or increased disability. A wise surgeon once said, “It takes 10 years for a surgeon to learn how to cut and another 10 years to learn when NOT to cut.” If the risk of complications, which can include postsurgical neuropathies, scar tissue damage, loss of function, or increased need for further surgeries, is greater than the surgical benefit to the patient, surgery may not be warranted. PAs can ensure that this question is answered by having a thorough and frank conversation with the patient, informing him or her of the risks, benefits, and alternatives to surgery and allowing the patient to take an active role in determining his or her treatment course. When a patient believes that a surgery is forced on him or her; the risks, benefits, and alternatives were not clear; or the urgency of the situation was inflated, it can lead to a mistrust of the surgical team and potentially a longer recovery because the patient does not trust the postsurgery instructions and becomes noncompliant with them. The best task a surgical physician assistant (PA) can perform is to be a staunch patient educator and ensure that the patient has made an informed decision.
Is Surgery the Most Appropriate Next Step?
In a trauma or emergency situation, this question is very easy to answer because the patient’s life or limb may be in jeopardy, but when the patient has a chronic disorder that has been treated for the past 15 years, the answer may be more difficult to come by. A thorough history and physical examination can elicit information about the length and quality of the patient’s previous treatment(s). This helps the PA to identify patients who have participated in a proper pharmacologic therapy and are still deteriorating and those who have not undertaken appropriate first-line treatment. Because of the increased risks of surgery over pharmacologic therapy, all efforts to ensure that the lowest risk treatment is administered first should be made.
Is this Patient a Surgical Candidate?
At this point, you have determined that your patient would benefit from surgery and that surgery would be the most appropriate next step; now you wonder if the patient is a surgical candidate. Will the patient recover from surgery, or will he or she even be able to survive the surgery itself? Does the patient have a known reaction to anesthesia medications, or does the patient have an electrolyte imbalance that may lead to cardiac arrest on the surgical table? A patient may have a carotid stenosis of 80% and be symptomatic, but if he or she has had radiation therapy to the neck, the surgical wound has a lower chance of healing; therefore, the patient may not be a candidate for a carotid endarterectomy. Likewise, if a patient is septic and having failure of multiple organs because of bacterial endocarditis, an attempted valve replacement may be fatal.
What do Physician Assistants in Surgery Typically do on a Daily Basis?
There is a wide variety of surgical PAs; some stay in the hospital, assisting on cases and rounding on the inpatients, and others perform in-office procedures and see patients in a clinical setting for surgical consults and postoperative follow-up appointments. We will explain all aspects so surgical PA students are familiar with them.
Hospital Operations
If a surgeon’s patient is posted for the first case of the morning, then it is usually the PA’s job to ensure that the patient has arrived at the hospital on time and is advancing through the preoperative clearance requirements. Some hospitals allow patients to come to the hospital a few days early to get their preoperative laboratory studies drawn and meet with the anesthesiology staff. This allows for the day of surgery requirements to proceed faster. If the patient has not been precleared, he or she will have to have blood drawn and usually electrocardiography and potentially chest radiography performed before meeting with the anesthesiologist. The anesthesiologist will perform an independent history and physical examination to confirm that the patient is a surgical candidate from the clearance requirements. The anesthesiologist will identify the proper type of anesthesia, whether it includes epidural, moderate, or general, as well as the best method for oxygenation, such as an endotracheal tube or a laryngeal mask airway. If the anesthesiologist identifies a reason why the surgery should be canceled or delayed, he or she will inform the surgeon and operating room (OR) staff.
After the anesthesiologist has cleared the patient, the PA will verify that all the preoperative information is correct and perform a preoperative history and physical examination. Discussing the risks, benefits, and alternatives again with the patient in a thorough manner will guarantee the patient is able to provide informed consent and allow the patient to decline the surgery if he or she has had a change of heart. The patient will provide his or her consent for the surgery, and then either the surgeon or the surgical PA (depending on the policies of the hospital) may sign the surgical site. The signature should be legible and in an area that is visible to the OR staff but not directly over the expected incision line.
The PA can then make a quick stop by the assigned OR for the first case and confirm that all specialized instruments are available, equipment representatives have arrived and will be aiding in equipment identification and acquisition, and all supplies are available. Information on patient positioning, potential bloodborne pathogen status (hepatitis- or HIV-positive patients), and operative procedures can be offered to the OR staff so that everyone is aware of the specific needs of the surgeon and patient.
While the patient is finishing up the preoperative clearance and being moved into the OR, the surgical PA can then begin to make rounds on any patients who are in the hospital. These patients may include those who are awaiting surgery, are postoperative, or have been readmitted for surgical complications or previous surgical patients receiving additional treatment in the hospital. Rounding occurs whenever there is a free moment. You may not be able to see all your patients before starting your first case of the day. Typically, a surgical PA will start with the patients in the intensive care unit (ICU) or critical care unit and then proceed to the lesser acuity floors. Rounding on patients involves reading the notes of all other providers involved in the care of the patient, reviewing current laboratory tests and imaging, identifying any new diagnoses, and confirming appropriate treatment. All of these aspects are required to complete a detailed progress note on the patient. In addition to completing a progress note on the patient, the surgical PA identifies patients who are appropriate for discharge home. Patients who are going to be discharged home require a discharge summary and medication reconciliation to be completed, and the surgical PA usually completes these. Patient education regarding follow-up appointments, proper medication administration, recovery restrictions, rehabilitation exercises, and wound care instructions need to be provided by a member of the surgical team before discharge home.
The surgical PA is frequently in contact with the OR staff over the course of the day. By calling into the OR to see if the patient is there and ready for positioning and draping, the surgical PA can make every effort to not delay the operation start time and waste the time of the OR staff. After it has been confirmed that the patient is in the room, the PA should head to the OR and assist in positioning the patient on the OR table. Patient positioning takes multiple people because anesthesiology staff needs to protect the airways and lines, and OR staff need to pad bony points on the patient to lessen the risk of skin breakdown and neurologic complications. The surgeon needs the best access to the area of surgical interest.
During surgery, the PA is the surgeon’s extra hands. The goal of the surgical assistant is to provide the surgeon with the best surgical view. This can involve retracting tissue, suctioning blood, or repositioning light sources. Tension and countertension during retraction are the hallmarks of surgery. The surgical PA is supposed to know the surgeon’s next four steps in his or her head so he or she can preemptively ask for instruments the surgeon will need and have the area prepped before the surgeon needs it.
Surgical scopes of practice vary among surgeons, specialties, and hospitals. Some surgeons may be very comfortable with their PAs’ abilities and allow them extensive procedural leeway, but other surgeons limit the amount of primary surgical processes that their PAs can perform. The amount of work you see one surgical PA do may be very different from the amount of work that another surgical PA does. Just plan on taking it all in, and use that information to determine if you would like to work in a surgical specialty. When the surgery is over, there is more paperwork that needs to be completed, including an operative note, medication reconciliation, and postoperative orders, and nonpaperwork items such as talking to the family of the patient. The surgical team may divide and conquer these tasks. For instance, the surgeon may dictate a detailed operative note and talk to the family while the PA completes a postoperative note and completes the orders.
Another aspect of working in a hospital are surgical consults. Consults can come from the emergency department (ED) or from another specialty in the hospital. The ED may consult you on a patient who was found to have appendicitis, which requires that you admit the patient to your service (meaning you are the primary for that patient) or you contact the patient’s primary care provider and ask that she or he admit the patient, meaning you could then act as consultant, schedule the patient for surgery, and follow the patient through her or his hospital course. An alternative scenario is an oncologist consulting you for placement of a power port in a patient who requires chemotherapy. For this type of consult, you don’t have to admit the patient or act as the primary provider, but you need to write a consult note, schedule the patient for surgery, and follow the patient postoperatively. Consults can come at any time of the day, and some PAs take calls that require them to see the consults on the nights or weekends that they are on call. Every surgical practice is different, and call schedules are unique to each individual surgical PA. Call shifts usually correlate to late surgery coverage as well. If a surgery is running later than the PA’s normal shift, some practices have a late PA who will scrub in to relieve the PA who is ready to head home; most of the time this is also the on-call PA. Just like call schedules, a late PA or late coverage is unique to each surgical group; sometimes the late coverage may be a physician rather than another PA, but it is seen as a way to keep the late nights more equally dispersed among the surgical PAs.
Clinic Operations
Some aspects of hospital operations can carry over into a surgical clinic, especially if the surgical practice also performs in-office procedures. These may include procedures performed under local anesthesia such as a lesion biopsy, removal of a tunneled catheter or incision and drainage of an abscess, or even procedures using moderate sedation. With moderate sedation, an anesthesiology practitioner will administer the short-acting anesthesia medications and monitor the patient’s vital signs and response to the medications. Patients undergoing moderate sedation procedures still need a full workup performed by the anesthesiology practitioner and proper preoperative laboratory studies with a postoperative recovery time. Because the moderate sedation medications are not given in the dosages and do not have the long-term affect as the general anesthesia, the recovery time is significantly reduced. These patients cannot drive home under their own accord, but they do not have effects of drowsiness or sleepiness for as long a period as general anesthesia patients.
Clinic patients may range from consults by other providers, presurgical clearance workups, postoperative checks, and disease surveillance appointments.
What will I be Expected to do During the Surgery Rotation?
Hospital Operations
The majority of a PA student’s surgical rotation will be in a hospital setting; as such, the expectations revolve around operative patients. Students will be expected to preround on their assigned surgical patients before the resident rounds on them. This requires that the PA student arrive at the hospital very early in the morning. The first surgery of the morning usually starts at 7:30 am , and depending on the size of the patient census and number of students on the service, sometimes an arrival time of 4:30 to 5:00 am is necessary. The morning goal of every surgical PA student should be to have performed a focused history and physical examination, reviewed laboratory work and recent imaging, and completed a detailed progress note on each of her or his assigned patients before meeting with the services resident for the morning. The residents, interns, and students will round on the patients as a team before the attending surgeon arrives at the hospital, at which time another team rounding session will occur with the surgeon. During each rounding, the student should be prepared to brief the resident and attending on the status of each patient.
Hospital patients can be broken up into three categories: preoperative patients, postoperative patients, and medical patients. Preoperative patients include those who are scheduled for surgery. They may be trauma patients who have to have other medical therapy completed before undergoing surgery (e.g., stabilization of blood pressure or correction of electrolyte imbalances), or they may be patients who have inflammation or infection (systemic or at the site of incision) that needs to be addressed before surgical correction. Postoperative patients are those who have just undergone a surgery and are recovering and patients who have already been discharged from the hospital after the initial surgery and have returned because of complications such as infection, wound dehiscence, or failure of the surgery. Medical patients include those who are being treated for a medical condition that doesn’t warrant surgery, but if the treatment fails, these patients may become surgical candidates. Sometimes surgery services are consulted on patients known to them because of yearly surveillance for existing conditions because they may be admitted to the hospital for other conditions, and the admitting doctors would like the surgical team to offer assistance with their care. An example of a medical patient is a patient who is admitted for chronic constipation by a gastroenterologist, who then consults the surgeon because the patient has a known abdominal aneurysm. In this case, the surgeon can offer advice if other procedures need to be performed and follow the patient’s hospital course.
A PA student ought to include the items listed in Table 30.1 in her or his brief oral presentation of each surgical patient.
