In cognitively demanding fields, there are no naturals. Nobody walks into an operating room straight out of a surgical rotation and does world-class neurosurgery. MALCOLM GLADWELL
Patient approach
Whenever a surgical provider approaches a patient, there are certain questions that should be considered, such as (1) “Will this patient benefit from surgery?”, (2) “Is surgery the most appropriate next step?”, and (3) “Is this patient a surgical candidate?” These questions are generally answered after a history and physical have been performed. A consulting doctor or a primary care provider may have given the provider information about the patient, but it is necessary for the provider to gather his or her own history and perform a physical examination. By taking a detailed history and performing a diligent examination, a surgical provider can prevent inappropriate treatment, the cancellation of a surgery, and surgical complications.
Will this patient benefit from surgery?
Surgery is not guaranteed to be beneficial; sometimes a surgery can leave a patient in worse pain than before or with 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.” Common surgical complications include postsurgical neuropathies, tissue damage, loss of function, or need for further surgeries. If the risk of these complications is greater than the surgical benefit to the patient, surgery may not be warranted. Physician assistants (PAs) can assist in making these surgical decisions by having a thorough and frank conversation with the patient; informing them of the risks, benefits, and alternatives to surgery; and allowing the patient to take an active role in her or his treatment plan. When a patient feels that a surgery is unnecessary or imposed; the risks, benefits, and alternatives were not clear; or the urgency of the situation was inflated, trust between the patient and the team is lost. Tension between the patient and the team can lead to longer recovery times, noncompliance with therapies or loss to follow up. Surgical PAs should be staunch patient educators and ensure that the patient has made an informed decision.
Is surgery the most appropriate next step?
When a patient’s life or limb is threatened because of trauma or another emergency, it is easy to determine that surgery is appropriate. The answer to this question is potentially more difficult, however, when a patient has a chronic illness that has not responded to other treatments. A thorough history and physical examination can elicit information about the length and quality of the patient’s previous treatment(s). A detailed assessment helps establish if the patient has participated in proper medical therapy and is still deteriorating or if he or she has not maximized medical therapy yet. Because of the risks of surgery, conservative therapies should be attempted before the patient undergoes an operation.
Is this patient a surgical candidate?
Once the need for surgery is established, PAs need to help determine whether the patient is a good surgical candidate. Is this patient likely to survive surgery? Can he or she tolerate anesthesia for the required length of the surgery? Does the patient have a known reaction to anesthetics, or does the patient have an electrolyte imbalance that may lead to cardiac arrest in the operating room (OR)? Will this patient heal well after the surgery? A patient may have a carotid stenosis of 80% and desire a carotid endarterectomy, but if he has had radiation therapy to the neck, he may not be a candidate for surgery, based on a low likelihood of wound healing. Likewise, if a patient is septic and having multiple system organ failure because of bacterial endocarditis, an attempted valve replacement may be fatal.
A typical day in surgery rotation
Although the duties of surgical PAs vary, most work in a surgical team composed of a surgeon and a PA. Surgical PAs may work in the hospital, assisting in surgeries, rounding on admitted patients, and performing hospital consultations. They may also work in the clinic seeing patients for consults, postoperative follow-ups, or surveillance appointments. Surgical PAs may also perform procedures in the clinic and help patients in surgical centers recover from sedation. Each surgical practice group uses PAs differently, but most surgical PAs will work in both hospital and clinic settings. Let’s delve further into these surgical environments for a better understanding of the surgical PA’s world.
Hospital operations
If a patient is the first surgical case of the day, then it is usually the PA’s job to ensure that the patient has arrived at the hospital and is advancing through the preoperative clearance process. Sometimes a patient is able to come to the hospital a few days early to get his or her preoperative laboratory studies drawn and to meet with the anesthesiology team. This allows the preoperative process to proceed more quickly on the day of the surgery. If the patient has not been precleared, she or he will have to have presurgical testing performed before meeting with anesthesiology. The anesthesia team, which may be an anesthesiologist or a certified registered nurse anesthetist (CRNA), will perform an independent history and physical examination to confirm that the patient is an appropriate candidate to receive the type of anesthesia needed for the scheduled procedure. The anesthesia team will determine the most appropriate form of anesthesia based on the needs of the patient and the type of surgery being performed. If the anesthesia team identifies a reason to cancel or delay the surgery, they will inform the surgeon and operating room staff.
After anesthesia has cleared the patient, the PA will verify that all the preoperative information is correct and perform a preoperative history and physical examination. Thoroughly discussing the risks, benefits, and alternatives again with the patient will guarantee the patient can provide informed consent and allow the patient to decline the surgery if he or she so desires. The patient will give consent for the surgery, and then either the surgeon or the surgical PA (depending on the policies of the hospital) will mark the surgical site. The mark, which is usually the initials of the person making the mark, should be legible and in an area that is visible to the OR staff but not directly over the expected incision line.
Before beginning a surgical case, the PA should visit the assigned OR and confirm that all of the necessary equipment and supplies are available. The PA will provide information to the OR staff on patient positioning, potential bloodborne pathogen status (hepatitis- or human immunodeficiency virus [HIV]-positive patients), and the procedure to be performed. Each member of the OR team has specific duties to facilitate completion of the surgery. The circulating nurse does not scrub into the case but is present in the room to obtain equipment and medications, keep the family informed about the surgery’s progress, and monitor the surgical field for any lapses in sterile procedure. The scrub tech/nurse scrubs into the case very early and lays out all the surgical instruments and equipment needed before the surgical team and patient enter the room. The scrub tech/nurse is responsible for passing instruments to the surgical team during the case and acting as an extra hand when needed. The scrub tech/nurse needs to anticipate the next step in the procedure to offer the correct instruments to help the case proceed smoothly.
PAs also perform rounds on patients admitted to the surgical service. These patients can be awaiting surgery, postoperative, or readmitted for surgical complications, or they may be previous surgical patients receiving additional treatment in the hospital. PAs round whenever there is a free moment. Sometimes a surgical PA may not be able to see all of the assigned patients before starting the first surgical case of the day. Typically, a surgical PA first rounds on patients in the intensive care unit (ICU) and then rounds on less sick patients. Rounding on patients includes reading the medical notes of all of the other providers involved in the care of the patient, speaking to the nurses caring for the patient, reviewing current laboratory tests and imaging, identifying any new diagnoses, and confirming or changing treatments. The PA should write a detailed progress note for each patient, including whether the patient should be transferred to another floor or discharged. Patients who are going to another floor require transfer orders, whereas those going home require a discharge summary and medication reconciliation. 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 in regular contact with the OR staff over the course of the day. Calling into an assigned operating room to see if the patient is present and ready for positioning and draping can help keep an operation on time and avoid further delays throughout the day. Once a patient has been placed under anesthesia, a surgical PA should assist in positioning the patient on the OR table. Patient positioning takes multiple people: anesthesia protects the airways and peripheral lines, OR personnel carefully pad bony prominences on the patient to lessen the risk of skin breakdown and neurologic complications, and the surgical team ensures the best access to the surgical cavity.
During surgery, the PA works as the extra hands of the surgeon, providing the surgeon with the best view of the surgical field by retracting tissue, suctioning blood, or repositioning light sources. PAs must have a good grasp on the concepts of traction and countertraction. A surgical PA must anticipate the surgeon’s next four steps and be prepared, with surgical instruments in hand, to provide balanced and coordinated movements for exposure. A surgical team that moves together as one decreases the amount of time patients spend under anesthesia and surgical complications. The ability of the surgeon and PA to predict each other’s needs and movements takes times to develop. If a PA works for a group with multiple surgeons, this phase of training can take even longer, as each surgeon has his or her own style and idiosyncrasies.
Once the surgery is over, the team transfers the patient to the postanesthesia care unit (PACU). There the surgical team will complete postoperative paperwork, including an operative note, medication reconciliation, and postoperative orders. The surgical team may divide and conquer postoperative tasks. For instance, the surgeon may dictate a detailed operative note and speak to the family while the PA writes a postoperative note and completes the orders.
Another important role for the surgical PA is to conduct surgical consults. Consults can come from the emergency department (ED) or from another specialty in the hospital. Common requests include consultations from the ED for patients with abdominal pain or deep abscesses, or requests from oncology for chemotherapy port placement. In some cases, a patient is admitted to the surgical service. In these cases, the surgical team is primarily responsible for the patient’s care. In other cases, surgeons may simply act as a consultant, following a patient admitted to another service each day to ensure that the patient’s surgical needs are met. Consults can come at any time of the day, and some PAs take call shifts that require them to go to the hospital to see the consults when they are on call. Those who are on call overnight also usually provide late surgery coverage. If a surgery is running later than a 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. Each practice has its own approach to providing 24-hour coverage for surgical patients.
Clinic operations
Some aspects of hospital operations can carry over into a surgical clinic, especially if the surgical practice also performs in-office procedures. In-office procedures may include those performed under local anesthesia, such as a biopsy, removal of a tunneled catheter, incision and drainage of an abscess, or even surgical procedures using moderate sedation. Patients receiving moderate sedation with procedures still need full anesthesia assessment with appropriate preoperative laboratory studies and a postoperative recovery time. Nearly all PAs see clinic patients, which typically include consultations requested by other providers, presurgical workups, postoperative checks, and disease surveillance appointments.
Expectations of physician assistant students on surgery rotations
The scope of practice for surgical PAs varies substantially among practices and hospitals. Some surgeons are very comfortable with their PA’s abilities and allow them extensive procedural leeway. Other surgeons may limit the surgical techniques that their PAs can perform. The procedural work you observe one surgical PA perform may be very different from the procedural work that another surgical PA does. Just take it all in, and use that information to determine whether you would like to work in a surgical specialty.
Hospital work
The majority of a PA student’s surgical rotation will be in a hospital setting. Students will be expected to preround on their assigned surgical patients before the resident or attending rounds. Therefore the PA student will arrive at the hospital very early in the morning. The first surgery of the morning may start at 7:00 or 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 their assigned patients before meeting with the surgery resident that morning. The residents, interns, and students typically round on the patients as a team before the attending surgeon arrives at the hospital. Once the surgeon arrives, he or she will conduct another set of rounds with all members of the team. During each rounding session, the student should be prepared to brief the resident and attending surgeon on the status of each patient. A typical oral presentation will last no more than 1 to 2 minutes and is usually performed while walking to the patient’s room. Be concise. The type of surgical patient (preoperative, postoperative, or medical) will determine which data you should highlight during the oral presentation. A PA student should include the items listed in Table 25.1 in their oral presentation of each surgical patient.
| Preoperative Patient | Postoperative Patient | Medical Patient |
|---|---|---|
| What procedure is the patient scheduled for and when? | Day’s status post and from what procedure | Why is the surgical team following the patient? |
| Brief overview of the patient’s hospital course to date | Brief overview of the patient’s recovery to date | Brief overview of the patient’s previous clinic visits with any surveillance studies |
| Any issues the patient has (e.g., if something has kept the patient from having the procedure) or that have come up overnight | Any complications or issues the patient has been having (e.g., wound issues, ileus, nausea) | Any current complaints |
| Physical examination (focusing on any previous abnormalities noted and their resolution or deterioration) | Physical examination (focusing on the vital signs, surgical incision, and complete examination of the organ system involved in the surgery) | Physical examination (focusing on the organ system involved with the patient’s chronic disease) |
| Current laboratory studies (including results from early morning laboratory draws and pending laboratory studies, such as cultures) with information on any trends (e.g., monitoring blood urea nitrogen and creatinine in a patient with kidney disease); current imaging with radiologist readings (if available) | Current laboratory studies (including results from early morning laboratory draws and pending laboratory studies, such as cultures) with information on any trends (e.g., monitoring hemoglobin and hematocrit after acute blood loss); current imaging with radiologist readings (if available) | Current laboratory studies and imaging that are associated with the patient’s chronic disease |
| Quick review of other providers on the patient’s care team assessment and plan (e.g., physical therapy, nephrology, infectious disease) | Quick review of other providers on the patient’s care team assessment and plan (e.g., physical therapy, nephrology, infectious disease) | Review of the admitting doctor’s planned course of treatment, with additional input provided by other consulting services |
| Identification of any potential consults | Identification of any potential consults | Identification of when the patient may become a surgical candidate |
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