Cardiothoracic Surgery

[goose37]

Been offered a job change to CT surgery. It's actually just the thoracic side with very little cardiac. Questions were, to folks who've been in this gig for a while, what procedures/assistance have you earned the right to do? This Dr uses a lot of robotics so lots of thymeectomies, chest wall tumors, wedges, lobectomies and the like. Just curious if this is something I could become skilled in or likely just loading the robot.

[CVTSPA]

CT surgery can be pretty rewarding.  I've worked in CT surgery for about 2 years or so in a community hospital (so no robotics).  We do about 50:50 cardiac and thoracic and we send any complicated cases downtown.  Thoracic surgery can have a pretty good lifestyle.  In my experience, thoracic surgery by itself doesn't have a lot of emergencies so if you're taking call with a mostly thoracic service, you shouldn't have to go in a lot. 

 

Unfortunately, as thoracic surgery has become more and more minimally invasive, the role of the first assist in those cases has become more difficult as it is difficult to see what is going on.  The few cases/emergencies I've done where we made a large thoracotomy, like they did in the old days, I was amazed at how much I could actually see and it made the operation so much easier than through the small thoracotomy. The mini thoracotomies we do, only one person can have their head over the hole and actually see the full picture of what is going on.  But as you get more experience, you'll learn how to help without actually seeing the full picture of what is going on.  You can get pretty helpful with the lung grabber.  I assume it would be a similar experience with robotics.  If I recall correctly, you still need to do a thoracotomy to even get the lobe out for a robotic lobectomy so I'm not sure what the appeal of the robot is. 

 

A PA friend of mine who did robotic thoracic surgery downtown for a while says that the cases she did mostly involved her firing the stapler for the wedge resections and lobectomies and, of course, helping to position the camera and instruments with the scrub nurse.  But you help start the case like normal.  The doc and you would be both scrubbed in to make all the thorascopic holes and, I assume, the thoracotomy in the case of a lobectomy.  I don't have much esophageal experience so I can't speak in that regard. 

 

You can become very skilled in this area.  Usually, PA's are much more valued on the cardiac side of things doing all the vein and radial artery harvesting.  Our cardiac surgeon always says that "it takes 10,000 steps to do a CABGx1" so once you know all those steps and can first assist, you are incredibly valuable.  You really need to have a first assist in all cardiac cases whereas some thoracic cases you might be able to squeeze by with just the scrub nurse helping.  If you really want to get skilled in just thoracic surgery, you would probably need to do some ICU/floor work. Managing ICU and floor patients  and even seeing people in the office is a great skill to have to complement what you do in the OR.  Is the position just straight surgery or does it involve any floor or office work?

 

And procedures that I've "earned the right to do", I guess: arterial line placement, central line placement, and chest tube placement are the things that first come to mind when I think of the thoracic side of things.  Again, if you can do saphenous vein and radial artery harvesting on the cardiac side, you're golden.  *I assumed you meant procedures that I can do on my own with no doc looking over my shoulder.  If you mean procedures that I can first assist on, there are no restrictions on what we can't first assist on at my hospital.

[SHU-CH]

I'm also from the pre-robot days, and also worked in cardiothoracic for about 2 years. My group was almost all cardiac.

 

One thing I found was that it was not really a great fit for my personality. For the most part, a CABG is a very choreographed procedure. After you get the hang of it, you know exactly what your day will look like tomorrow, next week, next year and in 5 years (except for an occasional groundbreaking technology change). The group would have been a great job for someone who wanted to laser-focus on a single procedure and do it better than anyone in the world. I find variety more appealing, so I eventually landed in emergency medicine.

 

I did appreciate the variety of the thoracic stuff we got to do. As noted above, assisting with smaller incisions gets very challenging because you cannot see the business end of the instruments you are holding a lot of the time.

 

Good luck!

[TheDude]

I am currently in a group where we do about 90% cardiac, 8% thoracic, and the rest vascular or "other." 

 

Robots are cool and good for patient outcomes in some cases, but I feel it can add A LOT of time to a fairly east case either doing VATS or open.  Get good at knowing how the surgeons you work with do the cases, some will always do it the same way every time, and some change their technique as much as they change their underwear.

 

As far as assisting with robotics, always ask what you can do to help, whether its draping or closing, no task is too mundane.  Participation and muscle memory helps tremendously.  You may get to the point of placing the ports, or like me, sometimes get to sit at the opposite console on heavier cases.

 

For cardiac, get good at taking vein.  This is a golden opportunity to make yourself an asset to the group or hospital.  It doesn't come easy, but do as many as you can.  Don't get down on yourself if you run into trouble or take a lot of time.  I work with another PA who has been taking vein both open and endoscopically for 12 years and he still has bad days, it just happens.  Also, get good at closing, it helps with motor skill technique.  A lot of people hate to close, I love it.  The patient only sees two things; your face and the incision.  I had a 30+ year surgeon tell me, you can botch an entire case, but as long as the incision looks good and they see your face every day, they may never know the difference....(this was a light hearted comment, so don't take it too seriously.) 

 

I guess in a nutshell, is just get your hands in every case as much as you can.  It will build good skills, technique, and just the exposure can be a massive help when it comes time to crash on pump on open a chest quickly.

 

Hope this helps some.