Has anyone experienced being undermined as a PA? I have been a Cardiothoracic surgical PA for 2 years now. And in this new hospital I work at, PAs are not represented much. I believe most of that’s because management is not familiar with what PAs can do, how they can bill, their autonomy, etc. Due to this, their structure has always been having NPs on the floor to round on the post op patients, and RNFAs (nurse first assists) in the OR. The surgeons don’t get involved as much because they‘ve compartmentalized the two groups, and have a head NP and head RNFA who leads their counterparts.
But since I’ve joined, and my credentials give me the ability and knowledge to do both parts of the job, I’ve been dealing with a lot of power trips and a lot of them seem to be threatened. And I can’t seem to find a median between being respectful and being assertive. (Especially since I’m still fairly new in my career) I want to work here but I don’t want this to be the issue why I can’t enjoy my job. Thoughts?
Interested in Surgery?
An introduction to the OR team
By Robert M. Blumm, MA, PA-C, DFAAPA
Whether you are a PA student scheduled to start a surgery rotation or an NP interested in moving into surgery, an understanding of the surgical team is beneficial. This article outlines the hierarchy and operation of the typical surgical suite.
The surgeon is the attending physician for the surgical patient, responsible for his or her care and treatment while in the operating room (OR).1 Among the responsibilities of the surgeon are to examine the patient, order and interpret diagnostic tests, and to formulate a preliminary diagnosis and a differential diagnosis. The surgeon then consults with the patient to explain the problem and the best approach to it. He or she obtains informed consent and answers the patient’s questions prior to admission to the hospital.
Under no circumstances should your personal conversation with the patient contradict the surgical plan previously discussed with the surgeon. The surgeon will be your supervising physician and mentor during the procedure, therefore be prepared to answer questions related to this procedure. If you have a pressing question, ask at the time of closure.
The Registered Nurse
The operating room is controlled by nurses who have many responsibilities both inside and outside the OR. Nurses are responsible for sterile process in the selection of the proper instruments, packs and gowns. You will encounter many nurses in the perioperative role, and it is important to know their function and how you may best learn from them. Surgical nurses are responsible for the day-to-day safeguarding of surgical patients.
The OR Supervisor
The OR supervisor has the skills necessary to intervene in all technical problems involving his or her staff, OR instrumentation and equipment and sterile procedure. He or she is the senior nurse who books and schedules cases, assigns rooms to surgeons and acts as coordinator with every other department with regard to the preoperative holding area, the OR and the post-anesthesia care unit (PACU). The OR supervisor is also the nursing officer in charge of preoperative testing.
The Preoperative Holding Nurse
The preoperative holding nurse is responsible for the timely preparation of the surgical patient. This responsibility begins 3 days prior to surgery by telephoning the patient and communicating important information about admission. This nurse then supervises the gathering of all laboratory results and radiologic tests, patient information and consents. Upon the patient’s admission to the hospital, the preoperative holding nurse interacts with the patient, checks the chart again for completeness, and assures that all consents, notes and orders are signed by anesthesia staff and the surgeon. He or she also starts the IV and administers ordered medications. This nurse is critical to the timely flow of surgical procedures.
The Circulating Nurse
The circulator is responsible for the acquisition of all supplies, sterile equipment, machines and sets needed for surgery. The circulator then works with the scrub nurse or scrub technologist to set up the case and assure that all necessary equipment and supplies are in order. The circulator then gathers all the necessary equipment for the administration of anesthesia.
After placing the patient on the OR table, checking the patient‘s ID bracelet, verifying the patient’s surgeon and the scheduled procedure, the nurse in this role reassures the patient and may provide warming blankets. The circulator then assists the anesthesiologist in the administration of anesthesia and helps dress all “scrubbed personnel.”
The patient must be in a specific position for surgery. The circulator works with the anesthesiologist, the surgeon and the first assistant to achieve the required position and documents all safety measures. The circulator then prepares the patient’s surgical site with the appropriate preoperative washing agent and prep materials.
Prior to the start of surgery, the circulator calls a time out in which the name of the patient, his or her condition, the site of surgery and the procedure is verified with the surgeon and all in the room. As the case commences, the circulator supplies the sterile members of the team with additional sutures and supplies, oversees the sterility of all the members of the team, communicates with all departments and facilitates the acquisition of emergency equipment and additional supplies such as blood.
The circulator is the manager of the OR record and is available to help any member of the team, particularly in an emergency situation, such as the onset of cardiac arrest or malignant hyperthermia. The circulator performs an important final step: He or she orders a count of all sutures, needles, sponges, lap pads, etc., and confirms the count is correct. He or she applies dressings and assists in the extubation of the patient and the safe transfer to the PACU.2
The Scrub Nurse
The scrub nurse may be an RN or an LPN. He or she has specialty training in surgery and surgical technique and instrumentation.3 The scrub nurse gathers supplies prior to the case (along with the circulator) and plans for additional supplies that may be needed. The scrub nurse then scrubs for the case and the setup of all sterile equipment. This person is the sterile staff member and supplies the surgeon and assistants with sterile instruments, sutures and other supplies. The scrub nurse is an excellent source of information for PA students or NPs who are new to the surgical suite.
The scrub nurse has the authority to note a break in technique and to request that sterile scrubbed personnel change gloves or gowns. The scrub nurse anticipates the needs of the surgical team. At the conclusion of a procedure, the scrub nurse may assist in applying dressings and the safe moving of the patient from the table to the OR stretcher.
The PACU or Recovery Room Nurse
The PACU or recovery room nurse accepts the patient from the OR and immediately provides a secure environment for proper airway, oxygenation, suction and care. This nurse is an expert in critical care and is responsible for the safety of the patient while he or she is in this area as well as the safe movement of the patient from the PACU to any other area of the hospital. The PACU Nurse can be a source of information for postoperative orders and medications and your right hand if an emergency occurs.
The Surgical Technologist
The surgical technologist has the same responsibilities as the scrub nurse, but he or she has less responsibility in an emergency because he or she is working under nursing and has limitations on the ability to administer drugs and blood products. The surgical tech is a trained (often certified) member of the team who can provide insight into the needs of the surgeon, his or her approach, his or her mannerisms in surgery, his or her areas of intolerance, and the specific requirements of the first assistant.
The anesthesiologist is a physician who is an expert in pulmonary medicine and the science of providing sleep and analgesia for the patient who is undergoing surgery.4 The anesthesiologist consults with the patient prior to surgery to discuss the planned procedure and anesthetic.5 He or she determines whether the patient should have local, regional, spinal or general anesthesia. This decision is based on the patient’s medical and surgical history, family history and psychological status. The anesthesiologist maintains constant awareness of the cardiopulmonary status of the patient.
After entering the OR, the anesthesiologist checks the IV line and makes sure that all preoperative medications have been administered. He or she connects the patient to cardiac leads and assures that the patient’s cardiac and pulmonary status are being monitored prior to and during the course of anesthesia. He or she attaches a pulse oximeter and blood pressure cuff and ensures that all necessary equipment and drugs are available to perform intubation.
During the surgery, the anesthesiologist maintains an open airway, proper breathing and circulation and keeps the patient in a highly oxygenated state to administer drugs as needed.
The anesthesiologist is also responsible for positioning and evaluating both the intake and output of the patient. The second anesthesia provider is the certified registered nurse anesthetist, physician assistant anesthetist. These professionals are experts in managing a patient under anesthesia.6 They have obtained graduate-level education in this area.7,8
The First Assistant
Numerous types of “first assistants” exist in the OR, and they include surgeons, residents, interns, medical students, family physicians, PAs, NPs, certified registered nurse first assistants, registered nurse first assistants, perfusionists and certified surgical technologists–certified first assistants.
The responsibility of the first assistant is to be the assistant surgeon during a procedure. This requires knowledge of anatomy and physiology, surgical handling of tissues, surgical instrumentation and surgical procedures. In addition, the first assistant must be skilled in suture techniques, positioning, sterilization, sterile technique, prepping and draping, pre- and postoperative care, and the use of suctioning equipment, splints and casts. The first assistant must have well-honed decision-making skills that can add to the successful completion of surgical procedures.9
Physician assistants who specialize in surgery have a specialty organization, the American Association of Surgical Physician Assistants (AASPA), which provides continuing education and networking opportunities.10 The surgical PA orders tests, interprets test results and writes admitting orders, progress notes and postoperative orders. Surgical PAs determine when a patient may ambulate or be discharged, write prescriptions, perform discharge summaries and plan postoperative follow-up.11 Nurse practitioners may also function in this role.
All hospitals establish criteria for who may “first assist” and on what cases. NPs apply for credentials in the same manner as PAs and must specify a supervising surgeon. This requires the NP to have a relationship with a surgeon or surgical group. For information on advanced practice nurses transitioning to a first assist role, see the following article: http://www.medscape.com/viewarticle/499689.
There is no better manner in which to conclude this overview of the OR team than to focus on prevention of surgical site infections. Surgical site infections affect 750,000 patients every year in the United States.12 These infections can increase length of stay in a hospital for up to 10 days. Increased length of stay adds $20,842 to the average patient’s hospital charges.12 These excess charges are now absorbed by the institution, not the insurance company. Appropriate implementation of the perioperative role can render these infections preventable. Visit www.AORN.org, the website for the Association of periOperative Registered Nurses, to find advice for preventing surgical site infections. Pay specific attention to recommendations for hand washing, hair removal, prepping and draping. Additional guidance is available from the Centers for Disease Control and Prevention at www.cdc.gov/handhygiene/24.
Robert M. Blumm is a surgical physician assistant who lives in Amityville, N.Y. He has served as president of the American Association of Surgical Physician Assistants, the Association of Plastic Surgery Physician Assistants, the New York State Society of Physician Assistants and the American College of Clinicians. He is a member of the editorial advisory board for ADVANCE for NPs & PAs. Blumm has completed a disclosure form and reports no relationships related to the content of this article.
1. Kurzweg FT. The patient, his surgeon and the record. In: The Surgeon’s Handbook. Garden City, N.Y.: Medical Examination Publishing Company , Inc.; 1982: 3.
2. Position statement of the Association of periOperative Registered Nurses. One Perioperative Registered Nurse Circulator Dedicated to every Patient Undergoing a Surgical or Other Invasive Procedure. http://www.aorn.org/Clinical_Practice/Position_Statements/Position_Statements.aspx. Accessed Dec. 27, 2011.
3. Centers for Medicare and Medicaid Services. Conditions of participation for hospitals: surgical services. http://www.cms.gov/manuals/downloads/som107ap_a_hospitals.pdf. Accessed Dec. 27, 2011.
4. Sweeny F. Who’s the person giving my anesthesia? In: Sweeny F. The Anesthesia Fact Book. Perseus Publications; 2003: 3-12.
5. University of Cincinnati Residents, Berry S. The Mont Reid Surgical Handbook. 4th ed. Mosby;1997.
6. Sumpter R. Anesthesia. In: Labus JB. The Physician Assistant Surgical Handbook. W.B. Saunders; 1998: 19.
7. All about anesthesia. American Association of Registered Nurse Anesthetists. http://www.aana.com/forpatients/Pages/All-About-Anesthesia.aspx. Accessed Dec. 27, 2011.
8. Facts about AAs. American Academy of Anesthesiologist Assistants website. http://www.anesthetist.org/factsaboutaas/. Accessed Dec. 27, 2011.
9. Weis MK. The first assistant and collaborative practice. In: Rothrock JC, Seifert PC. Assisting in Surgery: Patient-Centered Care. Competency & Credentialing Institute; 2009: 387-405.
10. American Association of Surgical Physician Assistants website. www.aaspa.net. Accessed Dec. 27, 2011.
11. Blumm RM, Condit D. Surgical physician assistants help solve contemporary problems. Bull Amer Coll Surg. 2003;88(6):14-18. http://www.facs.org/fellows_info/bulletin/2003/blummcondit0603.pdf. Accessed Dec. 27, 2011.
12. Manz EA, et al. Clipping, prepping and draping for surgical procedures. Managing Infection Control. 2006;August: 84-97.
I have a friend who is a fellow new grad PA, and she is considering a 2-year residency program in psych. She has a passion for psychiatry and could see herself making big differences there, however she is worried that she may begin to forget general medicine if she only works in psych for 2 or 3 years. Her other passion is ortho surgery (and other general surgery). She has also considered pediatrics and inpatient neonatal as other close-2nd choices.
So, I'm wondering if anyone has had to decide between two fairly distinct specialties or switched between the two, years down the road. In particular has anyone here gone from a psych residency program to another specialty (or moonlighted / floated elsewhere)... or any other residency program to something else?
In general, how difficult is it to find a general medicine or even surgery job after working only in psych for a while?
Hi there! I am a new graduate that recently accepted a general surgery job from a local metro hospital. I will have the opportunity to perform a lot of procedures and with time a lot of autonomy. I am excited, but I am also aware of all that I don't know and still have a lot to learn. Is there any advice or textbooks any of you could give? I was a scrub tech for years before attending PA school, so the OR life is like home to me.