lauraadora Posted July 5, 2019 Share Posted July 5, 2019 Posted this to the surgery sub-forum but got no replies so I thought I'd try here: I've been in the peds cardiac world since I graduated so I'm a little out of touch with regards to the adult world... I am interviewing at an adult hospital who utilizes NPs for all clinic/floor work and RNFAs in the OR, and they now want to introduce a PA in the mix. The position will be heavily OR-based which is what I want, but I want to have a better idea of the workflow in the OR. I know vein harvesting is a CT surgery PA's bread and butter so I'm aware that I'll have to learn that skill but my question is, timing-wise: how long does it take to harvest and prepare the vein? Once it's prepared, do you then take over the first assist position? If so, how far into the procedure is the surgeon (is the patient on bypass yet)? What percentage of your case-load involves vein harvesting versus valve replacements or other surgeries? Does every CABG utilize saphenous veins or are mammaries used some of the time? I hope I don't sound naive... I have tons of knowledge with regards to heart failure, hemodynamics, rhythm, etc and I have some surgical assisting experience so my skills should translate once I am in the field but I just don't know the adult world yet. Also, if I end up taking this job, recommendations are welcome for learning resources! Thank you all in advance for your help and insight! Quote Link to comment Share on other sites More sharing options...
SquarePeg Posted July 5, 2019 Share Posted July 5, 2019 Hiya. So, congrats on considering the adult world! It's pretty different, from what I understand... but cool nonetheless! Regarding vein-harvest/prep time: it varies quite a bit between harvesters. It can depend on many things, including skill - generally, when less vein is needed, it takes less time; patient variability add levels of challenge too! Some folks are very fast (and have very bloody legs) but may need more vein "prep/repair" time, some folks are slower but harvest with less hemorrhage and vein insult. If your case volume is high, you will likely pick it up faster. Find out what kind/length of training plan/expectations they have in mind to get you up to speed, what system they use and then get in touch w/the reps for training opportunities. Your questions about OR workflow is hard to answer because it varies between hospitals/surgeons. One job I had, I harvested vein then left to do rounds, and returned to seat a valve, come off bypass and close the chest. Another place, I entered the room w/the patient and didn't leave again until the patient left, so went straight from harvesting to first assist in the chest. Ratio of cases (CABG/Valve/"other") is also hospital and surgeon dependent. One surgeon may love or specialize in valves so you'll do many more of those cases... these are good questions to ask/research about the position you're considering. 99.9% of all CABG I have seen used LIMA, and most also use some vein, though if 1-2 grafts is needed and the patient is a young nonsmoker, bilateral mammary +/-radial may be used. Again, surgeon dependent. Regarding the staffing structure: I've been hired into a similar situation in the past, with SFAs (surgical first assist) in the OR, an office RN doing some questionable version of floor/ICU care, and then us PAs hired: 1 full-service CVT PA (me), 1 ICU PA, (and eventually a 2nd CVT PA). So, when I was in the OR, the SFAs were sitting in the lounge drinking coffee or (unofficially) taking the day off. When I was rounding, the other PA had nothing to do. And then I was seen as everyone's fill-in, since I could do all aspects of the care. So, when anyone wanted to be off, my job was to fill their duties... but no one specifically filled mine because no one else could do OR and rounds. I''m not describing this very well but it was really messed up. So, I recommend you find out exactly how they plan to incorporate PAs into the workflow, considering that the current players each do half of what most CVT PAs do regularly - OR and rounds. Ok - I hope this helps! 1 Quote Link to comment Share on other sites More sharing options...
lauraadora Posted July 5, 2019 Author Share Posted July 5, 2019 2 hours ago, SquarePeg said: Hiya. So, congrats on considering the adult world! It's pretty different, from what I understand... but cool nonetheless! Regarding vein-harvest/prep time: it varies quite a bit between harvesters. It can depend on many things, including skill - generally, when less vein is needed, it takes less time; patient variability add levels of challenge too! Some folks are very fast (and have very bloody legs) but may need more vein "prep/repair" time, some folks are slower but harvest with less hemorrhage and vein insult. If your case volume is high, you will likely pick it up faster. Find out what kind/length of training plan/expectations they have in mind to get you up to speed, what system they use and then get in touch w/the reps for training opportunities. Your questions about OR workflow is hard to answer because it varies between hospitals/surgeons. One job I had, I harvested vein then left to do rounds, and returned to seat a valve, come off bypass and close the chest. Another place, I entered the room w/the patient and didn't leave again until the patient left, so went straight from harvesting to first assist in the chest. Ratio of cases (CABG/Valve/"other") is also hospital and surgeon dependent. One surgeon may love or specialize in valves so you'll do many more of those cases... these are good questions to ask/research about the position you're considering. 99.9% of all CABG I have seen used LIMA, and most also use some vein, though if 1-2 grafts is needed and the patient is a young nonsmoker, bilateral mammary +/-radial may be used. Again, surgeon dependent. Regarding the staffing structure: I've been hired into a similar situation in the past, with SFAs (surgical first assist) in the OR, an office RN doing some questionable version of floor/ICU care, and then us PAs hired: 1 full-service CVT PA (me), 1 ICU PA, (and eventually a 2nd CVT PA). So, when I was in the OR, the SFAs were sitting in the lounge drinking coffee or (unofficially) taking the day off. When I was rounding, the other PA had nothing to do. And then I was seen as everyone's fill-in, since I could do all aspects of the care. So, when anyone wanted to be off, my job was to fill their duties... but no one specifically filled mine because no one else could do OR and rounds. I''m not describing this very well but it was really messed up. So, I recommend you find out exactly how they plan to incorporate PAs into the workflow, considering that the current players each do half of what most CVT PAs do regularly - OR and rounds. Ok - I hope this helps! This is amazingly helpful - thank you! I am glad I got you hear the different ways you were utilized in past positions because I am hoping to be a little more OR-bound and less rounds-heavy. The nice thing about this institution is there is another hospital in the same system with a team of CT surgery PAs so I’m hoping to get some orientation and harvesting training there and see how the PA workflow is in that institution. Thanks again for your thoughtful reply! Quote Link to comment Share on other sites More sharing options...
CVTSPA Posted July 7, 2019 Share Posted July 7, 2019 Also did cardiothoracic surgery for a while and completely agree with SquarePeg's response. Varies from hospital to hospital and recommend asking the specifics of what you'll be doing in the OR (i.e. harvest vein and leave, harvest vein then first assist, rotating the RNFA's out for a break from time to time, etc). Valve: CABG ratio varies on the population you are serving and what your surgeons are known for (generally speaking, younger patients = more CABG, Older = more valves). Also good to ask if you help position the patient, put in the Foley, and put in arterial and central lines. I did those things but most CVTS PA's didn't in my experience! My situation was once you are in the OR, you're in the OR until the case is done or the call person relieves you (at 5PM). Did vein/radial harvest then first assisted. If there were enough PA's available, another PA would come in to close while the surgeon talked to the family. Whether or not the surgeon starts working on the chest while you are harvesting is also hospital dependent. My surgeons would be opening the chest, harvest the LIMA, then start to place the venous and arterial cannulas while I was harvesting (so we would both cut at the same time). Wouldn't go on pump and cross clamp until the conduit was ready. Whenever I was done prepping the vein (tying branches), I would jump up to first assist and help them. Hopefully, I was done with the harvest by the time they were done harvesting the LIMA but it varies depending on difficulty of the harvest, whether or not nursing is paying attention to you, etc. It's an exciting field for PA's! Good luck! Quote Link to comment Share on other sites More sharing options...
SedRate Posted July 7, 2019 Share Posted July 7, 2019 34 minutes ago, CVTSPA said: Also did cardiothoracic surgery for a while. This being past tense, what are you doing now (if you don't mind my asking)? Quote Link to comment Share on other sites More sharing options...
CVTSPA Posted July 26, 2019 Share Posted July 26, 2019 On 7/7/2019 at 12:03 PM, Sed said: This being past tense, what are you doing now (if you don't mind my asking)? Medical school. Graduating in May 2020! Quote Link to comment Share on other sites More sharing options...
SedRate Posted July 27, 2019 Share Posted July 27, 2019 2 hours ago, CVTSPA said: Medical school. Graduating in May 2020! Congrats! Sending you a PM. (Sorry to hijack post.) Quote Link to comment Share on other sites More sharing options...
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