May 21, 2018Opting for Surgery
Richard Sherman, David Johnson, and Odell Beckham Jr. — three of the NFL’s biggest superstars — were sidelined this year with season-ending injuries that required surgery. Athletic trainers were there for the injuries, evaluations, and rehabilitations, but what if they could have been a part of the surgeries, too? Believe it or not, more and more athletic trainers are popping up in the operating room, expanding the ways in which we care for our patients.
The evolution of our profession has already seen a number of athletic trainers make their way off the field and into the physician practice setting, formerly known as the “physician extender” role. Now, athletic trainers can also be found in the operating room as surgical first assists. They are used in the field of orthopedics, as well as a number of other specialties, including primary care and emergent/urgent care.
The surgical first assist position is a vital member of the operating team and helps with many tasks. From patient positioning to graft preparation, suturing, and retraction, a surgical assist is considered an extension of the surgeon. Although this post requires some new skills for many athletic trainers, our background knowledge and ability to triage, perform under pressure, and cultivate relationships within a medical team can allow a seamless transition into the role.
I’m speaking from experience. For the past six years, I have been employed as both a clinical athletic trainer and surgical assist at Orthopedic + Fracture Specialists, a physician-owned private practice in Portland, Ore. The physicians and administrators at my organization have embraced athletic trainers in the operating room. Three of the nine athletic trainers on staff currently assist in surgery, and one more is being trained to do so. My typical schedule has me in the operating room one or two days per week (or whenever I’m needed for add-on cases) and in the clinic up to three days per week. In my time here, my knowledge and skills have grown in ways I never thought possible, while our use of athletic trainers in the operating room has increased revenue for the clinic and improved the level of care provided to our patients.
So what specific traits might make an athletic trainer a good fit for assisting with surgeries? First, our ability to triage medical conditions as well as workflow is invaluable. The ease with which we multitask, apply critical thinking, and problem solve add great value to any organization.
Applied to the operating room specifically, these characteristics can improve efficiency. We can anticipate and prepare for the next step, even before a case starts, so that everything goes smoothly and quickly. Our ability to work at a fast pace while maintaining a high level of performance can speed up the team and make the most effective use of time.
Athletic trainers will find the high intensity and fast pace of the operating room similar to what they experience on the athletic field. However, handling this type of environment can prove very difficult… so it’s important to get an accurate idea of what it’s like.
In addition, we can provide continuity of care. When there is excellent continuity of care, the patient feels secure. They know that you care about them as a person, not just as a knee or shoulder. As part of the patient’s health care team, I have the opportunity to evaluate and treat them prior to surgery. In many cases, I aid in their diagnosis and treatment. More importantly, I develop a relationship with them.
Then, by assisting with the surgery and being present for the patient’s post-operative care, I am able to help them understand exactly what they are feeling, explain the details of their procedure, go over intra-operative findings, and answer any questions regarding post-operative rehabilitation or return to activity. If the patient feels soreness or pain, I can explain whether it is to be expected or not. Assisting in surgery allows me to better understand the patient’s symptoms and, therefore, better aid in their recovery and help them in rehab.
From a business standpoint, utilizing athletic trainers in the operating room can significantly increase revenue for a practice. Historically, the idea of having a physician’s assistant (PA) as a surgical assist has been appealing to many institutions due to their relatively high reimbursement-for-service charges. However, insurance reimbursements for assistants in surgery are declining. As a result, the financial benefit of having a PA in the operating room has been minimized, if not altogether negated, at least in orthopedics. Instead, by having an athletic trainer in the operating room rather than a PA, the PA can be moved back to the clinic to see patients.
Overall, this increases patient volume and revenue. For example, let’s assume for a moment that an athletic trainer in the physician practice setting is paid 50 percent less than a PA. So for a given eight-hour work day in the operating room, the athletic trainer is paid $200, and the PA is paid $400. If an athletic trainer surgical first assist was used in place of a PA, the PA would return to the clinic. If the average Level III office visit reimbursement is approximately $100 per patient, and a PA can see 15 billable patients in one day, this equates to a revenue increase of $1,700 per day ($1,500 for clinic visits + $200 saved by having an athletic trainer in the operating room).
This number does not include any downstream revenue or additional billable procedures, either. Although these figures are estimates, this financial projection can be used to predict the subsequent increase in number of patients seen per year, physical therapy referrals, injections, diagnostic imaging, and the number of surgeries scheduled.
RESPONSIBILITIES IN THE OR
Even though athletic trainers already possess many of the inherent skills and intangibles to prepare them for success in the operating room, there are obviously some elements of the job that will be new. As a surgical first assist, I have a number of responsibilities prior to beginning each case.
To start, proper patient positioning is critical in providing maximum exposure of the surgical site and protecting the patient from injuries. I also ensure that any special equipment, implants, or grafts are in the operating room. In addition, I review the patient’s chart notes, including their signs, symptoms, and treatment to date and examine their diagnostic imaging, such as X-rays and MRIs.
Once the patient has been positioned correctly, the nurse applies a sterile prep solution over the surgical site. After aseptic hand washing, I don my sterile gown and gloves and apply sterile drapes to the patient. This is another critical aspect of my job, as proper technique can help maximize visualization and ensure sterility, thereby reducing the risk of infection. I am responsible for setting up the sterile equipment, as well.
During the procedure, I assist with tissue retraction to aid in visibility. This can mean holding the body part or joint in a specific position or using surgical instruments to move skin, tendons, muscles, nerves, and bones so the surgeon can adequately see the structure of interest.
Occasionally, I also aid in arthroscopy, electrocautery, hemostasis, fracture reduction, and graft preparation. Arthroscopy requires a steady hand and patience to learn. The arthroscope is a small camera that is used to visualize the inside of a joint capsule. It is important that I have a firm understanding of anatomy to properly “drive” the arthroscope and allow the surgeon to see. Hemostasis involves stopping excessive blood loss and making sure that any blood or other fluid does not obstruct our view, and fracture reduction entails aligning two parts of a broken bone.
Besides these technical tasks, it is my job to ensure that procedures go smoothly and anticipate all of the surgeon’s needs before they arise. This means that I must have a thorough knowledge of the specific surgical techniques being used, think in the same manner as the surgeon, and stay on the same page as them, if not one step ahead. If I do all these things, it ensures the patient receives the best care possible.
When the procedure is finished, I assist in wound closure and application of sterile dressings, post-op splints, and braces. Once the patient leaves the operating room, I help to sterilize the area and prepare it for the next case.
ENTERING THE FIELD
How does an athletic trainer actually make it into the operating room? It starts with knowing exactly what you’re getting into. Watching surgeries can be fun and educational, but it may not prepare you to truly understand the role of the surgical first assist.
Instead, it may be more beneficial to arrange for shadowing and/or mentorship with an athletic trainer who is already in the operating room. These individuals can be quite difficult to find, so a good alternative is to shadow a PA or a certified surgical first assist. Athletic trainers will find the high intensity and fast pace of the operating room similar to what they experience on the athletic field. However, handling this type of environment while maintaining the ability to think clearly and quickly can prove very difficult, even for the most seasoned professional, so it’s important to get an accurate idea of what it’s like.
Once an athletic trainer has had experience observing and shadowing, the next step is getting advice on where to find jobs from another athletic trainer who currently works in the operating room. Reaching out to state, district, or national representatives can be a good way of getting in contact with someone.
The Commission on Accreditation of Athletic Training Education also provides a list of post-professional athletic training residencies and the contact information for their directors. These programs offer advanced training, with some focusing on the operating room. This can be a very useful list, as many athletic trainers working as surgical assists have passed through such residencies.
After acquiring the necessary background knowledge, it’s time to start thinking about appropriate certification. There are many different credentials that permit an athletic trainer to aid in surgery. These include SA-C (certified first assist), OTC (certified orthopedic technologist), OPA (orthopedic physician assistant), RNFA (registered nurse first assist), and PA-C (certified physician assistant). Depending on the institution and the athletic trainer’s background, an additional certification may not be necessary.
I obtained my certification as an OTC through the National Board for Certification of Orthopaedic Technologists. With two years of experience in the field of orthopedics and a written statement of endorsement from an orthopedist, an athletic trainer may apply for this certification. Upon passing the examination, the OTC credential is granted.
Keep in mind that the credential itself does not come with additional training, meaning athletic trainers will still need some form of education before they can assist in surgery. At some practices, the orthopedic surgeons and staff are willing to take on an athletic trainer and provide on-the-job instruction.
But if you can’t find one of those practices, athletic training residency programs can provide the opportunity to accrue experience under the direction of nurses and surgeons. While many athletic trainers in the operating room have completed residency programs — myself included — it is not a specific requirement.
Even with the appropriate credentials and instruction, athletic trainers may still face obstacles to getting into the operating room. For example, if you don’t have documentation of formal experience in this setting, administrators may not allow you to assist with surgeries. Other roadblocks can include state legislation, hospital regulations, and lack of awareness within the administration. It is critical to research these areas prior to applying for jobs so all parties can be assured that the patient is receiving the highest level of care.
If you are able to participate in surgeries as part of a post-professional athletic training residency program, it is important to keep a log of all cases in which you assisted. This information can be presented to any future employers as evidence of competence.
Despite some of the potential challenges of working in the operating room, my experiences in this setting have been nothing short of outstanding. I have been fortunate to work with excellent surgeons who take the time to teach. I enjoy being an integral part of the surgical team, the technical aspects of cases, the constant pressure to perform at a high level, being pushed to know and learn new things every day, and being a direct participant in the patient’s care. While the role can be stressful and push me well outside of my comfort zone, it is also incredibly rewarding. Each time I walk into the surgical suite, I focus on getting better. I try to understand why I am doing what I am doing and acknowledge how it might impact the patient.
Whether you feel the operating room is a career path for you or not, it is exciting that the profession is moving in this direction. Athletic trainers are expanding their scope of practice and beginning to integrate themselves into larger portions of the health care system. As health care continues to move toward lowering costs while improving the quality of care, I believe athletic trainers must put themselves in a position to be the solution. We are experts in the delivery of high-level care on a budget, and we must continue to keep ourselves informed about changes in the health care system so we can most effectively solve problems that may arise. With our training and skill sets, athletic trainers represent the model for the ideal health care professional of the future.
A popular method for athletic trainers to gain experience in the operating room is through a post-professional athletic training residency. At Orthopedic + Fracture Specialists in Portland, Ore., our residency is currently in its second year. A yearlong program, it focuses on evaluation, diagnosis, and treatment of musculoskeletal conditions.
In addition, the curriculum prepares the athletic training resident to assist in the operating room. After obtaining their orthopedic technologist certification, they undergo an orientation session and learn about sterile techniques and various equipment used in surgery.
As the resident develops skills and awareness, their responsibilities grow. Eventually, they have the opportunity to be in the operating room anywhere from one to five days during the week, acting under the tutelage of our surgical athletic trainers, surgeons, and other members of the surgical team at all times.
Upon completion of the residency, the athletic trainer is prepared to aid in the operating room. For instance, the first graduate of our residency program was recently hired as a full-time employee at Orthopedic + Fracture Specialists and currently assists in the operating room one or two days per week.
This article appeared in the April 2018 issue of Training & Conditioning.