Andrew, Orthopaedic Trauma PA
Andrew Lim is a Canadian Certified Physician Assistant who works in Orthopaedic Surgery at Sunnybrook Hospital alongside their department of 16 Orthopaedic Surgeons.
Prior to pursuing PA, Andrew studied Kinesiology of Guelph-Humber where he discovered his passion for Anatomy and Physiology. He gained admission to McMaster’s PA program in 2014, and secured his first and current position through Health Force Ontario’s Career Start Program.
Working in Orthopaedic Surgery
What is Orthopaedic Surgery?
Orthopaedic Surgery is not just “fixing bones” – its much more complex than that. In my role in Orthopaedic Trauma, there is a lot of medicine involved when looking after acute issues such as post-operative complications, admitting patients, ensuring medications are ordered and pre-op preparation to ensure patient is going into surgery with best chances possible. There’s a lot of intricacies to Orthopaedic Surgery that I didn’t appreciate until I started working in it.
Who I work with
At the Orthopaedic Surgery service I work with, there are 16 Orthopaedic Surgeons. Each have different specialties and areas of expertise including foot and ankle, Ortho Spine, sports medicine, arthroplasty and more. In particular, I work with a few specialists who focus on soft tissue injuries and shoulder.
The Clinical Areas I work in
What I got exposed to as a PA student (clinical clerk) was different than what I do now as a PA.
As a learner, and the first few introductory months into my PA position, it was important that I got exposure to all aspects of patient care in Orthopaedic Surgery (before, during and after surgery). This has allowed me to be able to explain to patients and their families. Where I spend time has transitioned as I gain more experience as a PA.
“PAs have opportunities to improve care in all areas of the Orthopaedic Service – and there might be some areas that have a higher need than others. In the case of the hospital I work at, a large teaching hospital in Toronto, it was very important to focus on filling in gaps in the inpatient care aspect. This freed up trainees, both residents and fellows, to focus on obtaining surgical skills in the operating room”
Day in the Life of an Orthopaedic Trauma PA
1. Inpatient Medicine
I begin my day by touching base with team leaders and charge nurse on each unit I work on. I’ll speak with patients and determine if there are any overnight concerns, or if there’s anything I can do to help facilitate care and eventual discharge plans.
I will ask nursing staff, “Is there anything I can help out with today?” but often more than not nursing staff will come to me and request, “This patient has X medicaiton ordered. I was wondering if you could clarify this, or if you can update this family”.
I speak with nursing staff, patients and their families, and the members of the allied health team to help facilitate care.
From a staff perspective, having a PA onboard makes a huge difference in terms of improving patient care, patient flow, help facilitate discharge in a timely manner.
From the patient perspective, I have received positive feedback as sometimes the residents or physicians are not able to spend as much time as they have other duties and responsibilities not just for that patient, but other patients as well. As a PA I’m able to step in and take a little bit more time to go over patient questions for surgery, and the patients receive more satisfaction in knowing what has been done, and gives them confidence that “this person is looking out for me, I’m in a good place, and I’m happy this individual can carry on with my care.”
2. On-Call Responsibilities
I also take consults on behalf of the Orthopaedic Surgery Service from the Emergency Department both through the outpatient Emergency setting as well as traumas that come into our hospital.
Trauma Team: Both settings have different approaches and patients that come in. Trauma has higher acuity injuries, with patients coming in through EMS or ORNGE (air ambulance and medical transport). These can include large, often multiple injuries. As part of the trauma team I help facilitate the ATLS protocol and ensure as part of the Orthopaedic Surgery group assist with assessing the patient, identifying Orthopaedic issues ASAP and temporizing them while treating patients immediately.
Outpatient Emergency: When doing consults for outpatient Emergency, I liason with Emergency Physicians. Conversations often go, “Is this issue something that needs to be addressed as inpatient in hospital? Does the patient need to be admitted? Or is this something that can be referred out.”. We collaborate with other services to figure out the best disposition plan for the patient. Anesthesiologists also help facilitate care in the ER, when it comes to reduction of shoulder, and wrist dislocations. Reduction of elbow dislocations may require more expertise.
Common Conditions I see on call:
As with any aging population, we have a lot of consultations for direct admissions for hip fractures, insufficiency fractures, and pubic rami fractures.
I will get called for ankle reductions that are not easily reduced in the ER, and will assist to provide extra help with the reduction.
We get a couple of weird and wonderful presentations as well. You go in expecting a straight-forward reduction for a shoulder dislocation, but I’ll come across inferior dislocations, or fracture-dislocations which are more complex. It’s neat to see the things we read about in textbooks present in the patient in front of you.
Another interesting presentation I saw recently was a patient who unfortunately had the entire foot rolled over by an 18-wheeler truck. It seemed like a fairly innocent injury on initial clinical exam with just a swollen foot. Once foot x-rays were done, it turned out the PIP joints from D1 to D5 on the right foot were all dislocated “one-over”. D1 was located where D2 was supposed to be, D2 was located where D3 was supposed to be, etc. I popped each toe back into position.
I do perform these reductions myself, with the assistance of the anesthiologist or trauma team leader who is facilitating the anesthetic. Often more than not I am backup for the 1st or 2nd year residents.
I’ve found that over the years, as I grow into my PA role and become more confident in my abilities, I do a lot more teaching with the first years and second years residents. They will come to me and say, “I’ve never done this reduction before, can you show me how?” or “Can you do this with me?” And it’s always been a great experience for both us.
3. Fracture Clinic and Consultation Clinic
If issues with acute care patients have been addressed from inpatient/ward management and on-call, I will head down to fracture clinic and see if there’s anything I can help out with. Oftentimes I’ll be asked to come into fracture clinic and consultation clinic, especially when the service is short residents to run the clinics. As long as it does not interfere with the rest of my duties in clinical practice.
The procedures I perform in fracture clinic include reductions that need to be re-done, especially after taking off the initial plaster splint that was applied in the ER. I assist the Orthopaedic technicians to set as well as apply casts and splints.
Teaching Opportunities as a PA in Ortho Trauma
When I first started working as a PA, I tried to learn as much as I could. I wasn’t doing a lot in terms of teaching initially. However once you start to increase your knowledge and gain more experience you build pattern recognition and identify these injuries much more quickly.
That’s when I started contributing more to teaching rounds, where I can take on cases and identify and work through the cases with the residents.
Over time, I’ve been taking that opportunity to lead some of these teaching sessions with residents, and this has been a way for me to give back what I received.
Integrating a PA into an Orthopaedic Surgery Department
The physicians who hired me had already envisioned how they wanted the PA to operate in their service. They identified the need for a PA to extend the role of the physician, particularly in areas of inpatient management and be an important piece for continuity of care for patients.
This meant having someone consistent to be able to carry on service, especially when residents switch blocks and get everyone up to speed.
I helped foster this vision, and I took it upon myself to help fill in the gaps as I saw them come up in the service.
Tracking the Impact of a PA to an Orthopaedic Surgery Service
Initially for my year-end performance review, I took it upon myself to track quantitative data to demonstrate the impact of having a PA on board. Unfortunately the data was difficult to sift through to pinpoint one factor, as there were so many variables. Initially I wanted to track % of patients who were discharged below their expected length of stay (comparing that data to having a PA vs not having a PA), however with limited sample it was underpowered.
Instead we do a lot of user feedback and surveys to try to collect as much information from others and their thoughts on my role as aPA, how they felt I was doing, and how much I was contribution to the division of Orthopaedics as a whole.
I began my PA job with a probation period where I learned as much as I can. I developed my skills by attending many clinics and making staff aware of my presence and role.
Initially nursing staff were not familiar with the PA role, as I was the first one they had encountered on the unit. I started working with them, speaking with nurses to get a sense of what they felt the need was for an advanced practice provider. I was able to build that trust over time.
Implementing Medical Directives in My Role
Once medical directives were established, it was a seamless transition into my current duties and roles as a PA.
Medical directives are advanced directives set in place, through an agreement of the implementer (PA) and the physician which outlines what I can or cannot do with or without supervision. This document includes delegated tasks that are agreed upon myself and the supervising physicians.
This is a document that does evolve over time. Oftentimes the directors will either expand or narrow down to help define the PA role.
Through medical directives I prescribe medications, exceptions being narcotics and controlled substances such as benzodiazepines. I always ensure that prescriptions are done to help the patient, and fall within the same scope of practice as my supervising physician.
Reflecting on my Practice as a PA
What I love about working in Orthopaedic Surgery
I enjoy trauma, specifically the multi-system traumas that come in because it adds to the complexity of the case. When an patient comes in with multiple injuries I’m trying to problem solve how I can help this patient as quickly as possible while also ensuring they have the best possible outcome.
This is also something that is characteristic of Orthopaedics as a specialty – its satisfying to be able to, for instance, have bone sticking out of skin, and you put it back and all of a sudden the pain is significantly improved and patient feels much better.
You’re always putting the patient in a better position than when they first come in.
Challenges of Working in Orthopaedic Surgery
The main challenges with working as a PA in Orthopaedic Surgery lies in scope of practice and role clarity. You want to work well with your physician colleagues, along with learners like residents and fellows. It can be tough if they have never worked with a PA before, and they’re not sure of what your scope is and how you can help facilitate patient care.
This is a skill that needs to be developed, educating around the PA role and build rapport/trust with your colleagues so that you can work in tandem with them. With every rotating block of residents that come in (rotating every 3 months), you can run into these challenges.
PA vs. Residents/Fellows: Similarities and Differences
There are a lot of similarities, especially because both are trained in the medical model and the mindset and approach to patient care is similar.
Once you start to develop a better sense of what a PA does, then you’ll be able to appreciate the differences, and not necessarily the limitations.
I think the surgeons I have worked with have become good at identifying what is something that the resident physician should be managing and what the PA should be managing.
The PA/MD Relationship: Attributes of an MD who work well with a PA
Communication between the PA and MD is the number one thing to keep in mind. Both should treat each other like colleagues. Although there may be an hierarchy with the supervising physicians, I have been fortunate that the physicians I work are very open to communicating with me. They often ask for my opinion on things, and they engage me as much as they can.
Having role clarity about what a PA can do helps to build rapport is a great way to grow and level of comfort. It is a relationship thats important to foster because once you lose that communication and trust piece, things can go awry and thats when things start getting missed and patient care becomes affected.
Updates in Orthopaedic Surgery: Staying up to date with CME and Ortho Conferences
The physician group I work with are supportive of continuing education for PAs. They have been facilitators in these courses, and advocate for me to enroll in these.
The conferences I pursue for my own personal education, and I have also been introduced to conferences I had never heard of but have been a great way to expand my skills and network with others in the Orthopaedics.
I recently attended the Orthopaedic Trauma Association (OTA) conference, and found it a phenomenal course to attend. A portion of the conference was dedicated to PAs and NPs which I found helpful.
The AO North America Basic Principles of Fracture Management where residents and PAs go through bootcamp-like course. You get up to speed and review current knowledge for approach to patient care when it comes to fractures.
