Working as a PA in Transplant Medicine

My name is Cole and I work as a physician assistant for the multi-organ transplantation program at the university health network in Toronto. I specifically work with the liver transplant team and I’ve been working there since October of 2018.

My Background before PA School

I lived in my Undergrad at Western university there I worked with the campus paramedic team, the student emergency response team as an emergency medical responder. From there I got a job with a Canadian coast guard where I was working up on Georgian Bay doing search and rescue. And then from there I got into the UOFT PA program and I was able to complete it and get the job with University Health network (UHN).

Besides the student emergency response team, ended up taking a lot of my time and I had a part time job as well as a hockey referee, which was a very challenging job. And it was also a lot of fun was good exercise. And then working for the Coast Guard it improves my ability as a responder. So when I came back to work with the student emergency response team, I had a lot of my clinical skills were a lot better for emergency response.

How I decided to Pursue the PA Profession

I actually had never heard of the physician assistant profession until I was talking with a great family friend of mine. So she’s an obstetrician in Oregon and she was telling me about how if she can do it all over again, she’d want to be a physician assistant. So that kind of lit the light bulb in my head and I decided to do some research on it.

And to me it seemed like the ideal profession where you didn’t have to commit so many years towards medical school, you can still practice medicine and have that clinical environment, and really have that meaningful patient interaction. And it’s a challenging the profession that allows you to really, I guess personalize yourself to what you want to do.

Contemplating Careers other than a PA

So being a kinesiology student at Western, I think most kinesiology students think towards physiotherapy. So I guess initially started out with Undergrad, that was the first thing I thought about. But then as an emergency medical responder, and working with the coast guard, I started to think along the lines of a career as a paramedic and also joining the army route.

But then when I came across the physician assistant profession, and it really to me stood out. I decided it was something I wanted to do.

My Process for Applying to Canadian PA Programs

So I applied to all the Canadian programs and I was prepared to apply to the American programs if I were, if I didn’t get in, the Manitoba Program, I don’t know if they accept too many other province, applicants that were accepted.

And then the UOFT program to me stood out, first off because I’m from Toronto but I really liked how they delivered their curriculum.

Through the distance studies approach you do a portion of your experience, through online lectures. Then a lot of your clinical experience, you do in the community. So I really enjoyed that part. And University of Toronto being one of the top universities in the worlds, it seemed like a no brainer.

My favourite rotations in second year PA School

In second year, I really really enjoyed pediatrics. I had a phenomenal preceptor. And I think that really made me develop confidence as a clinician. Working in internal medicine, doing the, the word medicine I think helped me establish an approach towards these complex patients.

But I’d probably have to say my favorites, rotation would be up into Thunder Bay.

I did a placement in the intensive care unit there and that was pretty, it was a pretty phenomenal experience. They have a world class ICU up there. And it actually helped me prepare for my position, with the multi-organ transplant program because a lot of the work I do is actually in the ICU.

And in Thunder Bay there was, I dealt with a lot of fulminant liver failures, which helps me out with working in liver transplantation and working with the pre liver transplant patients. So, I owe a lot to the thunder bay ICU and that rotation.

Keeping on top of studies during 2nd year PA Clinical Rotations

I found, I think one of the things that you do in these kinds of clinical rotations is you’re trying to read around everything. And so when you’re actually working, you’re everything you encounter, you want to kind of read up, read up on, so you can kind of have something to refer to.

If you have a patient with an interesting presentation, you read around that and that’s something that you can refer to in the future and then after the rotations, when you go home, I think it’s great to also kind of have a balance.

I think, for instance, when I was in Thunder Bay, I just trying to explore the nature around there, but also set aside some time to prepare for the rotation. So you know what to encounter and you know how to be ready for certain procedures, and what you need to do.

Preparing for the North-South Swap of PA Consortium

I think that was for me, that was actually one of the biggest draws to the program. So I found that the north swap positions or the north swap rotations gave me the most clinical experience. For instance, in the ICU, it was me, the residence, at nights we would essentially run the ICU. But then like if we would be first assist in the ER.

When I was working in Sudbury, I was doing a psychiatry up at Thunder Bay. So you to be in these different environments where they first off don’t have a lot of healthcare providers, provides a lot of opportunity for students, whereas somewhere, I guess in southern Ontario like Toronto, it’s hard to get those opportunities because there’s just so many, many students and so many learners around. So I found the northern rotations were just excellent.

My Experience in the Job Hunt after PA Graduation

So I actually, I was lucky. I ended up getting the job, before the actual career start Grant came out.

But I was pretty involved in discussions with a lot of my classmates when the actual PA career start grant came out. And there was, so, there was some 50 to 55 to 60 jobs that came out. And I don’t regret accepting the job before it came out because I’m really satisfied with my position. But from my understanding, there were almost too many jobs for the amount of PA graduates that had graduated that year.

And the PA students really had that they’re choosing for what wanted to do.

Transplant Medicine

So in transplant there’s the medical side and then there’s the surgical side. So the medical side specifically, I work with a liver transplant mainly during the days. We manage all of the patients before their transplant, and then after their transplant and then even further after their transplant when they come back for any complications that we think could be related to their immunosuppression or their transplant.

“The medicine is very complex just due to the fact that a lot of these patients are immunosuppressed and have previously had an organ failure. There’s a lot of complications that can arise with that.”

So working parts of these interdisciplinary teams, it’s really phenomenal to see how everyone comes together and manage these complex patients. And it’s an every day I learned so much just about different presentations and some, there’s always some rare presentations that will appear and then you can get a read up on it. It’s, it’s really exciting to be a part of.

The multi-organ transplantation program is more than just that – there’s the heart, the lungs, the liver, the kidneys, there’s the kidney, pancreas, transplants, and then there’s small bowel. So there’s about six, but two of them aren’t as common.

With my position, I will work with the liver transplant team for two weeks and then I’ll be working call and weekends, covering all of the organ groups. So because of that, we have to have a thorough understanding of how to manage patients from any of these organ groups. Be it in an emergency setting where the patients are starting to not look very good, or require management of  blood sugar and blood pressures, etc.

What Patients can Expect from Transplant Service

With liver transplant from the time they arrive, typically they’re what we call it pre limbers. So there were individuals that either have acute or chronic liver failure. So we start the morning process where, we essentially evaluate them as candidates for liver transplant. And then once they’ve been approved for liver transplant by the board that discusses the MS candidates for liver transplants.

Then they stay until an organ becomes available either by the stoner or by a live donor. And then the surgical team, when one becomes available, we’ll offer the organ to that individual. And then so then we start the process of ordering all the medications for them before transplant. They have to be at a very high dose steroids. And then after the transplant, we manage their immunosuppression in the ICU and then when they come to us, then we managed them entirely as a patients.

When Patients are Discharged from the Transplant Service

Discharge depends on the patient and, and also the condition they were in beforehand.

For someone who walks into the hospital and has had more chronic liver failure, and is younger and healthier. They can be out of the hospital in a bit less than two weeks.

But for individuals that, for instance are in liver failure and have renal syndrome. So they also have problems with their kidneys. They are immunosuppressed, so they have problems with infections. And that can complicate their stay and I mean they can stay in hospital for months. So there is kind of this range it’s really specific to the patient’s case.

Complications we may come across in Transplant Medicine

Renal syndrome is going to be something that’s very common. And then mainly there’s a lot of infectious processes that may happen after a transplant.

We have an infectious disease transplant service that we consult routinely. But because of the immune suppression that every patient, aside from pre livers are going to be on, that predisposes them to some pretty serious infections. So we have to be very, very prudent with our approach to them.

We see a lot of diabetic problems as well and just mainly due to the steroids. And also some of the immunosuppression medications can throw a patient’s sugar’s out of whack.

Those are kind of the main things we see. But there’s always some random other things we see.

Working as a PA in Transplant Medicine

So I started working with liver transplants at the start of November 2018. Before that I had six weeks of orientation with all of the different organ groups. And I work with liver transplants, with their inpatient service for two weeks. Every two weeks. So every other two weeks I’m doing night and weekend calls.

My Orientation to the Transplant Service

So I started off and I spent a week with each organ group. So I did kidney firsts. And I really spent a lot of time just trying to figure out how each service works and just the logistics behind it because you’d be surprised that’s one of the most  difficult things to figure out just how they do their medicine. But then, there’s also the medical side of things that you need to figure out for every group. And from kidney I went to lung transplant and that UHN lung transplant team is one of the world leaders. So that was pretty special to be a part of and see kind of the transformation that they are able to achieve with lung transplant. And then a heart transplant after, there’s not as many heart transplant patients, but it was still very, very interesting. And I worked with some very, very smart people and then also liver transplant.

I spent a lot of time with liver transplant just because that was going to be the team that I was going to be with. And I mean I learned a lot in that in that orientation week, but even to this day of learning, learning more, just not only about the medicine around it, but also the logistics and kind of how, how things kind of work in the realm of liver transplant.

A Typical Week in Transplant Medicine

So the way my schedule works is, it’s a four week rotation. Where I do two weeks with liver transplant and that’s working 10 to 6 and then I get the weekend off, but then I do the nights and weekend calls, where I do Monday, Tuesday from 7 to 7 and work at the weekend from 2 to midnight.

And then next Wednesday, Thursday, Friday 7 to 7, and then I restart the two weeks with liver. So to me, I actually really do appreciate the rotation because it kind of changes things up. And I see, for instance, when I am on call, I’ll get to see patients from all of the organ groups as well. That’s where some of the more exciting medicine comes. Code blues will happen. More kind of serious of events will happen at night and they always happen at night for some reason.

And then, but then getting back to the liver team, it’s nice to kind of be part of a team working. We have three nurse practitioners on our team that have been super helpful with me kind of entering the team. And then we have fellows and then our staff position every week.

A Typical Day in Transplant Medicine

The liver transplant team gets to the hospital at around 7:00 AM and they do their round on all the patients. At 7, they finish their rounds by the time I get their pen and we meet as a team and they basically give a quick run through as to what happened over night, if there were any changes.

And from there as a team, we essentially map out our day what we need to do for our patients. From there we round on our patients at night, so I typically will have 8 to 10 inpatient liver transplant patients on mine roster, not all I’ll manage and then we’ll meet back up at 3. And then at 3 we’ll do our whole team round again. And then from there we’ll just kind of clean up anything we need to do before I go home at 10 or before I go home at 6.

My Overnight Shifts 7pm to 7 am

So I get there, I’ll get there a bit early and kind of just review the patients that we have in the acute care units because those are the patients that are typically going to be more active over night. They’re on continuous monitoring and they, they are in the acute care unit because they do have a bit more of a concern with their stability. So I round on those patients first and just make sure I’m familiar with them. In case anything does come up, and then I’ll kind of round on every floor. Right now we have about four floors that have patients on them. So I’ll just go check in with the nurses, make sure everything is all right, and then at this time I’m carrying a pager, so by then, the pager is going off –  managing blood sugars, Managing high blood pressure’s low blood pressures, ordering different medications, going to assess patients. It’s every, every shift. It’s always something new. So it’s always kind of exciting and it keeps you on your toes.

Consults to the Transplant Service

So we’ll do consults, for instance if there’s say, can you transplant patient that’s all of a sudden, kind of needs assessment for liver transplant. We’ll kind of do consults in that regard as well as if any, any transplant patient comes to the emergency at TGH, they’ll give us a call, we’ll completely assessed them in emergency. So at nights, typically the fellow will be down in emergency taking the new consults. But if I’m having the quiet night though, generally send me a message and asked me to get down there to give him some help. Cause typically we have a lot of patients coming in through the ER. But we don’t, I don’t really work in the note patient setting. No. Mainly inpatient stuff.

What I enjoy about transplant medicine

Well for me the most amazing thing is really the transformation that you see in these patients, specifically in liver transplant. And we have these patients that will come into hospital and they really don’t look that great.

“They’re bleeding, they’re swollen they are jaudiced, their stomach is distended and if we’re able to get them a liver transplant, all of these things change and they all of a sudden you get to see  this amazing transformation. So it’s pretty amazing to witness this change and also help facilitate it.”

That’s what been one of the greatest things about being in transplants and then also to work at UHN and seeing all of the work they’re doing and all the research that they’re coming out with, I’m very fortunate for that.

Challenges in Transplant Medicine

Well, these patients are quite complex. So I think for me, just as a recent graduate and just starting out, with the job, the biggest challenge I’ve had is really making sure I’m a pro, I’m managing the patient as a whole. So I’m making sure I’m not missing anything on patients and just being overly prudent, and if they’re really managing these complex patients. So really just developing a kind of step-wise approach to make sure I’m kind of covering all my bases for these patients has kind of been the challenge. But I think right now I’m starting to get a lot more comfortable and more confident

How I often I see the Patients and Physicians in Transplant Medicine

So I will see the physician at 10:00 AM, and I start with liver transplant that would be the staff physician. But typically the physician I work with most often is a fellow on the service and the fellow and I, we’re always in contact and whether it be like David did and they’ll contact me if we need to do a paracentesis and right now they’re kind of in the process of establishing a medical directives to just do Paracentesis and then other things. So with him in the relationship I’m able to spend a lot of time kind of working on my own, which is nice. Getting that autonomy, but then also working closely with the fellow physicians. They come from around the world. They have a lot to teach. So it’s been awesome.

Interacting with Nurses and the Allied Health Team on the Floor

So when I’m working with the liver transplant team, we do have the three nurse practitioners. So, we work together as a team. We all have our region rosters. They’ve been nothing but helpful for me, kind of showing me the ropes in liver transplant. On the floors the nurses will page me if they have any concerns about their patients and I can come in, assess them or if it’s just kind of nothing too big and I’ll just kind of give them a hand. And then for a lot of these patients, because these surgeries are so significant. I’m working with a physio therapy, occupational therapy, speech language pathology. Just to ensure that these patients are completely managed from all aspects of patient care.

Referring Patients to Transplant

So for individuals where their livers are looking like they’re not going to get better. Typically we’ll get the referrals and we do have the pre liver assessment clinic, where some staff physician and fellows will assess them. From there they can afford it or they can just be admitted to liver transplant as pre liver for assessment, and then afterwards, once they’ve been transplanted, anytime they come to Toronto General and they will be admitted with us regardless of what it is. So they can come for a heart related problem. But because we’re on liver transplant, they’ll stay with liver transplant and then cardiology will just follow them. So we see a lot, that’s why we see such a range of patients because some of these patients are so far out from their liver transplants. So you get to see a lot of different things.

Adding a PA to a Transplant Service

So I was the fourth PA they added, so I think with the first three pas, they really saw the benefits of PAs and kind of how they’re able to work, on an inpatient service. They’re able to roster with their own patients and work closely with their supervising physician to ensure that these patients are getting the best care they can get. And just with the multi organ transplantation group, because it’s growing so quickly and we’re doing more and more transplants, that just means we’re getting more patients and that’s exactly where PAs fit in. We’re able to help produce the patient load for some of the physicians on the service and it works out great.

Advice for PA Students Interested in Transplant Medicine

I think the best thing to do would be, I think the ICU rotation I had was instrumental and kind of just providing the groundwork for me to kind of build knowledge on complex medicine. So I think the ICU rotation I’d recommend doing an ICU rotation if you want to get into transplant. Having an understanding of managing general surgery, ward patients is also important. And I was fortunate to have, a great preceptor and separate as well for, that. And really just developing an understanding on how to approach a patient, I think is the most important. So as long as you do a lot of your studying during those rotations, I think that’ll set you up.

Toronto Notes was really helpful. And I relied a lot on Up-to Date when I was a student. Just like I said when I was reading around cases. Up to Date goes so far in depth and then almost provides you too much information. But it was very helpful.