VOLUME 2 •
NUMBER 2 •
SPRING 2020 •
www.japacvs.org
APACVS J
Journal of The Association of PAs in Cardiothoracic and Vascular Surgery
Official Journal of The Association of Physician Assistants in Cardiothoracic and Vascular Surgery
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
JAPACVS
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Editor-in-Chief David J. Bunnell, MSHS, PA-C Frostburg State University, Hagerstown, MD Associate Editor Stafford Scott Balderson, BS, PA-C, FAPACVS Duke University Medical Center - Durham, NC Editor Emeritus Doug Condit, PA-C Montefiore Medical Center – New York, NY Editorial Board Anitha Chandrasekhar, BS, PA, FAPACVS Fortis Malar Hospital – Chennai, India Steven Harrington, MD, MBA Henry Ford Macomb – Clinton Township, MI Marcus Hoffman, MD, President EuroPAC Stuttgart, Germany Kimberly Mackey, MPAS, PA-C Children’s Healthcare of Atlanta JoAnn Montecalvo, MPAS, PA-C Winthrop University Hospital—Mineola, NY Aaron Morton, MMSc, PA-C, ATC, FAPACVS Emory University Medical Center – Atlanta, GA Mitesh Patel, MSHS, PA-C Baylor Scott and White – The Heart Hospital – Plano, TX David Tecchio, MPAS, MBA, PA-C Vassar Brothers Medical Center Poughkeepsie, NY Publisher David E. Lizotte, MS, PA-C, FAPACVS Executive Director APACVS – Simpsonville, KY
EDITORIAL MISSION: The JAPACVS is the official clinical journal of the Association of PAS in Cardiothoracic and Vascular Surgery. The mission of the JAPACVS is to improve Cardiac, Vascular and Thoracic Surgical and CVT Critical Care patient care by publishing the most innovative, timely, practice-proven educational information available for the physician assistant profession. PUBLISHED CONTENT IN THE JAPACVS: Statements and opinions expressed in the articles and communications herein are those of the authors and not necessarily those of the Publisher or the Association of PAS in Cardiothoracic and Vascular Surgery (APACVS). The Publisher and the APACVS disclaim any responsibility or liability for such material, including but not limited to any losses or other damage incurred by readers in reliance on such content. Neither Publisher nor APACVS verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damage incurred by readers in reliance on thereon. Neither Publisher nor APACVS guarantees, warrants, or endorses any product or service advertised in this publication, nor do they guaranty any claim made by the manufacturer of such product or service. SALES OFFICE APACVS 1435 Taylor Wood Rd. Simpsonville, KY 40067 Phone (502) 321-6155 admin@apacvs.org JAPACVS/Journal of the Association of PAs in Cardiothoracic and Vascular Surgery is published quarterly (4 issues per volume, one volume per year) by APACVS 1435 Taylor Wood Rd., Simpsonville, KY 40067. Volume 1, Number 1, Spring 2019. One year subscription rates: $40 in the United States and Possessions. Single copies (prepaid only): $10 in the United States
© 2020 APACVS, INC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including by photocopy, recording, or information storage and retrieval system, without permission in writing from the publisher. 2
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Editorial
Cardiothoracic and Vascular Surgery and CTV Critical Care Physician Assistants: A versatile workforce working to save lives during the novel coronavirus disease pandemic (Covid-19)
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David J. Bunnell, MSHS, PA-C – Editor-in-Chief
Experience Caring for Covid-19 Patients
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Thomas Banks, MHS, PA-C
Chaotic Corona Catastrophe
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Anitha Chandrasekhar PA, FAPACVS
A Texan in Oxford
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Michael E. Champion, DHSc, PA-C, DFAAPA, FAPACVS
APACVS is the only association representing Cardiac, Thoracic and Vascular Surgery and CTV Critical Care PAs. By PAs, For PAs!
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David J. Bunnell, MSHS, PA-C, Editor-in-Chief
Cardiothoracic and Vascular Surgery and CTV Critical Care Physician Assistants: A versatile workforce working to save lives during the novel coronavirus disease pandemic (Covid-19) Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning. Winston Churchill, 1942 In March, when the idea of what the world was about to face was new, I was shopping at my local big box store. I came across a sign limiting shoppers to two bags of rice. I texted a picture of it to my friend and our Executive Director David Lizotte. “Looks like we have entered the rice rationing stage of the pandemic.”, I texted to him. “We are only a step away from Victory Gardens.” I added referring to the gardens people grew to supplement food rations during the second World War. David, being an avid historian, immediately understood the reference and agreed. Yes, we have entered territory not experienced in the modern era but eerily familiar to those who have lived through previous generationally defining global events. For the short time I am privileged to be a steward of our Association as President I have a unique role in being able to speak for the Association. I had hoped to present a series of articles by members telling their story of their experiences during this time. I reached out to members globally and individually. The response says a lot about PA practice in the era of corporatized healthcare where talking points and messages are tightly crafted. One-byone people were glad to talk with someone who cared about their experience but were in no way comfortable sharing their story on the record. So, while PAs may not currently feel comfortable telling their story now, I am honored to be a voice for them. A time will come when our community will feel comfortable sharing their experiences. When that time 4
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
comes the Journal of the APACVS will be here to document and honor their service. Leadership The AAPA Leadership and Advocacy Summit was the last PA event I was able to attend before the big quarantine. I spoke with a PA leader who was engaged in healthcare system level preparation. I asked for perspective and was shown a phone calendar which was booked morning until night with high level meetings on how to prepare their system’s response in a major US city. Another PA who was well connected on a global level had access to conversations with providers who first battled the virus outside of the US. While many of us were still processing what we were learning through media sources, this clinician had a clearer view than most in our community what was about to come. There was an urgency to prepare. There was a sense that this was unlike anything we had ever seen before. A Lead PA serving a regional healthcare system described days which started with video calls to all APP leaders to communicate directions and to assimilate what was learned at the bedside to inform executive level decision making. Another PA in a large medical center was tasked with assessing healthcare system needs and reassigning their versatile PA community to areas of need. The medical center leadership was aware of the unique ability our community has to adapt and respond to system needs. During a time when we are hearing about PAs being furloughed from other types of practices, it was good to know there was a place who understood our experience, knowledge, and skills. A champion of the PA profession, Ann Davis, was often quoted as saying, “PAs are the undifferentiated stem cell of the healthcare system. We are able to become what is needed.” Critical Care Clinicians I first met PA Joann Montecalvo, JAPACVS Editorial Board Member and former Executive Committee member, sixteen years ago when I was a new PA and she was sent to proctor my time as an endoscopic vein harvest operator. I asked her for advice on some area of practice she thought a new PA should focus. Without hesitation she replied, “Critical Care”. PA Montecalvo was exactly right. PAs in our specialties are at home in critical care units and know their way around ventilators during a time when these attributes are a vital need. Some work disappeared while other work exploded. One PA candidly told me that in a way it was good that there was no “B.S.”. Every consult was something real. Elective work had vanished but there was an urgency to the work which existed. I saw a picture of a large common area in a hospital which was transformed into a triage and screening area. It had the look and feel of a military operation. I heard from a PA who has unique perspective on the history of our specialty who described a scene where the hospital was managing hundreds of patients who required mechanical ventilation. PAs were falling ill. They had cared for colleagues who had died. This was apocalyptic. There are PAs who have a long history caring for people needing extracorporeal membrane oxygenation (ECMO) who were applying this tool for patients struggling with the virus. Each 5
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
patient was fighting death and for the first time what was attacking the patient also threatened the providers. Self-sacrifice I am an active participant in social media. I have seen friends who have volunteered to go from their area of relative safety to areas experiencing unmitigated disaster. I have heard how what they have seen has affected them. How this will take time to process. I saw another friend who has self-isolated from family for about six weeks and counting to continue to provide care to hospitalized patients without exposing vulnerable loved ones to the virus. I am aware of a PA unable to be near or provide support for a close family member undergoing major surgery when that PA would have naturally been the source of support during any other time. Peace of mind and recovery PAs are experiencing stress and vulnerability which are more commonly associated with the battlefield than the hospital. This stress and vulnerability comes with a psychological cost. We must face the effect this has on individuals in our community. We are not accustomed to accepting help. We will help any stranger with any need at a moment's notice and, at this time, put our own health at risk. However, we are not good at asking for or accepting help for ourselves. We need to change this.
JAPACVS publishes invited commentary and letters to the editor in response to published articles in which the authors are given the opportunity to respond
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Experience Caring for Covid-19 Patients Thomas Banks, MHS, PA-C It has been 15 years since I last stepped into an ICU. I have been a PA for over 35 years, my first 20 plus years were spent mostly doing cardiac surgery. At the peak of my clinical career, I had an opportunity to leave the clinical world and transition to the dark side into industry. Even though it was not my primary responsibility anymore, I was in the CVOR on a weekly basis proctoring cases to the cardiac OR team. In the last 2 years, I have been proctoring EVH cases with Saphena. Recently I had the opportunity with the help of an old friend, to get a PA position at Stony Brook University as a per diem PA in the CVOR. I had done about a dozen Cardiac cases when the COVID 19 virus struck us in March. I was asked if I would be available to cover COVID units. It was with extreme trepidation, but I knew it was the right thing to do. I wanted to be on the “front lines” with my colleagues fighting the fight. My first round I was deployed to a step-down unit to cover patients that were COVID positive but not on a ventilator. My first “Team” was a mix of two Attending Medicine physicians, a couple of local private Pulmonologists, several PGY2s, an Ortho PA, a Cardiac NP, and me. We all came from different specialties and backgrounds; they had put us together with no rhyme or reason. We were getting COVID patients from the ED in extreme respiratory distress. We watched them closely until the point where we had no other options but to intubate them. We were also getting patients that were recently extubated and downgraded to our unit from the ICU. A large percentage of these patients relapsed and got reintubated and transferred back to the ICU. The process of intubating the patients we called a” RRT - Rapid Response Team” which consist of a team of Anesthesiologists and a team of nurses in very protective PPEs that would stabilize the patients. In one day, we had done this process about 6 times in a 12-hour shift. The team had become so sufficient that we developed a written protocol on all the steps to be performed to stabilize the newly intubated patient. I was completely lost and spinning in circles but determined to be helpful to the team. Remember I never used EMR or the “Power chart” used to do orders and progress notes. In addition, my wife was at home who tested negative on Friday night but now developed symptoms of COVID the following Monday night on the 4 th day of my deployment. It was like riding a bike, I still had the medical instincts and the skills to place invasive lines. I knew which patient was going to “crash and burn” and would line the patient up with a CVP line, A-line, foley, and an NGT after intubation. I did not know EMR, but I became part of the team by doing all the lines needed for these sick patients. My team was renamed to “Team Delta” and we had developed an “Intubation protocol”, a COVID Hypoxia pathway, and a daily COVID checklist all in one week. It was all hands-on deck, looking like a war zone. My second deployment was to 11 South which had a nickname of “Little Wuhan” by the medical staff. It was a converted ICU floor to a COVID intubated ICU unit. We had 13 patients, eleven were intubated on multiple drips to keep the patients sedated and hemodynamically stable. My team this time was an Attending Trauma Surgeon, a PGY3, a PGY1, and me during the day and then two senior residents covering the unit at night. I felt better about my role with the recent week behind me and had learned enough about using the Power chart EMR to do orders, write a note, and complete a procedure note. These were the sickest of patients I have ever seen in my career. They looked like patients who had ARDS but were in septic shock with multiple organ failure. We made daily rounds which took hours of painful details on each patient with multiple
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interruptions to attend a patient who needed immediate care. I continued my role by changing lines that were needed change. I learned a new line that was not around 15 years ago called a PICC line. It was like the old days, “see one, do one, teach one”. I loved using ultrasound again that we had used back in the days of doing EVH to identify the saphenous vein. Stony Brook University has approximately 600 beds at the peak of the virus. We had over 300 patients who had tested positive for the COVID 19 virus. At the height of the virus, there were over 100 patients on a ventilator. Currently in the first week of May, they are down to half of the number of positive COVID 19 patients and down to about 60 patients on the ventilator. They are starting to trach some of the long-term patients, but it has been challenging due to the additional PPE equipment used in the OR. I did another week in the SICU taking care of non-COVID patients with multiple issues. We do not have all the answers and are trying multiple treatments fighting this virus. In speaking to my friends and colleagues in the “Hot Zone” from Columbia Presbyterian, Mt. Sinai, Maimonides, and Northwell in New York City, I am extremely proud of the PA profession. We have all step up to the plate, filled the empty voids, took on multiple challenges, dealt with fear, learn to adapt, and worked together to accomplished amazing things this last couple of months. I am so proud to be part of this profession and now I am pursuing a role back into clinical world hopefully. There is no better time to be part of the PA profession then now! God bless and stay safe.
Keep up With APACVS and Specialty News Every Friday. http:// www.multibriefs.com/ briefs/APACVS/
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Chaotic Corona Catastrophe Anitha Chandrasekhar PA, FAPACVS
“Human history is a race between education and catastrophe” – H.G. Wells.
The modern and sophisticated times have not only made life fast paced, but frenetic too. It had become impossible to slow-down life. Slow-down to catch a breath, to admire life and cherish the beauty around. Slow-down is what it has done by rapidly proliferating! The unprecedented
Covid-19 outbreak was unsettling and unpleasant to read in newspapers and hear in news channels a month back. But soon enough, it has just spread like wildfire across the globe and become surreal but real. ‘Social distancing’ seems to be the key word and superfluous purchase of sanitizers/ hand rubs and face masks has been inevitable. With 1.3 billion population in India, this spells doomsday. The pro-active Government enforced a one-day nationwide curfew and then was forced to summon a lockdown for 21 days to prevent the country from moving into stage 3 pandemic. The entire country has come to a halt. Only essential services remain open and everything else is shut-down and barricaded including schools, colleges, institutions, places of worship, malls, shops, parks, beaches and what not. Only groceries and vegetable/fruit
markets are open in the wee hours of the morning albeit with some empty shelves thanks to panic buying! Most offices have adopted Work-from-home policies and strict policing has made sure the roads are desolate and deserted. Family members cling to each other to discover strength and solace - probably not by choice but by force! Tragedy has struck across continents with the numbers of Covid-positive increasing exponentially and death surging drastically every single day. The disease is devastating. Elective cardiac surgeries have been stopped and we are catering to only emergency surgeries. Being a tertiary care private hospital, we are yet to start admitting Covid patients. We could be doing it in the near future once the government hospitals have exhausted their beds and it could spill over. There are separate Covid wards and ICUs in the hospital to be managed by the medical team and as a cardiac surgery super-specialty team- our role probably would be limited to initiating ECMOs as the need may be. We have been safe so far, but as Clinicians, we can never be sure of escaping from the pandemic. There is a constant fear and anxiety of exposure to the virulent virus. Essential service workers are terrified to go to work and healthcare professionals are petrified to go home to their families! Cardiac Surgery has always been enigmatic and unpredictable. In such times of global pandemonium, to perform a surgery on a Covid-positive patient puts a huge risk on every 11
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Member of the team. Lo and behold! We had to operate on a 3-month-old baby as an emergency
case with special permissions, who had a hole in the heart and congenital anomaly leading to gross cardiac failure and high lung pressures. As the baby was not febrile and we cannot test every surgical patient for Covid-19, it’s hospital policy to treat all surgical patients as Covid positive and take appropriate precautions with personal protective gear. We had to don 2-3 layers of each from top to bottom. And it was such an ordeal- so uncomfortable and asphyxiating to stand with the gear for close to 6 hours in surgery. My heart goes out to those who have to wear this for 16-18 hours straight in the ICUs taking care of Covid patients on ventilators. If we relax a bit on the gear, we are likely to put ourselves and our families at risk. If we don’t, it takes humongous tolerance to put self through such discomfort and concentrate on
the intricacies of surgery. It’s a double-edged sword! On the other hand, imagine those who can’t get any of these… Supplies of PPE are scarce across the world. Medical professionals have tested positive despite all of this! It certainly is a Damocles’ sword hanging dangerously over the head of every healthcare personnel, who is relentlessly dedicated to saving lives. As I drive home after settling the baby, my car zooming past the empty roads in one-fourth of the time that it usually takes, I reflect on the unhurried pace of life – with almost everything at a standstill. Is it nature’s way of slowing down? Did we, human beings invite it by fast tracking everything around us? Did Planet earth need a break to breathe some fresh air without pollution from the racing vehicles? Did we need a break from the fast-paced life to reflect on the precariousness and preciousness of life? These questions, rattling my mind end of the day, can never be answered! All we can do is- Hold on, Be brave, Have faith and believe that we are all in this together and we will come out unscathed with more wisdom.
Cardiac Anesthesia team geared up for receiving the patient in the operation room
Anitha Chandrasekhar, clad in multiple layers of PPE, first-assisting a pediatric cardiac surgery 12
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A Texan in Oxford Michael E. Champion, DHSc, PA-C, DFAAPA, FAPACVS Approximately two years ago, I was looking for another educational challenge that would be pertinent to my lifelong practice in surgery only to find a very interesting program at the University of Oxford in Oxford, England. Initially, when I reviewed the curriculum information and entrance requirements which stated this program, the Masters in surgical science and practice program, was only open to surgeons. Upon reading the entrance requirements closer my second and third review, suggested that “interesting applicants from other fields may be considered”. Of course, that statement piqued my interest, so I decided to send in my $75 application fee along with an abbreviated application with my CV. A few months passed before I heard anything from Oxford. The initial email from them was requesting a time that would be convenient for me to be interviewed by the program director. Certainly, I immediately replied with some suggested times since Oxford, England is six hours ahead of San Antonio time. At that point, I was afforded in opportunity to discuss my interests in their master’s program with the program director and the assistant program director, both surgeons by training and experience. Two questions stood out my mind and maybe feel I was not going to be a good candidate for their program. First, question of my age came up since most of their students are in their late 20s early 30s. I related to them that I’d been a surgical PA coming up on 30 years at that time and would be able to provide a good reference point to the young surgeons on how best to utilize the PA and their surgical practice. The second question was regarding my not being a surgeon. Certainly, this program is designed for young surgeons in training and an older American PA was certainly not in their thoughts when they created this program. Again, I referred to my lengthy experience a surgical PA and since the United Kingdom is a relatively young PA population, my experiences may help them with their own training in future practice as surgeons. In any event, the phone interview went well but I was convinced at that point that my future in their program was in doubt. Remarkably, about two weeks later I received an email from the faculty office and was pleasantly surprised that they had accepted me as a student. The question is at that point, what do you do now? You just been accepted to Oxford University. It would be foolish to turn down such an opportunity as that. Now the fun begins. This program at Oxford is not conducted online as a primary source of education. There are six modules you must complete over a 1 to 3-year time period. Each module is one week in length starting early on Monday and ending late Friday afternoon, so this requires your physical presence for six modules. Each module is only offered once per year, so timing can be tricky depending on the time you choose to spend pursuing this degree. I decided to take all six modules within one year, which I did successfully. This required me utilizing all my vacation time from October through June. Once you are finished with the six modules you are then free to do your dissertation which starts in September and runs to the next September. So financially and logistically, as program presents quite the challenge. I must say that it has been a very rewarding period since your studying with some very talented young surgeons, some who are still in training as “registrars” which translates to our resident surgeon. My classmates are all surgeons from a variety of locations including Germany, Australia, South Africa,
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Brazil and remarkably only one is from the United Kingdom. Several are orthopedic surgeons, one is a neurosurgeon, two cardiac surgeons, several OB/GYN’s as well as several ENT surgeons. Some have heard of PAs because some of them have trained in the US and Canada are very familiar with them. The others were a bit suspicious of PAs because they thought that we were “cheap doctors” designed to take their jobs. I believe during my six modules I helped allay those fears may educate them a bit more what a PA can do for them. For those of you interested, the following is the Oxford program website. I certainly recommend it if you are interested in being the second or third PA to be accepted. https://www.ox.ac.uk/admissions/graduate/courses/msc-surgical-science-and-practice?wssl=1 The courses would include: Becoming a Clinical Educator Human Factors, Teamwork and Communication Leadership and Management in Healthcare Quality Improvement Science and Systems Analysis Healthcare Innovation and Technology Evidence-Based Surgery Again, this is a school-based program that requires your physical presence in one-week increments. Much of your work will be done on your return home and submitted for grading, which is an interesting process. Grading is done by “readers” who read each 4,000-word essay. There is no objective grading that we are used to here in the United States. The final degree for this program is a masters, they do offer a post-graduate diploma if you decide not to do the dissertation. That requires completing the 6 courses, but nothing afterwards. In any event, I would like to ask all of you for a favor. I’m currently working on my dissertation, “The Physician Assistant and Surgical Curriculum Evolution”, so I would ask you to answer the following and send them back to me at my email address, surgpa@yahoo.com. You input will be tallied and reported in my dissertation which is due in September, so your info is very important. The goal of my dissertation will be to document the historical curriculum evolution of the American PA in terms of educational attainment at the undergraduate to graduate-level along with the difficulties of legislation within 50 States. The emphasis will be on surgical development and the creation of postgraduate surgical “residencies” as opposed to earlier on-the-job training (OJT) modalities. Describe your current/past surgical PA experience How has the surgical PA concept progressed during your career? Describe your professional leadership roles as a PA What have been your educational experiences been as a surgical PA? How do you envision the future of the surgical PA? Please add any comments you may find pertinent
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Thank you for helping me complete my dissertation and I look forward to hearing from each of you on how your journey in the surgical PA has done thus far. Michael Champion surgpa@yahoo.com
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