A Day in the Life

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Jeff Miller, PA-C

The author works at Tennessee Orthopedic, Lebanon, Tenn. He has indicated no relationships to disclose relating to the content of this article.

I was 42 years old before I returned to college to become a physician assistant. All the years—more than 20—that I worked as a scrub tech, I always wanted to be more involved in the care of orthopedic patients, and I finally went to school in 1995 to become a surgical first assistant. That helped me to understand the surgical side of orthopedics—but not the patient care side. Finally, an orthopedic surgeon I worked with suggested that being a PA would allow me to use my skills at their highest levels, and I decided to venture back to school.

As it turned out, my years as an orthopedic scrub tech and first assistant proved valuable when I started interviewing for PA positions in orthopedics practices. Prospective employers saw that they would not have to train me for the surgical side of orthopedics and that I would become a productive member of the team much faster. I was fortunate to find an ideal position with Tennessee Orthopedic in Lebanon, Tennessee. Our group contains three orthopedic surgeons, one hand surgeon, three PAs, and one NP. I work for one of the orthopedic surgeons, Dr. Douglas Freels.

7 AM

My week starts when I take a short, 10-minute drive down back roads from my horse farm to the hospital to round on surgical patients. On this day we have two inpatients. The first is typical, a 64-year-old farmer with severe, bone-on-bone osteoarthritis (OA) of both the medial and lateral compartments of each knee. He had bilateral total knee arthroplasty and was in the orthopedic unit for 4 days and walking with a walker on discharge. The second patient is not typical, in that he is 20 years old and required total hip arthroplasty. He had a slipped capital femoral epiphysis and a failed pinning that required a derotational osteotomy of the hip. This procedure had failed and had progressed to a collapsed femoral head caused by avascular necrosis. The patient had been unable to work because of pain and was using crutches full time, but after surgery he was discharged after 3 days walking with a cane. Both patients, after PT, were able to return to full activities within 3 months.

When making inpatient rounds, I like to spend some time just talking to the patients. So many clinicians talk and examine at the same time. The patient has to be thinking, “Is he really listening to me?” Conversation allows me to assess mental status, pain levels, and progress with PT. Although much of this information is readily available from the chart and staff, talking to the patient tells me so much more than the written reports. For instance, when patients tell me that they have not walked by the afternoon of the first postoperative day because of pain, I have to determine if their pain medication is inappropriate or if a fear of putting weight on the extremity is keeping them in bed. I find that time spent listening is time spent wisely because I can usually put my finger on problems fairly quickly.

I continue my assessment by examining the incision and dressings, and I finish with a neurologic and vascular check of the extremities. After going through this routine with each patient and talking to the staff, I write progress notes and orders. Then I head to the office to start clinic.

8 AM

Our clinic is located just a few minutes from the hospital. We have clinic all day on Mondays and surgeries all day on Tuesdays. The remaining weekdays are split half and half. On Monday, we will see 45 to 50 patients. On the half-and-half days, we see around 25. Most of our clinics are a mix of new patients, worker’s compensation cases, and surgical follow-ups. I see all the surgical follow-ups and do the workups on new patients. I also do all the preoperative evaluations and the joint injections.

We average around 15 injections a week—knees, shoulders, hips, and some trigger point injections. For knee injections, we first use a corticosteroid plus bupivacaine (Marcaine), and if this provides no relief after a couple of weeks, we give a series of hyaluronic acid injections. Most of these are done for OA. Shoulders and hips are injected with a corticosteroid plus bupivacaine, mostly to treat inflamed bursae.

As a general orthopedics practice, we provide a mix of surgical and nonsurgical treatment. With the nice weather that we have year round in middle Tennessee and a large variety of outdoor activities, we see many different types of injuries. Patients with injuries caused by activity are usually young and healthy. Our treatment plans are frequently nonsurgical and include fracture boots, splints, casts, crutches, and slings.

Patients requiring surgical treatment present with a mix of rotator cuff tears, meniscus tears, fractures, and OA. We do three or four total joint replacements a week—mostly knees and hips, but occasionally a shoulder. The number of shoulder problems seen in 40- to 60-year-olds was a real surprise for me. It is rare not to see at least two or three patients with shoulder problems in every clinic.

We also see a lot of knee injuries, be it patellofemoral injury, tears to the meniscus or anterior cruciate ligament, or Baker’s cysts. Because of advances in arthroscopic technologies, most knee problems—except for OA—can be treated arthroscopically.

This is one of my half-and-half days, so when the clinic ends, I head to my office to go over the paperwork for the new surgery patients and to dictate the charts from the clinic (if time permits). I then head over to the hospital for the day’s scheduled surgeries, making sure to bring along the radiographs for those cases.

1 PM

After a quick bite in the doctor’s lounge, I go to the holding area to make sure the patient consent form is signed and the history and physical examination is on the chart. I review the laboratory data, particularly checking potassium, creatinine, and BUN. We generally use ketorolac (Toradol) for postoperative pain control, and I must verify the patient’s renal function and make adjustments or use a different medication if needed. I always ask patients if they have any questions and make sure they understand what we are doing and what to expect after surgery. Even though we had this discussion with them in the office during their preoperative evaluation, I go over it with them again.

After changing into scrubs, I check in with the circulating nurse and surgical technologist to see that we have all the needed equipment and implants. My hospital is small, and we don’t have the large number or variety of instruments that larger medical centers may have. When something is missing or not available, we have to get creative with the instruments we have. I have seen things done many different ways and have learned effective ways of using supplies to accomplish our goals.

In the OR, I am the first assistant. Since I work with only one surgeon, I know his routine fairly well. I go over the instruments with the scrub tech and help with opening supplies, putting in the Foley catheter, putting up the radiographs, and positioning the patient. When Dr. Freels arrives, the prep work is complete and we are ready to start the surgery. In total joint replacements, I handle exposure and hemostasis. After the implants are in, Dr. Freels heads to the outpatient area to start a knee or shoulder arthroscopy as I close the incision on the total joint replacement.

4 PM

After we finish the last case—which is sometimes much later than 4 PM—I will usually make a quick stop on the orthopedics floor and check in with the nurses to see how the inpatients are doing and to troubleshoot any problems for the next day.

On one of his clinic days, at Tennessee Orthopedic, PA Jeff Miller
aspirates fluid from the knee of a patient.

Rewards

My main professional reward is that after all my years of working in the OR, I am finally in a position where I can be involved in a patient’s care from the first evaluation through to the last postoperative visit. I like being part of the team that helps patients to return to the activities they had stopped doing because of pain. I like hearing them tell me how nice it is to be able to walk without hurting after a knee replacement, or to throw a football to their son after a rotator cuff repair, or to go running after an ACL repair. I like actually seeing the outcome. It’s rewarding just to help people enjoy life again.