First Assists Any Good?

[UncleMinnie]

I'm an ENT resident in the job search, and just wanted to ask out of curiosity, what is it like working with a first assist? As I do thyroids, parotids, and neck dissections these days, I recognize that my attendings are very often retracting perfectly to make my life easy. I'm interested to know how many people are satisfied with first assists when they need some extra hands in the OR, versus how many people tend train up a PA/NP to help, or have one of their partners come scrub in.

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[anonperson]

I'm an ENT resident in the job search, and just wanted to ask out of curiosity, what is it like working with a first assist? As I do thyroids, parotids, and neck dissections these days, I recognize that my attendings are very often retracting perfectly to make my life easy. I'm interested to know how many people are satisfied with first assists when they need some extra hands in the OR, versus how many people tend train up a PA/NP to help, or have one of their partners come scrub in.

Usually have the scrub tech assist as much as they are allowed to do.

I used a PA for some cases. It worked fine. They were trained in general surgery and Ortho so they weren't completely familiar with the anatomy (gyn) but it was adequate.

I Sometimes bring in one of my colleagues for anticipated difficult cases but I try to limit that. They have clinic and their own cases so I don't want to inconvenience them too much.

I have asked some of the older community docs to help me out from time to time. That is hit or miss. Sometimes they are terrible.

I've learned to be more independent as I've progressed in my career and realized I can do a lot of cases safely on my own.

 

[operaman]

If you want to get a sense of what it’s like, do a case with a junior/intern while your attending isn’t scrubbed. You basically have to guide them at each step but they have good tissue handling skills and can certainly retract and be helpful. It’s just not that same perfect retraction your attendings are giving you.

I’m a new ent attending just out of fellowship and I rarely use first assists but I do use a lot of self retaining retractors, lone stars, etc. I’ve use FAs for big airway recons and some laryngeal framework stuff and it helps a lot. My partners would help if I ask them but they’re also busy and so far I’ve felt fine with the help I have.

I don’t really do parotids and thyroids and cancer necks because I just don’t enjoy them that much and my head and neck partners are super fast and their results are incredible. If I did one I would definitely book a FA though.

I’ve thought about the PA/NP thing. Our H&N folks have an NP who works with them lifting flaps and closing donor sites and helping with inset. Our ablative H&N guy usually uses a FA and I’ve watched him and he basically just places him where he’s needed and he holds hook.

I guess the difference is how much autonomy you need your assistant to have and whether they can operate while you’re scrubbed out. The flap guys like having a midlevel who can come prep and mark, then they raise the flap, midlevel closes the donor while they do micro and inset and then midlevel may even do final skin closure and dressing while they scrub out and dictate.

That said, I’ve seen well trained FAs do all that too - did a combined peds airway case in training with peds CT surg and after the CT guy wired the sternotomy back together, his FAs bumped me out of the way and said “we got this” and they just sewed the rest up while I did the note and orders - pretty nice actually!

Not sure how much that helps but that’s my rambling 0.02 so far. I definitely feel that operating solo has its own learning curve that I’m currently going through. As a chief, I actually did ask my mentors to do a couple cases solo just so I could watch how they did it without a resident. Definitely worthwhile for me.

 

[Smurfette]

I'm an ENT resident in the job search, and just wanted to ask out of curiosity, what is it like working with a first assist? As I do thyroids, parotids, and neck dissections these days, I recognize that my attendings are very often retracting perfectly to make my life easy. I'm interested to know how many people are satisfied with first assists when they need some extra hands in the OR, versus how many people tend train up a PA/NP to help, or have one of their partners come scrub in.

I use an SA (surgical assistants is what we call them) or my PA. When I first went into practice, it was just SAs. Going into practice is an adjustment because you have to figure out how to get the view you need with the help you have. Experienced assistants will usually know and are good, but they also have to figure you and your style out too. You also have to learn the local instrumentation or ask them to order certain things for you, as it can vary slightly by region and hospital and the SAs can tell you what others use. You already are aware that your attendings are doing excellent retraction for you, so you are already self aware. If you scrub in with just a med student or junior resident, can you get them to expose things properly for you? It's good practice for the future.

 

[OtoHNS]

I don’t do many procedures anymore that require an assistant, but for thyroids and parotids and the like, I just request an extra scrub tech. They can hold a retractor or skin hook just fine but they are not going to move it around on their own volition, so you will need to move them and have them tow in/adjust PRN to give you good exposure and tension. I think operating with a med student or intern would give you a good simulation of how it works (honestly they are probably worse than a scrub tech at a private surgery center 😂)

 

[Lem0nz]

I use an SA (surgical assistants is what we call them) or my PA. When I first went into practice, it was just SAs. Going into practice is an adjustment because you have to figure out how to get the view you need with the help you have. Experienced assistants will usually know and are good, but they also have to figure you and your style out too. You also have to learn the local instrumentation or ask them to order certain things for you, as it can vary slightly by region and hospital and the SAs can tell you what others use. You already are aware that your attendings are doing excellent retraction for you, so you are already self aware. If you scrub in with just a med student or junior resident, can you get them to expose things properly for you? It's good practice for the future.

Echo this. I have an NP and I'm considering changing jobs and am bringing her with me if I move as a condition of employment because I have zero desire to repeat this process. Anyone can be taught to do anything in surgery and you do not need a medical degree to reproduce reliable technical skills *ON A TEAM*. What is more important is consistency and the same people/team. Some places can provide that and some can't. For some specialties (general surgery) its a luxury, and others (CV, surg-onc, ENT oncology, microvascular plastics) its a requirement depending on the complexity of what you're doing.

Anywhere you go you'll have to train said person and it will take time but most seasoned (even just ~3 years or more) RNFAs don't need to be taught tissue handling, they just need to be taught the routines.

Find out what you realistically need and put some hard thought into it. If you're good at your skill and your surgery is not overly complex be honest with yourself - you could probably do a thyroid or a para with anyone. If you're doing repeat thyroids with tracheal invasion then... well, yea. You need someone who knows what is going on. If that happens once every other month you probably want another surgeon assisting you. If that happens every single day then you need an NP or PA. If it happens once every 10-20 cases but you think you can handle it an RNFA who knows what to do during 'normal' cases would probably be totally fine.

Personally, I *need* someone who has workable knowledge of retroperitoneal and hepatic anatomy, knows how the iron intern works for retracting and can place it independently, is confident and has steady hands in the face of massive bleeding with retraction and knows without being told what instrument needs to be in my hand, and can close fascia/skin. I am very slowly and very carefully working on low risk anastomoses mostly so that if/when we have residents she can guide them with me scrubbed out to give them autonomy on the GJ of a whipple which is a good anastomosis for a resident to do with low supervision and me physically not present. There are programatic goals I have to comply with and achieve as well as personal time management of a soul crushingly big service and I needed that. Part of that is also that the list of people I can call for help are 1) out of my discipline and 2) far away at any given moment and I need someone who can help me safely temporize a problem intra-operatively until my help arrives. Most people honestly do not need that. It is also a huge expense. My NP generates zero non-surgical RVUs and assistant RVUs, while not negligible, probably don't cover her salary. RNFAs way cheaper.

If you're doing primarily thyroid/para/neck dissections and not more complicated stuff a dedicated scrub tech would absolutely be fine and you do not necessarily even need an RNFA. But dedicated and consistent is key. If you *can't* get a dedicated scrub tech, I would start with an RNFA to see how that suits your needs. After a month on ENT oncology, I would never be an ENT oncologist unless you had an NP or PA *and* a partner available for when the **** turns into the stinky ****.

 

[VisionaryTics]

I'm a head and neck surgeon in pseudo-private practice and do much of my work (including free flaps) with a PA.

As you recognize, you need to get really good at setting up your retraction using people who aren't experts. In addition, you need to be a much more independent surgeon. I personally always have a cutting instrument in my right hand (either Bovie, Jeweler bipolar, or fine scissors). I can dissect and cut with all of them. If you only have a single assistant, you can't do the residency-style "one person retract, surgeon uses a clamp to dissect, and assistant clips and cuts". When I was finishing training, I worked on being as comfortable as possible operating efficiently with only a single assistant.

 

[Lem0nz]

I'm a head and neck surgeon in pseudo-private practice and do much of my work (including free flaps) with a PA.

As you recognize, you need to get really good at setting up your retraction using people who aren't experts. In addition, you need to be a much more independent surgeon. I personally always have a cutting instrument in my right hand (either Bovie, Jeweler bipolar, or fine scissors). I can dissect and cut with all of them. If you only have a single assistant, you can't do the residency-style "one person retract, surgeon uses a clamp to dissect, and assistant clips and cuts". When I was finishing training, I worked on being as comfortable as possible operating efficiently with only a single assistant.

Good point. 97% of my operating now is done with my finger or a bovie. 3% is instrument dissection where someone else bovies. I use the bovie without energy to do a lot of pushing tissue planes apart.

Those numbers were opposite in fellowship.

 

[dpmd]

So I actually quit having a surgical colleague assist me for thyroids because he would try to do too much and had a style that was more ok with bleeding than I am. Now I use an RNFA and I get whichever one is assigned to me on the random days I schedule cases (I don't have block time because I have no desire to start early and I have no set day I always want to be working so I prefer the freedom of picking when I want to work or not work whenever I want). Some are better than others but I direct their actions for the most part. I mean they know to pick up opposite me for the skin and muscle layers and the ones I have worked with more than once remember when I need the skin hooks or the self retainer but they let me place the army navy where I want it instead of guessing (or putting it where he wanted it rather than where I wanted it like the colleague I used to use did). I like it though because while I tend to do a lot of steps the same each time I will also adjust my strategy depending on what the thyroid is doing and and how much trouble my usual sequence is resulting in (i like starting with superior pole but sometimes the anatomy makes it easier to dissect out the lower pole before you can see all of the superior, and sometimes if it is way huge, dividing the midline and a short distance from medial to lateral helps you retract and see better to find the recurrent). Plus if a finger sweep is going to make something bleed I would prefer it to be my finger. Have done it was just an extra scrub tech but my state doesn't let them manipulate tissue so technically they could get in trouble for some of what they do and they can't close.