Sew 'n Tell
A peek inside a typical day in the OR, where a first assistant NP revels
in the challenges and rewards of treating surgical patients
By
Heather Stringer
June 19, 2002
Miranda Kramer, MSN, NP, a registered nurse first assistant, fixes her eyes on the needle as she delicately pushes it through the unconscious patient's latissimus dorci.
She looks up at the surgeon, who is sewing from the other side of the incision. Kramer takes a moment to evaluate her progress and wrinkles her forehead. This suturing job is more difficult than usual because the patient is overweight, but she doesn't have time to get flustered.
As a first assistant at the University of California, San Francisco Medical Center, one of Kramer's regular duties is suturing. In fact, she's the only first assistant at the medical center, and she revels in the added responsibilities that this nursing specialty allows her in the operating room.
To catch a firsthand glimpse of a day in the life of a first assistant, NURSEWEEK followed Kramer during a procedure in the cardiothoracic surgery unit at UCSF.
At 10 a.m., Kramer is briefed on the medical history of the man she'll be sewing up five hours later. He's been suffering from a respiratory infection for three months, and doctors need to remove the source of the problem: a papilloma that is blocking one of his bronchioles.
10:22 a.m.
Covered from head to toe in sterile blue scrubs, Kramer stands across from the surgeon, Peter Anastassiou, MD, and the duo begins the intricate task of cutting through layers of muscle and fat to expose the patient's bronchiole. A nurse passes instruments as Kramer cauterizes to stop bleeding and suctions blood whenever it pools enough to obstruct Anastassiou's view.
Kramer admitted that even though she cannot imagine a more ideal job for herself, her pathway to nursing has been somewhat serendipitous.
Drawn to the adrenaline rush of emergency situations, she started working in the medical field as an EMT in an ambulance. One of Kramer's friends suggested she apply for nursing school and, on a whim, she decided to apply to one school. She was accepted at Merritt College in Oakland.
She graduated from nursing school and launched her career at a small hospital in Sonoma. After four years of working in small hospitals, Kramer was eager to pursue positions at a larger research facility. She landed a job at UCSF Medical Center, but before long, the familiar hunger for more challenge began gnawing at her.
Kramer decided to pursue a master's degree to become an acute care nurse practitioner. She earned her degree while working full time at UCSF, then spent an additional year completing the course work and 2,000 hours of training required to earn her RNFA credential.
As a first assistant, she's trained to suture, sever tissue and provide hemostasis. Although she enjoys assisting in the operating room, Kramer, 35, said the combination of working as both a first assistant and a nurse practitioner is what makes her job thrilling.
As a nurse practitioner, she can see patients before their surgeries and work with doctors to decide on the ideal course of action. After surgery, Kramer helps manage patients in their recovery.
"It's rewarding to see the whole process from start to finish,"
Kramer said. "You develop a relationship with the patient."
2:37 p.m.
After four hours in the OR with the papilloma patient, Kramer takes a brief break from surgery to answer pages from doctors and patients. One call is from an oncologist who's been trying to diagnose a patient who has a tumor next to his spine.
The tumor has been biopsied twice, but the oncologist hasn't been able to determine whether it is malignant. Kramer and the oncologist discuss the option of removing lymph nodes in the patient to determine if the spinal tumor has spread and is malignant.
Just as she finishes the call, her beeper sounds again. It is Anastassiou. He needs her to return to the OR to assist with suturing the papilloma patient. Kramer suits up in scrubs and re-enters the OR, where Anastassiou reported that he and another surgeon have successfully removed the papilloma.
Pleased with the good news, Kramer slips her index fingers and thumbs through two needle holders, then picks up a rounded needle.
For Kramer, suturing is the most mechanically challenging part of her job.
"It's an art, like sewing clothes," Kramer said. "I not only need to fix it, but also make it look good."
She recounts a story of one woman who was more disturbed about an imperfect suturing job than the news that her cancer was malignant. Sometimes, the skin sewing requires thread as thin as hair for delicate areas, while other times she uses thread thicker than dental floss for large muscles.
After 15 minutes of mending the man's skin, Kramer asks Anastassiou for advice about how to improve the stitching. They exchange muffled words through their masks as the surgeon points at different parts of the incision. For Anastassiou, questions like this from Kramer seem a welcome chance to teach.
"Miranda is persistent," Anastassiou said. "She asks intelligent questions, and she has an unending work ethic."
After an hour of suturing, the incision is finally closed. Nurses gently roll the man onto a bed and begin unhooking tangles of monitor wires as they prepare to wheel him up to the ICU.
One nurse begins talking to the patient, who answers in slurred speech as he slowly revives. Kramer and the other nurses squeeze into the elevator on both sides of the rolling bed.
Once the patient is settled into his ICU room, Kramer checks his chart and increases the painkiller dosage to compensate for his larger size.
Kramer glances at her watch and rushes to a tiny desk that she shares with the unit's residents. Most days, she'll stay until at least 6 p.m., but tonight she is heading to the ballet with a friend and readies to leave by 4 p.m.
In minutes, she'll leave the world of scrubs, needle holders and beepers and step into the buzzing streets of San Francisco. For a moment, she reflects on the events of the day. In the end, she seems pleased.
"The patient with the papilloma was a very big man and it was hard [to suture], but I'm glad I had a supportive surgeon to go through that with me," Kramer says. "It felt good that it was harder, and I think I improved."