The orthopaedic nurse practitioner is an invaluable addition to our orthopaedic practice. Her expertise in patient management, her caring style, her ability to manage the patients' progress from the initial call to the office through the clinical examination, the surgical care, and the rehabilitation process dramatically improves the quality of care received by the patient. In our practice, the nurse practitioner also manages the research projects, first assists in surgery, manages the operating room flow, and provides on-field medical coverage for rugby and skiing events. To understand her role, I have chosen to describe a typical week.

MONDAY:

Monday starts off with an exercise session in the health club attached to our facility. The first patients come to the Clinic at around 9:15 a.m., and are usually our post-operative patients from the week before. The nurse practitioner will see these patients, change their dressings, answer their questions about medications and the surgical procedure that was performed, and direct them to the physical therapists who work in our clinic directing their post-operative rehabilitation programs.

The fact that the nurse practitioner knew these patients from the first time they entered the clinic and assisted in their surgical procedure makes her uniquely qualified to provide post-operative care and guidance. Patients will often initially communicate their anxieties and hopes in a more open fashion with the N.P. than with the surgeon. Additionally, since the N.P. has observed patients who have had the same procedure, she can speak from her experience about how different patients have fared over the years.

The first new patients arrive at the Clinic at 9:45 a.m.. The nurse practitioner will meet with each new patient in the examining room, obtain a detailed history, and perform the initial physical examination. This includes obtaining extremity measurements, KT 1000 knee ligament laxity measurements, muscle testing, range of motion testing, and joint stability testing.

Obtaining the skill to accurately perform knee and shoulder laxity tests takes years of practice. By having the nurse practitioner perform these tests on every patient and compare her results to the surgeons results provides daily training and improved patient care. When different results are obtained, the patient is re-examined together.

The N.P. will then direct the patient to obtain an x-ray, if necessary, prior to presenting the case history to the orthopaedic surgeon. In presenting the case history, the nurse practitioner will review all pertinent details of the mechanism of injury, previous injury history, as well as reviewing any previous studies that may have been obtained. If it is determined that an MRI or bone scan has already been obtained at another facility, the nurse practitioner will arrange to obtain the report by fax. For complex or unusual cases she will then be present with the surgeon during his examination of the patient. If not, she will proceed on to see the next new patient or follow-up patient, while the orthopaedic surgeon will see the one that was just presented.

If injections need to be given, the nurse practitioner will prepare the injection, prep and drape the patient, and assist in placing the injection. Any sutures that need to be removed from the previous weeks surgery will be removed by the nurse practitioner and the dressings will be changed. Since the N.P. usually was the person who closed the wounds at surgery, the quality of the wound closure and wound healing can be assessed.

During the day, calls that come to the Clinic that require medical expertise are fielded by the nurse practitioner in-between patients. Additionally, preparation for the subsequent surgical day is carried out. Any special equipment that may be needed for the surgical day is obtained by calling the company representative and discussing the special surgical needs with them.

After seeing the patients, the charts for that day are completed and the cases who have been scheduled for surgery are reviewed. The x-rays, the patient's history, and surgical equipment for the next day are placed into a travel bag for transport to the operating room. Follow-up calls are then made, usually by cell phone on the way home, to patients who had special questions during the day or to patients having any post-operative nausea, questions or difficulty with pain medication.

TUESDAY:

This is an operating day for our practice. The nurse practitioner usually arrives at the operating room half an hour before the orthopaedic surgeon. She brings with her any specialized equipment that may have been at our office or needed for the day, including the travel bag with the x-rays, MRIs, patient histories, and knee braces that might be required in the immediate post-operative period. The nurse practitioner and surgeon speak briefly with the patients in their pre-operative holding area to review with them the procedure that it going to be performed, and to again review the specific pain or complaint that the patient has prior to entering the operating room. This step helps guide the surgical procedure and ensures that the significant complaints and injuries are addressed.

The N.P. positions the patient on the operating room table, assists in the prepping and draping of the patient, and places the local anesthetic into the knee joint after the anesthesiologist has given relaxing medications. The nurse practitioner assists the surgical scrub technician in arranging the specific equipment that the orthopaedic surgeon prefers, and teaches the scrub technician about the upcoming procedure. The nurse practitioner then scrubs and dons a surgical gown, and sterilely drapes the patient for surgery. The nurse practitioner acts as the first assistant assisting the orthopaedic surgeon with the surgical procedure. At the conclusion of the procedure, the nurse practitioner closes and dresses the wounds and assists with transport of the patient to the post-operative recovery room. She fills out the orders for the post-operative medications, discusses the surgical procedure with the patient, places the post-operative braces, and arranges for home nursing care as needed. The nurse practitioner proceeds onto the next patient.

Our surgical day usually continues until approximately 5:00 p.m., although at times can go as late as midnight, or be done as early as noon. On routine surgical days that go until early evening, the nurse practitioner will complete the surgical day, and then start making phone calls to the first surgical patients that have been discharged, to see that they arrived home in good shape, and that they are not having any specific post-operative complications such as nausea or pain. All patients operated on that day will be called by the nurse practitioner, as well as any patients that may have called the office while the orthopaedic surgeon and nurse practitioner were in the operating room that day. Those messages will be forwarded to the nurse practitioner for telephoning on the way home that evening. If the surgical day should end early, then the orthopaedic surgeon and nurse practitioner return to the office in order to work on various clinical and basic science research projects ongoing at the clinic.

The nurse practitioner's duties extend into the research field, and include the follow-up evaluation of patients in the clinical studies, surgical assisting for animal research, acquiring necessary research supplies such as animal tissues or laboratory agents, coordinating with the research facilities in scheduling surgical research times, follow-up of animal studies, and obtaining of tissues in collaboration with other researchers involved in each project. These activities keep the practice intellectually stimulating and advance medical science. For the N.P., research provides the opportunity to be on the leading edge of her field, to publish, and to present papers at meetings.

WEDNESDAY:

Wednesday is usually a repeat of the Tuesday schedule, arriving at the operating room at 7:00 a.m. and continuing until the surgical day is completed.

THURSDAY:

Thursday is a repeat of the Monday schedule, starting again with an exercise program at 8:00 a.m., followed by a Clinic day.

FRIDAY:

Friday starts with an Orthopaedic Grand Rounds educational seminar at 7:00 a.m., which proceeds until 8:30 a.m.. Most Fridays are reserved for a research day, during which time clinical follow-up of patients in our various studies are performed, chart reviews, or research surgery is performed, sometimes requiring flying to another city on Friday morning, performing a surgical experiment at the research laboratory, and then flying home on Friday evening.

Additionally, the nurse practitioner travels to many of the national meetings in orthopaedic sports medicine, including the American Academy of Orthopaedic Surgeons, the Arthroscopy Association of North America, and the American Orthopaedic Sports Medicine Society. Attendance at conferences, although optional, is usually rewarding both educationally as well as in people contacts with the various company representatives, as well as other orthopaedic surgeons working in this same field.

Whenever we visit another city for an orthopaedic conference, we usually schedule a site visit of another orthopaedic surgeon while they are in their operating suite environment. The nurse practitioner then has an opportunity to observe other nurse practitioners, or usually physicians assistants, serving in a similar role. By observing other surgeons performing similar surgical procedures, both the orthopaedic surgeon and the nurse practitioner gain valuable insights and bring home new approaches.

WEEKENDS:

Weekends are usually spent in recreation, as well as with follow-up phone calls to the patients who have been operated on during the week or seen in the clinic. All surgical patients are called each weekend. The nurse practitioner during the week and on weekends takes first call for the clinic practice. Any patients calling the practice after hours are directed first to the nurse practitioner, who then can consult with the orthopaedic surgeon on an as-needed basis.

Although obviously quite time consuming, the role of the nurse practitioner in this orthopaedic sports medicine and research practice is tremendously rewarding in a professional and intellectual sense. By combining the research approach with the clinical and surgical practice, a deeper understanding of the possibilities for musculoskeletal care is obtained.

The level of patient care possible by having a nurse practitioner who sees the patients in the clinic environment as well as in the surgical environment is unparalleled. Patients know that the nurse practitioner they see in the office has first assisted in their case in surgery, understands their concerns, and can talk with them with authority when they call at night or on the weekend.

Neither I nor my patients can envision practice without our top flight orthopaedic nurse practitioner, Ann W. Walgenbach, R.N.N.P.