Cardiac NPs and Cardiac Surgeons

Advanced Practice Columnist / Guide · Dec 3, 2010

I've worked very closely with Cardiothoracic Surgeons at a previous NP job I had. Our role is basically ICU-based in a 16-bed Adult Cardiothoracic Surgery ICU with patients ranging from the usual CABG and valve replacements/repairs to the implantable VAD's, heart and lung transplants, aortic dissections and aneurysm repairs, and thoracotomies for lung tumors. We manage post-op patients including ordering of vasocative drugs, blood products, volume resuscitation, and temporary pacing in the immediate post-op period, extubations, starting post-op medications for pain management and the typical cardiac drugs depending on the case. As an ICU service, we place all sorts of central and arterial lines as well as chest tubes. This was a purely ICU role and we are basically the "eyes" of the surgeons in the ICU while they are in the OR doing their cases.

There are NP's who also work with the surgeons in the OR. In my experience, there are more PA's than NP's in this role (harvesting grafts, first assisting, etc.). You will also find NP's who provide management in the entire continuum of Cardiothoracic Surgery care from out-patient to admission to OR to discharge to clinic follow-up. That was just not the role I had. By the way, I am an ACNP and that is what is typically required in the ICU role I had. There are states that actually have that language expressed in their practice act (i.e. ACNP's for acute care settings, FNP's for primary care settings). I worked in a state that didn't have strict requirements for this so we've hired FNP's and ANP's with strong Cardiothoracic Surgery experience as RN's in that role in the past.

Lovelymo79 · Dec 3, 2010

Thanks so much, Juan! You are very informative! I've viewed other posts you have on here..you never know who's keeping track of you! :lol2:

First assisting and harvesting grafts? Yeah..don't think I'm so interested in that..lol. More like the pre- and post- op aspects. My "loose" timeline of goals is to do Cardiac nursing for some time..and then ICU (unless I can go directly in an ICU in a student internship..but I'm really looking for a good cardiac-based start since I'm interested in cardiac)...while getting my BSN. After some years, become a heart transplant coordinator and getting my MSN. Then work with post-op cardiac patients as an NP. I love the hospital setting but as I get older..not sure if I would want to stay in acute care. Maybe work with a cardiologist at his office and work in primary care of people with cardiac issues. My whole thing I'm wondering is then if it's best to get an ACNP or FNP...since I'm thinking, once I have my family and get older (not old..just oldER)..will I really want to be running around the hospital? Then again..we have doctors walking around, daggone near with canes...lol. j/k

This timeline is all loose..who know what can happen between now and then and I may change my speciality all together. Just wondering who different roads the cardiac NPs took on here.

Thanks again for your info! :yeah:

Advanced Practice Columnist / Guide · Dec 4, 2010

Good luck to you. It sounds like you have a reasonable plan laid out and is flexible enough to think that things may change as far as your interests and/or job prospects in the future. One thing I'd like to mention though, it seems like the FNP offers the most flexibility of all the NP roles if you practice in a state that doesn't strictly enforce the different educational tracks and specializations that NP's get trained and certified on and I think so far, Texas and Maryland are the only ones with clear language in their practice act regarding this issue. However, I would assume that even an FNP who has practiced in a critical care setting for a while because it's "allowed" in their state would have a tough time transitioning back to family practice or any out-patient setting after not having been in that field for a while. Healthcare changes so fast and things that are considered guidelines now may not be standard practice in a few years. I think it's important for would be NP's to realize that the degree of responsibility in providing care at the advanced level that we NP's do requires expertise that you have to hone over time and being able to jump from one specialty to the next might be a little tough in reality.

FutureCruzanRN · Jan 1, 2011

Thank you for the information Juan as well. I recently saw a program offering a FNP degree and an ACNP as well. It made me wonder if I would be more versatile.. I would also like to work in Cardiothoracic Surgery, first assisting, would be a dream of mines.

I am a little wary however, because there aren't that many schools offering a subspeciality in Cardiothoracic Medicine or even Cardiology. How did you do it Juan?

Advanced Practice Columnist / Guide · Jan 1, 2011

Thank you for the information Juan as well. I recently saw a program offering a FNP degree and an ACNP as well. It made me wonder if I would be more versatile.. I would also like to work in Cardiothoracic Surgery, first assisting, would be a dream of mines.

I'm trying to understand your question. Do you mean being versatile in terms of FNP vs ACNP? FNP offers the versatility of caring for patients of all ages. The training is limited to primary care but in some states, FNP's are allowed to work in acute care practices with no restrictions as long as they have the RN background to support the acute care role and they are trained appropriately on the job. In a couple of states (Maryland and Texas) FNP's are prohibited from practicing outside the primary care arena.

Cardiothoracic Surgery is highly specialized and very age-specific. Cardiothoracic Surgery fellows train in both adult and peds but end up practicing with adults alone once they finish unless they go though additional training in peds after their initial fellowship. Pediatric CT Surgery is very complicated and requires additional skills not learned from the basic fellowship. With that said, NP's who work in CT surgery either work with adults or with peds exclusively so an FNP, to me, is not mandatory. Because of the complexity of the patient population, it is even more beneficial for someone who is interested in the field to have solid ICU/CTICU experience and either ACNP or ACPNP training.

Fewer NP's who work in CT Surgery have first assisting roles compared to PA's but they are out there. I precepted an ACNP student who is already and RNFA in CT Surgery whose plans were to pursue the field of CT Surgey as an NP. He got his dream and is now working in the role he wanted which includes both in-patient management and first assisting. But then, he already had the RNFA skill prior to being an NP. This is typically how NP's get to venture into first assisting in CT surgery. Do some research in your locale and see what types of staff assist the surgeons in open heart surgery. In Michigan where I used to live, the hospitals are split in half between the ones where RNFA's assist and the ones where PA's assist.

I am a little wary however, because there aren't that many schools offering a subspeciality in Cardiothoracic Medicine or even Cardiology. How did you do it Juan?

You won't find a program specifically training for CT Surgery. Some NP programs have a focus in Cardiovascular Medicine but not CT Surgery. You can tailor an ACNP program to focus heavily on Cards but you risk being too limited with job options when you graduate. Some students do that but in most cases, they already have a job lined up and are being honed for their future role by the employer.

allnurses Guide · Jan 1, 2011

You generally do clinicals in the area you are interested in working in, even if the degree is not specifically aimed at say, cardiothoracic. My ACNP degree does have a cardiopulmonary major which I am doing.

If you haven't even worked in cardiac (or ICU) yet, be careful of planning too carefully for the future - you may not like it as much as you think you will. Your plans often change as you move along in your career and gain experience. A lot of people start out thinking they will love ER or ICU and then find they are not fans at all once they work there. So have plans, but be flexible. Gain broad experience early on and then specialize once you figure out what you like.

Also - I was going to say complete one NP specialty then do the other post-masters if you want (eg ACNP then FNP) BUT - and it is a big but - a lot of schools are pulling their MSN programs at the moment to transition to DNP, so I'm not even sure how that will go in future.

FutureCruzanRN · Jan 2, 2011

Thank you both for the advice. I have worked in Cardiology for about 8 years now and am pretty sure that Cardiothoracic Medicine is the path that I would like to take. It is just getting there.

##juan## I know that you said most NP that have done the First Assist were in those fields before they did the nurse practitioner field, but I feel as if a person would have to work under surgery/ operating room to obtain that. I was told starting in a cardiac progressive care unit would be essential to my dream.

^^ Do any of you know of Cardiology fellowships available as a NP. ^^

**ghillbert** Yeah you are right most programs are going toward DNP for nurse practitioners. However, I have noticed that a lot of DNP programs request that you have a masters before you enter the program. So.. I'm not really sure where that will be at by 2013 when I plan on entering into a program. I am sure it will be the same..

Advanced Practice Columnist / Guide · Jan 2, 2011

I have worked in Cardiology for about 8 years now and am pretty sure that Cardiothoracic Medicine is the path that I would like to take. It is just getting there.
##juan## I know that you said most NP that have done the First Assist were in those fields before they did the nurse practitioner field, but I feel as if a person would have to work under surgery/ operating room to obtain that. I was told starting in a cardiac progressive care unit would be essential to my dream.
^^ Do any of you know of Cardiology fellowships available as a NP. ^^

Yes, you will have to work under the OR or Dept of Surgery as an RNFA. If you are interested in an NP role that combines first assisting and in-pt management that may be a viable option for you. Nurse practitioner programs do not typically provide OR rotations as a rule. I think part of that is because of the RNFA specialty which is not an advanced practice role but is still a separate specialty within the field of nursing. As a result, fewer NP's have OR duties built in to their job description unless they are also RNFA's to begin with. There are exceptions though and I'm pretty sure others can cite anecdotal evidence to prove otherwise.

If you are interested in CT Surgery minus the OR role, your best bet is to work in CTICU and learn how to recover fresh post-op open hearts. It's a skillset that only those who work in CTICU have and is quite different from the typical MICU or general SICU stuff that nurses learn. A lot of it is protocols but you get to know the physiology behind valvular diseases or cardiomyopathies, for instance, to know how the type of open heart surgery and/or cardiopulmonary bypass will affect the patient post-operatively. I hope you have an opportunity to have that experience because it will definitely give you an idea if this field is right for you.

I actually learned a great deal of stuff in CT surgery as an NP rather than as an RN and many of it was learned on the job. Our surgeons were committed to teaching the NP's everything we needed to know to be successful clinicians in the field. Unfortunately, a lot of it can be surgeon-dependent and protocols may not be the same between different surgeons or even different medical centers. I do not know if there are actual fellowships for this stuff, I'm fortunate that I did not have to look for one to get a job in this specialty.

I actually now work in a role that is not exclusively CT surgery. I work with a faculty intensivist practice where we provide coverage to different ICU's including a CTICU. I find my current role more broad though I must admit that the adrenaline rush you get from bad things that can happen to pateints in CTICU probably gets the prize as the best challenge in my mind.

FutureCruzanRN · Jan 3, 2011

Juan thank you so much for all the information. Seeing as how this is so specialized I will take caution in your words of whether or not the field will be a good fit for me. Thanks again.