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Plastic & Reconstructive Surgery Nursing: Interview with Debbie Gaytan-Wallace, RN, CCRN, CNS, FNP-BC

Treating trauma, burns and cancer reconstruction

By Keith Carlson, RN, BSN
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Debbie Gaytan-Wallace, RN, CCRN, CNS, FNP-BC
Los Angeles County + University of Southern California (LAC+USC) Medical Center

 

Tell us about your career as a nurse.
I have been a nurse for 35 years, with my beginnings as a nursing attendant at LAC+USC. I have worked as a staff nurse on med-surg wards, as a critical care nurse in pulmonary ICU and cardiothoracic ICU. I advanced into nursing management in pulmonary ICU in my early career.

I continue to teach nursing students at East Los Angeles College as a clinical faculty member. I received my BSN and MSN as a critical care clinical nurse specialist from California State Los Angeles, with a postgraduate degree from USC as a family nurse practitioner. I worked in family practice for five years. For the past 16 years, I’ve been working for the Division of Plastic and Reconstructive Surgery. I paved the road as the first NP in the acute care setting when the division chair took a chance on me.

What can you tell us about your facility?

LAC+USC is one of the largest teaching hospitals in the world, with a 600-bed capacity. This is a level 1 trauma and teaching center for the military and the USC School of Medicine. The Medical Center is comprised of three sections: Inpatient Towers, Diagnostic and Treatment, and Clinic Tower. LAC+USC is the training mecca for a multitude of disciplines, not limited to residents, interns, pharmacy and nursing. Our patient population is multiculturally diverse, with limited healthcare resources.

A vast majority of the specialty services, such as cardiothoracic, vascular, tumor and the emergency department, have embraced mid-level providers into daily practice. With continuous rotation of medical-surgical physicians, mid-level providers are the only continuity of care for our patients. This plays a tremendous role in decreased length of stay, increased patient satisfaction, decreased duplication of services, and a focus on prevention, wellness and education.

Describe your position within the department.
The mid-level positions emerged to meet patient care needs after a reduction in physician hours. I interviewed with multiple services and was offered this tremendous opportunity without a any knowledge of plastic and reconstructive surgery or a job description in place. I was mentored daily by the attending staff about specific muscles, wound management, and facial and lower extremity trauma. I read every book and attended multiple conferences on this specialty. Professionally, I have a satisfying collaborative practice with all disciplines. Our team is composed of an attending staff physican, a chief resident, an intern and a medical student.

Does your facility perform cosmetic procedures?
Our primary mission is reconstructive surgery, not cosmetic. The population of patients that we manage falls into five major categories: cranio-facial trauma, lower extremity trauma, burns, cancer reconstruction and complex wound coverage.

When someone find out where I work, their usual response is, “Do you know a good doctor for my tummy tuck or Botox?” Many nurses will ask where they can be trained or connected with a plastic surgeon, which can be very lucrative employment. But I truly enjoy the long road of staged reconstruction, with its many detours. The impact of seeing someone walk after a near amputation, or a woman proudly wearing a new blouse after breast reconstruction brings me great happiness.
     
What are some of your responsibilities?
Much of my job includes indirect care, direct care and administrative responsibilities. Daily patient rounds with a plan of care is the focus. A major responsibility is the pre-operative work-up for patients, with frequent admissions, as well as coordination of surgical scheduling, ordering of diagnostic treatment and follow-up. Our service is very busy with requests for consultations related to wound management, salvage of limbs and complex lacerations. I have the privilege to follow patients pre-operatively, intra-operatively and post-operatively. I have also been trained as a registered nurse first assistant.

A vast majority of my scope is managing four major clinics: Plastics, Burns, Jail and Surgical Follow-Up. Patients come to the clinic for post-operative check-ups and initial evaluation of complex wounds and facial trauma. During this visit, a patient will be counseled about staged breast reconstruction, skin grafts, contracture release or muscle flap coverage. The clinic census may range from 10 to 40 patients per visit. Many of our patients will be followed for several years for completion of the reconstructive process. Because of the diversity of our patients, it is critical to be multilingual. I am of Hispanic descent and am completely bilingual.
    .
Is a great deal of specialized training required?
I was exclusively trained on the job by my attending staff and chief residents in the clinical setting. I have attended numerous conferences on our specialty. The American Society of Plastic Surgery conference is excellent. My continuing education has branched out to diabetes, pediatrics and advanced trauma, and I also obtained an esthetician license.

Are there professional associations in your area of specialty?
Yes. The American Society of Plastic Surgical Nursing is nationally recognized. They provide education on current trends, patient safety and legislative updates. Certification in this specialty is achievable.

How has technology changed your work over the years?

Many changes have occurred with wound management in the field of tissue engineering and stem cell research. Many products have changed, from dry gauze to silver-enhanced dressings and use of skin substitutes. The use of the microscope is pivotal for replantation of severed body parts and continues to be the workhorse of microsurgery. The use of implantable Dopplers to assess circulation of muscle flaps is also useful. As a group, we have become more research-based and very cost-conscious about new technology.
 
Can you share a patient anecdote with us that illustrates your work?
We are managing a 18-year-old female with a history of Ewing’s sarcoma of the breast who underwent a modified radical mastectomy at the age of 17. Having completed chemotherapy and radiation, she wanted to attend her first prom and wear a “fancy dress.”  She underwent mobilization of her latissimus dorsi muscle with placement of a tissue expander, which is a temporary breast implant. She returns on a weekly basis for the expander to be filled with normal saline through a small puncture in the skin. This process can take up to four months to achieve an adequate breast envelope. Granted, she will not be ready for a silicone implant in time for the prom, but she will have an esthetically pleasing temporary breast for her “fancy dress.” I will be following her for years.

Do you have further plans for your career?

Well, retirement is not in my vocabulary for now. I will continue to teach nursing at East Los Angeles College and precept NP students at UCLA. I would like to pursue development of a wound care center at our medical center. Who knows, I may even develop a wrinkle cream that really works! At the present time, this is a great place to work, and I love being paid for what I really love to do. Muchas gracias to the past, present and future attending staff and chief residents who have all made it possible. 

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OVERVIEW of PLASTIC & RECONSTRUCTIVE NURSING

Unlike other nursing specialties around which there is little confusion or ambiguity, many of us are likely to automatically picture the performing of procedures such as facelifts, liposuction, and tummy tucks when thinking about Plastic Surgery Nursing. While nurses are widely employed in practices offering such services, there is also a percentage of nurses (including our interviewee) who are involved in a much different form of plastic surgery related more closely to trauma than straightforward aesthetics (although aesthetics plays some role whenever we consider this particular specialty).

Nurses working in the field of plastic surgery or reconstructive nursing assist in the assessment and treatment of patients undergoing such procedures. This may involve pediatric reconstruction, burn recovery and grafting, facial reconstruction, pre-, post- and peri-surgical care, and a variety of settings including private offices and hospital-based surgical and trauma centers.

Only Registered Nurses can pursue employment in this specialty, and facilities may prefer candidates who have a surgical background.
Advanced Practice Nurses (APRNs) working in this specialty area may provide pre-operative, peri-operative and post-operative care for surgical patients, as well as long-term post-surgical follow-up.

Aesthetics
Some nurses who specialize in plastic surgery work in the field of aesthetic plastic surgery, assisting physicians who specialize in cosmetic surgical changes that serve to enhance or change the patient’s physical appearance. These nurses work closely with skilled surgeons in serving patients who are undergoing liposuction, Botox injections, facelifts, “tummy tucks”, and other cosmetic procedures. This type of plastic surgery is generally not covered by insurance and is paid for directly by the patient as an elective procedure without documentable medical benefit.

Bariatrics
Plastic surgery can also be involved in bariatric cases where patients have lost considerable weight following gastric bypass or other procedures. Massive weight loss generally results in a great deal of excess skin that can lead to breakdown, fungal infection and other complications. Plastic surgeons remove this extra tissue and help the patient to regain normal appearance and function following bariatric surgery. In most cases, this type of cosmetic intervention is covered by insurance due to its preventive nature and documentable benefits, despite the fact that there is also a significant cosmetic component to the surgical result.

Trauma and Reconstruction
As we have learned from our interviewee, another aspect of plastic surgery nursing is related to the recovery from trauma and disfiguring surgery. From bullet wounds and blunt trauma to mastectomies, burns and severed body parts, this form of plastic surgery serves a highly functional reconstructive purpose for many patients. Skin grafting, breast reconstruction, reattachment of severed limbs and facial trauma reconstruction are only a few aspects of what a nurse in this particular specialty will encounter.

Skills
Any nurses working in this specialty must have keen assessment skills. Burns, trauma and other disfigurement can easily lead to infection and other complications, and the nurse must be well-versed in these potential problems. Skin assessment is a particular area of interest to the plastic surgery nurse, thus the ability to provide detailed and accurate assessment of the integumentary system is essential.

For the advanced practice nurse in cosmetic or reconstructive surgery (like our interviewee), this specialty can provide a fascinating career that involves a high level of assessment skills, communication skills, and training to assist closely during surgical procedures. Follow-up with some patients may last for years, especially after breast reconstruction, so long-term nurse-patient relationships can be common.

In terms of patient relations, plastic surgery may involve recovery from disfiguring surgeries, accidents, trauma, violence, or other events. No matter the cause of the need for plastic surgery, the patient will doubtless present with fear, anxiety and a vast potential for knowledge deficit vis-à-vis the surgical and recovery processes, thus the nurse must be sensitive, compassionate, knowledgeable, and able to communicate clearly and effectively.

Salary
Salaries vary broadly due to the varied aspects of this specialty, including private plastic surgery practices that are not reimbursed by insurance and trauma facilities that provide reconstructive surgery. According to some websites, salaries generally range in between $50,000 and $60,000 for Registered Nurses in this field, although this will vary widely based on geographic location and facility. Advanced Practice Nurses employed in this specialty area can expect to earn considerably more, although this can also vary widely. 

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RESOURCES

As stated in the article, only Registered Nurses are employed within the field of Plastic Surgery Nursing, thus vocational nurses interested in this specialty area must pursue an Associates or Bachelors Degree.

Web resources:
American Society of Plastic Surgical Nurses: https://aspsn.org
Plastic Surgical Nursing Certification Board: http://psncb.org/
American Society of Plastic Surgeons: http://www.plasticsurgery.org/
American Academy of Cosmetic Surgery: http://www.cosmeticsurgery.org/

Nurses pursuing certification in the specialty of plastic surgery nursing must fulfill certain requirements prior to applying for the certification exam. The exam costs $195 for ASPSN members, and $295 for non-members. These requirements include:
•    Currently licensure as a registered nurse in the U.S. or Canada.
•    A minimum of 2 years of plastic surgical nursing experience (including general staff, administrative, research or teaching) within the previous 5 years.
•    A minimum of 50% of total practice hours spent within the specialty during 2 of the previous 5 years.

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Keith Carlson, RN, BSN, has worked as a nurse since 1996 and maintained the popular nursing blog Digital Doorway since 2005. He offers expert professional coaching for nurses and nursing students at www.nursekeith.com.
 

This article is from workingnurse.com.

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