Like anything else in life, advance planning pays off. Particularly in the case of surgery, the fewer surprises the better. In a previous post, we focused on how people can get ready physically and mentally to be in the best possible state of health for surgery. In this post we focus on some of the steps and processes before an operation. Some of these preparations can be performed by the patient and some will be required by the surgeon’s office and hospital.
In the setting of COVID-19, there will be new infection control protocols, designed to protect patients, health care workers and other hospital staff. As these new efforts roll out, you (and your visitors) can expect to encounter extra screenings and more complicated logistics. You will need a dose of patience and forbearance to navigate the hospital experience.
Do your research
Read up and get informed about your operation. The more you know, the better you will have the wherewithal to ask the best questions. Key issues to learn about include: realistic results to be expected, potential complications, pain management, duration of recovery, and rehabilitation requirements. Every individual patient will have a unique experience. However, finding out about how similar (age, condition, pre-existing illness) patients react to the type of surgery will be a helpful guide.
Find out who will be on the team in the operating room. Surgery functions as a team effort. Every member of the team has a role, including nurses, nurse practitioners, PAs and students. Who will do what? If your surgery will occur at a teaching hospital, will medical students or residents wield the scalpel? (You can say no.) Surgical PAs (physician assistants) and nurse anesthetists are frequently key members of the team, working closely with the surgeon and anesthesiologist.
Ask if the surgeon if they will be working more than one operating room at a time. In this scenario, an assistant starts (“opens” means the first cut with the scalpel) the surgery, the surgeon goes from room to room to supervise or participate in the complicated or delicate aspects of the operation, then leaves, and an assistant finishes (“closes” means stitching up the skin around the surgical wound). The more than one room scenario may occur in two different manners: concurrently or staggered. This is an area of hot debate among the surgical specialties. Some claim it increases efficiency, while others believe it adds significantly more risk for the patient. Nevertheless, it is reasonable to ask the surgeon if “running” more than one room is part of the plan for your surgery.
Anesthesia is a major component of the surgery experience. Typically, one meets with the anesthesiologist and other members of that team immediately before the surgery. However, if you have any special concerns about pain control, it is reasonable to obtain a separate consultation with the anesthesiologist any time before surgery.
Research rehabilitation facilities if you have been advised that you might need to go to one from the hospital before going home. Is it clean? Close to your home or near loved ones’ homes? What is the ratio of staff to patients? How often will you have therapies? The surgeon’s office may have some suggestions but we strongly advise that you visit in person to see for yourself.
Classes – Joint replacements (also called arthroplasty) are increasingly common. To help patients prepare for the surgery and its aftermath, many surgeons and medical centers require that patients attend a class or series of classes to learn what to expect during and after surgery such that expectations are realistically aligned with the peri-operative (the time around the surgery) period, recovery. and outcomes. These classes are a great opportunity to get answers to questions. Prepare questions in advance in writing, and record answers.
Closer to date of surgery
Presurgical testing (aka PST) or “surgical clearance” – Many surgeries require that you meet with a nurse or other provider before the operation to see if you are healthy enough to undergo the planned surgery. This visit typically occurs just a few days before the planned surgery. There is some variability in what tests will be administered, depending on the hospital, type of surgery and anesthesia planned. Vital signs will be measured (blood pressure, temperature, pulse) and an EKG will be administered. You will have been advised during pre-op counseling to hold off on some medications or begin other ones. During the clearance visit, you will have to answer questions pertaining to whether you have done so. You may also receive reminder phone calls. For some patients, the surgical clearance process will require more involved testing to determine if surgery and anesthesia will be safe for an individual, given the stress on the heart and lungs. Examples of further testing include stress testing, angiography, pulmonary function tests, and echocardiography.
I anticipate that your COVID-19 status will be assessed at this time as well.
This will be another opportunity to pose any remaining questions you might have.
Advance directives – If you have documents that explain your wishes should something catastrophic occur, it is important to have those with you. Equally, bring anything in writing about your designated health care proxy and their contact information. Knowing that a surgery is impending is an opportune time to make your wishes known in writing. It may be helpful to have these discussions with your primary care provider and close family members.
Designate key visitors and advocates – If possible, bring a friend or family member to advocate for you on the day of surgery and also when you emerge from anesthesia. This should be someone in whom you have confidence and who will be able to speak up in your stead if you are not feeling well. Make sure the surgeon’s office and hospital are aware that information can be shared with this individual and anyone else you designate. This sharing can occur in person or via telephone if loved ones are unable to be present.
Choose visitors in advance who will bring comfort. Put off others until you are home or ready to greet visitors. This is the time to take care of yourself and not worry about others. Be diplomatic but firm. Some individuals prefer to have many visitors after a surgery to distract, while others need time to heal quietly. This is a highly personal decision.
Plan what you will bring – Make a list well ahead of time to ensure you have everything you need for your inpatient stay. Hospitals will supply gowns, socks, toiletries and pillows but if you are particular about your comforts, plan on bringing your own items. Pack a separate bag for your key person to bring to you after surgery; books, music, electronics are examples. Put jewelry and other valuables in safe keeping and do not bring to the hospital. You will need your ID, however and any advance directive documents you have prepared.
Prepare the environment – Is your home ready to receive you after surgery? Will there be stairs, someone to look after you if you are not well or are unable to move around much? How will you get meals? Bathe? Will you need to set up a bed somewhere where you don’t have to climb stairs for initial time at home? If you are having orthopaedic surgery and will be on crutches, cane or walker, can you remove obstacles and throw rugs? Now is the time to organize rides to PT and follow up visits with your surgeon.
Right before/day of surgery
Follow instructions – In the days leading up to the operation you will have instructions about medications to start and medications to stop. It is important that you follow these instructions very carefully for your own safety. You will also have advice about when to stop eating and drinking prior to the surgery. NPO orders mean nothing by mouth. The one exception may be to take meds with a sip of water. (Ask the surgeon or staff about this.) You may be given a special soap to begin the cleaning process necessary to prevent infection through contamination. Along the same lines, it is also good idea to brush teeth very thoroughly before surgery.
At the hospital – Some people will be required to spend a night in the hospital just prior to surgery if there are special procedures or treatments necessary. Others will be directed to report to the hospital on the same day of surgery (called same day admit). Either way, you will be brought to the surgical holding area which is run by nursing staff, where you will change into special items for surgery to prevent germs from entering the surgical field (location on the body of the operation). The surgeon and team will check in with you as will the anesthesia team. The surgeon will mark the site of surgery and should put their initials on it. If for some reason they do not, you should feel comfortable asking them to do so. This is for your own protection. If you are in a teaching hospital, you may be visited by many individuals at different levels of training. It is important to remember that the attending surgeon and attending anesthesiologist are always in charge, no matter how helpful or self-assured trainees may appear. Nurses and PAs will be monitoring you at this point, placing an IV and ensuring that you are physically prepared for the operation. (The order in which the above occurs may be different, as will possibly the area in which you meet with the surgeon and anesthesiologist.) It is likely you will be transported to the operating room area on a gurney.
The wait – Your loved one(s) will likely wish you well at the door to the operating suites and will be directed to a waiting area. Possibly they will be given updates and/or a pager to alert them on your progress and end of surgery. It important that they know that there are sometimes delays to starting surgery, particularly as the day goes on. It can be as simple as the operating room must be cleaned, surgical instruments need to be supplied, or a key team member is stuck in traffic. When patients are given an estimate of the duration of the surgery, it may not include the prep time once patient arrives in the OR (antiseption of skin at surgical site, draping of sterile cloth, initiation of anesthesia — called induction). It can be tense time waiting for a loved to emerge from surgery; usually there is nothing to be concerned about.
The recovery room (PACU) – Most often the surgeon will come out of the OR to tell family members how the surgery went while the anesthesiologist brings the patient to the recovery area (post-anesthesia care unit or PACU). In the PACU, nurses monitor the vital signs of recovering patients and when it is determined that patients are stable, family members will be invited in to see the patient. The PACU is type of intensive care setting. Only when patients are found to be ready to go to a room will they be transitioned. Some surgeries necessitate transfer from the PACU to an ICU, however, patient and families will be informed of this in advance. In other cases, it will be determined after surgery that a patient requires the level of attention found in ICUs. No matter the unit or ward, patients will be closely followed after the surgery to ensure that recovery proceeds as expected and to intervene if complications ensue.
You CAN prepare physically, psychologically and practically for an elective surgery. You will come out ahead of the game if you approach your operation methodically and with a plan.