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Sunday, October 07, 2001

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Are you ready for surgery?

Persons who need to be operated upon most often arrive at the table emotionally, physically and financially drained. DR. UMA KRISHNASWAMY suggests guidelines to help both the patient and the surgeon.

SURGICAL operations are performed for numerous reasons in varying situations and facilities, electively, urgently or on an emergency basis. Fortunately, elective operations are the most common and this gives one time to prepare physically, emotionally, legally and financially for the procedure.

Driven by stress and well meaning, but not always well-informed, family members and friends, many patients spend the waiting period in a futile manner having unnecessary tests and seeking multiple professional opinions. They finally arrive at the operating table emotionally, physically and economically depleted. What should one do when faced with surgery? How does one tackle the doubts, the questions and the uncertainties? How does one annul or reduce the stress factor?

Once the decision to undergo surgery has been taken, one must obtain clear and unambiguous answers to the following questions (some may be irrelevant to the individual patient) from the surgeon:

Will the surgery improve my health or quality of life?

Who is the operating surgeon?

What presurgical tests will I need?

When and where is it scheduled?

Will the surgery be an outpatient or an inpatient procedure?

Is it a major or minor procedure?

Where will the incision be and what sort of scar can I expect?

Is it a well established operation with a good success rate?

What are the possible common complications?

Are there any factors in my health that make it unsafe?

Will I need a blood transfusion? If so, what is the hospital policy on safe transfusion?

What anaesthesia will I have: general, regional or local?

Who is the anaesthetist and when will I meet him/her?

What can I expect during recovery?

Will I need intensive care after surgery?

When can I resume normal activities?

What is the normal period of convalescence?

Will there be any permanent restriction in my life style?

Will I need further medical treatment or further surgeries in future?

What is the policy on stay, attendants and visitors?

What are the financial implications and what is the modality of payment?

Once the pre-operative investigations are ready, an anaesthetic assessment will be done by the anaesthetist to plan the anaesthesia suitable for the individual and the particular operation. One must be prepared to discuss the following with the anaesthetist clearly and honestly:

Allergies to medication.

Past and current illnesses.

Medications usually taken (prescribed or self administered).

Tetanus immune status.

Previous surgeries and any related problems.

Previous anaesthesia and any related problems.

Anaesthesia related problems experienced by blood relatives.

Tobacco, alcohol usage or substance abuse (including illegal drugs).

Dental work (dentures or cosmetic dentistry).

At the end of the assessment, the anaesthetist will give instructions on:

The time eating and drinking must be stopped prior to surgery.

The time one must report to the hospital.

The team member who will receive the patient.

Use of medication in the pre operative and immediate post operative period.

The type of anaesthesia, its safety and side-effects.

Post operative pain relief.

Intensive care details (if appropriate).

Once these tasks are completed, the patient must prepare physically, emotionally, legally and financially for the operation.

Physical preparation:

Stopping tobacco and alcohol use as early as possible before surgery.

Eating a well balanced diet with plenty of Vitamin C rich foods or adhering strictly to any diet prescribed.

Regular exercise such as walking.

Practicing deep breathing exercises.

Adhering to the correct doses of medications prescribed.

Avoiding aspirin and similar medication one week before surgery. If unavoidable, inform the surgeon.

Informing the surgeon if fever, cold or an allergic rash develops.

Arranging transport to and from the hospital.

Arranging for a responsible family member or friend to accompany one to hospital.

Readying the home with a bed on the ground floor if forbidden to climb stairs.

Arranging for appropriate food and help to be available at home.

Emotional preparation:

This involves the use of relaxation therapies to combat stress. These may include: deep breathing, yoga, tai chi, positive thinking and visualisation. Stress may have an adverse effect on blood pressure, diabetes and angina. It may depress the immune system, lead to headaches, irritability and tiredness. Emotional preparation is also advocated for immediate family members whose stress levels may lead to tensions which affect the patient.

Legal preparation:

Informed consent and signing the relevant forms (which vary from surgeon to surgeon and hospital to hospital in terms of content) is a vital task. Some general rules to be followed in this context include:

The consent form should be signed well ahead of the day of surgery.

It must be signed in an unhurried manner after understanding the implications in the language of one's choice.

The consent is best obtained by the operating surgeon or a designated member of the surgical team.

In high risk situations, some anaesthetists will obtain separate consent.

The form must be countersigned by the operating surgeon or a designated member of the surgical team.

It should be countersigned by the spouse or a responsible family member or friend.

In the West, it is now increasingly common practice for patients to draw up advance directives after discussion with one's surgeon and advocate, particularly when undergoing surgery for potentially fatal conditions. Advance directives are a set of instructions on health care decisions if one cannot speak for oneself in the future, eg. a comatose patient.

A simpler alternative is for the patient to nominate a level headed and responsible individual (preferably one who has countersigned the consent form) as the designated spokesperson who will interact as a decision maker with the surgeon after surgery. Most communication problems between patient and surgeon arise from well meaning family or friends who demand individual updates from the busy surgeon as a right and who insist on having a say in patient management.

Financial preparation is a must to avoid a major source of stress. It is common practice for many families to reduce themselves to penury to treat a family member at a "specialist" centre, particularly for life threatening illnesses such as cancer or organ failure. One must work out an estimate of costs inclusive of:

current surgery

loss of earnings during surgery and convalescence

future medical or surgical treatment

follow up visits to the surgeon

follow up investigations

travel

living costs incurred by stay - attendant, etc

The acceptable mode of payment (cash, cheque, credit card and insurance coverage) in the private sector of medicine may vary from surgeon to surgeon and institution to institution. Reimbursement forms must be clearly filled and submitted to the surgeon or institution for validation along with bills and receipts.

A well-informed and positive approach to surgery removes stress and paves the way to a smooth and speedy recovery. While these suggestions are primarily intended as patient guidelines, it should be noted that they are equally valid as practice guidelines for surgeons, particularly because, written guidelines on standards of surgical practice do not exist in India at a national level. Is it not time that this deficiency is addressed?

* * *

Pre operative preparation - diet an activity

* Fats and sweets - eat sparingly (weekly)

* Dairy products, beans, nuts (poultry, fish etc) 2-3 servings (daily)

* Fruits and vegetables 3-5 servings Rice, wheat and grains 6-11 servings (daily)

* Walking, meditation Leg and shoulder exercises (daily)

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