called “the itinerant surgeon.” Basically, he is the guy who “cuts” and runs. It probably evolved at the time when the surgeon was the only trained guy for many miles around and would go from town to town plying his craft, then leaving the patients in the care of a primary physician or a skilled nurse. If problems or complications arose, the followup personnel would have to handle them, sometimes with disastrous or even fatal outcomes!
Today's surgeon is expected to follow up on each of his cases himself or else sign out to a qualified partner or colleague who can handle any problem that might arise, and do it with about the same skill as the operating surgeon. In most cases this holds true, but there are some surgeons who are only interested in the “surgical case” and disappear after it is completed. I know a heart surgeon who is very busy, and after he finishes each case, he leaves the followup care to any other doctor on the case. Now, he is responsible enough to have a skilled backup person available, but the ethics of the situation are strange because he does not treat the patient as a whole, he just treats the heart. Nevertheless, he is a skillful surgeon and generally his patients do very well.
In one sense, he is doing his job as a technician, but in another, to my eyes, he is failing miserably as a physician. This, of course, is my own view, but I like to think of the physician, whether he be a heart surgeon, family practitioner, general surgeon, or other specialist, as a person who reflects a long tradition of concern and caring for the patient as a human being. And to this end he should be available and concerned for his patients, except when he is out of town or in some way incapacitated. Is that a big responsibility? Yes. But that is the responsibility each physician, in my humble opinion, takes when he completes his education and takes on the caring for the sick or injured.
So what does postoperative care mean? Of course, it means writing the appropriate postoperative orders for the patient, which includes some type of diet or, if the patient cannot eat, then intravenous fluids. It also includes pain management, such as intravenous or intramuscular Morphine, Demerol,and Dilaudid, and oral Vicodin, Percocet, or Tylenol. There may be need for antinausea medications, such as Compazine or Zofran, and the physician may want to check for bleeding or treat infection with one of the hundreds of available antibiotics such as Penicillin, Cephalosporin, and Erythromycin. There are also many appropriate blood tests to follow the patient's progress (see Chapter 25). The orders after major surgery usually include a plan for activity which may include being out of bed or bathroom privileges. The surgeon should take precautions to prevent pneumonia with breathing exercises, and pulmonary embolism (see Chapter 19), and to assure that emotional needs are met. The doctor should discuss the patient's surgery and the orders with the recovery room nurse, who will convey the information to the “floor” nurse. In the case of outpatient surgeries, the surgeon will usually discuss his findings with the patient and the family, and give written postoperative instructions and prescriptions for pain medications, antibiotics, and other medicines.
We will talk more about the postoperative care for specific surgeries in Part II of the book. The surgeon will need to follow the patient in his office for varying lengths of time in the recovery and postoperative period, and deal with any minor or major complications which may occur. This part of surgery is often the most pleasant for me and sometimes the most difficult if I am dealing with incurable cancer or complex problems. But that, to my understanding, is a major part of my being a physician. It is sad to see so many modern “itinerant surgeons” who have given up their role as comprehensive “healers” and have become mere skilled technicians. It reflects poorly on the profession and perhaps is one of the reasons physicians are not regarded with the high public esteem they had seventy-five years ago.
Postoperative care, like others aspects of surgery, is an art that unfortunately, has been given less attention in our hurried world with crowded clinics, HMO's, and volume-oriented specialists rather than individual patient-oriented physicians. Don't feel uncomfortable about asking your surgeon how often he will be visiting you after surgery or if he will be visiting at all, and for how many weeks or months you can rely upon him for any problems after the surgery is completed. After all, when you build a house or have plumbing work done, you expect your contractor or plumber to be around after the job in case problems arise. Expect at least this much from the person who is operating on your body!
Chapter 12
COMPLICATIONS
Though an earthling, made from sod,
The surgeon thinks he's just a god.
So if you mention complication,
He may ask what drugs you're takin’.
Crazy as it all may seem,
This perfect person cannot dream,
That in some way his operation,
Caused some major aberration.
Now I can tell he shouldn't oughter
Think that he can walk on water.
But you see the facts remain
He walks on water in his brain.
Okay. I hate to burst your bubble. But your surgeon is not a god, does not walk on water and unfortunately makes mistakes and has complications. Now, we should say at the outset that there are many causes of surgical complications, and actually very few are directly caused by surgeon error or incompetence. They are, of course, usually in direct proportion to the patient's overall health, the type, length and severity of the surgery, and a host of pre, intra and postoperative factors that we will discuss as briefly as possible. The ever-troubling question of the patient to the surgeon, “Why did I have that problem or complication?” should be answered by your surgeon as completely and simply as possible. Once a problem or complication arises, the patient may begin to lose faith in his doctor, and this can be prevented by careful and timely explanation.
First, I should emphasize that the surgeon must plan his surgery, and outline to the patient and his family the potential adverse events that can occur. I do not mean to frighten a patient who is already concerned about a procedure, but it is important that he have a realistic understanding of the possibility of problems, such as anesthetic problems, wound infection, or less-than-perfect surgical results.
The surgeon, of course, must plan carefully, have experience, be meticulous about procedural items and have minimal blood loss and a timely surgery. I have seen some surgeons who take three to four times as long as the average surgeon for a simple procedure, claiming that they are taking care not to let any complications occur, and yet the longer a patient is asleep, the greater the risk for anesthetic problems and the longer the exposure to microorganisms that could cause infection. Surgery should be done carefully, artfully, and swiftly for the best results! In the postoperative period, he should anticipate the potential problems as we have outlined in Chapter 11.
Now, let us go down the list of complications and problems with which the patient and the surgeon must contend. I emphasize the physician also because we surgeons do lose sleep worrying about problems and complications; it's not like changing a muffler on a car and then going on to the next repair!
The only true surgical emergency is hemorrhage. Of course, I am not minimizing all the medical problems such as cardiac arrest, respiratory arrest, or other acute medical emergencies. I am just stating that the purely surgical emergency is hemorrhage, and every surgeon is aware of this potential problem and knows he must handle it swiftly. When an artery is cut, the natural response is for it to constrict. Evolution has graciously given us a method for our bodies to stop minor bleeding by having the muscles in the artery wall cause the vessel to retract and constrict. During the short period of time that this occurs, the body's coagulation (clotting) system works to plug the open end of the artery so that, when the
