It is 3:30 p.m. on a Wednesday, and I am bringing my last patient out of the operating room. Everyone is in great spirits: a smooth case and an early finish at our surgical center. The patient has already awakened, stretching his arms, and clearly comfortable.
“Everything went alright, doc?”
I smile, knowing that I will be repeating what I am about to say a few more times as the anesthesia wears off.
“Everything was terrific. I’m sure you’ll be happy to see the results of your procedure.”
I give my report to the recovery room nurse, finish my paperwork, and get ready to go home. Traffic in Los Angeles is pretty bad in general, and our early finish today gives our crew a chance to beat the rush hour traffic back home. After reviewing a plan for pain control with the patient, I start to gather my belongings and head towards the door. I stop by my patient’s bedside. His wife is already there. I give them my card.
“Please call me when you reach home. I’d like to know that you made it back safely.”
They look at me curiously, and he stutters, partly surprised. “… R-Really? I’ve had many surgeries, but no doctor has ever asked me that before!”
The operating room is one of the busiest areas in any health care setting. At many hospitals, more than 100 patients travel through the perioperative area every day, all sporting different issues and levels of consciousness. One rarely goes a few hours without hearing the word “turnover.” There is always an invisible pressure on our team to finish taking care of a patient as quickly as possible, only to shift our focus to the next one.
What happens when they leave the recovery room?
Patients are encouraged to have a family member or friend accompany them on the day of their procedure. It is mandatory that the patient leaves under the care of somebody after surgery if any sedative medications were given. The reasons for this policy are clear. Anesthetic medications can take several hours to completely clear out of our system, and it could be even longer in patients with diseases affecting the liver and kidney. These medications can make the patient drowsy for several hours after leaving the hospital, impairing their ability to think clearly. Thus, patients are told to avoid risky activities such as driving for the rest of the day. Fortunately, all of this information is discussed with the patient and family prior to leaving the hospital.
However, we make many assumptions about our patient the second we turn around and walk away from the bedside. We start our encounter with our patient, collecting tons of data on vital signs, making complex clinical decisions, but we finish our encounter unaware about how our patient will do in the coming hours and days.
We assume that our patients will have a smooth ride home. Traffic, accidents, and bumpy roads can be uncomfortable coming home from surgery, and many patients with nausea will need special medications and instructions to make it more tolerable.
Pain is usually controlled by the time the patient is ready to go home, but may get worse for the first 24-48 hours after the numbing pain medication has worn off. Many patients report chronic pain issues, and the combination of new and old prescriptions at home can be extremely dangerous.
In sicker patients, leftover anesthetic can lead to untoward side effects, and breathing issues can occur well after the procedure has finished and the anesthetic has worn off.
With more involved surgeries, there is a possibility of bleeding and blood pressure issues that may not be realized until the patient has left, or starts to feel ill.
I always take some time to explain these concerns and highlight the ones that I feel are most relevant for my patient. But how much information can we expect our drowsy patients to understand in the span of a couple of minutes?
During our residency training, we are required to follow-up with patients who stay in the hospital after surgery. This includes a list of questions about the patient’s well-being, including diet, activity level, pain control, and a review of any adverse events that occurred during the initial procedure. While many trainees will initially see this as “busy work,” this practice is very helpful in fostering a culture of follow-up, and provides critical feedback about the anesthetic that we have given. I believe that vigilance in the operating room goes hand in hand with the care that we provide for patients, well after we have completed our basic responsibilities as an anesthesiologist.
Fortunately, there are initiatives that are influencing a model that favors continuity of care and encourages follow-up with our patients.
The Physician Quality Reporting System (PQRS) encourages physicians to address a standardized list of items that are known to affect patient outcomes after surgery.
The Perioperative Surgical Home (PSH), from the American Society of Anesthesiologists (ASA), promotes a multidisciplinary team to follow a patient continuously after their procedure.
Innovative startups are focusing on the instructions that are given to a patient prior to leaving the hospital so that they are more easily accessible and easier to understand.
Later that evening, my phone rings; they’ve made it home safely after a long commute back home. It occurs to me that they could have been driving into the night had the procedure finished any later. Fortunately, all is well, and it doesn’t take long to go through my follow-up checklist: he’s laughing, playing with his son, and eating dinner. He’s bragging about not having any pain, so I talk to him about expectations for the next day and review his pain medications. Before getting off the phone, I tell him that it is OK to reach out to be with questions in the coming days.
Excellent. I think I’ll now be able to sleep a little bit better tonight.
Aalap Shah is an anesthesiologist.
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