Wednesday, March 14, 2007
Walk and Water
Ambulation and hydration; the most important parts of post-operative care. Time was, people were kept flat in bed for a couple of weeks after major abdominal surgery. I've always assumed it was because in the days of crummy suture material, there was fear of people tripping over their guts if they got up. I can see where that'd be counterproductive. Send the wrong signal, as they say.
In any case, pneumonia and blood clots -- the handmaidens of bed rest -- were just part of the deal for those subjected to it, and they claimed a lot of lives in the surgical patients of yore. I'm old enough that in my training there was at least one surgeon old enough to require his patients to stay supine for days on end (he's the one, in my book, over whom I fantasized about a beating in the parking lot. He was so frail I think I could have taken him.) Anyhow, I obsessed over getting people up and watering them down. On the one hand, I thoroughly believe it played a major role in the fact that my major surgical patients tended to recover smoothly; on the other, I think I drove the nurses crazy.
"Ambulate q.i.d. (walk four times a day) starting this evening" was part of my routine post-op orders. Realizing nurses had more to do than escort my patients, I figured if I said four times, they'd be gotten up at least twice. And I'd check the IV rates and the recorded input each shift, having generally written for a comparatively high-volume amount. For a patient already in the hospital, and scheduled for surgery, I'd write an order for ambulation twice around the halls before going down to the OR. When patients were significantly behind on their IVs (no one but surgeons understands the enormous fluid requirements of the early post-op patient: inadequate replacement predisposes, among other things, to clots), or if they weren't being walked around, I let people know. These are by far the two most important things in a patient's recovery, I told them. Most of the nurses -- especially the ones that had been around a while -- bought into it.
One thing that facilitated early ambulation was that I used a ton of long-acting local anesthetic in all my incisions, no matter the size or location. For that reason, my patients were pretty close to pain-free for eight to twelve hours after they woke up. That's when I wanted them first up and out of bed. The added benefit -- beyond that for their lungs and legs -- is that it got them off to a good psychological start (no data here: just a really strong impression that starting recovery off painlessly sends a very positive message): hey, whaddya know, I'm walking four hours after giving up half my colon! Parenthetically, I think it's much easier to maintain comfort starting from the painless state, than to achieve it starting from misery. When I started doing the wound-injecting for general anesthetics, no one else I knew of was doing it; in fact, some scoffed when I recommended it. Until the recovery room nurses kept asking them "how come Dr Schwab's patients are always so happy post-op, and yours aren't?" Whereas it's probably not universal, I think most surgeons numb their wounds before finishing up, nowadays. (I also toyed with, but didn't pursue, leaving a catheter in wounds for continuous infusion with local. There are now systems for doing just that.)
Today, most major-surgery patients are getting low-dose blood thinners right before the operation, and many are fitted with pneumatic pumps on their legs during and often after surgery to prevent blood clots. It's a step forward. But the incidence of blood clots had already gotten way low by the simple measures of getting up and watering down. Pneumonia right along with it. Life is really simple sometimes.
(The dog is Dutch, our grand-dog, a sweet and beautiful Chocolate Lab. He considers everything that moves a potential friend, and everything that doesn't a potential meal.)