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.)


Annie said...

Just discovered your blog and have bookmarked it for daily reference!!! Kinda great to peek inside a surgeon's thought patterns, so thanks for taking the time to do this.

SeaSpray said...

You know Dr. Schwab - You have spoken to me right where I am at and I actually feel more reassured. I am still believing that I am not going to have to go down that road, but it truly helps to know what precautions will be taken if I do.

I often joke that ignorance is bliss or that a little bit of knowledge is dangerous, but really, your posts have been so informative and a blessing to me in many ways over the last few months and I just want to say thank you.

This past year I have been imagining the worst regarding a possible surgery and those thoughts colored my attitude to the point that I erroneously gave fear a place in my heart, which then affected so many things. Ugh! I really can't believe I allowed that to happen! Oh well, It is a waste of time to wallow in regrets. When we make mistakes, just rise up and walk forward with a good purpose in our heart and it will all work out in the end.

I remember how painful it was the 1st time I got up s/p c- section (classical incision)and the nurse was like a drill sergeant, informing me that it was going to hurt, but every time you do this it will hurt less and less. I appreciated her attitude and did exactly what she said and she was right.

In a surgeons perfect world, what would be beneficial for their patients to do a couple of months prior to surgery? Eat well, plenty of rest,exercise and a positive attitude? Anything else?

One of my favorite movies of all time is "It's a Wonderful Life" because I love how they presented the idea that we all make a difference in this world.

Certainly, Dr. Schwab, In your profession as a surgeon,with your book and this blog - you have sent forth many ripples of good that continue forward in your patients and your readers.

Your grand-dog Dutch is a beautiful dog. Our son and daughter-in-law have a beautiful chocolate lab (Lily)and they are sweet dogs.

Great post! :)

Larjmarj said...

It's convincing some of these older pt's that are raised on the "bedrest cures everything" way of thinking to actually get up out of bed. I'm an OT assistant, some days it's like pulling teeth.

Sid Schwab said...

annie: you're welcome! Come on back!

seaspray: you pretty much named the main things a person can do ahead of surgery (also: for smokers, STOP!!!) Walking is great exercise to do before surgery; regular and hefty distance.

Anonymous said...

Yep, we get pumps now-a-days. We get blood thinners until we puke blood and someone figures out we have a bleed! LOL. You do get up and around and start terrorizing the hospital asap. I agree, it is best. Used too they made you lay there for what seemed like weeks. You are so much less sore if you get your butt up and get moving. Also correct that most docs numb ya up good with a local. I am always thankful for that. It matters, you are right.

Anonymous said...

i gotta start moving, so i won't be mistaken for a meal:)


jmb said...

Hi Dr Sid,
You have received thisdubious award(well the award is not dubious, just the route it came by.) Ignore it as you will, no offence taken, just a mark of my esteem.

Anonymous said...

Maybe all surgeons where you live numb wounds but not where I live. Can you tell us your preferred local anesthetic, when you inject it, how much you give Many thanks and keep blogging...rural_obgyn

Sid Schwab said...

I used 1/4% bupivicaine, up to 1 cc/kg. After closing the peritoneum, I injected it or the fascia immediatley above it, depending on the nature of the incision; then below the various layers of fascia on the way up. I ignored the subcu, and did infiltrate the skin, but used most around the muscle layers. I stopped using it with epinephrine, only because if there were issues with tachycardia, etc, in the recovery room, I wanted to know it had nothing to do with the local. If you've never tried it, I think you'll be impressed with how comfortable the patients are on awaking, and how much more easy it is to maintain comfort.

Unknown said...

I stumbled across your blog and just wanted to give you a little insight into forethought on the patient's part. I have had several surgeries and after the first 2 as an adult, I refused to wake up screeming in pain in the pacu. So, for this last round, I made it very clear I wanted something a little different and asked for an epidural, hoping it would allow me to bypass the worst part and get going again. The word stop only exists in my life as a pace known as "spin tires on pavement". I am well aware of the risks of epidurals and blocks. It did exactly what I wanted it to do. Unfortunately, possibly due to placement, my right hip/leg was more or less temporarily but completely paralyzed and I could not move my left leg. All of these side effects completely resolved about 12 to 14 hours after the catheter was removed. Once it wore off, I was still impressed at how much difference it made. I was getting a combination of demerol and one of the long-acting caines at 8%. The place at which I recieve medical care doesn't particularly promote prophylaxis in post-op pain, just putting out the fire after flames are seen. Thanks for giving us your bird's eye view, lol.

Anonymous said...

I am Annette and a GP working in Sydney Australia. Surgery is one of my favourite subjects.
Thanks for taking the time to post your blogs. Its very educational to both patients and medical staff. I know how busy a surgeon is so I appreciate your time.
Regarding early ambulation post op, is there any problem if the patient walks around too much? Is there any real risk of pulling on the wound which may slow down healing?
Thank you very much and best wishes to you and your patients.


Sid Schwab said...

annette: except when there's a particular reason to worry about abnormal healing, I think the limit on ambulation ought to be pain and tiredness: it's possible to overdo it in terms of those things, which could delay recovery by not getting enough rest. But in the average situation it's pretty hard actually to damage a wound. Except in exceptional situations, I told patients they could do whatever they felt like as long as it didn't cause increased pain. I never gave "don't lift more than X pounds (kilos?" instructions. "Let your body tell you" was what I said.

Anonymous said...

Thank you very much for your answer. I believe common sense is still the best policy.
The reason I asked is I currently have a patient recuperating from a complicated appendicectomy where the appendix was gangrenous and had burst. There was also post op complication of cellulitis and localised wound abcess which the surgeon had to open up again to debrite. He now has a suction drain in situ. However he is a very heavy smoker ( 30-40 cigs /day ) and he has a phobia of hospital so he is constantly walking out of the ward to get outside for a smoke. He does feel increased pain after walking.
I am just wondering if his excessive smoking and walking are impeding on his healing rate. The operating surgeon did not seem to think so.


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