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POOR SURGICAL
RISK
“He says that the MIR shows that I
got herninated discus in my lower lumbar...and I reckon he said he
plans to take `em out and put plastic ones in.” (sic)
Defining the Patient
For
the purposes of this discussion, we are not talking about patients
facing elective surgical decisions or life-threatening surgical
emergencies. We are discussing the patient who, during the course of
post-injury care, is told that conservative measures have been
exhausted and that an invasive procedure is now indicated.
To the clinician, the surgical course
and direction may seem quite clear. To the patient, however, this
decision will likely be problematic, complex and fraught with fear,
anxiety, and anticipatory dread.
Determining surgical candidacy requires
examining the patient’s physical condition (the surgical need) and
psychological preparedness (the post-surgical risk).
The Psychodynamics of the Patient
Our focus will be exclusively upon
those patients for whom surgery is necessitated by a work-related
injury and/or those who have been in a motor vehicle accident.
Although many accidents and injuries
involve some error on the part of the injured person, very few
patients are philosophical enough to state the obvious: “I fell...I
fell at work...but I wasn’t paying attention, and I could have just
as easily fallen at home, in the store, or walking down the street”.
Instead, they are very descriptive
about how they see others as having been responsible for their injury,
how negatively they feel about the immediate care they received, and
how they feel about what they feel has been lack of employer support.
And, despite the risk factors inherent
in some forms of dangerous employment, few individuals report that
they expected that their work would ultimately lead to injury or that
taking a specific route to work could lead to MVA and injury.
Resentment And Blame
For many patients, the
occurrence of an injury and its aftermath are characterized by
withdrawal of support from employer and excessive nurturance from the
family. The human being is a blameful creature. If unable to attribute
the injury to the carelessness and negligence of others, the patient
will often become blameful of self. Thus, whether angry or depressed,
respectively, the patient may be unable to separate between that which
has already occurred and that which must now occur.
Preparedness
Most people lead uneventful lives and
neglect their health until something forces them to confront a change.
Those confrontations which emerge as a result of injury impact a
patient who exists chiefly in a state of unpreparedness and naivete.
When injury does occur, most people can
accept that there must be health care intervention, perhaps a trip to
the emergency room; perhaps being x-rayed, sutured or placed in a
cast. They are not prepared for extended recuperative periods and/or a
permanent compromise in function despite receiving the best of care.
The concept of surgery, while
understandably not intimidating to the surgeon, can impart to the
patient that, at least for some time period, he/she will be out of
control, uncomfortable, dependent and obedient. The patient will be
controlled by many people, many of whom are strangers and will be
exposed to both uncomfortable and, at times, both intimidating and
embarrassing situations. Privacy will cease to exist and immediate
availability of friends and family may not exist.
Despite adequate pre-surgical education
of the patient, when surgery is discussed, the now anxious patient
quite often ceases to incorporate data. The patient may hear little of
what was explained, understand little of what is to occur, and be
quite unprepared to function effectively in the surgical patient role.
Fear and Loathing
Many patients feel they have great pain
tolerance. In reality, most are unprepared for pre– or post-surgical
pain. They fear becoming dependent upon family. They either fear
becoming dependent upon analgesia, or they rapidly become reliant upon
medication which then dysregulates their mood, disrupts their
relationships, and may make them the bane of their surgeon’s
existence with endless requests for increasing dosages or seeking
medication from multiple providers.
Maladaptive and Addictive Health
Behaviors
A very significant roadblock to
recovery is the counterproductive habits and behaviors in which
patients engage. Consider the patient who needs a cervical or lumbar
fusion but continues to smoke after being told that this will impede
bone regeneration. Or the morbidly obese patient who has a torn
meniscus and needs his knee repaired but continues to binge eat and
fails to exercise. It is not a coincidence that many patients who
describe themselves as extremely anxious and unable to sleep are also
addicted to caffeine in the form of colas, coffee or tea.
Addictive behaviors are not confined to
alcoholism and drug abuse, although these disorders are seen with
great
frequency among injured workers. Any
behavior which prevents healing needs to be identified and
aggressively
Addressed. If the patient feels unable
to curb intake prior to surgery, they will be even less able to do so
afterwards.
In the immediate or acute period after
injury, everyone expects that pain will be at a peak and most
clinicians medicate accordingly. To the patient, there really is no
reason to expect that control of pain is on the immediate horizon.
They do not see that their tolerance to dosages is increasing, or that
their irritability and depression is correlated to the side effects of
their narcotics, as is inability to sleep and problems with headaches
and constipation.
Family members will often intervene
between the patient and the healthcare system, assuming responsibility
for filling out history forms, making telephone calls, and speaking
for the patient in office visits. And very importantly, this same
process repeats itself after surgery.
Additionally, patients are rarely
forthcoming about past or current addictive behaviors, including
alcohol intake.
The Determination of Poor Surgical Risk
Issues of expectancy and preparedness
are not solely concerns for the patient. The surgeon needs to know
what to expect from the patient and to be prepared for that patient’s
pre– and post-surgical responses. Increasingly, surgeons seek an
objective assessment of the patient’s psychological functioning:
fears, perceptions, beliefs, depth of understanding, and self-
responsibility for rehabilitation. This includes the planned
medication schedule and its goals. Without such a formal patient
assessment, we are falsely assuming we can operate upon patients
without knowing what operates within them.
DBA
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