Psychological Preparation

Imagine two different scenarios.  Patient being prepared for lumbar discectomy and has been prepared by his physician.  The patient has good family support with a satisfying occupation.  He also enjoys outdoor activities but is frustrated of the pain and disability imposed by the herniated disc.  Patient has not been depressed in the past and is looking forward to recover and return to a full functional life.  He undergoes surgery (discectomy) and is sent home to recover.  One week later he looks forward to returning to work.  To begin his outdoor and sport activities, he begins a physical therapy program and within one month is able to play golf.  Undoubtedly his healthy mental status contributed a great deal to his healing process.  His motivation to improve lead to full participation in physical therapy.  He also reached to his family for support and was looking forward for return to socializing with family and friends.  The second scenario involves the same medical condition in a patient that has a history of depression and also frustrated by his condition.  However, the patient works in a stressful office and is in constant battle with his employer.  The patient is also overweight since he does not participate in any sport activities.  His spine condition also provides him a mean to get attention from other family members and get special treatment at work.  This patient too undergoes an operation to remove the herniated disc failure of conservative treatment.  He wishes to stay in the hospital since he has no family support and is anxious to be home alone because he does not trust in himself.  He is discharged home after two or three days.  The patient requests to stay off work for a few months since his job is not satisfying secondly he is getting paid while laying at home.  He does not realize that his absence from work is de-conditioning his body and lowers his endurance.  He also continues down the path of depression which lowers his motivation in physical therapy.  He further gains weight and gets more depressed.  The cycle continues and his mental status keeps his back pain in place.

Very often we get surprised by patients that recover very quickly from very large operative procedures.  We compare these patients to others and the only difference is their mental status, attitude, and motivation.  Undoubtedly, metal well being contributes to faster recover with better results.  The mechanism that this works is still unknown, but it is without question that worst results are seen in depressed patients, people unhappy with their work, lack of family support, sedentary life styles, and lack of motivation.

The role of education regarding the disease process and treatment options resolves a great deal of anxiety.  It gives some control back to the patient elevating confidence and reducing the feelings of frustration.  Realistic goal setting is of outmost importance since it places the patient on a track to improvement and eliminates guess work.  Depressive episodes that may ensue from lack of hope may resolve by these realistic goal settings and may actually prove to make the difference between a motivated patient or the one that is waiting for a miracle.

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Inpatient Surgery

Inpatient surgery refers to surgery that requires a hospital stay after completion of the procedure.  After the procedure the patient is admitted to the hospital for several reason.  The intensity of pain following most procedures is known to the surgeon based on past experience.  If the anticipated pain can not be controlled by oral pain medication and requires injectable medications, then the patient will benefit for the stay for pain control alone.  Secondly, activities of daily living may be difficult to perform following the operation and a professional staff of nurses and aids can help in these activities until the patient is self sufficient.  The patient will stay under the care of a network of staff members.  These will include your surgeon, internist, nurses, physical therapist, case managers, social workers,  nurses aids, and more.  As needed other departments such as radiology, nuclear medicine, or anesthesiology may be utilized.  

Pain control is of outmost importance.  As the advancement of medical technology continues, so does our ability to control pain.  The department of anesthesiology and pain management may provide a Patient Control Anesthesia (PCA) pump.  This is a device that can release a continuous flow of medications through an IV and then release an extra dose of medication when the patient pushes a button.  The pump can be programmed to release only a set amount of medication to avoid excessive release of medication and can record the amount of medication used by the patient.  This record can be examined by the physician which will direct him to adjust the doses according to the patients needs.   Patients are kept comfortable allowing them to rest.  While resting comfortably, patients usually do not push the provided button and ultimately only use the lowest amount of medication needed to keep comfortable.  This is the most efficient method of pain control while using the lowest amount of pain medication.

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Outpatient Surgery

The two categories of surgery are inpatient and outpatient surgery.  Inpatient surgery simply means that the patient is admitted to the hospital after the procedure.  Nursing care, pain medications, and support is provided while the patient remains in hospital and is discharged home when stabilized.  In contrast, outpatient surgery refers to procedures after which the patient is discharged home on the same day without a hospital stay.  Many patients prefer outpatient surgery since they return home on the same day and can recover in the comfort of their own home.  Usually, simpler, less pain generating procedures are performed on an outpatient basis.  After the procedure, patients are cared for in the recovery room.  Patients are kept there for one or two hours to stabilize and recover from the medications used during the procedure.  Patients are then discharged home with instructions specific for their diagnosis.  Narcotic pain medications may be prescribed and its important to avoid driving while on these medications.  Transportation arrangement should be made prior to the procedure since driving is prohibited after these procedures.  Call and make an appointment for one or two weeks after the procedure so that your physician can evaluate healing progress.  Common to all procedures is the risk of infections.  Common signs of infection include redness to the wound, increased warmth, increased pain, or fluid discharge from the wound.  Inform you physician as soon as any of these signs are present.  Your physician can evaluate these wounds and initiate appropriate treatment if necessary. 

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Blood Transfusions

Most surgeries don't require blood transfusions and most surgeons will try to avoid these transfusions if possible.  However, if you absolutely need a transfusion several options exist that you should be aware of.  The patient always has a right to refuse a blood transfusion, but this decision may have life threatening consequences.  The information below will help and inform the patient in this decision making process.  This information is only a guide, but your physician can provide you more information regarding timelines and procedures.

Before beginning this page some terms need to be clarified.  Autologus blood means using your own blood. In cases that blood loss is anticipated, the patient  may choose to donate their own blood prior to surgery so that in case a blood transfusion is needed the patients own blood can be used.

Some points are important to remember.  If blood is donated before the operation, the patients blood will be used first.  However, if more blood transfusions are needed Volunteer donated blood must be used.  When requesting a family member to donate blood, one should never pressure them to donate blood.  They may have a disease not known to other family members and pressuring them to donate  may create an unfavorable situation.  If blood is donated by a family member, it may have to be irradiated to prevent certain biologic reactions.  Always remember, the safest blood is your own, use it when possible.  Other general consideration include medical conditions such as lung and heart disorders.  Elderly patients can not tolerate low blood volumes compared with young healthy individuals with good heart function.  So the threshold of transfusion is lower with elderly patients compared with young individuals.