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Not In My House

Have you ever wondered how many surgeries are performed in one day in the United States? I have.

On the inpatient hospital side of the question, the total number of procedures performed in 2015 was 51.4 million. Included in these procedures were: Arteriography and angiocardiography using contrast material: 2.4 million; Cardiac catheterizations: 1.0 million; Endoscopy of small intestine with or without biopsy: 1.1 million; Endoscopy of large intestine with or without biopsy: 499,000; Diagnostic ultrasound: 1.1 million; Balloon angioplasty of coronary artery or coronary atherectomy: 500,000; Hysterectomy: 498,000; Cesarean section:1.3 million; Reduction of fracture: 671,000; Insertion of coronary artery stent: 454,000; Coronary artery bypass graft: 395,000; Total knee replacement: 719,000, and Total hip replacement: 332,000.

On the outpatient surgery performed in a freestanding surgery center, the statistics are a bit harder to access because there is no clearing house for such data. In 2006, freestanding surgery centers reported performing 14.9 million procedures during that year. Surgery rates in the United States are climbing for various reasons. If we just add the number of inpatient (2015) and freestanding procedures (2006) together, roughly 66.3 million or more procedures are performed on our American population each year. We have roughly 300 million Americans living in the United States. So, one in five persons are getting some kind of operation or procedure each and every day.

If we assume that there are 365 days during which these procedures are performed, 180,822 operations or procedures are performed each day. These are not exact numbers, but even in the roughest inaccurate form, one can see surgery is big business in the healthcare field.

The good news is that if we need surgery, we have the skilled surgeons to perform invasive procedures with relatively small complication rates. And many times, emergency surgery is needed, such as in the case of trauma from a bad car wreck or appendicitis. Those patients have to be taken to surgery with very little preparation other than intravenous antibiotics and possibly pain medication. In most cases, time is of the essence.

Elective procedures are a bit of a different kettle of fish. Why? Because there is time to make sure every aspect of the patient undergoing the procedure is in excellent health. Why is that important? To avoid post operative complications and possible revisions of the surgical procedure itself.

Most surgeons performing elective procedures require a medical clearance of some kind or another. There is no standard for the medical clearance process. The surgeon usually has an idea of what they would require, the anesthesiologist has an idea of what they would require, and the patient's treating physician has their understanding of what they would require. Not everyone is on the same page when it comes to medical clearance. One thing is for sure: if you or any of your loved ones were going to have an elective procedure done, you better make sure everything possible has been checked and rechecked before you or they go under the knife. Once a surgery has been performed, you cannot go back in time and adjust something that was missed preoperatively. And, your postoperative course may become the worse nightmare possible.

I am probably one of the most meticulous physicians in town when it comes to preoperative medical clearance. That has its benefits and its detriments. Recently we had a patient that needed hip replacement surgery. She was a frail woman who suffered from COPD. In addition, she had a chronic urinary tract infection(UTI) condition that required antibiotics from time to time. During our medical clearance, we discover she had another UTI. I deemed her medically unfit for surgery. She was furious that a little UTI would keep her from having the procedure done. I spoke directly with her orthopedic physician and his remarks were simple, "Thank you for being so careful. I will never operate on a patient with a UTI. The replacement hip could get infected. You saved all of us a hell of a lot of trouble."

With the use of antibiotics, the UTI cleared up. However the surgery was postponed for about one month. Despite my insistence that the patient remain in antibiotics, she decided to discontinue her course of treatment after we reported that her urine was clean on the retest for infection. As we approached her rescheduled surgery date, we retested her urine. She had another infection. I again found her unfit for surgery. The surgery was cancelled and rescheduled. She was again furious. However, her husband, an attorney, acknowledged that she did not follow my instructions. The surgery was rescheduled for one month. Her UTI cleared up on antibiotics.

People are creatures of habit. And, sometimes habits are very difficult to break. As we approached her surgery date, we retested her urine, the infection was back. I found her unfit for surgery. Her lawyer husband was exacerbated over the findings and assured me that she was going to have the surgery regardless of my belief that she was unfit for an elective hip replacement surgery. I left a message with her orthopedic physician about my disapproval of the proposed surgery based on her UTI again. In addition, I forwarded him a letter stating my concerns for her unfitness, apologized for the delays, and I stated that although I felt she was at risk for complications, I believed he (the surgeon) could form his own opinion and take the full risk himself. I was merely a consultant on her case.

The surgery was schedule for a Monday morning. I reported the unfitness on the Friday before the planned Monday surgery. Her husband remained confident that the surgery would go on as scheduled. The orthopedic surgeon's nursed called the patient and assured her that she was going to have the Monday morning surgery, and they would just give her an antibiotic infusion prior to her surgery to cover the possibility of wound infection. Her husband, the attorney, was confident that his wife finally would get the proper care from the orthopedic surgeon. He was sure I was being over cautious about her condition and the office nurse confirmed his suspicions.

At about ten o'clock in the evening on that Friday night, the orthopedic surgeon called the patient's husband. He was kind but firm. He apologized for his nurse's call during the afternoon since he was not aware of my letter to him. His nurse had reviewed it and made her decision about the best way to handle the situation. He did not agree with his nurse and cancelled the operation on Monday. He also told her husband that if his wife wanted him to perform the surgery, she better follow her doctor's orders and get her UTI cleared. The lawyer husband was speechless. The orthopedic surgeon told him that until I cleared her for surgery, she was an unworthy candidate from his perspective. He apologized for calling so late. He had been in the operating theater at St. Jude all day.

The husband called the office Monday morning. He confessed that his wife did not follow our instructions which would have kept her urine sterile for the surgery. We gave him the same instructions that we had given him three months prior, and he promised his wife would follow them. She did. Her UTI cleared up. She ultimately had the surgery and recovered without complication. The surgeon was happy, the patient was happy, her husband was happy, and I was happy.

Of the 66.3 million surgical procedures performed each year, I wonder how many sloppy medical clearances were done and the outcome of the surgery was profoundly negatively influenced by the lack of attention to the patient's unfitness for surgery? There were no statistics to reveal the answer to my question and I suspect we will never know. But, I know one thing about sloppy.

At the Stone Institute, as LeBron James would say, "Hell No! Not in my house!"

So if you need a medical clearance from me, don't count on going to surgery unless I say it's okay.


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