A Patient's Guide to Surgery

INTRODUCTION

This book is written for all surgical patients—past, present, and future. If you are like most people who learn they need surgery for the first time, you are unprepared for the experience and frightened about going under the knife. Our intention is not only to help you prepare for the experience and assuage some of your fears but also to improve your chances for a successful outcome and enable you to recover more swiftly.

These goals can best be achieved by giving you the information you need to actively participate in all the important decisions required for a favorable surgical experience. If you don’t take an active role in the surgical process, others will make the decisions that may be of critical importance to you. Although these decisions will be based on their ideas of what’s best, even well-intentioned decisions by others may not be right for you.

Fortunately, the overwhelming majority of surgical operations performed in the United States each year are not emergencies; you can therefore take the opportunity to improve your chances for a successful surgical outcome by preparing yourself in advance.

Preparing yourself for surgery requires some of the same skills you use when making decisions about other aspects of daily life. You may have had to learn something about auto mechanics, gardening, home repair, or a host of other things: Does your transmission really need to be replaced? Can your lawn be saved? Should you invest in stocks now? If you’re a conscientious consumer, you inform yourself on the topic and then hire advisers to help you make the right decisions. The decisions you need to make about surgery can be among the most important you’ll ever make, and for these difficult choices you need absolutely reliable information.

This information may involve the quality of surgeons available in a prepaid health plan, so you can make an intelligent choice among competing plans. It’s not enough just to compare costs—you need to evaluate the qualifications of the physicians themselves. Of course, financial considerations are a strong secondary concern.

It is an unfortunate truth that inadequate and inappropriate surgery is performed every day in this country. In just one year, surgeons have operated on the wrong eye, the wrong leg, the wrong side of the brain, and even the wrong patient. Although it’s true such inexcusable incidents are rare, the fact remains that they do happen and they could happen to you. Without question, there are bad surgeons at work. Fortunately, you or someone close to you may be able to avoid them. This can be accomplished by working closely with your family doctor (or even by yourself, if you so choose) to materially affect many of the decisions regarding a proposed operation.

In these pages you’ll learn how to evaluate alternatives to surgery, why preoperative testing is necessary, how to choose a surgeon and the appropriate form of anesthesia, what the day of surgery is like, what you can and cannot expect from surgery, how quality control in surgery is maintained, and many other considerations of critical importance.

With this book you can also remove the shroud of mystery that envelops the surgical experience and the profession of surgery. Best of all, armed with the information contained in this book, you may be able to save yourself, or those you love, from the considerable suffering and expense of a bad surgical experience.

WHY YOU NEED THIS BOOK

In 1992, more than 25 million Americans underwent surgery. Statistically speaking, your chances of having an operation this year are roughly 1 in 10. Fortunately, 4 out of every 5 operations performed in the United States are not emergency procedures. This means that there’s usually plenty of time before an operation must be scheduled in which to consider your options and improve your chances for successful surgery by learning something about surgery and surgeons.

There are a few things people can do to improve their overall physical health. We all know the basic ones: eat a low-cholesterol diet, drink alcohol in moderation, cut out all tobacco, and exercise regularly. Now you can add another to this list: Protect yourself from bad surgery.

Do you really need to protect yourself? In a 1990 study of more than 30,000 patients randomly chosen from 51 New York State hospitals, researchers found that 4 out of every 100 patients were actually harmed while under care in the hospital. Of those who were harmed, 14 percent died as a result of negligence and more than half of those harmed were victims of surgical errors.

SURGERY IS AN ART, NOT A SCIENCE

Be assured that the overwhelming majority of surgeons are competent and dedicated. But what if you’re unlucky enough to find a bad one?

Despite constant effort, a great deal of surgery remains an art rather than a science. The word science is derived from the Latin word meaning to know. However, in the everyday practice of surgery, many decisions must be made without knowing absolutely that the decision is the correct one. This is because so much remains unknown about the human body and how it reacts to illness and injury. Surgeons fill in the gaps in scientific knowledge with educated guesses based on their experience. Those guesses are called surgical judgment. It is in the application of surgical judgment that a large part of surgery becomes an art.

Of course, the better surgeons have more control over the science aspect, which helps them to reach correct judgments. But only when both scientific knowledge and surgical judgment are properly applied to the care of patients are the best results achieved.

THE LOGIC OF SURGICAL ERRORS

Most of the bad surgery performed in this country is far less dramatic than glaringly obvious mistakes, such as operating on the wrong patient or the wrong limb. The principal dangers encountered by American patients are much more insidious and therefore even more dangerous.

When a surgeon selects and performs one of several available surgical procedures, there are four possible outcomes for the patient:

1. The right operation performed well

2. The right operation performed badly

3. The wrong operation performed well

4. The wrong operation performed badly

In only one case (the right operation performed well) will the patient have the best result. Even if the surgical procedure chosen for a given condition is the correct one, a patient may be subjected to dangerous complications if the technical performance is inadequate.

On the other hand, if the wrong surgical procedure is chosen, it really doesn’t matter how much technical skill goes into the performance: The patient will still not get well. The worst of all possible worlds, of course, is to have the wrong operation done poorly. Thus, in three ways out of four it’s possible for the surgeon to err and for your surgery to be unsuccessful. All of these examples are errors of commission—choosing the wrong operation or performing it poorly. Many such errors may be hidden—for example, persistent symptoms after surgery may be attributed to continuation of the underlying disease process, whereas in reality they were caused by inadequate operative technique—and not all are as obvious as operating on the wrong patient.

In addition to the errors of commission, however, there are almost limitless possibilities for errors of omission. These are even less obvious and more difficult to detect than errors of commission. Failure to correctly diagnose and operate on a perforated ulcer by mistaking it for intestinal flu, or neglecting to examine the breasts of a patient who is later found to have breast cancer, are but two examples of errors of omission.

In short, there are many opportunities for a surgeon to err; the success of your operation depends to a large part on everything being done correctly.

Your risk from surgery can be considerably improved by avoiding the bad surgeons. If you can do just that, you can significantly improve your chances of staying alive and having a successful surgical procedure. Practically speaking, how can this be done? And even if you could avoid the bad surgeons, would you be satisfied with a mediocre surgeon? Don’t you want the best?

One of the purposes of this book is to guide you in your selection of a surgeon. By giving you practical information on what to expect and what to look for, this book will help you to recognize a good surgeon and, if necessary, to find that surgeon yourself.

Unfortunately, finding a good surgeon is not all you have to worry about. Many professionals and support personnel must come together to forge a positive result. Physicians, surgeons, anesthesiologists, nurses, technicians, therapists, hospital administrators, and support personnel all work in concert to achieve one goal: your recovery. So although the surgeon plays a very important role in your surgical experience, the actions of the others also materially affect the outcome. When you finish this book, you will understand how each of these professionals fits into the surgical experience and what is the scope of their individual responsibilities. Finally, in addition to learning how to interact with your doctors and to play an active, informed role in your operation and recovery, you’ll be better able to avoid needless surgery.

1

AN OVERVIEW OF SURGERY

Surgery, from the Latin word chirurgia (in turn from the Greek, cheir, hand, and ergon, work), literally means handiwork. Simply put, it’s the treatment of disease by use of the hand. Yet the discipline of surgery would be useless if it weren’t for the innate ability of human tissue to heal. Imagine for a moment: Without that healing ability, the slightest injury or disease would result, at the very least, in a lifelong defect.

HISTORY

Despite the intrinsic biological advantage afforded by healing, the development of surgery as a useful method of treatment was hindered throughout history by the presence of two major limitations:

• Pain (designed for the protection of the organism)

• Infection, the ancient nemesis of surgery, with its attendant high mortality rate

Nonetheless, surgery has been practiced for thousands of years. Physical evidence of surgical procedures actually precedes recorded history. Archaeologists have found examples of healed fractures in prehistoric human bones, suggesting setting and splinting by primitive orthopedists. Skulls from the Neolithic period (10,000–7,000 B.C.) have been found with sections surgically removed (trepanation), a forerunner of modern skull decompression for head injury.

The first recorded surgical procedures—the Edwin Smith Papyrus (1600 B.C.), in which the care of 48 patients with various traumatic wounds is described—came from ancient Egypt. Quality control for surgeons was strictly maintained in those times. Surgeons must have selected their patients very carefully, refusing all risky cases, since Babylonian law called for removal of the surgeon’s right hand if a patient died. (By comparison, today’s malpractice suits seem mere annoyances.)

Primarily because of pain and infection, the full development of surgery as a useful method for the treatment of disease was delayed for more than 3,000 years. For all practical purposes, ancient surgical operations were restricted to lesions near the surface of the body. By the time of the Middle Ages, surgery had fallen into the hands of magicians, spell-casters, charlatans, and poorly educated but well-meaning practitioners. These surgical practitioners learned their limited craft in groups known as guilds, the forerunners of modern trade unions. The guilds were mutually exclusive trade schools composed of individuals with similar professional interests. Since sharp tools were required by barbers as well as surgeons, the graduates of this particular guild performed both functions interchangeably. They were known as barber-surgeons. In fact, the red stripes on a barber pole actually represent the ancient advertisement for bloodletting. Barber-surgeons were referred to as Mister, in order to further distance them from the real doctors, graduates of universities. As a result of this tradition, English surgeons even today are called Mister rather than Doctor. Itinerant graduates of this guild roamed Europe with occasional success, but more often wreaking havoc upon a helpless populace who had few alternatives. In the hands of such uninformed, undisciplined, and often unsavory practitioners, surgery fell into widespread disrepute. The term barber-surgeon remained an epithet for centuries.

With the discovery of ether as a general anesthetic agent by Crawford Long of Georgia in 1842, a major limitation was removed from the future development of surgery. No longer was it necessary for surgeons to operate with unsafe haste so as to reduce the magnitude and duration of pain. Operations could now be performed even inside the body.

The second landmark development in the history of surgery was the discovery by Louis Pasteur in 1865 that bacteria were the cause of surgical infections. It remained for Joseph Lister in Scotland to describe antiseptic surgery in 1867. By using a spray of carbolic acid on surgical instruments, the surgeons’ hands, and surgical wounds, infection rates were substantially reduced.

But the twentieth century has witnessed the greatest strides in medical and surgical progress. New and better operative procedures are being developed and studied with increasing frequency. Today we live in an era of dynamic change in surgical techniques in which everyone can benefit.

WHAT DOES