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DR. STEMMLER’S MONTHLY TEACHING ROUNDS

January, 2004

A Cut Above: Why, When and Where to go for Surgery

(COPYRIGHT STEMMLER, 2004)

Whenever surgery is mentioned, the first question should be why? Why cut it out? Are there other options? Once it is gone; it is usually an irreversible situation. I remember an older diabetic patient of mine, about fifteen years ago, who had developed an ulcer on her foot that was so severe, that it exposed her bone. My consulting surgeon had decided that her only option was an amputation. My patient was also physically impaired in that she had a speech defect, and appeared mentally retarded to the uneducated. Because of this defect she was disabled, and being unable to work, she was also poor. But she was a smart and charming woman, and was blessed to always be wheeled around by her loving, faithful boyfriend.

The night the surgeon talked to her about the amputation I was frantically called by the nurses near midnight, reporting that the patient had just had a grand mal seizure (her first ever major convulsion). I rushed to the hospital to find her a little drowsy after her seizure, but also quite agitated, repeating to me over and over, "I don't want to have my leg cut off!" I promised her that her leg would not be amputated, ordered some medications and returned home to do some thinking and research. I had just attended a conference a few weeks earlier at a hospital where a totally novel procedure had been developed to treat skin ulcers by bathing them in a newly discovered solution. Their success rates were very encouraging. I thought I would at least let the patient try this approach as an alternative to her amputation, since she had gone as far as having a seizure to avoid losing her leg. The surgeon just shook his head when I told him I would transfer the patient to that hospital, so that the patient could try the new treatment. Yet three months later, the surgeon shook his head once more, when I mailed him the pictures of the patient's foot, now 100% healed!

 

The second question when surgery is mentioned is when? It is always better to wait and think about it, if such a delay does not endanger the patient. But here again, beware of the businessman with an M.D. degree. They may urge you to go to surgery when there is really no urgency to do so. A good example is the number of patients I have seen over the years, who had "emergency hysterectomies" by the same local surgeon. All of these women just had benign fibroids yet, in the absence of any symptoms, they were taken to the hospital straight from the surgeon's office, and then to surgery the next morning. This surgeon had decided to expand the scope of his surgical practice to a family practice, although that had not been his original training. A patient would come in for a routine gynecological exam, and the doctor would suddenly frown while examining the uterus. "You've got a tumor there," he would say with a voice of grave concern. "We'll get you admitted right away for surgery." The patient would not even have a chance to go home and pack her gown and slippers, a book and a toothbrush. "No," the doctor would say, "we've got to take care of this right away.", and off they were rolled to the hospital next door. Nevertheless, many of these patients regarded this doctor as kind and concerned, never realizing that they had lost their chance for any further research, for a second and third opinion, or for simply saying no. Less than twenty-four hours later, they would wake up without a uterus and without their ovaries, thus further depending on this doctor for their long-term aftercare.

 

The third question to ask is where? Where and who go hand in hand. The surgeon diagnosing the condition may not necessarily be the best one to perform the surgery, and the hospital/s he uses may not be your first choice either. The surgeon's skills, experience and outcomes should be researched. If your condition is rare or complicated, you may be better off consulting an "expert" in your town, or even travel away from home to find the right physician for your problem. Here the Internet can be quite helpful. And of course, your physician advocate, if you have one, could give you wise suggestions. The hospital or medical center where your surgery should take place is just as important. You need top service, skilled and caring nursing personnel and good statistics of morbidity (illness) and mortality for the institution you choose. Successful surgery is not just about the surgical procedure alone, but also about the anesthesia, the pre-operative and post-operative care, and your long term follow up and post-operative quality of life.

So my general advice to you when you consider surgery is:

1) To always ask for options.
2) To take the necessary time to think about it.
3) To research your surgeon, his team and the hospital where he practices

Christina Stemmler, M.D.


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