I had originally planned for this post to continue with the previous discussion of the Pink Fog. However, Marcie had a surgical repair of her right rotator cuff last Thursday. From that experience l learned a few things that may be of value before your spouse has any type of surgery. These fresh thoughts seemed more relevant for this month’s post.
Marcie’s left shoulder had been repaired several years ago so we both knew some of what to expect. Consequently I decided not to go with her to her pre-operative visit. That was a mistake. Things have changed since then and this surgeon had different preferences. The most substantial change was in the equipment to be used for post-operative care.
I didn’t know that a sling for an arm could cost $1200. Yes, the two zeros is correct.
Last time the sling was a simple cloth holder with a strap to go around her neck. Almost anyone could help someone put it on. However, this new sling included multiple Velcro connected straps so it could be adjusted to fit her body perfectly. The problem was that I was not strong enough to easily break the Velcro seal on the straps and place them where needed. The first time I helped Marcie with the sling it took us 15 minutes to get it on.
While a nursing aid was putting Marcie’s new sling on after surgery, the nurse was showing me how to use a fancy ice bag contraption. This device consisted of a vinyl pad containing internal channels for ice water to run through. Ice and water were put into an insulated two quart cooler, connected to the pad by an insulated hose.
The pad fit over her shoulder and was attached by wide Velcro straps. The pad was lowered to fill it with water and raised to drain the water back into the cooler. The hose could be disconnected to allow her to walk around while keeping the iced pad in place.
This fancy new apparatus, and you might encounter others, had advantages but wasn’t without concerns. The biggest was understanding how to use it. For example, the Velcro straps used to hold the ice pack in place were not self-explanatory. A regular ice pack is usually applied to the incision and taped or held in place. Not so with this new gizmo.
Another issue with these new devices was that I wasn’t given the opportunity to practice using them while we were still in the hospital. Nursing standards require return demonstrations, which is not something we encountered before any of Marcie’s surgeries. Although I will admit I was comfortable with most of her care because of my nursing experience and didn’t have questions.
When reflecting on this recent experience where even I was uncomfortable at times I have arrived at a few suggestions. I strongly recommend you ask during the preoperative clinic visit for the chance to practice the skills you will need at home.
I propose you discuss this need with your wife’s surgeon ahead of that visit, maybe even before you decide on a surgeon. His or her reaction to your request will give you a sense of how they interact with their patients.
The justification for your proposal is that during this early visit your apprehension should not be as high as in the immediately post operative period. With less anxiety you will be better able to comprehend what you are being taught, resulting in better care for your spouse and ultimately fewer complications due to inadequate home care. This last point, reduction in complications, is the one which may have the greatest impact on your surgeon, even though it will be more work for their team.
Ice bags, suction bulbs to remove fluids from the surgical site, and dressings (bandages) are currently the most frequent equipment needed for patient care at home. Ice bags are common and will probably need the least instruction unless one of the complex contraptions as described above will be used. Information on how to measure the amount of fluid in the suction bulb, how to determine if the drain is still in place, where to dispose of the fluid, how to re-establish pressure, and how to attach the bulb to your spouse’s clothing are things that you should be taught regarding the use of this device. Practicing these skill is crucial for anxiety reduction.
Use of bandages is the item I’ve given the least attention to in the past but which has caused me the most consternation at home. I’m not an expert in this area. The gauze and tape being used today have changed since I practiced nursing. My biggest questions surrounded the best positioning of the gauze so as to covered the incision(s) completely and how to use the tape to keep it in place and not damage the surrounding skin.
These questions are not as simple as they sound once you are the only one at home caring for your spouse and seeing their incision for the first time. Having the opportunity to apply a bandage before there is an actual incision and before she is in pain should be helpful.
The next topic is one of my pet peeves, the requirement for preoperative fasting, (nothing to eat or drink after midnight). The American Society of Anesthesiologists (ASA) standards no longer require prolonged fasting for healthy patients1. However, for each of Marcie’s four surgeries in the last 16 months no one has discussed in detail the rationale for not using the new standards. These standards were published in 20171 and were reinforced in a 2023 article2, so should be well known.
This time I decided to push the issue, but not until after Marcie was out of recovery. I’ll admit by the time I considered this issue I hadn’t yet searched the research literature. I was afraid that without an understanding of the new standards I might irritate her anesthesiologist and delay her surgery. Because of this possibly irrational fear, I recommend having a discussion with your wife’s surgical team before you make your final decision on a surgeon. At this point in time you can consider if their awareness of and use of the 2017 standards matters in your selection of a surgeon, while also recognizing that fasting for 12 hours has its own risks such as discomfort, dehydration, and metabolic changes.
When I approached Marcie’s anesthesiologist after surgery I showed her the articles I had found and asked why she continue to require fasting from midnight onward. At first she assured me the hospital followed national anesthesia standards. I repeated that this requirement was no longer included in the published standards1. I had to again show her a copy of the standards, pointing out the title and authors of the article. She then asked if she could keep my copy.
If you don’t have access to the articles I reference below, I recommend you print out the reference list so the surgeon and anesthesiologist can access the original document. I also suggest printing out the following two statements from the standards:
Clear liquids may be ingested for up to 2 hours before procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia. These liquids should not include alcohol 1, p, 379.
A light meal or nonhuman milk may be ingested for up to 6 hours before elective procedures requiring general anesthesia, regional anesthesia, or procedural sedation and analgesia 1, P. 380.
Note that this information applies to any surgeries you, your spouse, or friends may be anticipating, not just gender affirming procedures. I know I don’t enjoy being fasting before surgery and plan to present this information to any caregiver I may need in the future. As always, be sure you discuss this with your surgeon, asking why they might disagree. However, I’ve been reminded that in the case of emergency surgery, surgeons don’t wait eight hours before taking a patient to surgery even if they had just eaten. Anesthesiologist are competent in dealing with the risks of aspiration in cases of recent food ingestion.
I will add that during my discussion the anesthesiologist said the hospital used the older standards because they wanted to be able to move patients around on the schedule, if a space opened up earlier. My perspective is that a patient may not want to be fasting for eight or more hours just in case an opening may appear. This approach appears to be hospital rather than patient centric. At the very least, the patient should be involved in the decision.
Thus I suggest you discuss this issue with your surgeon and/or anesthetist beforehand, maybe even before selecting a surgeon. One approach might be to ask them what ASA standards for preoperative fasting this use and the year of their publication.
A final concern I hadn’t considered before surgery was being asked to sign an agreement to pay for the cost of their expensive sling if insurance didn’t cover it. I had never encountered this before. This was particularly irritating because I wasn’t sure if I was agreeing to pay for the sling or the fancy cooler. I was just told all patients were asked to sign the form. I should have known better but the nurse was moving too fast for me to read the document (in small print, in triplicate, with costs only available on the back of the form) and ask questions. Besides, by the time the nurse asked me to sign the form the sling was already on Marcie’s arm and the cooler out of its wrapper.
I don’t consider this a true informed consent. I wasn’t given the reason for the complex sling but was too stressed to ask questions. I felt coerced into signing because the nurse didn’t describe why this sling was better (which it isn’t according to her physical therapist – although Marcie likes how it feels at times). I also didn’t want to be blamed for not giving Marcie the best care possible. She was still too sedated for me to consult her.
You won’t be asked about slings. However, you might be asked if you want some other new, fancy equipment such as the “ice bag” I described. My advice is that you ask at your preoperative visit, or earlier, if there is any equipment for which you will need to pay extra and why. I hadn’t seen this process before, but with costs rising and insurance companies restricting coverage, I wouldn’t be surprised if it became more common.
In summary I recommend that you attend the preoperative visit with your spouse. I suggest you question the surgical staff on preoperative fasting and extra costs you may encounter. Furthermore I suggest you insist on preoperative (not post operative) training on anything you will need to know to adequately care for your wife once she comes home. Go through the written patient instructions before you leave the clinic. Some are easier to understand than others. Being able to ask questions while you are not overly stressed and can take notes should increase your comfort level once you get home.
My next post will become available approximately July 1.
References
1An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration, (2017). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures, Anesthesiology, 126, 376-93. practice-guidelines-for-preoperative-fasting.pdf
2Marsman, M., Kappen, T., Vernooij, L. M., van der Hout, D. C., van Waes, J. A., & van Klei, W. A. (2023). Association of a liberal fasting policy of clear fluids before surgery with fasting duration and patient well-being and safety, JAMA Surgery, 158(3): 254-263. doi:10.1001/jamasurg.2022.5867. jamasurgery_marsman_2023_oi_220089_1678202793.98534(1).pdf
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