Pre-op: What if I am getting sick right before surgery?

So you've got your surgery scheduled, been through the pre-op appointments, got your prep ready to go and have the time when you're supposed to report to the hospital. And then it begins about a week before surgery: first a tickly throat, then a little sinus congestion, pretty soon a cough and before you know it, you're coming down to the wire and you're undeniably getting a big nasty ol' virus.

And this is the time of year when we see this most. The holiday season and early January seem to be popular times to schedule a hyst, but that's right at a time when holiday preparation stresses plus the higher exposure from shopping and visiting make us both more vulnerable and more available to pick up any little respiratory bug that's going around. And, of course, least wanting to see this happen. But it does, frequently.

The first thing to do is admit that wishful thinking is most likely not going to be an effective tactic. Waiting and hoping that it will go away is only going to take you down to the wire without having made any preparations for dealing with the situation. Here's the bottom line right away: yes, your surgery will canceled if you are sick when you arrive at the hospital. And that's as it should be: plans are one thing, but in some cases it simply isn't safe to have anesthesia and surgery when you are already ill. Is keeping to a schedule to die for, literally? Rationally: not. I'm not saying you don't deserve a few tantrums on the subject--it is woefully unfair. But there you have it.

So how do you cope with this? By admitting what's going on as soon as you notice it. Don't hide your head in the sand and do the wishful thinking thing. Instead, at the first suspicion of illness, start taking mega-good care of yourself. Most winter illnesses are viral, which means that antibiotics won't help them. The most important thing to do with a viral illness is supporting your own immune system's work in fighting it off. These are old trite remedies, but they remain the best:

• Do get plenty of fluids.
• Do rest when you are tired (I know, that's hard to do when you merge pre-op panic with holiday panic, but go back up and reread that bottom line if you're waffling).
• Do turn to the fruits and vegies for vitamins and get plenty of them, every day before surgery.
• Don't chug the vitamin pills: some of those may be on your list of things to stop pre-op because of effects they may have on blood clotting.
• Don't eat aspirin or tylenol thinking you're helping out: your body uses a mild fever to help fight infection, so unless it's very high, it's helping rather than hurting.
• Don't gobble cold remedies or herbs: many of them also suppress your own defenses or contain things that are contraindicated before surgery.

If you are down to that final week and counting, coming down with something also means that you need to call your surgeon. Yes, it does. Waiting until Friday night after office hours are over before you finally admit that you're not going to be well by your 7 am Monday surgery call cuts it too fine. That robs you of planning and effective treatment time, and is discourteous to the surgical staff who are expecting to see you in the OR on Monday morning. If you are in that final week and feeling the first sneaky tendrils of viral invasion or you've been fighting something all last week and aren't sure you're going to make it in time, pick up the phone at the start of that week and make your confession.

Your doctor will be the best person to advise you on whether you need to be evaluated in the office and on what particular remedies may or may not be safe preoperatively. And by bringing him in early, you are being both considerate of his time and giving him a chance to help that surgery actually be able to happen as scheduled. The antibiotics you receive during surgery are not going to turn a chest cold around and your anesthesiologist isn't going to want to work with someone with a head and chest full of snot. If you are down to the wire and it's the weekend before a Monday surgery, go ahead and call the office number and tell the answering service you have a Monday surgery, are sick, and need to speak with the on-call person covering for your doctor. Don't try to second guess your doctors with just how sick you are: the decision on how sick is too sick is a specialized one they need to make.

And if you need to reschedule, the person who has let their doctor and hospital staff know in advance that this is a pending situation and a possibility is going to get way better service than someone who shows up at the hospital Monday morning in no shape to go to the OR. And don't you want your surgical team on your side? I thought so.

Please do the mature and responsible thing, here. If you're suspecting illness and you're down to the final week before surgery, get in touch with your doctor and stay in touch. Make arrangements on Friday (or right before a holiday) if you think the situation will remain volatile through the weekend before a Monday/post-holiday surgery. It happens. Your doctor knows it; your OR team knows it. No one will blame you--if you do everything responsible to keep everyone informed and seek advice early. They'll get you rescheduled as soon as possible if you have to cancel. That's not ideal, but that's better than trying to go into the OR already sick. That's not good for anybody involved.

Postop: Pain

Because many of us come to a hysterectomy as surgery novices, one of the things that worries us most is the prospect of pain. Chat around at the water cooler or the hairdresser's and you'll hear plenty of scary stuff. But is that realistic? No, not really. Let's look at what we're facing.

You're entitled to a plan

No matter what previous experiences you may have had with surgeries and pain, a minimum expectation of the pre-op planning process is that you and your doctors develop a pain management plan. You should know how they anticipate dealing with the expected pain, what they plan to do if that is not adequate, and what alternatives they are holding in reserve. You should also know when you may have medication and how to get it, including what to take home with you and what to do if you run out. This is very very basic (however much doctors take it for granted and don't discuss it), and you have every right to ask for a discussion of it and to participate in making those decisions.

Immediate postop pain management

One thing that can be beneficial in dealing with pain in the first hours after surgery is the use, from the Recovery Room on, of a relatively new anti-inflammatory called Toradol. It is given IV, regularly, and it seems to keep the level of pain down such that narcotics may not be required or may be required only in lesser amounts than when they are used alone. It also seems to ease the transition to oral meds, particularly of the long-acting NSAID family (such as the 12-hour dose of naproxen), and does not carry the effects of the opiates (in either allergy or constipation).

[Update 12/20/04: FDA warning about naproxen: The FDA has issued warnings about possible heart damage that may be caused by using naproxen. More on this topic in this post.]

It is also reasonable to ask your anesthetist to medicate you for nausea before you wake up in Recovery, rather than waiting for you to request such medication because you are already nauseated. If you make this request at your pre-op appointment, they should be willing to honor it. And, generally speaking, if you can get past the immediate post-op period, nausea should no longer happen to you. In fact, nausea after the first few hours typically means you're being nauseated by something you're receiving after surgery, such as your pain med, not things you received during surgery.

Two fairly common pain management setups are the patient-administered IV and the epidural block. The former is a pump, connected to your IV, that contains morphine or demerol—very potent narcotics. The pump is set for a maximum dose per hour, but you may trigger it to deliver a dose whenever you need it, up to that maximum. This allows you to pre-medicate before doing something that you feel might cause pain (like getting up) and allows you to control the amount of medication you get. This pump is typically used for one to two days, and is gradually replaced by oral medication.

The epidural involves a pump supplying numbing medication into your spinal area, to block sensation from the lower part of your body. It is generally used in conjunction with spinal anesthesia. Women who use it tend to speak very highly of it, especially in terms of promotion of early mobility. It is only left in place for a day or two.

Another, lesser-used but still valuable technique is injecting the area of your incision with numbing medications or running a small continuous drip of medication to that area. This may or may not need to be your total pain coverage.

How bad will it be?

The goal of pain management is not oblivion. Even the best drugs cannot obliterate your awareness that you've had major surgery and your body wants you to be really really careful with it. There are also some tradeoffs with narcotic pain medications that need to be kept in mind: too much will cause you to stop breathing, and excessive use can cause respiratory suppression and pneumonia predisposition as well as increasing postop constipation.

The goal of pain management, then, is making the discomfort tolerable. Note that I don't say "pain." Rather, you are aiming for a level of not-too-bad when lying still and tolerable while moving and "ouch!" with injudicious movement. You have a right to this amount of coverage, but you may need (or you may need someone with you who will do this) to advocate for your needs with busy nursing staff. If your nurses are not responsive to your needs or you feel you are undergoing excessive delays in obtaining medication, you should contact your doctor to let him know this. Even during the night, there will be an answering service that can have the doctor on call for your surgeon's practice get back to you. You should not be left in pain due to lack of medication and the medication your doctor orders for you should provide adequate relief. If you have received your limit of pain medication without obtaining acceptable relief, your doctor should be able to switch to a different drug. We all have different physical responses to different drugs, and so some drugs work for some of us better than for others. The goal should be adequate pain relief.

What about the risk of addiction?

The addictive potential of postop narcotics is very low because you are taking them for pain relief, not for the sensation of taking the narcotics themselves. Taken in the amount necessary to control pain, the pain "uses up" much of the action of the narcotic and it does not provide the sensations that cause addicts to seek it out. The duration of postop use is not at all close to the amount of time required to create any physical addiction. Neither you nor your doctor should stint on your legitimate use of narcotic medications for pain relief.

That does not, however, mean that you should not take them for the shortest necessary time. Narcotics carry negative effects as part of their normal mechanism of actions. For example, they are quite constipating. Since gas and bowel motility are some of the most pressing concerns in the first couple postop weeks, it doesn't make sense to continue adding to that problem by taking narcotics longer than necessary.

The usual practice is to be on IV or injectable (narcotic) pain meds for a day or two postop. These are gradually replaced by oral drugs, usually those containing a narcotic such as codeine. Codeine and other oral narcotics have the same constipating effects as the injectables. So while they may be good at controlling pain, they are also not a great long term management drug. Many women go directly from injectables/IV narcotics to oral anti-inflammatories, or use anti-inflammatories to stretch the effects of oral narcotics. In the first few postop weeks at home, anti-inflammatories can gradually replace narcotics while providing still-adequate coverage.

One of the most convenient anti-inflammatory drugs is naprosyn (naproxen), because it has a 12-hour duration of action. This means you can take it at bedtime and still wake up with some in your system in the morning. Using the 4-6 hour anti-inflammatories can mean waking up in the morning in discomfort. Since some asthmatics or those with cardiovascular disease may be sensitive to this whole family of drugs, be sure to ask your doctor about what drugs you should take even when you are ready to leave the narcotics.

Now, all of this presupposes that you are not already on a pain management program or do not have an addictive problem. If this is the case, then you will obviously need to involve your therapists in your operative planning so that you meet your increased pain control needs without derailing your present level of control. The fact of a previous narcotic addiction should not mean that you cannot control your pain during your recovery, but it will obviously mean that you have a greater need for pre-planning and monitoring the situation.

Pain and medication on discharge from the hospital

By the time you are released from the hospital, you should be able to get around and get by, within the limits of exercise tolerance, on fairly mild oral medications. The gas/constipation problem is the source of the most discomfort in the first post-op week or so, and it yields better to specific medications/approaches (lots of fiber, drinking lots and lots of liquids, exercise, stool softeners) than to pain meds (and opiates are especially bad in that they slow your bowel activity down and compound the problem).

What about if my prescription runs out and I'm still hurting?

Your doctor sends you home from the hospital with a standard prescription. That doesn't mean that this is all you can have. If you have used the pills as directed and find that you are running out and will need more, call your doctor's office and let them know. Often, they are more than willing to call a refill to your pharmacy. Other times, they may suggest alternatives that will be effective for the point you're now at in recovery. Whatever the plan, don't feel you have to suffer once the first prescription runs out.

Do be sure, however, that you understand how and how often your take-home pain meds are to be taken. Typically the prescription reads something along the lines of "Take 1-2 every 4-6 hours as needed." That means that you may take them that often (if you need that level of pain relief), not that you must take them that often (to get any relief). All too often women in the fluster of getting ready to be discharged from the hospital are handed a fistful of papers and hear only "2 every 4 hours" and just tear through their prescription and wonder why, a few days later, the prescription that they thought was to last them till their two-week checkup is all used up. Those dose intervals are the most frequent at which you can safely use that medication; it's fine if you don't need to take it that often or if you find that you need only 1-2 in a whole day, just to give a little extra boost to your non-prescription medications.

On the other hand, if you need more medication than that or you feel that even at the largest/most frequent dose you're not getting adequate coverage, it's a good idea to call your doctor about this as well. Your prescription is based on your doctor's expectations of how you should be doing, given your surgery and the speed/extent of recovery he sees when he visits you in the hospital. If you are not progressing as he thought you might, you may need a recheck to be sure everything is going as it should. Your doctor makes treatment decisions based on what he sees in the hospital; he can't see you once you are at home, so if things change, it's your responsibility to let him know that.

You should expect, and demand if necessary, a reasonable and adult discussion of these things at your pre-op appointment. If your doctor is not willing to allow your participation in pain management planning or to discuss his plans with you, then you might be well advised to seek another consult. A surgery is about your needs, not the doctor's.

Postop: Should I call my doctor?

I see posting after posting in the online hyst forums describing all sorts of situations and asking this question. And the only possible answer is, invariably, yes.

Yes, if anything at all happens that worries you or makes you wonder whether or how your postop instructions apply, you should call your doctor.

Yes, you should call your doctor if it happens at 10 am on a weekday and yes, you should call your doctor if it happens at 1 am on Sunday. Every surgeon has a mechanism for taking calls and a relief on-call doctor who will be available if he is off. You may have to leave a message with an answering service and wait for a callback, but you can and should take your questions to a doctor. No one on a forum, no matter how well-educated or well-intentioned, has the information at hand to answer your questions safely and applicably. In fact, if your doctor or his on-call is in doubt because of the limitations of discussing things on the phone, he may ask you to come to the office or be seen in the Emergency Room just so that you can be evaluated more fully. Doctors understand the limitations of phone consultations; women on forums, however well-motivated they may be, tend not to.

"But I hate to disturb my doctor with what might be a silly question..." is an all-too-common response. Nonsense. You are paying the doctor for a service, and part of that service is postoperative supervision. Whether you have developed a complication requiring further treatment or whether your doctor failed to adequately instruct you on what to expect, the doctor is a contractor being paid for a specific service and you are entirely entitled to that full service for those big bucks.

There are things you can do to help make your call as effective as possible. First of all, before you even pick up the phone, jot down some notes. Write out as explicitly as possible what your worries or questions are. Include such background information as when you had your surgery, what surgery it was, what medications and hrt you are on (include when you last took them), what your temperature is or other pertinent information about your physical condition. Your doctor may take your call from a location where he doesn't have your chart or his notes available, and you don't want to rely upon his (crowded) memory for important details.

Doctors respond better to clear, objective information, not subjective responses. Saying in tears that "I feel totally horrible and I'm really worried!!!!" does not convey nearly as much helpful information to the doctor as "I am running a fever of 101, my head has been pounding for 6 hours despite taking [pain medication type and dose and time of last dose], and my incision looks red, puffy and is draining green pus that made a circle 1" in diameter on a dressing in the past 6 hours." The first comment will likely get a soothing response or a suggestion that you need an antidepressant; the second may see you with an office visit and an antibiotic prescription—very different results indeed.

So if you are describing your incision, you need to be prepared to report the following:

• location
• how long this has been going on/when you first noticed it
• color: red, pale, normal skin tone?
• temperature of the area: hot? same as surrounding tissues?
• presence or absence of local swelling, feeling of area: hard? soft? hard lump with distinct edges? dimensions of lump in inches/cm?
• sensation of area: hurts all the time? hurts when touched gently/pushed on? sharp pain or ache? burning pain or stabbing pain?
• smell: no particular odor? medicinal? foul or rotting meat odor?
• drainage description: clear pinkish-yellowish? bright red blood? old clotted blood? pus? green? yellow?
• drainage amount: size of stain on dressing in [whatever] amount of time, how many times you've changed what type of pad or dressing in past [whatever] amount of time?
• your temperature taken just before calling, as well as when you last took it and what it was then

If you think you are having hormonal problems, you need to be prepared to report the following:

• what you are taking for hrt
• when you take it and when you last took it
• what specific symptoms you are having that you attribute to your hormones: hot flashes? mood swings? rash? swelling? headache? nausea?
• for each symptom, further list: when it began, how many times you've had it, how long it lasts (for example: hot flashes started today, I have had 6 lasting 10-30 seconds each and each time more intense/causing heavier sweat or I have burst into tears inappropriately 4 times today and yelled at my kids when they really didn't deserve it twice)

By having this sort of information ready, you're giving your doctor the information he needs to identify and constructively deal with your problem, not your reaction to your problem. And that will make for a whole lot more satisfaction all around. And, hey, if it turns out to be something perfectly normal, then you have the reassurance and your doctor's learned a lesson about preparing you for what to expect that will benefit the next woman he treats. Everyone wins!