First, and most well known and utilized, is physical therapy. The objectives are to use exercise to bring back as much function as possible. Obviously, this may be more apparent with orthopedic cases, but it applies even to the patient who's had an appendectomy or a gall bladder removed. The objectives include exercises for strength, coordination, range of motion, and endurance, just to name a few. The therapist will work with the patient in an active or passive way: from the simple activity of getting out of bed and walking, to a complex set of active exercises where the patient moves himself, to passive ones where someone else moves the patient or his limb, and everything in between!
Physical therapists use massage, heat therapy, (which can include many different types hot-packs, whirlpool, infrared, and water therapy), electric currents stimulating nerves called electrotherapy, cold therapy with ice compresses, and just plain encouragement.
Occupational therapy helps get the patient back to doing things that will be worthwhile for him as a functional member of society and the work force, or just to be able to get along in daily life, whether it's managing a colostomy, a wheelchair or at home activities. This is very important for recovery, and the surgeon must be aware of all the modalities available to help his patient in the postoperative period.
Psychiatric and social work rehabilitation is also an area where we as physicians often fail in our care. With our focus on the surgical problem, we may ignore major emotional or psychosocial problems that leave the surgically-healed patient effectively incapacitated.
If you or a loved one is anticipating major surgery, be sure you ask about the rehabilitation services in your hospital; frequently, it's better to arrange for help before the surgery rather than afterwards. I will talk about amputations and prosthesis in the orthopedics chapter, about paralysis and dealing with the problems of the paraplegic and quadriplegic patient in the chapter on neurosurgery, and problems with urination in the urology section.
Patients with new colostomies and ileostomies—where for medical reasons the large or small bowel is brought out to the skin level where a bag is applied—need tremendous support from nurses who will tell them about the care of the opening at the skin called a stoma. They may need psychosocial support and also may benefit from talking with other individuals who are living with the same situations. I personally know many famous celebrities, always in the public eye, who function well with their postoperative disabilities including colostomies and prostheses without having them effect their lifestyles or public image to a great degree, if at all. In my book on “Comprehensive Breast Care,” I talk extensively about the problems encountered by women who have had mastectomies or axillary dissections. Similarly, patients, who have a disfigurement secondary to cancer surgery, or temporary problems such as hair loss during chemotherapy, have someone to turn to in a comprehensive program to help them get through the problems of daily living.
In conclusion, be sure that your surgeon and his hospital are sensitive to these important issues and can outline a rehabilitation program prior to and after a surgery.
Chapter 18
HEMORRHAGE, COAGULATION, AND TRANSFUSIONS
Whenever you are angry, you speak of “seeing red.”
To a surgeon this expression causes sirens in his head.
And though the right wing zealots spoke of “Better dead than Red,”
We know that surgically speaking, too much red and you'll be dead.
Ho hum, you say, if blood comes out, then put a little in.
It should be just as simple as to close a safety pin.
And so it is with surgeons, as we ply our nasty trade.
If blood emerges while we work, we get a blood bandaid.
Lose a little, get a little, sounds so simple now,
Yet hemorrhage is a problem, much more complex than the Dow.
For blood is not just colored water, to be put in later,
Much the way you pour the water in your radiator.
Blood is really an organ, with complex and diffuse conjunctions.
We need the volume, but we also must have all the other functions.
There's red cells carrying oxygen, electrolytes, and serum,
Platelets that form blood clots, immune proteins, and right near um...
Are white blood cells that help us fight off some obscure infections
And water and some lipid fats, and Rh fact connections.
So when the blood is gushing out upon an OR table,
Try to remember all the parts, that is, if you are able.
I want to present a simplified chapter on blood, hemorrhage, and transfusions. You should understand that this is a very complex subject that has been covered in large volumes and about which hematologists or blood specialists spend years learning. I will divide it into several sections and give some basic information about each one.
First, the components of blood: As in the poem, blood is a complex of red blood cells or corpuscles that compose about 45% of the blood and carry iron and oxygen to your cells; the white blood cells scavenge debris, fight off infection and contain immunological substances, and platelets or thrombocytes help form blood clots. It also contains many different clotting factors, which I will describe soon, that help the formation of blood clots with the platelets. The blood also contains many chemicals needed by your body to function properly, including electrolytes: Na sodium, K potassium, Cl Chloride, as well as Ca Calcium, Mg Magnesium and glucose, all suspended in a 90% watery substance called plasma. When a physician orders an intravenous solution, he must be sure to order the right components, the right amount of glucose and remember that diabetics have too much sugar in their blood, and electrolytes depending on the results of blood tests he has taken. Similarly, if a patient has been bleeding, we must not only replace blood volume, but also specific blood clotting factors and calcium, which is used up in clotting.
If a patient loses a small amount of blood, say one pint, there may not be a need to replace anything, since the body continually produces new blood. However, when massive bleeding occurs, such as in gunshot wound trauma, ruptured aneurysms (large ballooned out blood vessels), or during surgery, then transfusions may be needed and attention must be paid to all the parameters of the blood components. If the patient has a low platelet count, and you give him blood, he may continue to bleed and not form blood clots. So hematologists are often called in to help us restore normal blood homeostasis.
Now to some other basics: The average adult has about 10 pints of blood—and this varies with weight, age, sex, body build, etc., and can lose about a pint without much problem. When one donates a unit of blood it is equal to about a pint. The volume you lose with the donation is made up rapidly with transfer of fluids from one part of your body to the blood stream, so that the total volume remains the same. It takes about two weeks for your body to produce and replace the red blood cells.
The blood circulates through your body in a continuous circular pattern, driven by the contractions of the heart. It goes from the heart through the arteries to the tissues, such as brain, stomach, kidneys, skin, etc., where it gives off oxygen and other nutrients to the cells, and then returns to the heart by the veins. It is pumped into the lungs, where it picks up more Oxygen, returns back to the heart and then starts the trip again. Simply put, the flow of blood, with a certain volume present, gives us our blood pressure. If the amount of fluid in the system falls, as with bleeding, then the blood pressure falls, and the heart beats faster to keep the total amount of blood circulating at a constant number. So when there is hemorrhage, a patient's blood pressure usually goes down and his heart rate or pulse goes up. Those signs, together with measurements of the blood, will let the surgeon know how much a patient is bleeding and how much to replace. We'll talk more about the actual numbers in Chapter 25, when we will also discuss the white blood cell