Frequently, when the place is very busy, the nurse in the waiting room will use a triage selection system to bring the sickest patients in first. This sometimes leaves those bypassed very angry and complaining because they often do not see the urgency of the patient who is taken before them. Obviously, a patient with a heart attack in progress or a stroke needs to be seen immediately as a life-saving measure; similarly, patients who are bleeding or having difficulty breathing, as with severe asthma, must be attended to as soon as possible. So the E.R. physician pleads for understanding and patience from the public.
The emergency room is also the “dumping ground” for the obstreperous, obnoxious, and sometimes dangerous patient who has overdosed on illegal or legal drugs and the alcoholic with one of the many complicating problems of acute alcoholism. These patients are often very difficult to manage and try the most patient, considerate nurses and doctors.
Another use for some emergency rooms is as a minor surgery site. Many physicians, especially those who work in the hospital all day, find it more convenient to meet their patients in the emergency room for giving injections, taking blood, doing spinal taps, removing small skin lesions or checking on problems with surgical wounds. Frequently, I will ask a patient with a problem to meet me in the emergency room so I can evaluate the condition and have the option to run more tests, admit the patient, or send the patient home.
So, if you need to visit your local emergency room, be aware that these doctors and nurses are highly trained and able to help you, but they also have a job which can at times be stressful, difficult and tiring, and they need your understanding too!
Chapter 9
THE PREOPERATIVE WORKUP
I've fallen in love with Betty, the gorgeous preop nurse,
I keep on having surgeries, so we can just converse.
I've had three hundred blood tests and forty EKGs,
And had 600 xrays from my tonsils to my knees.
I think that Betty knows me now, but how shall I explain
The reason I keep coming back, perhaps she'll think I'm vain.
I think I'll have a heart transplant, and then I'll have a chance.
If I give her my own heart, she'll know it's true romance.
Surgery is obviously a stress on the human system. Not only the emotional anxiety of going through a procedure or worrying about whether you have some severe problem that's correctable, but also the physical impact. This type of stress, from the anesthesia to the actual surgery itself can be anticipated by your doctor, and to evaluate the situation he will perform certain tests in the days before you go for your surgery.
The first preoperative workup is the history and physical exam. Sometimes, most of the workup has been done by your primary care doctor, and this has been relayed to the surgeon. Nevertheless, between the two of them a complete history and physical must be done. Briefly, this consists of a description of the present illness (“I have a pain or a lump or a hernia”), the length of duration, and/or how it happened. There must be a past history including allergies, medications you are taking, previous surgeries (such as breast biopsies, hernias, hysterectomy, heart transplants , including complications or drug reactions), and a list of all your medical problems (such as heart disease, diabetes mellitus, high blood pressure, and AIDS). Note must be made of your social history (married, single, divorced, widowed, children, significant other), whether you smoke, and how much alcohol you drink. A review of systems is included, which consists of questions about general health, cardiorespiratory system (heart and lungs i.e., shortness of breath, chest pains, palpitations, coughing up blood), gastrointestinal system (such as nausea, vomiting, constipation, diarrhea, vomiting up blood, black or bloody stools, ulcer history), and genitourinary system (problems with the kidneys, ureters, bladder or other genitalia). This review also includes a gynecological history for women including age at first menarche (menstrual period), age at first pregnancy, whether you're still having periods and their regularity, age of menopause (when you stopped having periods), and whether you're using birth control or hormones. Then there are questions about neurological (nerve problems) and psychiatric history, as well as any orthopedic and skin problems.
By then your physician should have a pretty good history about your risks, and this will be followed by a complete physical examination. Naturally, a specialist such as a heart doctor, urologist or gynecologist will tend to focus more on his/her area of expertise, but a brief physical exam is always needed. This will include a general description of you (young, elderly, weak, in pain, thin, obese, etc.) followed by an exam of the head, eyes, ears, nose, mouth, and throat. Then the neck exam is done, looking for stiffness, lymph nodes, thyroid gland enlargement, and abnormal sounds from your carotid arteries, which supply the brain. General examinations of the chest, breasts of both men and women, lungs, and heart sounds are done, followed by abdominal and flank exams for tenderness, masses, and hernias, to name a few.
A woman should have a regular gynecological exam every year after age 21, and males should have a testicular and rectal exam by their family doctor every year. A limited exam of the arteries and veins in the arms and legs, as well as a neurological evaluation, is recommended. The examining physician will also want to give his impression of the patient from an emotional and psychiatric point of view to help in alleviating fears and misunderstandings. The physician must be sure that the patient comprehends what is being said and the nature of the surgery that is going to be performed.
This is a brief list of what is expected in a history and physical examination, and it should be completed to some degree before a patient has any major surgery.
Obviously, if someone is going to have a minor procedure, such as a lymph node biopsy or removal of a skin tumor under local anesthesia, the physical may not need to be as comprehensive at the time of the surgery. But everyone needs a good, complete H&P (History and Physical) on a regular basis (every 13 years).
Okay. So now that's done. Next, the doctor will need to order some special studies to help in assessing your physical condition and risk for surgery and to further evaluate a condition which he has already diagnosed. I will list a few of the more common studies: chest x-ray, electrocardiogram (EKG = heart evaluation), and a series of blood tests among which may be CBC, which means a complete blood count, including hematocrit and hemoglobin, to determine how much blood you have and whether you have been secretly bleeding. There are the electrolytes, Na (Sodium), K (Potassium), Cl (Chloride) and CO2 (carbon dioxide); these are measures of the chemistry of the blood and can tell a lot about the status of your health. Blood sugar is measured to determine if you have diabetes mellitus; BUN or blood urea nitrogen and Creatinine to evaluate kidney function; and the clotting factors PT (protime), PTT (partial thromboplastin time) and platelet count, a measure of how well your blood clots. Another study is the urinalysis checking for problems with the kidneys and infections in the urine. These are the basics, but there are a myriad of other blood and urine tests your doctor may order. You can ask him about these and how they apply to your specific problem.
The pre-op tests may cause the surgeon to delay your surgery until certain things have been corrected or rechecked. I always say that when a blood test comes back very abnormal and doesn't make sense...repeat the test! If your EKG is abnormal, you may be referred to a cardiologist for further studies, including a stress test, where you walk on a moving platform while your heart function is monitored to evaluate for coronary artery problems. This, in turn, may lead to the need for coronary angiography, which is an xray with dye, of the arteries to your heart.
An abnormal chest xray may lead to getting a CAT scan (computerized axial tomography) of your chest to rule out cancer, tuberculosis, or other problems.
Be aware that, as we increase in age, the chance for abnormalities in the preoperative workup also increases, and your physician may need further studies to get you cleared for surgery.
This brings