'some surgery'

roja · Oct 4, 2008

I am pretty used to people being unable to tell me what meds they are on. But I am continually surprised at how few people know what has happened under that massive midline scar on their abdomen.

Assisted an organ retrieval last week. The family said that she had (correctly) had her GB out and a few SBO's. One small surgery for it.

We get in there and she has had a partial distal gastrectomy and a reux in y.

It took 3 hours to sort through the bowel.

Pills are confusing, especially when you are on bunch, but I am consistently amazed when people have no idea that they have had large surgeries and no clue. Do you guys see this alot, or am I just seeing special people?

Castro Viejo · Oct 4, 2008

roja said:
Pills are confusing, especially when you are on bunch, but I am consistently amazed when people have no idea that they have had large surgeries and no clue. Do you guys see this alot, or am I just seeing special people?

Always. I mean, I think I would remember who put that scar on my belly and why, but like you, I'm always amazed at how little of this is remembered by the standard run of the mill patient. I just don't get it.

Over the last six years or so, I've learned that it's partly the relationship between a surgeon and a patient that fosters that. It's a fleeting one. You cut, they heal, and you followup a few times and that's just about it. People tend to have pretty short attention spans. In Vascular Surgery, by the nature of the disease process, patients tend to remember you better and remember what you did for them. It's sort of the same with patients and their PMDs.

It's a rare patient indeed who gets his or her surgical history right on the money. Most of the time they're close, but not quite close enough for my liking.

roja · Oct 4, 2008

Castro Viejo said:
Always. I mean, I think I would remember who put that scar on my belly and why, but like you, I'm always amazed at how little of this is remembered by the standard run of the mill patient. I just don't get it.

Over the last six years or so, I've learned that it's partly the relationship between a surgeon and a patient that fosters that. It's a fleeting one. You cut, they heal, and you followup a few times and that's just about it. People tend to have pretty short attention spans. In Vascular Surgery, by the nature of the disease process, patients tend to remember you better and remember what you did for them. It's sort of the same with patients and their PMDs.

It's a rare patient indeed who gets his or her surgical history right on the money. Most of the time they're close, but not quite close enough for my liking.

I'm glad I am not the only one who doesn't get it. I understand not remembering the name of the surgeon, or even the exact name or nature of the surgery, but when you have a giant ex-lap scar, you would think that you would remember SOMETHING of the nature of the surgery!

SoCuteMD · Oct 4, 2008

roja said:
I'm glad I am not the only one who doesn't get it. I understand not remembering the name of the surgeon, or even the exact name or nature of the surgery, but when you have a giant ex-lap scar, you would think that you would remember SOMETHING of the nature of the surgery!

Huh? What are you doing in the OR?

smq123 · Oct 4, 2008

Castro Viejo said:
Over the last six years or so, I've learned that it's partly the relationship between a surgeon and a patient that fosters that. It's a fleeting one. You cut, they heal, and you followup a few times and that's just about it. People tend to have pretty short attention spans. In Vascular Surgery, by the nature of the disease process, patients tend to remember you better and remember what you did for them. It's sort of the same with patients and their PMDs.

Is it easier with patients who get an operation with a simpler name? For instance, when I rotated through HPB, all the patients could easily tell the circulating nurse that they were going to get a "mini-Whipple." I doubt that any of them really knew what that operation entails, though - when asked, the best that any of them could do was that it had "something to do with the pancreas."

I imagine that it's even harder with operations that don't have a real "name," but are just descriptions - like a distal gastrectomy.

roja said:
Assisted an organ retrieval last week. The family said that she had (correctly) had her GB out and a few SBO's. One small surgery for it.

We get in there and she has had a partial distal gastrectomy and a reux in y.

Did the surgeons ask to double check? It's not really related to the topic, but I'm curious - because the scar that you'd get from a Roux-en-Y and a distal gastrectomy would be different from the scar that you'd get even from an open chole.

Winged Scapula · Oct 5, 2008

smq123 said:
Did the surgeons ask to double check? It's not really related to the topic, but I'm curious - because the scar that you'd get from a Roux-en-Y and a distal gastrectomy would be different from the scar that you'd get even from an open chole.

roja notes that the patient had a midline scar; its not unusual to use an existing scar to do a different surgery even if the typical approach would be through a different scar.

At any rate roja, this is EXTREMELY common.

Patients will deny they've ever had surgery and you open up their gown and see a large midline or sternotomy scar. "Oh yeah. I forgot about that."

Patients forget what they've had done, even simple procedures. Every day I go through my patient's medical history because they will leave operations off, or if they have had more than fit onto my intake form, they just leave stuff off.

Patients don't understand what they've had done and can't describe it, or they can describe enough of an operation that a surgeon can figure it out ("I had ulcers which weren't getting better so they took part of my stomach out and did something so I wouldn't get ulcers again").

It drives me nuts.

roja · Oct 5, 2008

SoCuteMD said:
Huh? What are you doing in the OR?

lol. a friend is a transplant fellow. We were catching up, I mentioned missing being in the OR when I was on trauma (love the OR just hate all the rest of it). He has trouble getting medical students to assist in the retrievals and so, insert roja: assistant ordinaire!

Winged Scapula said:
roja notes that the patient had a midline scar; its not unusual to use an existing scar to do a different surgery even if the typical approach would be through a different scar.

At any rate roja, this is EXTREMELY common.

Patients will deny they've ever had surgery and you open up their gown and see a large midline or sternotomy scar. "Oh yeah. I forgot about that."

Patients forget what they've had done, even simple procedures. Every day I go through my patient's medical history because they will leave operations off, or if they have had more than fit onto my intake form, they just leave stuff off.

Patients don't understand what they've had done and can't describe it, or they can describe enough of an operation that a surgeon can figure it out ("I had ulcers which weren't getting better so they took part of my stomach out and did something so I wouldn't get ulcers again").

It drives me nuts.

I can imagine that it is 100x worse when you are having to operate on someone as opposed to a retrieval.

MSHell · Oct 6, 2008

This frustrates me too.

A physician came in for a check up (don't remember why, don't care). I asked if she'd had any surgeries, answers: "no". When I examined her, I found a scar - 2 c-sections for her 2 healthy children!

So if ob/gyn is not considered a surgical specialty...

SocialistMD · Oct 6, 2008

Castro Viejo said:
In Vascular Surgery, by the nature of the disease process, patients tend to remember you better and remember what you did for them. It's sort of the same with patients and their PMDs.

Interesting. That has been the exact opposite of my experience with vasculopaths. They know they had some sort of lower extremity bypass, but don't know what kind, don't know if it is vein graft or synthetic, anatomic or non-anatomic, if they had a revision or a thrombectomy, etc...
Add to that the increasing number of patients who now come in with endoluminal stents (sometimes over bypasses) and you can't rely simply on the scars they have to tell you what is going on with their plumbing.

kaos · Oct 9, 2008

I always find it amusing how many people actually don't remember that they have that massive midline scar, let alone what it was for! I think the most enraging one had to be the VA patient with an AKA, who told me that he'd never had surgery.
"So are you sure? You've NEVER had surgery?"
"Yeah that's what I said, I never had any!"
I seriously started laughing then.

GoodMonkey · Oct 11, 2008

ooooh SO common. especially in my county hospital.

i get people showing up to my cast room or clinic (or down in urgent care/ED) all the time - people who have big-a$s casts on and are all "uh, someone called me. they told me to come in for surgery."
what's broken, sir?
"i don't know. i fell and now i need to have surgery."
when did you fall?
"wait, i didn't fall. someone just called me and told me to come get this cast off. and maybe have surgery. but i was in a car accident in 1984 when someone called my sister a b!tch and i chased them down in my car. it was a delta 88, tan, with three hub caps and every time i turned it on in the winter, it took three tries before the engine would turn. i may have hurt my third toe there - it always swells up in the winter."
but, sir, why are you here?
"oh, i need my cast off. do you think i need surgery?"

drives me UP A WALL.

Blade28 · Oct 11, 2008

This happens ALL the time.

Strangely enough, patients will remember that they've had a "partial hysterectomy" (don't get me started on THAT term) but not that they've had their gallbladder, appendix, sigmoid colon, thyroid, etc. removed.

PeepshowJohnny · Oct 11, 2008

I've met quite a few patients who only seem to remember their orthopaedic stuff.

"I had ankle surgery in 77, Had my knees done in 96, and a fusion in 05" and neglecting to mention their hernia repairs, their appendectomy, etc.

Pilot Doc · Oct 11, 2008

Best story I've heard along those lines ...

Routine physical by anesthesia before some minor surgery. History - no meds, no surgeries. Physical - subcostal scar noted and patient questioned. Patient slaps self on forehead and say "My liver transplant!"

Castro Viejo · Oct 13, 2008

SocialistMD said:
Interesting. That has been the exact opposite of my experience with vasculopaths. They know they had some sort of lower extremity bypass, but don't know what kind, don't know if it is vein graft or synthetic, anatomic or non-anatomic, if they had a revision or a thrombectomy, etc...
Add to that the increasing number of patients who now come in with endoluminal stents (sometimes over bypasses) and you can't rely simply on the scars they have to tell you what is going on with their plumbing.

Well, they're not going to know that level of detail. I'd frankly be uber-impressed if they knew that kind of stuff and I'd be suspicious at the same time.

Blade28 · Oct 14, 2008

It always amazes me when people don't know which organs are missing. Gallbladder? Appendix? Stomach? Colon? Right lung?

Amazing.

Winged Scapula · Oct 15, 2008

Sorta on topic:

do gynecologists *regularly* do an appy when doing a TAH (+/BSO)? Because for the life of me either the patient tells me they don't know if they still have an appendix or they think the gyne took it out with the other procedure.

I cannot remember that far back to med school and don't recall it being a standard part of the procedure, but every single patient seems to think it is.

smq123 · Oct 15, 2008

Winged Scapula said:
Sorta on topic:

do gynecologists *regularly* do an appy when doing a TAH (+/BSO)? Because for the life of me either the patient tells me they don't know if they still have an appendix or they think the gyne took it out with the other procedure.

I cannot remember that far back to med school and don't recall it being a standard part of the procedure, but every single patient seems to think it is.

An appendectomy with a TAH/BSO? That's a new one.

While (as you're well aware), I'm still fairly new to all this, I don't think that appendectomies would occur with a TAH/BSO secondary to benign reasons (i.e. fibroid, menorrhagia, etc.). If, though, the TAH/BSO was because of malignancy, or if the patient had had several other abdominal surgeries (particularly multiple c-sections), then I have heard of a few patients that had their appendix plastered to a pelvic organ. In that case, the gynecologist may have chosen to take it out, rather than trying to separate it. Still, that's a new one.

Blade28 · Oct 15, 2008

I've heard of appys being done during TAH-BSOs (and even seen some), both for fibroids and during cancer operations. I've never been able to get a clear answer as to the rationale behind this - which leads me to think that it may just be an "incidental appy."

SLUser11 · Oct 15, 2008

Blade28 said:
I've heard of appys being done during TAH-BSOs (and even seen some), both for fibroids and during cancer operations. I've never been able to get a clear answer as to the rationale behind this - which leads me to think that it may just be an "incidental appy."

One of our chiefs recently gave a talk on incidental surgery, and included a very thorough review of the literature. My takehome message was that we really should be doing more incidental surgery than we typically perform.

e.g. Palpating the gallbladder during a colon resection, and removing the GB if there are stones.

I would be willing to bet that an incidental appy in certain patient populations (likely younger pts) may be perfectly appropriate. But, honestly, I don't have the literature to back it up. I will see what I can find, since this interests me.....

Of course, a whole other discussion is whether or not it is okay for the gyn surgeon to do the appy, even though it's a simple operation, since we typically get flack when we operate on the girl parts.......

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roja

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