G
Georgia
Also found at the Denver Post, the transcript of a show on what one can expect immediately after OHS at home.
MARK POCHAPIN, MD: Hi, I'm Dr. Mark Pochapin, and welcome to our show. Today we're going to talk about cardiothoracic surgery, mainly open heart surgery, and what happens after the surgery is accomplished.
This is a very common procedure. In fact, over 500,000 open heart surgeries for bypass operations alone are done in this country.
Today we have three members of the cardiothoracic team at Columbia University in New York, at New York Presbyterian Hospital with us today to talk about this. I want to welcome them.
To my left here is Dr. Windsor Ting, who is a cardiac surgeon. He is active in many areas of research, including minimally invasive cardiac surgery, and consumer access to health care. Welcome, Dr. Ting.
WINDSOR TING, MD: Thank you.
MARK POCHAPIN, MD: Next to Dr. Ting is Ms. Roxana Shaw, who's a physicians' assistant. Now, a physicians' assistant actually helps in the open heart surgery, and follows patients throughout their hospital stay. And continues to follow them, I assume, when they go home.
Welcome, Ms. Shaw.
ROXANA SHAW, PA: Thank you.
MARK POCHAPIN, MD: To the left of Ms. Shaw is Dr. Neal Reich, who is a cardiothoracic anesthesiology fellow. His research interests include minimally invasive heart surgery, and anesthesia during cardiopulmonary bypass. He'll also be discussing some of the postoperative pain management. Welcome, Dr. Reich.
NEAL REICH, MD: Thank you.
MARK POCHAPIN, MD: Let's start with what actually happens when a patient goes home. They've been through this major operation, and now their home. Is there any type of support that they have? Who helps them through this period, Dr. Ting?
WINDSOR TING, MD: Actually, the most important support when they go home is their immediate family. Their spouse, their children and sometimes their friends. In most cases, it is a spouse.
MARK POCHAPIN, MD: Ms. Shaw, when they get home, what should they expect to feel like? Should they feel fine when they get home, or are they not really back to where they were?
ROXANA SHAW, PA: What we tell the patient is that they're going to have a six week period of time where every day they're going to fluctuate into different levels. One day they may feel absolutely fine, and the next day they may feel like sleeping all day. The most important thing for them to do during these periods is to rest when they feel like they need rest, and to try to keep active.
Active meaning walking, which is the most important thing to prevent pneumonia in these cases. And it also helps increase their circulation back to their heart.
MARK POCHAPIN, MD: Now, what about the pain? Obviously they've had surgery, they've had an incision in their chest, and I also understand that they would, very often for bypass, have an incision in their leg where the vein was removed. That sounds painful. Is it painful, and what do you do for their pain?
NEAL REICH, MD: I've heard both arguments, that the chest incision hurts more than the legs. I've heard that the legs hurt more than the chest. Not to cop out, I'll back off and say I'm sure they both hurt. I don't know which one hurts more.
Once you leave the hospital, we pull your intravenous out, so basically all you're left with is oral medications, pills. Various types of pills can be prescribed, anything from as simple as ibuprofen or Tylenol all the way up to things like Tylenol with codeine or Percocet or Darvocet or some of the higher-end drugs that you need a special prescription for.
I think the key, though, not to be under-emphasized in any type of pain management, be it chronic or acute, is the psychological aspect of it. And that is, don't wait till it hurts. Your doctor's going to send you home with some sort of pain medicine. Don't wait till it's unbearable. A lot of the chronic pain things you see are because the patient and their body have become so accustomed to pain that it's hard to get rid of.
Be comfortable, let your body acclimate to its new physiological state, and then worry about getting off the pills at the end. Don't be a hero. Be comfortable. Your body will be happier, and in the long run you're happier.
WINDSOR TING, MD: Mark, can I add something? Actually, interestingly, a common complaint with regard to pain is discomfort in the back and in the shoulders. We see that a lot after open heart surgery. That may have something to do with the fact that their breast bone is separated during surgery, for several hours. When they go home, the pain is not in the incision in the chest or in the leg, but rather pain in the back.
MARK POCHAPIN, MD: They must be surprised and embarrassed to even bring it up. Here they have a chest incision and a leg incision, and they're complaining about back pain.
WINDSOR TING, MD: Exactly.
NEAL REICH, MD: That's something called "referred pain," and it's kind of common. Also, the fact that you're working near and around the diaphragm lends to that type of pain as well, because diaphragmatic, or the big rubber band that stretches your chest cavity up and down, when that gets irritated, a lot of times you'll get pain from that. And it's manifested as pain elsewhere, like back pain or shoulder pain.
WINDSOR TING, MD: You know what else I see a lot of, that's very common after open heart surgery, is major depression.
MARK POCHAPIN, MD: Which is always surprising, because you'd think a patient would be so happy to have gotten the procedure, this operation over with. But that is a real entity, isn't it, of itself?
WINDSOR TING, MD: That's right. There are several possible causes of it, and we don't know exactly which one. It may vary from patient to patient. But it's important for the patient to realize that it's common after open heart surgery, and that it can pass. It will pass, and that it's treatable with medication.
Now, the other condition that's fairly common is some memory loss. Patients say "Well, my memory's not as good."
MARK POCHAPIN, MD: Memory loss when they get home, or memory loss of the hospitalization?
WINDSOR TING, MD: No, when they get home. Like they can't remember.
ROXANA SHAW, PA: Little details.
WINDSOR TING, MD: Yes, a little detail here and there. Again, that deficit will improve over time.
MARK POCHAPIN, MD: Now, what period of time are we talking about, Ms. Shaw? When should a patient start feeling back to themselves again when they get home? Let's say they get home, is it days, weeks, months? What are we talking about?
ROXANA SHAW, PA: It takes anywhere between weeks and months for them to feel themselves again. Normally it takes six weeks for the immediate recuperation, and then they would have a followup with their surgeon at that time. Then anywhere between six weeks to six months for them to completely be functional again.
During that time, there are actually activities that we advise them not to do, such as driving during the initial six weeks' period. The reason behind that being that, in case, God forbid, they got into an accident, we wouldn't want any damage to happen to their breast bone, that was actually put back together.
Other things that we advise them not to do between that period is activities such as golfing, tennis, any kind of activities that would use their upper arms in extreme motions. So there are a lot of activities that they have to curtail during that rehab period.
MARK POCHAPIN, MD: Do they get instructions about that? How do they know which activities not to do?
ROXANA SHAW, PA: They do. They actually get extensive information on this. We give them pamphlets and booklets at the time of their discharge, and specific instructions. What to do, what not to do. Again, we follow up with them when they come in to the office for their followup visit, just to make sure that everything's going all right.
The other thing that's important is for the patient to feel that they can call us at any time if they have any problems, and we're always there to answer their questions.
WINDSOR TING, MD: As Roxana has pointed out, there is a big variation. On one extreme, you have patients who are back to work the week after they're home, who are doing very well, in a rush to get back to work.
MARK POCHAPIN, MD: That's probably what got them in trouble in the first place.
WINDSOR TING, MD: I think so. On the other hand, there are patients who need to have more time for their recuperation. It's not uncommon that some of these patients will go to a convalescent home for a few days to a few weeks, until they're in better shape, and ready for independent living.
MARK POCHAPIN, MD: When do you start getting concerned? Is there a certain type of pain, for example, Dr. Reich, that you'd be worried about? That perhaps the pain medication isn't the answer, that something else needs to be done or some other evaluation needs to occur?
NEAL REICH, MD: That's a very good question, and I think the thing that comes to my mind first and foremost is, if a person does have similar symptoms to the ones that brought them in the hospital in the first place. Surgery can be curative, but not all surgeries remain curative.
Part of that goes to the effect that, when you're fixing the heart muscle in areas of the heart that were starved for oxygen and blood, sometimes other parts can get damaged. Sometimes you can overexert yourself in your exuberance to recover, and do additional damage to your heart.
I would say things that would concern me as a physicians, not necessarily an anesthesiologist, were recurrence of the things that brought you into the hospital. Pain that is inexplicable by anything whatsoever. As Dr. Ting mentioned earlier, pain in the middle of your back. Things that just are not consistent with what you would expect, albeit from having your breast bone totally --
MARK POCHAPIN, MD: So what should a patient do? They don't know what's normal or not after surgery, so they feel a pain. Do they call their surgeon, do they call the anesthesiologist? Do they call the physicians' assistant? Do they call the cardiologist? There are a lot of people involved now.
WINDSOR TING, MD: That varies depending on where the patient had his or her surgery. That issue should be addressed before the patient goes home. It should be very clear to the spouse or whoever will be taking care of the patient, or to the patient himself or herself, who are the people that can be called.
Now, going back to the question, what are some of the things that the patient should call? Fever, shortness of breath that's getting worse. Palpitations. Irregular heartbeat. Redness at the incision site. Drainage from the incision. Actually, any concerns that the patient may have. It's better to be on the safe side.
MARK POCHAPIN, MD: Ms. Shaw, when does a patient come to see the doctor? They've gone home, at what interval do they need to come back?
ROXANA SHAW, PA: Normally at our institution, the cardiologist asks to see the patient two weeks after their surgery. And the surgeon usually sees them anywhere between four to six weeks after the surgery. At that time, we evaluate their wounds, their leg wounds, their chest wound, the stability of their breastbone, and their medications. Although that is mainly taken care of by the cardiologist in our institution, we like to know what exactly is going on with the patient.
MARK POCHAPIN, MD: We talked about a lot of the things the patient needs to look out for, a lot of the physical activities that they should avoid. What are things that they can do? For example, when can they resume normal daily activity? When can they resume sexual activity? Is it patient by patient, or is sort of a set course?
WINDSOR TING, MD: A lot of it is from patient to patient. The patient can start walking, ambulating right after they're home. Sometimes it's difficult to walk because of the weather. So I frequently recommend a patient to go walk in a shopping mall. That's a great place to go walking. There are lots of things to see, and it's climate-controlled. But there's no reason why the patient cannot begin walking immediately after discharge from the hospital.
In terms of sexual activity, I think that can be resumed as soon as the patient feels comfortable. I don't see why that needs to wait.
Now, there's another thing about diet. What should a patient eat? I think a balanced diet. I don't think there's any special nutrition or any special diet. I think the most important thing is to eat a well-balanced diet. A well-balanced diet means vegetables, meat, fruits.
MARK POCHAPIN, MD: Low fat.
WINDSOR TING, MD: Low fat, and low salt.
MARK POCHAPIN, MD: Well, thank you all very much. It's really been a pleasure, and I'm sure our audience has learned quite a bit. I certainly have.
MARK POCHAPIN, MD: Hi, I'm Dr. Mark Pochapin, and welcome to our show. Today we're going to talk about cardiothoracic surgery, mainly open heart surgery, and what happens after the surgery is accomplished.
This is a very common procedure. In fact, over 500,000 open heart surgeries for bypass operations alone are done in this country.
Today we have three members of the cardiothoracic team at Columbia University in New York, at New York Presbyterian Hospital with us today to talk about this. I want to welcome them.
To my left here is Dr. Windsor Ting, who is a cardiac surgeon. He is active in many areas of research, including minimally invasive cardiac surgery, and consumer access to health care. Welcome, Dr. Ting.
WINDSOR TING, MD: Thank you.
MARK POCHAPIN, MD: Next to Dr. Ting is Ms. Roxana Shaw, who's a physicians' assistant. Now, a physicians' assistant actually helps in the open heart surgery, and follows patients throughout their hospital stay. And continues to follow them, I assume, when they go home.
Welcome, Ms. Shaw.
ROXANA SHAW, PA: Thank you.
MARK POCHAPIN, MD: To the left of Ms. Shaw is Dr. Neal Reich, who is a cardiothoracic anesthesiology fellow. His research interests include minimally invasive heart surgery, and anesthesia during cardiopulmonary bypass. He'll also be discussing some of the postoperative pain management. Welcome, Dr. Reich.
NEAL REICH, MD: Thank you.
MARK POCHAPIN, MD: Let's start with what actually happens when a patient goes home. They've been through this major operation, and now their home. Is there any type of support that they have? Who helps them through this period, Dr. Ting?
WINDSOR TING, MD: Actually, the most important support when they go home is their immediate family. Their spouse, their children and sometimes their friends. In most cases, it is a spouse.
MARK POCHAPIN, MD: Ms. Shaw, when they get home, what should they expect to feel like? Should they feel fine when they get home, or are they not really back to where they were?
ROXANA SHAW, PA: What we tell the patient is that they're going to have a six week period of time where every day they're going to fluctuate into different levels. One day they may feel absolutely fine, and the next day they may feel like sleeping all day. The most important thing for them to do during these periods is to rest when they feel like they need rest, and to try to keep active.
Active meaning walking, which is the most important thing to prevent pneumonia in these cases. And it also helps increase their circulation back to their heart.
MARK POCHAPIN, MD: Now, what about the pain? Obviously they've had surgery, they've had an incision in their chest, and I also understand that they would, very often for bypass, have an incision in their leg where the vein was removed. That sounds painful. Is it painful, and what do you do for their pain?
NEAL REICH, MD: I've heard both arguments, that the chest incision hurts more than the legs. I've heard that the legs hurt more than the chest. Not to cop out, I'll back off and say I'm sure they both hurt. I don't know which one hurts more.
Once you leave the hospital, we pull your intravenous out, so basically all you're left with is oral medications, pills. Various types of pills can be prescribed, anything from as simple as ibuprofen or Tylenol all the way up to things like Tylenol with codeine or Percocet or Darvocet or some of the higher-end drugs that you need a special prescription for.
I think the key, though, not to be under-emphasized in any type of pain management, be it chronic or acute, is the psychological aspect of it. And that is, don't wait till it hurts. Your doctor's going to send you home with some sort of pain medicine. Don't wait till it's unbearable. A lot of the chronic pain things you see are because the patient and their body have become so accustomed to pain that it's hard to get rid of.
Be comfortable, let your body acclimate to its new physiological state, and then worry about getting off the pills at the end. Don't be a hero. Be comfortable. Your body will be happier, and in the long run you're happier.
WINDSOR TING, MD: Mark, can I add something? Actually, interestingly, a common complaint with regard to pain is discomfort in the back and in the shoulders. We see that a lot after open heart surgery. That may have something to do with the fact that their breast bone is separated during surgery, for several hours. When they go home, the pain is not in the incision in the chest or in the leg, but rather pain in the back.
MARK POCHAPIN, MD: They must be surprised and embarrassed to even bring it up. Here they have a chest incision and a leg incision, and they're complaining about back pain.
WINDSOR TING, MD: Exactly.
NEAL REICH, MD: That's something called "referred pain," and it's kind of common. Also, the fact that you're working near and around the diaphragm lends to that type of pain as well, because diaphragmatic, or the big rubber band that stretches your chest cavity up and down, when that gets irritated, a lot of times you'll get pain from that. And it's manifested as pain elsewhere, like back pain or shoulder pain.
WINDSOR TING, MD: You know what else I see a lot of, that's very common after open heart surgery, is major depression.
MARK POCHAPIN, MD: Which is always surprising, because you'd think a patient would be so happy to have gotten the procedure, this operation over with. But that is a real entity, isn't it, of itself?
WINDSOR TING, MD: That's right. There are several possible causes of it, and we don't know exactly which one. It may vary from patient to patient. But it's important for the patient to realize that it's common after open heart surgery, and that it can pass. It will pass, and that it's treatable with medication.
Now, the other condition that's fairly common is some memory loss. Patients say "Well, my memory's not as good."
MARK POCHAPIN, MD: Memory loss when they get home, or memory loss of the hospitalization?
WINDSOR TING, MD: No, when they get home. Like they can't remember.
ROXANA SHAW, PA: Little details.
WINDSOR TING, MD: Yes, a little detail here and there. Again, that deficit will improve over time.
MARK POCHAPIN, MD: Now, what period of time are we talking about, Ms. Shaw? When should a patient start feeling back to themselves again when they get home? Let's say they get home, is it days, weeks, months? What are we talking about?
ROXANA SHAW, PA: It takes anywhere between weeks and months for them to feel themselves again. Normally it takes six weeks for the immediate recuperation, and then they would have a followup with their surgeon at that time. Then anywhere between six weeks to six months for them to completely be functional again.
During that time, there are actually activities that we advise them not to do, such as driving during the initial six weeks' period. The reason behind that being that, in case, God forbid, they got into an accident, we wouldn't want any damage to happen to their breast bone, that was actually put back together.
Other things that we advise them not to do between that period is activities such as golfing, tennis, any kind of activities that would use their upper arms in extreme motions. So there are a lot of activities that they have to curtail during that rehab period.
MARK POCHAPIN, MD: Do they get instructions about that? How do they know which activities not to do?
ROXANA SHAW, PA: They do. They actually get extensive information on this. We give them pamphlets and booklets at the time of their discharge, and specific instructions. What to do, what not to do. Again, we follow up with them when they come in to the office for their followup visit, just to make sure that everything's going all right.
The other thing that's important is for the patient to feel that they can call us at any time if they have any problems, and we're always there to answer their questions.
WINDSOR TING, MD: As Roxana has pointed out, there is a big variation. On one extreme, you have patients who are back to work the week after they're home, who are doing very well, in a rush to get back to work.
MARK POCHAPIN, MD: That's probably what got them in trouble in the first place.
WINDSOR TING, MD: I think so. On the other hand, there are patients who need to have more time for their recuperation. It's not uncommon that some of these patients will go to a convalescent home for a few days to a few weeks, until they're in better shape, and ready for independent living.
MARK POCHAPIN, MD: When do you start getting concerned? Is there a certain type of pain, for example, Dr. Reich, that you'd be worried about? That perhaps the pain medication isn't the answer, that something else needs to be done or some other evaluation needs to occur?
NEAL REICH, MD: That's a very good question, and I think the thing that comes to my mind first and foremost is, if a person does have similar symptoms to the ones that brought them in the hospital in the first place. Surgery can be curative, but not all surgeries remain curative.
Part of that goes to the effect that, when you're fixing the heart muscle in areas of the heart that were starved for oxygen and blood, sometimes other parts can get damaged. Sometimes you can overexert yourself in your exuberance to recover, and do additional damage to your heart.
I would say things that would concern me as a physicians, not necessarily an anesthesiologist, were recurrence of the things that brought you into the hospital. Pain that is inexplicable by anything whatsoever. As Dr. Ting mentioned earlier, pain in the middle of your back. Things that just are not consistent with what you would expect, albeit from having your breast bone totally --
MARK POCHAPIN, MD: So what should a patient do? They don't know what's normal or not after surgery, so they feel a pain. Do they call their surgeon, do they call the anesthesiologist? Do they call the physicians' assistant? Do they call the cardiologist? There are a lot of people involved now.
WINDSOR TING, MD: That varies depending on where the patient had his or her surgery. That issue should be addressed before the patient goes home. It should be very clear to the spouse or whoever will be taking care of the patient, or to the patient himself or herself, who are the people that can be called.
Now, going back to the question, what are some of the things that the patient should call? Fever, shortness of breath that's getting worse. Palpitations. Irregular heartbeat. Redness at the incision site. Drainage from the incision. Actually, any concerns that the patient may have. It's better to be on the safe side.
MARK POCHAPIN, MD: Ms. Shaw, when does a patient come to see the doctor? They've gone home, at what interval do they need to come back?
ROXANA SHAW, PA: Normally at our institution, the cardiologist asks to see the patient two weeks after their surgery. And the surgeon usually sees them anywhere between four to six weeks after the surgery. At that time, we evaluate their wounds, their leg wounds, their chest wound, the stability of their breastbone, and their medications. Although that is mainly taken care of by the cardiologist in our institution, we like to know what exactly is going on with the patient.
MARK POCHAPIN, MD: We talked about a lot of the things the patient needs to look out for, a lot of the physical activities that they should avoid. What are things that they can do? For example, when can they resume normal daily activity? When can they resume sexual activity? Is it patient by patient, or is sort of a set course?
WINDSOR TING, MD: A lot of it is from patient to patient. The patient can start walking, ambulating right after they're home. Sometimes it's difficult to walk because of the weather. So I frequently recommend a patient to go walk in a shopping mall. That's a great place to go walking. There are lots of things to see, and it's climate-controlled. But there's no reason why the patient cannot begin walking immediately after discharge from the hospital.
In terms of sexual activity, I think that can be resumed as soon as the patient feels comfortable. I don't see why that needs to wait.
Now, there's another thing about diet. What should a patient eat? I think a balanced diet. I don't think there's any special nutrition or any special diet. I think the most important thing is to eat a well-balanced diet. A well-balanced diet means vegetables, meat, fruits.
MARK POCHAPIN, MD: Low fat.
WINDSOR TING, MD: Low fat, and low salt.
MARK POCHAPIN, MD: Well, thank you all very much. It's really been a pleasure, and I'm sure our audience has learned quite a bit. I certainly have.
