Total Hip Replacement: A Personal Perspective

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Chapter V. The Eve of Surgery

I had arranged for a friend, Bob, to take me to hospital, a two-hour drive from where I live. The plan was to go through a day of pre-operation testing and qualification the day before the actual surgery. This is done as an outpatient. If I had lived closer to the hospital, I would have gone home afterward and returned in the morning for surgery. However, being a couple of hours from home, I decided to get a room in a local hotel for the night before surgery. Another friend, Margie, herself a physician, would arrive in time for dinner that evening and planned to stay with me for the first few days after surgery.

Pre-op testing and consultations

The purpose of the pre-op testing is to ensure that the patient is healthy enough to undergo surgery. I was a bit worried because I had set all the wheels in motion, particularly with respect to friends who had changed their schedules to accommodate mine. In Margie’s case, she had scheduled vacation time from her physician’s job in order to be with me. She flew in from 1,000 miles away. Gross inconvenience to many friends would result from my disqualification. I was concerned because I had a sore throat and a bit of a fever earlier in the week. I was afraid that it might recur. Fortunately, my fears would turn out to be unfounded.

The first stop on Pre-Op Day was the orthopedic clinic at the hospital, where I checked in and was quickly sent to X-ray for more glamour shots. There, things slowed down a bit, as there were six or seven patients there in the waiting room. Time to go with the flow. There was no way I could speed things up if I wanted to.

Bob wanted to talk with some friends, but his cell phone would not work deep in the bowels of the hospital. Therefore, while I waited for the next available X-ray setup, Bob went outside to make his calls. Thus, we initiated our game of hide-and-seek , which would continue throughout the day.

After getting the X-rays, I was given a large envelope to take back to the orthopedic clinic. There, I handed the envelope to the receptionist, who told me to take a seat. It was not long before they called my name (mispronounced, as usual) and ushered to one of the examining rooms. Here I would meet with the case manager, the surgical residents, and the surgeon himself to discuss final details of the surgery, what I could expect, and what would be expected of me. I was given some antimicrobial soap and was told to scrub myself very thoroughly with the soap that night and again in the morning. Humorously, the container holding the liquid soap was a urinalysis specimen jar, which I had to carry with me the rest of the day, precipitating some funny looks.

Most of the remaining questions were mundane. For example, I asked once again about using my own prescription medications instead of getting them from the hospital pharmacy. The case manager told me that it would be noted on my chart and that my drugs would be examined by the pharmacist to ensure that the contents of the bottles were what the labels said they were. Dr. G asked me if I would want a private room, which he recommended, stating that the difference in price was very small, around $25*. I agreed, because that is a small price to pay for privacy.

I was given instruction in how to use an incentive spirometer (IS), which is a simple device that helps you take deep breaths to fill your lungs after surgery. One of these devices will be supplied to you after surgery, and you will be expected to use it to keep your lungs clear. It is quite an easy exercise, which if you perform diligently, will make you feel better quickly.

I was then sent to Central Testing for an EKG, blood tests, and a urinalysis. All went smoothly, and I was almost into the home stretch. It was at this point that I began to lose my fear that something would get in the way of the next day’s surgery.

Anesthesia counseling

The next stop was Pre-Op Anesthesia. I had checked in, presenting my credentials, and sat down in the waiting room. Bob found me there. He must have been quite an expert on the playgrounds of New Jersey, playing hide-and-seek 60 years ago! As we waited, the receptionist fielded a phone call. I overheard, “Yes, Mr. Goldfarb is here. OK, I’ll send him.” What now? I was told to return to the orthopedic clinic. It did not take much rumination to figure out why they wanted me. What could be more important than medical testing on the day before surgery? Money, of course!

Show me the money!

Back downstairs at the orthopedic clinic, I saw the woman responsible for scheduling and wallet extractions. A large number of toy frogs of various materials and statures decorated her office. (I imagined that one of them would fling its tongue out at me and slurp up my wallet!) In conjunction with my insurance company, she had calculated that I needed to give her about $2,000 for the surgeon’s fees. I put it on my American Express card. I might as well get some miles for my misery! Moreover, if something went wrong with the surgery, I could dispute it with American Express. After it was clear that my card would not bounce, I was given a receipt and permitted to go back to see the anesthesia folks.

General or epidural?

Back at pre-op anesthesia, I sat down with a person who asked many questions. I was used to being asked about allergies to drugs and which medical conditions I have by that time, having answered the same questions at least five times that morning. I did not blow my cork because even if it meant that there was scant communication among departments of the hospital, all this redundancy could only give me some additional assurance that they would get it right. My vital signs were taken once again, and blood oxygen saturation was measured. I was then taken to a room where an anesthesiologist would take over to finish this phase of the pre-op day.

This was the most significant time snag. It took close to an hour for the anesthesiologist to arrive. Bob was beginning to get a bit impatient. I did not blame him; I was beginning to get antsy, too. Finally, the doctor arrived. More questions about drug allergies and medical history. No problem.

The big question for me was whether I wanted an epidural or a general anesthetic. I am not a doctor, but I think I have a rudimentary understanding of the differences between the two methods of anesthesia. The epidural anesthetic, sometimes called a spinal block, involves inserting a tiny catheter into the area around the spinal cord in order to inject the anesthetic. This will block any feeling in the area from the waist down.

A general anesthetic affects the entire body. The heart, lungs, circulatory system, and nervous system are all shut down to some extent. When you receive a general anesthetic, you do not sleep per se. If it were merely sleep, the pain from the surgery would quickly wake you up. The system shutdown, coupled with a dose of morphine to ease the pain of surgery, enable you to get through the experience without jumping off the operating table and screaming in pain. However, because all your systems have been affected, it will take a while after surgery for things to get back to normal. This effect is what is commonly referred to as an “anesthetic hangover.”

An epidural in itself does not cause you to sleep. However, it is usually used in conjunction with some sedatives. You will sleep lightly, but you will not remember the surgery. The epidural has one additional benefit. Because the epidural catheter is left inserted after surgery, pain control is simplified. A device called a PCA (patient controlled analgesia) allows the patient to self-dose measured amounts of pain medication. The device is regulated such that an overdose is impossible. In addition, with the epidural, recovery from anesthesia is quicker and there is much less of an anesthesia hangover.

Having prepared myself by doing the reading and self-education I have been pushing to you throughout this book, I would be ready with a decision after asking only a couple of questions on points that I thought needed clarification. My questions involved my experiences with Versed (pronounced ver-sed), a drug that is used as a sedative in conjunction with the epidural. I apprised the anesthesiologist that Versed had not produced the desired effect in two earlier encounters. The drug is supposed to sedate the patient and cause him or her to not remember what happened while it is in effect. My first encounter was an endoscopy, a procedure that involved pushing a fiber optic probe down my throat and into my stomach to look for ulcers and other problems. I was given Versed, but I remembered everything! The next procedure that called for Versed came about 10 years later. It was a colonoscopy, which involves pushing a similar probe into the other end. I apprised the doctor who performed that procedure of my seeming resistance to Versed, prompting him to adjust the dosage. “Give him nine of Versed,” he told the nurse. It didn’t work. I remembered the entire procedure, including how it felt when the doctor burned off two small polyps. I told the anesthesiologist that I did not want to have any similar memories of the hip replacement. I did not want to remember how it felt to have my bones sawed, drilled, and hammered.

The anesthesiologist thanked me for bringing this up. He further expressed appreciation for the extent of my preparation for this discussion. He assuaged my concerns by telling me that he would make a note the Versed problem and other drugs would be used in the operating room in conjunction with the Versed to ensure that I would not remember anything. That assurance was good enough for me. I decided to proceed with the epidural.

This experience reinforces the need for preparation, especially with respect to understanding your own physical condition and any problems you might have with particular drugs. Doctors are generally very good at what they do, but they are not psychic. It is your responsibility, not theirs, to ensure that all pertinent details of your health are known before you submit yourself to surgery. If you are not sure about something, ask questions. Above all, do not hesitate to volunteer information that you think might be important. You can never supply too much relevant information.

Anesthesiology being my last stop, I was finished for the day. I was relieved that nothing was found amiss that would cause my surgery to be cancelled or postponed.  It was time to have a quick bite with Bob and send him on his way after dropping me off at the Sheraton.

A relaxing evening

I had been told to call Ambulatory Surgery Scheduling that evening to get my appointment time for the next morning’s surgery. I had been admonished not to eat or drink after midnight, but to take any prescription drugs I required. Finally, I was told to get a good night’s sleep and remember to scrub myself as directed.

Margie arrived on schedule, shortly after Bob dropped me off at the Sheraton. We laughed, relaxed, caught up with old times, and had a mundane room service dinner. The toilet in the “luxury suite” provided some postprandial entertainment by threatening to overflow. I felt that this was a good omen—business as usual.

Soon, it was time to sleep. I took my extra-long shower with the antimicrobial soap in the specimen jar. Then, surprisingly, I got a good night’s sleep.

*Dr. G was wrong.  It turned out to be only $5 per day. Such a deal! Be certain to ask about the availability and cost of a private room.

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