By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
While I am currently on my Obstetrics & Gynecology rotation, there isn't often a lot that needs to be done in terms of pre-operative and post-operative medical care. This is because women undergoing OB/GYN surgery are often otherwise healthy young to middle aged women. However, next up will be my General Surgery rotation, so I need to be prepared to assess for and manage perioperative complications in patients who have a bit more going on.
Management of surgical patients begins in the preoperative period, ideally well in advance of any surgery they are going to have so as to best optimise their health pre-surgery. Optimising their health means to do 2 things:
It is important to start the pre-operative assessment with complete history. Elements that are particularly important to include in the pre-op history include:
Credit to the UpToDate article, "Preoperative medical evaluation of the adult healthy patient."
After you've gathered the above history, doing a focused physical exam is next. This includes the following elements:
After the clinical assessment is complete, consider using this nifty risk calculator to stratify the patient's likelihood of having a perioperative complication.
After clinical assessment, you can move on to informed investigations based on the assessment. Consider ordering (if you know an indication, not by default) any of the following investigations:
After the full clinical assessment, with the results of any necessary investigations, you can develop your management plan to optimize any medical issues as previously known or as detected based on your pre-operative assessment (ex: getting blood glucose levels better controlled in a patient with diabetes). Next on the to-do list is to communicate any perioperative risk factors to the patient, surgery team, and any other relevant care providers. This will help the patient and care team decide whether or not to proceed with the surgery given the risks, benefits, values, and specific circumstances of the individual patient. If the patient is to proceed with the operation, a detailed care plan will need to be outlined to optimize patient outcomes before and after the surgery. Common issues to work out will be when to stop and start certain medications such as anticoagulants, and what the strategy will be after surgery to try to prevent them from developing a clot (a common post-op complication, we think about this in everyone who undergoes any surgery that keeps them bed-bound for a little while)
Post-operatively care consists of monitoring the patient as they recover, checking for any signs of complication, and encouraging a quick return to their usual functioning, because this leads to better outcomes.
There is a well-known mnemonic for the medications you want to think about providing to the post-op patient if indicated: the 5 Ps. I've added a couple of extra Ps to include make it a completely useful mnemonic for me to remember not only some basic drugs to think about ordering to improve patients' comfort in the discomfort that is the post-op period, but also to remind myself of the most common concerns I want to check in about as the patient is recovering.
And then, on the surgical ward, they get sent home faster than you can say "no bedside manners."