So you're having surgery. Join the club! Every year 35 million Americans have surgery and the costs make up a significant portion of the 3 trillion dollars our nation drops on health care — certainly not chump change! And what do pretty much all of the other 34,999,999 souls, young and old, have in common with you?
Well, first of all, none of us are looking forward to it. Surgery hurts, surgery messes up our day-to-day routines, surgery causes pain (sometimes lots of pain), surgery causes us to miss work, surgery often requires us to spend a few days in the hospital — where we are exposed to some really dangerous bugs (bacteria), where we freeze in a skimpy hospital gown, where we get poked and prodded, awakened at all hours, get lousy food, miss our favorite TV shows, etc. etc. Yep, no one in their right mind looks forward to surgery.
Now pretend that you're watching a funny Geico commercial on TV with that adorable little gecko. But instead of offering you great rates on insurance, the little gecko says he can offer you an improved surgical experience. Yep, our gecko friend says if you buy his insurance that instead of cutting your insurance costs in half, he can cut your pain after surgery in half.
And not only that, our gecko says he can cut the length of your hospital stay in half, cut your risk of getting an infection or blood clot after surgery in half, avoid having you come into the hospital all dehydrated and with a headache from caffeine withdrawal and pretty much make the whole experience from start to finish a lot more bearable, a whole lot more bearable. And as the commercial for the super onion peeler or blender always says, wait, there's even more! Yep, Mr. Gecko says he can also help you avoid lots of those nasty pain pills like Percocet and Vicodin people routinely get after surgery, the ones that usually make you feel sick as a dog and can lead to narcotic addiction. And yep wait there's still more! For the same incredibly low cost Mr. Gecko can also have you up walking sooner, avoid annoying stuff like constipation and vomiting, feel less "drugged out" and blow your friends away with how well you're doing. And the "incredibly low cost" is not $1000, not $100, not $1.00 but free! Really, free! So what do you have to do? Not much really, as the title says, just know your alphabet.
OK, so now what do I mean by that, certainly I don't mean A, B, C, D. . . . Rather, I'm talking about 2 little acronyms: ERAS and PSH. And these stand for "Enhanced Recovery After Surgery," and "Perioperative Surgical Home." Now what do these terms mean?
ERAS: The Paradigm Shift in Surgical Care
According to the American Medical Association, ERAS protocols represent a "paradigm shift" in surgical care, require the cooperation of a team of people (primarily the surgeon and anesthetist but often also a nurse coordinator), reduce length of hospital stay by 30 to 50%, reduce complications by the same amount and finally reduce overall costs! It appears in this case there is really a "free lunch." As an anxious patient, the question isn't why you would want your surgical team to use an ERAS protocol, rather, the question is why wouldn't you want them to?
PSH: Individualized Care
Now let's take a look at our second acronym, PSH. According to the American Society of Anesthesiologists or ASA, which is kind of like the American Medical Association for anesthesia providers, the PSH is a "patient-centric, team-based model of care created by leaders within the American Society of Anesthesiologists to help meet the demands of a rapidly approaching health care paradigm that will emphasize gratified providers, improved population health, reduced care costs and satisfied patients." Now what this means is you get to meet your anesthesia provider days ahead of time (not 5 minutes before they wheel you back to the operating room), you get to ask more questions about things like "how much pain should I expect" or “will I be nauseated after surgery?” If you need some lab tests (and a lot of times you don't, but only the anesthesiologist would know for sure), they'd be done then, not the morning of surgery where an abnormal lab can get the operation cancelled. And since your care is individualized within the PSH, you might save yourself a needle stick and no one likes needles! And just like our onion peeler example, for the same price (nothing!) there's even more, a lot more! Some examples:
If you're a coffee drinker and you don't get your morning dose of caffeine, you likely will get a caffeine headache before surgery. The ASA and or your friendly neighborhood anesthesiologist will tell you that you can have black coffee or tea up until 2 hours before your surgery. Yep, drink all the clear liquids, water, Gatorade, etc. you want. Then you won't show up at the hospital miserable and dehydrated. Right now in the United States around 90% of surgical patients are told not to eat or drink anything after midnight and that admonition is often strictly enforced. And the reasons given are downright silly, namely, because it's always been done that way and most patients are too dumb to know the difference between a cup of tea and an Egg McMuffin.
If you're not dehydrated, your veins will be bigger and it will be easier for the nice nurse with the big thick glasses and shaky hands to hit your vein when she starts your IV.
If you're not dehydrated your blood pressure won't drop so much when you get your anesthesia, which means a safer procedure, since your heart and your brain don't like really low blood pressure.
Pretty neat huh? Are you ready to buy in yet? Well, if you're still not sold, there's still more, really!
The Importance of Genomics
The American Medical Association has stated that every doc from psychiatrists to surgeons to family practitioners should have a working knowledge of genomics, which is a word that means all your own personal, unique genes. Back in the year 2000 it cost around 3 billion dollars to measure all the genes in an individual, but enormous advances in technology, led by a company called Illumina, have reduced that cost to around $100 or so! This is really important since the average person (and no one is average, everyone is unique) gets around 10-15 different drugs during their surgical experience. If the anesthetist and surgeon know your genome ahead of time, they can tailor the medicines you get for your body, not for some "average" body. You'll get better pain medications for after surgery, your risk of having an adverse drug reaction (which sadly kills around 20,000 people in the US each year) goes way down, you can wake up quicker, have less nausea and basically have your own custom made procedure. This is called "precision medicine" and is the path that everything in medicine is taking, albeit very, very slowly.
Now returning to our PSH, when you meet with your anesthesiologist, he or she can do a mouth swab (the same kind of swab they use for Ancestry.com) and then there is time to get your genomic profile back before surgery. Still not sold? Well, let's suppose you're meeting ahead with your anesthetist for some really big operation like having your colon removed or your prostate gland removed, or maybe getting a knee replacement. The anesthesia person in the PSH — as well as the ERAS team of which anesthesia is a part — will talk to you about using a "block" to greatly improve your overall surgical experience and cut your pain by as much as 75-80%. The block (which is mostly numbing medicine) is put in before surgery by the anesthesia team. An example of a "block" is the epidural women get when in labor. I've seen thousands of very uncomfortable ladies become completely pain-free 10 minutes after I put in an epidural and the same holds true for many big surgeries. The trick is to put the block in before the surgery.
So Let's Sum up Some of These Ideas . . .
| Traditional Surgery | Reasoning Behind This Way of Doing Things | Surgery Using the PSH and ERAS | Reasoning Behind the Newer Model |
| Don't eat or drink after midnight | In the late 1940's people were worried you might throw up when you go to sleep. By 1995 it became clear that clear liquids were just fine up until 2 hours before surgery but many doctors felt like the patient would have a McDonald’s sausage biscuit in the morning because patients are inherently dumb. And then the surgery would be cancelled. | Drink all you want of clear liquids up until 2 hours before surgery | The ASA strongly endorses this. It's safer and leads to improved patient satisfaction. The patient is not dumb and wants to participate in their own care. And there is no "caffeine headache." |
| Don't place "blocks" before surgery | They take too long and the surgeon doesn't want to wait and there isn't an available anesthesia person to do the block ahead of time. Without the block, the patient requires large amounts of narcotics during and after the operation. And there is a risk of addiction. | The block is placed before surgery in a staging area | The hospital has a "floating" anesthesiologist to do the block. The anesthesiologist often doesn’t get paid for the block but the overall savings to the hospital is great, and the system is set up as a win-win so the hospital passes on part of it's savings to the anesthesia team. Narcotic use can be minimized and often eliminated. |
| Don't visit the anesthesia person a week or two before the surgery; rather, they will stick their head in and say hi after you get to the hospital | Anesthesiologists are a little like taxi drivers: they only get paid when they are in the operating room — they don't get paid to sit in a clinic and see patients ahead of time. | The patient is seen days or weeks before the surgery | Fewer cases get cancelled; the patient is much more satisfied; a genomics profile can be sent off if the patient or doctor thinks it’s indicated and be back before the surgery; routinely ordered labs can often be skipped since they can cause more harm than good; the patient is so much more relaxed. Everyone benefits and there is someone there to coordinate care during the entire surgical experience |
What’s the Catch?
So what’s the catch? — why wouldn't everyone want to use the PSH/ERAS protocol? There is no catch except you need to find hospitals (and there are many) where they do this. For example, the University of California at Irvine was one of the first places to implement the PSH and now uses it for many of their bigger surgeries. And many hospitals and younger surgeons have bought into the idea of ERAS, they've drunk the punch so to speak.
This is just a very brief summary or teaser, but all you have to do is be sure to find a hospital and surgeon that subscribe to the two acronyms, ERAS and PSH. You'll have a much, much better and safer overall surgical experience and save money to boot. Who says there's no free lunch!
Want to Learn More?
Here’s a few great resources and there are hundreds more great videos on YouTube: