My name is Shawn Bond, I’m an orthopedic physician assistant. I specialized in spine care. I went to the PA program at the University of Southern California, I have a master’s degree in science, and I’ve been working as a physician assistant for 16 years.
A physician assistant is an-an asset to the physician, to the practice, to assist the doctors during the procedures themselves as far as the care of patients of course, pre-operative, intraoperative meaning during the hospital stay, rounding on the patients make sure the patients are well taken care of, checking them physically, ordering again, laboratory tests, blood works as necessary, and then upon discharge, following the patients at home, make sure that the entire care that we provide to the patient from the pre-surgery, during surgery, post-surgery is taken care of and taken back to the office, and they can follow up the physicians at that point.
Obviously, what brings a patient in to see us initially is pain, but it’s not necessarily pain in that. Not every patient complaints of back pain. Some of them maybe have more neurological symptoms, the numbing, or tingling, or weakness of the extremities. That’s a common complaint that patients come in to see us with.
Something that we ask all patients to do, every visit that they come in, we ask them to fill out a pain scale. On a scale of zero to 10, where are you on your-your current visit, or were you in general over the last several days, two weeks. What that helps us do, is determined really the severity of the issue. It determine one, if they require surgery, or two, what kind of treatment do they require. And in a lot of it is based on, not only their exam. Are they weak? Are they numb? But also based on their pain.
Our goal is not necessarily to get everybody to a zero, and we actually know that that’s not gonna likely happen. We’re open with patients about that, if you came in to see us with uh, an eight, and we could reduce your pain conservatively or with surgery, we make them reduce that pain to a three. Well then our job is to try to reduce patients’ pain from something that they consider to be intolerable to something that is comfortable, and something they can live with. And so the pain scale allow us to not only determine the course of action that we need to take, how aggressive we need to be with that, but are we accomplishing our goals.
In addition to that, it is obviously our job to make sure that you will come through the surgery safely. And I’m not referring to surgical problems, I’m referring to medical issues. We’re gonna get some blood work on you. We’re gonna get an EKG on you, we´re gonna listen to your heart, we’re gonna listen to your lungs. And we’re gonna discuss with you that this is a surgical procedure where we would put you to sleep, we will put a tube down your throat, a machine will be working for you during that time, an anesthesiologist will be monitoring you during that time.
And make sure that they understand that not only are the risks and complications associate with the said procedure, but there’s also risks and complications associated with just putting you to sleep. And again, that is our job collectively as a team to make sure not only the treatment is correct as far as surgery, but the patient is safe to proceed with the operation.
You go to the hospital, you have the procedure, you might be in the hospital for 23 hours, you might be in the hospital for 72 hours. The length of stay in the hospital is depending, of course not only upon the procedure that we have recommended or performed, but it’s also based upon you medically.
So, somebody that may have a simple procedure such as a micro-discectomy, where you’re just removing a piece of the hernia that fragmented toward the fragment that broke off, that person may stay sometimes is an outpatient, sometimes only several hours, we may keep that patient in the hospital overnight. That person, however will not go home until they are medically safe to go home.
And that is the same thing that holds through with even the longer or the larger operation such as a fusion. Those individuals traditionally will stay in the hospital for two or three nights. Depending on the fusion maybe only one or two nights, but if we’re referring to a low back or a lumbar fusion, a more common operation that we do, most patients would spent the night in the hospital two to three nights depending on the physician, depending on the procedure, again, that might be more, that might be less.
Discharge, as far as sending the patient home, what determines that? In my view it’s really five different factors that you have to accomplish in order to go home. If all five factors are met then you could probably go home safely and that´s the number one thing, are you safe for discharge.
What are those five factors that I look at? One is your pain controlled. Number two is you disconnected from everything. You know, you can’t still have IV fluids; you can’t still have a pain pump, all the drains, all the tubes must be out of you at this point. Three, are you walking? We’re going to make sure you are safe to go home. When you go home the last we want you to do is go home and be confined to a chair, be confined to a bed. So, are you walking? Are you someone independent at that point? Next, are you safe? Are your vital signs good? Medically are you safe? Your blood pressure looks good, your vital signs look okay, and your heart looks okay. And the last thing really is that, you as a patient feel you are welcome to go home.
You have no more concerns, you have no more anxieties, and you feel like what you are there for in the hospital has been met. Your surgery was successful at this point, your pain is controlled at this point, your anxieties are met, you are walking, you are safe, your family, your friends are comfortable with your discharge and if all those things have collectively been met, then we usually could discharge you home.
The first thing I wanna tell patients, and I reiterate to patients is when you go home you will still have some symptoms or some pains that you even felt pre-surgery and that’s important to understand that. Because they don’t want you as a patient to be concern that something may have failed, something is going wrong.
The analogy I like to explain to patients is very similar to a broken bone, and that if you break your arm and you came to see me I’m gonna put you in a cast. Well that bone still has to heal, that bone still has to mend and has to go through its process of healing and that process may take several weeks, it may take several months depending on the type of fracture and. It’s the same analogy when you have your surgery. You go home, the first thing you have to understand and as a patient is, your symptoms will likely still be there.
And so whether your symptoms were numbing, or whether your symptoms were tingling, or even weakness. Those numbing, tingling, weakness symptoms will persists as things heal and recover, and they’d had to do exactly that. The body has to heal. The body has to recover. And it’s the same thing when it comes to pain, now your pain if it was back pain, your back pain may be superseded by surgical pain, and appropriately we give you medications to treat those symptoms while you’re at home.
What we do wanna know is we wanna know are there new symptoms? Okay, if there are new symptoms that you do not have prior to surgery, by example, pre-surgery your right foot was numb or weak, you go home now you develop new symptoms into the left leg that were not existing prior. That’s something we would not expect, and that’s something we want to hear immediately. As a patient you have to understand is there’s a lot of things that you can do to make it worse. There’s very little really that you can do to make it better.
If we give you rules and instructions that basically tell you keep it very sedentary, okay? Walk. Which is one of the things that we really like to encourage patients to do is walk. It is very, very therapeutic for you in many, many different aspects. But [CLEARS THROAT] by walking we refer to casual walking. And if you determine that you’re gonna take an [PH] strenuous hike by example, is not gonna help your body recover. It actually may weaken and make things worse and you’re gonna probably pay for it afterwards.
I like to tell patients, if you had a flu you came into the doctor’s office ‘cause you had a flu, you just felt cruddy, you felt weak, you didn’t feel good. You’re gonna go home, you’re gonna rest, you’re gonna drink fluid, you´re gonna lie in bed, you’re gonna sit on the sofa, you’re gonna watch TV, you may read a book, you’re gonna walk around the house, if you feel good enough you’re gonna walk outside, maybe walk down the block or back. And for the first week, maybe two weeks after surgery that’s what I encourage patients to do.
Okay, don’t plan on going out to dinner, don’t plan a run to the grocery store, may have those things set up ahead of time. If you need additional, uh, equipment that’s our responsibility pre-surgery, during the operation as far as the hospital stay to make sure you have that equipment when you get home. Whether be a walker, or whether be a raised toilet seat, or what I call reacher-grabber and those kind of things again, maybe an asset to you as far as your recovery goes. It’s not necessary for every patient, so I would not encourage every patient to go and purchase those things. It all again, depending upon the procedure you’re having, as well as your recovery.
In general most patients will go home with their pain prescription. We prefer to do it, where we actually give that patient the prescription days in advance. It is difficult to get a prescription upon your discharge and hope that the pharmacy is able to fill it, they are open, and everything works out where you concert to pay medication immediately. Which is one of the recommendations that we give, is try not to lapse in time on your medications, stay consistent with your medications for the first several days following the operation. Very important to your recovery. You don’t wanna allow the waxing and waning of your pain to occur. You wanna keep your pain very comfortable, very controlled for the first several days. So we encourage patients take your medications mm, okay. If you have no pain, well, I not gonna recommend that you take your pain medications, but stay consistent with your medications, narcotics unfortunately have a tremendous side effective constipation. And as I tell patients, you are having spine surgery, that alone is gonna make it very difficult to use the restroom, because we’ve operated on an area very close to the area you’re gonna use the restroom in and so strengthen or pushing creates pain.
Now, if you’re taking your pain medications that’s something you’re gonna struggle with. So we also discuss with the patients have a plan available, have something set up, so when this does happen you are already aware of it, you’ve already have a process in place, that hopefully prevent it.
There’s also separate side effects that go along with medications, obviously we tell patients please don’t drive a car. If you are taking narcotic medications contact your physician, contact your doctor, if any concerns or questions about your medications. And again, we try to get them off those medications or answering appropriate medication as quickly as possible.
SHAWN: Most importantly I do make sure patients understand, it is very critical that they know there is a mental component to the operation. You as a patient have to be mentally prepared for your surgery. Most of these operations are elective operations, and as such you have an opportunity to prepare.
You need to prepare not only physically but mentally what you’re going to go through after the operation. If your physical activity uh, prior to surgery was you’re an athlete, you swam, you ran, you played golf you may not be able to do those things for an extended period of time after procedure and that might be months. And as such, your life changes. Depression is probably very relevant following an operation and so I think is important to surround yourself with friends, with family, with things that are positive.
If it obviously gets to a point where the depression is now one of the more important things in your life, because you think about it all the time, it weighs upon you from morning to night, your behavior is definitely affecting those around you. At that point I think it’s time that you maybe seek help for that, and that’s available to you. Contact your physician, contact your surgeon, and they can help you those things, but depression, anxiety, fear, these are all normal things that patients have to understand are gonna be a part of your recovery from surgery.
And the more people that you can surround yourself with, the more friends, the more family, the more loved ones that you have is gonna help you recovery. So, the emotional side is really as important short term, I would say as it is the physical side. And so, it is preparing not only for the physical but also preparing for the emotional or the mental side and I think that’s what makes the best surgical outcome.
It’s important to really educate the caregiver and what I mean by that is, at your visits prior to your operation bring that individual with you. That is probably the most important thing that you can do. So, whether be your presurgical visit, or maybe a visit or two prior to that, where you can sit down and you can discuss the procedure, the pain associated, the recovery afterwards, what is normal and what is abnormal, what your life would be like after the operation, your limitations, both physically uh, is discussed maybe mentally or even sexually.
Those things are appropriate to discuss, in my opinion prior to the operation, as supposed to after the operation. And ask questions, come with a list. What can I do to help this person? What’s my role in this? How long is my role in this? And, what are that individual’s capabilities post-surgery? How intimately involved do I have to be? I think that would make the recovery period for both of you so much easier and so much better.
So, you have your operation. Your operation’s successful, you’re back to some normalcy in your activities, you’re back to some normalcy in your job, your life, and you’re feeling good. Unfortunately, it doesn’t end at that point. And that’s important to understand, that once you’ve had a procedure things have changed. Things have changed from that point forever. The analogy is a car that's been in an accident. You take it to the body shop, it gets repaired, and it’s still not the same car anymore.
As a patient you’ve been repaired. But there’s-you’re still vulnerable to problems, to situations occurring down the road, and it’s important to know that yes, I’m feeling good but I still have to do things properly to prevent maybe a recurrence of my pain, to prevent a future injury, but also knowing that I am susceptible to problems occurring maybe somewhere else, because of what I had done.
And so it is my job as a patient then, to make sure I take care of myself physically, of course mentally is well, but physically I maintain a good core exercise, and so I’m working on every day on my stomach, my gluts, my back muscles appropriately through, you know through the physical therapy and continue with the recommendations of the physical therapist and as important it is, it doesn’t stop once the symptoms go away.
The process of making sure you recover and heal are long term, they’re lifelong. It is your job as a patient to make sure that you do everything you can to make sure not only this operation is successful, but you are doing everything you can to make sure you prevent any future problems. And so you will work diligently, you will work every day to make sure that what we have recommended to you is done. And so you don’t come back to see us anymore. Our job is not to see you. Our job is to say good-bye and hopefully you get on with your life and you can get on with your life safely
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