Now that your operation is over and you have recovered sufficiently in the hospital, your surgeon is considering your discharge. For many patients, this is a frightening prospect. There is unquestionably a sense of comfort and security associated with hospital care. You probably do not feel well at this point; you may only have begun eating a day or two ago; and you still find that tasks such as sitting up in a chair exhaust you. This is all very normal, and the apprehension you may feel is understandable.
There are a few points to remember when you begin to think about your discharge. While a hospital is obviously the safest place for a critically ill patient, it is a poor place to recover from surgery. The staff of most hospitals is well trained to treat acute illness but is not well positioned to support recovery. This has not always been the case, but as the number of available hospital beds has dramatically decreased in this country over the past decade, so has the staff that went with them. Hospitals now are caring for only the sickest of patients, and they are the ones who get most of the attention from the limited available staff. This means that the healthier patients cannot get undivided attention. Physical therapy and rehabilitation departments have also been cut, with the result that most hospitals cannot fully support the long-term rehabilitation needs of their patients. Hospitals obviously do not have many of the comforts of home, such as home cooked meals, comfortable beds, quiet rooms, and loving family members. All of these things will contribute to your sense of well being after surgery, as well as to your recovery. Finally, in any community, the most dangerous and virulent infectious agents can be found in local hospitals. The reason for this is obvious if you think about it. Dangerous organisms cause the worst illnesses, and the sickliest patients are in the hospitals. Your risk of developing a serious and potentially life-threatening infection is high in a hospital. The quicker you get home, the safer from this risk you will be.
Patients typically ask several important but hard to answer questions prior to discharge. The first is always, when can I return to work ? This answer depends upon your surgeon’s preferences, the type of operation you had, and your overall medical condition. A good rule of thumb that I use is this: if you are able to eat normally, are moving your bowels, can easily walk up a flight of stairs, and do not require any pain medication (except maybe to help you get to sleep), then you are ready to return to work. Another thing you must consider is your activity at work. Clearly, someone who spends most of his or her time behind a desk or in a chair will be able to safely return to work sooner than someone who is operating heavy machinery or who lifts heavy loads on a regular basis. These same rules of thumb apply to driving a motor vehicle. You should not even consider driving until you have gone several days without pain medication. Driving sometimes requires quick activity and/or sudden movement. If you still experience pain with exertion or rapid movement, you should not be driving. This may seem overly cautious, but the few extra day of rest are a small price to pay for your safety and the safety of other motorists and pedestrians around you.
Another very important question regards resuming sexual activity. This is a personal decision; and frequently, you will find that your desire has not returned even after your feel your recovery is well progressed. Surgery alters our perception of ourselves, and this is a vital ingredient of our sexuality. If you find that you do not have your normal sexual appetite for several weeks, do not be alarmed. On the other hand, many people will want to resume sexual activity before they have been discharged from the hospital. In this case, a good rule is: if it doesn’t hurt, it’s probably safe. Your body is a very good judge of its condition, and if something is bad for you, chances are your body will let you know by providing a painful disincentive for the activity. As long as your incision line is not being abraded or strained in any fashion and you are not experiencing pain with any given activity, then it should be safe to proceed. My suggestion is to increase your activity slowly, experimenting with what you can and cannot do. If you don’t rush into anything too strenuous, you should not have a problem.
Upon discharge, you may find that you are on several new medications. You may also find that you are not given prescriptions for some of the medications you were taking before surgery. If you filled out the PreOp-Worksheet and brought it with you to the hospital, you can be sure that your surgeon knows what medications you were taking beforehand. If you forgot to list a medication, or if you did not bring the worksheet or a medication list with you, your surgeon may not have even known you were taking a certain drug. To ensure that you are not taking any drug you should not be taking and that you are not missing any drug that you need to be taking, there are several steps to take. The easiest is to use one pharmacy to handle all of your drug prescriptions. This allows your pharmacist to check all your medications for side effects and drug interactions, which may be dangerous. It is sometimes difficult in this day and age, when many prescriptions are filled by out-of-state companies, which mail you medication on a regular basis. This is an unfortunate consequence of some of the cost-cutting measures health insurance companies are using these days to keep their costs down. If you do not have a single pharmacist, your primary care physician can fulfill this role for you. Your surgeon should have contacted your primary care physician after the surgery to let him/her know what was found in the operating room and how your recovery is progressing. For your own safety, I suggest that you call your regular doctor as soon as you are discharged to let him/her know how you are doing, what prescription medications you were given, and what medications he/she wants you to take at home. You should also schedule an appointment with your primary physician within a few weeks after discharge. Your surgeon will want to see you to make sure you are doing well; but at some point, particularly if you have had a curative operation, your relationship with your surgeon will become inactive. This is why you should strive to keep your primary physician well informed, as it is this person who will continue to treat you on a regular basis.
When going home, you should normally resume the medications you were taking preoperatively unless the operation you had fixed the problem that required the medication, or you were specifically instructed by your surgeon to stop taking a particular drug. The only way this can be safely done is to inform your surgeon of all the medications you take. I cannot stress this point enough. It would be a terrible tragedy for you to have a successful operation only to have a complication develop due to a medication error. In the end, only you can be responsible for preventing this from happening, and the best way to do that is by providing accurate information and initiating appropriate communication between you and your physicians.
You may find that you do not have a normal appetite when you return home. This is not unusual and occurs with many types of surgery. You may even find that you begin to lose weight after your operation: this too is not unusual. As long as you are able to tolerate liquids sufficient to prevent dehydration and you continue to move your bowels regularly, you should not be alarmed. If, however, you develop persistent vomiting that lasts for more than a day, you find that your abdomen is getting bigger, or if you are suffering from serious constipation, your surgeon should be notified. Weight loss of up to 5% of your body weight is not worrisome, and you will likely gain the weight back as soon as your appetite improves. On the other hand, if a week or two has passed since your discharge, and you find that you cannot eat or that you are still losing weight, again you should let your surgeon know.
Depending upon your operation and your underlying medical condition, it may be necessary for laboratory tests to be performed after your discharge. If this is the case, your surgeon or primary care doctor will instruct you to have blood drawn. It is important that you faithfully have these tests completed. This is a process that may have occurred easily if you were hospitalized for an extended stay several years ago. In today’s cost conscious world, you will not be permitted to remain hospitalized for several days just so a lab test can be drawn, even if it is a vitally important test. I suggest that you know which lab tests are scheduled for you after your discharge and who will be receiving the results. Make sure you follow up to be certain that the test results were forwarded to the appropriate physician and that no changes in your care are mandated by the test results. If you are having outpatient-nursing visits after your surgery, these functions can be performed by the visiting nurse at the time of his/her house call.
Visiting nurses have become an extremely valuable tool to surgeons who discharge their patients before they are fully recovered. It is both comforting to you and your surgeon that a trained medical professional will assess your vital signs and wound condition, as well as make sure you are taking the proper medications and have all necessary lab tests drawn. Not every patient will need the assistance of a visiting nurse, but for those who do, the visiting nurse is an extremely valuable asset. If you are scheduled for discharge and you are uncomfortable with some aspect of your care at home, you should inquire as to the availability of visiting nurses in your community. Along those same lines, you may want to talk to a discharge coordinator before going home. If you anticipate that you will have unusual needs after discharge, such as a wheelchair, hospital bed, oxygen-delivery system, or other medical equipment, most hospitals have a coordinator who can see to it that everything will arrive at your home before you do.
In the course of normal recovery, there are ups and downs; so you will have good days and bad days. As such, it is not necessary for you to call your surgeon every time you notice a bit more pain from your wound or if you feel tired or fatigued one day. These are things you should expect, and until several months have passed, you should not expect to feel your old self again. Several conditions do require immediate notification of your surgeon, so by keeping your eyes open for these signs and symptoms, you could nip a problem in the bud. If you do not have a home thermometer, now would be a good time to buy one. There are few pieces of information that surgeons need more than they need your temperature. This is because so many problems first surface as an elevation in temperature. It is a good idea to take your temperature several times a day after you are discharged, and record the time, date, and temperature. Especially if you begin to feel weak, tired, or just plain sick, record your temperature, and note your symptoms. If you find you develop a fever of 102 F, you should call your surgeon. Temperatures this high may be early indicators of developing infections, and he/she will probably want to keep a close eye on your temperature, and possibly schedule an early office visit.
Other important symptoms to note are changes associated with the operative wound site. If you notice a developing redness around your incision, or if you begin to see drainage from the wound, you should let your surgeon know. These are both signs of wound infections, and the earlier they are treated, the easier they are to cure. Other signs of wound infection include a foul odor emanating from the wound, increased tenderness around the wound, or separation of the skin edges. On the other hand, if you notice a ridge developing under the incision or the incision site itches, this probably represents the process of wound healing, and you should not be alarmed.
There are a host of other symptoms that mandate early evaluation, which are simply listed below. If you develop any of these symptoms, let your surgeon know. The problems associated with these symptoms vary in importance, and you may be asked to keep and eye on the condition over several days, or you may be asked to come in for immediate observation. You should follow whatever recommendation your surgeon makes. Important symptoms include: chest pain at rest; shortness of breath at rest or with minimal activity; coughing up blood or green/tan sputum; pain or burning with urination; swelling of one or more extremities; persistent night sweats; weight loss that persists for more than two weeks; vomiting that persists for more than one day; constipation with no bowel movement in 2 to 3 days; increasing abdominal girth (with or without pain or nausea); pain/tenderness/redness at any IV or blood withdrawal sites; the passage of bloody stool; or the passage of black/tarry stool.
If everything is going well after discharge, do not neglect scheduling follow-up appointments. Your surgeon will probably want to see you within 1 to 3 weeks of your operation. As I mentioned above, you should also schedule a follow-up appointment with your primary care physician. This can usually be done at some time after the appointment with your surgeon. If you are being treated for several medical conditions, or if you were seeing your regular physician on a more frequent basis, schedule a follow-up with that physician sooner. You may have also been seen by one or more specialists while you were in the hospital. These people may have left you a professional card or asked your surgeon or primary care doctor to schedule an appointment with them. Don’t forget to make those appointments as soon as you are discharged, as it may be several weeks before you can be fit into the appointment schedule.
Once you have finished your initial follow-up visits and have been at home for a few weeks, you will be wondering when your full strength will return. The next chapter will give you an idea of the timetable you should keep in mind when judging your progress.