A post-operative tale: the story of a bandage and a boat

[two_third]It’s been a long time since I helped care for someone post-op, and I learned many lessons recently.

A friend of mine – let’s call him XY– had outpatient shoulder surgery on a Monday afternoon to remove bone spurs from his left shoulder; he had had similar surgery on the right shoulder about ten years ago, so felt he had a good idea of what to expect in terms of pain, recovery, and so on. There were, however, some changes in the circumstances: at the time of the first surgery he was married, living with his family, and living in a house; now he is divorced and lives alone on a sailboat.

XY was taken to the hospital by a friend who stayed with him until he was in recovery, at which point XY’s 18 year old son (XY Jr) arrived. XY Jr took him home and stayed with him overnight, making sure he took his pain pills, put the cold pack on his shoulder regularly, and checked the dressing on his shoulder at least once. (I should point out that the discharge instructions did caution about post-op nausea and vomiting, going slow on the food and liquids…but they stopped for egg rolls on the way home, and XY got sick. Sometimes even clear instructions aren’t followed.) XY Jr left Tuesday morning for school. I arrived that afternoon about 3:30, and so far so good: XY had been setting his alarm for every four hours to take his meds, and was resting comfortably. I checked the discharge instructions for information about dressing changes, limits on activity, and so on (I’m not familiar with shoulder surgery, and his arm was in a sling). The instructions for care of the dressing were “as instructed” – presumably verbally, as there was nothing in writing. There were no supplies provided by the hospital. The instructions for range of motion were “as tolerated.” The signature attesting that the signer understood the instructions was completely illegible: XY thought it was his signature, but couldn’t remember signing it, and remembered nothing about the discharge instructions. At that point I decided to look at the dressing; it was clearly soaked through and under a transparent occlusive covering, so we called the surgeon’s office.

When the nurse called back I described the appearance of the dressing and asked if I should change it. We had an interesting conversation that included the following points, in this order [my questions in brackets, my thoughts in italics]:

1. Don’t change the dressing until the post-op visit [Are you aware that’s 11 days from now?]. We prefer to keep them covered. (So you do want the wound to be all moist under a saturated, air-occlusion dressing for 11 days?)
2. If you change the dressing (you just told me not to!), you can just cover the site with a big band-aid. (So is it or is it not ok to change it?)
3. Don’t shower [for 11 days?]. If you do, keep the dressing dry; just use plastic wrap. (Which dressing is this – the original dressing, which is already soaked through, or the band aid? If it gets wet in the shower, is it ok to remove and replace it?)
4. If you want, come in to the office any time and we can change the dressing for you. (The office is 30 miles away, doesn’t have weekend or evening hours, the patient can’t use his left arm – or can he? – is on pain meds round the clock and is in a lot of pain, and lives alone; how do you suggest he get there?)
5. Regarding that ‘range or motion as tolerated,’ it’s okay to use the arm as much as you want, and discard the sling when you want; but don’t raise your arm above your head or lift or push anything heavy. (Clear as mud. Why wasn’t that on the discharge instructions?)

The reader can see where this is going, and probably could share similar experiences. Items 1-3 above were not addressed at all in the discharge instructions; the restrictions for use of the arm and shoulder were not covered in the phrase “as tolerated” in the instructions. Granted, XY may have been told all those things…but he doesn’t remember them. His son may have been told them, but didn’t pass them on. As XY asked, “Why didn’t they give me these instructions before the surgery?” Good question.

Critical points:

Important information was conveyed when the recipient could not understand or remember it, and/or was given to someone who did not pass it on, and/or was not written down for future reference (by the patient and/or his helpers). In any case, the right person(s) did not have the information.

The information and instructions given in response to an inquiry were unclear and frankly confusing.

Living circumstances: I don’t know if anyone (surgeon, hospital, etc.) had explored with XY his unusual, but not unique, living situation. The hospital and surgeon’s office are in a community with a large boating community, and is fed by several other nearby communities with many boaters and marinas. I am going to surmise that the staff assumed he lives in a house and that he was asked something like “Can someone help you out after surgery for a few days?” and that he said, “Yes, my son and some friends.” I doubt that he was asked if his living situation is inherently risky: every time one steps from dock to boat deck, there is a risk of a literal slip. XY not only lives on a boat, he lives alone, and the boat is at the end of the dock which itself is at the end of a marina. Thus his living situation itself is even riskier than most people who live-aboard, even without pain medications around the clock. I like to think that if it had been known to his surgeon’s staff, they would have recommended that he plan to spend at least the first few post-op days ashore at someone’s home. The lesson to me is to explore the patient’s circumstances a little more closely.

Working in patient safety and quality, I have the privilege of learning from so many colleagues and learning about the excellent work they are doing. I was truly and sadly surprised by this experience and the combination of inadequate discharge instructions coupled with unclear directions from the surgeon’s office. During those 18 hours I learned a lot more than I had expected to about how far we have to go.

Thoughts? [Share with me here] Miriam Marcus-Smith, Program Director, WPSC[/two_third]