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SICOT e-Newsletter

Issue No. 28 - January 2011

Editorial by Thamer A. Hamdan
Professor of Orthopaedic Surgery, Dean of Basrah College of Medicine, Basrah, Iraq

By proper patient selection we can avoid so many complications  

There are many different ways of reducing the incidence of complications. One of them might be answering the question "is the patient fit for surgery?", another "is he fit for this particular procedure or is a second option more appropriate?".

Being aware of this vital point will certainly reduce the surgeon’s if not the patient’s suffering. Prolonged morbidity or even mortality results from poor patient selection all over the globe.

Surgeons need to be direct in answering questions, to acknowledge the limits of their understanding and to encourage specialist consultation when the clinical situation warrants it. They also need to create a therapeutic climate in which patients and their families feel free, when necessary, to express their concerns about treatment or to request a second opinion.

Unfortunately, surgeons are notoriously variable in their ability to assess and predict complications in their patients prior to surgery. Education is of course integral to the good treatment of any illness, but this is especially true when the remedy to the illness involves surgery.

Patients and their family members should be encouraged to write down any question they may have, as many individuals are intimidated once they find themselves in a doctor's office. Any information that is given orally to patients should be repeated as often as necessary. In addition, it is vital to observe the patient and his family’s response to the information given. The patient psyche and behaviour prior to surgery is never the same after the development of complications and after poor or even unexpected results. Some patients are looking for the impossible; they have reached a state of disbelief in reality.

Some jobs or the fear of losing a job in the future may adversely affect the patient's behaviour.

Bear in mind that there are many parameters to be considered to achieve the goal of proper patient selection. Patient’s fitness for surgical procedures is divided into physical and psychological fitness. Physical or organic fitness is either related to the locally diseased parts or to the body system as whole. Certainly, the bigger the procedure, the more the metabolic response, and the greater is the need for better pre-operative evaluation.

To perform any particular surgical procedure, a proper matching of that surgical procedure and the patient's general or local condition is necessary.

Fitness for surgery can only be achieved at a high profile level, i.e. prolonged and clear interview, probing of the patient's psyche, and critical evaluation of the physical and mental status.

So many questions in the surgeon’s mind should be answered before drawing the specific map of treatment. The surgeon should be fully aware of the evidence based procedures for curing a particular pathology, and whether he is the one to choose which is which for this specific lesion depending on solid scientific basis.

Some surgical procedures are a one way valve or a river with no end. They may affect or even destroy some vital patient’s desires or lead to functional disability. The question here; is the patient ready to accept this drastic change? Is he able to cope with the new style of life? Is he ready to tolerate complications? And how patient is he? Next, but equally or probably more important than the pathological process, is the psychological status.

Being aware that psychological background will help greatly, it is vital to stabilise the personality prior to surgery. Some patients are marginally adjusted with definite risk of worsening after any surgical procedure no matter how minor it is. It cannot be said that the surgeon is blameless because of time shortage; he is guilty by the sin of omission or commission.

Patient understanding of the procedure, his/her particular requirements, willingness to co-operate and follow instructions, his/her awareness of the seriousness of the condition, financial and social status, are all vital points to be considered to ensure a trouble free and successful outcome.

No two patients are alike, and there is individual variation in response to the same pathology or procedure. Some patients are nice, polite, very co-operative, or even lovely. Others are trouble makers, for little or no reason; they try to make something from nothing. Probably, they are inherently trouble makers, because of their family background. It is therefore vital to have some ideas about the family circumstances. The family plays a major role in ameliorating or intensifying the patient's response to complications. It is of great value to clarify the expected complications and more importantly, to interpret the patient's response to the possible complication or bad outcome. We have to learn how to read eyes and brains rather than planning a procedure depending on the patient’s verbal reply.

Searching for any odd intention in the patient's mind is vital. Surgeons should be fairly sure that there is no trace of compensation neurosis. In an emergency situation the selection is out of order.

Despite all the years of my surgical experience, I cannot deny falling into the trap of wrong patient selection many times. It seems it is not an easy art to learn but here I may say confidently "complications can be avoided to a great extent only by applying the policy of a high degree of patient selection; it will protect you from nightmares, because it is one of the golden rules in surgical practice".