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Friday, June 8, 2007


Here is a very pedestrian article I have written for a senior-specific magazine called Harmony. The article deals with some points that should be known before a geriatric patient proceeds for surgery. There is published literature to support laparoscopic surgery in the elderly, and I believe these old birds don't take big incisions as well as the nicks of minimal access. However, more than the size of the cuts, it is what takes place inside the body (infections, leaks, blood clots, bleeding, etc.) that determines if the elderly patient lives after the surgery. While in most cases of mediocre surgeries, the patient survives in spite of the surgery rather than because of it (because Nature gives us a long rope), the elderly population is a clear exception. Their system is like a house of cards that comes crashing down if the balance is upset.
One thing I have realised in practice is: if you are successful initially operating on a few really sick old folks, you are going to sleep less for the rest of your life. Because the invisible social network of these patients drives more and more geriatric patients to you, crowding out the younger, fitter, easier cases, at least in the third world. If you come to my hospital OPD, you will see barely conscious, silvery hags carried horizontally over half-torn stretchers from hundreds of miles away for really advanced, Middle-Ages-level disease. For example, if you do a lap chole surgery on them, you would have to dissect out almost every upper abdominal organ that is irreversibly stuck on to a tiny, hard, fibrosed nodule that calls itself a gall bladder. If you do a hernia, the patient would look like he had, at some point in his youth, decided to transfer all his bowels from his tummy to a secret place beneath his trousers, and then suddenly, in the twilight of his life, decided that that was ALL that needed fixing in his otherwise perfect life! "Hey, commere, doc, just fix this hernia, will ya? And don't cut me up, d'ya hear? Only the best, latest, painless, bloodless keyhole surgery that you guys are doing these days! I am still getting my pension, so my kids don't want me to die!" Most of the grave 'bearers' of the bad news are very clear that they expect the surgery to take place this afternoon, and the patient should be up and about like a lustful monkey in a couple of days! And, of course, they couldn't possibly spend money on old, dying grandmothers and grandfathers, could they? "Be reasonable, doc! Okay, my maximum budget is ten thousand rupees (around $250)". Anything more than that, they say with their eyes and facial muscles, you will have to pay for, especially if she dies! At least, in my life, this has been my bane, and the reason for the premature greying of what hairs my head still proudly bears! And, of course, a reason for my still being so poor!!


NurseontheRun said...


Nice article. Very good points. The lucid and reading geriatric folk will find many useful, valid and important tips in this article. You should submit it to AARP -- the magazine of the US "grey panters". Seriously.

I have nothing but applause for your article. But I ask you this: is it a problem? Is there a conflict about operating on the reading and crossword solving elderly population? What about the hordes of gerries who don't read, who are confused, pooing into diapers (excuse me, "disposable briefs"), and talking nonsense -- and then they fall and break a hip, or break a hip and fall?

I see that as the more important issue of surgery on the elderly.
Do you operate on a severely demented, blind, babbling fossil or why not?
It seems to be the opinion of many US ortho surgeons that such patients are best served with an ORIF or somesuch.

As a nurse, it falls to me to torture the old person into a chair, push food into their mouth when they clench it shut, sneak pills into their applesauce and hope they don't notice, poke holes into their skin and replace IVs they have dislodged, turn them like a chicken on a rotisserie so they won't get pneumonia -- and so forth -- so they can return to having all this stuff done to them by the staff of the nursing home where they reside?

What do you think, Ramana -- is hip surgery on the demented and immobile a good way to ensure that the person is "managed" well?


B. Ramana said...

Thanks for being such a darling, at least here! ;-)
The published evidence....forget it! Let me spell it out in a short article.

NurseontheRun said...

Where is the short article?

B. Ramana said...

Welcome back!
Here it is!