Photo Credit: Foter / Creative Commons Attribution 2.0 Generic (CC BY 2.0)
“I’m Sorry Sir, We Have to Cancel Your Surgery Today”
Sure, there are worse things you can be forced to tell a patient, but seeing the reaction in my patient’s face after having to tell him we were canceling his hip replacement made me feel as though I’d just told him something far worse. He’d been having severe pain in his right hip for several months and had been able to walk only a few steps at a time for several weeks due to the debilitating pain. It’s hard to imagine how much he was looking forward to relief from pain and being able to walk again.
To make things worse, our patient was lying on the operating table preparing to undergo anesthesia induction when we got together with the anesthesia team and made the decision. We felt it necessary to postpone the surgery because the patient had a very large abdominal hernia. The anesthesia team was concerned that given the patient’s baseline COPD, the abdominal hernia would significantly impair the patient’s ability to ventilate during the case, placing the patient at too high a risk for cardiopulmonary complications. Additionally, the patient’s foot on the operative side had a fungal infection and his foot hygiene was poor. Our concern was that this would place him at increased risk for infection of his prosthesis. Thus, we asked the patient see a general surgeon to evaluate his hernia for possible surgical repair so that he could safely undergo a hip replacement and we asked that our patient see a podiatrist to help clear the foot infection prior to undergoing a hip replacement.
At some point, hopefully he will be cleared for surgery and we will be able to help him and replace his hip. Unfortunately, it’s likely to be a year or more before it would be possible. It will take several weeks if not months to clear his fungal foot infection and it could take a few weeks before he has the opportunity to be evaluated by general surgery and then potentially several weeks before he could undergo hernia repair and then he would have to appropriately heal. Then, he would have to request to see us in clinic which could take several weeks. From the time we would see him until we would be able to get him into the OR would be several months. We’re currently booking elective cases 4+ months out and the “next available” appointments in our clinic are 16 weeks from now.
This case highlights many of the issues that face our VA medical system. We have a plethora of veterans whose only real access to health care is the VA medical system and we are grossly understaffed and unequipped to handle the volume of patients who require care. The Philadelphia VA Medical Center is the orthopaedic referral center for over a dozen VA centers and many of our patients come from well over an hour away to see us. As such, it’s often difficult to get them back and forth for multiple appointments. This creates an issue when we’re scheduling patients so far out. We rotate through the VA on 3-month schedule, meaning that patients I sign up for surgery won’t be operated on while I’m on rotation (in fact, they might not even be operated on by the group following me). Thus, we rely on notes several weeks to months old to determine if patients are medically stable for major elective surgery and meet appropriate operative indications. So, while we all do our best to sign up appropriate patients and refer them to the pre-operative medical clearance center, from time to time we are placed in the unfortunate situation where we have to cancel a patient at the last minute – a patient who has been anticipating surgery and the pain relief and improvement in function for several months.
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