When Surgery Seems Too Good to be True

Bridgeport Hospital orthopedic surgeon David Bindelglass, MD, meets with Deborah Trumpower for a pre-operative exam before her second knee replacement.

Deborah Trumpower actually looked forward to getting her second knee replacement in August.

When she had her left knee replaced on March 28, 2016, the surgery and recovery went so well, her first reaction was: "There's something wrong here because I'm feeling great!"

Her surgery had begun at 7 am, and she was back in her hospital room by 10 am. "Soon after getting to the floor, they said to me, 'You're going for a walk,'" said Trumpower.

"I was not in a lot of pain and was able to walk around. I went home the next afternoon." Two days later, a visiting nurse saw her at home and a physical therapist came to her house the rest of that week and the following week. After that, she went to outpatient rehabilitation appointments twice a week and did exercises at home. The stitches came out two weeks later.

"I was fine," said Trumpower. "I thought, 'This is too good to be true.'"

Trumpower, a resident of Milford, benefited from a fairly new approach to surgery known as "Enhanced Recovery After Surgery."

Enhanced Recovery After Surgery (ERAS) is in use at all three Yale New Haven Health System hospitals. Bridgeport Hospital's first ERAS surgery was a colorectal procedure in July 2015, followed by orthopedic surgeries last October, and hysterectomies this summer. Urology surgery is next on the list.

Over the past few years, enhanced recovery programs such as ERAS have increased the speed of patients' recovery, decreased the number of complications from anesthesia and surgery, and shortened the amount of time patients have to spend in the hospital.

ERAS works its magic by standardizing care of the patient before, during and after surgery. There are specific areas of standardization: patient education, preoperative carbohydrate loading, anti-nausea medication and pain control, IV fluids, managing the patient's body temperature, limited post-operative fasting, Foley catheter removal and early walking.

"The whole philosophy is that we bring a healthy patient into the operating room for an elective procedure and keep that patient healthy with minimal pain throughout the perioperative period, thereby enhancing quick recovery of functions and discharge to their natural environment which is home," said anesthesiologist Rajesh Kumar, MD, who was instrumental in developing the anesthesia techniques used so successfully at Bridgeport Hospital.

"We limit and standardize the overall exposure of the patient to anesthesia and strive for a narcotic-free surgery experience using a multi-modal pain protocol. We inject a certain amount of local anesthetics right into the knee to block the sensation around the knee, which has proven very effective for post-operative pain control," said Dr. Kumar.

"We combine a minimal spinal with total intravenous anesthesia, eliminating the need for anesthesia gases and narcotics, which creates minimal nausea, so that after surgery, the patient wakes up right away, bright and shiny, and is able to participate in physical therapy within hours of surgery."

According to Dr. Kumar, the anesthetic mixture, which he refers to as a "special cocktail," is much better than the previously used nerve blocks which would affect the muscles as well as the nerves. The fact that the muscles are not affected permits the early walking.

Bridgeport Hospital orthopedic surgeon David Bindelglass, MD, agrees that new techniques in pain management, adequate pre-op hydration and patient education are key to the success of early recovery.

"There used to be an absolute Golden Rule with anesthesia — the patient could have nothing to eat or drink for eight hours before surgery," explained Dr. Bindelglass, of the Orthopedic Specialty Group. "With ERAS, patients drink a bottle of Gatorade a couple of hours before surgery."

He added, "The multi-modal anesthesia we use blocks the impulses coming from the spine, some of the excitability of the nerves and early inflammation. The general anesthetic is so light it avoids nausea, vomiting, dizziness and any kind of hangover, so patients are wide awake as soon as they leave the OR."

In the past, with traditional hip or knee replacement surgery, patients did not get out of bed until the day after surgery, largely because of the effects of the anesthesia.

With ERAS, patients start rehab almost immediately because they are wide awake and pain free.

Bridgeport Hospital surgeons have performed more than 300 enhanced recovery cases since the program started less than a year ago. According to Dr. Bindelglass, the length of time orthopedic surgery patients stay in the hospital after joint replacements has been decreased by almost one-third— from an average hospital stay of 3.6 days to 2.8 days.

"This is a movement throughout Yale New Haven Health to examine and improve all the clinical processes of caring for patients," he explained. "This clinical redesign, as we call it, has been good for patients and good for the hospital."

Another result of ERAS that surprises patients is that less than one-third of them need to be discharged to an inpatient nursing home or rehab center. It used to be two-thirds.

Karen Essig, RN, orthopedic program care coordinator, reviews discharge instructions with Kevin Bria, from Bridgeport, who is preparing to go home the day after a total knee replacement.

"Some patients are nervous when they find out they are not going to a nursing home after discharge," said Karen Essig, RN, the orthopedic program care coordinator. "It's a big cultural change. But I tell them, 'Stay open minded because you are going to do so well you won't need that level of care!'" Once the surgeon schedules the procedure, Essig calls the patient a week or two before the surgery. "I let them know what they can expect before, during and after their surgery, and we start planning their discharge before they even get to the hospital." She finds out about family support and equipment needs and helps them plan.

"Patient education is critical because it's elective surgery, so they really have time for education and preparation," said Essig. "Understanding and preparation decreases their stress and anxiety, which makes them even better candidates for surgery." Jack SantaMaria of Trumbull had one knee done "the old-fashioned" way in April 2015 and the second knee done the ERAS way in April 2016. Both surgeries were performed by Joel Malin, MD, and both were done at Bridgeport Hospital.

But "the difference was like night and day," said SantaMaria. "This time, I was up and out of bed an hour after I got to my room after surgery. I went home the next day and was able to climb the stairs and sleep in my own bed that night. I was back to work full time in less than three weeks," he said. "A year ago, I was in the hospital for three days and wasn't able to work full time for six weeks."

SantaMaria, who is a director of operations for Shop Rite, does a lot of walking at work and return to work was important. He said, "The rehab was so accelerated, and I found it to be so much better this time around."