PREPARATION PRIOR TO COMING TO THE HOSPITAL

Do I need a checkup by my family doctor?

Having a joint replaced surgically is a major operation. If any significant medical problems exist, and you have not seen your internist in a while, it would be a good idea to have a thorough preoperative evaluation. Let Dr. Bertin know of any medical problems you may have. Smaller illnesses should also be treated before surgery. This would include a bladder, sinus or any foot infection. Hernias, gallbladder, or stomach disease should also be treated before elective joint replacement.

What about medications?

Stop taking aspirin and all anti-inflammatory medication ten days before surgery. This includes medication such as Advil, ibuprofen, Alleve, Motrin, Naproxen, Relafen, Daypro, Feldene, Lodine, etc.  These medications increase the bleeding that occurs at surgery.  If you are taking blood thinners, MAO inhibitors, or diet pills (phen/fen or redux), please notify your surgeon immediately for instructions.

Continue taking all other medication that has been prescribed for you.  This includes all heart, asthma, blood pressure, seizure, diabetic medications and prednisone or cortisone.  You should take these medications on the day of surgery in the same manner that you would normally take them, but only with a small sip of water.  If you use an inhaler, bring it with you.

Diabetic patients: Do NOT take your insulin in the morning on the day of surgery.  When you come to the hospital, the nurse will check your blood sugar and the anesthesiologist will regulate your insulin accordingly.

Bring a list of your current prescription medications and dosages or the pill bottles with you to the hospital for review by the nurse. You will not be taking your own medications in the hospital.  These have to be recorded by the pharmacist and administered by a nurse to meet national laws and hospital policy.

Night before surgery

DO NOT EAT OR DRINK ANYTHING AFTER MIDNIGHT!! This includes coffee.  Do not chew gum or mints and do not smoke.  If you are taking prescription medications, these should be taken with a small sip of water at the same time that you usually take them. 

Coumadin tablet--Take this one pill by mouth after 6:00 p.m. the evening before surgery.

E-Z Scrub Brushes--These contain Hibiclens antiseptic soap.  Take a bath or shower the night before surgery and the morning of surgery using one brush each time. Pay particular attention to cleaning the hip or knee which will have surgery.

Duration of surgery

The average operation will take about one to two hours.  A revision could take as long as two to four hours. After your operation is completed, you will be taken to the APost-Anesthesia Care Unit.  This is the recovery room.  You will be kept there approximately one to two hours until you are ready to return to your room on West 3.

What is autotransfusion?

During surgery and recovery, some blood is lost, and your blood count (the hematocrit) may drop to the level at which a transfusion would be indicated. Most knee replacements do not need a blood transfusion. However, some hip replacements do. If you are concerned and want to donate blood before surgery for your own use, you may do so. The safest source of blood for any individual is himself. You can serve as a blood donor for yourself by giving blood before your operation. This is very simple and safe. The blood can routinely be stored for forty-two days and then given back to you during or after the operation. It is possible to safely donate one unit or pint of blood every five or seven days. This allows the accumulation of two or three units before the operation.  This covers most routine transfusion needs. During this preoperative period of donation, it is important to eat a good diet and take iron and vitamin pills to replenish the blood you are donating. For this purpose, you should take ferrous sulfate or ferrous gluconate, 300 mg., three times daily and one good multiple vitamin each day, until you come in for surgery. You should try and donate your first unit of blood about 40 days before surgery.  A second unit can then be donated 10 days later. Your body will then have time to build up the blood count (hematocrit) before your operation. To arrange the blood donation, just go to the blood bank with the prescription Dr. Bertin gave you.

Should I see a dentist before my surgery?

If you have any problems with your teeth or gums, you should have these taken care of before your surgery. This is especially true if there is any infection in your mouth. If treatment is postponed, there is the chance that dental manipulation or an infection might cause bacteria from your mouth to enter the bloodstream and settle in your operated joint. The risk of infection is especially high during the first few months after a joint replacement. All this is easily prevented by visiting the dentist before surgery. If you do not have a family dentist and need the name of a good dentist, ask Dr. Bertin for a referral.

What should I do to prepare my home for my return from the hospital?

When you return from the hospital, you will be walking with a walker or crutches. Make the pathways through your home easy to negotiate with these ambulatory aids. If there are wide, clear "trails, this will make walking safer. Remove any throw rugs on which you may trip or slip. These are often on the porch, in the kitchen, or near the shower. A stool (like a bar stool or tall chair) that can be put in the shower makes it much easier to shower. When you can use this, you do not have to stand during the whole shower. If you do not have this type of shower stool, one can be purchased from a medical supply house.

When you are in the hospital, you will be given a toilet seat extension and reach extender to use if you need them. Other aids to assist in daily activities are available if you need them: extra long shoe horn, stocking "puller-oner," elastic shoe laces, or wheelchair. Please tell the doctor or his assistant if you need one of these. Many of them will be covered by your insurance policy if a doctor’s prescription is written for the device.

HOSPITAL ADMISSION

Your insurance

Check with your insurance carrier before you are admitted to the hospital to answer any questions you may have about your coverage. The insurance company may require a second opinion. If they do or if you want one, please tell Dr. Bertin. He is happy and willing to have another opinion prior to your surgery and will help you arrange this if you need help. He will make your X-rays and records available to the other physician to minimize any expense or inconvenience to you.

Insurance companies often require "pre-authorization." This is the process of informing them before admission to the hospital of your plans for surgery. If they require this, they will only pay for your operation if it has been approved ahead of time. It is the patient's responsibility to know if this is necessary. If it is, let us know and we will help with the paper work. It usually requires specific code numbers and sometimes estimated fees. An approved length of stay is also often stipulated by your insurance company. This may or may not include a night before surgery and a certain number of days after surgery. If the insurance company only authorizes so many days, we will try to conform to that. Occasionally a longer hospital stay is needed, and if the doctor is aware of this, he can contact the insurance company and arrange for extended days in the hospital.

Admission the day before surgery

If you are scheduled to be admitted the day prior to your surgery, you should arrive at the hospital about 1:00 P.M. Go to the admitting office in the main lobby, and they will direct you further. It will be necessary to have some laboratory tests done prior to surgery, these include blood tests, EKG and X-rays.

You will be fit with white surgical stockings called T.E.D. hose. It is their purpose to prevent pooling of blood in your legs. This helps prevent blood clot formation (deep venous thrombosis or DVT) and clots from going to your lungs (pulmonary embolism). The T.E.D. hose also prevent swelling in the leg which may occur as a result of the operation. Swelling does not necessarily indicate a DVT and need not cause undue concern. If it seems more than expected, call it to the attention of your doctor. These hose should be worn for four to six weeks.

The evening before surgery you will be given an enema. This is so you do not have to worry about going to the bathroom for a day or two after surgery.

 One very effective way to prevent deep venous thrombosis or clot formation in your legs is to administer a blood thinner which will work after the operation. Coumadin, an oral anticoagulant or blood thinner, is used for this purpose. You will be given the first dose the night before surgery. This starts to work in about forty-eight hours after the bleeding associated with surgery has stopped. Every day thereafter your blood will be drawn and tests run to see how "thin" it is. A dose of Coumadin will be prescribed to get your blood to a certain level and keep it there. This will continue throughout your hospitalization and occasionally after discharge.

Admission on the day of surgery

 Many insurance carriers require you to be admitted to the hospital on the morning of your surgery. You also might well desire to stay home and sleep in your own bed the night before surgery. If either of these is the case, you should schedule an appointment for your laboratory tests and an evaluation in Dr. Bertin's office a few days prior to your admission. At that time you will receive several important preoperative instructions and any questions you have can be answered. You will be asked to take a shower or bath with a special antiseptic soap called Hibiclens the night before and the morning of surgery. This is to help sterilize the skin and prevent infection. An enema will also be prescribed. The Hibiclens and enema will be dispensed at Dr. Bertin's office for you to take home. Your first dose of Coumadin (blood thinner) will also be given to you so you can take it the night prior to surgery. The hospital will notify you on the day prior to surgery as to exactly what time you need to be at the hospital.

Things to expect in the hospital

Leave all jewelry and valuables at home. If you need your contact lenses or glasses, please bring a storage case with you. You will be measured for surgical hose called TEDS.  These are elastic stockings that you will wear to surgery and for six weeks following surgery. Pain medication will be ordered after surgery. You can have this every three hours if necessary.  Pain medication is not given automatically. You will need to ask your nurse for it. The pain medication does not take the pain away entirely, but should keep you comfortable enough to rest.  If the pain medication seems insufficient to you, let your nurse know.  The nurse will see if you can have more or a different medication.

If you experience nausea, you should tell the nurse before it gets too bad.  The nurse can give you some medication in your I.V. to help relieve this condition. You will have your blood drawn each morning. This will check your protime (how well your blood is thinning) and also your hematocrit (blood count or blood level).

Physical therapists will get you out of bed the very next day after surgery.  You will do this at least two times a day. They will teach you what to do and what not to do. For patients who have surgery early in the day, you may be ready to start ambulation the afternoon of surgery. Hip replacement patients have a big blue wedge pillow laced between their knees while in the operating room.  This is called an abduction pillow. You will only use this while you are in the hospital. When you go home, you do not need it any more.  Instead, you should just use a regular pillow between your knees while in bed for the first three months following your operation. Knee replacement patients are fit with a special machine in the recovery room. This is a Continuous Passive Motion (CPM) machine.  It bends and straightens your knee for you. You need to utilize this most of the time.  You can have it off at night for a few hours to turn on your side.

You will always have a nurse assigned to you.  She/he will be the one to ask for pain medication.  You will receive a sponge bath for the first few days; then you can shower.   Your TEDS need to be removed daily for bathing, then put back on.  If you have any questions or concerns let your nurse know. There is a charge nurse on duty every shift. If your concerns are not being met, ask to talk with her/him.  Debbie Mitchell, R.N. is the Nurse Manager who is responsible for West 3.  If your problems or questions are still not resolved, ask to speak to her.

You will be on West 3 for about 4 days after surgery.  The physical therapist will work with you teaching you what you need to know to be ready to go home. You should have a relative or friend that will be helping you after surgery at home come to the hospital to learn the correct exercises.  The therapist can teach them how best to help you.  You will need to do these exercises every day at home.

Discharge Information and Planning

You will be discharged from the hospital four days after your surgery.  For example if your surgery is Monday, you should plan on going home Friday. If your surgery is Wednesday, you would probably go home Sunday.

You will need to make arrangements for someone to pick you up the morning of the fourth day after surgery to take you home.

Someone who is going to be helping you at home should come to the hospital the day before you leave to learn the exercises you will be doing every day at home.

Your doctor will let you know on the second day after surgery if there are any different plans for your discharge.

You will need help at home after you leave the hospital.  Most patients do not need formal visits from a physical therapist.  You will most likely be doing the exercises with the help of a friend or family member.  You will need help for bathing, shopping, housework, dressing etc.  Plan on this ahead of time and make sure someone is available for these personal needs.

If you anticipate longer term care in a nursing home or extended care facility, please start these plans prior to admission. We would be happy to provide you with a list of approved and available facilities.

You will need a blood test every week on Wednesday for three weeks after surgery.  Please make arrangements to have someone transport you to the doctor’s office or another facility for this purpose.

Discharge Medications

You will be discharged from the hospital with prescriptions for pain pills and a blood thinner.   These prescriptions can be filled at the hospital for a lower cost than at a local drug store, and the hospital honors prescription insurance plans.  The pain pills can be taken based on the instructions written on the bottle.  The pain will decrease, and by four to six weeks from surgery you should be able to get by with no medication or simply an over-the-counter pain reliever. 

The blood thinner is taken every evening for four to five weeks from surgery.  You will have a weekly blood test to monitor the effectiveness of this medication.

YOUR HEALTH CARE TEAM

As your physician and surgeon, Dr. Bertin plans and performs your operation personally. He is responsible for your overall care and rehabilitation. However, several other mem­bers of the health care team provide important assistance to him and valuable care to you. The following information is given to you to help you understand the purpose and role of these other medical personnel.

Physician Assistant

Mr. Scott Frischknecht, PA-C, is a board-certified physician assistant for Dr. Bertin. Physician assistants typically undergo an intense two-year medical training program beyond a Bachelors Degree. They work in many health care settings under the supervision of a licensed physician. Mr. Frischknecht is qualified to perform many medical tasks for Dr. Bertin. These include taking medical histories and performing physical exams, ordering appropriate x-ray studies and laboratory tests, prescribing medication, and providing patient counseling. In addition, he assists Dr. Bertin in the operating room with the actual surgical procedure. You will meet Mr. Frischknecht in the off ice prior to your surgery. He will also visit you in the hospital daily and provide important assistance in your recovery period. You will often see him when you return to the office for routine examinations. He is a valuable resource in answering questions about your specific care.

Physical Therapists

The physical therapist plays a significant role in your recuperative process. Physical therapists have extensive training in the functions of the muscles and joints of the body and are skilled in the rehabilitation of patients who have undergone joint replacement surgery. A therapist will meet you in the hospital and work with you two or more times each day following your operation. It is important that you follow his instructions. The therapist will initially help you to get in and out of bed correctly and explain to you your exercise regimen. He will show you the proper use of walking aids such as crutches or a walker and assist you in walking. Your specific exercises will strengthen your muscles and increase the motion in your joint. If needed, arrangements can be made for a physical therapist to visit you at home for additional therapy after your discharge from the hospital.

Registered Nurses

The registered nurses (RN's) in the hospital provide full time care for you during your hospital stay. They are highly trained and experienced in caring for patients who have had orthopedic surgery. Since they are in the hospital throughout your stay, they are able to quickly ascertain and respond to your needs. Dr. Bertin writes specific orders in your individual chart for the nurses to follow. Each day during his visits (called "hospital rounds"), he reviews your bedside nursing chart and monitors closely your recovery process. The nurses themselves also keep him well informed as to your daily progress. They are adept at assisting you with any personal needs you might have and can answer many of your questions.