Archive April 2017 XVIII, No. 4

Editor's Page: More Questions Than Answers

The correct path is not always lighted and marked.

In this issue, we ask a couple of provocative questions that are sure to start a good argument around the break table:

While they're both rhetorical questions with arguments to be made for either side, they're also both highly inflammatory hot potatoes. Best to tread carefully, respectfully and armed with facts.

Let's tackle post-op pain first. Short-term opioid exposure following surgery is now linked to risk of abuse, but to lay the blame for the nation's opioid addiction crisis at the feet of surgeons seems harsh. The surgeon's sin: overprescribing opioids for post-operative pain relief, writing for 50 painkillers when 5 or 15 will do. And in so doing, getting moms, dads and kids hooked on the euphoria they experience while on these highly addictive drugs.

"Surgeons are unwittingly enablers of addiction, abuse and overdosage," says noted surgeon and author Atul A. Gawande, MD, MPH, of Harvard Medical School, in this month's Annals of Surgery.

What's a surgeon to do? Reduce pain and inflammation with non-opioids before, during and after surgery. Send patients home with regional blocks. And reduce opioid use after surgery. Yes, the multimodal analgesia movement is in full effect.

You can argue that inexpensive and readily available heroin is a major driver of the drug epidemic, but it's good to "raise patient awareness and help reset patient expectations," says Eugene Viscusi, MD, director of pain management at Thomas Jefferson University in Philadelphia, Pa.

Dr. Viscusi says U.S. surgeons are "generous" with opioids, compared with doctors in the rest of the world. Elsewhere, he's quoted as saying in a published report, "you will not get a big bottle of opioids when you leave." But he says it's fair to wonder if patients won't think they're being "shortchanged" if they're told to take Aleve rather than Percocet. "Most patients still want the good stuff," says Dr. Viscusi. "There's still this pro-opioid bias."

Let's now move to surgical attire. In this month's "Infection Prevention" column on page 80, Lisa Spruce, DNP, RN, CNOR, the director of evidence-based perioperative practice for the Association of PeriOperative Registered Nurses, argues that when your surgeons and staff don't follow correct attire practices, such as completely covering their hair and not wearing scrubs outside the OR, they're endangering patients by putting them at risk for infection.

There's some evidence that this is true, but this is an emotional issue. People feel very strongly about being told what to wear to work. Surgeons will continue to wear skullcaps emblazoned with the logo of their college alma mater that expose their sideburns and the hair at the nape of their necks. And OR personnel will continue to pump gas and grocery shop in their scrubs. Dr. Spruce knows AORN is fighting an uphill battle when it comes to enforcing a dress code on the surgical uniform.

"OR members refuse to follow the recommendations based on personal preference and not on the evidence, particularly with head covering," says Dr. Spruce. Still, she urges you to encourage your surgeons and staff to "reduce infection risks as much as possible — even if it's not always the easiest or most convenient choice."

Who's right? Who's wrong? Hard to say. But it's fun to argue.

Just as I am writing this, a reader emails with another interesting question, this one about patient modesty: Do you offer your patients same-gender care for intimate patient procedures?

Let the debate begin.

• • •
Please spend a few minutes checking out the OR Excellence program on page 83. We hope you'll consider joining us in Las Vegas in October for what promises to be a terrific conference. OSM

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