Surgery and Smoking
I did something today I didn’t think i’d ever do…
Today started out like any other day. Get up, walk the dogs, turn on the coffee maker, shower, breakfast, the whole time thinking about the day ahead. Two patients, small case first, the second is the bigger case.
Focussing on the surgical plan: marking, making sure my patient is ready, making sure they’re ready mentally, trying to ease their nerves, trying to chat about things so they won’t feel nervous.
Get to work, quick word with my anaesthetist; he knows the plan, two cases, anaesthetic as we always do it. The rest of the team is ready, the scrub nurse is scrubbing already, getting ready for the first case. The scout nurse has started to unpack gear, equipment counted. I have a quick word with both about the first one.
First case goes to plan, no issues, simple revision and into recovery.
Onto the big case, and I’ve been thinking about it as I have been all week. As I normally do. I run through the plan again in my head. Marking, into theatre and prone, buttock lift, fat grafting, closure, supine, abdominoplasty, and then focus on the breasts. The breasts are going to be tough; moderate tuberosity, with asymmetry. I’ve been reading throughout the week a few articles, and looking at some literature to cement what I want to do, and what I want to achieve with the patient. It’s not going to be an easy case, but I’m pretty confident in the plan.
I go to see the patient, and have a smile and a quick chat. All ready? Big day is here, let do this!! All the marking is done, patient is ready, she tells me that she’s ready, nothing to add to what we already know. Allergy to one type of tape (I won’t use it for dressings), add a little extra fat to the bum for some added shape, incision line slightly lower as thats what she wants. And my final question to patients before I let the team know whats happening: Any worries, thoughts, questions, concerns or confessions? It’s a silly question, and most people laugh, but its meant to let patients know I’m here for them, and they can let me know if there is anything they want to add last minute.
Patient: ‘I’m worried about wound breakdowns’
Me: Why are you worried?
Patient: Oh, you know, just reading things on the internet…
Me: And we talked about this during our consult, and the 5 groups of people who are at highest risk. Nothing has changed since our last visit?
Patient: No, maybe I’ve been reading too much.
Me: Maybe, but we have a good team in case something does happen!!
With that, I’m back to theatre, talk to the team, reinforce the plan, and get things underway. The scrub nurse is already counting and has unpacked all the equipment we need.
The anaesthetist comes in after me, and has a strange look on his face.
I keep looking at him, expecting him to say something.
Anaesthetist : So, did she tell you?
Me : Tell me what?
Anaesthetist : She’s still smoking.
My heart sinks, as I half expect him to say ‘just kidding’. He doesn’t.
Me : What do you mean?
Anaesthetist : She told me she was smoking 4 days ago.
Me : uhhh… (I’m a bit stunned)
At this stage the patient is at the theatre doors, and almost rolling into theatre.
In 1 second, I flash back to the 3 consults we had in the preceding 6 months. She used to be a smoker, quit 3 months ago. Swore black and blue she’d never smoke before her op. I showed her pictures of a patient I had in the previous year who was smoking leading into his surgery. He had a big wound breakdown, requiring an extra 3 weeks in hospital, and 3 extra operations. The photos aren’t amazing.
I approached the patient, and asked her bluntly if she had been smoking 4 days ago.
She didn’t say anything and froze. My heart sank even further.
We wheeled her back to the pre-operative bay and had a chat. She confessed she’d been smoking ‘But it was only a few, and not all the time!’
We’d had the conversation about this. I told her I would cancel surgery if she did this.
And it happened. I cancelled a patient on the day of surgery. Because they were smoking.
I could go into a long rant about the effects of smoking and surgery, and how its like oil and water. About all the complications that can happen, and how awful it is with healing, wounds, recovery, lung problems, DVT’s, PE’s, and everything else it does. But I won’t because we are adults making adult decisions. I won’t test my patients to see if they’ve been smoking because I’m not the Nicotine Police. But I expect them to listen to the advice a medical professional gives them about their surgery and the potential dire, and avoidable consequences from using cigarettes before a big operation. And I won’t allow my patients to harm themselves, and be out of work for an extra 3-4 weeks in recovery, having extra operations. So, while I didn’t think I’d ever have to do, it happened. I cancelled a patient on the day of surgery because they were smoking. I hope it never happens again.