Mu Sigma Phi Sorority of the UP College of Medicine presents MUla Kay Doktora: The Dr. Julita Ramoso-Jalbuena Memorial Women’s Health Forum, co-presented by InLife Sheroes:
“Ready, Get Set, Go Surgery!” (Tara na, Maghanda para sa Operasyon!)
August 10, 2021, Tuesday from 12-1 PM Manila Time!
Speakers: Dr. Grace Anne B. Herbosa and Dr. Maria Lilibeth L. Sia Su
Moderator: Dr. Anna York Cristina Bondoc
Reactor: Jane Kingsu–Cheng
Register for FREE to all webinars of the series at: https://tinyurl.com/MuWebReg2021
MUla Kay Doktora: The Dr. Julita Ramoso-Jalbuena Memorial Women’s Health Forum (Series):
• Executive Checkup: Design Your Own Health Checkup & Cancer Screening! (July 2021)
• How to Prepare for Surgery during Covid? (August 2021)
• How to Prevent Infection Post-Surgery? (September 2021)
Here’s the full transcript of the webinar:
[Dr. Herbosa’s Video Presentation]
Magandang tanghali sa inyong lahat. I’m Dr. Grace Herbosa, and I have no disclosures related to this lecture. So it’s a ready, get set, go surgery/tara na maghanda para sa operasyon. We will be focusing this afternoon on the female patient as a candidate for surgery, her preoperative preparation to ensure safety perioperatively. As an anesthesiologist, I will orient you as to what happens with you during anesthesia. So most people think that with the the flick of a switch anesthesia just happens and the gift of oblivion and the mystery of consciousness begins. Okay, so it’s not as easy as that traditionally we have been taught that anesthesia is defined by three pillars–that’s unconsciousness or amnesia, analgesia, and muscle relaxation–and this has been called the triad of anesthesia. But we are in the year 2021 and anesthesia is much much more complicated than that; it includes a myriad of pharmacologic agents techniques and monitoring, and monitoring goes from basic monitoring to advanced hemodynamic monitoring and spans the periodpre-operatively up to post-operative as well as recovery even up to 30 days after the operation.
So let’s look at general anesthesia. General anesthesia is not sleep as we know it is to be. It is actually a medically induced coma and so as you go through or maybe prescribe surgery, there are ways to lower your risk. That’s because that’s always a concern for the patient including meeting your anesthesiologist. Okay the female patient as the focus or candidate of surgery now a woman, especially in a matriarchal society like the Philippines, engages with the health care system during different times of her life. In factshe creates a relationship between the health system and her family and is probably involved in medical decision making processes for their families as well as for herself, and her views on the health system particularly for surgical care often stems from a positive childbirth experience. Now, a concern for most patients is pain management: Will I feel pain during the operation or after it? Now, there has been an introduction of several enhanced recovery protocols or ERAS (enhanced recovery after a certain procedure) thatminimizes reliance on opioids, and this emphasizes patient recovery early patient recovery as well as safety.
Now female patients often undergo c-sections, gynecologic procedures, as well as breast procedures. As key demographic decision makers in the health care systems, we look at certain needs and barriers of the female patient. There are opportunities foroptimization, implementation of an enhanced recovery program and focusing on pain management how to support positive outcomes faster recovery as well as improve patient experiences. Now this is a survey done in the United States by Wakefield University, and it made two surveys. The first survey are among women patients, and the second survey among the clinicians or practitioners. And, as you can see, the key motivators that make women want to recover faster and go home in 43% of women, they are the primary caregivers and they have responsibilities for children as well as for other family members. For 31%, they would like to get back to work faster. For 13% they have concerns about contracting a secondary illness or infection. For 6% of these women, they probably have an upcoming event or trip. And for other reasons for 7%, so there’s really a big value on improving the surgical experience of our patients, and the first step is really all about patient education especially among our Filipino patients. Now, for the PGH, we have whatwe call a pre-operative assessment testing and education center which is a pre-operative clinic. It’s a nickname is PATEC and at thePATEC, what happens there we try to manage patient expectations through counseling and education. We give them an overview of their experience. Whether it’s for anesthesia and surgery, they should be counseled on nutrition. They are provided with an overview of aftercare, the pain management, management of surgical drains etc, and it’s an opportunity to assuage any potential pain related fears aside from that. In the PATEC, aside from getting or educating our patients, getting them fully informed, we look for the co-existing medical illnesses and advise them on lifestyle changes, whether it’s smoking cessation, the drugs they’ve taken, or fasting guidelines. It is an opportunity to order diagnostic exams, including the COVID RT-PCR test, and we estimate the level of risk. And more importantly than risk assessment is risk modification or optimization, so our patient gets ready for the surgery. Lastly is getting a consent, an informed consent, wherein we allow the patient to take part in the decision making of their procedure. It’s also a time when they identify high risks for complications in the perioperative period; for example for medications, if you have pulmonary hypertension or any pulmonary vascular disease, it is advised that you should continue your medications. For hypertension, for beta blockers, which is a common drug that’s used for hypertension, and if you’re a chronic beta blocker user you have to continue your medication. If you have three risk factors like diabetes, coronary artery disease, heart failure, renal insufficiency, or strokes, it is wise to begin beta blockers, and if you have no other risk factors, it is of uncertain benefit. For statins, like lipitor etc, it is continued in patients currently taking statins chronically; it is important to start them if patients are going to undergo vascular surgery and is considered in patients with undergoing elevated risk procedures. or angiotensin-converting enzyme inhibitors or ACE inhibitors or ARBs or angiotensin receptor blockers, it is very important to consult with the anesthesiologist because some studies will um advise that we discontinue taking the ACE inhibitors and the ARBs the day of surgery or the night before surgery because this can magnify hypotension as we give anesthesia. Then we also ask about anti-platelets, anticoagulants, herbal supplements, allergies, as well aspain medications of our patients. Now functional status is another very important thing that we ask our patients because it’s a predictorof perioperative and long-term cardiac events.
METs as it is called is an estimate of how our patients can withstand cardiac events so it is expressed, as I said, in metabolic equivalence where one METs is the resting or basal oxygen consumption of a 40 year old, 70 kilogram man. Now, it’s classified as excellent if you have more than 10 METs, good, moderate, to poor if it’s less than four minutes. As your clinician, I would like tohear a greater than 4 to 10 METs among our patients, meaning the patient is able to climb a few stairs can walk on level ground at six kilometers per hour. They can run short distances; they can do heavy household chores or can do highly strenuous sports. Now, if you’re just resting and reading, watching television, that’s a very poor METs score. I mentioned earlier the enhanced recovery after surgery protocols that has been suggested, and this is worldwide. And in the Philippines we have started to implement ERAS; these are evidence-based aspects of pre-operative care to accelerate patient recovery. It standardizes perioperative management and achieves a reproducible improvement in the quality of care. Now this is an example of the ERAS protocol for c-sections at the Philippine General Hospital. It includes pre-admission information, education counseling; it includes pre-operative optimization and risk assessment wherein smoking and alcohol cessation is advised, and if you have a risk that needs pre-habilitations then we refer you to rehab. We advise on nutritional care, whether underweight, overweight, obese, or diabetic, and manage anemia. This goes on byidentifying patients who are high risk for nausea and vomiting because this can become a problem for patients postoperatively and goes on through intraop care for antimicrobial prophylaxis, skin preparation, fluid management; intraoperatively, fasting prior to OR and many thing, and many other things including anesthetic techniques, surgical techniques, hypothermia, surgical access. So asclinicians and for operative care we would like to expedite recovery because this is more critical than ever, and it really is a process that starts pre-operatively with risk assessment and risk modification, intra-op management whether it’s lung protective ventilation using minimally invasive surgery, moderate fluid management, low dose muscle relaxant use, opioid sparing approaches, and usingdirectional anesthesia, to post-op care, giving attention to pain management, your respiratory complications, achieving earlymobilization amongst our patients. As I mentioned earlier, risk modification is very important. Now this has to undergo a local reviewbecause more importantly from just extracting guidelines from abroad and bringing it to the local level, we have to assess theefficacy of our local algorithms and to localize all these guidelines and get optimum results for patients. So in a nutshell we took up why a female patient isan important patient and a different patient, the importance of pre-operative assessment, risk stratification, risk modification, the process of consent, as well as patient participation and decision making. So again anesthesia is not sleep as we know it, it is a medically induced coma so thank you.
Dr. Herbosa: I’d like to end with this picture that our emphasis is really patient safety. As you can see, in the 1900s the playground wasn’t really safe at that time. Apparently, then, only the strong survived recess. Now, when we see more critically-ill patients, we try our best to give quality care and to give reproducible outcomes and ensure patient safety for all our patients. Thank you and magandang tanghali po sa inyong lahat.
Dr. Bondoc: Thank you so much Dra. Grace, and ganda ng usapan! Not many people know a lot about anesthesia so this is something very interesting to know about. I failed to mention this earlier, we are welcoming questions from the audience. Please put them in the comments section if you are listening to us on FB Live. We promise we will do our best to read all of the questions though talagang inuulan na tayo. Now we move on to our second speaker, Dr. Lilibeth Siasu of the UP College of Medicine Class of 1985.Dra. Siasu is currently a practicing gynecologic-oncologist in PGH where she is also a professor and serves as a mentor to future gynecologic surgeons and also to future doctors among the Mu sisses. Personal note, Dra. Siasu was the ACR when I was an intern and talagang noon pa man, bilib na bilib na po ako sa kanya. It’s an honor to meet her,ang bait pala niya. Without further ado, let’s call on our very own, she’s a gynecologic oncologist, Dr. Lilibeth Siasu of the Mu Sigma Phi Sorority Batch 1985. Ma’am it’s an honor tohave you.
[Dr. Siasu’s Video Presentation]
Good day, everyone! I would like to thank the Mu Sigma Phi Sorority and UP-PGH for this opportunity. I have nothing to disclose. In December of 2019, the SARS-CoV-2 emerged from Wuhan, China and spread around the world. In March 11, 2020 the WHO declared the COVID-19 as a global pandemic. This resulted in lockdowns and curfews leading to suspension of less essential aspects of healthcare and caused disruptions and delays in elective work and surgeries. The health service had to adjust to the challengesposed by the pandemic. As there were concerns on the safety of performing diagnostic gynecologic services, as well as surgeries.Following the declaration of the pandemic, there were cancellations of elective surgeries in hospitals in order to optimize medicalresources for emergency cases and most of the staff were redeployed to attend to critical care units.
Several guidelines and protocols were issued for best practices, and from time to time, several changes and adjustments have to be made. This can be downloaded from their websites. Remodelling of services have to be made such as telephone triage-based system for consultations, virtual consultation thru video calls and telephone calls, telemedicine for follow up and post-operative reviews. Allpatients were encouraged to do teleconsultation. A system of waitlisting was set up for prioritization and validation of cases.
When a patient consults, a shared decision approach was adopted, which is highly encouraged. It is centered on patient preferences and values. Cases were classified according to risk and urgency of procedures. Emergency cases are those needing surgery within the hour; urgent cases are those that can be addressed within 24 hours; elective urgent within 2 weeks; essential elective, in 2 weeks to 3 months; and non-essential/elective procedures include infertility procedures and family planning procedures such as bilateraltubal ligation. We follow this risk stratification in scheduling patients for surgery.
The preoperative evaluation and preparation for gynecologic surgery pre-pandemic and during the pandemic are basically similar, and the addition of RT-PCR testing prior to admission. In some hospitals, an admission chest x-ray is being required. A detailed history taking including medical comorbidities should be obtained. Mandatory complete physical examination should be performed.Laboratory examinations pertinent for the case are requested. A pregnancy test should likewise be done on a reproductive age woman, especially if she has to undergo pelvic surgery because you would not want to do a hysterectomy with a missed pregnancy in situ. Testing for genital tract infections to minimize vaginal cuff infections is also recommended in women undergoing hysterectomy.Proper referrals to subspecialties are required.
RT-PCR testing is mandatory prior to admission, which was initially admissible for 7 days, and then 5 days, and now the HICU has reduced it to 3 days prior to admission. All patients requiring emergency procedures are managed as probable-COVID if their COVID test results are not yet available. Alternative treatment options, and risk and benefits of the procedure are discussed thoroughly.For example, a patient with procidentia uteri may be better off with a pessary rather than by vaginal hysterectomy with suspension procedures. Even cancer patients are advised neoadjuvant treatment while awaiting for their OR schedules, whenever allowed. Following testing, all patients are instructed to self-isolate at home until they are admitted. Patients who tested positive were deferred for at least 14 days from the onset of symptoms and retesting, as well as clearance, is done based on local policies.
The perioperative SARS-CoV-2 infection increases postoperative mortality. In a review of 140,231 patients, the 30-day mortality of patients without COVID was 1.4%. The timing of surgery following COVID-19 infection is important. The 30-day mortality is 9.1% if surgery is performed within 2 weeks of SARS-CoV-2 infection and it goes down to 2% if surgery is performed beyond 7 weeks following SARS-CoV-2 infection. The adjusted 30-day mortality in patients with a preoperative SARS-CoV-2 diagnosis was increased in patients having surgery within 0-2 weeks, at 3-4 weeks, and 5-6 weeks of the diagnosis. Surgery performed more than or equal to 7weeks after SARS-CoV-2 diagnosis was associated with a similar mortality rate to baseline. However, patients with ongoing symptoms, even after a delay of more than or equal to 7 weeks were shown to have a higher mortality if their symptoms have already resolved or when they are asymptomatic. Whenever possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection and patients with ongoing symptoms even after 7 weeks from diagnosis, may benefit from further delay.
The gynecologic services of our institution during the pre pandemic used to cater to about 20 elective gynecologic cases per week,but were drastically reduced to half or to ⅓ due to the pandemic. So much so that we have to prioritize cases which will benefit most from surgery, such as prioritizing early-stage endometrial carcinoma over advanced stages. In 2019, we had 834 cases operatedelectively. For the first 6 months of this year, we only have 248 cases. When the facility declares that the ICU complex is full, and whenthe preoperative evaluation reveals a need for postoperative ICU care, these cases are rescheduled until such time when they canbe accommodated. The expected duration and recovery period are also thoroughly reviewed.
The preoperative preparation includes issues that are addressed in the clinics and even prior to surgery or in the operating room. This would include medication management and blood loss preparations. We have to practice patient safety at all times and minimize or prevent a wrong person, wrong site, or wrong procedure done on the patient. Cessation of smoking is recommended, as smoking increases the risk for postoperative pulmonary complications. Interventions for surgical site infection prevention includes a timely administration of effective preoperative antibiotics and practice of meticulous operative techniques. The risk of venousthromboembolism is significantly increased during and after surgery.
Thromboprophylaxis reduces the incidence. Decisions regarding the method, dose, and timing of prophylaxis depends on thepatient’s risk of thrombosis versus perioperative bleeding. We use this table to score the patient’s risk of bleeding complications.
These other issues should be addressed adequately. In difficult surgeries, the most senior and experienced surgeon is tasked to dothe procedure or assist trainees in the performance of the surgeries.
On admission, COVID-19 precautionary measures should always be practiced. Reassessment of symptoms such as headaches, body ache, loss of taste and smell, stomachache, diarrhea, vomiting, sore throat and chills, fever, shortness of breath, fatigue, cough, difficulty breathing, and pain are monitored. Proper PPEs should be used at all instances. Surgeons engaged in aerosol-generating procedures of suspected or confirmed COVID-19 patients should use the appropriate PPE, which include an N95 mask or of a higher standard, a fluid repellant sealed well-fitted long gown, double gloves, apron, full face shield or goggles or viscer, scrub hat, and disposable shoe covers for dedicated closed footwear. The hospital has separate pathways for elective and non-elective patients, as well as for COVID and non-COVID patients, to protect both the patient and personnel. It is always important to establish a safety culture to prevent errors. With this new surge of COVID-19 cases, let us adjust and adapt. Being a member of the hospital services arm, we would like to encourage everyone to get vaccinated so that we can reduce the complications of COVID infection, especially those undergoing surgery. We should folow the best practice guidelines and embody safety measures to achieve good outcomes.Thank you.
Dr. Bondoc: Salamat po, Dra. Lilibeth. This is one of the most interesting discussions that I have heard in years. In medicine, we’re focused on COVID-19. This is the first time I’ve seen the COVID impact on surgery, especially gynecologic surgery. Ang ganda po ngdiscussion.
[LAY REACTION] 1:02:50 – 1:07:53
Dr. Bondoc: Now, we will have our reactor naman po. Again, you have the opportunity to ask questions. Please put them lang po sa comments, we will take them up along the way. Right now, we have our reactor to give her insights and reaction on preparations forsurgery. We have Ms. Jane Kingsu-Cheng.
Jane is a mom of three who loves DIY. Ako din mahilig sa DIY. So from cooking, baking, to creating anything from scratch, she tries tosqueeze in small pockets of learning with her 3 kids. Apart from being a mom, Ms. Jane is also the sub-editor and columnist of the Manila Bulleting Lifestyle, and editor-in-chief of Wedding Essentials. She has also worked with ABS-CBN Publishing for 10 years, where she had the positions of being liaison editor of Chalk Magazine, to editor-in-chief of various publications like Pink, Kris Aquino, and Working Mom Magazines. Miss Jane is also one of the people who launched Forever 21 in the Philippines were she served asthe Marketing Manager.
To share with us her insights for today, Ms. Jane Kingsu-Cheng.
Ms. Jane: Hello po. So yeah as mentioned I’m a mom of three. Actually, I’ve been a mom for over 12 years so that means my parents and all the seniors in the family are also getting older. This also means that I’ll be facing possible surgeries in the future, both for me and also for the rest of the family. We’ve seen it, we’ve seen our moms and grandmothers.
Like what Dr. Herbosa mentioned, tayo talagang mga moms ang nagttake charge when it comes to decision-making in the family interms of healthcare. I totally appreciate this talk because it’s also preparing me for what could happen in the future. I remember also before when my mom had her surgery to have her uterus taken out, and then my grandma had breast cancer as well. We were all there. It was three generations of women, watching and helping each other. Parang moms talaga ang nandyan sa hospital more than the dads, more than the men. Parang mas sila yung takutin. It’s really the moms who are stronger. Again, I appreciate that this talk will help me in my decision-making in the future.
What I love about this talk is that it’s been very informative. We’ve tackled pre-, during, post-surgery and even recovery, because that whole experience could be long. Its not that short. And there are so may concerns. To be honest, I’ve never had a surgery except for one — I did a ligation after my third baby. Doon lang talaga ako nagka-operation na close to CS, and that’s where I felt the pain andthe medications that I had to take. Doon lang ako nakarelate with all the surgeries my family has been through. There are a lot of issues that I’ve never personally experienced that I need to know because of this talk.
Now that we’re going through a pandemic, mas marami pang issues involved. Is there really a need for surgery? Bakit kailangang ngayon? Can I prolong it because I don’t want to go to a hospital right now? I hear that a lot in the conversations, even between me in my husband. We’re not going through a surgery, not one of my family has to. Even as simple as having your medical exam there,parang ayaw. Nakakatakot. Like what Dr. Sia Su mentioned, madami namang precautionary measures yung hospitals. And I thinkthe most important thing is to trust our doctors and to keep asking questions. Suddenly, all their anxieties have been taken away. Because that is the only time you can really trust the healthcare system. Which leads us to the next set of the program which is to askquestions.
I think I can start. My question would be for both doctors. I’ve seen this also when I accompanied my grandparents, my mom… they’re really very anxious if they should go through with it, how much… As someone who supports, and also me as a patient… Docs, how doyou handle the anxiety that you see?
Dr. Herbosa: Should I take that? This is Grace Herbosa.
Dr. Bondoc: Thank you so much, Ms. Jane for you insights especially yung family insights mo.
[QUESTION & ANSWER] 1:07:54 – 1:12:00
Dr. Bondoc: Siguro ikick off na po natin uyng Q&A with the first question from Ms. Jane. Meanwhile, before you answer Dra. Grace, for the audience, please put your questions in the comments. We will pick them up. So Dra. Grace? Please pick up the question. How do we deal with anxiety? Sa mga relatives, sa mga pasyente, at lalo na ngayon na napakaanxious na panahon itong COVID-19.
Dr. Herbosa: Okay, I think anxiety is best addressed pre-operatively as we go through a teleconsultation or a face-to-faceconsultation. The best answer to that is really education. Education spans varied populations. If you speak to a patient who has gone through an internet/google search, then you have to address this. Sometimes, you have to answer all the queries and either validate or just educate them well. The problem really is with low income populations. They have concepts that we have to change culturally.For example, we had a grandmother who said “Doktora, pwede bang ang schedule ng aking operasyon ay gabi kasi tulog ako?”. Youll be surprised that we get reactions like that. There are also patients who do not wish to listen to the way we educate them. Ayaw nilang marinig yun kasi bahala na kayo. We have to deal with this individually — it’s all personalized. If you see that your patient is overly anxious, whether it’s for operation or fear of pain, then we have to alert the anesthesioogist who will take care of the patient.They’ll probably need more medications post-operatively. A pre-operative visit makes up a huge percent of the preparedness of the patient. It is best that you always talk to your anesthesiologist. I know for some people we’re invisible, but I’d like to inform everybody that we are not invisible. Probably, we make up the most important part of your surgery. Whether you like it or not, your life is on our hands and it’s really a privilege and honor as you give your consent to us, that you trust us to take care of you. That is what anesthesia does — we are supposed to take charge of your physiology to be able to make surgery happen.
Dr. Bondoc: Thank you, Dra. Grace. Ang ganda nung sinabi niyo lalo na yung anesthesiologists are not invisible. So Dra. Lilibeth, paano niyo pakakalmahin mga pasyente niyo? Kasi nakakanerbyos ho talaga the word ‘surgery’ alone, tapos dagdagan pa po natin ng ‘cancer surgery’, then dagdagan pa natin ng ‘during the pandemic’. Talagang parang aatakihin na yung mga tao. What do youadvise po?
1:12:01 – 1:24:00
Dr Siasu: Well it’s very important to do very comprehensive counseling for these patients. First of all, we have to explain the necessity of the procedure, the procedure, the risk and benefits associated with surgery, as well as the anesthesia, and we have to address expectations of our patients and relatives as well. We have to go far beyond that, not only during surgery but we also have to discuss about the outcomes and future of our patients, especially very young patients who undergo cancer surgery. Kung ano yung kanilang survival rates, maybe we can discuss that already preoperatively. But we should not scare our patients off. We should be very factual regarding all of these, everything that we say to our patients preoperatively. So, all of these things I think, lahat naman natatakot sa surgery eh, kahit pa ilang stitches lang yan, takot na tayo. What more for major cancer surgeries?
Dr. Herbosa: You know even doctors, doctors are afraid of their own surgeries.
Dr. Bondoc: Mas lalo pa po yung mga doktor. Thanks so much Dra. Lilibeth. In the hands of Dra. Grace and Dra. Lilibeth, kahit maypandemic, i’m assure you that you will be safe. Okay. Dra. Lilibeth eto po para sa inyo, I was struck by this chart na nagsabing bumaba talaga ang rate ng elective surgery ngayong pandemic na to. Consider that you are a gynecologic surgeon, hindi ba po emergency lahat ng cancer? Can you guide patients on this issue? And I was also struck with how do you prioritize which casewill benefit from surgery in this pandemic?
Dr. Siasu: Okay, first question. Hindi lahat ng cancer kailangan ng operasyon. There are several cancers that can be addressed withsurgery, and there are some others that can be addresse through chemotherapy or radiotherapy. The striking difference there is that prepandemic we can just do out surgeries left and right, even for the advance stages, because we had the ICU for our post operative care. But during the pandemic, hindi lang personnel ang limited, pati and hospital. OR rooms are very limited. So, before we used to have four or five cases everyday, for just our service alone. We were left with four or five in a week during the pandemic. So much so that we had to stratify. The emergency siyempre lahat ng emergency ooperahan. Lahat ng urgent kailangan iprepare for operation. But for the electives, we have to choose. How do we choose? We have to choose with regard to the prognosis of the patient. Forexample, for early stage endometrial carcinoma, even the early stage endometrial carcinoma does not have an equal footing when it comes to surgical urgency. Yung mag patients with low grade, good histology, are put in first, they are operated on first. Because, the prognosis is greatly improved when surgery is done. Those with poorer histologies, medyo hindi naman kasi naaffect yung kanilangprognosis, even after surgery, then they can be dealt with with neoadjuvant treatment like for example giving them chemotherapy, or radiotherapy first, before they can actually be scheduled for surgery. Those patients who really need ICU care, talagang dependent yan sa availability ng ICU sa hospital. Pag sinabi ng team ‘wala nang beds for ICU care’, lahat ng pasyenteng preoperative atkailangan ng ICU care, postponed kayo lahat. And then, we resort to neoadjuvant treatment first. So that’s the impact of COVID among our patients.
Dr. Bondoc: Thanks Dr. Lilibeth. Very telling talaga yung nangyari noong COVID talaga, and how do you prioritize po who will benefit?May listahan po ba kayo ng mga emergent and non emergent surgeries?
Dr. Sia Su: Yes, may listahan ng emergent and non-emergent. At the start we had an adhoc committee, surgery ang team leader noon. So, they had a listing based on international standards. Kung sino yung dapat unahin sa surgery. All patients that would benefit from surgery the most were the first ones on line. And those, who, lets say would afford no advantage in their prognosis would the lastin priority.
Dr. Bondoc: Thank you Dra. Lilibeth. You know im familiar po with triage in IM ICU, as an ICU physician. Triage sa ER. Pero may triage din po pala sa surgery. Thats very interesting to know about. Thank you so much. Dra. Grace, kayo na po nagbanggit na some anesthesiologists are invisible. Napansin ko po lalo na kung minsan its the nuse na lang who does the consent form. How do we change this culture na kung minsan hindi mo man lang makausap yung anesthesiologist. Theyre like nagmamadali all the time. Howdo we make an anesthesiologist less invisible. And how will it help our patients?
Dr. Herbosa: Okay. You know thats the change in the specialty. The only way to sell our profession is really to just be involved, and really come out of our shell. So, slowly we educate our trainees about this because we are becoming an indigenous society and Ithink it is very important that our patients know who we are. Kasi it gives us credibility. They understand our role in a surgery. I thinkwe’ve always been in the background. But I don’t know why it’s been so. But I really think its really a problem with the specialty. This is not just in the Philippines, this is worldwide. Another think kasi is the introduction of group practice. It’s either your group should be very involved in preoperative explanation and seeing our patients, and explaining to them who is actually attending to them. Anotherthing, sometimes, anesthesiologists nga, kasalanan nila na hindi nila nakikita yung patient preop and thats why the concept sa patient is that gamot lang kami. Ang anesthesia ay gamot, walang tao. What they dont know is the role nga of us controlling physiology for surgery to happen. That is a specialty problem. I guess patients can demand to see the anesthesiologist, even just before the operation. So we, like me personally, I try my best to talk to the patients. Since I do cardiovascular anesthesia, it’s a little different, it’s more risky in the operation. So we make it a point to explain the risks to our patient. At the same time, assure them that we are there to care for them, and that we will be there, every second of the operation, until the early post operative hours of recovery. So it’s aspecialty problem.
Dr. Bondoc: Ayan, thank you Dra. Grace. You know I have a lot of respect for anesthesiologists, having worked closely with them. Sana mas maging involved sila kasi makakatulong talaga yan sa pasyente. I’d like to let every know na inuulan po tayo ng tanong so short answers lang po. Miss Jane, you have another question.
Ms. Jane: May I ask Dra. Sia Su, possible ba na with COVID, kasi marami ngang takot rin, possible bang outpatient? And the other question is, in relation to it, some naman in the US after operation within the same day pinapalakad na, hindi na kailangan magpahinga, so what is applicable here in our country. What type of operations ang pwede?
Dr. Sia Su: We do have out patient procedures. Meron talagang ginagawang on out patient basis lang. So papasok ang pasyente ng alasyete at uuwi din yan siya after a few hours when the procedure is finished, and they are stable enough and fit enough to go home. For some patients who cannot be done on an out patient basis, we encourage early discharge. So about one to two days, if pwede na yung pasyente, pwede na rin siya ipauwi. Personally, all our patients sa gynecology, kung physically fit to undergo surgery and physically fit to stand, mobilize, write after surgery. Hindi na uuso yung two days, three days, na nakahiga yung pasyente. In the past sasabihin ng mgamatatandang pasyente na one week kami pinapahiga sa hospital doktora. Ay hindi na po uso yan. First day pa lang, nakatayo na kayo dapat, naglalakad na. Pati nga sa pagliligo, allowed kayo maligo. Hindi na yung takot kayo sa tubig, kung anu-ano diyan. You know, we tell these patients, we tell them. So OPD procedures, we do them, but limited din. And the early discharges, earlymobilization and discharge.
Dr. Bondoc: May second question ka ba Miss Jane or okay na? Ms. Jane: I think Dra.Grace was raising her hand? Meron ba?
Dr. Herbosa: I just wanted to add that this is what we call the Enhanced Recovery After Surgery Program, which is really a group of protocols that we do. This starts from pre-op preparation; the fasting period has been shortened to reduce the catabolic state rightafter surgery. And then, we use shorter-acting anesthetics, neuraxial anesthesia. All of these are focused to improve or enhance the recovery after. So we use even prehabilitation pre-op para we teach them that they should stand already right away. And aside from physical rehabilitation, also psychological prehabilitation, meaning we explain to them the expected outcomes right after para alam nila, naintindihan nila, hindi sila nawawala. Important is cognitive dysfunction. We take that into consideration in anesthesia and in theirrecovery as well. Thank you.
Dr. Bondoc: Ah ayan, so Miss Jane, yes?
Ms. Jane: For the both of you, since we’re talking about surgery, and as soon as possible we can go out, go home, out-patient, what are the issues that we have to look out for? Since after post-surgery, wala nang health care professional with you. What do you have to be alerted on at home just to make sure that everything goes well post-surgery?
Dr. Sia Su: Depends on what type of surgery the patient has undergone through. Siyempre lahat ito discussed pre-operatively, kagaya ng wound care, fever, discharges especially from wounds, and then siguro sa anesthesia effects kung sumakit ang ulo, what to do at home kapag sumakit ang ulo 24-48 hours after surgery. So we tell them what to expect and what to do next. Yung mga long-term, onfollow-up, pwede na rin yun at dinidiscuss rin naman; we do them pre-operatively but we tell them again post-operatively to remindthem. Ayun.
Dr. Bondoc: Thanks Dra. Lilibeth and Miss Jane! Ito from one of the audience, from Mr. Al Nacional actually, “Is it true that surgeons are afraid to do surgeries because of the pandemic?”. Well I’m a doctor and I’m even afraid to go to the ER. Sige, Dr. Lilibeth, go!
Dr. Sia Su: That’s the perception, ano? That doctors are afraid to do surgeries dahil nga sa exposure sa COVID. But the more we understand about COVID, and the more we know on how to take precaution, on how to avoid the infection, lalong mas marami nangdoctors ang gumagawa ng trabaho nila, and there are more surgeons doing this. We have so many PPEs, we are instructed on the proper donning and doffing of PPEs. So I don’t think aayawan kayo kung kailangan talaga na i-attend kayo during surgery.
Dr. Bondoc: Yes! The more we know, the more precautions we can take. Ayan, tama ‘yun. And the better that we can advise our patients also. Ito parang common question ito to Dra. Grace. Since you mentioned cognition, totoo po ba na nagiging makakalimutinang mga pasyente after manganak or after anesthesia?
Dr. Herbosa: Okay, ang cognitive dysfunction kasi was never really proven… so they only found an association… most of the studies were done on animals. Why does this happen? Anesthesia is all about giving medications that has to interfere with brain function. And of course this has effects on the brain depending on the neuroplasticity of the brain, how it recovers after. Among animals, they found that giving short-term anesthesia, meron siyang long-term effects, which is again, temporary for some. So we always think of going through surgery and anesthesia as an inflammatory process. Surgery and anesthesia invokes… there’s some amount of inflammation that happens and there is a prothrombotic reaction as well, meaning you become hypercoagulable, meaning mas pwedeng mag-coagulate yung blood. So maraming risks na nangyayari. Ang cognitive dysfunction, we have a risk scale, so alam namin pre-operatively if this patient is prone to a cognitive dysfunction or even delirium post-op. And because of that, we have to taper our medications, we choose our medications wisely. At the same time we have a monitor for the brain, so we don’t put the anesthetic depth really really deep. Kailangan meron kaming numbers na tinitingnan, meron kaming tinitingnan na EEG waves as well, if your patient is prone to cognitive dysfunction. This is supposed to lessen delirium post-op and hopefully not affect memory and all. Butagain this has not been proven, hindi siya robust, yung evidence. Kasi nga it’s about the brain, and as all you know pag women especially, a lot of hormonal changes that happen… progesterone, estrogen, oxytocin that increases after cesarean delivery. So this all affects the brain. At the same time, you have sleep disorders, you have stress there. So, all of these play a part in the recovery,cognitively, sa pasyente.
Dr. Bondoc: Ayan, thank you so much Dra. Grace! One thing I wanted to ask, which is actually talagang naiibahan ako sa webinar na‘to, kasi ngayon lang talaga nag-usap ang anesthesia and surgery. Question, Dra. Lilibeth, you mentioned kasi group practice, which is common sa US and taking off dito sa Pilipinas. What is your take… kasi dati may mga surgeon na may partner silang anesthesiatapos di mo na pwedeng hiwalayin ‘yun no matter what. Merong iba naman, I’ve seen so many interactions sa OR, some of which are not mentionable talaga sa isang webinar, ano? But what is your take… I mean how about patients who demand na yung pinsan nilaanesthesiologist, paano ‘yun?
Dr. Sia Su: Group practice has taken off very well, I think with anesthesia, and not with surgery. Kasi ang culture ng ating mga pasyente, gusto nila kung sino ‘yung kausap nilang siruhano, siya rin ‘yung gagawa. Ang first question nga, “Doc, kayo po ba ang gagawa?”, kapag sinagot ng hindi… “Ay, lilipat na lang ako kasi gusto ko kayo talaga ang gagawa.” Pero sa anesthesia, it has worked very well. And in fact, I think even the scheduling of the anesthesiologist doing group practice has worked very well for us surgeons.Laging meron, laging merong anesthesiologist whenever you’ll have an emergency or any other surgery. Laging meron kasi may group sila. Merong tao talaga na ififill nila for your surgery. I don’t know with Dr. Grace?
Dr. Herbosa: I’ve been in several group practices, some are more successful than others in certain things. But the way I look at it isreally positive. One, you have schedules. You share specialties, if you need help, you help each other. There’s always an anesthesiologist on board, whether it’s an emergency, whether it’s pay or charity because we cover all, everything, and it’s also alearning process kasi you learn from each other as consultants. Maybe the only set back is that some surgeons will prefer a certainanesthesiologist at a certain… you know, in the beginning. But we tackle this by first… the real, the choice anesthesiologist will accompany the duty anesthesiologist, slowly introducing themselves. And then, I think it works well, talagang teamwork. Tapos if you’re, for example, you are a general anesthesiologist and you need a critical care [anesthesiologist], you just call for help and they come. So, as Lilibeth has said, group practice has worked very well for anesthesia. Maybe because we don’t also own our patientsourselves, so it works well.
Dr. Bondoc: Thank you so much! Ang ganda ng usapan! Thank you so much kasi kami we refer patients for surgery, and then hindi talaga namin alam yung interactions sa OR kasi hanggang doon lang kami. So magandang usapan, it also teaches how things work. Miss Jane, may last question ka ata? Ang daming tanong but [you’re free to choose] sa mga question.
Ms. Jane: Yes, actually there’s two na kinombine ko from the audience. “Which is more preferred for pre-op patients, a 10-day self home quarantine, or admission as a COVID probable case, or just an RTPCR done 3 days prior to admission or even longer or shorterprior to admission?” Tatlong options.
Dr. Sia Su: Ano ‘yan before admission?
Ms. Jane: Yes, before admission. How do we handle the pre-op?
Dr. Sia Su: Pre-operatively. Ganito kasi nangyari sa aming hospital, PGH in particular. The HICU has already sent out its new recommendation, which means magpa-RTPCR ka ngayon, kapag negative ka, good for 3 days lang yung RTPCR result mo. In the meantime, habang nag RTPCR ka, kailangan nagself isolate ka rin sa bahay, kasi you might get an infection when you go out, again even after you RTPCR. So combination of everything. I think that’s our hospital policy right now. Back to you.
Dr. Bondoc: Ayan, salamat! Thank you! One of the last question na siguro ito since naubusan na tayo ng oras. Sa inyo pong dalawa, we mentioned a lot about comorbidities, how about age? Ano po ‘yung oldest na naoperahan niyo? And how does age… kasi namention niyo rin po yung [metastasis], ‘yung functional capacity. But people are now living fuller lives as they get older, and parang hindi na nila… lalo na kung early stage ‘yung cancer nila. Or even, may nakikita pa nga ako kahit 90 years old, gusto nilamaoperahan kasi gusto nila humaba ‘yung buhay nila. Any thoughts, Dra. Grace and Dra. Lilibeth on age?
Dr. Herbosa: Age is always a consideration, but we’ve done coronary bypass graft surgeries in 90 year olds, close to one hundred. As long as their metabolic equivalents are high. Our anesthetics are so much safer now. We have better dynamic monitors that we can use. Even the surgical techniques are so much better now. We have minimally invasive surgery. We have robotics. We go into multi-disciplinary discussions with each other and the family. Everything should be laid down. It’s really education amongst the whole team, and so we’re ready for the patient. Age is not really a contraindication as long as it will improve the quality of life of the patient. That’s how I look at it. Everybody deserves a chance diba, if they consent to it.
Dr. Bondoc: Dr. Sia Su, sayo? Lalo na sa cancer surgery and age.
Dr. Sia Su: I fully agree with what Dr. Herbosa mentioned earlier. With regards to treatment options, if the patient consents to the risk of extended surgeries and if they are fit for surgery, then we go through with our surgery. Age will not be a factor. Otherwise, they can be given alternative options. Not alternative treatment as in non-medical. Alternative treatment as in chemotherapy, radiotherapy,targeted immunotherapy, or other treatments that we have on hand for our cancer patients. We do discuss these things with ourpatients. I have operated on an 89 year old and wala namang problem.
Dr Bondoc: Aside from patient and family education, kailangan din ng internist education kasi merong iba sa internist pa lang natatakot na. Maganda yung sinabi niyo po that anesthesia has really moved forward. Ang dami na talagang mga advancements andsometimes it is not scaled down to the GPs, so they tell the patients na “hindi sila pwede”. That practice should really be discouraged.
Dr. Herbosa: That’s true. Our monitoring in anesthesia has really advanced. We can see physiology in action intra-operatively now. We have what we call dynamic monitors. Baka iba kasi for internists and maybe they don’t see this in their institutions. We really are in control of many things in anesthesia. Of course it’s not perfect but it’s so much safer now in anesthesia. I’d also like to encourageanesthesiologists to learn all these new techniques (ultrasound, advanced hemodynamic technology, etc.). The information is globallyavailable virtually, so let’s all learn together as physicians.
Dr. Bondoc: Lastly, bakit bawal kumain kasi ang daming nag-aaway dito?
Dr Herbosa: Fasting guidelines have been changed already. You can have clear liquids up to 2 hours before surgery, a heavy fatty meal is 8 hours, and a light meal is 6 hours. If we have problems with fasting, we can do a gastric ultrasound to check if there’s still food in the patient’s stomach, so it’s not that difficult now. But fasting is important because we don’t want patients to vomit during the induction of anesthesia. When I say vomit, they can aspirate because they’ve lost their consciousness and food can travel to thebronchial tree. This is really a disaster if that happens.
Dr. Sia Su: We allow our patients to eat as Dr. Herbosa said. For major surgeries, we would want an NPO for at least 6 hours.
Dr. Bondoc: Sa mga natatakot na layperson ano masasabi niyong tatlo
Ms. Jane: I think I’m lucky cause my family believes in surgery, and I have a brother who’s a doctor. So iba yung environment ko. I think the most important, especially for those na low-income, it’s really about educating ourselves and trusting our doctors. So wag ka mahiyang magtanong at magtanong kasi buhay mo ang nakasalalay.
Dr. Sia Su: I would just like to remind everyone that what is very important is to do a proper preoperative and intraoperativeassessment so we can always achieve good surgical outcomes and we can address all the problems preoperatively. We also would like to practice universal health care precautions, especially now with COVID. Additional precautions pa yan. We should always put it into our culture that patient safety should be embodied in our hospital practices. I would like to again encourage everyone to get theirvaccination para gumanda ganda naman ang ating outcome during surgeries.
Dr. Herbosa: I look at feat as something good. There should be some amount of fear every time we undergo a procedure. That holdstrue for anesthesiologists, physicians, and the patient. It’s just a spectrum of fear. If it’s too much then we have to control it. But it has to be there because it keeps us on our toes, vigilant, and keeps us alive at the same time. As Dr. Sia Su said, let’s just take care of each other if something happens. We cannot guarantee 100% success in everything that we do. The human being kasi is different. We should always understand the risks. We’re not like God. We’re not in control of everything so something can happen. Our systems can malfunction as well. As a team, anesthesiologists, surgeons, and nurses, let’s just work together, take care of each other, watch over each other, and help each other if something goes wrong.