+ Pre-Surgery Instructions

MEDICAL CONDITIONS - The following conditions can impact the outcome and potential complications of your surgery. Please inform us if have any of the following conditions:

• Sleep apnea
• History of skin/bone infections (staph, MRSA)
• Diabetes
• History of blood clots or pulmonary embolism
• Current estrogen therapy (oral birth control, IUD, hormone therapy)
• Historical or current drug abuse
• Current tobacco use
• History of cardiac surgery, current heart disease, pacemaker, etc.
• Current use of blood thinning medications (Aspirin, Coumadin, Lovenox, Plavix, etc.)

TRANSPORTATION - You must have an adult (>18 years old) accompany you home from surgery. You may NOT drive yourself home or travel home by bus; you may take a taxi/Uber/Lyft, but only if you have an adult with you whom you know and trust.

FASTING - Do not have anything to eat or drink past midnight the night before your surgery.

INFECTION PREVENTION - Surgical site infections are rare, but do occur in approximately 2% of surgical procedures (1 to 3 infections out of every 100 patients who have surgery) therefore please take note of the information below:

• If you normally shave around the surgery area, do not shave or remove hair in that region for at least 2-3 days before your surgery.
• There are several patient factors that increase the risk of infection; being an elderly adult, having diabetes, obesity, vascular disease, cancer, being a smoker, etc.
  • If you smoke, please try to quit smoking 4 or more weeks prior to surgery.
  • If you have diabetes, please maintain stable blood glucose levels before and after surgery.
• We recommend all patients shower the night before + morning of surgery with CHG (chlorhexidine gluconate) soap (this can be purchased at any drug store or picked up in the clinic):

NIGHT BEFORE SURGERY

1. Lather the CHG in your hand or a washcloth.
2. Clean your body from the neck down….do not use the CHG on sensitive areas (face, bikini region, hair); use normal soap and shampoo in these areas.
3. Let the soap sit on your skin for 1 minute, the rinse.
4. Dry off with a clean towel, put on clean pajamas.
5. Sleep in a bed with clean sheets.

MORNING OF SURGERY

1. Follow steps 1 & 2 from your night shower.
2. Spend extra time on the surgical extremity.
3. Rinse. Pat dry with a clean towel. Put on clean clothing that you will be wearing to surgery.
4. Do not put on makeup, lotions, hair products, fragrances, etc.

ATTIRE – Wear comfortable, loose-fitting clothing…

• For shoulder/elbow/arm surgery wear a shirt with large arm holes (tank-top, t-shirt, button/zip-up shirt)
• For knee/ankle/leg surgery wear elastic-banded athletic shorts/pants that can get over your dressings/brace.

WHAT TO BRING

• Photo ID.
• Insurance card.
• Method of payment for any co-pays required.
• CPAP machine if you have sleep apnea.
• Inhaler if you have asthma.
• A case/container to protect glasses, contact, hearing aids, etc.

ANESTHESIA – You will have an opportunity to meet with the anesthesiologist prior to your surgery to discuss questions, concerns and different anesthesia options.

SURGERY – If you have questions or concerns about your surgical procedure please let us know; we want you to be as comfortable, familiar and prepared as possible.

RECOVERY ROOM - Most patients are in the recovery room for 1-2 hours before they are awake enough to return home (or transfer to the hospital room if you are having an inpatient surgery).

+ Post-Surgery Instructions

ACTIVITY RESTRICTION

• Different surgeries have different precautions; these will be typed out, in detail, in the post-operative instructions that you obtain before leaving your surgery. If you have specific questions regarding this before your surgery please let us know!
• If we require that you use a sling, crutches, walker, brace, cast/splint, etc. after your surgery, we will provide them for you. If you have your own items, we encourage you to bring them with you to surgery.

ELEVATION – You will notice swelling and bruising around and below the surgical site. Swelling and bruising are gravity-dependent and will work its way from the area of surgery towards the floor. Elevating the surgical area above the level of your heart a few times a day will help prevent this.

ICE

• You may apply ice over the surgical site or areas of discomfort.
• Please be aware there is a risk of frostbite when icing, therefore only apply ice for 20 minutes every hour.
• If you are interested in obtaining an ice machine, a DONJOY CLEAR3 ICEMAN may be purchased at the clinic (please contact the clinic for pricing).

DRESSINGS

• You will keep the surgical dressing on for a minimum of 4 days after surgery.

BATHING

• You may shower at any time, but must keep the dressing/incisions dry and protected until we evaluate them in the clinic at your follow-up appointment.

INCISION CARE

• Do not allow family and friends who visit to touch the surgical dressing or incisions.
• Always clean your hands before and after caring for your incisions.
• Keep pets away from your incisions until they are healed.
• Avoid lotions or perfumed soaps on the incisions until they are healed.
• Do not place antibacterial ointments (bacitracin, etc.) over the incisions. This will break down the normal, healthy bacteria on your skin and cause irritation/skin breakdown.
• Make sure the sheets on your bed and the clothes you are wearing are clean.
• Do not soak the surgical site (bath, hot tub, pool, lake, ocean, etc.) for a minimum of 2 weeks after surgery.

DRIVING – An estimated timeframe on returning to driving is determined on a case-by-case basis depending on your surgery. You may not drive until you are off all narcotic pain medications.

• For shoulder/elbow/arm surgery you must be out of the sling and have good range of motion at your wrist, elbow and shoulder.
• For knee/ankle/leg surgery you must be able to bend your knee beyond 60 degrees, be out of any ankle cast/boot, be able to put full weight through your leg/foot.

TRAVEL – Please avoid any long-distance travel via plane or car for a minimum of 2 weeks after surgery.

PHYSICAL THERAPY

• You will be sent home from the surgery with exercises that you may perform on your own at home.
• If you are having a total or partial knee replacement, you may begin physical therapy 5-7 days after surgery.
• For all other surgeries, you may begin formal physical therapy after your follow-up clinic visit with us. A PT prescription will be given to you at your post-operative visit.
• You may go to any physical therapy clinic; we recommend something close to your home/work/school and are happy to make recommendations.
• We recommend you call the PT clinic ahead of time to pre-schedule appointments.

+ Preparing Your Home Prior to Surgery

Whether having upper extremity surgery that requires a sling or lower extremity surgery that requires a brace, crutches, etc., making some simple modifications in and around your home can help prevent accidents, slips and falls during the recovery phase:

• Remove throw rugs, electrical cords, food spills and anything else that may cause you to fall.
• Arrange furniture so that you have a clear pathway between rooms.
• Keep stairs clear of packages, boxes or clutter.
• Walk only in well-lit rooms and install a nightlight along the route between your bedroom and the bathroom.
• In the bathroom, use nonslip bath mats, grab bars, a raised toilet seat and a shower tub seat.
• Simplify your household to keep the items you need within easy reach and everything else out of the way.
• Carry things hands-free by using a backpack, fanny pack or an apron with pockets.

Information provided by AAOS.

+ Infection

HOW COMMON IS SURGICAL SITE INFECTION? Most patients who have surgery do not develop an infection. However, surgical site infections do occur in approximately 1-3% of surgical procedures (1 to 3 infections out of every 100 patients who have surgery).

WHAT CAN THE PATIENT DO TO PREVENT INFECTION?

• Shower the night before and morning of surgery with CHG (chlorhexidine gluconate) soap.
• Shaving: Do not shave any part of your body that you do not already shave every day. If you normally shave near your surgical site, do not shave the area for 2 days before your surgery.
• Medical Issues: Being an elderly adult or having health problems such as diabetes, obesity, vascular disease, cancer, etc can put you at risk for infection.
• Quit Smoking: Patients who smoke get more infections. Talk to your physician about how you can quit before your surgery.
• Surgical Dressing: Keep your dressing clean and dry. Do not remove your dressing until advised by your surgeon.
• Surgical Incisions:
  • Do not allow family and friends who visit to touch the surgical dressing or incisions.
  • Always clean your hands before and after caring for your incisions.
  • Keep pets away from your incisions until they are healed.
  • Avoid ointments, lotions, or perfumed soaps on the incisions until they are healed.
  • Make sure the environment around your incisions is clean; the sheets on your bed, the clothes you are wearing, etc.

WHAT CAN THE SURGICAL TEAM DO TO PREVENT INFECTION?

• We clean our hands and arms up to our elbows with an antiseptic agent before the surgery.
• Immediately before your surgery, we remove the hair around your surgical site with electric clippers.
• We wear special hair covers, masks, gowns and gloves during the surgery to keep the surgery area clean.
• We give you antibiotics in your IV before (and sometimes during and after) your surgery.
• We clean the skin at and around the surgical site with a special antiseptic agent.

WHAT TO LOOK OUT FOR:

• Localized redness around the area where you had surgery.
• Pain, tenderness or warmth around the incisions.
• Drainage of cloudy fluid from your surgical incision.
• Fever greater than 38º C or 100.4º F.
• CAN SURGICAL SITE INFECTIONS BE TREATED? Most surgical site infections can be treated with antibiotics taken by mouth. Sometimes patients also need another surgery to treat the infections.

+ Constipation

WHAT IS CONSTIPATION? Constipation is a common problem after surgery that makes it hard to have bowel movements. Healthcare providers define constipation as having a bowel movement less than 3 times a week. Others define constipation as straining, having stool that is too hard or small, feeling of incomplete evacuation or a non-productive urge.

WHAT CAUSES CONSTIPATION AFTER SURGERY?

• Taking narcotic pain medication.
• Decreased daily activity.
• Altered diet and fluid intake.

WHAT OTHER RISK FACTORS CAUSE CONSTIPATION?

• Increased age, especially over the age 65.
• Female.
• Non-Caucasian.
• Taking multiple medications.

HOW TO PREVENT CONSTIPATION:

• Food:
  • Increase your daily fiber by eating high-fiber foods: cereal (Shredded Wheat, All-Bran, OatBran), fruits (grapefruit, cantaloupe, prunes), vegetables (parsnips, cooked carrots, peas), whole grains, peanuts, whole wheat bread, baked beans, kidney beans.
  • Avoid the bananas, apples, rice, white bread, processed foods/refined sugars, dairy (milk, cheese, yogurt, etc).
• Beverages:
  • Stay hydrated by drinking a lot of water (6-8 glasses or 1.5 – 2 liters per day).
  • Avoid drinking alcoholic beverages.
• Habits:
  • Get up and move around, walk around, etc. to stimulate your bowels.
  • Go to the bathroom when you have the urge to go…do not “hold it”.
• Medications:
  • Decrease your narcotic pain medication intake.
  • Take a fiber supplement (Metamucil, Citrucel).
  • Take one or more of the following over-the-counter medications as long as you are taking the narcotic pain medication. Stop taking if you develop diarrhea.
    • Docusate 250mg by mouth, 2 times a day
    • Senna 17.2 mg by mouth, 1 time a day
    • Miralax 17 gm by mouth, 1 time a day

HOW TO TREAT CONSTIPATION: If you have not had a bowel movement within 2-3 days, take one of the following over-the-counter medications until you resume a normal bowel regimen. Stop taking if you develop diarrhea.

• Miralax + Propel/Pedialyte/Nuun/Gatorade/Powerade
  • Mix 32 oz of one of the above electrolyte drinks with Miralax (4 ounces or 119 grams). Drink within a 1-hour period (roughly one glass every 15 minutes, until you’ve finished the 32 ounces).
• Milk of Magnesia 30 mL by mouth, 2 times a day
• Mineral Oil 30 mL by mouth, 1 time a day
• Magnesium citrate 150 mL by mouth, 1 time a day
• Bisacodyl 10 mg rectally, 1 time a day
• Fleet Enema 133 mL rectally, 1 time a day

SEE A DOCTOR IF:

• Your constipation lasts for more than 4 days or gets worse.
• You have abdominal or rectal pain, nausea and/or vomiting.
• You have thin, pencil-like stools.
• You have bright red blood in your stool.
• You have fever, weight loss or weakness.

+ Nausea + Vomiting

Having nausea and vomiting after surgery is an extremely uncomfortable experience. It can be so miserable that studies have shown surgical patients would rather suffer from pain than post-operative nausea and vomiting (PONV). There are several risk factors that can lead to nausea and vomiting as noted below:

PATIENT RISK FACTORS

• Sex: Women are more likely to experience PONV compared to men. It is the strongest patient-specific predictor.
• Motion sickness: Patients with a history of motion sickness or vomiting after previous surgery are at increased risk for PONV.
• Smoking: Non-smokers are more prone for PONV. Note: We do not recommend that patients start smoking in order to prevent/treat PONV!
• Age: Individuals less than 50 years old are at higher risk.
• Delayed gastric emptying: Patients with abdominal pathology, diabetes mellitus, hypothyroidism and pregnancy are at increased risk of PONV.

SURGICAL RISK FACTORS

• Type of surgery: Abdominal and gynecological surgeries are associated with higher incidence of PONV than orthopedic surgeries.
• Duration of surgery: Longer surgeries are associated with increased incidence of PONV.
• Anesthesia factors: There are several different forms of anesthesia (general, spinal, regional, etc.) and administered medications that can increase and decrease the risk of PONV.

POST-SURGICAL RISK FACTORS

• Pain: Abdominal or pelvic pain is a common cause of PONV.
• Ambulation: Sudden motion or changes in position can precipitate nausea and vomiting.
• Opioids: Post-operative narcotic pain medications increase the risk for PONV. This has a “dose-dependent” effect, meaning the more narcotic pain medication you take the more nauseous you can feel. The effect lasts for as long as opioids are used for pain control in the post-operative period.

TREATMENT OF NAUSEA + VOMITING The surgical and anesthesia teams keep the above-mentioned risk factors in mind when taking care of patients and can administer or avoid certain medications before, during and after surgery to decrease the incidence of PONV. If you experience PONV, please consider the following preventative/treatment tips:

• Take nausea medications: We typically prescribe nausea medication after every surgery, so patients have a treatment option in the event that they experience PONV once they return home after surgery. There are multiple different types of medication and routes (oral, suppository, transdermal) that can be prescribed.
• Decrease opioid/narcotic medication intake: Taking other forms of pain medication such as nonsteroidal anti-inflammatory (Advil, Motrin, Ibuprofen, Aleve) or Tylenol will help reduce opioid requirement.
• Keep your pain controlled: Effective pain control can decrease nausea. As noted above, narcotics can cause PONV, but patients can utilize other modalities to alleviate pain: anti-inflammatories, Tylenol, CBD lotion, ice, elevation, rest, massage, acupuncture, etc.
• Hydration: Adequate hydration helps reduce PONV. Water is the first choice, but electrolytes are often lost with vomiting and may need to be replaced. There are many types of electrolyte replacement drinks; we recommend Pedialyte. Avoid carbonated beverages as they can cause issues with nausea and vomiting.
• Avoid taking medications on an empty stomach.
• Avoid aggressively returning to a normal diet. A slow return to normal foods helps minimize nausea. Start with clear fluids in small amounts over the course of a few hours. If clear fluids are tolerated, other liquids such as juice, tea, milk, and coffee may be introduced. If these are tolerated, a soft food diet (pudding, canned or stemmed fruits/veggies, tofu, eggs, etc.) is next, with a full diet being introduced only when the others were successfully tolerated.
• Temperature: Sometimes patients are sensitive to the temperature of fluids, food and the environment. They may tolerate room temperature or warm fluids, but cannot tolerate cold drinks. The opposite may also be true. Additionally, being overheated can also be an issue. Find a cool place to rest, rather than being in a hot room or outdoors on a hot day.
• Avoid strong smells such as a heavily scented rooms or perfumes/lotions.
• Homeopathic options: Some patients have luck with eating ginger, sucking on a lemon, peppermint aromatherapy, acupuncture, etc.

+ DVT (Deep Vein Thrombosis) | Blood Clot In The Arm or Leg

WHAT IS A DVT (DEEP VEIN THROMBOSIS)? Deep Vein Thrombosis is a blood clot that forms in a deep vein of the legs (commonly in the calf) or arm. It forms when blood is not circulating well in the veins therefore the blood “pools” in the veins.

RISK FACTORS FOR A DVT?

• Injury to a vein caused by a fracture, severe muscle injury or major surgery.
• Slow blood flow caused by confinement to bed (due to medical condition or after surgery), limited movement (cast on a leg), sitting for a long time (especially with legs crossed), paralysis.
• Increased estrogen caused by birth control pills, hormone replacement therapy (HRT), pregnancy
• Chronic medical illness such as heart disease, lung disease, cancer, inflammatory bowel disease, having an implanted vascular device (stents, etc).
• Being sedentary/inactive.
• Having a personal or family history of blood clots.
• Obesity.
• Tobacco use.
• Age over 60.

SIGNS & SYMPTOMS OF A DVT?

• Pain or tenderness in the leg (especially in the calf where the pain is often described as feeling like a “Charlie horse” that doesn’t go away)
• Swelling of the leg.
• Warmth.
• Redness.

HOW DO I PREVENT BLOOD CLOTS AFTER SURGERY?

• Avoid sitting or lying in bed for long periods of time.
• Perform lower extremity exercises such as leg lifts, ankle motion, etc.
• Elevate the foot above the level of your heart.
• Change positions often.
• Do not take oral birth control pills or hormone replacement therapy if you have a personal or family history of blood clots.
• Do not smoke.
• Eat plenty of fruits and vegetables.
• Avoid crossing your legs when sitting.
• Do not put a pillow under your knee unless told by your healthcare provider.
• Wear special stockings (compression stocking, TED hose) – do not let them bunch up when you are wearing them.
• If indicated, take any medications prescribed or recommended by your surgeon for anti-coagulation.

SEEK IMMEDIATE CARE IF:

• You develop shortness of breath or difficultly breathing.
• You develop chest pain.
• You develop swelling or pain in your leg or calf.
• You feel faint or dizzy.

+ PE (Pulmondary Embolism) | Blood Clot In The Lung

THIS IS A MEDICAL EMERGENCY AND CAN BE POTENTIALLY FATAL…YOU MUST GO TO THE EMERGENCY ROOM IMMEDIATELY.

WHAT IS A PE (PULMONARY EMBOLISM)? Pulmonary Embolism is a blood clot that travels through the bloodstream to the lungs.

SIGNS & SYMPTOMS OF A PE?

• Difficulty breathing, shortness of breath.
• Chest pain – worse with deep breaths or coughing.
• Anxiety.
• Coughing up blood.
• Fast or irregular heartbeat.
• Fainting, lightheadedness, low blood pressure.

HOW DO I PREVENT BLOOD CLOTS AFTER SURGERY?

• Avoid sitting or lying in bed for long periods of time.
• Perform lower extremity exercises such as leg lifts, ankle motion, etc.
• Elevate the foot above the level of your heart.
• Change positions often.
• Do not take oral birth control pills or hormone replacement therapy if you have a personal or family history of blood clots.
• Do not smoke.
• Eat plenty of fruits and vegetables.
• Avoid crossing your legs when sitting.
• Do not put a pillow under your knee unless told by your healthcare provider.
• Wear special stockings (compression stocking, TED hose) – do not let them bunch up when you are wearing them.
• If indicated, take any medications prescribed or recommended by your surgeon for anti-coagulation.

SEEK IMMEDIATE CARE IF:

• You develop shortness of breath or difficultly breathing.
• You develop chest pain.
• You develop swelling or pain in your leg or calf.
• You feel faint or dizzy.

+ Pain

With the help of the healthcare provider, the patient should have a reasonable expectation about his or her recovery. Pain medications will not eliminate the pain entirely, therefore, taking more medication does not necessarily mean one will be pain free. In other words, pain medications are meant to make pain "tolerable", but they will not take pain completely away. Supplementing with other modalities such as ice, massage, elevation, etc can help.

WHY IS PAIN CONTROL SO IMPORTANT?In addition to keeping patients comfortable, having good pain control can help with faster recovery and may reduce the risk of developing certain complications after surgery, such as pneumonia and blood clots. If postoperative pain is well controlled, then patients will have an easier time completing important tasks such as walking, eating, and sleeping which are important for a healthy recovery, and taking deep breaths to decrease the risk of pneumonia.

HOW MUCH PAIN IS NORMAL? Surgical pain is the most intense 24-72 hours after surgery. Patients who have KNEE or ANKLE surgery will notice increased pain (described as fire rushing down their leg) when they go from sitting/lying down to standing. Patients who have SHOULDER surgery will notice increased pain when trying to sleep. For all surgeries, pain is typically worse at night, while trying to sleep.

Some patients, with risk factors noted below, will experience more pain than others and will have a harder time controlling pain after surgery (Source: Washington State AMDG Guidelines):

• History of severe postoperative pain.
• Opioid pain medication tolerance (daily use for months).
• Current mixed opioid agonist/antagonist treatment (e.g. buprenorphine, naltrexone).
• Chronic pain (either related or unrelated to the surgical site).
• Psychological co-morbidities (e.g. depression, anxiety, catastrophizing).
• History of substance use.
• History of “all over body pain”.
• History of significant opioid sensitivities (e.g. nausea, sedation).

+ Urgencies + Emergencies

There are many signs and symptoms to be aware of after any minor or major surgical procedure.

CALL THE CLINIC IF THE FOLLOWING CONDITIONS OCCUR:

• Incisions are red, warm, and extremely painful.
• Extreme calf pain or calf swelling.
• Drainage soaks the dressings and continues to expand 24 hours after surgery.
• Surgical dressing is foul-smelling.
• Fever greater than 101.5 F.
• Persistent nausea and vomiting.
• Constipation greater than 3-4 days and abdominal pain.
• Inability to urinate.

CALL 9-1-1 OR GO TO THE NEAREST EMERGENCY ROOM IF THE FOLLOWING CONDITIONS OCCUR:

• Difficulty breathing.
• Chest pain.
• Progressive numbness, tingling or skin color change that is not responsive to loosening the brace/sling, elevating the extremity or changing position.

+ Our Pain Medication Policy

• Request for medication refills may take 48 business hours to complete and will not be refilled on an “urgent” basis. (We do our best to refill prescriptions as quickly as possible, but we are not in the clinic/available everyday, therefore we kindly ask that you plan ahead and notify us in a timely manner when refills are necessary.)

• Refill requests must be made during regular weekday office hours; the on-call provider will not refill medications on nights/weekends.

• Federal law prohibits narcotic pain medication prescriptions to be be called, faxed or emailed to a pharmacy; patients must physically take a handwritten prescription to the pharmacy.Patients taking narcotic pain medications prescribed by another provider will have to return to that provider for any refills.

• Narcotic pain medications are only prescribed for post-surgical pain or acute fractures.

• Narcotic pain medications are not prescribed for more than 6 weeks after a surgery.

+ Effective Use Of Pain Medication After Surgery

• For the first 48-72 hours, take the pain medication on a routine schedule, by checking in every 3-4 hours and noting if the pain is increasing or staying the same.
  • If increasing, then do not wait until the pain is severe before taking the next dose of pain medications (in other words…don’t “get behind” of the pain, stay in front of it!). It is best to “stay ahead” of the pain/prevent the pain, rather than catch up once the pain is intolerable.
  • If the pain is the same as it was an hour ago, then do not take the pain medication at that time, but re-evaluate the pain level in an hour and follow the advice above.

• Supplement the narcotic pain mediations with over-the-counter medications such as Acetaminophen~ or a non-steroidal anti-inflammatory (Ibuprofen, Advil, Motrin, etc).

• Rather than taking the different medications (narcotic pain medication, Tylenol, anti-inflammatory) all at once, we recommend "laddering" them. This will help the pain level to be in steady-state rather then dramatically fluctuating between narcotic pain medication doses. It will also help you "buy time" between the narcotic pain medications doses, with the hope of decreasing the use for the narcotic pain medications.

~Please refer to article about Acetaminophen (Tylenol) to ensure proper use/dosing, particularly if you are taking Percocet, Vicodin, or Norco.

+ Narcotic Pain Medication

WILL I BECOME ADDICTED TO PAIN MEDICATION AFTER SURGERY? Short-term use of opioids for severe, acute postoperative pain management is safe, but a multimodal regimen should be provided to help patients obtain pain reduction with not only narcotic pain medication, but also with anti-inflammatories, acetaminophen, and other non-pharmacologic therapies (physical therapy, massage therapy, etc). We emphasize “short-term use” because the effectiveness of taking opiods on a long-term basis decreases with time and leads to potential risks and side effects. Becoming addicted to a pain medication when it is used for surgical pain is very rare and most patients do not require pain medciation for an extended period (> 2 weeks) of time.

WHAT IF I HAVE A HISTORY OF DRUG USE? Be honest with the surgical team about any current or historical alcohol and drug use; they can plan for pain control that minimizes the risk of relapse. If you're currently misusing alcohol or drugs (even those that have been prescribed for you) let the surgeon know, as this will affect postoperative pain control. Withdrawing from these substances can be difficult, and the post-surgical period is not the time to try it. According to the U.S. Centers for Disease Control and Prevention (CDC) there were 63,632 drug overdose deaths in the United States in 2016; 174 deaths per day; one death every 8.28 minutes; 42,249 (66.4%) of those deaths were due to opioids. More deaths than those as a result of firearms, homicide, suicide, and motor vehicle crashes.

NARCOTIC PAIN MEDICATION - WARNINGS:

• Narcotics can slow or stop your breathing, please take while under the supervision/care of a responsible adult.
• Never share this medication with another person.
• Misuse of narcotic medications can cause addiction, overdose and death. Please take as directed.
• Do not crush, break or open pills. Do not inhale, snort or inject pills. Swallow the pill whole and drink with plenty of water.
• Do not stop taking narcotic pain medications suddenly after long-term use or you could have unpleasant withdrawal symptoms.
• Seek emergency medical attention or call Poison Control (800-222-1222) if an overdose is suspected.
• Do not drink alcohol while taking narcotic pain medications.
• These medications can cause impaired thinking, drowsiness, unsteadiness, and slow your reaction time therefore avoid driving or operating machinery.
• Obtain immediate medical help if you develop hives, difficulty breathing, seizure, swelling of your face, lips, tongue or throat.

COMMON SIDE EFFECTS OF NARCOTIC PAIN MEDICATIONS:

• Stomach pain.
• Nausea.
• Vomiting.
• Constipation.
• Loss of appetite.
• Drowsiness.
• Dizziness.
• Headache.
• Fatigue.
• Dry mouth.
• Itching.

RESOURCES FOR NARCOTIC ABUSE + ADDICTION: The Substance Abuse and Mental Health Services Administration (SAMHSA) has a National Helpline, 1-800-662-HELP (4357), for those with a possible opioid use disorder. The Helpline is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations. Callers can also order free publications and other information.

+ Acetaminophen | Tylenol®

WHAT IS ACETAMINOPHEN? Acetaminophen is an effective non-narcotic pain reliever for mild to moderate pain. It commonly comes in the following forms:

• Tylenol® Regular Strength 325 mg
• Tylenol® Extra Strength 500 mg

HOW IS ACETAMINOPHEN BENEFICIAL AFTER SURGERY? Acetaminophen is often used to decrease the amount of narcotic pain medication required for pain control. We often recommend you “ladder” acetaminophen between your narcotic pain medication doses in order to help decrease the amount of narcotic pain medication required for pain control and to keep your pain level stable between narcotic pain medication doses.

HOW MUCH ACETAMINOPHEN IS SAFE? Please follow the instruction on the bottle, keeping in mind that for adults and children over 12 years old, the maximum daily dose of acetaminophen is 3,000 – 4,000 mg.

SEVERE LIVER DAMAGE MAY OCCUR IF:

• Adults takes more than 4,000 mg of acetaminophen in 24 hours.
• You are taking other medications that contain acetaminophen at the same time and exceeding the daily maximum dose.
• Adults have 3 or more alcoholic drinks every day while using this product.

DO NOT USE IF:

• You are taking other medications containing acetaminophen (Percocet, Norco or Vicodin, Benadryl, DayQuil, Dimetapp, Excedrin, Nyquil, Robitussin, Sudafed, Theraflu, Vicks, etc).
• You are allergic to acetaminophen.
• You have liver disease.

OVERDOSE WARNING: In case of overdose, get medical help or contact a Poison Control Center immediately (1-800-222-1222). Quick medical attention is critical.

+ Safe Disposal Of Medications

When medications are no longer needed, it is extremely important to dispose of them properly. Proper disposal will help reduce accidental exposure or intentional misuse. Rather than flushing or throwing away medication, the preferred method of disposal is taking the medications to DEA-authorized collector. Click here to find an authorized location near you that offers proper medication disposal.

Patients can also visit the DEA’s website for more information about drug disposal or call the DEA Office of Diversion Control’s Registration Call Center at 1-800-882-9539 to find an authorized collector in their community.

If there are no DEA-authorized collectors available in your area, and there are no specific disposal instructions on the label, you can also follow these simple steps to dispose of most medicines in the household trash:

• Mix medicines (do not crush tablets or capsules) with an unpalatable substance such as dirt, kitty litter, or used coffee grounds
• Place the mixture in a container such as a sealed plastic bag
• Throw the container in your household trash
• Scratch out all personal information on the prescription label of the empty pill bottle/packaging to make it unreadable, then dispose of the container.

+ Shoulder Sling

There are many different slings on the market...refer to our "Favorites" for more details! After shoulder surgery, you are often (but not always!) placeced in a sling. The sling will be applied and fit to your shoulder/arm prior to you awakening from surgery. We recommend you take a moment to familiarize yourself with the sling since you will be removing and replacing it on your own for several weeks during your recovery. Correct application is important for not only proper functioning of this device, but also for your comfort.

+ Knee Brace

There are many different knee braces on the market...refer to our "Favorites" for more details! Depending on the type of knee surgery you will be undergoing, you might be placeced in a barce. The brace will be applied and fit to your knee/leg prior to you awakening from surgery. We recommend you take a moment to familiarize yourself with the brace since you will be removing and replacing it on your own for several weeks during your recovery. Correct application is important for not only proper functioning of this device, but also for your comfort.

+ Cast + Splint

CARING FOR THE CAST/SPLINT

• Keep the cast dry.
• Keep dirt, sand, powder, lotions, liquids, etc away form the inside of the cast.
• Do not pull out/remove padding, as it is protecting the skin.
• Do not put any objects down into the cast to “scratch an itch”, this can cause skin irritation and even infection.
• Do not trim or re-shape the cast; it is designed to provide maximum support during healing.
• Never attempt to remove the cast yourself.

CARING FOR THE PATIENT WITH A CAST/SPLINT

• If itching occurs, use a hairdryer placed on a cool setting to blow cool air under the cast.
• Raise/elevate the casted extremity above the level of your heart to reduce swelling.
• For a casted lower extremity (leg): Place pillows under the calf of the casted leg, not under the heel area, to avoid pressure sores.
• For a casted upper extremity (arm), wear a sling while up and moving around for support and comfort and while sitting or lying down put your arm on top of pillows.
• Wiggle your fingers and toes to reduce swelling and increase circulation.
• Exercise any joints not covered by the cast to help increase circulation.
• Apply ice to the cast, taking care to keep it dry. Place the ice in a dry plastic bag and place it around the cast at the level of the injury.
• Closely check your skin frequently to make sure there is no irritation.

CONTACT YOUR PHYSICIAN IF...

• Moderate discomfort becomes severe and/or constant pain not relieved by rest, elevation and taking pain medication.
• Feeling of numbness, tingling, burning or stinging under or around the cast.
• The cast feels tight and the tightness does not improve after 30 minutes of elevation.
• Unable to wiggle or move fingers/toes.
• Fingers/toes are cold or change color (purple or white).
• Cast becomes damaged, cracked, dented or wet.
• There is a foul odor coming from the cast.
• The cast feels too loose.

AFTER CAST/SPLINT REMOVAL

• Skin will be dry, pale and scaly. To soften and remove the dead skin, soak the extremity in warm water and use a gentle skin moisturizer (Eucerin, Cerave, Cetaphil, etc).
• Pain may increase for 24-48 hours after cast removal; muscles will feel tight or sore from lack of use and joints will feel stiff and painful from inactivity.

+ Hibiclens (Chlorhexidine Gluconate) Soap

WHAT IS HIBICLENS?

Hibiclens is a soap containing Chlorhexidine Gluconate (CHG). It is effective against multiple microorganisms, thereby preventing skin infections. It kills germs on contact and bonds with the skin to keep killing microorganisms even after washing.

WHAT IS HIBICLENS USED FOR?

• Skin wounds and general skin cleansing.
• Surgical hand scrub.
• Healthcare personnel hand wash.
• Preoperative skin preparation.

HOW TO PREPARE THE SKIN FOR SURGERY:

Take a shower the night before and morning of surgery with Hibiclens or any soap containing CHG.

• Night Before Surgery:
  • Lather CHG soap in your hand or a washcloth.
  • Clean your body from the neck down (do not use the CHG on your face…use normal soap on your face and shampoo in your hair).
  • Let the soap sit on your skin for 2 minutes.
  • Rinse off.
• Morning Of Surgery:
  • Lather CHG soap in your hand or a washcloth.
  • Clean your body from the neck down (do not use the CHG on your face…use normal soap on your face and shampoo in your hair).
  • Before rinsing off, let the soap sit on your skin for 2 minutes and spend double the amount of time as normal washing the surgical extremity:
    • Upper extremity surgery...entire arm, from neck to fingertips.
    • Lower extremity surgery...entire leg, from hip to toes.

DO NOT APPLY TO THE FOLLOWING AREAS:

• Head
• Face
• Eyes - this can cause serious and permanent eye injury if placed or kept in the eye. If contact occurs in this area, rinse with cold water right away.
• Ears - this may cause deafness when instilled in the middle ear through perforated eardrums. If contact occurs in this area, rinse with cold water right away.
• Mouth.
• Genital area.
• Wounds that involve more than the superficial layers of skin.

WARNINGS:

• Do not use if you are allergic to chlorhexidine gluconate.
• Stop use and ask a doctor if irritation, sensitization, or allergic reaction occurs and lasts for 72 hours. These may be signs of a serious condition.
• Keep out of the reach of children.
• If swallowed, get medical help or contact a Poison Control Center right away.

+ Ice | Cryo-Cuff

Applying ice to the surgical site can help reduce pain and decrease swelling. When applying ice to the injured area, it will go from feeling cold, to burning, then aching and finally numb. Patients can use ice packs/wraps, crushed ice cubes, instant ice packs or even bags of frozen peas or corn.

Some patients prefer a more effective and continuous ice option, such as a cold therapy machine, cryo-cuff, ice machine, etc. These devices automatically recirculate ice and allow for consistent and accurate temperatures. They are very helpful with pain control and swelling after "major" surgeries. We sell the DonJoy IceMan Clear3 and associated universal cold pad at the clinic, but prior to purchase we recommend...

• Ask friends or family members if they have a unit that can be borrowed. If borrowing a cryo-cuff, please attempt to use the device prior to surgery, to ensure the motor works and there are no leaks. Additionally, if the device is in poor condition or dirty, we advise replacing it; for infection prevention, it is not advisable to apply a soiled cryo-cuff to the surgical site.
• Look online at other brands/types available for purchase.
• Unfortunately, Medicare and other insurance companies will not pay for these devices; the patient is personally and fully responsible for payment.

WARNINGS:

To avoid skin irritaiton, tissue injury, tissue damage or burns please…

• Avoid applying ice directly to the skin; a barrier of soft cotton/thin fabric should be placed between the skin and ice bag.
• Apply ice for only 20 minutes at a time with a 40-60 minute “thawing” period between icing sessions.
• Remove any leaking ice bags in contact with the surgical dressing or surgical incisions.

+ Crutch Training

CRUTCH FITTING/POSITIONING

It is important to accurately adjust your cruthces to your height in order to avoid pressure on the nerves in your armpit, back and neck pain due to poor posture, wrist/hand pain and potential falls. To ensure the proper crutch fit, please follow the steps below:

• Stand tall/straight, with the crutches under your armpits and your shoulders relaxed.
• The top of the crutches should be about 1.5-2 inches or 2-3 fingerbredths below your armpits.
• The handgrips of the crutches should be even with the top of your hip/pelvis bone.
• Your elbows should be slightly bent (15-20 degrees) when you hold the handgrips.

TIPS FOR CRUTCH USE

• Prepare your home by removing tripping hazards; clear the floor space, remove throw rugs and electical cords, etc.
• Squeeze the top of the crutches between the arms and the rib cage while walking.
• To avoid damage to the nerves and blood vessels in your armpit, carry your weight through your hands, not through your underarms.
• Keep your wrists straight when using crutches.
• Avoid looking down at your crutches while while cruthcing around, rather look straight ahead just like you normally do when walking.
• Avoid wet and slippery surfaces covered in snow, ice or rain.
• Make sure your crutches have rubber tips/grips without crakes, tears or worn areas.
• Make sure the underarm is well-padded.
• Wear supportive, well-fitting shoes when ambulating with crutches (avoid flip-flops, loose shoes, slippers, socks, etc).
• Carry items in a backpack.
• When not in use and leaning against a wall, crutches tend to fall over, rather turn the cruthces upside down and put the pads on the floor.

WALKING WITH CRUTCHES (WHEN ALLOWED TO PUT WEIGHT THROUGH THE LEG)

• Put all your weight into your well leg.
• Put the crutches about one foot in front of you and step forward with your injured leg so that the crutches and your leg contact the ground at the same time. Shift as much of your weight as needed into the crutches to unload the injured leg.
• Finish the step normally with your well leg. When your good leg is on the ground, move your crutches ahead in preparation for your next step.
• Always look forward; do not look down at your feet.

TO SIT IN A CHAIR WITH CRUTCHES

• Back up to a sturdy chair.
• Put the injured leg in front of you.
• Hold both crutches in one hand.
• Use the other hand to feel behind you for the seat of the chair.
• Slowly lower yourself into the chair.
• Lean your crutches in a nearby spot; lean them upside down as crutches tend to fall over when they are leaned on their tips!

TO STAND-UP FROM A CHAIR WITH CRUTCHES

• Inch yourself to the front of the chair.
• Hold both crutches in the hand on your injured side.
• Push yourself up and stand on your good leg.

CRUTCH USE ON STAIRS

Remember this...UP with the GOOD, DOWN with the BAD...go up the stairs leading with your good leg and down the stairs ledaing with your bad leg.

• Hold the crutches in the hand opposite of the side that needs support. For example, if the right leg is injured, hold the crutch on the left side of your body.
• To go up the stairs. Tuck both crutches under your armpit on the uninjured side. Hold the handrail with the free hand. Step up to the next step with your well/uninjured leg. Push down on your crutches, and then step up with your weaker leg so that both feet are now on the same step.
• To go down stairs. Tuck both crutches under your armpit on the uninjured side. Hold the handrail with the free hand. Hold the injured left out in front of you and put your crutches down on the next step below. Step down with your weaker leg, using the crutches and handrail for support. Then, step down with the well/uninjured leg.
• If you encounter a stairway with no handrails, use the crutches under both arms and hop up or down each step on your good leg, using more strength.

CAN'T DO STAIRS WITH CRUTCHES?

Negotiating stairs on crutches can be very confusing and physically demanding. If this is a daunting task, then we recommend just going up and down the stairs like a little kid...do a crab crawl by sitting on each step and moving up or down on your bottom.

• Start by sitting on the lowest step with the injured leg out in front.
• Scoot your bottom up to the next step, using your free hand and good leg for support.
• Face the same direction when going down the steps in this manner.

+ Cane

Canes are best used for minor problems with balance, stability, weakness in the leg/trunk or pain.

CANE FITTING/POSITIONING

• When standing up straight, the top of the cane should reach to the crease in the wrist.
• The elbow should be slightly bent when holding the cane.

CANE USE WHILE WALKING

• Hold the cane in the hand opposite of the side that needs support. For example, if the right leg is injured, hold the cane in the left hand.
• Have the cane hit the ground at the same time the opposite/injured leg hits the ground.

CANE USE ON STAIRS

• Hold the cane in the hand opposite of the side that needs support. For example, if the right leg is injured, hold the cane in the left hand.
• To go up the stairs. With the free hand, grasp the handrail. Step up onto the step with the good leg first, then step up onto the step with the injured leg.
• To come down the stairs. With the free hand, grasp the handrail. Put the cane on the lower step first, then the injured leg and then the good leg, which carries your body weight.

+ Driving

There are no established guidelines describing when it is safe to return to driving after an injury or surgery. Every case should be evaluated individually, taking into consideration the unique characteristics of the patient and injury. The National Highway Traffic Safety Administration offers medical guidelines for return to driving after an injury or surgery:

• Modified Driving: “Attempting to drive using the unaffected left leg to operate the pedals, using a cane or other device to operate the pedals, or having a co-driver work the stick-shift are not safe alternatives to temporary driver cessation in this situation.”
• Wearing a Cast, Brace, Sling or Splint: “As long as the immobilization is in place or the affected articulation has not achieved full mobility the driver should be advised to refrain from driving."
• After Removal of a Cast, Brace, Sling or Splint: “Removal of an immobilization after several weeks of immobilization does not imply immediate fitness to resume driving. After a 3 to 4 week immobilization, an ankle may take up to 9 weeks before the ankle achieves full function. While this does not mean that the resumption of driving requires an additional 9 weeks, it does mean that resumption should only occur when the mobility of the articulation is adequate for driving rather than immediately following cast removal.”

In general, we recommend patients refrain from driving or operating heavy machinery in the following situations:

• You underwent surgery/anesthesia 24-48 hours prior.
• You are in pain.
• For fear of pain, you have hesistation in slamming on the brakes or making sudden movements.
• You are wearing an orthopedic device (brace, sling, cast, splint, etc) that is limiting joint mobility.
• You are taking prescription narcotic pain medications or muscle relaxants.

+ Disabled Parking

A licensed physician, physician assistant, or registered nurse practitioner must determine if you qualify for disabled parking privileges. In regards to our orthopaedic practice, in order to qualify for temporary disabled parking privileges you must have a disability that meets at least 1 of the following criteria:

• You can’t walk 200 feet without stopping to rest.
• Your ability to walk is severely limited due to an arthritic, neurological, or orthopaedic condition.
• You’re so severely disabled that you can’t walk without the use of or assistance from a brace, cane, another person, prosthetic device, wheelchair, or other assistive device.

You must provide a vehicle licensing office with the following:

• A signed, original prescription from your doctor, physician assistant, or licensed registered nurse practitioner.
• A completeed Disabled Parking Application with the “Healthcare Provider” section completed by your doctor, physician assistant, or licensed registered nurse practitioner.

These forms and more information can be found at the Washington State Department of Licensing website.

+ Airport Security Screening + Patient Disability

The following information from the Trasnportaiton Security Administration website is helpful if traveling immediately after surgery with a brace, sling, crutches, walker, wheelchair etc., with medications or with metal implants (knee replacement, fracture fixed with plates and screws, etc).

To ensure your security, all travelers are required to undergo screening at the checkpoint. You or your traveling companion may consult the TSA officer about the best way to relieve any concerns during the screening process. You may provide the officer with the TSA notification card or other medical documentation to describe your condition. If you have other questions or concerns about traveling with a disability please contact passenger support.

If you are approved to use TSA Pre✓® lane at a participating airport, you do not need to remove shoes, laptops, liquids, belts, or light jackets during the screening process. You are required to undergo screening at the checkpoint by technology or a pat-down. Also, TSA officers may swab your hands, mobility aids, equipment and other external medical devices to test for explosives using explosives trace detection technology. You are not required to remove your shoes if you have disabilities and medical conditions. However, your shoes must undergo additional screening including visual/physical inspection as well as explosives trace detection testing of the footwear. You can request to be seated during this portion of the screening.

IMPLANTS + INTERNAL MEDICAL DEVICES

Inform the TSA officer that you have an artificial knee, hip, other metal implant or a pacemaker, defibrillator or other internal medical device. You may provide the officer with the TSA notification card or other medical documentation to describe your condition.

Advanced imaging technology can facilitate your screening and reduces the likelihood of a pat-down. You should not be screened by a walk-through metal detector if you have an internal medical device such as a pacemaker. Consult with your physician prior to flying. If you choose to not be screened through the advanced imaging technology or you alarm the walk-through metal detector, you will undergo a pat-down screening instead.

MEDICATIONS

Medications in pill or other solid form must undergo security screening. It is recommended that medication be clearly labeled to facilitate the screening process. Check with state laws regarding prescription medication labels.

You are responsible for displaying, handling, and repacking the medication when screening is required. Medication can undergo a visual or X-ray screening and may be tested for traces of explosives.

Inform the TSA officer that you have medically necessary liquids and/or medications and separate them from other belongings before screening begins. Also declare accessories associated with your liquid medication such as freezer packs, IV bags, pumps and syringes. Labeling these items can help facilitate the screening process.

You may bring medically necessary liquids, medications and creams in excess of 3.4 ounces or 100 milliliters in your carry-on bag. Remove them from your carry-on bag to be screened separately from the rest of your belongings. You are not required to place your liquid medication in a plastic zip-top bag. If a liquid, gel, or aerosol declared as medically-necessary alarms, then it may require additional screening and may not be allowed

Ice packs, freezer packs, gel packs, and other accessories may be presented at the screening checkpoint in a frozen or partially-frozen state. These items do not have to accompany medication or liquids to be considered medically necessary. All items, including supplies associated with medically necessary liquids such as IV bags, pumps, and syringes must be screened before they will be permitted into the secure area of the airport.

TSA officers may test liquids for explosives or concealed prohibited items. If officers are unable to use X-ray to clear these items, they may ask to open the container and transfer the liquid to a separate empty container or dispose of a small quantity of liquid, if feasible. Inform the TSA officer if you do not want your liquid medication to be screened by X-ray or opened. Additional steps will be taken to clear the liquid and you will undergo additional screening procedures to include a pat-down and screening of other carry-on property.

MOBILITY DISABILITIES, AIDS + DEVICES

Inform the TSA officer of your ability to walk or stand independently before screening. You may provide the officer with the TSA notification card or other medical documentation to describe your condition.

If you are able to stand with your arms above your head five to seven seconds without support, you may undergo screening through advanced imaging technology or the walk-through metal detector if you are able to walk through without support.

Walkers, crutches, canes or other mobility aids and devices must undergo X-ray screening. A TSA officer will inspect the item if it cannot fit through the X-ray. Notify the TSA officer if you need to be immediately reunited with the device after it is screened by X-ray.

TSA officers will screen wheelchairs and scooters to include the seat cushions and any non-removable pouches or fanny packs. Items will be tested for traces of explosives, and removable items will undergo X-ray screening.

If you can neither stand nor walk, you will undergo a pat-down screening while seated. If you can stand but cannot walk, you may stand near the wheelchair or scooter and undergo a pat-down screening. A pat-down procedure also is used if you alarm the metal detector or advanced imaging technology.