Surgery is stressful. Even before they start cutting into your body, something stressful is going on – a disease or other problem that led to a surgeon’s office. Except for the most minor health problems, most of us have limited understanding of what’s going on, what can be done about it and what the outlook is. “Not knowing is hard,” I frequently say, to acknowledge the stress that arises from lack of knowledge.
I’ve been accompanying my brother on this kind of journey, as he received a scary diagnosis and underwent a big operation (which went even better than we dared hope, I’m happy to say). His surgery took place at Medical Center of the Carolinas, where we learned about a set of protocols called ERAS – Enhanced Recovery After Surgery. As they walked us through its components, I realized that ERAS is all about stress management – both physiological and psychological stress (the two are inseparable, but we sometimes forget that).
Here are the startling results when a hospital implements ERAS. Stay time drop up to 30 percent, complications drop by up to an astonishing 50 percent and your chance of dying drops similarly. Wow. (I will never have surgery in a hospital that hasn’t adopted ERAS.) One study showed that for a big, open abdominal operation like my brother had, ERAS reduces the recovery time and complications to about the same as if they’d operated laparoscopically (through tiny incisions). As a result of shorter hospital stays and fewer complications, costs go down, often dramatically, which is good for everyone.
Like other kinds of stress management, ERAS starts with education. On our first visit with the surgeon and team, they took their time, gave lots of information and patiently asked for and answered all of our questions. None of the rushing in and out that seems to be so often the norm in medicine. Surprising, considering that his surgeon is so skilled that people come from all over the world for his care.
We were asked to take a “class” (only the two of us were in it), where a nurse quite patiently walked us through all of the possible procedures the surgeon might have to do. She stepped through each post-op day of recovery, detailing what he would be eating, when he’d get out of bed (almost immediately), goals for each day (walk this far, eat this kind of food) and so forth. Even though it was a ton of information, the result was that we had an good picture of all of the possibilities and what they would mean in terms of recovery and possible tubes and drains they might have to put into him. Knowledge reduces stress.
One of the surprises was that ERAS does away with the ban on eating or drinking just before surgery. Although he needed to skip breakfast, they gave him two bottles of high-carbohydrate drinks. One was for the night before surgery, the other was for a few hours before. If you know much about stress, you are aware that it messes with your body’s endocrine system – blood sugar and related hormones. ERAS addresses the physiological stress response by carb loading prior to surgery – much like marathon runners do – and careful blood sugar monitoring afterwards. All of the education also undoubtedly helps manage those levels, since psychological stress also raises your sugar, cortisol and other “stress hormone” levels, which ultimately slow down healing and eventually cause health issues.
ERAS also includes pain management protocols because pain provokes your mind and body’s stress response. When ERAS is used, patients need less pain medication. ERAS even addresses simple things like ensuring that patients are kept warm. There are other, more medical aspects to ERAS (such as preventing blood clots), which aren’t as directly related to minimizing stress response.
The hospital also makes available an app, SeamlessMD, which coaches patients through all of this. I was impressed when I saw that its very first suggestion is to rally your social support. In virtually every study, social support is the most important factor in bouncing back, mitigating stress and thriving under pressure
In short, ERAS encompasses information, nutrition, exercise, social support – these are always the ingredients for resilience and thriving under stress. The big takeaway for me is to reinforce that stress is always physical, mental and spiritual. They cannot be separated. If we want to be more resilient, to thrive under stress and bounce back fast when life tosses us challenges or threats, we need to address mind, body and spirit.
Yes, spirit, also. Although ERAS doesn’t directly address what we’d normally think of as spiritual concerns, it implies a set of values consistent with our spiritual needs. ERAS calls upon hospital staff, patients, their families and friends to be generous with their time, knowledge and support. Although that’s not explicit or part of the research I reviewed, I have no doubt it affects outcomes a great deal.