The First Procedure: Lessons in Vulnerability
In early 2023, at age 40, I underwent my first surgical procedure. I approached the experience with an open mind and a degree of trust in the process, in part because I was receiving care within the same health system where I worked as a clinical neuropsychologist, and also because I was professionally familiar with medical protocols and environments. At the time, I did not inform the anesthesiology team of any concerns regarding medication tolerance because I had no prior indication that I was particularly sensitive to medications.
On the morning of the 2023 surgery, I was administered a scopolamine patch due to my longstanding susceptibility to motion sickness. I later learned, by reviewing my online patient portal, that I had also been given midazolam, a benzodiazepine, as part of the general anesthesia protocol. This information had not been discussed with me at the time. Post-operatively, I received hydromorphone while in the PACU, another detail I would only discover later through that same chart review, which required both familiarity with medical documentation and the ability to interpret clinical terminology.
During my inpatient observation stay, I encountered a standardized pain management protocol that relied exclusively on opioids, despite my repeated requests for non-sedating alternatives such as NSAIDs. Beginning immediately postoperatively, I was receiving IV hydromorphone at regular intervals. When I declined a subsequent dose in an effort to reduce sedation, I requested a change in medication and was offered morphine as a substitute. After expressing concern about morphine, hydromorphone was administered again. Following a second request for alternatives, I was once more offered morphine, which I again declined, and was ultimately transitioned to oral hydrocodone, despite having clearly articulated, on multiple occasions, a preference for non-opioid interventions.
Prior to this procedure, during an earlier consultation regarding a more invasive surgical option for the same condition, I explicitly stated my desire to avoid opioids post-operatively. While this preference was documented in the clinical note, it was not consistently carried forward in my electronic health record. As a result, unless I restated this preference at every clinical encounter, it failed to carry forward in practice, a clear example of how individualized needs can be eclipsed by standardized workflows.
The scopolamine, which had been administered without any advance discussion of potential side effects, caused lingering visual disturbances that persisted for nearly a week. I independently identified meclizine as a potential reversal agent and self-administered it based on personal research. This experience raised an important question: how many other patients would have both the knowledge and cognitive clarity to identify and trial such a solution?
Following this experience, I submitted a written account to hospital leadership detailing the sequence of events and my concerns. The surgeon later contacted me to express appreciation for the clarity of the narrative, noting that while other patients had reported similar post-operative issues, they often struggled to communicate them effectively. Despite this acknowledgment, the experience had already taken a toll. I found myself struggling with overwhelm, helplessness, and a sense of not being heard, feelings consistent with medically induced trauma. Medical procedures, particularly when coupled with communication breakdowns or a loss of autonomy, can trigger lasting psychological distress, a phenomenon increasingly recognized across disciplines (Reeves et al., 2021). While I was able to make sense of these experiences in hindsight, I remained vulnerable to repeat missteps.
The Second Surgery: More Prepared, Still at Risk
Several years later, I underwent another outpatient surgical procedure at the same facility. Having learned from my prior experience, I proactively informed the anesthesia team in advance that I was highly sensitive to a range of medications. The nurse anesthetist reduced the standard midazolam dose by 50 percent, and I reiterated my adverse reaction to scopolamine, which had since been added to my allergy list because there was no appropriate alternative category for documenting adverse effects. Although it was documented in my EHR, the lack of integration into preoperative planning meant I still needed to remind staff of the prior adverse reaction on the day of surgery. Despite these precautions, I was again administered hydromorphone in the PACU without any discussion or warning. I was aware that an older patient who had entered surgery after me was discharged sooner, while I was still slowly regaining alertness, a contrast that reinforced the personal impact of even standard doses in my case.
When Efficiency Overrides Individualization
These two surgical experiences underscored a critical point: although protocols are designed for efficiency and general safety, they often fail to accommodate individual physiological differences. While medications are generally flagged as high risk for older adults or individuals with contraindications, less effort is typically made to identify younger patients who may also be vulnerable to adverse effects due to medication sensitivity. This oversight can result in preventable complications and prolonged recovery periods, issues that could be mitigated with more individualized assessment and planning.
Reflecting on the second procedure, I initially felt a sense of guilt for not having more explicitly refused opioids in advance. However, I had no reason to anticipate that hydromorphone would be administered automatically. I had assumed that communicating my sensitivity and the prolonged sedating effects I previously encountered would suffice. What I realized is that unless I explicitly enumerated each class of medication: anesthesia agents, benzodiazepines, opioids, anticholinergics, I remained vulnerable to a default approach that prioritized efficiency over personalization, an approach that may have inadvertently affected my recovery and overall well-being.
Recognizing Medication Sensitivity Across the Lifespan
While geriatric assessments have long emphasized the importance of identifying medication sensitivities, emerging research indicates that younger adults can also experience adverse drug reactions due to various factors, including genetic predispositions and polypharmacy. For instance, studies have shown that adverse drug reactions are not confined to older populations and that certain groups of younger adults, particularly those with chronic conditions, may be at increased risk (Menditto et al., 2019). Despite this, current protocols often lack standardized assessments for medication sensitivity in non-geriatric patients, leading to potential oversights in individualized care. Implementing routine evaluations that consider a patient’s complete medication profile, regardless of age, could mitigate risks associated with drug hypersensitivity.
Improving Documentation of Medication Risk in EHRs
The accurate documentation of medication sensitivities in electronic health records (EHRs) is crucial for ensuring patient safety and effective clinical decision-making. However, existing EHR systems often fall short in this regard. The American Academy of Allergy, Asthma & Immunology (AAAAI) has highlighted that current ‘allergy’ modules in many EHRs are inadequate, as they frequently conflate true allergic reactions with other adverse drug responses and lack standardized terminology (AAAAI, 2024). This lack of precision can lead to inappropriate prescribing and increased patient risk. To address these issues, the AAAAI recommends overhauling EHR allergy documentation practices, including the adoption of standardized nomenclature and improved clinical decision support tools. Such enhancements would facilitate more accurate recording of patient sensitivities and support clinicians in making more informed and appropriate prescribing decisions.
Final Reflections
This narrative extends beyond my personal experience. It underscores the importance of identifying subtle but meaningful mismatches between standard protocols and individual needs, mismatches that can leave even well-informed patients vulnerable. As board-certified psychologists, we are uniquely positioned to advocate for flexibility, attunement, and responsiveness across interdisciplinary care teams.
Our training in behavioral observation, patient communication, and systemic thinking positions us to identify and address these nuanced lapses in patient-centered care. What becomes of patients who do not know what hydromorphone is, or who cannot articulate that they remain overly sedated hours after administration? This account is offered in their service, and as a reminder to providers and systems of the importance of pausing, listening, and adapting when a patient says, “This is too much for my body.”
For those interested in improving their clinical practice or consultation, additional resources include the Narrative Medicine Program at Columbia and the Beryl Institute’s patient experience frameworks.
References
American Academy of Allergy, Asthma & Immunology. (2024). Position Statement on Changing Electronic Health Record Allergy Documentation. Journal of Allergy and Clinical Immunology: In Practice, 12(12), 3237-3241.
https://www.jaci-inpractice.org/article/S2213-2198%2824%2901051-1/fulltext
Menditto, E., Gimeno Miguel, A., Moreno Juste, A., Poblador Plou, B., Aza Pascual-Salcedo, M., Orlando, V., González Rubio, F., & Prados Torres, A. (2019). Patterns of multimorbidity and polypharmacy in young and adult population: Systematic associations among chronic diseases and drugs using factor analysis. PLOS ONE, 14(2), e0210701. https://doi.org/10.1371/journal.pone.0210701
Reeves, S., Shim, J. K., & Fins, J. J. (2021). Medically induced trauma: The unseen impact of adverse experiences in healthcare. The American Journal of Bioethics, 21(9), 26–28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8381543/
Michelle C. Hudson, PsyD, ABPP
Board Certified in Clinical Neuropsychology
Correspondence: hudsonmi@marshall.edu