State Politics

As Idaho’s ‘cowboy’ governor ages, experts say his surgeries carry more risks

Over lunch Monday, Gov. Butch Otter told Lt. Gov. Brad Little about the time a mule kicked former Gov. Cecil Andrus in the head during a hunting trip.

Otter was the lieutenant governor at that point. As the story goes, when Andrus got back to town, he joked that Otter got fitted for a new tuxedo in preparation to become governor should Andrus not return.

So, while Otter was in the hospital last month, did Little hightail it to a tailor?

“No, I did not get fitted for a tuxedo,” he told the Statesman.

While a lighthearted moment, Monday’s razzing hints at the true medical concerns regarding a sitting governor who has led an active life that has since affected his health.

Otter has required several surgeries in his decade as governor. Those have helped feed health rumors that have dogged him over the years — an irritation to him and his staff each time they arise.

People close to him say he’s in great shape, which helped him get through two surgeries and a related infection this summer. But his hospitalization and recovery time was the longest he’s ever been kept away from the governor’s office by surgery or illness. And because he’s 75, medical experts and studies suggest his hospital stays carry more risk.

Fortunate timing

On July 7, Otter underwent back surgery at Saint Alphonsus Regional Medical Center in Boise to treat a bulging disk. He went home the following day to recover, but after further evaluation, a second surgery was scheduled for July 14 to address the same disk.

He was released after the second surgery, but his fever spiked due to an infection, and he was readmitted the same day. He remained hospitalized in the intensive care unit for 10 days.

After leaving the hospital, Otter convalesced at home and worked from there for two weeks. He officially returned to the Capitol on Monday.

Otter was out for five weeks. To compare, he had hip surgeries in January 2008 and January 2015, each of which required two to three weeks of recovery time at home. In 2009 he had two shoulder surgeries. He also was hospitalized in April 2010 for a couple of days because of the flu.

Jim Weatherby, a Boise State University emeritus professor and political analyst, said he does not recall any other Idaho governor being out of office for such an extended period of time.

“This is significant. It is certainly cause for concern,” Weatherby said. “Whether or not it has affected his work in the office is not clear. It has postponed the interviews of the Supreme Court candidates, but I am not aware of any other major issue that has been held up as a result of these surgeries.” (Otter is weighing candidates to replace a retiring justice on the Idaho Supreme Court.)

The timing was fortuitous, Weatherby said. Had the Legislature been in session, the governor’s extended absence could have had more of an effect.

Also to Otter’s advantage is his management style, which Weatherby described as “similar to the Ronald Reagan style of decision-making.” Day-to-day operational issues are usually handled by staff, not the governor himself, Otter spokesman Jon Hanian said earlier this month.

“This governor, from almost the very beginning, is a less hands-on governor than some of our prior governors,” Weatherby said. “It has been his style to delegate considerable authority to his department heads and staff.”

Otter’s office declined requests for an extended interview with the governor, citing his need to catch up after five weeks out. But the Statesman was able to briefly talk to him as he prepared to preside over Tuesday’s Land Board and Board of Examiners meetings, among his first official duties he performed after returning to the Capitol.

“It feels great” to be back, Otter said. “The surgery really wasn’t the big deal. It was the infection.”

Otter said he and his doctors discussed the seriousness of the matter, but the situation never became grave enough for anyone to raise the possibility of stepping down.

He is not pain-free yet, he said, but “it is getting closer.”

“I am going to do exactly what my therapists tell me,” Otter said. “I am taking it easy. I am doing my physical therapy almost every day.”

And when will the governor be able to return to one of his favorite endeavors, riding horses?

“That will be a long time,” he said. “Maybe next spring.”

Risky business

Otter’s office could not provide certain specifics about the governor’s two surgeries, the subsequent infection or any other complications. But medical professionals have identified several risks that, given the governor’s age and what is known about his hospitalization, may apply now or in the future.

Age: Studies have shown that patients roughly 65 and older have a higher rate of postoperative complications due to the physiologic changes of aging and the stress of undergoing surgery, said Dr. Timothy Farrell, an associate professor and geriatrician with the University of Utah School of Medicine geriatrics division.

“If you have a robust 75-year-old, they may bounce back rather quickly,” Farrell said, “although there is a concept that older adults in general have less reserve in each organ system, so a robust 75-year-old would still, on average, take longer to recover than a robust 35-year-old.”

Postsurgery infection: The infection Otter developed was “significant and vigorous,” according to Hanian — but it’s not clear what type of infection Otter developed, other than it was at the site of his surgery.

Surgical-site infection is a significant complication at any age. Older patients with these infections had a death rate more than three times higher than other patients their age in research cited in the 2011 book, “Principles and Practice of Geriatric Surgery.”

“It is a different ballgame when you are talking about infections in internal organs or internal sites,” Farrell said.

The risk of acquiring an infection increases in older patients because they do not have the same degree of immune response, he said.

“What makes it really tricky in this population is a fever for an older adult is different than a fever for a younger adult,” he said. “The thresholds we use to define fever are a little bit lower. They may present not with classic signs of an infection but they may present by seeming to be a little bit off cognitively. It can be very challenging to pick this up.”

Readmission: Otter was readmitted to the hospital twice within a week of his first back surgery — once for the second back surgery and then later that day for the infection.

“We do not want people going home and then coming back to the hospital,” Farrell said.

“In general, hospitals can be dangerous places for older adults because just by being in the hospital generally increases your risk of delirium. For example, you are largely immobilized, you do not have the same sleep/wake cycle, you’re at risk of falls, risk of infection.

“We try to avoid multiple re-admissions, not because of cost, but because of patient outcomes.”

Other concerns: There are various other risks to older adults who undergo surgery. One example is general anesthesia — the aging brain is more vulnerable to it, according to the American Society of Anesthesiologists, and it can cause short-term delirium or longer-term cognitive problems. Otter underwent general anesthesia in both his July 7 and July 14 surgeries; there’s been no word that it played a role in his complications.

‘A real cowboy’

When it comes to reputations, Otter’s can be summed up in one word: tough. The governor’s doctors agreed that “had he not been in the health he was in, this would have been a lot more serious,” Little said, according to what Otter told him.

Skip Smyser, a longtime friend, called Otter “one of the toughest individuals I have ever known.”

Said Smyser: “He has had shoulder surgeries, hip surgeries and he has broken more bones than I could even enumerate. The guy is amazing.”

Otter may have met his toughest challenge yet in that infection.

“All of his friends and family were incredibly concerned because that was a pretty dadgummed bad infection,” Smyser said. “But I had no doubt that he would be back. He is a real cowboy.”

Little concurs.

“I would guarantee that if you had lined up all the 75-year-olds around the state a couple months ago and would have given them a physical, Butch Otter would have been in the top (10 percent),” Little said.

Of the infection, Little said: “I think it is because Butch is in such good shape, his body was able to tolerate it, which is a good lesson to all of us to take good care of ourselves.”

Term nears its end

After another year and a half, Otter will no longer be governor. Now in his third term, he doesn’t plan to seek a fourth.

Will he face more surgeries before his term is up? Asked whether his doctors have talked about future procedures, he said, “we haven’t gone there.”

Little, 63, is running to replace his boss, which gives him a full plate — performing his lieutenant governor duties and, if needed, acting governor duties, along with campaigning around the state. His main competitors for the GOP nomination, Raul Labrador and Tommy Ahlquist, will both turn 50 within the next year.

While being acting governor is nothing new for Little, this year and the next are different. During those four days in July, he was effectively serving as governor while campaigning for governor.

Little said he is very cognizant of those “optics.”

“You’ve got to compartmentalize things,” he said. And his responsibilities as an elected official will always come before campaigning, he said, especially when he’s filling in for Otter.

“I feel like it is an honor to be acting governor,” he said. “You should not politicize it. I know that when I become governor I do not want my lieutenant governor to politicize it.”

Little also wants to dispel any rumors that Otter might resign and install Little as the incumbent in time for the election.

“We have never had that conversation. I fully expect, and I’ve got every indication, the governor is going to go clear to the end of his term,” he said. “It has never been talked about between the governor and myself or the governor’s staff and myself.”

Cynthia Sewell: 208-377-6428, @CynthiaSewell

Filling in for the governor

Every year since he was in Congress, Gov. Butch Otter has held an annual horseback trail ride, bringing federal decision-makers together with ranchers and other Idahoans to discuss issues ranging from endangered species to fire and logging.

This year, since Otter was undergoing back surgery, Lt. Gov. Brad Little led the ride, which took place July 18-20 near the Montana state line.

While Little was on this trip — out of cellphone range and without a satellite phone — the governor’s office had to send someone out on the trail to notify him that he was acting governor because of Otter’s infection.

Whenever Idaho’s governor goes out of state or is temporarily unable to perform his duties, an acting governor must be officially designated. Under Idaho law, that task goes to the lieutenant governor, followed by the Senate pro tem and the House speaker, historian Marty Peterson explained.

Little has been acting governor on 400 days since first taking the lieutenant governor job in 2009. He served the most in 2013, at 64 days; and the fewest the following year, at 20 days.

So far this year, Little, 63, has been acting governor 38 days, including four days last month while Otter was undergoing surgery or otherwise heavily medicated. And even when he wasn’t formally in the role this summer, he assumed some of the governor’s duties because Otter physically could not. Those included the trail ride and presiding over an Aug. 11 “Capital for a Day” in Stanley.

Typically, the governor knows in advance when he is going to be out of state and needs an acting governor, even if it is just to go to Ontario for a one-hour meeting. (Yes. That requires an acting governor.)

“Ninety-five to 99 percent of the time, Butch comes to me and says, ‘I am going to be gone,’ ” Little said.

It’s that small remaining chance of serious illness, accident or other crisis that in effect, puts the lieutenant governor always on call — something Little said he has been cognizant of ever since taking the job.

The pair “have demonstrated very well the ability to transition the executive role back and forth when necessary, whether for health matters or out-of-state travel,” said Justin Vaughn, co-director of the Center for Idaho History and Politics at Boise State University.

“I took it seriously that if something happened I had to be ready,” Little said. “I understand the magnitude of the job, that is why over the entire period I have been more or less a full-time lieutenant governor even though the job isn’t that way.” (Idaho’s lieutenant governor position is part time, paying $43,552.60. All other elected state officials make six figures.)