Make sure you have a solid before and after plan when planning for an elective–scheduled surgery.

The who, what, when and where all need to be carefully planned.  Who will help with the immediate additional post surgery care?  What are the requirements (bed downstairs; medications etc.) ? When and How long will the additional care be needed?  In our case, we didn’t have a great plan and wound up in a scramble.

We were in crisis mode after George’s surgery.  I questioned George’s doctors about the struggles we faced. We did not have a sound after-surgery care plan.  The doctors reminded me that the surgery was “elective.”  “He wanted it,” was the retort from the surgeon when I brought up the struggles we faced once George came home.

So, I wondered, was the surgery necessary?  Why did the surgeon give such a defensive response to my concerns? Elective surgery doesn’t necessarily mean optional; it means it can be scheduled in advance.

Our situation

In our case, George would be home alone post surgery.  I lived 40 miles away in Manhattan and his family lived 20 minutes away.

Protip: Put together your own Plan in writing and review it with your family and the surgeon and your primary care physician. Make sure you are not missing any of the details. The nurses are the best health care providers to consult and ask them to review your plan to make sure you haven’t left out a vital part of the plan.

That Autumn, I was living on the upper west side of Manhattan. Friends were away for a number of weeks and offered their place. George and I were separating after a 20+ year marriage. George decided to have knee replacement surgery In the middle of all of this change. To compound the concerns, he was taking an incredible amount of psychiatric medications and struggling with an anxiety disorder– (more about the mental health and addiction issues in upcoming posts). Stating the obvious, there were more than the daily dose of life’s stressors at play.  Now we were adding the need for care after a major operation–namely knee replacement surgery.

So, George would be left to care for himself with some intermittent help. This was made clear to the surgeon and his team and they didn’t see an issue. “I have plenty of patients that live alone.” the surgeon told me when I mentioned that George living alone was a big concern.

Watch out for medical-specialist tunnel vision

What the surgeon didn’t take into consideration was George’s  underlying mental health issues and the medication management that would be necessary after-surgery.  Because George had other medical and mental health issues, I  wanted to hink through the after-surgery game plan.

Protip: If you have other health issues, make sure they are considered when planning a surgery for an unrelated condition. Don’t assume that the surgeons are connecting all the dots. Proactively have these conversations and include your primary care physician–you can even ask them to help coordinate the conversations to make sure you are getting a full view of your situation.

A knee replacement is a big surgery.  I hoped his healthcare team was thinking through all the angles when it came to the after-surgery care.  How would George manage his anxiety disorder and those medications and pain medicine all on his own? My assumption was his healthcare team had him covered.

When I questioned the after-surgery care plan, these orthopedic surgeons said: “but the surgery was elective.”  I still get upset when I remember their response.

So, when you are in a situation where the surgery is necessary but can be scheduled–elective–have the right conversations and agreements in writing as to the AFTER surgery plan for care–especially when there are other physical and mental health issues at play.

Have an after-surgery care plan

Have the after-surgery-care-plan conversations long before the surgery is scheduled.  You could wind up in a crisis-mode as we did, which is not a pleasant place to find yourself. After-care for a  major surgery like a knee replacement is hard. If your loved one has complicated, co-occurring issues, either emotional, psychological, physical or all of the above—take heed to really think things through with your surgeon and primary care provider. I can guarantee that the surgeon and his team will not bring up any of these issues proactively.

Protip: Talk over with the surgeon or his staff all of the options for after-surgery care.  Bring up  what you believe is right for your situation.  Figure out together how to ensure you get to that end-goal long before you check-in for the surgery.  In our case, we preferred 5-days of in-patient rehab because of other underlying medical conditions.  Be sure to advocate for your preferred option in advance. Make sure to document these conversations in your chart. Also directly alert the hospital team.  Do not assume that the the communication will take place. When it comes time for discharge, you will need to advocate for your preferred plan with the hospital/surgery centers.  Start talking about the discharge plan from the moment you arrive.

I did not go with my husband to the surgery his brother did.  I asked my brother-in-law to be clear with the doctor and the nurses: George lives alone and has noone to help him after-surgery.  He has a lot of medication to manage along with the powerful pain medicine for the after-surgery pain.  He needs to negotiate the 13 stairs to his bedroom.

Before-surgery red flags

George had fallen down that same flight of stairs a month before. That fall caused a one- month delay in the surgery because of open scrapes and cuts on his legs. Although he had contusions on his head and a black eye, neither the primary care doctor nor the surgeon ordered an MRI of his head. I saw him a couple of days after the fall.  He looked bad.  I was scared for him.  He seemed confused and I asked if he had seen the doctor.  He had seen both doctors and neither saw the fall as a red flag  (a fall is a risk factor for another fall) . They cleared him and rescheduled the surgery.

It was a baffling set of decisions. I sat amazed that this was going forward.  This after all is elective surgery not a matter of life or death.  As mentioned, the surgeon played back: “He wanted it” more than once.  (By the end of it all he agreed “we had our hands full”).  I wonder if the orthopedist ever understood that he needed to take into account George’s other health and mental wellness issues when scheduling the surgery.

Protip: The doctors will not always see what’s in front of them. In our case, they believed George’s explanation, that he had tripped over his cat while coming down the stairs. They did not see it as a red flag for something deeper.  If you suspect something deeper is going on with a loved one, be insistent with the healthcare team.   We could have avoided some of our crisis with earlier advocacy and insistence on other tests.  Later in George’s recovery, we became more insistent thanks to the coaching of other providers on our team.  Once we did insist on taking a  deeper look, it  paid off–but took time.

Planning for after-surgery care 

A week or so before the surgery, I called the surgical coordinator to reiterate my concerns regarding after-surgery care for George.  I asked them to release George to a rehab center for five days post-surgery instead of to home with homecare.  I  listed our reasons:

1- fallen down a flight of stairs the month before, therefore, was at risk for falls

2-lived alone and had no one to stay with him

3- taking very high doses of powerful psychiatric  medications and seemed confused

4- would need to manage  his powerful psych meds, which he had to take multiple times a day (Seroquel and Xanax) PLUS opioids for pain following the surgery

5-how could he manage all of this?

I reiterated our deep concerns as a family.  I again asked to place our request for after-surgery care in a rehab facility into his chart. We knew that this was an option that insurance would cover provided that the doctor ordered it.   Craving a written record, a paper trail of these conversations,  I composed long text messages to create  a record of our conversations and my concerns.  It is impossible to get an email address and the practice did not have a patient portal system.  The surgical coordinator was careful to stop answering my text messages as things progressed during the time of George’s aftercare.

I realized George’s surgeons and their staff labeled me as “difficult.”

Have the conversation face-to-face

During our call, the surgical coordinator  assured me that the nurses on the floor would monitor him. If  he did not follow directions, he would go to a rehab and not home. I implored her to write this in his chart. The doctor and the discharge coordinator needed to know our strong concerns and real risks.  I am not sure if any of this documentation happened.

Of course, what none of these providers  took into account were the dangers waiting at home in the form of bottles of powerful psychiatric medications that would need to be taken as directed by a very shaking after-surgery George.  They only focused on the knee. If the knee looked good and he got around with the prescribed walker, then off to home.

Protip: Have the after-surgery care conversation face-to-face with your surgeon and the surgical coordinator present.  In our case, I had these conversations over the phone and via text messages.  I thought I was doing the right thing.  But to really have an impact, and create a game-plan, have a face-to-face conversation (can be a video-conference) and outline expectations and concerns.  Bring your primary care physician into the equation if your concerns continue to go unheard.  In our case, we trusted in the system to do the right thing, and not all of the variables were taken into account.

What’s in the electronic medical record (EMR)? Be sure it is accurate. 

Here’s how.

During this conversation, I also asked the surgical coordinator if she had a record of the powerful psychiatric medications and dosages that George was taking.  I thought for sure that the dosages of these medications would be a red flag to the healthcare team.  After all they were to me and I was a “lay” person.

“Yes,” she responded,  “we are aware of all of his medications.  They are in his electronic medical record.”  She sounded confident.   I exhaled.  “Okay, they are aware and monitoring him,”I thought to myself.  Short-lived relief I am sorry to say.  Days after his discharge, we learned the dosages listed in the electronic medical record (EMR) were incorrect.  They got the information from George.  He provided the information on dosage from a faulty, foggy memory. In his case, he was at great risk, when those medications were not given in the correct dosages.

Protip: When a healthcare practitioner says the medications are reflected in the electronic medical record (EMR), ask if they got the list of medicines and doses from the prescribing healthcare provider or the dispensing pharmacy.  If the patient provided the information from memory; the information could be incorrect. Accuracy is critical.

She said that everything was in the EMR with so much conviction. I assumed a doctor-to-doctor communication.  I assumed the record was accurate.   I was wrong.

Protip: If you or a loved one is taking multiple medications, be sure to go to one pharmacy for all of your medications.  This way there is a centralized source for medication information in case of an emergency or for an elective surgery, like in our case. The pharmacy will ensure that everything you are taking including vitamins and supplements are in the system.  If there is ever the need for someone to get a list of those medications and dosages, the pharmacist can provide the accurate information in minutes.

Our discharge disaster

I spoke to my brother-in-law and encouraged him to advocate for the rehab center vs discharge to home with homecare.  Easier said than done.

When we walk into a healthcare facility, we expect that everything will be done through the lens of the patient’s best interests. What we learned is that the only way for the care providers to have a true 360-degree view is through a lot of communication and self advocacy.  Self-advocacy can be a critical component in getting appropriate care.

When the white-coated doctor arrived to announce the discharge to home, no questions asked.  My brother-in-law and George accepted the decision without additional questions.  Our family had to live with the consequences of that decision in the months that followed.

Protip: When you arrive at the hospital or surgery center, be sure to discuss the plans for discharge from the first moments. Get to know the discharge planner and reiterate the conversations with your surgeon and the surgeon’s surgical coordinator. Assuming that the communication is flowing between the two groups is not always an accurate one.  In our case, we assumed wrongly.