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.
In our case, George would be home alone post surgery. I lived 40 miles away in Manhattan and his family lived 20 minutes away.
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.
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.
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.
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.
What’s in the electronic medical record (EMR)? Be sure it is accurate.
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.
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.
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.