WHAT’S IN A RECHECK?
And another way to say it, “The devil’s in the details.” May I
speak to the folks on your veterinary team who get the privilege of rechecking all of your cases that experienced the scalpel?
Hello. Your recheck job is essential. Remember all of the signage about essential workers during early COVID? Well, this job is essential. All of the warm fuzzies and goodwill generated from a successful surgical procedure will be forgotten and replaced with grumpy-face if postoperative complications develop…persist…go unaddressed…result in a crisis at 2am…remain unexplained. The “recheck” concept is thus essential—two days, two weeks, two months—whatever is a logical schedule for the procedure in question. Your recheck job is essential. Yep.
What are the components of a “recheck” that make it useful (and why)…rather than just a bothersome hoop to jump through in your day? As you are reading below, craft a template to plug into your medical record software. Filling in the blanks is SO much more efficient, thorough and fun. (Ok, fun is an overstatement…)
Quality communication and interpersonal connection between veterinary professionals and pet owners.
- Everyone wants to be seen, heard, cared about, to have someone in their corner…and I mean that without meaning to be too touchy-feely. It’s true. Who isn’t happier when they see a flicker of acknowledgement in the person you are standing across from?! When I am out of my element, I want an expert to hear my concerns, see what I am seeing and offer me support. Even when the stuff hits the imagined fan, I am soooo much better able to deal with it when I have that person/expert/team. You are the pet owner’s person/expert/team. Essential.
- Additionally, a little bit of “why” goes a LONG way with pet owners (and everyone, really) toward accepting the reality in front of them. The “why” must come with a confident delivery and be humble and honest. No shoveling the caca to obfuscate (love that word!) the situation when you have no clue. The “why” might be unknown to the veterinary profession, and that is OK, say that. But if the “why” is just unknown to you, that can be fixed with a little leg work.
Thorough and detailed inquiry into the history since last you met (i.e. discharge appointment or last recheck appointment/phone call).
- The change-over-time concept is absolutely crucial to prognostication for me. It is a diagnostic test in and of itself. Do I act on vomiting if it is less than yesterday…maybe not. Ask questions to uncover the change over time with all recheck topics.
- Steer away from accepting an interpretation by the pet owner and seek a description by the pet owner. Interpretations will get you in trouble. Let me say that again, interpretations will get you in trouble…every time. Think about a classic scenario of a patient coming out of anesthesia and experiencing emergence delirium (i.e not pain); flopping, vocalizing, drooling. Now imagine a client seeing that. “My god, my dog is in pain, help her!” That is an interpretation by the client; if you act on just the interpretation, you will be treating the wrong thing. Ask for the description…flopping, vocalizing 5min after stopping the isoflurane and removing the ET tube. Different treatment, most likely. (Hey, don’t nitpick my example here about pain/no pain! Just illustrating a point. 😊)
- Know what areas are of interest based on the anesthesia/surgical procedure. Ask open ended questions (avoid yes/no answers; instead “Tell me about…) to get at a good description, then hone in with more yes/no to flesh out the story.
Close observation (or request for description of owner’s observations by phone/email/photo) of the surgical site and region.
- Look from a distance and look up close. Touch the area to feel what is there to be felt. Observe the patient and observe the site/region. Don’t get tunnel vision to the incision and don’t be hands-off.
- Record, record, record. Knowing what things looked like, in detail, from 1-2wk before is crucial (see change-over-time concept above!!)
Identification of all deviations from typical/normal/expected.
- A little bit of homework is needed for this one. Knowing what is typical/normal/expected is important and makes you the expert the owners are seeking. So do your homework; a surgery textbook is a great place to start (there is always some “postop” and “prognosis” language in there); the medical
record notes can also be helpful (from an outside surgeon, for example 😊). Analysis of and plan for all deviations from typical/normal/expected.
- A little bit of research needed for this one. Ask your textbooks. Ask your colleagues. Ask your outside resources. Don’t be shy, don’t scrimp and “hope it will go away”. The plan might not be “do something”, rather “watch something”; but watching something must be very specific and proactive with criteria such as timeline; if this…then this…; “go to ER; no need to go to ER, come here next day”.
- Keep all team members informed. No surprises. “Yep, I saw that drainage last week, but I crossed my fingers and didn’t tell you.” (Insert image: top of my head popping off with a burst of steam.)
Communication about “what’s next?”
- Have you ever had a patient come in with sutures from a surgery they had 6mo ago? I have. My knee jerk is to say, “WTF; why didn’t the owners bring him/her in!! Sheesh!”. But then, I have also had the experience of talking with an owner and hearing “we thought the stitches would just dissolve.” So, at some level, no fault/blame, communication did not happen regarding “what’s next?”. Communication is the sum total of a conversation between more than one party. There is talking, there is listening, there is understanding…all need to happen with all involved. Again, no fault/blame; just make sure you are pulling your weight, controlling what you can control, in the communications.
Below are a couple of examples in template format. Tailor your rechecks to your clinic, your common procedures, and your level of desired interaction with owners.
CHECKLIST: 2-DAY PHONE CALL
Ask: How did the first night home go?
Ask: What questions do you have?
Prompts: Comfort Level-– Appetite? Resting ok?
Prompts: Bandage removal— Padded bandage remove when directed (see medical notes)
Prompts: Bruising– Any bruising noted when removing bandage? Location? Size of bruising (example: flip phone vs. smart phone vs iPad size)?
Offer: Alternating cold packs and heat packs for swelling/bruising Advise: Return for in-clinic postop recheck in 10 days.
Record: Add client info and questions to medical record and advise attending DVM.
CHECKLIST: 14-DAY RECHECK IN-CLINIC APPOINTMENT
History
Ask: What questions do you have? What concerns do you have? Prompts: Comfort level (Describe mobility?)
Prompts: Normal routine (Describe appetite, attitude?)
Prompts: Medication review (Tell me about current medications?) PE
Examine: Incision Health (Clean, quiet, dry vs moist, redness. If noticed bruising previously, has this resolved?)
Observe: Leg Use (Wanting to use leg/place paw in the ground vs. walking gingerly vs. 3-legged)
Plan
Advise: Moist incision abnormal→treat with topical antiseptic; send photos of incision in 2 days
Discuss: Physical Therapy (What is working? Any advice needed for a particular exercise?)
Schedule: Postop xrays (orthopedics); Blood tests (blood count, organ function); Diagnostic tests (monitoring tumor metastasis)
So there ya go. This “routine” concept of a recheck really is a high-level activity with wonderful ramifications done well and compounded disaster done poorly. Preventing just one dehiscence (guts on the ground) or one bandage complication (toes dropping off) or one undiagnosed orthopedic implant failure (irreparable malunion) in your career, and it is all worth it!
Go team! (Cheeze dog, I know )
Lara Marie Rasmussen, DVM, MS
Diplomate, American College of Veterinary Surgeons Direct Veterinary Surgery, PC
