2 questions....

[Guest guest]

Hello to all.

I have 2 questions. One is a business/professional relationship issue, the second is a clinical case issue.

1. I work in a multi-doctor practice, one of the veterinarians has a special interest in surgery. This works great for me because I have my own in-house referral potential. I've been brought in on many cases before surgery and had the opportunity to insert myself into case management from the beginning. I know that I'm being fairly conservative and safe with some of my protocols, but I'm still learning so I want to gradually improve my skills and comfort level by sticking with what I know at this point...work in progress. My question is this: The other day I got called in to consult on a case of a german shepard puppy with a sub-luxated hip from hip dysplasia. The owners had just noticed a lameness which sparked the radiographs. The surgeon brought me in to talk to the owner relative to setting up a post-op protocol after he had discussed an FHO.

I am uncertain how to approach this issue in-house because I would have preferred to have been given the option to try 6 months of rehab on this dog before giving the owner the option to do surgery...but the surgeon didn't give them that option, so I feel like I am over stepping my boundaries to talk the clients OUT of surgery. In addition I don't want to make the surgeon angry at the idea that I'm questioning his recommendations...because then my flow of post-op cases will also potentially dry up.

Any thoughts on how to approach this. I'm VERY impressed with the frequency that he pulls me in on cases because I had thought he would be initially opposed or at least skeptical, so I'm very protective of the relationship we are building, but he is still opinionated enough that I think if I outright suggest that this dog does not need surgery he will not be open to it.

My clinical question is relative to a lab that has a swolling at the insertion of the gastroc apparatus. The sheath palpates intact and there is no flexion of the hock independant of stifle flexion. I lasered the area and the surgeon applied a splint to protect the tendon from full rupture. What recommendations (aside from laser and stretching) does anyone have for rehab after the splint is removed. I have NO experience with injuries of the gastroc. tendon.

Thanks.

a

[Guest guest]

Hi a,

I haven’t seen any other responses

yet, so I am going to pitch in my 2 cents. First, regarding the surgeon’s

choice of surgery over rehab; The ONLY way to deal with this situation is

directly with the surgeon. You might ask him his thoughts (in a non judgmental

way) about his recommendation and then tell him that you think you could make a

difference in the pup’s life with rehab rather than surgery. If the

CF joint is subluxed, you probably will not be able to make much improvement,

even with aggressive rehab, adequan etc. I would ABSOLUTELY not talk to

the owners about alternatives to FHO, unless the surgeon asks you to speak with

them. If you speak to them about your personal recommendations you will

shoot yourself in the foot and will truly limit your ability to help other

patients. The surgeon will (rightfully) stop referring to you. The place

to make your case is with the surgeon, not with the owners.

As far as the gastrocs insertion pooch

goes… I finished rehabbing a similar case a few months ago. I did

use ultrasound to image the area to discern damage versus a rupture. You

might consider that. I did not splint, but used heat, then laser, then

ice several hours later for about 6 weeks. She completely resolved with a tiny amount

of firm dense scar tissue in the area and no lameness I will be curious

to hear about the surgeons ideas, I was opposed to splinting because I think

that taking the load completely off the tendon may actually weaken it. I also

rested my patient and used UWTM to wear her out a bit (german short haired

pointer) I rehabbed an Achilles tendon rupture/repair at the same time and used

the graded splint to add 2 mm flexion every few weeks over 6 months. I

will be interested to hear if others agree that splinting may exacerbate

weakness or if it would help.

Pam Nichols DVM, CCRP

From: VetRehab [mailto:VetRehab ] On Behalf Of a Grange

Sent: Monday, January 23, 2012

12:27 PM

To: VetRehab

Subject: 2

questions....

Hello to all.

I have 2 questions. One is a business/professional relationship

issue, the second is a clinical case issue.

1. I work in a multi-doctor practice, one of the veterinarians

has a special interest in surgery. This works great for me because I have

my own in-house referral potential. I've been brought in on many cases

before surgery and had the opportunity to insert myself into case management

from the beginning. I know that I'm being fairly conservative and safe

with some of my protocols, but I'm still learning so I want to gradually

improve my skills and comfort level by sticking with what I know at this

point...work in progress. My question is this: The other day I got

called in to consult on a case of a german shepard puppy with a sub-luxated hip

from hip dysplasia. The owners had just noticed a lameness which sparked

the radiographs. The surgeon brought me in to talk to the owner relative

to setting up a post-op protocol after he had discussed an FHO.

I am uncertain how to approach this issue in-house because I would have

preferred to have been given the option to try 6 months of rehab on this dog

before giving the owner the option to do surgery...but the surgeon didn't give

them that option, so I feel like I am over stepping my boundaries to talk the

clients OUT of surgery. In addition I don't want to make the surgeon

angry at the idea that I'm questioning his recommendations...because then my

flow of post-op cases will also potentially dry up.

Any thoughts on how to approach this. I'm VERY impressed with the

frequency that he pulls me in on cases because I had thought he would be

initially opposed or at least skeptical, so I'm very protective of the

relationship we are building, but he is still opinionated enough that I think

if I outright suggest that this dog does not need surgery he will not be open

to it.

My clinical question is relative to a lab that has a swolling at the

insertion of the gastroc apparatus. The sheath palpates intact and there

is no flexion of the hock independant of stifle flexion. I lasered the

area and the surgeon applied a splint to protect the tendon from full

rupture. What recommendations (aside from laser and stretching) does

anyone have for rehab after the splint is removed. I have NO experience

with injuries of the gastroc. tendon.

Thanks.

a

[Guest guest]

RE: 2 questions....

Hi a,

I haven’t seen any other responses yet, so I am going to pitch in my 2 cents. First, regarding the surgeon’s choice of surgery over rehab; The ONLY way to deal with this situation is directly with the surgeon. You might ask him his thoughts (in a non judgmental way) about his recommendation and then tell him that you think you could make a difference in the pup’s life with rehab rather than surgery. If the CF joint is subluxed, you probably will not be able to make much improvement, even with aggressive rehab, adequan etc. I would ABSOLUTELY not talk to the owners about alternatives to FHO, unless the surgeon asks you to speak with them. If you speak to them about your personal recommendations you will shoot yourself in the foot and will truly limit your ability to help other patients. The surgeon will (rightfully) stop referring to you. The place to make your case is with the surgeon, not with the owners.

Thanks, Pam. I am very careful with the owners to discuss only the issues related to pre or post op rehab when brought into a situation by the surgeon. I am very protective of the communications that I have with our colleagues and do my very best to stay in my lane when brought in to consult on a case. Even if the owner asks me if there is anything that can be done without surgery, I discuss that with the surgeon before addressing it with the client if it was his case before mine. I agree 100% with you on that.

As far as the gastrocs insertion pooch goes… I finished rehabbing a similar case a few months ago. I did use ultrasound to image the area to discern damage versus a rupture. You might consider that. I did not splint, but used heat, then laser, then ice several hours later for about 6 weeks. She completely resolved with a tiny amount of firm dense scar tissue in the area and no lameness I will be curious to hear about the surgeons ideas, I was opposed to splinting because I think that taking the load completely off the tendon may actually weaken it. I also rested my patient and used UWTM to wear her out a bit (german short haired pointer) I rehabbed an Achilles tendon rupture/repair at the same time and used the graded splint to add 2 mm flexion every few weeks over 6 months. I will be interested to hear if others agree that splinting may exacerbate weakness or if it would help.

How many times a week did you treat the lesion?

Pam Nichols DVM, CCRP

From: VetRehab [mailto:VetRehab ] On Behalf Of a GrangeSent: Monday, January 23, 2012 12:27 PMTo: VetRehab Subject: 2 questions....

Hello to all.

I have 2 questions. One is a business/professional relationship issue, the second is a clinical case issue.

1. I work in a multi-doctor practice, one of the veterinarians has a special interest in surgery. This works great for me because I have my own in-house referral potential. I've been brought in on many cases before surgery and had the opportunity to insert myself into case management from the beginning. I know that I'm being fairly conservative and safe with some of my protocols, but I'm still learning so I want to gradually improve my skills and comfort level by sticking with what I know at this point...work in progress. My question is this: The other day I got called in to consult on a case of a german shepard puppy with a sub-luxated hip from hip dysplasia. The owners had just noticed a lameness which sparked the radiographs. The surgeon brought me in to talk to the owner relative to setting up a post-op protocol after he had discussed an FHO.

I am uncertain how to approach this issue in-house because I would have preferred to have been given the option to try 6 months of rehab on this dog before giving the owner the option to do surgery...but the surgeon didn't give them that option, so I feel like I am over stepping my boundaries to talk the clients OUT of surgery. In addition I don't want to make the surgeon angry at the idea that I'm questioning his recommendations...because then my flow of post-op cases will also potentially dry up.

Any thoughts on how to approach this. I'm VERY impressed with the frequency that he pulls me in on cases because I had thought he would be initially opposed or at least skeptical, so I'm very protective of the relationship we are building, but he is still opinionated enough that I think if I outright suggest that this dog does not need surgery he will not be open to it.

My clinical question is relative to a lab that has a swolling at the insertion of the gastroc apparatus. The sheath palpates intact and there is no flexion of the hock independant of stifle flexion. I lasered the area and the surgeon applied a splint to protect the tendon from full rupture. What recommendations (aside from laser and stretching) does anyone have for rehab after the splint is removed. I have NO experience with injuries of the gastroc. tendon.

Thanks.

a

[Guest guest]

Hi a,

I was treating 3 times weekly… Pam

From: VetRehab [mailto:VetRehab ] On Behalf Of a Grange

Sent: Tuesday, January 24, 2012

1:23 PM

To: VetRehab

Subject: Re: 2

questions....

2 questions....

Hello to all.

I have 2

questions. One is a business/professional relationship issue, the second

is a clinical case issue.

1. I

work in a multi-doctor practice, one of the veterinarians has a special

interest in surgery. This works great for me because I have my own

in-house referral potential. I've been brought in on many cases before

surgery and had the opportunity to insert myself into case management from the

beginning. I know that I'm being fairly conservative and safe with some

of my protocols, but I'm still learning so I want to gradually improve my

skills and comfort level by sticking with what I know at this point...work in

progress. My question is this: The other day I got called in to

consult on a case of a german shepard puppy with a sub-luxated hip from hip

dysplasia. The owners had just noticed a lameness which sparked the

radiographs. The surgeon brought me in to talk to the owner relative to

setting up a post-op protocol after he had discussed an FHO.

I am

uncertain how to approach this issue in-house because I would have preferred to

have been given the option to try 6 months of rehab on this dog before giving

the owner the option to do surgery...but the surgeon didn't give them that

option, so I feel like I am over stepping my boundaries to talk the clients OUT

of surgery. In addition I don't want to make the surgeon angry at the idea

that I'm questioning his recommendations...because then my flow of post-op

cases will also potentially dry up.

Any

thoughts on how to approach this. I'm VERY impressed with the frequency

that he pulls me in on cases because I had thought he would be initially

opposed or at least skeptical, so I'm very protective of the relationship we

are building, but he is still opinionated enough that I think if I outright

suggest that this dog does not need surgery he will not be open to it.

My

clinical question is relative to a lab that has a swolling at the insertion of

the gastroc apparatus. The sheath palpates intact and there is no flexion

of the hock independant of stifle flexion. I lasered the area and the

surgeon applied a splint to protect the tendon from full rupture. What

recommendations (aside from laser and stretching) does anyone have for rehab

after the splint is removed. I have NO experience with injuries of the

gastroc. tendon.

Thanks.

a