Because we all hate OB at some point...

[soonerfrog]

I know there's already been a pseudo topic/thread about this but I'll revisit because frankly sometimes this OB gig is just a bunch if voodoo. 39wk multip (G4, P3) in active labor, no SROM, dilated 3/25%. She asked for some metal in her back. Easy enough: Uneventful epidural, followed 3 hrs later by quick, uneventful vag delivery. Fast fwd next AM. Pt c/o after epidural wore off: severe back pain at site and right leg motor deficits and pain with movement. No paraethesias, no hypoaeshesia, no other sensory deficits like temp, ect. Only able to partially wt bear. Pt afebrile. MRI to r/o abscess or hematoma comes back, wait for it, stark raving negative. Started gabapentin, steroids, and some PT. Fast fwd 3 days later: still no improvement. Pt not worse but not better. Still limited motor with extreme pain with movement. Lying in bed, she's happy. Up and at em, she's in tears. Still weak plantar/dorsiflexion. No foot drop. Labor epidural was as benign as possible. Thoughts?

---

Members don't see this ad.

 

[Planktonmd]

I know there's already been a pseudo topic/thread about this but I'll revisit because frankly sometimes this OB gig is just a bunch if voodoo. 39wk multip (G4, P3) in active labor, no SROM, dilated 3/25%. She asked for some metal in her back. Easy enough: Uneventful epidural, followed 3 hrs later by quick, uneventful vag delivery. Fast fwd next AM. Pt c/o after epidural wore off: severe back pain at site and right leg motor deficits and pain with movement. No paraethesias, no hypoaeshesia, no other sensory deficits like temp, ect. Only able to partially wt bear. Pt afebrile. MRI to r/o abscess or hematoma comes back, wait for it, stark raving negative. Started gabapentin, steroids, and some PT. Fast fwd 3 days later: still no improvement. Pt not worse but not better. Still limited motor with extreme pain with movement. Lying in bed, she's happy. Up and at em, she's in tears. Still weak plantar/dorsiflexion. No foot drop. Labor epidural was as benign as possible. Thoughts?

When you say pain with movement is that pain in the back at the insertion site or pain in the leg?
If the pain is a sciatica type pain then it might be injury to the sciatic nerve during the delivery caused by excessive flexion of the thigh.
I have seen nurses pushing the thigh excessively backwards on parturients since the epidural is usually masking the pain and decreasing the muscle tone.
The good news is that these injuries are usually just stretch injuries and they improve in a few weeks.
I would get a neurology consult and possibly nerve studies but if truly she has pure motor deficit as you said and no sensory deficit then this makes no sense and it can't be related to your epidural.

 

[pgg]

When you say pain with movement is that pain in the back at the insertion site or pain in the leg?
If the pain is a sciatica type pain then it might be injury to the sciatic nerve during the delivery caused by excessive flexion of the thigh.
I have seen nurses pushing the thigh excessively backwards on parturients since the epidural is usually masking the pain and decreasing the muscle tone.
The good news is that these injuries are usually just stretch injuries and they improve in a few weeks.
I would get a neurology consult and possibly nerve studies but if truly she has pure motor deficit as you said and no sensory deficit then this makes no sense and it can't be related to your epidural.

First post nails it. This is surely sciatic stretch injury from an overzealous helper during delivery. Agree with calling neuro. OB will blame the epidural, if they haven't already.

Maybe even an education opportunity for the L&D nurses.

 

[fakin' the funk]

Pt c/o after epidural wore off: severe back pain at site and right leg motor deficits and pain with movement. No paraethesias, no hypoaeshesia, no other sensory deficits like temp, ect. Only able to partially wt bear. Pt afebrile. MRI to r/o abscess or hematoma comes back, wait for it, stark raving negative.

And you didn't get a neurology consult...why?

 

[soonerfrog]

Would normally agree with stretch injury, in fact I had exhaustively discussed this with pt and OB who, surprisingly, are both reliable. Vag delivery was quick, 4 -5 pushes, no crazy flexion of the pelvis. This seems unlikely in this scenario even though I REALLY want it to be the root cause.

 

[soonerfrog]

She's being shipped to larger tertiary center today for Neuro consult (we're kinda in the stix). I'm dying to see what EMG studies show in the future if she doesn't improve.

 

[fakin' the funk]

She's being shipped to larger tertiary center today for Neuro consult (we're kinda in the stix). I'm dying to see what EMG studies show in the future if she doesn't improve.

It doesn't matter what EMG shows, this problem is not due to the epidural.

The fact you're even thinking that it could be due to the epidural shows you are concerned about the patient's outcome and keeping an open differential diagnosis, something your other colleagues (it sounds like) aren't.

Maybe anesthesiologists are too genial in this type of scenario. Maybe we should be throwing our colleagues under the bus like every other specialty does.

 

[gasp]

I know there's already been a pseudo topic/thread about this but I'll revisit because frankly sometimes this OB gig is just a bunch if voodoo. 39wk multip (G4, P3) in active labor, no SROM, dilated 3/25%. She asked for some metal in her back. Easy enough: Uneventful epidural, followed 3 hrs later by quick, uneventful vag delivery. Fast fwd next AM. Pt c/o after epidural wore off: severe back pain at site and right leg motor deficits and pain with movement. No paraethesias, no hypoaeshesia, no other sensory deficits like temp, ect. Only able to partially wt bear. Pt afebrile. MRI to r/o abscess or hematoma comes back, wait for it, stark raving negative. Started gabapentin, steroids, and some PT. Fast fwd 3 days later: still no improvement. Pt not worse but not better. Still limited motor with extreme pain with movement. Lying in bed, she's happy. Up and at em, she's in tears. Still weak plantar/dorsiflexion. No foot drop. Labor epidural was as benign as possible. Thoughts?

Of course you should be concerned about the Pt since she was at some time yours. However, I do not think her symptoms are due to your epidural. Neuro consult sounds good. Other specialties are always looking to blame anesthesia for everything but the truth will eventually prevail. She probably has Sciatic/common peroneal injury from stretching/lithotomy position during delivery.

 

[dotcb]

I bet the work-up will be negative and the patient will have full resolution of symtoms within a few weeks, or persistent mild symptoms w/ no clear etiology.

At worst it's a nerve root neuropraxia that should improve. Not your fault.

 

[Random Anesthesiologist]

When you say pain with movement is that pain in the back at the insertion site or pain in the leg?
If the pain is a sciatica type pain then it might be injury to the sciatic nerve during the delivery caused by excessive flexion of the thigh.
I have seen nurses pushing the thigh excessively backwards on parturients since the epidural is usually masking the pain and decreasing the muscle tone.
The good news is that these injuries are usually just stretch injuries and they improve in a few weeks.
I would get a neurology consult and possibly nerve studies but if truly she has pure motor deficit as you said and no sensory deficit then this makes no sense and it can't be related to your epidural.

Anecdotal, but this type of pain happened to me after I had my son. I also had some sciatica prior to delivery so I pretty much knew this was the culprit. I was curled around my belly and lithotomied as you can get during delivery (sorry if tmi). I would have married my anesthesiologist after my epidural if I wasn't already married. Went away completely by 3-4 months postpartum.

 

[caligas]

classic lumbosacral plexus injury from labor, resolution in a few weeks to months.

 

[Doctor4Life1769]

Anecdotal, but this type of pain happened to me after I had my son. I also had some sciatica prior to delivery so I pretty much knew this was the culprit. I was curled around my belly and lithotomied as you can get during delivery (sorry if tmi). I would have married my anesthesiologist after my epidural if I wasn't already married. Went away completely by 3-4 months postpartum.

I get these proposals all the time.

 

[Random Anesthesiologist]

I get these proposals all the time.

it really is a wonderful thing!

 

[Planktonmd]

Would normally agree with stretch injury, in fact I had exhaustively discussed this with pt and OB who, surprisingly, are both reliable. Vag delivery was quick, 4 -5 pushes, no crazy flexion of the pelvis. This seems unlikely in this scenario even though I REALLY want it to be the root cause.

How many "pushes" does it take to stretch the sciatic nerve?

 

[Doctor4Life1769]

it really is a wonderful thing!

seeing the husband's reaction = priceless.

in my mind, i assure them that i wont no part in the responsibility of the baby currently in the womb.

 

[Planktonmd]

Anecdotal, but this type of pain happened to me after I had my son. I also had some sciatica prior to delivery so I pretty much knew this was the culprit. I was curled around my belly and lithotomied as you can get during delivery (sorry if tmi). I would have married my anesthesiologist after my epidural if I wasn't already married. Went away completely by 3-4 months postpartum.

Thanks for the input... your case is actually very common

 

[soonerfrog]

Just FYI, Neuro thinks its Piriformis Syndrome. Seems reasonable. Doesn't change my love-hate affair with OB.

 

[jetproppilot]

When you say pain with movement is that pain in the back at the insertion site or pain in the leg?
If the pain is a sciatica type pain then it might be injury to the sciatic nerve during the delivery caused by excessive flexion of the thigh.
I have seen nurses pushing the thigh excessively backwards on parturients since the epidural is usually masking the pain and decreasing the muscle tone.
The good news is that these injuries are usually just stretch injuries and they improve in a few weeks.
I would get a neurology consult and possibly nerve studies but if truly she has pure motor deficit as you said and no sensory deficit then this makes no sense and it can't be related to your epidural.

Plank is SPOT ON

 

[soonerfrog]

Plank is usually spot on. Thx guys.

 

[Oggg]

http://jvsmedicscorner.com/Anaesth-Obstetrics_files/Neurologic Deficits and Labor Analgesia.pdf

P347: Lumbosacral Plexus, Sciatic, and Peroneal Nerve Injury

 

[ear-ache]

Some more Cynthia Wong literature.... She's pretty much the big-dog of OB anesthesia

A. Wong, C. (2003). Incidence of postpartum lumbosacral spine and lower extremity nerve injuries. Obstetrics & Gynecology, 101(2), 279–288.

"Results
Six thousand fifty-seven women delivered live-born infants; 6048 were interviewed and 56 had a confirmed new nerve injury, an incidence of 0.92%. Factors found by logistic regression analysis to be associated with nerve injury were nulliparity and prolonged second stage of labor. Women with nerve injury spent more time pushing in the semi-Fowler–lithotomy position than women without injury. The median duration of symptoms was 2 months.

Conclusion
The estimated incidence of postpartum nerve injury was greater than reported from previous studies and is associated with nulliparity and prolonged second stage of labor."

i.e. - neuraxial analgesia was NOT a found to be a factor

 

[Yo GabbaPentin]

How many "pushes" does it take to stretch the sciatic nerve?

And whoever can answer this question just HAS to know how many licks it takes to get to the center of a tootsie pop.

 

[Planktonmd]

and whoever can answer this question just has to know how many licks it takes to get to the center of a tootsie pop.

 

[cincincyreds]

I know there's already been a pseudo topic/thread about this but I'll revisit because frankly sometimes this OB gig is just a bunch if voodoo. 39wk multip (G4, P3) in active labor, no SROM, dilated 3/25%. She asked for some metal in her back. Easy enough: Uneventful epidural, followed 3 hrs later by quick, uneventful vag delivery. Fast fwd next AM. Pt c/o after epidural wore off: severe back pain at site and right leg motor deficits and pain with movement. No paraethesias, no hypoaeshesia, no other sensory deficits like temp, ect. Only able to partially wt bear. Pt afebrile. MRI to r/o abscess or hematoma comes back, wait for it, stark raving negative. Started gabapentin, steroids, and some PT. Fast fwd 3 days later: still no improvement. Pt not worse but not better. Still limited motor with extreme pain with movement. Lying in bed, she's happy. Up and at em, she's in tears. Still weak plantar/dorsiflexion. No foot drop. Labor epidural was as benign as possible. Thoughts?

There are a lot of people out there who are looking for money. The economy is bad and I've seen a few of these bs lawsuits. Luckily we have unlimited liability and get judged by a jury of our peers, i.e. the general public.

 

[olaf]

Man I want a Pliny the elder now

 

[deleted682700]

Apart from neuro consult, get the psych involoved. What is the secondary gain? May be she has a few little ones at home and the good for nothing husband is late on child payments, and of course post partum, depression.
It's not from epidural. We need to put the other specialists in their place and educate them.

One time a medical students wife was deliveringwith the best obgyn in town. The most senior anesthesiologist placed the epidural. Everything seemed fine in the evening. The next morning heard the baby died. They conveniently blamed the anesthesiologist. He was from Taiwan and English was not his mother tongue. I was new to anesthesia and got scared after coming to know of this, went to my anesthesia boss to get the scoop.

Postpartum of the baby and placenta showed chorioamnionitis. There was never a law suit, but the memory is etched with cases. Now if a baby has questionable variables and the regular nurses are good at identifying those, I reserve my right to refuse epidural service, till they can figure out the FHR tracing.

 

[pgg]

Now if a baby has questionable variables and the regular nurses are good at identifying those, I reserve my right to refuse epidural service, till they can figure out the FHR tracing.

Wait, what?

When you're doing OB, you delay/decline anesthetic services if the RN thinks variables are, what, funky?

 

[deleted682700]

Yes I want the obgyn to come at 2 am in the morning and have that for reviewed, before I do my epidural. If there were any questions raised. Sometimes I hear this from the obstetricians, the fetal heart rate is not reassuring so I don't feel comfortable giving I'v opioids. My response if you are uncomfortable giving I've opioids and then u want me to take care of the pain with epidural?
I do not trust the judgement of the obgyn.

 

[22031 Alum]

Yes I want the obgyn to come at 2 am in the morning and have that for reviewed, before I do my epidural. If there were any questions raised. Sometimes I hear this from the obstetricians, the fetal heart rate is not reassuring so I don't feel comfortable giving I'v opioids. My response if you are uncomfortable giving I've opioids and then u want me to take care of the pain with epidural?
I do not trust the judgement of the obgyn.

You know variable decels come from transient cord compression, right?? I'm not one of those who thinks an epidural is a god-given right, but to deny services based on an RN's strip interpretation strikes me as crazy town.

 

[WholeLottaGame7]

Yes I want the obgyn to come at 2 am in the morning and have that for reviewed, before I do my epidural. If there were any questions raised. Sometimes I hear this from the obstetricians, the fetal heart rate is not reassuring so I don't feel comfortable giving I'v opioids. My response if you are uncomfortable giving I've opioids and then u want me to take care of the pain with epidural?
I do not trust the judgement of the obgyn.

They probably don't like giving IV opioids for morbidly obese women with sleep apnea, also. Does that mean you wouldn't put an epidural in that patient, either?

The OB's willingness or unwillingness to give IV opioids has no bearing whatsoever on whether we place an epidural.

In the scenario you've given, if anything I'd be more inclined to push that patient towards an epidural in case you have to stat section her for non-reassuring FHR.

 

[PainDrain]

I reserve my right to refuse epidural service, till they can figure out the FHR tracing.

If the FHR looks questionable that is certainly not a reason to deny an epidural. If anything I would place the epidural so atleast you have something in the event you head to section. Atleast then you aren't fumbling around doing a spinal at the last minute. Just bolus the cath while wheeling back and she will have a level by the time the prep is dry and they are ready to cut.

 

[deleted682700]

I agree, if it's a morbidly obese pt, I'd like to have the epidural early, however when the fetal strip is questionable and with history of thick mec, do you wait for the baby to magically descend down without any problem after the mother has labored sufficiently longer, just because they don't want their csections rates to be high?

If there is a problem strip and the obstetrician is hesitating to give opioids, I want the baby out. I am not sitting with an epidural on the top of a questionable strip and give more ammunition to the lawyer. Whether it is related or incidental, I practice cya anesthesia.
If it's stat stat, and am confident of the airway, will do general

 

[IveGotTwins]

I agree, if it's a morbidly obese pt, I'd like to have the epidural early, however when the fetal strip is questionable and with history of thick mec, do you wait for the baby to magically descend down without any problem after the mother has labored sufficiently longer, just because they don't want their csections rates to be high?

If there is a problem strip and the obstetrician is hesitating to give opioids, I want the baby out. I am not sitting with an epidural on the top of a questionable strip and give more ammunition to the lawyer. Whether it is related or incidental, I practice cya anesthesia.
If it's stat stat, and am confident of the airway, will do general

If it's "stat stat" and you're not confident of the airway what do you do? Push prop/sux and hope the VL is good enough? Tell them to hold on while you place spinal? Get bronch cart for fiberoptic?

 

[WholeLottaGame7]

I agree, if it's a morbidly obese pt, I'd like to have the epidural early, however when the fetal strip is questionable and with history of thick mec, do you wait for the baby to magically descend down without any problem after the mother has labored sufficiently longer, just because they don't want their csections rates to be high?

If there is a problem strip and the obstetrician is hesitating to give opioids, I want the baby out. I am not sitting with an epidural on the top of a questionable strip and give more ammunition to the lawyer. Whether it is related or incidental, I practice cya anesthesia.
If it's stat stat, and am confident of the airway, will do general

I'm not sure what you're getting at with the first paragraph. But in general, I prefer to let the OBs do their job and let me do mine. If they feel like mom can labor longer, that's their call. If they feel like the baby needs to come out now, again that is their call. I will communicate with them if there is a safety issue (i.e., how "stat" is this case in a 400lb woman with a c-spine fusion and full stomach who just rolled in the door), but they're the mom/baby experts.

I've never heard of an anesthesiologist getting nailed for having an appropriate epidural running in an appropriate patient. Can you be named in a lawsuit if something bad happens to the baby? Sure, but you can be named for just putting your head in the door. If you're really that worried about opioids, why don't you just run a local-only epidural? Won't work quite as well, but will be a hell of a lot better than all of your stat C-sections getting GAs.

If you have an epidural running and the baby starts developing non-reassuring FHT, do you pull the epidural and GA the mom for the C-section?

 

[IlDestriero]

I agree, if it's a morbidly obese pt, I'd like to have the epidural early, however when the fetal strip is questionable and with history of thick mec, do you wait for the baby to magically descend down without any problem after the mother has labored sufficiently longer, just because they don't want their csections rates to be high?

If there is a problem strip and the obstetrician is hesitating to give opioids, I want the baby out. I am not sitting with an epidural on the top of a questionable strip and give more ammunition to the lawyer. Whether it is related or incidental, I practice cya anesthesia.
If it's stat stat, and am confident of the airway, will do general

I don't understand your logic here. A labor epidural, properly placed, with attention to bp changes isn't going to hurt the baby. My limited OB practice is exclusively jacked up babies, they all tolerate epidurals just fine, if anything they tend to do better as it removes the stress of pain, etc. coming from momma.
I'd rather have a working epidural to bolus when things go south than just default to GA, and I've done plenty of that, so I'm not afraid of GA for a c/s.

 

[deleted682700]

You are called to put in the epidural at mid nite. Patient is happy and pain free. Obgyn is happy because he doesn't get any more calls. The nurses are super happy. The next morning you start doing elective cases with a different gynecologist. The pregnant lady hasn't delivered and nurses have documented that the fetus is tachycardia and they have notified the obgyn.
In the middle of the elective case, the obstetrician from the previous nite wants to section ASAP. The gynecologist who now has a full line up and has patients to see galore wants to continue with his elective cases. There is only one or staff and only one anesthesiologist.
What do you think happens next, I don't start the elective case, but want to make sure that the pregnant with the epidural delivers a healthy baby. The gynecologist is now impatient and wonders why there is delay? Anesthesiologist unleashes his fury at the gynecologist and stands up and refuses to do an elective case. Administration is nowhere to be found.
So the logic that works in some other place may not work in my situation.

 

[bcat85]

You are called to put in the epidural at mid nite. Patient is happy and pain free. Obgyn is happy because he doesn't get any more calls. The nurses are super happy. The next morning you start doing elective cases with a different gynecologist. The pregnant lady hasn't delivered and nurses have documented that the fetus is tachycardia and they have notified the obgyn.
In the middle of the elective case, the obstetrician from the previous nite wants to section ASAP. The gynecologist who now has a full line up and has patients to see galore wants to continue with his elective cases. There is only one or staff and only one anesthesiologist.
What do you think happens next, I don't start the elective case, but want to make sure that the pregnant with the epidural delivers a healthy baby. The gynecologist is now impatient and wonders why there is delay? Anesthesiologist unleashes his fury at the gynecologist and stands up and refuses to do an elective case. Administration is nowhere to be found.
So the logic that works in some other place may not work in my situation.

This is bizarre. You don't want to place an epidural because the patient may require a stat c/s later, which may delay elective cases? Why any fury at all?

"Hey, we have an emergent c-section from OB, so we're doing that first" seems like a reasonable piece of medical decision making. I can't imagine any surgeon not understanding that logic.

 

[pjl]

I think maybe he is concerned that epidurals slow labor immensely, making the labor last until OB wants to go home, so he wants a C/S to finish the job? Or that epidurals increase rate of c/s? No idea, but that is what some people think.

A lot of conjecture on my part and a lot of "different" thinking if that is the case. Just do the epidural. The last I read they change labor times by 30 min +/- depending when placed. Should not change c/s rate.

Epidurals are a great procedure, relatively quick, great pain control for women, very minimal downsides, give you another option if going to c/s, you know the patient if you go to c/s, your patient who is awake actually smiles at you and says thank you, great PR for anesthesia, and they pay decently...what more could you want?

All that said, I have had raging surgeons because they are delayed by a stat c/s. I just calmly tell them that a potentially dying baby takes priority over their carpal tunnel, and that I am sorry about that. If it continues I remind them about the case I delayed so their wife could have a c/s.

 

[ranvier]

Probably should not bill for a running epidural if in a room doing elective gyn surgery the next day. We hand off these epidurals to the ob anesthesiologist coming on but OP clearly does not have that option.

 

[nimbus]

Probably should not bill for a running epidural if in a room doing elective gyn surgery the next day. We hand off these epidurals to the ob anesthesiologist coming on but OP clearly does not have that option.

What if you're in a room with a c-section?

 

[IlDestriero]

This is bizarre. You don't want to place an epidural because the patient may require a stat c/s later, which may delay elective cases? Why any fury at all?

"Hey, we have an emergent c-section from OB, so we're doing that first" seems like a reasonable piece of medical decision making. I can't imagine any surgeon not understanding that logic.

Exactly. If there are competing urgent but not emergent cases, the Surgeons can discuss amongst themselves which is more important and has to go first. Elective Gyn wouldn't even rate a call. On hold to complete urgent c/s for failure to progress/non reassuring fetal heart tones.
None of that has anything to do with an epidural either. If you are supposed to be available to cover OB, you are on the hook for that patient if they have an epidural or not.
BTW, if you are doing elective cases while covering a labor patient, I don't think you can meet the standard of care of 30 min decision to incision for urgent/emergent cases. I wouldn't participate in that malpractice/tragedy time bomb. Even at my old low volume low acuity OB practice, we had true crash c/s every year.
When I was in the .mil I did a tour in a little hospital where one person was on call for the whole weekend for everything. Surgical scheduling for urgent cases had to be made around the labor deck, and if we had laboring patients, the appy etc would have to wait or transfer. If we had a rare long OR case, we had to close to OB as I would not have been available to do a c/s and there was no back up. Nobody likes that arrangement, but with no back up call it was that or nothing.
Zero elective cases got done on nights or weekends.

 

[deleted682700]

Exactly. If there are competing urgent but not emergent cases, the Surgeons can discuss amongst themselves which is more important and has to go first. Elective Gyn wouldn't even rate a call. On hold to complete urgent c/s for failure to progress/non reassuring fetal heart tones.
None of that has anything to do with an epidural either. If you are supposed to be available to cover OB, you are on the hook for that patient if they have an epidural or not.
BTW, if you are doing elective cases while covering a labor patient, I don't think you can meet the standard of care of 30 min decision to incision for urgent/emergent cases. I wouldn't participate in that malpractice/tragedy time bomb. Even at my old low volume low acuity OB practice, we had true crash c/s every year.
When I was in the .mil I did a tour in a little hospital where one person was on call for the whole weekend for everything. Surgical scheduling for urgent cases had to be made around the labor deck, and if we had laboring patients, the appy etc would have to wait or transfer. If we had a rare long OR case, we had to close to OB as I would not have been available to do a c/s and there was no back up. Nobody likes that arrangement, but with no back up call it was that or nothing.
Zero elective cases got done on nights or weekends.

I think you are right on here. In fact I won't be able to meet the 30 minute rule if we do long laparoscopic cases. How do I educate the administration there is a big problem here particularly with elective cases being ramped up? I think legally u are right on.

 

[pjl]

Are you employed by the hospital?

Do they have a written policy regarding timing for c/s for "from decision to incision/delivery"
Do they choose staffing, without input from you, or is your department in charge of choosing how many are on staff, and have a smaller than ideal amount to optimize income?

If they choose the amount of staff available daily, and have a clear policy for c/s, one would think you would be able to describe to them the risk of performing long cases which take away your ability to respond to an emergency. Hopefully your relationship with them is good enough for it to be that simple.
Just be careful what you ask for because they are not going to want to increase their overhead by hundreds of thousands without getting something in return.

 

[PainDrain]

Are you employed by the hospital?

Do they have a written policy regarding timing for c/s for "from decision to incision/delivery"
Do they choose staffing, without input from you, or is your department in charge of choosing how many are on staff, and have a smaller than ideal amount to optimize income?

If they choose the amount of staff available daily, and have a clear policy for c/s, one would think you would be able to describe to them the risk of performing long cases which take away your ability to respond to an emergency. Hopefully your relationship with them is good enough for it to be that simple.
Just be careful what you ask for because they are not going to want to increase their overhead by hundreds of thousands without getting something in return.

I think it would be fairly easy to explain to the hospital administrators that based on the 30 minute standard of decision-to-incision you have to have the ability to leave a case or delay a case for a stat section. Just bring up the fact that one fetal demise would likely bankrupt the hospital and be a PR nightmare. Enough said.

 

[jwk]

We don't ever make the decision on what is emergent vs urgent vs whatever. We have a finite number of people that can do cases at any given time. The later in the day or on nights and weekends, that number is very low. The surgeon has to declare if it's a "bumping emergency". The nursing staff will notify the other surgeon that he is being bumped. If he disagrees or argues, then the bumping surgeon is required by policy to contact the surgeon he is bumping and come to an agreement. If they can't decide, then it gets elevated to the chief of surgery and their decision is final. Clearly some things are more obvious than others - prolapsed cord, ruptured AAA, etc. But we're not going to decide between "laboring all day with non-reassuring FHT's" and "lap appy that's been in the ER for six hours and needs to be done now".

 

[deleted682700]

Are you employed by the hospital?

Do they have a written policy regarding timing for c/s for "from decision to incision/delivery"
Do they choose staffing, without input from you, or is your department in charge of choosing how many are on staff, and have a smaller than ideal amount to optimize income?

If they choose the amount of staff available daily, and have a clear policy for c/s, one would think you would be able to describe to them the risk of performing long cases which take away your ability to respond to an emergency. Hopefully your relationship with them is good enough for it to be that simple.
Just be careful what you ask for because they are not going to want to increase their overhead by hundreds of thousands without getting something in return.

No not employed, contracted to provide anesthesia. The hospitals are not afraid of getting sued as much as individual physician. There are only 2 hospitals in this county and the other hospital is an hr away. So whatever the hospital does, they are not going to go bankrupt. Thank you tax payer. I wonder which companies cover the malpractice for the hospital? In fact iam worried that my malpractice carrier may not cover me when I need it because I did not follow all the rules in tiny fonts by different societies.

 

[deleted682700]

Probably should not bill for a running epidural if in a room doing elective gyn surgery the next day. We hand off these epidurals to the ob anesthesiologist coming on but OP clearly does not have that option.

I bill only for the time of attendance with the patient, usually 30 minutes. Since I do other cases with medical or Medicare as the insurance, I don't need any more hassles such as Medicare fraud

 

[IlDestriero]

In fact iam worried that my malpractice carrier may not cover me when I need it because I did not follow all the rules in tiny fonts by different societies.

If you're contracted to provide coverage, it's your responsibility to provide adequate coverage. Doing elective cases while covering a labor floor with no back up ain't it. The small print you need to concern yourself with is the standard of care. Violate that and you're asking to be sued. And you will lose.
I'm not sure what your situation is exactly, but you certainly sound like you're at risk and you can't provide what is the standard of care for OB emergencies if you are doing an elective schedule without back up.

 

[pjl]

It would appear to me that you are understaffed for the expectations of the hospital. If they have you contracted to provide x elective rooms and ob coverage, even though the economics suck, you need to provide x elective rooms plus trauma/ob coverage. If they have you contracted for x rooms and they are trying to add OB without it in your contract, maybe it is time to renegotiate.
With how conservative you sound from elsewhere you put yourself at much higher risk by not staffing as you are contracted to than the rest.

 

[deleted162650]

I bill only for the time of attendance with the patient, usually 30 minutes. Since I do other cases with medical or Medicare as the insurance, I don't need any more hassles such as Medicare fraud

It's perfectly acceptable to bill for epidural management while in another case i.e. a C/S, just like it's perfectly acceptable to bill for managing multiple epidurals simultaneously. Our OB population is overwhelmingly Medi-Cal. Either that or our group has gotten extremely lucky and not been audited in the last 30 years.