Anesthesia in two rooms

[nitroglycerine]

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I got into a serious dilemma and I am looking for opinions. A new department that I joined ( a community hospital 40 min drive from a large urban center) seem to have expectation that I should provide an anesthetic to an emergency c/s while having another patient under anesthetic. We have a second on call at home who usually takes more than 30 min to arrive if called stat. My argument that it is not acceptable and that that the OB should start it under LA until one of us is available was not well received because the OBs "do not have the experience". There is no CRNAs here. I feel very uncomfortable being on-call for just this reason and actually think of quitting even though there is no other jobs in the area.
Thank you.

 

[sevoflurane]

I got into a serious dilemma and I am looking for opinions. A new department that I joined ( a community hospital 40 min drive from a large urban center) seem to have expectation that I should provide an anesthetic to an emergency c/s while having another patient under anesthetic. We have a second on call at home who usually takes more than 30 min to arrive if called stat. My argument that it is not acceptable and that that the OB should start it under LA until one of us is available was not well received because the OBs "do not have the experience". There is no CRNAs here. I feel very uncomfortable being on-call for just this reason and actually think of quitting even though there is no other jobs in the area.
Thank you.

Unacceptable. That is patient abandonment. Second call needs to be w/in 30 minutes or in house. Tell the surgeons to learn how to start a local c/s case.

Where are you from? We usually say patient under GA... not "patient under anesthetic".

 

[deleted126335]

I got into a serious dilemma and I am looking for opinions. A new department that I joined ( a community hospital 40 min drive from a large urban center) seem to have expectation that I should provide an anesthetic to an emergency c/s while having another patient under anesthetic. We have a second on call at home who usually takes more than 30 min to arrive if called stat. My argument that it is not acceptable and that that the OB should start it under LA until one of us is available was not well received because the OBs "do not have the experience". There is no CRNAs here. I feel very uncomfortable being on-call for just this reason and actually think of quitting even though there is no other jobs in the area.
Thank you.

"In the event that an emergency requires the temporary absence of the person primarily responsible for the anesthetic, the best judgment of the anesthesiologist will be exercised in comparing the emergency with the anesthetized patient's condition and in the selection of the person left responsible for the anesthetic during the temporary absence."

-standards for basic anesthesia monitoring.

 

[2ndyear]

I believe ACOG standards say a stat c section should be started in 30 minutes decision to incision. If your second call is 10 minutes away then they can start the anesthetic in 15 minutes from the time the section is called which is very reasonable for a community hospital. If it takes them 30 minutes to get to the door then you probably have to consider other options like having second call come in when first call goes to the OR, but that really depends on how much and how high risk your OB department is. Do you do VBACs?

 

[jwk]

"In the event that an emergency requires the temporary absence of the person primarily responsible for the anesthetic, the best judgment of the anesthesiologist will be exercised in comparing the emergency with the anesthetized patient's condition and in the selection of the person left responsible for the anesthetic during the temporary absence."

-standards for basic anesthesia monitoring.

I think that one would have a hard time defending that position in court should something happen to the patient that was abandoned.

I have always understood since day 1 that your primary responsibility is to the patient you have in front of you. We used to routinely be asked to handle neonatal resuscitation on C-Sections "because we were right there". That task now falls to a separate team, as it should, since our primary responsibility is to the mother who is our patient.

I believe ACOG standards say a stat c section should be started in 30 minutes decision to incision. If your second call is 10 minutes away then they can start the anesthetic in 15 minutes from the time the section is called which is very reasonable for a community hospital. If it takes them 30 minutes to get to the door then you probably have to consider other options like having second call come in when first call goes to the OR, but that really depends on how much and how high risk your OB department is. Do you do VBACs?

"On Call" is a responsibility that needs to be taken very seriously from a medico-legal standpoint. Living 30 minutes from the hospital obviously doesn't meet the 30 minute "decision to incision" concept. Either live closer to the hospital, come in when your first call person becomes occupied (which is very common for us) or stay in-house or a close-by hotel. Really.

 

[Fooper]

My partner & I are in the exact same scenario. He has had to do emergency c-sections twice over the last 5 years when already doing another GA (since there is only one doc on call to cover both OR and OB.) Everyone -- administration and the medical staff -- seem to approve of this, even though it seems weird to do two cases at once. You certainly can't bill for it (we are hospital employees and they cover our malpractice, so we do what they want.) I tell my friends & family never to deliver at this hospital for this reason.

If this is not ok, why does the ASA have the above language in their practice guidelines?

We are a small hospital (36 beds) and there's no way they would pay for a second doc on backup all the time for the rare emergency c-section.

 

[drccw]

I think it depends on what you feel comfortable with...

We take in house call for OB. Our general OR is a separate home call person. I've frequently started a second emergent C/S in the middle of the night, provided the first patient was stable. The one lucky thing we have is that our C/S rooms are right next to each other, separated by a door. In fact, our anesthesia machines are both right next to the door, so I can stand in the doorway and really watch both cases. There was one time I had both patients under GA. I rarely call the other OR guy in because our OBs know to hustle hustle hustle and can get at least one of the C/S's done by the time the other guy gets in.

FDW

 

[countingdays]

I think it depends on what you feel comfortable with...

We take in house call for OB. Our general OR is a separate home call person. I've frequently started a second emergent C/S in the middle of the night, provided the first patient was stable. The one lucky thing we have is that our C/S rooms are right next to each other, separated by a door. In fact, our anesthesia machines are both right next to the door, so I can stand in the doorway and really watch both cases. There was one time I had both patients under GA. I rarely call the other OR guy in because our OBs know to hustle hustle hustle and can get at least one of the C/S's done by the time the other guy gets in.

FDW

Where I am, we can pull up a picture-in-picture showing the display from another OR within our monitor's display. If you did have to cover two locations, it would be a lot more comfortable if you can actually see what's going on with your other room. It would be well worth the software upgrade to be able to monitor both patients at once. Maybe not cheap, I have no idea really, but cheaper than a patient injury/lawsuit and cheaper long-term than having a backup anesthesiologist.

 

[pgg]

I got into a serious dilemma and I am looking for opinions. A new department that I joined ( a community hospital 40 min drive from a large urban center) seem to have expectation that I should provide an anesthetic to an emergency c/s while having another patient under anesthetic.

That seems a pretty dodgy plan for routinely handling a 2nd emergency, but I guess it's not totally outlandish.

My hospital's written policy states, in part

b. Because of the multiplicity of inputs, simultaneous demands for anesthesia coverage may arise from separate services. During these rare occurrences at ---, the following guidelines are provided:

(1) The on-call anesthesia provider must exercise judgment. Reasonable actions MAY INCLUDE, BUT ARE NOT LIMITED TO:

(a) Advise second surgeon to send his case to another facility if it will not wait until current case is completed.

(b) Contact a second anesthesia provider

(c) Stop the first surgery, if feasible, maintaining visual and verbal contact with the OR Nurse while in the adjacent OR doing the second case. This situation should only be utilized in a dire emergency. The primary responsibility of any provider is to the patient already under the care of that provider.

(d) Provide verbal orders for IV labor analgesia, anticipating neuraxial analgesia when case completed.

(e) Have all other cases sent to another facility when high-probability C/Section(s) are on L&D.

(Small edits to conceal my location, though I'm sure anyone who cares to could figure out exactly who and where I am based on my posting history.)

I've done all of the above except (c) since I've been here. If patient #1 was totally stable, I'd be willing to park the OR nurse in front of the monitor, tell the surgeon to stop, and then do the section next door. We have windows between ORs so I could maintain eye contact with the other nurse.

I'll also add that this is a military hospital so the malpractice environment is very favorable. Even so, if something happened to patient #1 under anesthesia while rushing off to handle patient #2, it'd be utterly indefensible in court.

 

[zzzDoczzz]

x

 

[seinfeld]

Your non-OB case better be a true emergency.

I think it also depends on what the nature is of the first case you are doing.
If the case is unstable i would find it very hard to leave, but if its been on autopilot then i would be less hesitant, Regardless i would have my 2nd call in route.

We keep an overnight CRNA for just this reason. At the very minimum you could start another emergency in a pinch while your back up makes his/her way in.

Remember this could situation instead of OB may be a ruptured AAA or trauma as well

 

[Impromptu]

Just went through the simulator lab this morning (quite a good session). The first case was an emergency C-section for a patient who we deduced had a high spinal and a placentia previa with bleeding. After the delivery the baby wasn't doing so well and the OB team was trying to get us (us being a single anesthesiologist in a private hospital) to leave the mother to tend to the baby (mother had just started to stabilize). The correct answer was not to leave our primary patient, the mother. If we did attend to the baby and anything bad happened to the mother there would be absolutely no defense in court. We could certainly offer advice, and even have them bring the baby nearer to where we were, but our services were to be directed to the mother.

 

[nitroglycerine]

Unacceptable. That is patient abandonment. Second call needs to be w/in 30 minutes or in house. Tell the surgeons to learn how to start a local c/s case.

Where are you from? We usually say patient under GA... not "patient under anesthetic".

Thanks for the correcton, Sevo. I work in North America but English is not my first language.

 

[Bertelman]

Remember this could situation instead of OB may be a ruptured AAA or trauma as well

If we're talking about a community hospital, they'd be turfing that crap down the road. There isn't going to be a surgeon in house to take care of those things, anyhow.

 

[nitroglycerine]

Thanks to all. Has anyone ever seen a C/S done under LA? Is there a description of the technique?

 

[jwk]

Thanks to all. Has anyone ever seen a C/S done under LA? Is there a description of the technique?

One - it ain't pretty, but it's do-able, and every OB doc should know how to do one. If you're not in-house in your tiny rural hospital, will your OB wait 15-20 minutes (or more) for anesthesia when the cord has prolapsed and FHR is in the 30's? They shouldn't.

 

[jwk]

Where I am, we can pull up a picture-in-picture showing the display from another OR within our monitor's display. If you did have to cover two locations, it would be a lot more comfortable if you can actually see what's going on with your other room. It would be well worth the software upgrade to be able to monitor both patients at once. Maybe not cheap, I have no idea really, but cheaper than a patient injury/lawsuit and cheaper long-term than having a backup anesthesiologist.

Software upgrades are relatively cheap. But never think much less speak your last statement in the presence of the plaintiff's lawyer. 😉

 

[periopdoc]

If we're talking about a community hospital, they'd be turfing that crap down the road. There isn't going to be a surgeon in house to take care of those things, anyhow.

Depends on the community hospital. Today I did a leaking AAA, a stat c-section, an ortho trauma a couple of sedations for procedures and was slated to clean out a belly full of pus and air from a perforated colon on a true ASA IV-E (one of the partners agreed to do it so that I would be free for the AAA).

Not everything gets shipped to the big house.

Interestingly, one of my patients had an old-school Guidant "self-destruct if exposed to magnet" pacer. They are still out there.

- pod

 

[countingdays]

Software upgrades are relatively cheap. But never think much less speak your last statement in the presence of the plaintiff's lawyer. 😉

I meant to say, if you can't recruit someone to do backup call at any price, then a software upgrade allowing you to monitor two rooms at once is better than nothing.

 

[C.P.]

wow, this is kind of a classic boards questions.

here's my answer: It depends.

If the hospital is staffing the OB and surgical services with the expectation that you cover both.
It's not only unethical, it's illegal.

If the hospital IS NOT set up as a trauma, or high risk/emergency OB service (in other words, expecting this to happen as part of their regular function), and your stated responsibility is to "try" and cover a C/S just in a catastrophe situation. That's slightly different.
The important point to make is that under this situation, your responsibility still lies, 100% with your primary patient. Your ability to provide ANY care to the C/S is only at your discretion, and it should be a very stringent discretion, in a very unique situation, and again, ONLY in a catastrophe situation.
That same situation also justifies you telling them that you're busy and they have to proceed under local.
If they're uncomfortable or unable to conduct a C/S under local, then you SHOULD NOT agree to potentially accept responsibility for leaving your patient to take care of theirs, as they have no other backup if you are tied up.

On the mother/baby topic:
A friend of mine is a board examiner and failed an examinee for answering that he would not, under any circumstances, leave the mother to help deal with the baby (this was after offering up a dozen different versions of the situation).
The basic principle is that you're primary responsibilty is to your patient.
If the baby is in distress, and the mother is chilling, walk over and take a look.
If the mother isn't doing so well and requires a bit more of your attention, to the point where walking across the OR to look at the baby is too difficult. . . have them wheel the baby over to you.
If your hands are so full that, with a newborn in the warmer, right next to you, within arms reach, and you still can't try and intubate/assist. Then it should be pretty bloody obvious that they shouldn't be asking you to help anyway.

Just to clarify, so I don't get people enraged about the guy who failed.
The situation was finally boiled down to the examinee like this:
your patient, the mother, is under spinal anesthesia and is rock stable. Her vitals are fine, she's satting 100% on room air, she's begging you to go save her baby, the father is sitting next to her and is doing the same. The nurse has wheeled the baby over to you and is holding a laryngoscope in her hands. Would you still not evaluate the baby or try to assist?
His response was a consistent and robotic: "my primary responsibility is to my patient, under no circumstances will I leave her care."

The mother baby debate though is a LOT different than being asked to leave a room with someone under general to potentially, completely, tie yourself up with a critical patient.

We cover codes in our hospital as part of our responsibilities, but if we're already busy with something else (often an emergency C/S), we call them back and tell them their on their own.

If your hospital is expecting crash C/S's, then they need to better prepare for them, if their contingency plan for a rare, catastrophic kind of situation involves stretching you, that's acceptable, as long as they are comfortable with the fact that you may very well need to refuse and be unavailable, in which case they need to have another back up plan.

I'm post-call right now so I might be rambling a bit.

 

[Arch Guillotti]

I'm post-call right now so I might be rambling a bit.

I thought it was a pretty good answer. Willingness to adapt is a key to surviving the oral boards.

 

[fakin' the funk]

Interestingly, one of my patients had an old-school Guidant "self-destruct if exposed to magnet" pacer. They are still out there.

Please elaborate! 😱

I suppose this is why the older cardiac guys always insist that we know what the magnet does to a pacer before putting it on...

 

[nitroglycerine]

"In the event that an emergency requires the temporary absence of the person primarily responsible for the anesthetic, the best judgment of the anesthesiologist will be exercised in comparing the emergency with the anesthetized patient’s condition and in the selection of the person left responsible for the anesthetic during the temporary absence."

-standards for basic anesthesia monitoring.

So it looks like it is quite defensible. I recall a case when I was told by my collegue who was doping next door to go and start an emergency section ( I had a patient intubated and cruising for a knee arthroscopy). My collegue was giving another GA and would watch my patient. I went and started the c/s under GA and 10 min later another guy arrived and took over so I could go back to my room. He said that I should not have started the case no matter what but the first one disagreed with him. The OB said that if I had not come he would have started the case under LA.😀

 

[nitroglycerine]

wow, this is kind of a classic boards questions.

here's my answer: It depends.

If the hospital is staffing the OB and surgical services with the expectation that you cover both.
It's not only unethical, it's illegal.

If the hospital IS NOT set up as a trauma, or high risk/emergency OB service (in other words, expecting this to happen as part of their regular function), and your stated responsibility is to "try" and cover a C/S just in a catastrophe situation. That's slightly different.
The important point to make is that under this situation, your responsibility still lies, 100% with your primary patient. Your ability to provide ANY care to the C/S is only at your discretion, and it should be a very stringent discretion, in a very unique situation, and again, ONLY in a catastrophe situation.
That same situation also justifies you telling them that you're busy and they have to proceed under local.
If they're uncomfortable or unable to conduct a C/S under local, then you SHOULD NOT agree to potentially accept responsibility for leaving your patient to take care of theirs, as they have no other backup if you are tied up.

On the mother/baby topic:
A friend of mine is a board examiner and failed an examinee for answering that he would not, under any circumstances, leave the mother to help deal with the baby (this was after offering up a dozen different versions of the situation).
The basic principle is that you're primary responsibilty is to your patient.
If the baby is in distress, and the mother is chilling, walk over and take a look.
If the mother isn't doing so well and requires a bit more of your attention, to the point where walking across the OR to look at the baby is too difficult. . . have them wheel the baby over to you.
If your hands are so full that, with a newborn in the warmer, right next to you, within arms reach, and you still can't try and intubate/assist. Then it should be pretty bloody obvious that they shouldn't be asking you to help anyway.

Just to clarify, so I don't get people enraged about the guy who failed.
The situation was finally boiled down to the examinee like this:
your patient, the mother, is under spinal anesthesia and is rock stable. Her vitals are fine, she's satting 100% on room air, she's begging you to go save her baby, the father is sitting next to her and is doing the same. The nurse has wheeled the baby over to you and is holding a laryngoscope in her hands. Would you still not evaluate the baby or try to assist?
His response was a consistent and robotic: "my primary responsibility is to my patient, under no circumstances will I leave her care."

The mother baby debate though is a LOT different than being asked to leave a room with someone under general to potentially, completely, tie yourself up with a critical patient.

We cover codes in our hospital as part of our responsibilities, but if we're already busy with something else (often an emergency C/S), we call them back and tell them their on their own.

If your hospital is expecting crash C/S's, then they need to better prepare for them, if their contingency plan for a rare, catastrophic kind of situation involves stretching you, that's acceptable, as long as they are comfortable with the fact that you may very well need to refuse and be unavailable, in which case they need to have another back up plan.

I'm post-call right now so I might be rambling a bit.

Thank you. I agree 100%. What makes me uncomfortable (and mad) is that we are expected to be the ones who should put our bottoms on fire. In case of mother-baby situation: why not a Family Doc who is assisting? He can step aside and start NRP sequence. Why not have an emergency doc to come to OR to be there for the baby? We can come and intubate but there should be someone who can actually do the whole NRP protocol all the way up to Adrenaline after 90 seconds, IV access. If you busy with the baby and suddenly the mother is vomiting, or SOB, or BP 70 or whatever, or a happy father suddenly collapsing like it happened the other day then you quit the baby. We will be constantly made to accept the medico-legal risk for everyone else.😡

 

[jwk]

So it looks like it is quite defensible. I recall a case when I was told by my collegue who was doping next door to go and start an emergency section ( I had a patient intubated and cruising for a knee arthroscopy). My collegue was giving another GA and would watch my patient. I went and started the c/s under GA and 10 min later another guy arrived and took over so I could go back to my room. He said that I should not have started the case no matter what but the first one disagreed with him. The OB said that if I had not come he would have started the case under LA.😀

You can defend it (or rationalize it) but whether it's "defensible" or not is another issue.

There was a case in Atlanta 30 years ago at the same time I was doing my anesthesia training. A patient had been dropped off in the PACU by the CRNA, who then went back and started another case. The patient in PACU developed a life-threatening problem and the CRNA left her patient in the OR to deal with the patient in PACU, but forgetting her patient in the OR was on a Sux drip. Both patients died.

I'll be the first to admit that I don't work in a small hospital with limited resources, and it sounds like several of you have been between a rock and a hard place on more than one occasion. However - if this is happening with any frequency whatsoever, it seems like some better planning or staffing would be in order. One of my biggest pet peeves is doing "emergency" surgery on nights and weekends that all of us know is done for the surgeon's convenience, and then facing the very real possibility of a true emergency coming along that is then put at risk because of us doing the other case that shouldn't have been done in the first place.

 

[nitroglycerine]

I believe ACOG standards say a stat c section should be started in 30 minutes decision to incision. If your second call is 10 minutes away then they can start the anesthetic in 15 minutes from the time the section is called which is very reasonable for a community hospital. If it takes them 30 minutes to get to the door then you probably have to consider other options like having second call come in when first call goes to the OR, but that really depends on how much and how high risk your OB department is. Do you do VBACs?

No, they do not. To me the answer is simple: LA ASAP and call in any physician who may be in the hospital ( I would start with ER docs). OBs should be prepared to do it. I have never done a cricothyrotomy to save the airway but for some reason I feel that I should be prepared to do it and therefore should have some idea how to.

 

[urge]

I got into a serious dilemma and I am looking for opinions. A new department that I joined ( a community hospital 40 min drive from a large urban center) seem to have expectation that I should provide an anesthetic to an emergency c/s while having another patient under anesthetic. We have a second on call at home who usually takes more than 30 min to arrive if called stat. My argument that it is not acceptable and that that the OB should start it under LA until one of us is available was not well received because the OBs "do not have the experience". There is no CRNAs here. I feel very uncomfortable being on-call for just this reason and actually think of quitting even though there is no other jobs in the area.
Thank you.

I would look for another job.

In the mean time, I would suggest calling the second call to do the OR cases leaving you free to do any emergencies.

I would not leave a patient under GA just because some OB is uncomfortable doing local.