Back-up call coverage question?

[panetrain]

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Is it standard to always have a back-up call person available for every surgical site that requires call coverage (OR and OB)? 😀 Or, do some small practices just have a primary doc and that's it (no back up dude available)?

 

[pgg]

Is it standard to always have a back-up call person available for every surgical site that requires call coverage (OR and OB)? 😀 Or, do some small practices just have a primary doc and that's it (no back up dude available)?

We have no backup call person. There are usually only 3-4 of us in the call pool, so having a primary AND backup would quickly become unbearably painful. It's primarily OB coverage, with very rare gen surg or ortho at night. Our after-hours volume is pretty low. Typical night might be 1 or 2 epidurals or sections.

If the SHTF we call the people who are 'off' and if they're available and sober they come in. But there's no expectation or requirement that a 2nd person be available.

 

[pgg]

I personally know of a small department that fell apart for exactly this reason. Primary call person was in a multi hour OR case. The other three people were not available. So an elective labor epidural never got done. Administration mandated a 2nd call person be available. Two of the four people subsequently resigned. They were replaced after about 18 months of locums.

This is my military job so nobody's gonna be resigning. 🙂

 

[periopdoc]

3 call slots. "Trauma"/ OB/ Backup. Hospital offsets the expense of doing this and we have a big enough group to handle it. "Standard practice" is as highly variable and impossible to pin down as "standard of care."

- pod

 

[sevoflurane]

Primary/Secondary. Our secondary guy gets called out about 5x per year (usually for epidurals). So really... besides holding the pager and having the 2nd longest room... you are not working once you go home. 300 bed hospital.

 

[panetrain]

Thanks for your rapid responses. The call coverage I have in mind would be OB only. Is it unreasonable to assign only a first call (no back up guy) to a 24-48 hour relatively slow OB shift? Thanks.😀

 

[pgg]

And you have got a high degree of liability protection.🙂

This is true. 🙂

Thanks for your rapid responses. The call coverage I have in mind would be OB only. Is it unreasonable to assign only a first call (no back up guy) to a 24-48 hour relatively slow OB shift? Thanks.

I think that's fine. A 48 hour shift implies a volume low enough to permit sleep. If the primary guy is routinely sleeping, mandating a backup seems excessive.

Not getting to an elective epidural because you're in a section isn't a big deal IMO.
a) You'll probably be done with the section in 30 min anyway, which is my institution's upper bound of the acceptable amount of time we can take to get to the hospital when we're on pager call in the first place (I think ACOG & ASA are deliberately silent on time-to-hospital issues).
b) It's elective. Give her some fentanyl, turn down the pit for a few minutes. Not to trivialize it, but she can safely deliver without an epidural.

If a second urgent/emergent section gets called and you're in the OR, that's a tough spot. How often does this really happen at the institution? But what if there is a 2nd anesthesiologist, and a 3rd section gets called? It can't be turtles all the way down, or anesthesiologists all the way back.

If you make the call schedule so oppressive that no one is willing to work there any more, that's not good for patient safety either.

 

[IlDestriero]

Thanks for your rapid responses. The call coverage I have in mind would be OB only. Is it unreasonable to assign only a first call (no back up guy) to a 24-48 hour relatively slow OB shift? Thanks.😀

We have a slow fetal surgery/OB practice. A few months ago I had just placed a spinal in for a c/s due to flr to progress. As it was setting up, the nurse ran in to get the OB. The second laboring woman decided to have a "terminal" decel. Some turb, panic, O2 and flailing later. She was ok. I had to call the b/u person (who was back up for fetal surgery) in. 1st time in 7 years. It happens. I COULD have kicked that lady out of the OR, but 5 min later and I would have been in trouble. Can they do local? technically yes, how do you think that would go. Maybe I could direct ketamine from the other room.
They have a 2nd OB, so we need a 2nd anesthesiologist.
I'm betting your liability protection is not as good as PGG.
If you're trapped in the OR with a non OB case, you can probably be successfully sued for not placing an epidural. Maybe not in the case of an OB emergency.

 

[Idiopathic]

If you're trapped in the OR with a non OB case, you can probably be successfully sued for not placing an epidural. Maybe not in the case of an OB emergency.

wait, what?

 

[wine thief]

You'll probably be done with the section in 30 min anyway, which is my institution's upper bound of the acceptable amount of time we can take to get to the hospital when we're on pager call in the first place (I think ACOG & ASA are deliberately silent on time-to-hospital issues).

acog and asa have had a statement for over 20 years that time to hospital is 30 minutes, once a stat section has been called.

 

[IlDestriero]

wait, what?

If you are trapped in a non OB case with no back up available for several hours and a woman delivers w/o an epidural, etc, I wouldn't be surprised if you were sued. They come expecting pain relief, you didn't even try. I see a settlement there.

 

[deleted126335]

If you are trapped in a non OB case with no back up available for several hours and a woman delivers w/o an epidural, etc, I wouldn't be surprised if you were sued. They come expecting pain relief, you didn't even try. I see a settlement there.

+1. I suspect that it depends a lot on your written agreement for coverage with the hospital.

 

[wine thief]

NO. Decision to incision. Not time from anesthesiologist responding to page to incision. Except VBACs. The word there is immediate

That is correct. i was imprecise.

i thought actually that re: vbacs, the spirit of the guideline was interpreted to mean that the 30 minute guideline still was in play-meaning that an anesthesiologist/obgyn do not have to be in house during vbac.

 

[wine thief]

If you are trapped in a non OB case with no back up available for several hours and a woman delivers w/o an epidural, etc, I wouldn't be surprised if you were sued. They come expecting pain relief, you didn't even try. I see a settlement there.

if junior can sue mom's obgyn for "wrongful life" as a result of failed sterisation, then people can sue for anything.

 

[IlDestriero]

That is correct. i was imprecise.

i thought actually that re: vbacs, the spirit of the guideline was interpreted to mean that the 30 minute guideline still was in play-meaning that an anesthesiologist/obgyn do not have to be in house during vbac.

When we did vbacs both the ob and anesthesia had to be in house the whole time. Immediately available seems to mean in the hospital, waiting for disaster, not 20 min away. Otherwise they wouldn't have to say anything about availability. That's already the standard. Fortunately the old group discouraged them, and we don't do them at all where I am now.👍

 

[gaspasser2004]

Labor & Delivery Deck + non-OB cases in OR = 2 frontline anesthesia providers on call.

Example: you're on call and Dr. Takeallnight brings a belly case to the OR. 2 hours into the case with no end in sight, a laboring patient has a prolapsed cord necessitating a STAT c-section. There is no way your gen surg case is going to finish in time for the 30 minute rule, much less in time to actually save the baby. Some would argue that it could be defensible to leave the intubated, "train tracks" patient with the circulator RN and tend to the crashing C-section. Others would argue that the C-section can be done under local. No one would argue that this is an ideal set-up.

Example: you're on call again with Dr. Takeallnight and this time it is an epidural that needs to be placed. You decide (wisely) not to leave your intubated "train tracks" patient to do an epidural. The patient delivers without an epidural. End of story? Maybe. Unfortunately, said labor patient was the daughter/wife of a hospital board member/influential surgeon/local politician/you name it and they are now out for a pound of flesh - that pound of flesh would be yours.


I'm sure there are many practices out there that cover OB and non-OB cases with one call doc. I'm glad that I'm not in such a practice.

 

[panetrain]

The call coverage I have in mind would be just OB (slow service 3-5 deliveries per day), not OB and OR.

Labor & Delivery Deck + non-OB cases in OR = 2 frontline anesthesia providers on call.

Example: you're on call and Dr. Takeallnight brings a belly case to the OR. 2 hours into the case with no end in sight, a laboring patient has a prolapsed cord necessitating a STAT c-section. There is no way your gen surg case is going to finish in time for the 30 minute rule, much less in time to actually save the baby. Some would argue that it could be defensible to leave the intubated, "train tracks" patient with the circulator RN and tend to the crashing C-section. Others would argue that the C-section can be done under local. No one would argue that this is an ideal set-up.

Example: you're on call again with Dr. Takeallnight and this time it is an epidural that needs to be placed. You decide (wisely) not to leave your intubated "train tracks" patient to do an epidural. The patient delivers without an epidural. End of story? Maybe. Unfortunately, said labor patient was the daughter/wife of a hospital board member/influential surgeon/local politician/you name it and they are now out for a pound of flesh - that pound of flesh would be yours.


I'm sure there are many practices out there that cover OB and non-OB cases with one call doc. I'm glad that I'm not in such a practice.

 

[Idiopathic]

if junior can sue mom's obgyn for "wrongful life" as a result of failed sterisation, then people can sue for anything.

how are the two situations the same? if i ask you to perform a procedure on me and you do it wrong and i have a negative outcome and all these things are clear then shouldnt i expect recompense? im not saying thats what happened in the above but if it did happen that way, then it seems valid.

i do not expect to get sued for not being able to put in an epidural, for whatever reason. should I?

 

[Mman]

If you're trapped in the OR with a non OB case, you can probably be successfully sued for not placing an epidural. Maybe not in the case of an OB emergency.

A labor epidural is not an emergency lifesaving procedure. If I'm in the OR with a case, I have a duty to the patient under anesthesia. I cannot abandon that patient. A malpractice suit requires showing the physician had a duty to the patient which was violated and as a result of that had harm done. They can file whatever lawsuit they want, but they won't win anything.

The only possible target for a suit the patient would have is the hospital itself for not providing more comprehensive anesthesia coverage. But even that wouldn't really have a leg to stand on.

 

[sevoflurane]

Labor & Delivery Deck + non-OB cases in OR = 2 frontline anesthesia providers on call.

Example: you're on call and Dr. Takeallnight brings a belly case to the OR. 2 hours into the case with no end in sight, a laboring patient has a prolapsed cord necessitating a STAT c-section. There is no way your gen surg case is going to finish in time for the 30 minute rule, much less in time to actually save the baby. Some would argue that it could be defensible to leave the intubated, "train tracks" patient with the circulator RN and tend to the crashing C-section. Others would argue that the C-section can be done under local. No one would argue that this is an ideal set-up.

Example: you're on call again with Dr. Takeallnight and this time it is an epidural that needs to be placed. You decide (wisely) not to leave your intubated "train tracks" patient to do an epidural. The patient delivers without an epidural. End of story? Maybe. Unfortunately, said labor patient was the daughter/wife of a hospital board member/influential surgeon/local politician/you name it and they are now out for a pound of flesh - that pound of flesh would be yours.


I'm sure there are many practices out there that cover OB and non-OB cases with one call doc. I'm glad that I'm not in such a practice.

Agreed. In said practices, it is only a matter of time before you need to make like Stripe and feel the urgent need to duplicate yourself.

Every patient on the OB floor deserves to have an anesthesiologist available. End of story. I can't understand how this risk is allowed to happen... if it happens at all 😕

We all know how he ended up:

 

[wine thief]

how are the two situations the same? if i ask you to perform a procedure on me and you do it wrong and i have a negative outcome and all these things are clear then shouldnt i expect recompense? im not saying thats what happened in the above but if it did happen that way, then it seems valid.

i do not expect to get sued for not being able to put in an epidural, for whatever reason. should I?

no they're not similar at all. point is, anyone can sue for anything, and they do. sure you (usually) have to prove certain elements for a successful suit, but that may not be necessary to receive a settlement.