Pediatricians at Urgent C Sections

[MEN2C]

I'm a pedi resident and for sure you should have pediatrics there.

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[Ronin786]

Our peds come in for all red sections, and some of the yellows. It is the OB discretion whether to call in peds for the yellows. The problem is the OB doesn't leave the mother to attend to the neonate; it falls on us. It doesn't seem fair that the one who decides whether or not to call peds has no skin in the game when something goes wrong with baby.

We had a good meeting today with the CMO and pediatrics department. The hospital is going to look into hiring nurse practitioners with neonatal training and/or experience. The cost of these practitioners has to be justified, and since we do about 1000 deliveries a year, we will try to get the OBs and pediatricians on board with this. Having a neonatal NP attend all deliveries, including vaginal ones, could help justify this cost. Many times the OB will have a neonate in distress after a vaginal delivery, with no anesthesiologist or pediatrician close by, and for this reason they seem to be in favor of the NP. The L&D nurses favor it to ease their workload, and the NP could also ease the burden off the peds when they have to leave their office for deliveries. Again, the issue is cost.

We will see how this plays out, but the meeting today was productive. Everyone agreed that the anesthesiologist can't be responsible for both mother and neonate, and this is evident in our practice guidelines as well. The NP route may take some time, but in the meantime we will surely document our concerns. I will have our malpractice carrier draft something to that effect. If after a couple or months or so things still aren't moving, then we will bump this up to the CEO/risk management people.

Thanks to everyone for their input! I really appreciate these forums.

The physician's answer to everything: "Let's find an NP to do our job for us"

 

[Socrates25]

The best scenario is to have the hospital hire an in-house neonatologist to cover all precarious deliveries (you can decide as a group what precarious means).

Of course the hospital won't do that because neonatologists cost money.

An experienced NICU NP would be a decent 2nd option -- but what happens if they have trouble with the airway? Are they going to "consult" the anesthesiologist to secure the airway?

Just like anything else the experience matters most and is not consistent from one physician to another. During peds residency I did several NICU rotations and attended at least 100 high risk deliveries that resulted in the baby needing resuscitation to some degree. However I don't do hospital call or attend deliveries in the last 5 years so obviously my skills in that area have languished, so even though I'm a fully trained attending I'm not as good at neonatal resuscitation as I used to be as a resident.

 

[pjl]

Just to clarify, I’m not involved in this situation at all. I believe the OP is near the opposite coast. Still if a hospital wants to provide a service they should do it right and not cut corners. I’m all for everyone getting healthy stipends commensurate with their efforts.

I suspect at my hospital the addition of this coverage would be ~300k per year. They may choose to adjust your expectations instead, depending on how their budget is padded.

Would definitely create a nice fat paper trail documenting your concerns if you want it to change. Nothing worse for a hospital than getting sued for a kids death when an anesthesiologist has repeatedly pointed out a lack of safe practice in a very discoverable way.

That said, we have a NICU that comes to every section except healthy elective ones. They are great and very helpful. There was discussion briefly about them not coming for the middle urgency sections, which ended when I discussed the legal implications of me leaving the mother to help the baby.

 

[skypilot]

The physician's answer to everything: "Let's find an NP to do our job for us"

We are a small community hospital. About 600 births a year. We used to have a Pediatrician at every Cesarean. About a year ago we started using a Neonatal Nurse Practitioner during the day and Pediatricians after 5 pm. This is an issue. But we are choosing our battles and chose not to battle this one.

 

[Gas]

We are a small community hospital. About 600 births a year. We used to have a Pediatrician at every Cesarean. About a year ago we started using a Neonatal Nurse Practitioner during the day and Pediatricians after 5 pm. This is an issue. But we are choosing our battles and chose not to battle this one.

Sounds like you don't have a battle: all we want is a dedicated independent practitioner (NP or Peds) at only the urgent sections. You seem to have that at every Cesarean - even the elective, non-urgent ones.

I'm going to reschedule a meeting with the CMO shortly after the holidays to ask for some follow-up.

 

[IlDestriero]

We are a small community hospital. About 600 births a year. We used to have a Pediatrician at every Cesarean. About a year ago we started using a Neonatal Nurse Practitioner during the day and Pediatricians after 5 pm. This is an issue. But we are choosing our battles and chose not to battle this one.

Make sure the NP has the necessary skills for the job. There was a lawsuit I read about a few years ago where the peds group hired a NP to cover at night. A CRNA was doing the c/s. The operation went fine but the baby developed respiratory distress and the NP couldn’t intubate. They called the anesthesiologist to help who came 5-10 minutes later as they were also covering a case in the OR. The anesthesiologist intubated the kid relatively easily but by that time he was hypoxic for 15-20 minutes. It turns out the peds NP hasn’t intubated anyone in several years and hadn’t intubated a newborn since NP school ~6 years earlier.
Peds was going to take the fall for that one.
The CRNA said she wasn’t comfortable leaving the mother and also no longer did any kids. I have to wonder if she should have tried. Of course nobody knew how useless the NP really was.


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Il Destriero

 

[Psai]

Make sure the NP has the necessary skills for the job. There was a lawsuit I read about a few years ago where the peds group hired a NP to cover at night. A CRNA was doing the c/s. The operation went fine but the baby developed respiratory distress and the NP couldn’t intubate. They called the anesthesiologist to help who came 5-10 minutes later as they were also covering a case in the OR. The anesthesiologist intubated the kid relatively easily but by that time he was hypoxic for 15-20 minutes. It turns out the peds NP hasn’t intubated anyone in several years and hadn’t intubated a newborn since NP school ~6 years earlier.
Peds was going to take the fall for that one.
The CRNA said she wasn’t comfortable leaving the mother and also no longer did any kids. I have to wonder if she should have tried. Of course nobody knew how useless the NP really was.


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Il Destriero

They want to do pediatrics and call themselves intensivists until shtf. Don't blame the nurse anesthetist at all.

 

[Perrotfish]

They want to do pediatrics and call themselves intensivists until shtf. Don't blame the nurse anesthetist at all.

To be fair this is a problem regardless of who is covering: its just getting harder and harder to learn neonatal procedures. Part of the problems is that there are just fewer procedures: the guidelines are moving away from intubations in general, and more and more training programs also have NICU fellows who take all of the procedures away from residents and NP students. Graduating pediatric residents a generation ago would have intubated hundreds of infants, including every child with meconium. Now a Pediatrics graduate would be lucky to intubate more than a dozen during all of residency even if they aren't competing with a NICU fellow, and even graduating Neonataology fellows might not have intubated more than 50 kids. We're also having the same problem with umbilical lines and chest tubes.

 

[nimbus]

To be fair this is a problem regardless of who is covering: its just getting harder and harder to learn neonatal procedures. Part of the problems is that there are just fewer procedures: the guidelines are moving away from intubations in general, and more and more training programs also have NICU fellows who take all of the procedures away from residents and NP students. Graduating pediatric residents a generation ago would have intubated hundreds of infants, including every child with meconium. Now a Pediatrics graduate would be lucky to intubate more than a dozen during all of residency even if they aren't competing with a NICU fellow, and even graduating Neonataology fellows might not have intubated more than 50 kids. We're also having the same problem with umbilical lines and chest tubes.

Then it sounds like care should be shifted to centers of excellence that do a high volume of deliveries. Maybe every small community hospital should not be doing low volume obstetrics.

 

[Perrotfish]

Then it sounds like care should be shifted to centers of excellence that do a high volume of deliveries. Maybe every small community hospital should not be doing low volume obstetrics.

If there was a way to do this I would agree, but how would you make this work? OB is not the same as hip replacement surgery where you schedule it for one day six months out and then arrange transportation on that day. It's 9 months of continuous care, usually with at least half a dozen scares requiring urgent evaluation, and ending with an admission that is usually unscheduled.

Most of the patients in my community don't even have cars. The nearest NICU is over 100 miles away. How do they even get there? My hospital isn't a worst case scenario either, there are plenty of low volume hospitals in flyover country that are much farther from their tertiary care center than we are.

Sometimes the perfect is the enemy of the good. I think a reasonable compromise (and what my hospital does) is that Pediatrics manages the code, but if they have trouble with the procedural side of things they call for help. Anesthesia will help with difficult airways and ER will do chest tubes on those rare occasions that a needle D won't work.

 

[shepardsun]

Interesting dilemma that captures all of the issues Perrotfish has raised in a nutshell. As someone who went through a peds residency and is now doing anesthesia residency, it's crazy looking back how little procedural training I received in peds at a quaternary freestanding children's hospital. Intubated maybe 2-3 neonates across three NICU rotations with an equal number of lines, and I didn't even train at a place with a neo fellowship, just NNPs. I could have maybe been a little bit more aggressive but frankly the opportunities were just often not there. Intubated a few kids on ED rotations, zero in ICU (fellows took all intubations), never did a central line.

Maybe beyond the point of this thread but what this basically means is that most newly trained general pediatricians have gone from managing the whole spectrum of illness including ICU level care to being glorified mid levels. Kind of sad. I would feel comfortable doing coverage for high risk C-sections on the pediatrics side but only because of my anesthesia training.

 

[Perrotfish]

Interesting dilemma that captures all of the issues Perrotfish has raised in a nutshell. As someone who went through a peds residency and is now doing anesthesia residency, it's crazy looking back how little procedural training I received in peds at a quaternary freestanding children's hospital. Intubated maybe 2-3 neonates across three NICU rotations with an equal number of lines, and I didn't even train at a place with a neo fellowship, just NNPs. I could have maybe been a little bit more aggressive but frankly the opportunities were just often not there. Intubated a few kids on ED rotations, zero in ICU (fellows took all intubations), never did a central line.

Maybe beyond the point of this thread but what this basically means is that most newly trained general pediatricians have gone from managing the whole spectrum of illness including ICU level care to being glorified mid levels. Kind of sad. I would feel comfortable doing coverage for high risk C-sections on the pediatrics side but only because of my anesthesia training.

Currently Family Medicine had started labeling programs as 'OB familiar' vs 'OB competent', with the idea being that residents whose programs only involved 2 months of OB shouldn't be delivering babies. Maybe we need the same thing I Peds: NICU familiar vs NICU competent, with a minimum of 6 months of NICU and a minimum number of intubations and umbilical lines to be NICU competent.

The system we have right now sucks. A lot of these small hospitals are covered by really old Pediatricians, and it doesn't seem like anyone is coming to replace them as programs decrease NICU training for residents.

 

[skypilot]

If there was a way to do this I would agree, but how would you make this work? OB is not the same as hip replacement surgery where you schedule it for one day six months out and then arrange transportation on that day. It's 9 months of continuous care, usually with at least half a dozen scares requiring urgent evaluation, and ending with an admission that is usually unscheduled.

Most of the patients in my community don't even have cars. The nearest NICU is over 100 miles away. How do they even get there? My hospital isn't a worst case scenario either, there are plenty of low volume hospitals in flyover country that are much farther from their tertiary care center than we are.

Sometimes the perfect is the enemy of the good. I think a reasonable compromise (and what my hospital does) is that Pediatrics manages the code, but if they have trouble with the procedural side of things they call for help. Anesthesia will help with difficult airways and ER will do chest tubes on those rare occasions that a needle D won't work.

Yes, even with all the consolidations and hospital bankruptcies we still need community hospitals. Not everyone can be cared for at a tertiary Hospital. And most of our surgeons are as fast and skilled as any you will find at a teaching hospital.

 

[MEN2C]

Interesting dilemma that captures all of the issues Perrotfish has raised in a nutshell. As someone who went through a peds residency and is now doing anesthesia residency, it's crazy looking back how little procedural training I received in peds at a quaternary freestanding children's hospital. Intubated maybe 2-3 neonates across three NICU rotations with an equal number of lines, and I didn't even train at a place with a neo fellowship, just NNPs. I could have maybe been a little bit more aggressive but frankly the opportunities were just often not there. Intubated a few kids on ED rotations, zero in ICU (fellows took all intubations), never did a central line.

Maybe beyond the point of this thread but what this basically means is that most newly trained general pediatricians have gone from managing the whole spectrum of illness including ICU level care to being glorified mid levels. Kind of sad. I would feel comfortable doing coverage for high risk C-sections on the pediatrics side but only because of my anesthesia training.

Difference between mid levels and physicians is not procedural experience. That is a ridiculous statement.


Unless you're going into PICU or NICU, you're just not going to be adept at most procedures in kids. Kids simply need them a lot less.

In any case, given the paucity of intubations in neonates these days, it makes sense not to give intubations to residents going into gen peds or rheumatology. At my institution, those who are going into practices where they will attend c sections or do hoapitalists do procedural rotations where they rotate through various units and get intubations and other experiences. It's not possible for all 80 of the categorical pediatric residents in the program to each get 50 intubations and 20 central lines. That volume simply does not exist anywhere, no matter how large your institution.

The neonatal fellows and the residents who are going into practices where intubations would be needed are the ones who need to get the lions share of these procedures.

 

[Perrotfish]

Difference between mid levels and physicians is not procedural experience. That is a ridiculous statement.


Unless you're going into PICU or NICU, you're just not going to be adept at most procedures in kids. Kids simply need them a lot less.

In any case, given the paucity of intubations in neonates these days, it makes sense not to give intubations to residents going into gen peds or rheumatology. At my institution, those who are going into practices where they will attend c sections or do hoapitalists do procedural rotations where they rotate through various units and get intubations and other experiences. It's not possible for all 80 of the categorical pediatric residents in the program to each get 50 intubations and 20 central lines. That volume simply does not exist anywhere, no matter how large your institution.

The neonatal fellows and the residents who are going into practices where intubations would be needed are the ones who need to get the lions share of these procedures.

The problem is that the ABP is still saying that a Pediatrician is qualified to cover a nursery. Not a small subset of Pediatricians who think they're going to end up at community hospitals and who do extra rotations, the ABP is saying every Pediatrician is qualified to cover nursery. Also the Pediatricians who end up in the community often didn't think they were going there. Community hospitals, like it or not, are places that people tends to wash up at rather than places that they intended to go to. Its not reasonable to expect residents to know if they're going to end up somewhere where intubations and central lines will be needed.

The ABPs job is to make sure that all Pediatricians are qualified to do a Pediatrician's job, and that includes NRP and all of the associated procedures. If the ABP certifying programs that aren't meeting that training standard then they need to rethink how the certify residency training. Maybe we need minimum numbers of procedures? Requirements for NICU rotations unopposed by fellows? A requirement for more total NICU rotations? Mandatory anesthesia rotations with a minimum number of airways for every resident? Maybe graded NICU megacodes as part of our board certification? The requirement for a one month anesthesia rotation in particular seems like a good place to start.

 

[MEN2C]

Let's say we do what you say. The problem is at a deeper level. If you expect every pediatrician to be an expert intubator, how do you maintain that skill? Once you're out and you're covering a nursery and going to low or medium risk deliveries, you'll intubate how many kids now that we don't intubate for meconium? Once a year, if that?

I intubated 30+ times in med school with two anesthesia rotations. Then I didn't for a two years, and when I did again, it was probably only slightly better than my first time.

You're just not going to be able to have that many people out in these small community hospitals who remain proficient at pediatric airways. So either you have a neonatologist at every delivery or you will just have to be Ok with a pediatrician/pediatric np who can bag and do other things until someone else can be called in. Whether that's the neo, or failing that, another anesthesiologist.

Just statistically the data suggest probably 1 in 500 babies need intubations (likely less if the high risk deliveries are shipped out). At a delivery center like the one in the original post - say 1000 deliveries a year - that's 2 intubations per year. Say 4 pediatricians cover the nurseries. So each pediatrician will average one intubation every two years.

I don't care how good an experience you had in residency - that's not gonna get you someone who you want intubating your newborn.

 

[Gas]

Update: had a big interdisciplinary meeting with administration, anesthesia, OB, peds, and OB nursing. Consensus was we aren't going to participate in neonatal resuscitation, and no one really argued with us. Kept coming back to staffing. OB nurses also want some backup (not necessarily us) and like having peds there. We told the hospital that after 90 days we expect some plan to be in place to staff these cases appropriately, or we will have to escalate the discussion to indemnification, which will involve attorneys. They took this seriously, and are looking into hiring a neonatal NP, or at least contracting with the other hospital which does have one. My hunch is that won't work, and hospital will end up incentivizing peds to show up to all urgent sections. I will post another update when I have one.

Thanks again to everyone who posted!