Quasi-Interesting OB Case

[Twiggidy]

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Cmon, dude, it may not be our call but an anesthesiologist who has been around the block on OB is more than capable of understanding the reasoning. Is the mother at risk for an impending serious physiological derangement? Is the fetus? If the answer to both these is no then I don't think having the OB explain the rationale for a twin section at 9pm is me being an obstructionist. Likewise, if someone wants to question my glidescope use, I have no problem educating them and explaining to them that while the MP was ok, the TM and neck circumference are bad and the literature about OB airway says blah blah

They gave you the rationale in the stem. If the OB is ok at 9 and the nurse are ok with 9 but the anesthesiologist says no because it’s elective, who’s being the obstructionist?

No one likes it and trust me you’re getting this from they guy who loathes OB and loathes C sections even more but I also don’t like my colleagues names brought up in meetings when 1 hour of their life could’ve prevented it.

I also understand a lot of this has to do with type of practice and where your practice is located. As I said in another post, my practice is in a location where people are lined up waiting to get a piece so we do what we can to stay in the good graces, off the radar, and not the topic of meetings. I want them only to mention the 3 A’s when it comes to my group. To quote The Wire, “It’s all in the game”. Im sure in other places you can’t probably put your foot down with less worry.

 

[vector2]

They gave you the rationale in the stem. If the OB is ok at 9 and the nurse are ok with 9 but the anesthesiologist says no because it’s elective, who’s being the obstructionist?

No one likes it and trust me you’re getting this from they guy who loathes OB and loathes C sections even more but I also don’t like my colleagues names brought up in meetings when 1 hour of their life could’ve prevented it.

I also understand a lot of this has to do with type of practice and where your practice is located. As I said in another post, my practice is in a location where people are lined up waiting to get a piece so we do what we can to stay in the good graces, off the radar, and not the topic of meetings. I want them only to mention the 3 A’s when it comes to my group. To quote The Wire, “It’s all in the game”. Im sure in other places you can’t probably put your foot down with less worry.

Neither the IUGR nor breech are reasons to deliver urgently in the presence of a reassuring strip and ultrasound. If anything, the increased risk of postpartum neonatal hypoxia, meconium asp, hypoglycemia etc with IUGR makes waiting til morning more reasonable. But, I see where you're coming from and at the end of the day I'd probably do the case too if everyone (including NICU) is on board.

 

[Southpaw]

They gave you the rationale in the stem.

Nothing in the stem states why it needed to be done that day. The lady isn’t in labor. The strips are fine.

But again, if your contract states, and your culture is to do totally 100% elective whatever your surgeon brings to the pre op holding area, then I won’t lift a finger in protest.

I just want to be clear in calling this what it is. I’m sure most hospital systems don’t routinely do 100% elective cases after hours.

 

[Twiggidy]

Off topic and derailing of the post:

Isn’t it interesting the CRNAs are fighting to do our cases in the OR but it’s damn near crickets when it comes to OB anesthesia. I could be wrong

 

[kmurp]

So your value as an anesthesiologist is measured by whether you type in 37c on the electronic chart somewhere

It’s a payment thing with CMS

 

[Mman]

Off topic and derailing of the post:

Isn’t it interesting the CRNAs are fighting to do our cases in the OR but it’s damn near crickets when it comes to OB anesthesia. I could be wrong

it's always about the money.

The problem with OB anesthesia is that it is a 24/7 job that requires a lot of work on nights and weekends in comparison to other areas of anesthesia. In many (most?) areas it also has a poor payer mix.

 

[MoMoGesiologist]

Does anyone like OB? It always inevitably always ends up being such a cluster... even when the day is going well and you think you get to relax, BAM! They call multiple epidurals at once, call for them very late as mom is about to push out baby, or call for a c/s just as the OR books a case or it's shift change or your extra CRNA or MD is about to go home... or maybe my luck is bad...

 

[Psai]

Does anyone like OB? It always inevitably always ends up being such a cluster... even when the day is going well and you think you get to relax, BAM! They call multiple epidurals at once, call for them very late as mom is about to push out baby, or call for a c/s just as the OR books a case or it's shift change or your extra CRNA or MD is about to go home... or maybe my luck is bad...

Nope I think this is universal. I hear the nurses encouraging the patient to wait to get the epidural. Then when you are busy af, they blow up the phone saying that the patient is in agony and you have to come immediately. Well where was the call when I was chilling for the past four hours and you know they just called for a stat?

The worst is when they call when you have a milllion things to do but the patient needs to go to the bathroom or they're unsure if they want the epidural or a toxic family member/doula is giving you extreme hostility.

 

[Monty Python]

......or a toxic family member/doula is giving you extreme hostility.

I tell the toxic family member and/or doula that I am there for the patient. If the patient wants an epidural, then the conversation is over. If the toxic folks continue to distract me, interfere with patient care, or create potentially unsafe conditions then they are directed/told/ordered to leave the room.

 

[pgg]

It’s could be elective but again that’s not our call.

It would be like if you decide to use a glidescope and another doctor is telling you it’s an easy airway so you shouldn’t use it. Granted they don’t have control over your actually using it but where do they get off telling you what’s easy or not. They’re not the airway experts just as we’re not the OB experts.

?

It is elective, and it was the OB's call. That's why they put it on for 2100, after the patient was NPO. It's completely, totally, 1000% elective, and the OB said so. If it wasn't elective, it would've been done at 1300, NPO status being irrelevant to the go time.

The question of the hour is whether or not we should do elective cases at 9 PM, when staff is short and the ability to care for emergencies might be affected. And the answer to that is wholly dependent upon the specifics of each hospital.

 

[pgg]

Does anyone like OB? It always inevitably always ends up being such a cluster... even when the day is going well and you think you get to relax, BAM! They call multiple epidurals at once, call for them very late as mom is about to push out baby, or call for a c/s just as the OR books a case or it's shift change or your extra CRNA or MD is about to go home... or maybe my luck is bad...

I like OB. It's the only patient population that is (usually) excited and happy to be there. Well, maybe some plastic surgery, too. But that's a different sort of excitement for the patient.

The procedures rank way up there in terms of instant gratification and patient appreciation.

Much depends on the patient population. The OB portion of my military practice (all insured, all had prenatal care, no teen moms, 95% married, no drug use) is great. The OB portion of the locums I used do out in rural redstate BFE (mostly uninsured, minimum BMI 40, lots of drug use, lots of single and teen mothers) ... well, sometimes it was nice, and sometimes it was just a parade of broken dreams and despair.

 

[Twiggidy]

?

It is elective, and it was the OB's call. That's why they put it on for 2100, after the patient was NPO. It's completely, totally, 1000% elective, and the OB said so. If it wasn't elective, it would've been done at 1300, NPO status being irrelevant to the go time.

The question of the hour is whether or not we should do elective cases at 9 PM, when staff is short and the ability to care for emergencies might be affected. And the answer to that is wholly dependent upon the specifics of each hospital.

Agree. We're a sports radio show right now in that we're arguing the same thing. Our hospital just has the culture of keeping the people bringing in the business as happy as possible. It's not optimal, but we need to eat and we like sunshine.

 

[GravelRider]

Since when do we turn into pumpkins at 9pm? Do people not do elective add-ons at 9pm (if so, I’ll send you my CV)? Every hospital I’ve been at I’ve done elective cases “after hours.” Either a case gets postponed because of something like NPO status, the add-on list is a disaster in the morning when you walk in, or the add-ons pile up on top of a very busy OR schedule. Maybe a surgeon has to bump himself or takes a lot longer on another case and starts his 4pm case at 8pm. Whatever the reason, ORs keep on chugging along. The case is elective, but doing it at 9pm doesn’t seem that unreasonable to me.

 

[fakin' the funk]

It’s could be elective but again that’s not our call.

It would be like if you decide to use a glidescope and another doctor is telling you it’s an easy airway so you shouldn’t use it. Granted they don’t have control over your actually using it but where do they get off telling you what’s easy or not. They’re not the airway experts just as we’re not the OB experts.

The idea that what an OB tells you is the stone cold truth will get you in trouble.

The corollary, that your input on the timing (or nature) of surgical cases is immaterial, is a number of bad adjectives as well. There's an MD or DO following your name right? Do you have reasonable opinions on how to safely deliver perioperative care? If so, why are you selling yourself short? My sentiment here is something less inflammatory than "grow a pair."

 

[pgg]

Since when do we turn into pumpkins at 9pm? Do people not do elective add-ons at 9pm (if so, I’ll send you my CV)? Every hospital I’ve been at I’ve done elective cases “after hours.” Either a case gets postponed because of something like NPO status, the add-on list is a disaster in the morning when you walk in, or the add-ons pile up on top of a very busy OR schedule. Maybe a surgeon has to bump himself or takes a lot longer on another case and starts his 4pm case at 8pm. Whatever the reason, ORs keep on chugging along. The case is elective, but doing it at 9pm doesn’t seem that unreasonable to me.

Again, it's all hospital dependent.

Hospitals that do elective cases after hours generally have staff for those expected elective cases. They have "late" teams (nurses and OR crew) that come in at noon or 3 PM and expect to work until 9 PM or midnight. They might have multiple in-house call people and late people to handle the day's overflow and emergencies.

Regardless, if you're going to do 9 PM elective cases obviously you need a plan, and staff, for emergencies.

The problem with 9 PM elective cases is usually out at Podunkville Community Hospital where the day's cases usually finish at 4 or 5 or 6 PM, and then everyone goes home and the lights are turned off. When someone randomly adds on an elective case for 9 PM, it's not a "late" person or a 2nd call or backup call person doing it, it's the call person. And that has implications for actual emergencies.

Some of the larger but still Podunkville hospitals cover emergencies with a primary team and a backup team. Often the backup team is paid nothing or a pittance to be backup, and they're OK with that arrangement because backup almost never gets called in. They plan to be sober and within 30 minutes of the hospital, but mostly they plan their lives around not working. If some jackass starts throwing garbage elective cases on the schedule at 9 PM, the odds of the primary being tied up and the backup being called in go up. All of a sudden, the deal has changed. Everybody understands the deal, except the jackass surgeon who thinks he's still in Not-Podunkville University Hospital, so the jackass surgeon is corrected and introduced to How Things Are out here in Podunkville.

It's not that people turn into pumpkins at 9 PM. They just have better things to do than drive to the hospital in darkness to do an ankle ORIF.

Podunkville is always hiring, so they'd be happy to receive your CV. 🙂

 

[Twiggidy]

The idea that what an OB tells you is the stone cold truth will get you in trouble.

The corollary, that your input on the timing (or nature) of surgical cases is immaterial, is a number of bad adjectives as well. There's an MD or DO following your name right? Do you have reasonable opinions on how to safely deliver perioperative care? If so, why are you selling yourself short? My sentiment here is something less inflammatory than "grow a pair."

It's not a pissing match. This is chess not checkers. I've seen people flex their muscles right out of the door of my hospital. Being affable allows me and my family to worry about 1%er problems, ie "Damn, I have to sit in 1A instead of 2A on the way to Europe?" instead of grabbing my sack and being a problem. I grab it when it's needed for when there are real problems, not when it's a couple grand on the table at 9pm and I can make a bunch of people happy. But where you work is your BBQ, so cook it how you want.

 

[Twiggidy]

People want to talk about "being a doctor", well yeah, "doctor up" and do the case.

 

[deleted162650]

a) risk of infecting hardware
b) risk of block difficulty/pain for pt
c) risk of block failure
d) risk of MS exacerbation

A) Maybe an issue if you're gonna leave a catheter, but a single shot SAB under sterile conditions carries such a remote possibility of infection (even in the presence of hardware) it's a non-issue
B) Ya, probably not gonna be the easiest spinal - so what. She prefers spinal knowing it could be difficult. If she tells you to stop, then she just goes to sleep anyway
C) Then she goes to sleep (which sounds oddly similar to your plan A)
D) You miss the part where her neurologist recommended spinal and felt it carried lower risk of exacerbation than GA??

I'm surprised at the controversy surrounding the timing of this case. I could understand delaying it till the following morning if you work at some

kinda flim flam operation

, but I work at a real hospital. Level 2 trauma. OB, OB Anesthesia, NICU, trauma surgery, ICU Doc all in house. Anes techs just a phone call away in the MOR. If it really gets hairy, I can call a code hemorrhage and get O- blood, a Belmont, and a dedicated trauma RN to run it in 5mins. For me, doing this case at 2100 is no less safe than doing it at 0700.

Additionally, while I though this case had some valid teaching points regarding MS and spinal fusions, it isn't "scary" from an anesthesia standpoint. You're looking at an SAB that might be a bit tricky to get in, or a GA on a skinny pregnant chick with a good airway. Neither of which should get your HR above 60. Some of you guys are acting like the OB called up and said "Hey, Salty. I've got a 450lb Eisenmengers Jehova's Witness with a percreta we're gonna do at 0200 - cool?"

 

[GravelRider]

Again, it's all hospital dependent.

Hospitals that do elective cases after hours generally have staff for those expected elective cases. They have "late" teams (nurses and OR crew) that come in at noon or 3 PM and expect to work until 9 PM or midnight. They might have multiple in-house call people and late people to handle the day's overflow and emergencies.

Regardless, if you're going to do 9 PM elective cases obviously you need a plan, and staff, for emergencies.

The problem with 9 PM elective cases is usually out at Podunkville Community Hospital where the day's cases usually finish at 4 or 5 or 6 PM, and then everyone goes home and the lights are turned off. When someone randomly adds on an elective case for 9 PM, it's not a "late" person or a 2nd call or backup call person doing it, it's the call person. And that has implications for actual emergencies.

Some of the larger but still Podunkville hospitals cover emergencies with a primary team and a backup team. Often the backup team is paid nothing or a pittance to be backup, and they're OK with that arrangement because backup almost never gets called in. They plan to be sober and within 30 minutes of the hospital, but mostly they plan their lives around not working. If some jackass starts throwing garbage elective cases on the schedule at 9 PM, the odds of the primary being tied up and the backup being called in go up. All of a sudden, the deal has changed. Everybody understands the deal, except the jackass surgeon who thinks he's still in Not-Podunkville University Hospital, so the jackass surgeon is corrected and introduced to How Things Are out here in Podunkville.

It's not that people turn into pumpkins at 9 PM. They just have better things to do than drive to the hospital in darkness to do an ankle ORIF.

Podunkville is always hiring, so they'd be happy to receive your CV. 🙂

Local rules and customs aside, there is nothing in the stem that gives me pause from an anesthesia standpoint where I think I would need backup immediately available. Although, this patient should probably not electively be in Podunkville Medical Center in the first place. Most places I’ve worked can run two ORs all night plus OB. Many places I’ve worked have staffing for 2-3 rooms until 11pm. If the OB wants to do this at 2100, no amount of whining and foot stomping from me is postponing this. I’d honestly rather do this at 2100 and be back in bed at 2200 than have it be a stat section at 0300.

My take on improper after-hours OR usage or any other abuse of OR time by surgeons is that I will do the case (obviously patient safety first) and let whatever chairman or committee review that particular surgeon’s cases in the morning. I’m a path of least resistance kind of person...especially at night.

 

[MoMoGesiologist]

Local rules and customs aside, there is nothing in the stem that gives me pause from an anesthesia standpoint where I think I would need backup immediately available. Although, this patient should probably not electively be in Podunkville Medical Center in the first place. Most places I’ve worked can run two ORs all night plus OB. Many places I’ve worked have staffing for 2-3 rooms until 11pm. If the OB wants to do this at 2100, no amount of whining and foot stomping from me is postponing this. I’d honestly rather do this at 2100 and be back in bed at 2200 than have it be a stat section at 0300.

My take on improper after-hours OR usage or any other abuse of OR time by surgeons is that I will do the case (obviously patient safety first) and let whatever chairman or committee review that particular surgeon’s cases in the morning. I’m a path of least resistance kind of person...especially at night.

Where are you working that can run two ORs all night plus OB?! My current gig it's me and a CRNA at night for OB and ORs so any case booking or c/s at night makes it difficult to start any additional emergency. I'm still learning how to manage this and when to call in people and not gonna lie, it can get stressful.

 

[Twiggidy]

Where are you working that can run two ORs all night plus OB?! My current gig it's me and a CRNA at night for OB and ORs so any case booking or c/s at night makes it difficult to start any additional emergency. I'm still learning how to manage this and when to call in people and not gonna lie, it can get stressful.

You accomplish it by basically having 2-3 docs on call or I imagine if you're a practice with nurses you have 2 nurses on call with the 1 doc covering 2 sites and still available to place blocks.

I've definitely heard of a place in my area that has someone on call for OR and 2 MDs on call for OB, both in house.

 

[Southpaw]

You all live and work in a very different USA than me. I finished residency 5 years ago at the flagship referral center for an entire state and we didn't run 2 ORs all night every night. There just aren't that many emergencies, and there was OR time available during the day. We also didn't do 100% elective (not in labor, strips fine) 9pm 36 wk IUGR twins routinely because the neonatologist was at home along with most of the resources required to care for those twins. So many of you are confusing complexity of the anesthetic (none!) with complexity of the kids (potentially great!).

 

[nimbus]

You all live and work in a very different USA than me. I finished residency 5 years ago at the flagship referral center for an entire state and we didn't run 2 ORs all night every night. There just aren't that many emergencies, and there was OR time available during the day. We also didn't do 100% elective (not in labor, strips fine) 9pm 36 wk IUGR twins routinely because the neonatologist was at home along with most of the resources required to care for those twins. So many of you are confusing complexity of the anesthetic (none!) with complexity of the kids (potentially great!).

It varies widely.

I’m in a multisite practice and it’s pretty common to have 1 room running all night and a 2nd room til 1-2am at our busier hospitals. We have other slower sites where they rarely do cases after midnight. The busy places are all trauma centers and the cases have to get done at night because they will be stacked into oblivion the following day when there will be more addons. We often don’t have OR time available during the following day for addons. The cases aren’t always interesting but there’s a lot of them and they need to get done.

 

[Mman]

You all live and work in a very different USA than me. I finished residency 5 years ago at the flagship referral center for an entire state and we didn't run 2 ORs all night every night. There just aren't that many emergencies, and there was OR time available during the day. We also didn't do 100% elective (not in labor, strips fine) 9pm 36 wk IUGR twins routinely because the neonatologist was at home along with most of the resources required to care for those twins. So many of you are confusing complexity of the anesthetic (none!) with complexity of the kids (potentially great!).

I'm just gonna say that doesn't sound like a very busy state. While I work in a big level 1 trauma center, it isn't even the biggest in our state and we run crap all the time. I mean sometimes it isn't busy, but sometimes you have multiple GSW patients in the OR at the same time plus c-sections and other crap going on. Most I've ever seen us running after midnight is 6 rooms. I think it was a trauma or two, a dissection, a crani, a c-section, and something else that wasn't quite as emergent but had been running for a long time before those other things started happening.

Do we run stuff all the time after midnight? Of course not. Sometimes I can even sleep for a few hours when I'm there. But we have the capability of taking care of lots of emergent stuff at once. I mean every surgical service has patients that can potentially be emergent and not wait.

 

[GravelRider]

You all live and work in a very different USA than me. I finished residency 5 years ago at the flagship referral center for an entire state and we didn't run 2 ORs all night every night. There just aren't that many emergencies, and there was OR time available during the day. We also didn't do 100% elective (not in labor, strips fine) 9pm 36 wk IUGR twins routinely because the neonatologist was at home along with most of the resources required to care for those twins. So many of you are confusing complexity of the anesthetic (none!) with complexity of the kids (potentially great!).

There are some states out there that are way too large or way too populated to have a single flagship referral center for the entire state. ORs are busy and it’s often difficult to cram in add-ons onto and already packed OR schedule. Smaller, but busy trauma hospitals also don’t have 40 ORs to decompress the backlog. The solution is to keep the ORs running longer. I’m not saying two ORs are running all night, but it’s not uncommon to have a case going and have a trauma roll in past midnight.

 

[jwk]

You all live and work in a very different USA than me. I finished residency 5 years ago at the flagship referral center for an entire state and we didn't run 2 ORs all night every night. There just aren't that many emergencies, and there was OR time available during the day. We also didn't do 100% elective (not in labor, strips fine) 9pm 36 wk IUGR twins routinely because the neonatologist was at home along with most of the resources required to care for those twins. So many of you are confusing complexity of the anesthetic (none!) with complexity of the kids (potentially great!).

"Flagship referral center" without in-house neonatology?

We are a totally private and non-academic practice. We can easily run two OR's all night long at two of our hospitals and four at the largest one (including totally separate OB operating rooms not dependent on regular OR staff) . We also have designated backup staff on top of that, and can always start going down the phone list if we need to. It's generally the surgeon/OB decision on when they want to do their case. If we ever get into the situation where there are too many "emergencies", which is more frequent in the late afternoons and evenings for us, it becomes a surgeon to surgeon discussion on who gets to go first. We don't make the decision on who's case is most emergent.

 

[Southpaw]

"Flagship referral center" without in-house neonatology?

NICU NP in house overnight. Even for new admissions flow in from wherever at all hours of the night. Neonatologist there if needed, but more often than not at home at night. Not my pony. Not my show.