Question for those in Private Practice

[Noyac]

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How many of you are placing epidurals in OB pts without the primary (OB, midwife, or FP) having seen the laboring pt yet? For example, pt comes to the labor deck at 2 am and wants an epidural. The primary provider knows the pt is in and calls you requesting an epidural after the L&D nurse has evaluated the pt but has not seen the pt personally.

 

[pmichaelmd]

How many of you are placing epidurals in OB pts without the primary (OB, midwife, or FP) having seen the laboring pt yet? For example, pt comes to the labor deck at 2 am and wants an epidural. The primary provider knows the pt is in and calls you requesting an epidural after the L&D nurse has evaluated the pt but has not seen the pt personally.

Realistically, I know the OB is supposed to see the patient and evaluate her first, but it seems that we often get the call before that happens. My partners tell me that that is how it often is in the world of private practice. I'll do my own quick eval, ask how far along she is and check her labor pattern. Assuming she is banging away, is stable, I will usually proceed. Is that how it is where you practice?

 

[urge]

What happens if the fetal heart rate craps out after the epidural and the pt needs a stat c section? Who is going to do it?

 

[VentdependenT]

How many of you are placing epidurals in OB pts without the primary (OB, midwife, or FP) having seen the laboring pt yet? For example, pt comes to the labor deck at 2 am and wants an epidural. The primary provider knows the pt is in and calls you requesting an epidural after the L&D nurse has evaluated the pt but has not seen the pt personally.

Happens all the time at Rush's private hospital. However the OB is within minutes of the hospital.

 

[jetproppilot]

How many of you are placing epidurals in OB pts without the primary (OB, midwife, or FP) having seen the laboring pt yet? For example, pt comes to the labor deck at 2 am and wants an epidural. The primary provider knows the pt is in and calls you requesting an epidural after the L&D nurse has evaluated the pt but has not seen the pt personally.

I'd say this happens near 100% of the time after hours, Noy.

At least at every gig I've worked at.

 

[Noyac]

Well this came up at our hosp. b/c a partner of mine got called by a FP (family practice) doc for an epidural at 3am. Come to find out, the FP was over an hour away and had not seen the pt. Well we had been sort of allowing this practice to occur but this really pissed my partner off and he made an issue of it not to mention, he didn't place the epidural. And I don't blame him since the Fp was not able to respond to an emergency had something gone wrong with the epidural placement or the baby or whatever. There was an on call physician who may have been able to respond but the FP's manage there own pts in labor so the on call physician doesn't know of the pt to begin with. Well this issue has sort of blown up since hosp policy states that a pt must be seen and an H&P on the chart b/4 an invasive procedure or regional technique be performed. It doesn't mention OB at all but is felt to include OB. I sort of would like to deal with this b/w the services but I think it may be too late now since it goes to med exec tomorrow.

 

[militarymd]

we put them in all the time, but I don't like it......too much regional differences in practice...

I guess if your group was the only game in town, you could simply put your foot down and not put them in....

but we have competition....

 

[Noyac]

we put them in all the time, but I don't like it......too much regional differences in practice...

I guess if your group was the only game in town, you could simply put your foot down and not put them in....

but we have competition....

We are the only gig in town and we can put our foot down but I don't want to be an as either. I want whats best for the pt. I want to minimize my exposure to liability (we have midwives managing pts alone as well as FP and OB). We often place epidurals at 10pm without the pt being seen until the next morning. Thats 6+ hours with an epidural and not being seen by the primary.

 

[militarymd]

We are the only gig in town and we can put our foot down but I don't want to be an as either. I want whats best for the pt. I want to minimize my exposure to liability (we have midwives managing pts alone as well as FP and OB). We often place epidurals at 10pm without the pt being seen until the next morning. Thats 6+ hours with an epidural and not being seen by the primary.

OB anesthesia is a pain...UNLESS...you're in a practice where the volume is high enough to justify FULLTIME ..ie 24/7 coverage.

The ACOG and their Bul l Sh it "technical STAT" calls for section pretty much gives an OB free range on when they want to go to the OR...or NOT...making running a low census OB unit along with managing an OR efficiently next to impossible.

Just finished a BS "technical STAT"...with one of our OB's....I'm considering firing him from our practice.

 

[joshmir]

you work in a hospital, right?

can you elaborate on what u mean by "fire the ob from the practice"...meaning your group would refuse to provide anesthesia services for that OB?

 

[militarymd]

you work in a hospital, right?

can you elaborate on what u mean by "fire the ob from the practice"...meaning your group would refuse to provide anesthesia services for that OB?

yep,

what this means....joe blow schedules cases....patient shows up....joe blow shows up....but NO ONE to sit on stool unless joe blow arranges his own stool sitter.

and unless joe blow has major numbers to support the income of his personal stool sitter, he won't be able to do his cases.

 

[Planktonmd]

yep,

what this means....joe blow schedules cases....patient shows up....joe blow shows up....but NO ONE to sit on stool unless joe blow arranges his own stool sitter.

and unless joe blow has major numbers to support the income of his personal stool sitter, he won't be able to do his cases.

Wow, you must have a very solid relationship with your hospital administration and no strong competition in town.

 

[numbmd]

Cool, mil, I wish we had that kind of juice at our hospital. We do upwards of 6400 deliveries a year. Two anesthesiologists on call at a time, one from home. Plus a full time PA to hook up bags, pre-op pts, and the occasional bolus.

We have a OB residency so the attendings don't need to be in house for us to do an epi. But there is one disadvantage... Some times there is a crash section, you look around the room, and you realize that you are the only attending present.

 

[militarymd]

Wow, you must have a very solid relationship with your hospital administration and no strong competition in town.

I'm considering it.....but don't get me wrong.....there'll be HELL to pay if we decide to do it.

Political ramifications of refusing service is something to consider before pulling something like this.

 

[pmichaelmd]

What happens if the fetal heart rate craps out after the epidural and the pt needs a stat c section? Who is going to do it?

That's why it isn't optimal, but it is a reality. There are several OB groups in our small town and all of the OBs live within 5-10 minutes of the hospital. That decreases the risk somewhat. I can say that I've seen more "level 1" C/S in my short time here as an attending than I saw in all of residency. Amazing how often these happen in a smaller, community-sized hospital. So it goes in the small town areas of GA/AL.

 

[Noyac]

Anyone have an idea of what your hosp bylaws say regarding this topic? Are you just choosing to look the other way on this for the sake of the OB's?

 

[pd4emergence]

Our group will place one befor the OB has seen them. But this is with the understanding that they are always covered by a physician that is within 20 min or so of the hospital (most of the time the OB's don't get more than ten minutes away before they are called back). We did have some partners who were uncomfortable putting them in when the patient had been followed primarily by a nurse midwife. Now the midwives have dedicated physician backup if any problems arise. I don't blame your partner for being angry. I don't know what your bylaws say. I think ours spells out that the OB has to be within 20-30 minutes of the hospital when on call. With this understanding, I have no problem with putting an epidural in a patient who has not seen her ob especially if labor is rapidly progressing. It seems that the issue here is more that the FP covering this patient was an hour away and not able to take care of any problems that may have arisen with or without the epidural.