Solo coverage at small hospital

[Neogenesis]

I started doing some locums work at a small community hospital providing weekend coverage. When there, you are the only Doc and cover both main OR and L&D (about 35-50 deliveries a month). There seems to be a fair amount of fighting over when and how surgeons can utilize the OR in otherwise non-emergent cases. (I.e. No OR cases if there is a laboring patient at all). The guidance I received from the normal Anesthesia folks was that the decision needed to be made between the surgeon and the OB and that we don't make the call.

I'm just wondering if any of you who work in similar environments could share how it goes at your places. What is the culture? What are the policies you have in place? Any tips?

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[aneftp]

Some small rural hospitals like one I know in Mississippi the Ob places his own epidural! Problem solved.

Anyways doubt thAts in ur case.

U can't be in two places at one time. Plus u are locums. Do what you THINK is best. What are they gonna to do to u?? Nothing

I doubt many high risk ob patients or vbac.

Our rule of thumb when I covered a level 2 community hospital MD only on weekend in California.

Ob light as well.

I just did the OR cases. Left OB alone. We did have "backup" anesthesia doc within 30 minutes. But never called one in. Cause acog rules just require 30 minutes call back time.

The ob and surgeons need to work it out. That's the bottom line.

 

[DrCommonSense]

I started doing some locums work at a small community hospital providing weekend coverage. When there, you are the only Doc and cover both main OR and L&D (about 35-50 deliveries a month). There seems to be a fair amount of fighting over when and how surgeons can utilize the OR in otherwise non-emergent cases. (I.e. No OR cases if there is a laboring patient at all). The guidance I received from the normal Anesthesia folks was that the decision needed to be made between the surgeon and the OB and that we don't make the call.

I'm just wondering if any of you who work in similar environments could share how it goes at your places. What is the culture? What are the policies you have in place? Any tips?

If you do any OR cases, make sure there is a DOCUMENTED system of a BACKUP anesthesia member within 30 mins that can take any emergent C sections that can be covered. You want this documented or you probably could be sued for "abandonment". Don't be foolish. Without that documentation, I would REFUSE to do "elective" OR cases and would put in writing that you can't cover OB during that time.

When I worked in a more rural area with similar situations, I told surgeons that put an "elective" case on at 6PM that was supposed to "only go for a couple of hours" (went >12 hours the next day when rescheduled) that I can't do the case because OB could have an emergency and there wouldn't be any anesthesiology staff to cover it safely.

Also, let the OB know that you can't place epidurals while in the OR.

 

[Neogenesis]

Some small rural hospitals like one I know in Mississippi the Ob places his own epidural! Problem solved.

Anyways doubt thAts in ur case.

U can't be in two places at one time. Plus u are locums. Do what you THINK is best. What are they gonna to do to u?? Nothing

I doubt many high risk ob patients or vbac.

Our rule of thumb when I covered a level 2 community hospital MD only on weekend in California.

Ob light as well.

I just did the OR cases. Left OB alone. We did have "backup" anesthesia doc within 30 minutes. But never called one in. Cause acog rules just require 30 minutes call back time.

The ob and surgeons need to work it out. That's the bottom line.

That's the crux of the problem, there is no backup available. Although I have a feeling that's coming shortly.

 

[anbuitachi]

I dont get it. How can you be sued for abandonment when you are actively taking care of a patient in the OR. How is it your fault that you can't divide into 2, or that the hospital has no staff. I can't see you losing this case in court , what argument will they say. Ditch your current patient and go take care of OB? Even if you have a backup 30 min away, what if there are 2 OB emergencies... should we have unlimited anesthesiologist backups just in case?? If anything hospital may be can be sued.
I mean we do that here when we have multiple cases at once, we triage, b/c dont have unlimited resources.

 

[Noyac]

I dont get it. How can you be sued for abandonment when you are actively taking care of a patient in the OR. How is it your fault that you can't divide into 2, or that the hospital has no staff. I can't see you losing this case in court , what argument will they say. Ditch your current patient and go take care of OB? Even if you have a backup 30 min away, what if there are 2 OB emergencies... should we have unlimited anesthesiologist backups just in case?? If anything hospital may be can be sued.
I mean we do that here when we have multiple cases at once, we triage, b/c dont have unlimited resources.

You are right, you can't be held liable if you are doing an emergent case. Much less any other case if the hospital only staffs one anesthesiologist.

 

[Noyac]

I started doing some locums work at a small community hospital providing weekend coverage. When there, you are the only Doc and cover both main OR and L&D (about 35-50 deliveries a month). There seems to be a fair amount of fighting over when and how surgeons can utilize the OR in otherwise non-emergent cases. (I.e. No OR cases if there is a laboring patient at all). The guidance I received from the normal Anesthesia folks was that the decision needed to be made between the surgeon and the OB and that we don't make the call.

I'm just wondering if any of you who work in similar environments could share how it goes at your places. What is the culture? What are the policies you have in place? Any tips?

Stay out of the debate. Let the surgeon and OB settle it. Just do which ever case they decide is next. You can't be in two places at once. Surgeons will always feel the need to operate when they want and OB's will always feel like they have priority. You are not going to settle this. So stay out of it and let them duke it out.
Or you could step in and do what you think is best, and never be invited back again.

 

[deleted682700]

You are right, you can't be held liable if you are doing an emergent case. Much less any other case if the hospital only staffs one anesthesiologist.

But how often do you really get a stat csection? In my 12 years of working at a small rural hospital 3-4 times a year we get into a bind. we do elective cases all the time.
Only worry when we have more than multiple laboring patients and full OR schedule and I am alone.

However the cases are appys, gall bladders etc. may be I am foolish and lucky. Finally we have 2 ortho surgeons who have come to town and the admin has agreed to have 2 anesthesiologists during day time only. Night time i.e. After 3-4 pm only emergencies, one at a time.

Yes we triage and give obs and csection priority. And luckily the surgeons and obstetricians and admin listen to us

 

[IlDestriero]

When I was at a tiny Naval hospital we had one provider for the whole weekend, no back up. In fact most weekends the others in the department were almost always out of town. We really were alone and unafraid. The CRNAs, and the previous anesthesiologist, had no problem doing "quick" cases while women were in labor. I refused. We did about 30 deliveries a month. If I had to do an emergent case and nobody was in labor, I called the midwife and OB myself and gave them the no BS estimate of how long I wasn't available. If they admitted someone knowing I was not available, that's completely on them. I never did elective cases on the weekends and didn't give a damn that the surgeons wanted to do them and would with the CRNAs. Administration must have secretly agreed, because I never had to explain my position to the front office and I'm sure some of the surgeons complained. As I had said before about some surgical nonsense that I refused to accommodate, the CO is welcome to call me and order me to do the case against my judgement, but as he wasn't a physician, I'm not sure he'd want me to write that in the chart. XOs want to be COs and COs want to be Admirals and you don't want baggage from a physician complaining about non physician administrators overruling the medical decision making of well trained and board certified specialist that lead to a bad outcome. Especially one that is getting out and will happily get on with his career far, far away.
I also posted detailed instructions for a CS with local and ketamine on the wall in the OB OR and discussed the possibility for the emergency physician to administer ketamine sedation and fluid resuscitation during an unexpected crash section when there was no emergent patient in the ER.



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Il Destriero

 

[Noyac]

I also posted detailed instructions for a CS with local and ketamine on the wall in the OB OR and discussed the possibility for the emergency physician to administer ketamine sedation and fluid resuscitation during an unexpected crash section when there was no emergent patient in the ER.



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Il Destriero

That is awesome!!!

 

[Neogenesis]

That is awesome!!!

Agreed. I really like that.

 

[deleted50478]

Your facility should have crna backup. The surgeons and OBs would be happier= more business, the patients will be better taken care of, and if the crnas almost never get called in it should be pretty cheap.
I used to do solo call OR + OB with crna backup, a slowish OR and 30 deliveries a month, and I only had to call in my crna backup once or twice a year. They were paid a reasonable amount, certainly more than what the actual work demanded, but it beats making surgeons wait 8 hours or having stat c sections while you are stuck in the OR.

 

[Neogenesis]

Your facility should have crna backup. The surgeons and OBs would be happier= more business, the patients will be better taken care of, and if the crnas almost never get called in it should be pretty cheap.
I used to do solo call OR + OB with crna backup, a slowish OR and 30 deliveries a month, and I only had to call in my crna backup once or twice a year. They were paid a reasonable amount, certainly more than what the actual work demanded, but it beats making surgeons wait 8 hours or having stat c sections while you are stuck in the OR.

Agree. That is a great way to do it (my opinion), but alas, I am merely a hired gun in this situation so I'll take it as it comes. If it becomes a problem, I'm under no obligation to come back.

 

[anbuitachi]

will that work in a state that requires supervision?? can the attending be in one OR and crna be another??

 

[IlDestriero]

The OB can supervise. I'm sure they'd rather cut the crash CS with the CRNA than try to do one with local.


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Il Destriero

 

[Mman]

The OB can supervise. I'm sure they'd rather cut the crash CS with the CRNA than try to do one with local.


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Il Destriero

they certainly can do that, but their liability skyrockets in a patient population that has one of the highest rates of a bad outcome.

 

[MoMoGesiologist]

So with CRNA back up, if you are in the OR doing an emergent or elective case, what happens if a stat crash CSx rolls back? Does the CRNA have 30min to show up? Or do they get called in whenever you are in the OR?

At my place, we always have to have one free resident on the OB floor for any potential OR emergencies that may come through triage.

 

[Man o War]

So with CRNA back up, if you are in the OR doing an emergent or elective case, what happens if a stat crash CSx rolls back? Does the CRNA have 30min to show up? Or do they get called in whenever you are in the OR?

At my place, we always have to have one free resident on the OB floor for any potential OR emergencies that may come through triage.

Yeah, at my old place we had a fairly busy OB service. We always had one doc in house and 2 CRNAs on OB 24/7. 2 worked the day 12 hour shift and 2 worked the night 12 hour shift. We paid a differential for the night shift and always had takers.

 

[Mman]

So with CRNA back up, if you are in the OR doing an emergent or elective case, what happens if a stat crash CSx rolls back? Does the CRNA have 30min to show up? Or do they get called in whenever you are in the OR?

At my place, we always have to have one free resident on the OB floor for any potential OR emergencies that may come through triage.

In small hospitals, the person on call is at home, or at least that's my experience. They don't have OMG screaming to the OR emergencies and even if they have a case that would get that treatment elsewhere, they are almost universally not set up to be able to handle it that way. Small hospital OBs tend to have low risk patients and they tend to be conservative and call a c-section very early in the process if it's not looking good rather than have it become an emergency later on.

The financial realties of small hospitals essentially preclude them having always have an anesthesiologist or CRNA free and waiting for the emergency that might only happen once a year.

 

[ElmerFudd]

I started doing some locums work at a small community hospital providing weekend coverage. When there, you are the only Doc and cover both main OR and L&D (about 35-50 deliveries a month). There seems to be a fair amount of fighting over when and how surgeons can utilize the OR in otherwise non-emergent cases. (I.e. No OR cases if there is a laboring patient at all). The guidance I received from the normal Anesthesia folks was that the decision needed to be made between the surgeon and the OB and that we don't make the call.

I'm just wondering if any of you who work in similar environments could share how it goes at your places. What is the culture? What are the policies you have in place? Any tips?

No OR cases if there's a laboring patient? Even if they don't have an epidural in place?