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ER covering deliveries/neonatal resuscitations

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  • Avatar trebizond 
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    Let me also add that I would be hard pressed to believe many (any?) general peds primary care attendings or hospitalists would feel comfortable with being the person to cover disastrous deliveries, neonatal intubations, etc. There’s a reason they do a NICU fellowship to get *somewhat* comfortable with these scenarios.

    #198294 Reply
    Avatar snowcanyon 
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    NICU is not an option at a small hospital- maybe NNPs, but we don’t have a NICU. Peds has been doing it but now refuses.

    #198296 Reply
    Liked by Zaphod
    Avatar SValleyMD 
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    Not only does that sound like a logistical nightmare and possibly a soul scarring traumatic experience waiting to happen, but it also puts you in the crosshairs of the absolute worst case scenario from a malpractice liability standpoint of a Lifetime of lost wages and emotionally ruined family. I wouldn’t want my name 10 feet from that chart.

    #198298 Reply
    Avatar snowcanyon 
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    Agreed on all these points. Not worth it. Hopefully they will give us a few months notice so I can give notice 🙂

     

    #198302 Reply
    Zaphod Zaphod 
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    We do have telenicu, but I’m not really sure what they can do.

    Click to expand…

    “you’re doing great buddy, just like that…hey hon what did Cersei say?!, no sorry, talking to my wife”.

    #198307 Reply
    Avatar G 
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    do I quit over this?

    Click to expand…

    I would.

    I would also tell the CEO that if he/she really wanted to save money, he/she should come in and mop up the amniotic fluid after each delivery.

    This attitude has been effective to keep me off of additional BS hospital committees.

    #198309 Reply
    Avatar SLC OB 
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    It’s not just NRP but arranging transfer (this can take hours in the winter) and taking care of the baby until the chopper or ground arrives. With single coverage.

    Click to expand…

    The L&D RN’s should all be trained in STABLE (which is the part after NRP before the transfer can occur).

    Things I would image you would have to do… intubate (does your RT do this? I’m in a rural hospital and they manage all the airways for our neonatal resuscitations), put in an umbilical line (super easy! Especially for an ED doc who is use to procedures), and get the tele-NICU on the line for instructions/orders (They will look at x-rays, help order/dose meds, decision to transport, interpret lab values (oh so very different in the little guys).

    The nurses should do the rest.

    HOWEVER, how can the pediatricians refuse to see their patients? Are they not being required by your bylaws to take call? How can they refuse to come in? I bet, if you don’t want to do this, then go to your Bylaws or Rules/Regs, bet there is something in there.

    As an OB in a rural setting, I know NRP and can intubate my own babies, if needed, as I know that in a snow storm, I may be the only one there to do it. My partners refuse to be NRP certified, I think that is just too much risk. Likely I will never have to. I have had to put in an umbilical line (sometimes I wish I could just do it instead of watching the peds struggle to do it with shaking hands!) and was glad I was there, since RT and RNs can’t do that (without special training).

    Good Luck!

    #198312 Reply
    Liked by Zaphod
    Avatar HopHunter86 
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    #198368 Reply
    Liked by Vesalius
    Avatar mpdoc 
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    I am trained in IM and peds and there is nothing that scares me more than a crashing neonate, especially one that’s slippery, cold, blue, and apneic right out of the womb. I can recall more than a few cases of babies coming in where someone who was not a neonatologist had attempted intubations and it was….not good. Hypoxic ischemic encephalopathy with seizures and encephalomalacia, intraventricular bleeds with cerebral palsy in the VLBW infants, etc.

    Your adult based instincts which carry over relatively well into PALS will be wrong. It’s not compressions, fluids, epi, and shock. It’s intubate them (meconium everywhere), bag them, warm them, some fluids and pretty quickly pressors.

    I would recommend you say hard no and if they try to push this crap you walk. It’s just not worth the knowledge that with inadequate training you may have played a role in a kid being bedbound and neurologically devastated for life because of prolonged hypoxia and hypotension because there was no 2.5 tube around, no appropriate laryngoscope blades, and you didn’t know how to put in umbilical catheters. Nor the lawsuits that will be sure to follow.

    Click to expand…

    Also IM and peds trained, agree 100% with the above – there is nothing worse in all of medicine than a baby going bad in the delivery room.  We attended hundreds of deliveries in residency and even when you’re trained and do it regularly it’s still a high pressure, high risk situation where seconds count, and if you aren’t competent and up to speed on NRP this is a recipe for disaster.

    #198542 Reply
    Liked by Vesalius
    Avatar Wiscoblue 
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    “The anesthesiologists are in house. Let’s dump it on them! They intubate kids everyday!”

    This is what happened at my hospital 10 years ago. The neo group from the neighboring town that had been covering us asked for a subsidy and our ceo turned them down. Then he started looking around to see how he could get free neo services from our group. We said a hard no. None of us are trained in neonatal resuscitation and we are in charge of the mother during a section. We are not putting our license on the line so the hospital can save a few bucks. Then they tried the ED guys and they also turned it down. Hospital ended up having to pay the neo group and bring them back in!

    #198543 Reply
    Vagabond MD Vagabond MD 
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    I would also tell the CEO that if he/she really wanted to save money, he/she should come in and mop up the amniotic fluid after each delivery.

    Click to expand…

    I love this!

    Reading this thread scares the crap out if me, and it’s not even me on the line.

    "Wealth is the slave of the wise man and the master of the fool.” -Seneca the Younger

    #198545 Reply
    Liked by Vesalius, Dusn, Anne, Zaphod
    Avatar Anne 
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    Status: Physician
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    Sometimes it’s most effective to have the patients fight the battles for you, especially those battles where they are really the ones who could potentially get hurt.

    How many expectant mothers would be upset if they found out that the doctors being asked to potentially save their newborns lives have limited expertise and practice in this area and may be simultaneously responsible for other emergencies in the same hospital?

    Word travels quickly in small communities.  It’s never clear where the rumor started.  Just saying.

    #198550 Reply
    Avatar Dilaudidopenia 
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    Status: Physician
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    I think this is one of those circumstances where the “emergency fund” turns into the “F-U” fund.  I would quit so hard and use that E-fund to fund expenses if need be while I found another job.  Totally inappropriate.

    #198570 Reply
    Liked by Vesalius
    Avatar Wiscoblue 
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    Status: Physician
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    We actually called our malpractice insurance company and found out that our premiums would increase if we were to take on this additional responsibility of covering neonates. It was quite easy to say no.

    #198576 Reply
    Liked by Zaphod, SLC OB, MPMD
    MPMD MPMD 
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    Status: Physician
    Posts: 1969
    Joined: 05/01/2017

    I am trained in IM and peds and there is nothing that scares me more than a crashing neonate, especially one that’s slippery, cold, blue, and apneic right out of the womb. I can recall more than a few cases of babies coming in where someone who was not a neonatologist had attempted intubations and it was….not good. Hypoxic ischemic encephalopathy with seizures and encephalomalacia, intraventricular bleeds with cerebral palsy in the VLBW infants, etc.

    Your adult based instincts which carry over relatively well into PALS will be wrong. It’s not compressions, fluids, epi, and shock. It’s intubate them (meconium everywhere), bag them, warm them, some fluids and pretty quickly pressors.

    I would recommend you say hard no and if they try to push this crap you walk. It’s just not worth the knowledge that with inadequate training you may have played a role in a kid being bedbound and neurologically devastated for life because of prolonged hypoxia and hypotension because there was no 2.5 tube around, no appropriate laryngoscope blades, and you didn’t know how to put in umbilical catheters. Nor the lawsuits that will be sure to follow.

    Click to expand…

    Also IM and peds trained, agree 100% with the above – there is nothing worse in all of medicine than a baby going bad in the delivery room.  We attended hundreds of deliveries in residency and even when you’re trained and do it regularly it’s still a high pressure, high risk situation where seconds count, and if you aren’t competent and up to speed on NRP this is a recipe for disaster.

    Click to expand…

    A few years ago I thought I was going to have to handle a precip twin delivery with no prenatal care and unclear dates. Mom yelling that she needed to push, thought she was about 27 weeks pregnant with twins.

    I don’t sweat at work hardly ever but….

    #198592 Reply
    Liked by Vesalius, Zaphod

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