er vs. ob the battle goes on sort of

  1. i truly don't know how to make this short, but i'll try.

    i work in ob in a small community hospital. we are a level one facility w/ no ob dr. in house after hours. if we need the dr we call him or her at night and they come in. if it's a big problem, they are almost always very good about coming in.

    we triage or should i say we did for things like r/o labour, ptl ,uti's, etc. for awhile, we like most other similar units were getting pt's from the er w/things like "i have bronchitis, but i am six months pregnant." so up to ob they go. we even got a spanish speaker who was thought to be pregnant (because she had a round belly) and looked to be in pain. turned out she was 10 weeks w/ constipation. this went on for years as it does in many hospitals and yes it was irritating.

    Now our er triages pregnant pt's unless they are at term and appear to be in labour. this is very troubling to me. no, i don't want to see your broken arm if you are six months pregnant and otherwise o.k., but this weekend was a real eye-opener to me. they had not let our staff in on the policy change yet, but the er knew about it.

    i get a call from the er about a lady 25 weeks w/ cramping and bleeding. they are asking if the ob dr. happens to be in the house. no he is not. o.k. we'll see her and then maybe we'll send her up to you. her ob physician comes to our hospital,btw. huh? to me she needs efm and a ve. maybe she's in ptl. hard to evaluate w/o monitoring and ve unles dr. (hahaha) or er nurse (she's got all the time in the world right?) is gonna stand there and palpate uc's. i thought this was totally bizarre that they were keeping this pt., but i offerrred to send down the prenatals, but they didn't think they needed them. (in mean time i called ob dr. on call who informs me this is the NEW policy, but he is not as angry w/ me as he could've been considering i woke him up at 00:30)so they keep her for about 30-45 min. and send her to be monitored. bleeding is very miniscule and occurred a few days ago and has mostly resolved. they did spec exam and cervix was closed. she c/o cramping, but i don't see and can't palpate uc's. i po hydrate her. they get better, but she still feels a little lower abd. crampiness. so i call er and ask to send clean caught uac on the off chance she has a uti. well why? i was just told to monitor her. that's all. why do i think i have to do anything else for her. (not that the er dr. interprets the strip. ob dr looks at it the next a.m.) then i go through the whole explanation of how and why a uti could cause these sx's. why is er dr. tx'ing pt. if he doesn't know uti could cause this? scary to me.

    next pt. is a very young young girl in the early third trimester w/bleeding and cramping after intercourse. they triage her too. she is losing her baby. spec. exam shows bulging membranes. we get her. she delivers for ob dr. ob dr. was called by er (nice for us) and arrives just after we get pt.

    is anyone else doing this now too? am i way off to think if they have a pregnancy problem we should be seeing them. this is what we do after all. this is our area of expertise. management says it has to do w/ new emtala rules. please share your thoughts...
    Last edit by imenid37 on Mar 4, '03
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  2. 26 Comments

  3. by   cindyln
    wow! Any woman that walks thru our ER's door who is more than 20 weeks pregnant they don't even triage. Go straight to L&D, do not stop here.
  4. by   L&D.RN
    EMTALA states that you have to treat every same patient the same way...so if every pg pt is sent to L&D for the MSE, there's no problem.

    Our ER is the opposite, they send everyone who is pg, was pg, or ever will be pg up to us, like the pg pts have the plague!
  5. by   luv l&d
    Over 20 weeks they come to us. Even had on at 30 wks with acute MI come to us. Sent her right to tele. They had a fit, but the supervisor agreed with me. Honest to Pete, what do they think we are???
  6. by   dawngloves
    I broke my toe at 32 weeks and they wanted to send me to L&D! I told them no way are you sending me up there to get strapped to a monitor for an hour and BTW xray is right over there and it is 3 floors away from L&D! They let me stay.
  7. by   ShandyLynnRN
    our policy is anyone over 20 weeks, no matter WHAT the prob is, is to come to OB. If it is not OB related complicated prob... and EFM shows no probs, then they go back to ER.
  8. by   bagladyrn
    ShandyLynnRN - that sort of policy is why I have seen an accident victim on a backboard with a collar on rolled down the hall to OB before being triaged! We can always roll a monitor down to ER (have done it many times), but I think it's a question of priorities and common sense.
  9. by   kids
    Originally posted by imenid37
    ...next pt. is a very young young girl in the early third trimester w/bleeding and cramping after intercourse. they triage her too. she is losing her baby. spec. exam shows bulging membranes. we get her. she delivers for ob dr. ob dr. was called by er (nice for us) and arrives just after we get pt.
    I am the VERY first one to admit that L&D is not my thing (I prefer babies after they are born and cleaned up).

    Wouldn't this babe be around 27-28 weeks gestation?

    What was the out come for the baby?
  10. by   ShandyLynnRN
    well, I haven't seen any actual MEDICAL emergencies sent to OB. The one time I can think of was a 31 weeker with seizures, turned out to be eclampsia, but they just called me to the ER and treated her there, and straight from there to the OR...
  11. by   sbic56
    Hard to believe a patient with a non-pg related emergency would be diverted to OB! That's ridiculous. That is treating the pregnancy as an illness in and of itself. And what in the world are the ob nurses going to do with an MI?? Every patient should be triaged and treated for the presenting emergency. Do a strip or whatever later, but get the priorities straight!
  12. by   deespoohbear
    I also work in a small hospital, except I work med/surg, not OB. Over the weekend we had a situation where a mother delivered a full term stillborn infant at home but the placenta never delivered. She was brought to the hospital and into surgery for removal of the placenta. By the time surgery is over, she is about 6 hours post-partum. Guess what floor got her? Med/surg. Not OB. Why? I have no freakin' idea but I wouldn't know where the fundus was suppose to be if it came up and slapped me. Our facility is just the opposite. Unless the patient is full term and ready to go, OB doesn't want them. (they will take pre-term labors). Otherwise our floor gets them. One time we had a woman who was pregnant with twins 34 weeks along. She was having abd pain but the pain wasn't contractions. We begged the doctor to put her in OB for EFM monitoring. His reply was, her problem isn't OB related. Maybe not, but sure as hell could be real quick. Ended up having the woman transfered to a facility with a NICU-the woman had an acute appendicitis.....go figure. And another time we had a lady who delivered at home and ruptured her uterus during delivery. Guess what department got her? Med/Surg.

    My theory is if the woman is far enough along that the baby is viable and she is not contagious she should go to OB (unless it is something critical such as the MI mentioned in a previous post). Just as an OB nurse doesn't know what to do with an MI patient, I sure don't know diddly about OB....just my .02 worth....
  13. by   bagladyrn
    deespoohbear - regarding the term stillborn delivery - it's not unusual for mothers who have lost a child to be moved off OB, especially if they express that preference. Sometimes being within hearing range of mothers and babies is just too much for them. However, I think your OB staff should have come over for fundal checks, etc. to help out.
  14. by   mark_LD_RN
    Originally posted by luv l&d
    Over 20 weeks they come to us. Even had on at 30 wks with acute MI come to us. Sent her right to tele. They had a fit, but the supervisor agreed with me. Honest to Pete, what do they think we are???
    same way here! supposedly anything over 20 wks comes right to us if cleared by us they go to er. usually er just keeps sending them back like its the plaque or something

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