No physician in-house? - page 2

by winter_green 2,396 Views | 18 Comments

I'm wondering how it is like for those who work on L&D unit who do not have a physician in-house? I'm a little afraid of that because I'm looking at job and that's how it will be. At my old unit, we always had a physician on... Read More


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    Sorry, I wasn't finished and hit Post by accident. The national standard for emergency sections is that they be done in 30 min of when they're called. When I worked in the big city medical centers where we could have a baby out within 5 minutes of the helicopter landing on the roof, half an hour seemed forever. But it is reasonable. I delivered babies at the big teaching hospitals from time to time. I don't deliver that many more here. We work closely with our docs and when we say "come in now" they come. There is a shortage of physicians in my state and it is worse in our rural area. None of our docs are more than 20 min away, I'd be worried if one was an hour away.
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    There would be less issues with shortages if physicians would simply support and/or work with CNM's.
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    I am also in a situation where I used to work in a busier hospital with plenty of resources, and now work in a rural setting where the unit is only staffed with 2 RNs. I feel like my confidence level has increased by working here, and we have great working relationships with our physicians and they trust our judgement completely. Are there situations where things might have gone better with additional staff and resources? Of course. But resources are finite, and rural hospitals can only do so much.

    I will also point out that there needs to be a certain level of patient responsibility here. As a patient, if you live in a rural location you have to understand that you just can't have the resources of a bigger city. Hospitals have an obligation to make contingency plans for what to do when situations arise that are out of their scope of care, but patients need to fully understand the limitations of where they live and what that might mean for their medical care.
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    I worked at a facility similar to this for about 2 years. We didn't have doctors, anesthesia, or a surgery crew in house at night. Yes, it was scary at times, and there were outcomes that, unfortunately, may or may not have been different, had we had those resources. However, I do think agree with the statement someone made that everyone was very close knit and trusted and helped one another. We also had a very good relationship with the docs on call, where if we said we need you now, they didn't question, they just came. We had more issues with anesthesia and the surgery crew not being in house, not the docs. Yes, there were times that we caught babies because they docs didn't make it, but that happens anywhere, even bigger hospitals, where I currently work and I have those afore mentioned resources.
    To compensate for these things we didn't have, the facility had protocols and policies in place. You might check these things out to help with your decision. For example, we were all crosstrained to triage patients and in our SCN. So if we had bad babies, we were trained for resuscitation (NRP) as well as starting IVs and managing O2 on these kiddos. (we did have RT in house at all times). We also had rules that if a patient was on Pit at or above 20 milliunits, we had to have an OB in house. We also had to have someone in house if they were managing 2 or more labors consecutively.
    Believe me, there were definitely issues with patient safety at this facility, but they weren't contributed with not having a doc in house. I was working on the anesthesia and staffing issues before I resigned. But I was completely comfertable with the way the physicians were staffed.
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    I work in a small hospital. We do both L+D and Outpatient/Ambulatory care. We do not have a DR in house. I have worked here for 12 years and I love it. Not having a doc MAKES you step up your skills ASAP! I can intubate a NB with the best of them! Just learn from you older nurses and trust you gut!! If you have a bad feeling, listen to it, but don't be paranoid and calling the doc with every little thing. If you only call him when you need to, he/she will learn to trust you and will come anytime you say the word because they will trust your judgement. We have had pretty much all the OB emergencies here at one time or another (precip del, emergency c/s, abruption, previa, eclamsia, pph, not to mention all the baby's stuff), and we nurses work well together, and things work out OK.
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    I work in a small hospital.  We do both L+D and Outpatient/Ambulatory care.  We do not have a DR in house.  I have worked here for 12 years and I love it.  Not having a doc MAKES you step up your skills ASAP!  I can intubate a NB with the best of them!  Just learn from you older nurses and trust you gut!!  If you have a bad feeling, listen to it, but don't be paranoid and calling the doc with every little thing.  If you only call him when you need to, he/she will learn to trust you and will come anytime you say the word because they will trust your judgement.  We have had pretty much all the OB emergencies here at one time or another (precip del, emergency c/s, abruption, previa, eclamsia, pph, not to mention all the baby's stuff), and we nurses work well together, and things work out OK.
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    My local hospital has no in-house. We have only one group practice staffed by something like 8 providers. They see 2-3k births per year. All of the births are highly medically managed, with "required" continuous EFM, a c/s rate in the 40s, an epidural rate in the 90s (but good luck getting one if the on-call only anesthesiologist isn't in the building or is already in a procedure elsewhere), and generally very dissatisfied moms. You can either go there or drive an hour down the road, which has the same staffing, but significantly less medical management of labor, so much better experience and healthier outcomes. I have always wondered why our hospital doesn't just hire on a CNM or three, but I guess they don't see the need for it. I wouldn't work at this hospital here because of how terrible the care is in general, but I would work at the one an hour away, gladly. As a previous poster said, birth doesn't usually go wrong that quickly, and the occasions that it does are so, so rare. The providers that are on call have 30 minutes to arrive, but most times just stay in site when they know that they have someone in active labor. It works well for them.
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    I started at a larger center (4000/year) and moved to a rural hospital at my two year mark (1000-1200 a year approx with a huge cachement area). I started out terrified but after the first six months I loved it! Our docs were required to be no more than ten min from the hospital when on call and they stuck to that consistently. They could be a little crusty if I called them at 2 am to ask if I could send an assessment home but as we learned to trust each other our teamwork became more and more seamless. We had anesthesia but out of hospital and had a pretty low epidural rate (25% for multips and around 50% for primes). We had one of the lowest section rates in the country. I learned to do my own specs, FFN testing, apply FSEs and I got to know my patients in a way I never had in a bigger hospital. Often we would see someone 2-12 times in triage before they delivered and because we floated back and forth to post partum if ld wasn't busy we got to see them there too. We teletriaged and that was a whole new skill too!

    Was it always roses? No--sometimes you were holding your breath for peds and RT to get there for mec and a crappy strip, sometimes you bagged a baby until transport got there, sometimes you could tell someone was abrupting at home and you wouldn't find a FHR when they came in. But I always felt well supported and challenged and that we were practicing evidence based care. IA unless there were risk factors, induction only for medical reasons, letting people go home with SRM until the 24 hour mark etc. stuff I had only read about in books!

    I caught more babies there in the first three months I worked than I had in two years in the city! And our only Female OB was delivered by two of our RNs, and she knew that was a possibility and still chose to deliver with us.

    There is a sense of family in rural OB that I really miss (we recently moved back to the city and I'm working in a facility that does almost 7000 deliveries a year now)--I would go back in a heartbeat. But it does take a certain personality and comfort level that aren't for everyone!
  9. 0
    Quote from Fyreflie
    I started at a larger center (4000/year) and moved to a rural hospital at my two year mark (1000-1200 a year approx with a huge cachement area). I started out terrified but after the first six months I loved it! Our docs were required to be no more than ten min from the hospital when on call and they stuck to that consistently. They could be a little crusty if I called them at 2 am to ask if I could send an assessment home but as we learned to trust each other our teamwork became more and more seamless. We had anesthesia but out of hospital and had a pretty low epidural rate (25% for multips and around 50% for primes). We had one of the lowest section rates in the country. I learned to do my own specs, FFN testing, apply FSEs and I got to know my patients in a way I never had in a bigger hospital. Often we would see someone 2-12 times in triage before they delivered and because we floated back and forth to post partum if ld wasn't busy we got to see them there too. We teletriaged and that was a whole new skill too!

    Was it always roses? No--sometimes you were holding your breath for peds and RT to get there for mec and a crappy strip, sometimes you bagged a baby until transport got there, sometimes you could tell someone was abrupting at home and you wouldn't find a FHR when they came in. But I always felt well supported and challenged and that we were practicing evidence based care. IA unless there were risk factors, induction only for medical reasons, letting people go home with SRM until the 24 hour mark etc. stuff I had only read about in books!

    I caught more babies there in the first three months I worked than I had in two years in the city! And our only Female OB was delivered by two of our RNs, and she knew that was a possibility and still chose to deliver with us.

    There is a sense of family in rural OB that I really miss (we recently moved back to the city and I'm working in a facility that does almost 7000 deliveries a year now)--I would go back in a heartbeat. But it does take a certain personality and comfort level that aren't for everyone!
    Love it, I also work in a rural hospital and feel I am a way more diverse because of it! Especially when you deliver multiple family members, you get attached!!


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