No physician in-house?

KJM10 · Apr 28, 2012

I interviewed and was offered a job with a similar situation. No residents or physicians in house, just on call. It was a smaller hospital so there was only 2 nurses on each shift, no SCN or nursery nurse and minimal ancillary staff just a tech/clerk.

I was told that the ER Dr's would come up and "help put in your IV's and stuff if a pt was imminently delivering and OB Doc wasn't there yet". Um, I don't need the Dr to start my IV... Needless to say, I declined the offer even though it was 12 hr shifts, much closer to home and full time. Just the thought of not having a Dr or resident to bounce things off of, or step in when needed made me too nervous. I didn't feel like it was safe for my patients or my career.

To be fair, I am a newer nurse with only 1 1/2 years experience and if I were more seasoned maybe it wouldn't have seemed so overwhelming but I cant imagine it would have been a good situation for me.

I would imagine that in this type of unit the nurses have to work together, as there are many situations where you need support and assistance. Even with Docs and Residents we need assistance from each other sometimes.

You could always ask the nurse manager when you interview how well the staff works together and how situations like this are handled.

Good luck with your decision!

NurseNora, BSN, RN · Apr 29, 2012

I was terrified when I started working in a small hospital with no in house OB docs after over 30 years working in large teaching hospitals where I sometimes had to fight my way through the med students, interns, residents, fellows, and perinatologists to get to my patient. I've found that we have a good relationship with the docs and they trust that when we say, "I need you to come in NOW." they come without much question.Yes, I've delivered more babies here than I did in the bigger places, but not that many more. I may get a really bad cramp in my hand holding the head up and off a prolapsed cord because we can't do a section as quickly as we could in the bigger places. I had to learn a new set of reflexes to work here. In the bigger places, we'd watch a strip that was not looking too good because we could react so rapidly if things went bad. Here, since everything takes longer, we react sooner. It's scary at first, but there are advantages to working in a small place. It may be worth your while to give it a shot.

passionflower, BSN, MSN, RN · May 10, 2012

Honestly, it can be terrifying. Labor is fast and unpredictable and i really dont know how any place gets away with not having a dr or midwife in house at all times.

NurseNora, BSN, RN · May 10, 2012

Birth is not a disease process, it's a normal natural physiological event that goes very well most of the time. When a problem does develop, most of the time it develops gradually and there is time to get someone there. Yes, there are rare occasions when not having a provider in house results in a bad outcome. But I practice in a rural area. If we closed because we don't have 24/7 in house coverage, the nearest hospital that does OB would be 3 1/2 hours away. This would open the door for even more possibilities of bad outcome. That's how we " get away" with not having someone in house at all times.

dreamworx07 · May 11, 2012

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 call. It was nice to have a physician who was always available to us because especially night you never know what can walk through.
I am nervous to accept a job like this because I don't feel as confident taking care of my patient from labor to pushing, then having my doctor just pop in and catch the baby. Is it like that everywhere? My old unit, doctors would come by and check in time to time.
What if I can't get a good examine on vag exam? Will my fellow co workers mind if I need to ask someone to double check after my exam???
Any thoughts? Input?

I have been working L&D at a small rural hospital for 8months. No Dr or midwife in house. At night they are sometimes an hour away. No OR team, no nursing supervisor and no ancillary staff to speak of. And sometimes a baby nurse is hard to come by. Epidurals take an hour to get someone in, and if i was to call an ER doc to come help, they would think we had lost our mind! Two nurses on duty (if we are lucky). I have been a nurse for 15 months. I can honestly say I have delivered my share of babies- fretted for hours over ugly strips and recovered not so healthy babies. I has been a great experience and it makes me realize I am much Better prepared than I would have been working at a big hospital. I recommend everyone to Try a small hospital, you will probably enjoy it!

PetsToPeople · May 11, 2012

Wow, I can't believe this stuff!

passionflower, BSN, MSN, RN · May 11, 2012

Birth is not a disease process, it's a normal natural physiological event that goes very well most of the time
When a problem does develop, most of the time it develops gradually and there is time to get someone there. Yes, there are rare occasions when not having a provider in house results in a bad outcome.
But I practice in a rural area. If we closed because we don't have 24/7 in house coverage, the nearest hospital that does OB would be 3 1/2 hours away. This would open the door for even more possibilities of bad outcome. That's how we " get away" with not having someone in house at all times.

Most of the time? - What about the times it does not go well and could have had a better outcome had the provider been in-house. I know things happen but this should not be because of inadequate staff. We are talking about two lives here.

You say Yes, there are rare occasions when not having a provider in house results in a bad outcome.

- Again why is this okay with anyone?

I understand your dilemma about the rural area - other areas do this as well but It is not the responsibility of the nurses to staff physicians and this is a practice that should not be acceptable. It puts all of the nurses licenses in jeopardy. Each time I'm on a delivery I hold my breath waiting on the provider when mom has a contraction because I never know if this one will be the one that goes bad. I can deliver that baby but rather the doctor did, that provider went through many hours and years of training and it wasn't for nothing.

Please don't take this the wrong way, not trying to be harsh but we should be speaking up for each other about unsafe practices labor is a litigious area and we should not be stacking the deck against safe practice. If something went wrong because the doc was an hour away and the nurse caught the baby the RN would be hung out to dry. It's really not a lot to ask to expect the provider to be at the delivery and we should stop thinking that it is.

stephienichole23 · May 11, 2012

Most of the time? - What about the times it does not go well and could have had a better outcome had the provider been in-house. I know things happen but this should not be because of inadequate staff. We are talking about two lives here.
You say Yes, there are rare occasions when not having a provider in house results in a bad outcome.
- Again why is this okay with anyone?
I understand your dilemma about the rural area - other areas do this as well but It is not the responsibility of the nurses to staff physicians and this is a practice that should not be acceptable. It puts all of the nurses licenses in jeopardy. Each time I'm on a delivery I hold my breath waiting on the provider when mom has a contraction because I never know if this one will be the one that goes bad. I can deliver that baby but rather the doctor did, that provider went through many hours and years of training and it wasn't for nothing.
Please don't take this the wrong way, not trying to be harsh but we should be speaking up for each other about unsafe practices labor is a litigious area and we should not be stacking the deck against safe practice. If something went wrong because the doc was an hour away and the nurse caught the baby the RN would be hung out to dry. It's really not a lot to ask to expect the provider to be at the delivery and we should stop thinking that it is.

I work nights in a hospital that does not always have a physician in house. They are anywhere from 20-30 minutes away at times. It requires you to be quick on your feet and work as a team, as our nurses do. There are plenty of really busy nights and nights that you need the doctor there and it's up to you as the patient advocate to get on the phone and tell your doctor that you would feel more comfortable with them there, sleeping in a call room if necessary, because of a questionable strip. You document that you spoke to the physician, that the physician acknowledged and whether they felt they needed to come in or not. There are programs with EMR that are allowing the physicians to log in to the strips from a home or office computer now. If your hospital hasn't done this ask them if they have planned to do this or if it's something they have considered. When the doc isn't in house this is another way for them to make a well informed decision about the status of the patient and baby. Ultimately is a choice. Watch your strip, if ANYTHING looks questionable let your physician know. If it just doesn't seem right, let your physician know. They might be irritated your waking them up in the middle of the night, but they'll get over it, especially if you see something that prevents a bad outcome. It can be quite exciting working at night in LDR. Women roll up 6-7 cm or complete and have babies in 10-50 minutes from being put on the monitor. The natural deliveries are amazing and there are less inductions it seems. I was scared to death when I first accepted a night position right out of school, 7 months ago, but I love it. The team of nurses I work with are incredible and I have never felt like I've been left out to dry. Good luck in whatever decision you make. I do agree that in the emergent situation it would be nice to have a doctor in house (even if it was an ED doc that could intervene in some way) there to help, but we can't staff for emergent cases and full census all the time, it wouldn't work for budgets, productivity, and insurance reimbursement (which sadly seem to run the medical work now). Just things to consider when making the decision to work in a smaller hospital. :)

NurseNora, BSN, RN · May 12, 2012

Americans have an expectation that every pregnancy must result in a healthy baby and a healthy mom. It would be nice if it did happen that way, but the reality is that despite the best care in the world, some babies will be damaged or die and some mothers will die. I have lost moms when I worked in big city medical centers with lots of attendings

NurseNora, BSN, RN · May 12, 2012

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.

PetsToPeople · May 14, 2012

There would be less issues with shortages if physicians would simply support and/or work with CNM's.