"I'm not listening to you" says the doctor

[beachmom]

One of the peds is out of town for a couple weeks, and a locum tenens took his place. We had a 34 weeker in labor and needed a ped at the delivery, so we called Dr. "LT."

This is a small hospital that ships out early moms if we can, but it's 2-3 hours to the bigger facility, so this mom was going to deliver here. From Dr. LT's questions before the birth, I got the idea he didn't help with early deliveries. The big hospitals have specialists to attend early ones.

Our main nursery nurse that night, whom I will call "Jo", has over 20 years experience with babies and teaches our NRP classes. You would think experience and knowledge would trump a degree. But no.

At the birth, Dr. LT took over, did little according to NRP. Deep suctioned the mouth, then asked Jo for a smaller catheter to deep suction the nostrils. Jo respectfully told him that it was not indicated for a vigorous, screaming, baby at age 2 minutes. The baby might vagal down and lower his heart rate. The doctor insisted babies were obligate nose breathers, and he must be suctioned, and then he said "I'm not listening to you."

He pointed out some other things we were doing "wrong" when we were following NRP. When he decided to ship the baby, we all thought, "Good, then we don't have to deal with you anymore." Baby was doing well, so I gave him some skin on skin time with mom while waiting for the team. I felt sad for the parents. The other peds would have kept the baby here.

Moral to the story: I am SO thankful for the peds that we have here.

[LibraSunCNM, BSN, MSN, CNM]

What a nightmare! So sorry you had to deal with that. Kudos to you for advocating for the baby (even if he didn't listen) and for the mother by giving her some precious STS time before the transfer.

[CrufflerJJ, BSN, RN, EMT-P]

The doctor insisted babies were obligate nose breathers, and he must be suctioned, and then he said "I'm not listening to you."

Being kind, sensitive, and ever sarcasm-free, I'd have been inclined to respond "Huh? Did you say something?"

[Jolie, BSN]

I would like to encourage you to take this case to your department manager, medical director (when s/he returns), QA committee, hospital risk manager, chief of medical staff, and anyone else up the chain of command, in order to prevent a repeat performance.

My sister is a very busy medical specialist in a small town. She is rarely able to get coverage and when she does, she goes far, far away for well-deserved rest and relaxation. Your pediatrician is entitled to the same, but the care delivered in his/her absence needs to be the same standard as when s/he is present. To do otherwise is unfair to the patients and legally dangerous. If the rent-a-doc hired to cover vacations is not capable of providing care in your unique setting, due to lack of training, experience, current practice or attitude, it is imperative that other arrangements are made in the future.

Dinner's ready. I'll be back to complete my thoughts :)

[sauconyrunner]

Jolie is on the money! You need to write it all down and let the regular physicians know. That way you don't get the same locums back. We had a guy like that, he was HORRIBLE to me personally and then to several others. Once our Hospitalist found this out...that man was pretty much banned form the facility... very nice.

[Jolie, BSN]

I spent 12 years working in all aspects of OB and NICU, so I understand very well the differences between small outlying hospitals and referral centers, including the expertise of the medical and nursing staffs. The person who hired your rent-a-doc obviously does not. General pediatricians in medium to large-sized cities rarely, if ever, see the inside of a delivery room or NICU. That care is delivered by NNP's, neonatologists, medical residents, RNs and RRTs, any of which would have been better qualified to manage your little patient than the non-NRP trained pediatrician you had. But then, you already know that. The important point is to convince your hospital administration to choose more wisely next time. When you review this newborn's care with the pediatrician upon his return, I suspect that he'll want a different fill-in next time. The OB will probably be on your side as well, since they don't like to see their patients separated needlessly from their long-awaited infants.

And to win over the QA/Risk Management people, consider this lesson taught by a very wise neonatologist to a group of fresh-faced new NICU transort nurses: Neonatal transport is not a benign procedure. It is one fraught with risks and hazards, the most likely and most serious being the rapid deterioration of the infant's condition during the transport process. There is no faster way to take a mildly ill borderline preemie, and cause him to become him critically ill and dependent on life support, than to load him into the back of an ambulance for a bumpy 2 hour ride to Big City. Or worse yet, put him in a helicoptor.

In the process of doing so, even the most skilled transport clinicians will test the baby's ability to maintain thermoregulation, glucose control, spontaneous breathing, and hemodynamic regulation. Risks during transport, other than the obvious motor vehicle crash, include hypothermia, unstable glucose, respiratory failure, and blood pressure fluctuations that can lead to intracranial hemorrhage or hypo perfusion of vital organs.

So at the very least, this pediatrician took a baby stable enough to rest on his mama's chest, interrupted a critical bonding period, subjected him to a multitude of physical risks and created tens of thousands of dollars in health care expenses to send him "up the road." I think that's worth a review upon your pediatrician's return. Good luck!

[GitanoRN, BSN, MSN, RN]

i applaud the seasoned nurse for her ethical efforts on trying to lookout for the patients welfare, my hat goes off as i bow for her professional gesture

[NicuGal, MSN, RN]

I would write that incident up and take it to the managers and your practice council. I do have to ask, does your nursery routinely take 34 weekers as a level 2 nursery? Maybe you need an algorithim set into place that outlines if a baby can stay or not. Even in our hospital, 34 weekers go to NICU for at least 24 hours since those can be tricky kids and may seem good for the first 4-12 hours and then take a route down the I need surfactant and can't keep my glucoses up. I used to do transports and we did prefer air over ground for what Jolie said, but it is up to the referring doc to make that call or else insurance won't pay for transport.

[babyktchr, BSN, RN]

Grrrrrr. This always burns me. This needs to go to your facilities risk department AND to the medical staff office. You DO NOT want this person back. Medical staff department is responsible to make sure that the docs/num nums they bring in are qualified and credentialed. This is also generally where you find out how far out of standard your present credentialing criteria are (because they don't get updated when they should). Locums are VERY VERY expensive, no matter who pays (the doc who is being covered or the hospital), so hearing complaints is the ONLY WAY you won't get this one back. Also, if they used a service to find this particular locum, they will be contacted about their behavior and perhaps will not be used again period. Ultimately, you have to write it up to get anything done.

I have personally been involved with 3 less than desirable locums and successfully had them removed from our facility. One of the things we did find was that the pediatric department had not updated their credentialing requirements in years, so having NRP was not on the list Needless to say, that was added as well as some other things. You would really be surprised at how many docs in this arena do NOT keep up on their NRP certification.

Write it up. Period.