ACOG Green Journal Publishes Dr. Klatt’s Article

ACOG Green Journal Publishes Dr. Klatt’s Article

Physician Needs Help Stat in Room 3

by Timothy E. Klatt, MD

It happened when I was working in an adverse medical–legal environment. A little more than a year after completing my residency, the charge nurse slammed through the door into the operating room and shouted that I was needed in room 3. The physician there had delivered the baby’s head but was unable to deliver the shoulders. I was performing a repeat cesarean under epidural anesthesia. We had just displaced the bladder out of the operative field and were about to incise the uterus. The charge nurse’s request surprised me. The unit was busy that morning, and I was pretty sure that a number of other obstetricians were readily available. Even so, I respected her judgment and knew that she would not call me out of surgery unless this was an emergency and no other options were available. I asked the resident to place a warm, wet sponge over the field, leaned over the drape and said something quickly to my patient and her husband, tore off my gown, and ran down the hall after the charge nurse. On the way into room 3, I passed at least six (I didn’t count as I was moving fast) physicians of vastly more experience sitting at the nurses’ station just outside the room. None of them followed, and one recommended against going into the room. The physician in the room was unpopular and often disruptive and was generally considered a low performer.

A little puzzled, I entered the room. As I gloved, I asked the physician for a quick summary. The patient was healthy, her baby was not expected to be large, examination had shown an adequate pelvis, and, despite a number of maneuvers, the shoulders remained stuck. This matched what the charge nurse had yelled as we ran. As I performed my own examination, the patient’s primary nurse repositioned the patient and we were able to deliver the baby with only suprapubic pressure and the McRoberts maneuver. The baby responded rapidly to resuscitation. I then stepped out. Most of the experienced obstetricians, including I could now see, one of the involved physician’s partners, pretended nothing had happened. The one who tried to warn me opined that I would someday learn not to do this.

Fast forward about 16 years to morning rounds recently where we discussed a case of shoulder dystocia that had occurred the previous night. As the discussion progressed, a few of the senior residents and faculty shared a sampling of their worst shoulder stories, including a few pearls related to their favored techniques. One then shared the story of a very difficult delivery at a nearby institution that resulted in a long delay in delivery, poor Apgar scores, a blood gas consistent with severe metabolic acidosis, and unilateral brachial plexus injury. This person reported that a highly skilled obstetrician in our community had responded to the primary attending’s request for help and, with great difficulty, finally accomplished the delivery. I commented on how great it was to now work in a state with a favorable medical–legal climate, where, even in cases such as this that could result in litigation, providers readily help each other. Sadly, the resident then listed a number of attendings who had not responded to the request for help. Others shared similar stories.

Why, in all of these cases, did qualified physicians decide not to help one of their colleagues and a patient in need? We will all need help someday. One physician alone cannot consistently deliver optimal outcomes. Maybe those who did not respond felt themselves unqualified; maybe they were not comfortable with shoulder dystocia or felt that they were less skilled than the provider already in the room. Superior skills are not always required. Often the most valuable contribution a respondent can offer is a fresh perspective, unencumbered by recent experiences and the resultant emotions.

In the first case, the physician who requested help was considered by other staff to be an unpleasant, low performer. Perhaps the more experienced physicians felt they had already bailed out this physician too many times. Even so, allowing potentially preventable harm to occur is not the appropriate action. If we observe truly substandard care, it is our unwelcome duty to submit objective documentation of the event to the review, decision, and follow-up processes at our hospitals. It is not enough for physicians to talk quietly among ourselves. Medical staff leaders cannot act without objective data.

I had thought for a long time that the legal climate was the problem, but this issue occurred and continues to occur in my current, favorable legal climate, where lawsuits are rare instead of common and my professional liability insurance costs a small fraction of what my former partners pay today. The perception of assuming unnecessary risk may be the issue. Perhaps those who decided not to help were scared by stories about physicians who had responded and were sued. Maybe, even worse, they had been scarred by personal experience. A recent American College of Obstetricians and Gynecologists survey showed that 77.3% of Fellows have been sued.1 Being a defendant can be one of life’s most stressful experiences, and this stressful period can last several years while the case moves toward resolution. Defendant physicians may experience a wide range of distressing emotions. Their personal lives, the lives of their families, their relationships with patients, and their medical practices can be disrupted. Physicians may need help from professionals to cope with this stress.1 Why should we expose ourselves to these risks when even payment for rendering assistance is uncertain?

As physicians we routinely expose ourselves to risks, such as communicable diseases, while caring for those in need. Perceived medical–legal risk should not hold us back. Many of us have taken a modernized version of the Hippocratic Oath similar to the Declaration of Geneva, where we “solemnly pledge to consecrate our lives to the service of humanity” and recognize that “the health of [our] patient[s] will be our first consideration.”2 Even though, initially, I had no formal, legal patient–physician relationship with the woman and her baby 16 years ago, I considered them my patients the moment the charge nurse crashed into the operating room. A few months after our morning rounds session, I had the chance to talk with the responding physician in the recent case. He felt the same. We discussed that these cases are not unlike the cases in which women unknown to either us or our practices arrive at our hospitals’ doors seeking emergent care: high-risk cases for which we regularly assume responsibility. We also shared examples of when, with little notice, we assumed responsibility for the care of other providers’ patients for issues such as a fetal heart tracing necessitating emergent intervention, because their provider, for whatever reason, was unable to respond quickly enough.

As physicians, we are called to assist those in need, even when it may place us at risk. It is an honor when another physician asks you for help. My previous chairman said it best: “The life of a physician should not be one of ‘being comfortable.’ If you are not occasionally uncomfortable then you are not doing the best you can for your patients.” Go when called.

Article in ACOG’s Green Journal