The hospitalist’s role in the critical care team

Contemporary OB/GYN:  Not all institutions have hospitalists on staff. Explain the role of the hospitalist in your institution during times of emergency. 

Rakhi Dimino, MD, Medical Director of Operations, Ob Hospitalist Group: The hospitalist team is the glue that makes a unit stick together and act like a team. It’s part of our duty to understand what the resources are in the hospital and how to rally them. The hospitalist is the one who knows exactly how long it takes to get anesthesia to open an OR, or how quickly our nurses can move into an emergency and take care of their other patients. It’s the hospitalist’s role to understand how to get support from the code blue team and communicate, “This woman is coding, you need to treat her like she’s not pregnant. I’m going to be your advisor on the pregnancy part, so let’s run this code together.” And in the OR, even when there’s a private physician there, somebody has to step back to the foot of the bed and determine the patient’s overall needs. A hospitalist might say “I need these particular blood products, somebody call the blood bank,” because when you’re focused inside the patient’s belly, you can’t see what’s happening in the rest of the room and coordinate the emergency. It’s that kind of coordination of resources during an emergency that makes hospitalists so incredibly vital for in terms of getting a great outcome for the patient.  

Contemporary OB/GYN: How have that understanding and coordination worked in one of your cases? 

Dr. Dimino: In one of our hospitals, our team received a frantic call from a midwife at a birthing center. She had an extremely preterm patient who was bleeding. We actually had 5 minutes of warning before the patient arrived but that made all the difference in the world. We were able to alert anesthesia, neonatal intensive care unit (NICU) and the nursing staff. We opened the OR and had the room ready for her. In fact, we were waiting for her at the door when she arrived. We assessed the patient very quickly and were able to quickly take her to the operating room (OR) for an emergency delivery with a great outcome. If the midwife had not called and we did not have a hospitalist team preparing for her arrival, her outcome would not have been the same. Our team is faster now because we are conditioned to respond. When your team is always ready to respond together, especially mentally prepared, it decreases your time to respond and improves your outcomes. We are all striving for a healthy baby and healthy mom.  

Contemporary OB/GYN: How can other teams achieve this level of efficiency, even if hospitalists are not part of the picture? 

Dr. Dimino: The best thing that you can do is to make sure your unit’s team has practiced. And that you, as a physician, are part of that practice. The nurses tend to be really well-prepared but sometimes private physicians are too busy to practice. When you’re running a drill for your team, you need everybody to be part of it from the unit secretary who is calling out the code, to the operators who are ringing the code bells overhead, to your nursing staff and the people who are your runners to the blood bank. Your surgical techs opening your OR, your private staff, anesthesia with the certified nursing assistant team, and your NICU team need to be part of those rehearsals or practice drills because when it really happens, you don’t have the time to work all that stuff out. It’s not the time to learn how to swim when you are trying to get away from a shark. Your team on labor and delivery should have practiced enough that they work like a well-oiled, dependable machine when they are faced with a life-threatening situation. They should be in a constant state of readiness to react. 

Contemporary OB/GYN: How can the team support each other through complicated emotions that come up as part of these intense and traumatic situations? 

Dr. Dimino: Supporting each other through traumatic events is the only way for your team to keep working together. The “second victim effect” is real and sometimes hits us when we least expect it. I’ve seen hospitalists and private physicians alike who have had a traumatic event with their patient and have trouble putting one foot in front of the other to keep going to take care of their other patients. Sometimes they can’t eat or sleep. Sometimes when they go home and hug their kids they feel guilty that their patient doesn’t have a baby to hug. Hospitals have really become better at supporting their nurses and others in the hospital, but physicians often miss this support. We as physicians should seek it out. Our organization has a second victim’s program where a colleague will reach out to you if you go through a traumatic event and then stay with you, supporting you emotionally for as long as you need it. As a hospitalist, when I see a private physician experience a traumatic event, I try to take it upon myself to call them the next day and check in with them periodically to make sure they are doing OK. This collegial support is important because ultimately it affects how future patients are cared for. 

Contemporary OB/GYN: How can doctors prepare themselves for that moment when everyone in the room is looking to them to lead?

Dr. Dimino: As physicians, we are often very adept at the clinical aspects of a case. We can recite how to run a clinical protocol and take care of the case medically, but we don’t always know how to coordinate a team. I think that is the part we are sometimes missing as physicians. Your team is looking for you to not just go through the motions of releasing a shoulder dystocia, but also to guide the team in a coordinated effort while maintaining a sense of calm. 

Many physicians report that they go on autopilot when responding to an emergency. Physicians often say, “I get really quiet and I do talk but I’m focused on what is happening.” In serious emergencies many will get very quiet and seem to be lost in their own thoughts as they respond to their patient’s needs. When they do talk out loud, they often do not direct their requests to anyone on the team in particular. They might ask for a medication and someone leaves to get it. Then the physician makes the request again because he/she doesn’t know if someone actually went to get the medication or not. Then another person leaves the room to get the medication while the physician remains alone with the patient. Other times, everyone is standing in the room waiting for instructions and the physician, lost in thought, is wondering why no one else is helping the patient in the way they expect. This lack of communication makes the whole team suffer, and dramatically affects the patient. 

When your team has rehearsed it and you know your team’s response inside and out, your demeanor changes. You become more directive. You don’t just talk, but you talk with purpose and clarity. You look to the person who is standing immediately to your right, where your team’s runner is designated to stand. You say to that particular person, “I need this medicine,” and that person responds with, “I’m getting this medicine,” and they leave the room. So you have your clinical checklist in your head and you’re directing your team members clearly to help you carry it out. When teams practice how they work together in an emergency, physicians are able to also practice how they communicate to their team to make sure the response is coordinated, and valuable minutes are not lost in assisting the patient and her baby. 

Contemporary OB/GYN:  Do you have any words of wisdom or advice that you think is the most important for all team members to remember when the emergency is hot?

Dr. Dimino: One piece of advice to others is to make sure that everyone on the clinical team is able to speak up and contribute when they notice something. Thank goodness for experienced nurses who have lived through many emergency responses. They often know what to do and try to kindly prompt the physician, but an emergency is not the time to kindly prompt anybody. An emergency is not the time to ask permission from the physician to start weighing pads. If the nurse knows from the team’s rehearsals that this is the next correct step, just say. “We need to be doing this, I’m going to start weighing pads.” Or the nurse might say, “I’m going to go ahead and draw our complete blood count because we’re 500 ccs down.” In this scenario my response would be a simple, “Thank you.” Great teams have a culture that promotes everyone contributing the important information they are observing and every team member having the ability to keep the team on the right track. If you want your team to reach this level of collaboration you must create this type of culture, and that starts with respecting each team member as an equal member with particular expertise. Collaborative teams save moms and babies because they are working together toward a common goal.