Ob Emergency Books
Posted 13 December 2009 - 04:55 PM
Thanks for the help!
Posted 13 December 2009 - 10:57 PM
"Manual of Pediatric Critical Care" AND "Nursing Care of the Critically Ill Child"
By Mary Fran Hazinski
We do not encounter many High Risk OB/GYN (thank god) so I can't recommend a text
University of Mississippi Medical Center
Posted 13 December 2009 - 11:19 PM
For high risk OB take a look at someone's ALSO text. We don't have one at home anymore; but the course covers OB emergencies.
Mordechai Y. Scher
NRP, FP-C, RN
It's all about kind, competent patient care; and getting home safely to tell about it.
Posted 14 December 2009 - 04:35 AM
Posted 14 December 2009 - 11:30 AM
I was just thinking that we could get ourselves into a pretty chaotic situation w/ a high risk OB in a helicopter. Tough decisions huh? Not much fun either if shit were to hit the fan! I will check out the ALSO book, but still looking for more guidance with the OB books.
First some praise - knowing that you don't even know what you don't know is the first step.
If your program is seriously planning to do HROB - you better do it right. That is one of the most litigous areas in medicine in general! And legal action for poor delivery outcomes can be filed until the child is 18... Plan on a training program that includes didactic, clinical and ridealong as well as ongoing didactic and clinical/experience components.
First I recommend a few courses above NRP. STABLE (all 3 versions = 24 hrs, the Provider, Gestational Assessment and Cardiac modules) for dealing with the post NRP newborn, ALSO (Advanced Life Support in Obstetrics - 3 days at the GP level with megacodes (delivery scenarios from pre through to post) and of course OB-STAT (2 days). In my opinion that is the MINIMUM - any less would be dangerous for one or both of the patients. An EFM course is a good idea as well.
This only covers the theory - so additional clinical experience is essential. As much as possible - what I outline below is the MINIMUM to make you not comfortable or skilled - but at least not panicked and dangerous. To start, plan on 6 shifts. I would get at least 12 hours in the antepartum unit performing non-invasive obstetrical assessments (get so where you are 90% or better at assessing the fetal lie and position) and fetal/toco monitoring and do lots of EFM strip interpretations/doppler auscultations.
Then another shift of supervised practice in cervical assessment then a third in the delivery suite catching babys and and placentas and doing the postpartumm care. Next would be a 4th and 5th as the NRP resucitator and stabilising person including placement of ETT's, peripereral IV's, initial fluid and ventilatory resuscitation and low (rescue) and high UVC and UAC lines. Surfactant administration at least once is also a good idea.
On the 6th shift try to hang with a neo team and/or play with the transport isolettes available at sending facilities - even if your service does not have one. That includes ventilator set-up and management. Neonatal intubation practice should continue on this day if you do not have a 80% or better success rate and at least 5 good tubes. Also do at least one failed intubation or LMA and 3 umbilical lines.
Ongoing clinical days should be one in L&D per quarter maintaining obstetrical and cervical assessment skills, catching and stabilising babies for transport and packaging Mom and babe. Skill wise, for the first four years you should get at least one additional ETT, cervical assessment and umbilical line per month in either the field or hospital. Once you have at least 25 of each the retained memory can allow reduction to a quarterly requirement (which can be met during the monthly/quarterly clinical day).
Lastly I recommend getting 3 shifts and 5 transports each with a HROB team and a Neo team as an observer. If your program already does these transports that should be easy - as it will be if your program supplies the HROB or NEO team with a ride and a bag carrier. But do not count any of these trips unless you were an interactive part of the team throughout the hospital assessment/stabilisation and transport.
So we have a total of 9 eight hour didactic shifts (= 72 hours), 6 twelve hour clinical days and 3 more transport days for a total of 15 twelve hour shifts or 180 hours of initial training. Ongoing clinical requirement for the first 4 years add 144 hours a year and certificate renewal (ALSO x 5 years @ 24 hrs, NRP x 2.5yrs@ 8 hrs, OB-STAT x 5yrs@ 16 hrs, STABLE x 2.5yrs@24 hrs) will add another 16 hours per year on average for con-ed. After year 4 the clinical requirements drop to 48 hrs.
Then there are the whole equipment / technical training to operate and troubleshoot it / protocols (learning them as well as CQI etc) issues. Overall, adding HROB to an Adult/Pede program is NOT a decision to be taken lightly or without significant market research and Medical Director buy-in and support (highly recommend hiring an associate Med Dir for HROB/Neo...)
To forestall some questions:
Take an isolette and dedicated neo stabilisation and OB assessment/monitoring bags in addition to delivery supplies OR you can make your transport policies / protocols such that you NEVER deliver in transport. The isolette can be omitted if you have/there is a dedicated Neo team that can respond to the same places you do (assuming all those locations are at least clinics with neo warmers or isolettes and not scene calls). Plan on staying and assisting the small facilities etc with the patient (that you were called for then assessed and determined you were not going to fly) and baby after she delivers and until the neo team arrives - many neo teams will not launch until after delivery (and may not be needed with many deliveries). Obviously you need well thought out, comprehensive and robust protocols for these calls - again the need for a knowledgable medical director in these specialty areas. Ideally one who can be reached by phone when sending MD's start trying to push you to leave.
I've never had to use forceps - but we were trained in them. Vacuum is another story and was occasionally needed. Check out your RN and EMS boards about scope of practice issues for these devices and episiotomies / cervical assessment / bimanual uterine massage and get waivers if needed. You also need to carry both warmed fluids and refrigerated meds/blood (in some areas of the country where sending facilities have low or no stock). Surfactant is expensive but when needed, crucial. Third line PPH meds are a good idea. Have at least 3 options (plans A, B and C) for dealing with PTL and PPH. We carried abx and steroids (for PROM) as well.
From my experience (4 years on a generalist team that also did Pede, Neo and HROB as well as 2 years on a specialty pede/neo team) 90% of your transports will use 10% of the knowledge/skills/equipment/meds described above. The other 10% use the remaining 90%.... A lot CAN go wrong with the HROB transport of a premature mom. Your job is to anticipate it and prevent where possible/facilitate delivery and care for both until relieved when not. Get a new elastic for your pucker orifice... Remember the 5 P's (Prior Preparation Prevents Pissing your Pants)
All of the above are my 5 cents worth after 148 HROB and 154 Neo transports and 18 deliveries where we refused to transport due to maternal condition and transport time/conditions. NONE in the transport vehicle - but we did fly a serious PPH mom and twins (one a footling breech) in our isolette after delivery and had almost all the problems ALSO warns you about at one time or the other. Not all were easy calls or with ideal outcomes - but none of those outcomes were due to anything we did or didn't do. One memorable case (PTL transverse lie with decels) was a thread on the old Flightweb site back in the late 90's. We were a FW team with response legs of up to 3 hours north and the closest level III NICU 2.5 hours south - 6 hours from our furthest pickup (had to land to refuel on the loaded leg). Since 90% of the runways were gravel, ice or snow the NICU team would NOT respond any closer than our base. And we also did scene calls by unpressurised bush aircraft/pickup/skidoo to peoples houses and construction trailers.
Dedicated with much thanks and appreciation for the mentoring to the memory of the late Dr. Kerry Morrissey (nee Telford), MEDFLIGHT (Yellowknife)'s OB associate medical director for several years, killed in a plane crash on November 29, 2009 and to Pat O'Conner RN/AEMCA our CFN who after 30 years of flying in that environment and literally thousands of such flights NEVER had an in-flight delivery.
Posted 14 December 2009 - 01:39 PM
not strictly pre-hospital / emergency, but I'd like to add Merenstein to the list for neonatal texts.... truly awesome book!
Sean G. Smith, RN-Alphabet Soup
Posted 14 December 2009 - 03:18 PM
Thanks for yalls time!