Cheating On Call

Failure of Duty

Part 1:

I have never encountered anyone that actually enjoyed taking call, especially at night. This dedicated time probably represents a majority of the effort we put forth as maternity care providers. When on call, midwives, doctors, and advanced practice professionals are expected to be available for consultation, evaluation, reassurance, and a plan of care, either in-person or by phone. For pregnancy-related issues, patients may initially call, or just present to a labor and delivery/triage unit. On call issues can be critical, concerning, or routine. In any case, the midwife is expected to be actively engaged with the patient. His/her physical presence should be expected for clinical evaluation and new plans for care of the mother and unborn infant.

Call consults involving pregnant patients can be mundane or critical, ranging from discomfort, anxiety, or exhaustion, to unexpected bleeding, premature contractions, or immanent delivery of an immature fetus. An unborn baby is usually affected by alterations in the condition of its mother. An on call evaluation might focus, primarily, on reports that a baby is moving too much (mostly reassuring), to concerns that the baby is moving too little, or not at all.

The challenge of initial, phone evaluation is the ability to determine emergency circumstances from non-acute, manageable situations which are only mild deviations from normal. A phone consult is limited but may offer reassurance, with recommendations to follow-up with care providers at the next scheduled appointment. There may also be a recommendation that the patient present to the triage/ labor and delivery unit for evaluation. In most instances, the on call midwife should be willing and available to personally evaluate the patient.

Provider availability on call is expected and one of many duties that you owe your patients, legally and medically. Each pregnancy is unique, and may exhibit a wide range of benign or concerning presentations. Your legal and professional duty is, once again, to be physically and intellectually present for them, as the clinical situation dictates.

Hospital call can be quiet, allowing for rest and sleep, or it can be a hell-scape of activity, drama, and stress. In any scenario, these are your patients. Their expectation for safety is the assurance that you and your associates have promised this time for them. In the middle of the night, your patients want to know where you can be found. You will be there for them because: 1) it is your duty. 2) You are being paid a premium, above and beyond your salary, for taking these hours, 3) for many cases, current federal law requires that you, personally, perform a screening evaluation to assure that your patient is physically stable before being sent home. Delegating this duty to a subordinate may be deemed substandard, unacceptable and, in some situations, illegal. (See EMTALA – Emergency Medical Treatment and Active Labor Act) https://www.midwivesontrial.com/articles/emergency-medical-treatment-and-active-labor-act

In addition to taking calls from patients that you are familiar with, you may also be consulting with individuals that you have never met. Fielding routine calls for questions are easily handled. More complicated and concerning communications may involve the difficult task of gathering information from someone who might be experiencing the most terrifying and stressful moments of her life. Although some patient concerns may be routine, they are unique to the individuals that expect your time and attention. Pregnant patients, particularly, want to be in your presence, read your facial expression, and take these moments to develop trust and reassurance; knowing that they can count on you to support them no matter what transpires.

Many lawsuits against nurse-midwives (and physicians) stem from the following:

1. Taking call at home and failing to come to the hospital to personally evaluate their patient.

a. Delegating the triage evaluation and screening of the patient to a labor and delivery RN or the L&D Charge Nurse. This is careless and substandard behavior. Period. Every CNM patient who presents for evaluation deserves a history and physical and thorough labor evaluation from a qualified care provider.

b. If you think a charge nurse or labor and delivery nurse, unfamiliar with your patient, is the appropriate choice to conduct a history and physical, evaluation for rule-out labor (premature and term), possible placental abruption, pre-eclampsia, fetal well-being/monitor tracing evaluation, membrane integrity, or maternal wellness exam as competently as you can, then who are you? What is your purpose when taking call for your patients?

c. Are you not primarily responsible for this patient and her baby? Do you think a second person, over-the-phone evaluation of your high risk patient is the level of attention that she deserves? Why do you believe that you can stay home for your call, letting someone, less qualified than you, perform your job? While you are receiving enhanced compensation to do so? This is cheating.

d. Sure, the doctors do it all the time, so why not you? I’ll tell you why. Your standards as a CNM and the integrity of the profession. Your certification and practice model establishes that you will be with your patient when she needs you. Yes, there are doctors neglecting to personally assess their patients. Let them. They are cheating, too. OB/GYN physicians continue to be sued more frequently than any other specialty, and for the same irresponsible delegations of care that I am discussing, here.

I can almost hear some of you groaning in protest, right now. And I will utilize this opportunity to emphasize that blowing off your call responsibilities may result in the worst mistake you will make in your career. Yes, you may repeatedly get away with it. Keep taking these chances and stay at home in your warm bed. But. There is a real chance that you end up regretting it. Any chance of being swept away in a current of litigation is not worth a few more hours of sleep, or extra family time while on call. It certainly is not worth the risk of harming someone by your neglect, inattention, or laziness. For the circumscribed time frame of call, your time belongs to your patients.

More malpractice lawsuits against Obstetricians and Midwives stem from on call negligence than you can imagine. Examples of situations that have occurred when the responsible on call provider stays home :

- a patient in labor, with a fetal breech presentation, was sent away by an ED nurse without a rescue plan. On the road to another hospital, the patient delivered in the back seat of her car. The baby eventually died after the body delivered and its head was retained in the pelvis.

-a patient with pre-eclampsia was sent home without sequential blood pressure monitoring and/or laboratory screening. This mother experienced a grand mal seizure at home. She and her baby both died.

-an inadequately examined patient in premature labor ruptured membranes after being sent home. She delivered a premature baby in the bathtub who later died in the NICU.

-a patient at 34 weeks, with history of previous C/S and complaints of abdominal pain , presented to labor and delivery and was not evaluated by the on call care provider. She was briefly attached to fetal monitoring which showed intermittent uterine tachysystole. This patient was sent home by a triage CNM. The patient returned to the hospital, in shock, with a ruptured uterus. Mother survived but her baby did not.

-a high-risk patient at term with waist-down paralysis presented to the hospital, with vaginal bleeding, cervical change since a clinic exam, and palpable-only labor contractions. She was not personally assessed by her care provider when she presented to the hospital. The charge nurse on duty was delegated to perform a cursory labor evaluation, after which the patient was allowed to go home. Baby delivered at home in bed a few hours after discharge while its mother slept, unaware that she had given birth. The infant was not resuscitated, post delivery, since its mother was asleep. Having asphyxiated in its secretions and amniotic fluid, baby did not survive.

These examples relate to situations when responsible care providers were too tired, or reluctant, to leave their beds and come in to evaluate patients that they were responsible for. Inadequate evaluations and screening may, also, result in violations of EMTALA, the Federal “anti-dumping” Statute which, at the very least, requires a medical screening exam by a qualified provider and evidence of stabilization prior to being sent away from the labor and delivery unit. Please remember that charge nurses and labor and delivery nurses are not always authorized, or qualified, to perform medical screening exams for the purposes of EMTALA. When they are not, the on-call provider has a duty to perform a bedside screening and assessment. This is federal law. Hospitals will pre-determine which individuals/employees are approved to perform required discharge screenings that meet the requirements of the Statute.

Legal risk in midwifery practice is probably never more acute than during the time you are on call, particularly in the middle of the night. There may be a strong temptation to take your call at home, choosing sleep and family over duty to your patients. For the safety of your patients and the integrity of your profession, resist the temptation to cheat. (Refer to: CNM/CM Duty of Care and Foreseeable Risk)

A History of “Nurse” in Nurse-Midwife

Myth of the Ordinary Midwife Part 2