How to Manage Obstetric Deserts
With more than four decades of managing health care and obstetric deserts, I know what does and what does not work, and what should work, but doesn’t.
My experience is extensive. Five years in St. Paul and Minneapolis, about two decades in Fargo, and two more decades on the front lines in what can only be called genuine obstetric deserts. Since North Dakota is 80 percent a healthcare desert, it follows that obstetric deserts are even more common.
The Benefits of a Hospital Hotel
I did primary, secondary and tertiary care in St. Paul and Fargo. In Fargo I had patients coming from 200 miles in all directions. Some of these were high risk; for example, placenta previa, abruption, preterm cervical dilatation, and multiple pregnancies. In order to keep the women in the Fargo area when they were near delivery but lived so far away, I was able to create what I called a hospital hotel one floor above the labor and delivery floor.
Three and four decades ago, patients who were having surgery on Tuesday morning would come to the hospital on Monday night. They were checked into acute get their labs, and histories and physicals. We made sure they were ready to have surgery the next morning.
When placing the patients in the hospital the night before got to be very complicated due to insurance coverages, one of the hospitals I worked at developed what they call the “hospital hotel.” In other words, rather than admitting the patient to an acute bed the night before, they put the patient in wht they called hospital hotel rooms. Histories and physicals were done before they got to the hospital. Since many patients had to travel hundreds of miles, it was reasonable for them to arrive the day before. As a courtesy to the patients and because the hospital had a few extra beds, the patients and their relatives were allowed to sleep in the hospital hotel the night before the surgery. The hospital hotel included a hospital bed with sheets, blankets, a bathroom, and a shower. There were no nurses on this floor. I used this hotel service for my patients who were high-risk and lived a long distance from the hospital.
My main criterion for placing patients in the hospital hotel was distance. I could keep the patient in Fargo in the hospital hotel for $15 a day. The hotel was one floor directly above the OB unit so was very convenient. The results were unanimously good. There was no maternal fetal distress, no maternal or neonatal deaths, and what’s more, all deliveries occurred in labor and delivery and not in the hotel room. Naturally the health insurance companies had “No code” for the hospital hotel service, so they wouldn’t pay r $15 dollars a day but the patients didn’t mind paying for good healthcare.
Most insurance executives can’t wrap their heads around real prevention. With my patients in the hospital hotel, I saved insurance compaies about 500 dollars a day for the labor and delivery room and about $2000 dollars a day for by keeping babies out of the Neonatal Intensive Care Unit (NICU). Real prevention is something that most insurance companies including Medicare and Medicaid are not capable of understanding. This is much more important than watching cholesterol or weight.
After I left Fargo, I moved to a genuine obstetric desert in a small town with about twenty five hundred people. This town still had a struggling obstetric program and the hospital CEO and board wanted to save that program. I made a trip to visit the one remaining doctor, the CEO at that time, the hospital board members, and the nurses. The CEO said “if you come here, I’ll have an anesthetist here by the time you arrive.”
Those people discussing why physicians won’t practice in rural areas are fond of saying physicians’ wives won’t live in small towns. In this day and age you can have anything you want or need delivered to your door. I grew up in rural North Dakota and my wife has deep roots here, so this old saw about wives didn’t apply here.
When we arrived in June, trouble awaited on the first day. The administrator who I had talked with had been replaced. This was a private, not-for-profit hospital owned by an order of nuns whose motherhouse was several hundred miles away so rather than having the local hospital board make decisions, the nuns had another board which actually made the decisions. And finally, the nuns themselves answered to the bishop. So, we had at least five layers of administrators, if we included the hospital administrators.
I quickly learned it was easy to run a-foul of one of these layers of administrators. The upshot of these several layers was a tremendous difficulty getting anything done even if this progress would have benefited the community, the hospital, and all layers of administration. There were even more administrators if you counted the nurses, whose decisions were stuck in the previous century. So, on my first day in the hospital I discovered that the administrator I had come to know and trust was gone. The option of an local anesthetist was replaced by an on-call anesthetist 85 miles away on a heavily travelled two-lane road . With few exceptions, the next six years became a deeper dive into the rabbit hole.
Too Many Administrators
The room we had for labor, delivery, recovery and postpartum was very small, dangerously so. By the time we got the bed, the fetal monitors, the maternal monitors, the instrument table, the neonatal warmer, for resuscitation, the husband, the nurses, and the IV poles along with me, we couldn’t even move. And although there were two larger rooms nearby we could not seem to manage to move to one of the larger rooms in the six years I was there.
After a few months we had a young woman with previous cesarean sections and pregnant with twins. The patient had asthma and she smoked. On several occasions she was hospitalized prenatally with breathing difficulties. Eventually this patient got to 39 ½ weeks. None of these hospitalizations bothered anybody probably because nobody understood the risks involved. I talked to the Chief of Staff. We agreed that this repeat C-section delivery would be like delivering two full term babies. No problem. I talked to the CEO, no problem. I talked to the head nurse who seemed to be okay with the plan. But she talked to the head nurse at the hospital and the CFO. The three of them decided “no high-risk obstetrics here.” So they called the medical malpractice carrier for the hospital. The words from the “seventh” layer of administration sided with the CFO, the hospital head nurse, and the then head OB nurse. So not only was that patient forced to suddenly go elsewhere for her care, but also our struggling OB program was dealt a serious blow from the “inside.” The upshot was that the Med Mal carrier wanted a “plan of correction.” I knew that nobody in the hospital had the slightest idea how to make a such a plan. So my wife and I made a correction plan which was accepted by the Med Mal insurance carrier. True to form, this plan of correction was never implemented, and nobody seemed to care, no surprise to me.
Obstetrics limped along in this way for several years. The head OB nurse and the long-term doctor liked a medication called Mepergan which was given IV during labor. This was a combination of two drugs, neither of which was to be used then or today in labor. This medication combination included Demerol and Phenergan, neither of which has been used for several years since the violin player lost her right arm due to cellulitis caused by IV Phenergan use.. I couldn’t get them to stop the use of the “Mepergan.”
A few months later 22-year-old came in at term with preeclampsia. It was her first baby. Her blood pressure rose to the point that I didn’t want to put her in an ambulance to go to a medical center 100 miles away. The on-call anesthetist was busy and couldn’t come. Since I wanted an anesthetist present for her delivery, I found one who wasn’t on-call, but who would come anyway. He was 90 miles away and it was windy, with rain, sleet, and ice. After 2 ½ hours he arrived. My patient worked well and did not have a seizure, but since she was on magnesium sulfate she had uterine atony, a big episiotomy, and a lot of bleeding. Now the small room was really dangerous. The nurses had a hard time just getting the blood transfusion started. Nor could they connect the IV tubing to the catheter in the patient’s arm. The tubing kept falling off the catheter. Not very sterile, but our patient was on her way to bleeding to death.
Once the IV was finally connected, the nurses were accustomed to giving blood to 80-year-olds and running the blood slowly. With OB or trauma, blood is often being lost fast and therefore needs to be replaced fast. So once we got the tubing connected, the Pitocin running, the blood running at the right speed, and with a lot of fundal massage and effective episiotomy repair, the bleeding slowed and the patient and her baby did well. Two years later the patient returned and had a completely unremarkable vaginal birth.
Coming soon, more about delivering babies in an obstetric desert. And although there are reasons for the obstetric desert, I’m confident that there are viable solutions if anyone can get out of their mind the notion that physicians’ wives refuse to live in rural areas.