I would echo with Dr Rodney, that bringing up all the “possible” problems that might occur for those of us doing full scope FM and OB should NOT be a source of dismay and discouragement. Basic surgical skills, diagnostic acumen and decision making can be applied to all the possibilities mentioned without the need for specialty surgical consultation IMMEDIATELY available. We DO need to make sure our training programs and OB fellowships give robust exposure to a wide spectrum of surgical procedures so in those remote locations, we can handle these issues and more… I would think most if not all rural hospitals that CAN do C-Sections also have general surgical backup for these kinds of problems as well. If they don’t, then I would work on getting the credentials myself.
John Gibson, MD
Great question. Surgical backup is almost impossible in rural Alabama. We have involved our fellows in performing hysterectomies and surgical management of ectopic pregnancies for the obvious reasons. We have published a technique for cesarean hysterectomy that FM/OBs could do in the AJCM. So many techniques for managing PPH have become available that cesarean hystectomies are far less common today. Of interest, many graduating OB/GYN residents have never seen a cesarean hysterectomy, much less perfomed one.
Daniel Avery, MD
Tuscaloosa, AL
While laparoscopic approach to ruptured ectopic requires extensive training, doing exploratory laparotomy approach is not much harder than C/S at all.
I have personally never performed a single C-Hyst in my life. However, while consulted by FP OB fellows in Memphis, we avoided C-Hyst a few times by B-Lynch, O'Leary's Stitch, and vigorously correcting accompanying DIC. Bakri balloon, sand bags are also useful in dealing with PPH. Those approaches for PPH are relatively easy to learn for FP fellows. My point here is: If we can avoid C-Hyst, we can minimize disatisfaction of patients and potential lawsuits.
I have also done a few TAH with OB fellows here. I am extremely satisfied by the surgical skills those fellows demonstrated: some are much better than average OB residents. However, without GYN or surgery backup, in emergency situation, supercervical hysterectomy is safer and easier than the whole TAH.
Bo Charles Li, MD, FACOG
Memphis, TN
I'll Echo Bill and Dan. When GI is doing scopes do they have Surgery back up in house in case of perforation? When Cardio does an angio they have in house back up in house in case of need of CABG or laceration of an artery?
I can go on and on......
What I do think is very important is to know how to handle the emergency with O'learys or Mgmt of the ectopic emergency for 45 minutes with fluids, blood, and others.
My 2 cents.
Eduardo Scholcoff, MD, FAAFP
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