12,000 square miles without obstetrics? It’s a possibility in West Texas

The message from Big Bend Regional Medical Center was clear: The only hospital in a sparsely populated area of ​​far west Texas informed local doctors last month that due to a shortage of nurses, its unit of labor and delivery was to temporarily close its doors and that women in labor should instead be sent to the nearest hospital – an hour away.

That is, unless the baby’s arrival seems imminent and the hospital unit is closed at that time. In that case, a woman would give birth in the emergency room, said Dr Jim Luecke, who has practiced in the area for more than 30 years.

But it can be a tough call, he added. Luecke described his concerns for two patients, both close to their due date, who had already given birth, increasing the chances of a faster delivery. “They can go from 4 centimeters dilated to fully dilated in a matter of minutes,” said the family doctor, who estimates she has delivered 3,000 babies.

Big Bend Regional Medical Center in Alpine, Texas.(Google Street View)

Some pregnant women already travel an hour and a half or more to reach the 25-bed Big Bend Regional in Alpine, said Dr Adrian Billings, another family doctor who gives birth there. “Now, to divert those ambulances at least 60 more miles, it requires more deliveries to occur en route to the hospital, and potentially poor maternal or newborn outcomes.”

Luecke can’t remember when Big Bend Regional’s obstetrics unit closed.

But it’s happening in other parts of the state: Ten rural hospitals have stopped giving birth in the past five years or so, leaving 65 out of 157 who still do, according to the Texas Rural and Community Hospitals Organization. .

Hiring and retaining rural nurses has become even more difficult amid the pandemic as nurses have been recruited to work in urban Covid-19 hotspots and sometimes do not return to their communities, John said. Henderson, Managing Director of TORCH. More recently, some Texas hospitals have offered signing bonuses of $ 10,000 or more to recruit nurses, he said. “Covid has caused a market rate reset and a nursing reshuffle. “

The circumstances at Big Bend Regional, which serves an area of ​​12,000 square miles (about the size of Maryland), illustrate the ripple effects of the potential loss of obstetric services in a larger region. The hospital, owned by Quorum Health Corp., serves a strip that stretches southwest to the Mexican border and includes Big Bend National Park as well as the communities of Presidio and Candelaria. The nearest hospital, the 25-bed Pecos County Memorial at Fort Stockton, is 68 miles northeast of Alpine.

At the end of July, Big Bend Regional’s obstetrics departments were still on the move, with the unit closed for four- and five-day periods, Billings said. Doctors have been told the unit will generally remain open Monday morning through Thursday morning each week until more nurses arrive, he said.

The workforce crisis highlights the need for more state and national efforts to train rural nurses and other clinicians, Billings added. “The big concern I have is that if we don’t fix this it could be the start of a rural maternity care desert here in the Big Bend.”

The hospital, which delivered 136 babies last year, said it was “working feverishly to ensure adequate staffing levels in the coming weeks”, recruiting to fill 10 nursing positions in the work unit. and childbirth, according to a statement to the KHN. “When our hospital is routed for elective OB patients, we communicate in advance with emergency transport services and nearby acute care providers to ensure continuity of care,” the statement said.

Alpine’s Kelly Jones, who was worried about having contractions, couldn’t ask anyone to pick up the phone for a few hours in the Big Bend unit in mid-July. She decided to drop off her son at a friend’s house and go to the hospital.

Jones, who is nearing term, knew the unit had been closed a few days earlier that month, but had not realized that closures were still underway. “I walked in and said, ‘I think I’m in labor.’ They said, ‘Well, you can’t go into labor and delivery because they’re closed. So we’ll take you to the emergency room. ‘ Eventually, the medical staff determined that she was not going to give birth that day and she went home.

Since the hospital first alerted medics last month, the unit has been rerouted from July 5 to 9, July 14 to 18, and then again from July 22 through Sunday, July 25, according to Billings. . Efforts were being made to recruit nurses from Odessa, 150 miles away, to replace them, but the outcome was uncertain, Billings said.

Luecke scheduled an induction for a patient on July 26, when her pregnancy would be 39 weeks – one week before full term – and the unit was to be opened. “We try to entice them [women] the days when they [the hospital’s unit] are open, ”he said.

Jones, who is being treated by another doctor, is due to be inducted on August 2, at 39 weeks. “For a while, I wasn’t asleep. I was really stressed out. I panicked about every scenario, ”said the 30-year-old, whose pregnancy was initially considered high risk because her son was born prematurely.

But Jones felt better once his induction date was set. What if the baby arrives earlier and the unit is closed? She was told to go to the ER, to be taken from there by ambulance to the local airport and flown to Fort Stockton.

Malynda Richardson, director of emergency medical services for the town of Presidio, located along the Mexican border about 90 miles from Alpine, said her first responders transport more than two dozen women with health problems each year. pregnancy, most in labor, with an average of two delivering on the way. First responders, including paramedics, are usually not trained to assess cervical dilation, making it more difficult to assess an impending delivery, she said.

Additionally, when responders make an additional two to three hour round trip to Fort Stockton, it affects the community of Presidio, which can only reliably count one ambulance, Richardson said. “What happens when we have this means of transport? [of a woman in labor] and have to go to Fort Stockton and then we have somebody else here that’s having a heart attack and we don’t have an ambulance available?

Rural obstetrics units need far more nurses than doctors to stay open, so it makes sense to divert women elsewhere in the short term, said Dr Tony Ogburn, who chairs the Department of Obstetrics and Health. gynecology at the University of Texas School of Medicine at Rio Grande Valley. “If you don’t have qualified nurses there, it doesn’t matter if you have a doctor who can do a cesarean or a delivery; you can’t take care of these patients safely, ”he said.

Registered nurses who work in labor and delivery have undergone specialized training, such as reading a fetal heart monitor, so that a nurse in the emergency room or other hospital unit cannot easily intervene, Billings said. “It’s kind of like having a small football team or a small football team and not being able to step off the bench,” he said.

Billings said he contacted Dr Michael Galloway, who chairs the Department of Obstetrics and Gynecology at Texas Tech University Health Sciences Center in Odessa and helped coordinate efforts to recruit nurses from that city. But even if Odessa nurses agree to take shifts at Big Bend Regional, they are likely a stopgap solution, said Billings, who wonders how long they would be willing to work so far from home.

Luecke believes Big Bend’s regional administrators are doing all they can to improve nursing staffing. But, like Billings, he fears those temporary July shutdowns will become longer term.

“We hope that August will be a different situation,” said Luecke. “But it’s pretty uncertain right now.”

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