Why super-specialists should have compulsory clinic duty

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http://www.trying-to-conceive.com/wp-content/uploads/2012/02/large_family-300x224.jpgWe were on call again last night. The CHC was going through a quiet patch (the last delivery had been just past 01:00) and my friends and I were sitting in the students’ room eating cookies, scaring ourselves by looking at all the additives and making silly jokes that are only really funny when you have been awake for that long.

At about 03:45 a nurse told us that she had a patient for us – a 37-year-old grand multipara! This means that she has given birth to at least five previous infants. She was progressing fast and the nurse in charge decided that there was no time to suspend labour and refer to a level 2 or 3 hospital.

We started readying her for delivery, checking up on her periodically. She warned us that she could feel the baby’s head, and we saw that she was crowning. One of my friends ran to get the nurse and I got the gloves on just in time to support the perineum. Out came baby’s head and nurse was still not there. Third year medical students are not supposed to do these things without supervision. It was quite easy to deliver the shoulders though, and then the rest of the 3200g baby girl just popped out.

She cried well, had passed no meconium and was moving around very well. The umbilical cord had a lot of false knots, which I’ve looked up and it seems it is just a normal variation.

The mother lost more blood than any of my (or my friends’) previous deliveries, but there was no active bleeding and it subsided very quickly once we administered oxytocin for the third stage of labour. The uterus was also well contracted and her blood pressure remained stable.

The baby seems to have epicantic folds, which is a feature of Down’s Syndrome, but the absence of hypotonia, other facial dysmorphologies or a simian line leads me to believe she’s fine – my clinical group and the nurse think so too. Also, we don’t know what the patient’s husband looks like, so for all we know he is Asian.

This morning, less than an hour after our shift ended, I presented the patient to a consultant (an “attending” in American-speak). I was still on a bit of a high, but she brought me down real quick. She accused us of placing the woman’s life in danger by not referring her to a hospital. Really? Firstly, the woman was 8cm dilated! Secondly, we work on orders from the nurse and have no right to tell her how to do her job. The nurse has been doing this for much longer than we have – who were we to question her judgment? Thirdly, our theoretical module did not at all prepare us for the management of a grand multipara – in fact, it did not even offer a definition for a grand multipara. So if we knew nothing about the high risk for this patient, we truly had no ground on which to doubt the nurse’s judgment.

I do not pretend that I am right and the consultant wrong – I am not that stupid. She told us that the patient could have suffered a fatal post-partum haemorrhage. She is right, but we had never been taught that (that I can remember). What I do think is that she displayed no insight, no sensitivity and consequently displayed characteristcs not befitting someone of her high intelligence.

This consultant gave an excellent tutorial on the management of a grand multi, but I have to wonder when last she spent a night shift in a CHC. During her reprimanding of us she showed absolutely no insight into the problems encountered by CHCs on an average night, nor into the method of running such a clinic or the efficiency of the staff on sight.

She was also extremely judgmental of the patient’s situation, claiming that she was probably a disinterested mother with no comprehension of contraception and who’s children would suffer the consequences of her multiparity.

Not once did she ask us if she was right. In fact, our patient was a respectable Muslim lady who has spaced her children two years apart each – except for the first two, who are three years apart. They are all of excellent health and when she talks about them you can see that she far from disinterested. This is her last child, as was decided by herself and her husband.

My friends and I have gained such perspective after reading so many pregnant women’s charts, and I am disappointed that a consultant as brilliant as this one does not have that respect for a woman’s life story.

I know I am supposed to have some kind of reverence for a consultant, but at this point I just… don’t.

At least the next time we have a grand multi, we will be able to manage the patient more safely…

I have to keep reminding myself that I did the best job that I was capable of, and the best job for which I had received instructions. I had an amazing evening and I can’t let a tactless consultant ruin that for me and my friends.

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One thought on “Why super-specialists should have compulsory clinic duty

  1. Pingback: Le Document Pour MB.ChB.III « Whispers of a Barefoot Medical Student

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