Discussion on C-section

hi paul
something has been bothering me about your last entry
its the ' learn to do c section' bit
remember the bit in 'duties of a doctor ' where you have to work within your own competency? i know you are the only chance for these people in a god forsaken hell hole but does that mean you should perform procedures beyond your capability? you wouldn't be allowed to do one here unsupervised - do the same rules apply to pygmy care?
i know that you are vunerable at the moment and supportive emails are what you need - but these are the professional ethics by which we work - aren't they?
keep it real and to end on a lite note- don't get caught shagging a goat
anon

Hi Anon,
Thanks for this. Time to start a discussion...What do other people think?
For what it's worth, here's my response...
In a resource-poor setting different rules do apply. Many clinics are entirely staffed by nurses with minimal training. Most doctors in Uganda perform Caesarean Sections, and they learn to do this as medical students. In my case, I assisted in many C-sections when I worked in Obstetrics in Australia, although didn't complete one by myself. To 'step up' to doing them by myself will be daunting, but not impossible.
The duties of a doctor are a set of principles by which we must work, but sometimes they are conflicting. It could be argued that to not intervene when a mother has obstructed labour with cephalo-pelvic disproportion (big baby, little pelvis) and her baby would certainly die without a Caesarean Section would not be 'making the care of your patient your first concern'. It's not as though there are pygmies who are 'too posh to push' - I'll only be doing them when the next best available alternative gives a higher probability of death.
How far to go with this is difficult, though, especially if it comes to doing elective C/S to reduce risk, or doing other operations that I have less experience of. I have to balance doing good with not doing harm...and that's where the point about limits of ones own competency comes in.
Actually, most patients here aren't pygmies. The outreach clinics are to Batwa (pygmies) who are particularly poor, but as most people aren't particularly loaded all attend. We've seen quite a lot of racism towards pygmies here - mainly in the form of derogatory comments from Bakiga (the majority racial group).
As for the goat - Embuzi in Rukiga, the local language - I'll do my best not to get caught. Thanks for the advice.
Love
Paul

Reminds me of conversations we had when I was running the EBP workshops with Antony Franks. For about 3 years he was the only doctor in the Gilbert Isles (Middle of the Pacific, huge geographical area, thousands of small islands inhabited by subsistence fisher/farming communities). One of his most profound experiences was taking a woman in obstructed labour from her island back to his (where he had a rudimentary clinic and theatre) where he unsuccessfully attempted c-section (he had successfully performed others). The consequences in their culture of a woman not dying on her home island were large and he has spent years afterwards wondering whether he had done the right thing. On the whole he didn't perform c-section (despite the horrendous perinatal infant and maternal mortality rate) because he felt his solution to the problem was too 'sticking plaster' to be worthwhile and came with problematic changes in the community's expectations. It was also an excessive strain on him. He mainly tried to improve the situation in terms of infection and mostly avoided surgical interventions.

Anyway, the situations are too different for it to be clear how this story relates to your situation, but I share it in the hope that it is useful to think about the experiences of others.

Tony

Thanks Tony.

I’ve been at Kisiizi Hospital for the last few days in an ‘operating theatre’ environment and feel like I’m completely retraining. Part of my feels like it’s foolish to try and train to do something completely new…but the other part feels like it’s expected. All ‘Medical Officers’ – equivalent of SHO’s – here do c-sections. Bwindi Community Health Centre will be opening an operating theatre in September, and women do come with obstructed labour (or other indications for c/s). To not do them will seem as though I’m abdicating my responsibility as a doctor. But surely I should be helping to set up an effective antenatal service instead – that’s what I’m good at???

Paul

Hi Paul,

I'm sure you are now feeling less scared by C Sections, but I am also sure you will find there are plenty of other instances where you feel there are procedures or treatments, located well outside your zone of comfort/competency, that provoke the same questions. "Anon" asks a very important question about whether the same ethics apply to care of medically underserved communities, and I felt constrained to comment, if somewhat belatedly.

The answer has to be both yes and no. The over-arching ethic of respect for the autonomy of the individual, and the hypocratic injunction to do no harm are, in my view, good blocks to build an ethical response to the question on. Blind adherence to a code of practice constructed in the over-resourced environment of an obese western health care system funded by the rape of the poor and the rape of our environment, is not.

Western medical practice can only be afforded because of the system of global injustice that leaves our national media howling if treatments are withheld costing >£100,000 per quality adjusted life year added, as in the recent herceptin farce, whilst offering only the tired cliché of impotent sympathy and knee-jerk charity regarding the status quo of an under 5 mortality of >10% in so many countries of sub-saharan Africa.

The number needed to treat to prevent one death for C section, even in the hands of a relative novice, will be extremely low and the QALY count per pound rather spectacular, even if we include Paul’s loss of earnings in being in Uganda.

John