By Dr. Chibuike Joseph chukwudum
[ Mirroring Why Acquisition Of Skills, Without Commensurate Knowledge: Apprenticeship, Should Be Discouraged In Medical Practice]
Sometime last year, I made a comment on a thread saying that medicine can never be learned effectively by apprenticeship alone ; that it would be dangerous learning the skills without optimal knowledge to back it up.
Unfortunately, this was misconstrued as the “superiority complex” that doctors are allegedly known for, and I was vilified on that thread for “insinuating” that it is only doctors that have what it takes, the intellectual capability, to manage cases effectively.
Someone even went on to quote the popular saying in medical school that “medicine is an apprenticeship;” and that “going to the wards [the ‘apprenticeship’ aspect of medical training] without reading is like sailing an uncharted sea; but reading [medicine] without going to the ward is like not going to the sea at all.” And he ended up saying he would rather sail an uncharted sea, than not go to sea at all.
While he was, no doubt, right in a way; e failed to understand my stance, which was that a combination of the two is necessary for effective practice. While sailing an “uncharted sea” sounds poetic and brave, it could lead one to the Doldrums, or the fabled Bermuda triangle.
Bringing it home; human life is nothing one should practice the inevitable trial and error that comes with “sailing an uncharted sea” with/on. So, before you embark on that “apprenticeship,” you MUST first have a good grasp of the basic principles underlying the science of the practice. Else, you would be more or less like the carpenter who learns how to drive a nail into a particular spot without necessarily knowing why [no offence to the carpentry profession please; this is just FIGURATIVE]
This, right here, is the major problem we have with TBAs [Traditional Birth Attendants]; while they may excel in the necessary skills required for taking delivery, most often than not, they lack the optimal knowledge to back it up. Unfortunately, the most important aspect of clinical practice is not utilization of skills, but the DECISION-MAKING process. I stand to be corrected on this.
Yesterday, a 25 year old woman, who has had a previous miscarriage and was pregnant for the second time, was referred to us on account of “failure of the cervix to dilate [open], after 3 days of laboring.”
Initially, when I read the referral note, I thought to myself: probably a case of cervical dystocia, or even obstructed labour. However, when I reviewed the case, it was neither of these, but a sheer case of gross mismanagement.
The woman had started feeling cramp-like abdominal pains 3 days prior, and promptly presented to the “maternity.” In the course of the admission, multiple vaginal examinations were done to ascertain the status of the cervix. She counted approximately 15 vaginal examinations, done by 4 different people, who were running shifts over those 3 days, and in a not-so-sterile conditions.
By the end of the second day, she had developed a high grade fever, vomiting, and anorexia.
When I examined her, her body was burning up [39°C], her heart was racing [140bpm], and needless to say, the baby was in a very bad shape, as the heart was doing 200 beats per minute.
The shocker was that she wasn’t having adequate contractions, the cervix was still closed: ergo, she was still in the latent phase of labor, or may have just been having a “false labor” all the while, and they had done 15 VEs, putting both her, and her baby, in harms way!
Things could have turned out differently, and the maternal sepsis and fetal distress that ensued could have been prevented, if they had the following KNOWLEDGE ;
1. That cervical dilation depends of optimal uterine contraction; that without optimal uterine contractions, the cervix would remain closed, unyielding.
2. That instead of doing multiple VEs, and referring after 3 days for “failure of the cervix to open,” prompt monitoring of the contractions would have told them that that woman wasn’t having adequate contractions.
3. That if the woman wasn’t having adequate contractions, doing VEs, especially multiple number of times, due to number one above, was UNNECESSARY.
4. That if she wasn’t having adequate contractions, and she was term, and all the other factors checked out, they should have STIMULATED or AUGMENTED the labor [as the case may be] in order to achieve optimal contractions.
5. That every VE potentially pushes microorganisms/infections upwards, towards the womb; and that once the membrane, the baby’s protective covering, has been ruptured, there’s high chances of infecting and compromising the baby; that in such circumstances, therefore, VEs should be reduced to the barest minimum, and done only when ABSOLUTELY NECESSARY.
6. That due to number 5 above, if the membrane has ruptured, and delivery is not anticipated in the next 4 hours from then, or multiple VEs were done for whatever reason; the woman should be placed on IV antibiotics.
7. That intrauterine resuscitation should be started immediately fetal distress is noticed.
A lot of things that if those women had knowledge of, things would have turned differently!
And this, right here, is one of the reasons why the incidence of maternal morality remains alarmingly high in the “Giant of Africa.”
Shhh. Swallow back that your heart that has jumped into your mouth; for DANTE was able to salvage the situation, and mother and child are now in good health.