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Dr Gray: When we allow politicians to tell us about medical practice

Health Minister Aaron Motsoaledi last week suspended two doctors who performed a caesarian in a maternity ward, and subsequently lost both the mother and baby. But DR THOMAS GRAY says the doctors did the right thing, and that the health minister got it wrong. He explains why.

Doctors seem to be dominating the media recently, but for all the wrong reasons. Negligence, incompetence and refusal to treat dying patients are but some of the allegations levelled against doctors working at various public hospitals around the country.

Other than the undue sensationalism and hype these accusations seem to usher in, what amuses me is the tendency for people both inside and outside the medical profession to express their “expert” opinions on the matter.

Let’s just say commentary from the gallery is as useful as my insight on say, an engineering fault at Moses Mabhida stadium.

Another aspect, and though less amusing, is the indiscriminate suspension of doctors without due process and their demonisation in the media prior to any formal investigations or their findings.

A case in point is the recent suspension of two doctors at Evander Hospital in Mpumalanga following the death of a 19-year-old girl in labour and the death of her newborn baby. The department of health accused the doctors of “misconduct” and “failing to adhere to prescribed medical guidelines”.

Again much has been said about the case, mostly by underachieving libtards. But never mind them, let’s try to understand what happened.

The case
The patient in question was suffering from a severe form of hypertension (high blood pressure) in her pregnancy know as eclampsia. This causes the patient to have severe seizures, as in an epileptic patient, which sometimes – but not always – responds to treatment.

In this case, the condition was so severe that the patient went into cardiac arrest – basically her heart stopped beating. In a desperate attempt to save the life of the baby and the mother the doctors performed a perimortem caesarean section, that is, they performed the caesarean section immediately after the death of the mother.

This act, brutal as it may sound provides the only chance of saving the baby and the mother.

It saves the mother by removing the source of the seizures and subsequent cardiac arrest, that being the pregnancy. For the baby, it would restore oxygen to the brain and vital organs post delivery and, if done in time, one can then attempt to kick-start the mother’s heart again.

It is a difficult and tricky procedure. It’s a last gasp-effort in a desperate situation. It has a low success rate. In a situation as dire as this, however, there really are no other alternatives. But, do note, the doctors involved were senior clinicians, with more than adequate qualifications to tackle it.

To no avail, the baby didn’t survive and the mother died after 10 days.

After the expected media tirade over the incident, our honourable Minister of Health, Dr Aaron Motsoaledi, paid a visit to the hospital where he immediately suspended the two doctors involved. Indefinitely.

He was reported as saying: “The manner in which the operation was done on this young girl outside theatre was never done before. I have never seen that in my experience of 32 years in the profession.”

But that is an odd thing to say. Was the minister saying the doctors didn’t know what they were doing when they tried to save the mother and baby? What hasn’t been done before?

In the world of medicine and science, there are strict rules and regulations. Usually, clinical practice is standardised, and backed by evidence in the guiding literature and research.

In short, yes, doctors can make mistakes. They – we – are only human.

But did the minister know what he was talking about?

The research
I decided to check up about perimortem caesarean section. I wanted to make sure I understand the risks, the variables and most importantly, the clinical practice – how it’s done.

The first article I find, in Journal: Obstetrics and Gynaecology, which is described as a “core clinical journal”, is from 1986, in which practice is described to have gone on since “antiquity”. The article then reviews known cases from the previous 100 years. They further suggest that the optimal time frame for the special procedure that the doctors at Edenvale conducted is to be done in four minutes.

In the British Journal of Obstetrics and Gynaecology (BJOG), another well-respected clinical journal, I found a number of studies between 2010 and 2011 on the topic. Another reference alluded to a speedy procedure: “An important factor to improve outcome is more timely application of this potentially life-saving procedure.”

The most recent study on the subject, appeared in the Journal: Obstetrics and Gynaecology, and involved simulated patients of manikins (models of the human body) to determine the time taken to undertake a perimortem Caesarean section. It made the following conclusion: “Perimortem cesarean delivery during actual arrest would require more than five minutes and should be performed in the labour room rather than relocating to the operating room.”

Now, given the information we currently have on the incident that took place, and given the stated literature on the topic, how should we understand the actions of the doctors and the response of our dear minister.

Let’s not forget that a young woman and her child died tragically. Understandably, to the naked, untrained eye the rushed and bloody operation appeared bizarre.

But according to what we know, and based on her medical condition, the young pregnant woman fell into cardiac arrest. As a result, the doctors decided to act immediately, choosing to perform a “perimortem cesarean delivery”. The procedure, by its nature, needs to be done rapidly, within five minutes or so, and there is no time to enter an operating theatre. This is the recommended procedure.

All of which makes our minister’s actions and words seem misguided and wrong.

The verdict
If anything, we ought to be praising the doctors for their commitment to trying to saving the lives of the mother baby. More so, we should acknowledge their adherence to already established, internationally recognised clinical guidelines, especially given their location on the periphery of the major academic hospitals.

If there is doubt or concern, the onus is on the Health Professions Council of South Africa (HPCSA) to investigate the matter on a scientific level based on the most current evidence in the literature.

When we allow politicians to pass judgment arbitrarily, we throw mud in the face of centuries of medical science.

Furthermore, the absence from work of our colleagues through these suspensions further jeopardises the only overly burdened, understaffed and under-resourced health service. Ironically the main people affected by such actions are none other than the ones the politicians claim to be protecting: you, the South African people.

Dr Thomas Gray (*not his real name) is a doctor living (and slowly dying) inside a public hospital. He’s here to tell us what’s happening inside our hospitals. He would share his name with you, but then he’d have to kill you, and that would be unethical. If you have information to share, about this story, or any other aspect of our public healthcare system, do get in touch.

The cited works if you want to do more of your own research on the topic.

Katz, Vern L., Deborah J. Dotters, and William Droegemueller. “Perimortem cesarean delivery.” Obstetrics & Gynecology 68.4 (1986): 571-576.

Dijkman, A., et al. “Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training?.” BJOG: An International Journal of Obstetrics & Gynaecology 117.3 (2010): 282-287.

Vencken, P. M. L. H., M. H. A. Van Hooff, and R. M. F. Van Der Weiden. “Cardiac arrest in pregnancy: increasing use of perimortem caesarean section due to emergency skills training?.” BJOG: An International Journal of Obstetrics & Gynaecology 117.13 (2010): 1664-1665.

Warraich, Q., and U. Esen. “For perimortem caesarean section, the surgical knife is the most important instrument.” BJOG: An International Journal of Obstetrics & Gynaecology 117.6 (2010): 768-768.

Lipman, Steve, et al. “Labor room setting compared with the operating room for simulated perimortem cesarean delivery: a randomized controlled trial.” Obstetrics & Gynecology 118.5 (2011): 1090-1094.

– Featured image: By SSgt Derrick C Goode, via Wikimedia Commons.

10 Comments
  1. James says

    well written, well argued but will Dr Gray also admit when doctors mess up also? Or this just another opportunity to bash government. doctors are overpaid in our country and always complaining.

    1. JGN says

      That is very harsh James. When a Dr makes a mistake, I feel that he or she must be called to take responsibility after the matter has been investigated thoroughly and fairly. Drs are not overpayed. In this country you can rake in millions with no qualification at all. Wherass medicine remains a grudge expenditure. You work hard, take a lot of flak without the necessary resources and support, and every armchair critic has a license to criticise you.

  2. Mohamed says

    This case seems Strange. If they did a peri mortem caesar that’s acceptable practice as the article and the sama statement points. But then why the big furore? If it was anything else, as the minister seemed to suggest on safm on wed eve then it’s probably malpractice. The facts don’t seem clear by What’s presented in the Media. Dr Gray seems to have know for sure that it was in fact a peri mortem cs. Where does that info come from?

  3. Glenn says

    Two sides to the story – reality is that doctors have to make the call on the fly and live with how things pan out. They cannot live by protocols alone – in life and death situations you make things up as they unfold.
    However the writer would do well to temper his/her political opinion. The argument is only weakened by calling critics “underachieving libtards.” This simply shows the writers intolerance. It is simply a case of immaturity that does nothing but polarise the debate by hinting the writer may well be an intolerant white/ neo-liberal reactionary. There are lots of shades of grey in this story, it is not clear cut. Yes there was eclampsia and yes the doctors made their best call. The minister may be wrong but he may still have something worthwhile to say. I do believe he is insensitive to condemn the doctors in the face of this double tragedy. The fault is not the doctors alone. However we must always remember that in these sorts of complex, quick call life and death decisions things can go wrong. Also there is such a thing as a contradictory reality and complexity in diversity. Doctors may be smart but they – and many other highly qualified people – constantly amaze me with their stupidity and lack of common sense. And yes, people can be simultaneously smart & dof! Calling people libtards simply illustrates my point.

  4. Muhammad says

    When people are put on trial by media, even worse convicted and demonised prior to the outcomes of due procedure and rule of law it’s never fair game. So with regards to Dr Gray’s approach: touché.

    I doesnt seem like Dr Gray has more facts than those already produced in the cited articles and most importantly the press statements from SAMA regarding the issue which are a must read if you want to put Dr Gray’s views in perspective. Dr Gray’s article even had me thinking this guy may also be jumping the gun at first glance. Rather it’s sort of a satirical take on the trade unions established position. https://www.samedical.org/

    IOL interviewed Prof Guy Richards on the issue (also in one of the cited articles above), and he too based on the facts available and current knowledge on the literature agrees that the doctors in question acted appropriately.

    However Dr Motsoaledi has proven himself to be a positive force for change in the current health sector, and undoubtably he acted with due consideration. The question is now that the issue has received so much media attention: what are the facts that we haven’t heard, which prompted his drastic response???

  5. Robert says

    I think its reasonable to conclude that we dont have all the facts. But the author’s points still hold: 1) what does the Minister mean when he says he hasnt seen such a case before? I think he needs to explain that. And 2) why were the doctors suspended? Because the patients died or because of negligence? and if its the latter, how did the minister reach that conclusion without an investigation?

  6. Barry says

    ALS guidelines (which are one of the best reviews of available evidence) state that pregnant women are a special case in resuscitation, and that when a pregnant woman is in cardiac arrest a Caesarian Section should be performed within five minutes. The doctors involved acted according to best practice and evidence – based medicine; maybe Motsaledi needs to go on a refresher course. Which brings to mind, he is registered with the HPCSA… I wonder if his CPD portfolio meets requirements?

    1. Adiboo says

      Short…sweet…and to the point! Well said.

  7. Voice of Reason says

    Our Minister was right in suspending pending a thorough investigation. Why is it that when he does well.. we keep quet.. the slightest controversy.. then the whole world must know!
    PROPAGANDA!

  8. Pat Redman says

    Good commentary ! Speaking of which , people want a What My Family Needs to Know , my husband saw a sample document here http://goo.gl/Xd4Fh1

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