Bursary Reports 2019
Site of Elective: Trauma Department Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
Introduction:
Chris Hani Baragwanath Academic Hospital is the third largest hospital in the world and the largest acute hospital. It is located in South-West Johannesburg and serves more than 5 million people. Many of the patients come from Soweto – A township of approximately 3.5 Million people and one of Johannesburg’s poorest townships. (1)
The Chris Hani Baragwanath Hospital occupies around 173 acres (0.70 km2), with 3,200 beds and 6,760 staff members. The facilities are housed in 429 buildings with a total surface area of 233'795 m2. 70% of all admissions are emergencies, including 160 victims of gunshot wounds per month.
South Africa is regarded as a leading authority on trauma medicine and surgery, primarily due to the high rates of trauma admissions. South Africa has a noticably high rate of murders, assaults, rapes and other violent crimes compared to most countries (2). Over 90% of global trauma deaths occur in Low- and Middle-income countries (3). Recent publications from the World Health Organization place the global injury mortality rate at five million per annum, with almost one-fifth in Africa.(3) In the near future, the injury mortality rate will exceed that of HIV and AIDS, tuberculosis, malaria and obstetric causes combined. (4) Over 50 000 trauma- related deaths were recorded in 2009 across South Africa, with the majority related to transport and violence. (5) As someone interesting in emergency medicine, I chose trauma in South Africa as a way of gaining exposure to an area of medicine that is seen far less often in the UK.
“Casualty” at Chris Hani Baragwanath Academic Hospital know as just “Bara” to the locals is divided into three separate areas; Medical – for all medical issues, Surgical – for surgical emergencies such as acute appendicitis, cholecystitis or renal colic; Patients must be referred by a local clinic to access this department. Finally, Trauma – again patients should be referred from one of the smaller clinics as Bara is a tertiary centre and much of the more minor trauma can be dealt with elsewhere.
On arrival patients are “screened” by a senior doctor. This functions as a triage service, although no observations are available. It designates patients as either unstable, stable or unsuitable for Bara. Unstable patients are transferred immediately to the resus department. There are fourteen monitored beds in the department with approximately three nurses, although often only one nurse is fully registered. The department also has a “LODOX” machine. This is a low dose x-ray enabling patients to be scanned within the department upon entry. This allows patients’ larger injuries to be immediately recognised and managed early. The resolution does not allow for detailed assessment but does identify pneumothoraces, long bone fractures and bullet trajectory. Patients are stabilised in the department and then transferred to theatre, trauma ward or trauma ICU.
Stable patients are sent to the admin department to book in; this is where patients are registered, and payment is arranged. Payment amounts are based on income. Most patients have very low or no declared income. Once registered the patients can return to the department to be seen. They may then be sent for x-rays or other investigations, reviewed by senior doctors and either discharged or admitted. A lot of these patients are referred to orthopedics who are not based in the trauma department. All patients have to be cleared by trauma before they can be referred.
Outcomes of Intended Learning Objectives
Major trauma is managed expertly in South Africa if Chris Hani Baragwanath is representative; as one would expect from a country that experiences so much trauma on a daily basis. The average week in resus saw at least 100 cases. These were divided into penetrating (shooting and stabbing), blunt trauma (vehicle accidents and mob assaults) and burns. I was able to be involved in many of these – especially during the course of the 24-hour shift. My interest was primarily in the stabilization, initial investigations and management of these patients and I got a good understanding of the general system employed. In particular the use of sedation, intubation, fluid resuscitation and initial management such as burn scrubbing, pressure dressing and skin traction. Overall, I felt that I achieved this objective. As expected, the vast numbers of trauma patients meant I was able to assist in a lot of cases. In fact, unlike at home, students are a vital part of the workforce. On many occasions I was the only assistant to one senior doctor expected to do everything required. I was then often left to complete primary management alone, while I was initially apprehensive about this, I came to enjoy the responsibility and it allowed me to develop my skills at a much faster rate. Generally senior doctors were available if I was unsure or didn’t know how to proceed but there was an expectation that more basic tasks would be done unsupervised. Finally, Bara is well equipped compared to many of the more rural hospitals in south Africa; as a result I don’t think it would be fair to claim that I know how trauma is managed throughout the country but Bara is the undisputed centre for trauma and many protocols were developed there.
Learning Objective 2:
I was able to and in fact, expected to preform many procedures. For basic things like suturing I was able to do daily. I was able to improve my ability and speed. I also had to suture in layers for deep injuries, most memorably a pig bite and in numerous difficult areas such as the scalp, face and hands. Resource limitations also forced me to improve my abilities as well; On one occasion, I had to suture a stab victim using only a large colt needle and hand tying all the sutures as there was no suturing equipment in the department. In the resus department I did many large bore cannulas and blood gases a day which has massively increased my confidence in this area. I was also able to do more advanced procedures under supervision. I inserted a chest drain for a haemothorax and assisted on many central lines. The senior doctors were very keen to teach these procedures and the majority were very patient teachers. After working in such busy departments, they had seen everything and remained unphased in all situations, this helped instill confidence in me. When I initially struggled with the chest drain, my supervisor was able to encourage me to carry on and ultimately it was successful. Compared to the UK I felt that they were much more comfortable in letting junior member of the team do things even in unstable patients. This is probably a reflection of their own training, in many hospitals a doctor with two years’ experience would be the only doctor available and so skills are expected to be built much quicker as it is often a case of “me or no-one”.
Discussion:
The volume of patients as well as poor organisation means things take a long time, especially for those that are not unstable. At first, I kept wondering why parents were bringing their children in at 2am with injuries sustained at school – in reality they weren’t but due to the number of different stages and the waiting at each point it was taking several hours until they were properly assessed.
The nurses were, like many were underpaid, underappreciated and over worked. However, many were also living in the poverty and violence of Soweto. Many of the nurses were not fully trained. Most traditional nursing tasks were performed by medical/elective students. I got used to being ignored by nurses and having to repeat requests several times. After several days I started to appreciate that this wasn’t personal but rather a reflection on the system. I got used to being more demanding and repeating requests. Often this was for analgesia, I’m not used to working a system that requires multiple requests to get something so basic; especially for patients who in many cases had very serious injuries. Patients themselves are often completely ignored by the nurses so I had to advocate on their behalf. I hope to take this advocacy back to the UK, as well as an even greater appreciation of our very dedicated and caring nurses.
Financial limitations, doctor shortage, exhaustion and an attitude of “you find it broke; you leave it broke – your job is to survive your trauma rotation” means service improvement does not happen easily. Many of the doctors had spotted the easy improvements but the grueling hours and resistance from nursing staff meant that after one or two shifts the vast majority of doctors gave up on trying to improve anything or even think about the problems. Surviving the rotation became the priority. The week before I arrived, a gunman (trying to finish what he had started with another man now in trauma resus) managed to get into the department and threaten staff. In another area of South Africa, a junior doctor finished a 40-hour shift and drove home, exhausted they crashed, killing themselves and another driver - the survival they talk of is more than figurative. I worked 24 hours shifts that turn into nearly 30 hours by the time the morning work is completed; The exhaustion is unbelievable. The interns and residents maintain that you get used to it, but I definitely noticed how many mistakes I was making; luckily nothing serious but even simple tasks took much longer. Again, this plays a part in the inefficiency of the system. It is worse for more senior doctors who are making big decisions and preforming more complex tasks with this level of exhaustion.
Initially I was completely overwhelmed by the cases I was seeing. I have never seen a gunshot victim before, and I saw six in my first six hours. I had seen one stabbing and within twenty minutes I was suturing stab wounds. I didn’t even know what community justice was but after two days I was able to do the initial management on my own. However, after the initial shock at the types of injuries and sheer amount of cases another feeling was at the forefront of my mind; Why, why is there so much trauma. Six weeks is not enough time to fully understand this incredibly complex nation, but I tried to develop some appreciation. Chris Hani Baragwanath is a microcosm of what is happening in South Africa. The stresses of the broad social, economic and political changes in the country are reflected here. South Africa is the most unequal country in the world; some of the poorest people in the world live in close proximity to people who can afford private education, cars, large houses and staff to clean those houses. Much of the wealth is still focused in the white population as a hangover from apartheid. Both poverty and inequality contribute to the high levels of crime. Attempts to redistribute some of the wealth have also created problems. Corruption is also a massive problem and again could be seen in Bara. I had previous experience of low-resource medicine in Ghana and I believed I was prepared for the limitations I would face in south Africa – I was not. Primarily because in many ways the resources were not limited, at least not in the way I expected. Bara has 4 CT scanners, an MRI machine, the ability to run all urgent blood tests and on one occasion I was even able to witness a trauma patient getting a same-day barium swallow for a suspected oesophageal perforation. There are several trauma theatres in which to perform the many surgeries that take place daily. There is laparoscopic capability. None of this was what envision from resource limited healthcare. However, there were often times when there were no gloves in the department, or normal saline or cannula of the right size. Large parts of several shifts were spent looking for the requisite equipment, which was somewhere in the department, but nobody knew where. This was not the end of the inefficiency; often cheap simple things were not available so more expensive items were used in place. For instance, catheter tubes were often stuck using tegoderm cannula dressings as there was no simple tape. Normal gloves weren’t available so sterile surgical gloves were used for simple examinations. With the numbers of patients this obviously represented massive inefficiency in time and money. I did speak to several of the doctors about this and they pointed towards corruption; the staff purchasing equipment often purchased from friends or family; there was no tender process or transparency. The items therefore were often of poor quality or not available. This is apparently an open secret in South Africa.
Overall it was a fantastic experience, I learnt a lot and improved many of my emergency medicine skills however, my biggest take home is how much I appreciate the NHS. The staff, the resources and the organisation.
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References:
1. “The Chris Hani Baragwanath Hospital, South Africa | The World’s 3rd Biggest Hospital, in South Africa - Accessed June 7, 2019. https://www.chrishanibaragwanathhospital.co.za/.
2. Matzopoulos, Richard, Megan Prinsloo, Victoria Pillay-van Wyk, Nomonde Gwebushe, Shanaaz Mathews, Lorna J Martin, Ria Laubscher, et al. “Injury-Related Mortality in South Africa: A Retrospective Descriptive Study of Postmortem Investigations.” Bulletin of the World Health Organization 93, no. 5 (May 1, 2015): 303–13. https://doi.org/10.2471/BLT.14.145771
3. Lozano, Rafael, Mohsen Naghavi, Kyle Foreman, Stephen Lim, Kenji Shibuya, Victor Aboyans, Jerry Abraham, et al. “Global and Regional Mortality from 235 Causes of Death for 20 Age Groups in 1990 and 2010: A Systematic Analysis for the Global Burden of Disease Study 2010.” Lancet (London, England) 380, no. 9859 (December 15, 2012): 2095–2128. https://doi.org/10.1016/S0140-6736(12)61728-0.
4. “Crime in South Africa.” In Wikipedia, May 20, 2019. https://en.wikipedia.org/w/index.php?title=Crime_in_South_Africa&oldid=897903898.
5. “WHO | The High Burden of Injuries in South Africa.” WHO. Accessed June 7, 2019. https://www.who.int/bulletin/volumes/85/9/06-037184/en/.
6. Hardcastle, Timothy C, Damian Clarke, George Oosthuizen, and Elizabeth Lutge. “1 5 Trauma, a Preventable Burden of Disease in South Africa: Review of the Evidence, with a Focus on KwaZulu-Natal,” 2016, 12.
Hayley Slater
Daniel Desogus
Letter from Daniel after qualifying
I am just contacting you for an update. I am at the end of my fourth year now and about to do my elective. I find it hard to believe that it was four years ago I was contacting you about a bursary! How have things been with you?
I am thrilled to be able to tell you that I have just had my results from finals and I passed. I will start working in July/August in west midlands south deanery (I haven’t received a job allocation yet, but I am likely to be based in the Coventry and Warwickshire area). I am due to start my elective this week. I have kept it simple, and will be doing 6 weeks at George Eliot hospital with a focus on anaesthetics and ITU. I am still unsure what I would like to specialise in in the future, but anaesthetics is on my list of considerations, as well as emergency medicine, a medical specialty in hospital and general practice. I also have an interest in psychiatry but I am unsure if that is something I would want to pursue as a career. I am hoping to get a foundation placement that covers emergency medicine, psychiatry and general practice so I can experience those as a doctor and not just as a student.
I would like to once again thank the Kidderminster Medical Society, and you personally, for your generous support. Without your bursary I would not have been able to afford my tuition fees in the first year of study and I wouldn’t be here today. Thank you so much, I will always be grateful for the opportunity,
Best wishes,
Dan Desogus
Graduate Entry Medicine Report
Jeremy Rison
Firstly, I want to express my thanks to the Kidderminster Medical Society for the 2018/19 grant. It is such a generous amount and has been a great help in my first year of Graduate Entry Medicine (GEM) at the University of Nottingham. Not only has the grant eased the financial burden of returning to study and the associated living expenses but it has also covered my travelling costs which have enabled me to keep volunteering with a charity called Birmingham PHAB Camps. We organise and run holidays for disabled and non-disabled children from Birmingham. I have volunteered with this charity for a number of years and being able to continue volunteering with them has been wonderful, as well as providing nice breaks from studying medicine!
The first year of studying GEM has been incredibly intense but I have really enjoyed the challenge. It is quite incredible the amount I have learnt this year. Whilst walking into university each morning, I have regularly pinched myself that I am actually studying medicine, something I have wanted to do for many years. I have also made many new friends at medical school and we have helped support each other through this challenging first year of GEM.
At Nottingham, we have covered 6 modules in the first year (an introductory module; respiratory; cardiovascular; limbs and back, alimentary; and endocrine). Despite the daunting amount of information we need to commit to memory for exams, I did enjoy bringing the knowledge together at the end of the year. It is difficult for me choose which area of medicine has been my favourite so far as I have found it all so interesting. However, I really enjoyed endocrinology, despite having to revise everything we had covered this year during the module in preparation for summer exams. I also particularly enjoyed my GP placements and the ‘Community Follow-Up’ project where pairs of students have been connected with patients and their families to learn about their use of health and social services. I think this is a great project for medical students as it reminds us of the reasons we chose to study medicine in the first place; something we sometimes need when we spend so much time with our heads down reading and studying. I am currently enjoying a well-earned summer break and am looking forward to completing the last 3 modules of GEM before beginning the Clinical Phase of training which starts in February next year.
Once again, thank you so much for the grant. It has made a great difference to my life this year and it will also help cover some of my living costs next year.
Jeremy Rison
Graduate Entry Medicine Bursary Report
I would like to thank the Kidderminster Medical Society immensely for the support that they have given me on the Graduate Entry Medicine Course at University of Birmingham. This has been a year of immense change in my life, where I have taken the leap from a paid job back to university to pursue my ambition of becoming a doctor. The Kidderminster Medical Society bursary has been instrumental in supporting me on this Graduate Entry Medicine Course.
This year I have had to adapt again to the lifestyle of a student, and the daunting prospect of supporting myself without a source of income. The first year of the graduate entry medicine course was a challenging and time consuming year. Having just finished, I can now see that undertaking part time work would have been detrimental to my studies. I therefore thank the Kidderminster Medical Society for their support in allowing me to fully concentrate on my studies.
With the support of this bursary, I have quickly adapted to the Graduate Entry Medicine course. I have thoroughly enjoyed this first year and the problem based learning environment and I am delighted to have just found out that I have past the first year of this programme. This summer I found some short term work purifying and characterising recombinant surfactant protein D protein in a research laboratory, a protein currently being developed to prevent inflammatory respiratory disease in premature neonates. I have also found some additional work to help write grants and research papers to understand the dysregulation of the immune system in patients with chronic obstructive respiratory disease.
I am looking forward to learning in a clinical environment from September. I am excited about my future as a clinical doctor and would like to thank the Kidderminster medical Society for supporting me along this journey.
Alastair Watson
Bursary Report from Bethany Davies
Firstly, I would like to thank the Kidderminster Medical Society for their contribution to my elective this year. It helped fund the trip of a lifetime to the Princess of Wales Hospital in Sydney, Australia. I was based in the Oncology Department in the suburb of Randwick-located hospital just outside of the big city. I was anxious about visiting a place so far away alone however I soon settled in. I soon became to realise that while there were many differences between the UK and Australia, there were also several similarities.
One of the similarities was the level with which the hospital treated patients at. By this I mean, it was very much a ‘developed country’ hospital – with up to date technology, various highly trained and specialised departments with cutting-edge treatments and clinical trials. My day to day schedule was also familiar to me – sitting and participating in different oncology clinics with a consultant, attending multi-disciplinary team meetings and joining ward rounds. Other activities I took part in included observing radiotherapy-planning sessions, going on home visits and attending genetic counselling. However, there were particular days that stood out to me.
One such day was when I was placed with the palliative care team and we conducted home visits. We attended a lady with advanced multiple sclerosis who was only in her 40s. Her husband and young children could only just understand how she spoke and she could no longer eat solid foods. It was extremely moving to see the family dynamics and to hear about her rapid decline of a year. The team organised adjustments to their house, for carers to come in and, of course, the medical side of helping with breathing and eating. This experience touched me and allowed me to appreciate what I have but also understand how palliative care can truly help someone and their families.
Another day that stood out to me was seeing someone get told they have stage 4 cancer for the first time. It was a gentleman in his 60s, and his wife and 3 children had all come to the appointment to support him. He had an idea that it was a serious diagnosis but did not understand the gravity of the situation. When he and his family broke down upon hearing the news I could not help myself welling up. I observed tremendous communication skills from the doctor who displayed empathy and humility alongside professionalism and control. Whilst being extremely upset, the family left with a plan and the support they needed at this distressing time, which was invaluable. This is definitely something I will take forward in my future career.
A final day I remember is attending genetic counselling sessions. I was fascinated with how the diagnosis of one can affect so many. I understood the concept before but had never seen it ‘in action’. A woman had been diagnosed with Li-Fraumeni syndrome, an autosomal dominant disorder caused by a mutation in the p53 gene. I had never seen anyone with the condition let alone appreciated the effect it can have on their wider families. The consultation consisted of going over her diagnosis (she had had breast cancer a few years ago and just had a sarcoma removed), and then discussing any ongoing treatment and wider implications. A family tree was made and she gave consent for her family members to be contacted for genetic testing. It was interesting to see genetic counselling in ‘real life’ and the importance of helping the patient with their troubling diagnosis, maintaining confidentiality, whilst also considering other family members.
I also appreciated how Australia have their version of NICE that contains their recommended treatments. However, how people access this medical treatment over there is different due to the dissimilarities in funding – private or public. You can pay for private medical insurance or be a part of the government funded Medicare system. In the UK, money does not even get mentioned in any public healthcare setting. However, in Australia, funding is at the forefront of conversations, even just to ask to see their Medicare card on reception. There were also multiple forms to fill out and coding systems to ensure the correct money was billed to the right place. It definitely made me appreciate our National Health Service and how it should be protected.
In conclusion, I cannot thank the society enough for contributing to this trip. It gave me the chance to see how healthcare can differ in another well-developed country, but, also highlighted the similarities of how we all strive for the same thing. The experiences I encountered will help me be a better doctor both in terms of knowledge and non-technical skills. I would definitely recommend the beautiful Australia as an elective destination and I look forward to starting my career this August.
Bethany Davies
Final Elective Report from Kim Esquivel
Reflective summary
The organisation of ICU in Bach
Mai Hospital
During my elective placement, I spent 3 weeks in the Intensive care unit (ICU), where I was able to shadow Consultants on their ward round and have bedside teaching where we discuss each case on the round. The ward round involved daily investigations to monitor the progress of each patient whilst altering the management plan accordingly.
The ward round consists of medical students and doctors, where 2 consultants was in charge for one half of the patients in ICU. After the ward round, both doctors would have a daily handover with nursing staff so that they are both fully aware of each patient case regardless if they are in their delegated half.
The roles of the team were different to my clinical experience in the UK because apart from nursing staff and doctors, there was a limited variety of healthcare professionals.
For example, I expected to see an ICU ward with specialised physiotherapist to aid patients in their long term stay in ICU. However, it was the nurse’s role to perform physiotherapy to mobilise patients if possible and perform respiratory physiotherapy to remove secretions.
In this situation, I felt that by having nurses’ conduct a physiotherapy, it reduced the amount of healthcare professionals looking after the patient and patients would form a stronger relationship with their nursing staff as it was one to one care. However, the nursing staff may be more stressed with an increased workload.
Management of patients in ICU
Many of the patients in ICU had a hospital stay in average of 40 days. I found this very unusual as most patients in critical care in the UK would only have 7% of patients stay longer than 11 days.
The main trouble was that new patients requiring ICU beds were often dealt with in normal wards as there would be no beds available in ICU. I think that this is a common problem in both east and west with bed management, as the need for healthcare services increases but the availability to provide services remain static. Patients would become frustrated with the doctors, and in Vietnam, the family members would stay in the waiting lounge with their sick family member until they can get a bed in ICU.
This increases the strain in the doctor-patient relationship as patients get frustrated, doctors feel inadequate as they can not provide the care without extra hospital space.
The problem in ICU is that long-term patients would usually be very complex, and doctors are often at a loose end with their management plan.
In Vietnam, palliative care has not really been established. Doctors would have discussions with the family members of an unconscious comatose patients in ICU, and although they say the prognosis is dire, the family would still wish to carry on life sustaining treatment. Often the family would pay extra to keep the patient in their ICU bed and maintain life sustaining treatment.
On the ward there was a patient who has suffered a myocardial infarction and required stenting to re-open the coronary vessels. Whilst most patients post stenting would be allocated to a bed in the cardiology ward, this patient had special treatment due to the family’s wealth.
The consultant in
charge disclosed that because this patient’s
family is paying extra, they have allocated the
patient an ICU bed for more close monitoring due
to family wishes.
This case is not uncommon in Vietnam and studies have shown that monetary gain can equate to better treatment in hospitals. However, with regard to the doctor-patient relationship, the doctor may feel that their judgement is undermined by the patient or the family members because they have paid for the medical decision. The best interest for the patient may not necessarily correlate with the family members decision but with money involved the doctor may feel pressured to cave to the family’s wishes.
I think that this behaviour is detrimental to the doctor-patient relationship, as family members would not know the best medical management for the patient and it is the doctors job to communicate effectively what they believe should be the next step.
The culture in Vietnam with regard to preserving patient’s dignity and comfort during examinations was very different from my experience in Medical school. I found that patients during ward rounds would usually be unconscious or have a low consciousness level due to the severity of their disease in ICU. All of the bays on the ward did not have curtains for privacy and many patients would have no gown on the upper body so their chest would be exposed to other patients and members of staff.
I found this uncomfortable to see, as we are always told in Medical school to maintain patient’s dignity during physical examinations. I felt that doctors should have made the comfort of the patient a priority, as they were too unconscious to object to the insufficient care provided.
Walking past other wards in hospital I found that procedures were being done in front of families such as catheterisations, with no curtains to preserve the patient’s privacy. I was shocked to see this when moving from ward to ward. This showed me the importance of the family members role in the doctor-patient relationship.
In Vietnam, the family members would be given equal or more priority than the patient when it came to making decisions. The impact between the doctor-patient relationship means that the decision would often lie between the doctor and family member, as the patient would be to ill to advocate for themselves.
This situation has taught me that as Doctors we should always advocate for the best interest of our patients and have the confidence to make our point across to family members, as stated in the medical ethics of beneficence.
My experience in
Obstetrics and Gynaecology
For the last 3 days of placement, my rotation was in Obstetrics and Gynaecology. During our clinical years, we have not had any experience of this specialty previously. My daily activities involved observing in outpatient clinics, ward rounds and theatre lists.
The structure of the department was interesting as it encompassed everything in one ward: from outpatient clinics for antenatal scans, to the labour room and post delivery suite. The theatres for caesarean sections was located in the floor above with a post-surgery maternity ward.
In the outpatient clinics, women would come for their antenatal scans and be surrounded by 15 medical students, the doctor and one ultrasound machine. As a patient, I would have felt very intimidated in this situation, as a crowd of people were observing my scans.
Fortunately, most women were unfazed, however most clinics in the UK would have a maximum of 2 students to preserve patients’ privacy.
I think that in this situation the medical student’s education was prioritised, and it could be improved if the doctors asked for consent to having only a few medical students during the clinic.
By having a crowd of people in the clinic, this would have been a barrier between the doctor and patient communication as it would have felt quite impersonal.
Therefore, if the patient wanted to disclose any personal concerns or if the doctor had to break bad news, it would have been very difficult to form rapport with a large group of observants watching the consultation.
The labour room could occupy 10-20 patients, whereby patients would not be separated by curtains, therefore during intimate examinations the patient would be overtly exposed. Being taught that the patient’s dignity should come first before any examination, I found this quite shocking as other patients could see the intimate examinations taking place. I felt that in this situation, the patient was in excruciating pain to have the strength to contest the doctor in conducting an intimate examination in front of others.
Most women in the labour room were all nearly fully dilated before being taken into the delivery suite which is mainly midwife-led with an overlooking doctor on duty. In the labour room, the women would not be given any painkillers such as Entonox, epidurals, pethidine or even having the choice of being in a birthing pool. This has taught me to value the luxury of medications in the UK, and value a healthcare system where our comfort is made a priority.
Kim Esquivel