Death and Dying on Rural Placement

It was Friday afternoon of the first week of my rural term. I was in a town of approximately 4000 people, located over 500 kilometres away from any metropolitan centre. We had seen the last booked patient for the day and the outpatient VMO had left to make an early start on his weekend. As I walked across the hospital driveway, the pleasant silence was suddenly interrupted. Sirens blazing and engine roaring, an ambulance sped down the road and pulled into the hospital. With a rush of excitement, I made a move for the emergency department.

In the ED, a nurse gathered a resuscitation trolley while talking on the phone. Two heavily built ambulance officers stormed through the back door, wheeling an unconscious man on their trolley. He had a suspected ruptured abdominal aortic aneurysm requiring immediate surgical attention. Before I knew it, I had a gown and gloves on and was counting compressions. As I counted, people streamed in. A doctor was at the head of the patient measuring a Guedel airway. Almost immediately, the patient started vomiting. The Guedel was yanked out and a suction tube was shoved down his throat.

Drama after drama ensued. Countless attempts were made to insert an IV line; followed by an attempted intraosseous line that never happened due to broken equipment. After another five attempts, one nurse was able to get an IV in. Airway support proved equally challenging. The patient aspirated his own red wine vomitus.  Two GP registrars attempted to intubate the patient but struggled to get through all the vomitus. Following an hour of torment, and despite the efforts of numerous medical staff, the patient passed away. Just as suddenly as it had started, it was all over.

For weeks afterwards, my mind was filled with uncertainty. Did we do everything we could for this man? Are rural hospitals properly equipped for such catastrophic events? Does medical school prepare us for these emergencies? In the end it was all irrelevant. Even if we had managed to get an airway in straight away, even if adrenaline had been administered immediately, it would have made little difference. What this man really needed was a vascular surgeon, and the nearest one was at least three hours away.

As a medical student, it was very difficult coming to terms with such an event. I hazard to say that many of us are poorly equipped to deal with matters of death and dying, particularly when it is unexpected or occurs in younger patients. Although some medical schools provide courses for coping with death, there is limited evidence about how they should be run or if they are even beneficial. Such classes are impeded by an already overloaded medical curriculum, and a potential lack of perceived importance by untested students.

This experience made me realise that, although people may teach you about dealing with death, such as Kubler-Ross’ five stages of grief, it is always unique and different when you experience it. From my own experience, and that of my peers, being in a rural placement can be especially challenging. This stems from a combination of isolation, delayed counselling and support services, potential frustration at the limitations of rural hospitals, and the lack of nearby friends and family. Whilst at times, there was nothing I would rather than to avoid dealing with it, I have found that it is not only worthwhile, but essential, to reflect and reach out to others, in order to better understand our own emotions and inner conflicts.

Our own death is indeed unimaginable… At bottom no-one believes in his own death, or to put the same thing in another way, in the unconscious every one of us is convinced of his own immortality”

-S. Freud, 1915

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