- Expecting the Unexpected: Frontier Medicine from a Student Perspective
The University of South Dakota Sanford School of Medicine offers the opportunity for third-year medical students to complete a nine-month immersion experience in rural medicine through their Frontier And Rural Medicine (FARM) program. I applied for the program and was placed in a town of 3,500 people. The 25-bed Critical Access hospital and emergency room serve a five-county area with a population of 17,000, including a large reservation, based approximately 100 miles from a tertiary center. My role as a student in this community gave me a unique opportunity to be privy to many ethical dilemmas associated with frontier medicine. I watched providers navigate ethical issues and then reflected on those issues through my ethics course work. My education has allowed me to explore the unparalleled ethical dimensions to providing care in rural and frontier medicine, as shown by a recent trauma code involving multiple stab wounds.
It was a quiet afternoon in the internal medicine clinic when I got called into the emergency room for a trauma code. Without time to change into scrubs, I threw a plastic gown on over my dress clothes and helped transfer the patient from the ambulance gurney to a bed. He was a young, Native American man, maybe twenty-one or twenty-two years old. He was clearly agitated and confused as to his location. The paramedics relayed to us that he sustained multiple stab wounds on his abdomen and upper back. We needed to assess the wounds for ourselves, but our patient was quickly becoming combative. I remember him lashing out at me, grabbing me by the stethoscope around my neck. It all happened very quickly, and a nurse pulled his hands off me while calming him down.
He finally stopped fighting, whether that was due to the calming nature of the middle-aged nurse sitting at his head or his increasingly unstable vital signs, I’ll never know. He was mildly hypotensive and mildly tachycardic. We started an IV bolus of normal saline and were finally able to assess his wounds. There was a superficial laceration below the umbilicus and a deeper puncture wound to the left of the umbilicus. The wounds on his back were deemed to be superficial as well, but a portable chest x-ray was taken to be sure a pneumothorax was not present. Meanwhile, the on-call provider called for an air transport from a tertiary center approximately 100 miles away.
Despite two liters of normal saline, his blood pressure continued to drop with systolic numbers in the low 70s, and his heart rate was creeping into the 130s. His skin was cold and clammy to the touch. The Bair Hugger, a forced-air patient warming system and our only method of warming, was wheeled into the emergency room and attached to the patient to try to raise his temperature while we debated a blood transfusion. The hospital’s blood bank is supplied by the tertiary center 100 miles away; a very limited supply is kept on site. A unit of O negative blood was hung, and the transfusion began as we did not have time to wait for the type and screen to return. This situation poses an interesting dilemma unique to rural healthcare centers: what happens if another patient needs blood as well? In a larger tertiary center, blood banks are well-stocked. In a [End Page 96] rural hospital, the supply dwindles quickly, and there may not be enough to treat multiple patients. Thankfully, we did not encounter this situation. Our patient received two units of O negative blood.
It was determined that the patient was experiencing internal bleeding from the abdominal wound. A few months prior, the general surgeon on staff retired; his position had been filled, but the new surgeon had not yet started, leaving no option to move to the operating room for exploratory surgery. Recruiting physicians to a rural area poses a difficult task for hospital administration. There is only enough funding for one general surgeon to be on staff, which means this person is tasked with on-call hours 24...