AMA Journal of Ethics®

Illuminating the art of medicine

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AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. November 2001, Volume 3, Number 11.

Out of Africa

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Stopping for Death

Commemorative Issue: Reconnecting to Essential Ideals

Robert C. Davidson, MD, MPH

The new year began on a decidedly bad note. On December 30, a Peace Corps volunteer from one of my eastern Africa countries was killed in an automobile accident while on holiday in a south African country. Because the death occurred in the area covered by my colleague based in Pretoria, I was spared the necessity of traveling there to take charge of the death review and autopsy.

I began to make plans to travel to her host country to assist with grief counseling. This was the first death in my area, and I reviewed the protocol developed by the Peace Corps on what to do when a volunteer dies. Unfortunately, this review was prophetic of another tragedy that pulled me into a series of extraordinary events.

One week later, on a rainy Sunday afternoon, I got a call from another of the eastern Africa countries I cover informing me that a volunteer had been critically injured and was probably dead. Could I come right away? I told them I would come as soon as possible and to have the nurse in the medical office call me as soon as she knew the details. The next available flight was not until Tuesday morning. We forget the luxury of frequent flights between the major cities in the States. The country nurse called back that evening advising me that the volunteer was dead and had been killed by an elephant. "What? An elephant? How did it happen?" "We do not have all the details. You will need to get these when you get here." No one else was injured but a friend observed her death. We went through the details that would need tending to since we all wanted to be able to transfer the body back to the States as soon as possible. The country nurse would arrange for the body to be brought to the capital and for a host country pathologist to perform an autopsy with me.

On Tuesday morning, we went to the morgue at the public hospital. I had been warned by more experienced medical folks in eastern Africa that the handling of bodies in this area of the world was quite different. I felt like I had been through enough in 30 years of medical practice that I could handle anything. When I arrived at the morgue, I was surprised to see 200 to 300 people arranged around the building. My driver explained that tribal customs required that the family stay with the body until burial. I thought there must be either several bodies in the morgue or a very large family. The morgue building consisted of 2 rooms. One was a body holding area and the other a room for autopsies. The body room was completely full of stacked bodies so the overflow of bodies lined the corridor and the walls of the autopsy room. Some of the bodies were still in their clothing, but others were in the clothing they were born with. There was no refrigeration or even air-conditioning. The odor was predictable. All the windows in the autopsy room were wide open for ventilation. I felt like we were center stage in a theater in the round as all the relatives were sitting outside looking in through the windows.

The pathologist was very helpful. He had gone to medical school in Africa but had done his post-graduate work in Great Britain. He apologized for the room and bodies but said the laws of the country required a release from the authorities before an autopsy could be done or a body released. I asked if we could drape a sheet over at least the 2 closest windows. He laughed and said, yes. He agreed that an autopsy on a white body would attract a lot of attention. The autopsy itself was relatively easy. There was no mystery about the cause of death. There was massive blunt trauma to the thorax and abdomen with a flail chest, ruptured left apex of the heart, bilateral hemo-thorax, a huge liver laceration and a ruptured spleen. We both agreed that microscopic examination was not necessary, and he signed off the cause of death to allow us to start the process of getting the body released for transport to the States. Meanwhile, I was charged with writing up the autopsy and getting the facts surrounding the death.

The volunteer’s college roommate had been visiting and they had hired a driver and car for an animal safari in one of the National Parks. Around 10:00 in the morning, they came across a herd of elephants near the road. They stopped to watch and take pictures. The driver warned them to stay in the car, but after some minutes, the elephants started to move away and the 2 young women got out to get some better photos. After they moved about 10 meters toward the elephants, a large female, probably with a young elephant ward, charged. The volunteer was knocked to the ground and the friend and driver related that the elephant then kneeled on the body and rolled back and forth. This is apparently how elephants kill. The story was consistent with the autopsy findings.

The rest of the week was taken up with government releases, securing a hermetically sealed casket for transport, and arranging for transport of the body back to the States. We had several sessions with the staff and other volunteers for grief counseling. I was impressed with how the country personnel handled this very difficult situation. A counselor was sent out from Washington to assist the process. She was very helpful. She asked how I was holding up and of course I said I was fine. She then pushed me to describe the autopsy and surrounding events, and it all came flooding out. Tears are therapeutic, and I was getting therapy. As strong as we feel we are as physicians, situations like this extract their toll. It is okay after the emergent situation to be human. To grieve. To cry. To be angry. If you ignore this human need, it just builds up inside. I am convinced after all these years that we in the profession do not do enough to support each other. A colleague who takes the time to listen and allow a physician to talk about feelings provides a very important service.

When I got back to Nairobi, there was an e-mail awaiting me from one of my sons. He is in his third year of medical school and is currently assigned to the trauma surgery service at a large, urban public hospital. He had just experienced his first intra-operative death, which happened to be a police officer. He described how he did not even think about it during the surgery. As he left the OR after it was all over, he noticed that the lower part of his scrubs below the gown were blood soaked. He laughed to himself—now he knew why they wore rubber boots. As he headed toward the locker room, he realized that some of the police officers were staring at his legs and the blood. The reality of what he had just been through and the impact on the lives of the officer's family came pouring over him. I felt so helpless here on the other side of the world. I wanted so badly to be there to let him vent. I want him to retain his humanity. I can only hope that one of his colleagues provided an atmosphere in which it was okay to be vulnerable as a physician.

The views expressed are those of the author and do not represent the opinions of the Peace Corps or the United States Government.

Question for Discussion

Dr. Davidson asks us to consider how treating dying patients and witnessing death affect the physician’s physical health and emotional well-being. How can physicians tap into social support from colleagues in a culture that expects them not to show signs of weakness or vulnerability? How can physicians strike a balance between their own health and well being and that of their patients?

The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.