Last week I had a flight up the Gibb River road to the community of Kupingarri. This remote community is on the Kimberly plateau, near the Mount Barnett Roadhouse. For the last 10 years or so, there has been a full time nurse in the community, staffing the clinic. Because its affiliated with Jurrugk and DAHS, there is an emphasis on preventive care, although that doesn't keep the locals from eating the ice cream and junk food stocked at the Roadhouse. The environmental health worker for the Shire of Derby flew out with us to inspect their water and sewer systems. He found them very satisfactory- a huge contrast to my Yulumbu flight. The clinic as you can see in the pictures [click it for slideshow] is clean and relatively modern. I saw a wide variety of children and adults on a very busy day.

Kuppinjari

We turned around on Friday and drove to Broome, taking the late night flight back to Perth for the WACRRM meeting (see blog entry below). It was a very nice conference on Men's Health, and I was pleased to find an emphasis on Aboriginal health.

Perth WACRRM Meeting

I attended talks on mental health, nutrition, ear health and infection, and a review of "Brief Interventions for Blokes". Vicki found me a nice sport jacket which I wore to the Conference evening dinner & dancing entertainment. We did a bit of browsing at the bookstores and had some nice walks in the brisk "cold" (55-65 F) autumn weather.


Returning from Perth Sunday night, my colleage Cyril drove us back to Derby in the dark. Although we saw many cows, often in the road, we managed to avoid any close encounters. We spent the drive listening to Cyril's story. Son of a university professor in Burma (Myanmar), he was a medical student and involved in the human rights movement of Aung San Suu Kyi. Now 36 years old, he spent 6 months in their prisons for being the president of the student body and demonstrating for human rights. All of his family left Burma, but he had stayed behind hoping to finish his medical studies. After his prison term, he emigrated to Australia and finished medical school here. He is now a Registrar, training to get his GP "Qualification". (This is similar to being a Resident in the U.S. except that GP training is onsite, in a working practice, supervised by older, more experienced GPs.) A devout Buddist, Cyril has been called to medicine to relieve the sufferings of others. He plans to go on to study Palliative Care next January after he finishes his term at DAHS.

I spent most of this week, except for Anzac Day, at DAHS seeing patients, although yesterday had a flight to Ngallagunda (the first "g" is silent), a beautiful community farther up the Gibb River road. This was the first "slow" clinic we have had, with my time spent seeing only one very old woman, and doing a bit of talking and teaching with the nursing staff. [Click picture below for slideshow]

Ngallagunda

Ngallagunda is high on the plateau, up over 500 metres altitude. The community as been well laid out, it has a Catholic school and also has a full-time nurse, Mary Jane, who staffs the clinic. The dentist was also visiting yesterday, so many of the children and adults were up at the school having their teeth examined. In a week of so, those that need care will travel south to Kupingarri where the dentist will haul in a dental chair and do tooth repairs for a few days.

Today is a day of rest, with a swim in the pool, a few home repairs, and getting ready to go to Broome. We will spend next week with the students from Derby, Broome and Port Hedland all in Broome for FARTS (Formative Assessments in Rural Training)- essentially midterm exams that don't count for a grade, and do some workshops for the group of 18 while they are all in one place. I will be teaching about ear health, and pneumatic otoscopy and tympanometry. The RCS has booked us into the pricey Cable Beach Resort. It is tourist season, and hard to find inexpensive accomodation in Broome.

I must admit to feeling a bit whipsawed, going between Aboriginal rural communities and the Western high tech ambiance of Perth and Broome on such a reciprocating schedule. It certainly brings home the disparities in wealth and housing here. Its hard not to feel both guilty and lucky to be able to do this. Vicki and I are both looking forward to the beach, as we have not yet dipped ourselves in the Indian Ocean.

Click the pictures below a "you are there" 360 degree movie of a beautiful Ngallagunda morning. Listen for the birds, and the children on the swings.

We woke up at 4:30 AM to go down to the Civic Center for the Anzac Day Dawn Ceremony. Today is a national holiday in Australia and New Zealand, commemorating the landing at Gallipoli in the First World War, where over 10,000 Australia/New Zealand Corps (ANZAC) men died in a futile attempt to invade Turkey.

Here in Derby, the Police, Fire Brigade, Scouts and some veterans made a predawn parade through the streets to the War Memorial on the lawn in front of the Shire Offices. About 200 people stood in the darkness for the service, which included prayers, a short address, songs, the national anthems of both countries, and finally the Final Post, the Anzac prayer, and closing with Reveille.

Most of the crowd were European descendants, although there were a scattering of Aboriginal people present. After attending Anzac Services 2 years ago in New Zealand, we had been curious to see how Anzac Day was celebrated in the Kimberly, in this land where the indigenous people do not speak the name of the dead or look at their pictures. The SBS News tonite had coverage of the first-ever Aboriginal Anzac Day Parade in Sydney. My medical students were not aware that any Aboriginal people had served at Gallipoli, but the truth is that Aboriginal people have served Australia since the Boer Wars. It is hard to tell exact numbers, because they were required to deny their Aboriginality by passing as white, or Pacific Islander or Maori in order to join up. But current estimates place about 500 Aboriginal soldiers at Gallipoli and over 5000 serving in WW2, with more serving in VietNam, the Solomons, and now in the Middle East.

The Anzac service is meaningful and poignant. We arise at dawn, as traditionally soldiers were awakened before dawn to stand watch, it being the favored time for the enemy to attack. The grey light filters through the boab trees, turning crimson on the horizon, mixing with the words of remembrance, and the haunting sounds of bagpipes, and finally, the call of the bugle.

Winston Peters, the Foreign Minister of New Zealand spoke at Gallipoli today, and we found his words chilling. When talking about the needless loss of ANZAC troops due to failures by their British leaders, he said:

" "They were to learn that courage and natural ability cannot compensate for failures in planning, leadership and logistics."

It is sad to contemplate that 92 years later, similar mistakes have been made in the Middle East by our own country and our Australian and British allies.

Also from Winston Peters' speech:

"After the war, it was Mustafa Kemal Atatürk, a divisional commander at Gallipoli and later founder of the Turkish Republic, who paved the way for reconciliation.

His generous words, which are engraved on the battlefield here and on the memorial to Atatürk back home in Wellington, continue to have resonance for New Zealanders and will never be forgotten.

'In remembering the suffering and loss on both sides, let us commit ourselves to working for a world where differences between nations can be resolved without resort to war.

That is the way that we can best honour the men who fought and died here.' "

The ANZAC Dedication:
For the Fallen
by Laurence Binyon

They shall not grow old,
As we that are left grow old.
Age shall not weary them,
Nor the years condemn.

At the going down of the sun,
And in the morning,
We will remember them.
We will remember them.

We are taking a 4500 km jaunt to Perth today for the weekend. I will attend the WACRRM meeting on Men's Health, and Vicki gets to come along. WACRRM pays for the airfare and pricy rooms at the Sheraton, and all I pay for is the tuition. This is a great program WA has to support both rural doctors in their education, and also their families by reducing isolation. (If we had kids there is a family weekend program for them in Perth.) Vicki and I have a list of things we need to purchase, and on Saturday night we will attend the "Star Studded Extravaganza", whatever that is. Hopefully we can show off some of what we've learned at our ballroom dancing classes.

Over Easter I took a bunch of photos of "downtown" Derby. Click on the Goanna below for a tour of the shops and places of note in our metropolis.

Derby Easter 4/2007

Last month I read Michael Shermer's always excellent column in Scientific American. He was discussing happiness, and makes the point that "happiness is better correlated with satisfaction, than with pleasure. .[because].. Satisfaction is an emotion that captures the uniquely human need to impart meaning to one's activities"

Tuesday morning I called the local CAT office to follow up on the dead bore at Yulumbu. As a result of our phone calls, CAT had a team flown out to the Community on Monday and had the well fixed by early afternoon. I also learned that the local Shire (government) staff have been alerted and are going to work with CAT to be sure that if vital services like power and water are interrupted for repairs, that standby or temporary equipment will be available so remote communities do not have to go without.

Throwing stars makes me happy...

A short week here after the 4 day Easter weekend. Many people are still "gone bush" and there is no school for 2 weeks, so the kids are out and about and people have gone visiting. Because it is autumn here (the Ozzies give me a very funny look when I call it "Fall"!) we are giving flu shots like mad. However, with the time of year we are having our first outbreak of respiratory viral illnesses, so I've seen a lot of sick kids and adults this week. A lot of people come in to be "just checked out" and get the Section 100 (free) medicine that an Aboriginal Health Service dispenses. Here in remote Australia, a package of 24 500mg generic paracetamol (equivalent to Tylenol) runs about A$ 5.00. Mums particularly have concerns about small children with fevers, as well they should, given the historically high death rate from sepsis for Aboriginal children. And then there are very high rates of ear infection, with it being very common to see ruptured eardrums draining pus in small children. The theory is this is due to high carrier rates of streptococcus bacteria species in the nose and throat, which invade during every viral illness. So we end up prescribing a lot of liquid Amoxycillin antibiotics.

But beyond treating sick people one by one, and doing opportunistic preventive care in a systematic fashion, a rural and remote doctor occasionally needs to become a public health officer.

Friday I was rostered for a remote flight out to the sister communities of Tirralintji and Yulumbu. These communities, about 35 km apart across the Fitzroy river are about 350 km due west of Derby. So we flew out of the Derby Aerodrome around 0730 and landed at Tirralintji first, where the morning was spent giving flu shots and doing some routine checkups. The people at Tirralintji told us that their relatives at Yulumbu had no water- their "bore" (well) went out around April 1st. In fact, two of the teen aged boys had walked across country and swum the crocodile-infested Fitzroy to visit their Tirralintji relatives after this happened. Otherwise the two communities had been cut off from each other completely for the entire Wet season.

We loaded up the plane again and took the 20 minute hop to Yulumbu, which is situated right on the river. Yulumbu has 23 people living in the community, 9 of them are small children and 4 are teenagers. One woman is pregnant. Most of the adults were older and a few very old (for Aboriginal people), with many medical problems. This community has historically found hygiene to be a challenge, but now all of them had now been without running water for 2 weeks. They had been carrying drinking and washing water out of the Fitzroy, which besides having crocodiles, is in the middle of cattle country. And overheated cows are fond of standing in the small streams and pools in the area, and contributing a nice load of manure into the water. It was clear that the people did not have the resources for- and therefore had not been- boiling all their water. The RFDS nurse and I were very concerned to hear that the estimate for repairing the bore pump was "sometime after Anzac Day" (which is April 25th). This would mean almost an entire month without water for this community, and surely this was an outbreak of dysentery just waiting to happen. The cost for a new pump was A$5000 so CAT had recommended that the old pump be pulled and repaired because it would save $2000.

Gail got on the satellite phone and called the Center for Appropriate Technology (CAT) office in Derby who told her that "the contractor was on annual leave for a week and there wasn't much that could be done". So she asked me to call them back. I explained that I was on the ground in the community, that the hygiene situation was terrible, how many small children were around, and that my assessment was this was an urgent health crisis. They told me they were "not aware the situation was so serious for so many people and they would see what they could do". They are on my call back list for Monday morning. We will see what happens.

It just strikes me that there is so little concern about this situation in wider Australia, at a time when the earthquake/tsunami relief for the Solomon Islands is on the news nightly. Australia has donated A$3 million for relief there, but can't find $5000 for a new pump for its own people. And $A5000 is a good deal when you consider the cost for each chartered fortnightly flight to the community was over A$3000. One RFDS evacuation for a dehydrated shocky child will be many times the cost of a pump.

Yulumbu

Click picture above to see the album.

An amazing thing has happened to me recently. About a month ago I started noticing that I was getting dizzy and lightheaded when standing up suddenly from gardening or stooping over. A quick check of my blood pressure showed it was running about 105/70, so I quit my 12.5 mg of Atenolol. So far the BP is hanging in there at 112-118/80-85 range without medicine.

Now, I have been taking BP medicine for over 14 years. Hypertension runs strongly in my family. When we went to New Zealand 3 years ago, I lost about 10 kg and started walking more, and was able to cut down from my then 50 mg dose to 25 mg. I lost more weight in early 2006 and cut down from 25 mg to 12.5 mg daily. But my weight has now been stable for the last year, I am exercising and eating about the same.

The only explanation I can come up with is that I am sleeping better. I now get at least 8 hours of uninterrupted sleep every single night, usually getting up only one time to the toilet. I did a PubMed search yesterday, which confirms that this may have a significant effect. Last year a huge study on health and nutrition showed that short sleep is associated with hypertension. There have also been Japanese studies of shift workers showing more severity and faster progression of hypertension.

Usually we doctors think of lifestyle changes as weight loss and low salt diet and exercise, and neglect to talk to our patients about adequate sleep. But I am more convinced than ever that our 24/7 world, epitomized by 24 hour Wal-Mart in the U.S. is really bad for cardiovascular health. For me especially, the many phone calls and night calls I have been doing the last almost 30 years of medicine have not been healthy. I am convinced there are also a lot of not-so-obviously-obese people out there who also have sleep apnea and terrible sleep hygiene causing high blood pressure and vascular disease.

And this does not even take into account the other good effects of adequate sleep, which for me include better energy, more upbeat mood and an easier time "living in the moment". So when considering recent events like flying cows and bogged aircraft wheels, I don't feel especially stressed.

One social difference between the U.S. and both New Zealand and Australia are the limited shopping hours. Most everything here closes at 5PM daily, except the groceries which might stay open until 7 pm. This leads to busy noon hour shopping, but most people do not work late shifts or night hours, except for "emergency personnel" and hospital staff.

Certainly this gives me great pause when considering returning to a busy call schedule when we come back to the U.S. It should make all of us think twice about the work schedules of key people in our society: not just doctors and nurses, but aircraft and auto mechanics, police and fire personnel, and even factory workers and the poor guys behind the counter at 7/11 at 1 AM. We all may pay a terrible price for being "24/7".

It is Easter break here in Australia, and pretty much everything is shut down for this next two weeks. Good Friday and Easter Monday are national paid holidays. Easter also kicks off the start of 2 weeks of school vacation as it is end of the autumn term. So many people are taking annual leave, and Derby is a bit of a ghost town as many Aboriginal and local people have "gone bush" as they say here. The big activity this weekend is a fishing tournament.

Vicki and I have joined the local pool and have begun swimming laps every day. Yesterday we camped out in the shade of a huge palm on the swimming pool lawn and read and dozed the morning away. Unfortunately the pool is closed except for morning lap swims today and tomorrow.

Despite the stats that say Australia is overwhelmingly Christian, most of the emphasis on Easter has been on chocolate. Australia is said to have the highest per capita consumption of Easter chocolate in the world. At dance class Thursday night, we all had to bring a chocolate egg and put it in a basket for an egg exchange. Cadbury's holds the major market share, although the Lindt dark chocolate bunny has been biting their ears off in recent times. Despite reading about the Easter Bilby (instead of bunnies, which still have a bad rep in Oz), we did not see any in the Kimberly stores. Vicki and I still prefer the Whittaker's (New Zealand) chocolate bars. She likes any of the dark bars, and I could eat an entire block of the milk chocolate/hazelnut at any one go. These are hard to find, but I've tracked them down in Cole's in Broome. Unfortunately, we have been unable to find the Rum Raisin block so far on this trip.

Today Vicki is cooking up lamb for Easter, and a surprise dessert. She quite enjoys cooking I believe, although is having a bit of an adjustment to using the gas oven with its huge yellow flames visible at the back.

She also decorated with an egg tree. This was interesting, as we can only get natural brown hens' eggs here. She uses plain food coloring and tried a bit of wax tracing for designs. They are hung on a fruiting branch from one of our palms around the house. The results are a quite "earthy" egg tree, which is a rather nice effect. I have really enjoyed her creativity and artistic sense. Next to them she has placed our collection of carved and painted boab tree nuts. These are works of art done by local people from Mowanjum, and are quite unique to this area.

For the Easter Gallery, click on the picture below:

Easter Egg Tree

Wednesday morning Derby Hospital doctors, and DAHS doctors met with the Royal Flying Doctor Service (RFDS) doctors for our monthly case review. This month we discussed the care and transport of victims of a rollover accident 40 km outside of Derby. The RFDS doctors were particularly interested in talking to us about patient transport from their perspective, so we may better understand what to expect when we call for a "Miracle Flight".

First, let me say again that Western Australia is BIG. It is hard to convey how big it is in words. This map may help (click on it for better resolution):
It is about 2300 Kilometers from Derby to Perth. This is about the same distance as from Chicago to Phoenix, AZ in the U.S. From takeoff in Broome, on a jet, it is a good 2+ hour flight time (and we always have an in-flight movie!)

Now the RFDS does not have jets. (I'll get to that below). They fly twin prop Beechcraft Kingairs or similar planes. The planes are fitted to take one very high needs patients (e.g. unstable, ICU level, ventilated, etc.) or sometimes two stretchers stacked up if both patients are lower care level.

The facts about evacuation from Derby:
• Best in-air time from Derby to Perth is 4.5 hours.
• However, at least ONE refueling takeoff and landing is required.
• With load-up and offload times at each end, minimum evacuation time door to door from Derby Regional Hospital to Perth hospitals is thus 8.5 hours.
• However, if the patient must be transported at "sea level" cabin pressures, this means the pilot must follow the coast, because inland airstrips are over 1000 metres altitude. Low level flights have much lower airspeeds and a longer route. This means up to 3 to 5 refueling stops. These flights may take from 12 to 15 hours.
• BUT the CASA rules (based on sound science) only allow pilots to fly up to 12 hours (14 hours if in the middle of a "mercy flight"), then they need a 12 hour rest break.
• There are only two pilots and two planes at Derby base right now.
• Often they try to coordinate a swap of pilots or planes by having a crew fly up from the south and meet them halfway, usually at Meekathera, which is about 1000 km from Derby. This can only happen if there is another crew available from one of the other RFDS bases.
• Thus, if an evacuation leaves the Kimberly, the doctor and crew are usually gone for 30 hours.
• Right now there are only two RFDS doctors at the Derby base.

In the case of the local rollover accident, there were 7 injured persons. One was very minor, 3 required hospitalization here in Derby, and 3 ultimately required evacuation to Perth for a variety of serious injuries. One of those patients was hemodynamically unstable (i.e. could not maintain blood pressure and circulation well). As you can imagine, this presented a serious triage and transport problem.

The situation would not be so serious if the Kimberly hospitals were not so under-resourced. Despite the name, "Derby Regional Hospital", the designated regional hospital for the area is in Broome, 220 km away. Derby is supposed to have a full-time surgeon on site, and a full-time OB/Gyn. Since I have been here we have had neither, and I understand this is not unusual. The gap has been plugged by hiring locums surgeons who come for 2-3 days every month. Clearly this is OK for booking elective procedures like tubal ligations or circumcisions; but it does nothing to help deal with trauma, which is quite common in the Kimberly. So the local GPs do the best they can. (We do have 2 "GP-OBs" who can do C-sections, assisted by the 2 "GP-anesthetists".) But if someone comes in bleeding internally, there is only one surgeon in the Kimberly, and he is in Broome and quite overworked as you can imagine. With 27,000 people in the West Kimberly, one surgeon is hardly sufficient.

There may be many reasons why there are no surgeons based in this remote town. Lack of amenities, schooling opportunities for kids, family distances, lack of career opportunities for spouses- in fact, all the factors that make it hard for any rural community to attract doctors are all in play here. But one factor is fixable and that is reimbursement. I heard on arrival here that the Hospital lost the opportunity to hire a 1-year locums OB/Gyn over a difference of a few thousand dollars. This type of funding problem has a measurable impact on access to services for the community. The current referral wait time for a colposcopy (follow-up test) for a pap smear showing pre-cancer cells is over 4 months. A general surgeon here in Derby would be quite busy with not only elective surgery, but regular cases of wound care, abscesses, orthopedics and fractures, appendectomies, and could provide some roster coverage for Cesareans, spreading the load out and making it easier to recruit GPs.

Our discussion with RFDS was originally supposed to be a review of the decision to evacuate the unstable patient to Broome first for stabilization, before moving on to Perth. But is developed into a wide-ranging discussion among the doctors about everything from communications problems, to triage, to community barriers to seat belt use (its hard to buckle up when you are riding in an overloaded 1970s vintage ute that barely has seats). We discussed RFDS needing jets, but that is really not the answer. For one thing, it does not solve the pilot rest problems very well. But the bigger problem is that it requires a quantum leap in support staff and services, including technicians who can maintain jet engines. This is a big issue in country with severe labor shortages, and especially a problem in the Kimberly. For example, there is only 1 licensed plumber for Derby and the West Kimberly, and great concern over his upcoming retirement.

I have suggested that we doctors as a group compose a letter to the Minister of Health for Western Australia, expressing our concerns over the lack of manpower in the area hospitals. Certainly the more things we could handle locally, the easier triage and transport would become for RFDS. And this would be a better use of current infrastructure and local funds. (Maintaining a trained surgery support staff costs money no matter how often they are used.) We will see what becomes of it.

For myself, I am going to be very careful not to hit anymore cows.

Figures compiled by Oxfam and the National Aboriginal Community Controlled Health Organisation (NACCHO) show the gap between indigenous and non-indigenous life expectancy in Australia is approximately twenty years compared to seven years' difference in New Zealand, Canada and the US.

There are some success stories in the report- see the example of DAHS on page 16!

And the local press responses:
Abbott admits to 'inadequate' Aboriginal healthcare.

Lolly cash would fix black health

Another Wet Season storm rumbled in the distance, the sky darkened ominously, and the smell of imminent rain came on the wind. Looking at the landing gear half buried on the runway, I wished I had thrown a spare set of underwear in my pack, because it looked like we might be here for awhile.

It had been a pretty long week. I'd begun by flying to Perth for the quarterly Medical Coordinators meeting. All 18 site coordinators met with the staff of the Rural Clinical School, and our Head, Campbell Murdoch to review this year's progress to date, plan for upcoming assessments, and deal with concerns and issues. The meetings took two days, but required 4 days of my time, there being no way to get from Derby to Perth either in time for a morning meeting, or on the flip side, home after a 3pm adjournment. The trip involves driving the 220 km from Derby to Perth, then logging 4400 kilometers of air travel from Broome to Perth and back, finally driving back to Derby. My plane home on Wednesday was delayed 4 hours in Perth, so I didn't arrive in Broome until after 4 pm. This is what led to my "Close Encounter of the Bovine Kind", (as Dr. Atkinson called it). And the week was only just begun.

Friday I was due to fly to Kandiwal for a remote clinic, having been scrubbed the week before. This Aboriginal community is 350 Km north of Derby. The indigenous people who originally lived in this are from the Wunambal language group. They lived on the Mitchell Plateau of the Kimberly from time immemorial, but were removed in 1942 (due to fears of Japanese invasion) to the Kunmunya Mission, and finally to the Mowanjum community, located 10 Km outside of Derby. In the 1980s many Aboriginal people moved back from relocation sites to their ancestral lands. Kandiwal is a community that resulted from such a return to the land. There is a nearby airstrip, built by a mining company that has prospecting rights to aluminum deposits in the area. The Aboriginal people have been trying to reclaim their land rights to the entire area for many years, and are concerned about the impacts of proposed mining, tourism, and other activities upon their ancestral home.

We got up early and were at the airport at 0630 AM. The medical flights to Kandiwal are organized by the Royal Flying Doctor Service, which provided our flight nurse, Gail. DAHS provides the Aboriginal Health worker, Shelly and the doctor, me. Gail had all the medical equipment packed. Because the site is so remote, she brings a flying pharmacy, all kinds of bandages, a cold Esky for vaccines and medicines, and all the medical equipment we need including baby and adult scales for weights. The Kandiwal community has only a small number of adults and a large number of kids, so we packed everything needed for child health checks and sick kid visits. Gail has been a flight nurse for a long time, and was completely organized when Shelly and I arrived with the charts. I only had to bring my medical bag and a backpack with lunch. Truly "no worries".

The flight up was smooth, and I spent the time watching the land and sea slip by below. The flight path went north over the Kimberly coast, which has to be one of the last true wildernesses left on Earth. There are no roads into the area, and the tidal rips and whirlpools are said to be the worst on the planet. For an hour and a half we flew over mudflats, mountains, and scrub plateaus lacking any signs of human impact. The geography is unique- some of the oldest rocks on the planet, over 1.3 billion years old, worn and weathered to flats, and nubbins of hills, and remnants of mountains. The community car met us at the field and took us the 5 Km to the community. We spent a busy morning and early afternoon seeing patients and handing out balloons to the kids. Then we packed up, and returned to the airfield, reloaded and taxied to the end of the runway, where the plane suddenly stopped and lurched to the right. Our embarrassed pilot shut down the props and we trooped out to examine the problem. A quick try at pushing the plane out of the mud was futile, and our hosts had already left the airfield. The pilot and I decided that perhaps we could dig a ramp forward out of the hole and drive the plane out of trouble. The field was mostly gravel, and we seemed to have found the one soft spot on the entire runway. He found the nosewheel pullbar, and I walked out into the bush and found a large tree branch, which we used to dig and scrape away the mud in front of the wheel. Then with the plane unloaded of the 3 of us passengers, and the rain minutes away, the pilot revved the engines to full power, released the brake, and slowly, centimeter by centimeter the wheel moved up the ramp and we were free. We piled back into the aircraft, and as we shut the doors, the rain pounded onto the aluminum skin. The pilot gunned the engines, we shot down the runway and out from beneath the storm, and I vowed to at least bring a toothbrush, if not a shovel, on my next remote clinic flight.

For larger, detailed views, click ON THE PICTURES in the blog above. For more photos, click this picture below:

Kandiwal Trip