When I left my teaching job at CRMEF last December, the Residents, Faculty, Staff and friends threw a going away party, and instead of a gift, took a collection of monies for me to use in some community health education projects here in Derby. This was a wonderful gift that greatly touched my heart. So when the opportunity came up to do a Men's Pit Stop here in Derby, we jumped at the chance.

The idea is based on research that shows, in the U.S. at least, that 88% of men have looked under the hood of their car in the last year, while only 60% have had any kind of health checkup.

So to get by around the problems of coming to a health clinic (full of women usually) for care, we take the care to the men, in the form of a "Pit Stop". In a short time the blokes can travel around each station, and get "run their car (body) through the pits".

We use automotive analogies for the various stations. For example, the Fuel Mixture station is a finger stick blood sugar test, and the Fuel Additives is a short alcohol abuse screening questionnaire. Exhaust is smoking, Shock Absorbers is emotional stress screening, and Radiators and Spark Plugs are "Men's Business" (safe sex, STDs, prostate, urine flow problems, etc.)

I've spent the last few weeks adapting this concept, originally developed in the Gascoyne and Pilbara regions of Australia to the Kimberly and Aboriginal Health concerns. Vicki helped me order "Pit Crew" shirts in the colors and with logos containing found in the Aboriginal Flag. We built "Work Orders" which each man carries through the pits on a clipboard. At each station, they are marked "Roadworthy" or "Work Needed", and at the end the doctor reviews it all and slaps either a Yellow Temporary Registration or Blue Certified Roadworthy sticker on the guy's shirt.

This last week we placed posters all over town. My 3 students and I each took a turn on the local radio station, 6DBY, at the noon program to explain the Pit Stop and talk about one or more aspects of good health practices for men.

Friday morning, the big day, we set up on the lawn in front of the Shire offices and opened for business. Our drivers cruised around town all day and gave men lifts to the Pits for checkups.












I was the "cleanup batter" at the end of the chain, and I learned a lot, spending the entire day doing motivational interviewing. Men here have little or no idea of proper nutrition, and underestimate the dangers of smoking.And all Australians, black or white, drink too much alcohol. James spent the day giving "DrinkCheck" questionnaires, and said that he had never understood what "one standard drink" was until doing the station. He really liked the chart in the government pamphlet- although it reminded me a lot of the aircraft identification charts my mom used as a plane spotter during WW2.

The turnout was rather sparser than we hoped, but we did cycle 19 men through the Pits, and had several alarming findings, including a gent with previously unknown severe proteinuria, and several with hypertension and high blood sugars. We had hoped for over 50 men, but our timing may have been off. (We set the date for a Pay Week when many people would be in town- however, Friday may not have been the best day because Centrelink pays out on Thursday and many of the men had been up all night drinking and partying the night before.)

But the great thing is that the concept is now all set up for DAHS, and we have all the materials and run through it once. We will plan on setting up more Pit Stops later in the year, and we've scheduled a time to take it "on the road" up the Gibb River Road in September, to the Aboriginal Communities there.

And as Narelle and I agreed while doing the extensive planning- if we find just one man with a preventable disease or death risk that we can change, then it is all worth it.
Click the photo below to see the album:

PitStop

But Dangerous! Note Warning Label!

Another week flown by and its raining here, in the middle of Dry Season! After over two months of clear blue sky sunny days- so much so that Vicki would joke by going to the window and saying "I wonder what the weather is today- Oh my, another blue sky day!"-we've had two days of dark cloudy overcast and rain. In fact, its rained so much the Gibb River Road has been closed and my flight to Ngallagunda was scrubbed this morning due to a soggy runway. This wouldn't be a bad thing, except its not the hot rain of January. This morning the temp was 50 F when we awoke, so it feels a lot more like New Zealand weather. And we don't have the clothes for it. And no heater. All the space heaters walked out the door of Retravision this last weekend- the locals are complaining of the cold. We bought a small quilt for nights. Down in Sydney and the Hunter Valley they are having "massive floods", so we can't complain. ("Massive" is the most overused word on the TV here- Vicki and I laugh whenever we hear it.)

Last weekend was Race Weekend here in Derby. We puttered around on Saturday and went to the Races in the afternoon. This was some of the sorriest horseflesh we've ever seen. Definitely not Keeneland. It was an orgy of beer drinking and punting. One of the U.K. med students hit a Trifecta and won $120, and my boys reportedly did pretty well. When people ask me this week how I did, I've said "I lost my shirt!" which gets a funny look. Not an Aussie idiom I guess. We had a good time watching the people as much as the horses. At least there was also a funny hat contest.

Sunday the horse races were followed by the mudcrab races. These were sponsored by the local Fishing Club. At least half of the crowd seemed to be tourists. Anyone may buy a crab, put a name on its back (girlfriends/wives/de factos were popular!), and enter it into a race. Again, beer and betting were rampant. Between the races, bush poet Murray Hartin recited a rambling rhyme about a jackaroo riding his swag on an airplane named "Turbulence".

Saturday night we ate some of those mudcrabs. One of the doctors at the hospital, Eric is from Singapore. He and two of the local pharmacists, Andrew and Cameron caught a mess of mudcrabs and invited us over for a taste. They cook them by breaking them up and popping them in a wok full of peanut-chili sauce. Over rice they are delicious.

Two more weeks until the end of the term. I've been working with the staff like crazy to help organize the Men's Pit Stop for this Friday. We will set up on the lawn in front of the Shire offices and do quick health checks for men all day long. I just hope it stops raining tomorrow!

Click the pic below to see the races:

A Day at the Races

Last week the SEWB worker and I make a home visit. An elder is in the hospital in Perth with cancer, and things don’t look so rosy. No one from this large family is with her, as she’s been there for weeks getting treatment. Fran has called a meeting for anyone who wants to come. I grab the file and we drive across town and pull up in front of a small house. It is hot and dry and shady. Legions of kids have frustrated any green thing’s chance of growing in the front yard, which is now inhabited by 8 small dogs, each with their own cool hole in the dirt. We sit on old plastic chairs and overturned milk bins, 10 adults in a circle. We start reviewing what people know, which is not much. I try to explain what I know from talking to the Perth doctors that morning. We go around and around. It is like the archetypical discussion in Ten Canoes about what happened to the wife- we go around the circle and say the same things over and over in several ways. People hear different things- some hear that the elder will die soon, others wonder if she’ll be able to walk “and would a wheeled-brace help?” when she comes home soon. We go around until the questions run out. I have few answers and I'm talking to people who rarely think of time in the same way I do. The family decides they will send two people if PATS will pay. They come to the office later and I fill out the large yellow forms. We later find that PATS will only pay for one person to travel, but I’m not involved in that family talk circle.

The paediatricians have invited 6 medical students from the U.K. to spend their summer experiencing medicine in the Kimberly. They talked to the hospital administrators but not to any of us at DAHS or the University. My students find out a week before these Year 4 students arrive from England. This ignites many hours of discussions with the paediatricians, development of a roster and negotiation of “attachments” for the students. In the end I cooperate and help the Paeds guys in order to preserve our teaching ties and not have my own RCS students penalized. I like the Paeds specialists here in Derby, and they are good teachers for my students. I just wish they had talked to us before inviting a so many students into a small place. After all, there are only 8 beds on the Paediatric ward. Today I get a letter from the University of Notre Dame (in Freemantle, WA) that they are bringing 82 students up on a tour of the Kimberly in August and September and that I should RSVP for their seminar. I walk around DAHS for 10 minutes, cooling down, before sitting down and writing an email. I wonder if clinics and hospitals in Hawaii or Colorado have troubles with this kind of junket.

Stopping into the BP Colec for a “coffee, white, with 2 sugars” (for A$2) on the way to Jarlmadangah, I notice the cigarettes in the rack behind the counter have wonderfully explicit, gross warnings on them. We should do so well in the U.S.

Saturday Vicki's little friend 7 year old Hannah comes over to visit and we end up taking her and older brother Colin to the pool. The water temp is getting cool- 24 degrees C. - and she is blue and shivering after only a few minutes. (She reminds me of the waif in the poster for Les Miz.) The kids have a great time however playing tag on the lawn, on the slide, eating peanut butter sandwiches and just being kids. I fall asleep on the grass and they amuse themselves by throwing paper airplanes at me until I finally rouse. What simple fun!

Sunday morning we read the paper on the back veranda. It is much dryer and pleasant these days. We agree that sometimes the best "tourism" is just being in a place.

Monday I go to Jarlmadangah by myself. Halfway there I run out of radio, and belatedly realize the DAHS car I'm in only has a tape player. Who listens to cassette tapes anymore?! Its the first time I've been alone with my thoughts for quite a while. Maybe 6 cars pass me the entire 110 km. The landscape slowly slides by until the Grant Ranges rise up, out of the plain.

I take a lunch break outside the trailer-clinic at Jarlmadangah. A black kite is slowly hovering above the house across the road. Sudden he drops like a missle into the earth and comes up with a lizard, which he gulps down. Not like a red tail at home: he just shoots down into the ground. Amazing.

After the clinic, on the way back, I stop and walk 100 yards through the bush to climb up the rocks a ways and record the 360 degree view...

{click image to download and enlarge it in viewer: can you find my car? Can you see why you should NEVER leave your vehicle in the outback if you get stuck, and certainly NEVER leave the road?)

This thing was in the pool today. A giant water bug. At the end of my lane. It was at least 7 cm long and could swim like mad. Locals call them "toebiters" (but say they don't really... ?)

Diary of a Week in Practice.

• Flight out to Ngallagunda again. This time the place is full of patients, and the nurse from Dodnun even drives a bunch down to see me from that community. One baby has a swollen forearm, and I have to decide if it can wait a few days for a drive down the Gibb River Road for an x-ray or not. Another patient has back pain. I demonstrate the history and exam for my student, Michael. He is leading the tutorial on back pain 2 days later, so this comes in handy.

• Harriet, the Rural Clinical School researcher, who visits all the sites comes on Thursday and interviews everyone at our site. The students chance to say how awful everything is, but they surprise me and seem very pleased so far. Harriet did her undergraduate degree in Theology but decided she wanted to do something useful so became a medical researcher and statistician. She is a wonderful listener.

• We drive to Broome for the WACRRM Kimberly meeting. There is one radio station in Derby, 6DBY. Once you get 20 km outside of town it fades out. On the car radio, for the next two hours, you can scan around the dial in both AM and FM and never find a station. There are few places on Earth one can still do this. In preparation for these long car trips, I have been downloading podcasts. We listen to “Roadtrip” from This American Life, WA Reloaded from the ABC ("A" as in Australian) and The Writer’s Almanac with Garrison Keillor.

• Saturday morning one of the speakers, an older GP is enamored with his “low-intensity” laser. He spends 70 minutes of his 90 minute lecture time showing us grayscale electron micrographs of the structure of human muscle spindles and their innervation. Then he describes how he uses the laser. He holds it against a sore spot for 2 minutes and the patient tells him they feel better. I can only think of my daughters laughing over the “Sharks with Lasers” in the Austin Powers movies, or of the famous cartoon, “…then a Miracle occurs”. During the Q&A he is unable to explain the physiology of how it works. In the Men’s room, all the doctors agree we are still skeptics. I am still looking up the literature.

• Sunday morning I swim in the hotel pool, than arrive at 0730 to learn how to implant Implanon. It is slick, much easier than Norplant. Not that this will be much use to me at DAHS, where
Aboriginal women will only see women physicians, for cultural reasons.

• Monday I am back on the road to Jarlmadangah. This time I have a new arrival, a 6th year student who is one of the very few Aboriginal medical students. She has family ties to the Kimberly. She is related to some of the people we see. I am heartened to see her sit down in the waiting room and just yarn with people. Aboriginal people need Aboriginal providers.

• Tuesday morning its bedside teaching at the hospital. I do this on Tuesdays and Thursdays. It’s “teaching without a net”. I look at the patient list on the general ward and pick something to talk about. Extemporaneously. The students usually have to go do a history and part of a physical exam, so its “learning without a net” for them also. Among other people, this particular morning there is a patient with a spontaneous pneumothorax, so we see her and review her x-rays, and how to read a chest x-ray in general. The nearest CT scanner is 220 Km away in Broome, and is an older model. There is no easy, fast way to diagnose a pulmonary embolism in the Kimberly.

• Wednesday I work in the office all day. My students have videoconference in the afternoon, and one of them has driven 2.5 hours (one way) to Fitzroy Crossing for their Cardiology clinic. I worry about him hitting a cow while driving home with the sun on the highway at sunset. The 6th year student sets up across the hall from me and we shuttle back and forth. This is helpful as our Registar, Marina, is sick today, and two of our doctors, Charles and Leeli are on annual leave, so we are very short-handed. The flu is going through town, so I see a lot of people with cough. I should probably get my “autumn” Southern Hemisphere flu jab, as my “autumn” Northern version has probably worn off by now.

• Thursday is teaching day again. I attend the hospital doctors “Discharge Rounds”. The Social/Emotional/Well-being worker and I visited a patient the day before at her home. The hospital called the SEWB worker to pick her up, and the nurses took her out in a wheelchair with all her things, including some big boxes of medical supplies and her “machine”. Nevertheless when we called for a Discharge Summary, we are told that she had “absconded” from the hospital, therefore no Summary is available. I bring this up at rounds- the hospital doctors are also very understaffed. It turns out the doctor caring for this lady had to go to Broome for a meeting, and the covering doctor was unaware he had promised the patient she could go home. So much for the unplanned exodus, which is now called a “negotiated absence”. Some communication problems are Universal.

• However, going to D/C rounds has helped the Hospital/DAHS relationship a lot. As in most relationships, if we don’t talk to each other, misunderstandings arise. The hospital doctors are all Overseas-Trained Doctors, like me. Australia takes advantage of us by restricting our visas and licenses to rural and remote practice only. Essentially, if you are an OTD, you must serve your 5 years in Hell before being allowed to practice anywhere else. And many of the OTDs are specialty-trained. One has certification as an OB-GYN in the U.K. but will never be allowed to practice that specialty in Australia. He will be forced to be a GP-OB; that is a country doctor who delivers babies and does Caesarians. They work long hours, take too much call, have little or no staff support in the hospitals, and then if things go wrong, the state Hospitals let them take the fall. I have found a niche in being the “University” teaching doctor for them. They need support. The week before we had a lot of questions about metformin use in diabetes, renal failure and pregnancy. I have time to look this stuff up, call Royal Perth, and synthesize a “two-minute drill” email which I send around to all the Derby docs and my students. I enjoy this Academic Detailing.

• Friday and it’s a flight to Kandiwell again. Of all the places I’ve been this one truly feels like the End of the Earth. Probably it’s because of the 65 minute plane flight over the rugged, uninhabited, drowned coastline of the Kimberly, followed by the swoop onto the rocky airstrip among the palm trees. Today there is air traffic however, and tourists flying into the strip to swap from planes to helicopter over to Mitchell Falls. We wait at the strip for an hour as the people in the community seem to have slept in and forgotten us. They finally come and I spend the day seeing mostly kids with huge smiles. They have mostly nothing and are quite happy. They are also very shy, not seeing many outsiders. I have never seen such trusting children, who willingly open mouths wide for me to see their terrible tooth decay. Even the infants hold perfectly still while I check their ears. Many of these kids are rostered into the Dental schedule for general anesthesia to repair really rotten 6 year old molars. This despite signs of fluorosis on some teeth. I wonder if there is fluoride in the water supply here.

• Saturday, long weekend and I’m happy to stay home. One of the docs from Fitzroy is in town and rings me from Woolies- he’d like to have a chat about a job at DAHS next year? I go down to collect him and his family. There are no street numbers in town- he would never find our place. While he is finishing his shopping I pop into the liquor store to buy a bottle of wine for tomorrow. The place is jammed on Saturday afternoon. 12 beers cost A$28. Both European and Aboriginal people are stocking up for the weekend. A large, orange butterfly flits about in the store and lands on the wine bottles. I wonder why all the labels extol Nature, with pictures of animals, mountains and trees?

• The Professor, Campbell Murdoch, Head of School, and his wife Annie come up from Broome on Sunday for a social call. Vicki prepares a wonderful lunch ahead of time on Saturday- so for Sunday dinner all I have to do is throw the steaks and veggies on the grill and we are ready to eat in 15 minutes. We give them the “Tour of Derby” and finish by having Vicki’s low-fat chocolate cake, with frosting made of Whittaker’s dark chocolate. Yum. I really enjoy talking to Campbell. He is a wonderful storyteller. After we swap a lot of tales, he says, “Being a GP is like being a solid rock in the ocean, you just have to let the waves wash over you….” I tell him one of the things I miss by getting older is not having even older doctors around so much anymore to listen to. And one gets tired of being the tale teller. He graciously takes it as a compliment.

• Monday morning and it’s the Queen’s Birthday in the rest of the country, but not in Western Australia, where it is somehow Foundation Day (and the Queen will have to wait until October for her birthday). Anyway it’s a Holiday and everything is closed. We get up early and Vicki takes me out to the lakes and the brumbies. We see 7 brolgas and hear their haunting calls. On a whim we take the turn out onto the mudflats with the 4WD. The sky is huge, blue, mostly empty. We can see smoke rising in the distance- it is dry season and there is always a fire now somewhere in the bush. It’s still hot, and a shiny rock will set the spinifex on fire, it is the natural way of this ecology. But it does ruin our leaving the windows open at night, to have the smoke and soot drift in on the wind. But that is emblematic of Australia, occasional bad smell in the midst of intense stark beauty.

Kandiwell 2