Tuesday, June 05, 2007
Snapshots
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.
• 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.
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| Kandiwell 2 |
