I slip into the water. Vicki and I are the first ones into the pool. This often happens because we are waiting when the doors open. She wants her lane, #6, and as they say here, "first in, best-dressed". I take lane #3, walking right into the cool water, push off and breast stroke the first 25 meters. It feels great on this 104 F. day. The surface of the water is glassy, still and reflects the brilliant blue of the Australian sky. I love being first one down to the end, first to break the surface tension.

Today (as usual) I'm listening to eclectic stuff. A little Paul McCartney, Over the Rainbow by Izzy Kamakawiwo Ole', Podrunner techno music at 148 beats per minute (good for 20 laps), DragonPage Cover to Cover podcast about how to find old, out of print books on the Internet, and Aretha Franklin singing "Think!". I do this with my SwiMP3 headset, a birthday gift several months ago from my folks. This is a funny device that charges off my computer USB port and carries 256MB of music or podcasts. I think its the best thing since sliced bread to combat the boredom of cranking out 66 laps every day. I just load it with stuff I have on my computer. It is very simple, has only 3 buttons, and I turn it on and just go. The sound is fair, and I think it would be better if I had better hearing. Its not like listening in my car after all, because there is splashing, water moving past my head, and oh by the way, I have to breathe which means noisy bubbles blowing out my nose and mouth. This interferes a bit with the bone conduction of the sound. Music seems best if I know the piece, as my brain will fill in the missing notes or lyrics. Bach's Chaconne, for example, works in the water, as I know the piece well. Spoken word is harder to get. The recording needs to be high quality. Men with deeper voices are better in my ears, and if I backstroke or sidestroke I can follow most conversations. Dr. Karl's Great Moments in Science is great; Slate Explainer and the poetry in Writer's Almanac are much more difficult to follow. I do get a lot of funny looks when I strap this thing on. I think it kind of gives me a bit of a Captain Midnight look.

A week of so ago I was listening to Cover to Cover and heard about DailyLit.com. This is a great website for those of us who always meant to "read that Great Book" but never got around to it. The idea is simple: pick a book, enter your email address, and the site will send you a 1 minute chunk of the book every day (or MWF, or once a week or whatever you want). They have tons of the classics, but also some contemporary literature that the authors have released from copyright restrictions.

Vicki had never read Moby Dick, and I last read it when I was 12 so I'm sure I never really understood it from a very deep perspective. We've both signed up for Moby, and are on part 10 (of 252). Its great. And very appropriate for travelers planning to settle in New England. I also subscribed MWF to Down and Out in the Magic Kingdom, a modern novel by Cory Doctorow. These are a great break in my day, and just the right amount. Like a piece of Whittakers wonderful chocolate, best consumed in small bites.

Vicki picks me up from the Derby Aerodrome, hot and sticky after an hour and a half in the plane returning from the remote community flight. All I can think of is getting into the shower as quickly as possible. I detest feeling dirty and germy. I can’t help it. I dump my backpack on the back porch, and strip off my clothes in the 38 C. heat so I won’t carry vermin into the house.

I’ve worked with poor people all my professional life, and I hope I have a small inkling of the psychology and environment of poverty. But most of the time, I have seen “the poor” in EDs, my own office, or the hospital or residency setting. I’ve made more than a few house calls over the years, so I’m not shocked anymore. But visiting an entire community is different. There is no place to rest your eyes; nowhere I am not confronted with the stark reality of my patients’ lives.

We fly in to the dusty airstrip in a GA8 Airvan, a very light, high-wing, single engine Australian-built plane. One of the old men in the community drives the 5 k to the strip in a battered ute to fetch us. The truck has a homemade wire bench on the bed, which is loosely attached. We pitch our many bags and boxes in the back. We have to bring everything from meds to band-aids to our own scales. The four of us: pilot, RFDS nurse, health worker, and I then clamber up and sit hip to hip for the bumpy ride to the community center.

The “center” itself is just a big dirty room with a beat up table. There is a kitchen counter which has hot and cold water. There is a dirt encrusted shower room, and around the back, the loo which has no toilet seat and rivals the worst service station johns. Four months ago when I was here the cockroaches were so bad, they were crawling into my doctor bag and all over the files within seconds of my setting the items on the small desk. DAHS threatened to cancel clinics unless the place was cleaned up. The community did a spit and swipe and bug-bombed the place, which helped for awhile, but now the insects are returning. The cockroaches always win in the end.

We set up our gear and I dive in to see patients. I review the older peoples’ chronic disease files. We drew bloods 2 weeks ago, and some are doing well, some need their meds adjusted. The RFDS nurse spends a lot of the morning filling dosette boxes, those clever little plastic devices that set up a weeks worth of meds. Many of the patients speak poor English, so these are essential. I see a child with ringworm of the scalp and head lice. The mom is trying hard, but only had topical antifungal cream, which won’t kill the fungus at the roots. I only have adult strength Griseofulvin, but we work out that she can whack the tablets in half with a knife and a hammer. A gent I saw two weeks before shows me that his extensive pyoderma- boils that reminded me of Job’s sores- has improved, although is still not completely gone. A teenage boy got in a fight 4 days before, knocking out the lower teeth of his opponent, and now he has pus coming out of the human bite he sustained on his middle finger. It’s not bad enough to require the hospital yet, and I hope some high dose Augmentin and wound care might do the job. The last man is young, in his 30s, and has just moved to the community. He seems lost and wants something to help him sleep. I pull him into the back of the center’s not-so-private office, and he admits he is thinking of walking out into the bush and hanging himself. We talk about that, I express concern as best I can across the cultural gulf, start him on some antidepressants and make a referral to community mental health. God knows when they will get a worker out to him. I only know one community mental health worker, and blonde, white Sara is not someone this bloke will be able to easily talk with. He promises to come to the next clinic in a month at least. I hope confessing his black thoughts will help. I’m uneasy, but I’ve done the best I can.

I work right along. “Who’s next” I keep asking the nurses. Part of it is a desire to be efficient, but another part is just revulsion at the working environment and a wish to get the hell out as soon as possible. Prepared this visit, I’ve brought my own towel and dry handwash. I wash my hands as often as I can, but I have to touch the equipment as well as the patients. Everything is a fomite here.

At one point in the morning I step on the back porch and see 3 brilliant blue kookaburras on a branch in the back. But when I turn around, there are piles of trash, scattered cans, garbage bags, rusted machinery, paper, wire, horse manure and dog poo everywhere. It looks like some of the yards I used to see in my grandparents Appalachian community when I was a kid. I remember my parents encouraging me to actually see the poverty, if for no other reason, to appreciate what I had.


But this is poverty in more than one dimension. Financial poverty is the least part of it- as the people get CDEP and pension payments. There is emotional poverty and pain, related to the stealing of family relationships and structure. There is educational poverty: the older generation grew up on stations and never knew school; and now their children and grandchildren are truant and no one cares. With no training, there is vocational poverty, so that the annual cattle muster is the only work event providing any self-esteem, for 1 week a year. There is a spiritual poverty here, where life is out of whack, and the traditional owners of the land are no longer its protectors or custodians. And the end result is a poverty of hope. The people here live in the moment because the past is full of pain, the present is uncontrollable, and the future, unimaginable.

I realize the people in this particular community are mentally not "running on all cylinders". (Thank God not every community here is like this.) Combined effects of deprivation, isolation, racism, cultural loss, diseases, and too much grog leading to loss of neurons have done their damage. It’s not something I can fix on a fly-in. All I can do is really try to be with them in the moments when I visit. And I feel guilty, because a shower sure feels good afterwards.

Labels: Aboriginal Health

It looks like I will have to grow wings here soon, as the Royal Flying Doctor Service locums "no showed" for this month, leaving the two RFDS docs here very stressed. This means they have no time to help with our remote clinics, leaving it all to DAHS doctors. Last Wedsneday I went back to Imintji, and next week I have two flights, Yulumbu and Dodnun, and then a flight the week after next as well. It is really starting to heat up here- it was over 100F several times in the last week. The tin box airframe of the planes becomes a furnace sitting in the sun on the red dirt strips while we do our clinics, and I sweat from the heat on takeoff and then freeze when we hit 9000 feet and it cools off. I sat on the porch at Imintji store eating my lunch, and a willi willi blew around the corner, dust flying and pulling the trees sideways. The clouds, absent for the last 5 months have returned and the humidity is ramping up as well.

The Imintji trip did have a bit of happy news, in that the patient we organized to see the psychiatrist was actually hospitalized, and started on meds. An adult in the community who has known her for her entire lifetime, has given her a job with lots of structure. Getting up in the morning for meaningful, daily work; quitting ganga and taking some medication has had a wonderful effect. So while mental health is a real problem for remote communities, it's nice to see that some community caring can make such a difference.

The RCS students have been more focused on tutorials, and getting all their assignments done. E-logging of cases is due by the end of the month, so suddenly the computer records of the cases they have seen has become more important. They also wish we could cover everything in the next month before exams. We have been focusing on Paeds and GP this week, and will review some O&G in the next 2 weeks.

Yesterday in the clinic we saw a gentleman who desired some medicine for a rotton tooth. Turns out he is a heavy drinker. Thursday was "payday" when the Centrelink (welfare) payments are made. Typically there will be 50 people at Woolies waiting for the "bottle shop" to open to buy grog. This gent had consumed 4 "casks"- these are also called "balloons" for the silvery linings of the 2 liter wine boxes, seen blowing around town the next day. After 8 liters of wine he was not running on all cylinders, but we were amazed that he could even walk.

I have been talking with my students about social attitudes towards drinking, and asking them to reflect on how these affect health care. We found some great international comparative statistics on the Wikipedia, which I've abstracted into the table below. I'll paste in the quote from the Wiki page, and let you, dear reader, reflect and draw your own conclusions...

From: http://en.wikipedia.org/wiki/Recommended_maximum_intake_of_alcoholic_beverages

This article summarizes the recommended maximum intake (or 'safe limits') of alcohol as recommended by the health agencies of various governments. These recommendations are highly varied, reflecting the fact that they tend to be more political than scientific in nature. The recommendations are distinct from legal restrictions that may apply in those countries. Therefore, consumers need not follow the recommendations of the country in which they happen to live and are free to choose those of another country.

Here's my table:

Country	Drinks per day	Drinks per week	Std Drink size (g)	Max per day (g)	Max per week (g)	Rec OR Calc'd g/w	Legal BAC
Australia	6	28	10	60	280	280	0.05
Italy				40		280	0.05
Japan	2		19.75	39.5		276.5	0.03
Portugal				37		259	0.05
Denmark					252	252	0.05
New Zealand	3	21	10	30	210	210	0.08
Ireland		21	10		210	210	0.03
Spain	3		10	30		210	0.02
Hong Kong	4	21	1 glass wine/pint beer)			210	N/A
Netherlands	3		9.9	29.7		207.9	0.05
USA	4	14	14	56	196	196	0.08
Canada	2	14	13.6	27.2	190	190	0.08
UK	4	21	8	32	168	168	0.08
Switzerland	2		12	24		168	0.05
Austria				24		168	0.05
Czech Republic				24		168	0
Finland		15	11		165	165	0.05
Sweden				20		140	0.02

For a further exercise, check out the international recommendations for permissible alcohol intake in pregnant women. I can't believe that some countries still believe it's ok to drink while you're pregnant!
http://www.icap.org/PolicyIssues/DrinkingGuidelines/PregnancyTable/tabid/254/Default.aspx

I just had to steal that title above- its from a talk given by one of our RCS students who just returned from an Option in Ontario, Canada last month.

Headline:
Stonington
Island Family Medicine hires new physician


Now that it official, I can announce our plans for January 08. We are moving to Maine, where I will be joining Island Family Medicine, in the beautiful seaside town of Stonington. Well, I assume its beautiful- that's what everybody tells me. I have never been there!

Vicki and I were married in Maine back in the time of the dinosaurs, and have returned regularly to visit family, and enjoy the views from her cousins' homes in Belfast. We had always talked about moving there one day. So beginning last year, I chatted with a recruiter from the Maine Medical Recruitment Center, sponsored by the state hospital association. We talked about what I was looking for in a practice, and the type of community we would like to join.

Once we arrived here in Australia, we began to explore the options in more depth, and the practice in Stonington really seemed to fit. Several months ago, we scheduled a videoconference interview. This took some planning, due to the 12 hour time difference. We turned on our machine at 7 pm and said "Good morning" to the people in Stonington! We talked for over an hour, and things just seemed to click.

We are both very excited about the move. Vicki is anticipating lupines, pie contests, blueberries, bell buoys and lighthouses. Both of us think snow sounds great (101 F today!). I am looking forward to returning to a full time private practice. I know the people of Stonington will have much to teach me about their community. I'm hopeful I can apply some of the theory I have been teaching my students for so many years in a real practice again. And we are looking forward to joining a very interesting community- at least that's how it seems reading the local paper!

I have long been a believer that when a door opens to a new life, or new experience, best to just take a deep breath, and like the pelican, fall. [Jan 2,2007]

Its going to be great.

Read the article in the Island Ad-Vantages newspaper here: http://www.islandadvantages.com/ianewsfeature1.html

Another week gone by here in Western Australia, and although it is SPRING here and patients are coming in with allergic rhinitis and asthma flares (more from the dust now that the Dry season has hit its stride) it still mentally feels like FALL to me, as I see things starting to wind down. We have made our plane reservations to return to the U.S. and there are only 84 days left. (It was good that we made them when we did two weeks ago- as the trans-Pacific legs were already starting to fill up. School (summer) holidays and Christmas coincide in Australia, and essentially the entire country will shut down in December, I am told.

The good news is that I have hired my own replacement for DAHS and the RCS. In checking references for another doctor we were trying to hire, one of the referees wondered if I "knew of any good jobs working in Aboriginal Health" in the Kimberley. One thing led to another and it appears we have hired a young British woman to take my place here. We are very hopeful she will arrive by end of October so I may train her for a month before we leave.

My students are starting to feel the pressure, as exams begin the last week of October for them, with finals in Perth in mid-November. We are working to fill in the gaps of any subjects they feel they might have missed, which at this point they have decided is "all of them!". Procrastination is a universal attribute, although it was not enough to prevent two of them from spending a week with the Orthopaedic specialist in Kununnura. That left me with one 5th year, and a 6th year student last week.


Last Tuesday the flight rotations took me back to Yulumbu for the first time since April. The small community, very remote, in the Tablelands area of the Kimberley did not look much better, but with water now, they had cleaned up the community room we use for visits. Many people are traveling this time of year, before the rains return and lock them into their communities for 5 months. So instead of 20 kids and 10 adults, there were only about 6-7 very old (that means 50-60 years old) people, a few teenagers and smaller kids in the community. We did "diabetes clinic" for most of the adults, talking about diet and exercise and the importance of taking tablets. One of the innovations I have instituted here is an integrated care plan summary, called a GPMP (GP Management Plan). Setting up these flowsheets has made it much easier to keep track of labs, meds and observations in patients charts. Using the flowsheets really helps in remote clinics, where the doctors and patients rotate around so frequently.
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One old lady in Yulumbu showed me her new wheelchair with pride. She had fallen into the fire and suffered a bad burn on the leg, but while in the hospital, was fitted with a chair with tires that are wide- they look like a mountain bike tire. This allows her to wheel her chair all over the dirt tracks in the community and get around for socialization. She was quite happy with it.

We also admired the two large King Brown snakes the boys in the community had dispatched the day before. They were hanging in a tree- to what purpose I'm not sure I understand. But they were quite impressive.


The rest of the week was the usual mix of teaching and practice, with the added visit of Mr. Jim McGinty, WA Health Minister, who dedicated the new wing of the local hospital. This despite the fact that the landscaping has been bare red dirt now for 8 months, which the patients and visitors have been tracking in all over the new floors and rooms. We contrasted this delay to the new community school in Jarlmadangah, where the elders put in a sod playing field around the school, at great community expense. They were quite proud of that foresight, which has protected their new school building from the current ubiquitous dust and soon-to-be sticky mud (come Wet season).
Central planning for the hospital has also provided it with new rooms and equipment, but serious personnel shortages. Two weeks ago the entire Kimberley region, from Broome to Wyndham had no surgeon on call for 5 days. This meant that any orthopedics fractures, appendicitis, serious trauma, etc all had to go directly to Perth (at least 10 hours transfer time) without surgical consultation. Derby still has no staff Ob/Gyn, despite being a regional birth center with >240 births a year and rising- something much applauded at the dedication. And the current hospital staff is overworked, and stretched thin with night call and ED responsibilities. My sense is that the community is pleased to have the hospital still here in Derby, and happy that it wasn't downsized in favor of a larger facility in Broome (220 km away). .


Vicki and I have enjoyed a couple of weekends at home. We are both still swimming every day- she notched 100 25m laps today- and enjoying the tropical garden in our backyard before it gets too unbearably hot. It has been over 100F here twice this last week, but so far the humidity has stayed in the lower ranges. However, we can feel it heating up, and have had to use the air-con some days just to get the bedroom cool enough to sleep. I'm hoping to make one more sight seeing trip, to Windjana Gorge, before the buildup gets too far along. We had planted tomatoes, which have come on full, and my papayas and mangos are starting to really grow quickly. The ripening of fruit in the spring here also contributes to the mix-up of my Northern Hemisphere mind thinking it is fall here in the South

Things have been "crazy" the last two weeks, and I'm way behind on writing. Our daughters left 10 days ago, and we've been busy since.

Two weeks ago today we flew to Imintji up the Gibb River Road. This is a long day, as the flight lands on the airstrip at Kupungarri and we have to get in the Land Rover and drive 70 km down the GRR to the Imintji community. DAHS and Jurrugk Health Services run a remote clinic. I saw the usual assortment of sick kids and chronically ill adults. But a patient was brought in from another community. This young person's mum wanted me to "send x to the place you go to get off the ganja" (marijuana). "What place is that?" I asked her. "Like where you go to stop drinking.." she said. I did a mental status exam and discovered the patient was actively hallucinating and had not slept in a week. This teenager had been yelling all night and throwing rocks around the community. This in itself is not unusual in Aboriginal communities where a lot of people drink, so for family and friends to bring the patient into the clinic was alarming. Now this is a difficult logistical problem so far out in the bush. We spent a couple of hours on the phone talking to Mental Health in Broome and Derby. I happened to know the visiting psychiatrist was coming to Derby in the next week, so I was able to book her in. Then came the question of travel to Derby. This is about a 5-6 hour drive down the Gibb River road. The local nurses had already organized another patient to go in the community vehicle, so that was a possibility, if everyone could stand to ride together. I flew out, leaving the details in the Remote Area Nurse's capable hands. Thank God for these great ladies, who live and work among the people out in the bush. (The appointment was ultimately kept, after a couple more frantic phone calls when the patient arrived in Derby and the local system somehow did not have an appointment with the correct person.) The patient was treated and we will see how it turns out. {click on thumbnails below to open web albums}

Imintji

On the way back, we put down at a very remote station to see a young girl suffering from anorexia nervosa. She and her mother had come back from Perth a few weeks before, and it had been arranged for us to stop and weigh her and interview her weekly for awhile, with phone calls back to Perth to aid in management. The staff were mustering several thousand head of cattle, who were waiting in pens for the trucks. We could see the plumes of dust from the air for 50 miles. The station however, was a green oasis with duck ponds and lilly pads, tucked into some rocky outcrops in the Kimberley. It was several hours drive by dirt track just to reach the Gibb River Road. We popped in and I incidentally saw a worker who had dropped a metal can and avulsed a toenail. Start antibiotics and the flying RN will check it next week.

Last week I was off to the RCS Scientific Meeting in Geraldton. This in itself is an odyssy, as I flew OzJet from Derby to Perth, stayed overnight, and took the early flight back north to Geraldton. There is no other way to get there from Derby, and few connections.

The first day was our Site Coordinators meeting, in conjunction with a meeting of the administrators of ALL the RCS's across Australia. There is a lot of variation among Rural Clinical Schools, with many of them in the more populated NSW and Victoria states sending their students to small towns within 30 minutes drive of Sydney and Melbourne. This is not quite the same as living hellandgone in a place like Derby or Esperance. It seems the WA Rural Clinical school is the model for the rest of the country in our support for our students, and having the students in the country for an entire year of medical school.

Australia restricted their medical student slots in the 80's and 90's, resulting in their current severe shortage of doctors. This policy was predicated on the supply-side theory that if there were less doctors, there would be less medical care, which would cost less. Unfortunately, people continued to get older and sicker and the population has been growing steadily. So now the number of medical students has doubled. The graph looks like a tsunami, and there was much discussion at the meetings about ways to train this tidal wave of students, soon to be young post-graduate doctors. Because the urban clinical experiences have always been well subscribed, rural placements will have to fill the gaps.

Friday was spent in an Anesthetics workshop. I have to admit I chose this topic because I have taken or taught the others (Wound care, suturing, OB ultrasound, Advanced Obstetrics) SO many times, I thought I'd take a workshop in something I knew little about to avoid boredom. Not the best strategy in hindsight. The speaker was knowledgeable but disorganized. He had computer troubles, and all his equipment was in boxes that he was forever rummaging through. Not something that would inspire my confidence if he had to put me to sleep. His audience was quite mixed, from students to "Procedural GPs". In Australia, because of the shortages, many rural doctors take additional training in Obstetrics, Surgery, or Anesthetics. And I have no objection to adequately trained generalists doing procedural medicine- heck I did C-sections, appendectomies and spinal anesthetics myself in the 80's.

But one doctor told a story that made my hair stand on end. Because of the distance, many psychotic rural patients are heavily sedated and kept in rural emergency rooms in Western Australia, sometimes for days, awaiting transport. There is only one secure psychiatric hospital in Perth. Local doctors tell me even psychotic patients in the city sometimes have to wait 5 days, sedated and sometimes intubated (tube down the trachea), in an ED before getting a bed at Graylands Hospital (really, that's the name of the hospital!) . Now we were discussing drugs and anesthetic procedures for this situation, and a doctor told a story of using a particular drug which caused too much respiratory sedation. The patient had a respiratory arrest, and unfortunately coded and died. This is terrible enough, but what was most upsetting for me as a foreign observer, was the attitude that, "oh well, this is rural medicine, these things are going to happen because this situation occurs so often". Over and over I find that the acceptance of second class care for rural and especially remote Australians is taken as just a fact of life. Unfortunately this has really made me appreciate U.S. lawyers in a new light. They may drive up the cost of care, and the system is surely not very fair and just, but also, one gets what one pays for (and is responsible for).

The last two days of the long meeting were spent listening to scientific papers. Some of these were very interesting, and some, not so. Like any meeting. Listening to these papers, it is clear to me that regarding rural and Aboriginal Health, Australia is in a time (to quote Franklin Roosevelt) "when certain historic ideas in the life of a nation have to be clarified".

Geraldton

As for me, Vicki and I only have 94 days left before we leave Australia. I have a lot to do to help my student finish, to complete my projects at DAHS and train my replacment. But you can be sure I won't lose my mind over it. Not in this environment.