Wednesday, September 05, 2007
Not a good place to go insane...
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}
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".
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.
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.
