The last two weeks we've both been under the weather. I caught the flu and felt really rotten for about 3 days, then started to feel better, then got sicker again. I posed the problem to my students: purulent nasal discharge, right sided facial pain, + face pain on bending over, and "double sickening" over 10 days. Classic history and signs for sinusitis. It was so bad I actually took a sick day last week. (Not to be confused with a "sickie", which is Australia is a common practice of abusing a sick day to escape from work. And also not to confused with American "sicko" which has entirely different connotations.)

I believe I took about 4 sick days in the 14 years I worked in Cedar Rapids, so this was really unusual for me. I had to beg off my Wednesday flight, which meant that Cyril flew up to Gibb in my place. As always happens when one takes call as a favor to a colleague, a man collapsed just down the road, and was lucky enough to be only 10 minutes from the clinic. He was having a heart attack and at one point had a pulse of 23. I met this gent the next day in the hospital and he realized that he beat the reaper. He had his MI on the ONLY day a doctor or nurse was in the Community, he was close to the clinic and had someone who could drag him in, the ECG machine and other equipment sort of worked (always a problem up the Gibb), and the RFDS had a plane only 2 hours away and was willing to divert and let Cyril fly back as the flight surgeon. The chances of the stars aligning in such a fashion are rare in the Outback- he is one lucky man. And I was so glad I didn't try to fly with a clogged up, fuzzy head. Another stroke of luck for him that I wasn't on duty!

About the same time Vicki also came down with the flu. So we have been snorting and coughing at each other now for a couple of weeks. To add to the fun, one of the two aircon units in the house has busted. The replacements for these very old units are sitting on the back porch, but waiting on the workmen to come from Broome to install them. And the Kimberly is heating up now. Our back porch thermometer has hit 40C (102 F) daily this last week, so the aircon business is hopping. We took the bed apart and moved it into a room with a remaining working unit, and are praying that the cranky machinery can hold out till the workers get to us.

This week is the last week of instruction for the RCS students. My RCS guys have been in review mode for the last 2 weeks as we prepare for their OSCEs. They will have OSCEs in Port Hedland on Monday, so we all drive the 766 km on Sunday, then drive back on Tuesday. The exams are 7 minutes each, among 8 stations, with a minute between stations. They will walk up to the door, read a precis such as "A young mother brings in her 5 year old who has a fever and a large swollen gland beneath the jaw (see picture). Explain to her what the problem might be, and outline your diagnostic and treatment plan." Then the student walks through the door and performs the skill.

My guys have justifiably high anxiety, because the problems could be anything they have seen in the entire year, from reading an ECG or x-ray, to delivering the bad news of a terminal diagnosis, to demonstrating how to deliver a stuck baby. However, this type of exam should better predict later performance as a physician. Once they complete the RCS OSCEs, they have two more weeks to study, and then will join the Metro Perth students for final written examinations as well as a last round of OSCEs in Perth.

The written exams are NOT multiple choice, but the more traditional British-style exam, with questions such as "Discuss the differential diagnosis of urinary incontinence. Detail the optimum diagnostic algorithm, and discuss treatment for the most common problems." Vicki and I will fly to Perth for an RCS Coordinators meeting and I will help with the OSCEs there as well.

So we have been spending the last two weeks trying to fill in the gaps for things the students haven't seen here in the Kimberley. This mostly includes advanced cancer cases, cancer screening, musculoskeletal medicine, complicated gynecology, endocrinology, and advanced obstetrics.

And despite the heat, it is Spring here in the tropics. My tomatoes continue to produce. We have had wonderful papayas from trees in the yard, and the mango's should be ripe in a week or two. The frangipani are blooming and their heavy sweet fragrance hangs in the air when I come home in the evening cooling. I am enjoying the rainbow lorikeets and black cockatoos each day, and savoring the time left while anticipating the coming contrast to silent, snow-covered Maine.

(see Sept. 22nd post below)

From last Sunday's Australian:

"The nation's top health advice body is set to call time on our obsession with grog by slashing by up to two-thirds its recommended limits on how much people can drink before putting themselves at appreciable risk of illness or injury.

The draft guidelines advise men and women to drink no more than two standard drinks a day. For children and adolescents under 17, pregnant women and those breastfeeding or planning a pregnancy, avoiding alcohol altogether is "the safest option". "

Read the full story at: http://www.theaustralian.news.com.au/story/0,25197,22577560-2702,00.html
The draft guidelines can be read at: http://www.nhmrc.gov.au/consult/index.htm I found Part A: Section 4 with its public health information about "Drinking in Australia" very interesting.

Previously I'd sent the the Sept. 22 "table" as an email to all the RCS Faculty and Students. The reaction was varied but interesting. With follow-up flurry of emails after this weeks news, its been quite a discussion.

One fellow faculty member claimed that "if you tell the blokes 'only 2' they'll just ignore you as its unrealistic." I've countered with the fact that research shows primary care doctors can make a difference with as little as 10 minutes of brief counseling on a couple of visits. For the evidence see : http://www.annals.org/cgi/reprint/140/7/557.pdf

This revision of Australian Guidelines for Safe Drinking is a good start at dealing with a very large problem.

so Cheers! and happy SAFE drinking!

Labels: alcohol

When I was a 3rd year med student my intern used to refer to patients to be discharged as OTD- or "out the door".

Here, it means Overseas Trained doctor. In Australia OTDs are an issue because they make up 30% of the workforce. In the 80's the government decided the way to control medical costs was to train fewer doctors. They cut training posts in half, which led to the current severe shortages of doctors and nurses. In addition, the chronic underresourcing of hospitals by state governments has led to events such as the recent uproar in New South Wales where a woman miscarried alone in an ER toilet after waiting 2 hours just to be triaged. Of course, this kind of thing probably happens all the time in the U.S., but because of the abundance of lawyers, hospitals are held accountable and work to prevent such horrors. Or at least pay for their mistakes. Here, it becomes an election issue, which is ironic, because health care is a State responsibility. But the Prime Minister and his Opponents are threatening to take over health care because of public discontent.

OTDs have become an issue in politics as a side issue to service inadequacies. Several years Australia had a doctor who killed a large number of people through bad practice. Jayant Patel, Queensland's "Dr. Death" was an OTD who was not credentialed properly by the Queensland Medical Board, but this case has tainted the reputation of all OTD's in the public mind. So there is much discussion in the press about foreign trained doctors and perceived problems in language, culture, and knowledge base.

Add to this the case of Mohamed Haneef, an Indian-trained doctor who was detained incommunicado by the authorities for 5 days under anti terrorism charges after the bombings in the U.K. this year. One of the bombers was a distant cousin. But after an exhaustive investigation the police were forced to drop charges. Never ones to admit error, the government nevertheless cancelled his visa and deported him back to India. He was greeted there as a hero wrongly persecuted by Australia. By all accounts he was a good doctor in Queensland and is missed by his colleagues. Inquiries from Indian doctors for Australian jobs have subsequently dropped by 80 % .

Last week the Rural Health Network sponsored a social dinner for Derby doctors and their families at The Point restaurant. As I looked around the tables, I was struck that we were the U. N. of medicine. The Hospital's Senior Medical Officer is one of two Australian trained doctors in the room (the other is a temporary Pediatrician). The SMO is the youngest doctor in the room. Besides working full time as a GP/Anesthetist, she is expected to supervise and direct medical care at the local hospital. Yet as far as I can tell she is not supported by the WA Country Hospitals with the time nor staff to do this.

Who are the doctors we SMOs support? Starting at the hospital, Chris is a tall, dignified Nigerian doctor, trained in GP/Obstetrics in Ireland. His wife, our pregnant Paediatric registrar, worked in the hospital caring for sick children until she herself delivered last week. Duncan is from Papua New Guinea, a single parent of 3 kids, he did over 200 anesthetics last year in addition to clinics and inpatient work. Eric, from Singapore, climbs mountains and makes delicious chili mudcrab. He has extensive experience in emergency medicine and Aboriginal health from working in the NT. Gowri is a Tamil from Sri Lanka, happy to have escaped the violence there. The students love him for his supportive teaching. Finally my friend Arvind, from India, is a lovely, gentle pediatrician who has worked all over the world, including experiences in the war zones of Ethiopia.

At DAHS, where I am SMO, Cyril is a devout Buddhist doctor who spent 6 months as a teenager in Burmese prisons. His crime was being a leader in the medical student association during the time of the 1988 demonstrations. He got out, came to this country, learned English, and finished med school. He just passed his RACGP exams and will leave soon to study palliative care. Lilley and Charles are a Malaysian couple in their 60's. They have a son living in Melbourne. They worked in Aboriginal Health in Kununnura for 2 years before coming to Derby. Finally, Marina, our DAHS GP Registrar emigrated from Irkusk in Siberia and is retraining here. She came to Australia for a better life for her daughter, who now lives in Perth.

All these doctors, like me, are granted visas restricting their practice to "areas of need". In other words, only places so poor, remote, and/or underresourced that Australian doctors don't want to be there. Many of them have spouses and children who must deal with the isolation, lack of family and cultural support, and poor schools in rural towns. Additionally, in Derby there is the added stress of the cultural collision between European and Aboriginal peoples.

And all OTDs must deal with the inevitable homesickness the results from being an expatriate. About 10 years ago I read My Own Country: A Doctor's Story, Abraham Verghese's powerful description of his life and adaptation to being an OTD caring for AIDS patients in America. But I don't think I ever really had a chance to understand how it feels to be away from your native country for a prolonged period of time until this experience. And Australia, while having many similarities to the U.S., also simultaneously feels like a very alien planet. I strongly suspect that all the OTDs here suffer similar episodes of missing their own places.

Yet despite these challenges, the Derby OTDs do the best they can for their patients. Daily they try to bridge the cultural gaps. They apply their knowledge and hands humanely. The wide array of training they bring might not make it easy for them to pass the written RAGCP exam. But they have immeasurable and invaluable skills and memories that help them adapt to practice here. And in some cases, as in undernourished infant needing IV access or a woman having a vaginal breech birth, OTDs have the experience that young, city-trained doctors could never have.

I have learned a lot from my association with these fine doctors and their families. It is a shame that they suffer discrimination and exploitation on the basis of their OTD status. Australia's gain is under-appreciated, although it comes at great cost to these doctors' home countries.

So it is with humility that I join their ranks, firmly in the back row, and say, "I am proud to be an OTD!"

It's the Queen's Official Birthday, October 1st here in Western Australia. Actually, it's not really her birthday which is April 21st. And it's not her Birthday anywhere else in Australia except Western Australia. The rest of the country celebrates on the 2nd Sunday in June which is the beginning of snow season. The Governor of WA sets the holiday for this state, which just coincidentally happens to be the Monday after the biggest sports weekend of the year- the Grand Finals for the Australian [Rules] Football League, and the Australian Rugby league- held on Saturday and Sunday, respectively.

Windjana Gorge

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Because we are not into celebrating a history of colonization, or watching the impacts of sweaty men on the playing fields, we decided it would be more appropriate to visit Windjana Gorge and Tunnel Creek.

We had planned to visit Windjana Gorge for a long time but had put it off for various reasons. I'd read that this was a sacred spot, but actually walking in this place brought home its magical nature. This is an area with deep spiritual historical significance to the local Aboriginal people.

Windjana Gorge is a chasm where the Lennard River cuts through the Napier range. For centuries it was a holy place to the Bunuba people. They believe that the spirits of their unborn children rested in the permanent waterhole beneath a giant boulder. And the people did not live in the Gorge despite its abundant wildlife. For them it was a place of life and power; it was the place they laid their dead, wrapped in bark, in the cliffs.

So in the 1860's, when cattlemen invaded the country, enslaving the men, raping the women, and moving cattle into these sacred places it sparked resistance. Jandamarra, a Bunuba man, turned on the police who were enslaving his people, and waged a guerrilla war for over 3 years. He led a battle to protect the Gorge and hid out in Tunnel Creek. Vicki and I read his story in Jandamarra and the Bunuba Resistance and we are here to visit these battlefields on the Queen's Birthday holiday.

We left the house at 0630, and bumped up the Gibb River Road to the turnoff to Windjana. It is a very hot day, forecast to hit 40C. By 9 AM we are on the track up the gorge, with camera and water bottle. We walk through a narrow crack in the rock-the gateway to a magical world. A cloud of butterflies rises out of crevices in the rock walls and flutters about our head. The trail is listed as 7 km round trip. Vicki took off at her usual blistering pace and within 45 minutes was out of sight. I lagged behind, stopping to photograph the wonderful birds and wildlife. The gorge is magnificent, with red rocks radiating both heat and power. The cries of the cockatoos and other birds echo within the canyon. The still green water reflects the cloudless sky and freshwater crocodiles swim lazily. But it is hot. After a couple of kilometers the trail rises and runs close to the cliff base. I see there is quite a distance to the end of the gorge still. I come upon Vicki who is sitting on a rock, not looking so well. She is overheated and starting to get a bit nauseated. I make her drink most of the water and sprinkle some on her hair. By this point the Gorge is like an oven, with the sun higher, and reflecting off the rock walls, the water and the sand. Out of the shade the sun feels 20 degrees hotter. I am reminded of the old movies, where parched men slog across the desert seeing mirages, as we run out of our water and are still a kilometer away from the car. We keep to the shade and take it slowly. The last 100 meters across the parking lot are torture, but we open the car, turn the aircon on high, and guzzle more water from the esky. It feels great, but we are parched and just sit there for 20 minutes, nibbling on our peanut butter sandwiches for the salt. Even prepared, it is so easy to get heat exhaustion in this country, I can understand how many people die just meters away from their vehicles.

We drive down to the Lillimilura Police Station. This is where Jandamarra's conscience finally led him to start resisting. The only marker here is to the policeman he shot. And while it's true he shot him in his sleep, he did it only after severe and prolonged provocation. Later in his guerrilla war, he and his men tried to drive the settlers and police away with psychological warfare- raining rocks down from the heights on top of the police station at night, stealing the cops' food and weapons- when they could have very easily massacred every policeman in retaliation for enslaving their families. It is ironic that the only monument in these national parks is to the white man. One of my medical students told me this made him so angry, that when he visited he pissed on this marker. From the stains it is clear he was not the only one. I like to think I am too civilized- but the truth is I'm just too dehydrated- to join in. But I mentally applaud those who do.

Tunnel Creek

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Twenty-nine kilometers down the road, through dry, scrubby, rocky hills and boabs, we come to Tunnel Creek. We put on our wading shoes, and again enter a sacred place through a narrow cleft in the mountain. It is amazing: dry, cool, very wet- a cave full of life. There are small fish in the water, and a colony of large flying fox bats hanging from the ceiling and from a tree outside. Water drips from the flowstone and stalactites overhead. We walk on through, using our little crank flashlights. Just as it gets so dark we can't see anything but the narrow beams, a glimmer of light appears ahead, and we come to the middle, where the tunnel has opened to the sky. The dark to light transition happens again after walking past this area to the far end- but here the water from the cave flows out into a lovely creek with water bugs, little fish and kookaburras in the gums overhead. It is remarkably cooling- the yin to the yang of the Gorge.

We complete the loop by driving through the Bunaba people's current lands. These resemble nothing more than a post-nuclear attack landscape, with burned over rocky soil punctuated by blackened, twisted trees. It is awful country. A sign to one of the communities has a cow skull hanging on it. It is a relief to regain the Great Northern Highway and drive the two hours back to Derby.

I am struck by the lack of Aboriginal involvement in these Australian National Parks. Imagine the Little Big Horn monument without Native American input and presence. It is a sad legacy. Here in Australia, Ned Kelly, a lowlife criminal, is admired, while Jandamarra is still seen as a terrorist, instead of the freedom fighter he truly was.

Labels: Aboriginal Health