Sunday, May 3, 2009
Community Outreach
Ramingining
Ramingining is an Aboriginal community in the north-central part of Arnhem Land. One of the pediatricians & I set off for the town on last Monday morning for a two-day overnight visit. There was about an hour delay in our flight because of “mechanical difficulties.” When it was finally time to set off, I was terrified to discover that our pilot looked like he was about 19-years-old & our rickety plane was smaller than any I’d been on previously. For some reason, the planes keep getting smaller & smaller—this one looked like a toy plane. It seated four of us—the “teenage” pilot, the pediatrician in the co-pilot seat, & a special education teacher who was coming along. We had to climb over the wing of the plane to enter the plane through a door on the side of the co-pilot seat. I’m convinced I’m going to die every time I get on one of these planes.
Luckily, we made it to the community safely & landed on the dirt airstrip. There was considerable turbulence during the landing because as we descended the air currents, created by uneven warming of the ground, buffeted our plane. Like my visit to Croker Island, we waited on a covered platform to the side of the landing strip until one of the clinic nurses arrived. The community was a short drive from the landing strip. First, we dropped off the schoolteacher at the school & then continued on to the clinic. We made a quick trip to the doctor accommodations, which were a short walk from the clinic. The small cabin was in a ramshackle state, & there was only one double bed & a small twin mattress leaning against the wall for the three of us—apparently, no one had bothered to arrange any accommodation for the pilot . . . We decided to sort out the sleeping situation later, left the pilot in the cabin, & went to the clinic to start seeing patients.
We had a very busy day. I saw about 10 patients over the course of the morning & afternoon & the pediatrician saw at least twice as many. She comes to the community every month & knows most of the children whereas I was considerably slower as I was meeting the children & their families for the first time. Many of the children came for weight checks for poor weight gain. In the process, I discovered that many had other issues like perforated ear drums with frank pus oozing from their ears or crusting skin infections like scabies. I examined a child who I suspect had a tibial fracture. The closest location to obtain an x-ray is Gove Hospital, which is about an hour flight away. We ordered the x-ray nonetheless, but it won't be speedy process. Similarly, I diagnosed a young boy with a urinary tract infection, but he’ll have to fly to Darwin to get an ultrasound of his kidneys & bladder at some point. It forces one to think very carefully about every single test that’s ordered.
We finished at the clinic in the early evening. We discovered that there was another accommodation available in the community where the visiting dentist & his assistant were staying which had two extra beds. We decided the pilot & I would join the dentist & the assistant & the pediatrician would stay alone in the doctor's cabin. The place I ended up staying was also a quick walk from the clinic right across from the tribal council building & art center & next to the community store. I was pleased to find that it was in better upkeep than the other cabin. It consisted of a commons area with TV, seating area, kitchen, & two bedrooms, each with two twin beds & adjoining bathrooms.
The next morning, I was pleasantly surprised to discover the community “alarm clock” which is a town-wide broadcast of 60s & 70s music starting at 8am. We had another busy morning in clinic. I discovered a murmur on a one-month-old. She’ll have to get an echocardiogram, which will need to be arranged at Darwin Hospital. I visited the community store during lunchtime, which I was pleased to find had just received a fresh shipment of vegetables. Otherwise, it was similar to the Croker Island store with a limited selection of processed foods & dry goods all marked up considerably from Darwin prices.
On my way back to the clinic, I spotted a young woman carrying a limp dog by the legs with the dog’s head bobbing along as she hauled the dog. I then saw her deposit the dog on the open hatch of a pickup truck while a man came alongside carrying another limp dog. Fascinated, I approached them & discovered them performing surgery on the first dog—apparently they were veterinarians hired by the government to go to the various communities to spay & neuter the dogs. They give the dogs a shot of ketamine & then under questionably sterile conditions perform the procedure on the back of a pickup truck. They also give the dogs a shot of penicillin in the neck to prevent infection & apparently have low rates of infection. They clip their ears to mark which ones have been spayed or neutered so they can spot them easily on their next visit. Before this program started, the dogs in each community numbered in the many hundreds—almost outnumbering the people! In Ramingining there were still many packs of dogs roaming & lying about but a huge improvement from what it was before the program.
The flow of patients tapered off early that afternoon, so we were able to make an early start for home around 3pm. As we were taking off on the plane, some kind of crank or handle at the base of the plane’s floor behind & between the pilot & co-pilot seats at my feet started spinning wildly in circles. The pediatrician & I let out screams & notified the pilot who grabbed behind him to stop it. I also noticed a red light started flashing on the “dash-board” along with two green lights. The pilot tried to explain the situation over the din of the plane’s engines, but I couldn’t make out what he was saying. I was sure there was something terribly wrong with the plane!
Things were smooth up until we reached Darwin & started descending for landing & this lever/handle contraption started spinning again & ripped up the carpet at our feet, which got jammed up around the lever. I also noticed a burnt smell. I was sure we were going to die. The pilot, while trying the land the plane, reached back with one hand trying to pry the handle out of the carpet. He finally managed to pry the carpet loose, & seemed to “click” the lever into a locked position. I noticed the red light was flashing again. Somehow, we landed safely. Once on the ground, I asked our “teenage” pilot what the heck was going on with this wildly spinning lever & he said something to the effect of: “if there’s only one red light & two green lights then it’s okay,” but if there’s three red lights than you’re basically in serious trouble! He went on about some hydraulic emergency system . . . He ended by saying “the mechanics are going to be busy tonight.” All I have to say is that if on my two remaining charter flights it looks like I’m getting on the same plane, I’m going to refuse to board!
Yirrkala
Yirrkala is a coastal Aboriginal community on the northeastern edge of the NT. It's a short drive from Gove, which I visited last week. The community is in a beautiful location on the sea & is more well maintained compared to other communities I’ve visited. I believe the community benefits from money from the Gove mines, which are on “leased” Aboriginal land. A new clinic was recently built, so the clinic facilities were quite nice. The pediatrician & I split seeing patients through the morning. We had a steady flow of patients, but a slower flow than we’d had at Ramingining. Despite their proximity to the city, I was surprised to find that the people were so lacking in their English speaking abilities—probably the least English fluency of any community I’ve visited. I found myself becoming increasingly frustrated by my inability to communicate with the patients. A few times I asked one of the Aboriginal Health Workers to come into a room to assist with communication, but they are not trained interpreters & it was obvious to me they were not comfortable with this role.
The patient flow tapered off in the afternoon such that I had some downtime to explore the community. I visited the art center, which featured Yirrkala bark art, which is quite distinctive from other Aboriginal art. Some of the artists featured are internationally renown & have pieces hanging in museums & galleries throughout the world. Therefore, much of the art was well out of my price range, but in a dusty, out of the way corner I found some small & therefore more affordable pieces of bark art. I decided to splurge on a small bark with a painting of two intertwined snakes. I then made my requisite visit to the community store, which was similar to other community stores, which little fresh produce & exorbitant prices. I then walked along the shore & watched as a woman & two children fished with plain fishing line standing atop rocks along the sea shore.
Milikapiti
Milikapiti is an Aboriginal community on Melville Island, one of the Tiwi Islands. The other main Tiwi Island is Bathurst Island, where the Tiwi Football Finals took place in March. The community consists of about 500 people. I again had to fly on a small charter plane, but this one was larger the one I took to Ramingining. Two other doctors & a medical student rode along. The plane made two stops at two other Tiwi communities dropping off the other doctors & student before reaching Milikapiti.
I was scheduled to work on my own for the day completing school screenings, which basically involved listening to heart & lungs & deciding if any children needed referral for further tests. The NT has very high rates of rheumatic fever & rheumatic heart disease, so the major question I needed to answer was whether or not I needed to refer children with heart murmurs for echocardiograms. Another doctor had come earlier in the week & completed many of the school exams, so I had to review the ones she hadn’t gotten to & re-listen to a few children about whom she was concerned. Most of the exams were normal, but I agonized over the slightest murmur that I might have otherwise dismissed as a benign murmur in the US because of the known high rates of rheumatic heart disease in the NT. In the end, I only referred one patient for an echocardiogram.
I completed the school screening by the early afternoon. Then, one of the community nurses took me on a tour of the town. We visited the community farm, which was started by one the nurse’s husband & employed some of the local Aboriginal people. It was an impressive operation with mango trees, bananas, sweet potatoes, pineapples, citrus trees, hydroponic green house, & nursery with local plants for mine re-planting. Overall, I found Milikapiti to be the most well organized community I’ve visited. I also visited the art center, &, of course, walked away with another piece of art, this time a beautiful print.
Ramingining is an Aboriginal community in the north-central part of Arnhem Land. One of the pediatricians & I set off for the town on last Monday morning for a two-day overnight visit. There was about an hour delay in our flight because of “mechanical difficulties.” When it was finally time to set off, I was terrified to discover that our pilot looked like he was about 19-years-old & our rickety plane was smaller than any I’d been on previously. For some reason, the planes keep getting smaller & smaller—this one looked like a toy plane. It seated four of us—the “teenage” pilot, the pediatrician in the co-pilot seat, & a special education teacher who was coming along. We had to climb over the wing of the plane to enter the plane through a door on the side of the co-pilot seat. I’m convinced I’m going to die every time I get on one of these planes.
Luckily, we made it to the community safely & landed on the dirt airstrip. There was considerable turbulence during the landing because as we descended the air currents, created by uneven warming of the ground, buffeted our plane. Like my visit to Croker Island, we waited on a covered platform to the side of the landing strip until one of the clinic nurses arrived. The community was a short drive from the landing strip. First, we dropped off the schoolteacher at the school & then continued on to the clinic. We made a quick trip to the doctor accommodations, which were a short walk from the clinic. The small cabin was in a ramshackle state, & there was only one double bed & a small twin mattress leaning against the wall for the three of us—apparently, no one had bothered to arrange any accommodation for the pilot . . . We decided to sort out the sleeping situation later, left the pilot in the cabin, & went to the clinic to start seeing patients.
We had a very busy day. I saw about 10 patients over the course of the morning & afternoon & the pediatrician saw at least twice as many. She comes to the community every month & knows most of the children whereas I was considerably slower as I was meeting the children & their families for the first time. Many of the children came for weight checks for poor weight gain. In the process, I discovered that many had other issues like perforated ear drums with frank pus oozing from their ears or crusting skin infections like scabies. I examined a child who I suspect had a tibial fracture. The closest location to obtain an x-ray is Gove Hospital, which is about an hour flight away. We ordered the x-ray nonetheless, but it won't be speedy process. Similarly, I diagnosed a young boy with a urinary tract infection, but he’ll have to fly to Darwin to get an ultrasound of his kidneys & bladder at some point. It forces one to think very carefully about every single test that’s ordered.
We finished at the clinic in the early evening. We discovered that there was another accommodation available in the community where the visiting dentist & his assistant were staying which had two extra beds. We decided the pilot & I would join the dentist & the assistant & the pediatrician would stay alone in the doctor's cabin. The place I ended up staying was also a quick walk from the clinic right across from the tribal council building & art center & next to the community store. I was pleased to find that it was in better upkeep than the other cabin. It consisted of a commons area with TV, seating area, kitchen, & two bedrooms, each with two twin beds & adjoining bathrooms.
The next morning, I was pleasantly surprised to discover the community “alarm clock” which is a town-wide broadcast of 60s & 70s music starting at 8am. We had another busy morning in clinic. I discovered a murmur on a one-month-old. She’ll have to get an echocardiogram, which will need to be arranged at Darwin Hospital. I visited the community store during lunchtime, which I was pleased to find had just received a fresh shipment of vegetables. Otherwise, it was similar to the Croker Island store with a limited selection of processed foods & dry goods all marked up considerably from Darwin prices.
On my way back to the clinic, I spotted a young woman carrying a limp dog by the legs with the dog’s head bobbing along as she hauled the dog. I then saw her deposit the dog on the open hatch of a pickup truck while a man came alongside carrying another limp dog. Fascinated, I approached them & discovered them performing surgery on the first dog—apparently they were veterinarians hired by the government to go to the various communities to spay & neuter the dogs. They give the dogs a shot of ketamine & then under questionably sterile conditions perform the procedure on the back of a pickup truck. They also give the dogs a shot of penicillin in the neck to prevent infection & apparently have low rates of infection. They clip their ears to mark which ones have been spayed or neutered so they can spot them easily on their next visit. Before this program started, the dogs in each community numbered in the many hundreds—almost outnumbering the people! In Ramingining there were still many packs of dogs roaming & lying about but a huge improvement from what it was before the program.
The flow of patients tapered off early that afternoon, so we were able to make an early start for home around 3pm. As we were taking off on the plane, some kind of crank or handle at the base of the plane’s floor behind & between the pilot & co-pilot seats at my feet started spinning wildly in circles. The pediatrician & I let out screams & notified the pilot who grabbed behind him to stop it. I also noticed a red light started flashing on the “dash-board” along with two green lights. The pilot tried to explain the situation over the din of the plane’s engines, but I couldn’t make out what he was saying. I was sure there was something terribly wrong with the plane!
Things were smooth up until we reached Darwin & started descending for landing & this lever/handle contraption started spinning again & ripped up the carpet at our feet, which got jammed up around the lever. I also noticed a burnt smell. I was sure we were going to die. The pilot, while trying the land the plane, reached back with one hand trying to pry the handle out of the carpet. He finally managed to pry the carpet loose, & seemed to “click” the lever into a locked position. I noticed the red light was flashing again. Somehow, we landed safely. Once on the ground, I asked our “teenage” pilot what the heck was going on with this wildly spinning lever & he said something to the effect of: “if there’s only one red light & two green lights then it’s okay,” but if there’s three red lights than you’re basically in serious trouble! He went on about some hydraulic emergency system . . . He ended by saying “the mechanics are going to be busy tonight.” All I have to say is that if on my two remaining charter flights it looks like I’m getting on the same plane, I’m going to refuse to board!
Yirrkala
Yirrkala is a coastal Aboriginal community on the northeastern edge of the NT. It's a short drive from Gove, which I visited last week. The community is in a beautiful location on the sea & is more well maintained compared to other communities I’ve visited. I believe the community benefits from money from the Gove mines, which are on “leased” Aboriginal land. A new clinic was recently built, so the clinic facilities were quite nice. The pediatrician & I split seeing patients through the morning. We had a steady flow of patients, but a slower flow than we’d had at Ramingining. Despite their proximity to the city, I was surprised to find that the people were so lacking in their English speaking abilities—probably the least English fluency of any community I’ve visited. I found myself becoming increasingly frustrated by my inability to communicate with the patients. A few times I asked one of the Aboriginal Health Workers to come into a room to assist with communication, but they are not trained interpreters & it was obvious to me they were not comfortable with this role.
The patient flow tapered off in the afternoon such that I had some downtime to explore the community. I visited the art center, which featured Yirrkala bark art, which is quite distinctive from other Aboriginal art. Some of the artists featured are internationally renown & have pieces hanging in museums & galleries throughout the world. Therefore, much of the art was well out of my price range, but in a dusty, out of the way corner I found some small & therefore more affordable pieces of bark art. I decided to splurge on a small bark with a painting of two intertwined snakes. I then made my requisite visit to the community store, which was similar to other community stores, which little fresh produce & exorbitant prices. I then walked along the shore & watched as a woman & two children fished with plain fishing line standing atop rocks along the sea shore.
Milikapiti
Milikapiti is an Aboriginal community on Melville Island, one of the Tiwi Islands. The other main Tiwi Island is Bathurst Island, where the Tiwi Football Finals took place in March. The community consists of about 500 people. I again had to fly on a small charter plane, but this one was larger the one I took to Ramingining. Two other doctors & a medical student rode along. The plane made two stops at two other Tiwi communities dropping off the other doctors & student before reaching Milikapiti.
I was scheduled to work on my own for the day completing school screenings, which basically involved listening to heart & lungs & deciding if any children needed referral for further tests. The NT has very high rates of rheumatic fever & rheumatic heart disease, so the major question I needed to answer was whether or not I needed to refer children with heart murmurs for echocardiograms. Another doctor had come earlier in the week & completed many of the school exams, so I had to review the ones she hadn’t gotten to & re-listen to a few children about whom she was concerned. Most of the exams were normal, but I agonized over the slightest murmur that I might have otherwise dismissed as a benign murmur in the US because of the known high rates of rheumatic heart disease in the NT. In the end, I only referred one patient for an echocardiogram.
I completed the school screening by the early afternoon. Then, one of the community nurses took me on a tour of the town. We visited the community farm, which was started by one the nurse’s husband & employed some of the local Aboriginal people. It was an impressive operation with mango trees, bananas, sweet potatoes, pineapples, citrus trees, hydroponic green house, & nursery with local plants for mine re-planting. Overall, I found Milikapiti to be the most well organized community I’ve visited. I also visited the art center, &, of course, walked away with another piece of art, this time a beautiful print.
Thursday, April 23, 2009
Pediatrics
Last week I made the switch from ID to pediatrics. There are three pediatrics units at RDH on the 5th, 6th, & 7th floors. The 5th floor consists of all general pediatrics admissions. The 6th floor encompasses the well-baby nursery, the special care nursery, & NICU. The 7th floor is the isolation ward for children with potentially contagious conditions like diarrhea or respiratory infections. There's no children's ICU, rather any children who require ICU level care go to the general ICU & are managed jointly by the pediatricians & ICU doctors.
The schedule on pediatrics is similar to the medicine schedule starting every morning with an 8am handover from the overnight registrar to the day teams. Every other Tuesday, there's an ID meeting after handover to go over any interesting ID cases with the ID team. On Wednesday there's a journal club after handover. On Thursday morning there's radiology meeting. There are also teaching conferences at noon with registrar teaching on Wednesdays, psychosocial rounds on Thursdays, & Grand Rounds on Fridays.
The workload is split among three pediatrics registrars, with an RMO assisting, who are each responsible for the units during the day. Often, another registrar or two handle emergency department admissions, transfers, & outside calls. There's a scheduled evening handover every day at 4pm during which the day teams hand-off to the evening registrar & RMO. The evening team then hands-off to the night registrar who comes on at 10pm & holds down the fort managing all admissions & cross-cover until the am handover the next day.
My first week on peds, I joined the 7th floor team. As I said earlier, this unit is the isolation ward composed of patients admitted with diarrhea or respiratory issues that could potentially be contagious. The vast majority of children admitted to the ward are Aboriginal & have severe malnutrition in addition to diarrhea & dehydration. It is estimated that up to 20% of children in the NT meet the WHO criteria for malnutrition, which by WHO definition constitutes a "health crisis." Because these children are already compromised by malnutrition & poor living conditions, they are especially vulnerable to diarrheal illness. It's not uncommon for the children to be infected with multiple organisms at once: giardia, rotavirus, salmonella, & cryptosporidium being the most common as well as other parasites like strongyloides. They often come in with severe electrolyte abnormalities with dangerously low potassium, sodium, calcium, & magnesium levels & acidosis. Many of the children also have other vitamin & micronutrient deficiencies as well as iron deficiency. We have to monitor them very closely, constantly adjusting their fluid & electrolyte replacement.
In addition to my time on the 7th floor ward, I've been on another outreach trip. One of the pediatrics consultants & I flew to the town of Gove, also known by its Aboriginal name Nhulunbuy, for a one-day clinic. Gove is at the very north-east edge of the NT. Historically, the Aboriginal communities of Nhulunbuy & Yirrkala were located there. The town of Gove was primarily built up around aluminum mining & a large ALCOA aluminum plant. The clinic was held in the hospital & the vast majority of the patients were non-Aboriginal children of parents in some way affiliated with the mines & ALCOA. These children had primarily "western" complaints with the vast majority being evaluated to developmental issues. In contrast, next week I'll return to the neighboring community of Yirrkala, which is an Aboriginal community. Next week, I will also be going to another Aboriginal community in the midst of East Arnhem, the vast region of the NT between Kakadu & the eastern border of the NT. It will be my first overnight trip to a community!
The schedule on pediatrics is similar to the medicine schedule starting every morning with an 8am handover from the overnight registrar to the day teams. Every other Tuesday, there's an ID meeting after handover to go over any interesting ID cases with the ID team. On Wednesday there's a journal club after handover. On Thursday morning there's radiology meeting. There are also teaching conferences at noon with registrar teaching on Wednesdays, psychosocial rounds on Thursdays, & Grand Rounds on Fridays.
The workload is split among three pediatrics registrars, with an RMO assisting, who are each responsible for the units during the day. Often, another registrar or two handle emergency department admissions, transfers, & outside calls. There's a scheduled evening handover every day at 4pm during which the day teams hand-off to the evening registrar & RMO. The evening team then hands-off to the night registrar who comes on at 10pm & holds down the fort managing all admissions & cross-cover until the am handover the next day.
My first week on peds, I joined the 7th floor team. As I said earlier, this unit is the isolation ward composed of patients admitted with diarrhea or respiratory issues that could potentially be contagious. The vast majority of children admitted to the ward are Aboriginal & have severe malnutrition in addition to diarrhea & dehydration. It is estimated that up to 20% of children in the NT meet the WHO criteria for malnutrition, which by WHO definition constitutes a "health crisis." Because these children are already compromised by malnutrition & poor living conditions, they are especially vulnerable to diarrheal illness. It's not uncommon for the children to be infected with multiple organisms at once: giardia, rotavirus, salmonella, & cryptosporidium being the most common as well as other parasites like strongyloides. They often come in with severe electrolyte abnormalities with dangerously low potassium, sodium, calcium, & magnesium levels & acidosis. Many of the children also have other vitamin & micronutrient deficiencies as well as iron deficiency. We have to monitor them very closely, constantly adjusting their fluid & electrolyte replacement.
In addition to my time on the 7th floor ward, I've been on another outreach trip. One of the pediatrics consultants & I flew to the town of Gove, also known by its Aboriginal name Nhulunbuy, for a one-day clinic. Gove is at the very north-east edge of the NT. Historically, the Aboriginal communities of Nhulunbuy & Yirrkala were located there. The town of Gove was primarily built up around aluminum mining & a large ALCOA aluminum plant. The clinic was held in the hospital & the vast majority of the patients were non-Aboriginal children of parents in some way affiliated with the mines & ALCOA. These children had primarily "western" complaints with the vast majority being evaluated to developmental issues. In contrast, next week I'll return to the neighboring community of Yirrkala, which is an Aboriginal community. Next week, I will also be going to another Aboriginal community in the midst of East Arnhem, the vast region of the NT between Kakadu & the eastern border of the NT. It will be my first overnight trip to a community!
Thursday, April 9, 2009
Croker Island Clinic
Today the Medical Outreach Registrar took me along on a trip to one of the remote Aboriginal community clinics on Croker Island. The day started off at the small charter plane hangar at the airport, an event that’s becoming all too common on this trip to Oz. There were two DMOs (District Medical Officers), a pediatrics consultant, a medical student, & a nutritionist on our flight. The pilot let me ride up front in the co-pilot seat (for the 2nd time).
Croker Island is about a 50-minute flight from Darwin off the coast of the NT. I listened to my ipod on the flight to block out the deafening sound of the plane’s engines. We landed on a dirt airstrip. The registrar, the nutritionist, one of the DMOs, & I disembarked while the rest of the group continued on to another remote community. There was a covered platform next to the dirt landing strip where one of the clinic nurses was waiting for us. There wasn’t enough room in the truck for all of us, so the nutritionist & I waited on the platform while the first group drove into the community, which is about a 15-minute trip on the other side of the island from the airstrip.
The area around the airstrip is a floodplain filled with sundry wildlife including all varieties of birds, wild horses, & crocs. The community consists of about 300-400 people & is nestled over the island’s coast. The clinic building is spacious & new because it was recently rebuilt after the original was destroyed by a cyclone a couple years ago. The community, consisting of the tribal council building, a school, homes in various stages of disrepair, & a small store, spread out before the clinic, which sits atop a hill overlooking it all.
The patients slowly trickled in over the course of the day. Patients aren’t given scheduled appointments. A nurse simply rides through the town in the ambulance announcing that the doctors are here & makes a special effort to encourage patients with issues to come to clinic. I saw a few patients along with the other registrar, & then broke away to see a few pediatric patients on my own.
I saw a pair of brothers, one with a recent asthma exacerbation & the other with recurrent boils on his hands & feet, which had previously cultured out staph & group A strep, which luckily were sensitive to most antibiotics. I prescribed flucloxacillin for the skin infection. I then saw a 19-year-old first-time mother with her seven-day-old baby. The mom had a bad case of mastitis of her right breast, which engorged, painful, & woody hard, but the baby was doing well & almost back to birth weight & managing okay feeding off the unaffected breast. I prescribed the mom a course of antibiotics (dicloxacillin) & asked the community nurse to check the baby’s weight again in a few days.
At the end of the day, after all the patients had been seen, I took a walk through the community. Families were sitting underneath the shade of trees in front of their homes while children ran about & dogs slept on porches. It only took a few minutes to make a round about the entire community. I visited the store, which had a meager selection of foods all of which were priced about 60% more than what they’d cost in the city. I was warned to take a stick along to keep the dogs away, but the dogs didn’t pay me any interest in the afternoon heat.
Above is a picture of the clinic as seen looking up from the community.
Tuesday, April 7, 2009
Kakadu Adventure
Kakadu is Australia’s largest national park, covering over 4 million acres, & is designated a World Heritage Area. It’s a vast place of beautiful landscapes & diverse wildlife. We set off in the early morning on the two-&-half hour drive on the Arnhem Highway eastwards out of Darwin. We reached the Jabiru area of the park by mid-morning & made a quick stop at Aurora & checked in to our cabin.
We then made our way to the small Jabiru airstrip for a scenic flight. This time of the year a flight is the only way to see two of the park’s main attractions, Jim Jim Falls & Twin Falls, because much of the park floods during the Wet season making the roads to the falls impassable. A flight is also the best way to get a full appreciation of Kakadu’s expansive landscape escarpments, ravines, & flood plains. The plane was tiny, seating only six passengers. To give us the best view possible, the pilot tried to fly as low to the ground as possible, so the plane was constantly buffeted by winds. Then, to give each passenger a view of the waterfalls, he made two corkscrew turns around each waterfall, wing tip down in alternating directions so both sides of the plane could get an equal view. Unfortunately, for the weak-stomached, like myself, this is a recipe for sickness. Amazingly, I managed to keep it together during the circling around the falls though I was sweating bullets & am sure I looked green. Despite my best efforts, I lost it about five minutes before we landed.
Even though I got sick, if I had it to do over again, I’d take the flight because there is no other way to see the waterfalls in their full strength & Wet-season swell. Even in the Dry, the falls are only accessible by four-wheel-drive & often not until June & by that time, they’ve often slowed to a trickle. However, in the Dry two magical plunge pools, perfect for swimming, remain at the base of the falls. I’m hoping I have the chance to make it back out to Kakadu in May before I return & make it to the waterfalls.
We then made our way northeast towards Ubirr. The ranger at the Visitor Center warned us that the road to Ubirr was closed to non-4WD vehicles due to flooding. However, we decided to venture out & assess the situation ourselves. About halfway there, we came to the first flooded portion of the road, which was submerged under about 20cm of floodwater across approximately 15 meters of road. We contemplated the situation for a bit & decided to brave it with our little Toyota Corolla. Luckily we made it. There was only one other flooded area a short distance further covering about the same depth & distance of road, which we also easily forged. Ubirr Rock is one of Kakadu’s famous Aboriginal art sites. There are reportedly over 5,000 art sites throughout Kakadu dating back as far as 50,000 years; however, only a few are open to visitors. We climbed about 820 ft. to the top of Ubirr Rock, which was dotted with art sites throughout the climb. We remained at the top until the spectacular sunset over the flood plains.
The second day, we woke at the crack of dawn for the Yellow Water cruise. The Yellow Water Billabong is a lake south of Jabiru near the center of the Park that is surrounded by freshwater mangroves, water lilies, & countless varieties of birds including sea eagles, magpies, kites, kingfishers, jacanas, & many more. During the Wet, the billabong floods to join with Alligator River. The cruise started at sunrise at the billabong & wound along down Alligator River. In addition to all the birds, there were several large saltwater crocodiles that swam alongside our boat.
Following the cruise, we visited the Aboriginal Cultural Center, which took us through the history & lifestyle of the Bininj Aborigines & Dreamtime creation myths. Then, we took two bushwalks ending the day at Nourlangie Rock, which is often considered the best of the Aboriginal art sites. During the walk, I came a across a wallaby! It stood about five feet away from me just looking at me. Then, it suddenly bounded away on its powerful legs.
Friday, April 3, 2009
Sunday, March 29, 2009
Tiwi Island Footy
Last weekend I had a unique Australian cultural experience--attending the Tiwi Island Football Finals. The Tiwi Islands are located off the coast of Darwin. One can get there by ferry or by taking a 20 minute flight. The islands were proclaimed an Aboriginal Reserve in 1912, & the vast majority of the inhabitants are indigenous. For tourists, there's no overnight accommodation--just day trips to the islands.
Every March, the Tiwi Islands host the Football Grand Finals, which attracts thousands of visitors for the day. A large contingent from the hospital goes every year, & I decided to join them. The first thing I did after I got off the plane, was visit one of the local Aboriginal Art Galleries, where the local artists proudly displayed their art. I decided to splurge & purchased two beautiful works.
The crowd slowly gathered around the football oval. The game was fantastic! It was Australian rules football, which is sort of something of a hybrid between soccer & rugby. The game is played on a large oval shaped grass field. There are 18 players on each team & the goal is to score a goal by kicking the ball between the middle two goal posts. Players can kick, "handball," & run with the ball. There's some weird rule about bouncing the ball on the ground periodically & players should not get caught holding the ball. The game is played in four quarters that are about a half hour long, so the entire game lasted slightly more than two hours. It was a very hot day & the game is extremely physically demanding. I was exhausted just spectating in the heat.
The locals really take their footy seriously. It was wonderful to see the indigenous people in their element so happy & proud to have all us visitors their to see them at the their best. The best footy players are Aboriginal & the vast majority of the players last Sunday, if not all, were indigenous. Then, to top off what was a wonderful day, on the flight back to Darwin, the pilot let me sit up front with him in the co-pilot seat!
Every March, the Tiwi Islands host the Football Grand Finals, which attracts thousands of visitors for the day. A large contingent from the hospital goes every year, & I decided to join them. The first thing I did after I got off the plane, was visit one of the local Aboriginal Art Galleries, where the local artists proudly displayed their art. I decided to splurge & purchased two beautiful works.
The crowd slowly gathered around the football oval. The game was fantastic! It was Australian rules football, which is sort of something of a hybrid between soccer & rugby. The game is played on a large oval shaped grass field. There are 18 players on each team & the goal is to score a goal by kicking the ball between the middle two goal posts. Players can kick, "handball," & run with the ball. There's some weird rule about bouncing the ball on the ground periodically & players should not get caught holding the ball. The game is played in four quarters that are about a half hour long, so the entire game lasted slightly more than two hours. It was a very hot day & the game is extremely physically demanding. I was exhausted just spectating in the heat.
The locals really take their footy seriously. It was wonderful to see the indigenous people in their element so happy & proud to have all us visitors their to see them at the their best. The best footy players are Aboriginal & the vast majority of the players last Sunday, if not all, were indigenous. Then, to top off what was a wonderful day, on the flight back to Darwin, the pilot let me sit up front with him in the co-pilot seat!
Saturday, March 14, 2009
The Patient Absconded
There's a phenomenon here I don't see in the US of patients "absconding." It's a fairly common occurrence here--it seems to happen at least daily & with very sick patients who unquestionably should be in the hospital. It almost exclusively occurs with the indigenous patients. They will literally pull out their IVs & vanish. In the US, we more commonly have the opposite problem of patients who are not sick enough to be in the hospital but refuse to leave.
To illustrate this point, we admitted a young Aboriginal woman with a condition called ITP (idiopathic thrombocytopenia) where the body, for unclear reasons, destroys its platelets, which can result in life-threatening spontaneous bleeding. She'd previously been treated with immune-suppressing medications for her ITP & as a result developed a blood stream infection with two different types of bacteria, one being melioid. On Friday, she just took off with a platelet count of three (normal platelet counts should be in the high 100s at least), dangerously low potassium level, & two bacteria infecting her blood stream.
When this happens we notify the police & they try to track down the patients, but I still haven't figured out the legal aspects of restraining patients against their will in the hospital so that we can provide them with potentially life-saving treatments. In most cases, someone convinces the patient to return or they'll eventually get sick enough that they return of their own volition. In the US, if one is deemed to have decision-making capacity, even if that decision is a very bad one, we have to respect it & have no grounds for holding someone against their will unless they have a disease that poses a threat to the community, like active tuberculosis.
"Absconding" needs to be put in its cultural context--the hospital environment is extremely repellent & frightening to most Aboriginal patients. Most live in remote villages with no previous contact with large, cold, air conditioned buildings. For many, English is their 4th or 5th language, & even if they seem to speak it well, they generally don't understand half the medicalese we say to them. On top of this, we make them take medications & do noxious things to their bodies like putting in IVs & taking blood. To them, the hospital is a prison, & absconding is their prison break.
To illustrate this point, we admitted a young Aboriginal woman with a condition called ITP (idiopathic thrombocytopenia) where the body, for unclear reasons, destroys its platelets, which can result in life-threatening spontaneous bleeding. She'd previously been treated with immune-suppressing medications for her ITP & as a result developed a blood stream infection with two different types of bacteria, one being melioid. On Friday, she just took off with a platelet count of three (normal platelet counts should be in the high 100s at least), dangerously low potassium level, & two bacteria infecting her blood stream.
When this happens we notify the police & they try to track down the patients, but I still haven't figured out the legal aspects of restraining patients against their will in the hospital so that we can provide them with potentially life-saving treatments. In most cases, someone convinces the patient to return or they'll eventually get sick enough that they return of their own volition. In the US, if one is deemed to have decision-making capacity, even if that decision is a very bad one, we have to respect it & have no grounds for holding someone against their will unless they have a disease that poses a threat to the community, like active tuberculosis.
"Absconding" needs to be put in its cultural context--the hospital environment is extremely repellent & frightening to most Aboriginal patients. Most live in remote villages with no previous contact with large, cold, air conditioned buildings. For many, English is their 4th or 5th language, & even if they seem to speak it well, they generally don't understand half the medicalese we say to them. On top of this, we make them take medications & do noxious things to their bodies like putting in IVs & taking blood. To them, the hospital is a prison, & absconding is their prison break.
End of Life
I conducted my first Australian family meeting with end-of-life discussion on Friday. Prior to this trip, I considered myself fairly adept at conducting family discussions. However, attempting an end-of-life discussion with an indigenous patient & her family made me realize that I was way out of my league & have a great deal to learn about Aboriginal culture & will hardly scratch the surface during my few months here.
TG is a 32-year-old Aboriginal woman who is in the end-stages of bronchiectasis, a lung disease that has resulted from multiple recurrent lung infections over the course of her life. Many indigenous patients develop bronchiectasis in childhood from recurrent lung infections & the condition often progresses & worsens over time & eventually comes to resemble a condition much like cystic fibrosis, except these patients start off with genetically normal lungs that are damaged over time. Eventually, as is the case with TG, the heart is also damaged from years of pumping blood against sick lungs. TG has severe pulmonary hypertension & heart failure as a result of her condition.
TG was on the inpatient ID team when I arrived in Darwin completing a prolonged course of IV antibiotics for another lung infection. During that hospitalization, it became apparent to us that she would now be dependent on supplemental oxygen. It took a great deal of maneuvering on the part of the resident to discharge TG back to her remote village on supplemental oxygen. Not surprisingly, a few days later she returned to the hospital with another lung infection & difficulty breathing. TG is not a candidate for a lung transplant, which is the only measure that could prolong her life at this point. So, it's just a matter of time until she succumbs to one of these recurrent lung infections.
On Friday I felt that she was not improving despite our treatment & was working very hard to breathe, taking over 30 breaths a minute & tiring. I was worried that with the weekend coming, her condition would deteriorate & wanted to make sure she & her family were aware of this, her overall prognosis, & had a chance to discuss her goals of care & what she would want to happen should she no longer be able to breathe on her own. So, I scheduled a family meeting with TG, her family representatives, & the ALO (Aboriginal Liaison Officer).
TG's "auntie" was the head family representative at the meeting along with one of TG's cousins. There was complete silence while I was speaking with no obvious body language clues or other feedback from the family. Then, the family broke into a loud, heated discussion among themselves, speaking in their native language which even the ALO does not understand. Then, the auntie said that TG had enough & from then onwards we could only speak to her (without the ALO). Finally, the resident & I took the auntie to another room & finished the discussion. It was not entire clear to me what was understood, but she stated that she understood everything & would communicate what was said to TG & that she'd also had enough & did not want to hear anymore . . .
TG is a 32-year-old Aboriginal woman who is in the end-stages of bronchiectasis, a lung disease that has resulted from multiple recurrent lung infections over the course of her life. Many indigenous patients develop bronchiectasis in childhood from recurrent lung infections & the condition often progresses & worsens over time & eventually comes to resemble a condition much like cystic fibrosis, except these patients start off with genetically normal lungs that are damaged over time. Eventually, as is the case with TG, the heart is also damaged from years of pumping blood against sick lungs. TG has severe pulmonary hypertension & heart failure as a result of her condition.
TG was on the inpatient ID team when I arrived in Darwin completing a prolonged course of IV antibiotics for another lung infection. During that hospitalization, it became apparent to us that she would now be dependent on supplemental oxygen. It took a great deal of maneuvering on the part of the resident to discharge TG back to her remote village on supplemental oxygen. Not surprisingly, a few days later she returned to the hospital with another lung infection & difficulty breathing. TG is not a candidate for a lung transplant, which is the only measure that could prolong her life at this point. So, it's just a matter of time until she succumbs to one of these recurrent lung infections.
On Friday I felt that she was not improving despite our treatment & was working very hard to breathe, taking over 30 breaths a minute & tiring. I was worried that with the weekend coming, her condition would deteriorate & wanted to make sure she & her family were aware of this, her overall prognosis, & had a chance to discuss her goals of care & what she would want to happen should she no longer be able to breathe on her own. So, I scheduled a family meeting with TG, her family representatives, & the ALO (Aboriginal Liaison Officer).
TG's "auntie" was the head family representative at the meeting along with one of TG's cousins. There was complete silence while I was speaking with no obvious body language clues or other feedback from the family. Then, the family broke into a loud, heated discussion among themselves, speaking in their native language which even the ALO does not understand. Then, the auntie said that TG had enough & from then onwards we could only speak to her (without the ALO). Finally, the resident & I took the auntie to another room & finished the discussion. It was not entire clear to me what was understood, but she stated that she understood everything & would communicate what was said to TG & that she'd also had enough & did not want to hear anymore . . .
Thursday, March 12, 2009
Crusted Scabies
Another disease that's rare in the US but prevalent in the NT is crusted scabies. Scabies is a fairly common skin condition that results from infestation with the mite, Sarcoptes scabiei. Crusted scabies, is caused by the same mite that causes scabies in the US. However, crusted, or Norwegian scabies, is a severe form of the disease that results from hyper-infestation with thousands of mites. It's thought that it results from a failure of the infected individuals immune system to control the proliferation of the mite.
Scabies is endemic among the Aboriginal population of the NT with estimates of up to 50% of Aboriginal people infested with the mite & the NT has the highest rates of crusted scabies in the world. It's a very serious disease & has a reported mortality rate of up to 50% over five years & requires admission to the hospital for intensive treatment.
This week, I saw my first case of crusted scabies. We admitted a 64-year-old indigenous woman who was found outdoors unconscious, severely malnourished, & infested with a rampant case of crusted scabies. Practically every surface of her body was involved with her scalp & arms being the most severely affected with heaped up layers of crust. She's such a sad wisp of humanity--severely cachectic weighing little more than 70-80 lbs. We've suspected systemic sepsis from secondary pyoderma & have been treating her with antibiotics in addition to the scabies treatments. This morning, she had an asystolic cardiac arrest & is now in the ICU . . . Very sad. I've never seen anything like this. The severity of & extent of pathology in the diseases I'm seeing here really hit me today, ans the indigenous patients carry a disproportionate burden of disease & so many of them are young & extremely sick.
Scabies is endemic among the Aboriginal population of the NT with estimates of up to 50% of Aboriginal people infested with the mite & the NT has the highest rates of crusted scabies in the world. It's a very serious disease & has a reported mortality rate of up to 50% over five years & requires admission to the hospital for intensive treatment.
This week, I saw my first case of crusted scabies. We admitted a 64-year-old indigenous woman who was found outdoors unconscious, severely malnourished, & infested with a rampant case of crusted scabies. Practically every surface of her body was involved with her scalp & arms being the most severely affected with heaped up layers of crust. She's such a sad wisp of humanity--severely cachectic weighing little more than 70-80 lbs. We've suspected systemic sepsis from secondary pyoderma & have been treating her with antibiotics in addition to the scabies treatments. This morning, she had an asystolic cardiac arrest & is now in the ICU . . . Very sad. I've never seen anything like this. The severity of & extent of pathology in the diseases I'm seeing here really hit me today, ans the indigenous patients carry a disproportionate burden of disease & so many of them are young & extremely sick.
Tuesday, March 10, 2009
Melioidosis
I've already seen such fascinating cases here including multiple cases of melioidosis, which I will likely never encounter again elsewhere. Melioidosis is an infection caused by the gram negative bacterium Burkholderia pseudomallei. Under the microscope it has a safety pin appearance & is motile. It is found in soil & water & is endemic in the NT, especially during the wet season. Patients can become quite ill with acute melioidosis & I've already admitted a few patients with melioid in the less than two weeks I've been in Australia.
My first case of melioid was in a 27-year-old indigenous woman with type 1 diabetes who is from Darwin City & initally presented to the emergency department with complaints of a couple of days of cough with yellow sputum production & severe left sided back & chest pain with coughing. Her blood sugars had been elevated, she was experiencing sweats & chills, decreased appetite, & weight loss. The intial chest x-ray in the ED revealed a large cavitary lung lesion in her left upper lung lobe. Based on these findings, we were highly suspicious for melioid & recommended she be admitted to the hospital for further evaluation. However, like many patients here, she refused to be admitted to the hospital & insisted on leaving. After failing to convince her to stay, we released her on augmentin but after first obtaining blood, urine, & sputum cultures as well as a BPS (Burkholderia pseudomallei screen).
Two days later, her sputum came back with the positive identification for melioid, so we contacted her & convinced her to come into the hospital. We are now treating her with ceftazidime 2g IV every 6 hours as well as bactrim DS 2 tablets every 12 hours. She'll need in the IV antibiotics for at least two weeks & will remain on bactrim for at least another three months. In her case, it is unclear how she was infected with the bacterium. However, diabetes is a known risk factor for melioid.
Today I admitted another another patient with confirmed melioid. This patient is a 57-year-old caucasian man with type 2 diabetes from Gove, which is a small town in the north-west edge of the NT. He works outdoors & remembers scratching his left leg while working sometime in February. Those abrasions have since healed well. However, towards the end of February he also developed elevated blood glucose levels, fevers, chills, rigors, nausea, weight loss, & right flank & back pain. On initial presentation at a local hospital, he was presumed to have a UTI. Cultures were obtained, & he was discharged home on bactrim for his presume UTI.
Despite the bactrim, his symptoms persisted. Subsequently, a gram negative rod organism grew out of his blood cultures so he was admitted to Gove Hospital & started on ceftriaxone & gentamycin. A few days later, melioid was definitively identified & he was switched to ceftazidime & transferred to RDH for further care. He is still having fevers, right flank pain, & abnormal liver function tests, which is concerning for possible liver abscesses, which are a common complication of melioidosis. He will be undergoing a CT of his abdomen & pelvis, which is standard in all patients admitted with melioid given how common it is to develop abscesses. It is unclear how he developed the infection. It may have resulted from the abrasions he sustained sometime in February.
Lastly, I saw a most interesting case today of a 36-year-old indigenous man with no past history who was admitted with four weeks of "flu" like symptoms, fevers, chills, severe right sided abdominal pain, weight loss, cough productive of white sputum, & shortness of breath. On ultrasound & subsequent CT of his abdomen, we discovered multiple large (up to 6cm in diameter) nodules/cysts in his liver. His liver enzymes are also elevated & his coagulation numbers are dramatically deranged with a PTT>200. His BPS is positive & he also has gram negative rods growing from his blood culture, but we are still awaiting final identification. We are treating presumptively for melioid pending the final ID. However, other causes are on the differential including hydatid infection or amoebic infection. As soon as his coagulopathy is corrected, we will obtain a sample from one of the liver lesions. Interestingly, he went fishing in the rain prior to the onset of symptoms & he works as a lawn mower & admits to mowing the lawn barefoot.
Above is a picture of RDH as seen from the "village."
Sunday, March 8, 2009
The Bike
I'm loving the bike. Saturday evening I & two other "village people" biked from the hospital, along the Casuarina Coastal Reserve to Nightcliff for a dinner party at Asha, Dina, & Cath's. They fled the Village after a very short stay to rent a beautiful three bedroom flat in Nightcliff on the top floor of a building overlooking the shore. We got there just in time to watch the sun set over the Timor Sea. The dinner party was wonderful--the best food I've had in Darwin. Three other doctors plus Asha's boyfriend joined the party so all in all there were ten at the party. We made quite an international group, which is typical for Darwin. James, a pulmonary reg, is most recently from London. His girlfriend, Kathy, a nephrology reg, is from Northern Ireland. Ed, a critical care reg, spent most of his childhood in Hong Kong. Uma, a medicine reg, is from Sri Lanka . . . You get the picture. There was also an odd over representation of vegetarians, which is unusual for Australia, but gives you an idea of the kind of people Darwin seems to attract.
The bike home was wonderful . . . Most of the bike path was well lit except for one short stretch, but Ray had a very bright light & there was a bright half-moon in the sky to light our way. The temperature was perfect around 60 degrees & we hardly passed a car or a soul.
Today, Nicole & I biked halfway across town along the shore to the East Point Recreation Reserve & the Dudley Point Lookout. I'm including a picture of a sweaty me alongside my bike at the Dudley Point Lookout. As much as I love the bike, I'm starting to suffer from a severely sore backside, shoulders, legs, etc. It's been almost a decade since I've biked with any regularity & I'm finding that I'm definitely not in bike shape. But, she's beautiful. You probably can't appreciate it from the picture, but she's a dusky pink & my helmet matches with purple & white flowers. I'll be very sad to leave her when the time comes to return to the states.
Friday, March 6, 2009
Parap Street Market
My social life is starting to pick up! My first couple of days here I had the frequent, irrational thought of "what the hell have I done?" & I'd convinced myself I'd spend the next three months living an isolated monkish life staring at the four uninspiring walls of my room. Luckily, that has not turned out to be the case . . .
I had my first real outing last night in Nightcliff, one of Darwin's seaside suburbs. I joined Dina, a senior pediatrics "reg" (short of registrar), Kath, a senior critical-care reg, & James a nephrology reg at the Beachfront Hotel Restaurant. We sat outside & I had my first drink of Australian beer. I started off with a VB (Victoria Bitter), which had been recommended to me & chased that with a Coopers, which is similar to a Blue Moon orange colored & somewhat opaque. I also had my first "real" Australian meal of grilled Barramundi, which is a delicious white, flaky fish native to the Northern Territory.
Today, I ventured to the Parap Street Market with Nicole, an intern, & her friend Simon. The Parap Street Market is a local institution. It's a weekly Saturday open-air market in Parap, a Darwin suburb, & features multi-ethnic food vendors, produce, arts, crafts, musicians etc. I stocked up on some weekly groceries including local honey, enjoyed some a Vietnamese vegetable noodles followed by a freshly made mango-lime smoothie, & purchased two beautiful black & white photos, one of an indigenous child holding a sleeping baby wallaby which had an uncanny resemblance to Smedley when he was a baby . . . I miss Smedley. I also saw a Staffy Bull, which I had to meet, & kiss on his beautiful, smiling face.
My First Week
It's hard to believe I've only been here slightly more than a week. My humble living quarters & the ins & outs of my daily life here are beginning to feel like home. I've settled in quite well here.
While here, I'll be dividing my time between infectious diseases (ID) & pediatrics. To ease the transition to working in the Australian health system, my sponsors thought it would be best that I start on the ID team. The ID department at RDH is one of the largest & well respected departments at the hospital & there's a long-time connection with Duke because several of the RDH ID "consultants" (attendings) completed their ID fellowships at Duke. The ID service consists of the adult ID inpatient team & a very large & active consult service. The inpatient team is composed of patients whose primary admitting issue is infectious & they are primarily managed by us, rather than being admitted to general medicine with ID consulting. Our ID team census has been in the low teens but added to that is a large group of active consults ranging anywhere from 20-30 patients. We also cover pediatric ID consults. There's a dedicated peds ID ward, for which the pediatricians are the primary caretakers with ID consulting.
Here's a rough outline of my weekly schedule:
Daily 8am medicine handover of new overnight admissions & daily 11am-noon microbiology plate rounds.
Monday
8:30-9:30: ID case presentation conference
11:00-12:00: plate rounds & ICU micro rounds
Afternoon: ID clinic
Tuesday:
Morning: blood-borne infections clinic (HIV & hepatitis)
Wednesday:
7am-8am: general medicine teaching conference
Morning: TB clinic
12:00-1:00: medicine grand rounds
Thursday:
11:00-12:00: micro plate rounds & ICU rounds
12:00-1:00: ID journal club
Friday:
8:30-9:30: ID teaching
10:00-11:00: pediatric ID rounds
12:00-1:00: radiology conference or pediatric grand rounds
In the midst of all these formal learning opportunities, we spend our time rounding on & caring for the inpatient ID team, seeing old & new consults, completing new admissions from the emergency department, & rounding formally with the ID consultant, so the days are quite full. The earliest start is Wednesday with the formal general medicine teaching session. Otherwise, the workday always starts at 8am & ends by early evening, generally around 5-6pm.
The ID team is composed of two ID senior "registrars" (US equivalent of a senior ID fellow), an "RMO" or "registered medical officer" (US equivalent of a 2nd year resident), & two medical students. One ID registrar generally acts as the inpatient registrar leading the inpatient team & seeing most of the inpatient consults while the other ID registrar oversees the three weekly ID clinics & "Health in the Home" or the home-health team that manages home IV antibiotic infusions. There's a third ID registrar who is on the medical outreach teams & flies to remote villages for one- or two-day clinics.
I'm the equivalent of a senior medical registrar here but I'm essentially functioning as an ID registrar in something of a hybrid role: I've been seeing & following new consults, helping with emergency department admissions, seeing patients in clinic, & rounding on the inpatient team & generally helping out where I can. I may also get to visit some remote villages with the outreach registrar.
While here, I'll be dividing my time between infectious diseases (ID) & pediatrics. To ease the transition to working in the Australian health system, my sponsors thought it would be best that I start on the ID team. The ID department at RDH is one of the largest & well respected departments at the hospital & there's a long-time connection with Duke because several of the RDH ID "consultants" (attendings) completed their ID fellowships at Duke. The ID service consists of the adult ID inpatient team & a very large & active consult service. The inpatient team is composed of patients whose primary admitting issue is infectious & they are primarily managed by us, rather than being admitted to general medicine with ID consulting. Our ID team census has been in the low teens but added to that is a large group of active consults ranging anywhere from 20-30 patients. We also cover pediatric ID consults. There's a dedicated peds ID ward, for which the pediatricians are the primary caretakers with ID consulting.
Here's a rough outline of my weekly schedule:
Daily 8am medicine handover of new overnight admissions & daily 11am-noon microbiology plate rounds.
Monday
8:30-9:30: ID case presentation conference
11:00-12:00: plate rounds & ICU micro rounds
Afternoon: ID clinic
Tuesday:
Morning: blood-borne infections clinic (HIV & hepatitis)
Wednesday:
7am-8am: general medicine teaching conference
Morning: TB clinic
12:00-1:00: medicine grand rounds
Thursday:
11:00-12:00: micro plate rounds & ICU rounds
12:00-1:00: ID journal club
Friday:
8:30-9:30: ID teaching
10:00-11:00: pediatric ID rounds
12:00-1:00: radiology conference or pediatric grand rounds
In the midst of all these formal learning opportunities, we spend our time rounding on & caring for the inpatient ID team, seeing old & new consults, completing new admissions from the emergency department, & rounding formally with the ID consultant, so the days are quite full. The earliest start is Wednesday with the formal general medicine teaching session. Otherwise, the workday always starts at 8am & ends by early evening, generally around 5-6pm.
The ID team is composed of two ID senior "registrars" (US equivalent of a senior ID fellow), an "RMO" or "registered medical officer" (US equivalent of a 2nd year resident), & two medical students. One ID registrar generally acts as the inpatient registrar leading the inpatient team & seeing most of the inpatient consults while the other ID registrar oversees the three weekly ID clinics & "Health in the Home" or the home-health team that manages home IV antibiotic infusions. There's a third ID registrar who is on the medical outreach teams & flies to remote villages for one- or two-day clinics.
I'm the equivalent of a senior medical registrar here but I'm essentially functioning as an ID registrar in something of a hybrid role: I've been seeing & following new consults, helping with emergency department admissions, seeing patients in clinic, & rounding on the inpatient team & generally helping out where I can. I may also get to visit some remote villages with the outreach registrar.
Saturday, February 28, 2009
Getting Around
Prior to my arrival, I didn't fully appreciate how isolated the hospital & my accommodations would be. RDH is located in the Tiwi suburb of Darwin. You can see downtown Darwin in the distance from the upper floors of the hospital, but it's a $25 cab drive away & not within walking distance. The hospital has small cafeteria with an assortment of drinks, a cafe, & a limited selection of food (mostly fried) & the hours are fairly limited. The area surrounding the hospital on one side is residential with streets of well-kept houses then the other side of the hospital is surrounded by the Casuarina Coastal Reserve with miles of uninhabited coastline & mangroves.
Luckily, Darwin's major shopping center, which is the equivalent of a mall in the US, is located in the adjacent suburb of Casuarina. However, it is a $10 cab drive away, but it's my closest source for buying groceries. On my second day here, I caught a cab to the shopping center & bought myself some food staples at Woolies (Woolworths) & made my two major, essential purchases: a mobile phone & a bicycle or "push bike" as they call them here.
I bought the bike a Kmart, which is considered a major department store here, & it only cost about $100 ASD which comes to about $65 USD! I got a prepaid mobile phone for about $50 ASD which comes to about $32 USD. I'm extremely lucky in that the Australia dollar has fallen considerably against the US dollar despite our miserable economy, so everything seems relatively cheap by comparison.
I'm still waiting on the bike--Kmart is assembling it & it should be ready for pick-up today. This will significantly improve my life here as most people get around on bike & the cities streets are safe & easily navigable by bike. I haven't made it to the downtown area yet, but I'm told it's about a 25-30 min bike ride--I may venture there today if I get my bike in time.
Luckily, Darwin's major shopping center, which is the equivalent of a mall in the US, is located in the adjacent suburb of Casuarina. However, it is a $10 cab drive away, but it's my closest source for buying groceries. On my second day here, I caught a cab to the shopping center & bought myself some food staples at Woolies (Woolworths) & made my two major, essential purchases: a mobile phone & a bicycle or "push bike" as they call them here.
I bought the bike a Kmart, which is considered a major department store here, & it only cost about $100 ASD which comes to about $65 USD! I got a prepaid mobile phone for about $50 ASD which comes to about $32 USD. I'm extremely lucky in that the Australia dollar has fallen considerably against the US dollar despite our miserable economy, so everything seems relatively cheap by comparison.
I'm still waiting on the bike--Kmart is assembling it & it should be ready for pick-up today. This will significantly improve my life here as most people get around on bike & the cities streets are safe & easily navigable by bike. I haven't made it to the downtown area yet, but I'm told it's about a 25-30 min bike ride--I may venture there today if I get my bike in time.
Staff Village
While working here, I'll be living in the the Staff Village, which is on the hospital grounds. As I mentioned earlier, Darwin is full of "transients" like myself who come to RDH for a brief stint to rotate & study at the hospital. Many of them end up living in the Staff Village. It's pretty "bare-bones" dorm room style accommodations.
I have a one-room flat comprised of a twin sized cot, which a surprisingly comfortable mattress & pillow, a closet, built-in desk & bookshelves, a small table, three mismatched chairs with one very threadbare armchair. There's also a small kitchen area with a two-range stove, small oven, small fridge, & an assortment of utensils, dishes, pots, & pans. Luckily, I also have my own private bathroom with a stand-up shower & small washing machine (no dryer--there's a clothing line set up outside my front door). The bed has hospital issued linens on it & they've provided me with hospital issued towels.
I will admit that I was in slight shock when I first walked through the front door, which only reflects how "soft" I've become over the years. Compared to the dorms at Beaufort, the Staff Village is luxurious. I've settled in nicely now & am quite comfortable. Plus, the "village people" are quite a social bunch since they are all from somewhere else & looking to make friends. Also, the hospital is a stone-throw from my front door--about a three minute walk from my stoop to the hospital lobby. Plus, there's a nice swimming pool & squash & tennis courts on the grounds & a medical library with Internet access.
I have a one-room flat comprised of a twin sized cot, which a surprisingly comfortable mattress & pillow, a closet, built-in desk & bookshelves, a small table, three mismatched chairs with one very threadbare armchair. There's also a small kitchen area with a two-range stove, small oven, small fridge, & an assortment of utensils, dishes, pots, & pans. Luckily, I also have my own private bathroom with a stand-up shower & small washing machine (no dryer--there's a clothing line set up outside my front door). The bed has hospital issued linens on it & they've provided me with hospital issued towels.
I will admit that I was in slight shock when I first walked through the front door, which only reflects how "soft" I've become over the years. Compared to the dorms at Beaufort, the Staff Village is luxurious. I've settled in nicely now & am quite comfortable. Plus, the "village people" are quite a social bunch since they are all from somewhere else & looking to make friends. Also, the hospital is a stone-throw from my front door--about a three minute walk from my stoop to the hospital lobby. Plus, there's a nice swimming pool & squash & tennis courts on the grounds & a medical library with Internet access.
The Hospital
While I'm here, I'll be working at Royal Darwin Hospital (RDH). RDH has about 363 beds & is the only major hospital & major referral center for the entire Northern Territory as well as South East Asia. It's a teaching hospital & is affiliated with Flinders University of Southern Australia, the University of Sydney, Charles Darwin University, & the Menzies School of Public Health. Because of its university affiliations, there is a large population of "transients" like myself who come to Darwin for brief stints to rotate & train at the hospital. In fact, the vast majority of the residents & medical students I've met are not from Darwin & only recently arrived within the last few weeks to months. More about medical system & training program later.
Darwin
Darwin is the capital city of the Top End of Australia or the Northern Territory (NT). It's a port city situated on the Timor Sea & is in close proximity to Indonesia & East Timor. It's the largest city in the vast NT but even so is comprised of a population slightly under 100,000. The rest of the NT, which occupies over 520,000 square miles, is sparsely populated with a total population of slightly more than 200,000 for the entire territory. With half of the total population living in Darwin & the other half dispersed among the other major settlements, Kathrine, Alice Springs, Tennant Creek, & Nhulundbuy, & multiple smaller remote communities.
Over 30% of the inhabitants of the NT are Aboriginal Australians with the remainder being primarily of European descent & a minority of Asian descent. There's a surprisingly large Greek community in Darwin of about 10,000--that's 10% of the population of Darwin! As a reflection of this, there's a large Greek Orthodox church in downtown Darwin, which I plan to visit.
The climate in Darwin is tropical with distinct wet & dry seasons but otherwise very little variation in the temperature year round with lows in the 60s & highs in the 80s. I'm catching the tail end of the wet season which runs from December through March. It reminds me of Durham in June & July (though it never gets quite as hot as Durham can get) with mostly sunny, humid days marked by sudden, brief rainfall.
Over 30% of the inhabitants of the NT are Aboriginal Australians with the remainder being primarily of European descent & a minority of Asian descent. There's a surprisingly large Greek community in Darwin of about 10,000--that's 10% of the population of Darwin! As a reflection of this, there's a large Greek Orthodox church in downtown Darwin, which I plan to visit.
The climate in Darwin is tropical with distinct wet & dry seasons but otherwise very little variation in the temperature year round with lows in the 60s & highs in the 80s. I'm catching the tail end of the wet season which runs from December through March. It reminds me of Durham in June & July (though it never gets quite as hot as Durham can get) with mostly sunny, humid days marked by sudden, brief rainfall.
Getting There
The trip to Darwin is arduous. I departed on Tuesday 2/24 in the early afternoon & arrived in Darwin on Thursday 2/26 in the afternoon. Granted, Darwin is about 14 hours ahead of North Carolina. Even accounting for this, be prepared to travel a full day-&-half to get here. I flew Raleigh to Chicago, Chicago to LA, LA to Sydney, & Sydney to Darwin. The hospital was a short $15 cab ride away from the airport.
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