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!
Sunday, March 29, 2009
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.
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