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!

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.

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.

Tiwi Island Photographs

Here are some photos from the Tiwi Island Footy adventure!