Postcard from the Edge in the Middle

aka Postcards from the Edge 007

The first story I heard about the community, as we were descending onto the once upon a time graded dirt strip, was that several months ago, when ‘the’ television had stopped working, the kids erupted, and spent weeks setting fire to anything in reach, including the dogs. And, then, hopping out onto the vast expanse of spinifexy nothing, where the airstrip flowed into the endless red, desperate to void my bladder after a bumpy charter flight from the tropical hub of the Kimberley, I went to find a ‘passenger terminal’ boarded and locked up with heavy iron, not a toilet in sight. I admitted a pathetically panicked desire to hang onto that plane – seeing it shrink off into the rude blue reminded me of those first days of graduating as a doctor, or the first night shift as a registrar, or even as the debutant consultant (actually, will I ever be rid of this feeling?).

What was I doing there, in the arid guts of the Australian desert, somewhere just off the Canning Stock Route, near state borders which were nothing more than a dusty idea? I’m an Emergency Physician, working at a tertiary teaching hospital, most comfortable when surrounded by arterial lines, laryngoscopes, intuitive nurses, specialists within 3 rings of a phone, and minions. What possible role could I have here?

Simply put, I am somewhat tired of being on the arse-end of medicine. Emergency Medicine should not really exist. Or be needed. Particularly when it comes to dealing with complications of chronic disease, and diseases of society. And this is sometimes embodied in the indigenous patients that we see – where the deprivations of a lifetime result in the worst ravages of disease. Nobody needs reminding of these. So I was joining in with a small group looking at ear health initiatives – if a child can hear, they can have an education. If a child can have an education, then anything is possible. The front end of medicine. The right end.

Anyway – very much aware of my own ignorance, naivety and inexperience, I was, of course, surprised to discover a thriving hub of residents and workers, particularly in the medical field. The incumbent doctor was charming, infinitely more knowledgeable with regards to yaws, rheumatic fever and pertussis than I, and was surrounded by a bevy (well 2 anyway) of gorgeous GP registrars, to say nothing of the magnificent warriors of nurses that were even more of a permanent fixture.

But our role was not at the clinic (to where I had been hauled out of bed in the dead of night, that first sleepless night I was there – as a baby was being delivered; babies are not meant to be born in this community, whose facilities were minimal, and the services of an unexpected Emergency Physician were happily welcomed in the possibility of a neonatal resuscitation). It was at the school itself, where we would look at every single child’s ears, upskilling the accompanying Aboriginal Health worker in otoscopy, using the video-otoscope to record the images, with a view to using this equipment remotely, and more importantly working out which kids would need daily dilute betadine syringing (wet, discharging perforations) and which would need daily nose blowing (a skill I was rather expert at demonstrating – oh yes, it was great to know I had expertise in one area). Simple, extraordinarily effective interventions, yet Herculean in attempted implementation.

As accidentally incendiary as always, I ignited a small twitter debate in considering some novel way of providing the next level of intervention – minimal surgical procedures under dissociative (ketamine) anaesthesia (in particular grommets and possibly non-grafting tympanoplasty – more on that another time). The very sage and experienced @BroomeDocs and @RFDSDoc were quick to point out that the answer is nutrition and hygiene, and incumbent in that is an engaged indigenous community who are plumbers, gardeners, builders, teachers. But until we can guarantee an education for those kids in primary schools who are currently missing out on years of plastic auditory/cerebral development because of gummed up or drumless ears, this functional future seems remote.

We visited three small and mindblowingly remote communities, all with their own character and personality. It became obvious that we could estimate the percentage of ear pathology in the kids in a glance at the state of the children lined up on the plastic seats in front of us, using intuitive variables such as brushed hair, state of clothes and presence of wet purulent rivers cascading from noses and ears. At worst it was over 80%.

The drives out to the communities were staggeringly beautiful, in that immeasurable limitless Australian way, not a pastel colour in sight – instead commanding and vibrant contrasts, broken up by surprisingly regal brumbies, jabirus, dingoes and the odd broken down car (one, astonishingly, full of little kids, waiting some fortuitous rescue, fueled only with a can of spam, 100ml of hot coke, and a campfire which transformed itself into hectares of raging bushfire within a short time of their deliverance)

The kids were uniformly fantastic – funny, bright, engaged, inquisitive, and affectionate. I succumbed to cuddles whilst examining their ears, and then a reciprocal look in my ears so the kids could play with the video-otoscope. I am able to now sadly relate that up close the desert nits are a whole different juicy breed than the delicate genteel ones experienced in the private schools of the western suburbs.

And just as soon as I had become comfortable, eating roo tail, figuring out that carrying middle sized rocks whist walking was an excellent dingo repellant, and wearing shoes would protect me from the endemic Strongyloides, I was gone. Back to my comfort zone, of gin and tonic with fresh lime, and a job applying band aids (albeit pretty exciting and amazing band aids, that I wouldn’t really swap for the world). I hold nothing but awe for the people working full time in these communities, making differences where they can, despite the constraints. I am immensely privileged to be included in this extraordinary initiative, and intend to carry on helping; in whatever capacity I am of value. There are many more trips planned, spearheaded by an extraordinary Infectious Diseases Physician, and incredibly admirable and capable ENT surgeons, as well as coordinators and Aboriginal Health Workers.

Till next time.

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  1. says

    Michelle, really enjoyed this article. Reminded me of times I spent in remote parts of Honduras, Panama and northern British Columbia. You have a real gift with words. I could picture the landscape based just one your vivid descriptions. I encountered a similar paradox when in remote northern BC talking with a seasoned local Doctor about the appropriateness of the term “health care”, he argued it was more correct to say “medical care” since we are good at intervening when a problem arises but not as good at preventing it in the first place or bringing about a state of “health”. Interesting to consider. I have found that patients who live in rural/remote/low-resource settings often have more reasonable expectations of health care and medical professionals, they seem to inherently understand the precarious state of affairs and understand that life in these remote and often unforgiving environments is not without risks.

    • says

      Paul, well said. you and Michelle reminded me of a life anthem that an ex registrar of mine lives by. this is a guy who won a marathon race across Antarctica. in surgical training now. typical.

      “All it takes is one decision,
      a lot of guts and a little vision,
      travel light, and leave your fears at home.”

    • says

      Thanks so much Paul. I/we’d love to hear more about your experiences. It is incredible that the answers are so simple in theory, yet so elusive. No question though, that the more people in health engaged in the process, the more accepted/acceptable they become.

  2. caseyparker207 says

    Great piece Michelle. Sorry to miss you in Broome.
    Brought back memories of my time in the Western desert -- frog and chips (tubers) on the hot coals. The trick is to break the legs so they can’t hop of the flames! The painters, the 20 + kids in a Landcruiser out for a ride in the bush!

    I like you work with my finger in the dike -- patching a hole, but until we can get a cultural shift in the way we approach these problems our jobs will be unfortunately secure. Not a day goes by when I don’t wonder at the absurdity of “health care in Australia” -- the money and equipment spent in large centres seems cray when you see what can be done with cents in remote areas.
    Don’t get me started on HD chairs vs. nutrition and prevention…..

    The great leadership shown by eminent surgeons, Ophthalmologists etc is wonderful -- we need heroes to create momentum in this change. The plight of the kids you saw is invisible to the wider community.

    I admire your motivation to go and see, as most specialists are happy to remain in the city and be appalled by the state of health of our indigenous people.

    As a GP-anaesthetist who does a fair bit of elective Paeds anaesthesia I can see how it could work. The irony of working in WA is that I am required to provide the same wonderful, 1st world standard of care that you would get in your tertiary hospital -- no matter how much this limits access. It is safe to do basic grommets etc with an ancient Boyle’s machine -- I have done it for years -- but one or two bad outcomes and it would be the end of my career! Quality seems to trump quantity (which equals access)

    Keep up the push.

    • says

      tonight I have been flying around most of Cape York so just landed and before the sun rises thought I would reflect on what Casey wrote here.
      I gave a ketamine sedation to a girl with a nasty fish hook embedded in her face. It went very well and she made an excellent recovery but I could not get all of the hook out so she still needed to go to hospital. Why? Because in these remote clinics and locations there comes a point when any good GP anaesthetists or EM physician , let alone half decent retrieval doctor should say, enough is enough , I can only conduct this procedure and anaesthesia so far here where I am. This kid needs to be in a proper operating setup with good anaesthesia and a surgeon who can remove this damned hook embedded in the zygomatic arch!
      So my point is related to Michelle’s and Casey’s discussion on providing remote anaesthesia for elective ENT procedures like grommets.
      When its a facial injury emergency, its easy to justify performing the remote anaesthesia and procedure. But when its elective, Casey is right , you are judged by a high standard and you have to be very careful about cutting corners.

      Now my next point is related to Casey’s comments about specialists being happy to remain in the city and never leave to see how many remote communities and Indigenous folk live , to try to understand some of the issues in health for them.
      This is somewhat unfair statement but has a degree of blunt truth. This month, I heard of news locally that specialist outreach services like ENT might be scrapped for telehealth provided specialist services. The specialists no longer have to leave the city at all, ever, as their service can be provided over the internet or video call.
      But not every specialist in the city is of that viewpoint and indeed some are actively doing the opposite, right Michelle?

      • says

        Both you and Casey make eloquent points, with which I agree. The consideration for using ketamine for grommets/non-grafting tympanoplasties, however, arose from seeing the process by which if a child was considered in need of grommets (again, with which I am in accord, is a bandaid solution where there is failed primary prevention), then their name would be put on a scrap of paper and put… somewhere. Getting one of these kids to the ‘local’ regional centre means travelling, out of school, with several family members, to the big (non-dry) smoke, at least 600km away. There is a sense of futility about even getting on to those lists. Therefore, I felt if we are to say that a child needs a procedure, but is denied it because of these unique logistical problems, are we then again delivering third rate care? Thus the thought, that if you saw a child, right there and then, who could have a safe quick sedation for a 60 second procedure, would this not be a viable alternative -- even if there are some theoretical risks -- where is our equipoise here? I do not know.

        Regarding visiting specialists, it needs to continue. Telehealth is an amazing adjunct, but it has many limitations, and there are many situations where the right people, with the right training need to be physically present and hands on (and by specialists, I mean those with the appropriate training and experience, not just the ones with the letters, as we have discussed previously :-)). We are fortunate in that we are not relying on Government funding, therefore are less prone to political vagaries, election cycles and fatal bureaucracy.

        As always, more questions than answers. I am fond of this quote (Anonymous, I believe) “Any man who knows all the answers most likely misunderstood the question”.
        What we do know, is that within us all lies the responsibility to continue to strive for equitable health care for all.

        • says

          The equipoise for ENT procedures is that we should aim to deliver the same standard of specialist procedural care afforded children in Perth. If you try to cut corners, the politicians will always budget for the least expenditure and pay you to provide a third rate service, until you have a bad outcome and then they will point fingers.

          I recently spoke at a rural doctors conference on a panel with eye surgeon, Dr Mark Loane who has setup an outreach eye service to a few remote places, inc Cape York. His belief is that you must deliver world standard care regardless of location, otherwise you are perpetuating disadvantage. He takes the best operating eye laser and gear available with him and a team and does laser operations on remote clinics as well as cataract surgery. He brings his own anaesthetist as well as another surgeon and a few optometrists.
          In the lucky country, I think we should strive as he says to provide best of practice care.

  3. says

    Working in the Pilbara region in the north west of Western Australia I noticed many (probably most) indigenous patients were hard of hearing. Hearing loss adds another layer of complexity on top of the language gap (English is frequently not a first language) and cultural divide when caring for and communicating with these patients.

    I enjoyed reading this so much Michelle that I had to post a link from my tumblr :)

  4. says

    Hi Michelle,

    I really enjoyed reading this beautifully written piece!- The article captures many things that for me lie at the heart of international emergency work -- such as that deep sense of adventure and simultaneous trepidation when one delves into unchartered territory, but also that avalanche of pathology that doesn’t seem to hit us in the city hospitals or less remote locations in the same intensity. This write up may also be of inspirational value for others who are interested in doing overseas work and have not yet managed to negotiate leaving the shores of Australia -- as the flavour of what you have seen at this destination seems to easily match the flavour of medicine that one practices in many of the “lower income countries” that form the basis of many an article in this section of the blog -- wouldn’t you say? (Which perhaps highlights an age old challenge in our society)

    Like Lyall (who is incidentally one of my twitter friends -- otherwise known as @lyall), I recently worked in the Pilbara on an Emergency Medicine locum, and I was amazed at how different everything seems -- for me it was like teleporting into a different universe -- how does one capture that -- well this article seem to do just that -- so fanks for the article and the pics :)

    Bish (@trainthetrainer)