As promised, I took a trip out into the bush last week. I went out with Malcolm McDonald, who did his infectious disease fellowship training at Duke some years ago (the first in a line of Aussies to train at Duke, and I am the latest in a line of Yanks, and the first in a few years, to go from Duke to Darwin). Malcolm takes about seventy trips a year out into Aboriginal communities, all of which are essentially accessible by plane only given their remoteness. On Monday, he and I and our pilot Chris flew a couple of hours to a town called Yarralin, a small settlement of about 400 people. Malcolm was content to let me sit up front while he did some work in the back seat, and I was happy to be able to look out the front window, which aside from the views would also hopefully suppress my tendency towards motion sickness (ahh, Thomas and the barf bag, that staple of all the old Holland summer vacations). The flight was beautiful, with brilliant views of Darwin, the harbor, and out into the Timor Sea right after takeoff, followed by two hours over the trackless interior, with just the occasional cow seen wandering below. Even upon approaching Yarralin it didn’t exactly seem like we had reached the metropolis - at about ten people per house, you can imagine that a town of four hundred doesn’t make much of an impression from the air. On our first attempt at the runway, Chris had just put the wheels down when he violently pulled back on the stick and we catapulted back into the sky. Two cows were grazing on either side of the dirt strip, and in the early morning light neither of us had seen them. There was room to land between them, but then you never know which way a frightened cow will break, and it would not be a pretty sight if a 4-seater Cessna met a 1200 pound Brahmin at high speed. So we circled around and then buzzed the runway again, with Chris laying on the horn as we passed the cows about 15 feet above their heads (who knew planes had a horn?). They were unperturbed, which evoked some unprintable language from Chris, and a wry smile from Malcolm in the back seat. Fortunately someone in Yarralin noticed the commotion and came out to clear the path, and on the third attempt we were safely down in the dirt.
A fifty yard hike from the airstrip brought us to the center of town and the Yarralin Health Center. We had planned to set up in two rooms and crank through as many patients as possible. But patients were slow to trickle in, so we had a cup of tea and then saw the first few people together. The first man to drop in was Roger, a man in his mid-40s with hypertension. Malcolm took almost ten minutes to get to know him - where he was from, who he was related to in town, what his family was like, and in turn explaining who we were and why we were in Yarralin. To those of you not in the medical profession, you may have no idea what a luxury that was - ten minutes of small talk, taking the time to build up some trust, no pressure from a full waiting room or a barrage of calls from the hospital. Roger had nominally come in for evaluation of chest pain, but it turned out he had just moved to Yarralin because there was “too much sadness” at home. His second of two daughters had just died. Malcolm didn’t ask why or how, or really any questions about his daughters - later he told me in Aboriginal culture it’s inappropriate to mention the name of the dead or ask anything about them. But Roger volunteered that his first daughter had been murdered, and his second had just died of complications of alcohol abuse, so he had moved away to get a fresh start. He didn’t usually drink much himself, but recently he had been drinking more in his grief. His chest pain didn’t fit any real pattern - right-sided, not pleuritic, not reproducible, very vague. Malcolm thought it was a manifestation of his grief, and we wouldn’t be doing him any favors to send him overland by truck on a two-day drive to Katherine, where he could then catch a bus to Darwin, where he could get a more thorough evaluation of chest pain. The clinic did have an EKG machine, but his EKG had some nonspecific changes that weren’t really convincing in either direction. This, then, is one of the central challenges of practicing medicine in a remote location - what do you do when you would ideally like to get some more diagnostic tests, but that would entail at least a week of roundtrip travel for a man who needs to go out and hunt every day just to feed himself. In the end, Malcolm went with his instinct that the chest pain was a physical manifestation of his grief, and not a sign of cardiac disease. He encouraged Roger to cut back on the drinking if he could, and to eat bush tucker instead of “white man’s food.” This was a recurring theme of the morning; with the influx of packaged, high fat and low nutritional value foods (all the way from the US of A), the scourges of obesity, diabetes, and heart disease have found their way to the bush. Malcolm repeatedly encouraged each patient to stick with bush tucker, and all the patients, even the older ones, said they still went out hunting and gathering, where they got a balanced diet of kangaroo, goanna, wallaby, fish, and turtle, to name a few. I must confess that in my naiveté I didn’t realize that kangaroo was a staple food, I guess I thought they just bounced around and engaged in the occasional boxing match.
As patients trickled in, Malcolm and I eventually split up. I saw a woman with rheumatic heart disease - relatively rare in the US these days - who was taking care of fourteen kids but had no complaints. I saw an old stockman with the flu and the distinctive walk of a man who has spent several decades in a saddle. Then an eleven-year old boy, who looked about six, with rheumatic heart disease, developmental delay, and deafness from chronic ear infections. Lots of folks had trachoma - a Chlamydia infection of the eyes that untreated commonly leads to blindness from corneal scarring. Over and over I was amazed by the complexity of the medical problems that were being cared for so remotely - people on ten pills a day for diabetes, heart disease, and hypertension; valve replacements for rheumatic heart disease, or patients with atrial fibrillation taking warfarin, which requires frequent blood tests to monitor the dose. When Malcolm and I would get nearly caught up, the two nurses at the clinic would go out and see who else they could find that wanted to be seen. By the end of the day we had seen about twenty or so people, and we retired next door to the doctors’ quarters, where Chris had been lounging all day. I unfortunately did not realize that we would need to bring our own food, so I went to the store were I managed to find a can of beans, a package of (very) stale crackers, and a Coke to supplement the apple I had put in my bag at the last moment. If only I knew how to kill a kangaroo.
The doctors quarters were nice enough, with two rooms, two beds and a couch. But not enough blankets for three people, so it was a cold night in the desert. The next morning Chris didn’t look so good, and he said he felt like he had the flu. But it’s not like there’s another pilot in Yarralin to take his place, so he hauled his feverish, miserable self into the driver’s seat and we took off for Kalkarindji. Kalkarindji is about twice the size of Yarralin and has a paved airstrip. Unfortunately it wasn’t Chris’ best day of flying, and he managed to land about twenty feet short of the strip on some not-so-level ground. Which led to a most unnatural ricochet off to the left of the runway, before he eventually brought the Cessna onto the tarmac. “Now that was a shit landing” was all he had to say, then he went straight to the back of the health center for a nap.
As before, Malcolm and I split up and saw a steady stream of patients - a woman with lupus, an eight-year old with a lung disease called bronchiectasis, complicated by frequent infections and long trips to the hospital for intravenous antibiotics. I saw a 65-year old man with lung cancer - also a common diagnosis since most adults seem to smoke - who had not gotten better with several trips to Adelaide for chemotherapy. He was now back in Kalkarindji for palliative care, with a life expectancy of only a few months at best. He is a white Australian, the only non-Aboriginal patient I saw in the two days. I asked about his family, keeping in mind some advice I got in med school - don’t ever ask a question if you aren’t prepared to hear the answer. Meaning that you shouldn’t ask, “Do you have family helping you through your illness?“ unless you are ready to hear, “No, I’m all alone in the world.“ As it turns out, he is estranged from his two daughters, and divorced, and had moved to Kalkarindji to live with an Aboriginal woman who he said would take care of him until the end. He was very much at peace with his decision to stop chemotherapy and accept that he wasn’t going to beat his cancer, and his affairs were all in order. He was pleased that he was going to be able to leave some money to his partner, enough to take care of her for a long while, although he joked that he would have rather stuck around to spend the money himself. He wasn’t having any pain yet, but he got out of breath very easily, even having to stop and rest just from the exertion of telling me his story. He wasn’t afraid to die, but he didn’t want to suffer. The nurses had already arranged an oxygen tank for his home and some bronchodilators - they would arrive whenever the truck (that doubles as the ambulance) made it back to town. He had some liquid morphine waiting for him in the clinic too, but he hadn’t picked it up because he was afraid to use it. We talked for a long time about how to use the morphine to control his air hunger, and eventually the pain that is likely to come as his tumors enlarge. Mostly I tried to give him a sense that he still had some control over how he felt, and how his last days would go. The nurse told me later that he stopped on his way out to say how appreciative he was of the visit, he felt like he had regained control of his life. So that was nice, even though the realist in me knows that he probably has some dark days ahead.
Back in Darwin I continued in the groove of seeing the infectious disease patients. I could get really get used to working 45 hours a week, with no nights, as I am doing now. Although this won’t last - I’m scheduled to take over a large general medicine team in a few weeks, when I’ll also start taking call and weekends, and generally working more like I’m used to. I will say, though, that the rest of the world seems shocked at the hours residents work in the US. The thirty-hour stretches and only a few weeks off a year sound just terrible to the rest of the world. But before my self-pity starts to run amok, I am reminded of a recent speech by Atul Gawande at Harvard’s commencement, where he laid out five rules for new med school grads (quick aside - you should read his book Complications, which is a collection of essays he has written for The New Yorker. Highly recommended. You can also read the whole commencement speech at http://www.hms.harvard.edu/news/grad2005.html). Here was rule #2: “My Rule #2 is: Don't whine. To be sure, doctors have plenty to complain about: computer system crashes, 2 a.m. pages, insurance companies, work getting dumped on you at 6 o'clock on a Friday night. We all know what it is to be tired and beaten down. Yet nothing in medicine is more dispiriting than hearing doctors whine.” And then later, “Resist it. It's boring, and it will get you down. I'm not saying you have to be all Julie-Andrews-Mary-Poppins about everything. Just be prepared with something else to talk about: An interesting patient you saw, an idea you read about, even the weather if that's all you've got.”
So let’s talk about the weather. Another sunny day in Darwin, should be more of the same tomorrow. If you’re a meteorologist, the Darwin local news job must be the least desirable position imaginable. I mean, they still have a weather portion of the morning news, and every day all this guy says is, “Will be sunny again in Darwin today, high of 29 degrees [C]. Back to you, Kevin.” And then once a year I suppose he gets to switch to, “The rainy season has arrived. It will now rain every day for the next eight months.” If he’s feeling spunky, he can say, “Yep, looks like there won’t be another cyclone today like there was in 1975.”
I took advantage of these sunny days to get out to the nearest national park last weekend. Litchfield is about 100km south of Darwin, and is mostly known for having a series of waterfalls, scenic overlooks, and perfect swimming holes, at least in the non-crocodile infested dry season, so I rented a car and headed down on Saturday. It actually felt good to sit on the right and drive on the left, I haven’t been behind the wheel in a left-side drive car since the ‘89 Corolla that Josette and I owned in Malawi. And I was pleased that my Toyota Yaris for the weekend was a straight drive too, although it would have felt manlier if it weren’t a hatchback with wheels that are smaller than those on my son’s stroller. As expected, I usually turned on the windshield wipers when I meant to go for the blinker - that’s the single hardest habit to break, you just get so used to having the turn signal on the left side of the steering column. The drive was pleasant, not much else out on the highway outside of Darwin except “road trains“, the trucks that pull three big trailers instead of one, which are common crossing the desert out here in the Territory. And Litchfield was as pleasant as advertised, I took some nice short hikes to the various waterfalls and had refreshing crocodile-free swims. I wish they had been free of the grape smugglers, but apparently I wasn’t the only one who thought it was a nice day for a swim in Litchfield, I was just the only one there who thought a man’s bathing suit should cover at least some small portion of his thigh and most of his buttocks.
Hope you are all well, send news from the US, except don’t bother telling me about Lindsay Lohan’s latest arrest - that was the lead item on the Australian news this morning (cue Lee Greenwood…. And I’m proud to be an American, where at least I know I’m freeeeee….).
Wednesday, July 25, 2007
Sunday, July 15, 2007
July 15, 2007
Folks,
Hello again. I’ve hemorrhaged out several single-spaced pages of text here, so be forewarned. But if you make it to the end you will find delightful tales of nudity and focaccia.
I’m learning my way around the hospital - it’s actually not a small place. It has about four hundred beds. It’s the only sizeable hospital for hundreds and hundreds of miles, and it’s the referral center for all of northern Australia. That said, the whole population of the northern territory is only 200,000, so it’s not that it serves a huge population, just a huge area. This is why so many of the aboriginal patients come in with advanced disease - it’s just hard to get here if you live out in the desert fifty miles from the nearest road. There are probably a hundred or so doctors serving these patients, with pretty full medical and surgical services, including things like dialysis and coronary angiography. But at the same time the hospital is dependent on individual doctors for the services it can provide - there was one cardiothoracic surgeon, and he left, so now there’s no CT surgery done. Which in turn means the cardiologists can’t put in stents, because there’s no backup if a procedure goes badly and a surgeon is needed urgently.
One of the striking features of working in this hospital is the feeling of a true cultural chasm that I’m not able to cross. Not with the other doctors and nurses and staff, who basically have the same background I do, just with a different accent. But I’m realizing that the Aboriginal patients come from a world I can’t even comprehend, at least not in a three-month snapshot. It feels different than when I lived in Malawi, when I was clearly very culturally different than my students and colleagues, but never felt quite so unable to make a connection. I’m sure part of it is the language, but I’ve been plenty of places where I couldn’t speak the language but still felt on more solid ground. It starts in the morning when I walk to work, and I always pass a row of Aboriginal people sitting on the ground outside the hospital. They’re not used to being indoors, the air-conditioning in the hospital is too cold. The patients who can’t leave their beds are invariably under as many blankets as they can get. Those who can leave the hospital are outside as much as possible. So there they are in the morning, lined up in wheelchairs and on the ground, flanked by IV poles, or with an NG tube in the nose, extremities bandaged, whatever - just sitting outside expressionless. There seems to be this resignation to wait it out, take whatever tests and treatments are doled out, and then leave when told it’s okay. On the wards conversations are often just a few words on either side. Interpreters are available but are far outnumbered by the aboriginal patients, so by necessity doctors and nurses often make do the best they can without an interpreter. Most patients, unless their English is pretty good, are accompanied by a relative or someone from their village who can help translate. But even so, it’s not clear how much gets through.
I was seeing one patient with the team who has diffuse melioidosis, a bacterial infection in multiple organs, requiring a long course of IV antibiotics in the hospital. He wants to leave, and in fact on a couple of occasions has left the hospital for a few hours or even a day, but he comes back. At the bedside we offer pleasantries, and he answers yes or no to questions about pain, fever, cough, and his bowels. We talk about the results of a CT scan from yesterday, which showed some improvement in the lesions in his liver and his prostate. He says a word that no one can quite understand. Scad, or cade, or something. Finally someone catches it, he’s saying ‘scared.’ But scared of what? With his index finger he makes a big circle in the air. We don’t understand. He repeats ‘scared’, and makes the circle again. After a while it comes across that he’s talking about the CT scanner; it was noisy and it scared him, he doesn’t know what it was. You can imagine it’s hard to talk about the results of a CT scan, and the implications for treatment of his melioidosis, when one word sentences take minutes to figure out, and all he knows is that the noisy machine that circled around him was pretty freaky. I went to all the classes in medical school on bedside manner, and informed consent, and patient autonomy in medical decisions. On a test - and since patients routinely complain about their doctors’ bedside manner, this stuff is now tested in national licensing exams - I would say that of course I would get an interpreter to the bedside. And I would explain each treatment in terms he could understand, and I would enable him to make his own medical decisions, and I would be sensitive to cultural differences. But there are twenty more patients to see, and these things don’t happen. And this scenario is repeated over and over all day. And patients are getting invasive procedures like colonoscopies and needle drainages of fluid around the lungs. What must they think?
This same guy, Romanus, made a joke this morning. I was talking to him as every morning, just kind of being there in hopes that it’s reassuring for him to know that someone is looking after him, knowing full well he didn’t understand much of what I was saying. And towards the end he said, “Where’s the doctor?” I said that I’m the doctor, I’m helping take care of him. And he shook his head no, and said - and I’m paraphrasing here - “You’re a doctor. But there’s a fat one, a woman. Where’s the fat one?” And then he laughed. I still don’t know who he was talking about. There aren’t any fat female doctors who have been taking care of him. Maybe a nurse, but he said no, not a nurse. It’s yet another snippet of conversation that I am destined never to understand, but it was nice when he laughed. And when he heard that he will go home next week, he was pleased.
Today I saw a woman who had just arrived in Australia the day before. She is Burmese and has been living in a refugee camp on the Burmese-Thai border for the past four years with her three children. As part of a refugee relocation program she was brought to Darwin where she will be assisted in settling into a new life. Upon arrival she had a fever so was brought to the hospital. Talking to her (through an interpreter), it turns out she’s been sick for about a month. I’m again overwhelmed by how little I can comprehend of this woman’s life. I try to be a little worldly and keep up with international affairs. I know Burma has had civil unrest for a long time, and that there is a persecuted minority. But I couldn’t name one Burmese person, and I’m only about 50% confident I could correctly identify Burma on a map. I had never heard of the language she speaks. If I am going to figure out why she’s been sick, I have to know more about who she is. Is she at risk for HIV? Has she had tuberculosis? Is she sexually abused at the camp? Has she ever had any medical care? It turns out her husband died a few years ago, apparently killed in the conflict. She weighs 88 pounds, but says she is treated fine in the camp, and gets enough food. She thinks she has been treated for malaria before. I spend a long time with her, things are slow working through the interpreter. But there’s so much I still don’t know - I realize afterwards that I can’t picture at all what her life was like in that camp. I wonder if she was in some kind of a house, or a tin shed, or a mud hut, and how she got her food. I forgot to ask. It turns out she has malaria. She does not have HIV. She’s had TB before but it’s not active now. She leaves with antimalarials and is escorted out into the brilliant midday sun, a new kind of life awaiting in Darwin.
I’ve made a big stride in my mobility around Darwin - I took the bus into town yesterday and bought a bike. Some nice soul had actually lent me a bike the day before, which was exciting. But he didn’t tell me beforehand that it was an old-school woman’s bike, circa 1975, with wide handlebars, a small curvaceous frame, three speeds and a healthy amount of rust. I toodled around on it a little bit, thinking I was comfortable enough in my manhood to cruise around on a pink albatross. But it turns out I’m not that comfortable in my manhood, and it‘s kind of hard to imagine long trips into town at 5km/hour, ringing my bell all the way. So I got a manly bike, and it opens up a whole new world. I took a nice long ride back out to the hospital, about 20km in all, mostly along the coast. The water has that impossible turquoise blue that tropical waters seem to have, under a cloudless sky. I went through mangrove forests and palm groves, mostly without ever seeing very many other people. I stopped about halfway out of town at the Museum and Art Gallery of the Northern Territory. I’d heard good things about it, I figured I should take a gander. In truth, taking in a museum by myself seemed mildly unappetizing, it just felt like something I ought to do. So I was pleasantly surprised when it turned out to be truly fascinating. There are a couple of big events in Darwin history - it was bombed in WWII by the Japanese, as it was a strategic outpost in the Asian theater. In fact, there’s a big blockbuster being filmed here now about that time - Nicole Kidman and Hugh Jackman are in town, which is stirring up the locals. Then, more recently, there was an enormous cyclone (Cyclone Tracy) on Christmas Eve 1974 that essentially destroyed the town. The museum has an impressive exhibit, complete with a recording of the storm piped in. It was worse than Katrina was for New Orleans, although a smaller scale since only 40,000 people lived in Darwin at the time. But over half of the homes were completely destroyed by 260km/hr winds, the rest were salvageable although all were badly damaged. Evidently forty houses survived basically intact, I’m not sure who those lucky souls were, but then with no water or electricity, and the predictable post-storm scourge of typhoid rolling in, they couldn’t stay either, the whole town had to be abandoned for a while. So it’s really a new town, all rebuilt since the 1970s, and the museum does a good job covering that. Plus it had some cool exhibits with all the animals and plants that can kill you in the northern territory - did you know that Australia has the most venomous snake species of any continent? And that you can’t swim in these turquoise seas nine months of the year due to deadly box jellyfish (though now is the time of year when you can swim)? Not to mention the saltwater crocodiles - a stuffed 17 foot, 1800 pound specimen named Sweetheart was on display in the museum, captured after he attacked twelve dinghies in the span of a couple of months, although no one was killed. And there is a snail that can paralyze a human in 3 minutes, which just seems unnecessary. Then there was an extensive aboriginal art collection, which, well, I buzzed through in a few minutes flat. I’d already spent an hour just staring at all the creatures, pouring sweat from the first 10k of my ride; I think the curators were starting to find me a bit creepy myself.
Anyway, it was a good museum, and it had a nice café hooked on the side, where I lunched on lamb and pesto on focaccia and looked at the ocean and finally stopped sweating. Then I rode another 10k until I reached the official nudist beach that lies directly west of the hospital - evidently I am a hundred pounds too light and a few decades to young to go on the nudist beach, judging by the clientele that appeared over the dunes while I was stopped for a drink. I don’t know, maybe they are just the sentries put out there to ward off the faint of heart and the thrill seekers, perhaps if I took it all off and ventured out beyond the dunes I would find a veritable paradise of attractive naked people having a light game of volleyball. On this day, the sentries warded me off, and I turned onto a dirt track through the mangroves that led me back to the hospital.
Tomorrow I’m heading out into the desert. I’ve finagled a place on a charter flight with one of the infectious disease physicians here. He goes out periodically into remote communities and staffs a makeshift clinic, just sees whoever needs care, whether it‘s infection or diabetes or minor surgery or anything else. So we’re flying early tomorrow morning to a place called Yarralin, where the two of us will see patients all day and then stay out in the desert, then fly the next morning to another town called Kalkarindji and do the same thing, then fly back that night. These places are aboriginal communities way out in the desert, should be interesting.
Time for another bike ride (not to the nude beach),
TH
Hello again. I’ve hemorrhaged out several single-spaced pages of text here, so be forewarned. But if you make it to the end you will find delightful tales of nudity and focaccia.
I’m learning my way around the hospital - it’s actually not a small place. It has about four hundred beds. It’s the only sizeable hospital for hundreds and hundreds of miles, and it’s the referral center for all of northern Australia. That said, the whole population of the northern territory is only 200,000, so it’s not that it serves a huge population, just a huge area. This is why so many of the aboriginal patients come in with advanced disease - it’s just hard to get here if you live out in the desert fifty miles from the nearest road. There are probably a hundred or so doctors serving these patients, with pretty full medical and surgical services, including things like dialysis and coronary angiography. But at the same time the hospital is dependent on individual doctors for the services it can provide - there was one cardiothoracic surgeon, and he left, so now there’s no CT surgery done. Which in turn means the cardiologists can’t put in stents, because there’s no backup if a procedure goes badly and a surgeon is needed urgently.
One of the striking features of working in this hospital is the feeling of a true cultural chasm that I’m not able to cross. Not with the other doctors and nurses and staff, who basically have the same background I do, just with a different accent. But I’m realizing that the Aboriginal patients come from a world I can’t even comprehend, at least not in a three-month snapshot. It feels different than when I lived in Malawi, when I was clearly very culturally different than my students and colleagues, but never felt quite so unable to make a connection. I’m sure part of it is the language, but I’ve been plenty of places where I couldn’t speak the language but still felt on more solid ground. It starts in the morning when I walk to work, and I always pass a row of Aboriginal people sitting on the ground outside the hospital. They’re not used to being indoors, the air-conditioning in the hospital is too cold. The patients who can’t leave their beds are invariably under as many blankets as they can get. Those who can leave the hospital are outside as much as possible. So there they are in the morning, lined up in wheelchairs and on the ground, flanked by IV poles, or with an NG tube in the nose, extremities bandaged, whatever - just sitting outside expressionless. There seems to be this resignation to wait it out, take whatever tests and treatments are doled out, and then leave when told it’s okay. On the wards conversations are often just a few words on either side. Interpreters are available but are far outnumbered by the aboriginal patients, so by necessity doctors and nurses often make do the best they can without an interpreter. Most patients, unless their English is pretty good, are accompanied by a relative or someone from their village who can help translate. But even so, it’s not clear how much gets through.
I was seeing one patient with the team who has diffuse melioidosis, a bacterial infection in multiple organs, requiring a long course of IV antibiotics in the hospital. He wants to leave, and in fact on a couple of occasions has left the hospital for a few hours or even a day, but he comes back. At the bedside we offer pleasantries, and he answers yes or no to questions about pain, fever, cough, and his bowels. We talk about the results of a CT scan from yesterday, which showed some improvement in the lesions in his liver and his prostate. He says a word that no one can quite understand. Scad, or cade, or something. Finally someone catches it, he’s saying ‘scared.’ But scared of what? With his index finger he makes a big circle in the air. We don’t understand. He repeats ‘scared’, and makes the circle again. After a while it comes across that he’s talking about the CT scanner; it was noisy and it scared him, he doesn’t know what it was. You can imagine it’s hard to talk about the results of a CT scan, and the implications for treatment of his melioidosis, when one word sentences take minutes to figure out, and all he knows is that the noisy machine that circled around him was pretty freaky. I went to all the classes in medical school on bedside manner, and informed consent, and patient autonomy in medical decisions. On a test - and since patients routinely complain about their doctors’ bedside manner, this stuff is now tested in national licensing exams - I would say that of course I would get an interpreter to the bedside. And I would explain each treatment in terms he could understand, and I would enable him to make his own medical decisions, and I would be sensitive to cultural differences. But there are twenty more patients to see, and these things don’t happen. And this scenario is repeated over and over all day. And patients are getting invasive procedures like colonoscopies and needle drainages of fluid around the lungs. What must they think?
This same guy, Romanus, made a joke this morning. I was talking to him as every morning, just kind of being there in hopes that it’s reassuring for him to know that someone is looking after him, knowing full well he didn’t understand much of what I was saying. And towards the end he said, “Where’s the doctor?” I said that I’m the doctor, I’m helping take care of him. And he shook his head no, and said - and I’m paraphrasing here - “You’re a doctor. But there’s a fat one, a woman. Where’s the fat one?” And then he laughed. I still don’t know who he was talking about. There aren’t any fat female doctors who have been taking care of him. Maybe a nurse, but he said no, not a nurse. It’s yet another snippet of conversation that I am destined never to understand, but it was nice when he laughed. And when he heard that he will go home next week, he was pleased.
Today I saw a woman who had just arrived in Australia the day before. She is Burmese and has been living in a refugee camp on the Burmese-Thai border for the past four years with her three children. As part of a refugee relocation program she was brought to Darwin where she will be assisted in settling into a new life. Upon arrival she had a fever so was brought to the hospital. Talking to her (through an interpreter), it turns out she’s been sick for about a month. I’m again overwhelmed by how little I can comprehend of this woman’s life. I try to be a little worldly and keep up with international affairs. I know Burma has had civil unrest for a long time, and that there is a persecuted minority. But I couldn’t name one Burmese person, and I’m only about 50% confident I could correctly identify Burma on a map. I had never heard of the language she speaks. If I am going to figure out why she’s been sick, I have to know more about who she is. Is she at risk for HIV? Has she had tuberculosis? Is she sexually abused at the camp? Has she ever had any medical care? It turns out her husband died a few years ago, apparently killed in the conflict. She weighs 88 pounds, but says she is treated fine in the camp, and gets enough food. She thinks she has been treated for malaria before. I spend a long time with her, things are slow working through the interpreter. But there’s so much I still don’t know - I realize afterwards that I can’t picture at all what her life was like in that camp. I wonder if she was in some kind of a house, or a tin shed, or a mud hut, and how she got her food. I forgot to ask. It turns out she has malaria. She does not have HIV. She’s had TB before but it’s not active now. She leaves with antimalarials and is escorted out into the brilliant midday sun, a new kind of life awaiting in Darwin.
I’ve made a big stride in my mobility around Darwin - I took the bus into town yesterday and bought a bike. Some nice soul had actually lent me a bike the day before, which was exciting. But he didn’t tell me beforehand that it was an old-school woman’s bike, circa 1975, with wide handlebars, a small curvaceous frame, three speeds and a healthy amount of rust. I toodled around on it a little bit, thinking I was comfortable enough in my manhood to cruise around on a pink albatross. But it turns out I’m not that comfortable in my manhood, and it‘s kind of hard to imagine long trips into town at 5km/hour, ringing my bell all the way. So I got a manly bike, and it opens up a whole new world. I took a nice long ride back out to the hospital, about 20km in all, mostly along the coast. The water has that impossible turquoise blue that tropical waters seem to have, under a cloudless sky. I went through mangrove forests and palm groves, mostly without ever seeing very many other people. I stopped about halfway out of town at the Museum and Art Gallery of the Northern Territory. I’d heard good things about it, I figured I should take a gander. In truth, taking in a museum by myself seemed mildly unappetizing, it just felt like something I ought to do. So I was pleasantly surprised when it turned out to be truly fascinating. There are a couple of big events in Darwin history - it was bombed in WWII by the Japanese, as it was a strategic outpost in the Asian theater. In fact, there’s a big blockbuster being filmed here now about that time - Nicole Kidman and Hugh Jackman are in town, which is stirring up the locals. Then, more recently, there was an enormous cyclone (Cyclone Tracy) on Christmas Eve 1974 that essentially destroyed the town. The museum has an impressive exhibit, complete with a recording of the storm piped in. It was worse than Katrina was for New Orleans, although a smaller scale since only 40,000 people lived in Darwin at the time. But over half of the homes were completely destroyed by 260km/hr winds, the rest were salvageable although all were badly damaged. Evidently forty houses survived basically intact, I’m not sure who those lucky souls were, but then with no water or electricity, and the predictable post-storm scourge of typhoid rolling in, they couldn’t stay either, the whole town had to be abandoned for a while. So it’s really a new town, all rebuilt since the 1970s, and the museum does a good job covering that. Plus it had some cool exhibits with all the animals and plants that can kill you in the northern territory - did you know that Australia has the most venomous snake species of any continent? And that you can’t swim in these turquoise seas nine months of the year due to deadly box jellyfish (though now is the time of year when you can swim)? Not to mention the saltwater crocodiles - a stuffed 17 foot, 1800 pound specimen named Sweetheart was on display in the museum, captured after he attacked twelve dinghies in the span of a couple of months, although no one was killed. And there is a snail that can paralyze a human in 3 minutes, which just seems unnecessary. Then there was an extensive aboriginal art collection, which, well, I buzzed through in a few minutes flat. I’d already spent an hour just staring at all the creatures, pouring sweat from the first 10k of my ride; I think the curators were starting to find me a bit creepy myself.
Anyway, it was a good museum, and it had a nice café hooked on the side, where I lunched on lamb and pesto on focaccia and looked at the ocean and finally stopped sweating. Then I rode another 10k until I reached the official nudist beach that lies directly west of the hospital - evidently I am a hundred pounds too light and a few decades to young to go on the nudist beach, judging by the clientele that appeared over the dunes while I was stopped for a drink. I don’t know, maybe they are just the sentries put out there to ward off the faint of heart and the thrill seekers, perhaps if I took it all off and ventured out beyond the dunes I would find a veritable paradise of attractive naked people having a light game of volleyball. On this day, the sentries warded me off, and I turned onto a dirt track through the mangroves that led me back to the hospital.
Tomorrow I’m heading out into the desert. I’ve finagled a place on a charter flight with one of the infectious disease physicians here. He goes out periodically into remote communities and staffs a makeshift clinic, just sees whoever needs care, whether it‘s infection or diabetes or minor surgery or anything else. So we’re flying early tomorrow morning to a place called Yarralin, where the two of us will see patients all day and then stay out in the desert, then fly the next morning to another town called Kalkarindji and do the same thing, then fly back that night. These places are aboriginal communities way out in the desert, should be interesting.
Time for another bike ride (not to the nude beach),
TH
Monday, July 9, 2007
July 9, 2007
Hello family, friends, and possibly a few scattered enemies -
I have decided to resurrect the mass email idea while I am here in Darwin. For the first time since I lived in Malawi seven years ago, I have limited access to the internet. And, hopefully, there are people interested in what I have to say, who might want to read an occasional email from me. I suppose, this being 2007, I should just set up a blog. This is probably very easy to do for the motivated technophile. But I am not that motivated, or that philic, so it’s email [well, until now, when I am putting this up on a blog. Is that irony? Or just idiocy.]
I arrived in Darwin last week to begin a three month stay working at the Royal Darwin Hospital. Darwin itself is the largest town in the famed Northern Territory, better known abroad as the outback. The Northern Territory is very different than the rest of Australia - not even a state, just a “territory.” And it kind of has that frontier mentality. It’s the jumping off point for most of the bushwalking and adventure activities that are associated with Australia - “Australia in hyper drive”, as it’s described in the guidebooks, with the rugged terrain and very few people (the entire territory only has about 200,000 people, and half of those are in Darwin). But it’s also unique in that it’s home to most of the Aboriginal population, as well as a healthy number of Asian expats, given that it’s closer to Jakarta and Papua New Guinea than to Sydney or Melbourne. Most of the territory is desert, but in the Top End, where Darwin sits on the Timor Sea, it’s tropical, with a monsoon season and year-round heat. It’s actually almost exactly due east of Lilongwe, so the seasons are the same. Right now is the dry season, and technically winter, but really very comfortable with endless cloudless skies and temperatures in the 80s every day.
My job is to work as an infectious disease registrar (called a fellow in the US). It’s basically what I’ll be doing at Duke starting in mid-2008, so is another step above where I am right now in my training. I wanted to come here because I’m interested in tropical diseases - all that time in Central America and East Africa left its imprint - and the Royal Darwin Hospital is a very unique place to see tropical diseases. I can’t think of many places in the world where you can see lots of tropical disease, but English is spoken, and there is access to modern medical care such as CT and MRI scans, a full complement of medications and diagnostic tests, and specialists including ICU-level care. In fact, I can’t really think of anywhere else that meets all these criteria, except maybe South Africa, which isn’t quite tropical but does see patients flown in from the tropics. Essentially you see what is usually third-world disease, but in first-world conditions. So in my first day I saw leprosy and malaria and melioidosis, and suspected dengue fever, and several cases of tuberculosis.
It's hard to be away from the family. Josette took the boys to Maine the day after I left, which made it easier for Andrew, he's been to Maine without me before. Here is a snippet of the update I got from Josette:
"Andrew was in hog heaven with the July 4th parade that went by the house in Limestone. There were tons of tractors, fire trucks, ambulances, buggies, and clowns. At one point, Andrew left my sight, and I turned to the side and he was peeing on a bush near the house. All by himself. Just peeing. Shorts and underwear around his ankles, bare butt, no-hands, but his body was turned so that he wouldn't miss a minute of the parade. Pee was spraying everywhere. My cousins took a picture, and Andrew told everyone that his daddy taught him how to pee outside. 'It gives the earth a drink. Can't you hear the grass saying 'thank you'?"
So at least im my absence he has retained some of the important lessons I have instilled.
More to come later.
I have decided to resurrect the mass email idea while I am here in Darwin. For the first time since I lived in Malawi seven years ago, I have limited access to the internet. And, hopefully, there are people interested in what I have to say, who might want to read an occasional email from me. I suppose, this being 2007, I should just set up a blog. This is probably very easy to do for the motivated technophile. But I am not that motivated, or that philic, so it’s email [well, until now, when I am putting this up on a blog. Is that irony? Or just idiocy.]
I arrived in Darwin last week to begin a three month stay working at the Royal Darwin Hospital. Darwin itself is the largest town in the famed Northern Territory, better known abroad as the outback. The Northern Territory is very different than the rest of Australia - not even a state, just a “territory.” And it kind of has that frontier mentality. It’s the jumping off point for most of the bushwalking and adventure activities that are associated with Australia - “Australia in hyper drive”, as it’s described in the guidebooks, with the rugged terrain and very few people (the entire territory only has about 200,000 people, and half of those are in Darwin). But it’s also unique in that it’s home to most of the Aboriginal population, as well as a healthy number of Asian expats, given that it’s closer to Jakarta and Papua New Guinea than to Sydney or Melbourne. Most of the territory is desert, but in the Top End, where Darwin sits on the Timor Sea, it’s tropical, with a monsoon season and year-round heat. It’s actually almost exactly due east of Lilongwe, so the seasons are the same. Right now is the dry season, and technically winter, but really very comfortable with endless cloudless skies and temperatures in the 80s every day.
My job is to work as an infectious disease registrar (called a fellow in the US). It’s basically what I’ll be doing at Duke starting in mid-2008, so is another step above where I am right now in my training. I wanted to come here because I’m interested in tropical diseases - all that time in Central America and East Africa left its imprint - and the Royal Darwin Hospital is a very unique place to see tropical diseases. I can’t think of many places in the world where you can see lots of tropical disease, but English is spoken, and there is access to modern medical care such as CT and MRI scans, a full complement of medications and diagnostic tests, and specialists including ICU-level care. In fact, I can’t really think of anywhere else that meets all these criteria, except maybe South Africa, which isn’t quite tropical but does see patients flown in from the tropics. Essentially you see what is usually third-world disease, but in first-world conditions. So in my first day I saw leprosy and malaria and melioidosis, and suspected dengue fever, and several cases of tuberculosis.
It's hard to be away from the family. Josette took the boys to Maine the day after I left, which made it easier for Andrew, he's been to Maine without me before. Here is a snippet of the update I got from Josette:
"Andrew was in hog heaven with the July 4th parade that went by the house in Limestone. There were tons of tractors, fire trucks, ambulances, buggies, and clowns. At one point, Andrew left my sight, and I turned to the side and he was peeing on a bush near the house. All by himself. Just peeing. Shorts and underwear around his ankles, bare butt, no-hands, but his body was turned so that he wouldn't miss a minute of the parade. Pee was spraying everywhere. My cousins took a picture, and Andrew told everyone that his daddy taught him how to pee outside. 'It gives the earth a drink. Can't you hear the grass saying 'thank you'?"
So at least im my absence he has retained some of the important lessons I have instilled.
More to come later.
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