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