July 25, 2007

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….).