August 11, 2007

Hi again.


I’m continuing to see interesting infectious disease cases, the kind that make you wash your hands twice when you leave the patient’s room. Crusted scabies is a big problem here, a man-eating mite infestation that in its severe form consumes great swaths of skin, building a crust harboring thousands upon thousands of mites. I don a hat, gown, gloves, and shoe covers just to enter the room, and spray my shoes with Raid when I leave, but that itchy sensation nags at me for hours anyway.


Another traveler turned up in Darwin with a fever – this time a Spanish guy who lives in Ecuador, but had been surfing in Sumatra prior to coming to Australia. He was quite ill and turned out to have both malaria and dengue fever, but pulled through okay. There is a woman now on the ward with typhoid fever, and another with acute rheumatic fever – both quite rare in the US these days. And there are three cases of necrotizing fasciitis on the service right now – the famous “flesh-eating bacteria” as it tends to be called in media outlets trying to maximize the sensational value of their story. All three guys will be okay although one has lost his scrotum – feel free to list Fournier’s gangrene on your list of diseases you don’t want to have.


For every rewarding diagnosis I am stymied by another. There is an eighteen-year old girl with a weird necrotic lesion just beside her left eye. Really very interesting – could be tuberculosis or a related mycobacterium, or melioidosis, or a fungal infection, or cutaneous anthrax. But she doesn’t want it biopsied because she’s eighteen and it’s her face and she’s scared of needles. And it’s actually getting better, so it’s hard to force a biopsy on her just because I want to know what it is. Another lady was diagnosed with osteomyelitis of the skull from an invasive ear infection. She seemed to be on the right track, improving with antibiotic therapy, and then when I came in this morning I found out she died last night. It’s hard to get authorization for an autopsy on an Aboriginal person, so I’ll never know what went wrong there. And given the cultural prohibition against talking about the dead, I can’t even ask her family what happened.


And my old friend Romanus has finally left the hospital. He actually got out a few weeks ago, transitioning to the “self-care” area where patients can go if they are well enough to leave the hospital but still need some treatment (in his case, intravenous antibiotics) that they can’t get at home. The self-care area is actually part of the staff village, so on his day of discharge I passed by him on my way home, sitting happily in the sun. He said “Hi Tom” and then about four other things that I had no prayer to understand. Then six hours later he was found by the staff lying on the floor, confused, agitated, and in a condition of some filth – I will spare you a description. I don’t know if he got back into the grog; he has very little liver function left after some years of hard drinking. Or maybe there was something I had been missing before he left. In these situations I’m always internally annoyed when I can’t understand what happened – I like to think it’s a healthy drive to want to know it all. But I’ve chosen the wrong profession, and the wrong branch of medicine, if I can’t accept that I make the majority of my decisions based on incomplete information – just gather the best data available, and fit it into the clinical scenario, and make a set of choices about how the patient should be cared for. But I was still privately fuming that I had missed something with Romanus. Anyway, he gradually got better again, and now he’s been gone almost a week, so maybe he’s on the right track.


News from the (temporary) home front - I think I have mentioned before that I am living in the staff village which is next to the hospital. There are some other doctors in the village, but most MDs come for a longer stint and choose not to stay in these mildly unappetizing accommodations. Thus most of my neighbors are actually nurses, as there seems to be a population of RNs who travel on short-term contracts, moving around Australia following the good money and travel fun. Most also have gone to the UK where the pay is good, until they can’t stand the weather any more. And like me, they don’t mind the dorm rooms for a few months. At any rate, I have fallen in with a group if ICU nurses, and on Monday we went as a group to the Carlton Cup.


The storied Carlton Cup is the Northern Territory equivalent of the Kentucky Derby. It’s a public holiday, and here in Oz doctors usually take public holidays off (a brilliant idea), so after a quick check on the service I headed to the Fannie Bay track. The female nurses were all dressed in their finest Derby-wear, with hair immobilized in various extreme creations. The male nurses had a collection of monochromatic suits over tight black t-shirts – Keith in a blazing fuchsia number, Bill in aqua blue, etc. I was sadly not included in this sartorial coordination, so there I was in khaki pants, plain white shirt, and the only (conservative) tie I brought with me. We arrived around noon, in time for the first of nine races culminating in the Cup race itself. Already there were about 15,000 people there, not bad for a town of 100,000. I suppose if I had taken time to think about it beforehand, I would have realized that the kind of town that has an annual boat race for crafts made of beer cans would not be able to take a horse race entirely seriously. In my first five minutes at the track, I saw an older man in a suit (complete with top hat) made entirely of coconut leaves – he makes one every year just for the Cup. Another gentleman was entirely nude, a dubious choice as he went from Caucasian to Pinkasian over the course of a blistering afternoon. Overall, I believe it was the largest confluence of ridiculous outfits, cleavage, tattoos, heavy drinking, and reckless gambling that I have witnessed, at least since my wedding.


I set out immediately upon a quest to make some money – how could Captain Thundabolt lose? He could finish in last place, as it turned out, and the first ten bucks of the day went down the drain. Il Duca was the safe bet in the next race, a heavy favorite who faded down the stretch and took another ten-spot with him. I took to studying the racing form more intently, breaking down each horse by overall record, performance on dry dirt tracks, time since last race, and various other factors which seemed like they could be important. I missed a quinella and chased a trifecta. I took a race off to restore my karma. I thought maybe my early two-beer-per-race pace was clouding my thinking, and tried a bit of water. Nothing worked, even as everyone around me seemed to be cashing winning tickets. By the time the Cup race came around, I had come full circle to completely irrational betting (who was I kidding anyway – how did I really expect that it would help me to know how Catwalk Minnie and Mister Raw had run on a wet track in Melbourne?). For the Cup, I noticed that one of the favorites had run very well in his last three races with a jockey who I have unfortunately come to know, as he was thrown during a race a couple of weeks ago and now resides in the Royal Darwin Hospital ICU with a devastating brain injury. It seemed like a good tribute to back his horse – wouldn’t that make for a nice story? It would, I suppose, if he hadn’t been replaced with a jockey who apparently had never seen a horse before. I actually think he may have ridden his mount backwards, flailing at empty air with his riding crop while screaming in terror. He couldn’t have done any worse if he had ridden a three-legged Jersey cow. Ah well, you win some, you lose some, except when you lose them all.


As soon as the Cup was over, an eighteen-wheeler pulled out on the track, the sides dropped off, and a band was revealed, fully set up and cranking out the rock. The crowd spilled out onto the track and started dancing to the sweet, sweet (cover) tunes of Bob Seger and Dexy’s Midnight Runners. A predictable number of inebriated males took to staging their own races out of the starting blocks. I am fairly certain that this does not happen after the Kentucky Derby although I have not been there myself. I was a model of restraint – usually the combination of ethanol and sprinting is irresistible to me. The nurses and I stayed on well into the night, and then took a packed, jovial bus on into town for more revelry. This town knows how to do a public holiday right.


I haven’t uploaded any good pictures recently, and I had camera trouble (ie I forgot it) on Cup day, so I’m waiting to get some pictures from everyone else. So I’ll give you a picture from one of my long weekend bike rides. And maybe a family picture or two. Not exactly related to Darwin, but since when did a dad ever need an excuse to show pictures of his kids.