I’ve spent most of my free time this past week in bed trying to shake off my own infection. Nothing exotic I’m afraid, just the same sore throat/fevers/cough/body aches that the rest of the world gets from time to time. It would make for a better story if I had malaria, or melioidosis, or Orientia tsutsugamushi. Alas, no such luck. My list of “interesting diseases I have had” remains stuck at one – my Malawian cholera episode some years back. Not very impressive for a future ID physician, I really feel like I should hatch a botfly out of my head, or have a light touch of leprosy. I don’t need Ebola or SARS, just something to get some street cred.

I did manage to have dinner this week with Tim (hopefully without infecting him, his wife and lovely children), an ID physician from Malaysia who has the same job here (medical registrar) that I do. All of his training had been in Malaysia until this point, and just as I did, he wanted to get some experience in another country and medical system. Despite the fact that he has been a physician for a decade, including serving as the sole infectious disease specialist for an entire state in Malaysia for the past few years, his credentials are recognized as the same as mine in Australia. This is understandable, I suppose, in that the training in the US is probably held to a more consistent standard; it’s likely difficult to assess the qualifications of a Malaysian physician. But having worked alongside Tim for the past few months, there’s not much he hasn’t seen and that he’s not comfortable with. And the stories he has to tell – managing an entire state hospital, traveling throughout Malaysia as the only HIV doctor in his region, responding on the front line for the SARS outbreak – it makes an impressive résumé.

Tim’s story has been a recurring theme here in Darwin (a leitmotif, you could say – putting my Infinite Jest vocabulary to work). Darwin is a popular place for temporary employment for doctors from all over the world, offering tropical medicine in an English-speaking town in first-world conditions. And most physicians from outside the US or UK have to accept working below their level of training, just as Tim has. Thus Martha the Zambian doc with five years experience in Africa starts as an intern along with the newly-minted Australian graduates. And the “intern” who worked with me for the past three weeks is Harish, who had been a general practitioner in India, then in England, and now is again working as an intern in Australia. Which for me was a blessing – he was in no way overwhelmed by our service when it ballooned to fifty patients, and when we were getting slammed with admissions, we could separate and work in tandem, with my oversight consisting mostly of agreeing with what he was doing. This week he has moved onto another service and has been replaced by an Australian intern – a fantastic guy, and quite bright – but who is orders of magnitude less efficient. If I ask him to do an admission, he’ll do a great job, but I will have admitted eight other patients by the time he finishes with one, and he’s not comfortable with any autonomy in medical decision-making, so all management issues great and small run through me.

So where does Harish go from here? I perhaps shouldn’t have been surprised to learn that he is applying for residency positions in the US, where once again none of his training will be recognized, and he will start again as an intern. And that’s only if he can get a position; he has applied to over a hundred programs in hopes of getting a few interviews.

On my general medicine service we are currently preparing for a potential influx of Indonesian refugees if the earthquakes continue to cause problems. Thankfully no tsunamis, but we are discharging anyone who can go to free up beds. Royal Darwin Hospital is the primary medical evacuation point for East Timor, but could potentially accept patients from anywhere in Indonesia if need be – the quakes have been off the coast of Sumatra, which is near Jakarta, and north of Sulawesi, which is on the far side of Indonesia from Darwin.

And at any rate my time is drawing to a close here. Saturday after my morning round I’m off for a long weekend in Sydney, just to get a taste of another part of Australia. Although I don’t know if I’m quite urbane enough to take in a performance by myself at the famous Opera House, I’m pretty sure I’m sufficiently couth to climb the harbor bridge, and visit Bondi Beach, take a train up into the Blue Mountains for some hiking, and swill a beer or two in the Sydney pubs. Then a few days back in Darwin to wrap up at the hospital before my bride arrives at the end of next week. I’m thinking our reunion will be one of those deals where we run to each other from opposite ends of a long terminal, and cameras will be flashing and there will be lots of general applause. We’ll do a bit of light touring, biking, hiking, canoeing, swimming, and general national park gazing. Then time to head home to unite with my progeny; I’m definitely approaching the limit of how long I can bear to be apart from the little men.

Thanks for reading my blog.

I have entered the homestretch of my time here, with another ten days on the general medical service, then a bit of time for travel prior to heading back to the States. Due to the somewhat strange call cycle here, I was accepting all general medical patients for three out of four days last weekend, so my service ballooned from a manageable eighteen patients to a rather more unwieldy fifty. The typical day on a general medical service is basically the same here as in the US - it starts with a ward round, where my intern and I check in on each patient and plot out the day, prioritizing what needs to be done. For each patient on the ward round we chat with the patient, see how the night was, do a physical exam, review labs and medications, make a plan, write a note and orders for the day, answer questions from the patient and family, and communicate with the nursing staff. When I was a medical student, I remember budgeting forty-five minutes for each patient in the morning, which seems insane now. These days, when I am really cruising, it’s possible to accomplish all of this for a single patient in four or five minutes, at least if the patient as no complicated medical issues. But with fifty patients, of course some are inevitably complex, requiring active management and lots of time at the bedside, and it becomes very, very challenging to stay on top of the changing status and needs of two score and ten individuals (and this is further complicated in a place like Darwin, where alcoholism and tobacco abuse are especially rife, so on every call day I admit multiple medically similar patients – smokers with chest infections and alcoholics with complications of liver disease). And I’m not sure it’s an art, but it’s at least a life skill to maintain an appearance of unhurried calm with each individual patient, as well as with nursing and ancillary staff who all need my time. It’s tough at the end of the day to avoid feeling like I must have missed something, and probably no one was that satisfied with the quick care received.

Of course, all patients eventually leave the hospital (and no one left pulseless last week), so after a few days the service started to dwindle, and my intern Harish and I stopped looking at each other and saying, “Wait a second…. John Smith…. Who is he again?” Now we have a census back down in the twenties, and everything starts to seem easier. I have time to really read and think about whatever is wild and wonderful on the service this week - Legionnaire’s disease, erysipelothrix endocarditis, Machado-Joseph disease, and ascending aortic dissection are the new diagnoses of four of my current patients (well, except the man with the dissection, he’s on a med-evac flight to Adelaide for emergency surgery).

My social life has picked up a little bit, too, perhaps inevitable even for one as retiring as I. I received an urgent call on Saturday morning that it was almost time for a big cricket match between the Menzies School of Health Research and the Center for Disease Control, and would I like to come along? I understood this as an invitation to spectate some cricket; I did not grasp that I was being asked whether I was competent to fill in on the Menzies team. In fact, this crucial distinction was not clear to me until we actually arrived at the field – err, pitch – and I was instructed to proceed to silly point. As is often the case as a medical resident when faced with an unusual situation requiring an appearance of proficiency, I decided to just fake it until I could make it (or is that AA’s slogan?). I established myself confidently on the pitch – unfortunately nowhere near this purported “silly point”, and it just unraveled from there. Thankfully, the overall level of athleticism on the field what was you might expect if asked to envision a group of medical researchers, PhD students, and laboratory staff. And Nick, who had asked me to play in the first place, confided that he met his wife when she and he both joined a cricket team that was founded as a team for people who were so bad they would never be asked to play on anyone else’s team. So in the end I even managed to contribute to a winning effort, and I assure you that no one has ridiculed me for being struck out (no doubt the wrong term) by the seven-year old daughter of one of the senior faculty. She threw a googly, what was I supposed to do (run, apparently).

I’ve also been out for a few barbies with the other hospital staff. And I finally ventured out to the nude beach, after I learned that you don’t have to be nude yourself to go out on the beach. I reckoned I should check that scene out, how could I spend my entire time here several hundred meters from a nude beach and never look over the dune. What I saw may shock and amaze you. Or maybe not, if you already knew that: 1) grown men fly kites, and 2) grown men fly kites naked, and 3) when there is not a brisk breeze, sometimes grown men of dubious physical conditioning must jog to keep their kites aloft. I had a short stay on the nude beach.

Next weekend, I’m off to Sydney for some tourist action, then back to Darwin to greet my lovely bride as she arrives fresh from a few months of high-intensity parenting (and full-time wage earning, and moving into our new house). It’s even our sixth wedding anniversary the day after she arrives, so I’ll have to get her a new iron or something.

(waiting for the lightning bolt to strike)