I'm going to lapse into med-speak in these medical posts. I'll clarify really specific terms in a glossary at the bottom of the page but generally I hope those non-medical friends and family will get the gist if they're interested enough to read this!
The clinic here is large but with no hospital. There is a very experienced GP (Chris) with a full time registrar (at least for another 6 months) and 2 other who job share fly-in-fly-out. I don't know how many permanent nurses we have. There seems to be a core staff of perhaps 10 or 12. And me! Aboriginal health workers and drivers make up the team with some health workers running the Aged Care facility across the road. There are at other times locum GPs and nurses to fill gaps and an assortment of specialists and allied health professionals doing clinics from diabetes education to TB(1) screening and management. Every Thursday morning the clinic is shut to allow everyone to get on top of paperwork that piles up (as it does everywhere), have team meetings and run education sessions. Of course it is regularly disrupted by emergencies. The education sessions have been incredibly helpful to me so far as they have all been on topics I knew next to nothing about. The trachoma(2) team actually won't be back because Maningrida has had 2 years without a new case of trachoma but thanks to the talk they gave when they came for their very last clinic, I know what to look for in their absence.
The nursing staff cover the clinic for emergencies until 9pm and are then on call over night and on weekends. It has been amazing to see how independent they are. Essentially these nurses are used to working without doctors much of the time. They only call us if they can't readily resolve an issue or rarely to come in for some disaster that could use support until Careflight take over (and I have yet to experience this). The CARPA(3) manual which provides guidance and nursing protocols for the management of common presentations and guides the prescription on many drugs. Some of the nurses are clearly very experienced and very capable and I am taking every opportunity to learn form them.
Below you see Shannon one of the Aboriginal Health Workers who is much more gentle than he looks in this photo, Beth an excellent midwife and Pam a nurse who has a special touch with kids.
The bread and butter of medicine in this remote community are not unexpected. Scabies, skin infections, diabetes, otitis media and pneumonia walk in every day, often several times a day. An enormous amount of time and energy is invested in managing the huge number of patients with Rheumatic Heart Disease (RHD). They need their three weekly benzathine penicillin injections, twice yearly check ups and 2 yearly ECHOs(4). Many have mechanical valve replacements and need INR monitoring. Some have carefully calibrated heart failure and are looking ahead at a transplant. And I'm not talking about old people. I'm talking about kids. The school nurse Roz chases these kids up. Most are at school but there are so many kids who attend rarely so she dives around town finding kids hanging out with Grandma or staying at Aunty's house and jabs them as consistently as she can. She tells me there are 80 kids under 18 in Maningrida who have RHD. The reality of this number drives home the need for primary prevention. RHD is rooted in poor hygiene and chronically untreated bacterial (group A strep) infections. So the infected scabies, skin infections, and sore throats suddenly become incredibly important.
Working in a place where so many people are chronically unwell, inevitably there are some pretty extreme presentations. One day the poor school nurse stumbled in with a patient with very advanced Sydenham's Chorea(5) slung across her shoulders. The poor teen couldn't walk or talk. I was dumbfounded but many of the other staff knew immediately what this was, though it was a particularly impressive case. Another time a middle aged gentleman with a horrifyingly unlucky medical history was wheeled in saying he felt a little unwell and had undetectable peripheral pulses and unreadable blood pressure secondary to urosepsis. Poor vehicle safety causes an incredibly high road mortality in remote Australia and I've seen one crash with 7 unbelted family members. 2 were flown out but luckily no one died. Diabetes is often really out of control despite the best efforts of the staff in the clinic. The highest HbA1c(6) I have seen so far is 17. Most recently I decided to review a hypertensive pregnant patient over the weekend. Her mild hypertension on Friday became florid pre eclampsia by Saturday such that she had BPs as high as 190/110.
The decision to fly someone out can't be made lightly. The NT Health budget is apparently massively blown out and each Careflight costs something in the order of $15000. The clinic has a whole heap of interesting gadgets to help treat patients and also make these clinical decisions. Below are pictures of the istat machines which can give us a blood gas or a basic creatinine and electrolyte profile(7). Chris also procured one of the only WCC(8) machines in Australia. The clinic was part of a study on the value of point-of-care WCC measurements. When funding for the study was pulled he negotiated to keep the machine. He tells me that on many occasions the WCC has been the deciding piece of information.
Importantly the local culture really does impact on medical management and this is one of the most interesting things about being here. When there is a body in the morgue the family chant and play their clapping sticks outside and sit under a nearby tree until the body departs (to be buried or to go to Darwin for a coroner's case). Patients have very different view about disease causation and some presentations are delayed because it is believed that the illness is caused by black magic and therefore outside of our expertise. Several times patients have requested the presence of a traditional healer (they call them witch doctors) in the clinic. I view this as ideal. I tell them I'm delighted to work together. The worst thing would be to make a patient choose which treatment to take - it may not be ours! This baby had bronchiolitis. She was quite unwell and I was fascinated to see this Witch Doctor at work. The family gave me permission to share these pictures. He spent quite a long time rubbing the chest, using sweat from his armpits and rubbing his hands together before placing them on the baby. When she became unsettled he continued to work on the baby while she settled on the breast. The family seemed much more at ease with our plan to fly baby to Gove Hospital for admission after his ministrations.
Over all I find work stimulating and challenging and the team there skilled and supportive and I am really pleased to be there. Here we are "de-fragging" on a friday evening at the beach:
Support work for non-medical readers:
(1) Tuberculosis is alive and well in remote Australia. Not common but definitely still on the radar.
(2) Trachoma is an eye disease associated with poor hygiene. Essentially a lifetime of snotty noses rubbed into eyes is its cause. The key primary prevention is clean faces and this is actively promoted.
(3) Central Australia Rural Practitioners Association produces a clinic manual for primary health care practitioners in remote and Indigenous health services in central and northern Australia.
(4) Echocardiogram. Ultrasound of the heart.
(5) A movement disorder associated with Group A streptococcus infection and Rheumatic Heart Disease. The patient has involuntary movements often of the upper limbs but at the extremes involving the whole body including jerking of the legs, writhing of the neck and lip smacking.
(6) HbA1C is a blood measurement of sugar which reflects diabetes control.
(7) Blood gases show blood acidity and creatinine reflects kidney function.
(8) White Cell Count. The white cells increase in bad bacterial infections.