An unique outreach

So there we were on a remote island, a couple of hours flight from Darwin. We had arrived on our own little charter plane, crossing a crescent of deep blue ocean onto a lushly wooded island. The clinic was practically closed as there was a death on the island the day before, and everything was in lock-down mode. It appeared as if we had fatefully chosen a bad day to come to the island (and we only visited three times a year!)

We spent most of the morning seeing just a handful of patients. As we were having a cup of tea and getting ready to pack up and call it a day, a nurse ran into the tea room and shouted "We need a doctor! Emergency!"

It was almost a little surreal, as the tearoom really felt like someone's lounge room, and it didn't seem like we could be called to attend an emergency in such a cosy relaxed place. But as we ran outside, reality sank in - there was a landcruiser with a handful of locals, shouting and gesturing frantically at the motionless figure sprawled across the backseat.

For a split second my brain froze as I thought it was the lady I had just seen in clinic, but as I got closer I realised it was someone else. She didn't appear to be moving at all. My boss started doing chest compressions and all of us together managed to get her onto the trolley to move her inside the clinic.

Inside we realised that she was in a terrible way, and that she was probably "gone" as convention would say. Her heart had gone into a seriously abnormal rhythm and was unlikely to recover. We carried on the resuscitation, knowing the grim prognosis at the back of our heads. We looked at one another sternly and decided on ten minutes as a cutoff point, thinking that everything would probably end there and then.

Ten minutes later we were surprised to find that she had started to show signs of life. So we kept going, and going, and eventually got to a point where we had to make a decision to evacuate her to Darwin. It was a bad day to fly - Darwin was a no-fly zone because Obama was in town, and we ourselves had even seen the giant US airforce planes parked across the runway at Darwin like alien spacecraft as we took off in the morning. Careflight took several hours to come, and things had taken a serious turn for the worse during that time, though she was still alive.

I have never been called upon to bag ventilate a patient for four hours. The repetitiveness of the muscle strain aside, my mind was adrift in a sea of thoughts, about what had happened during the resuscitation, about what would happen to the patient once she made it out of this place (or would she?), about all the things that we didn't have on hand at the clinic.. about all the ways things could have been better.

But there was nothing I could do, other than rhythmically squeeze that bag. It was almost hypnotic, watching the oxygen go in and out. Eventually when Careflight came it felt like there were so many people in the room it was almost like a circus. As we got ready to leave the clinic, I looked outside and it was completely dark. There were dozens of faces in the front yard peering anxiously inside the security fence, and beyond those faces were even more, spilling out onto the main road. We drove to the airport and there was a crowd there too, all lined up along the fence near the Careflight plane. It felt like half the community was there, and though everyone kept quiet, it felt like a potentially unrestful situation.

Later I heard that she passed away in intensive care, which was more or less the expected outcome. Though she'd fought the odds to come back, the time before she got to the clinic that her heart had not been working and the long time it took for her to be retrieved, meant that she didn't really have a chance at long term survival.

I had never done an out-of-hospital resuscitation before, and getting to grips with the difficulties of being in such a remote location was certainly an eye-opener. A lot of things we take for granted in the hospital setting simply do not exist out there, and we were having to "make do" with what we had. There was a lot of thinking on one's feet, and given the circumstances I thought everyone involved did extremely well. On one hand there was certainly the feel-good factor that even in the community there were competent doctors and nurses serving the community, but there was also the sombre undertone that this is the harsh reality of life - getting sick 1000km away from the nearest major hospital is tough, and it's really touch-and-go. And not every community is going to have such a wonderful clinic, though it really makes one appreciate the work that remote health workers do.

A few favourite quotes

Patient with STEMI:  Doctor, I have this terrible pain in my chest, it's just like a buffalo is sitting on my chest!

Kirsty: Why would the surgeons even ask for an ECG? So they can fold it up and fan themselves?!

Dr Chacko (trying to explain to a patient going for a mitral valvuloplasty using a model of the heart): Guys, where is the mitral valve?

Patient with a stroke: my body was just swaying, like a tree in a cyclone

At handover, after 30 admissions: we need to marinate our brains in coconut liquor to continue

Dr McDonald: some patients are clearly obligate anaerobes

Dream: Johanna and the LV store

In this dream Johanna and I are a bit older, perhaps about 40. We are at a party where there are about 20 people and I don't recognise any of them except her, so naturally we start talking. She is wearing a pink striped shirt, much like the one I have hanging in my wardrobe right now, black pants and red heels. We are talking pretty excitedly about how I recently got married, and she berates me for never having introduced him to her.

"So here he is!" I turn around in the dream and see this short obese man, basically a conical Christmas tree shape with arms sticking out of a circumferential ring of fat. And I feel slightly nauseous.

"This is Tim Flannagan." I say to Johanna and feel shocked at myself in the dream. Me and some fat Irish man? What in the world?

They exchange some pleasantries and Tim waddles away.

"So what do you do with yourself these days?" Johanna asks me.

"Well, nothing really. Tim is really rich so I'm just a housewife." I reply and feel horrified at myself.

"Let's go to the LV shop then!" She suggests.

So we go to the Louis Vuitton shop in the city and Johanna says she is looking for a red bag to match her mother's red shoes. As she is browsing the bags, I see the world's most hideous necklace. It is made out of several circles of stone, a fungal shade of black-green. I pick it up and can see some bile coloured swirl inside the stone.

As I am staring at the yellow swirls, my alarm goes off.

Dream: a vomiting man and a water canal ride

In this dream, I am called to go to CCU to see a new patient. When I get there, there are hardly any nurses around and I walk all around looking for the patient. I find him in bed 1. A skinny old man, he is absolutely soaked in brown stuff that looks either like vomit or diarrhoea. More is coming out of his mouth in spurts and the gown and bedsheets are just totally covered in brown goop.

I turn away feeling nauseous, and find myself in a different scene. I am in Xiamen where I am meeting Marek and his friend Peter, who is a thin tall man with brown hair and brown eyes (no recognisable features to link him to anyone I know). They tell me that flights to Beijing are super cheap, only Y100 today. So we go to the airport and get on the next plane to Beijing.

On the flight I try to text star to tell him we are coming to Beijing but I find I have erased his phone number. I manage to find some pxt he sent me and send it to that number but the mobile doesn't tell me whether the message was sent properly. We take a taxi to star's place, which has warped back into his old place. Peter says he is exhausted and goes off to take a nap. So Marek and I are sitting outside in the living room when I suddenly realised that star is going to be absolutely furious if he came home and found that I'd let myself in and brought these strangers! So I tell Marek that we have to leave and go stay somewhere else, but he seems really non-chalant about it all.

Then the scene chops to a water canal town which looks like the region south of Shanghai. We are taking a small boat through the canal. The paddling is a little difficult at first because we keep striking things in the water, but we can't really see what the things are because the water is quite dark and murky. Then the canal broadens and we can see beautiful old whitewashed houses with grey slanting roofs on both sides of the canal. People are milling about doing their own thing. It seemed like the whole scene was in black and white with not much colour.

At some point we decide to go back and as we turn the boat around, gentle waves start to come down the canal. Our boat rocks a little, then the waves get bigger and water is splashing in. Marek says just keep calm and push on, so we paddle and paddle until we get back to the landing where we started. The stairs down to the water are completely flooded and we have to get out of the boat and swim to the top. We struggle to swim against the tide and whilst I can see the top of the stairs I can't quite make it there. Then I look up and there is a row of children standing on a balcony watching us.

Then the alarm clock  goes off and I have to go to work.

Maubisse

After a day in hot dusty Dili, I decided to head to the mountains for some cool air. The taxi driver left me on the side of some random road to wait for a bus going to Maubisse. After ten minutes no bus came along so I went to ask a random truck driver, who was quite enthusiastic and encouraged me to climb into the truck. Note to self, if climbing up the side of the truck into the back is rather difficult, it may be a sign from god that bumping down a pot hole track in a truck isn't the best idea.

But anyway I got in and ended up sitting on the floor next to a billie goat whose legs were tied up and it was forced to lie on its side. It bleated softly at first, but as the truck went around the mountains it got about as motion sick as me and started vomiting. Then it was screaming and gasping like it was having a stroke. It was just about how I was feeling too.

The truck was totally packed - the entire back cabin was taken up with women and children sitting on two wooden planks along the sides of the trucks, with men hanging off the sides and the back. Eventually I got upgraded to sitting on a bag of rice after a couple of vomiting girls got off, and about half an hour from Maubisse I even landed a seat on the planks, next to an old man holding his prized rooster like it was a baby.

The road was pretty rough, at some points leaving one wondering where the road actually was amongst the potholes. The steep winding around the hills made me want to vomit so I had to close my eyes. Intermittently when I opened them I would see lush green rice paddies, beautiful coconut and banana trees and the odd coffee tree. Children and animals played in the dirt, occasionally chasing the trucks down just for fun.

The main monument in Maubisse, next to a Fretilin flag

Four and a half hours later (depressingly, Maubisse is only 70km from Dili!), we arrived in a bustling market. But I felt so sick that I decided to go for a walk. The poussada (guesthouse in old Portugese building ) was set high up on a hill, overlooking Maubisse. The 10 minute walk up the hill was beautiful and one was rewarded with breathtaking views over the mountains. Halfway up there is a small memorial commemorating deaths in the local area, one of many I would see in Timor. The poussada is set amongst ruined walls of a Portugese era fort, and has a really abandoned feel to it.

 Steps up to the poussada

I went down to the market again but it was packing up for the day, everyone was getting into trucks to go back to their own villages, so I ended up having lunch with a bunch of UN police at one of the only eating joints in town. A strange old man who clearly wasn't part of the UN but was wearing some faux police jacket came up and started talking to me, then started shaking my hand vigorously whilst sporting a toothless grin. He insisted on buying me a bottle of water, which I guess was nice of him..

Man passing his chicken up the truck

There wasn't actually anything to do in Maubisse, which was just perfect. So I sat on my little verandah at the poussada, reading The World According to Garp, which reminded me of when I did anaesthetics last year and Dr Ferris was telling me about John Irving books. Dinner was served in the massive dining room (there's a lounge with old-school leather couches too) and I was the only guest. Rice, green beans and "Timorese steak", which was a steak marinated in tomato & onion salsa then grilled and served with the salsa reduced. It was pleasant enough though the steak was hard to chew.

 At the poussada

I woke in the morning to the sun casting a lovely soft light on everything. Breakfast was the most wonderful chewy bread rolls, still slightly warm.

I was happy after breakfast, so I dawdled down to the town to get the bus back to Dili. I sat in front of the market waiting for the bus to come, and vowed that I wouldn't go back to Dili on the back of a truck again (especially since the people at the poussada were adamant that no-one goes on trucks, everyone goes on buses!) I waited and waited, and eventually saw the "policeman" from the day before, who clutched my hand and semi dragged me across the road to a toothless woman with stained gums from betel chewing. I couldn't understand anything she said, but eventually (after trying to put me in a refridgeration truck) she shoved me on the back of an ute, and despite my vows that I wouldn't go back to Dili on a truck... I went back on the back of an ute which was probably worse...

Because when we went through several towns, there were convoys of trucks carrying lots of men, and lots of them had guns. I felt pretty exposed, the only foreigner on the back of an ute. But luckily I didn't get shot and made it back to the mindbogglingly luxurious hotel in Dili where I was to meet Namiko and Jade.

East Timor: random first day in Dili

I flew to Dili early one Saturday morning. The flight was just one hour and ten minutes, and it felt like we hardly had time to scoff down our pastries before we were landing. We walked out onto the tarmac and into the single square building that is the airport, waited at the only conveyor belt, and pretty soon I was in the "waiting area" which was just a handful of plastic chairs out in the open air.

I had no idea where I was headed, but on the flight I decided I would try to get to Atauro Island on the ferry that morning. It was early so I took a taxi to the wharf, thinking I'd just wait for the ferry there. When I got there, hundreds of people were trying to push their way onto the wharf, frantically waving their pre-purchased tickets. I had no hope of getting a ferry ticket, so I gave up and went for a walk instead. I wasn't carrying much stuff, so it was nice to walk in the early morning (relative) coolness.

Some deserted blocks later, I made my way to the only backpackers place in East Timor - the East Timor backpackers, run by a Pom and his Timorese wife. As I walked in, they were trying to chop down a tree full of beautiful yellow flowers, a rather strange activity for Saturday morning, I thought. After a short nap I spent the whole morning talking to some random guy working as a volunteer for Arte Moris, a local organisation supporting young Timorese artists. He had finished university in Brisbane and decided to move to Dili - he seemed like the archetypal wanderer, so by the time I finished talking to him I felt like I was back on the road wandering too.

Eventually I went for a walk around town in the almost unbearable midday heat. Near the water it was not too bad, but everywhere else the air was so still that it was almost suffocating. Everything seemed to be closed, and there were not many people walking on the streets. I walked along the waterfront where people hid under huge banyan trees and drank coconuts, then I had lunch of fried fish and fish curry at a padang style joint.

Dili was strange to walk around - most of the time it was just hot, dusty and unpleasant, but one would come across some strange surprises. Sometimes, turning a corner, one would suddenly see the hills that surround Dili, and it was actually pretty picturesque.

Also there were a number of colourful murals around the place, a lot of them with a Tour de Timor theme. I guess the bike riders or organisers must have painted them.

And once in a while there would be pretty trees and flowers, such as this one near the cathedral.

The strangest surprise for me was when I went back to the hostel and sat drinking iced tea. The men who had chopped down the tree with yellow flowers earlier in the day were busy building a shelter-like structure out of palm leaves. After laying down the layers of palm, they had to trim the shelter, which they did with a machete and a mango stick! Sitting under the palm cover once it was done, it exuded a sweet smell which reminded me of rain in the wet season.

So I drank iced tea, gazed at the sky and unwound. At sundown I went for another walk, but I was uncertain about the safety situation so I stuck near the hostel and had a masala dosa for dinner.

I saw lots of UN vehicles that day, both standard ones (so easy to spot white Landcruisers) and UN police vehicles. I had my first taste of the demonstrations - there was a peaceful protest in the city centre, where lots of people old and young marched through the streets carrying signs. At this protest I did not feel uncomfortable to watch (unlike others later), so I stood on a corner near the National University and watched the hordes of UN police carrying heavy weapons direct the protest away from the city centre. How surreal it was..

Outreach to Nguiu clinic

One beautiful sunny day, I went to Nguiu for outreach clinic.

I sat on the ferry reading Joe Cinque's Consolation, which was an intriguing tale of love, death and psychosis. I kept reading till I felt like I was going to vomit from seasickness, then I went to sleep. When I woke up the ferry was perfectly still, and when I looked out the window there was a small boat speeding away from the ferry. We are sinking! was first my first thought. But no, a group of unhappy youths had burnt down the jetty on the island and the little boat was our only way to land.

Once on the beach, there seemed to be not much other than red sand and coconut trees. I was picked up by the clinic in a brand new white government-issued 4WD which looked really quite out of place, and drove a few hundred metres down the road to the dialysis centre.

My consulting room consisted of a bed, a desk with broken drawers and two broken chairs (everyone sat on the bed). The clinic assistant drove off in the 4WD to "round up" the patients from all their houses, and soon there was a queue outside my door.

It was much like any other clinic in the NT, but the Tiwi islanders are really quite sweet (always smiling, they are pretty much my favourite group of patients!). I always have the most hilarious conversations with patients in clinic, for example:

Patient: Doctor, doctor, I need you to help me.
Me: What can I do to help you?
Patient, opening mouth real wide: Can you take out this rotten tooth? It's really annoying me.
Me: I'm the kidney doctor, not the dentist.
Patient: That's ok, you look like a nice one, take it out anyway!

Patient: Doctor, now I'm on this dialysis thing, it's really affecting my life, you know.
Me: Yes, I understand it's hard to come to dialysis three times a week.
Patient: No, no, I like coming to dialysis, all my friends are here.
Me: What's bothering you then?
Patient: Well, I've got to wear shoes... I don't like wearing shoes.
Me: Well, you've got diabetes and the feeling in your feet is not so good.
Patient: Oh, but I like going walking in the mangroves without shoes.
Me: If you go walking without your shoes you might cut your feet and it might get infected.
Patient, reluctantly: Ok, I'll put my shoes on once wet season comes.
Me: What's the difference between dry and wet season for shoes??
Patient: Well I don't want to die from soil sickness (meliodosis)

(See, even patients have their priorities straight).

After we saw all the dialysis and transplant patients, we had lunch on the verandah, looking out to the sea. The dialysis centre is in a really beautiful spot, right on top of a cliff, looking out to Melville island.

In the afternoon we went to the local health clinic for our other clinic, but no-one knew we were coming so it was cancelled. We ended up roaming down the street to the art centre where I bought a Tiwi bird carved out of wood and painted using pigments from the earth. Then I went back on the ferry and read some more Joe Cinque.

It was such a relaxed day, if only I could go on outreach more often....

 The Indigenous food pyramid!