Felicity Arthur / Foundation Doctor
Flic, originally from the Island of Arran, is a recently graduated doctor from the University of Glasgow. Here is an account of her experience of spending a month with the Royal Flying Doctors Service of Australia.
For my junior elective I travelled to Port Augusta a small town in South Australia approximately 3 hours drive north of Adelaide. It is home to the Royal Flying Doctor Service (RFDS) base for South Australia. This base controls three separate airbases, Port Augusta itself, Adelaide to the South and Alice Springs to the North. Within the town there are three RFDS doctors, all of whom fly with the RFDS on clinic one day a week, cover an on call rota and fill the rest of their time with local GP clinics and hospital work.
I spent my elective attached to one such RFDS doctor who acts as a first port of call for patients and as a gateway to medical services. He is also first on scene in the event of accident or acute illness is available for telephone consultations 24 hours a day 7 days a week. Most of all though, he is their one security in living hundreds of kilometres from the nearest medical care.
As well as the small towns, the area covered by the Port Augusta base comprises many aboriginal communities dotted throughout the outback, arisen from the Aboriginal populations’ attachment to the land. It also includes several mines, each with its own population of miners, as well as families who work on both sheep and cattle stations. These communities, mines and stations are very much remote populations.
In the aboriginal communities the only contact with a doctor is on clinic days which are conducted between once a week or once a month, depending on the location. The RFDS fly for up to 2 hours, 800 kilometres from Port Augusta, with a freight consisting of a doctor, a flight nurse, a pilot, and supplies such as drugs, vaccinations, equipment for investigations such as urine samples and blood tests, minor surgical procedure equipment and a defibrillator. On arrival the plane is unpacked and “set up” in a clinic within the community, which is managed by a nurse within the community. From here the doctor conducts a routine GP clinic.
If the condition of any patients is serious enough to warrant hospital treatment then an emergency evacuation flight is requested by the doctor. Mines and stations necessitate a young working population. Because of this and because of the nature of the work, many of the health problems encountered are trauma related as opposed to chronic health problems. For example motorbike accidents incurred whilst droving cattle are not uncommon. This is the type of medical problem that in Scotland would be dealt with by hospital accident and emergency departments but which the RFDS GP needs to be experienced and competent in dealing with, especially over the phone, both to deliver initial treatment and to assess the necessity for an immediate evacuation. As there are only 2 planes at each station, resources are limited and so flying out to one casualty can put a potential more serious patient at risk. Being from a Scottish island I am used to being fairly out the way. However, I could not imagine living so far out from access to health care, especially when surrounded for so many hundreds of kilometres by nothing but the unforgiving outback.
In the Aboriginal communities the main health problems are those of chronic disease attributed to the introduction of a western lifestyle in an unaccustomed population. For example hypertension, type II diabetes, obesity, heart disease and chronic kidney disease are common place and are the main target for education, prevention and health interventions.
Health issues resulting from customs of Aboriginal culture and tradition are an interesting aspect of the job which I was not expecting. Death is an event which comprises a great many of these customs. When someone in the community dies, a “sorry camp” is held where family and friends within the community, and those from farther afield who travel especially for the event, set up camp and grieve for the deceased for weeks at a time. The funeral will take place at some time during the camp’s duration. During this period even children and the elderly will live in tents with the only heat in winter provided by camp fires. Burns, hypothermia and joint pains in elderly people sleeping on the ground are all common occurences at these camps. Self harming – cutting the skin of the arms or chest – is performed as a ritual in order to leave a scar as a reminder of the deceased. These “sorry cuts” can become dangerous if large blood loss or infection occurs.
One specific example of health care issues related to Aboriginal customs was evident in the case of one patient seen in a remote community. In this case an elderly woman presented to the GP clinic complaining of stress and not sleeping as a result of her home situation. Aboriginal people are obliged to take in any family member who requests a place to stay. In this case the patient, who had a medical history of chronic lung disease and who was already quite frail, had taken in her cousin who was an un-medicated schizophrenic. The cousin was keeping the patient up all night and was causing disturbance in the household. However, the patient was not permitted, by custom, to ask her to leave. The GP in this instance is ill supported by social work bodies or metal health workers who may be able to arrange alternative accommodation, section the patient in order to medicate them etc, unlike the Scottish GP. They must respect that the patient is obliged to look after their family member and must try to accommodate this in their care of the patient.
Poor hygiene is of major significance in Aboriginal communities both in adults and children. One 5 year old girl evacuated during my stay with the complaint of tape worm was on investigation found also to have chronic otitis media in both ears and a Giardia infection in her bowel. Health care campaigns in these regions start as simply as posters in the clinic stating “Have a bath, you might enjoy it”. This seemingly condescending message highlights the basic level at which healthcare could be improved in these communities.
I was particularly struck by how different not only these communities were in terms of their culture and rituals but also by the health conditions faced by them. I saw one 9 year old girl in an aboriginal community who had rheumatic fever. It was quite shocking to learn that a now essentially 3rd world disease was presenting in a westernised country. Over my time in Australia, outwith medical practice, I was frequently affronted by the negative attitude towards aboriginals by Western Australians. This was an attitude I had not foreseen and it was unsettling. Many projects are now in place to “close the gap” of health inequalities between the two populations and many of the doctors, nurses and midwives were working very hard to achieve this. It seems however that this may be a bigger problem than individual projects can manage alone.
Despite what I have said, the doctors and nurses in the RFDS working with the aboriginal population held a very different opinion of their patients. They worked alongside communities appreciating their beliefs and cultures and did everything they could to treat them as best they could whilst respecting their wishes.
This proved difficult for one male GP who performed antenatal checks on a pregnant aboriginal woman 800k north of Port Augusta. The patient had gestational diabetes and the doctor therefore wished to deliver her by Caesarian section in the hospital in Port Augusta before her due date. Aboriginal women are very modest and will often not speak unless prompted. It is not unusual for them to keep their eyes lowered and not look males in the eye. Additionally, childbirth is considered “woman’s business” and traditionally they will leave the community to a sacred birthing site and return only when the baby is born. I was fascinated to witness the doctors ability to communicate effectively with the patient despite these barriers, to explain to her the issues in her pregnancy and to sensitively encourage her to deliver her baby in the hospital despite it being so far from her community. I was very honoured to be able to assist in the delivery of her baby on the last day of my placement.
The vast and varied aspects of life as an RFDS doctor mean a broad knowledge of medicine is essential, as well as a sound basis in emergency medicine. Furthermore, the social aspects of working with Aboriginal communities, with their differing customs and beliefs is an important part of the job. The trust the patient’s have for their RFDS doctor makes his job not only easier but worthwhile. The RFDS is an organisation which gains a huge amount of respect from not only its patient’s but also the media and the Australian population. It is a symbol of national pride, certainly not an accolade afforded to the average Scottish GP.!
- Witnessing a very different way of life
- Flying over the australian outback and seeing the scenery on a daily basis
- Having the privileged opportunity to be a trusted person in aboriginal communities
- Working alongside a close knit team of doctors, nurses and pilots
- Frustration at not having simple tests on hand in aboriginal communities
- Unpredictable hours
- Australia is not cheap anymore!
Where / Port Augusta, Western Australia.
When / June-July
Weather / A wintry 20 degrees
Costs / Around £2000 all in for a months elective plus travel time
Necessaries / Walking boots and a good book for long flights back to clinic