Dr Aaron Hollins, Atherton Tablelands QLD

It’s appropriate, so soon after International Nurses Day on 12 May, to pay tribute to the Remote Area Nurses of Australia. As part of my outreach work for the Mamu Health Service in Far North Queensland, I met one of them yesterday. Her name is Lyn Strohfeldt and she’s based in Croydon, a town in the Gulf country 560km west of Cairns. Croydon is known for its Poddy Dodgers festival and the Gulflander train that runs from Normanton.

Lyn is passionate about making a difference to the health of the community. Some of the stories she told me included caring for a patient palliatively so that she could die on her own country, in her own home. Lyn provided home visits, monitored the syringe driver and is caring for the relatives as well.

Croydon receives fortnightly visits from the Mamu Health Service (GP & health worker) and the Royal Flying Doctor Service calls in 3 days a month. The partnership between Mamu, RFDS and Queensland Health works well for this community, with Lyn as the pivot point. It’s also worth noting that since the introduction of s100 medication (see below) to this community, Lyn says she has not had to evacuate any of the locals because of exacerbation of their chronic disease.

The trip to Croydon is a pleasant hour-long flight over scenic grazing land, with minimal disturbance, thanks to our pilot, Simon from Barrier Aviation. Georgina Stacpoole, an Aboriginal health worker from Mamu was also on the trip. This was her first time in an aeroplane of any sort. She was only nervous on take-off and landing!

The previous week, Georgina, Veronica Anning (another health worker from Mamu) and I drove out to Chillagoe. This place is know for its limestone caves and annual wheelbarrow race where competitiors in teams push a wheelbarrow 140km from Mareeba.

At Chillagoe we met Susie Wilkins, who does relieving work at many of the remote nursing posts in this region. Susie is another nurse who is supportive of the partnership approach for the wellbeing of the whole community.

Remote Australia could not survive without the help of these tireless nurses, so thank you!

By the way, Mamu is recruiting for a GP to join the remote outreach team. Please let me know if you are interested. The service is based in Innisfail with clinics in Tully, Babinda, Cardwell and Ravenshoe. It runs outreach services to Mt Garnet, Chillagoe and Croydon.

(Footnote re s100 medication:  Section 100 of the National Health Act was extended to Aboriginal Health Services in remote areas in 1999. It removes barriers to accessing medication in remote areas. Patients receive medicines directly from the service at the point of consultation, without the need for a normal prescription form, and without charge, Couzos <2005: p843> says it is “one of the most significant improvements in health service delivery for many years”.)

Couzos S. 2005. PBS medications: improving access for Aboriginal and Torres Strait Islander peoples. Australian Family Physician; 34 (10): 841-844

Dr Patrick O'Sullivan, rural locum based in Hobart

“So, what can I do for you today?” It was a fairly typical opening question to get the feel for the consultation. “Hurt my back doc,” came the reply. Then silence. No two minutes of his narrative tumbling out; but then, of course, I’m doing another short rural locum one hour south of Hobart. No frills here.

“So, did anything happen to cause the pain?” I asked. “Tried to kill a snake doc; it got away.” Definitely in the bush again where you never know what might come through the door.

Having moved to Hobart in 2010 for family and sailing reasons, I had spent a very enjoyable three months doing locums in various small towns in rural NSW in the winter of 2011. The locums were all organised with minimal fuss, and all I had to do was show up and work. The accommodation was good, all the staff and patients made me feel very welcome, and I thoroughly enjoyed the work in the GP surgeries and as the VMO at the local small hospitals. The pay was good, too!

During the summer I worked at the Hobart surgery which is very pleasant, and does the usual city style GP work. However, I realised that all the days seemed to meld one into the other and I wasn’t getting a “kick” out of my job and I found that my wife and I spent a lot of time reminiscing about our three months doing locums. It seemed such a long time, whereas the last six months have just flown by with no obvious excitement. I was missing something.

Hence, I’ve started doing some short-term locums again and feel that “something” has returned. I’ve also organised a locum for the month of July in Kakadu; three weeks work in an area of need, and then a week to explore that wonderful region. It might just be a little warmer than Hobart too, and I’ve always wanted to catch a barramundi. Will keep you posted.

Then we’re off to an Island in the Tasman Sea as the sole GP for August and September. No obstetrics or anaesthetics but certainly will be a challenge. The clincher for me was that I also got to drive the ambulance to work every day; unfortunately the speed limit is 25kmh. Not sure how many police there though! Can you guess the name of the island?

By the way, the snake still lives but the patient’s back pain has settled.

Dr Pieter Mourik, Albury Wodonga

Before you start reading this, I want you to go and get a nice glass of wine; an Australian wine, of course. Either a red, a white, or the new rage, a chilled fortified port or muscat. I will wait until you return…

Oh, I approve, a nice, north east Durif, my favourite!

This month, I want to talk about another definite benefit of rural life; all the significant wine regions in Australia are in the country. What better reason to choose to live and work beyond the cities?

As rural residents, we are very privileged to have world-class wines at our doorsteps. I live in the north east of Victoria where the wineries are fabulous. There are family vineyards that go back up to 7 generations. The names of these famous winemakers include Brown Brothers of Milawa, Campbell’s, Morris and Stanton and Killeen in Rutherglen…just to mention a few.

It’s not surprsising that a local sign proclaims: “Sydney has a great harbour but Rutherglen has a great port!” The reputation for fortified wines from Rutherglen is internationally known. Last year, a fortified muscat won the best wine in the London Wine Show. Imagine
accessing that kind of quality right on your doorstep.

The other attraction is the concept of wine and food matching which started in our area in Milawa at the Brown Brothers Epicurean centre 25 years ago. Living in the country we think nothing of driving from Wodonga to Milawa to enjoy a gourmet lunch with our friends who come up from Melbourne and while in the town, buy local cheeses from the Cheese Factory and locally grown and made mustard from the mustard shop. These gourmet delights are in our backyard!

Many of our holidays are to the other wine regions of Australia: the Hunter Valley, Margaret River, Coonawarra, Freycinet and Barossa Valley. The standard of wineries, accommodation, food and rural ambience cannot be beaten.

When travelling overseas, my wife and I like nothing better than to visit regional areas in other countries so we booked a 4 day wine tasting in Burgundy, France. While some of the wineries we visited have international reputations, we soon discovered that our Australian wines are more than comparable and in many instances better.  The quality of our Australian wines is world class and they are relatively inexpensive compared to imported wines.

So while you sip on your glass of locally made wine and nibble a locally created cheese, consider where the grapes are grown and where the cows graze. And imagine making your dream of living in the country a reality.

Finally, a word of caution – remember to enjoy your wine in moderation; it is a marvelous servant, but a terrible master!

Cheers!

Dr Ashraf Takla, Boort VIC

One of my main ambitions since coming to Boort has been to see at least one of our local students take up medicine as a career and become a future Boort doctor. Indeed, it would be a wonderful thing for this town of 700 people.

Why not? We have a great school to which my medical practice is the proud provider of two scholarships each year. The scholarships, for Year 12 students, are presented at speech night – in itself a dazzling display of the overwhelming young talent that the children of this remarkable community have.

It’s a privilege as the local doctor to be invited to attend this event as part of the official party. Of course, it helps to already have rapport with the young people in our community. There are very few, if any, of the usual barriers that can exist between young people and “the doctor”. This is probably due to my close association with local sport as the team doctor for our footy, netball and hockey sides.

On speech night, it’s a pleasure to see so many familiar faces. After congratulating everyone on yet another successful year, I take the opportunity to put in my plug for the profession. I encourage the students to consider medicine and tell them about the fulfilling and rewarding career that awaits.

Well, this year I finally got my reward, albeit still in its infancy. One of this year’s graduates, who has expressed interest in medicine for the last few years, has actually taken the first steps and is applying to medical schools.

Maybe in a few years Boort will have its own home-grown doctor. I look forward to welcoming her into the profession and sharing the responsibility with someone who really
understands this community’s unique nature, its way of life and who can help shape its future.

Dr Aaron Hollins, Atherton Tablelands QLD

Working in a rural town means you end up doing a lot more than you might in an urban setting. It also means you end up seeing things that you may not encounter in a city clinic. I routinely look in people’s ears – this is part of the health check process, but I also recommend it for routine visits.

It is amazing what you find. I remember working one day in Normanton, northwest Queensland, syringing an old fella’s ears out after he fell asleep on a meat pie. I was not syringing the offal from the pie, but rather the maggots that were attracted to that offal!  The magnification of the Otoscope made them look like space aliens.

Ever since then, I have been interested in ears. Not a day goes by in the clinic without
seeing a perforation or infection. Suctioning ears – to alleviate otitis externa or suppurative otitis media – becomes a fun chore in the tropics. I love the sound of pus being vacuumed up! Ears and consequently hearing are so important for learning, and education is one of our best tools to promote healthy lifestyles.  So I keep looking at ears…

Moving to the opposite end of the body from the ears: the feet. If I had known how much I
would look at and treat feet as a GP, I think I would have become a dentist.  As a GP, you do realise that most people are built upside down – their noses run and their feet smell!

The access to podiatrists in my area has improved incredibly recently, but there is still a lot of fun to be had with feet.  Certainly, this is an area of treatment I quickly teach medical students. They really enjoy the chance to trim nails, and debride calluses or ulcers.  I have often found beads from necklaces embedded in my patients’ feet. North Queensland is where the minimum dress requirements of pubs specify thongs and a shirt. This is also an area where telehealth has been improving – send a picture or have a videoconference with
the surgeons to ask – am I doing the right thing? Do I keep shaving? What is
the next dressing? Will you just amputate the blasted thing?

Another thing that students enjoy is pus. There is plenty of opportunity to drain abscesses
as well, and recently our nurse had a great experience with sky rocketing pus from a young kid. The only problem was when she talked about it at lunchtime with the non-clinical staff!  Summer is a time when the pus shoots up and the rain falls down. Raised voices in a consult room are just an indication of how heavy the rain is. On a related but serious note, my thoughts and wishes go out to those in NSW and Victoria currently cleaning up after their deluge.

Dr Shannon Nott, Intern at Orange NSW

In early January, I started work as one of the new interns at Orange Health Service in New South Wales. It was a moment that I have been looking forward to since entering medical school but despite having had a great grounding at university, you still cannot help feeling like you are being thrown in the deep end. Your level of “management” changes from those scenarios (‘osces’) that we all practised when we were at med school. Now that you’re a doctor, you can’t get away with the tagline “I don’t know; I’m only a medical student”.

However, from day one at my new job, I have felt welcomed and most importantly completely supported in my role as a junior doctor.  Our orientation made us feel at ease and the senior doctors are very approachable.

The people starting out with me were also a huge support. This is a great aspect of training as a junior doctor in a rural area – you can get all the great training of a metropolitan hospital but also a great sense of community and camaraderie.

It’s nearly two months down the track and I still absolutely love it here in Orange. I chose a rural location for my first few years as a junior doctor because I felt that I would get fantastic teaching from experienced doctors and achieve work-life balance.

So far, all the boxes are being ticked. I live on five acres, 10 minutes out of town.  My partner has brought her horse up from Victoria so we can ride on weekends. We have some fat lambs to keep the grass down and have just acquired a beautiful Hungarian
Viszla pup that we have named Bandi.  I don’t know what you think, but life isn’t too shabby out here in Orange!

Bandi getting life balance right in Orange

Dr Pieter Mourik, Albury Wodonga

This month, I want to report on the three best things about rural medical practice; they are lifestyle, lifestyle and lifestyle!

Let’s face it, medical practice is much the same wherever you go, except that the breadth of practice grows the more isolated you are. If you only want to consult (and I would be bored to an early death doing this), you can work in the city, refer all your procedures and do no night calls.

If you want a lifetime of interesting and rewarding work, go bush, learn extra procedure skills and join a group to share the after-hours calls. I have just read the Rural Doctors Association of Australia’s “Rural Pulse” magazine. Several rural lifestyles are described and all report on the satisfaction of living and working in a rural environment. The comment from one writer was, “I have never been bored at work”; could a city GP honestly say this after 30 years?

Out-of-hours calls are onerous, but rural people are different; they rarely call the doctor unless it is something serious. These calls can really test your skills, but this is where your
advanced training kicks in and knowing that you can have back-up a phone call away, reduces the stress of managing potential life and death situations. It is vital therefore, to advance your skills to be able to manage these emergencies. The other thing you need to practice in the bush is courage and this comes naturally with experience and adequate training.

A doctor friend of mine recently “retired” from a consulting general practice but soon became bored, so she upskilled and is now doing locums for isolated and often solo general practitioners and is loving it! Even in retirement, she will continue to make a valuable contribution to medicine for several more years. National registration makes it easy to go anywhere in Australia to help out and it’s not a bad way of seeing parts of Australia you may never have dreamed of visiting.

I am delighted that the state governments are coming to realize that procedural general practitioners are essential in the bush and the programs are providing the training and the skills necessary to practice in the country. Having appropriate training reduces your stress when faced with an uncommon or serious medical or surgical emergency. It may sound bizarre, but you almost look forward to your next emergency to practise your skills!

When I started in general practice in 1979, the “old style” general practitioners were still practising high quality medicine and surgery. These doctors did all emergencies (there was no-one else to hand them over), did all the confinements including Caesars, did all their own patients’ appendectomies, gave all the general anaesthetics, looked after all the sick neonates and children (no specialist paediatricians then), managed road trauma until the patient could be transferred to a city and used a wide range of skills for a wide range of medical possibilities. This was truly “holistic” practice.

Perhaps this broad scope of practice is no longer possible or recommended, but it is important to have advanced skills in one or perhaps two areas. Then, if you join a group of doctors with a different skill mix, you can provide a rural community with high quality service and prevent having to send “routine” cases to the city. Joining a group of well-trained procedural doctors to share the workload gives you the opportunity to enjoy the lifestyle, lifestyle and lifestyle; the three best things about rural medical practice.

Dr Jasmine Banner, intern at Darwin Hospital

The wet season is well and truly in full swing in the Top End. As I write, the hammering rain on my roof is making it difficult to hear myself think! The rain is actually a blessing as it provides relief from the heavy humidity, dropping the temperature by a few vital degrees. It takes a bit of getting used to and is not everyone’s cup of tea, but I love the constant heat and stormy evenings of Darwin at this time of year.

A favourite way to relax after work is sipping a cool drink on my balcony, as awe-inspiring electrical storms play out over the harbour. The lightning shows never cease to amaze me – each one like a new set of fireworks every night.

This spectacular, tropical weather also seems to bring some interesting and potentially dangerous diseases rarely seen in the rest of the country. It is hard to imagine now that just over a year ago I had not heard of Melioidosis, caused by a gram negative bacterium Burkholderia Pseudomallei, and seen endemically in many patients during the wet season.

It is most often found in water and soil (hence it’s alternative name up here, Nightcliff Gardener’s Disease – so called after a local suburb). The bacterium has even grown in the clay underneath the hospital! It most often affects immuno-compromised individuals, and presents varyingly with symptoms such as pneumonia, flu-like illness, or full blown sepsis.

Affected patients will often stay in hospital for months, require weeks if not months of intravenous antibiotics, and sometimes need more drastic management such as surgery for abscess drainage and washout, or amputation of limbs to save their life.

The Northern Territory is one of those places where the variety of medicine is incredible. As a young health professional, one encounters late presentations of various conditions, from common chronic diseases to exotic infections. Thus far I have seen multiple cases of dengue fever, crusted scabies and TB.

On a personal level, I am slowly moving up the medical food chain from intern to resident medical officer. It certainly looks like a busy year ahead, with rotations in and away from Royal Darwin Hospital already lined up. I encourage anyone interested in doing something a bit different to consider working in the NT. I cannot speak highly enough of my experiences up here, having found a balance of small town friendliness and large referral centre medicine.

Dr Aaron Hollins, Atherton Tablelands QLD

There are certain benefits to living in Mareeba on the Atherton Tablelands west of Cairns. One is the daily drive to Ravenshoe for my clinical work – 82km away.

This trip takes you through some amazing countryside. First up are the banana, sugarcane, mango and coffee farms on the outskirts of town. Then comes the remnant rainforest near Tolga and Atherton, followed by rolling green pastures stocked with dairy and beef cattle.

As the road climbs and curves its way towards Ravenshoe, there is more rainforest followed by stands of eucalypts. This is officially the highest road in Queensland (elevation 1,143m) and it takes you to Queensland’s highest town (Ravenshoe is 930m above sea level).

It’s mostly an enjoyable commute – caravans and B-double trucks just mean I get to listen to the radio or Ipod for longer.  There is only a one-minute stretch where the radio doesn’t work, and that’s even with a dodgy aerial!  Nor is it too much of a problem that my airconditioner is on the blink as you’re driving into the cool air of the true “highlands”.

Our patients are also used to being on the road, with the nearest general specialists visiting 50km away, and the specialised specialists two hours away in Cairns.  The health service I work for delivers care to people as far west as Croydon and Chillagoe (known for its caves and marble). One of our GPs travels there fortnightly.

Before moving to the Tablelands, I worked in Mt Isa, including short stints in some of the remote communities out there.  In Western Queensland, it is not uncommon to have patients drive four hours for health care.  This puts my current commute into perspective.

I probably spend as much time as city GPs driving – except without the traffic lights. This leads me to a new classification on rurality to replace the current ASGC-RA, but I will save that for another time – suffice to say it is to do with traffic lights and McDonald’s “restaurants”!

Dr Pieter Mourik, Albury Wodonga

One of the attractions of living in Albury Wodonga is that we are close to pristine, clear streams meandering around the mountain ranges and into the valleys. “So?” I hear you ask. Well, these streams are teeming with trout. In fact, it is one of the reasons why I like to live here; I can catch a trout for dinner less than an hour’s drive from home.

Trout fishing has been a popular sport for centuries; it combines the excitement of catching wild fish, wading crystal clear mountain streams and enjoying the abundant natural beauty of the bush frequented with native animals and birds.

I often see platypus swimming in the stream, and one actually swam between my legs! As we quietly wade upstream in search of fish, we may see wild deer grazing nearby. There are some snakes, mostly red-bellied blacks, which are docile and harmless if you leave themalone, and being in the water in waders, you are completely safe.

Giant tree ferns line the streams and with many other native ferns and plants, it is a naturalist’s delight. In these remote and protected environments, there are numerous native birds that appear to be unafraid of humans and come quite close.

There is a downside of course, and that is the introduced blackberry which is a dreadful pest in the Australian bush, but after the record floods, most streams are clear, for a while at least. Apparently there is a “rust” being developed to eradicate blackberry bushes, so I live in hope that our beautiful native bush will be restored.

Trout were introduced from England in 1864, and they have successfully adapted to our streams. Some say too successfully as they have destroyed a lot of native fish, so it is our ‘duty’ to fish for trout.

Every mountain stream has trout, mostly brown and rainbow, with a rare catch of a brook trout. Trout prefer icy cold steams. In fact, if the water temperature is over 18 degrees forget trying to fish, as they won’t be there!

The three main ways of fishing streams is with bait, (worms, grasshoppers, crickets and mud-eyes), a spinner (thatsimulates a tiny swimming fish), or fly fishing with an artificial fly, either ‘dry’ (which floats on the surface), or ‘wet’ (which sinks below the surface). As most of the trout’s food is from below the surface, dry flies are only used when the trout are seen to be feeding on the surface. Some perfectionists net the emerging insect life and tie a similar fly to ‘match the hatch’! I find this unnecessary in a moving, crystal clear mountain stream, as the trout are so ferocious, they will attack anything which is in their view.

The adrenaline rush when a large trout leaps at your fly and hooks on has to be experienced. Then you need the skill to play and land the fish which is not an easy task for the novice. I prefer the ‘catch and release’ method (apart for one for the table!), so that the majority of trout caught are returned to fight another day. However the trout must be handled gently before releasing or they will not survive.

To be bitten by the trout fishing bug has been one of my life’s greatest joys. I have fished most of the Northeast mountain streams now for over 30 years and the pleasure is undiminished. I have taken many of my city based medical students trout fishing and it is exciting to watch them catch their first trout. Hopefully some of my medical students will catch the trout fishing bug too and will return to the bush to practice both medicine and trout fishing skills.

*Between catches, Dr Pieter Mourik lectures in obstetrics and gynaecology at the University of New South Wales’ Albury Rural Clinical School. He is pictured casting about at a favourite fishing hole.