Walungurru (Kintore) , is a Northern Territory Aboriginal Controlled Community, situated in the Gibson Desert, about 30 km inside the State border with Western Australia and close to the corner of the South Australian border. It is nearly 600 km west of Alice Springs with only the first 160 km of road bitumen sealed.
It has an Indigenous population of about 600, growing to around 1000 during Footy Carnivals and special occasions.A number of non-Indigenous workers live there to assist in providing many of the essential services, such as the Health Services Clinic and its’ associated branches, the Council,the School,Police Station, General store and garage etc.The nearest other small Communities are 130,170,200 and 350 km away over bush and dirt roads.
The climate is temperate to warm in the mid year months and hot to very hot from September to April .Humidity in Winter is moderate only and in the Summer it is low.
The terrain is flat generally but is dominated by a ”Womens’ Mountain” and a Men’s Mountain , both of which have very significant cultural and historical meanings, to the traditional owners , the Pintubi People.
Kintore was quite a bit different in July 1996 when I arrived there in a small Cessna 210 single engine, “two and a bit person plane”.There was very little work on offer, for the locals, and trying to get wheels to travel to Alice Springs and elsewhere was a major, understandable preoccupation.
The Pintubi People had been removed from their traditional land in the late 1950’s and early 1960’s as a result of Rocket trials at Maralinga and Woomera in South Australia.The Rocket trial flight paths crossed major areas of the Pintubi Homelands ,causing potential serious dangers to the Pintubi. The US and Australian Governments Welfare Dept removed almost every person from their land and placed them in Papunya and other small Community venues some 300-400 km away but near Papunya. They were thus only about 250 km from Alice Springs.This exercise caused massive social,cultural and medical problems for the new mix of indigenous groups and 50% of them died within twelve months from influenza and other infections,car and other accidents, alcohol fuelled fighting, and numerous other social, housing, economic and cultural determinants.
A major disaster had overtaken the whole exercise. It was not until 1981 that the Pintubi Elders took their people back to their own Country and began re-establishing Kintore. They drilled a bore in the desert, built some very substandard humpy type houses, started a little school and erected a tiny Church.
When I arrived, for my initial six week Medical Locum, the people had only been back for 15 years and were struggling to cope but happy to be there, with what was left of their families,and determined to get Kintore going again.
I didn’t have ANY previous knowledge of the Pintubi events concerning Maralinga, Woomera ,Rockets, removal from their Homelands, transfers to Papunya and coming back home again in 1981,when I arrived on that little bumpy plane . I recall feeling a bit queezy as we got sucked up by the warm winds and then fell three hundred feet in seconds.My Pilot looked terribly young, as policemen look young to 59 year old doctors.He was, I think, confidently in charge of our lives.
Kintore , in 1996 , had a dirt runway. It was a dry day and I was thankful to be plonked down,intact, after enjoying the magnificence of the Western Mountains Range from 7000 ft for the first two hours of the three hour trip.
A number of large cars arrived as I stepped from the Cessna and onto the airstrip, shook hands with the Clinic Manager and was whisked away to the Doctor’s house.The cars were full of big Indigenous blokes whose job it was to check out the old bloke and, probably take a bet on how long the poor bugger would last in Kintore.
Many doctors had been to Kintore in the previous twenty four months as locum,short term periods . None of them had agreed to return for a significant length of time.
I had a good look at the doctor’s house and realised that, for the locals it looked very comfy, but it didn’t work for the doctor who was expecting a TV set and radio and doors and windows that prevented local fauna and other creatures from visiting you late at night.
My first night’s sleep was rudely interrupted by an unpleasant and violent, resonating ,snoring sound emanating from under the floor boards above which my bed was perched.At first I experienced fright then curiosity and the need to get up and see what was happening.
A very big, pink , pig had taken over the space underneath the Doctors’ house, whilst the doctor was in absentia. There was a dripping tap underneath the house which provided a constant supply of water on the hot nights and enough to give him/her a mud bath when required.After the second night, of snoring and interruptions, Elders captured the pig.It disappeared, without a squeal, but whether it was taken out bush or was barbecued locally was a hush-hush, giggly subject.
The problem was no longer,and I slept …like a pig in clover!
Ineke Tremellan, a middle aged Nurse, who lived with her very deaf husband a couple of similar houses away , came over to see me, and have a chat, shortly after I had arrived and unpacked.
Ineke had worked in Kintore for two years, knew everything about everybody, and was very highly respected among the Elders,and, indeed the whole Community. As it turned out I realised that she was the best qualified and culturally respected Remote Nurse that I was ever to meet and work with.
On the very first day she took me to the very shabby clinic which still relied on card medical records,no computers for anything, and a team of Aboriginal Health workers who loved their jobs but who were manifestly a long way away from being clinically competent in the modern sense of the meaning of the word. Things can always change, and improve, and they did.
I confess to feeling culturally impotent, though clinically well qualified, to perform my six weeks of challenging situations and daily crises.
The first big challenge was an epidemic of Pneumococcal pneumonia.
Unknown to me Kintore had the highest rate, statistically, of this killer disease in any Country, although Papua New Guinea were runners up. .
It happened every year, and there was , as yet, no pneumococcal vaccine available to immunise children (only Adults) . The disease was treated by administering big, painful injections of Procaine Penicillin Intramuscularly daily for five days.We treated thirty kids in three weeks. They all improved, and then got better, without being transferred to Alice Springs via the RFDS .
We had a big blackboard on the Clinic wall which detailed every child ,their Clinical diagnosis without x-ray ,treatment dose,time given, attendance record, follow up and outcome.Any child, missing a dose on time,was sought out by Aboriginal Health workers ,treated, and taken back home.The little kids loathed the needles and I loathed giving them. Back up extra lollies for the recipient and the giver reduced the problem a little.
This regime was so successful that we requested that the Dept of Health in Canberra give us special permission to have a trial of giving half of the adult vaccine next year to children in Kintore. This was granted because the especially prepared children’s vaccine would not be able to be made available in time for the next year’s epidemic.
I was in Kintore again in the following year and our Pneumococcal infection rate fell by 85% as a result of this ploy.
I learnt a huge amount about Aboriginal Communities, their culture ,health and other problems whilst spending a mere six weeks in Kintore.
The levels of appreciation and the acceptance that I might not be able to come back was, quite devastating.
I had forgotten about my back surgery, and possible outcomes, and had realised that I had undertaken my own rehabilitation by walking miles and miles out bush, after work and at weekends. I realised also that, when I was out walking 4-8 km outside of the Community mornings or evenings, nobody interrupted me, bothered me or humbugged me.I had my cassettes and got lost in the shear joy of the songs .
It was, as though, there was an unspoken conspiracy to keep me well and get me back again to help the Kintore mob build themselves up again as well.
After six weeks the Cessna 210 arrived with the same young Pilot.
In minutes we took off from the red dirt strip,and settled down at 9000 ft for a very smooth trip back to Alice Springs .The four big cars carrying six big Elders and a mob of excited youngsters had pulled up to see my plane leave Kintore and then turned away ,as we left the runway, to return to another same, same,slow day in the life of the Community.
I WAS ENJOYING A COFFEE, IN HOBART’S SALAMANCA, A FEW WEEKS LATER AND A CALL CAME THROUGH WITH SOME IMPORTANT KINTORE NEWS.
The CEO of Pintubi Homelands Health Services contacted me with a proposal about the future of Walungurru’s (Kintore), Health Services, going forward, medium and long term.
There was clearly an urgent need to provide stabilised, up to date services with regular Doctors, Nurses, fully trained Aboriginal Health workers, appointed traditional Ngangkaris and full and part time reception and social work staff to the Community. In the immediate short term, the existing clinic would be upgraded a little, and continue to be used, but significant Capital and ongoing funding would be Guaranteed to build, and staff, a brand new Clinic in about three years.
Dr Peter Tait , a well known Senior FRACGP and Pintubi Speaking GP, from Alice Springs Congress Medical Centre, and I, contracted, with Kintore, to provide the Medical Officer input for two years on the basis of two months out bush each and two months away for a two year period. During this period we would try to get everything running more smoothly and take the remote Clinic through AGPAL Accreditation.
The Accreditation was a Government approved Standards Level,accepted by Medicare, The Government Health Department, and the Royal Australian College of General Practitioners .It applied Standards equally throughout Australia, whether Metropolitan ,City, Country, rural or remote practices. It was only granted after lengthy bureaucratic standardised testing, on site visits and interviews with the Senior practising Doctors,the Manager,nurses and receptionists .The interviewers were specially trained by the Accreditation Bureau
Dr Peter Tait, and I, signed up for the joint Medical Officer appointment.There were some fairly formidable tasks ahead but that’s what challenges are all about aren’t they?
I attended a course, for five days, in Alice Springs,learning the basics of Pintubi language. I also attended, and passed, the Emergency Management of Severe Trauma Course and Associated Exams at The Royal Australian College of Surgeons In Melbourne.
Because I was eternally grateful to Mr Fred Binn’s surgically successful management of my severe spinal canal stenosis, in early 1996, I made a silent vow and deal, with ” my maker”, that I would continue to work, in Remote Australia, as long as I continued to keep well and clinically up to date!!
I stayed true to my promise, although almost nobody outside of my immediate family was aware that I had made it.
I last worked as a Doctor in the Desert in my 81st year in 2017, and, on March 10th 2021, I will enter my 85th year on Planet Earth. So mote it be.
SO LET’S LOOK AT MY WORKING “DOCTOR IN THE DESERT’ TIMELINES. I WENT TO 56 REMOTE ABORIGINAL COMMUNITIES . WHERE, WHEN, WHY AND WHAT WAS I DOING THERE, AND FOR HOW LONG ? THIS ALL HAPPENED BETWEEN OCT 1994 AND JAN 2017.
Having completed Katherine and Kintore locums,I returned to Kintore in January 1996 to start my two year shared contract, 8 weeks in and 8 weeks out.
I was excited about returning to Kintore. Upon my arrival by Cessna 201 aircraft, a similar group of Elders ,who had greeted me when I arrived as a Locum in July, were at the airstrip with an even bigger bunch of kids.
I could sense immediately our mutual re-connection.The CEO took me to the same old house , as before, but reassured me that, within a few months, a new house would be built, well furnished,3 bedrooms, a new TV, cooker, telephone and washing machine.There were no pigs or other fauna snoring or sleeping under the house this time around.
I had brought my Yamaha Electronic Music Keyboard with me and would leave it there for the full 2 years.The Kintore mob, of every age group, love their music and nobody else in the Community had such a multi- purpose instrument. As it happened, I was able to play all of their favourite hymns and songs.The old ladies were especially happy to be able to enjoy a sing -song .
The old Clinic had change very little, and, to my horror, I was informed that, because of financial problems, one of the two Nursing posts would need to be discontinued.
Medicare had started in most General Practices in Australia in 1988 and was accessed as a patient if you had a Medicare card.There were no Remote Communities in the Territory that used Medicare, and it’s bulk billing facility, to assist income generation in the Clinic.
All Indigenous people had a Medicare Card. I contacted Medicare to confirm that we could bulk bill our patients and was provided with the necessary forms and equipment to implement it. I did this as a matter of urgency.
The result was, instead of a deficit of $A 40,000, as estimated in the our current Budget, we generated over $A 100,000, in our first year, enabling us to retain both nurses during the following few years. Careful use of drug purchasing and prescription prescribing of medications for clients brought in another saving of between 10000 and 40000 dollars.
Pintubi Health Service, Kintore, needed a Computerised Community Health Register to enable permanent medical record keeping and facilitate the planning of preventive services such as Immunisation and STD recalls ,Pap Smear follow ups, and recalls for assessment and planned treatment of all Chronically sick and disabled residents.
These are sine que non essentials. They are very difficult to introduce and implement remotely, and require a big team learning approach and effort . In a Metropolitan General Practice, this would occur in a smoother way and in a more timely environment, for every obvious reason.It happened ,though we did it, and this was a big move towards Accreditation.
Kintore had a prevalence rate, amongst all residents in the Community, of 35% Trachoma, 30% Scabies, 15% Diabetes , high rates of Pneumonia,childhood gastroenteritis, STD’s, Trauma, Acute Nephritis, Rheumatic Heart disease and End -stage kidney failure (requiring kidney dialysis in Alice Springs).
On average we requested a Royal Flying Doctor Service Emergency evacuation flight ,for one or more patients, every six days.The approximate cost of each Evac flight was about $A 5000 in 1996.
The pattern of diseases, among The Central and Western Desert Communities, is vastly different to those experienced in Metropolitan, City or rural regions.
In our Clinic we were able to provide day to day teaching to first year,third year and final year Medical students seconded to Kintore for 2-6 week attachments from the Universities of Melbourne, Monash and Tasmania (including to Alicia, one of my own medical student daughters) .Regular on-site teaching sessions were also held for the Remote nurses and Aboriginal Health Workers at the Clinic or in association with Bachelor College, Alice Springs.
Kintore was pretty grubby in 1996.All manner of rubbish was blown from east to west in the Community on one day , only to be blown from west to east ,in the Community the next day. Adults and kids tended to drop their empty packet of chips exactly on the spot , in front of their feet, where they had finished eating them.
Regrettably, there was a petrol sniffing epidemic in most Communities and it was never properly addressed as a Community problem. Kids age 6 to 17 would wander the streets, after dark , wearing polystyrene cups over their faces.They held their cups tightly against their nose and mouth and inhaled the dangerous fumes.The effect was to give brain numbing effects to the user and ,at least for a while, an ability to disengage from the world , their lives and their problems ,at least for possibly an hour or so.
In Metropolitan, City and rural Australia people were managing to get a similar effect with alcohol , benzodiazapines , magic mushrooms, cannabis, ecstasy and a plethora of other mind boggling and health damaging non -prescription and prescription alternatives .
It is iniquitous, hypocritical and self righteous , that so many Australians, and the media, choose to alert the rest of Australia to the problems of petrol sniffing in Remote Communities, whilst relying on their own, available, toxic compounds.
I recall a well known TV Channel coming to Kintore ,at the height of the “sniffer problems.” They flew in, on a chartered plane,roamed the Community streets at night and even gave children, age 4 or 5 years of age, little polystyrene cups to cover their nose and faces to mimic real petrol sniffers .This was then presented ,on a popular night- time TV program as a norm for these innocent kids.Undoubtedly viewer numbers soured that night.The Community Elders were rightly furious that they had been duped by an unscrupulous media company.
Communities have their own serious problems with regard to sourcing, supplying and selling alcohol, cannabis and (in recent years) MDMA ecstasy, Ice and other synthetic mind changing drugs in their Communities.
Persons, within and outside of Communities, somehow seem to evade the organisations that are responsible for,locating, preventing , detecting,tracing and dealing with these problems , including education in schools and Communities and prosecution of the villains.
I am pleased to report that ,with the introduction of Av-gas , instead of petrol in most Communities, the petrol sniffing problems have substantially subsided. Av-gas does not give the same hit and numbing effect as Petrol. Instead it causes the user to have a nasty headache and nausea, usually, and is now out of fashion.
TELEMEDICINE! WHAT IS IT ? DID YOU EVER GET INVOLVED WITH IT IN THE EARLY DAYS…1997 ..IN KINTORE? YES? WHAT HAPPENED?
In 2021 we are able,through Broad Band, if you are lucky, to use Telemedicine from your Medical Practice, Local or Central Hospital, Royal Flying Doctor or other Service providers, to contact Remote Communities and use video consultations to see patients and deal with many of their problems professionally without them actually coming to your Clinic or you travelling out Bush to see them.
There is an increasing degree of sophistication, as to,which professionals and patients can benefit most from these consultations.
Gradually we are finding huge cost and time saving benefits, for example, in assessment, diagnosis and management, of skin conditions ,eye problems,mental health illnesses, diabetes management, initial surgical assessment and a host of other problems .The list expands exponentially and is dependent on the level of IT available at any point in time.Sending ECG ‘s,Ultrasounds, x-rays CT scans and MRI’s, between someone who has requested them and someone who has performed them is now common place.
Back in Nov 1997 these things were in their complete infancy out bush.
I received a phone call from the Queen Elizabeth Hospital in Adelaide in November 1997.
I was told that they were very interested in testing out the possibilities of developing Computer based consultations and diagnoses from Kintore to Specialists at the QEH in Adelaide,
Kintore was the most Remote Community in Australia to have a regular clinic and a regular doctor, and, because a new telecommunication line had been developed across the Tanami Desert,it was possible to install and provide on line, real time Computers that would enable real time communications and consultations to be established between Kintore and QEH, Adelaide Consultants.
They also explained that this would be a 3 day trial and that further Kintore two way live consults might be a longer term possibility down the track
They had had discussions and negotiations with the largest Hospital in Hong Kong and obviously had bigger fish to fry. A long term personal friend of mine was the CEO of the unnamed Hong Kong Hospital , as it happened, but we never discussed it at the time, and have never discussed it since.
This is what happened.
The Organisers delivered all of the gear to the Council Chambers in Kintore, because this was the largest and most electrified, and computerised place in town.Lots of the patients were contacted and agreed to taking part in the experiment.
We were connected by phones and computers with QEH Adelaide so that I could see and talk to many of the interested specialists at the Hospital,either individually or collectively.
I was supplied with, a top of the range, electronic Auriscope (to examine lots of patients’ ears), an electronic Dermatoscope (to examine lots of patients’ skin lesions or rashes) and a super- duper electronic Ophthalmoscope (to examine lots of patients’eyes from front to back including their Fundi).
The live pictures, of all of the areas examined, were seen online by myself, the specialists involved, and monitored by IT technicians and administrators.
Many other specialists watching at the QEH, in the final 2 hour session, expressed interest and asked questions as to the current value and the usefulness, going forward, of the Computerised and video application to their particular specialities.
This is old hat , nowadays, but I was happy to have been at the right place at the right time!
QEH administrators expressed their gratitude to the elders of Kintore,the patients and the Health Service staff, for their overall enthusiasm and cooperation in the project.
We had hoped that, following our success with the project, Pintubi Homelands Health Service would have been able to develop a network akin to that described. Our inquiries revealed an overall astronomical cost of setting up such a system during the next couple of decades or so.
I believe, that from little things, big things DO and will grow.
WHO ARE THE NGANGKARI(Traditional Healers)OF CENTRAL AUSTRALIA? WHAT DO THEY DO? WHAT DID THEY DO IN KINTORE?
The Remote Western Desert is about 350,000 sq km in size. It contains the Lands of the Ngaanyatjarra, Pitjantjatjara, and Yankunytjatjara Indigenous peoples.The Ngangkari are the traditional healers who have nurtured the emotional, physical and social well -being of the people on these lands over many thousands of years.
Mainstream doctors, other health professionals and the rest of the wider Australian community have been almost entirely unaware of the existence and pivotal role of the Ngangkari in these regions.
There are now trusting, shared, partnerships between Western medicine practitioners and the Traditional Ngangkari healers.Their natural techniques. their cultural understanding, wisdom and knowledge of the history of the Indigenous peoples over the last 65.000 years, is of great continuing benefit to Communities.
Indigenous communities in different regions of Australia may use different names for their Traditional Healers, and have different views concerning the nature of illness or the roles played by spiritual matters.
Walungurru (Kintore) in 1996, when I arrived, had four very well known Ngangkari.
I name them, here, out of the great respect I held for them in their own profession, the kindness and understanding that they always showed to me as a colleague, and their abundance of wisdom, knowledge and techniques that they possessed.They had, basically, all been identified by known influential Elders as persons possessed with all of the qualities that a potential Ngangkari should have.They then undertook “training” with one or more other experienced and accepted Ngangkari. Commonly the candidate would have felt, that they were destined for their career and already possessed many of the essential qualities.
I think that strong eyes , leadership, precision of thought, inscrutable perception, empathy and a deep sense of fairness,truth and duty were among the accepted requirements.
1.BENNY PINABOOKA TJAPALTJARRI.
2.DR GEORGE TAKATA WARD TJAPALTJARRI.
3.NYURAPAYIA NAMPITJIMPA(MRS BENNETT).
4.DR JOHN JOHN BENNETT TJAPANGATI.
BENNY led the Pintubi people back from Papunya, to re-settle in their own country, Walugnurru(Kintore), in 1981.The super new Clinic, opened in 2005 was appropriately named ‘The Benny Tjapaltjarri Clinic”,in his honour.Benny occasionally called me”his brother”(meaning special friend, I think) but my skin name, given a little while after my arrival, was Tjapanangka . I was referred to as TJILPI ( meaning “respected old one”) and I added a first name to this, “RAMA RAMA”(meaning “crazy one”).The combination thus read the “Old Crazy Crazy Tjapanangka.”I was quite happy with that name and felt it was singularly appropriate.
DR GEORGE was a character .He roamed the Western Desert treating many, many, people was immensely popular and worked with our team in Kintore from time to time.
NYURAPAYIA AND HER HUSBAND DR JOHN JOHN BENNETT lived for some years in a little humpy house in Kintore, as a measure of their long term sorry business after their daughter died. She was always working in the old Clinic and kept her cash locked up in the 80 kg strong box in the Clinic Pharmacy alongside the dangerous drugs .She was thus assured that it was safer than the CBA or ANZ Banks.
CAMERON TJAPALTJARRI ,Chairman of the Council, spent some time as a Ngangkari in Kintore,as did one of his sons.Cameron had been designated the title whilst in Papunya when the Pintubi people first arrived there from their Homelands in the early 1960’s.
All of the Ngangkari became well known Papunya Tula artists, in the 1990/2001, era with Nyurapayia leading a fine field with regular National and International Exhibitions via Papunya Tula Artists Company.
VALE;- all of these special Indigenous friends and colleagues. Lest we forget.
WHAT DOES “SORRY” REALLY MEAN? WHY IS SORRY BUSINESS SO NAMED?
Most Australians have absolutely no idea what the term ”SORRY “means in the context of a discussion with Indigenous people. I hope that my explanation is OK and acceptable, but , as with all things, I stand corrected if I’ve got it a bit wrong without stuffing it up altogether.
If I say ”I’m sorry ” about an issue that has occurred at some time, past or present, it means that I am really sorry that the event occurred, but it doesn’t mean to say that I personally caused it and should be blamed for it .I am , in fact , acknowledging, what happened, feel really cheesed off about it, empathise with you about it , and will do my best to make sure that it doesn’t happen again.There is a truthful sense that I have given it a lot of thought, and understand that you have certainly been badly done by.
I find that Politicians, in Canberra in particular, seem to want to argue the “blame game” and this perpetuates the problem.
WHAT’S THAT GOT TO DO WITH SORRY BUSINESS AND FUNERALS?
DEATH IS AN ALL TOO COMMON OCCURRENCE IN REMOTE COMMUNITIES, OFTEN AT A YOUNGER AGE THAN NORMALLY EXPECTED.
When you are a doctor, serving in a Remote Community over some years, you notice that , on a very regular basis, people pass away. Whereas it is usually the elderly with many co- morbidities (Diabetes ,Renal disease,Cardiovascular problems, COPD and pneumonia), less commonly a baby, child, young or middle aged person dies.Motor vehicle smashes account for a number, drug and alcohol diseases, acute serious illness and infections a few.
You can understand that in some Communities someone passes away every few weeks, at least, even with excellent locally provided appropriate Clinic treatments and the availability of evacuation of a serious problem by the RFDS to a Hospital in Alice Springs, Darwin, Adelaide etc.
A death in a Central Western Desert Community is immediately followed by prolonged wailing and crying by close family and friends.Provided that there are no unusual circumstances, that require further Police or Coronal investigations, the mourners dress in black (usually) ,apply appropriate Tribal skin paints to various parts of their body, collect samples of hair from the deceased and visit all of the most recent places in the Community that the deceased had been to in their last days of life.The mourners carry small tree branches, with leaves and twigs still attached, and sweep and brush the houses or clinic rooms involved, after staff have been contacted and warned that this will occur.The wailing and crying continue through the traditional cleansing ceremony. This is the beginning of the “sorry” or “sorrow” business.
Communities have designated land, just outside of the main housing and communal areas, which belong to each different kinship or tribal group. All of the deceased available family (local and those arriving from other communities) gather in these areas and set up, very sparse bush accommodation. It is here,in the sorry business camp, that all necessary funeral arrangements are made, by the family elders, and official mourning occurs. A widow or widower,can be contacted there,through the family. The doctor or nurse visits there daily ,or whenever required, providing tablets, medicines,injections and bandages .Nobody at the sorry camp is allowed to visit the Clinic whilst mourning is continuing, though sometimes artists will wile away their spare time painting.
It is customary for all clinic staff to visit the camp on the first or second day. You should whisper ”I am sorry ” to family members, whilst at the same time gently touching the hand of the person you are addressing. An ordinary handshake is seriously bad manners and so is looking the recipient directly in the eye…just look downwards towards the ground and you’ll be right.
Funerals are a matter that is arranged between family and a Funeral director from Alice Springs (in the case of Western Desert funerals). A small plane arrived , takes the deceased back to town, prepares the body for burial and, on the appointed day arrives,weather permitting , back in the community ,for a simple church service. Depending on the status of the deceased there could be 50 to 400 persons in attendance.
After the celebratory service, and burial , most of the people return to the Sorry camp to clean up and abandon it. Occasionally , for personal reasons a few will stay there for days or weeks.
Postscript:-
A few years before my final visits to Kintore, one of the sons of one of Papunya Tula most prolific and famous Indigenous artists, died of Chronic Kidney failure.He had been seriously ill for a long time and declined Renal dialysis for personal reasons.
His famous father prepared a wonderful funeral and send off for him.Hundreds of family and visitors attended the simple Church service and it was a moving experience.
There were seven bearers of the coffin which was carried from the Toyota Landcruiser Sahara vehicle, into the flower laden hall and onto the resting place in front of the presiding Pastor. I was asked, personally, by the famous artist, to be one of the seven bearers of his son’s coffin at the funeral. I accepted humbly, proudly and very tearfully.
THE DEVELOPMENT OF A REMOTE DIALYSIS UNIT IN WALUNGURRU (KINTORE) AND ESTABLISHING “THE PURPLE HOUSE”2004.
In the mid 1990’s, an increasing number of Central Desert residents were developing Kidney failure, and if dialysis was needed, it had to be performed three times a week for about five hours a day in Alice Springs, their nearest Centre.
A common, but not the only cause, of kidney failure was Type 2 Diabetes, and at least 15% of the middle age and older residents had it.
Diabetes has many complications and,initially many of them can be controlled and are manageable in Remote areas with lifestyle changes,patient and family education, compliance and specific medications.
Kidney damage causes raised blood pressure, heart damage,brain damage and other serious issues. A point is reached where the kidneys can’t wash out various poisons from the body,they build up and begin to damage the person all over. When this happens, treatment, with a Kidney dialysis machine, is the only way of getting rid of all the toxins and helps the patient feel a lot better and assists them to live longer and more productive lives.
Now, if you can only have the treatment some 600 km away in Alice Springs, it means that it takes you away from your own Community and country, and also from family and friends who can still live in Kintore.
That’s a serious problem to ponder over, and, whereas some would choose to live in Alice Springs, others chose to live and die, without dialysis back in their own country.
I was involved in listening to, and commenting on, the pro’s and con’s of this dilemma.
Of course, given the choice everyone wanted to have a Dialysis unit in their Clinic. There was a possible choice, of Peritoneal Dialysis, where a tube was connected to the patient through a hole in the abdominal wall and the toxins drained in this way.
I regarded this an an impossible choice in our situation because of a risk of serious infections developing in the patient as a result of poorly sterilised conditions.The method was a recognised and fairly safe treatment in very different ”Hospital ” conditions.This method, however, was much cheaper than full Renal Haemodialysis, where a permanent shunt with an artery and vein connection is made, by a surgeon in the arm, so that it can be connected easily with the machine.
The choice made was the latter, but the initial Clinic and other setting up infrastructure and other immediate and recurrent costs were pretty astronomical.
Kintore had a significant number of very well known Aboriginal artists, through Papunya Tula, an artist owned Company and Board, based in Kintore and Alice Springs.
Major Australian art auction houses ,including Sothebys, auctioned their artworks regularly, The works were sold to purchasers world wide.
I decided to go to Melbourne , meet the Managing Director of Sothebys Australia, and put a suggestion to him as to how Sothebys, in a sensible business transaction , could benefit, both themselves, commercially, and a Kintore Renal Dialysis fund appeal in particular .
The news soon leaked out, politicians ran with it, and within about twelve months an Auction at The New South Wales Art gallery realised a massive $A1.2 million dollars at an auction of four massive Aboriginal Artworks, each approx 12 ft by 9 feet, painted by the men of Kintore,The men of Kiwirrikura, and the women and men of each of the two remote communities.
This money formed a huge initial fund to establish two renal dialysis chairs at the Benny Tjapaltjarri Pintubi Homelands Health Service Clinic in 2004.
The Organisation, implementation and successful ongoing future, of this project ,was, to say the least ,an absolutely massive task requiring someone with outstanding previous experience, dedicated to what could have been a totally thankless task of making a success with a project that had never been attempted before in any remote area in Australia ,let alone possibly the world.
ALONG CAME SARAH BROWN, an experienced Remote Nurse with every single qualification, and more.
Sarah was a mother of three ,and an excellent, widely collected artist of remote landscapes .
Sarah became a superb ambassador to her cause, and, as a part of her bouncy, charismatic character, was able to source funds from a willing, generous network of Clubs and organisations that came to her, from all over Australia, offering financial and other assistance.
Sarah transferred the Dialysis Unit to a purpose built house next door to the Clinic and called it the Purple House, because they painted it purple!
In Alice Springs another Purple House base was set up to complement the one in Kintore and to act as a Dialysis Unit for Central desert patients who went to Alice for various periods of time and who needed regular dialysis.
An Indigenous owned and run business was formed with a Board and Chairperson. The details of how it was developed and continues to expand can be accessed on their website. Kintore has expanded to four dialysis chairs.
By 2020 the Company had morphed into 17 other Central Australian Communities thanks to a dedicated elected Board and to CEO Sarah.
In recent years a “Purple Bus,” fully equipped as a Dialysis unit, and capable of being driven around The Central and Western Desert region , has been purchased and made available to Communities as a travelling Dialysis Emergency facility. A number of famous Desert artists, all of whom had undergone dialysis themselves , generously gave their time and artistic skills to this project. The exterior of the bus is covered, by their Indigenous artworks, and carefully sealed to protect them from the sun.
Sarah has, deservedly, received many accolades, including Australian Nurse of the Year and the Queen’s birthday Australian Medal. She commands great respect in Central Australia as a gifted, fine, special, selfless woman.
SUCCESS WITH RENAL DIALYSIS !! THEN A COMMITMENT TO BUILD A SALT WATER SWIMMING POOL IN KINTORE TO REDUCE SKIN INFECTIONS( and their complications), AND INCREASE COMMUNITY FITNESS LEVELS.
Most Communities have high levels of bacteria lurking in houses,beds, couches and other living areas.Life is difficult, when you try to keep your house clean and in order.Vacuum and other cleaning aids get broken quickly, can’t be mended and are expensive to replace.Showers, baths and hand basins get broken and there is no-one locally who is trained to repair or replace them.
As a consequence hygiene deteriorates, and the bacteria hang around, in and on the skin of every bodily crack and cranny. Small skin abrasions become festered quickly and the bacteria become widespread as a result of heat, sweating,and scratching the itchy skin. Bacteria get in the nose and throat and never seem to disappear completely .Kids with anaemia or low immunity commonly get ill , don’t recover completely and are put on short or long courses of appropriate or inappropriate antibiotics. Resistance to many antibiotics occurs and the whole cycle recurs regularly.
A study by medical students, spending a few weeks at Kintore,with me in 1998, revealed that 50% of all of the children in the school were carrying significant numbers of pathogenic bacteria on their skin or in their nose and throat. Streptococcal, Staphylococcal and Pneumococcal bacteria , in particular, were present.
A proposal was made,by the Clinic Staff and administration, to the Elders,The Council ,School and NT Politicians to consider building a salt water swimming pool in an area adjacent the Clinic.The water supply to Kintore could easily support such an idea and a precedent had already been set to obtain money. Most of the money would be generated by a further sale of a large number of artworks, painted by willing Papunya Tula artists living in Kintore and sold at a well advertised auction in Sydney.An equivalent amount of money would be supplied to the project via budgetary and other sources .
The proposal was excepted and a Swimming pool was built and opened in 2007 on a hot day attracting hundreds of attendees ,many of whom had their first”dip” for many years.
I have many photos of the cherished event.
Some young men became trained lifeguards ,on duty, others were employed as pool cleaners. A little band of happy employed people had been created.Children were allowed access to swim if they attended school .They received a coloured stamp on their hand ,acknowledging that they had been to school ”today”and then raced home for their bathers,had a shower in the pool changing rooms and spent as long as they wanted ,under pool rules, swimming and playing until closing time.
A Bacterial swab study, identical to one taken more than four years, before, was performed on all of the school kids. This showed a huge reduction from 50% of the kids being contaminated DOWN to 8%. Many groups of older people chose to book and use the swimming pool for fitness purposes
An immediate rule was made at the school that ” If you don’t go to school (without good reasons) you can’t use the pool. Additionally, a lot more attention was given to making sure that housing, and other accommodation, was looked after more hygienically .
From time to time things went wrong with the pool. Repairs were done , with more gusto than usual, and , on a long term basis, it provided a sterling example of how employing and applying simple public health prevention programs can, effectively and efficiently, provide an overall improvement in the health of residents in a Remote Community.
Several other remote communities have followed Kintore’s example and now enjoy ”their pool, after school, and it’s benefits”.
IT’S 1998, IT’S CORROBOREE TIME IN KINTORE….I’M ALL DRESSED UP, PAINTED, AND READY TO GO.
What was it that Whitney Houston blasted out ,in song, in 1987?
Huh, yeah, woo
Huh, yeah, woo
Ooh yeah,uh huh, yeah
I wanna dance with somebody!
The four day Kintore sports weekend had finished a few hours ago. Six Communities had brought their best “Footy,” Softball, Spear throwing, and Running teams to take part in a massive weekend of celebrations on and around the Footy field. Young men and women plied their personal and team abilities against each other.
These annual Sports Carnival matches, are fast and furious, and played with a pretty much “no holds barred ” attitude, where winning is everything, and loss of face (metaphorically speaking) is hard to take. Old scores, family and footy ones, are settled as an annual right of passage. In the final analysis, there are winners and losers, lots of gold and silver coloured trophies to take home, photos galore and plenty of bandages applied to fingers, wrists, shoulders, forearms ankles and toes.
By the end, of the Sports, the entire supply of the Clinic’s paracetamol pain tablets and rubbing medicine stock has usually run out, the Shop has run out of everything and so has the garage and petrol pump.
Few people undertake the long drive back to their own Community, until the next day, because of the dangers of night driving out bush.
There is one later celebratory event that most locals and visitors stay to watch. It takes place in the twilight and lasts until about an hour after dark. Seven of the male Elders, perform the traditional Emu dance, and , after they have completed it , about a dozen Senior women, perform a couple of their special traditional dances.
The plot thickened earlier,however, and strange secret words and actions were happening, about an hour before the dancing, behind a group of carefully hidden Toyota’s .
As I passed by, near to the hidden vehicles, a firm voice summoned me with a ”Hey, Tjilpi Tjapanangka, come here, yes come here, now!” I was escorted, to an inner Sanctum sanctorum,by a bearded male Elder ,who was sitting quietly with about six other Elders.They were covered, in Pintubi red dirt soil, all over their visible bodies. In addition they wore red woollen headbands ,which signified power and authority, and had special white paint covering chosen areas of their bodies. Shaped leaves and twigs of bush acacia were then wrapped onto their arms and legs. Finally a small bunch of fronds and twigs were made for each of them to hold and which they they would swing across their bodies as they danced the Emu dance.
I recognised them all, despite the painted flesh, rubbed in red dirt, twigs and headbands.
Spencer,not his real name, was the head honcho. He simply said ”You’re gonna dance with us tonight Tjilpi, we reckon, so we’d better get you all fixed up,ready to go, and teach you how to do the Emu dance.”
Shock,shock. I couldn’t refuse such an enormous privilege. I simply said “Thank you, that’s very kind of you Spencer.” They got on with making the headband, brushing on the paint , red dirt, the acacia leaves and the bits of twig. They painted small areas on my arms, shoulders and chest with specific marks that they carefully watched only one artist apply. I never got to find out why these marks were so meaningful, but it was clearly related to what was OK as far as their absolute correctness was concerned.
It didn’t take long, to work out the steps involved, when performing an Emu dance, and they were happy with my efforts and enthusiasm.
As the sun started to sink, Benny, who was sitting at the front of the crowd, started to play special wooden painted sticks and was then joined by others using slightly different ones.No ones plays didgeridoos at this Central Western desert ceremony because they are not a feature of music in this region.
I was told it was my turn to go to the front, accompanied by one local Elder,to do our dance. It wasn’t instant stardom, but was greeted with happy smiles, laughter and low grade Pintubi clapping.Two others followed , then three and finally Spencer.
Spencer was brilliant,rather like a professional Scottish bagpiper would perform in Edinburgh, only with much more pan-ash , high stepping abdominal fat rolling, and widespread flailing of limbs, but without the hideous, squeezy, wheezy bits that a bagpiper drags out interminably.
After an interval, the Senior women appeared, similarly painted, and dressed in all of the appropriate local finery,
They were well trained, very experienced in performing their gig, greatly appreciated and loudly applauded .Their timing was precise. Darkness descended ,the ladies floated away into the night, everything went quiet and everyone found somewhere to sleep, after a busy, busy long weekend.
My daughter Alicia, a medical student in Kintore in 1998, was at the long weekend celebrations, attended the twilight dancing and took some photos of me ,painted up to the eyeballs .We were not allowed to take photos of my headband, arm and leg bands, twigs and leaves,for cultural respect reasons.
I don’t think that Whitney Houston was thinking about Emu dances,in 1987, when she blasted out her words ”I wanna dance with somebody”.
I doubt whether she, or any of her millions of followers, have had, or will ever have, the privilege of sharing an hour with six experienced Emu dancers, performing in the red dirt, on the stage of their Western desert homelands makeshift theatre.
AUSTRALIANS SOMETIMES HEAR THE WORD “‘PAYBACK “‘ IN RELATION TO HAPPENINGS IN AN INDIGENOUS COMMUNITY. WHAT IS IT? DOES IT OCCUR? WHY IS IT DONE ? HOW IS IT DONE? IS IT ACCEPTABLE IN COMMUNITIES? WHAT DOES “WHITE FELLA LAW “SAY, AND DO, ABOUT IT? DOES IT HAPPEN OFTEN?
“Payback” is mainly an Australian Aboriginal term, commonly understood to refer to settling a grievance, which has been caused by a person ,family or group of people to other persons. A traditional method of satisfying the need for justice to be done is required.
Customary Aboriginal tribal law ensures order and discipline, and this is therefore a means of conflict resolution, thereby, hopefully preventing escalation.
It aims to restore peace to the Community and acts as a healing process .At the end of the day, the result should be accepted and treated with the total respect of the both parties.
Even though payback conflicts with” White fella ” law,it is still widely practised in 2021.
Common causes for a reason to declare that payback is demanded:-
1.Someone has died and there is a likelihood that another person or persons were deliberately involved.
2.A vehicle crash has caused death or serious injury, to a passenger, and the driver ,or another person in the vehicle is blamed for causing the accident.
3.Wife, or vehicle, stealing.
4.Deliberately damaging someone’s car or house by fire or physical means.
5.Serious assault whether domestic ,social or otherwise.
Tribal Elders will listen carefully to evidence,mediation and argument , and ,with their full knowledge of tribal law ,will spell out what payback process should be applied, and where and when it should take place.
Common punishments:-
1.Spearing of a leg or thigh.
2.Fracturing of one or more bones (usually fingers or toes and occasionally forearm or wrist).
3.Running the gauntlet of a number of the affected family members,who are allowed to strike them on the body,usually with a nulla- nulla, and up to twice per member.
4.Burning of the hair on various parts of the body.
5.Duelling, against a skilled, offended, family member whilst protecting themselves with a hand held wooden shield.
6.Financial Compensation after mediation.
7.Exclusion from the Community for a lengthy period of time.
8.DEATH(rarely)
Where is the perpetrator speared?
1.Stabbing in the outer thigh with a specially made sharp wooden spear is the traditional method. It does not cripple.
2.Stabbing to the back of the thigh and buttock.This is directed at the sciatic nerve,is exceedingly painful and causes substantial lifetime disability.
3.Stabbing to the inside of the groin region. This can puncture the femoral artery and cause death from severe bleeding within a few minutes.
What happens if the perpetrator is in prison and can’t be let out?
Occasionally a situation arises whereby a person pays bail, after being arrested, and requests traditional payback before the Court case is commenced. In this case they are pleading guilty by tribal law, receive the tribal punishment and that , clears things up for their family in the Community and they are unlikely to suffer further retribution.However, the Court ,in which they appear later, has no authority ,officially, to reduce any further sentence that they recommend should be served.
If, instead of receiving payback, the perpetrator had run away, and disappeared into another State before the Court case, then the aggrieved family would rightly appeal that the Elders must administer payback to one or more other members of the perpetrator’s family. In that event, it is likely that a son ,( possibly the eldest), would be hauled up and severely punished.In addition the family would be ostracised permanently, and never be allowed to return to that Community again.
I have seen that scenario in another Central Australian Community. It resulted in long term outbreaks of serious,violent and damaging family fighting, house, clinic,school and vehicle burning, and multiple retrievals of injured persons by the RFDS.
Advice to Doctors working in Communities where payback is performed.
I have enjoyed nearly every minute of working in each of my 56 Communities.
ANY DOCTOR working in Central Australia in a remote Community may find themselves involved in payback issues .It is unlikely that you will be asked to attend where and when the payback is taking place. It is quite likely that a friendly Elder will ask you to make sure that you are around , at home ,on a particular evening, just in case there are any problems out bush where”some people” have got to go to tonight. It’s a bit like a serious “”Nudge nudge, wink wink, know what I mean” Pythoneque scenario. You will already have worked out that you have, pretty much, all of the medical knowledge, bags, bandages, bottles and other bits to deal with, whatever occurs.
Most likely you won’t see or hear anything because people tend to disappear quickly after receiving payback.Family and Aboriginal Health workers respond magnificently and it is a big shame job for your patient.
Honour has been restored and expensive lawyers dispensed with.
Just respect the Aboriginal ,cultural ,traditional tribal ways of doing things, don’t get involved in criticism, unnecessary interference or public reprimand…just do your job cause that’s what you are here for!
POSTSCRIPT.
In 2008 the Alice Springs Hospital Emergency Dept,when The Head of Surgery reviewed their Emergency and In- Patient operative statistics, noted that, during the previous seven years, 1550 stab victims were treated at the Hospital and 99.99% were Aboriginal persons. The domestic violence related stabbings annually were 390 per 100,000 persons and 30% of the violated women were under the influence of alcohol .The local newspaper justifiably screamed a headline ”ALICE SPRINGS, THE STABBING CAPITAL OF THE WORLD.” It must have been true because I read it in the Courier Mail and heard it on the ABC.
Neville Shute’s 1950’s novel ”A Town like Alice”,was filmed mainly in Pinewood Studios UK, with a few locations added in Malaya and Australia. It is often said that people reading the last page of the book shed more tears than when reading any other book in the English language.
If Neville Shute were alive today, read the 2008 Courier Mail head line”Alice Springs the stabbing Capital of the World”
and listened to the ABC report, I guess that he would shed enough tears to start the Todd River flowing again and keep it flowing for another 70 years.
IF YOU ARE A DOCTOR, WORKING IN REMOTE COMMUNITIES, ALWAYS EXPECT THE UNEXPECTED.
The following FOUR stories, are all true, not embellished, and occurred in different Communities in the years 1999-2009 The names of the persons involved have been changed, for cultural respect and ethical reasons. There are important messages to be gleaned from each event, whether you are a doctor, other health professional or lay person.
1. BELT UP AND GET A LIFE.
In 2009 whilst working in an extremely remote Community, I was standing next to the clinic Ambulance preparing for a non-urgent evening house visit . An ageing Toyota Trooper Landcruiser vehicle, travelling at 80+km per hour, flashed past, and, after just avoiding me, within 5 seconds ,was impaled against a live power pole. It rolled onto it’s side, leaving the power pole angulated at 45 degrees.
A large number of community members came rushing forward to view the scene and offer help .Within 30 seconds I was at the scene ,with the Ambulance and a couple of trauma treatment packs. Within a minute my skilled nurses also arrived.
So what do you do ?
The Golden rule for attending medical Emergencies like these is, to NOT PANIC, and remember and apply your DR ABCDE formula .
D is for Danger. In this event you cut off the power to avoid Electrocution. get rid of the smokers ,(who have already possibly lit up their cigarettes), so that any spilled petrol doesn’t cause a fire. Also get everyone to move a very safe distance away .
The single occupant of the Toyota ,in this case ,was Andy, who was lying on his right side ,in a foetal position. His legs were trapped underneath the pedals ,the steering wheel was collapsed ,he was still, fortunately wearing his intact seat belt, and there were no airbags to be seen. I put on some protective gear.
R is for Response .The only response, to my simple questions, were groans. Even when I shouted loudly he was unresponsive to questions.
The local Community based Police arrived , and cordoned off the whole area.
A is for Airway. Andy’s bull-neck was fully flexed .Tilting of his head was not attempted so as protect his cervical (neck) spine. A simple chin lift was applied and it was then possible to open his mouth, note whether there were any fractured teeth, or other objects obstructing his main airway. His immediate clinical observation signs indicated a reduced oxygen level at 88%,a rapid pulse level of 142/min, a slightly increased breathing rate and a reduced blood pressure at only 90/60.
Statistically these findings, combined with unconsciousness and a serious accident mechanism and speed, would indicate that he may have serious injuries ,even life threatening ones , even though he was wearing an unbroken seat belt.
It is very difficult to enter a vehicle, which has rolled and crashed ,and be certain that all of your initial survey of the situation , is 100% correct. Andy had no obvious head bruising, but his dark, Aboriginal skin colour would have made this difficult to assess .There was no evidence of bleeding from his ears ,nose or throat and his pupil tests were normal.
We had popped on a cervical collar to protect his neck, put in a large iv line and run in an initial one litre of Normal Saline. We also gave him high level amounts of monitored oxygen.
B is for Breathing . His chest expansion was normal and without any signs of a punctured lung. His abdomen did not reveal any serious immediate damage.
C is for Circulation. Was he bleeding outside or inside ?..Outside, nothing obvious,, Inside we didn’t know.. so we monitored his heart rate and blood pressure.
He remained unconscious for 40 minutes but his oxygen levels and blood pressure came back to normal.
He needed to be extricated from the vehicle because his head was stuck against the squashed roof. A fireman arrived with extricating equipment and tried to remove Andy.
All of a sudden Andy, a 98 kg garrulous character, who had served several periods of Correctional Time, woke up and spluttered in a confused voice…..”I need a fucking piss, get me the fuck, out of here.” I quietly assured him where he was, and that everything was OK, and that we would be getting him out of the vehicle very soon. In the meantime I suggested that he might pee in his trousers because we couldn’t get a large plastic pee bottle to him.
Andy was confused and impatient. Even though he had all of the emergence equipment still attached to him, he wiggled his toes, then his feet, flexed his huge thighs, ripped off his neck collar, pulled out his iv drip line and tore off his life saving oxygen mask. Little by little he extricated himself ,flailing his limbs at anyone else in his bid to get out of the Toyota.
He stood up ,had a massive gushing pee against the door of the Ambulance and was escorted ,staggering , onto the Ambulance trolley.
D is for Disability…none found so far.
E is for Environment….a hot summer’s evening.
We expected Andy to collapse , but he didn’t . Within 10 minutes minutes he was in the Emergency room with all of his Emergency equipment re-attached and all of his wet clothes removed and replaced with warm ED blankets and sheets. He was surrounded by a large number of wailing family members and other, insistently immovable onlookers .
We did another complete reassessment on him and added other simple appropriate tests. All of these were normal and , apart from complaining of fairly widespread non -specific pain, Andy was ready to go home.
I discussed his story and findings ,with a Senior Alice Springs Emergency physician , and , unsurprisingly, we all felt that he needed to be flown into Alice Springs by an RFDS Emergency Evac flight. We were looking for any injuries, that he might have be sustained, that were hidden away somewhere without them being obvious clinically, for example fractured ribs, bleeding inside his chest or tummy, a fractured vertebra were high on the list of possibilities. He had been unconscious for over 40 minutes so here was another red flag… could he have a brain injury?
Andy was sure that there was nothing wrong with him and argued bitterly until the local Ngangkari ‘doctor’ came in and told him he must go to Alice Springs Hospital, to be under constant observation , at least overnight.
Andy spent a few hours at the Hospital, and, after further tests and observation , was discharged at 8 am the next day with some paracetamol pain tablets and some written instructions .
When Andy was leaving the Hospital, he was met by two burly Cops. They were inquiring about the large amount of alcohol that was found, in a secret area, tucked away under the floor of the back of the Toyota that he had crashed.
Andy served a further period of Correctional Time for multiple related offences, before returning to his Remote Community.
2. SARA CATCHES A DEADLY DISEASE ON THE WAY TO HER AUNTIE’S FUNERAL.
I had returned to work for a few weeks at one of Australia’s most remote Aboriginal Communities. I knew the people here well but , as always, was prepared to expect the unexpected .The events unfolding on this day were, however, VERY unexpected.
Late one evening, a family of 23 persons , various ages from 2 yrs to 71 years arrived in the Community, having travelled 160 km in two large, substantial, but well worn, vehicles . The following day they expected to travel a further 170 km to another Community, where an important family member had died, ‘sorry business’ was taking place, and the oldest member of the travelling family , was ,as a Pastor, in charge of the Church service and associated ceremonies.
At 9 am the following morning they were all ready to move on when 6 years old Sara had a major convulsion affecting her whole body. It had lasted for a few minutes. She then woke up feeling drowsy, confused and hot.
None of the family could, or would, volunteer a complete description of the convulsion and I was told that she was “a hot one” (ie. she had a high temperature).
High temperatures are common, in Aboriginal children, and are sometimes accompanied by a febrile convulsion. These were our initial thoughts before Sara arrived at the Clinic.
She was a little drowsy, and no longer fitting.
Her temp was 38.8 C, Heart rate 140 per min, Resp rate 24 and Oxygen Sats 98% on room air. Nothing unusual.
Her ears ,nose and throat appeared normal apart from an early Rt ear infection and a yellowish nasal discharge.
Shy was shy ,drowsy and cooperative and the rest of the examination of her systems was entirely normal .She didn’t have a stiff neck. Her skin was entirely normal and a simple urine test, Hb test and blood sugar were normal.
Because of her longish convulsion I gave her an anticonvulsant medicine( Midazolam ) into a muscle and some paracetamol medicine by mouth.
The other 22 family members were happy with the treatment but kept asking, ”When can we go ? The funeral is really important. We gotta go soon Doc!”
Both the Nurse and I decided that, since the family were due to travel a further 170 km ,to the funeral, we should exam Sara every 15 minutes .Forty minutes after her initial arrival in the Clinic, Sara was sleeping peacefully following her Midazolam injection. I did another complete examination and , even though everything seemed generally alright , I discovered three tiny red spots, each the size of a pin- prick on the skin of the right side of her lower tummy.
The only case of Meningococcal meningitis I had ever seen, in 48 years of Medical practice were in Tertiary Hospitals where the patients had been admitted suffering from extreme skin loss, and a combination of loss of an ear, tip of the nose, a couple of fingers and a toe.
Such is the ferocity of the toxins, of widespread Meningococcal disease, that death is almost inevitable at that stage of it’s development. The possibility of a fever, even without a stiff neck, a convulsion and a few little red spots, prompted me to consider that this was a very early stage of the deadly disease.
We treated her immediately with appropriate, best practice, intravenous antibiotics and left two iv lines in place, in case one got damaged at any time.
After a chat, with the RFDS Doctor on call, he arranged and confirmed a Code 1 Remote evacuation flight to Alice Springs Hospital. That meant that the plane would leave Alice Springs, and be in the air within 45 minutes.
Nurse and I performed all of the other required investigations and treatments prior to Sara’s flight.
After a flight time of 75 minutes, our plane arrived . Sara was comfortably packed onto a bed accompanied by a wise ,instructed family member. The pilot landed his Pilates plane and Sara arrived at Alice Springs Hospital two hours later. A Consultant Paediatrician and Paediatric Flight Nurse stayed with her throughout the flight.
Within 30 minutes of noticing the first little red spots on Sara’s tummy, they had spread onto her groins and both wrists. After four hours in the Paediatric Intensive Care Unit in Alice Springs they were covering about 50% of her body.
She was evacuated and transferred to an Adelaide Paediatric Special Intensive Care, early the following morning in a specially equipped RFDS plane.
After four days of Induced coma Sara was sitting up in bed watching Sesame Street on Television. She had to have minor surgery , to remove some dead skin on her tummy, a few days later but did not need any plastic surgery.
I was able to speak with her treating Team in Adelaide, twice a day, and then talk to her mother every day about Sara’s excellent progress. Mum, of course, was with her the whole time at the Hospital.
What about the other 22 members of the family? Did any of them catch Meningococcal disease from her?
When I told the family that Sara needed to have immediate Hospital treatment, I also said, that because they were all travelling close together, it was possible that one of the others could get it as well. The grandfather ,who was the Pastor and Head of the family ,listened very carefully, talked to them all, and gave us permission to give each of them a injection to stop them getting it . We were lucky enough to have a sufficient supply of the special preventive injection to give to each one. The Ceftriaxone Intramuscular injection, combined with lignocaine is a horrible mixture to push into a muscle. They scarcely batted an eyelid and we succeeded. Then they all went to back to their beds, dragged themselves out in the morning ,hopped into their noisy, rickety vehicles, and, after 170km arrived , to attend to their ‘sorry business’ duties at Auntie’s funeral. It is incredible how resilient Aboriginal families are, especially when confronted with difficult situations, and, particularly where family loyalties are involved.
What happened to Sara? Did she have any long term physical or intellectual disabilities as a result of her illness?
Three months after she had been discharged from Adelaide Paediatric Hospital, I was having a coffee near the Papunya Tula Aboriginal Art Gallery in Alice Springs. Sara’s grandfather came and sat with me and we shared some sandwiches. Sara was ”Palya” (meaning ”fine”).She was very happy, had done well at school and played softball a lot. I could see how important it was for him to tell me. As he left, he whispered “Thank you Tjilpi. ”
Their Community is 290 km from Uluru. I have not, as yet, been able to take up a long standing invitation to drive the dirt road there and share a kangaroo tail and a cup ‘from the billy’ with the family. Here’s Hoping!!!
3. MY MENTORS ALWAYS TAUGHT ME, ” NEVER GET LOCKED UP, ALONE, IN A CLINIC ROOM WITH A DANGEROUS PSYCHOTIC WHO IS BRANDISHING A WEAPON”. I NEVER DID …….UNTIL I WAS 62 YEARS OLD !
It was the fifth time that I was visiting this particularly very remote NT Community. I was staying, and working there, for 4 weeks. Previous visits had had their moments of unexpected happenings, though never any to match what occurred on Easter Tuesday afternoon.
I was alone, in a 12ft x 8 ft Clinic consulting room. The rest of the team had finished work, packed up and gone home.
Suddenly, unannounced, Ivor (not his real name) staggered in. Ivor was a 32 year old Aboriginal man who, historically, was feared in the Community for his aggressive personality and his short temper. He was carrying a 1 metre long x 5cm diameter steel pipe.
Ivor had spent a few months binging, in an alcohol permitted town, and yesterday had returned home. He was experiencing paranoid delusional alcohol withdrawal symptoms .His speech was very slurred, but he managed to indicate that Johnno, the senior male health worker, was chasing him with a spear and was going to shove it into his leg.
Johnno was, in fact, chasing Ivor with a syringe full of 10mg of Valium to sedate him, reduce some of his withdrawal symptoms, and workout a plan to assist Ivan’s mental health and dampen down the Community’s concern .
Ivor raced into my room, slammed and locked the door, and stood upright guarding the door and cursing Johnno at the top of his voice. He defiantly refused to part with his steel weapon.
About 9 months previously, Ivor had locked himself into the same room when he consulted me about his excruciatingly painful, swollen testicles. He had locked the door, on that occasion, because of his embarrassment and shame at having a serious gonococcal infection. which I cured with a course of painful antibiotic injections into his buttocks and other additional treatments.
I had to admit to myself that I was, to say the least , in a bit of a pickle, but that , traditionally I should stay calm. I recall wetting my trousers and suffering a burst of unpleasant palpitations, but felt that reassurance was the correct ploy to adopt and might help both of us.
He gripped tightly onto his steel pipe so I detracted him by asking if he remembered how well I had looked after him when was suffering from his “great balls of fire ” infection on my previous visit last year. During the distraction I managed to slide my chair a little and reach a box containing some vials of 10mg Valium injections .
Ivor was trying hard to recall his “great balls of fire” consultation. It gave me enough time to put 30 mg of Valium in a syringe and stick a sterile needle on the end of it.
He now seemed a bit more comfortable. There were clear indications of de-escalation occurring. I promised him that if he let me give him a strong sedative injection, which I had in the desk drawer, it would get rid of the voices and get him feeling better, quicker.
He took the injection without any problem. Unfortunately even in a biggish dose the Valium would take about 30 minutes to settle him down.
In the meantime Johnno had driven off to fetch the Community’s elderly Ngangkari, a highly respected Traditional Healer.
30 minutes after the Valium and distracting conversations, Ivor sat down on the only other chair in my room, still tightly holding his steel pipe. Moments later an Indigenous voice, with some command behind it, demanded that I should be allowed to open the closed , locked door. I opened it , the Ngangkari strolled in, put one hand on top of Ivor’s head and Ivor fell asleep and started to snore. He dropped the steel pipe, which Johnno retrieved, and a crowd of onlookers appeared in the clinic to witness and broadcast the success of the Ngangkari who had rescued the doctor and cured Ivor of his affliction!!!!The powerful charisma of the healers is such that exceedingly anxious persons are put into hypnotic and post hypnotic states almost immediately.
The next day I drew up a management plan, for Ivor’s ongoing withdrawal treatment. It was complex, standardised , personalised and successful.
The Community opinion, around the traps, was that Ivor’s succumbing to sleep was the direct and immediate response of the touch on the head by the Aboriginal Healer, a result seemingly unattainable by the white fella doctor. I endorsed that perception because that was the right thing to do.
Ngangkari treatment is still , rightly , very powerful in many Aboriginal Communities and is a highly respected and sought after alternative treatment. Mental health problems , their causes and treatments, are often difficult for Western trained doctors to comprehend and treat appropriately because of the different social determinants and cultural and family relationships that contribute in Communities.
SO, AS A MENTOR, WHAT ADDITIONAL ADVICE DO I GIVE TO MY STUDENTS AND YOUNG DOCTORS IN THIS SITUATION THAT I SEEMED TO HAVE SUCCESSFULLY STUFFED UP IN MY DOTAGE?
Clearly the advice is the same , yesterday , today and tomorrow, about the dangers and the need to be cautious and alert to the problems.
In 2021 all practices need to be equipped with structural alternative exits, furniture positioning allowing the doctor to be the closest to the exit and secret alarm mechanisms or codes which alert receptionists and other colleagues that a tricky situation might unfold. Our own personal management of any mentally disturbed client needs to be well- rehearsed and entrenched but flexible enough to cover any circumstance. Accredited GP practices in Australia require the implementation of specific processes which deal with these matters correctly. Emergency Departments in Hospitals have strict ,well rehearsed processes, which are necessary, in the current age of ease of access to known and unknown recreational and other drugs available to the public.
POSTSCRIPT:-
I attended a one week Diploma of Hypnosis course in Sydney conducted by Dr Alan Fahey, Psychiatrist, at the College of Medical Hypnosis. I attended follow up Advanced Courses there as well. I found Alan’s course very stimulating and very practical both in relation to mental health conditions, that can easily be treated in General Practice, but also in the use of personal Advanced Self -hypnosis in Remote Communities and, in particular when working in Saudi Arabia during and after the first Gulf War 1989-94.
4. EAR’S THE PROBLEM DOC. CAN YOU FIX IT?
Ross (not his real name) watched me close the Clinic door, hop into the Troopie, drive home 400 metres to the Doctor’s house , hop out, pop into the house and shut the door.
Five minutes later he was hammering on the door, leaving his best mate in his rust bucket with the engine still running.
It was 6-15 pm , and I had hoped that , barring an Emergency, I might have been able to settle down and watch Collingwood v Richmond live on the telly.
Ross looked sheepish and embarrassed .We knew each other well. I had looked after a lot of his family during my many visits to his Community over the years.
He was wearing his yellow and brown Hawthorn supporters beanie, his head was tilted somewhat awkwardly to the left and, underneath his beanie was a heavily blood stained grubby collection of cheap and tatty bandages held together by black electrical tape. Rather than bursting forth with a barrage of surprised expletives, I simply said “I see Ross!”
It was Ross who burst forth with a combination barrage of expletives , initially in English followed by more in language.
“Shall we have a little look Ross, then we can slip into the Clinic, via the back door, and try to sort it all out for you? ” I suggested.
Both Ross and his mate nodded and grunted approvingly.
We carefully unwound Ross’s maharajah -sized turban to expose a floppy left ear which had struggled to keep itself attached to the side of Ross’s scalp and skull during the 3 days since someone tried to cut it off with a broken glass beer bottle. There had been a fight outside of an Alice Springs pub, late at night, 2 nights ago. His medical notes would later describe his version of the events. I would imagine that he was fearful that the Police would pick him up, if he had gone to the Hospital with his injuries, and , therefore the convenient thing to do would be to run away, get the hell out of Alice Springs and make it back home asap.
At the Clinic, Ross apologised for ”stuffing up your footy game on the telly, Doc.”. He told me that, after his mates and their girl friends, in Alice, had cleaned him up a bit, and stopped the f…..g bleeding with pressure from all of the f…..g bandages, he sobered up and wondered ”what the f..k should I do?”
It took me a long time, to work out, which bits of the rather shredded ear belonged to which other bits, much in the same way as you select possible pieces when sorting out a jigsaw puzzle. I cleaned up everything carefully under as sterile conditions as possible, given the history and the present circumstances.
I had never been confronted with this kind of surgical dilemma before.
I had heard that the nerves supplying feeling to the ear came from at least four different sources and that all of them needed to be numbed by local anaesthetic before doing anything else. I had to search through a big book about anaesthetics until I found an illustration of an ear with every nerve pathway demonstrated.
Ross was scared stiff of needles, he said, and almost left the Clinic without us proceeding any further.
He accepted a large combination of a very strong sedative and a very strong painkiller and fell into oblivion about 10 minutes later.
He was still fast asleep, and unaware of what had happened, when I put in the last of the 23 stitches to his ear and surrounding skin. I had no way of predicting what level of result he would get.
He woke up, I took him home to his family and drove the Troopie back to the Doctor’s house. Collinwood had lost to Richmond by 28 points, and the match had finished over two hours ago.
I had explained to Ross, very clearly, that he MUST come to the Clinic before lunch tomorrow, so that I could have a good look at his ear. I told him that I would need to see him ,without fail , every single day ,including the weekend, for the next 10 days.
I wrote up his medical notes meticulously in the Clinic the following morning. Ross failed to come to the Clinic and could not be found in the Community. After a second and third day of non- attendance a Health worker told me that Ross and his mate had gone to Balgo some 250 km away. A call to the Balgo clinic and a search in that Community failed to locate him, or his mate. I talked to his family, fully and frankly, but no-one admitted to knowing where Ross was. They realised that I was concerned about his well being post- surgery and that there was an urgent need to reassess him.
I suspected that Ross was still running away from the consequences of his fight in Alice Springs. Police and others can usually find someone when it is really necessary….”The Bush Telegraph is pretty reliable!”
POSTSCRIPT:-
Months later I was in Alice Springs again. It’s a small town and news travels fast. Ross’s Mum strolled up to my coffee table. “Hey Doc, Ross is up the street, I’ll bring him down to see you eh?” she said shyly. Five minutes later Ross and his mate arrived.
“Hello Ross ,how are you travelling?”
“F…..g brilliant, Doc, thanks to you mate, “he said ,with the nodding approval of his mate. Ross bent over and peeled off his yellow and brown Hawthorn supporters beanie,inviting me to have a peek at his right ear.
His jig saw puzzled ear was pink, intact, and no longer drooping. The cartilage had regrown and everything had reattached.
He disappeared before I could ask him who had removed the 23 stitches . I never did find out.
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