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February 28, 2012

Day 6 of the Australian Journey 2012

By Lewis Mehl-Madrona

Today is Day 6 of the 2012 Cultural Exchange Adventure in Australia. It was also the first day of culture camp at Boole Poole with the aboriginal coop. The driving rain prevented our crew from Northern Australia from doing much outside. We had planned a sweat lodge ceremony but that was cancelled also due to the rain. So instead, while we tried to stay dry, I interviewed the new doctor at the Coop.

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Today we arrived at Boole Poole, the ancestral land and burial grounds owned by the aboriginal cooperative for the formal start of Culture Camp 2012.   Several of us were wearing Culture Camp 2011 T-shirts in bold red, black, and yellow, the colors of the Australian aboriginal flag.   Boole Poole is only accessible by boat which was a rough ride in a rainy sea.   Flocks of pelicans sailed overhead, experts at riding the currents of wind.   Black swans floated gracefully on the swells, while young cormorants appeared to be walking on water as they got out of the way of the boat, flapping their wings faster than imaginable.   The rain had begun as we unloaded the boat at the pier.   By the time we had pulled the trolley with our things to the house, it was a downpour.

 

The food at Boole Poole is continuous and one meal runs into the next.   Looking for an alternative to eating, I decided to interview Miriam, the newest physician to work for the Aboriginal Cooperative and their first and only full-time physicians.   My colleague, Rocky, had already spent time with her on his last journey to Australia when he consulted to the physicians who worked for the Cooperative.    The rain drummed on the roof as we talked in the living room of the house while most everyone else watched films of aboriginal dancing from the community at Mullingimby, the home of Shadow and Lily.

"How long have you been at the Coop now?" I asked.

"Since last August, 2011.   Now, it's six months."   Miriam answered.    She had trained in Brazil and had practiced for some time with aboriginal people there.   In Brazil she had a catchment area of 4000 people.   She worked for the public medical care system.   In her clinic, she had four health workers, one nurse, and her.   I wondered how it was to have that many families under your care.   She said it was a matter of doing the match.   In any given month, one expects 4% acute care visits.   She used the morbidity tables for the percentages of chronic diseases in her practice to calculate how much time to allocate for chronic disease care.   Time was very scientifically managed.   Next I asked her what was her biggest challenge in coming to the Coop in her first week.

"My first week was one of introductions and cultural awareness.   I was taken to the different sites I needed to know about; taken to meet the people with whom I would be working and whom I would be calling. They (the coop) introduced me to elders.   That first week was also an introduction for the community to me.   It was a pleasure.   They believed it was fundamental for me to understand the geographical space in which the patients lived.   They were open to all my questions.   They introduced me to all the places that were important to know.   The two aboriginal health workers did that -- Shane and Judi Ann.   Judi worked with the midwife and could bring her all the issues with pregnancies in young people and what they need, their expectations.   That was my first week." I was impressed with how culturally sensitive the Coop was to Miriam.   I hoped we had contributed something to that awareness. Then I asked Miriam about her second week.

"During my second week I was in the unit of my mentor, Dr. Jane Greason.   She was able to introduce me to the program and what they had been doing in the community.   She has been there more than 12 years."   Then I asked her what other doctors work for the Coop.

"Dr. Greason is my supervisor.   There is Dr. Gene Wofurt who was raised in Bairnsdale, then Dr. Schoefeld, and Dr. Black.   We have two offices at the health center.   Usually only one session or two sessions occur at the same time."   I learned that the other doctors had contracts with the Coop and did their own billings.   Miriam was on a salary.

"My challenge is, not by the production, but to help people get well.   I am not billing medicare like the other doctors who have to see patients one after the other, 1, 2, 3, 4.   I have A, B, and C consultations.   An A consultation is scheduled for 10 to 15 minutes.   B is 40 minutes and C is one hour.   Because we have the other doctors, if I have another doctor at the unit, the other doctor does their patients and I do the health assessments with the aboriginal health worker and do the gp planning."   I hadn't heard the term "gp planning" so I asked what that was.   Assessments are always category C consultations.

"After the assessment, you have at least some idea of the risk factors, medications, and social information.   That supports the gp planning.   We identify the patients with the chronic disease and the special needs.   After that, you have to work in a way that you agree with the patients and negotiate with them what can be done and how.   We set some goals between us.   I have to write this down.   That is the product we call GP planning.   The Coop is a very special situation because they have more than just general practice.   They have the family service, the alcohol and drugs follow-up, the midwifery service, and many more community outreach services.   With these special services, it's easier for us to go further than a simple gp plan in mainstream medicine.   There they have hard work because they don't have the facilities to refer as I have here.

"When I arrived in the heatlh center, I realized some of the aboriginal health workers were not having time with the doctors.   Every doctor had a small time with the patient.   I started doing the health assessments with the aboriginal health worker and the patient together.   I also did the gp planning with the patient and the aboriginal health worker together.   This seemed like a natural way to do this. It would be a longer appointment if we did it together, but we would get so much more done.   It is the job of the aboriginal health worker to visit the patient in the community and to make sure the plan that we have negotiating is being implemented.   If I cannot finish the gp planning with the patient, I will finish it with the aboriginal health worker.   Sometimes that's necessary because I didn't have all the necessary background.

"We have a clinic coordinator who is a nurse practitioner and we have Leslie who is a nurse practitioner who is more responsible for immunizations and wound management.   She's a more unit centered nurse.   Another nurse does diabetic education.   We have another midwife who works with Liz Boyer, who is one of the doctors responsible for antenatal care and deliveries at the hospital.   The midwife is a nurse, too.

"After gp planning, I keep in contact with the aboriginal health worker to be sure every action that we have planned is happening.   In that stage I had some concerns because the aboriginal health workers belong to the families.   If I have a male patient, they have male business and they will be ok with these patients, but if they belong to other families, maybe they will not be ok.   We lost one aboriginal health worker because she couldn't do the male business.   Judi worked with the midwife and had good support in the women's business.   It's very hard because you know they belong to their families and sometimes they don't want to get involved in other families' business.   I have to be very careful, because I don't know where I am walking.   Some of them are close to these patients.   I have to be very respectful.   Once I went to aboriginal health worker and said what I wanted to do with this patient and he said, doctor, I prefer not to work with this patient, because she is my wife.   He could help her as a husband but not as a health worker.

"Patient confidentiality is minimal.   Everybody is a relative.   You have to be very careful what you have as a goal.   What we have to do is ask the patient.   I have the opportunity to talk with the patient myself before we discuss things with the aboriginal health worker.   I explain what is a good aboriginal health worker and they agree with me.   Then I ask them if they are ok with who will be assigned to them.   Some of them don't accept the aboriginal health worker."   I asked Miriam about the challenges to health in the community.

"People in the community want to be heard.   They have a hard time with drug addiction, alcohol, domestic violence, but when you open the door, they go through it.   If you listen to them, they will tell you things which will give them some relief.   I remember one patient who was very upset.   In their community, it's not normal practice to have an elder in a retirement home.   She was very upset with that.   She came for high blood pressure.   She was very upset.   She was fighting with the family because one of the sisters got the guardianship of their mother.   The sister wanted their mom in this specific retirement home.   I started to treat her blood pressure but I knew the stressful situation was    part of what was raising her blood pressure. Part of my job was to be a problem solver strategist.   To help her make small changes to cope with the situation was what I needed to do.   She is still working through her issues but she is changing.   She asked me to support her with her alcohol issue because that was why her mother was in the retirement home.   She was not able to take care of her mother because of her drinking.   She was then able to go to alcohol treatment.   She could choose an alcohol counselor. " I have this problem and how can I solve with the resources we have here.'   Now her mom is in the retirement home and she is struggling to cope with alcohol problems and she accepted the situation as transitory because she wants to recover so she can take care of her mother.   She is in the middle of her process now.   She has access to the consultations.   Every time she needs to contact me, I have an agenda for her to come every week as a crisis like, trying to support her in this journey.  

"Second I have a list of resources we can present to the patient.   Patients can choose what they want.   If it's housing, I have people who can help with that. One of her [the above patient] issues was that she didn't have a house.   She got connected to the aboriginal legal services and I could do a letter supporting her for housing.   It was important for her for the crazy stress.  

"The aboriginal health worker is very important, because they know how to work the system.   If the patient doesn't allow me to contact the aboriginal health worker, I have the list of the resources and I ask the patient how to help them.   Sometimes they say it's impossible.   They give me the limitations.

The nurse coordinator is also from the community.   She helps me work at the hospital.   She knows the system too."   Next I asked her about mental health issues she had seen.

"This man had complaints for at least the past 10 years.   Not acute.   He was hearing voices, and the voice was telling him to do something dangerous for himself and for others.   I was concerned about that.   He has alcohol issues too.   I contact the nurse from Tendara, the coordinator of Tendara Alcohol and Drugs.   They also have a counselor.   In that stage, I contact him and I start to work with the staff in the Tandara House.   We start to work with this patient.   He and I went to the clinical mental health triage because we thought it was an urgent matter to assess this patient.   The clinician assessed him.   He had an assessment by the end of the week.   The patient was concerned about the very intense voice.   He had fast speech and was aggressive.   We started with olanzapine 2.5 mg and the voices decreased at that stage.   [That's a very low dose by U.S. standards!)   He gets a follow-up every day either by the nurse, the aboriginal health worker, me, or the mental Health clinician."

We were impressed with the community based support.   Both Rocky and I commented that we had nothing like this in our practices to support us with our risky patients.

Miriam continued, "Sometimes here the patients are in jail because of their mental health problems.   The police don't know what to do.   They're worried about safety and they are scared.   Once we had a fight in the community.   They don't want to go there because they know it's two families fighting.   They don't want to get involved.   They went to us to get the training.

"I started to do home visits on Thursday and Friday.   Some patients don't like it because they want to have their party.   I went to one home.   "Look doctor.   I already had four beers.'   Some of them are alcohol but they drink as a community event.   It's specific houses.   They put out high levels of sound.   They are very nice.   They say, "Don't come here Thursday or Friday.'"  

Rocky pointed out that Miriam had instances of working with elders in the community that had gone well.   He knew that from his previous visit to consult to the physicians.   Miriam added to that:

"When I arrived here, I didn't understand the concept of elders.    With time, I understand.   I went to some meetings they had and the elders are there.   I was invited to a meeting with the governor.   Uncle Albert was there.   Elders were there.   I asked about some of the elders looking young.   Marion, an elder, told me about some of the families who have these specific people as a role to be taking care of the community.   Sometimes Marion brings the case and tells me what the patient needs.   I listen to her.   When I come to the patient, I take the issue to the patient.   Marion is an aboriginal health worker too.   Uncle Albert is another elder.   He told me whenever I need something, call him.   He explained to me the relationship among the families and within the families.   Some elders bring the patient.   They are taking care of the community."

Are there instances where you've been able to connect patients with their traditional healers?

"They are not open.   That is the first time.   With your consultation I have more contact with Marion because of my background with her.   I had contact with Elaine, another elder.   She was very strong in the bush medicine.   She invited me once to go but I didn't have the real opportunity to go there.   Death is very common here.   Since I arrived here, every month I have one death.   First month was Linda T.   I had seen her at the hospital.   She had aspergillosis and a big cavity.   She came to me and was so nice.   She told me that you have a lot of work.   She knew she was at the end of her life.   Last week we had another funeral.   Every month someone has died usually of chronic disease complications.   They have grief.   They have been missing some important people in the community.

"The traditional healers are still elusive but I know who some of them are.   It's a gradual process, but there is movement in a good direction for me to know who they are."

Rocky noted that Miriam builds relationships with the people.   She said that she sees that they watch her.   "They want more black people in the health center.   They want less white people.   A good elder is Bonnie, a hospital liaison.   Bonnie is very important for me.   Bonnie is another person I ask about very sensitive issues because she is very knowledgeable about the health system and she is an elder.   She started the Coop.   She was one of the original circle of women.   Marion was the other.  

"I remember a patient who came from Queensland with abdominal pain.   She had pinpoint pupils every time she came.   I sent her to emergency.   They gave her naloxone and the pinpoint pupils returned.   Bonnie came to me and told me they are using morphine.   I sent her back to the hospital.   That way, it was easier to understand what was happening with the patient.   Bonnie brought me the problem.   She knew the patient and her partner.   Her abdominal pain was actually narcotic withdrawal.   Tramadol was there too.   It was lovely to have her as a patient.   I remember when she decided to talk to me about the issue.   She said, "You cannot help me'.   She told me she would go back to Queensland.   It was more issues than even I could help.   Her husband came once and was very upset with me because I took the medication from the hospital and held it at the hospital.   He was so upset because he wanted that morphine.   I told her this was not the medication for her (morphine).   She was abusing morphine, then going to emergency with acute pain and getting morphine, which relieved her withdrawal symptoms, and then returning when the morphine wore off again."

"I couldn't help that patient because her husband didn't want help.   Part of the process was to get help   for both.   I was walking outside.   She went first.   He went after.   Then I followed.   I heard him demanding her to ask for morphine.   She told me that the pain was inside her and that it wasn't in her abdomen or her back.   It was a deeper pain than I could understand.

"When I arrived at health center I learned about Schedule 8 drugs.   One of our doctors is a police officer, too.   Some of her patients are methadone patients as a harm reduction program.   I don't have the permission to have the schedule 8 medication.   I can only prescribe for two weeks.   Whenever I get a patient with Schedule 8, I refer to three different doctors.   Two are from mainstream and have Schedule 8 permission.   One is from health center.   Some of patients from the methadone program are not on the program any more.   They come only to review or get drugs in an acute setting.   They are not in the methadone program any more.   They are still trying to get the drugs.   I have been consistently sending them to alcohol and drug follow-up with the nurse in Tandera.   The number of patients with these same issues are large but they are decreasing for me since I started.   Some of the patients looking for drugs, stopped.   They started to go to mainstream doctors as their prescriber.   They stopped trying to get more drugs from us.   I have contact with these two mainstream doctors.   Patients say they can't get the medication.   Then I call the doctor right away and that doctor says send them right there.

"Patients sometimes go to several different doctors.   They are very complex patients.   They are not only shopping for medications, but are very addicted patients. They are trying to get more benzo's, more narcotics ". It's easier to send them back to the prescriber.   They start not coming back to me.  

"Schedule 8 drugs are everything with morphine, oxycodone, fentanyl and the like.   I have the right to prescribe for two weeks.   There is a pharmacology course for those who want to prescribe for longer.   You have to do it and apply for MedCare.   You have the right to put your name on the Medicare only for aboriginals.   Bairnsdale is the end of the train line from Melbourne.   We don't want every addict to come to Bairnsdale to get these drugs.

  We finished the discussion by talking more about my pain group in Vermont and her pain patients.   More about that discussion will come later.   The night was getting late and everyone wanted to go to bed.



Authors Website: www.mehl-madrona.com

Authors Bio:
Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and Narrative Medicine.

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