An Outback Elective

Dr Bobby Greig / Clinical Development Fellow / Scotland

Bobby Greig is a runner, climber and mountaineer who is currently working in South Scotland. He spent his elective in Alice Springs, Australia during spring 2017. In his article, Bobby tells us about work and play in The Outback.

For my elective I wanted a placement that would offer new and challenging scenarios unlike any I had experienced in Scotland, but also enough support for me to learn and grow. I was in my second year of university when I first heard about Alice Springs from my supervising consultant who had spent their own elective there 30 years ago.

As I stepped off the plane, I couldn’t have felt further away from the dark Scottish exam hall I had sat in just a week before. Welcomed to Australian winter by 35⁰C  heat and an unrelenting sun, I was burnt just walking from the plane to the terminal. Alice Springs is a medium-sized town of small orange-roofed buildings and greenery surrounded by the golden yellows and oranges of the outback.  The Todd River ‘flows’ through the middle of the city, but for 11 months of the year it is just a dry river bed with thick ‘river red gums’ rising up and out of the sand.

Alice Springs Hospital is in a unique position in that it has all the facilities that you would expect to find in an economically developed country hospital, but it also serves a large indigenous population spread across 1.2 million square kilometers. The indigenous population has a much higher burden of ill-health than the rest of the population; the life expectancy of indigenous men is only 63 years, 16 years less than the rest of the male population of Australia. One of the most common presentations to the department, and the third most common reason for hospital admission, is missed dialysis. Another common presentation is trauma following assault.

Communication

Culture and tradition are very important to the indigenous Australians, and shape their health beliefs. The indigenous family groups are made up of their ‘skin names’, a method developed thousands of years ago to help avoid recessive mutations by ensuring that people married as distantly as possible within the tribe. Everyone with the same ‘skin name’ as your mother is called your ‘auntie’. Children would frequently be accompanied into hospital with their ‘auntie’, although this did not necessarily indicate the same degree of familiarity as it would in the UK. This, along with a language barrier and unfamiliar non-verbal communication, meant that you had to be very clear with the patient and their relatives to ensure that you were picking up the full story and not missing any details that might be important for the diagnosis.

Culture Shock

I had the opportunity to go out with both the St John’s Ambulance Service and the Royal Flying Doctors to experience health provision in an environment far removed from the hospital. Despite the excitement of being out on emergency calls, my visits to town camps with the teams were often saddening experiences.

Town camps are enclosed areas on the edge of town that are inhabited exclusively by members of the indigenous population. They are often areas of severe poverty in which the population do not have adequate housing. A building that on the other side of town would house a family of four, could be a home for up to 20 people in one of these camps. Every call out had its own challenges, whether it was the logistics of getting the patient out to the ambulance or trying to talk to and calm a crowd of people around you (who may be intoxicated).

Alcohol-related presentations were a major challenge faced by the emergency department, the ambulance crews and the communities themselves.  I was shocked by the scale of this problem given that Alice Springs is a relatively small town. I saw a number of patients presenting both due to acute intoxication and from injuries sustained while intoxicated. Two events in particular stand out in my mind. The first was a woman in her forties who presented with a 15cm scalp laceration from her forehead to the back of her skull. It had been inflicted by her sister using a ‘big stick’ (which, on taking a history turned out to be a crowbar) following a drunken argument. The second was when I was with the ambulance service and we were called out to a town camp where there were two women in their twenties being attacked by an intoxicated older man. We were unable to stop due to the potential risks to ourselves, but fortunately we were chased by the two women who were then able to climb into the ambulance.

Alcohol-related problems have additional consequences for the indigenous population. The houses are already massively overcrowded and the communities will cast out those displaying violent behaviour, forcing them to sleep rough (often in the Todd river bed) or present to the emergency department. The department does not turn these people away despite the fact they do not have a medical issue; instead they are allowed to sleep in the waiting room providing they do not cause any trouble.  Homelessness is the third most common reason for presenting to the emergency department in Alice Springs, with 653 presentations during the first three months of 2017 alone.

Out on the trails

Although Alice Springs does have its problems, it is one of the most amazing places that I have ever visited. In Edinburgh, I enjoy running around the hills and frequently take the bike down into Midlothian and the Borders. Alice Springs offers all the outdoor experiences you could ever want and even more. The weather was always beautiful, without a single drop of rain. There are hundreds of kilometers of mountain biking trails running along rocky ridge lines that are burnt orange under the sun, and through deep sandy river beds.  On arriving at the hospital, it quickly became public knowledge that I loved cycling and one of the consultants kindly lent me their mountain bike for my time there. I would be out two to three times a week with many of the mid-grade doctors and consultants, keen for a few hours blasting through the red dust of the outback.  It really was full of thrills and spills; you would be flying along the trail with a sharp turn into a shaded area of bush and suddenly a massive Red Kangaroo would shoot out and bounce only a meter or two ahead of you before disappearing again. Or you would ride straight through a giant spider’s web frantically trying to pull it off your face without ending up in the dust.  I quickly realised that everything in the bush was either spiky or very sharp as I came flying off my bike trying to take a rocky drop too fast and tore straight through my shoe! I also learned to be careful of the riverbeds after ending up eating a mouthful of sand. It was always important to remember my suncream and about three litres of water in order to make it back to town without turning into a lobster.

If cycling is not your thing, then the walking is also incredible and the views magical. Just at the south end of Alice Springs, the McDonnell Range runs for over 600km through central Australia. The highest point near Alice Springs is Mount Gillen and a very sweaty 45 minute walk up to the tops gives you a 360 degree view over all of Alice Springs and the endless outback.  It was also the perfect sunset spot which I found was best enjoyed with a few newly made friends and couple of cold beers. Many Thursday evenings were spent here before heading to Montes for the weekly pub quiz where you would find the majority of the hospital staff in attendance.

I also made several trips further afield. These would involve at least a two hour drive, something the locals think nothing of due to the vastness of the area.  On my third week, one of the intern doctors asked if I’d like to climb Mount Sonder. Of course I said yes. After a Saturday of mountain biking, I got a call to say I was being picked up and to remember my sleeping bag. It quickly became apparent that we were going for a Sunday sunrise. We arrived in the pitch black and set about making camp and a fire. Australians often sleep in ‘swags’ which are like a one-man tent with a blow-up mattress sewn in. I slept out in the open in my sleeping bag, hoping our fire would keep any unwanted visitors at bay. As the fire burnt out, the sky put on its own show with the Milky Way on clear display and frequent shooting stars. We were up at 3am to pack up and set off on the four hour plod up a mountain just higher than Ben Nevis. As we were climbing, we saw a lightning storm on the far horizon. On approaching the peak, we were treated to a dark red band of light climbing out of the horizon with a deep blue sky hanging over it and bright white stars throughout. The band became brighter and wider until the sun appeared over the horizon, turning the sky into a kaleidoscope of oranges and yellows with a scattering of light blue. The rock turned from a dull grey to bright orange.  After this incredible spectacle, it was time to head down before the hot morning sun could catch us.

I could go on and on about my time in Alice Springs  (I have not even mentioned going to Uluru, Kings Canyon or any of the bush walks I went on). It truly is a special area with wonderful people and I will always look back on my elective with the fondest memories of the places I visited and the friends I made. It has left a lasting impression on me both from professional and personal points of view; I have been able to learn so much about communication and I was truly humbled by the challenges faced by the indigenous Australians as well as the sheer size and beauty of Central Australia.  I will always carry a small amount of Alice with me – I still cannot get the red dust to wash out of the bottom of my trousers!

Top tips

• Make your interests known. I made it clear that I loved the outdoors and it resulted in offers of a loan for all the equipment I could ever need. Almost every day somebody would offer to take me out on an exciting trip – mountain biking, running outbush, 4x4ing to name a few.
• Don’t be afraid to go it alone. Travelling alone can open up many new opportunities. I was apprehensive at first, but it forced me to get out and meet new people.
• Try something new. An elective is an amazing opportunity to see a country you would never think of visiting on a holiday and to gain an insight into their potentially unique medical challenges.
• Listen to the the locals. They can tell you the best spots to see wild wallabies or to go for a swim. They can also advise you about dangers of the local area such as driving at dusk and dawn. Wild horses and kangaroos are frequently found on the roads at this time and if you are unaware of this risk then you could face trouble.
• Stay safe. Avoid getting into situations where you feel uncomfortable and ensure you know the local numbers for the emergency services.

Further Information

Where / Alice Springs, NT, Australia

When / April-June

Costs / I was not required to pay any fee for my elective.  However, Alice Springs is an expensive place to stay due to the difficulty in getting goods to the town.  Daily living costs (excluding accommodation) for 2 months was just shy of £1000 (including gifts to take home).

Weather / About 30 degrees during the day but could drop to as low as -5degrees at night.

Vaccinations / All standard UK vaccinations. Hepatitis A and Tetanus/Diphtheria/Polio booster advised before visiting. I was also recommended to get a pertussis booster due to frequent epidemics amongst the indigenous population.

Accommodation / Flinders University were able to provide self-catering accommodation. This cost about £100/week but all accommodation is expensive due to a limited amount of housing.

Essential items / Suncream, hat and sunglasses.  A comfortable pair of trainers to explore in.

Addition items / You will need an Ochre card (similar to a DBS or PVG) which can take several months to arrange so this should be organised well in advance as you cannot start without it.

Contact / Elective placements for visiting medical students