December 2014 – January 2015

The Medicine

The rural doctor problem

By Karen Hitchcock
Practising medicine away from the big cities

Rural and remote hospitals are chronically short of doctors, and they rely on locum agencies to source staff. The agencies recruit aggressively: I used to receive a couple of emails each week. Fancy a stint on the sunny coast? These rates are not to be missed! The closer the start date the more money the agencies offer, like a discount hotel website with a reverse economy. If you refer a friend, they give you a loaded credit card. For as long as the hospital has you, the agency will earn a doctor’s salary, simply for arranging the hook-up.

I did a locum stint as a registrar in 2010 during a six-month break in my training. The pay wrenched me from the city but it also filled me with guilt: What junior doctor could be worth a public hospital paying that much? What job could be that bad?

I was midway through a placement in northern Queensland when the rain started and didn’t stop. The waters quickly rose until they were lapping at my doormat. Roads became speeding rivers. The roof of the pathology lab collapsed, so all the blood tests had to be flown to Brisbane. There was no milk, bread or fresh vegetables. I started to think of the rain as a thing with character and malicious intent. I dreamt of galleries and trams.

On a Wednesday morning we heard that the airport would close on Friday. Patients who needed transfer would have to be choppered out from the roof. The itinerant staff could stay and be trapped in the town “indefinitely” or they could leave on the last flights. Doctors drained from the hospital. My family had been planning to join me the following week. I couldn’t bring four-year-old twins into a flood zone, and I couldn’t be away from them “indefinitely”. Standing in our full ward, I told my intern I might have to leave. He looked at me, swallowed and looked away. “Don’t worry,” he said to the floor. “I’ll be fine.”

The boss shrugged. “Look, the hospital’s on a hill; we have beds, a generator, plenty of Weet-Bix …”

I flew my family in the next day. My daughters spent the weeks splashing round in their gumboots, playing with fat green frogs and catching tadpoles. In the hospital we did the best we could. A son brought in his elderly mother, who’d been forcefully evacuated from her semi-submerged home. She gripped her chest, gasping for breath. “The looters … They’re out there in boats.” The town was melting down.

The waters receded, and I went to a smaller, even more remote hospital. I flew in and out each week on an eight-seater toy plane. The airport was filled with happy farmers’ wives, their arms full of children. The air was so humid your clothes were instantly damp; the hospital was so cold the patients shivered and we all wore jackets. Besides the bonded intern – a tall farm boy, super smart, who spoke a slow-drawling English – I was the only Australian-trained doctor. The tough Aussie nurses ran the show, bossing the doctors and keeping their eyes on the duds. They were often the only thing standing between the patients and death. They gave me gifts: enormous duck eggs with shells that felt and looked like old-fashioned linen; 1940s sunglasses with Bakelite frames, left behind when an old lady died; stickers for my children. They pushed squares of chocolate into my palm with a wink. I was constantly thinking that they should’ve been getting the big cheques.

A man back in town after city surgery for facial fractures came in overnight with a headache and fever. He was sent to the ward by a doctor who spoke very poor English. In the morning I read the scant notes and walked onto the ward to find the patient white and shaking. I started intravenous fluids, got the intern to take blood cultures and checked the computer for the patient’s most recent results. He’d had a scan overnight that had revealed a collection of fluid in his brain, a fact that the overnight registrar had failed to mention. I called the patient’s neurosurgeon in Brisbane, thinking it was likely a complication of the surgery needing his urgent attention. “So was it CSF leaking from his nose or not?” the surgeon snapped. CSF: cerebrospinal fluid, the sugary liquid that bathes and floats the brain. “Excuse me?” I said, thinking he must have confused a couple of patients. “I was called at 2 am, and I asked them to check if the nasal discharge was CSF.” “What nasal discharge?” I said, increasingly alarmed, it being no small thing to have a leaking skull along with a pool of something potentially expanding in your brain.

I trotted to the patient, phone clamped to my ear. “Is your nose running?” “Yep.” Resisting the urge to cry into the phone “It wasn’t me. It was that guy from overnight”, I asked the surgeon how I could tell if it was CSF. Laboratory testing would have to be sent to the city and could take days. He sighed, not unkindly. “Use a urine-test dipstick. If it’s glucose positive, it’s CSF.”

I held a plastic cup under the patient’s nose: he snorted out a stream of crystal-clear fluid. I twirled the stick. Positive.

“Jesus Christ,” said the surgeon.

I called the helicopter retrieval team.

I love my city job. The neurosurgeons – should I require them – are two floors down. The need for rural doctors is extreme, but Médecins Sans Frontières won’t send you to the back of Bourke. Recently I’ve read a number of agitated newsletters from locum agencies, commenting on the increased number of doctors we’ve started to graduate in Australia. They claim that there is no doctor shortage, that these new graduates will flood the market. That there’ll be no place for them to go.

Karen Hitchcock

Karen Hitchcock is a doctor and writer. She is the author of a collection of short fiction, Little White Slips, and the Quarterly Essay Dear Life: On Caring for the Elderly.

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