Here, in Kalgoorlie, Western Australia, we have a population of 30,000 that is surrounded by a vast area with only a few small towns, generally 200 to 400 kilometres away, but there are sites that are much more remote and these present problems. Firstly, the problems of information and support; secondly, transport; and, thirdly, when to leave home for delivery.
Most requests for information are directed to the nursing staff in remote clinics and they are the mainstay of advice. If there is any doubt, the nursing staff will ring in for advice. From time to time, the region has also been blessed with doctors who have become disillusioned with city life and ‘go bush’. These doctors, with nursing staff, travel from clinic to clinic and readily help, treat or ask for help. The Royal Flying Doctor Service (RFDS) also provides clinics to remote areas. RFDS staff also ask for advice.
The usual problems of pregnancy are ever-present. Blood pressure is always a concern, but as monitors have become readily available and cheap, anyone with suspected high blood pressure is advised to purchase a monitor and update results to the clinic or RFDS. In several cases, blood pressure has been managed from a distance of 600 kilometres away. Likewise, urinary test strips are available and can be obtained. These have been used and similarly reported. Diabetes is also managed in the same way.
The RFDS medical box deserves a mention on its own, as all outposts and stations have such a box. Instructions on how and when to use the medications are available on the regular RFDS radio schedules or on direct calls in emergencies.
Perhaps the most significant form of information spread is the ‘mulga wire’, also known as the bush telegraph. Among distant communities, word of pregnancy spreads quickly, whether hoped for, or not. With the mulga wire, local support from neighbours as far away as 200 kilometres always seems available. In the remote Aboriginal communities, the elder women have always been the mainstay of advice and actively promote medical care as they remember when it was not available.
Of course this has been supplemented recently by the internet, but as anyone who works with people can tell you, the old wives’ tales have greater relevance than something written anonymously on the internet.
When I arrived in Kalgoorlie, the Country Women’s Association of Australia (CWAA) was of considerable assistance, as this organisation had a presence in most towns and, more importantly, accommodation in most centres for the use of members and others at modest rates. However, the images of pumpkin scones and crocheted doilies have not attracted new members. In mining areas, the increase of ‘fly-in, fly-out’ personnel has also dramatically reduced the number of women in the bush and the CWAA has fallen on hard times because membership has decreased. Teachers and the police have also been essential to providing a comprehensive medical service to this sparsely populated area. They are familiar with the families – their potential problems and accidents – and have been relied on by many local people for their knowledge and, when uncertain, they too have rung us for advice.
The rural doctor is also an amazing source of information and help. The doctors who go to these remote areas are ‘stand alone’ units and use many skills. They are erudite and many have a small degree of madness. Why else would one go bush? However, they have been lifesavers by examining and describing unusual or difficult patients, and have shown patience if a specialist’s answer is not immediately forthcoming. For example, a doctor rang to say that on completion of a caesarean section that ‘it didn’t seem right’. He wanted to know what had gone wrong. As mother and baby were fine, the only problem I could imagine was in the closure. Later, I suggested he put the largest Hegar dilator into the uterus via the vagina and take a lateral x-ray. This showed the dilator anterior to the body of the uterus. So a few days later this was corrected by approximating the correct edges of the lower segment.
The overriding principle of dealing with various staff that go bush is of course to support them. If they don’t know what’s happening to the patient, then that patient needs to be seen and soon, so that the uncertainty is contained and stresses to these staff removed or at least relocated. It has been of great interest in situations like this to be trying to find a patient only to be told they have gone and it could be to Ceduna, Port Augusta, Alice Springs, Geraldton, Perth, or as the bush poet said, ‘We don’t know where he are’.
At the end of the day, everyone in rural and remote locations is a source of help. One such case was the manager of the Nullabor motel, who radioed the RFDS to say a Lebanese passenger on a bus trip had presented with an ectopic pregnancy. Keeping the line open, the RFDS manager in Perth rang me and, in a three-way relay of information, I asked if the woman in question had a shock of white hair and Louis Vuitton luggage. The surprised manager answered in the affirmative. I then requested that this person continue her journey across Australia, but by the time the connections had been made the bus had departed. Hours later she turned up in our emergency department, but departed with her luggage, as soon as she had recognised both the general surgeon and myself. We had both been conned by this pethidine addict previously.
On arriving in Kalgoorlie, I was surprised to find that all pregnant women were moved to a larger centre at 35 to 36 weeks. For many of the patients, this was difficult not only because of their young family and finding inexpensive accommodation in a busy town (no children, no pets), but also many complained of the physical separation from their partner and loss of support. There were also anxieties about the husband and what he was ‘up to’. Another anxiety was related to dangers to a husband in the mining industry.
Initially, I tried to convince clinics to hold on to patients until at least 38 weeks or, if the cervix was favourable, to come in for induction and then return home, taking about a week for the round trip. This of course depended on the confidence of the doctors, nurses and RFDS. Being usually on call helped in that there was a continuity of information and this helped to keep track of problems or the unusual patient. However, as often happens, not all plans succeed. For example, a midwife from a very remote location rang concerned about a breech in labour. The RFDS was to return this patient to Kalgoorlie for delivery. After waiting up all night, I was informed that the wind was in the wrong direction so she had been flown on to Alice Springs. Years later, I found out the pilot’s girlfriend lived in Alice Springs and this was probably more influential than the direction of the wind.
The idea that 36 weeks was the critical time to leave was frustrating and the only basis I could find for this was simply the commercial airlines’ ban on flights after 36 weeks pregnancy. As far as I can tell, this seems to have been the problem of birthing on the trans-Atlantic flight. Some interesting dilemmas must have arisen: place of birth, time of birth and birth attendants. Presumably, the ban was to reduce the number of such awkward deliveries and the associated paperwork problems.
However, medical myths take on a life of their own. On enquiry, I was told it was unsafe to fly after 36 weeks. As the RFDS is our guardian angel, and it was unsafe to fly, the locals deduced that travelling by any means was in itself unsafe. To correct this myth I tried to find where it was written. Neither the Health Department, nor the relevant Shires had such a policy, and eventually I was informed that the Mining Act was the authoritative source. However, research failed to find any such advice. Eventually, it was found on the doctor’s desk in Leinster: a handwritten list of do’s and don’ts that someone had written anonymously. This had been handed down from doctor to doctor, like some medical heirloom. As most doctors were short-term locums, few were prepared to question ‘the myth’.
There are of course cases which are remembered for the spectacular failure of the system to provide care or for those who choose not to have care. One such case was a 40-year-old who wanted to have a homebirth on land she and her partner had declared as an independent province of Australia. They wanted the child to be the first-born resident, thus having a land rights claim. After being in labour for three days with no outcome, she went to the nursing post and was eventually transferred by the RFDS. After a further delay and augmented labour, she ultimately had a caesarean section and a healthy baby. Then there was chaos, as the patient demanded to be taken back, by air, to their ‘true’ home. Years later, I found out they did not want to be absent at any time in case the relevant government department reclaimed ‘the province’, which indeed happened some years later.
The RFDS provides an overall mantle of care to the region and abuse of this system is fortunately rare. However, a trip in the region is for some people sheer boredom. On the Nullabor train at Cook Station, a woman presented with severe pains in early pregnancy. An ectopic pregnancy was considered the likely diagnosis and the RFDS transported the patient to Kalgoorlie. On examination, the woman let it slip that she was so sick of the trip she had invented the symptoms so she could be flown on to Perth. She was certain that no local facilities existed to easily diagnose an ectopic pregnancy. While a vaginal scan was in progress, the Indian Pacific train was heard pulling into the main station. The scan confirmed an intrauterine pregnancy. A taxi voucher was quickly obtained to put the person back on the same train and seat she had left six hours before, ‘to enjoy’ the remaining ten hours to Perth.
Every so often there are moments of great delight in dealing with long-distance problems. One such moment of interest was to be taken 400 kilometres to see an anaesthetised patient who had continued to bleed after a caesarean section. I was transported by the RFDS with some blood and platelets. As I walked into the theatre there was applause from the theatre staff, as they had been waiting a couple of hours. A hysterectomy solved the problem much more quickly and safely than transporting a bleeding patient.
There is no doubt that anyone who lives in a remote area has an innate ability to cope and adapt. Perhaps the greatest challenge to providing services and information is to those who are just passing through, or more recently those in detention centres. There is also a group in ‘bonded slavery’ who have to go bush to satisfy visa or employment requirements. Among this group, of course, are the ever-present problems of cross-cultural and language difficulties. The range of cultures and languages we need to deal with seems to be increasing, but equally there are more resources, better communications, interpreter services and faster transport to deal with these complex situations.