Indigenous Health in the top end

Image credit:  Jessica Tidswell

Indigenous Health in the top end

Oct 2, 2016 0
General medicine,indigenous health,onthepods,rural and remote medicine

Dr Nathan Trist talks to Dr Kerrie Jones and Dr Jessica Tidswell from the Royal Darwin Hospital. Learn more about indigenous health in the top end and the social and communication challenges associated with indigenous health in this podcast.

Summary writer:  Jessica Tidswell

Editor:  Bruce Way

Interviewer:  Nathan Trist

Interviewee:  Kerrie Jones, Jessica Tidswell

About Dr Kerrie Jones

Kerrie Jones is a Senior Emergency Medicine specialist with postgraduate qualifications in advanced paediatric emergency medicine, family planning, counselling, and humanitarian aid. She is a senior lecturer at Flinders Medical School, and has served as Director of Emergency Medicine training at Royal Darwin Hospital. As Clinical Dean of the Northern Territory medical program, Kerrie is committed to providing better healthcare to rural and Aboriginal communities.

About Dr Jessica Tidswell

Jess Tidswell is an Emergency Registrar, currently working in the Top End, at Royal Darwin Hospital’s Emergency Department. She started her training in her home town of Adelaide, at the University of Adelaide, completing her undergraduate degree in 2012. Jess then interned at the Royal Adelaide Hospital, before heading north to work in the Northern Territory. For the past few years Jess has worked in a variety of areas of the Royal Darwin Hospital and the Top End, including remote communities. She committed to Emergency training last year and plans to continue her training in the Top End, where she finds the work fascinating, the people diverse and the lifestyle enjoyable.

About Dr Nathan Trist

Nathan Trist is Senior Resident Medical Officer with an interest in indigenous and remote health.

Indigenous Health in the Top End

With Dr Kerrie Jones, Emergency Consultant and Dr Jess Tidswell, Emergency Registrar, Royal Darwin Hospital and Dr Nathan Trist, Senior Resident Medical Officer, Royal Darwin Hospital

Introduction

This podcast includes 2 cases from Darwin, in the Northern Territory, which present some interesting pathology and exemplify the social and communication challenges associated with indigenous health. Hopefully, it enthuses you to come to the territory and experience some of our fascinating cultural landscape. An adult case is discussed first, where female health is a prominent feature. This is followed by a classic paediatric presentation in the Northern Territory.

Case 1

A 38-year-old female with abdominal pain, weakness and headache. On examination she is febrile and has abdominal tenderness. She presents to her remote clinic 440kms from the closest hospital.

  • Firstly, the complaint of weakness can often mean something quite significant in the Indigenous population. We find this descriptor used when a person feels malaise, lethargy and fatigue, but struggle to translate this into English. You should be suspicious of something significant going on when someone reports this symptom.
  • More information can be gathered by using the clinic notes, which can be accessed electronically, and can supply you with a record of their recent presentations, medications and initial observations. Hence, it is a useful source of information to build your picture of the presenting complaint.
  • History
    • Consider whether the history should be taken by a female practitioner
    • Establish rapport and ask generally about where she is from, her social circumstances, her family and her role in the community, before exploring some history about the presenting complaint
    • Be sure about your patient’s ability to understand English and offer an interpreter early on in the interview
    • Direct questioning can be considered quite rude or result in ‘yes’ answers to everything
    • Use plain language
    • Allow for long pauses to enable the patient to speak
    • Given we have the presenting complaint of abdominal pain, consider exploring differentials include, infective symptoms, associated bowel changes, localisation of the pain, consider prior trauma
    • You will need to get a gynaecological /obstetric history
    • Often asking them what they think is wrong can elicit very interesting suggestions and can lead you to a timeline of what has happened. Time can mean quite different things to Indigenous people as it does to caucasians
  • Examination
    • Be holistic and examine the whole patient, as the presentation can be quite vague from the history
      • Co-morbidities are common in these patients so take the opportunity to check in with the patient on the status of their chronic illnesses
        • E.g. engage women on contraception, educate about diabetes when possible, encourage regular immunization, refer to dental services where required
  • A full blood count, electrolytes, liver function, renal function, inflammatory markers, blood culture if febrile
  • Bedside: ECG, urinalysis
  • Consider CXR when considering perforated viscous and lower lobe pneumonias, which can present as abdominal pain
  • During gynaecological examination, taking a high vaginal swab or first pass urine for STI screening is also important
  • Further investigation should be guided by your exam – such as upper abdominal or renal tract USS or CT scan
  • A soft, benign abdomen and positive urinalysis, consistent with a UTI was found
  • This can be treated with a course of oral antibiotics (check local guidelines, or as on the Therapeutic guidelines)
  • Follow up in one week with repeat urine MCS is required to ensure clearance of infection
  • Take your time and establish rapport with your patient to enable a clear history and exam
  • Try to understand the person’s illness in the context of their community
  • Be opportunistic when these patient’s present to hospital and check in on their other illnesses
  • Therapeutic guidelines, Antibiotics Guidelines, online access through most institutions. ©Therapeutic Guidelines Ltd (eTG July 2016 edition
  • Fenwick C. Assessing pain across the cultural gap: Central Australian Indigenous peoples’ pain assessment. Contemp Nurse. 2006 Sep;22(2):218-27
  • Brown A, Cadogen M, Emergency Medicine, Diagnosis and Management, 2014, 6th Edition. CRC Press

Case 2

A 4-year-old boy with a limp and left leg pain. On examination the child is febrile and has an antalgic gait. He has come in with an auntie, who isn’t sure of the history of the presenting complaint.

  • We are going to need some more information in this presentation and so the first priority would be to establish a family tree, including ascertaining who is the primary carer for the child and call the clinic to collaborate and provide as much information about the child and their health as possible
  • The auntie may have contact numbers of other family members
  • It is important to get consent from the escort / primary carers as to who you can talk to
  • Clinically, a limping child is always a concern and you should be suspicious for a significant pathology
  • History
    • We will need to establish if there has been any trauma
    • Attempt to establish a timeline of the limp / leg pain
    • Has there been any prior rheumatic heart disease or acute rheumatic fever – which is
      common in the NT indigenous population
    • Other differentials include: septic joint, cellulitis, transient synovitis, fracture
  • Examination
    • Try to establish whether this is a joint or bone problem
    • Assess for predisposing conditions such as skin sores (impetigo) and pharyngitis
    • Check for a heart murmur and other signs of acute rheumatic fever (Jones criteria: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules)
    • Bedside examinations include: ECG, urinalysis, throat swabs
  • Investigate for the Jones criteria: ESR, CRP, ECG (increased PR in ARF)
  • CXR to assess for heart failure
  • Serology: Anti-streptolysin O titre (ASOT), Anti-Dnase B
  • Echocardiogram
  • Analgesia and rest in hospital initially, especially if evidence of heart failure. Aspirin / NSAIDs for arthritis. Diuretics and fluid restriction are occasionally required in severe cases
  • Benzathine Penicllin IM – then initiate monthly administration plan
  • Establish the patient on the Rheumatic Heart Register
  • Any Indigenous patient presenting with a monoarthralgia should be considered for ARF
  • Acute rheumatic fever is not specific to children
  • Again, consider the patient in the context of their community
  • RHDAustralia (ARF/RHD writing group), National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand. The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition), 2012
  • Smith MT, Xurynski Y, Lester-Smith D, Elliott E, Carapetis J,.Rheumatic Fever: Identification, management and secondary prevention, Australian Family Physician. Volume 41, No.1, January/February 2012 Pages 31-35

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Tags: #Aboriginal health care,#careers in medicine,#indigenous health,#indigenous health in the top end,#indigenous medicine,#medical careers,#Northern Territory,#remote health,#rural health,#top end,#working in medicine

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