In September 2008, an ad appeared in JAAPA: Exciting Opportunity for Physician Assistants in Queensland, Australia. Eight months later, I left for Cooktown, Australia, to participate in a 12-month trial that would introduce PAs to Queensland.
A vast, largely rural, 668,000-square-mile state in northeast Australia, Queensland has a population of 4.3 million and is bordered by the 1,200-mile long Great Barrier Reef. Many remote and rural communities in Queensland have difficulty attracting and retaining doctors. The PA concept was recognized as one possible solution to this chronic health care shortage. Cooktown, a small community of 1,500 located on the Coral Sea in far north Queensland, is 50% aboriginal. This small town also serves a "bush" area of another 1,500 people, including two indigenous communities and visiting tourists.
7:45 AM
Every morning, I walk two-thirds of mile to the Cooktown Multipurpose Health Centre. After nearly a year in the tropics, I remain disoriented by the reversed seasons. As the dry season of "winter" approaches, I notice the decrease in morning temperatures and humidity. Today will reach 27˚C (80˚F). It's Saturday, so traffic is light. Most drivers give a friendly wave. The recent increase in campervans means the tourist season is full on (very busy). Grey nomads, especially, are escaping the colder south.
8:00 AM
The Friday night doctor-on-call reports the status of hospitalized patients and newly admitted patients to the weekend doctor and me. Our hospital has 14 acute beds and a 14-bed aged care facility named Sunbird Cottage. Every other weekend, I cover the outpatient department (OPD) and emergency department (ED) and help manage inpatients. There are no scheduled appointments on weekends, but I sometimes see recalls from earlier in the week. Working weekends is a win-win situation: We practice more autonomously, as we're accustomed to in the United States. The doctor-on-call spends more of her or his weekend at home, available by phone.
There have been two admissions so far this morning. The first is a middle-aged male with chronic pain issues, anxiety, and a history of drug addiction. He wants a head CT for an alleged injury sustained during an altercation that occurred 3 weeks ago. There have been no abnormal neurologic findings. If we refer him, the closest place for a CT is Cairns Base Hospital—a 3½-hour drive or 1-hour flight. The other admission is an 8-month-old with a cough and fever, brought in by his maternal grandmother. The threshold for admission is low here for babies, especially when there are complicating social issues.
8:20 AM
Inpatient rounds begin, and we see the 8-month-old baby first. He has just finished breakfast and has been wetting his nappies (diapers) frequently. He looks well and has no fever after two doses of paracetamol (acetaminophen). His mother has arrived so the grandmother has gone home to rest. She is a tiny, quiet 18-year-old aboriginal who looks 13 and bewildered. She is pregnant again, and the young father is in trouble with police. Grandmothers hold together many such tenuous families.
8:30 AM
A man in his late 60s who appears much older is next. He returned earlier this morning by commercial flight from Cairns, a city in Far North Queensland, where the Royal Flying Doctor Service (RFDS) had flown him 3 days ago for a chest CT. The RFDS—an Australian icon—provides free air ambulance service. Partly dependent on private donations, the service has been helping seriously ill and injured people in remote locations of Australia since 1928. Before this trip, our patient had presented with exacerbation of chronic obstructive pulmonary disease (COPD), pneumonia, a 90-pack year smoking history, and an ominous-looking chest x-ray. The CT confirmed a diagnosis of lung cancer. He has opted for palliative care. Because he lives "out bush,"
he will stay here until transportation can be arranged. A shocking number of people here are heavy smokers. COPD and cancer are frustratingly common.
8:45 AM
Next we see a 76-year-old man with late-onset schizophrenia. He is being managed with the help of a psychiatrist in Sydney, a 3-hour flight away. Since he lives alone and is located 45 minutes away, he will remain hospitalized during titration of his antipsychotic medications. He seems better and has not verbalized psychotic or paranoid thoughts for a few days, but I think he's in the "twilight zone" of therapeutic drug levels. I have a former psychiatric nurse gut feeling that he's guarding.