Rhaïa March 2024
The theme for this issue is ‘Experiences in Rehabilitation Medicine across differing cultures and communities’ and I wish to express my gratitude to my colleagues for taking the time to write about their personal experiences and for contributing to this edition.
Most of us have travelled overseas and some have worked overseas. My own experience of Singapore was when I travelled there in 1972 as a medical student during the Christmas break. I was not impressed when immigration took me off the bus and cut my hair and gave me one day to leave. Vowing never to return I was tempted back over 30 years later when I transited on Singapore Airlines and Dr Sherry Young invited me to apply for a position at Changi Hospital. It was obviously the right move when the first advertisement I saw was one for hair restoration for my now thinning scalp. All was forgiven!
I was impressed by the cleanliness of the hospital. My own Adelaide hospital had felt the effects of the collapse of the state bank resulting in the cut back of services including the cleaning of hospitals. Many years of grime had accumulated on the windows.
As would be expected, technology was important. I was interested in the automated ground vehicles (AGV) travelling through the hospital delivering food to each of the wards. When someone stood in front of one they announced in polite female robotic English “get out of the way please, AGV coming through”. Occasionally two would come across each other and become stuck, imploring each other with the same phrase over and over, neither moving out of the way. One time, I was at a patient feedback session and after the complaints or compliments of hospital food and waiting times, an elderly lady explained that she had come to take her cognitively impaired husband home. She and the transport driver collected him in a trolley and wheeled him into the lift but instead of getting out at the ground floor, they ended up lost in the basement. In the matrix of the basement were where the AGVs resided.
Of course, the husband’s trolley collided with one, and the AGVs instantly thinking it was a food trolley, started to lift the trolley and deliver it. At that point the husband woke up, completely disoriented and confused, screaming that he was being attacked by a giant cockroach. The wife started to beat the AGV with her walking stick. Eventually they extracted themselves and made their escape. It was the best (and most unique) feedback session that I have ever had.
AGVs in the basement
Ever since then I have treated the AGVs and the cleaning robots with great respect. You never know when Arnold Schwarzenegger may appear.
When maid robots eventually appear, I can forsee the problems that rehabilitation has with maids in Singapore being repeated. It has always been interesting to me for the team to be spending days/weeks assisting elderly patients with disability to re-learn to be independent in ADLs, but as soon as the maid appears, many are happy to lie back to be fed or pushed around on a wheelchair.
Maid in Singapore
Terminator aside, I am very thankful for having experienced the different atmosphere of differing culture and interactions with my patients and the support and comradeship of colleagues in Singapore.
One of my colleagues, Dr Tze Chao Wee experienced the reverse journey, from Singapore to Australia
Roy Lee
Editor
Time flies. It has been ten years since I started my training in Australia. I am writing to share my experience as a rehabilitation medicine Advanced Trainee in Australia from the perspective of a Singaporean. Singapore has a well-established training program in rehabilitation medicine. It is a three-year program that one enters after exiting from a three-year internal medicine training program. Being a local graduate, it was an unusual decision to pursue training in rehabilitation medicine via the AFRM training route. As unusual as it may seem, I decided to do it anyway with many uncertainties in my mind.
I started training at Changi General Hospital in the eastern part of Singapore. The unit is an accredited training unit with the AFRM. My supervisor was Dr Roy Lee, who happens to be the current editor of Rhaïa. All was going well, and I could have spent four years in Singapore to complete my training. However, I thought it might be a good idea to get overseas experience, and my supervisor concurred. Thus, my journey down under began, and excitement and uncertainties were to follow.
I started looking for a suitable training position, and I recall that it was already the latter part of the year, and most jobs were already filled. I chanced upon an advertisement in the fortnightly AFRM Bulletin for a registrar position at Royal Darwin Hospital (RDH). I had been to Australia many times but never to Darwin; hence I thought it might be an excellent opportunity to spend some time in Darwin should I be accepted. I wrote in and was granted an interview. I do not have much recollection of the interview, but I guess it went well enough for me to get the job. This was followed by submitting mountains of paperwork for employment, visa, and medical registration. The whole process was very well taken care of by the medical recruitment officers at RDH.
It was early morning at the end of January 2013 when the plane touched down at Darwin International Airport. I was fortunate to secure on-site accommodation at the hospital, so I hopped into a taxi and headed straight for RDH. It was pitch dark, and I could not see much on the taxi ride. I arrived at the main door of RDH in less than 15 minutes. I went up to the security who was already expecting my arrival. He promptly took me to the temporary hospital accommodation, located across a car park, a few hundred metres away. As my family would join me soon, I was allocated a three-bedroom house. The house was rather dusty but essentially self-contained. I spent the next few days sorting out paperwork, orientation and so on before work started officially.
The first few months were a struggle. I was unfamiliar with the workflow, the computer system and did not know a single soul. Fortunately, I had a great team to work with, who were patient and tolerant of my ignorance. This included the many interns, RMOs, therapists, nurses, social workers, the all-knowing CNC, fellow rehabilitation registrars and rehabilitation physicians.
There were many interesting experiences, and I would like to highlight a few examples.
RDH has a general rehabilitation unit. It was great as the case mix was diverse and you got exposure to various rehabilitation patients, from mundane strokes and the usual brain injuries and spinal cord injuries to exotic infections, some with devastating consequences. A few notable cases included a patient who was referred for functional decline or deconditioning but turned out to be a case of Gullian Barre syndrome. Another case was that of a morbidly obese amputee who lived in a remote part of Australia for which discharge planning was a nightmare. However, it was a case where you probably learnt all the things that can possibly go wrong with discharge planning. I shall refrain from any further specifics to avoid breaching patient confidentiality.
I was very excited to be told that I would attend outreach clinics, but I did not imagine the distance involved. Coming from the island state of Singapore, where travelling 20km to work is considered far, the sheer distance of the outreach clinics was beyond my imagination. The most extreme was a trip to Gove District Hospital, just over a thousand kilometres from Darwin. We caught an early morning one-hour flight to Gove Airport in Nhulunbuy before returning the same evening. Other outreach clinics included trips to Katherine District Hospital, three hundred-odd kilometres from Darwin. In this case, the Director of Rehabilitation Medicine drove the prosthetist and I to Katherine. We set off early in the morning in darkness, and seeing the sunrise along the way to Katherine was terrific. I remember sitting in the passenger seat, trying my best to stay awake as I thought it would be rude to doze off while the boss was driving. This trip was slower paced as we stayed overnight for a second clinic the following day. However, on another occasion, it was a day trip. I cannot imagine how tiring it was for my boss to have to drive us back after a full day of clinic, but we made it back safely.
The long-case presentation was never something I enjoyed as a trainee, but I am fully cognisant of its educational value. I recall my first long case in Darwin. Before this, I had already done several long cases, so the process was not foreign to me. It was a Saturday morning, and I clerked the patient assigned to me for the long case and then presented to my consultant. I did badly, and my consultant certainly did not mince his words during the feedback. As a result, I probably suffered from ‘borderline’ post-traumatic stress disorder and dreaded long cases for some time. Looking back, I learnt a lot from that single long case, and it profoundly impacted how I approached my long cases and the rehabilitation management of patients after that. Needless to say, I passed all my other long cases after that. Being actively involved in the local rehabilitation medicine training program, I now use the long case format as the basis for case discussions with the trainees. I hope I have not caused any distress in the process.
One of my consultants arranged for us to drive around in a modified vehicle. If I recall correctly, it came with a spinner knob, and hand-operated accelerator and brake. It was not entirely intuitive, but it was an exciting experience, and I was glad I did not crash the car in the process.
Aboriginal and Torres Strait Islander peoples. I initially thought one interpreter would do all the interpreting for Aboriginal and Torres Islander languages, but I was wrong. There are some 250 Indigenous languages, including around 800 dialects, as I came to understand. While many Aboriginal and Torres Strait Islanders have conversational English skills, an interpreter is still highly valuable in the consultation to draw out specific nuances. Ineffective healthcare communication can lead to poor outcomes and distrust of medical professionals. The kinship system can be highly complex to an outsider and could have a bearing on some of the choices that Aboriginal and Torres Strait Islander people make, including healthcare decisions. I found that gaining trust through effective communication is paramount, as once I earned their trust and they understood that I was trying to help as much as possible, they were very grateful for what I did.
Apart from training and work, let me move on to something non-academic.
The weather. I arrived in January, usually the wettest month of the year with monsoonal storms. I was caught in a storm on my first day after returning from the shops with some groceries and was thoroughly drenched. No umbrella is built to handle the storm. The cool season from May to July was probably the most pleasant for me. The humidity during the build-up from October to December was stifling. Darwin is in tropical cyclone territory, and I was fortunate not to experience any cyclones during my one-year stay in Darwin. The horrors of Cyclone Tracy in 1974, which devastated Darwin, are well documented by the Museum and Art Gallery of the Northern Territory, with an entire section dedicated to it. I did ask my landlord (I had moved to a private rental after staying a few weeks in the temporary hospital accommodation) what to do should there be an impending cyclone. She told me to ensure I had sufficient food and water and to hide in the bathroom. The bathroom is located right in the middle of the house with no windows and is “cyclone-proof”.
Friends. I became good friends with my fellow rehabilitation registrars in Darwin, and we remain in contact. Dr Krystal Song is a rehabilitation physician at Royal Melbourne Hospital while Dr Lucy Madebwe is a rehabilitation physician at Royal Hobart Hospital. I remember the times we spent in tutorials with the consultants, hunting down various allied health professionals for more teaching, messing around in the P&O workshop, practising for OSCEs and so on. We enjoyed coffee at the café and meals over the weekends. They were hard-working people and remained steadfast in their work. I learnt the art of perseverance from them. We shared something in common; we were born outside Australia, which is perhaps why we gravitated towards each other. We have caught up several times since I left Australia and one complaint that I have is that they have yet to visit Singapore!
I found frogs in the toilet bowl. It happened not once but several times. I did have a shock as it was totally unexpected. My first instinct was to flush it down the toilet bowl, but it did not work. All it did was give the frog a nice shower. Eventually, I had to coax it to leave the house and back to the yard where it belonged. Google says it is not uncommon, but again having lived in an apartment all my life in Singapore, frog in the toilet bowl has never been a problem.
Lastly, I must mention the good fortune that descended upon me the first week into my rotation. I was offered a car for my use during my stay in Darwin. This offer came from one of the rehabilitation physicians. The kind gesture touched me. It was a first-generation white Toyota Prius. The car was probably more than ten years old and came with a perpetual engine fault warning. We tinkered with it for a while but could not pinpoint the problem. In any case, the car functioned flawlessly for the entire year I was using it. I felt so special driving this ‘classic’ petrol-hybrid car around. It was unique and perhaps one of the few in the Territory or even Australia at the time. I took great care of the car, washing and polishing it from time to time. I am happy that I returned the car to her owner a year later, looking as ‘new’ as she was a year earlier, and accident-free.
I can go on and on. I hope I have given a snippet of my life as an international medical graduate working as a rehabilitation registrar in Darwin. It was a great experience, and I encourage trainees in other Australian states to consider a training stint in Darwin. Things may have changed since my trainee days, but I am sure time spent in Darwin will bring on a different valuable dimension of rehabilitation medicine training. I want to end by extending my appreciation to Dr Gavin Chin and Dr Howard Flavell for turning an ignorant Singaporean registrar into a rehabilitation physician, during my stint in Darwin.
Dr Tze Chao Wee FAFRM (RACP), FFPMANZCA
Changi General Hospital, Singapore
Dr Jonathan Strayer also had a mild culture shock coming to Australia from the USA:
For those looking for a pithy analysis of the American medical system contrasted with that of Australia, this is not that article. For a lighter take on the Australia-USA contrasts – read on!
On 18 March 1997, my wife Lori and I found ourselves at an altitude of 35000 feet, somewhere over the South Pacific Ocean. We were grimly chuckling at the Qantas overhead video as a duo sang a humorous ditty detailing the many blue ringed, funnel-webbed, taipan snakey and white-sharky ways one could die in our soon-to-be new home, Australia. What had we gotten ourselves into?
At that time, I had been in physiatry (PM&R) practice for four years at a top facility, The Institute for Rehab & Research (TIRR) in Houston, Texas. I was working as junior faculty in a busy academic/neurotrauma-focused facility at the biggest medical center in the USA. Certainly challenging, busy, productive and lucrative but not meeting the itch for exploration, novelty and (dare we say) adventure.
My entry into medicine was not without obstacles. At age 18, I survived a C6,7 fracture leading to incomplete tetraplegia. As such, I was challenged throughout my training to ensure I was physically up to the task. Upon completion of my MD, I realised that working in rehabilitation medicine (US Physical Medicine & Rehab; aka physiatry) allowed me to capitalise best on my strengths and experiences. The safe course would have been to stay focused on my American academic medical career. But what fun is there in the safe course?
I had met Ruth Marshall at an ASIA (American Spinal Injury Association) meeting in 1995 and 1996. She mentioned she was recruiting for a Staff Specialist to join her in Adelaide, in exotic South Australia. We were mesmerised by tales of Oz: the climate, culture, wildlife, and of course, the Barossa Valley viticulture. We had other Australian links: I worked with Dr Stephen Wilson at the Paralympics; a colleague Bill Donovan had spent time in Perth, working with Sir George Bedbrook. Lori and I were at an opportune moment in our lives: no debt, no kids, and healthy parents – an ideal time to live abroad. One of Lori’s colleagues questioned our sanity saying, “Why are y’all going to Australia? It’s just like Texas!”
It is hard to migrate to Australia – especially as a physician. It takes persistence, endless faxes, notarising, interviewing, record requesting, and a vast amount of paper. My disability necessitated additional medical statements since Australia does not readily admit those with permanent disabilities. Our insistence on moving with our auto-baby – a 1967 Oldmobile Cutlass (dark blue with white convertible top), certainly complexified things. But in the flush of youth (and ignorance), we Strayers were absolutely up for a challenge. We landed in Sydney, met by our friend Stephen Wilson, shown around the Rehab and SCI royalty, before renting a car so we could drive to Adelaide. We were mostly successful coaching each other to keep to the LEFT, and it went well. We were struck by the beauty, lush vegetation, winding roads. Canberra was a hidden gem. Melbourne was an exciting metropolis. The Great Ocean Road inspired awe and not a little anxiety! All along friends and future colleagues introduced us to Australian art, song, and culture. We even had a short course in ‘Strine’ (thank you Stephen Wilson).
Our arrival in Adelaide was similarly warm and sunny. We loved Adelaide, with its wide streets and parklands, cafes, museums, concerts, and people. It was, as they say, ‘a large country town’. We had a temporary rental flat in North Adelaide, and I started work while Lori established our resources in the community: banking, stores, and the lot. Of these jobs, I had it easy. Certainly, there are differences in medical practice, jargon, and procedure, but humans are humans. Figuring out how to get a pint of milk in Adelaide after 7pm is (was) hard!
My initial weeks of work were struck by several facts: first Americans and Australians are as Shaw said, “two nations separated by a common language”. Second, that medical decision making was driven largely from medical need, not corporate greed. And third, that there was virtually NO gun violence. When I’d left Houston, nearly half my SCI service was gun-related, as the USA was in the grips of a terrible wave of drug fuelled firearms injury. We were gobsmacked when we heard an Adelaide news report that ‘a convenience store was held up with a man armed with a big stick’. Yes Dorothy, we were not in Kansas anymore!
The rehabilitation community was incredibly friendly and drew me into the AFRM fold. I was quite touched, and found my new colleagues supportive, warm, and quite accepting of my disability – as Rehab Specialists should. There were caveats though. My American specialty training went far enough to start work. But to continue I’d need to complete the AFRM examinations. At that time the oral exams were modelled on the RACP – quite different to American Oral Boards. Having never failed a test since kindergarten, it is humbling to admit it took me two tries to crack that ‘short case nut’.
With time I grew acquainted with challenges in the Australian medical system. It is a system directly accountable to the patient. Elective surgery wait times were a matter for the news headlines. It was inconvenient that my patients could (rarely) appeal to the government for perceived problems with their care in the form of a ministerial. However, it was empowering to know that I could do the same. The system was accountable to each patient, not faceless insurance corporations.
Contrast two similar patients: In the US, BR, a 28 year-old mother of two with a C6 complete tetraplegia due to car crash. She underwent surgeries acutely then diligently completed her six weeks of rehab at our centre. At the end of her rehabilitation, she was functional in her wheelchair, requiring moderate assistance for aspects of self-care and mobility. Since her private insurance didn’t provide for this, family were called upon, requiring her husband to provide care, arrange for housing adaptations, spend all their assets, and quit employment to qualify for state-provided care. A similar patient, mid-twenties woman in rural SA survived a C7 injury due to road traffic accident. She survived her acute surgery and rehab courtesy of Medicare, went home to a situation where she received support for accessible housing and limited care hours, allowing her to live independently, seek education and employment. (Specific details obscured to maintain patient confidentiality). It is (or should be) a source of national shame that in the USA more than a half a million people file for bankruptcy due to their medical expenses, contrasted with virtually none in other similar countries.
The vast thinly populated interior of Australia posed distinct challenges in delivering care. This is solved in part by bringing patients vast distances to the medical centre at Hampstead, frequently for longer hospitalisations – stay lengths inconceivable in the USA. We ran clinics in remote locations – Port Lincoln and in the Northern Territory. I participated in the initial deployment of telemedicine systems – a feature we are now all too familiar with in this post-COVID world. I was pleasantly surprised at the cultural diversity I saw in Adelaide: heavy with Asian, European, and Aboriginal influences. I had expected plum pudding and got an international smorgasbord.
As for the administrative aspects of medical care, I found these to be similar to those in the USA, varying in structure and name, but similar in function and practice. These concerned quality measures, functional measures, hospital safety, patient confidentiality. I did chafe at the smaller menu of medications available to me, but largely did not miss these. I found the expertise at every level to be high; from doctors and nurses; to psychologists and social workers; to physios and OTs. I saw professionals proud of their work, eager to learn, collaborate, and innovate. It was not all smooth sailing, but the Ozzie collaborative spirit really came through. We did great things with modest resources.
Our path also allowed us to experience Australian medicine from the patient side as well. In 1998 our son Daniel arrived with only minor complications, and we were extremely gratified by the support services available to new families. Two years later, our daughter Brianna came along, though surprised us by making her appearance 11 weeks early. She spent many weeks progressing through Neonatal ICU to an eventual discharge home. Her care was top-notch – our neonatologist had trained in Cincinnati – my alma mater. I would note that the financial impact of this stay had it occurred in the USA would have been brutal.
In 2001, we started asking some critical questions as to when we should head back stateside. I started casually asking my contacts and was a bit shocked at a slightly cool response. I was a bit of an exotic; not on the reliable American path anymore. It took a while to find a situation that worked, and in June 2003 we sadly bade our friends and colleagues goodbye and headed back to the USA. I entered a practice at the University of Cincinnati Medical Center, and the Cincinnati Veterans Administration Hospital. Interestingly, I found that VA medical care to be strikingly similar to that in Australia – a single payer system of care largely driven by patient medical needs, without profit mania. Though the USA has made gains in providing a fair health system to all, it still falls quite short of this mark. I am certain that many people have grown tired of me pointing to Australia as an example of what a fair, cost-effective and flexible medical system could be for us Yanks. Alas, I do not see this happening any time soon.
At this time, I continue to work directing the Dayton VA SCI clinic. Both kids are in the middle of long, costly university careers, so I must stay in the trenches. We look back fondly at our time in Australia, and proudly regard our achievements in the Land Down Under. I am so grateful for the help and friendship we received from the medical community and specifically those in the AFRM: Ruth Marshall, Stephen Wilson, James Middleton, Miranda Jelbart, Adrian Winsor, Peter Anastassiadis, Roy Lee, Maria Crotty, Doug Brown, Sue Rutowski, Howard Flavell, Gavin Chin, and many more. It may be confusing to some of my American colleagues, but I am proud to sign my name including the letters FAFRM (RACP).
Dr Jon Strayer FAFRM (RACP)
University of Cincinnati Medical Center
Although this article from Spinal Cord was published in 2013, readers may find this item comparing SCI rehabilitation units between a number of countries including India, Netherlands, USA, Australia etc interesting.
Distances are not insurmountable in rehabilitation medicine as I found out from Dr Jennifer O’Riordan who was once working in both Singapore and Australia at the same time.
In 2011 and 2012 I worked at Dubbo Private Hospital doing a fly in/fly out service twice a week. I established an inpatient rehabilitation unit for them and an outpatient service. The outpatient service rapidly became one catering for pain and cognitive impairment as these were the areas GPs were looking for help in.
I had planned to stay on in Dubbo for quite some time, but family circumstances took me to Singapore. The ward work was taken over by another doctor and my departure to Singapore was delayed by red tape. My outpatients were left in limbo.
It was the manager of the hospital in Dubbo at the time saying to me “you should do this new telehealth so that you can keep looking after your patients” that started my whole journey into telehealth.
So, I contacted all my referring GPs and asked them if it would work, and after ironing out a few technical issues, the overwhelming response was YES!
For rural NSW, in areas where the closest big centre is at least an hour’s drive away, telehealth has been life-changing. Imagine being the sole GP in a small town where you look after the hospital and the nursing home, and everyone else in between. Your population of patients is ageing and pragmatic and they don’t want to or can’t drive for over an hour on high-speed country roads to see a specialist. They are likely to say to you, “It’s okay doc, we trust you to do your best” but you know that your best is not what they could get if they could see a specialist.
Then these patients who trust you come to you to get their medical forms filled out for their driver’s licence, but you’re really not sure if they are safe to drive and you wonder how you are meant to work that out. You know that the patient will be devastated by the loss of their licence as it may leave them stranded on a rural property. Situations like this arise all the time for rural GPs and telehealth has given them a way to get help.
The consultations are often heartwarming, with elderly patients trying to understand this new technology, struggling to work out where the camera is, and usually talking to the accompanying practice nurse rather than myself. I have had patients jump with fright when I start talking to them, and others who kept trying to hold my hand through the screen.
I have come to know many of the GPs and nurses in these towns very well over the years and I have so much respect for what they do. The nursing homes in small rural towns are the best in the country, with staff who know the patients on a personal level, home cooked meals, and a genuine desire to keep their patients close to their homes and their families for as long as they possibly can. The remuneration in terms of financial return is poor – I bulk bill all of the patients, and many of them are very complex; but the remuneration in other ways is significant. In these consults you know how much your advice is appreciated; how much you are genuinely helping the GPs in these remote places; and most of all you know that you are providing a service to these patients that they could never access otherwise.
I have been doing this telehealth for over 10 years now and I have no plans to stop.
Jennifer O’Riordan
Rehabilitation Physician
Readers may be interested in some further information regarding telemedicine in rehabilitation. Useful links include:
In September 2022, I experienced a life changing moment that made me realise that rehabilitation medicine has the potential to change people’s lives immensely. I shared my story with a few of my mentors and it was recommended that I write it up as an article.
In January 2017, I visited a rural sub-acute rehabilitation centre in South India called Amar Seva Sangum (ASS) – this was during my family holiday. This centre is an NGO but very unique as it is run by the disabled for the disabled. I was fascinated by the work that is done at ASS and I have been returning and doing clinics annually in person, plus fortnightly telehealth rehabilitation clinics from Australia since 2017.
ASS was founded in Ayikudy, Tirunelveli District, Tamil Nadu, India, in 1981 by Shri S. Ramakrishnan, with a handful of disabled students. At the age of 21, Shri S. Ramakrishnan was keen to become a naval officer. After completing his engineering course, during the last round of his physical fitness testing he fell and sustained a cervical spinal cord injury and became tetraplegic. In 1992, a young, chartered accountant, a wheelchair user affected by muscular dystrophy, Shri S. Sankara Raman, left his lucrative practice at Chennai and joined Shri S. Ramakrishnan. Their dream was to build a ‘Valley for Disabled’ by empowering and rehabilitating disabled people. I feel they have achieved their dream.
I wanted to contribute my expertise to this centre as it includes a sub-acute spinal rehabilitation unit, outpatient stroke, cerebral palsy, and other neurological conditions clinic. They also have a school for cerebral palsy children (from newborn on) and a normal school for low socio-economic income family’s children and children with disabilities attend this school. A few of the kids with disabilities are from very remote towns and from extremely low socio-economic backgrounds so they board at ASS for their schooling.
During my first ever visit to ASS in January 2017, I was asked to do spinal clinics. I was seeing many male spinal patients and suddenly I realised there were no female spinal patients, and in fact, there was no female spinal unit. When I asked about female spinal patients, they said we don’t have any and females don’t get spinal cord injury (SCI). I was upset and said that there are no female SCI patients because you are not catering for them, and anyone can get SCI. I rebelled and said I would not see any more patients until they let me see a female spinal patient or any female patient.
One of the female physios said there is a female polio patient, and she is in a wheelchair, if I want, I can see her. I told them to take me to her and I went to another outpatient setting and I met this girl. She was a tiny little shy girl in a small wheelchair. I was shocked to hear she was 18 years old, and she looked like a spinal bifida patient rather than a polio one. She was three feet tall and 24kg. She did not give any eye contact as she was extremely shy, so I asked her how long she had been in a wheelchair. She said she didn’t know but she hadn’t walked since childhood and her parents always carried her everywhere. She had been in a wheelchair since entering ASS.
The next question I asked was how she was managing her bladder and bowel. She said she usually didn’t get out of the wheelchair once she got into it, but if she has to, she puts plastic sheets between her wheelchair and bed, as she leaks urine continuously. She sleeps on plastic sheets, otherwise she will mess her bed. Her bowels are always a problem. She had diarrhoea one week and constipation another week, and she alternated between enema and diarrhoea stopping tablets. Clearly this girl had never been educated on bladder and bowel continence.
With her permission I asked if I could examine her genitals and do PR examination to find out about the type of bladder and bowel she had. She reluctantly agreed after all the female staff convinced her. On examination, I discovered that she had completely excoriated genitals and she had no anal tone and sensation. I suggested intermittent self-catheters to enable her to empty her bladder completely. Everyone was surprised to hear that as they had never heard of female intermittent self-catheters, but they were well aware of male self-catheters. I educated all the female staff and the patient with diagrams, and after my return to Australia, I sent them information on self-catheters.
Although I had been doing telehelath rehab clinics at ASS since 2017, I was mainly asked to see spinal patients in the subacute spinal unit. Once I asked a staff member about that girl and they said she was doing her self-catheters and got discharged from ASS as she completed her year 12 schooling.
I regularly receive pictures of the kids with special needs achievements, and at one such incident in February 2022, I was sent a picture of a girl with a trophy for playing in the national basketball championship. I felt it might have been the same girl whom I met in 2017. When I asked about the girl’s details, they said, “oh no she is the polio patient” and they called her by some other name so I didn’t give it any further thought. In September 2022, I received another picture of the same girl representing India in international wheelchair basketball winning a silver medal. This time I sent a message to the ASS secretary’s wife asking her to check with the girl to see if she remembered seeing a doctor in 2017 at the clinic. Within 15 minutes, I received a very sweet voice message from this girl saying that her name was Kanaga and she has been looking for me for the last six years to thank me, as I had changed her life completely.
I contacted the girl and asked her what she meant by it. Kanaga said that she was always told she had polio and never heard of the word spina bifida until I mentioned it to her. She was born in Elangi, a very remote town near Tenkasi and both her parents are daily wage labourers. She has two younger brothers. Since the time she was born she has had problems with her bladder and bowel and her parents took her to many hospitals for bladder issues and everyone told them that she had to live with her bladder incontinence. She and her family were used to her bladder problems and never felt it was an issue. Her parents and her brother always carried her to school. She joined the ASS boarding school as she moved to high school.
In January 2017, someone came to the hostel and said that there is a doctor from Australia who is happy to see patients, and if anyone had any problems, they should go to the clinic rooms. She thought she was fine and never considered her bladder and bowel issues real problems, so thought she needed to put up with them – and therefore she did not attend the clinic. Then at midday, she was called in and told that the Australian doctor is refusing to see patients unless she visits her – and that’s how Kanaga came to see me.
Kanaga told me that she couldn’t believe how, within five minutes, I had changed her life. She told me that no other doctor had ever asked her about her bladder or bowel. She learnt how to do intermittent catheters and has been managing her bowel and bladder independently. She said that prior to seeing me every week, she would have urinary infections with severe tummy pain and foul smelling urine, and didn’t like to leave her home or hostel and socialise. She said she frequently had heat boil in and around her genitals and was in lot of pain.
Since the time she became continent she never looked back. She started progressing and excelling in her studies and sports and is now representing India in women’s wheelchair basketball. She completed her Bachelor of Commerce degree and is doing her MBA degree. She has developed so much confidence and is speaking up for women in wheelchairs. She has also been selected for national-level para powerlifting and won a silver medal. She said she has not had any UTIs or heat boils and she is continent of her bowels as well. She never knew she could have a normal life and achieve things.
When I heard her story, I was completely dumbfounded as I never realised that simple advice, which we take for granted in Australia, could change someone’s life so much. I still can’t believe how a tiny person like her – just three feet tall with such tiny arms – can be a wheelchair basketball player. This girl is mentally so strong and was just waiting for an opportunity to prove herself to the world. She had the fire in her belly to achieve so many things but was restricted due to her incontinence.
I am so proud to be a rehabilitation physician and it is true that we rehabilitation physicians definitely “make the saved life worth living”.
Dr Sumitha Gounden
Head, Rehabilitation Medicine
Orange Base Hospital
Professor Mark Slatyer was working with the ADF in Afghanistan. This record of one of those days is reprinted from Rhaïa in 2014.
The morning started early at 0430 hours. I went for an 8km run around the airfield, and then popped off to the mess for breakfast, and had a trauma call at 0630 hours to check that all of the equipment, and all bays, were ready to receive whatever trauma comes in today.
We started our clinic in the morning at approximately 0800 hours. I saw a range of injuries, including a cervical spine injury with radicular pain, meniscal tear, and a hyperthermia. The ambient temperature is 40° today. It is a dry, dusty heat that moves across the valley, which is part of the Silk Road that dates back thousands of years. The Base is surrounded by high mountains and in the summer, there is a sweltering heat complicated by dust and sandstorms. In the winter, in the immediate Base area, the temperature goes down to -10°, whilst outside the gate and up in the mountains the temperature can go down to -30°. Today, that is not our problem.
The beeper goes off and we run over to the other bombproof building across the road and prepare for three Afghani nationals who have been injured today in an Improvised Explosive Device (IED) blast. There were two young boys who were goat herding with their uncle in the mountains. Before we were allowed to see the patients, the patients must be cleared of any possible weapons or anything else that may injure us. Those are taken off them so we can commence our treatment. As this in an American facility, treatment is according to the American Facility standard, the Early Management of Severe Trauma (EMST) or Advanced Trainee Life Support (ATLS). We were running one of the trauma bays and the Americans were running the other two bays.
The use of ultrasound is very important. The only diagnostic imaging we have access to is plain x-ray and ultrasound. We have a small Sonosite machine, and it is used for rapidly assessing abdominal trauma or other thoracic trauma. If need be, we can do a very crude echocardiogram.
One of the boys comes in and we are able to diagnose that he has some fragments in his liver as we can see active bleeding. We commence resuscitation. His airway is okay. His brother is not so lucky, and he requires urgent aggressive resuscitation with blood, and he goes straight to theatre, whilst the first brother waits. He has multiple fragment wounds, and even though I am a rehabilitation physician, I end up assisting in the resuscitation before I scrub to assist two other Australian Medical Officers in the abdominal surgery.
What strikes you is the severity of the injuries. Blast injuries give you much more complex injuries which can involve the airway, the abdomen, and limbs, and the change that has occurred in the surgical management of these patients is incredible, very dramatic, and very different.
Many of the changes that have occurred in surgical care will not enter civilian practice for many years. There is even implementation now of freeze-dried blood, and some of the evacuation techniques, e.g., the use of unpiloted drones as aerial ambulances, is currently undergoing trials by various Defence Departments.
We finish the surgery: it went for about two and a half hours, and then we go back for a cup of coffee and a little bit of sit down for a while. I see a couple of patients, one with heatstroke, another with gastroenteritis requires IV infusion, and then we get organised, put on our body armour, get out weapons and go up to the Afghani National Army (ANA) camp, to mentor the medical officers in their compound at Tarin Kowt.
It is easy to be critical about the ANA: we come from a different culture, and we are very different.
ANA have very different backgrounds: their training is not the same as it is in Australia to be medical officers, and they require a lot of assistance. Some of the medical officers are incredibly bright and very motivated, and require little supervision, while others require a lot more supervision and training.
It is good work, I enjoy it. You cannot be impatient with them. You have some chai, as long as it is not Ramadan, and continue on and try and do what you can to make things better for the local population, as well as the army personnel.
The Afghan people are very hospitable and very generous people and, despite the religious and cultural differences, I find them easy to work with. Not everyone does but I enjoy the work although it is very demanding. There are other jobs that I cannot really talk about, but overall, it is a long day that can go on from early morning up to twenty hours/day. We are on-call for emergencies in the hospital as well as primary care activities, which can occur at any time. Some of it is primary care, some of it is rehabilitation, a lot of it is trauma emergency medicine, but I enjoy it.
I have done eight trips to the Middle East in the last six years, and it has taken its toll in terms of my absence from practice. Mostly my colleagues are understanding, but sometimes they are not.
How long will it go on? Our political leaders are telling us that it is phasing down, however there is a lot of medical work, and I am not sure what role, if any, I may play in the future.
I commend being in the ADF as a specialist. It offers unique and very satisfying experiences under extreme circumstances.
By Mark Slatyer
It is not just overseas, but also in Australia, that rehabilitation medicine can be a challenge when faced with someone with a diverse background as Dr Wan Mei Ang explains:
I was working in with my experienced orthotist, Sarah when a new patient walked in with an altered gait, not unexpectedly. It was Mrs M. She was a Middle Eastern lady in her fifties, accompanied by a caucasian lady of similar age. My first thought was ‘this must be the interpreter’. The note in the ‘remark’ column of my clinic list, however, said “Interpreter offered but patient declined”. I was slightly puzzled. We went on introducing ourselves to each other. Mrs M was from Afghanistan. The lady with her was Annie who said she was a family friend who knew Mrs M well and could help in the communication process, although she did not speak Mrs M’s language, Farsi. I became a little more puzzled. I started by explaining that we would usually prefer to have an interpreter. Both Mrs M and Annie declined.
As the history taking began, I got to know that Mrs M had late effects of poliomyelitis. She had her first knee-ankle-foot orthosis (KAFO) made after arriving in Australia, about 15 years ago. The KAFO was very aged, way beyond repair, but she had insisted on continuing to use it and had refused to try using her spare KAFO made (overseas) two years ago.
“Do you have falls?” I asked Mrs M. “Yes”. “What causes the falls?” She smiled politely at me. “How do you fall?” “I go on the floor. Then pain here,” she said, pointing to her lower back. Annie tried. “What makes you fall?” “What are you usually doing when you fall?” No response apart from nodding.
Our orthotist picked up the KAFO. The knee joints were flimsy. Mrs M probably fell when the knee failed to lock. I suggested getting an interpreter at this point. “I think we’ll be okay. We’ll see how we go.” Annie insisted. Annie went on to explain that Mrs M struggled with many domestic tasks. With the bilateral Trendelenburg gait, she showed on her short walk in and her failing KAFO, it was not difficult to understand why. She lived with her brother and her elderly mother who had Alzheimer’s dementia. She was the carer for her mother and, in fact, received Carer Payment. I asked whether Mrs M had any formal support services. She told me she had applied for the National Disability Insurance Scheme (NDIS) recently but had been rejected. I tried to explore the reasons for rejection. This time I was met with head shaking, and a faint smile with a sense of bewilderment.
After completing a physical examination, the orthotist Sarah and I decided that it was safest for Mrs M to start using her spare KAFO while we kept her preferred, aged KAFO in the department as reference for fabricating a new one. We knew that getting accustomed to a new KAFO would not be easy, as she would be like many other patients who preferred their old shoes, old prostheses, and old braces.
Pointing to the spare KAFO Mrs M brought in, which was made two years ago and appeared to be appropriate and functioning, Sarah said, “We’d like you to start wearing this new brace. The old brace is too old, it’s not safe to be used any more. We have to keep it here. We will make you a new one similar to it.”
“When can you repair (this)? This is falling down,” Mrs M asked, pointing to the thigh band of the old KAFO with torn leatherwork. “Can you do this today? I can’t walk without it.” Annie intervened. “No, you cannot take it home with you. It’s not safe to use anymore.” At this point I decided that it was impossible to continue without an interpreter. After a long wait, we finally gained access to a phone interpreter. It took another 5 to 10 minutes to get the message about the new KAFO across.
We then talked about NDIS. I explained that I was happy to provide a medical support letter for her reapplication. I explained that I was concerned about her current carer role for her mother. After another 15 minutes of talking via the interpreter, it turned out that Mrs M had responded in her first NDIS application that she was ‘completely independent’ in all her functional tasks, for fear of losing her entitlement to the Carer Payment. It took yet another 15 minutes to explain to Mrs M that continuing to provide hands-on care to her mother when she herself suffered deteriorating mobility could prove detrimental to both her and her mother, and that she should accept help whenever required, whilst exploring alternative income sources that might suit, such as the Disability Support Pension.
In the end, Mrs M walked out after 1 hour and 30 minutes of consultation time, while my next two patients waited with growing impatience. Before walking out (in her spare KAFO which seemed to fit perfectly - well, at least for now), she said in her limited English, smiling and pointing to the orthotist Sarah and myself, “Thank you to the two doctors. Other doctors don’t tell me what happens.” I smiled back, and for a moment, we connected – without needing a word in common. My ordinary day in clinic was perhaps not so ordinary after all.
This scenario will not be new to many of us. It is just yet another example to highlight that challenges in providing healthcare to people of culturally and linguistically diverse (CALD) backgrounds lie not just in the language itself but cover the realms of health literacy, as well as cultural expectations and understanding.
NB: Names have been changed for identity protection.
Dr Wan Mei Ang
The theme for the next editions of Rhaïa are:
- Physician health and lifestyle
- Ethics and rehabilitation medicine
- Administration, research, education and AI
I welcome any charities from our AFRM family on any of these or other topics.