Okay – BE WARNED right now this is NOT a happy story. If blood and stuff upset you don’t read this! This is NOT SUITABLE FOR CHILDREN!!

It was a day pretty much like any other. The Community Mental Health clinic was in full swing with patients lined up waiting to see the psychiatrist who was already running an hour behind schedule.

I was on call this day for any random drop ins or urgent call outs.  At around 11am Keith unexpectedly presented himself to reception and asked quite calmly if he could see one of the workers.

I met him in the waiting area. His first words to me were “I’ve done it”. Now, I was a little puzzled initially because I thought I knew what he meant and if he had done what I thought he had done why was he standing there in front of me looking so calm!

I gestured toward an empty interview room and we both entered. I closed the door. As I turned around Keith was holding a white plastic jar with a screw top. He presented it to me. I may have said something like “Holy crap!” – I can’t quite recall, but I took the container and carefully unscrewed the lid.

Yes, he had done it all right! Inside the jar I could see folds of blood stained scrotal tissue and pubic hair. He had castrated himself and brought in the evidence to show me! I was staggered by his demeanour – calm and quite “matter of fact” about the whole ordeal.

It had taken him several laborious hours using a razor blade and scissors. Keith had been thinking about this for some time. He was constantly troubled by sexual thoughts and desires which he felt interfered with his creativity and inner harmony – this was his solution.

Even though he still had the tourniquet on, and walked awkwardly with some discomfort, he was not in a great deal of pain.

I promptly transported him to the nearby hospital where he required surgery (not to reattach anything – just to patch him up properly).

Keith was obviously a seriously troubled man. He had a diagnosis of paranoid schizophrenia. He was very intelligent, well read and very keen on philosophical debates. Unfortunately he suicided by an overdose of anti-depressants a few months later, but not before severing an ear and planning how to amputate one of his own fingers!

Bob Goodwin – StoriesAndPlays.com

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NOTE: This post is NOT for everybody. It contains strong images of serious injuries!!!

The incidence of violence in the remote indigenous communities that I worked in was high.

For the most part this was associated with excessive alcohol use, although there was certainly quite a bit of suturing work generated from the “pay back” system. What this meant was that if a family member was badly injured or died there was generally someone who was in some way responsible. Not necessarily because they inflicted the injuries, but sometimes because they were not there to look after the person concerned. Domestic violence (usually, but not always, male to female) incidents were high and often alcohol related also.

A knife slash after too much to drink!

A compound dislocated thumb – from a bull kick!

A “pay back” boomerang injury.

Sliced triceps. Went through a plate glass window.

Items most commonly used in violent episodes included boomerangs; nulla nullas; star pickets; sticks; glass and fists.
Suturing was a regular occurance. Sometimes an injury required medivac (off to hospital by plane) – as did the triceps one which was a little too involved for our clinic. As I have said in previous articles, I believe education is the most essential ingredient to decreasing the incidence of violent injuries and deaths in remote indigenous communities. As a nurse in the community providing such education at any meaningful level was near impossible given the staffing arrangements and the extreme morbdity in so many lifestyle areas.

Bob Goodwin – StoriesAndPlays.com

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For me, one of the highlights of remote area nursing in the NT in Australia was the 3 or 4 day health trips to numerous out stations and pastoral properties. The roads, to say the least, were difficult and at times almost impassable. Four wheel drive was essential and avoiding the wet season was a must if you ever wanted to get home again.

Feral Donkeys on the road to Mistake Creek

After a long dusty drive we (i.e. myself and another nurse or aboriginal health worker) would find ourselves at a remote aboriginal outpost with a population of just 3 or 4. The appreciation of our visit was always obvious and we were made very welcome. There would be a range of health screening measures required including checking for trachoma, diabetes and hypertension. Overdue immunisations would be given and sometimes TB and leprosy monitoring was required. We would attend to other health concerns as best we could given the equipment and supplies we had. Living conditions at these isolated areas was as basic as you can get, but did usually include a corrugated iron dwelling with a wide open verandah and several smaller rooms along each side and very little, if any, use of glass. Bore water was often provided.

Occasionally we would need to drag out our swag and sleep under the stars, but as far as possible we tried to be at a cattle station by days end. Here we could get a shower and enjoy the hospitality of the owners who really went out of their way to make us feel at home. Of course we would be attending to the health needs of the station hands and updating and checking the medical/first aid kit as well.

Along the road to Nelson Springs

Conditions were often hot, dry and dusty with lots of flies. Driving was difficult often in areas without any radio contact and sleeping arrangements were far from ideal – yet I still look on this as one of the highlights of my remote area experience. Really, it was these challenges that made it so memorable – topped off with the warm reception we always received and the spectacular scenery along the way.

Bob Goodwin – StoriesAndPlays.com

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The incidence of ill-health in remote aboriginal communities was astounding. As mentioned  in a previous article 90% of the population were seen every month. Skin infections of various varieties ranked highly with scabies, boils, fungal and non-specific skin sores the most popular.

Infected scabies

Of course head lice was pretty much the norm in kids and many adults.

Lice being removed – see all those tiny black specks!

Ear infections were in good supply and many school age children were seen with pus running from their ears. I washed out maggots and dead flies from ears many times. Take a moment to think – how are these kids supposed to learn when they can barely hear!

Younger children with thick yellow mucous running from their noses was also common – we called these “number 11s”.

Chest and upper respiratory tract infections in youngsters from just a few months of age to toddlers were all too frequent and unfortunately the recommended treatment was an injection of penicillin – a very painful procedure for such little people!

Skin sores – “biggest mobs of”

I would like to think that there has been some improvement in remote aboriginal community health but relatively recent information unfortunately suggests otherwise.

Two reliable links are included here if you wish to be staggered by the lack of improvement in health and the appalling health statistics (article 1 and article 2)

Bob Goodwin – StoriesAndPlays.com

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(Mental Health series – part 11)

Lisa was 30 years old and had a history of substance misuse and episodic incidents of self harm (usually by taking an overdose of prescribed medication). She was a single mother with two children, a baby girl of 9 months and a boy of 4 years.

I had not long be appointed as her case manager (with the Community Mental Health Service) when I received a call to say she had presented at the local hospital emergency department with her kids in tow.

I assessed her at the ED – there were no clear symptoms of any mental illness and her primary reason for presenting was to obtain some drugs for her “anxiety”.

She did not seem particularly anxious during her presentation and there was no chance of her being given any drugs. I spoke with her for sometime and suggested I could follow her home and discuss matters further with her there. She agreed to this, bundled the two kids into the car and I followed her home.

We talked about many things, but Lisa kept returning the focus back to acquiring drugs. After 30 minutes I indicated that I would need to leave but we could catch up again soon.

Okay… well this is when the “shit hit the fan”!

She started shouting and cursing. The baby on her hip was virtually thrown about 2 metres into the cot. She screamed at her young son and roughly shovedhim into a room which was then locked. Lisa then took to the kitchen – she grabbed the cord of the kettle and swung it round and round – smashing the louvres – knocking cups and plates off the kitchen bench. Shards of glass and broken crockery went everywhere. I was seriously concerned for my own safety but even more for that of the children. At least they were no where near the broken glass.

After some short sharp, but ineffectual, “Don’ts” and “Stops” from me I decided my counseling skills were unlikely to make any further contribution so I left the house. Out in the street I rang triple zero (ie 911 for non-Aussie folk) and spoke with the police. They asked if the children were injured to which I had to say “not so far” but I was very concerned for their safety. The police said they would refer the matter to Family Services! So that was that – the first time I ever had to call 000 in a work situation and no one was coming! On the positive side at least I couldn’t hear any further shouting and smashing sounds eminating rom the premises.

My hands were visibly shaking. I felt completely helpless. I called work (which was difficult as I could barely push the words out) and a colleague came to a nearby shopping area and we went for a coffee and talked it through. This may well have been the best coffee of my life!

Lisa was discharged from the service a few weeks later. There was some debate as to whether she should have ever been accepted in the first place. I ceased being her case manager immediately.

There is no doubt she had a mental health problem but not a mental illness as per the text book. While I don’t know the final outcome usually referral to rehab or counselling would be a good place to start.

Bob Goodwin – StoriesAndPlays.com

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Judith had been an inpatient in the mental health unit for 2 weeks. This was her second admission for a major depressive illness over the past 2 years, but on this occasion she had attempted suicide by drowning and was rescued by the police after they were alerted by a passer by. She was unable to swim.

Judith’s marriage had fallen apart and she believed she was now totally alone and that no one cared for, or was concerned about, her.
I had been her case manager since her admission. She initially had many of the classic features of depressive illness with low self esteem, sleep disturbance, loss of appetite and suicidal thoughts.
She was commenced on a course of anti-depressant medication shortly after coming to hospital.
It wasn’t long after this 2 week period that she requested weekend leave to her home. I had noticed that the 2-3 days prior to her request she had seemed considerably brighter in her mood. She was interacting more with other patients and talking more freely with the staff. Her underlying thoughts of negativity however still remained and I was sufficiently concerned as to mention this in the ward rounds and note in her file that weekend leave would be premature at this time.
A sudden flight into health can be a warning sign, and to me her depression remained severe despite her not admitting (but also not denying) any more suicidal thoughts.
I was rostered four days off from Thursday to Sunday. I returned to work on the Monday to find out that not only had the psychiatric registrar approved her leave but also that she had successfully drowned herself on the Saturday.
The doctor’s file notes noted her improved mental state, current stability and approved her weekend leave request.
I was obviously both angry and very distressed about this and even more so when any attempts to discuss this further were quickly dismissed.
There was no debriefing – no enquiry – no inquest.

Bob Goodwin – StoriesAndPlays.com

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In the locked male ward at Wolston Park Psychiatric Hospital in the late 1970s the staff were allocated various roles for the shift. So you would be called the “inside man”, the “yard man”, “kitchen man” or “second man”.

A single or seclusion room – heavy shutters in the “open”position

Second man was essentiallly 2^nd in charge and usually directed others and gave out the medication. There was also the “first man” and the charge nurse.

The charge nurse was a Monday to Friday 8 till 4 worker who was apparently the ward manager – although it was often unclear to me as to what they actually did because they were seen so rarely and the ward functioned in its maladjusted way perfectly fine without their input.

One particular evening I was the “inside man” which was a pleasant change from my usual “yard man” responsibilities. This was my first time in this role and as a student mental health nurse it did seem a little special.  To my way of thinking I thought it showed that my skills were not just one dimentional and I had been recognised as being was capable of more complex tasks and responsibilities. This was a gross misunderstanding on my part!

One of my inside duties was to go round to all the single rooms and close all the heavy shutters before the patients come back inside from the yard (you can see these in the above picture – in the open position). There would have been about 16 rooms. The “first man” approached me around 4pm and asked me to attend to this task which I dutifully attended to – it took about 10 minutes after which I assisted the “kitchen man” with counting the cutlery.

The same type of room as above as seem from the outside of the ward

About half an hour later the First Man came over to me and said “I thought I told you to close all the fucking shutters.” I responsed positively saying “Yes they are all locked down.” His eyes widened and some colour filled his cheeks and then he ripped trough me with a tirade of abuse. When the barrage was finally over I walked back around to the 16 rooms and yes he was correct – they were all open! I once again went around and closed them. I never did find out who set me up and unlocked all the shutters but I did realise that it was just a way of getting in my face, making me look incompetent and exacting some WPH justice on a GT (General Trained nurse – see articles “Mental Health in the Dark Ages” and “Bathroom Blood”). I know other GTs got more negative attention than myself so on balance I think I endured the system fairly well.

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Running the health clinic and the multitude of health programs is both challenging and demanding, so when the opportunity to get away on the weekend presents itself we were quick to grab it.

While the road trip was often bumpy and dusty arriving at a remote billabong was well worth the ride.

These isolated waterholes are part of the river in the wet season, but after the waters subside these beautiful areas become a great picnic area and what’s even better – a great fishing resort for barramundi!!

For the most part they were caught on lures with a careful cast near a submerged log or rock. Unfortunately for me my skills (or luck) didn’t always serve me well and I had to be content to enjoy someone elses catch – but this was just fine and we were rarely short of a big barra steak!

Barramundi can get pretty huge as seen in the pic below. This monster was caught by an elderley aboriginal in the local community.

Jenny and Lesley display a big catch!

We got to taste quite a variety of different foods in the Northern Territory including goanna, bush turkey, crocodile and witchetty grubs (I had to toast mine – just couldn’t eat them while they were still squirming!).

Bob Goodwin – StoriesAndPlays.com

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Many people say that in the Northern Territory there are only two seasons – the “wet” and the “dry”. From a health point of view both these times have their own set of challenges.

A massive storm approaches during the “build up”

The “build up” is a period of extended hot days or weeks with frequent violent storms preceeding the “wet” season. With the wet comes isolation - and for many remote aboriginal communities and cattle properties access to health care, outside of their own first aid supplies and a phone or radio, is non existent. Preparation is the key – with restocking of supplies and checking of equipment essential. Even emergency evacuation may be compromised if runways are too wet or weather conditions unsuitable.

The wet can contribute to increased cases of diarrhoea (particularly in children) and vomiting, chest infections, and some skin infections. While the dry sees more ear nose throat and eye problems. Alcohol is a little harder to acquire during the peak of the “wet”, but where there’s a will there’s a way, and it seems to find its way through regardless.

Many dusty dry areas are completely transformed as the following two pictures, taken at the same location, demonstrate. The Territory is a place of dramatic change and breathtaking scenery.

Bob Goodwin – StoriesAndPlays.com

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Unfortunately one of the immediate tragedies to greet unsuspecting visitors in a remote aboriginal community is the standard of living – in particular the housing.

Being used to the middle class areas of cities and suburbia it is extremely confronting and disturbing to see families living in broken down dwellings with broken fixtures, windows, walls, ceilings etc. To add to this the filth and untidiness in many homes is hard to come to terms with.

From a health point of view the impact is significant. The inumerable cases of diarrhoea and skin infections, particularly in children a clear case in point. Who knows how many other conditions could be included here. When you have 920 clinic presentations in one month in a community of 1,000 – 1,100 it is indicative of some serious problems.

(Imagine in a city like Sydney or New York if 90% of the population needed health care interventions every month!!)

The problem is of course exacerbated by lack of appropriate housing and overcrowding. Health education and understanding also a significant issue. Not to mention of course adequate government funding and proper use of such funds!

I would like to think that since my experience in the late 80′s & early 90′s that circumstances have improved!?

Bob Goodwin – StoriesAndPlays.com

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