Reflections

Work, as well as life, can lead to surprising placesIf someone had suggested in my medical student days that I would end up working where I do, I would have laughed. But, no one knows where experiences, conversations and opportunities might lead. Like many idealistic medical students, I did electives in areas of need. My first was in north-east Arnhem Land. Returning to lectures, I remember ...

Marianne E Jauncey BMed, MPH(Hons), FAFPHM

oday, I am going to open a corpse. I’m eighteen and in my first year of university. Apprehension jars my every movement as I approach the white sheet stretched tight over a humanoid form. I stare, try to imagine, try to prepare myself. But no preparation is enough. This could be my grandfather, my grandmother, my uncle. An aunt. But it’s not. “Be respectful.” My lecturer raises his ...

Yin Lin

You wake to a doctor, sitting where your leg would be. How brave, they say, as if a body is to be endured. Through a closed window — a wind-tossed tree. You wanted to be normal, not to be reassured. What is lost? An empty room soon fills with echoes. How brave, they say. As if a body is to be endured, you keep score, sitting in the stands. Who ...

Andy Jackson

It is a pleasure to announce the winner of the MJA, MDA National Prize for Excellence in Medical Research 2011. This $10 000 award honours the authors of the best original clinical research article published in the Medical Journal of Australia in each calendar year. The Journal’s Content Review Committee has awarded the 2011 prize to a team of seven authors led by Nola Olsen and Professor Bill Musk ...

Annette Katelaris

PATIENTS WITH eating disorders are like canaries in the mines warning of some of the ills of Western society. In broader society, we have lost our way with eating. There are mixed messages on desirable weight and eating. We fret about obesity. No wonder a young person with little sense of self-worth stumbles into dieting and develops an eating disorder. The publisher’s website states that “Fast ...

Judith Fleming

GORDON PARKER describes himself as a “contrarian”. He admits that he’s difficult, combative, impatient with received wisdoms in psychiatry that he thinks don’t work, and dogged — even aggressive — in tackling problems, clinical and conceptual. And it’s clear in this intellectual autobiography that these personal qualities, combined with his enormous energy and brilliance, have been central to his enormous contributions to the field. Professor ...

Rebecca E Adams

In the Gawler program, the positive aspects are paid for with considerable sacrifice In the state of turmoil following a cancer diagnosis, many patients are drawn to complementary treatments, which may provide an explanation, hope, and a sense of autonomy not provided by conventional medicine. In Australia, one figure who has attained a great following ...

Tanya L Hall BMed, FRANZCP

How do decisions change if we can assess risk of “unacceptable badness”?The concept of medical futility has been debated for many years, but a precise definition remains elusive.1-3 This is not surprising given the evolving nature of modern medicine. Progressively more complex decisions are required when considering increasingly sophisticated diagnostic and therapeutic interventions. Providing a ...

Stephen Honeybul FRCS, FRACS · Kwok M Ho FCICM, PhD · Grant R Gillett FRACS, MPhil · Christopher R P Lind FRACS · Susan O’Hanlon MB BS

Nothing!” Jill said. “He didn’t say nothing”, said Warren, as he eased the car into the outside lane. No horns, no fist-pumps, no swearing. Warren was driving considerately. He was not himself. “Yes, but he didn’t exactly paint a rosy picture of what he did say I could do.” Jill put on her sunglasses, then dropped them ...

Philip A Sprott MB BS, FRACS

DID YOU KNOW that the McMurray test has been shown to have a specificity of 86% and a sensitivity of 48% for meniscal injury? This text describes a wide range of such clinical signs and also evaluates them for effectiveness, adding invaluable detail not available in other clinical texts.The three authors, two of whom are ...

Sarah J Abrahamson

David Wigg MB BS, MD, PhD, FRCR, FRANZCR,made a considerable contribution and left a lasting legacy to radiation oncology and radiobiology in Australia. David was born in Adelaide on 14 September 1933 into a family with strong medical ...

Margaret M Wallington · Linda M Swaney

IT’S 3 O’CLOCK in the morning, and the phone rings. There’s an initial fog of disorientation and, then, I remember ... I grab my smartphone, pen, paper and my trusty handbook and move to a quiet ...

Robert P Dowsett

Might science need philosophy for a precise and complete understanding of pain? We were invited to reflect upon brain–mind–pain interactions and to opine on whether modern neuroscience adequately considers pain phenomena and experience. One might suggest that adequacy is not a particularly lofty goal in this respect. However, if we were to consider whether ...

Michael A Thacker PhD, MSc, FCSP · G Lorimer Moseley BAppSc(Phty)(Hons), PhD

The winners of the MJA Dr Eric Dark Creative Writing Prize were announced at the inaugural Dr Eric Dark Memorial Dinner, held at the Fairmont Resort in Leura, New South Wales, on Saturday 10 March 2012. The prize is sponsored by Varuna, the Writers’ House and “Doctors Who ...”, a Varuna initiative to nurture creativity, innovation and advocacy in the medical profession. Named in memory of Dr Eric Dark (1889–1987), Australian general practitioner and public health activist, the MJA’s new writing competition obviously inspired many of our readers: there were 110 entries based on the theme of “splendid isolation”, with a very high overall standard. We needed all the help we could get from the creative writing experts at Varuna and our new literary editor, Dr Leah Kaminsky, to come to a final decision! The winners were Dr Susan Fox, a GP from Daylesford, Victoria, in the medical practitioners category, and Australian National University medical student Paulina Wojciechowska in the medical students category. Both winners attended a 2-day writing workshop at Varuna, led by Dr Hilton Koppe and Dr Kaminsky, on the same weekend as the dinner. The medical practitioners prize also includes a 1-week residential writing retreat at Varuna. We thank our external judges and, of course, those of you who shared your stories and insights with us. Keep writing and watch out for the announcement of next year’s competition. MJA editorial staff congratulate the winners: (L-R) Dr Tania Janusic, Dr Annette Katelaris, Dr Susan Fox, Paulina Wojciechowska, Dr Ruth Armstrong, Dr Astika Kappagoda. Eric Dark (painting): inspiring doctors to create, innovate and advocate; pictured with “Doctors Who ...” panel members Dr Michelle Cahill and Dr Hilton Koppe.

Ruth M Armstrong BMed

“The baby’s breech, come quickly.” The midwife’s voice was sharp and squeaky. She had already hung up the phone. My head, muddled with sleep, began to pound. I staggered out of bed, stripped off my pyjamas and dragged on an old shirt and jeans, pulling my straggly hair into a rough ponytail. I grabbed my jacket on the way out the door. Outside, the mist enveloped me in stillness. An early morning frost had coated the windscreen with ice. I scraped it with my hand, but it was stuck tight. I turned the car’s heater on full, put the windscreen wipers on to maximum and pulled out of the driveway. With my head out the window, I could just negotiate my way between the gum trees lining the road. The mist swirled kaleidoscopically in the headlight beams. My eyes began to water, and I wiped them with fingers numb from the cold. As I finally reached the highway, I pushed down harder on the accelerator, trying not to spin my tyres on the icy bitumen. In the birth room of the tiny rural hospital, Matildhe was emitting short, low moans in between loud pants. Julie had got Matildhe’s legs up in stirrups, but she was lopsided on the bed. I pulled her buttocks to straighten her up. I noticed my hands were shaking as I took up position between Matildhe’s legs. She smiled briefly at me with her mouth but her eyes were fixed on the wall behind me. The baby’s buttocks were visible, with thick bottle-green meconium oozing out of the anus. There was no one else to call for help; the other GP in town was on holiday. Julie was the only nurse on duty for our small country hospital, and this baby was coming soon. Julie was an experienced midwife but I doubted she had delivered many vaginal breech babies in the past 20 years or so. The only breech birth I’d ever seen was when I’d been called in to observe as a medical student; I had been one of twenty or so people in the room. I shuddered. “You can push, Matildhe”, I said, trying to stop my voice from trembling. My mind was a muddy puddle. My eyes were fixed solely on Matildhe’s perineum; everything in my peripheral vision was blackness. I could hear Julie murmuring words of encouragement to Matildhe, but I couldn’t see her. Phrases came to me from deep within, the voices of professors and tutors long gone: Hands off the breech Keep the back up Let the body hang when you see the nape of the neck I heard each of these slowly and clearly intoned in a deep and authoritative voice. I uncurled my thumbs from where I was clenching them under my fingers. Matildhe continued to pant and moan as I coaxed her through the birth. I followed the voices in my head, leaving my hands off except to assist the delivery of the baby’s arms, and ensuring its back was uppermost in the birth canal. At one point, I heard Julie murmur to me, “I can’t find the heartbeat”, as Matildhe pushed, shrieking. I clamped my teeth together, biting down hard. I now held the baby’s legs in my hands, with its head still inside Matildhe. Its blue feet hung down limply over my wrists, lolling to each side. “Come on”, I said to Matildhe. “Another push.” I placed forceps on the baby’s head, but an image came to me of a different manoeuvre I remembered from the textbooks. I placed my hand tightly over the baby’s face, my middle finger in its little mouth, my ring and index fingers on its cheeks. “Come on baby”, I cried. Finally the baby’s head slipped free of Matildhe’s vagina. I held it in my hands, willing it to take a breath. “We have to take your baby for a bit of breathing help”, I said to Matildhe. She nodded, her eyes closed, her face still. The baby was cold in my hands and rapidly turning white. I wiped it down with a towel and began the resuscitation. My hands were shiny with sweat and vernix; it was hard to get a good seal on the facemask. “Is Matildhe okay?” I called to Julie. “Bit of bleeding over here”, Julie replied. “Can I give some extra oxytocin?” I took a shallow breath before I began to bark orders at Julie for more drugs. “Your baby’s a bit flat”, I said gently to Matildhe as I continued the resuscitation. I had already started pumping the baby’s tiny chest with my index and middle fingers, trying not to break its ribs as I pressed down quickly, again and again. With the ventilation mask slipping off the baby’s tiny face with every puff of oxygen, I grabbed a small tube to insert into its lungs. My hands were shaking so much, it was hard to hold the baby’s head still to see the vocal cords. I tried once, twice, three times. Each time, the baby’s chest failed to rise as I pumped oxygen down the tube. I tried for a fourth time. My fingers felt numb. My chest was heavy. I could feel Matildhe’s eyes on us. Please, I willed. Finally, the tube was through the cords. Something shifted in the room. A flick of the baby’s eyelid. A slight movement of a tiny fingernail against the resuscitation cot. The baby had a heartbeat again. “The bleeding’s slowing”, called Julie. “Matildhe’s blood pressure is holding and her pulse is settling.” I breathed out the air I’d been holding in tight against my heart. “You have a baby boy”, I said finally to Matildhe. She smiled. “Will he be okay?” she asked, craning her head towards the resuscitation cot. “We need to wait”, I said quietly. “But he’s okay for now.” At the nurses’ station, I struggled to write my notes. Despite the blood pumping hard through my arteries at my wrist, the pen wouldn’t move on the page and my sentences didn’t make sense. I found myself staring into space on several occasions. The retrieval team were kind on the phone, asking me to repeat myself over and over. They said it would be three hours until they arrived. I paced back along the long, empty corridor to the birth room, with the sound of my footsteps bouncing off the sterile walls. Matildhe was cradling her son’s head in her hands. He was lying peacefully. “Thank you”, she said. “Thank you for everything.” As I walked outside the hospital entrance into the morning, the air opened up around me. The sun was shining through the clouds, sending rays of light high into the sky. Magpies cawed to each other across the bitumen. The window of my car was still open. I wound it up and drove home, watching the sunlight dance over the defrosting ice crystals on the windscreen.

Susan E Fox MB BS(Hons)/BA, FRACGP, FACRRM

Every morning I wake just to hear him get up and head for the bathroom. Then I fall back to sleep. Somewhat later, I wake up again. I hear him leave the bathroom and go down the stairs. Slowly. No reason to rush. Like on thin ice of a lake, one step after another. Just to make it to the other side. I fall back to sleep. When I wake again, I know it’s time for him to leave the kitchen. He does. I can hear the clonking of the dishes as he clears the table, and then the door slightly creaks. Steps across the hallway. Another creaking door opens and closes. He’s in the lounge: it’s time for the news. Later, after I have finally emerged from my bedroom, he will enumerate to me the famous people who died last night. But now I fall back to sleep and continue along twisting hospital corridors, through half-open hospital rooms. I burst into one after another. Where is she? She was here just a second ago, just then, before I woke up! I look for her in the empty beds and gurneys. Sometimes I find her. But she’s there less and less often. They say it is normal. She will be nearest for the first six months. And then not. I am still in my dream, bubbled in, when the phone starts. I pretend I’m asleep. He pretends he cannot hear it. It rings for a few minutes. When it ceases, I know there have been too many interruptions and I will no longer meet her today. Leaving behind the rusty twilight of the corridors, I struggle out of bed. When I see him, we both choose not to mention the phone. In an undertone, we make remarks about recent political unrest in some faraway countries. “What will it be?” we ask, trying to avert eyes from her picture on the left, just by the vase with pansies. Then it’s the phone again. We knew we would not be able to get away for long. It is now like some new law of nature. They ring us. A procession of acquaintances, friends and relatives. They check on us, give advice we never asked for, enquire about our daily routine. Some of them behave like they are bringing a special message. They say, “She came to me in a dream last night. She looked well. Your mother looked happy”. I know they mean unlike that day in the chapel, supine and dressed up by foreign hands from the funeral home because it is no longer our tradition to prepare our loved ones ourselves for their last journey. They tell me things as if they were some long forgotten details. What a great nurse she was. Not the fastest but so well organised that she’d always finish everything before everyone else. How patients wanted her to be their nurse. How they said, “Sister, I hope you are making my injections today”. And how she stayed in a boarding house and was afraid of mice. “I know, I know”, I answer. But what I really want is to be able to smell her hair. I go and sniff her pillow, but every day the scent becomes vaguer and vaguer. The phone rings again. He and I look at each other. “Why don’t you answer, this is your house now”, my father tells me. It is. The phone angrily buzzes as I walk out of the room. When he isn’t there, I sieve through clutter assembled on her side of their bed. There is a small urn with ambers, because they’re supposed to take away any pain you have. I try warming up a few golden pebbles in my hands but everything stays the same. There is also a basket with dried petals for better sleep. I sneak them out to my room — if I could dream for longer, I might get to see her more often. Then there is a porcelain elephant with a lifted trunk. It seems incredible that it’s no longer needed. I catch him dusting it when he thinks I’m out. I too wait. I feel that if only I could stay motionless for long enough, she will change her mind and come back. “The human was not meant for inaction”, voices in the receiver tell me. “To survive, one needs to keep busy. This is the only way.” In the evenings, we sit in front of the TV. He dozes off and wakes up to the sound of his own snoring. I work through a pile of photocopies from my Anatomy colouring book. Over and over again, like a madman, I colour the brain, the parts that failed her when we needed them to work. The parts where the blood leaked out and gave her a big scare, and neither of us were with her. The parts that gave her such a headache. The headache so big that they call it “thunderclap”. Like a loud clap of some large hands from above to announce that your time has come. Days are always fine. It’s like she went to work. At night I’m back in there again, when we hovered at her ICU bed like scared birds whose hatchling had fallen out of the nest. “Let us leave her rosary in case she wakes up when we aren’t there.” “Let us leave her some cookies in case she wakes up hungry.” “And the eyeglasses, why didn’t we think of that, if she wakes up and cannot see, she’ll be petrified.” One morning I fall asleep to wade through the brown dusk of a cave. I feel she’s somewhere around, but cannot tell her apart from the other silhouettes that populate it. They corner me in and stare. Then they drag me inside a cube as dark as a fucking Rosetta Stone: “You have to stay here. You are not meant to wander around”. I fight them tooth and nail. I will not be locked up! Never will it happen! The muddy darkness around me shifts with uncertainty, and then I feel her by me and can smell her hair. As if I had any bargaining power, I declare, “I will stay put as long as I have to, providing she holds my hand through all this time”. It is allowed. They put me in the cube but I get to clutch my fingers around hers. I sit in complete darkness. My senses tell me nothing except that my hand is out there with her, in a brownish grotto. “I don’t even get to dream”, he says when I tell him. It’s the phone again. They ask me about my dreams. I fear they will be like him, a bit envious of my little dark box. “I wish there was something to tell”, I reply. “How is he?” they ask. “He walks”, I answer. Kilometres of footpaths daily. I know he is trying to remember. He had no way of tearing her away from the cold claws of the other side; he had no way of stopping her from slipping through, all blue on her lips, and face, and arms. But now he will save her. He will pick up every memory of her that lingers in the parks and cul-de-sacs, pin the pieces together and turn them over in his head so many times that they will finally hold strong. He will close his eyes when the spring wind blows from the mountains, and she will be in it just the same as years ago when he would meet her on her way back from work, shivering from cold in an unbuttoned trench coat. He will listen to footsteps echoing on the pavement; a slightly uneven gait, yes, just like hers when she was in a hurry. He will labour like an ant in the infinity of mazes; he will not forego any avenue, will check every nook, collect every grain of sand and drag it back home. The doctors may have had to let her go, and it was not up to him to do anything. But this is the part that rests in his hands. And this time it will be different. She will not end as long as he goes on. I sometimes see him meandering around alleys of the cemetery and trails of neighbouring hills. I now know it. We are both dragging our own stones on our own ropes attached to our own necks. These are our private stones; we will guard them with our lives. Only we and no one else can rid us of them. When I look at him through the knots of twigs and their fresh sprouts, I know he sees me. He knows I see him. We gently alter our routes so that they don’t intersect. The weather is clear. Wind caresses my cheeks. I close my eyes and test how far I can walk without seeing. In the darkness I create.

Jeremy Bunker, MB BS, FRACGP, was born in Swindon, England, on 10 August 1957 and came to Sydney at the age of 2. Educated at Epping Boys High School, he completed Year 12 in 1975 and, as an accomplished pianist, initially studied at the Sydney Conservatorium of Music. During this time, Jeremy decided he wanted to pursue a medical career and enrolled in medicine at the University of New South Wales. He obtained a first class honours degree in 1983 and was awarded the University Medal, the Wallace Wurth Prize for General Proficiency throughout the Medical Course, the Paediatrics Staff Prize and the Australasian Faculty of Occupational Medicine Prize. Jeremy’s broad interests and genuine liking of people made general practice a natural career choice. After completing his residency at the Prince of Wales Hospital, he set up practice in 1986 in Ultimo with his friend and colleague Dr Kathleen Burns. In 1994, Jeremy attained Fellowship of the Royal Australian College of General Practitioners. First as a general supervisor in 1992 and then as a medical educator in 1996, Jeremy became involved in the Royal Australian College of General Practitioners Training Program, where he helped mentor many registrars in both the science and art of general practice. Over the next 15 years, Jeremy took on many academic and leadership roles in general practice. In 2003, he left the Ultimo practice and was appointed the foundation Director of Training at the Sydney Institute of General Practice Education and Training, which later became GP Synergy. At this time, he also joined the General Practice Unit at Fairfield Hospital as Staff Specialist, where he pursued his interests in chronic disease management and the integration of health service delivery. At a local level, Jeremy served as Chair and as Director of the Central Sydney GP Network. In 2010, he received the RACGP award for Best General Practice Research Article in the Australian Family Physician Journal. Jeremy’s wit, extraordinary facilitation skills, humility, openness and compassion made him a truly exceptional educator. He died in Sydney of lung cancer on 4 May 2011, and is survived by his partner Max, and his children Sophie, Tim and Amelia.

Elizabeth K Marles

EVER WANTED an update on rheumatoid arthritis (RA) without having to wade through pages of complex science or a heavy hardcover volume? If so, then Fast facts: rheumatoid arthritis is for you. This adjunct to core knowledge for the non-specialist covers all the requisite points in the smallest possible space. Blending the necessary content ...

Phillip C Vecchio

Viewing germs through biological and sociological lenses. In 1922, Simon Flexner, the director of the Rockefeller Institute in New York City, observed that “each generation receives its particular impression of epidemic diseases”. After the influenza pandemic of 1918, the postwar medical generation was trying to ...

Warwick H Anderson MD, PhD

Robert MacMahon AM, MB BS, MS, FRCS, although publicly renowned as a paediatric surgeon, was far more — teacher, innovator, a family man with a delightful sense of humour, and founding governor of the Make-A-Wish Foundation Bob was born in the Sydney suburb of Eastwood on 22 April 1931. He studied medicine at the University of Sydney, graduating in 1954. He undertook 4 years of training at the Royal Newcastle Hospital, and spent his spare time in the surf and on the rugby field for the Newcastle Wanderers. He then studied in the United Kingdom, where he decided to become a paediatric surgeon. After obtaining a Master of Science from the University of Colorado Denver, he returned to Sydney in 1965, to become the first James Fairfax Surgical Research Fellow at the Children’s Medical Research Foundation. In 1967, he was appointed inaugural Head of the Department of Paediatric Surgery at the Queen Victoria Medical Centre (later Monash Medical Centre), Melbourne. In 1970, he became Associate Professor of Paediatric Surgery at Monash University. At Monash, he developed his interest in the nutrition of premature infants, running a research program in amino acid and mineral metabolism. Between 1970 and 1975, through intravenous feeding, he increased premature infant survival from 18% to 71%. In 1974, Bob founded the Australasian Society for Parenteral and Enteral Nutrition and was its inaugural President. He served on the Monash University Human Research Ethics Committee for 40 years, and was its Chair from 1999 to 2009. He was President of the Australian and New Zealand Association of Paediatric Surgeons from 1991 to 1993. He performed the first human fetal operation in Australia and the first in-utero repair of a diaphragmatic hernia. He also pioneered in-utero laser vesicostomy and helped create the Fetal Diagnostic Unit at Monash Medical Centre. Throughout his career, Bob contributed to 10 textbooks and authored more than 60 research articles. In 2010, he was made a Member of the Order of Australia. After he retired from medicine, he enjoyed camping in the bush, surfing and golf. Bob died on 1 April 2011 from prostate cancer, and is survived by his wife Bessie and four daughters. He will be remembered for his personal integrity, enthusiasm, achievements, intellect and judgement, and his wonderful sense of humour.

Robert J Stunden

Gone viral. The germs that share our lives. Frank Bowden. Sydney: University of New South Wales Press, 2011 (216 pp, $32.95). ISBN 978174223273. FRANK BOWDEN tells a good story. As a sexual health physician and professor of medicine at the Australian National University Medical School he is well placed to provide an informative account of 15 “germs that share our life”. The anecdotes from his years of clinical and public health work in Australia make for interesting reading for both health professionals and the public. Fairfield Hospital for Infectious Diseases was, indeed, a “beautiful anachronism” in the 1980s, remembered fondly by generations of Victorian medical students who rotated through there, especially by the registrars who had the good fortune to be mentored in the science and art of general medicine and infectious diseases by Fairfield’s legendary infectious diseases physicians. Bowden provides a poignant account of his training at Fairfield during the early years of the AIDS epidemic: “There were 16 patients with AIDS on Ward 4. They were all men, all homosexual, and they were all dying”. Indigenous health has been an important part of Bowden’s career and many of the organisms he bases his stories on remain major causes of morbidity in Australia’s Indigenous population. Several controversial aspects are raised. The author is for an aggressive approach to screening and treatment of sexually transmitted infections (STIs). He laments that the success of the national donovanosis eradication campaign, which he was centrally involved in, has not been matched with similar results for other STIs, and that historically there has been opposition to the concept of mass treatment as a means to address the high rates of infectious diseases in Indigenous communities. The argument has been that a “sheep-dip approach” fails to address the primary issues of socioeconomic disadvantage, housing, health hardware, and access to health services and education. Nevertheless, the stars may be aligning finally to include the possibility of population-based treatment for infections such as syphilis, scabies, trachoma and chlamydial genitourinary infections in the setting of improved primary health care. Having to reach for the dictionary often when reading can be annoying; or it can be amusing, or even enlightening. Bowden takes the reader along from the role of necromancy in WHO decision making to the adverse impact of HIV misinformation by a pulchritudinous female surgeon. I remain baffled, however, by his allusion to the “metaphorical cojones” of cardiologists!

Bart J Currie