John's Blog – Rants and Rambles from the NT

Over the long weekend at the end of July, the Harts Range Amateur Race Club hold their annual race day at their race course near Harts Range on the Plenty Highway.  It is a family weekend, with events and entertainment for children and adults.  Catering is a mix of BYO and a canteen kitchen usually operated by volunteers from the Ioslated Childrens Parents Association (ICPA). 

For the past 3 years, I have been catering coordinator for ICPA for the Harts Range weekend.  This involves organising the required permit to operate the kitchen and sell food, ordering all the necessary supplies, arranging a roster of people to do the cooking and serving on the weekend, and then overseeing the operation of the kitchen.  The first year was very stressful, as I had no idea what I was doing and no idea what I needed to know.  This third year was much better, despite the usual crop of setbacks.  Most of the orders arrived without a hitch, except we received 20 loaves of bread instead of the 20 cartons of bread I ordered (that was 240 loaves!!)  Fortunately we were able to contact a latecomer who could collect the other 220 loaves from Alice Springs for us.  Everything else arrived as ordered.

The weather was quite warm.  It was not so hot as to be uncomfortable in the open, but certainly warm enough to prompt people to want lots of cold drinks.  For the first time that I have been involved, we sold all of the drinks we had available, which was both good and bad.  Good because we had no leftovers to dispose of, and bad because we could have sold more if we had them!  Ice blocks and bags of ice we also quick sellers, and we ran out of them too.

Staffing the kitchen is always a problem.  This year was better in that a team of volunteers took the morning shifts out of my hands and ran the kitchen from opening at 8am until 1pm.  Then I took over, assisted by two of my girls and another volunteer, until 8pm.  The occasional hour or three from other volunteers allowed us to take short breaks , but it was still a long day in the heat of the kitchen.

Once again I was unable to see much of the activity on the racetrack and in the rodeo arena.  When the events were on, I was in the kitchen, and after the kitchen closed the girls and I collapsed on our swags until morning.  Maybe one year I’ll go for the fun of it!!  The best thing about this year’s effort is that we were able to raise a lot of money for ICPA, so they can continue to advocate for bush kids to get quality education and appropriate support to make the most of the educational opportunities that come their way.

Maybe we will tackle the coordinating role again next year.  Time will tell, as it depends on whether we are still in the NT this time next year.  It’s been a good experience, but don’t ask me too much about what goes on at the Harts Range Races.  I can only tell you about the kitchen, for everything else you’ll have to talk to someone who actually gets to see the races!!

I have recently become interested in the concept of uncertainty, particularly as it relates to remote clinical practice.  Uncertainty is a normal part of human existence, and very often it is an uncomfortable part.  People tend to try to minimise uncertainty, to reduce the discomfort it causes.  This occurs in a number of ways, and these have consequences for the safety and quality of clinical practice.

• Avoidance is a common technique.  It involves manipulating the environment to eliminate or at least reduce the amount of uncertainty.  For example, a nurse who lacks confidence in dealing with children will avoid working in paediatrics, as this reduces the uncertainty he or she feels in this setting.  In a remote setting, this nurse may have no choice but to deal with children, and attempts to avoid doing so will have consequences for the health care team.
• Denial is also common.  Uncertainty can be denied by simply ignoring the fact that it exists, and seeing all issues as black and white.  For example, if a patient is labelled as a drunk, there is no uncertainty about inconvenient differential diagnoses such as subarachnoid haemorrhage or hypoglycaemia.  The consequences for denial are obvious, and mostly stem from corrupting the evidence base for quality clinical practice.  If you ignore relevant alternatives, you do reduce uncertainty, but also increase the risk of being wrong.  Being wrong in clinical practice is typically detrimental to patients.
• Logic can be used to try to reduce uncertainty.  Evidence is collected and weighed, and used to make a decision about a course of action.  The more comprehensive this process, the more valid the outcomes.  However, it requires time and effort, both of which can be in short supply at times.  There will always be another possibility that ‘should have been considered’, and the weighing of evidence is itself fraught with bias and uncertainty.  Logic and reasoning are valuable tools, and should certainly be used, but they do not eliminate uncertainty.  I’m not sure they even reduce it!
• Dogma is another all-too-common approach to uncertainty.  For millenia, humans have sought explanations for things they do not understand, and religion has evolved to meet this need.  By attributing the unknown, and often also the known, to an omnipotent omnipresent diety, uncertainty is eliminated by stating that it is ‘God’s will’ or the ‘will of Allah’ or whatever.  Uncertainty then becomes evidence of a lack of faith, so the ‘faithful’ strenuously pretend to be certain of what they claim to believe.  Unfortunately, this does nothing to actually reduce uncertainty, and in fact makes it worse by pushing it underground.  In clinical practice, dogma is detrimental to safety and quality, as it absolves practitioners from responsibility for decisions – after all everything is ‘in God’s hands’.
• Probably the least common approach to dealing with uncertainty is acceptance.  By accepting that uncertainty is normal and expected, practitioners can allow for the fact that they will make mistakes sometimes.  Reducing mistakes is part of professional development, but it is unreasonable to expect that they can be eliminated.  

I think the reality for most practitioners is that they use a bit of everything.  A dash of avoidance, a hint of denial, a cup of logic, a pinch of religion, and top up with acceptance.  The important thing is to be reflective and know what your coping mechanisms are.  This allows the practitioner to assess whether their approach contributes to or detracts from safety and quality.

Most of my education has been by one form or other of distance education.  My first 2 years of schooling were Grade 1 and Grade 2 at Meadows Primary School, then just as I was starting Grade 3, we moved out bush.  Our farm was 20km from the nearest bus stop, and the school was a 1 1/4 hour bus ride from that bus stop.  Rather than spend such a huge chunk of time sitting on a bus each school day, I was introduced to the South Australian Correspondence School (now SA Open Access College) and began my lifelong love affair with distance learning.  Every fortnight I would receive a package from the Correspondence School, which I would complete in 2 or 3 days then have the rest of the fortnight off.  Compared to the boredom and lack of intellectual stimulation of the classroom environment, it was Utopia!  It wasn’t until Year 11 that I had to spend more than a week to complete each fortnight’s package, and my grade sheets showed A’s across the board.

I left school at the end of Year 11 to start work as a farm labourer, shearer, grain handler, truck driver, and fence fixer.  The plan was to get together enough resources to acquire my own land and become a farmer.  I was given the opportunity to do some cereal sharefarming in the mid 1980’s which was to be my foot in the door.  Unfortunately both crops I was involved in financing failed, and I saw the writing on the wall.  Now what to do?  I decided to go back to school and complete Year 12, then go to university.  Year 12 was a culture shock, as I was 21 in a crowd of 17-year-olds, and had not set foot in a classroom since early 1974.  However, my independent study skills learned from the Correspondence School helped me to do well and complete Year 12 with a 96% grade.

Then came four years at university trying to find out what I wanted to do.  A year of Electronic and Electrical Engineering, a year of Mechanical Engineering, and two years of Surveying left me still confused what I was going to do.  During all of this, I was a volunteer Ambulance Officer, and in my second year of Surveying I starting going out with the daughter of a GP.  I spend many hours with this GP (and the daughter of course!!) discussing health care etc, and she suggested I should try medicine as a career.  So I applied, but was knocked back as a bad risk due to three uncompleted degrees already.  The Dean of the School of Medicine at Adelaide University suggested I acquire a nursing degree, then if I achieved high grades he would give me a place in medical school.

Three years later I graduated with a Bachelor of Nursing with the highest grade point average of my class over the three years.  Much of what I learned during my nursing degree was self-directed as I quickly found the lectures and tutorials were pitched at the lowest common denominator and were unbelievably boring.  So I spent much of the three years teaching myself from textbooks and journal articles, just like I used to do with the Correspondence School.  It worked for me, as I achieved a high enough grade (High Distinction average) to go to medical school.  Unfortunately for entering medical school, but fortunately for my life in general, I married Anita shortly after graduation and decided to stick with nursing for the time being as I was sick of being a penniless student.

My next educational endeavour was two years later when I was working is a busy metropolitan ED, and began a graduate program for Emergency Nursing.  This was almost entirely by distance education, and left me with a graduate certificate in Emergency Nursing.

Then after yet another change in my career, I ended up working as a Remote Area Nurse in Oodnadatta SA.  It didn’t take me long to realise that I knew almost nothing that I needed to know to be effective, so it was back to distance education to fill the gaps.  I enrolled in the Master of Remote Health Practice and completed it over 3 years, then the Master of Remote Health Management over two more years.  The possibility of becoming a Remote Nurse Practitioner became achievable in 2010, so I then completed a bridging course to convert my first Masters to a Master of Remote Health (Nurse Practitioner).

What’s next?  Well right now I’m refreshing my ALS certification via an online unit with CRANAplus, and in the next few months it is possible that I’ll have the opportunity to start a PhD program.  So the love affair with learning, and in particular distance education, continues.  I am thrilled that my children have had the opportunity to do some of their schooling via Alice Springs School of the Air, as it has exposed them to the self-discipline, challenges and rewards of distance education.  If the skills they acquire through this form of learning are as useful to their lives as they have been in mine, then they will be fortunate indeed.

One of the things that makes work worthwhile is the opportunity to make a difference.  In my experience, this is a factor which is often underestimated, or perhaps undervalued, by managers.  It goes part of the way to explain why throwing money at remote health jobs does little to resolve the chronic shortage of personnel.  In fact, in some ways throwing increased money at remote staff has the effect of attracting mercenaries who are only ‘in it for the money’.

So if it’s not the money, and let’s face it, the salary package for a Remote Area Nurse is among the best you can get in the profession, then what is it that keeps people in the field?  Well, my opinion is based on my experience as a Remote Area Nurse, as a remote Health Centre Manager, and as a manager of volunteers.  I think it depends to a large extent on the ability to make a difference, and to see and feel that you are doing so.  For many nurses, life is one of boredom and drudgery, doing the same work over and over again in a never-ending cycle until their backs pack up or they burn out physically and emotionally.  For a few, the rewards that come from helping a patient to find the road to health and follow it make up for all the failures.  It’s all very well to patronise struggling nurses and tell them to ‘focus on the successes and let the rest slide by’.  Unfortunately that ignores the reality of human nature, where we feel deeply our failures and they erode our confidence underneath the veneer of professional cheerfulness.  Making a difference to people is what makes the difference to us.  This is true of many endeavours, but I think it is most relevant when caring is part of the job description.

During my time in the SA Country Fire Service, I came to realise that most volunteers were giving their time and energy to the organisation because they could make a difference, and that met a need within themselves for their lives to mean something.  This was true even, or perhaps especially, of those who professed to believe religious dogma which was supposed to meet this need.  I used to think it was about the need to belong, and maybe in some ways that’s a frequent starting point.  Now I think it is more about making a difference, and being recognised for doing so, that keeps people doing things that others find amazing.  Whether it is fighting fires in your own time, or living and working in a remote community away from family and friends, it is the opportunity to make a difference, and the recognition for doing so that is a potent driver for people sticking with it.

What this means for remote health is that if managers want to be serious about attracting and retaining good staff in the field, they need to stop their senseless bickering and bitchiness about little things that don’t make a difference.  They need to focus on making it possible for staff to make a difference.  In Aboriginal communities, this means making a real effort, not the usual token gesture, to include Aboriginal Health Workers as part of the team.  Remote Area Nurses are hampered in their drive to make a difference if they don’t have the tools and support they need, and a big part of this is the Aboriginal Health Workers.  Any RAN who doesn’t see this needs to do themselves a favour and get the hell out of Aboriginal health ASAP.

To stop the soul-destroying revolving door of acute health care, the health system needs to be reformed to put more money into prevention than it does into cure.  Most of the work in remote Health Centres is acute care arising from preventable causes, yet bugger all is spent on prevention.  Managers tend to express their awareness of this stupidity by blaming the Remote Area Nurses for neglecting prevention, when it is the almost total lack of support and funding for prevention activities that stops it from happening.  You can’t make a difference when the cards are stacked against you, and when your own employer is doing the stacking and then blaming you for it, it is not long before no amount of money will compensate for the disillusionment.

So what’s the solution?  Give remote health professionals the tools they nned and the support they need to do what most of them are there for, to make a difference.  If you can’t do that, or don’t know how, then do everyone a favour and get out of remote health and give the job to someone who can.  Either that, or stop pretending that we are in the business of Primary Health Care and rename the health centres “Remote Band-Aid Stations”.  Then we can keep wasting time and money and dedicated staff for another 50 years!

One of my long-held beliefs is that people who live in rural and remote areas need to support their local businesses, or risk losing them.  After all, city-based people are not going to drive to the middle of nowhere for the privilege of paying higher prices for a restricted range of lower quality goods.  So if those of us who live outside the cities don’t pay up, country businesses will go belly-up.  I’m OK with that, because as far as I’m concerned, the country life is worth the extra expense, especially when you often get to save money in other ways so it balances out.

However, there is a limit.  In Tennant Creek, the sole local supermarket has a captive market which they shamelessly milk for all it’s worth.  A regular fortnight’s shopping at Tennant Creek will cost me at least $800, and that leaves quite a few items that I can’t get at all until I go shopping in Alice Springs.  A comparable shopping trolley full in Alice Springs costs around $500, and includes everything I need.  The quality of fruit and vegetables is highly variable, ranging from OK to inedible, and staples like milk powder and bread are nearly twice the price that they are in Alice Springs.  There have apparently been a number of attempts to start up a bakery in Tennant Creek, but each time the supermarket conducts a price war until the bakery goes broke.  Then the price of bread goes through the roof again.

This is where Bush Orders comes in.  I am a Woolworths customer, so can only talk about their service, but I know Coles do it as well.  Every fortnight I fax a list of what I need to Woolworths in Alice Springs.  The Bush Orders team do the shopping for me, for a $20 fee (which is being scrapped soon) and pack it into boxes.  Meat and bakery items are frozen, fruit and dairy goods chilled, and the rest packed as general goods.  Most times it takes 6 boxes to pack my order (2 frozen, 2 chilled and 2 general).  I then pay $6 per box to have them freighted to Tennant Creek where they are held at the freight depot for me to collect at my convenience.  I could get them delivered to my door, but since I work nights, it’s better if I collect them myself.  Then when I get home, it’s like Christmas!  Everyone is keen to see what came in the boxes.  I’m caught up in it too, even though I placed the order, because the Bush Orders team usually throw in some freebies as well.

So for me, the benefits of Bush Orders are:

• Avoiding the extortion of a monopoly business
• Ordering groceries eliminates impulse shopping, as all purchases are planned
• I can still buy specials, by referring to the specials catalogue online that applies to Alice Springs
• It saves me having to drive to Alice Springs to buy the items that are not available in Tennant Creek
• I save the cost of the $20 shopping fee just in the bread, and more than recoup the $48 freight on everything else. On top of that, I save over $200 by not having to drive to Alice Springs.

Disadvantages are:

• It is hard to explore new items that we might like to try, so this has to wait until we travel to a Woolworths store. I can browse Woolworths online, but not the Alice Springs store.
• I have to keep money available in my account for up to 3 weeks as it seems to take that long for Woolworths to deduct the payment.  If I change to using a credit card for these purchases, that will eliminate this delay.
• We end up with a mountain of boxes that need to be disposed of.
• I like impulse shopping!!  Not that it’s good for me.

Overall then, Bush Orders allows us to enjoy the services, range and quality available from a major regional supermarket for a relatively minor fee.  While I would like to support local business, I cannot support extortion.  I understand that businesses need to make a profit, but they need to understand that we live in a global economy and if they can’t compete, they’re out.  If that means no local supermarket, so be it.  The reality of course is that there will always be a supermarket here, and if a second one opens, competition will bring prices down to a fair level.  The supermarket pay their staff a pittance and don’t open long hours, and freight is very competitive, so that doesn’t justify the high prices.  Therefore I refuse to accept them.  Long live Bush Orders!!

One of my favourite places near Alice Springs is Redbank Gorge, about 220km west of Alice Springs in the West MacDonnell Ranges. The road is sealed except for the entry into the gorge carpark, which is about 8km of rutted dirt track. It can be accessed by normal car most of the time, but you’d have to take it very easy. A 4WD is a better option.

Once at the carpark, there is a strenuous 1.2km walk along the creek bed to get to the gorge. If you like clambering over rocks and wading through deep sand, then you’ll enjoy the walk. Otherwise, just keep plugging away at it, as the gorge at the end is well worth the effort. Because the gorge is so narrow, it gets little sunlight, so the water tends to be chilly. This is OK as you have to work hard to swim through the gorge and this keeps you warm. Also, some flotation is a good idea. I’d recommend something like a small car inner tube, or a floatie ring, as anything big like an air mattress won’t fit through.

At several points through the gorge, you have to climb over rocks worn smooth by millenia of water flowing over them. This can be tricky, and I would suggest always having someone with you in the gorge. It’s not a tourist spot, so if you get injured, you may have quite a wait for someone to come along and find you. Most visitors to Redbank Gorge stop at the entrance and take photos there before leaving. I’d say only about a third of them attempt the swim through, and maybe 5% make it all the way through. There used to be a chain in the rock about 3/4 of the way through, but it was washed away in 2010, and I don;t know if it’s been replaced. You can still get through (I have done it since the chain vanished) but it’s difficult and most tourists give up at this point.

If taking a camera, make sure it’s waterproof, or in a waterproof case.

Finally, keep an eye out for snakes in the water. I’ve seen one in the six times I’ve been to the gorge, and due to the cold it was very sluggish and easily avoided. Just make sure you see it first!

I received my registration renewal notice via email recently for the Landcruiser.  Don’t know how much it is because I can’t open it!  And yes, I elected to have renewals sent to me via email not post.  Whatever the cost, I know it’s due for a roadworthy inspection, so once again it’s time to check everything over.

• Brakes have been replaced, so no worries there.
• All light bulbs working for once (though a couple will inevitably pack up just as the inspector looks at them as usual!).
• No oil leaks, as all previous leaks have been repaired and no new ones have appeared.
• All new steering joints, so steering is tight.
• New universal joints on the driveshafts.
• All suspension bushes replaced.
• New coolant hoses and fan belts.
• Headlights aimed properly.
• Seats and seatbelts in good condition.
• No rust in the bodywork.  Now what that has to do with road-worthiness is anybody’s guess, but I know from bitter experience that some inspectors think it does.  I used to have a Falcon wagon which I kept in top mechanical condition, but it had a small rust spot over the rear wheel arch.  I was informed that I could not re-register the vehicle without having the spot repaired by cutting and welding, and would need re-inspection before painting.  Since this would cost more than the vehicle was worth, I didn’t bother.  The infuriating thing is that the spot was there the previous year, exactly the same (and I mean exactly, as I had treated it with rust preventer) and there was no hint of a problem.  I wasted $240 putting in a new windscreen before inspection, and ended up having to scrap the vehicle.  My question is if nonstructural rust is such a major issue, why was it passed the previous year, and why do they pass rusted vehicles in much much worse shape owned by people with darker complexion than me?  I’ll leave you to decide your own answer to that.
• Wipers work, horn works, windscreen washer works, all indicators and other lights work.
• Handbrake – well there we may have a problem.  I have completely replaced the handbrake system with new components, and it is still absolutely woeful.  It is the one thing I don’t like about the 80 series Landcruiser.  Even brand new, the handbrake just barely passes the NT road-worthiness inspection.  My only hope is to adjust it right up till it has almost seized, have the inspection done, then back it off before driving home.  There’s no point taking it to a brake specialist, as it is already new and still doesn’t work.  They will simply adjust it up until it almost seizes, and charge me $500 for 5 minutes work with a screwdriver.

Anyway, I guess I’m just about ready for the inspection, so like all drivers of older vehicles, I’ll go in with my fingers crossed and hope the inspector is not having a bad day.