Here

there is something comforting about sitting here with my hand on Robert’s breast

he says, here, steady yourself against me here, he says, after a pause, he is thinking how best

to fit me, he says it must have been bad but you’re here, you’re with us

the surroundings burst with surgical fittings

it all looks very Weimar, very neue Sach

i expect fishnets, a crossed leg, a trail of cigar smoke somewhere

but there is only Robert and me and all the boxes

and Robert saying again, here, steady yourself against me here

Practising in PNG: pidgin, rugby and yaws

Anthony Radford was the inaugural professor of primary care at Flinders University in Adelaide, South Australia. Before and after that appointment, he accumulated a total of 50 years of experience in Papua New Guinea (PNG). Radford first went to that country as a student in 1951; from 1963 to 1972, he was a public health officer there; and later, he consulted on PNG for the World Health Organization, UNICEF and AusAID. This book records these three phases of his service to Australia’s nearest neighbour.

As a junior doctor in PNG, Radford’s practice was remarkably broad: obstetric emergencies requiring symphysiotomy; surgery for late appendicitis; common medical conditions such as pneumonia and diarrhoea, as well as uncommon ones like yaws and leprosy. Public health was in the mix: sanitation, safe water and immunisation. And he carried out research into infectious diseases and health care delivery. Meanwhile, his colleagues there were solving the riddles of infectious diseases like pig bel (from eating uncooked pork) and kuru (from eating dead relatives).

Radford and his wife Robin embraced the different cultures of the country; all three of their children grew up speaking pidgin and were given tribal names.

Radford acquired fellowships from three Royal Colleges, a diploma in tropical medicine and a Harvard master’s degree and, in 1971, was appointed associate professor to the emerging medical school in Port Moresby.

He was also active in the local sports scene, and found the time to conquer the Kokoda Track and climb Mt Wilhelm. However, the acme of his rugby career, national selection, was scuttled when an aggressive tackle resulted in a dislocated hip.

Radford’s tendency to name-drop might be a bit distracting, but the prominent people named, many of whom are his relatives, help put the events described into context.

I would have liked to have had a few more maps. It would also have helped if Radford had indicated the chronology where contemporaneous diary entries or letters are inserted. These are minor quibbles, however. On the whole, it is a superb life story. And in telling it, Radford reviews the historical, ethnolinguistic and religious origins of the German and British colonies that became PNG. He then goes on to describe the region’s transition to nationhood, and to foresee its problems and lament its failures.

The hobbit — an unexpected deficiency

A striking feature of fantasy literature has been the consistent victory of good characters over bad. While the consensus has been to attribute this to narrative conventions about morality and the necessary happiness of endings, we hypothesised that a major contribution to the defeat of evildoers in this context is their aversion to sunlight and their poor diet, which may lead to vitamin D deficiency and hence reduced martial prowess.

Vitamin D is a fat-soluble, secosteroid hormone, which in humans is largely synthesised in the skin when exposed to ultraviolet light, and is sometimes called “the sunshine vitamin”.1 Vitamin D is also found in some foods, particularly oily fish and, in small amounts, in egg yolks, cheese, beef, liver and some mushrooms. It has a well described role in calcium metabolism, with deficiency resulting in rickets and osteomalacia. Vitamin D also has immune-modulating roles with potential effects on susceptibility to conditions ranging from multiple sclerosis to tuberculosis and accelerated lung function decline.2,3 Skeletal muscle weakness is known to be a feature of vitamin D deficiency although it has not been found to contribute to muscle dysfunction in chronic obstructive pulmonary disease (COPD),4 despite patients with COPD being noted for poor diet and reduced time spent outdoors.5

A PubMed search performed on 29 July 2012 for studies that fulfilled both of the search terms “imaginary populations” and “vitamin D” returned no publications, suggesting that our hypothesis was untested, and leading to the work presented here.

Methods

We performed a pilot study using textual analysis to extract data relating to diurnal habits, dwelling, light exposure and diet from The hobbit by J R R Tolkien. Results are reported in an approximately consecutive narrative fashion. In addition, protagonists were identified as good or evil and victorious or defeated on binary scales by consensus. Sun exposure was scored from 3 (lots) to 0 (none at all) and diet was scored as 1 or 0 depending on whether any vitamin D-containing item was mentioned. These were summed to give a vitamin D score (range, 0–4), and this score was related to victoriousness by unpaired t tests.

Results

Bilbo Baggins, a hobbit, lives in a hole in the ground but with windows, and when he is first encountered he is smoking his pipe in the sun overlooking his garden (it is worth noting [parenthetically] that smoking is itself associated with skeletal muscle dysfunction6). Dwarves and wizards smoke too, and the production of smoke rings is unfortunately glamourised. The hobbit diet is clearly varied as he is able to offer cake, tea, seed cake, ale, porter, red wine, raspberry jam, mince pies, cheese, pork pie, salad, cold chicken, pickles and apple tart to the dwarves who visit to engage him in the business of burglary. The dwarves also show evidence of a mixed diet and, importantly, although they “like the dark, the dark for dark business”, they do spend much time above ground and have plenty of sun exposure during the initial pony ride in June that begins their trip to the Lonely Mountain.

Sun avoidance is a recurring theme among the evil characters. The trolls the party encounter shun the sunlight to avoid the petrification to which they eventually succumb and have been living on an exclusively mutton diet. They are certainly strong but undeniably stupid, and consuming jugs of “good drink” has further befuddled their wits.

Gollum, himself “as dark as darkness” lives in the dark, deep in the Misty Mountains. He does, however, eat fish, although the text describes these only as “blind” and it is not clear whether they are of an oily kind and thus a potential source of vitamin D. He sometimes eats goblins, but they rarely come down to his lake, suggesting that fish play little part in the goblin diet. Interestingly, these occasional trips to catch fish are undertaken at the behest of the Great Goblin, leading one to speculate that his enhanced diet may have helped him to achieve his pre-eminent position within goblin society. In due course, the Great Goblin is replaced by the Son of the Great Goblin. While simple nepotism is a likely explanation, we are unable to exclude an epigenetic process whereby the son’s fitness to rule has been influenced by parental vitamin D exposure.

Goblins’ aversion to sunlight includes bringing a huge cloud of bats to accompany their army on the march. Like the Spartans at the Battle of Thermopylae, they expect to gain some advantage from fighting in the shade.7 However, despite their numbers, the goblins are defeated by their enemies. At the Battle of Five Armies, the strongest goblins are defeated by Beorn, a vegetarian who can assume the shape of a bear. His diet is largely cream and honey, but he spends much time outdoors.

Wood elves linger “in the twilight of our sun and moon”, feasting merrily in clearings in the woods. They seem to be less potent than the high elves, perhaps because of their crepuscular habits, but their cave is described as “lighter and more wholesome” than goblin dwellings. Few details are given about their diet, but roast meat is involved, and butter and apples are brought to them by the river, as is wine.

Spiders dwell in the dark and seem to eat caught prey exclusively. The dragon Smaug comes out at night to eat people and particularly favours maidens, though he will also eat ponies and Lake-men.

The dietary and sun-exposure habits of the protagonists are shown in the Box. The mean vitamin D score was significantly higher among the victorious (mean, 3.4; SD, 0.5) than the non-victorious (mean, 0.2; SD, 0.4; P < 0.001). However, the absolute concordance between goodness and victoriousness precludes an assessment of this as an independent effect.

Discussion

Systematic textual analysis of The hobbit supports our initial hypothesis that the triumph of good over evil may be assisted to some extent by the poor diet and lack of sunlight experienced by the evil characters.

For the purpose of this study, we have not discriminated between creatures that can be considered, broadly speaking, to be mammalian and those that are not and whose physiology is more obscure. These include dragons, whose generation of fire has been discussed previously,8 as well as giant spiders and birds of unusual size.

Unfortunately, the principal purpose of the author of The hobbit was not to provide a systematic dietary history, so reporting bias is a possibility. In particular, there is an emphasis in the text on meat items similar to Homer’s Odyssey, where feasting is a recurrent motif but where few references to salad are made.

More research would be needed to establish whether the results of the current pilot investigation are representative of the wider Tolkien corpus and indeed of fantastic literature in general, although this will need to be balanced against the problems of proportionality of effort. A further limitation is that the concordance of dark-dwelling and evil make it more difficult to infer causation from the current data. Further reviews of the literature will need to focus on more morally ambiguous tales to elucidate this further, and the outcome of well constructed randomised controlled intervention studies may need to be imagined.

Characteristics of inhabitants of Middle Earth

Inhabitants

Good

Victorious

Vitamin D score

Hobbits

Yes

Dwarves

Yes

Beorn

Yes

Men

Yes

High elves

Yes

Wood elves

Yes

Eagles

Yes

Smaug the dragon

Trolls

Goblins

Gollum

Harriet’s hats

Sometimes a special patient brings colour to clinic

Loaded down with four volumes of medical records, I struggled into the clinic room to see the next patient. Beaming from under a bowler hat covered with silver glitter, a plump, dishevelled woman greets me enthusiastically: “Hello, I’m Harriet! Are you my new neurosurgeon?” There is clear fluid dripping from the tip of her nose, and throughout the consultation she continues to wipe the recurrent drops of leaking cerebrospinal fluid (CSF). I listen in increasing despair as she stoically recounts 12 years of neurosurgical management, a litany of operations like a Michelin tour of the central nervous system. Flummoxed, I tell her I will have to seek advice. Afterwards I learn that she has delivered chocolates to all the staff she knows: the receptionist, the typist, the nurse unit manager, the physio and the surgeon who did her last operation.

At the next visit, I too am on the recipient list for chocolates. Harriet is wearing a hat of purple artificial velvet with appliqué trains. Still CSF drips from her nose. She wipes the drops with white tissues and drops the crumpled blooms to join the growing pile in her lap. I send her away with a bundle of coloured forms for further tests and scans.

Returning months later with her test results, Harriet is clutching her bus ticket and a broken sandal in one hand, and the ever present pile of tissues in the other. Yet more exotic headgear covers her scarred scalp. Is it possible she never wears the same hat twice? I suggest that we do yet another operation, and ask her if she thinks it’s worth the risk and bother. She wipes away a drop: “Definitely doctor. This dripping is awful!”

The operation is painful and leaves her with a bruised, purple face and swollen eyes, but still she smiles. Her concern and consideration for the staff make it difficult to tell who is looking after who. She is reduced to a rainbow knitted cap as she potters about the ward cheering and encouraging everyone.

At the post-op visit she is wearing a large floppy hat decorated with a plastic flower and a painted clown’s face. The clown’s smile is echoed underneath by Harriet’s grin as she reports that she no longer drips! I share her delight and tick the form to indicate discharge from clinic.

Moments later I hear a commotion at reception. Harriet is almost in tears. In spite of everything she has been through, this is the first time I have seen her upset. “But I always have another appointment”, she wails. The receptionist catches my eye and shrugs helplessly.

There are 1000 patients on the waiting list and outpatients is booked out for weeks. But for half her adult life, Harriet’s existence has been punctuated by visits to neurosurgery. I give in and overbook her for clinic in 6 months.

Next time I see Harriet, she is up on the ward, wearing a Santa hat and enormous red and green earrings. The faces of the ward-weary staff light up when they see her, as she hands out chocolates and jokes. She now comes to an appointment twice a year. We tell her she is doing well, and she reminds us that, in the end, medicine is about making people’s lives happier, and that doesn’t always take a fancy operation.

Disclaimer: Although this piece has been inspired by people and places I have known, the resulting story is entirely a figment of my imagination and is not intended to portray any real persons, alive or dead, hatted or bare headed.

The Da Vinci Code and the alphabet of research

We offer an alphabetical guide into the opaque and mystical world of research

Many are called to do research, but few are chosen. How is this possible in an era of improved gender equality, educational access and global connectivity? The answer lies in the secret “Da Vinci Code” of research: the unwritten interpretation of the alphabet of research that touches us all through serial rejection of grant applications and scientific articles. Out of a sense of duty to fellow researchers, and with just a subtle hint of projection, we have chosen to share the secrets of this Code with you.

A is for analysis: biochemical analysis, statistical analysis and the psychoanalysis needed after a few years in a research career. A is also for ambivalent.

B is for blot. There is nothing like a Western blot to induce a collective lather of excitement in a room full of lab scientists — talented, bespectacled people with terrible skin, seldom seen during daylight. B is also for borrowing, a kinder word than plagiarism.

C is for Cochrane reviews. More righteous than a reformed smoker, the Cochrane collaborator preaches the eternal benefits of telling the wood from the forest plots.
C is also for consistency, reflected in the universal finding of any Cochrane review that more studies are needed.

D is for destiny. You will achieve yours either by becoming Dean of the Faculty of Medicine or working in the community. D is also for doctor, as in PhD.

E is for EBM or evidence-based medicine, the mantra of the academic clinician. EBM also stands for expressed breast milk. In neonatal intensive care, where acronyms reign supreme, this can cause considerable confusion.

F is for fantasy. Little research has been done into fantasy but a great deal of fantasy has gone into research. F is also for failure.

G is for governance, a concept that has risen more quickly than the sovereign debt of many European countries. G is also for gratuitous.

H is for your research habitat. Here you will be in a womb of your own, dressed like a sloth but with the mathematical acumen of an actuary. H is also for hierarchy.

I is for Ig Nobel Prize, awarded to researchers with modest ambition and limited aptitude. I is also for island, which no man is, although the researcher comes closest.

J is for jaded, describing the post-traumatic stress disorder arising from receiving the umpteenth rejection of your most precious manuscript by another J, for journal.

K is for the keynote address which all researchers aspire, but never get asked, to deliver. K is also for knowledge, or the absence thereof.

L is for lies, damned lies and scientific fraud, as in the autism and vaccination debate. L is also for lyonisation, whatever that is.

M is for Machiavellian, describing an academic competitor who, by an amazing coincidence, publishes an article
6 months after your grant application on the same highly specific area was rejected. M is also for maturity. You both know what has happened, but it is never discussed.

N is for normal distribution, which applies to data from large cohort studies that you have not performed. N is also for native cunning, as you log transform your limited data to generate a significant P value.

O is for Ondine’s curse, the threat delivered by your PhD supervisor if you do not complete your thesis by the due date. O is also for OMG.

P is for a significant P value, the Holy Grail of research, with the exception of qualitative nursing research, where statistical significance is an oxymoron. P is also for passport, the true reason for your supervisor’s timely review of your abstract for the meeting in Rio.

Q is for qualitative research, which uses patient-reported outcomes as its basis for justifying conclusions, rather than, say, a 20 mL improvement in your FEV1 with a new wonder drug taken five times daily. Q is also for quantitative research, to which the qualitative researcher aspires.

R is for rejection, a character-building exercise that does not get more enjoyable with another R, for repetition.

S is for statistics. A good statistician speaks a language that is unknown even in Babel. S is also for sorcerer, a numerical alchemist who can transform raw data into publication gold.

T is for test tubes, the conduit to conception without copulation. T is also for thesis, if you are lucky.

U is unique (or, more grammatically, u are unique). Unique is a word that cannot be used too often to describe your research. U is also for useless.

V is for validity, which can be internal or external. Your study can be reliable, measuring the same thing, but invalid. V is also for vengeance, usually externalised.

W is for wading through the data to derive your interpretation. As a reviewer this proves challenging, so you suggest further statistical review. W is also for wolfpack, the collective noun for members of a local ethics committee.

X is for exceptional spelling, a legacy of spellcheck. X is also for Generation X, the last generation to read a book from cover to cover.

Y is for yardstick, the benchmark to which your work is compared and others aspire. Y is also for the yacht you will own after you move across to work in industry.

Z is for zzzzzzzzzzzzzz at the end of a lecture on Fourier transformations and their utility in clinical research. Z is also for zeal, reflecting your gift for self-promotion.

Disclaimer: While we will guarantee the integrity of our observations, we cannot necessarily vouch for the statistical rigour with which we concluded that the correlation coefficient with the truth was 0.78.

Initial outcomes of using allografts from donation after cardiac death donors for liver transplantation in New South Wales

Despite liver transplantation being an established treatment modality in Australia, there continues to be a significant disparity between donor liver availability and demand.1 One way to reduce this gap is to maximise the use of extended-criteria deceased donor livers, with donation after cardiac death (DCD) being one such option.2 However, the additional warm ischaemia time (WIT) incurred during the DCD donation process has led to a higher reported incidence of complications.3,4

Until recently, all deceased donor liver transplants in Australia were performed with liver allografts retrieved from donors after brain death. However, prior to brain death legislation being established within all jurisdictions, all the early experience in deceased donor organ transplantation was done solely with DCD renal allografts.5 In New South Wales in the 1980s, when transplantation of the other solid organs became a reality with donation after brain death, the practice of DCD renal transplantation all but ceased. All the preliminary experience with liver transplantation in Europe and the United States was with the use of DCD liver allografts,6,7 but the focus switched to donation after brain death after the recognition of brain death as an entity and the enactment of legislation.

With controlled DCD organ donation becoming re-established internationally in the 1990s,8–10 reports then emerged of reasonable outcomes in renal followed by liver and then lung transplantation.11–14 Hence, interest was rekindled in NSW with respect to the DCD pathway for organ donation. This culminated in the release of a jurisdictional policy guideline document by NSW Health in 2007, which also facilitated the development of collaborative multiorgan retrieval surgical protocols between the Australian National Liver Transplantation Unit (ANLTU) and the regional lung transplant unit for DCD donors.15

Methods

Data collected prospectively from 1 July 2007 to 31 December 2010 were analysed. Donor data were obtained from the NSW Organ and Tissue Donation Service, while data on the acceptance and utilisation of the DCD livers for transplantation were obtained from the ANLTU database. Patient and graft outcomes data were also obtained from the ANLTU database, as well as hospital records, with a minimum of 6 months’ recipient follow-up. The study was approved by the South Eastern Sydney and Illawarra Area Health Service and Sydney South West Area Health Service ethics review panels. Statistical analysis was performed with StatsDirect version 2.7.8 (StatsDirect).

ANLTU protocol for liver retrieval from DCD donors

The ANLTU protocol based on international best practice is outlined in the Appendix (online at mja.com.au).15–18

Selection of recipients

Before listing, all potential liver transplant recipients were evaluated by a multidisciplinary liver transplant team. Informed consent about the possibility of the use of a DCD liver allograft was obtained. Patients were accepted onto the liver transplant waiting list in accordance with the Transplantation Society of Australia and New Zealand consensus statement protocols.19 Donor livers were preferentially allocated to recipients in whom the surgical hepatectomy was expected to be straightforward, in an attempt to limit the cold ischaemia time of the donor liver to less than 8 hours.14

Liver transplant process

Liver transplantation was performed with standard operative techniques. A routine postimplantation postreperfusion biopsy sample of the liver was obtained for histological testing, including the grading of steatosis.20 Recipients were managed postoperatively according to ANLTU protocols.

Outcome measures

Data on the donors included donor demographics, underlying cause of death, and the outcomes of the donation and surgical retrieval process. Data on early outcomes (within the first 3 months) were obtained for 14 of the transplanted livers. This included liver allograft function and recipient intraoperative and postoperative course (including biliary and vascular complications). Late outcome data included significant recipient complications as well as recipient and graft survival. Primary non-function and initial poor graft function were defined according to previous publications.20

Results

Acceptance of donor offers for liver transplantation by the transplant team

The number of DCD offers steadily increased over the first 3.5 years as seen in Box 1, with acceptance rates being relatively consistent after the first year. Forty-five of 84 donor offers were not accepted mostly because the donor parameters fell outside of the ANLTU DCD acceptance criteria. The most common reason for non-acceptance was advanced donor age alone (21/45), followed by medical abnormalities combined with advanced donor age (12/45), isolated medical abnormalities (8/45), and other factors (4/45), including organisational logistics and withdrawal of consent for donation. However, thirty-five of these 45 potential DCD donors subsequently provided other organs for transplantation.

Outcomes of the planned DCD surgical retrieval

Surgical retrieval teams travelled to donor hospitals of 39 potential DCD donors during the study period. The liver was successfully retrieved for subsequent transplantation in 15 of these donors. There was no difference in demographics between the donors where the liver was successfully able to be retrieved and the donors where it was not. The median γ-glutamyl transpeptidase level was higher in the donors where the liver was not retrieved (81 IU/L) compared with the donors where it was retrieved (47 IU/L).

For the DCD donors where the liver was successfully retrieved, the location of the potential donor at the time of withdrawal of treatment was within the intensive care unit (ICU) in 12 donors, and in the operating theatre complex for the remaining three. The median time from withdrawal of treatment to declaration of death was 11 minutes (range, 4–19 minutes). The subsequent median WIT was 26 minutes (range, 17–35 minutes). The most common reason for non-retrieval of the liver was that death did not occur within the predetermined time frame of less than 30 minutes (14/24 donors), followed by an abnormality detected in the donor liver (8/24 donors) and unforeseen issues with logistics (2/24 donors). Of the 39 donors where liver retrieval was attempted, 25 provided other organs for transplantation.

Outcomes of DCD liver transplants

There were 13 adult and one paediatric recipients, with a median age of 57 years (range, 4–63 years). One donor liver was not used. All the recipients underwent primary liver transplantation. The paediatric recipient received an urgent transplant with a cutdown of a DCD donor liver. The underlying primary liver diseases were hepatitis C virus (six patients), postalcoholic cirrhosis (four patients), hepatocellular carcinoma (three patients) and fulminant hepatic failure (one patient). At the time when a potential donor was identified, 11 recipients were at home, two were hospitalised and the paediatric recipient was in the ICU. The median cold ischaemia time was 7.7 hours (range, 4.9–9.7 hours). The patient and graft outcomes are shown in Box 2, with a median patient follow-up period of 14.8 months (range, 4–39 months).

The early outcomes were favourable, with no primary non-function or significant initial poor graft function despite the peak serum aspartate aminotransferase levels. This was despite five allografts having moderate isolated microvesicular steatosis on postreperfusion biopsy and one having moderate macrovesicular steatosis. The two vascular complications occurred within the first 3 months, and the hepatic artery stenosis was managed with percutaneous balloon dilatation on two occasions. The one case of early bile leak necessitated reoperation and revision of the biliary anastomosis. An anastomotic stricture of the Roux-en-Y was then diagnosed 3 months later, and corrected through endoscopic management (dilatation). The one patient with an early anastomotic biliary stricture underwent endoscopic retrograde cholangiopancreatography (ERCP) and stenting.

The two patients with anastomotic biliary stricture after 3 months required ERCP and stenting. For both patients, multiple ERCPs and stent changes have been required. In one patient there was also biliary sludge and stone formation. One of these two patients required no further stents after 13 months.

Discussion

Since the re-establishment of organ donation through the DCD pathway in NSW, it has become possible to undertake liver transplantation with liver allografts from DCD donors. However, the relatively high rate of non-acceptance of DCD liver offers during the study period reflects the ANLTU acceptance criteria, which are based on known outcomes of DCD liver transplantation internationally.4,21,22

The high percentage of attempted donor retrievals resulting either in non-retrieval or discarding of the liver is consistent with the nature of the DCD process; additionally, in potential donors, death must occur within a short time frame such that the resulting WIT is less than 30 minutes.3,14 The number of liver allografts discarded at the time of retrieval because of steatosis or perfusion abnormality is also consistent with other reported experience.12

The liver allograft outcomes are consistent with other reports including for the rate of biliary complications.23 Although ischaemic cholangiopathy was not seen in this small series, this may reflect both the short follow-up period and the relatively small number of cases compared with other reported series.3 The increased incidence of vascular complications including hepatic artery stenosis,23 along with the increased requirement for retransplantation, was not seen in this initial experience with DCD liver allografts.22

As the results from the initial experience with the use of liver allografts from DCD donors have proven to be favourable, the ANLTU has made a decision to raise the upper age limit for potential donors to 50 years. As the utility of DCD organ donation remains limited, with only 18% of the donors providing liver allografts, the more common practice of obtaining liver allografts through donation after brain death appears to be a more resource-efficient option.

1 Rates of acceptance of and livers retrieved from donation after cardiac death donors

Year	Donor offers	Non-acceptance of offer for liver transplantation	Livers retrieved for transplantation/potential suitable donors

2007	6	5	1/1
2008	16	8	2/8
2009	26	14	4/12
2010	36	18	8/18

2 Patient and graft outcomes of donation after cardiac death liver transplantation

Outcome

< 3 months
after transplant

> 3 months
after transplant

Early graft function

Median peak AST level (range)

3667 IU/L (919–11 264 IU/L)

Median AST level on Day 3 (range)

371 IU/L (92–1375 IU/L)

Biliary complications

Bile leak

1/14

—

Anastomotic stricture

1/14

2/14

Vascular complications

Portal vein thrombosis

1/14

—

Hepatic artery stenosis

1/14

—

AST = aspartate aminotransferase.

MJA Dr Eric Dark Creative Writing Prize – Esther

Winner, Medical student category

I’ll never forget her smile as she waddled into the makeshift treatment room. Esther was considerably shorter than the rest of her classmates in Two Lion, so much so that most of the other students at the Abedare Ranges Primary School treated her like an invalid toddler. With a student on each hand helping her to walk, Esther’s slender, bowed legs betrayed a spot diagnosis.

“Rickets”, my supervisor whispered as he knelt to shake our new patient’s hand and commence the paediatric charm offensive. Esther coyly withdrew, blushed, and scrunched her donated uniform between her fingers, two sizes too big and certainly not African in origin. Dr James Robertson, a six-foot-one white man with a shaved head from an Aboriginal medical service in Sydney, was the epitome of an oddity in Kenya, and the children were understandably awed by his impressive presence.

Our mission was to screen all 300 children in the school, living in either the adjacent orphanage or the internally displaced people’s camp a few kilometres down the road. Known as “Pipeline”, the camp is home to 6000 Kenyans living in ramshackle tents donated by aid organisations after the 2007 national election riots. Families of ten or more live in dirt-floored spaces most accurately compared with a chicken coop. Even more heart-rending was the hard truth that the charity-run school could only support one child from each family.

Joanna, the school librarian now improvising as interpreter, formally introduced us. “Esther is from the orphanage”, she announced. This comment brought with it the silent acknowledgement from all present that some horror had afflicted this poor child’s family, most likely poverty and the desperate behaviour it unearthed: primordial hunger, anger, abuse and neglect.

Esther had been rescued from the rubbish dump in Nakuru, a smaller city north of Nairobi that became a safe haven during the riots. As an enterprise, the dump was serious business. Every day, the self-appointed matriarch put children as young as three to work finding food scraps among the mounds of waste and refuse. What the children couldn’t get their hands on, pigs rooted out with their snouts and hooves. When fat enough on garbage, the pigs were sold illegally in town to buy fresh water for the 200-odd inhabitants dwelling on the dump’s margins. Children and pigs, fighting over spoilt food on a continent with more starving mouths than there are people in Europe. It was here that Esther probably developed a serious nutritional deficiency.

Esther was clearly appreciative of the attention, giggling as I applied the blood pressure cuff to her arm. In my best Kiswahili, I fumbled some muddled instructions asking her to sit still. As the needle slowly came down past 120 on the mercury, it began to bounce irregularly, some beats strong, some weak and others completely absent.

I repeated the measurement and felt for her pulse. Again, the same. Confirmed: irregularly irregular.

“This is how I pick up most of the asymptomatic atrial fibrillation in my clinic at the Aboriginal medical service”, Dr Robertson said as he pondered Esther for any sign of distress.

There are no statistics on stroke risk for atrial fibrillation in a 5-year-old; and even if there were, we didn’t have a means of paying for treatment. Still smiling, still giggling, Esther watched on as if we were conducting a children’s performance while we discussed what to do for her bendy bones and hiccoughing heart. We were as powerless as many of the other medical pilgrims who had made their way to Africa, driven to make a difference and yet helpless without funds or the accoutrements of modern medicine.

The afternoons were spent seeing people from the camp on a walk-in basis, mainly parents of children at the school. Wilson, a security guard and father of one of the students came to us complaining of breathlessness and hearing whistling from his lungs during patrols. Forced from Nairobi with his three children and wife during the violence, he recounted making the walk to Nakuru over 2 weeks. Every night, they slept in fields or next to the road; no roof, no bed. He thought he might have contracted tuberculosis from exposure to the night-time fog on the journey. Now, some 5 years later, he was lucky enough to have secured a steady income through the charity, and even luckier to have the use of a car.

When you’re constantly dealing with weird and wonderful infections, throwing bilateral pitting oedema and severe hypertension into the casemix provides an unexpected clinical respite. We knew the story well from back home; work had allowed Wilson to adopt a decidedly Western lifestyle, paving the way for his newly diagnosed heart failure. At 55, he’d never had his blood pressure taken, and had little idea about diet and exercise. After loading him up on what was left of the available antihypertensives, it was my job as the apprentice to give the preventive health spiel: walk 30 minutes per day, lose weight, drink less, reduce salt consumption and don’t smoke. I thought little of the talk as I tore out a page from my notebook and neatly transcribed the instructions in block letters.

On the first evening, Wilson could be seen doing laps of the camp, waving and smiling to the other inhabitants as if on a royal tour. Curiosity built, and on the second evening five men could be seen walking in a V formation with Wilson at the front. A long line of adults all wanting their blood pressure checked formed on the third day, and we were swamped. Rarely has a public health message spread so fiercely, like a message stick passed from house to house, summoning all and sundry to devotion. The whole camp seemed to be exercising that night, men in three-piece suits and women in flowing dresses dragging babes behind. An army of the displaced, marching on the fuel of new-found knowledge. For us, it was the medical equivalent of a drought-stricken farmer witnessing a downpour for the first time in years. With this procession of community solidarity and affirmation, the burden of counselling patient after patient in the suburbs to change their habits disappeared.

“God says it is a good day”, our neighbour Leah called out to us from her potato patch. She saw the scene occurring on the road in front of us as evidence of the divine, thanking the Lord and giving us her blessings. “God says it is a good day because we are here in His presence. Witness the marvel of His creation, we are happy people doing our best with what He has provided.”

The hardest part of the experience was collating the contradicting stimuli into a coherent picture. If I shut my eyes, the deep earth of Kenyan soil still tussles with the acrid stench of rubbish fires in my nostrils. I hear children playing in the daylight hours, and howls of abuse from husbands drunk on bootleg liquor in the evening. But the overriding vision is of hope and joy and oneness in a community with nothing. I’d come prepared to experience a godforsaken land, and conceded that I was at the blissful mercy of its people.

In the middle of it all was Esther, the child most in need with the widest smile.

MJA Dr Eric Dark Creative Writing Prize – Enough?

Winner, Practising and retired doctors category

Casey stared, expressionless, at the floor. The floor returned the favour. It was salmon pink linoleum, with flecks of grey. Her eyes lifted to where it met the cheery mint green walls. She wondered what sadist had decided to deck the place out in the upbeat garb of a 1960s ice-cream parlour. Her body suddenly lurched, without warning, and she vomited. Generously. Last night’s mushroom risotto cut a swathe across the salmon. That’ll show them what I think of their interior design efforts. She afforded herself a thin-lipped smile. “Woman crusades for muted tones in labour ward décor” . . . she could see the headlines now. She’d be a national bloody hero.

Unfortunately, there was no audience for her sarcasm here, for the spontaneous quips and sly witticisms that were such a hit with her social circle. She was completely alone. And she was uncomfortable. Not just from pain, although there was that, inexorably stronger and more frequent, grinding her forward to what seemed like the end. More upsetting was that she’d stuffed up, as usual, and generations of handed-down Irish-Australian pride had prevented her apologising. And so she was alone, here where she most needed not to be. He wasn’t coming. Not ever. The fear of the years stretched out ahead of her was real and uncomfortable. Pethidine wasn’t helping that pain.

***

“Sorry I’m late”, said the woman as she shuffled into her place and sat heavily, her bulk exceeding the ungenerous proportions of the standard-issue chair. “Claire’s not having a good week.” Muffled sounds of pity followed. The woman, Bev, looked up fiercely, as though challenging the others to convert those sounds into actual sentences. No one took the bait. Bev had it tough, no argument there — disabled adult daughter, alcoholic husband — but she coped by making it tough for those around her. A pretty hopeless strategy, really. No one could get close enough to help. They all remembered the scene when the head of midwifery had suggested a period of leave from work. Work was all she had, couldn’t the moron see that? They all remembered, and they buttoned it. “Well, we were just doing handover. How about you take room 3?” said an evening shift girl, keen to get on with it. Bev grunted assent. “She’s a 32-year-old primip, professional girl, 38 plus; membranes ruptured at home at 20:45, good contractions happening. Three-to-four in ten. She was five centimetres at 21:30. She seems to have a lot on her mind . . . bit distant. No support person, and she doesn’t want to talk about it, okay?” A life summarised in point form. “Room 4’s empty, I just took her up to the ward.” Short pause for politeness, then a hurried “That’s me done, so I might head off”. They all said their goodbyes, and in a rustle of purple cloth she was out into the muggy summer night.

***

All except Naomi, sitting silent and ignored in a corner. A new registrar on secondment, she felt invisible and unwanted here. She wondered what her predecessors had done to deserve this. Or were they punishing her particularly? Because she deserved it? She sipped her brown drink. Coffee? Possibly. She had made it automatically on arrival. Powder. Water. Milk. Sip. Grimace. Night shift resulted in a lot of automatic behaviour.

The handover sounded straightforward — only three labouring women. Which unfortunately meant more time for her to stew. She tuned out as the talk turned social, and fingered the corners of a bundle of official papers in front of her, emblazoned with health department insignia. The “adverse outcome” was going to result in litigation, as well as a root-cause analysis. Naomi couldn’t escape the feeling that she herself was the root cause; her poor judgement, her lack of experience had combined and a little life was worse off. People had been encouraging. It happens to the best of us. Night shift. Panic. A difficult instrumental attempted too late. But it hadn’t happened to her before.

The coarse scraping of chairs invaded her private lynching. The midwives were done. She smiled shyly at the first face she focused on, wordlessly asking the standard question of the new: “What now?” Bev bored through her with impatient eyes. “We call you if we need you, which is rare. Most registrars hang out in the office, use the computer, or try for some shut-eye.” Subtext: “Go away”. Naomi was happy to comply. She had plenty to keep her busy, right inside her head.

***

Casey now felt as though nothing outside that room could possibly exist anymore. Had she been there hours? Days? She couldn’t tell. It felt like all she knew. “I’d like to go home now . . . please . . . just pass my bag and I’ll go. I really can’t do this any more.” She heard the polite, ridiculous request and took a moment to recognise her own voice. It sounded small. Another contraction hit and she lost even that small voice. She buried her face in the uniformed shoulder of the older woman, and breathed in the familiar smell of talc and nicotine. Like her own mother, Bev was a smoker. “You’re doing well, use your breathing”, said Bev, firmly but kindly, not minding the combination of snot and tears on her sleeve. “I can’t . . . shit-it-hurts-make-it-sto-o-op.” “Now you’re going to be a mother and mothers don’t swear” was the retort. “Up on the bed; let’s see where we’re up to.” The pain now over and the fog of gas thinning, Casey moved to the bed and muttered, “Well you’re supposed to be a health professional, and health professionals don’t smoke”. Unexpectedly, Bev laughed, roughly and loudly like a motor out of regular use. She was enjoying the banter. Bev was always pleased when the girls were plucky. She loved women. She believed they could cope with anything God threw at them, and she knew from personal experience what a strong arm He had. But to cope with humour rather than mere stoicism was impressive. This one would do alright, man or no man. “I’m the last of the old guard”, Bev replied. “Besides, one look at me should tell anyone smokes are bad news. If you think about it, I’m performing an important public service, just by existing!” The examination revealed full dilatation. “Now let’s get pushing!”

***

Naomi was vacantly scrolling through an online newspaper article when the buzzers sounded. Three sharp bursts — code for “help” in any labour ward anywhere. She hurried out into the corridor and followed the other staff and wounded noises to room 3.

“Give me another push, girls give me a hand with these legs . . . up to her chest, that’s it”, Bev called.

“What’s happening to me?”

“Baby’s shoulders are stuck, Casey, we need to get her free”, then in an undertone to a colleague, “Call the paediatrician. Now!”

Shoulder dystocia. One of those heart-in-mouth situations, like a sudden bradycardia, or heavy postpartum haemorrhage. Seconds mattered. Naomi rushed on gloves and took her position. The baby’s face was deep purple. The last contraction and repositioning of the patient had achieved nothing.

“I’m going to try to free baby’s back arm, use your gas”, Naomi said, too loudly. She always felt the need to shout in emergencies, but over what? The feeling of fear and chaos in the room, perhaps. It screeched and knocked about her like so many bats. She fought the urge to put more pressure on the head, and instead forced fingers inside Casey. She couldn’t get to the posterior arm . . . wait, was that it? Casey screamed, begging her to stop, to take her hand away. Then she thought she had it, a finger in the axilla. She swept it forwards firmly, and the arm slipped across the body and out, hanging floppy and blue, creating vital space. She quickly delivered the baby, clamping and cutting the twisted rope of cord, and reached the resuscitation area in two ungainly steps. She rubbed the slippery, inert human with the towel, and its mouth opened wide in a mime of indignation. She rubbed again, ready to start ventilating if needed, but this time the little person took a breath and added sound to that complaint. A pink hue spread across chest and face.

She returned the baby to her mother’s chest and sat by the bed, ready to run through her explanation of what had happened and why. But when she looked up, Casey was fully absorbed, inspecting her baby in wonder. The other midwives had drifted away, and it was just Naomi, Bev and Casey, sitting on and around the bed, looking at the angry new little girl. “She doesn’t seem too impressed with the world!” said Casey proudly. “Smart cookie”, Bev replied. She offered a nod of appreciation to Naomi. The rising panic of thirty seconds earlier had been replaced by a softness, a quietness they couldn’t name. Relief? Fellow-feeling? Yes, those too, but there was also joy. It would be enough for today.