Written by Dr Silas Webb, ST4  in Emergency Medicine

Edited by Bethany Sampson

Nearly 3 in 5 Territorians live in the tropical city of Darwin, on the Northern Australian coastline looking out over the Timor Sea. And Darwin, the smallest and wettest of Australia’s state capitals, was to become my home for a year during my Out of Programme Experience (OOPE) between ST3 and ST4 of EM training.

My first 6 months were working as an EM registrar in The Royal Darwin Hospital (RDH). The hospital has 360 inpatient beds and a 28 bed ED, seeing 75,000 presentations per year, comparable in size to most London District General Hospitals. However, RDH is the only tertiary referral centre for the NT and patients needing specialist medical and surgical care are flown into the hospital from all over the territory. The hospital’s 18 ICU beds (mixed adult and paediatrics), Coronary Care Unit and Neonatal Intensive Care are the only ones available until you reach Alice Springs 1500 km to the South. As such, RDH has to cope with far higher acuity than any other comparably sized hospital where I have worked.

Crowding and Access Block are not just NHS issues

I arrived in Australia with slightly blinkered visions of the healthcare system and working conditions for medics. We all have friends who had “seen the light” after their foundation years and now seem to be subcontracted by Australian Tourist Boards, painting pictures of empty waiting rooms, bulging paychecks and surfing during lunch breaks. In my experience, although the pay was certainly better than in the UK, working in ED in RDH had many similar challenges to my life working back home.

Coming from the UK, where EDs  are so often dangerously understaffed and the role of emergency physician is more akin to a firefighter, it was refreshing to hear it being called out for what it is: practising in a way in which patients do not receive the care they deserve and staff are unable to deliver the patient care they want to.

One of the main issues I encountered in Darwin was Ambulance ramping; with only 5 ambulances on the roads at any one time in the city, the pressure to get them to offload was felt acutely amongst senior decision makers. I would always try and expedite ambulance offloads whilst working in London, but it is a different beast when all 5 working crews are on the doorstep of your ED with no available beds, knowing that currently there was no possible pre-hospital response across the city. Worryingly, ambulance turnaround time has nearly doubled in the last decade in the NT and with such small numbers in the first place, this is felt acutely across the healthcare system.

Access block and lack of social care beds were constantly cited as causes of increasing ED pressures. A recent article published that 15% of RDH beds are currently occupied by patients awaiting social or aged care placements. Although these numbers are of course too high, they read far better than the situation in the NHS – where shockingly, 1 in 3 acute hospital beds nationwide are occupied by patients medically fit for discharge.  Without trying to proselytize too much, if my experience in RDH is anything to go by, Australia should learn that RDH represents the canary in the coal mine for overcrowded ED care, and unless things are improved quickly, the situation will become the norm, as I have seen back home.

Indigenous Healthcare

The absolute and relative deprivation experienced by Indigenous people worldwide is well documented and is clearly seen across healthcare outcomes in the NT. Life expectancy amongst Indigenous people in the NT is 67 for men and 70 for women, over a decade lower than the national averages, closer to that of war-torn nations in Sub-Saharan Africa than one of the world’s largest economies. These disparities are not only a result of socio-economic factors but also deeply rooted in the legacies of colonialism, systemic racism, and the historical marginalisation of Indigenous communities across Australia. 

It was stark to see this health disparity play out in presentations to the ED. Indigenous patients were over 3 times more likely to be admitted than their non-indigenous counterparts and were more likely to present with severe complications of both infectious and chronic diseases. Diseases of poverty that were confined to textbooks and grand-rounds in my NHS practice were a daily presentation in Indigenous patients in RDH, including acute rheumatic fever (ARF) and subsequent rheumatic heart disease (RHD) and scabies infestations. 

The incidence of ARF is one of the highest in the world, and between 2012 and 2021, doubled in Indigenous communities in the NT. If recurrences of ARF occur, cumulative damage to cardiac valves can be sustained, leading to rheumatic heart disease (RHD), a chronic and debilitating condition. As well as being a marker of extreme health inequity, there is also a predominance among younger people, with 60 % of new RHD diagnoses in the NT in those aged under 25. To compound this burden on an already stretched healthcare system, there is just one single paediatric cardiologist working across the NT with no service offering valve replacements.

Scabies infestations are likely contributors to the scourge of RHD. In 2023,  the Australian Centre for Disease Control (CDC) alerted that scabies diagnoses were rising in the NT, with the incidence of the most severe form, crusted scabies, tripling since 2016. In some communities, 50% of children are affected with the mite and across the NT at least 90% of new infections are amongst Aboriginal or Torres Strait Islanders. The intractable itchy and sores from the burrowing mite predispose to secondary Streptococcus A infections and subsequent ARF and post strep-glomerulonephritis. 

Scabies is another indicator of poverty, with outbreaks occurring in the most overcrowded communities, without access to easy washing and drying facilities to clear clothes and linen. One NT Charity, Remote Laundries, has successfully rolled out fully automated laundromats specifically designed to kill the scabies mites in high prevalence communities, with significant subsequent reductions in scabies presentations. Although both treatable and easily preventable, managing the condition requires public health interventions that target the root causes of poverty. 

Retrieval Medicine:

With such a large, sparsely populated landscape, the need for aeromedical coverage in the NT is much more persuasive than in urban environments. Remarkably, the NT has over 300 airstrips – many of which are the only access to the remote communities they serve, particularly in the wet season where many roads are left under water. As such, the only access beyond clinic level healthcare is via air. CareFlight is the aeromedical provider for the Top End of the NT, with a fleet consisting of fixed-aircraft, helicopters and jets providing interstate and international retrievals. I was lucky enough to work for them as a retrieval registrar for 6 months whilst living in Darwin.

CareFlight has been my first exposure to pre hospital and retrieval medicine and thankfully the job started with an intense 3 week crash-course in the specialism, learning everything from the physics of aviation medicine (Dalton’s lawanyone?), being winched out a helicopter in the dark and how to extricate people from crumpled vehicles. Oh and escaping out of a replica helicopter upside down in a swimming pool of course. The clinical simulations were scarily high-fidelity and the teaching was some of the best I’ve ever received.

But the daily reality of the job is pretty far from being first on scene at helicopter crashes or overturned cars, it is the privilege of providing emergency and critical care to patients who have no choice but to wait for you to bring them into hospital, whether that is mental health crises, preterm labour or septic shock from melioidosis (just one of the many dangerous organisms that live in the tropical NT soil). Often these patients will have waited multiple hours because of the travel distances and will have been supported in small clinics by Remote Area Nurses (RANs), under the remote guidance of one of the retrieval consultants. I was blown away by the scope of practice of the RANs, from starting peripheral inotropes to decompressing tension pneumothoraces,  often single handedly managing patients who I would only feel comfortable with in a tertiary ED resus bay. 

The challenges of providing emergency care to remote indigenous communities, both in and out of hospital, has been eye-opening every day and it has been a huge privilege to get to see and work across the NT, which is as beautiful and fascinating as it is sparse.