A Pharmacy Student Placement Out Bush

Over the last nearly ten years I have had a large number of students visit me out bush. They came from a mere week to a month or more. Unfortunately they never have time away from me, sharing my house and my working hours. I try to get them to write an article,or their university does. And sometimes they do it! Here is one of their stories. Some slight editing so patients from past years cannot be identified.

A Pharmacy Student Placement Out Bush

Outback, remote, arid, red dirt, abandoned Fords, Landcruisers and Jag left to mark the passing of time. Vast landscape that remains changeless despite the impact of bush fires, adaptation of people and spirit. Somewhere in miles of red dirt, we travel the connecting roads from Jameson to Kiwirrikurra, 750kms, many parts across the Sandy Blight.

Bore on the Sandy Blight Road
Bore on the Sandy Blight Road

Robbo drives with ease of experience along sandy bush tracks, visited by him only two weeks prior, he warns me of impending corrugations, found along this now dry twelve hour drive. The long range tanks filled with diesel at $2.80 a litre will theoretically make the distance, a rogue pot hole threatens to undo the chassis.

I am relaxed during the drive despite the potential chance of danger, a remote possibility the wind might change southerly. The bush fire as our neighbour taints a smokey horizon creating a spectacular sunset, a burning flame of a sun that dips slowly in the sky as a full moon of the same colour meets it, a change of guard from day to night.

Robbo is well versed in outback travel and spending just a week with him its obvious that his knowledge has a practical side, combined with a teasing humour that puts me at ease. On the other hand, do I really have a choice!

I talk a lot at first, when Robbo asks me about my experience so far. One week at Jameson. A small community of under 200 people, I am not sure yet if I am getting what I want out of the journey. It’s always dangerous to invite expectation, it takes time for people to trust you, to share themselves and to gain respect. I feel like an alien, white skin dominated by black, the foreign tongue of Ngaanyatjarra in my ears, and a complexity of issues witnessed from a distance.

The challenges faced in terms of medications and health outcomes are intertwined with family tensions, living conditions, a shifting of culture and language barriers, to name a few.

The challenges faced in terms of medications and health outcomes are intertwined with family tensions, living conditions, a shifting of culture and language barriers, to name a few.

Robbo’s interventions are equally social as medical. Over the course of the week I have observed him warmly embracing a young man who climbed the water tower whilst he was away in an attempt to commit suicide. Ensuring timely medication infusions for a patient with an auto immune disease, giving a lift to Warburton for a fortnightly monoclonal antibody treatment 125km away. A discussion with the grandmother who looks after her grandson’s phenytoin medication. She wishes to go out country with the ladies, who will be responsible that the dose is not misplaced or forgotten.

These experiences and many so far had consolidated my understanding that being a pharmacist and achieving concordance is about relationship building. Coupled with many additional challenges, management of chronic disease, seizures, mental health, boils, scabies and lice to name a few, management of aboriginal health requires management on many fronts.

Robbo’s experience and relationship with the people enabled him to address some of the social issues, whilst ensuring other aspects of pharmacy also ran smoothly. Remoteness requires a timely and adequate supply of stock, making available to other health professionals useful tools and multi-tasking with a nurse or doctor at a distance.

Apart from personality and experience, I also witnessed the use of many resources and tools whilst working with the Aboriginal people. Just now I noted on Robbo’s blog a series based around alcohol with a theme to reshaping drinking habits and misconceptions over alcohol in Aboriginal communities. Pharmacists in a remote setting must also be teachers and use these valuable resources as tools.

In the end I would say I learnt many things from those around me as well as the location and the people themselves. I think its important for us newly fledglings that we are green and so looking to the guidance of experienced people and adopting and adapting there methods, as well a being guided by resources and tools will enable me to fashion my practise. Watching it in action is for me the best way to learn.

Summing up my lessons would be:
1) Don’t judge a book by its cover
2) Humour is a tool
3) Be genuine
4) Write down dosages and calculations,
5) How to pack metformin into dosette boxes
6) Get the client to demonstrate how they will take their medications
7) Use your mirrors when backing out of driveways or avoid reversing all together
8) Life and people are complex understanding good management in this context takes time and experience
9) Being in remote Australia requires multiskilling, working closely with nurses and doctors
10) Systems are useful to avoid errors
11) The joy of quality research and tools in order to avoid reinventing the wheel and wasting time.
12) It’s better to drive of the road then scare your student by fishtailing!

George Tambassis, Pharmacy Guild President interviews Robbo

If you follow the blog you would know the Pharmacy Guild President, George Tambassis, came and visited me a few weeks ago and he wrote this piece on The Challenges of Bush Pharmacy

As well as that piece George also interviewed me. See the agonising the seven and a half minutes below.

George Tambassis, Pharmacy Guild President interviews Robbo

The challenges of bush pharmacy

A couple of weeks ago I had the Pharmacy Guild of Australia President George Tambassis and the Guild’s Communication Manager Greg Turnbull travel with me in remote Western Australia. Here is George’s view of the trip originally published in the Guild newsletter “Forefront”.

ForefrontIf I had to choose three words to summarise my recent tour of pharmacy services in remote Aboriginal communities in Western Australia, they would be: educational, confronting, and inspiring.

The idea for the four-day tour arose when I bumped into my old university friend Andrew ‘Robbo’ Roberts, at the FIP international pharmacy conference in Thailand in September last year.

Robbo has been a remote pharmacist attached to the Ngaanyatjarra Health Service for the past ten years. The health service, with headquarters in Alice Springs, covers an area the size of Victoria, including 10 clinics equipped with drug rooms. All of the communities are actually in Western Australia, in the remote lands to the west of Alice Springs.

The catchment area includes about 2500 people – 90 per cent Aboriginal. Robbo’s job as a salaried pharmacist is to maintain the medicine stocks across the ten clinics, provide professional pharmacy services directly to patients at the clinics and in homes, and to provide medication continuity across the vast area.

For one thing, this means more driving than I imagined could be inserted into anybody’s workflow! On day one of my tour, Robbo picked me up at Alice Springs Airport, we stopped for a meeting with the CEO of the Health Service, James Lamerton, then drove 924 kilometres to Robbo’s home in the community at Jameson.

One of the key achievements I observed was Robbo’s organisation of the remote clinic medicine facilities – through an ‘imprest’ system he has devised. The purpose of this is to ensure that the medicine stocks at all of the clinics are the same, and fully replenished as needed. The stock comes through bulk supply under Section 100 of the National Health Act – medicines packed and supplied by community pharmacies in Alice Springs and Kalgoorlie.

Near Windborne Rocks

One area of concern for Robbo is the inability of pharmacists to claim Medical Benefits Schedule funds for services within his scope of practice and where no community pharmacy is available, while a nurse delivering the same service can make a claim. This is a vexed and longstanding issue, but I feel it is one that should be addressed in recognition of the primary health care role that can and should be played by pharmacists in remote parts of Australia.

What I saw on this brief visit was quite confronting in terms of living standards and cultural differences. It was a first-hand glimpse of why our society has found it so hard to bridge the gap in morbidity, mortality and education. The Third World conditions in which some people are living in these areas is quite disturbing. Health literacy is very poor and is reflected in adherence rates. I wish to sincerely thank the Ngaanyatjarra health Service for the work it is doing, and for allowing me to visit some of its clinics. I also pay my respects to Robbo for his commitment.

I was pleased to learn that some of the medicine shelving in the clinics was provided with the assistance of the Guild under the Fourth Community Pharmacy Agreement. I believe there is more we can do to assist, and as we work on the shape of the next Pharmacy Agreement we will look for opportunities to assist Aboriginal health, through rural and remote community pharmacies, and through services such as the one that employs Robbo.

Two Meetings Highlight Disparity in eHealth in Remote Australia

Meeting 1. E-Health Conference, Revolutionising Australia’s Health Care

An invitation only two day seminar on e-Health was held in Melbourne on November 30 and December 1st. Apparently a “draft concept” of the shared e-health record concept was shown. It seems like there is $55 million splashing about for projects based on the personally controlled e-health record (more about money later on).

The Minister for Health and Ageing, Nicola Roxon gave the opening address. Here is part of what she had to say.

Part of our job in embracing this change and exploring further opportunities is to explain to the wider public the benefits of this big step into the future.
Let’s consider some of the situations that face clinicians and patients today.

Take the case of a young mother whose two children suffer from asthma.

The children might have tried many asthma drugs on and off, and keeping track of what each child has tried is challenging – for parents, for doctors, for hospitals.
Or consider the case of a Melbournian retiree escaping to Darwin for a holiday, becoming sick and being raced to hospital by ambulance.

He arrives without his current tablets and is not in a condition to talk about his medical history. What does the ED team need to know to make the treatment effective?

Or let’s think about a carer’s perspective for a moment. Hundreds of thousands of Australians care for a loved one, many of whom can’t participate in their own care which might involve a GP, then local pharmacist, the district nurse, specialists and the local hospital.

There’s a constant worry that the wrong medication might be taken at the wrong time. These fears are well grounded – medication errors currently account for 190,000 admissions to hospitals each year (my italics).

And take the case of the hundreds of thousands of Australians with chronic disease. Many of whom want to better manage their diseases, but lack the connection over their information that can make this happen.

These scenarios reflect the kinds of real-life situations that occur all around Australia every day.

national electgronic health transition authority

Let me digress a bit here. It does have something to do with the second meeting.

Pharmacists reviewing medication histories and more pharmacists in wards in hospitals reduce error rates. And an electronic patient record should reduce them even further.

Aboriginal Community Controlled Health Organisations (ACCHO) are where Aboriginal Australians wish to receive their healthcare. There are five pharmacists I know of that work full time for an ACCHO.

Meeting 2. 28th June 2010 No title, attended by stake holders in remote Indigenous Health

This meeting was called after a presentation and some networking at the National Medicines Symposium. It was to discuss the lack of dispensing software, tools and training for remote area S100 ACCHOs and other Aboriginal Health Services.

  • Dispensing is usually done by Aboriginal Health Workers, Doctors and Remote Area Nurses who in the main have have no specific training for this task and may under-appreciate its importance in Quality Use of Medicines. In some states this may be illegal
  • Dispensing systems either stand alone or incorporated into electronic patient management systems for tasks such as labelling, recording of supplied medication and stock control are for the most part primitive or non-existent. Indeed in many cases medicines are dispensed with handwritten, incomplete, or no labels at all.
  • Yes, that’s right. We are spending millions on eHealth but in remote Australia we still can’t print a legible label for a patient’s medication. Does it surprise anyone that there seems to be no money to rectify this lack of not only dispensing, but no pharmacist involvement?

    Is it too far a stretch to think we are building a whizz bang house, but out bush it is on very poor foundations?

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