Student CaSe

MELBOURNE

MEDICAL SCHOOL

Aboriginal Health

Case 1

Case writers:
Gillian Webb Shaun Ewen Jacinta Tobin The University of Melbourne

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The United Nations Millennium Goals

Goal 1 Eradicate Extreme Poverty and Hunger Goal 2 Achieve Universal Primary Education Goal 3 Promote Gender Equality and Empower Women Goal 4 Reduce Child Mortality Goal 5 Improve Maternal Health Goal 6 Combat HIV/AIDS, Malaria and other Diseases Goal 7 Ensure Environmental Sustainability Goal 8 Develop a Global Partnership for Development

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Tutorial
Patient Presentation

Part One

Terri is a 26 year old Aboriginal woman with three young children; aged 6 years, 4 years and 18 months. She lives with her mother and the three children in a poorly maintained house on the outskirts of a small rural town. There is often extended family staying in the house which does not have running water or effective sewerage. The oldest child attends school irregularly and neither the mother nor the grandmother have had much school education, with the mother finishing school in Year 8 when she still could not read English although she does speak 2 Indigenous languages. The children generally appear to be undernourished. The youngest child, David, is nursed by his mother and appears lethargic and does not take a lot of interest in his surroundings. The mother has come to the community health centre in the town as she is struggling to cope with her children particularly David. Neither she nor the children have had many visits to the health centre and appear very apprehensive. She is not sure about the immunization status of the children. The community health centre has 2 fulltime nurses, a doctor who visits once a fortnight, and a physiotherapist who visits once a month. Both the doctor and the physiotherapist fly in on the Royal Flying Doctor Service (RFDS) flight and the visiting medical physiotherapy and nursing students -YOU!

Discussion possibilities
1. Discuss the implications of poverty and lack of education on the rights of children. 2. Discuss the reasons for why this family and others in similar positions do not take advantage of available health services. 3. Discuss the importance of opportunistic screening, and its role in primary health care.

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Tutorial
Patient Presentation

Part Two

On examination, David is found to have skin covered in sores (scabies, with possible secondary infection), an upper respiratory tract infection, inflamed ears with diminished light reflexes on bulging ear drums (indicating Otitis media) and pale conjunctivae (indicating likely anemia). He has low muscle tone and bulk, and is below the 2rd percentile for height (75cm), weight (8kg) and head circumference (44cm) on the WHO charts. Davids development appears delayed on screening on a number of measures including language, social and fine motor skills. Todays developmental screening is limited because David is unwell and is likely to underestimate his true capabilities. He reacts slowly to bells and other loud noises but appeared to follow visual stimuli well. During the examination of David, it is noticed that Terri appears withdrawn and sad, and has difficulty in controlling the older children who play boisterously with the toys in the clinic. Terri describes the sleeping arrangements, where most of the kids, often including cousins, sleep together and usually with several dogs. You teach the mother the nose blowing song, (http://www.snotsong.com/) and help her teach all three kids the song, and how to clear their noses. You consider the use of antibiotics for the ear infection, and scabies treatment with 5% permethrin cream. Later on, antibiotics for secondary infection of the scabies may be necessary (if it doesnt clear), as well as treatment of possible Strongyloides infestation (if the family have been up North) because of the association with iron deficiency. The iron deficiency will mostly be due to nutritional intake so this will be addressed first. Nutritional supplements and iron are then given temporarily (after a blood sample confirms anemia) while referral is made to the food co-operative which is run by the Elders of the community where the issue of food security is addressed with purchases of meat, fruit, vegetables, milk and eggs at a subsidized rate. You are aware that a thorough physical examination needs to be undertaken, so that an assessment regarding Davids physical development including formal hearing test (including audiology), and potential developmental delay, can be made when he is well, and services and interventions considered to address his problems. You also consider the need for something to be done about the sleeping arrangements, particularly the dogs and the impact that they may be having on both the skin condition, and the crowding with upper respiratory tract infections (URTIs) and subsequent ear infections. For the older children, the school has a team to ensure the children get to school and have breakfast. The team includes the Elder women in the community whose role it is to support the family, and the health care staff, in their roles. They are trying a new method of instruction which the children are making more progress with based on phonetics and visual aids (THRASS) Whilst having an afternoon cup of tea, Terri and Davids case is mentioned by the indigenous health worker. You are not totally surprised to hear that Terri didnt have any ante natal care, and that it was a very difficult birth, which turned into an emergency evacuation of mother and baby by plane to the nearest tertiary hospital. You are surprised that this information wasnt clear in the records, although you are aware that the health records system is a bit chaotic.

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Discussion possibilities
4. What long term impact on learning and development does chronic middle ear infection have? 5. Are age weight charts culturally specific? 6. How might access to a clean well maintained swimming pool, or the ocean or river, affect this childs health? 7. What opportunities for adult education (health literacy) could you suggest would be suitable for the mother? 8. Discuss the importance of robust health information systems (either electronic, or paper filed), and their role in ongoing patient care.

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Tutorial Extension
Patient Progress

(large group)

Terri comes back after 2 months (you had asked to see her during your next visit), and you are surprised at the improvement in Davids general condition with a substantial weight gain (now 10kg see chart), although he is still obviously language delayed. With the nose blowing song being done at least 3 times a day, his ears and upper respiratory tract are much less inflamed and David is much more alert and responsive to sounds. Terri has managed to keep the dogs from sleeping with the kids, and with the permethrin 5% cream, the skin is much better, and the sores are less inflamed than before. Everyone in the family did the Scabies treatment. Catch up immunizations have been provided. Terri is still withdrawn and sad, and starts crying during your consultation. Whilst she is pleased with the progress, she says it is hard for her to manage all of the children in the house, and she often runs out of money despite the food co-operative. During this visit to the community it is the first time for several months that the entire team (doctor, physiotherapist, nurses and health care workers) have been able to meet together. This provides an opportunity to raise a coordinated approach to Davids care, in particular, a consistent approach to key messages. This includes the importance of providing a stimulating environment for David; including the playgroup run by the aunties from the community where the developmental team drop in from time to time to support the Indigenous childcare workers. It is important to find ways to provide opportunities for Terri and David to have adequate support and health care when the health specialists are not present. The community is now running a literacy and computer skills program for the parents as there are many parents in the same position as Terri who would like to work to provide for their family but are hindered by the poor education they had received.

Reflection and Feedback

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References
Websites
http://www.youtube.com/watch?gl=AU&hl=en-GB&v=-2l_mao5CWY http://www.snotsong.com/ http://archive.healthinfonet.ecu.edu.au/html/html_community/ear_health_ community/resources/ear_resources_families_com.htm http://www.who.int/childgrowth/en http://unicef.org/crc http://www.rch.org.au

UN Convention on Rights of the Child RCH PDF on Scabies

MJA Articles
Parry, T. 12.Assessment of developmental learning and behavioural problems in children and young people MJA 2005; 183: 4348 Silva D et al. Effect of Swimming pools on antibiotic use and clinic attendance for infections in two Aboriginal communities in western Australia MJA 2008; 188: 594598 Wiertsema P and Leach A. Theories of otitis media pathogenesis,with a focus on Indigenous children MJA 2009; 191: S50S54 Larkins S et al. The transformative potential of young motherhood for disadvantaged Aboriginal and Torres Strait Islander women in Townville MJA 2011;194 (10);551-555 McCarthy J. Editorial Parasite elimination programs: at home and away. MJA 2002; 176; 456-457 Brimblecombe J and ODea K The role of energy cost in food choices for an Aboriginal population in northern Australia MJA 2009; 190 (10): 549-551

National Indigenous Health Equality Council :Child Mortality

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