Correspondence to

Dr Prashanth Ramachandran,

Department of Neurology, Royal

Darwin Hospital, Casuarina,

Australia; prash.ram7@gmail.com

Accepted 5 January 2017

To cite: Ramachandran P.

Pract Neurol 2017;0:1.

The Northern Territory, Australia

Prashanth Ramachandran

Having done all my medical education

and training in Melbourne, Australia, I

decided to spend my second year of

neurology training in the Northern Terri-

tory. It is a very different world to

medicine in Melbourne, being a unique

and beautiful region of Australia, often

forgotten and undiscovered by many

Australians.

THE NORTHERN TERRITORY

Situated in the centre of Australia, the

Northern Territory is the third largest

state in Australia and is roughly the size

of France, Spain and Italy combined

(figures 1 and 2). It has a unique environ-

ment that ranges from arid desert down

south to tropical regions on the coast in

the north. The Northern Territory is

often considered the quintessential

Australian outback and boasts many stun-

ning sites such as Kakadu (figure 3),

Litchfield National Park, Katherine

Gorge (figure 4) and the world famous

Uluru (previously known as Ayers Rock).

The year is divided into two seasons, wet

and dry, with high temperatures, high

humidity and monsoonal rain dominating

the wet season. Darwin, the capital city,

is the most northern Australian capital

and is the main city in the territory.

The first documented arrival of Indige-

nous people to Australia and the

Northern Territory through land bridges

from south-east Asia dates back to

roughly 50 000 years ago. European

settlement arrived in 1770 and to the

Northern Territory in the early 1800s. It

is a sparsely populated region, with a

population of 211 945. Most live in the

‘Top End’ (165,517), the northern region

of the Northern Territory, of whom 120

586 reside in Darwin. Twenty eight per

cent of the population are indigenous,

compared with 2.5% nationally.1 There is

a large socioeconomic disparity between

the Northern Territory and the rest of the

country. Health outcomes are also

considerably poorer in indigenous

patients compared with non-indigenous

patients.2

NEUROLOGY IN THE NORTHERN

TERRITORY

There are more than 400 neurologists in

Australia. The population per neurologist

in Australia ranges from 40 000 to 80

000.3 In the Northern Territory, there has

been only one neurologist for the last 25

years, Dr Jim Burrow. He arrived in the

early 1990s as the first neurologist for

the region. With the so few physicians in

the Northern Territory, he also practised

general medicine alongside neurology.

Now a stand-alone neurology service

with a neurology trainee and another

junior doctor, time is spent between inpa-

tient management and a busy outpatient

department (including EEG, nerve

conduction studies and a botulinum toxin

clinic) at the Royal Darwin Hospital,

which services the ‘Top End’ of the Terri-

tory. The southern region of the state is

serviced by a visiting neurologist from

Adelaide.

The neurology team runs nine half-day

outpatient clinics per week. Roughly five

to eight patients attend each clinic with a

mixture of new presentations and clinical

reviews. Given the vast distance of the

territory, many patients south of Darwin

drive 3–4hours to come to clinic. Patients

on the eastern coast of the Northern

Territory are flown into Darwin, a 1 hour

flight as opposed to driving over

1000 km of unsealed roads. During the

wet season, most roads in these areas are

impassable due to flood waters. A large

percentage of indigenous patients live in

small rural communities ranging from

500 to 2000 people and many come

from smaller outback stations that are

further isolated. Three or four times a

year, the neurology team flies out to

several large towns and communities to

run clinics and perform nerve conduction

studies. Patients living in outback stations

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or nearby communities are driven in to attend these

clinics. Patients who require further investigations are

flown to Darwin where these can be expedited in an

outpatient setting (figure 5).

Stroke is the most common inpatient presentation

to the hospital. Most acute strokes in the Top End are

transferred to the Royal Darwin Hospital. The stroke

incidence of 138 per 100 000 in non-indigenous

patients is similar to the rest of Australia. However,

the indigenous population has a three times higher

incidence (307 per 100 000), a younger age of onset

(10 years), higher case fatality, higher stroke recur-

rence and more comorbidities than non-indigenous

patients.4 5 The year 2016 was the first year that

thrombolysis of acute ischaemic strokes was intro-

duced at the Royal Darwin Hospital. This was

coupled with a code stroke service with early mobili-

sation of the neurology, medical and intensive care

teams to assess and manage acute stroke patients

presenting to the emergency department.

There is no neurosurgical service in the Northern

Territory so all neurosurgical patients are managed

between the neurology department and the trauma

service. General surgeons in Darwin can perform

basic burr holes, extraventricular drains and

hemicraniectomies, but most cases are flown down to

the closest neurosurgical service in Adelaide, 3.5 hours

by air. A visiting neurosurgeon attends a clinic in

Darwin every 3–4 weeks.

The Northern Territory has tropical and exotic

infections that are rarely seen elsewhere in Australia.

Many of these present predominantly in the indige-

nous community but can affect anyone. One of which

is Burkholderia pseudomallei (melioidosis), which is

almost synonymous with the Northern Territory. A

bacterium that causes severe pneumonia and prosta-

titis in immunocompromised patients, its prevalence

rises exponentially during the wet season. Severe cases

lead to central nervous system (CNS) infiltration

causing abscess, rhombencephalitis and transverse

myelitis. Cryptococcal meningitis and CNS cryptococ-

comas are also a not uncommon presentation in even

immunocompetent patients.6 Leprosy used to be prev-

alent in indigenous patients in the 1970s but over

time its incidence has reduced drastically. Unfortu-

nately, the disease is yet to be completely eradicated

and there are still one or two new cases per year7 .

There is also a very high prevalence of neuroimmu-

nological disease, especially in the indigenous

population. The indigenous population has a high

prevalence of systemic lupus erythematosus and

Figure 1 The Northern Territory (Courtesy Wikimedia

Commons) https://commons.wikimedia.org/

Figure 2 Flag of the Northern Territory https://commons.

wikimedia.org

Figure 3 Jim Jim Falls, Kakadu National Park (Courtesy

Wikimedia Commons) https://commons.wikimedia.org/

Figure 4 Katherine Gorge, Nitmiluk National Park (Courtesy

Wikimedia Commons) https://commons.wikimedia.org/

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Sj€ogren’s syndrome that anecdotal experience suggests

present and manifest in an atypical manner. Severe

and early myositis and CNS involvement are not

uncommon and require aggressive management.

Patients with multiple sclerosis and neuromyelitis

optica spectrum disorder are also regularly managed

at the Royal Darwin Hospital.

East Arnhem Land (the most eastern region of the

Northern Territory) and the island Groote Eylandt

have a high prevalence of spinocerebellar ataxia 3

(SCA3, Machado–Joseph disease) with roughly 100

patients. The initial presentation of this syndrome was

observed in the 1960s and named Groote Eylandt

syndrome. It was initially attributed to poisoning with

manganese that was mined in the area. Later studies

found no correlation between manganese concentra-

tions and disease, and it was later discovered the

syndrome was truly SCA3. It was initially thought

that the gene had been passed though Portuguese-–

Macassan traders 300 years earlier. However, further

genetic testing in 2012 confirmed that the gene muta-

tion likely originated from Asia and was not the

Portuguese variant.8

The Northern Territory has some of the most

picturesque and beautiful scenery in the continent and

is the often considered the quintessential Australian

outback. It is sparsely populated and faces many

socioeconomic issues. Though understaffed, there is a

fascinating variety of neurological cases that makes

work in the Northern Territory both rewarding and

challenging.

Acknowledgements The author thanks Dr Jim Burrow for his

guidance and support during his time in the Northern Territory and

on the manuscript. The author would also like to credit figures 1, 2

and 4 to Wikimedia Commons, Figure 3 is courtesy of Nigel Maone

from Wikimedia Commons, and Figure 6 courtesy of J Bourne.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer

reviewed. This paper was reviewed by Martin Zeidler, Kirkcaldy,

UK, and Colin Mumford, Edinburgh, UK.

Open Access This is an Open Access article distributed in

accordance with the Creative Commons Attribution Non

Commercial (CC BY-NC 4.0) license, which permits others to

distribute, remix, adapt, build upon this work non-commercially,

and license their derivative works on different terms, provided the

original work is properly cited and the use is non-commercial. See:

http://creativecommons.org/licenses/by-nc/4.0/

© Article author(s) (or their employer(s) unless otherwise stated in

the text of the article) 2017. All rights reserved. No commercial use

is permitted unless otherwise expressly granted.

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Figure 5 Flying over Arnhem Land to regional community

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Figure 6 ( A, B) The famed crocodiles of the NT. (C) In the NT

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National Park. Figure courtesy of J Bourne.

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