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Darwin Dry


We recently got to spend 2 wonderful months back in Darwin for the dry season.  One of my colleagues asked us to housesit, dogsit and jobsit while she went off to Europe for a couple of months.  My partner managed to organise a project back at Danila Dilba and we scored a short term spot for the girls in child care. How could we possibly say no?

I had the pleasure of working on the beautiful Tiwi islands at Julanimawu health centre in Wurrumiyanga aka Nguiu – try saying that in a hurry.  Lucky for me I got to work with the formidable @ClintonLeahy (who you may recognise as the GP in Chloe Hoopers ‘The Tall Man’). He is seriously obsessed with fly fishing and loves his island life.  The clinic is staffed by some impressive remote nurses, Aboriginal Health Practitioners, drivers, community workers and many others and it was a very different vibe to some of the other remote communities I have worked in.

It was a big change from my 3 month locum stint on the East coast of Tassie and it took a little while to get back in the swing of remote Indigenous health again but luckily it all came back fairly quickly.

One of the few evacuations I was involved in was for a man who came in for a check up and had a routine ECG.  His ECG showed some abnormal findings and when we questioned him further it turned out he had an episode of severe chest pain 1 week earlier.  We did a few tests and it turned out he had a large heart attack.  When I spoke to him a bit more he mentioned that his brother had died of a massive heart attack a few years earlier on the football field.  He was sent urgently off to the cardiologists for an angiogram  and succesful stents.  A good reminder of the importance of asking about family history.  Now why doesn’t come into the cv risk calculators?

I spent a lot of time visiting a young woman in her 20s with severe malnutrition, limb deformities and skin sores.  She was unable to get out of bed and didn’t want to be transferred to hospital for investigations in treatment.  Her family were understandably upset about the situation.  We did our best to provide supplements, antibiotics, pain killers and comfort but in the end palliation was all we could provide.  She passed away soon after I left.  Such a tragic situation.

One day was spent doing a Remote Area Trauma Education Course which served me well a week later when, for my dads 70th birthday, we travelled to Litchfield for a day of swimming and relaxation.  Unfortunately while we were there a young tourist drowned in the falls and I spent the afternoon attempting resuscitation.  The image of performing CPR while being carried on a stretcher up a rough dirt track to the carpark as the rescue helicopter attempted to land blowing branches, dust and dirt all over the us and the carpark is one that will stay with me forever. A note to anyone who has responsibility for a first aid kit, be sure to check you have a bag and mask (not just a bag) that would have made things a lot easier.

Back in Tas for the time being and working in Communicable Disease Control at the Public Health Unit.  I still travel virtually to the NT each week to provide on call support for remote communities and each week is a new adventure.  Something that I get called about far too often is domestic violence.  Some awful injuries have happened including a young woman who was recently stabbed in her chest, abdomen and vagina.  Kudos to the amazing Dr @CatGargan for her prompt early management and transfer to RDH for surgery.  There are some pretty amazing young doctors that I am proud to know who work in the remote NT.

Bye for now!


Goodbye Wadeye

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One week of work before going on maternity leave and one more flight to Daly River.  Every community I have worked in over the last 14 months is different, and each has their own unique stories and challenges so I would hate to generalise about remote Indigenous communities when I talk about Wadeye.  From what I have learned, its size, remoteness, history and inter-generational family relationships have caused some long-lasting issues and I would love to go back in 30 years and see some real change.  My short fly-in, fly-out experience meant that I didn’t integrate into the community. although I don’t think many local white people would call themselves integrated, white and black live very separate lives.  For young people there are few options for work or education beyond school and I think if they leave the appeal of returning to country and family would be a real conflict against the humbug, stress and limited opportunities available.

A young woman came into the clinic with her mum last week asking me to complete a Centrelink Disability Support Pension certificate. When I asked about her disability she told me it was for her heart.  She couldn’t tell me any more than that so I looked up her file on the computer. A long list of outstanding recalls flashed in front of me, almost all for check-ups for Rheumatic Heart Disease, for which she had not been seen in the clinic for over a year.  I took the opportunity to catch up about her RHD and find out how she was feeling.  I was pleased to hear that she was feeling well, had no problems with chest pain or shortness of breath, or swelling and was able to go about all her normal day to day activities.  So why then did she think she should be on a Disability Support Pension?  I still don’t have the answer for that, I certainly don’t know much about the operations of Centrelink or how they decide what qualifies as a disability.  All I could do was fill out the form with her diagnosis and describe how it impacts on her life, which, given she denied any symptoms and hadn’t been seen in the clinic for over a year, appeared pretty minimal.  A week later she returned, again with her mum, skipped the waiting room and came straight to my room with a new form, exactly the same form as the week before, asking me to fill it in.  Unfortunately neither her or her mum could explain why they had returned and all I could do was ask them to get Centrelink to call me with more information about her request.  This reliance on Centrelink payments at the age of 24 and lack of desire or motivation or understanding or belief in work and education shows such limited aspiration for the future.  I’m not sure whether this young woman has thought about her future, or where she would like to be in 10 years time, I doubt she has thought much beyond the hopes of money that a disability pension will bring (considerably more than other Centrelink payments I believe).  And I guess these day to day pressures consume her life not leaving much time for career planning.

Another young man returned to the clinic this week with a hugely swollen knee joint.  I mentioned him last week as the man attacked by a spear then involved in an altercation with police where his knee was injured.  Following his transfer to hospital he had been recommended to have a wash out of his knee joint in theatre by the orthopaedic team.  Unfortunately he left hospital before this was done and so, after much discussion, we treated him with a single dose of intravenous antibiotics and some oral antibiotics to take home.  At least he was honest about his refusal to go to hospital, otherwise that could have been another costly transfer where he may or may not have received treatment.  I hope for his sake that his knee heals quickly and he has no long-term consequences from the injury but we will wait and see.  The clinic, I’m sure, will do their best to provide whatever treatment he needs down the track if he seeks treatment at a later stage.

To finish on a more positive note, I have a special interest in women with diabetes in pregnancy.  Having worked on a project around improving care for women with diabetes in pregnancy in my previous public health job, it has been great to focus on the clinical aspects of this.  I caught up with all six of our ‘gesties’ this week, and feel like we are really providing a high level of care.  Given that the complications are so significant, and the epigenetic effects on the baby in terms of developing diabetes and cardiovascular risk factors later in life, it is so important to manage well.  It was great to see women coming back who have been recording their blood glucose levels and taking medication and really motivated to undertake treatment.  Its also really nice to work with a great team of midwives, diabetes educators, endocrinologists and with the clinic manager to look at all aspects of care from diet to group education sessions to medication supply and postnatal follow up.  Working as part of a team is so rewarding, something that mainstream general practice really struggles with.

And finally, my final evacuation was for the same reason as my first ever urgent evacuation way back in January 2013.  A pregnant woman came in first thing on Tuesday morning at 32 weeks pregnancy with ruptured membranes and having regular contractions. The babies heart rate was faster than it should have been so we knew she had to be flown into Darwin urgently.  We gave her some fluid and antibiotics, an injection to mature the baby’s lungs and some tablets to stop her contractions.  It all felt so streamlined and efficient compared to the stress of a year earlier.  We did have the birth kit and neonatal resuscitation kit ready and I was brushing up on my neonatal resus algorithm just in case the plane was delayed but fortunately it was not needed.  I checked later and her baby was born later that day.  From what I hear all is going well but it will be many weeks before she can return to Wadeye.

So that’s it for this week.  I’ve still got lots of things I want to write about so it won’t be the end of this blog.  The pics above are of some tshirts and fabric that I bought this week from the Wadeye Women’s Center.

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Cases of the week

Working in Indigenous health (particularly remote) is unlike working anywhere else!  

Here are a few of the things I saw this week:

A young man with a huge knee joint effusion which came up after being hit by a spear (yep, a spear) in the thigh a week earlier and then being kicked by the policed (allegedly) the previous night.  We weren’t sure if it was infected or just fluid.  I did a joint aspirate and we sent him into Darwin.

A middle aged woman with the worst headache of her life for 6 days associated with facial weakness and reduced sensation on one side of her face.  Yep, we evacuated her to Darwin too.

A 19 year old girl who is in a wheelchair for systemic lupus erythematosis (an unusual autoimmune condition that is quite common in NT Indigenous people) not helped by childhood neglect.  She is extremely underweight at just 35kg and was brought into the clinic by a nurse who had been doing a home visit to give her rheumatic heart disease monthly injection after being found at home covered in infected scabies and skin sores.  Her whole hand which is fixed in a claw shape was weeping.  We treated her with intravenous antibiotics, scabies treatment and she has reportedly made a good recovery over a few days.  

A middle aged man with multiple cardiovascular risk factors with chest pain.  He stayed in the clinic for monitoring and blood tests and we ruled out a heart attack.  He hasn’t attended cardiology appointments for investigations in the past when he has been flown in and has instead gone long-grassing (ie. drinking) so can we justify sending him in again to get the angiogram that he needs?

2 teenagers aged 13 and 14 requesting implanon insertion

A 16 year old girl with an unwanted pregnancy who presented to the clinic at about halfway through her pregnancy

A 31 year old morbidly obese diabetic with poorly controlled diabetes.  Her HbA1c was 14 (twice the upper limit of normal) who does not take her tablets and is extremely reluctant to take insulin

Several women with diabetes in pregnancy

Work was busy as always.  We were down a locum doctor so I didn’t get to spend any time following up on recalls or catching up on overdue health checks.  Instead spent time rushing around seeing patients and trying my best to write notes on our cumbersone computer system any chance that I got.  

One of the biggest challenges I think in remote practice is deciding who needs to be evacuated.  There are the easy choices such as ectopic pregnancy or sepsis but the in-between cases such as severe headaches, severe pneumonia, babies with bronchiolitis or children with asthma or gastro which can be difficult.  You need to consider not just how they appear now, but whether they may deteriorate later that day or overnight, and if they do, will there be enough time to fly them to Darwin.  A high acuity Careflight plane can potentially get to Wadeye in an hour, but they are often tied up with other emergencies and this can mean delays for several hours even up to a day.  There is also the weather, particularly during the wet season, which can close airstrips, as just happened at Daly River for several weeks, and prevent planes getting in to fly out to evacuate people.  All things considered living in a remote area can leave you quite vulnerable.  It is one of the challenges I love about the job.  That and the fact that we manage a lot more on our own without relying on xrays, pathology and specialists in the town centre.  

I finished the week with our fortnightly journal club looking at issues around communication about chronic diseases for Indigenous people and a talk from a resigning doctor in our Darwin office hearing about his suggested approach to better manage the larger remote health clinics in the NT in order to keep up with the burden of chronic disease. He thinks we should be taking the clinic out into the community rather than bringing people into the busy and overwhelmed clinics, and most in the room agreed with him.  In most states and territories a community of 3000 people would have a small hospital as well as a GP clinic but that is not the case in the NT. With an average of 20-30 evacuations per month from the larger communities which cost around $6500 each, not to mention staff fatigue, overtime penalties and subsequent effects on the clinic workload it would be interesting to see the figures comparing the costs with implementing short-stay type hospital facilities in these areas.  



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Weak blood

In the last few months I have been working mostly in Women’s health.  One of the things I have found disturbing is the number of women who have severe anaemia.  It is so common as to almost seem normal for me now for a young woman to come in for the her first antenatal visit late in her pregnancy with a haemoglobin of 80 (normal is greater than 120), weighing around 40kg and with a BMI of 13 or 14.  When I ask I usually find that these women eat a maximum of one meal a day and often go several days without food in the days leading up to pay day.  Often they are still breastfeeding a toddler, who is also anaemic (NT audits shown 25% of Indigenous babies are anaemic at 6 months). Unfortunately there are no easy answers.  All the education I can give about the importance of regular meals and iron-rich foods is easily lost amongst the fortnightly cycle of money, cigarettes, ganga, gambling and men eating most of the food.  Some women have a basics card which can be partly quarantined for food but this doesn’t affect what happens to the food once it leaves the store.  Our medical solution is to offer a pregnancy multivitamin which contains some iron to all pregnant, breastfeeding or pre-conceptual women, which, like most medications, I have absolutely no idea if it gets taken.  We have also recently started giving iron infusions like they are going out of fashion and we have a great new product Ferinject which can give a gram of iron intravenously in just 15 minutes.  

This week I saw a young woman who wanted to have her implanon (contraceptive implant) removed.  She was referred by one of the nurses who had done a spot check of her haemoglobin level which was 66.  Normally I would consider anything less than 70 to be fairly critical and would consider transferring to hospital for an urgent blood transfusion if they had symptoms of racing heart, shortness of breath or chest pain.  This 18 year-old had no symptoms and no reason to be so anaemic other than a poor diet.  At risk of sounding authoritarian we really try hard to ensure women are as healthy as possible before removing their implanon contraceptive.  Priorities are to quit smoking, check for, and treat, any anaemia or diabetes, make sure women are immune to rubella and other infections, and try and address any psychological or social issues.  For this woman I explained that I was reluctant to remove her implanon (despite the fact that it was well overdue to be removed) as I was worried about her ‘weak blood’ and that we needed her to be strong for any future babies to be strong too. Reviewing her notes I found that late last year she had been to the clinic for exactly the same reason and at that time her haemoglobin had been 80 and appeared to be due to iron deficiency.  We had arranged an iron infusion at that time, but had never managed to get her back to the clinic.  According to her notes staff had visited her house on several occasions to try and encourage her to come to the clinic but she had always refused.  I guess we either didn’t try hard enough to explain the reason for the iron infusion or she had other priorities in her life at that time.  At least now we have a second chance and hopefully next week we will be able to arrange the iron infusion.  Sadly though there is not much I can do to address the food situation. The clinic is clear that we can’t be seen to be giving out free food.  Occasionally we can prescribe sustagen-type supplements, usually for severely malnourished kids who are not gaining weight, but these are unpopular and not a long term solution.  

Any suggestions?

Flying in the wet

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Plane bogged

Murin air flight NT news

We have had some heavy rain and wild weather recently.  In the last few weeks I have had one flight return to Darwin after being unable to land (and yes the co-pilot and several passengers did vomit), two weeks of cancelled flights to Daly River because of flooding, one aborted take-off attempt and one blown tyre resulting in a bogged plane!

Life in Wadeye

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Here are some snaps from my most recent trip to Wadeye

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Jacksons versus Longmirrs

In the community where I work we currently have our own Capulet versus Montague situation. To put things in perspective it was only 80 years ago that the town was formed by bribing the different clan groups of the region with tea, sugar and cigarettes to form a mission. Unfortunately those different tribes don’t necessarily get on with each other, even today.
In 2012 media reports of riots in the streets culminated in the death of a Longmirr (names have been changed) and a young Tim Jackson being sent to jail. The house where he was living has been unoccupied since that time and family members have been unable to return due to threats of violence. At the end of last year the court acquitted Tim Jackson who claimed the death was a result of self defence. His return to his home town was anticipated with a heightened level of anxiety that was palpable around the community. What would the payback be? Mainstream courts are not allowed to take into account Indigenous cultural laws, and Indigenous people don’t always respect the authority and decisions of mainstream law.
I was away for a few weeks over christmas during which time I heard on the news that 2 young men had drowned off the coast of the Top End. 7 young men had driven out to an island which is only accessible at low tide.  Unfortunately they mistimed the tides and got bogged when they tried to return.  5 of the men survived by clinging onto a drum while the other 2 drowned.   When I returned to work I was filled in on the events that had transpired. Tim Jackson had returned to community but was living in an outstation just out of town.  The police task force had been called in to keep the calm.  Unfortunately the 2 men that drowned were also Jacksons.  His family believed this was due to black magic on the part of the Longmirrs.  The Longmirrs, while not accepting responsibility, essentially said that the Jacksons deserved what happened.

And so the tension and violence persists.

In the clinic we have seen a mixture of families scared to leave their houses due to fear of being caught up in violence, and minor injuries.  People seem to be taking sides and getting caught up in low-level violence.  I have treated people for head injuries, chest injuries, infected hands from punching people in the mouth but fortunately nothing serious at this stage.  As an outsider, it is hard to get a sense of what is actually going on.  Groups of young men dressed in black megadeath tshirts walking around carrying axes is quite an alarming sight – but it seems like threats and fear are more at centre stage then any real violence. The media are almost never seen, which I assume is because the cost of flights in the NT is fairly prohibitive.  A flight to most remote communities in the NT is more expensive than a trip to Melbourne, Sydney or even Bali (more on that in another post).

It’s hard to see how this will end.  The police task force are in town, at least until the funerals of the 2 men who drowned which will be held in a few weeks, and then we shall see what happens.  A community meeting was held last week but the TO’s (Traditional Owners) didn’t show up.  I hope that some of the TO’s and community leaders will be able to get together to resolve some of these longstanding issues.  Of course it’s complicated by high levels of unemployment, childhood neglect, poverty, substance abuse and cultural insecurity.  I have to remind myself every week that the work I do is actually helping a few individuals, and these complex social issues will take more than a generation to resolve.

Boiling the billy in Wadeye.Photo courtesy of Justin McManus


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The body mixup

For some reason I find myself retelling this story over and over again. For me it summarises the crazy, chaotic nature or remote Indigenous health. For those it affected I’m sure it was a deeply distressing incident and I apologise sincerely if it causes offence to anybody reading this.

But before I start a note about death. For a community of around 2500 people I have never been surrounded by so many deaths. Perhaps I have become more attuned to people dying or perhaps it is because I work in the clinic where we often have such close contact with people, but it seems that there are funerals happening every 2 or 3 weeks. I had the sobering experience of declaring the death of a 17 year old girl who had committed suicide by hanging herself a few weeks ago. There were no warning signs that anyone had noticed. She had minimal past contact with the clinic and no known mental health history. Our visiting psychologists are concerned that this may precipitate more suicide attempts, which are often quite spontaneous, and if prevented are often not attempted again. They also describe the frequent habit of self-strangulation which is socially popular in some communities in the western Top End and potentially lethal.

While completing the death certificate for the 17 year old girl I glanced back through the previous deaths from our community in 2013. Roughly 10 people had died in community and there have been many more deaths in hospital. By estimates, around 20 deaths in total giving a crude death rate of …… The causes were typical, cardiorespiratory rest secondary to heart disease associated with diabetes, kidney disease etc. etc. But the ages were much younger, 40, 50, 60. Just last week from the other side of the country I heard about 2 young men that had died in a fishing accident. It is not just deaths due to heart, lung and kidney disease but injuries and accidents make up a huge bulk of the discrepancy, particularly for young men. I’m not going to start a diatribe about the difference in life expectancy between Indigenous and non-Indigenous Australians but when you work in the area it really hits home. While in the last 2-3 years I have heard regular reference to the NT being on track to ‘close the gap’ in life expectancy (based on annual measures of death rates) from COAG (Council of Australian Governments) annual reports I don’t feel like we can be reassured as the difference is still shocking.

Another patient who I knew well died earlier in the year. She had end stage renal disease and was waiting to move to Darwin to spend 6 months learning how to use a dialysis machine with the ambitious hope of returning to community to undergo daily haemodialysis in her home. We have a few patients using peritoneal dialysis (much simpler to perform by oneself) but nobody on haemodialysis and I have to admit the idea I found a little challenging given the regular power outages and lack of technicians on hand to fix any technical issues with the machine. She never got to start her dialysis because she developed an infection in her thigh which, given her compromised immune system, she was never able to fight despite extensive surgery. Her close friend who I had also come to know well was left with the burden of caring for her children. Aside from being morbidly obese, this friend also suffers from heart failure, atrial fibrillation, subclinical hypothyroidism, primary hyperparathyroidism, diabetes, obstructive sleep anoea, fatty liver and polycythaemia… at least that’s all I can recall right now. She is a model patient, attending the clinic every week for her INR testing and warfarin dosing and she seems to take all her tablets (apparently they make her feel better!) but doesn’t like to travel to Darwin, particularly during the wet season when the flight can be quite bumpy, and is hardly a picture of health to be caring for somebody else’s children. She has been a great source of information on family dynamics and cultural issues for me throughout the year.

In town we have a 2 bed morgue. It serves the surrounding region as well, and occasionally if there are more than 2 dead bodies the surplus get stored in the town museum (as far as I’m aware they are not available for public viewing). A few months ago a traditional ceremony took place and a body was buried in a closed casket in the local cemetery. A week later a second funeral followed and this time an open casket was displayed. To the horror of those attending the funeral the wrong body was on display, which could only mean that the wrong person had been buried a week earlier. What to do? The Chief Health Officer was on the phone to my supervisor, the senior GP at the clinic, late on a Friday night. Whose job was it to retrieve the buried body and identify it as the correct person? Unfortunately to add to the problem it appeared that the original burial had not been carried out according to official NT legislation – and the body was buried too shallowly meaning in a week of scorching NT build-up heat and humidity quite a lot of decomposition may have occurred. The NT News had a field day about this story and the clinic copped a bit of wrap about the incident. Windows were broken, the clinic went into a brief lockdown, but luckily all was resolved and everybody moved on. Just another day in the remote NT.

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A year in Wadeye

A year has gone and my intention to write this blog weekly, like any good New Years resolution, lasted less than a week. I am sitting far from the remote NT that has been my workplace for 12 months and am reclining on the deck at the family shack in eastern Tasmania. So where to start? In chronological order or with the events that have stuck with me most throughout the year?

To begin on a small plane flying high above the Coburg peninsula is as good a place as any. I can’t forget the feeling, once the sweat of the pre-takeoff plane had dried, of sitting in a small plane gazing out at the islands below, scattered clouds, and the sense of anticipation of flying to a remote place where I wouldn’t have the option of calling an ambulance if someone was unwell. I recall gazing at two of my colleagues, both tall and lanky with shaved heads, who would be flying further afield after leaving me at the tiny airstrip near Minjilang, a community of 400 people on Croker Island. Aside from the usual nerves of starting a new job, I felt such a sense of pride and privilege to be doing this job, instead of following the usual path of city medicine like my colleagues in the south. Unlike most communities there is no mobile phone reception on Croker island, a decision made by the locals (and I am assuming not the young ones) after telstra refused to pay the community to build a mobile phone tower to provide mobile phone access.

I learnt a few good lessons in the early weeks. The decision to fly someone to Darwin is not always easy. Organising a simple xray in Darwin is a matter of printing the form and asking the patient to rock up to one of many radiology clinics scattered across the city. From Croker Island it involves a return plane trip, a trip to the Emergency Department, several phone calls and referral letters to ensure any xrays abnormalities are detected and dealt with promptly while in town, plus the risk of patients choosing to head off long-grassing with friends or family while in Darwin and never making it to the xray department. Not to mention the embarrasment that ensues when the patient you referred with a suspected fractured ankle is sent back with the official discharge diagnosis of sprained ankle.

My first emergency medical evacuation was for a woman in premature labour. It was late in the afternoon and she arrived in the clinic at 32 weeks having contractions. I spoke with the district medical officer on call for advice as she settled down after some Panadeine forte, but we decided to evacuate her that afternoon as we couldn’t risk her having the baby in the clinic that evening. As it turned out she had the baby 2 days later in Royal Darwin Hospital after some antibiotics and steroids to mature the baby’s lungs so it was a good outcome and the right decision at the time.

It’s strange how quickly things can begin to feel normal. My first encounters with complex patients with multiple chronic diseases, particularly kidney disease and diabetes, felt like such a challenge. Now I feel like the challenge is not so much in the medical aspects of these diseases – something we doctors love to sink our teeth into – but in the social and lifestyle aspects. The healthy diet when food security is a real issue, or exercising for health rather than just to hunt or gather. More on that later.

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Tales from the tarmac

Imagine you are in a sauna.

Now imagine you have all your clothes on

Your hair is sticky on your neck and sweat drips down your cheek

your backpack sits wedged and heavy on your lap

and you are surrounded by a plane load of people.

Sit there for a few minutes while the pilot checks the equipment

then wait another 10 minutes for some planes to take off

finally you are in the air and the aircon switches on

tickling the sweat moustache on your upper lip, teasing you with its coolness, unsatisfying.

and then you land and go to work for the day, hoping your deodorant is powerful enough to override all that dried sweat

And try and remember not to wear white!