drawings by Jeni Binns

I have been prompted to write this due to an adverse incidence of a patient who received a Boostrix vaccine and went on to have serious problems that followed. It was basically a bursitis of a shoulder that resulted from the vaccine having been administered too high in the upper arm. This left the patient with an inability to abduct the arm for weeks. 

In view of the large number of vaccines being given in these times it may be worth considering the site of injecting. It should be neither too high nor too low. This may involve removing layers of winter clothing to give the injector good access to the correct site in the deltoid muscle of the upper arm – see diagrams. This can be time consuming in a busy clinic under pressure. 

Although a rare complication of vaccination it can be disabling for the patient causing an immune-mediated inflammatory reaction in the shoulder joint. The resulting problems can be bursitis, tendonitis, rotator cuff tears and fluid accumulation in the deltoid or rotator cuff. 

In summary, all vaccines can produce this adverse reaction if the injection is given too high. 

For more information see the RACGP article on Avoiding shoulder injury related to vaccine administration.

Drawings by Jeni Binns

NorDocs has completed over 12 months of webinars since the onset of COVID19  restrictions. Highlights from last year were interactive sessions with local specialists on the subjects of carotid vascular disease management, modern psoriasis treatments, management of breast cancer and new options in the treatment of restrictive lung disease. 

This year there have been meetings on the team approach in addiction medicine, the relatively common North Coast malady of mammalian meat allergy (MMA) and the options for advanced upper gastro-intestinal surgery at Lismore Base and St Vincent’s Private Hospitals.

Drs Helen Lloyd and Susan Tyler-Free discuss MMA pathophysiology and diagnosis
with facilitator and Nordocs Co-Chair Dr Louise Imlay-Gillespie

Between May-July this year the NSW Agency for Clinical Innovation ran a crowdsourcing challenge, inclusive of a Twitter chat, to gain insights and perspectives from clinicians, managers and consumers to contribute towards an action plan to tackle unwarranted clinical variation in NSW. 


It was a tweet on this feed that led to an invitation to author this article in which I discuss the background of clinical variation in health care with a focus on primary care, the Australian experience of identifying, understanding and managing variation, followed by strategies to address variation.

Variation in healthcare is not a new phenomenon. For example, a 1930s review of tonsillectomies across London boroughs found a 20-fold variation, leading to the conclusion that there was a ‘tendency for the operation to be performed as a routine prophylactic ritual for no particular reason and with no particular result’. A troublesome conclusion, particularly because at that time tonsillectomy operations led to the death of seven children every month in England.

Now, almost a century later, we continue to observe wide variations in clinical practice that cannot be explained by patient preference or illness severity. These variations are unwarranted.  There are three types of unwarranted variation:

  1. Variations in effective care and patient safety
  2. Variations in preference-sensitive care
  3. Variations in supply-sensitive care

ADHD in adults


Adult ADHD with psychiatrists Drs Hugh Morgan and James Whan in conversation with Dr Peter Silberberg




Afghan war rug

I weave what I have seen: The War Rugs of Afghanistan, an exhibition at the ANU’s Drill Hall Gallery.

In the mid-1970s, when I was last there, the rug shops of Afghanistan’s capital Kabul stocked a treasure trove of handmade creations, notably the deep-red rugs and hall runners for which the country was, and still is, famous. The designs were abstract yet symmetrical, rarely featuring human or animal figures, or identifiable objects, certainly not guns and fighter aircraft.
But that has changed, as Afghan society at large has changed.
From late 1979, when the USSR’s troops entered the country to preserve a puppet regime, Afghanistan has been on a timeline of conflict that continues to this day, and the images of its unasked-for war have been recorded on an unusual tableau, its woven rugs.