The trip started last Tuesday with a flight on LIAT (also known as Leave Island Any Time) from the E.T. Joshua Airport. True to the more popular explanation of its acronym (rather than Leeward Islands Air Transport), the Dash 8 turboprop had a bit of mechanical difficulties before take-off. Every time the pilot attempted to start the engines, the entire electrical system shut down. After the 10th attempt, we were finally off to Grantley Adams International in Barbados only slightly delayed. But hey, what can you really expect for a $22 fare?

In Barbados, I survived the grilling by the Immigrations Officer, and was able to convince her that I really didn't want to stay in her country and I really did need to get to the check-in counter for my BWIA flight to Miami. Since I had no luggage to check-in, I did make it, but not without a chiding from BWee staff that I needed to "run" to the gate. The BGI –> MIA flight was on a relatively empty B737, and was relatively comfortable. Not only did BWee provide pillows and blankets for everyone (that couldn't be used for take-off/landing for some reason), but they also provided a hot meal. (Did anyone ever think it would become a luxury to be served airline food?) The transfer to USAir in MIA went smoothly, save for me almost forgetting my jacket at the check-in counter. (Since all flights were booked as separate E-tickets on each carriers website, I had to check in separately for each segment. There wasn't enough time to get a unified paper ticket from one of the travel websites mailed down to me.) The USAir flights to Charlotte and then home were uneventful.

Upon arriving at my home airport, I hopped in a cab to guess where? Yup, the ambulance station. In my defense, 1) there was no one at home anyways for the next 3 hours, 2) I didn't know if my car at home was working or even present, and 3) I had promised an on-duty medic that I would stop by. After a couple of hours of not doing calls, I went home to surprise my parents with my visit. When they finally arrived 3 hours late due to airline delays, it did not dawn on them that I might be home when they saw an ambulance parked in the street in the vicinity of my house. Their first instinct was that they should go check on the neighbors and make sure that they were ok (which didn't please my sister, who had just come home from work, and thought that my parents first instinct should have been to make sure that she wasn't dead.) The parents were definitely surprised (sister not so much, as I had to enlist her help with some of the bookings). We talked for a bit, but then the parents had to go to sleep, seeing as they are old and all.

The next day, I picked up a shift working at the hospital ED with both my father and sister (for the latter, I should be getting a nice bonus for referring, which should cover most of the cost of this trip.) Nothing too interesting that I can remember, case-wise. I got stuck doing the sub-acute stuff (i.e. lacerations, extremity injuries) for the first few hours, and then I got moved to the main ED side where it was a little busier. A few old faces, a lot of new faces, and some people in new roles. Evidently I was moving too fast for some people, who hadn't yet adopted the "treat'em and street'em" mentality yet. Oh well, I get paid either way.

Over the next couple of days, I alternate between being on call at the ambulance, and spending time at home with the family (and eating some really nice home-cooked meals.) Pretty quiet call-wise, I even did a 12-hour "no-hitter." Otherwise, some pretty run-of-the-mill stuff. An Urgent-Care to ED transfer for "Rule Out Cardiac" Back Pain, where the 12-lead EKG showed no acute changes. Another Urgent-Care to ED transfer for a 3yo who swallowed a cashew, which was aspirated into the right mainstem bronchus, causing a bit of wheezing. Oh, and the call where we got to fill out two crew member injury reports (myself and one of the medics). The call goes out for a "1-Bravo Unknown Medication Reaction." Even though I am not up for a call, I tag along with the crew since the dispatch info sounds pretty BLS and if so, I could send the medic back to finish her homework. We pull up to find a 40-ish, 400lb-ish gentleman sitting in the bushes outside his house. The patient's wife reports that the patient is on high doses of narcotics (Fentanyl patch and Vicodin po) for chronic pain secondary to multiple orthopedic surgeries. He also has a rather large abdominal scar for multiple GI surgeries to relieve "obstructions." (Constipation secondary to narcotics, anyone?) Anyway, it appears as though the patient is highly dependent on the narcotics, and hasn't had any for 4 days since he didn't get his prescription refilled. So in order to combat the withdrawal, the pt's wife gives him the same dose of Vicodin that he is supposed to be spreading out over 24 hours in just 2 short hours. So is the patient in withdrawal or is he overdosed? Heck if I know. Either way, he has altered mental status (as evidenced by him attempting to eat oh-so-nutritious rocks), and he is combative. All I can say is thanks for the new stretchers which allowed us to lift the 400-lb pt with the touch of a button. After getting the pt. into the ambulance, it became clear that we would need to restrain the patient. That's where I got my injury - a small abrasion on the leg. The medic got hers on her hand trying to start an IV (though thankfully not a needlestick.) The rest of the ride and transfer went relatively uneventfully (except for the hospital claiming that we didn't call to notify them. Which we did, twice. So we just kept walking by the charge nurse desk without breaking stride and put the patient into a bed we thought most appropriate.)

The flight back to SVG was relatively uneventful, and the same 4-stopover convoluted flight-plan. Though on one of the USAir flights, I did have a rather childish 50-yo woman sitting behind me. When I leaned my seat back the generous 17-degrees to take a nap, she proceeded to kick the back of my seat until it was straight up again. Really, people, have you no manners? And what gets me, is that there was an open seat with no one sitting in front. If the whole 17-degrees of my right to recline bothers you that much, why not just do the civilized thing and move? Oh, and LIAT was late again due to mechanical problems, but I made it back ok.

Only 37 days until I am back in the US for good!

Halfmoon Officials Confirm Hospital Plans - "Halfmoon officials have confirmed they are in talks with an area health care provider to open a hospital on Route 146, east of Route 9. The new hospital would be a 120 bed facility with a 24-hour emergency room."

Wow, an emergency room that's open 24 hours a day. Isn't that kind of the definition of an ED? "Emergency" facilities that are open 9-5 are called "Urgent Care Clinics," and we definitely already have enough of those in the district. I welcome a place to drop off emergency patients in the district, rather than another Urgent Care that will call at closing time to transport a non-emergency patient that could just as safely travel by private vehicle to the real ED.

And the staff of your local Emergency Department thanks you for being able to read the sign as well.

What I wouldn't have given to put up a sign like that in the ED where I work(ed), though I would make it 4AM instead.

Other than that, we didn't get to see much of the A&E (other than the fact that it had about 10 rooms, 2 resuscitation rooms, and an "asthma bay," where two kids were happily sucking on nebulizers), as we were whisked off to do guess what? Yup, another history and physical. Our patient was a 45yo male salesman who c/o lower abdominal pain which radiated to both flanks, accompanied with nausea and vomiting. Unfortunately, it was not anywhere near the critical care level the adrenaline junkie side of me hoped to see in A&E, but still a learning experience. Though the physical exam less so, as the pt had been drugged up with pain relievers, and the abdominal exam revealed absolutely nothing. As laboratory and imaging studies were not back yet, we didn't have a diagnosis more definitive than rule out kidney stones or rule out appendicitis.

After reviewing our history and the differential diagnoses with us, our precepting physician was signing our "green cards" (hospital rotation cards to prove we actually attended), the adrenaline junkie once again got the better of me, and I asked if it were possible to do an EMS rotation. His reply?

"Aren't you here to learn the history and physical? I don't think they do that on the ambulance."

Ok, so while some people who abuse the EMS system think it is a taxi service, it is in fact not. Seriously, does he think that EMS just throws the patient in the back of the rig and drives them to the hospital without saying a word in the 30 or so minutes it takes to get there? Most EMS providers do perform a history and physical to figure out what is wrong with the patient, so they can 1) give appropriate treatment and 2) give report to the hospital. Though to be fair, I don't know what level of training the EMS has in St. Vincent, and they may be just "ambulance drivers."

The precepting physician also added:

"Doctors do not go out on the ambulance, so you would have no supervision."

Of course he did not know that I have been a certified EMT/AEMT for the past 6 years, and haven't killed anyone yet. (Despite trying once or twice.) And to be honest with you, I really wouldn't trust some of the students here, or some of the students that rotated through the ED where I worked back home. Either 1) they know absolutely nothing, or 2) they'll rattle off every possible diagnosis out of Robbin's Pathology without ever mentioning the obvious one.

Oh well, maybe one of the other docs will let me play with the lights and sirens. (And save some lives, of course.)

My home state of New York received an overall grade of C+, brought down in part by the D- in the area of medical liability climate…

Reminded me of the guy complaining of a cough that recently spent 4 hours in the ER to rule out what he believed was manifestations of a hantavirus after reading about it on the internet. He was triaged to a low priority class, and sent to the Sub-acute area (not the main ED). I'm sure he couldn't have been too happy when he was told he wasted all that time for a common cold. People, if you are going to read something on the internet, read all of it. Like this map that shows that less than 0.3% of cases (only 1 to be exact) were diagnosed in my current geographic location…