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.

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.)

I have my first ED rotation in a week (excuse me, Accident and Emergency), so we'll see if that priority driving has any point or not…

Last week one of the campus Physician Extenders (campus EMS) calls me up to ask for some assistance back boarding a student that fell on slippery, wet, outdoor tile stairs. Believe it or not, the campus "ambulance" runs with only 1 crew. They have to improvise if it's anything more than a sore throat and the patient actually needs care on the way to the hospital. Crazy. And did I just spell improvise with an "s"? Wow, I've been in an English-English-speaking country too long. [Edit: It's even funnier now that after running spell-check, that even my spell check seems to think it is spelled with an "s," even though the server is located in Houston, TX. Well, I guess they did give us that brillant scholar we have for a president.) Anyways, up to the hospital for some x-rays and an overnight observational stay for "pain management." Or maybe the census was low at the privately run hospital, and the opportunity for income was seized?

Anyways, today someone knocked on my door to tell me that someone hurt themselves playing basketball (a seemingly-daily occurrence). A 23-yo male had an anterior-inferior dislocation of his right shoulder (for the 7th time.) Ice, immobilization and a trip up to the General Hospital. After films, and the orthopedic surgeon reducing the shoulder, the patient possibly has a second surgery to repair the labrum to look forward too. Which would kind of suck 3 weeks from the start of finals…

Oh well, that's all the excitement I get around here…

However, a new study concluded that response times of 8 minutes or less were not associated with increased survival in most instances:

Results: Of 34,111 calls involving emergency response, 11,078 patients (32%) were transported to the study institution and 10,382 (94%) had response time data available. Of these, 9,559 patients (92%) had data available to categorize them into groups based on their level of illness severity and were thus included in the study. A survival benefit was identified for response times 4 minutes (odds ratio [OR], 0.70; 95% confidence interval [CI] = 0.52 to 0.95). No survival benefit was identified when response time was modeled as a continuous variable (OR, 1.01; 95% CI = 0.98 to 1.04) or when dichotomized at 8 minutes (OR, 1.06; 95% CI = 0.80 to 1.42).

Conclusions: A paramedic response time within 8 minutes was not associated with improved survival to hospital discharge after controlling for several important confounders, including level of illness severity. However, a survival benefit was identified when the response time was within 4 minutes for patients with intermediate or high risk of mortality. Adherence to the 8-minute response time guideline in most patients who access out-of-hospital emergency services is not supported by these results.

EMS House of Defrance, unable to find original journal.

An earlier study by the same author also found no correlation between survival of trauma patients and the 8 minute response time standard:

Emergency Medical Services (EMS) agencies are increasingly being held to an ambulance response time (RT) criterion of responding to a medical emergency within 8 min for at least 90% of calls. This recommendation resulted from one study of outcome after nontraumatic cardiac arrest and has never been studied for any other emergency. This retrospective study evaluates the effect of exceeding the 8 min RT guideline on patient survival for victims of traumatic injury treated by an urban paramedic ambulance EMS system and transported to a single Level I trauma center. Of 3576 patients identified by the hospital trauma registry, 3490 (97.6%) had complete records available. Patients were grouped according to ambulance RT: < or = 8 min (n = 2450) or > 8 min (n = 1040). After controlling for other significant predictors, there was no difference in survival after traumatic injury when the 8 min ambulance RT criteria was exceeded (mortality odds ratio 0.81, 95% CI 0.43-1.52). There was also no significant difference in survival when patients were stratified by injury severity score group. Exceeding the ambulance industry response time criterion of 8 min does not affect patient survival after traumatic injury.

J Emerg Med. 2002 Jul;23(1):43-8 via PubMed.

Many ambulances still respond emergency to every request for service, or at least a great majority of them. My county uses Medical Priority Dispatching, which has reduced the problem somewhat. However, we still respond emergency to the scene about 75% of time, yet only about 5% of the patients are deemed to have enough of a life threat to justify driving to the hospital with the red lights and sirens activated. The studies above that reducing response time to the "standard" of 8 minutes or less does not decrease mortality, so I propose making the criteria for an emergency response to the scene more stringent. Patients in extremis, where the first study showed a response time of 4 minutes or less correlated with a survival benefit, should obviously get an emergency response. (Though my district at home is 80 sq. miles containing suburban and rural areas, so it can take over 10 minutes just to drive to the scene, but that's another story.) Examples include respiratory/cardiac arrest, ineffective breathing, airway obstructions, etc. (Basically 1-Echo's, some 1-Delta's, and possibly some 1-Charlie's.) But why should we risk the lives of the crew and to the general public by driving emergency to a patient at a doctor's office, a patient that has been having "trouble breathing" or chest pain for two days, or a patient with an isolated extremity sprain rule out fracture. None of these patients will experience any increased morbidity or mortality in the 1-2 extra minutes it would take for a non-emergency response, but the risk of an ambulance accident is greatly increased. Despite this, Medical Priority Dispatching sends ambulances to all these cases in emergency mode.

Let's use some common sense, and by reducing the number of emergency runs, we will reduce the number of ambulance collisions, and mitigate the risk to the crew, and to the general public.

(You never thought you'd hear me advocating for less lights and sirens use, did you? Must be the heat. )