Thursday, May 30, 2019

Emergency Medicine in the Tropics


2019-05-30


My second (annual?) Caribbean Regional Hospital Emergency Department contract began with four consecutive 12-hour day shifts followed by two days off including today. I had hopes of going to a neighboring island yesterday or today and taking a snorkeling outing but the weather has not cooperated, with a dense cloud cover and rain squalls all day long, so here I am picking my long-disused blog. Things are better compared to my trip here last year, a short few months after two hurricanes battered the island. The inpatient service in the hospital that was destroyed has been rebuilt and reopened. The cancer center is still condemned due to massive mold, and the cath lab is repaired but still closed because there is no technician to run it. More cruise ships are calling. Last year there were only about four a week, now there are 2-4 per day. The island economy is slowly recovering.

The ER is busier than last year. I am seeing about 25-30 patients in a 12-hour shift. The list of chief complaints runs the gamut. Lots of peds fever/diarrhea/vomiting including a young girl who came in absolutely looking like appendicitis and ending up being admitted with pyelonephritis. A bunch of patients flown over from another island because their CT scanner is down. A drug dealer who was shot in the shoulder, the second bullet of his life. Again, he literally dodged the bullet without any internal chest damage. Several sickle cell patients (the local heme-onc doc did her fellowship at Yale), a woman who broke her foot (pseudo-Jones fracture) but waited four days to get authorization from the VA clinic to be seen in a civilian hospital. An early middle age man with a STEMI who was flown to Miami for angiography (the next day by the time all the arrangements were made). An additional four-hour wait while the plane that was to fly him was being repaired. UTI’s, two miscarriages including a young muslim woman who became dehydrated by observing Ramadan in the tropics without air-conditioning. And so on.

The most memorable case so far has been a young adult who was a back seat passenger in a car that had a head-on crash. Not wearing a seatbelt, he smashed into the rear of the front seat breaking and dislocating his cervical spine with immediate quadriplegia. There is no neurosurgery here and no Gardner-Wells tongs to place him in cervical traction, so I jury-rigged a cervical sling using two soft wrist restraints and ten pounds of traction. He remained on a stretcher in the ED for the next three days before being transferred to the mainland. The issue was that, as an undocumented alien, he would be refused entry by ICE at the Miami airport and probably flown back to his native country without receiving any treatment to stabilize his neck. This would be a further disaster because he had some proximal upper arm strength and losing that remaining function would make him totally paralyzed below the neck. Thanks to a persistent family, pastor, and immigration lawyer, an asylum petition was hastily filed and ICE gave the go-ahead to allow him into the US mainland. Of course, by the time he was transferred he developed a stress ulcer and major bleed which fortunately stopped long enough so that he was relatively stable for the transfer. I can only imagine the snide remarks of the receiving hospital staff at the sight of this patient being held in cervical traction with wrist restraints around his chin and occiput. Well, we did our best with what we had at hand.

Except for the first day I have been good on my food regimen. The hospital cafeteria was closed over the weekend so on my first shift I had an egg mcmuffin for breakfast, a Wendy’s hamburger for lunch, and after work went to a chinese seafood restaurant for grilled snapper and chinese vegetables with brown rice. I then went grocery shopping and have done my own cooking since. Breakfast is 1/3 cup oats, 2 cups water, 1 tbsp chunky organic peanut butter, and a sliced banana. I also cooked batches of chopped red cabbage and onion, boiled eggs, and macaroni with mixed vegetables and cheese sauce. I bought disposable/reusable containers and have lived on that ever since except for the evening of my fourth shift when I met Andy, Marilyn’s old BF who happens to be here working in the hospital lab on a three-month contract, and had greek salad and fish (with fries) for dinner.
I sure would love to have Karen and the kids come and spend a few days here, although I doubt that they would like to be in this apartment for more than a long weekend. It’s okay with good air-conditioning, kitchen, etc., but no pool and nowhere to go without getting in a car. I also haven’t had a really good night’s sleep, which is not unusual of course but I think I would sleep better at home in our bed. At least until about 4 in the morning, ha ha (I am a terrible sleeper.). I also miss our walks which I think we will pick up immediately and twice a day when I get back.

Big hugs.









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