Lekha Bapu Reflection – St. Croix Emergency Medicine Clinical Experience

Lekha Bapu, D.O., is an emergency medicine resident at MUSC. She was awarded a Center for Global Health Student & Trainee Travel Grant in the fall of 2023 to pursue a project with in St. Croix. View more photos of her time in St. Croix in this Flickr photo gallery.

Similar to emergency rooms in the United States, I found that the mission of the Governor Juan F. Luis (JFL) Hospital and Medical Center’s Emergency Room in the U.S. Virgin Islands a noble one. It is to provide medical care to anyone who walks in through their door regardless of his/her background or ability to pay. However, I experienced firsthand the unique challenges to carrying out this mission faced by the physicians working there. These included working with limited resources, navigating off island transfers, continuing operations through hospital boarding, and at the most basic level garnering patient trust.

Working in St. Croix opened my eyes to the basic things I take for granted on a typical shift in the MUSC ER: unlimited supply of laboratory vials, sterile gowns for performing invasive procedures, wireless phones to communicate with other staff members, and electronic charts just to name a few. I remember a shift in St. Croix where we found ourselves needing to ration CBC vials, knowing that a CBC is an essential test in the ER, ordered when infection or bleeding is a concern. On another day when we had a sufficient supplies, the lab machines shut down for several hours mid-day due to overheating. And on a daily basis I had to chase down my patient’s nurse who was carrying the paper chart so that I could hand write my orders.

Being a resident at MUSC, a Level 1 trauma center, has allowed me to develop an understanding of the higher level of specialist and sub-specialist care that exists for patients. When working in St. Croix, I often felt distressed knowing that this “higher level of care” existed but realizing that many patients would not have access to it. For instance, for those diagnosed with cancer on the island, there was no surgical oncologist and chemotherapy was very limited. Their best chance at survival was often to seek care in the U.S. However, lack of social support in the U.S. and costs associated with the back-and-forth travel and treatment itself were often prohibitive. When it came to more emergent conditions, being a non-U.S. citizen certainly limited access to care. For instance, a patient who was a Honduran migrant worker with an open globe injury, which is a vision-threatening injury, was denied transfer to Miami for definitive surgical repair because he was not a U.S. citizen.

While “boarding” is a national crisis in the U.S., it took on a whole new meaning in St. Croix. Due to insufficient inpatient beds or a delay in transferring a patient to an outside hospital, patients would remain in the ER for longs periods of time. This would often be 24 hours or more. And as a result, I found myself more often being the one, rather than the inpatient team as is common practice, to initiate goals of care discussions. This allowed me to understand what patients would or would not want done if their condition were to worsen, including being placed on a ventilator or receiving CPR. Another direct consequence of boarding was the long waiting room times to a degree that most of us have never encountered. I recall one day the wait being on the order of 19 to 21 hours. And then I found out that patients called the ambulance to take them back home because they simply could not wait any longer and had other responsibilities.

During my time in St. Croix, I certainly sensed some degree of distrust of western medicine by the local population. As a consequence, I noticed that patients would often delay seeking care and presented at more advanced stages of their condition. Another consequence was the relatively low childhood vaccination rate, meaning as the physician I had to consider conditions that we rarely see in the States anymore. And to compound this distrust, the hospital largely relied on locums (visiting) physicians. There were few physicians who primarily resided on island and even fewer who were native to St. Croix. I could certainly see how patients would be more likely to trust physicians who looked and sounded like them. And I also think patients responded well to physicians who made St. Croix their home and who were involved in the community outside of the hospital.

Ultimately, I am so grateful for having had the experience of completing a clinical rotation in St. Croix and to have had the opportunity to take care of such a deserving patient population. It has certainly made me a better emergency medicine physician to have had to adapt my practice patterns to a very different clinical setting. I look forward to the opportunity to return to JFL and St. Croix sometime in the future. But in the meantime, I look forward to taking this experience with me as I graduate residency this summer and begin the next phase of my career as an attending in a new hospital system.