Bloody lovely.

There were some interesting responses to my last post about the treatment of a minor collision victim by firefighters. The general thought was that they immobilised the patient to prevent being sued by overzealous lawyers. In addition I was told that only doctors were able to remove the immobilisation collars, that the ambulance staff wouldn't touch the collars.

This makes me incredibly angry.

At what point did we stop performing good medical treatment and instead treat everyone as if they are angling to make money off of us.

The placing of a C-Spine collar is something that should only be done where there is a clinical need for it. We are trained to decide if there is a risk of a C-spine injury. We shouldn't be putting collars on just because we might get sued. Once we start doing that there is an argument that we should just follow written protocols. If we are doing that then we are be going to lose our skills and this will impact the care of our patients.

If I place a C-spine collar on someone it is because I have a reasonable suspicion that they have a neck injury - if I have this suspicion then the patient will be cut out of their car and placed on a hard backboard.

If I have someone cut out of their car and put onto a hard backboard (which can cause injuries itself) for no good reason then there could be the case for me to be sued for unnecessary treatment. And for ordering the destruction of the patient's car.

One more case of damned if you do and damned if you don't.

But unlike some of the dilemmas we have in this job (and there are plenty of them) we have the training to rule out serious neck injury. We shouldn't be doing this treatment unless it is needed.

Whenever I treat, or don't treat a patient I am thinking constantly of what benefit this has for the patient. I am always able to justify my treatment of a patient, whether to the patient, to the hospital staff or to a judge, magistrate or coroner. This isn't 'defensive medicine' this is 'good medicine'.

I try to keep up to date on the current research, and for those of us who don't, we also have medical bulletins from our management explaining the correct way to do things.

This isn't even counting the research that is initiated by the LAS.

We aren't stupid and we shouldn't be doing treatments 'just because', we should be confident in our use of evidence based medicine. We should also be confident enough to correctly document our treatment so that we can justify our decisions to anyone.

To do anything else turns us into taxi drivers.

In San Francisco for a 'free day' where we are allowed to do whatever we want. There are only two of these on this holiday (until I get to Hawaii) and this lack of freedom annoys me somewhat.

Speaking of Hawaii, Mother Earth was a bit previous in throwing a hurricane at it as I'm not there for a few days, so that'll count as a miss then.

In SF we seem to be staying in a fair rough part of town, there are a lot more homeless than I see in London - five or six on each street corner here. I'm guessing that this is the 'American Dream' that we hear so much about.

I also saw the the instance of emergency aid here. It started off with a huge fire truck racing through the streets - I then turned the corner and saw them treating someone at the site of a car crash. Well, I say 'car crash', but it wasn't even a fender-bender. There was a tiny mark on one of the bumpers of the cars, no damage to either vehicle.

But for some reason they had 'collared' the patient and was holding her head as if she had been in a 40 mph head-on collision. I didn't hang around to see if they were going to cut the top of the undamaged car off - I also thought that they wouldn't appreciate my advice, so I kept walking. It all seemed a bit of an over-kill although I don't know how the services work out here.

My guess would be that a 'proper' ambulance would turn up and take the collar off and walk the patient into the back of the ambulance, it's most likely what I'd do.

American TV news is also insane - the anchor's teeth eerily follow you around the room, and one of the main stories yesterday was about a dog with air conditioning in it's kennel. Thankfully I've been able to get onto the BBC news site. Sad news about the two year old stabbed to death on my patch. I am also hearing rumours about a local ambulance crew who saved a woman and child from a burning building - well done gentlemen, you deserve a commendation.

Alcatraz later today, which should be fun.

As I type this I'm sitting in the bar of Mammoth Mountain hotel surrounded by posh people wearing black ties and dinner dresses, while I'm sporting black jeans and a Lemon Jelly T-shirt. A nice bright red.

Bryce canyon was beautiful, one of the highlights of the trip so far. The natural beauty of the late afternoon light through the rocks was breathtaking and if you ever get the chance to go snap it up. The Grand canyon was big, but in this case big does not mean beautiful - perhaps I would have a different opinion if I had been able to visit the floor of the Grand canyon, but as it is Bryce canyon wins hands down.

If you don't believe me, go and do a Flickr search for Bryce canyon.

Las Vegas was neither as exciting, nor as seedy as I expected it to be. It reminded me more of a sunny and dry Blackpool rather than the 'Sin City' it promises to be.

In my wallet I have the proof of the only money I've ever won gambling - 25 cents on a $1 stake. I've decided not to cash it in, but to frame it and count myself ahead of the game for the rest of my life.

What was astounding was the Cirque du Soleil show 'Ká'; I was bowled over from the moment that I walked into the theatre fascinated by the steampunk style gangways all the way to the explosive finalé. If you ever have a chance to see this show it is well worth spending money on the best seats in the house.

And now I find myself relaxing after a 12 hour drive on the coach listening to the tour guide wax lyrical on the strata of the rocks in the areas we were driving through (although it would be truer to say that I was avoiding listening to him by the blessed release of my iPod).

Tomorrow - Pismo beach. And yet another chance to get out of bed at six am...

The good news is that the high temperature that I had lasted less than 12 hours, which meant that I pretty much slept it off. I suppose that I could blame some of the half cooked meat that I've been eating, but considering I'm used to the takeaway places of East London I would imagine that I'm used to it.

The Grand Canyon is indeed rather spectacular and once I get a convergence of free time and internet access I'll be uploading them. There has also been a small geek-out as we have driven past Black Mesa - one for all the 'Half-life' fans out there.

I also think that I'm getting more into the swing of things, although it does rankle that we are given only a few minutes to stop and explore at various places. We were allowed out at Monument Valley for long enough for me to get a slightly over suntanned arm.

Now I'm at a hotel at a place called Page just by Lake Powell, which I'm lead to believe is 'quite big'. Hiking tomorrow, which should be fun - or painful...

Even after looking at all these rocks that are billions of years old I'm still looking forward to the utter unreality of Vegas.

I don't think that I'm the sort of person who 'does' tours. Being ferried from place to place (including having to get out of bed at 6am, which is as bad as work).

I'm also a person who desires some degree of 'aloneness', which is the main reason why I don't keep any of my girlfriends. The only time I'm alone is when I'm in the toilet.

It seems that we are missing the really good stuff in order to go and stare at some rocks. Again, this lack of freedom rankles.

It would seem that the English really do pack our weather with us - there have been torrential floods in the desert state of Arizona. Which made our escape past the fire service rescuing people while wearing lifejackets rather interesting.

The tour guide is a pillock - just thought I'd get that in there.

And now there is a life-threatening heatwave heading our way (or rather, we are heading toward it.)

The really excellent bit is that I seem to have picked up an infection and am sitting here typing this (on the first internet capable place I've come across so far) shivering and shaking like one of my patients. While it may make a little vomit appear in your mouth I'm typing this topless with a wet flannel across my neck.

So... you know... Not a huge amount of 'joy' yet, but I think it's going to get better with LAs Vegas and San Francisco.

But I mustn't moan - really I mustn't, I'm lucky to be here watching awful American TV adverts (including my favourite of blokes singing about Viagra to the tune of 'Viva Las Vegas'.

I'm sitting round my mum's place waiting to catch the tube at 5:30 towards Heathrow. Once more my stomach is in knots because (a) I'm leaving my 'comfort zone' and (b) because I have the unreasonable fear that flight UA935 will plummet into the sea.

As long as I don't die in a flaming ball of twisted metal I should be touching down in Los Angeles at 13:51 where we spend the night.

Then I spend the next fortnight sitting in a coach being driven around the South West of America.

On Friday I spend the night in San Diego.

Saturday and Sunday I spend the time in Tucson.

On Monday, the Grand Canyon, Tuesday Lake Powell and Wednesday Bryce Canyon.

Thursday and Friday are spent in Las Vegas (which is the bit I'm second most looking forward to.

Saturday we go to Mommoth Lakes, Sunday is Yosemite.

Monday and Tuesday we stay in San Francisco, then a night in Pismo beach before finishing the mainland bit with a night in Los Angeles.

Then on Friday the bit I'm most looking forward to, five nights in Honolulu, Hawaii.

Finally on Wednesday it's flight UA934 all the way back to Heathrow and normality landing 12:15 on Thursday.

This is of course in the hopes that everything goes to plan...

If you are wondering how I have so much annual leave and the money for this holiday. It coincides with a lot of rostered days off from work and it's costing me about a third of the money I got from sales of my book. So if you bought a copy, thanks very much, because of you folks I get a holiday this year.

There may be blogging, there may not. It depends how tired I get from sitting in a coach doing nothing all day and on the availability of internet services. And the weather. And my laptop not crapping out. And my motivation.