The holidays are coming!...

I'm sure back at home all the Christmas lights are up already, and the supermarkets are packed full of mince pies, puddings, Christmas chocolates, Christmas trees, decorations, etc. Here though Christmas still seems a long way off, because the focus is on Thanksgiving which is on Thursday.

We're all really excited about it here. An extra cause for celebration and we get 4 days off (well - I'm working the Wednesday night - but it's not bad really), and we get to try American thanksgiving dinner! Traditional thanksgiving dinner is Roast Turkey and trimmings, which are apparently more like a mashed vegetable pie, rather than our parsnips and sprouts affair. Dessert is pumpkin pie or something similar. The following day is traditionally the opening of the Christmas shopping season, and a lot of stores open up at 5am for special holiday season sales. It is called Black Friday - presumably so named by someone with a phobia of shopping like me.

As well as eating, drinking and shopping, it's all about visiting family, so a lot of people travel. No-one seems to know what they are actually giving thanks for. I've asked quite a few people about the history of it and no-one seems to have ever even thought about it. I always thought it was something to do with the early colonists giving thanks to the Indian tribes for giving them food but apparently this is not true. Even wikipaedia my trusty source doesn't seem too sure, but for those who are interested in the various theories follow this link...

http://en.wikipedia.org/wiki/Thanksgiving_(United_States)

Anyway - its a holiday, and we shall eat, drink and be merry... and very thankful.

The football season is coming to an end. Just as I am writing this Michigan have just lost their last home game to Wisconsin. I went to one game two weeks ago. The department chair has some amazing season tickets at the 120,000 seater "Big House" stadium, and was unable to go himself, so kindly donated his tickets to the rotators. They were probably the best seats in the house.

The game was Michigan vs Illinois. We took our seats half an hour before kick off, all wrapped up in about 6 layers (it was chilly) though I actually ended up quite hot. We were so close to the visiting players bench - and they had gas powered hot air blowers to keep them warm. There's not much emphasis on eco-friendly - even in lefty liberal Ann Arbor. The marching band kept us entertained before kick off, and then all the way through the 4 hour plus game the band play and cheerleaders entertain. The game itself stops every 10 seconds or so, as anyone familiar with American football knows. It really is a weird sport. For a start they have a completely different team for offense and defense, they play for 10 seconds then stop for a minute or so before restarting. A game of four 15 minute quarters can last for 4 hours or more.

The game I went to went into overtime as well. Final score was 67-65 to Michigan. It was very exciting though, and there's a great atmosphere in the stadium. The band play every time there's a pause in the game just in case the football doesn't keep you entertained. It's quite a spectacle. Not as good as rugby in my humble opinion, but it's a huge deal here. The city is taken over on match day - even the skies above it are filled with planes towing banners.

Where we live close to the stadium - we can even hear the cheers when they score. This season though the cheers have not been that frequent... I think I may have jinxed them.

All the rotators have Christmas off. There is a tradition that the Brits work most of the American holidays here, but we usually get Christmas off. We've decided to stay here in Ann Arbor. Some of us with young kids are planning to get together on Christmas day and have a big feast. Hopefully we'll have lots of snow, log fires, snowmen, an obscenely large Turkey, chestnuts roasting on an open fire.... We've had to get Christmas pudding from home of course.

The elections are coming!... (in 2 years)

The news here seems to be full of predictions of Obama's downfall. The midterm elections were a bit of a disaster for him and the Democrat party. They now have a completely ineffective government for the next 2 years at least, as the 2 houses - the house of representatives and the house of senate battle it out, with neither likely to be able to get a bill through. Obama's health care bill is likely to be toned down if not scrapped. All of which makes very depressing reading for an Obama fan like me.

I really don't get it. If you asked what defines America, most would say freedom and democracy. Obama was democratically elected to be president by the will of the people. They voted him in on a manifesto of Change and in particular health care reform. God knows they need it. You ask anyone here whether they think the current system should stay as it is and most would say no. They spend far more per head on health care than any other country in the world, and yet nearly 1/3 of the population have no insurance and no access to it. The money is all being spent on a very small proportion of the population. Many despise the notion of universal health care because they link it to socialism and because they feel it's too expensive, but they don't realise that they are already paying for it in other ways.

Those on medicare and medicaid are getting hugely expensive health care paid for by taxes. If someone has no insurance and does not qualify for medicare or medicaid they are not just left to die on the streets, they still get treatment - at hospitals like the U of M, and that has to be paid for still somehow - either by taxes or by hyperinflated insurance premiums for everyone else.

Health care here is the most common cause of bankruptcy. It is sending the country into huge debt, but it also make a lot of money for those companies involved in delivering it, and they appear to be more effective at campaigning than Obama at present. Many who support health care reform have turned against Obama because of the way in which the bill was passed. They have a point that there were so many concessions made in order to pass the bill that the final product was going to be an expensive unworkable disaster. Yet the reason for most of the concessions was to get support from enough senators and representatives to pass the bill.

Obama should argue that the current health care system is unaffordable, and the only way to reduce costs is via reform - however he can't do anything now, because everything he will try to do to reform health care will be blocked by the republicans in the Senate. I suspect that nothing much will happen for the next 2 years, Obama probably will lose the next election and health care will not change. Hopefully Sarah Palin will not become the next president of the USA. The end of the world - you heard it here first.

The British are coming!... (in April)

I have also been in contact with the next batch of rotators who are due to come here in April. Currently they are all going through the fun phase of filling hundreds of forms, writing letters, sending off some $$, having photos taken in US passport size, fingerprints taken, (DNA samples are not currently a requirement but they are working on it) - happy memories! Of course the real fun will start next month when they begin the visa application process... Last year seems like a really long time ago. A year ago it didn't really seem real that we were going to America for a year. It was very exciting and at the same time quite scary.

I can say very confidently to the new rotators who will be starting in April that they will have a great year. They will not regret their choice to come here. At times it will be very challenging, sometimes scary, and they will be out of the comfort zone a bit, but I have learnt so much from being here, and am still learning. I've learnt different ways of giving an anaesthetic (even different ways to spell it) - some of them I will use, and some I may just file under experience, but it definitely opens your mind up to different options. I've also learnt that you can anaesthetise most people just fine with a decent iv cannula and an endotracheal tube. It doesn't always pay to do anything too fancy.

It is also funny how we worry about different things on either side of the pond. A few examples: Etomidate, Suxamethonium, Nitrous Oxide and Isoflurane are not evil and dangerous, but target controlled infusions and suggamadex are so dangerous they are not approved by the FDA. Apparently it is OK to wear theatre scrubs in the supermarket or diner, but patients hair must be covered by a paper hat, and all personnel must wear surgical masks in the theatre at all times to prevent infections. It is also not necessary to scrub or wear a gown when placing a spinal or epidural - just sterile gloves over your watch will suffice, but an arterial line requires full aseptic precautions. Protecting the eyes with tape takes priority over checking you have an airway and patients will get definite corneal abrasions if they raise their hand above their belly button. Those who know what I am talking about will recognise my tongue in cheek tone and no offence or criticism is intended - It's just funny how our neuroses have a different emphasis.

I've met some really intelligent and interesting people and I've made great friends, who I'm sure I'll keep in touch with for the rest of my career. In short, coming here was a great decision!

So on Thursday I will have a lot to give thanks for, and top of the list will be thanks for this great opportunity, and for my new friends, and of course my wonderful family.

Happy Thanksgiving to all,

Drake.

Trick... or treat...???

Belated Happy Halloween everyone!



Halloween is a strange thing. It's not as most people see it now an American thing. It's celebrated in different shapes and sizes by many different cultures, and has been for centuries. The Scots called it All Hallows Eve, the Irish called it Samhain, the Welsh had Nos Calan Gaeaf, the Romans had Palantalia, the Spanish had the Day of the Dead. The underlying theme is very similar in all of them. It's basically a pagan celebration of the autumnal equinox - the passing of the light half of the world to the dark. It is the opposite of Easter - which of course is the festival of the Spring Equinox, a festival of the new light, and of new birth and fertility. The Celts thought of it as a time when the living and the dead came closer together and they would get a chance to see dead ancestors. The wearing masks and costumes was to scare off any bad spirits that may come with them. It was also a celebration of the end of the harvest and bonfires would be lit to burn off the carcasses and inedible waste after storing food for the winter.

The church of course tried to rebrand the festival like they did with Christmas and Easter, to All Saints Day - which is also a celebration of the dead.


Back at home I always felt it was more of an irritation. A night when extortion and minor vandalism was encouraged and of course for supermarkets to cash in on sweets, costumes, party gear, etc. I have to say I've never really thought much about it's Celtic roots and meanings before.

In America though it is huge. They really go mad for it here. It's a bigger thing than Christmas to some people. People decorate their whole house and garden - starting from the end of September, with ghosts and ghouls, skeletons, cemeteries in the garden, lights, spiders webs, fog machines and strobe lights. Speakers playing haunted music when you walk up their drive. Pumpkins and scarecrows are everywhere. It's also a big party time. There are lots of fancy dress parties for both children and adults, and the University students (in particular the girls) use it as an excuse to dress up and go out in Ann Summers gear.

We really got into the spirit this year on Halloween - (When in Rome...) - we had Pumpkins and scarecrows and decorations, and costumes, and we went Trick or treating with the kids, and spent a small fortune on Candy for the trick or treaters.

We had a great evening, but we were totally unprepared - despite being pre-warned by some of the previous rotators and our neighbours. The really nice thing was that it was a big family orientated community celebration. Our street was closed off, all the houses participated in some form. Some of the neighbours had parties. People gave out free hot apple cider. Some of the neighbours hosted a "haunted house" to explore. All the kids got dressed up and went round collecting candy in little orange pumpkin faced buckets. We met lots of neighbours we had never spoken to before and it was all very nice. Well - at the start of the evening at least. There were no "Tricks" at all. No egging of windows, or flour on cars, or general misdemeanours. It was just about giving out candy to the kids.

Now it just so happens that where we are living is a popular place for trick or treating amongst the local kids. So popular in fact that children from poor areas of Detroit get coached in by charities to our street for the evening to take part in trick or treating. This of course is very admirable but resulted in us being somewhat swamped and overwhelmed. So it wasn't a case of how many times did the doorbell go off.... We took it in turns sitting on our front porch while kids queued up to 30 deep by our door to get sweets and then move on to the next house!! Our neighbours counted 700 children had been through their front door in the space of a couple of hours. Our street was flooded with little ghosts, witches, superheroes and buzz lightyears. There was a papier mache procession at some point, but we didn't really get to see it because unfortunately we had bought not nearly enough sweets, so when the inevitable awkward moment came when we ran out and I had 30 kids at the door looking suddenly slightly more menacing, we bailed, turned out the lights and pretended to be out.

To anyone who has never experienced Halloween here - it really is strange. I definitely liked the street party atmosphere and the decorations, the family orientated activities, and the fact that the whole community participates - but I couldn't get my head round the candy-grabbing fest. The vast majority of kids were very polite and controlled and had a small bucket of sweets, but there were some who had bin liners that they were stuffing with as many sweets they could get their hands on and would grab from our supply without uttering a single word. It was an experience that I was very glad we took part in, and am very glad we won't be next year...

Oddly enough the passing of our world from the light to the dark and the beginning of winter occurred simultaneously with it getting pretty cold here. It is now minus 2 centigrade in the morning when I cycle to work, and the first snowfall is forecast for Friday. I am planning to cycle to work throughout the winter and have just invested in some good thermals. I think it is something that only the Brits do - sort of a badge of honour, but as we only have the one car I don't have much choice. I'm actually looking forward to it in a funny way.

Work goes on and I actually feel like a proper attending now. It's still hard work at times, but it comes more naturally, and my confidence has grown a lot after managing so many challenging cases. I look forward to difficult airways, and big liver resections, to super morbidly obese patients (as long as they are not too often). I lectured on an Airway course last week, and I've helped out with some human factors training in the Simulation Centre. The Sim centre here is incredible, and I can't believe I have only just found it. It is very well equipped, and has amazing resources. The only problem is a very familiar one - no-one is given time off clinical duties to go there and learn, so I think it is relatively underused for it's potential, but that is something they are trying to change. Simulation training is going to have a big place in the future of medical training and assessment, and at present I actually think that things are a little behind here than in the UK. The equipment and resources here are very impressive - but it is not being used. One of the problems of having a much shorter residency programme is that there are fewer residents around to do the clinical work, and less time available therefore for non-clinical activities. There are people who are very enthusiastic about it and are trying to change this however.

Till next time - Happy Divali - the light after the dark?

Drake.

The road less travelled.

We are now past half way through our year here. Fall is here, and Ann Arbor, famous for having lots of trees, has had a beautiful explosion of Fall colours. Our street has turned bright red, orange and yellow. The Halloween decorations are coming out too. Some of our neighbours are going for the whole haunted house, complete with animatronics, strobe lights, fog machines, fake graveyards and skeletons in the garden. The shops are full of Halloween decorations and costumes, pumpkins, pumpkin pie. The pubs have Halloween pumpkin beer, Starbucks has Pumpkin spiced latte...
Football season started last month, and despite all the warnings I was still amazed by how big it is. The Big House is the University of Michigan football stadium, about 5 blocks from where we live. It holds 110, 000 spectators, and it sells out for every single game. On match day the whole of Ann Arbor is taken over by football mania. Everything is blue and yellow, and emblazoned with the Michigan "M". Even the sky gets decorated with a huge M. People from all over Michigan, and meet up with mates to have trailer parties - they fill their trunks with cool boxes of food, beer, barbeques, and make a whole day of it.



The weather has cooled, it's not humid, but we've had some beautiful hot sunny days. I think it's been my favourite time of year so far.

We have been exploring quite a bit too. One of the best things about taking a year to work abroad is the opportunity to travel and really get to see a country, go to places that you wouldn't normally visit, get out to the roads less travelled. America is the perfect place to do that. It is a huge country, it has every kind of landscape, climate, activity that you could ever want on a holiday - whether you are in to city breaks, or getting away from it all, beach holidays, mountains, skiing, ranch. It is also incredibly easy to get around, and from Ann Arbor we are lucky enough to be only 30minutes drive from a major airport (Detroit), and on 2 major interstates, 1 going North-South, and one going East-West. We are an hour drive from Canada, within 5 hours drive is Niagara, Toronto, Chicago, Cincinnati, Northern Michigan, Pittsburgh. Within 1 hours flight is Washington DC, New York, Boston. We have tried to make the most of our free time.

Last month we had a lovely city break in Washington DC. An amazing city to visit, with so many interesting museums, buildings and great restaurants. The Smithsonian museums are definitely not to be missed.

Last week we came back from a mammoth 2 week long road trip, taking in 7 states. We visited the beautiful beaches of the Outer Banks, North Carolina, and the awesome Great Smoky Mountains national Park of Tennessee - just 10 hours drive from Ann Arbor. The USA is built for driving. It's so easy just to get in a car, and drive somewhere with no plan except to explore. Motels are commonplace and reasonably priced, and there is no shortage of places to eat. Petrol is pretty cheap too, thankfully, as I'm driving a big gas guzzling tank. I think there's something ingrained in the American spirit about the freedom of the open road and exploring the road less travelled. Now with Sat Nav and an iPad, it is also much easier to find!


Separated by a common language...

I still find myself having to repeat things over and over at work, in restaurants, or especially on the phone. I don't think I've picked up an American twang, although sometimes at work I hear myself saying things in a very American way. Reassuringly there are some Brits who have been here for 20 odd years who sound very English still. Not that there is anything wrong with talking with an American accent of course! (Unless you're travelling anywhere else in the world).

I have been known though to say some American phrases - especially at work. You have to really, to fit in and be understood. To Quote George Bernard Shaw... Two countries separated by a common language...

Some examples that are useful phrases to know for anyone planning to come and work here:

Labs = Bloods
Vitals = Obs
EKG = ECG
Flashlight = torch (if you say torch they think of a flame - I spent ages once trying to ask for a pen torch with the poor nurse thinking I was mental)

H&P (History & Physical) = Clerking (History & examination)

OR (Operating room) = Theatre (I keep saying theatre by accident though which results in either strange looks or smirks)

PACU = Recovery

MAPS (Monitored Anesthesiology Provided Sedation) = Sedation (conscious or unconscious - something more like a General anaesthetic without an airway...)

MAC (Monitored Anesthetic Care) = A case under local with or without sedation with an anesthesia provider present.

QA event = Critical incident

Scooch your heini... = Shuffle over

Stretcher / Gurney = Trolley

You all set ?.... = Are you ready?

You're all set. = Yes you are ready

It's all gooood. = It's fine / No problem / No big deal

It's Dandy. = It's nice.

Good job! = Well done!

One of my biggest bugbears here though is the use of trade names for drugs instead of generic names. It's really confusing and embarrassing when I have to keep looking up drugs or asking what they are.

What surprises me still though is how much is the same. It's reassuring that we get taught the same stuff on both sides of the Atlantic. Physiology, pharmacology and physics do not magically change when you cross the pond (although the SI units didn't quite make it over), and the anatomy is the same (but sometimes just expanded!!).


Work has had its crazy moments. One day last month I was looking after a case in one room who was having jet ventilation for a subglottic stenosis with a CRNA who had never done it before, and next door looking after a novice resident doing his first craniotomy. It's all good.....


Till next time,

Drake

I have a dream...

Apologies for such a long wait for this blog entry. I've had a few complaints from people. To be honest nothing much has happened. Work is still the same. A few new rotators have appeared. They started August 1st which is not ideal for them for several reasons:

1. The will have to declare their income here to the inland revenue and get a big tax bill on their return to the UK - hence why most rotators come here from April to April so that they are out of the UK for a whole tax year.

2. It's stinking hot and humid in August.

3. The rest of us (8) all started together and have formed quite a close bond. There are only 8 desks in our office, so the new guys have had to find their own office. Of course they come and socialise in ours, and they're very welcome any time, but it's not the same having a desk somewhere else. It's really nice sharing an office with the other rotators so that we can ask each other questions, get advice, and sometimes have a communal whinge...

4. They are thrown right in to the deep end and are looking after much more junior resident, some of which have only done one month. When we started the most junior resident had done at least 9 months training.

Of course we have all done our best to help them settle in, and are very happy to have some more fellow Brits here. The more the merrier. There are some days when nearly every theatre in the Main theatre complex has a Brit rotator as the anesthesiology faculty.

My general advice to them when they started was - "keep things simple, if in doubt just go for a general anaesthetic, intubate them and have a big iv drip." You have to go for an anaesthetic technique that the resident or CRNA will be happy to do - which means very often when we would do a case with a LMA or regional technique at home, we default to a GA and a tube here because that's what the resident or CRNA is most comfortable with.

Work has been very much the same... I've had some "interesting" conversations with a couple of surgeons here. On the whole, most of the surgeons I've worked with here have been OK. Some are very nice and pleasant to work with, most are neither particularly nice or nasty. They don't talk to us as much as the surgeons at home. They often don't even acknowledge us unless I make a point of going to introduce myself. There are one or two though that lack even the most basic social skills and are so rude as to be actually quite comical. I shouldn't describe any specifics, but once I had to run down the corridor after a surgeon who refused to speak to me because I had the audacity to insist that the consent was signed before we take a patient to the operating room. Not only that but he hurt the patient and made them cry in the process of marking which side to operate on. I have seen some surprising behaviour that would less likely be tolerated at home, although I know a few oddballs at home too.

I've started doing some work on my research project. I don't want to say much about it but I'm hoping to get some interesting results at the end of it.

Life in general is good. We went to lake Michigan for a weekend which was lovely. We stayed in South Haven - a very pretty town and marina, with a lovely beach. Accommodation was expensive - $300 per night for a B&B, but we were very close to the beach. Besides, everything else was booked up because of a blueberry festival. I suspect if we went back there's be a cherry festival, or something.

I've got two weeks holiday at the end of September. We're currently debating whether to drive to the East coast and visit New York & Washington or fly West and go to Yellowstone and the Rockies. East or West. It may come down to the flip of a coin.

We've just said goodbye to a friend who came to visit for 2 weeks, and we're waiting for the in-laws arrival next week so our own B&B is doing great business.


This week has been a week of some interesting anniversaries. Five years ago today Hurricane Katrina hit New Orleans, the woefully inadequate levy's broke, and the city was in the sea for a good few weeks. The weeks that followed were not proud weeks in American history. If the failure of the levys was bad, the failure in the government planning for emergency aid and relief was disastrous. The city has still not recovered. The levy's are still being rebuilt, hundreds of thousands of people who fled have still not returned, and huge parts of the city are still in ruins and boarded up.



Forty-seven years ago yesterday, Martin Luther King made his famous "I have a dream" speech in the Mall, Washington DC, being watched by a giant statue of Abraham Lincoln, and a crowd of about a million people. This has to rank as one of the greatest speeches in American history. The turning point in the civil rights movement. The end of terrible injustices and unfair treatment of the black American population, and overdue delivery of the rights that were promised them by the founding fathers. The time when when America would finally honour it's words in their declaration of independence:

"that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness."

.....

Forty seven years later there is another March on Washington. Another speech in the Mall in front of Abraham Lincoln. This time the make up of the crowd is noticeably whiter, more middle class perhaps. The movement this time is "Restoring Honor" (sic). It's more difficult to work out what this movement is about. Their website quote "a tribute to America’s service personnel and other upstanding citizens who embody our nation’s founding principles of integrity, truth and honor." They don't really say which upstanding citizens exactly they are talking about, but the general gist is anyone who opposes Obama.

The clue is only in the list of those who are invited to speak. Glenn Beck is a right wing TV talk show presenter on Fox news who is quite vocal about how Obama is a socialist who is hell bent on destroying the USA and other things along the same line. Sarah Palin is also there of course - the hero of the TEA party, and possible 2012 presidential candidate for the republican party. Interesting fact - Fox news apparently employ Sarah Palin as a political commentator with a 7 figure salary. (So much for impartial media).

The mission statement is to return America to the principles set up by the founding fathers. (Actually - much like the Civil rights movement when you think about it)

The TEA party is an amalgamation of several protest groups who all have issues with the current president, ranging from normal conservative concerns about government spending and over taxation, to the down right ridiculous (claiming that he is not an American citizen, that he is a communist, that he is an anti-white, anti-christian racist). Anyone who think that these are just right wing nuts - think again. The Tea party are aiming to get into the Senate with the promise to cut taxes, scrap health care reform, reduce government spending - which may appeal to many, but more worryingly some have agendas such as banning abortion even for rape victims. One of their followers is Pastor Terry Jones who is planning to build a bonfire out of Korans on September 11th outside his church in Florida, to "send a clear, radical message to Muslims, to sharia law, that it is not welcome in America". Was religious freedom not one of the founding principles on which the USA was born?

There has been a lot of arguing and debating over the last month about plans to build a mosque or actually an Islamic centre in Manhattan, 2 blocks away from the site where the World Trade Centre once stood. Those against it claim that it is disrespectful to the victims of 9/11. There are those though who accept the difference between Islam and a terrible act of terrorism, and the best way to stand up to terrorism is to show what America is really about - freedom and tolerance. The next couple of years will be an interesting couple of years for the USA. We will soon see what America is really about. Has Martin Luther Kings Dream really been fulfilled?




Excerpts from Martin Luther King Jr's Speech:

* "In a sense we've come to our nation's capital to cash a check. When the architects of our republic wrote the magnificent words of the Constitution and the Declaration of Independence, they were signing a promissory note to which every American was to fall heir. This note was a promise that all men - yes, black men as well as white men - would be guaranteed the unalienable rights of life, liberty and the pursuit of happiness. It is obvious today that America has defaulted on this promissory note, insofar as her citizens of color are concerned. Instead of honoring this sacred obligation, America has given the Negro people a bad check, a check which has come back marked 'insufficient funds.'"
* "It would be fatal for the nation to overlook the urgency of the moment. This sweltering summer of the Negro's legitimate discontent will not pass until there is an invigorating autumn of freedom and equality. Nineteen sixty-three is not an end, but a beginning. Those who hope that the Negro needed to blow off steam and will now be content will have a rude awakening if the nation returns to business as usual."
* "The marvelous new militancy which has engulfed the Negro community must not lead us to a distrust of all white people. For many of our white brothers as evidenced by their presence here today have come to realize that their destiny is tied up with our destiny and they have come to realize that their freedom is inextricably bound to our freedom. We cannot walk alone."
* "I have a dream that one day this nation will rise up and live out the true meaning of its creed: 'We hold these truths to be self-evident, that all men are created equal.'"
* "I have a dream that my four little children will one day live in a nation where they will not be judged by the color of their skin, but by the content of their character."
* "I have a dream that one day on the red hills of Georgia the sons of former slaves and the sons of former slave owners will be able to sit down together at a table of brotherhood."
* "This is our hope. This is the faith that I go back to the South with. With this faith we will be able to hew out of the mountain of despair a stone of hope. With this faith we will be able to transform the jangling discords of our nation into a beautiful symphony of brotherhood. With this faith we will be able to work together, to pray together, to struggle together, to go to jail together, to stand up for freedom together, knowing that we will be free one day."
* "Now is the time to lift our nation from the quicksand of racial injustice to the solid rock of brotherhood. Now is the time to make justice a reality for all of God's children."
* "Let freedom ring. And when this happens, and when we allow freedom ring—when we let it ring from every village and every hamlet, from every state and every city, we will be able to speed up that day when all of God's children—black men and white men, Jews and Gentiles, Protestants and Catholics—will be able to join hands and sing in the words of the old Negro spiritual: "Free at last! Free at last! Thank God Almighty, we are free at last!"

Another status update from over yonder...

It's August. It's still hot and humid. The Ramoray family have all packed up and gone. No Tornado warnings for a week now, but still occasional thunderstorms.

We've managed 4 months now - a third of our year, so I thought it would be a good time to reflect on what I've learnt so far.

My objectives when I came here were:

To experience working in a totally different health care system

To have more experience of supervising junior colleagues

To develop my teaching skills further

To do more challenging cases (eg transplants, bariatric surgery, challenging airways) (I was actually hoping to do some liver transplants, but that hasn't worked out)

To see a different way of organising the whole process of surgery, and see if they were more efficient than how we do things in the NHS.

To see different methods of anaesthesia.

To see a bit of America, and live a bit of American culture.

To enjoy it!

So far I think I can safely say that I've ticked all the boxes (especially the last two), but there's still loads more to see, do and learn about the way of life and the way things are done here.

My log book is filling up - when I remember to keep it up to date...

For anyone who is interested in what kind of experience we get here:- So far in my 4 months I've logged 350 cases - but I know I've not logged a lot of my on-call cases. The break down according to specialty so far has been:

ENT 56
General 88
Gynae 45
Max fax 11
Neuro 14
Orthopaedics 28
Plastics 29
Trauma 18
Urology 47
Vascular 2
plus a few miscellaneous

173 have been ASA 3 or 4.
78 have been with CRNAs
The others with residents.

Only 41 have had an LMA, 264 have been intubated. 28 have had "sedation" (which can roughly translate to a general anaesthetic without an airway... but that's another story), 11 have had a spinal. 11 have had an epidural. Only 16 have had TIVA.

I've done 8 awake fibreoptic intubations and 3 cases using the jet ventilator. 38 patients have had arterial lines, but only 3 have had CVP lines.

I've run some teaching sessions with the residents, a couple of tutorials with medical students (on cardiovascular physiology), I have run a journal club, and when I'm working with a resident I try to cover one topic each day with them (although it's often hard to fit it in if you have 2 busy lists). I'm also working on a project that will hopefully result in a publication at the end.

It's been.... intense - and it still is. It's easier after the first month, cos you adapt to the system here, but then you start getting harder cases, and then the residents change and you are supervising novices - so there's always new challenges around the corner.

In terms of learning about another health care system... I still don't really understand the health system here. It may sound odd, but it isn't really relevant to my job. I just make sure that I electronically sign the right documents so that the hospital can bill for my services, but I have no idea what happens about funding. I know some patients are insured, and some are insured via medicare or medicaid (Medicaid is government funded health care for those who are poor enough to qualify - as long as you fall into one of the eligibility categories. It is means tested. I don't really understand what it will and won't cover. Medicare is government funded health care for those over 65 - and is not necessarily free and has a very complicated set of rules about what is and is not included.) There is also a significant size of the population that fall into "none of the above" - ie they don't get insurance from their employers, and they can't afford their own, but they are not poor or old enough for government funded health care, yet ironically their tax is funding it. I don't really know which patients who I see are insured, and who are on medicaid - although it is in the documentation if you look for it. You can often guess, but everyone gets treated the same - you do your best for everyone - just like at home. It's not like - Patient A is on premium insurance so we'll crack open the expensive drugs.

Health care is expensive and it's big business. Luckily we get insurance mostly paid for by the University of Michigan employee benefits office. For me, my wife and 2 children it costs $1200 per month. I pay nearly one third of that, the university pays the rest. To many who don't have such a generous employer the choice must be to either pay for a mortgage / rent or pay for health insurance. $1200 a month is more than my mortgage at home.

It's not hard to see why health care is so expensive either. Nearly everyone is on a drug to treat something or other (OK - admittedly I am seeing a very skewed population who are all the least fit in Michigan, which is one of the least healthy states in the US), but even seemingly fit and healthy 18 year olds can be on 5-6 drugs for asthma, depression, high blood pressure, migraines. Drugs are nearly always prescribed by brand rather than the generic drug name (much to my irritation - everyone always use brand names rather than generic drug names).

As technology has become more and more advanced, it has been possible to keep people alive when pretty much every organ has failed. It's not uncommon to have a patient come to theatre who has a left ventricular assist device (basically an electric pump that supports a heart that has failed) or someone who has had multiple organ transplants. This is great, but it all adds to the rising health care costs. It's the same pretty much everywhere in the Western world. Medicine is a self fulfilling profitable business. The more successful you are - the more patients you have - and they will keep getting older and sicker. The hard facts are that if there were no restraints at all, health care costs would spiral up and out of control.

It's not just immediate costs of health care either. Patients who are surviving are going in to long term nursing home care, lawyers are making a fortune on medical negligence claims, there is also a big industry of specialist lawyers here who will help people become eligible for medicaid. There must be a whole army of administrators who deal with the billing. The insurance companies will go through every detail of a medical bill and contest anything they deem unnecessary, so all the paperwork has to be perfect. (I say paperwork - but everything here is electronic records.)

I can see now why there is such opposition to Obama's health care reform - it will affect a lot of these other industries that have built themselves around this current system. A lot of people are making lots of money from it at present. Also, if they introduce government funded insurance for all, but do nothing to reduce the costs, the country will be even more bankrupt than it is already.

I came here very open minded - generally fed up with the inefficiencies and bureaucracy of the NHS; the government interference and micromanagement. I expected things to be very different in the states - and don't get me wrong, things are significantly different - but there are just as many debates about health care costs and inefficiencies here. Some criticisms of the NHS could be just as applicable here. I can't say either system is better or worse. They are both flawed, and I don't think there is any health care system that isn't.

I am if anything more grateful for the NHS. For one, at least you can be confident when you go to the doctor they are not going to profit from prescribing a drug or operating on you. The NHS is something worth saving, as long as we can keep some restraint on it. I hope there'll be something of it left by the time I return please Mr Cameregg.

Till next time,

Stay Healthy,

Drake.

Life, Liberty and the Pursuit of Happiness...

Can't believe it's nearly a month since my last post - apologies to my fans (both of you). Life has been busy, so I'll try and summarise it.

Independence day (known here as July 4th holiday by everyone - oddly no-one calls it Independence Day) came and went. I worked on the Saturday 3rd July (the weekend was staffed basically by the Brits - which is fair enough). It was busy. Really busy. We had 5 theatres running at one point - meaning I had to call in 2 back up faculty, and on top of that we had emergency airways on "The floor" (the wards). The done thing on July 4th holiday is apparently have a BBQ, drink lots of alcohol and then set off fireworks - usually resulting in a surge of emergency hospital admissions for burns, etc. However, all our emergency's were non-firework related. We had a couple of laparotomies, 2 simultaneous emergency craniotomies for extradural haematomas, a spinal emergency, an ENT emergency, a few fractures (but not as many as you'd expect) and other stuff that I've forgotten by now.

Some of the towns hold parades with marching bands, flag waving, etc., but we didn't get to go to any because most of them were on the Saturday when I was at work. On the Sunday the Chair of the Department held a July 4th party at his house / farm on the outskirts of Ann Arbor for the whole department plus families. It was a very pleasant evening with food, drinks, a volleyball competition and fireworks. Volleyball got added to my list of "Sports I'm crap at".

On independence day I made an effort to read the declaration of independence (online... not the actual one). I didn't make it all the way through. I have to say it starts really well, and if I was a colonist I would have been stirred into rebellion by it. Then it peters out somewhat.

This is the most quoted line in it:

"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness."

This is a great philosophy and a great national motto . Real nation building stuff. It was much quoted by the anti-slavery movement, the civil rights movement, Abraham Lincoln and even now by Obama. The only sad bit is that it took such a long time for people to actually take the "all men are created equal" bit to heart. Slaves were apparently excluded at the time - maybe it should have been a bit more "All men are created equal, but some are more equal than others". Still a good start anyway. Unfortunately the declaration of independence then turns into a long-winded whinge about King George III which gets a bit boring.


Anyway - after reading it I've tried to take it to heart and pursue "life, liberty and happiness" in true american style. After a while though it gets a bit expensive so I've downgraded a notch to "life, obedience and being content"... If Britain were to declare independence, I think that should be our motto.

We've also been entertaining visitors (The Ramoray family) for the last month. We've canoed down the Huron river, picnicked in the state parks, mountain biked on the Pottawatami trail, Played Golf on one of the local courses (and nearly got thrown off for being so crap), played baseball in the park (and basketball), taken a road trip to Canada, Niagara Falls, and Cedar Point theme park in Ohio, had a trip to Las Vegas, shopped till we dropped and had lots and lots of wholesome american food (Pizza, burgers, wings and Chilli Dogs). In short, we've been going for the full American experience. Baseball and Basketball also got added to my list of sports I'm crap at.

Niagara falls are about 5 hours drive from here. The Canadian side of the falls are by far the more impressive view. It's definitely worth a visit for anyone who comes here. They are spectacular - though I wouldn't spend too much time in the actual town of Niagara falls which makes Blackpool look classy. A trip on the "Maid of the Mist" boat at the bottom of the falls is a must.



Cedar Point theme park is a huge theme park about 2 hours from here with roller coasters that would impress the most seasoned adrenaline junkies.

Las Vegas is... well I'm sure you've seen the movies.

Work is going well. My list of new things I've done here keeps growing. I had one day where I had 5 of the most difficult airways I've ever managed in one day (maybe with the exception of 1 I had in Bangor once). I haven't had any disasters or any complaints, so I assume I'm doing OK. We're meant to get an evaluation in the next month. The residents and CRNAs fill out a daily online form scoring us on our supervision and teaching skills.

The newbies are settling in very quickly. They work very hard, and are given a lot of responsibility from the start. It's a quick learning curve and it must feel like sink or swim. I really feel for them, cos they look so scared half the time. I quite like teaching the new guys though cos they don't yet know any different, so they're quite happy to do everything my way.

And so life goes on... nearly a third of the way through our year here already. It's still living up to everything we hoped for and more. We've made great friends here, but we really miss our friends and family back at home, and hope we're going to have lots more visitors to entertain.

Until next time - live, be free, be happy.

Drake.

Days of our lives - part 1.

Monday June 21st 2010.

4.30 am. Woken up by severe thunderstorm outside. Amazingly the boys and my mum sleep right through it. Manage to drift off to sleep again after about half an hour.

5.30 am. My alarm goes off. Time to get up and go to work. Seriously. I mean - it's still night time. Why do they have to start so bloody early?? Monday morning comes around far too quickly.

This weekend was especially short as I was on-call on the Friday night, finishing Saturday morning. The on-call would have been pretty quiet if it weren't for the fact we were doing a routine elective case till 3am. Unbelievably the surgeon wanted to start another routine elective case after that. There's no such thing as CEPOD here. (For non-medical readers - CEPOD is Confidential Enquiry into patient outcome and death... - a national QA audit in the UK. They worked out quite a long time ago that doing routine surgery in the middle of the night led to worse outcomes, due to tired overstretched staff making poor judgement calls, less staff and resources, etc.) Some people here though believe they are immune to tiredness.

Still we had a nice weekend. On the Saturday night the senior residents had their graduation ceremony, which was a really nice evening - 3 course meal and free bar, and some very entertaining videos ( see http://www.youtube.com/watch?v=0YIFdy82r6c )

06.00 am. Down my coffee and get on my bike and cycle to work. Thankfully the thunderstorm has stopped

06.30 am. Unfortunately have to miss out on the morning conference (residents teaching session) because one of my first patients has potential airway difficulties. I'm running two ENT rooms today. In one room I've got 5 laser cases - 4 of them for vocal cord lesions under direct laryngoscopy, and 1 for a subglottic stenosis. In the other room I have a tympanoplasty, cochlear implant, 1 neck dissections and a repair of fractured mandible. My residents for both rooms had discussed all the cases with me the night before as usual, and so we already had a plan laid out for each of them. There was a plan for one awake fibreoptic intubation later in the day, but apart from that it was all fairly straight forward. As is often the case, the surgeons had asked for no long acting muscle relaxants for the tympanoplasty because they wanted to do nerve monitoring.

We see all the patients pre-operatively, go through the history and discuss the plan with them. All the rooms start at 07.30 am so it gets pretty busy in the morning.


07.30 am. Both my rooms are ready to start so I have to quickly start one case off then run to my other room next door and start the other case. It's usually pretty stressful trying to get both rooms going on time. Sometimes the surgeons will get arsey if they have to wait a few minutes. By 08.30 if both rooms are going smoothly I'll grab a quick coffee, check up on my e-mails and wait for the next patients to arrive in the pre-op holding bay. I can monitor my rooms from the computer in my office and speak to the resident or page them if there's any minor problems. If things aren't so smooth I'll stick around in the room.

The day progresses with me rotating between my rooms, trying to fit in some teaching for the residents, and running to pre-op holding bay to assess each patient as they come in just to keep the lists moving smoothly. When the cases are coming near the end I get paged to go and supervise the wake up. It's a pretty exhausting day overall and I get about 5 minutes to sit down for lunch.


16.00 pm - I'm now down to one room after one of my lists finishes. Within 30 minutes I'm relieved by one of the attendings on a late shift, and I get to go home. That is after I've looked at my cases for the next day and discussed them with the residents.

In the evening I just relax, watch some of the football world cup replays and have an early night.


Tuesday June 22nd

05.30 am - it's no easier this time round...

07.30 am - Both my rooms are starting at 07.30 am. One patient needs a spinal for a gynae procedure, the other is a liver resection so needs a GA, an arterial line and some good iv access. Every morning there are usually a couple of reserve attendings on the rota that will help us get a room started if we have a complicated case. Unfortunately this morning they are already booked.

I get the resident to start prepping for the spinal then run next door and get the liver resection to sleep. Turns out to be a difficult intubation and the resident fails, so I have to take over. Once the tube is in I tell the residents to get a couple of 14 gauge iv's and an art line in, then I run back and supervise the spinal going in. The resident can't manage to get the spinal in. Aaaaaaaaaaghhhhhhh!!!

I go back to the liver resection and see how things are progressing. They've got iv access but are struggling with the art line. I'm really starting to sweat now and the surgeon is getting a bit inpatient. I ask the more senior resident in there to take over the art line, then go back to helping with the spinal. The surgeon there is also getting a bit inpatient. I scrub up and take over the spinal. In fairness it was pretty difficult - but I manage to get it in. Once the spinal is in and starting to work I go back to the liver resection room. Art line is still not in so I help out with this, and thankfully the resident gets it in. I stay to help with positioning and getting the warmers on. We decide against a central line.

Central lines are done much less frequently here than where I've worked in the UK. They do not monitor Central venous pressures generally, preferring systolic pressure variation to monitor filling.

After the liver resection is settled I go back and check on my spinal patient to find things are going well and the surgery has started, much to my relief. The surgery is booked for two hours so I pray the spinal will last long enough.

It's now 08.15 am and I feel like I've done a whole days work already. I grab a quick coffee and download some literature about liver resections to discuss with my residents. On my way back to the room I check first on the patient with the spinal. The resident in there is happy with how things are going and everything looks smooth. I then go into the liver resection room to find about 8 other anesthesiology attendings in there. Uh-oh!

While I was in my other room the surgeon managed to create a substantial hole in the inferior vena cava and the patient lost 3 litres of blood in as many minutes. Needless to say they did not tolerate this very well. My resident very sensibly put out a "Stat" call for help, so everyone who was free came to the room to help out. What happened next is a bit of a haze in my memory because it was one of those highly intense, adrenaline fuelled moments you get now and again in anaesthetics, when your brain goes into hyperdrive, but you don't necessarily store any specific memories.

We managed to get a large gauge central neck line in, lots of blood products and the rapid infuser going in a fairly short space of time. The ongoing resuscitation lasted for hours, and we must have come close to emptying the blood bank, but the patient survived. The team pulled together and I had great support from some of my colleagues when I needed it. It was also great that what ever we asked for - be it equipment, drugs or blood products just appeared within minutes without us having to chase anyone or justify our reasons. You want platelets / cryo / Factor VII? You got it. All I had to concentrate on was looking after the patient.

Needless to say I spent the rest of the day in that room, until we transferred him to the Intensive Care unit afterwards. Someone else started my cases in the other room for me for the rest of the day.

17.00 pm To de-stress after a rather eventful day I go for a round of golf with some of the other rotators. I am still rubbish at golf, but it's nice walking around the course on a warm sunny afternoon and having a laugh. We have a beer and a burger afterwards in town. I sleep like a log after.


Wednesday June 23rd.

05.30am - it's really, really hard to get out of bed....

06.30 am - Arrive in work to find out that the cases I was expecting in one of my rooms have been replaced with 2 kidney transplants. One of which has already been started by the on-call team, so I go straight there and take over the case. At least I only have one room to start at 07.30 am. What luxury! In my other room I have a colectomy, gastrectomy and open cholecystectomy. We plan on epidurals for all of them, but 1 patient declines, 1 turns out to have a coagulation issue, and the other one gets an epidural. The epidural is done by the Acute pain service in the pre-op holding bay, but I supervise it.

Some time in the afternoon it is announced over the Tanoy that we have had an earthquake 5.5 on the richter scale and there is no need to panic. Came as quite a surprise to most people.

I manage just to catch the last 5 minutes of the USA vs Algeria match - quite a good 5 minutes as it turns out. I think I was more excited about it than a lot of the American staff. I'm very pleased for them, as I think they were robbed in the Slovenia match. Most of the americans who like "soccer" are under the mistaken impression that England are a good team.

Later that night I go out for food and a drink with Mrs Drake to one of the microbreweries in Ann Arbor. It happens to be open mic night and we listen to the first couple of singers. We both agree that Simon Cowell would not have approved of either. Whilst in the bar we get informed of a tornado warning affecting Ann Arbor. No-one seems to do anything about it. On the way home however we witness the biggest electrical storm I have ever seen. The whole sky was like a strobe light for at least a couple of hours. The tornado warnings flash up on TV and radio for a couple of hours, and we can just about hear the Tornado sirens going off in the parks. We consider going down into the basement as recommended, but I'm too tired and we take our chances in bed.


Thursday June 24th.

05.30 am - Well... at least we're still in one piece.

06.30 am. There is no Thursday morning M&M meeting and lecture this morning. Instead the residents are having mock oral exams. I have "volunteered" to help out with mock oral exams for the residents. The residents get given a long case to study earlier in the week and then get quizzed about it in viva style by us. The cases are moderately difficult, and the format is similar to the final FRCA long case.

08.30 am - Lists on Thursday always start an hour later because of the usual educational meetings. Today I'm on a Reserve day so I have no dedicated rooms. I offer my help around, and help to start a list for someone, then I help someone else with a difficult airway. I spend some time catching up on admin, then I get told I can go home around 10.30 am. I enjoy my day off by taking the family swimming.

I get phoned at 7pm to be told that my schedule for Friday has changed. Instead of covering the MPU (Medical Procedure unit where they do Endoscopies, ERCP and colonoscopies under GA / sedation) I'll be covering 1 ENT room and 1 open room (no booked cases) instead. I'm very happy with this news. I hate covering the MPU.


Friday June 25th

05.30 am. TGIF!

06.30am - make it to the resident teaching. Today they discussed Malignant Hyperthermia, and drug of the day was Etomidate.

07.30am - Today in one room I have 2 neck dissections. The first one has a mass the size of a baseball on the front of the neck. We get all prepared for a difficult intubation, but it turns out to be easy. The third case is an ICU trauma patient with facial and neck fractures that sounds pretty challenging. In my open room they've booked 5 emergency cases. Two are tracheostomies from the ICU. Apparently they very rarely do tracheostomies on the Intensive care unit. They nearly always come to theatre. I've been told the reason for this is billing. They can charge more for a procedure done in the operating theatre than a bedside procedure. Incredible really if this is true. Take note all critics of the NHS.

The trauma patient gets cancelled - very unusual, but the one of the surgeons is unavailable. This means I finish by 3pm and get let out.

The weekend starts early! In the evening me and the family got to Chili's - good all american food and cocktails. We overeat as usual and end up bringing some home in a box.

Plan for the weekend includes sleep, mountain biking, watching football, eating lots and spending quality time with the family. I know it go quickly as always, and before I know it it will be Monday morning 05.30am again. It's been yet another eventful week, and I wonder what surprises next week will have in stall.

We'll see..

Till then,

Drake.

The Great Outdoors

Greetings from our lakeside beach house in Northern Michigan (well - rented for the week). If you are having a bad day or are currently stressed out then please do not read any more or you may suffer from sudden attacks of uncontrollable envy. Don't say I didn't warn you....

I'm typing this whilst sipping a couple of cold ones, digesting a lovely pizza and gazing out at a gorgeous lake and beach, blue skies and lush green trees and grass. My main dilemma right now is what to do tomorrow - hire a boat and go fishing on the lake, go mountain biking or simply chillax on the beach doing nothing.

Actually, if I'm being honest we spent most of the day trying to entertain ourselves in the cold wet pouring rain. Not an easy thing to do in Northern Michigan on a Sunday before the school holidays start. I mean - it's really nice here, but most of the activities kind of rely on it not peeing down with rain. And most things here close on Sundays. It feels a bit too familiar going away on a beach holiday to find it rained off. I didn't think it would happen here though. I was assured it was guaranteed sun after Memorial day (May 31st) - or at least that's what I think they said. I didn't even pack a coat or jumper! Oh well, at least we've avoided the storms and tornadoes (!) down in Ann Arbor. Tomorrow is supposed to be sunny for a bit so we're going to pack a whole weeks itinerary in to one day.

On Friday we drove up via a place called Frankenmuth. It's a German, Bavarian style town complete with Bierkellers and Bavarian style inn's, Bavarian ice-cream shops, Bavarian Toy shops, Bavarian hot dog stalls, Bavarian McDonald's... You get the picture. It was a really pretty town, and spotlessly clean and well kept. Tourism is the main business there and it had just a touch of the Disney feel about it, complete with prestine horse drawn carriage tours. We had a nice lunch there and walk around town. We also visited a Christmas decoration store near there like no other on Earth. It's open all year round and it's about the size of a super size Tesco in the UK. It's big enough to get lost in and it's full of every Christmas related ornament / decoration you could think of, complete with staff dressed as elves and Christmas music. It's a tourist destination in it's own right. We spent an hour wondering around just the baubles. You could buy a bauble for just about any occasion - child's first Christmas, pets first Christmas, graduation, new home - fair enough - but "My Child's First Christmas in Heaven"? - Not sure on that one. It's a place you just have to see to believe.

We then drove up the "sunrise side coastal highway" along side Lake Huron till we reached Mackinaw City - right at the Northern tip of lower Michigan. A really nice but touristy town with some interesting history (there is a reconstruction of an old British fort there), but mostly it's full of fudge shops. The area was very important for fur trading, and benefited the local Indian tribes (Chippewa, Ottawa and Potawatomi), the British, the French and the Americans. It's not surprising that there were some arguments over it. You can get a ferry from here to Mackinac Island. If we went further North we'd have to cross a big suspension bridge to the upper peninsula, and about an hour North of there is Canada. We haven't been up that way yet.

We're staying near a place called Petoskey, near Boyne. Petoskey is apparently an Indian word for "Where the light shines through the clouds" (If only...) Again Tourism is the main industry here. In the summer it's all beaches, boats, fishing, hiking, bikes. In the winter the attractions are skiing, snowmobiles, etc. The Lake Michigan coastline seems to be a lot wealthier than the Lake Huron side.

There are a lot of holiday cabins here. The dream of having a holiday cabin by the water, with acres of land, and a boat is a reality for many here. They love the Great Outdoors here. It's all about getting away from modern day stresses, getting out to the wilderness and getting close to nature (and often shooting it). It wasn't very long ago here when it wasn't so much a life-style choice, but more of a necessity, so I guess it's also about getting closer to their roots. Anyway, if I lived here, I'd love to have a holiday cabin with a few acres on the lake with my own pontoon and boat... (big sigh)

It's nice to be away from work for a while. I'm still enjoying work, and the novelty hasn't worn off yet. There's been new challenges still every week, and a really fun atmosphere within the department. It has been exhausting though. It is mentally very draining to be looking after two theatre lists at the same time. It's fine when there are just one or two cases on each list with residents that I trust looking after the patients, but you get days when there's five or more patients on each list, and staff that you feel you have to watch more closely. You feel like you're going all out just to keep your head above the water. Doing five early morning starts catches up with you too. By Friday I'm usually like a zombie. The other week me and a couple of the other Brits had a Friday evening round of Golf which was a great way to round off the week. Just to clarify though, I have never played golf before in my life. I was pleased with my final score of 60 over par (for 9 holes). It made a change from going to the pub after work (although the pub still made it on to the agenda of course).

Looking forward to the football world cup next week. We're having a sweepstake at work and I'm hoping to get back to Ann Arbor just in time to watch England vs USA. Not sure yet who I'll be supporting though. - Just Kidding... I don't even want to imagine what would happen if USA won that game. Maybe I should stay out in the wilderness just in case. Luckily the wilderness has wifi in the USA so I'll still keep in touch.

Till next time,

Drake.


PS - Due to problems with the eblogger website I couldn't post this for an extra day. Just thought I'd let you know that doing nothing on the beach won. Just lighting the BBQ now and tucking in to the nachos, enjoyinh the sunshine. :-)

PPS - Also got to see the Wales v South Africa game on BBC iplayer (using a UK host proxy IP address). Good effort by Wales but not quite enough.

Oh I Say, Can you See?

Interesting facts of the week:

Apologies to Wikipaedia for plagiarism...

1. The music of the Star Spangled banner came from a drinking song written by a British composer John Stafford Smith (apparently born in Gloucester - but I always thought he was Welsh.)

2. United States Code, 36 U.S.C. § 301, states that during a rendition of the national anthem, when the flag is displayed, all present except those in uniform should stand at attention facing the flag with the right hand over the heart;

3. Members of the Armed Forces and veterans who are present and not in uniform may render the military salute; men not in uniform should remove their headdress with their right hand and hold the headdress at the left shoulder, the hand being over the heart; and individuals in uniform should give the military salute at the first note of the anthem and maintain that position until the last note;

4. Recently enacted law in 2008 allows military veterans to salute out of uniform, as well.

5. This behavioral requirement for the national anthem is subject to the same First Amendment controversies that surround the Pledge. For example, Jehovah’s Witnesses are not required to stand for or sing the national anthem.

...........

I guess that's another law I've broken since I've been here. Mind you, they seem to be very relaxed over certain laws here. I'm not sure whether it's illegal or not to talk on your mobile whilst driving here, but you'd be forgiven for thinking it was mandatory.

Patriotism, however is pretty serious business. I like Patriotism - I think it's healthy, as opposed to nationalism. It's a fine line though, which I think is often crossed. They recently passed a law here in Arizona allowing the police to stop and search anyone who looks Hispanic to check whether they are illegal immigrants. Incredible - the Land of the Free? Really?? It's got lots of debate going on the cable news channels though. Speaking of which - it would be nice if just occasionally CNN would say whats going on in the rest of the world. Just a thought.

...

I only really worked out this week what the US national anthem is about - The British bombardment of a fort in Baltimore in 1812. Still - no hard feelings... They won in the end so I guess they're not bitter.

In fact I'd say most people here love the Brits, or at least they have been very friendly. Not a day has gone past when someone hasn't said to me "Wow - I love you're accent!", then quickly followed by: "Are you British / Irish / Scottish / English / Australian/ Canadian / from New Jersey?? (my personal favourite)" Never Welsh, but never mind - I'm quick to correct. At least everyone knows where Wales is - Thanks to Tom and Catherine Zeta.

I don't get sick of it - I quite like the attention, and if I'm being honest I probably put on my poshest British accent. It's a good ice-breaker I suppose. It's quite normal to start up a conversation with a complete stranger just walking down the street. The sort of thing that would be met with a confused blank stare in London. ("How dare you invade my personal bubble!") As soon as I speak though I know whats coming. There usually follows a potted family history of where in Europe their great grandfather was from, and which ship he came over on. The reaction I get from patients is mostly positive, although a few seem uncertain about a foreigner looking after them. I guess they're worried I'll flee the country if it all goes wrong. Too right I will! (only kidding - I'm sure they'd extradite me anyway).

We went up to Northern Michigan for a weekend last week. A beautiful place called Glen Arbor - next to Sleeping Bear Dunes Park. Lovely tranquil lakes, miles of white sandy beaches, and big sand dunes. We had a great time and felt like we were really on holiday.

On Sunday we went to a closer lake and park area and I went mountain biking with some friends. Pretty good Mountain bike trail (though not quite up to North Wales standards). I'm loving the Great outdoors. Still a mountain or two wouldn't go amiss. We're planning another weeks holiday in North Michigan in June - we're hiring a cottage on a lake with it's own beach.

Work is still exciting, with new challenges every week. Last week I got to use a jet ventilator on someone. All went well. Not so much "See one, Do one, Teach one", as "Read it up, Have a quick play with it, then hope for the best". The support from the other faculty has been great.

So remember - if you're ever arrested for not standing, removing your hat and putting your hand on your heart when the Star-Spangled Banner is being played, just say you're a Jehovah's Witness.

Till Next Time,

Drake

Go Blue! (and Yellow)

Howdy,

Greetings again from a soggy Michigan. May so far has been distinctly cooler and wetter than April, though by the time I finish writing this post I'm sure the weather will have changed again. It varies a lot here depending on whether the wind is coming straight down from Canada, or straight up from the Gulf of Mexico. It seems those are the only 2 places that wind comes from.

We had really a really good storm last week, and even a tornado warning that flashed up on the TV. Exciting stuff - but no tornado, and we're all still in one piece. The boys' basketball net did get blown over though. Some in Oklahoma were not so lucky.

We went to a cool crab restaurant last week. Every now and again the restaurant would be magically transformed into a disco - lights and music would start, and all the waitresses would suddenly stop what they were doing and all start dancing in sync - all choreographed. At the end of the song they just carried on where they left off. Surreal! We've had lots of great meals out (and take-aways) including Italian, Mediterranean, Arabic, Sushi, Fondue and lots of pizza.

If lots of the operating lists are overrunning at work and we're likely to be there late the department orders in about 10 pizzas complete with cheese sticks, garlic bread, chicken wings, drinks and desserts. It keeps morale up and makes everyone feel appreciated - as well as being really tasty! (and probably really bad for you).

I did a 24 hour on-call on Saturday. 7am - 7am resident in the hospital. Work wise it wasn't much different to doing a typical on-call at home, although a few cases get done that would probably wait till the Monday at home. There's the usual familiar arguments from the surgeons about whose case deserves to go next - but the senior resident on-call holds the phone and usually does all the arguing. It surprised me how little trauma work there was (like fractured hips, etc). I don't know if it's because the population of Ann Arbor is very young, or if they all go somewhere else. We did some neuro cases, laparotomies, laparoscopies, a few trauma cases. By tea-time we had finished all the booked cases and we all got together and ordered a take away to be delivered. Yum - I could really put on weight here. At night I got lucky so I got to make good use of the on-call room.

It was a bit daunting at first going back to 24 hours on-call instead of shifts. My memories of 24 hours on-call from when I was a baby surgical house officer are not good, it obviously makes a big difference whether you're up all night or whether you have a few hours when you can sleep. After doing 9 years of shifts though I have to say that I hate night shifts with a passion. At least with a 24 hour on-call it's all over in 1 day, there are less frequent on-calls, and everyone has an incentive to get the work done in daytime hours, and there are proper on-call rooms to relax in. I think I get depressed when I have a run of night shifts coming up. They also interfere with training. Sadly because of EWTD there is no going back now in the UK. Some of the American residents have said to me they wish they could have our working hours and shift systems, but I really think that would be a bad move here.

There is a very different work ethic here on the whole. Everyone seems much more motivated and there is very little complaint of work to do. Every case is seen as an opportunity for training. The residency programme for anesthesiology is only 3 years (after 1 year intern - like a PRHO year), so they are generally keen to do as much as possible in that time - they fight each other off for opportunities to do lines, blocks, epidurals, etc. After their 3 years they are board certified (if they do the exams - which aren't compulsory!!!) - and they can work as an attending (consultant). Some do a year extra fellowship (eg in Pain / regional, cardiac, etc). Pain is a really popular specialty here.

A lot is expected from the residents from day one. They are given a lot of responsibility and can be left alone with difficult ASA 3/4 cases (sick patients). The learning curve at the start must be huge.

The new batch of residents start in July. Currently we have some newbies that will be starting in July shadowing the existing residents. They really are starting from scratch. Some know nothing about anaesthetics or physiology (eg how much oxygen is there in room air?!!) and have never before managed an airway. That does not stop them wanting to take on pretty difficult cases.

After a years training some think they know everything. I overheard a first year resident complaining the other day that they were not allowed to do a newborn paediatric cardiac case on their first paediatric module... Scary. They say a little knowledge is a dangerous thing.

The residents have this "can do" attitude to everything - which is great for many things, but it really can catch you out. I've learnt quickly never to ask them if they are happy to do a procedure. The answer is always yes. Saying "no - I'm not that confident, can you help me" would in their eyes be seen as a weakness. Instead I ask how many times have you done this? Often the answer is zero, but they wouldn't admit that unless you asked specifically. The third year residents on the other hand are usually pretty experienced, although I still find that their main weakness is over-confidence. They are always very confident, even when (just occasionally) not that competent. This is not just the anesthesiology residents. It applies to the surgeons, the nurse anaesthetists, in fact most people. This is not a criticism - it's just an observation. It is very much ingrained in the culture here. The culture along the lines of "Don't let anyone say you can't do something", or "Nothing is impossible, impossible is nothing", and other such sound bites. One of my favourite quotes I've seen was at the Henry Ford museum, from the great local hero himself:

"Whether you think you can or whether you think you can't, you're right."






You see it everywhere in different forms - TV adverts, posters, bumper stickers, T-shirts, self help books. They teach it in schools, in sports, business meetings, church. It is like the universal religion and dogma. It is a philosophy that everyone believes in, no matter what their politics or religion. I'm sure it is the reason why the USA is world leader in many things. It is probably why the USA won the space race and sent men to the moon. It is what inspired the Wright brothers, the Empire State building and so many other great achievements. On the flip side, it is also probably the reason they got into a mess in Iraq and with the recent economical disasters. But then failure is not seen as necessarily bad. It is "just another step to success". To quote Mr Wayne, "Why do we fall? So we learn to pick ourselves up".

I like this part of the culture here. In fact if there was just one thing that I wish I could take back and import to the UK - it is this self belief and willingness to try something. Not to fear failure so much that you don't even try. It fits very well with the ideology that everyone is responsible for their own successes - The true American Dream. The general optimism and positive attitude is infectious, and it keeps general morale up.

The disadvantage of this kind of attitude in medicine (especially anaesthetics) though is that you can easily get into deep water without knowing if you can swim yet. It is something I have learnt to be constantly vigilant for here. In fairness, the residents on the whole are mostly conscientious - I'm not saying they are cowboys, but there is a fine line between being confident and being rash. The residents don't appreciate it if we don't let them "try out something new" that they want to do, or take over a procedure when they are having difficulty. I have on occasion had to be very direct and assertive when things look like they are getting out of control. Balancing the training needs of the residents with what I think is within an appropriate safety margin for the patient has got to be the biggest challenge of this job so far. It goes without saying of course that safety always comes first.

I'm doing a lot of teaching with the residents, and now brand new interns. I'm also giving a lecture to the medical students next week, which hopefully will become a regular slot. It's a part of the job I really like.

This weekend we're going away for a break to Glen Arbor in the North of Michigan. It's supposed to be beautiful beaches there and quaint little towns. We're really looking forward to it, it will be our first overnight trip away from Ann Arbor. Will let you know how it goes next week.

All there is for me to say now is congrats to all in Blighty on your new blue and yellow government - coincidentally the university of Michigan colours. I wish I could sum up something enthusiastic to say about them but I'll just steal from the locals here and say "Go Blue (and Yellow)!" This of course can have more than one meaning depending on where you place the emphasis...


Till next time,

Remember -

"Only those who dare to fail greatly can ever achieve greatly" (Senator Kennedy)


Drake.

YES WE CAN!!!!!

It feels strange that it was only a week ago that I wrote the last blog update. I've had so many experiences since then that it feels impossible that they could have all happened in a single week. The climax of the week (in fact maybe even the climax of the whole year) was going to the University graduation ceremony today in the 110,000 seater "Big House" University football stadium where none other than Barack Obama, the president of the US (as if he needed that extra introduction), the leader of the free world (as they like to call him here) was to be conferred an honorary degree and give a speech.

Needless to say, Ann Arbor has been getting very excited over the last few weeks about the visit of the president. I was certainly very excited being a big fan of Obama since his election campaign, but not everyone here shared this enthusiasm.

I find the attitude of some here towards Barack Obama to be very odd indeed. There are those who hate him with such a passion that you would think he was the cause of some terrible genocide or holocaust. The explanation given for such hatred is usually along the lines of Obama being the root cause of all the USA's economic woes (funny as I'm sure the economy crashed before he was elected) or he is a socialist (because he is trying to reform the very unfair health care system here), non-American (they even doubt his nationality!), and so on...

I've not met many people who will even admit they voted for him, and those who say they did often tell me how disillusioned they are that he is introducing "socialism" in the form of a health care bill. The fact that a health care bill was a very clear priority in his election campaign seems to have been forgotten.

The truth is that there are those who are doing very well in the current unfair system who do not want "change we believe in". There are also those who do not like him simply because he is a Democrat and they are life long Republican and always will be. Sadly there are also those who hate him because he is black. (Most strange of all is that often these are people who could benefit most from the changes he is introducing).

The Americans are passionate about democracy. Everyone talks about politics here. Yet many are now complaining that a guy who was elected by majority vote is now delivering exactly what he promised. And the response by some has been most undemocratic in nature, including death threats. I'm certain that every place he visits breathes a huge sigh of relief when he leaves in one piece.

By any politicians record, Obama's is pretty impressive. In his short term to date he has passed most of his manifesto - and all done with high levels of opposition, and a press that has been critical at best, and at times vitriolic.

Sadly, most of the doctors in the hospital are very much against a universal state funded health care system where no-one will go without health care cover. They fear our NHS model partly because of the loss of their independence to increasing government interference (probably with good reason), and also because of a potential reduction of their income. (Before you get too judgemental about this, I would like to point out that most of the residents I have spoken to have debts accumulated of about $400 000 from tuition fees. It is not unreasonable that they fear they will not be able to pay this off as easily as they thought they could when they took out the loans).

So anyway, I managed to get a ticket to go to the graduation, and I got through security without hitch. The logistics of searching 100 000 people must have been a nightmare, and the queue to get in was pretty awful but it was worth it. The ceremony on the whole was a great occasion (including Glee Club style choirs, brass bands, and of course the Star Spangled Banner sung in ear-piercing ultrasonics).

Much better than my graduation ceremony, that's for sure, and the highlight of course was Obama's speech. Despite the battles and negative press he has had, he has lost none of his passion for what he does. He comes across as very well read, educated and knowledgeable. He has a great sense of humour and humility, and he sure can deliver a speech. I could have listened to him all day. He talked about the importance of furthering your knowledge, engaging in debate in a civil way, understanding all sides of an argument even if you disagree (all very apt...). The speech was very well received by the audience and he had several standing ovations. I found the experience very moving and inspiring and it was a day I will remember as long as I live. Almost as impressive was watching the motorcade and entourage leave, followed by 5 helicopters (3 Chinooks!) to take him away again afterwards. The cost of the visit must have been $millions.

So enough about Obama.

The rest of my week was pretty eventful too. I did my first overnight on-call on Monday. When on-call we come in at 3.30pm and take over some-one's cases so they can go home. We get told which rooms to take over by the floor runner - one of the senior attendings who co-ordinates the staffing of the rooms. We keep taking over cases until there are just 2 rooms left running. Then the last late person leaves, and it is just us for the rest of the night covering everything except Obstetrics, Paeds, Vascular, Liver transplants and Cardiac. There are 3 residents on at night. The most senior one co-ordinates the work throughout the night. The on-call was OK. Busy-ish but never run off my feet. There was an on-call room for us which I managed to get to for half an hour. Normal can be anything from no sleep to 6 hours or more. We get the next day off, then back at work the day after (Wednesday).

I had a case of anaphylaxis during my night. At least I'm pretty sure it was. Severe Hypotension (nearly arrested) just after morphine, responding only to adrenaline. (I even got to ask for "Epi stat" - though it didn't sound right in a British accent. It was a sort of "Would you mind giving some epinephrine stat please?" - not quite ER)

Then later in the week there was a case of Malignant Hyperthermia (a really rare life threatening reaction to an anaesthetic) in recovery, which I got to help out by drawing up lots of Dantrolene. Anaphylaxis and MH in one week? I keep meaning to work out the odds of that but it makes my brain hurt.

I also got to do some liver resections that I've never done before and a couple of Bariatric (Laparoscopic Gastric banding) cases.

I sometimes think that even if I got kicked out of the country now, after only a month, I would have gained invaluable experience from this. I cannot recommend a year out of programme highly enough. It opens your mind to different techniques and different ways of working, as well as different ways of living. Honestly, if you have the opportunity then definitely take it. If anyone is interested in coming here then get in touch and I will tell you more.

Oh yeah. I got paid too. Boy did it feel good to check the bank balance on Friday.



Can we spend it?..........

YES WE CAN!!

Till next time,

Drake.




P.S. - Hope everyone at home gets out on Thursday and votes. I'm not able to because I didn't register for postal voting in time.