"Sunday, Monday Happy Days....."

Nearly at the end of my first month here. I can't believe I'm a month in already - it has flown by, but as far as money goes, the end of the month can't come quick enough. We're down to our last few cents pretty much, and I'm dreading my next credit card bill from the UK, cos we've had to rely on the credit card a lot this last week. Still 6 days to go till pay day, then hopefully we should be alright.

Certain things here are cheap (petrol, car rental, eating out) but I was surprised by the cost of other things like car insurance, phones, internet, cable TV, fresh food from supermarkets - so we seriously underestimated how much we'd need to survive the first month. The good thing is we are paid very well here (and I won't have to pay any income tax), so after pay day we should be good. For anyone who is considering a year here, there's other cost considerations that you don't necessarily think about - like I lose a years pension, and also my added years conribution contract gets cancelled and I lose it permanently. This was disappointing, but in the whole scheme of things was never going to put me off coming. I will probably have to send some money home to keep the bank balance in the black, but thankfully we have rented out our house at home so it's not as bad as it could be. I'm also hoping to save a little lump sum by the end of the year to make up for the pension.

It's always nice to hear from friends and family back at home. I think I speak to them more now than when we were at home. With e-mail, texts and Skype it's so easy to keep in touch. I haven't been home sick at all really, but there's been a few things I miss - I miss rugby (I've got 16 sports channels here, and not one shows any non-American sports), proper hills and mountains (Michigan is lovely but pretty flat).

I'm quite glad we don't have to hear about the election every 5 minutes though. In fact if I didn't check the BBC website now and again I'd have no idea there was an election going on at all. US news channels don't report much from outside the US. (The icelandic volcano did get a brief mention but only because transatlantic flights were affected). I think I check the BBC website now and again just to check that home is still there and not sunk under the sea.

Work last week was good. I had to visit Occupational Health - it was reassuringly the same painful crap experience that it normally is. I had a bonus day off - I was a Reserve one day - so I just go in in the morning to help start lists, and in case someone is sick, but after a couple of hours I could go home again.

I was anaesthetising for robotic laparoscopic surgery all week. It was a bit weird at first to see a robot operating. The surgeon sits in the corner of the room and controls it like a playstation 3 basically. It's pretty much the same as any laparoscopic (keyhole) surgery but takes three times longer. Thats my take on it anyway. It's quite impressive though that they manage to do a radical cysto-prostatectomy (removal of bladder and prostate) by keyhole surgery with about 200mls blood loss! I would argue that the 10 hour anaesthetic time may negate some of the benefits however, but who am I to suggest such a thing. Also a hysterectomy and radical prostatectomy are done in this way. From an anaesthetic point of view there's not much to do - stick a tube down the trachea, make sure you've got good iv access, watch for the usual complications of laparoscopic surgery - which I also got to see and had my first experience of handling a critical incident. (In 1 case - surgical emphysema with suspected pneumothorax which turned out not to be, in another case a ET tube herniated out half way through!) Things went very smoothly - as soon as I reported to the surgeons there was a problem I had their full cooperation, and basically we fixed the problems and they continued - no dramas.

Hopefully by my next post I'll be paid and we'll be on a spending spree! Happy Days! :-)

Till then,

Drake.

Another day, another dollar....

So another week is nearly over already....

This one has really flown by. Having got used to the system a bit better now, I'm really enjoying the work more. It's been a great week for the logbook. A couple of kidney transplants, pancreas transplant, a laparotomy for bleeding post liver transplant, a rotational flap for thoracotomy wound, a free flap to the face, an awake fibreoptic and a load of orthopaedic stuff as well for good measure.

I also did my first real late shift (like a day on-call). Basically having done my normal 2 lists during the day I start taking over other lists so people get to go home on time, (But I can still only run 2 lists max at any time). Then when there are only 2 lists left running I can go home and be on call from home, and the attending on call for the night has to stay for the night. I was lucky - it wasn't too busy and I got sent home at 8.30pm. I could have potentially been called back in but luckily I wasn't. I got the next day off as an "academic" day. No-one has really defined to me what counts as academic....

The residents have been super keen to learn this week, so I've been doing lots of teaching. They generally prefer clinical teaching rather than science, so I've been basically discussing long and short cases with them mostly, and discussing critical incident management.

Outside of work we've been having a great time. We've had 3 BBQs already. Last weekend we invited the other Brit "rotators" round (There's 8 of us here) so everyone's other half could meet up. Everyone has hadd similar experiences (good and bad) Re: immigration, social security, etc. They're all a very nice bunch from various places in the UK. Some are post CCT, but most are pre-CCT like me with 18 months to go or so.

My latest whinge is with the Gas & Electric company. Unlike the UK, there is absolutely no competition here, so we only have one choice of energy company. Currently the bills are still in the name of the previous tenants. We haven't been able to change them over until I got my social security number paperwork through. (Land of the free... my arse). Even now I have that paperwork, I'm supposed to drive an hour to Detroit and show myself at the DTE energy HQ with my passport, visa and social security number - just so they can change the name on a bill. Honestly - you can't do anything here without showing some form of ID (especially buying a beer...)

It's a small price to pay though. Life on the whole has been very good here. We've had some beautiful weather here, and have gone to some lovely parks, had some lovely drives and picnics. We're already planning some holidays. The upper peninsula of Michigan is supposed to be very beautiful, so we're planning a trip up there in the summer. There's still a lot of Ann Arbor we are yet to explore. Although the place is quite small in American terms, there's a lot to do here, mainly I think because of the University here. It's very cosmopolitan, and lots of Parks, museums, cafe's and restaurants. There's also quite a few micro-breweries here with very nice beer.

Take Care all,

Drake.

Oh boy....

I've nearly finished my first week at work and am really looking forward to the weekend. Work has been fun, interesting, sometimes scary, sometimes terrifying (well just once and briefly), but mostly exhausting. I guess part of it is starting a new job and so much to learn and think about.

I'm really grateful to all the other faculty in the department who have been very supportive, welcoming and helpful. I wonder sometimes how they cope with a big bunch of brand new rotators every year. We must all look like startled rabbits to begin with. There's certainly a lot to take in in the first week. No matter how much you talk to people about it, nothing quite prepares you for the culture shock of supervising 2 lists at once.

Every day this week I've had 1 general surgical list with the same 1st year anaesthetic resident (who is near the end of the year so is actually pretty good), and 1 gynae or general list with a nurse anaesthetist or 3rd year resident. There's anything from 2 to 6 cases on each list. As an example - yesterday in 1 room I had a parathyroidectomy and 2 colectomies, in the other room a live kidney transplant (recipient) and 2 AV fistulae. Today in 1 room I did 3 thyroidectomies, and in the other room a mixture of CEPOD type stuff. Tomorrow I've got another 3 thyroidectomies in one room and 6 hysteroscopies in the other room. By the end of the week I'll have done about 30 cases.

Sometimes I feel like I'm continuously running from the pre-op holding bay to one theatre then the next theatre, then reviewing the next patients, then it's time to wake one room, then start again.... It's quite intense and hard work at times. I counted my pager went off 25 times today. It's nice though when the last patient is on the table and I can retire to the office, supervise the monitors from my computer and check my e-mail. I probably hang around longer in theatre than I need to, but at present it feels very strange to just walk out. I try to stay till at least knife to skin, but it's impossible in the morning when there are 2 cases to start at 07:30.

I try to fit in some teaching where possible, but so far I haven't had as much time as I'd like. I'm sure though that as I get more used to the system I'll get more efficient and be a bit more productive. I'm supposed to teach the residents on at least one subject every day. I had to make my excuses for a quick exit though when one of the third year residents asked me to teach him about renal pathology. I brought out my A-Z of anaesthetics textbook for such occassions so that I can have a quick revision at lunch time...

I've had a couple of moderately difficult airways so far and some challenging cases by my standards (but I've been told they're all normal for Michigan). My highest BMI so far was 52. One of the other rotators has already had a patient with a BMI of 60. We're probably going to have a prize for the biggest of the year.

Supervising the nurse anaesthetists is strange. It feels very unnatural to supervise someone who has been giving anaesthetics for a lot longer than I have (like since I was in primary school!) Especially when they do things in a way that I wouldn't. I've found so far that I can suggest things - and it's OK as long as they were planning to do it anyway, but not if they weren't planning to do it. My experiences with them have ranged from very positive to the absolutely terrifying. But that's a story for another day....

The hours have been good so far. It's early starts, but I've been relieved and sent home at 15:30 on 3 days so far, and on the other day I was meant to be there late, but I actually got sent home at 17:00. Having kids, this is a huge bonus. I get to spend some quality time with them before bed time. I'm usually in bed not long after them though.

Life out of work is good, and it's like we're on a holiday because there's so much to explore. We have an awesome car, the house is feeling like home now we have some photos up, the weather has been great - it was 27 degrees centigrade yesterday (although weirdly there is a chance of snow tonight). There was a great thunderstorm the other morning when I was cycling to work.

Sorry I let you down on the photos, but the camera battery was flat. Am working on it. Next time for sure...

Take care all,
Thanks for reading,

Drake.

First day huh?

Howdi

Can't believe we've been here a week already. We've had a pretty busy week, setting up phone, TV, internet, mobile, getting a car, insurance, etc. I've already created a pretty impressive paper trail. We've had some fun too. Ann Arbor is really nice. The town centre is small but has really nice restaurants, cafe's and bars. There are some nice boutique shops, book shops, etc. There's a big shopping Mall for all the usual stuff out of town. There's lots of parks too. People here are friendly and will start up a conversation on the street or in a cafe.

Next blog I'll post some pictures of the house and the area.

We've had a few trips to the supermarkets too which are huge. Like 3 supersize Tescos under one roof. Or maybe it just feels like that.

We've also spent a small fortune. Moving country is expensive. The USA is also expensive. However, we are well paid here, so I'll be OK when I get paid. The first month will be a bit tight though. I've spent the $10,000 loan we got already. Car, rent and car insurance. Ouch.

I had my induction at work yesterday. A nice welcome from the chief, an explanation of the job and our roles, a (long) explanation of the computer system and the billing system (which feels very foreign - there are no paper notes here - all the records are on computer - and it is actually amazingly easy to use, it really works.)

We had pagers, personalised white coats, ID badges and everything all ready for us on starting. No tedious fire lectures, no manual handling lectures and no long boring whinges from the pharmacist / security / etc. In other words this was actually an induction that was useful and to the point. Although the lectures on billing was a bit over laboured - but then it is really important here. Basically if we don't say we did something, the hospital can't bill for it, and the hospital loses money. The anaesthetic dept alone needs $2 million just to pay the bills.

Today I had my first work day - although I just shadowed one of the attendings, so it was a nice easy intro. The day for me started at 05:15 with an early wake up call. A quick cycle in to work in time for the 06:30 M&M meeting. This lasted an hour and was well attended by most faculty and residents. A few critical incidents were discussed briefly, then a difficult case was presented and the residents were grilled on it. I found it really interesting and educational. The case was complex but not small print stuff. It was in a big lecture theatre but there was a very non-threatening environment. People were very open to different opinions. Best of all there was Starbucks coffee and bagels, muffins and fruit.

After the meeting I met up with the attending I was shadowing and met our first two patients (1 for each room we were in charge of). Both rooms were staffed by CRNA's - nurse anaesthetists. This was my first real encounter of a CRNA - and I have to say that if I wasn't told they were CRNA's I wouldn't really know. They are well trained, knowledgeable and experienced. And they do really complex cases. I guess they're a bit like staff grades at home. When I go solo I've been told we'll be supervising residents mostly rather than CRNAs.

In 1 room we did 3 laparoscopic prostatectomies, and in the other room a laparotomy and a thyroidectomy. Not a bad day for the logbook. We (the attending and me) were there for the induction and positioning and emergence. The rest of the time I chatted to the CRNAs, checked my e-mail and submitted yet more paperwork.

The biggest differences I noticed at work so far were:

No anaesthetic rooms (which I definitely agree with)

Fully computerised notes (Absolutely the way forward)

NO ODPs (which is disconcerting)

Covering 2 rooms at once (which is really not that bad - but maybe I was just lucky today)

Seeing the patient for the first time in the holding bay. (The holding bay is more like a pre-op HDU though. It is well staffed and has full monitoring. There's 20 or so beds so the patients can come down really early to minimise delays. We do review the notes online before though and discuss any problems)


Anaesthetics are not much different. Cost is if anything more of an issue here than the NHS. Isoflurane is definitely first choice volatile. Sugammadex is a no-no. There is a lot more investment in equipment and infrastructure however. Like I said before the medical centre is huge, and state of the art.


Well done if you made it this far and haven't been bored to death. I'll try to put pictures and more interesting anecdotes in future blogs.

Oh yeah - The weather here has been fantastic . Sunny and warm.

Keep reading,

Drake.