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.