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.