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.