Back in Blighty

Coming Home.

Well, we’ve been home roughly 6 weeks now and I’ve finally got round to righting up the final chapter of our USA adventure.

So our first impressions on returning home?

Britain is beautiful and amazingly green. The green is really striking at first glimpse when you’re flying over. It has a real sense of living history – everywhere from the local village pub, to the Royal wedding at Westminster Abbey. Despite it’s reputation, the food is great. Proper sausages, Roast lamb, Yorkshire puddings and gravy, fish and chips with loads of salt and vinegar, proper bacon (and proper bacon sarnies), chicken tikka masala, and the choice of Thai, Chinese, Indian, Malaysian, French, Moroccan, Lebanese, Italian Cuisines. I haven’t had a single burger since we’ve been back. The beer is lovely and warm. Even the weather was great for the first few weeks – probably the best we’ll have all year though. People are more modest, and definitely more reserved.

It’s also very crowded. There is far too much traffic. There are speed cameras and surveillance cameras everywhere. Parking is an issue almost everywhere. Everything seems smaller – the cars, the parking spaces, the houses, the food portions…

Moving back has not been without its drama – nearly missing our flight back, then arriving without any luggage, and a long frustrating search for a home to rent in our new location in the UK. Then taxing and insuring the car, setting up mobile phones and Internet, etc. Moving home 5 times in 5 years has not done the credit rating much good and it’s a real pain filling in the forms. Maybe our memory is short, but it does seem like the move out to the USA was easier than the move back home. I say home, but it’s really hard to define where home is at the moment. Moving house is supposed to be one of the most stressful life events – after a death in the family, and a divorce. Our 5-year-old boy has lived in 5 homes. Now we are in our new home in the UK for at least 6 months before it’s time to move again. We still haven’t unpacked everything yet. In fact I only unpacked my suitcase 5 days ago. It’s taken a month to find somewhere to live, and we still haven’t been able to get our children into a school. We seem to get past one hurdle then find another hurdle of red tape to get past. To find out that nearly all the schools in our region are full and we have no control over which school they are allocated to is frustrating and thoroughly depressing. Moving home has been harder than I ever thought it would be. With retrospect I think I just didn’t plan the return home as well as the trip out to Michigan.

What about going back to work in the NHS? I have been asked many times which is the better healthcare system. I can’t answer that question, because I genuinely can’t decide. The best I can do is to say that both have their pro’s and con’s.

I knew going back to being a trainee after a year working as an instructor in a supervisory role would be tricky and it has been. I’m currently working in a hospital that I never worked in before so I’m completely knew to them, which means I have to give a short potted Curriculum Vitae about 5 times a day. I also have to be constantly mindful that I am not the boss and someone else is often ultimately taking responsibility for my actions. You would think it would be easier going to a job with less responsibility, but it’s not. I still have that responsibility but I also now have the problem of how much responsibility do I take and how much to pass on to the boss. Those who have been in the same position will probably understand. Nearly everyone I have worked with since returning has been genuinely interested in my USA experience, and I have been very happy talking about it. I’m sure I have bored a few people to death about it by now, but I make no apologies for that.

The NHS itself hasn’t changed that much in a year, despite the doom and gloom in the media. It still provides excellent world-class care to whoever walks through the door, completely free, regardless of your position in society. That is still something to be proud of. After returning from a place like the University of Michigan to an NHS hospital it is easy to find things to criticise. The hospitals look old, tired and dirty. I have seen some shockingly poor maintenance issues. I’ve heard of new wards closed for repair months later because corners were cut and the roofs were not sealed properly. Medical equipment is sometimes unavailable because it has broken, and maintenance contracts have not been maintained. Adult patients are being nursed on wards that were meant for paediatric day surgery because the adult wards are full of medical patients. Bed occupancy is constantly at crisis level. The staff in the NHS are generally frustrated and fed up with these recurring chronic problems, and seem powerless to do anything about them. The managers are caught between trying to manage the hospital and constant pressure from the politicians to do more with less money. The politicians of course are only interested in the statistics that they can sell to the public – waiting list times, MRSA rates, 4 hour target achievements in A&E – the headline grabbers. The funding and investment therefore is possibly disproportionately spent on things that give good headlines.

There are lots of areas of the NHS that have suffered from underinvestment over time, but the thing that stares out at me as a huge difference between the NHS and my experience in the USA is in the use of technology. Patient records consist of piles of paper notes in folders that are often falling apart, and the first hour of my day consists of running around the hospital running from ward to ward trying to find my patients for the day, then trying to find the notes somewhere on the ward, then trying to find the information I need somewhere in the 4 folders of notes. Consequently I’m often not ready to start the lists on time. However, there aren’t enough theatre porters to get the patients to theatre on time so I’m still ready before we have a patient. Lists often start late. It’s also difficult to contact members of the theatre team or be contacted about changes in the list or to relay some vital information about the patient. Even communication between myself and the consultant I’m working with is difficult and often relies on the hope that we’ll both turn up on the same ward at the same time. We don’t carry any bleep or paging system, and mobile phone signals are very variable. Switchboard is still completely unautomated and it can take 10 minutes just for them to pick the phone up. In a specialty and an industry where poor communication has been known for years to be the leading cause of medical errors, it is still remarkably difficult to communicate with your team members unless you are in the same room as them.

These things are not new. They have been the same problems to a greater or lesser extent I have seen in every hospital I have worked at in the UK (8 in total) or been a student at (another 7) over the last 16 years. 16 years ago (1995) was around the time it feels to me like the world we live in started to change in a major way. In 1995 few people had mobiles or e-mail or laptops. Some had desktop computers, but no-one had the internet. There were no smartphones, satnavs, WiFi , Automated phone menus. There was also no such thing as automatic check in, call centres, online banking, e-billing. No touch screens and electronic form filling. No Wifi cafes; No Google; No online data storage. You may think that not all of these changes have been for the better, but it would be hard to imagine a world now without any of these things. As the technology has been invented, companies have invested in them to keep ahead of the game. Those that have not kept up with the game have perished. How many people would open a bank account now that did not offer online or telephone banking, and worked on paper records for your account? How many businesses would not provide any method of mobile communication to it’s employees? In short – the world has changed, we have changed, but the NHS has not. Whilst private companies were investing millions into technology, and the University of Michigan was investing millions in it’s electronic records systems, the NHS received some of its biggest ever increase in budget (during the early years of New Labour from 1997 onwards). Rather than using this money to invest in new technologies that would improve efficiency, productivity and safety, it was spent on meeting the headline grabbing targets. Now the money has dried up the waiting lists are growing again, and the efficiency, productivity and clinical outcomes are lagging behind. The governments response is of course to blame the staff, rather than blame themselves for such short sightedness. To see how important technology is for patient safety at the University of Michigan anesthesiology department you can read this excellent article by the chair of the department Dr Kevin Tremper, who also gave a lecture on the subject at the ASA conference in San Diego.

This link should take you to the publication in April’s Anesthesiology. I highly recommend it, especially if you are an anaesthetist or have an interest in patient safety. In the article, Dr Tremper describes the change in anaesthetic monitoring in relation with changes in the cockpit of aircraft. Both industries with a keen interest in safety. (Picture is from the article published in Anesthesiology)

Of course there are other issues. The geography of the UK has resulted in lots of hospitals offering the same services with a small geographical area. All of these hospitals require a certain minimum number of staff to keep them running. The EWTD (European Working Time Directive) has had a huge effect on working hours and on-call rotas in particular. This has 2 effects. First – it is difficult for smaller hospitals to staff the on-call rotas. Second – it means that the staff do more shift work, and less Monday to Friday 9-5 work. This is bad news if you are in a training post. The current generation of trainee doctors are suffering from less experience and on the job training than previous generations. Despite this though, it is my opinion that training here is very high quality – though it is more spread out than the American training, which is shorter and more intense. After all - my training allowed me to go to the USA, work in a very different health care system, work as an attending, and manage some difficult cases on some complicated patients.

The unions also have a powerful grip over the NHS and in my opinion are responsible for a certain element of resistance to change. Whilst the NHS is kept in such a tight grip of government and union control, and politicians work on 4 year cycles I think it will always suffer from poor long term investment, and it will ultimately fall behind the rest of the world in terms of efficiency and patient safety. I hope this doesn’t happen, because I still believe in the NHS. It is ultimately a more efficient way to deliver healthcare – without the costs involved with insurance and billing. It needs to keep up with the times though. It needs good leadership with an eye on the long term plan, without the inevitable bias and baggage that comes with politics. Otherwise it will be run to failure, then privatization.

In the mean time I’m going to start looking for a consultant post in the NHS, and try to do my bit to use what I have seen and learnt from this experience in my practice here. It has been an amazing experience. One that I am very grateful to have been allowed to do. I can’t recommend a year abroad highly enough, and I can thoroughly recommend a year at the University of Michigan. I hope to return there one day and I look forward to seeing friends and colleagues again. As for my blog, this is Dr Ramoray signing out. Thank you for sharing our journey. I hope you have enjoyed the ramblings, and I hope it has inspired some of you to go and explore, broaden your horizons and see different ways of working and living. If you do please share your experiences!

For the last time,

Take care,

Drake.

Dreams come true...

It's done then.

Our year in the US of A has come to an end. For the new bunch of rotators the adventure is just beginning, and we were just a tad jealous meeting them last week.

Last week I finished work, said some very sad goodbyes, cleared out my office desk, packed up and left. The last few months seem to have gone by quicker than any others. Possibly because I've been pretty busy. As always there is never any let up or easing off at work. I was busy right up to the end, as was my very patient wife. On top of our usual day jobs we also had to plan our trip home (including a nice holiday in Florida en route), organise shipping of some of our stuff, pack up the rest, fill out paperwork for leaving, fill out paperwork for starting my new job in the UK, try and find somewhere to live in the UK - (still working on that one), pack our bags, clean up and go. It's been a pretty stressful month. It seems moving home has been more stressful than the move out here. All is good now though. Nothing a bit of sun, sea and sugar coated Disney can't fix.

So the final tally for our year in the States (non-medical readers feel free to skip this bit):

I was the recorded attending anesthesiologist for 1100 cases. About 350 cases were Head and Neck - my chosen speciality here. I learned how to manage an array of difficult airway problems using techniques I'd never used before, as well as brushing up on a few skills I already had. I managed some interesting surgical cases that I'd never seen before - radical head and neck dissections with free flaps; robotic surgery for anything from prostatectomy, cystectomy, even a tonsil tumour - ectomy; bariatric surgery, liver resections, craniotomies for deep brain stimulator insertions to name a few. I've learned to modify my techniques to allow different neurophysiological monitoring like MEPs & SSEPs. I've learnt that you can give an anaesthetic that consists of Propofol, Remifentanil, Isoflurane, Nitrous Oxide and Ketamine all at the same time. I've learned to use new drugs such as Sufentanil, Dexmedetomidine, and used other drugs such as Ketamine a lot more than I had ever used before. I've managed much sicker patients than ever before, with the majority of patients ASA 3 and 4 with multiple medical problems, and a huge list of medicines (and allergies) Everyone in the States seems to be allergic to Sulfa. To this day I'm still not sure what drugs that's relevant for but there you go. I've learned that you can anaesthetise pretty much anyone as long as you're careful. I've also had good experience with managing the larger patient. My highest recorded BMI was 67. I got off lightly though - one of my colleagues had a patient with a BMI of 78.

I've learned to supervise two rooms at once (although I don't think I ever mastered this). It's good though to see different ways of working. I have had plenty of opportunity to teach the residents - some of whom are very intelligent, keen and a joy to work with, others who seem disinterested or think they know it all already. I have found that often residents use confidence to hide gaping holes in their knowledge, and it doesn't take long to work out who knows what they are doing and who needs closer watching. The majority though have been excellent. Intelligent, hard working and good fun to work with. I also interviewed candidates for the residency programme which was a new and interesting experience.

As well as teaching up to two residents a day I've had plenty of other teaching opportunities. I've lectured the medical students (I had a standard lecture on cardiovascular physiology) who are much brighter and much keener than I ever was as a student. I've helped with starting a Simulation course to teach Human Factors to the residents, including programming a scenario in to the Meti Simulator. I gave a lecture and taught on an Airway course arranged by the department. I also supervised some of the residents core teaching sessions and journal clubs.

I've also had some great research experience, including transforming an idea in to a formal research proposal, then collecting and analysing data, and writing up our findings, though it's still some way from being submitted. Hopefully I'll get the opportunity to present it at this years ASA conference in Chicago.

So all in all, I think I have surpassed my objectives for coming here. It is unlikely I could have done all of the above had I stayed in the UK for the last year. I probably could have done most of the above in the UK, but it would probably have taken a couple of years. It's felt like I've had 2 years of training crammed into a year. The reasons are complicated, but the European Working Time Directive and the New Deal have affected working patterns, reducing our clinical experience. There is also a big service commitment to our job, which means lots of night shifts, lots of time covering intensive care or labour wards. I am not saying that this is bad. In fact one other thing I have learnt in the last year is that our training is actually excellent. I was able to come and work in a big academic department in another country at an attending level (the equivalent here of a junior consultant). If I had stayed at home I'm sure I would have had excellent training. But it would have just been more of the same. By going abroad, and in particular the USA I have experienced a whole load of different things. Of course one of my main reasons to come to the USA was for none of the above, but to travel and see more of this great nation.

The places we wanted to visit but didn't include New York City, California, Yellowstone National Park, Hawaii, Oregon and Alaska. We have no regrets about this though, because I'm sure we'll be back. America is too big to visit in a year. Most Americans don't see it all in a lifetime. We've done pretty well though.

We saw a lot of Michigan obviously, and I really think it has a lot to offer. It's a beautiful state with lovely parks and beaches. Detroit is a fascinating city - Sadly much of it derelict, but I'm sure it will be back on it's feet soon. The Henry Ford museum is a must if you ever go there. The beaches on lake Michigan, Sleeping Bear Dunes, Glen Arbor, Petoskey, Mackinac, Taiquonamen Falls, Kensington and Pinckney Parks were our favourite places in Michigan. And Ann Arbor itself of course. Ann Arbor is a great place to live - A city with a town feel, and so much to do there. We also went to the following states:

Ohio, New York, Pennsylvania, West Virginia, Virginia, Washington DC, North Carolina, Tennessee, Kentucky, Indiana, Illinois, Colorado and now Florida. Only 36 states we didn't go to!

It is fitting in a way that we have chosen to end our year at Disneyworld Florida. It is in some ways a small concentrated extreme version of America. Somewhere that you can love or hate, or sometimes both at the same time. A cynical person will tell you all the things to hate about it - it's brash, fake, over commercialised; everything is designed to extract as much money from you as possible; everything is sugar coated (not just the food); it brings out the worst in people - greed and selfishness; it's busy and crowded unless you can afford the VIP treatment. I can't really disagree with any of these arguments. But it's also such a positive place. Efficient and professional yet warm and friendly. Vast and crowded yet with great little places to get away from it all. It brings out the best in people - a sense of community and shared happiness. It is magical and inspirational. A place where "Dream's come true" - (as long as you can afford them). Love it or hate it - it is what it is. I for one hope it never changes. There are things I'd like to change about America, but if I did it wouldn't be America.

I think the American within me has come out a bit more in the last year. I haven't become American, I've always been one at heart. A friend of mine once said that we are all Americans now, we just can't vote there! He has a point. What ever happens in America affects the whole world - just look at the affect of some Americans defaulting on their home mortgages! We look to America to bring the rest of the world out of bad economic times. We rely on America for military security - whether we like it or not. We seem to need reassurance from America more and more. We've grown up watching American TV shows and films and our culture has become more and more American. Whether you like it or not, Britain today is more like America than Britain of two generations ago. If I could bring one more bit of America home with me it would be the optimism and "Can do" attitude to everything. Rather than whinge about a problem, wouldn't it be great if people just went out there to fix it.

What I've come to realise is that politically I am actually more American than I thought too. I don't mean we should legalise guns and abandon the NHS. What I mean is there should be rewards for working hard. People should never be in a position where they are better off not working, thereby staying on state benefits for years and years. Work is good for people and good for society, and to encourage people to work you have to make it worth their while. It shouldn't matter where you are from or what class you are, or what your family did. All that should matter is what you can do. Of course there should be a safety net for those who can't work or who have been unfortunate, but it should be just that - a safety net to help people get back on the show. People should be more responsible for themselves - if you don't like the situation you are in, get out there and fix it. If this sounds obvious to you then maybe you're American too.

My advice to anyone coming here - whether it is to work or to play - is leave any preconceptions and prejudices at immigration (they have plenty here already) and just explore and experience as much as possible. Take it all in, and embrace the American life. I'm sure you won't like everything here, but I'm also sure there is something for everyone here.



So... Will we be back?



Of course! - but most likely just for holidays. To come back to work would mean having to sit the USMLE exams, and jobs and visa are hard to come by. It's not beyond the realms of possibility though, and in true American fashion, If we really wanted to we could probably do it - with hard work.

We'll be spending our last night watching the fireworks at the Magic Kingdom with a few cocktails. We arrive back in the UK on Wednesday 6th April (new tax year). I have 12 days before starting back at work. Looking forward to seeing y'all again real soon and keep checking in - I intend to do at least one more blog after we return.


Hope all your dreams come true!

Drake.

The home straight

Time is flying here. Winter seemed to reach it's peak last week. We had a couple of weeks of really cold mornings - down to -25C on a couple of mornings and -30 with wind chill factored in. At that temperature the cycle to work becomes a race to get there before your nose and fingers drop off.

The snow is now melting, and it's warming up. We had a couple of feet of snow altogether. The boys are very disappointed we didn't get to build a snowman. It's too cold - When it's cold here there is no moisture in the air - and the snow seems really dry like powder, so the snow doesn't stick together. We had to buy a humidifier for the house - I was getting nosebleeds overnight because of the dry air. We'll miss the snow - it's been fun - sledding with the boys, cross country skiing, and skiing in Brighton - just 30 minutes drive North of Ann Arbor.

We also had a holiday in Breckenridge, Colorado. We hired a condo there via VRBO.com - a great website for finding private holiday lets. Breckenridge was awesome. We had a fantastic week, and we will definitely be heading back there. A lot of Brits skiing there said to us they would never go back to Europe after skiing in the USA. I highly recommend it for any skiers. Fly to Denver, hire a car. 2 hour drive from the airport. Rent a condo from VRBO.com or Homeaway.com. Rent ski's from Blueriversports.com. See Breckenridge.com for lessons, passes, etc.


It's unbelievable a whole year has nearly gone. They are planning the annual Rotator leaving party (aka "Go back to your own country" party). A year ago we were frantically making arrangements to come out, and we had already had our leaving party. We are less frantic about the move back to Britain. That's not to say we haven't got a lot to organise. At the time of writing we still do not have anywhere to live sorted out in the UK. The move back to the UK is exciting in some respects, and sad in many others. None of us really want this year to end because it's been such a great experience. It's been intense - like a couple of years worth of experiences squashed into one year. We've worked hard, played hard - it's a cliche, but it's true.

All the rotators here know it won't be the same when we go home. In our time here we've had holidays / breaks to Chicago twice, Las Vegas, Niagara, Washington DC, Colorado, North Carolina & Tennessee, 2 holidays in Northern Michigan and one long weekend on Lake Michigan. We're also having another holiday in Florida before we return to Blighty. As well as the frequent holidays, we've got a taste of the good life in general. Big house, big car, nice city to live in. We've got used to eating out 2-3 times a week, and have got used to big portions and service with a smile (and always having to tip..) . We've got used to beautiful parks and clean streets. Good coffee and crap chocolate. Most of all we've all made very good friends - who no doubt we will keep in touch with, but we will be sad to say goodbye.

In work we have got used to more responsibility, and also more respect. We are not treated like children, but like professionals. In return we're expected to act like professionals. It's not uncommon for us to be working later than our official hours here to make sure that all the lists get finished (Cases never ever get cancelled because we ran out of time). In return we are paid well for our extra hours, and we get fed (Usually 30 pizzas from the local takeaway). We get fed a lot here at work. Bagels or yoghurts from breakfast every day, Fruit and danish pastries every Thursday morning with the M&M meeting. There is often a free lunch, and pizza or mexican in the evenings if you're here late. And of course there is Starbucks filter coffee on tap all day long. We have a nice on-call room for our on-calls. The residents have on-call rooms too. They realise the importance here that even on a night shift, a short sleep and a break helps you function.

I'm worried that because we've had such a good year I will have to come back down to reality with a thump. It's not just me - it's a sentiment shared by all the rotators. A fear of going back to normality - back to "life before". Back to a small house, small car, eating out less, fewer holidays, nights shifts, no on-call rooms, less responsibility, less respect, less money, and all the latest pointless tick boxing exercises forced upon us by the government.

In a way I think the differences illustrate the difference in how the US and UK societies value their doctors and healthcare in general. In the US people pay a lot for healthcare. They pay huge insurance bills, then often have to pay co-payments on top of that. They know it is expensive. Perhaps because of that they value it more. The doctors earn a lot from healthcare. They justify this because of the amount of personal money and time they have had to invest to become doctors. The doctors here get a lot of respect from the public in general because people know they have worked hard to get to their position.

In the UK society has become used to free healthcare. Very few people understand the true costs of their treatments. Fewer and fewer people appreciate what they get from the NHS. Those that do value the NHS are often those old enough to remember the days before the NHS. Everything is expected to be provided for free. Perhaps because everything is free it is undervalued. Doctors have invested just as much time (although admittedly less money till now) to get to their position, but earn substantially less. Doctors in the UK are still relatively well paid, but when you compare doctors earnings in the UK with other professionals, and doctors earnings in other countries against other professionals it appears that in the UK we are relatively undervalued. I'm not just talking about doctors, but healthcare in general. And it's not just about the money either. We put up with worse and worse working conditions and are powerless to complain about it. We don't even get tea or coffee or milk provided anymore. No hot food after 8 in the evening. No on-call rooms. Over crowded office space. Small, cramped and dirty changing facilities.

Of course going home is not all that bad and every cloud has a silver lining - and I can't wait to go to a nice pub and drink a nice warm beer, eat a big roast dinner with yorkshire puddings, watch some rugby, go walking in the welsh mountains, see the sea, drive on proper roads. In work - I'm looking forward to doing my own cases again, and doing my own procedures rather than supervising most of them. I'm looking forward to doing my paediatric module, finishing my training and getting my CCT. And of course I'm looking forward to catching up with all my friends, family and work colleagues.

It's not over yet of course - and we're determined to make the most of our last 6 weeks or so. I'll be working for most of it - I've got my research project to finish off and write up. I'm hoping to present it at this years ASA conference in Chicago. We've got 10 days in Florida before we return to the UK though which will be a great way to end the year.

That's all for now - Keep checking in -

Drake.

Happy New Year!

Apologies to all my blog readers for the lack of blogwork over the last month or so - hope you had a great Christmas and Happy New Year. I've been keeping busy - as I'm sure you have. December was a great month. Quite possibly my best yet!

Since my last entry we had a fantastic Thanksgiving Day party hosted by one of the other rotator families, we've had not one but two trips to Chicago (courtesy of a bargain on hotels with priceline.com), we've been sledging and cross country skiing, we had an awesome Christmas hosted by another rotator family, we also had a lovely 4 course fondue meal on New Years Eve, and a New Years Eve party hosted by yet another rotator family. We've also had quiet nights in front of the log fire with a bottle of Napa Valley's finest and occasionally I've been to work.

"The Holidays" are a great time to be here. America does holidays well, especially Christmas. Decorations and lights, Santa Clauses and Grottos, Candy canes and Gingerbread houses, Egg Nog and Gingerbread Lattes (and my personal favourite - peppermint mochas. Yum!), Turkey and trimmings, Log fires and Gigantic Christmas trees... Just like the movies.

For those, like me, who love their home comforts it is possible

to find proper Christmas pudding and mince meat for mince pies - though they are not easy to come by. Christmas TV wasn't quite the same, although if you are moderately technologically minded it is quite easy to set up a VPN (Virtual Private Network) on your home computer that will allow you to watch BBC iPlayer from the USA (normally it blocks foreign access).

On the plus side of course, there is snow - an essential ingredient for the perfect Christmas. Lots of it - although not as much this year as there was in Wales - typical! We were very excited about it and couldn't get enough of it, after growing up with grey drizzly winters for most of my life. It's made the 12 minute cycle to work a bit more interesting. Previous rotators have developed a guide to cycling to work through the winter, as most rotators with families don't buy a second car here, it is the only choice. It's really not too bad as long as you're prepared. Essentially you want to make sure every inch of skin is covered. So far the coldest it has reached since I've been here is -15 Centigrade. It has been known to get down to - 28. That's frost bite territory! The wind chill can also really make it much colder too. I've been told to cover up or risk losing bits of body...

There is a list of essential equipment to buy that includes:

Snow tyres for your bike (metal studded tyres) - As well as the cold, there is also the risk of slipping and breaking some bones of course. They're great in the snow, but not so great on black ice as I found out,

Thermal underwear - best $$ I've spent since arriving!

Good thermal breathable tops,

Waterproof breathable jacket and trousers,

Balaclava / Woolly hat, neck warmer,

Snowmobile goggles (like ski goggles but not tinted - as it's dark on the way to work and usually on the way home too)

Really good thermal, waterproof gloves or mittens,

Good thermal socks (some people say not just for the feet, but I haven't had to do that yet),

Snow boots - thermal and good grip.

I spent about $650 on thermal clothes. They work though. The only problem is when you arrive at your (heated) destination you have to strip as quickly as possible before you overheat. They will also come in very handy for future skiing holidays.

Speaking of which - the Ramoray household is very excited about another vacation in a few weeks. We're going on our first ever skiing holiday - to Breckenridge, Colorado. Flights from Detroit are about $220 return, and we have found a bargain condo to rent online. There are some Ski resorts in Michigan which are apparently quite good. We were originally planning to go there instead. The two main resorts are Boyne Highlands and Crystal Mountain - both roughly 4-5 hours drive away, so close enough for a long weekend trip. In the end though it worked out only slightly more expensive to go to Colorado for a week.

It's funny how every time it snows in the UK the news is of catastrophe. The country has come to a halt. Airports are closed. Travellers are stranded. Roads are blocked. Councils have run out of grit. Etc. Then someone always pipes in and says how shameful it is when other countries manage perfectly well every year it snows. Well, it's true - no catastrophe here. But not because of the government that's for certain. The council here doesn't run out of grit probably because it doesn't seem to bother with grit. For weeks after it snowed all the roads in Ann Arbor still had a thin layer of super slippy compacted ice. I was amazed that the roads weren't gritted or cleared at all. Not even the main interstate between Chicago and Detroit which was a bit of an ice rink on our more recent drive back. I had to walk instead of cycle to work for 2 weeks when the roads got really bad. Yet there was no news of disaster, no despair or panic. I'm not sure why, but I suspect the difference is purely down to the population here go through it every year, so they make much less fuss about it. It snows, the roads

are treacherous, so just be careful! No big deal. Oh, and most people seem to have a 4WD which probably helps a bit. We love our big 4 WD. It's a gas guzzling beast, but if I could afford to fill the tank in the UK I would seriously consider shipping it home.

It has also struck me this last few weeks that my time here is getting near the end. 2010 went so quickly. It's been a great year in and out of work. I've seen a lot of America, and I've had the chance to see some amazing Medicine in work. You really feel at the cutting edge of health care (so to speak) when you're here. Robotic surgery is a big thing here, and is the next big thing after laparoscopic (key hole) surgery. For more details take a look at www.davincisurgery.com

At home keyhole surgery is limited to Gallbladders, diagnostic procedures, appendicectomies, sometimes colon surgery and a few other things. In the last month I saw patients having their tonsillar tumour and also a thyroid gland removed by robotic key hole surgery. The thyroidectomy was particularly interesting as the incision point was via the arm pit. Now I know what you're thinking... WHY??? Well - that's what I was thinking anyway. The thing is, in a competitive private healthcare system, you always have to offer something above the competition. One of the problems with a thyroidectomy is a scar at the front of your neck where everyone can see (unless you wear turtle neck jumpers for the rest of your life - which is probably worse). Now you can have your thyroid removed with no visible scar. If your insurance will pay for it - why not? People probably questioned laparoscopic cholecystectomies (Keyhole gallbladder removal) when they first started doing them. Now they are doing them endoscopically in some centres - so no scar at all. It really is fascinating, and feels great to be part of. It's more expensive of course, but that's not a problem if someone will pay for it. How long before someone declares it a travesty of justice that robotic laparoscopic thyroidectomies aren't available on the NHS? Of course if I was employed by the company that sold the robotic equipment, I'd be outraged that anyone would consider any other type of surgery.

Thats the thing about healthcare. Everyone always wants the very best, but it would be impossible to pay for everyone to have the very best. It would be like all travellers going first class, or all hotels being five star. If that were the case then 5 star hotels and first class travel would have to be more like economy class and 3 start hotels. I know this is a statement of the obvious, but nothing annoys me more than people complaining about drugs or operations that are unavailable on the NHS. The NHS is great because what it manages to provide for everyone is actually a very good standard. There will always be those who can afford it who will search for bigger and better though. Of course if politicians had any balls they would just state clearly what the NHS will and won't pay for. Then if you want something that's not on the list you pay for it yourself or you pay for extra insurance. Unfortunately politicians like to perpetuate the myth that everyone can travel first class and stay in five star hotels.

The reality is most people are quite content with economy flights (and bargain condos booked online). And are still very grateful for it. After all, they still get you there!

My other mission this month is to try and find a pub in Ann Arbor that will show the 6 nations. I will let you know how I get on with that and with the skiing.

Thanks for listening,

Till next time, Drake.

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!"