by Dr. R I Davidson FRCA
Visiting Instructor in Anesthesiology
“I am 4' 11", my wife weighs 350 pounds (including her wooden leg), and we have three obnoxious brats in tow,” is how I described my family to Dr. Doug McLaren, who had rashly agreed to pick us up from Detroit Metropolitan Airport on our arrival in the USA. Of course, anyone who has subsequently met us will realize that this description is not entirely accurate, as I am 6' 4".
On my first day of work after a week of acclimatization, I entered the University Hospitals through the Taubman Center (which looks uncannily like the Hanging Garden’s of Babylon). The immediate contrast to my previous place of work, St. James’ Hospital in Leeds, was remarkable. St. James’ had originally started as a workhouse for the poor, ultimately ending up as the largest teaching hospital in Europe, but the U-M Hospitals positively oozed opulence and reeked of money!
Spending the morning filling in forms with Jenny Mace, my eyes rapidly glazed over as I reached information overload. There was, however, an entertaining interlude when a tall chap with a mustache and a Californian accent burst in, offered me a handshake and warm words of welcome. On his departure I turned to Jenny asking, “Who on earth was that?” To which she replied in reverential tones, “That was the boss.” (OOPS! Close one, but I think I got away with it!)
I was broken-in gently on my first clinical day, with strange anesthetic machines, and even stranger drug names, which when translated were in different concentrations from back home. The surgeons seemed extremely bizarre, and I couldn’t even begin to comprehend the healthcare system, although I was beginning to realize that money was the driving force. Still, at least the case was only a hemi-hepatectomy in an ASA 4 patient! I was thankful I had the resident to fall back on. Wrong again! The CA1 was on their first day of anesthesia. Anyway to cut a long story short, the anesthesia resident, the patient, and myself all survived the ordeal pretty much intact, give or take half a liver.
There was no on call for the first month; divine! Except for the obligatory general call on the first holiday available, Labor Day; the significance of which incidentally, you Yanks were woefully in the dark! (Perhaps I should leave that bit out, or I’ll be working Thanksgiving as well!)
The day started off reasonably enough, although my pager started to give me clandestine messages such as 911, which I thought was a bit curious, especially when I tried calling the extension number. All became a little more obvious a few minutes later when I got the message, “Dr. Davidson, STAT OR 12”. (Hey, was this like ER or what?) I ran straight past the anesthesia chief resident who was going in the opposite (and correct) direction, clutching an armful of Cordis catheters, and giving me a rather bemused look. Using my initiative, I decided to follow him into the appropriate OR, to be greeted by a scene of unbelievable bedlam with everyone shouting excitedly at once, and very few doing anything remotely useful with the patient seemingly oblivious to the pandemonium. As I was unable to get anywhere in the proximity of the patient, but could see he was conscious and breathing, I did the most useful thing I could think of in the circumstances, sign the charts!
Over the remainder of the year it would seem that I am to join the liver team. I have done one or two livers back in good ol’ blighty, but was required to demonstrate my prowess prior to my official inauguration. So far, in the last couple of months I’ve been involved in about eight transplants, and have forged a number of close relationships with my surgical colleagues who are universally renowned for their wit, charm and charisma.
I endeared myself to one in particular, during a moment of light-hearted banter, by asking if he had had the opportunity to see transplants done anywhere else other than in the US, although I’m not sure if this was taken as it was intended.
Apart, of course, for the chance to be involved in anesthesia at the cutting edge, the other attraction of the liver team was a meeting held at the West End Grill. My initial thought was, “wayhay! Nice one Doug!” I thought the agenda laid out at each place setting was a convincing touch, but there followed such erudite discussions of pure academia that I was rendered speechless by the end of the evening, and for much of the next day too.
The remainder of the last two months here has been without such intense excitement, although equally entertaining. The contrast with practice in the United Kingdom is remarkable. Essentially, in the UK we have later starts, and get more work done during the day. We have an ODA (operating department assistant), which is like your anesthesia tech, but there is one allocated for each OR. They are present in the OR throughout the list and have the role of generally assisting the anesthesiologist with intubation, line insertion, etc. We also have anesthetic rooms which are nice and peaceful, with all required equipment at hand. There is no holding area, and the patients are brought directly to the anesthetic room where they have lines or blocks inserted, anesthesia induced, and the patient positioned with the help of the surgeon prior to going into the OR. Incidentally, operating lists take account of anesthetic time. On arrival in the OR, the surgeon is invariably already scrubbed, and knife to skin is virtually immediate. Generally the surgeon keeps to their side of the blood-brain barrier, not interfering with us endeavoring to keep the patient alive, while they concentrate on trying to inflict mortal wounds.
While in the UK we appear to be without any restrictions in terms of anesthetic drugs, there is much more consideration of the cost implication in the US. Conversely, you have much more extensive equipment stores in terms of level one infusers, Bair huggers, infusion pumps, etc. In the UK, we tend to have to share less equipment between more operating rooms. We use more colloid, while you use crystalloid. You have CRNAs, we don’t. You have Rotweilers in PACU, while we have demure nursing staff. You say 'tomaydo' we say 'tomahto'. You get paid more money than us.
The one most striking difference across the pond is the inordinate amount of time any surgery seems to take here, without any obviously better results, although I suspect the same observations could be made when comparing the working practices of teaching hospitals and private hospitals in the US.
You may recall that I brought my family with me. All in all I think we’ve coped pretty well with your strange accents, driving on the wrong side of the road, etc. (which is pretty curious, don’t you think, as you are a former colony of ours?) I even managed to pass the State of Michigan driving test, assisted by the immaculate timing of Princess Diana’s demise, enabling me to use my 'when I met Diana...' story, to distract the examiner. The vast majority of natives have been more than welcoming, although there have been a few alleged incidents of quite breathtaking rudeness, predominantly from the surgical residents.
The children have now settled at school and tell me they would like to stay in America. They are even developing American accents. More disconcerting is that like my fellow Brits, even I have started coming out with phrases such as, “good job!” and, “way to go!” My wife’s social life appears to have taken off exponentially although she did get the blues around day ten in the US, when she organized to go to the Ann Arbor Newcomers meeting in one of the local parks. She was the only one who turned up. To make matters worse, when I returned home, I found her in a bit of a tizzy as I apparently had not been answering my pager all day. It turned out, when asked for the ID, she had spoken my pager number into the telephone (presumably followed by the pound sign), prior to hanging up. Good grief!
Yup, all in all first impressions are extremely favorable. You have a great working environment, in a lovely city, and an extremely well organized anesthesia residency program. I look forward enormously to the remainder of our year here. But just one question, why do Americans reply to a thank you with, “Uh huh”?