True mumblings, from a junior doctor...

Chestnut Avenue

Chestnut Avenue is dead, long live Chestnut Avenue.

So for some reason the beautiful arcade of horse chestnut trees that lined Tooting Bec Common's middle road have been removed and replaced by new ones. Whether it's because ALL of the old ones were rotten or (more likely) new trees need less maintenance I don't know.

It does now however look weird.

The council are not popular.

17° Mostly Cloudy
Tooting Bec Road, London, England, United Kingdom



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Curse of the Trauma Centre


Major Trauma Centres are the pinnacle of modern evidence based care for those unfortunate enough to be involved in significant trauma.
However
The hospital that contains the MTC is hamstrung (cf Royal London, St Mary's) with constant lack of TU and HDU facilities.
Why is this? It's because trauma is never ending, and you triage up not down, meaning that cases previously treated in a local A&E now end up at the shiny hospital. All well and good if the care and outcome is better provided that someone has remembered to plan appropriately.
Of course, in the UK we have tendered low bids and come up short. Trauma is a disease of the young predominantly. These patients survive horrendous injuries, and in the case of head injuries their bodies function very well. This means of course that they take up beds. For extended periods of time. WHich no one has thought about. The budgets for these MTCs are for a couple of patients in ITU and a few in an HDU setting (<20%). In reality the patients often occupy >50% of the critical care beds at any one time. This leads to elective cancellations, higher patient load elsewhere and speedy step downs. This then leads to worse outcomes all round.
If they had been honest when planning then this would be sorted, as the money would have been utilised to make a proper team and wards and critical care capacity. But obviously no one did "cos it can be done for less than that". Then all the staff pay with their sanity.
51.5167° N, 0.175763° W
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Next steps in research

So what now then?
You work hard. You get your PhD in clinical research. You fancy doing more. You work hard again, but this time on your own time only.
You eventually get the opportunity to take the next step up. You apply. You interview. You are lucky enough to get the job.
Now you're a lecturer. What the hell are you meant to do next?
Research, obviously. But what and how. That's the key, as you need to start making your own waves, making your own noises. Pushing your own agendas.
So how do you do it?
Well, first part is making a game plan - what do you want to investigate? Then, how do you want to do it? What is the boss going to allow you to do? How long will it take. How much will it cost. Where is the money coming from.
Once you've answered all of these tricky questions, you merely have to do it.
That's easy.
Right?
13° Mostly Sunny
51.5229° N, 0.15717° W
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Surgical Training?

Why is Surgical Training so Brutalising?

Surgical training is learning how to be abused. Registrar's are treated like subhumans.

Often they are treated to such conflicting advice as:
"In my day we didn't get trained like you guys do. We just had to learn from our mistakes"
and
"I did hundreds of hours more of operating than you - how on earth are you going to be experienced enough?"

So what do they want? Hundreds of training cases or thousands of non-training cases? I would suggest that like in sport, a few hours with an appropriate trainer unleashes far more than many hours with an inappropriate trainer.

As one of my excellent trainers has said to me (and he learnt it from his golf pro):

"What does practice make?
Permanent.
Perfect Practice Makes Perfect!"

So why do we persist in making surgical registrars run the gauntlet? Long hours, aggressive trainers, service provision in clinics and lists, administration duties and a wish to break them down? Is this a plan to make the infantry better?. Except with (in theory) the brightest and best?

Now some places have moved into the 21st century with supported training, gradually increasing responsibility and appropriate compensatory rest.

It is inevitable that trainees do more and more as the time goes on, but there has to be give and take - the boss still needs to supervise, and maybe take on more of the admin duties so that the clinical aspects can be taken care of. This is done by the very best trainers and trainees in tandem. They understand that time has moved on and that medical expertise is far more in depth in certain areas, and what they were taught is often no longer of interest or importance. Instead of one option we now have 10 or 15 to know and understand. Intensity of work is far higher with huge levels of oversight and reporting of outcomes. There are no dark little corners anymore.

So where does that leave us then? With hundreds of type A personalities that have ground their way through to be at the top, training a cohort of people who have morphed from pure type A to a more relaxed (but still intense) generation. This is a generation where work does not equal life. Where family is important. A generation who realise that they have to work until their 70s, and yet will still be poorer than their parents. A generation where nothing is certain or triple locked.

The balancing will happen, but it will take time, and there will be significant wastage of excellent trainees who are not willing to put up the abuse and mundane. The ones who will trade long hours and no recognition for high salaries, happy lifestyles and stress due to poor sales not dying patients.

One day we will look back and wonder if we could have seen it coming. We could and we did. No one was listening to the canaries.

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Cleaning Up London’s Air - What Should We Do?

Living in London and walking my daughter to and from the childminder with a current chest infection makes me acutely aware of the difficulties smog poses in London at the present time.


London is a busy place, with millions of people milling around.  Buses and cars take many people to office jobs that could be done from home.  Lorries deliver produce and goods in addition to huge carbon loads and smog.  The new bankside towers prevent any form of airflow, whilst encouraging massive polluting trucks.  To show how bad things are we have the [The London Air Network](http://www.londonair.org.uk/london/asp/nowcast.asp) which has an updated daily pollution map.  Not sure however how this correlates with the ridiculous humidity that 8.75 million people generate - currently 60-80% every day.  This is why so many articles pop up in regards to early deaths and long term morbidity due to the air: [The London Standard in April 2016 for example](http://www.standard.co.uk/news/london/1000-londoners-killed-in-four-months-by-the-capitals-toxic-air-a3235841.html).


So what is the much vaunted devolved Mayor doing about it?  Well let's see - the [Mayoral Website](https://www.london.gov.uk/what-we-do/environment/pollution-and-air-quality/air-quality-and-health)  and the [Mayor's Air Quality Fund](https://www.london.gov.uk/WHAT-WE-DO/environment/pollution-and-air-quality/mayors-air-quality-fund).  It *looks* as if things are being done.  Slowly.  And frankly **not** enough.


What do I think should be done?


1.  I think that all internal combustion engines should be banned from within the M25.  Within the M25 only zero-emissions vehicles are allowed.  [Tesla](https://www.tesla.com) has shown what is possible with its amazing cars and its development of batteries and solar grids.  Obviously this will require some changeover time.


2.  All taxis and buses should be converted to zero-emissions.


3.  All new private hire licences (and renewals) must to have zero-emissions.


4.  No parking permits or registrations are allowed for emission cars in London.


That sorts the cars (in theory) but what about the electrical use of these huge glass tower blocks?  There needs to be a requirement for them to use glass such as these [Solar Panel Windows](http://planetsave.com/2015/09/05/solar-power-windows-ready-for-production/).  The Solaria ones look especially good [Solaria](http://www.solaria.com).  Now if all council buildings and new developments were to use these the amount of energy generated would be immense.  And reasonably free in the long term scale of things.


We really need to be pushing forward on this and frankly no one in government has any idea or any will to do so.




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Read by QxMD another app of use

I've been using this as a journal article reader for some time now and think I should probably tell you all about it.
"Read" by QxMD - really good place to select the journals you want for it to scrape the online first sections and bring you up to date and fresh research. Works on iPad and iPhone.
Overall it's actually really nice - you need an Internet connection to use it, but it caches each journal as it goes. Not perfect, but definitely the best I've seen for discovery.
Download here: http://qx.md/read
From there bit:
"'Read by QxMD' provides a single place to discover new research, read outstanding topic reviews and search Pubmed.
A really simple interface that drives discovery and seamless access to the medical and scientific literature by reformatting it into a personalized digital medical and scientific journal. Only 1 tap to download full text PDFs!
Free iPad and iPhone download: http://qx.md/read"
21° Mostly Cloudy
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Apple MacBook

New MacBook…

My wife needed a new computer. So we eventually decided on the excellent little MacBook. It is a remarkable device and truly the future for Apple Laptops. Tiny, with excellent battery life and wonderfully quick, despite the size limitations. Keyboard is actually really good and takes no time to get used to. The SSD is a revelation, despite me having an air and a pro with a hybrid drive.

Fantastic.

I expect the next fews years to be split into:

MacBook
MacBook Pro (suspiciously similar to Air)
Mac (previously 5K iMac)
Mac Pro (with multiple 5K screens).

17° Mostly Cloudy
London, England, United Kingdom



Sent from my iPad mini
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Xenosys Surgical Loupes

**Xenosys Surgical Loupes**

R & D Surgical and Xenosys have just supplied me with the most amazing set of loupes.

They are not free, but you get what you pay for.  Beautifully light, perfectly adjusted for me and frankly a snip at the price.

I got a pair of the Looks 2800 - 2.8x with a massive field of view, and only something stupid like 50-60g!

I would recommend them unreservedly and R&D were fantastic.

Stitching is already better!




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RSM Venous Forum 2016

Busy day indeed.

Final sessions of the Joint meeting of the Royal Society of Medicine Venous Forum and the European Venous Forum held at the RSM in London this year.

An excellent meeting with lots of delegates (it was full!) and I had to judge a session of eposters. Still in the teething stages that session, but some excellent presentations.

The big thing this year, as in recent years, is the explosion of treatment options and rationale for deep venous disease. It's a little like the Wild West, but now with the internet nowhere is can go off-piste. Which is definitely good, but also hinders development as often the mistakes and hunches are the options that prove the best.

Overall though a really good meeting, which will hopefully encourage more younger trainees and fellows into the venous world.

A good bit of coffee networking and catching up prior to hot footing it across town to get my shoes fixed and phone repaired.

22° Mist and Fog
51.4724° N, 0.122501° W

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Arrival of the LOOPY Case

Arrival of the loopy…

Only just got it (and smashed the screen just before it arrived too) but already I think it's a keeper - excellent feel and great little stand. Not sure what I think about when I want to put it down properly, but so far has worked very well.

I got the green one.

Obviously?

51.4529° N, 0.147573° W



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