Tuesday, 27 November 2007
It’s around 03:30 and it’s time to go home. Me and my mates are in the taxi queue and it’s bloody freezing. All of us who are waiting are shivering, jumping up and down or huddling with friends to try and keep warm. The usual late-night banter is going on there’s the usual last-gasp efforts to try and pull and take someone home that evening.
Behind me in the queue is a rather attractive tall, young lady with her friend and behind them are a group of three guys. One of the men suddenly says to the tall girl.
“Oh my God! Look at your foot!”
The young lady has a small cut on the top of her foot that has bled. She’s wearing strappy high-heels so you can clearly see rivulets of dried blood across the top and down the sides of her right foot. The lady herself is pretty oblivious to it, like the rest of us, she’s more concerned with keeping the hypothermia at bay.
“You’re BLEEDING!” he continues.
She looks at him impassively, “Yeah, I know”
“You should go to hospital!” the man urges
A little alarm bell goes of in my head and I decide to cut in. “No, she doesn’t,” I say.
The man fixes me with a look. “Yes she does! Look at her foot, man.” He looks at her foot again, eyes nearly bulging out of their sockets. “You should go o A&E, you might bleed to death!”
“Look,” I say. “You don’t need to go to A&E, you just need to go home, wash your foot and put a plaster on it.”
I think that a little common sense can often go a long way.
Friday, 23 November 2007
"If you are a junior doctor, you now belong to the only profession in the developed world where you can be REQUIRED by contract to work a basic 91 hours in a week 'on-call'. When you work nights over Christmas and New Years you will be the lowest paid person in the whole hospital per hour (roughly minimum wage).
This group is for everyone who has been on call, on ward cover, or carrying a bleep of any kind. At medical school you longed for the day when you could carry one, and be a REAL doctor, didn't you?! Now you think of a few places you would like to shove the irritating, noisy, crappy bleeping thing...
We all love nurses, because they do the jobs we hate, and look out for us when we are just learning. They also gave the correct dose of drugs when you accidentally wrote milligrams instead of micrograms on your first day. We need them. But...
...there are a few points of etiquette that are unwritten, unspoken, but you just wish every nurse read, understood and inwardly digested:
1. Bleeping is not a spinal reflex. Please take a few seconds to breathe, think and organise your thoughts, and stop flapping about. Half the time you may realise you didn't even need to pick up the phone.
2. Mention what ward you are on. I don't have the whole hospital directory of numbers memorised. This is called the 'bingo-bleep'.
3. If you bleep someone, please wait by the phone. How can there be no-one picking up the phone at your end when I ring back?! This is called the 'bleep-and-run' and is exceptionally irritating.
4. Have the notes, obs chart and drug chart in front of you. Chances are I need to know what the obs were without waiting for you to run over to the bed and look, then run back over to the trolley to get the notes when I ask the next question. This is called the 'relay-bleep' and is probably not fun for you.
5. Please mention the name, age, and working diagnosis of the patient. The following is not acceptable: "Hello doctor, please see patient in 4, 6, she has chest pain". That is 'bleep-spam'
6. All patients with chest pain need an ECG. Don't bleep me until one is being done or there in front of you.
7. If I'm in theatre (surgery), leave a clear message. The following is not acceptable: "Can you come to the ward afterwards, there are a few things to do". This also counts as 'bleep-spam'
8. Once in a while I will not respond to my bleep. This is because I am jumping on top of someone's chest trying to save their life. I am NOT 'on break'. Doctors don't have these.
9. Please check with the other nurses that you aren't asking the same question as them. I really hate being bleeped from the same ward from two phones and two nurses for same patient. This is called the 'déjà-bleep' and is distinctly un-fun
10. You spend twenty times as much time with each patient than we do. We appreciate your opinion and pertinent information. The following is not acceptable: "Well you're the doctor, you should know". Well actually I'm on call and have never met this patient who has spent 5 weeks with you.
11. Please be cheery on the phone and perhaps even flirt a little. I've just spent 12 hours running around the hospital doing mundane tasks, talking to angry relatives, putting my finger up bums, taking blood and ordering xrays. You will get your way far easier by making me smile.
12. When I answer the bleep please don't say 'Oops, sorry I had a question but not any more". This is called the 'fart-bleep' and gets on my nerves (See also point 1).
13. Please don't ask me to see virtually every patient on your ward. That's called a ward round.
14. If you do cannulae on the ward regularly you will be my favourite nurse and I will do anything you say.
15. If I answer my bleep and the line is engaged because you are bleeping me from that phone again, I may well explode. This is called the 'torpedo-bleep' because of its incessant battle with my morale. Three hits and the boat may sink.
16. If a patient has died, he/she no longer cares how long it takes me to get to the ward. That's a medical fact. Chances are I can do a few other jobs on my way there. If you bleep me again for this patient it better be because they have miraculously come back to life. This is called the 'Lazarus-bleep'
17. The 'MEWS / EWS / EWSS / PARS' score is a trigger for you to call me and is useless after that. I don't give a crap what the score is. Tell me WHY the patient has scored it (e.g. respiratory rate? BP? heart rate?).
18. Please don't start a sentence "Just to let you know..." or "Just so you know..." I hear this 50 times per shift. This is called the 'zombie-bleep' and you have just inadvertently disengaged my brain.
19. Please don't make the person who picks up the phone have find to you from the other end of the ward. This is called the 'bleep-and-hide' (See also point 3).
20. Don't have someone else (e.g. a student) bleep for you. It's cruel to them, and they are not your secretary. This is called the 'kamikaze-bleep' (see also points 4, 5 and 19)
21. Dosing a patient's warfarin (whom you have never met and don't know their history) at 4am is horrible, tedious, legally dubious and just plain bad for the patient. Please slap the day team round their faces when they arrive the next morning and don't let it happen again.
22. Sit down! You may be surprised with how much this helps points 1, 2, 3, 4, 5, 9, 11, and 19
23a. If you happen to have a spare moment, eavesdrop when a doctor bleeps another doctor. The majority of the time you will see how it should be done.
23b. Sometimes point 23a doesn't work because the doctor is a week old and still learning the 'etiquette'. He/she will learn very quickly as their senior on the other end shouts them down!
24. When a patient is in an ACUTE confusional state, please do not repeatedly ask me for, or demand sedation. This is not the year 1912. I might give sedation AFTER ruling out an infection, over-medication, drug withdrawal, metabolic cause, trauma, neurological, hypoxic, endocrine, and vascular causes, and AFTER using every other method of calming down the patient.
25. Read the latest entry/entries in the medical notes. Your question may be answered already (see also points 1, 4, 12, 13)"
Thursday, 22 November 2007
“What’s the matter with you?”
“Huh?” I reply, bleary eyed and only just coming back to consciousness. The time is about 4am and I’m a second year medical student. I’m in the bed on my girlfriend at the time, but I can tell that she’s really pissed off and (not for the first time) I have no idea why.
“All you do is fidget, fidget, fidget all night bloody long! You keep kicking me and nicking all the fucking duvet! I never get a decent night’s sleep when you’re here. Why can’t you just KEEP STILL?!?”
Though I was only semi-conscious, I’d learned not to mess around when she used that tone of voice and I considered myself told off.
I was with my consultant in the anaesthetic room today, and we’d successfully put our patient, Mr Elwood, to sleep. She turns to me and says “Have you seen any femoral nerve blocks being done?”
“Yes,” I reply “but I’ve never done one myself.”
“Well, now’s your chance. Tell me, how would you go about doing it?”
“I’d get a nerve stimulator and an insulated needle, then I’d draw up 30ml of 0.25% Bupivicaine and flush the needle through. I’d sterilise the area and I’d feel for the femoral artery. I’m go 2cm lateral and 2cm caudal to the pulse and push the needle through the skin. I’m looking for twitching of the quadriceps at the patella and if the twitches are present between 0.3 and 0.7 mA, then I’m in the right spot and can inject the local anaesthetic.”
“Very good, go for it then.”
I’ve got the needle in the top of my patient’s leg but I’m getting twitching of the adductor muscles, not the quadriceps. I angle the needle to the right a little and his kneecap starts twitching.
The consultant turns the amplitude down to 0.3 and the twitches cease.
“That’s perfect,” she says. “You know the tip of the needle is in exactly the right spot. Now, all you have to do is KEEP STILL while I inject the Marcain.”
I take a breath out and hold it. I manage to keep myself, my hands and the needle perfectly still while the consultant inject the anaesthetic.
Three hours later, on the orthopaedic ward:
“Hello there, Mr Elwood.”
“Oh, hello doctor.”
“How are you feeling?”
“Not too bad, I’m a bit tired like, but I’m alright really.”
“Do you have any pain?”
“No, not really”
“How’s the knee feeling?”
“It’s fine, it feels a bit numb, like you said it would, but it’s not sore or anything”
(This means my femoral nerve block is working perfectly.)
“Fantastic, well I’ll leave you alone to have a rest. I reckon you’ll need it because the physios will be after you tomorrow. I wish you all the best, sir.”
“Thank you very much doctor.”
And I went home feeling very happy. I wonder if my mother and my ex-girlfriend would be proud of me if I told them how I’d finally learned to KEEP STILL…
Monday, 19 November 2007
I drive to work every day. I do what’s known as a “reverse commute” in that I live in the city but travel to work in one of the surrounding towns where the hospital is. This means that I miss the bulk of the rush-hour traffic because I’m travelling in the opposite direction, but, despite this, driving to work, is still a slow process that tests my patience on a twice-daily basis.
Environmetal groups seem to have the media in their pocket these days. You can’t open a newspaper or turn on the T.V. without being lambasted for putting your keys in the ignition. Our prime minister was at it yet again today. This ongoing guilt-tripping, coupled with the forever rising cost of petrol, made me decide to attempt to get to work without the car today and it was actually quite an interesting experience.
To be fair, for me, my car is a choice, not a necessity. I have a train station literally at the end and trains that take me the 15 miles to New Town run every 10 minutes at peak times. At the other end, the buses that go to the hospital are every 10 minutes as well. I don’t even need to look at the timetable!
So here’s my thoughts on going green and ditching the car for a day:
The first thing to note is that the door-to-door journey time is 15-20 minutes longer if I go by train. This may not seem a lot initially, but it’s the difference between leaving my house at 07:00 and 07:15. I’m not a morning person at the best of times and losing that quarter of an hour first thing puts bed and breakfast in direct conflict with each other.
Result: Car Wins
The council here do a quite nifty thing where you can by a regional travelcard that lets you travel around all day. This has the dual benefit of both being cheaper and not having to faff around trying to find loose change to give the bus driver at the other end. The travelcard cost me £4.50, which is about 50p more than the petrol costs of driving to work and back. I suppose, if I were to give up my car completely, the train would be relatively a lot cheaper because I’d save an awful lot of money on road tax, insurance and maintenance: but I’m not going to give up my little car just yet.
I don’t know if any of you listen to radio first thing in the morning. If you do, you’ll agree that it’s shit. If I try tuning into Radio 1, my journey will consist of listening to Chris bloody Moyles laughing at the same unfunny joke for 40 minutes until I turn it off again. The CDs in my changer get boring after a while, so I’m spending more and more journeys in silence. On the train, the story is different. My mp3 player holds literally thousands of songs, so I can listen to whatever the hell I like. It’s much more enjoyable. It’s also got a radio on it, so in the unlikely event of me missing Moyley’s dulcet northern tones, I can tune in if I want to.
Result: Train wins
I suppose this is obvious but it’s worth stating that taking the train means I DON’T HAVE TO DRIVE. I’m not one of these people who finds driving for the sake of driving an enjoyable or worthwhile thing to do. Driving in the rush hour(s) is fun for nobody. Catching the train meant that I didn’t have to worry about being cut up by angry businessmen or being tailgated by some tool in a white Ford Transit or literally being crushed to death because someone driving an articulated lorry didn’t see me or missing my junction because someone won’t let me change lanes or being involved in one of the accidents I see on the motorway every three or four days… I could go on. The effect was that I arrived at work much more relaxed and in a better frame of mind to start the day.
Result: Train wins
Taking the train means that I have to do more walking: from my house to the train station, from the train stop to the bus stop, from the bus stop to the hospital. The longest of these walks is only about 100m or so and I actually think they are a good thing. I tend to go from my house to my car to work to my car to my house and never really venture outside. At this time of the year, it’s dark when I leave home and dark when I return and if I’m not careful I end up just sort of becoming a creature that never sees the daylight or the outside. And that can’t be a good thing. Admittedly, when it’s freezing and raining like this morning, it’s not much fun. I’m not sure if I really want to start every day with a face-to-face confrontation with the British weather.
Not having to drive means that I can read. I really enjoy reading and feel I don’t do it as often as I would like. As I’m still very new to anaesthetics, I’m having to do a lot of studying at the moment. Using public transport means I can study on the train, it effectively gives me an extra hour every day to read up on stuff – if you were on the train at 07:30 today sitting next to a guy reading about isoflurane – that was me! If I’m not is a studying mood, I can just read a novel or newspaper instead. I think if I use the train everyday, I’ll end up being cleverer and more knowledgeable.
Result: Train wins
As I said before, I do the “reverse commute.” This means that I had no problem at all getting a seat on the train or the bus today. The times I travel avoid annoying schoolchildren and it’s far too early for the chavs to be out of bed, so the journey was actually very pleasant.
All in all, I was pleasantly surprised by my public transport experience. I feel that if I take the train every day, my life will be “richer” in terms of mood, stress and learning. On the other hand, the extra 15 mins in bed that the car gives me is really important to a late-riser like me.
Overall though, I had such a good experience today that I’m definitely a convert to public transport. I can see myself going by train almost every day except supermarket shopping day.
I think anyone reading this should consider making the switch too.
Tuesday, 13 November 2007
Remember, we can’t see what you are doing from where we are and a little warning about things makes our job so much easier.
Monday, 12 November 2007
One of the side-effects of the anaesthetic our patients is that they can rapidly drop the patient’s blood pressure. (For the medics among you, they cause a decrease in myocardial contractility whilst simultaneously causing profound vasodilation). This means that we always check the blood pressure and make sure it is stable before we allow the surgeons to start operating.
I press the button to start the blood pressure check, but the screen just reads:
Error: Cuff Leak.
The blood pressure cuff isn’t working and our ODP goes off to get a new one. The consultant turns to me and says, “What are you going to do now?” Referring to the fact that the machine was unable to ascertain if the patient’s blood pressure had fallen to dabgerously low levels.
“I’ll feel his pulse,” I say
“The carotid” I feel the man’s carotid pulse. “He’s got one.”
“And this tells you the blood pressure is at least how much?”
“I don’t really know the exact figures”
“60 systolic. What are you going to do next?”
“Feel his radial pulse.”
“Good. Does he have one?”
“Yes, but it’s not very strong”
“If he’s got a radial, how high do you think his blood pressure is?
“Yes, that’s right. You said it’s not very strong, so this man’s blood pressure will be just over 80 systolic.”
Our ODP has now returned with a new blood pressure cuff and we get a reading from the machine:
Blood pressure: 84/51
I was super-impressed.
Sunday, 11 November 2007
This wasn’t the first time I’ve ever been propositioned, but what really took be aback this time was that it seemed to come totally out of the blue. I was standing in a circle of a dozen or so nurses who had now stopped their conversations and were all looking at me…
Let me rewind a bit and tell you about how I managed to end up in this situation.
A couple of weeks ago, the intensive care nurses decided they were going to go for a night out. I spoke to David, the other novice anaesthetist, about whether or not we should go along for this night out with the nurses. David furrowed his brow and said “Hmmmm… maybe.” Going out on the town with a big group of nurses is invariably drunken and raucous and can be a hell of a lot of fun. One of my good friends once said to me, “you never see as much flesh on a night out as you do on a night out with the nurses.”
David is a fellow MTAS refugee. That debacle means he is now separated from the woman he loves by a few hundred miles and, understandably, they try to spend every free weekend together. David told me he was bailing out on me and goes to visit his missus. I was actually quite disappointed because I was quite up for going out, but didn’t really want to be the only man on the girliest of girl’s nights out.
So, I’m sitting in my apartment, chowing down on a curry and watching No Angels on DVD (great show they should so bring it back) when my phone rings. It’s Asif, one of the anaesthetic registrars.
“Are you going out with the nurses tonight?”
“I was thinking about it but David’s seeing his girlfriend and I didn’t want it to be just me and the nurses. Why – are you going?”
“Yeah, I’d like to – do you fancy coming along?”
“I may as well, I’m not doing anything else tonight apart from watching TV”
We get to the pub/bar and the party is already in full swing. It’s really different seeing people you work with “out of context.” Some of the nurses I didn’t even recognise in their normal clothes. It was good though, the loud ones were still just as loud in the pub and the quiet ones were still quiet.
I really enjoyed chatting with the nurses and their husbands/boyfriends about stuff over a beer or eight. It was surprisingly civilised until Anna, one of the younger ones, got her camera out.
That was it. There was cleavage everywhere and it was all getting more and more risqué. A group of the younger nurses wanted to hit the club for a boogie and by this stage, I was well warmed up. Unfortunately, I couldn’t join them because Asif wanted to leave and he was giving me a lift home.
We start saying our goodbyes to everyone and we get round to the table where one of the nurses, Debbie, was chatting to some of her friends that I didn’t know.
“We’re heading off home now, Debbie. Enjoy the rest of your night.”
Debbie smiles at me, stands up, wraps one of her legs around me, plants a kiss on my lips and says, “Do you come to mine tonight? We could have lots of sex, if you want to.”
I’m sure this is the sort of stuff that teenage wet dreams are made of, a slightly older woman making a brazen, upfront offer of sex. The thing is, I don’t really fancy Debbie that much and, whilst I get on ok with her at work, I don’t know her that well either.
I weighed up her proposition in my mind. Sex is almost always great fun. Doing in with someone new is exciting. On the other hand, I didn’t particularly fancy her, and I think my “sex for the sake of it” days are behind me now – there are too many complications, especially in a situation like this.
I turn down Debbie’s offer. I can’t remember exactly what I said (that’ll be the Stella!) but I think I was quite gracious and gentlemanly about it.
It’s funny to think that I ended the evening being driven home by a large hairy, Asian man. I’m pretty sure if I was in the same situation five years ago, the end of the evening would have been very different indeed!
Friday, 9 November 2007
This is a question I’ve been asked at just about every interview I’ve ever been to. It’s quite a fair question, because I reckon that a being a junior doctor is one of the most stressful jobs you could do. I’d say I’m a pretty chilled person most of the time. I’m very mentally tough but I’m very laid-back as well. It’s rare that events get on top of me or get me down, but there have been times when things have happened that have brought me to tears. I’ve had several sleepless nights when I’ve replayed events in my head again and again in an eternally repeating cycle like some sort of sick cinema viewing.
There have been times when I’ve felt all alone and times when I’ve just asked myself “Is it worth it? Is the job worth feeling this bad for? Should I just pack it in and do something else?” In short, there have been loads of times when I’ve felt stressed.
The Beatles once sang “I get by with a little help from my friends” and I’m lucky enough to have fantastic family and friends to help me through the dark times.
One of the other things I do when I feel things are getting on top of me is pay a visit to the streets. I pull out my trainers from under my bed, pull on an old t-shirt and tracksuit bottoms, set my iPod to shuffle and go for a run. I love it.
I love that there’s just me, the beat and the streets; and for the time I’m on the streets, nothing else really matters. The streets have been there since before I was born and will be there after I die. The streets won’t care if I don’t shave before I run. The streets won’t gossip about me and won’t assume that because they can’t see me, I must be in the pub or playing golf. The streets won’t attempt to undermine me because I took a different route to my destination. The streets won’t hassle me about protocols or breeches or bed-crises and will just let me get on with running. The streets don’t expect me to run on all of them at the same time, in fact they expect me to visit them one by one. The streets are always there if I want them, no matter how long it’s been since my last visit.
Thursday, 8 November 2007
I'd like to apologise to all you who emailed me when I was offline and I couldn't reply.
I was looking through my inbox and found this little gem that Mousie pointed out to me.
So funny, so true...
Tuesday, 6 November 2007
Operating theatres are staffed by the anaesthetists, surgeons and ODAs (operating department assistants). The job of the ODA is to make sure the theatre runs smoothly. To check the right patient has some for the right procedure, to keep the theatre tidy and to pass things to (assist) the anaesthetists and surgeons.
I was working in a new operating theatre today and, when I entered the anaesthetic room, after seeing my patients on the ward, I introduced myself to the Susan, the ODA and Marcus, her student.
Sarah, the first patient, comes in and Susan and Marcus complete their checks and then I set about the business of actually giving Sarah the anaesthetic. I start putting the drip in back of the patient’s hand and Susan says,
“Why are you putting it there? Why don’t you put it in her wrist? It’s better in the wrist.”
This annoys me. I may be young but I’ve probably sited close to a thousand drips so far in my career and I KNOW how to do it. I feel that she is trying to tell me how to do my job. I let it pass and the drip goes in to the patient’s hand first time.
Susan and Marcus had got the intubation stuff ready and I did my mental check so that I knew where everything was before I started. Oxygen? Yes. Suction? Yes Laryngoscope? Yes. Bougie? I couldn’t see it.
“Do we have a bougie?” I ask.
“It’s over here” Susan replies, pulling one out from behind the anaesthetic machine, “I’ve been in anaesthetics a lot longer than you, you know” she adds.
I wonder if she’s deliberately trying to wind me up. I know she’s been “in anaesthetics” a lot longer than me. She’s about 50 years old and was probably doing the job the day I was born, but I also know that I’m the anaesthetist and she’s my assistant. I have to look after this patient. I’m about to give her medications that will first send her into a coma and then paralyse her so she can’t move or even breathe for herself. I have a duty to make sure I can keep her alive and unharmed, so I NEED to know EXACTLY all the equipment I may potentially need is because I have only a few seconds to intubate my patient before she starts to suffer ill effects. When I spoke to Sarah on the ward, I made a promise to her that I’d look after her and the best way to look after her is to anticipate things that could go wrong and to nip them in the bud.
Once again I let Susan’s comment slide and I inject the anaesthetic drugs into Sarah’s vein. Marcus passes me the laryngoscope and I slide the blade into Sarah’s mouth.
“Don’t damage her teeth will you?” Susan pipes up
I can’t see what I’m looking for and I slide the blade further into Sarah’s throat.
“Watch out for her teeth!”
The blade is not near her teeth, so I ignore Susan and concentrate as the epiglottis pops into view.
I lift the blade to visualise the vocal cords.
“Careful with her teeth!”
The blade is still nowhere near Sarah’s teeth and Susan is really annoying me because I’m concentrating all I can and she is distracting me at a crucial moment.
“I’m nowhere near her teeth! You are NOT helping” I snap.
I push the endotracheal tube into Sarah’s trachea then connect the ventilator. We can now start the operation safely. I look up and Susan is giving me a look that could kill.
No doubt I’m now a “cocky young doctor” who “thinks he knows everything” and “doesn’t respect experienced staff members.”
Saturday, 3 November 2007
As a doctor working in general medicine, the intensive care unit (ICU) seemed to be a mystical place. When our patients became very, very sick, we would ask the ICU doctors for help and then they’d swan down onto the ward and point out all the things we hadn’t done. What usually happened next is that they’d then say that they didn’t want to take the patient onto the unit, offer a little advice and swan off again. However, very occasionally, they’d they WOULD take the patient and within minutes, the patient would be whisked off to the intensive care unit. They’d vanish off behind big, locked doors and we never knew what happened to them there. It was like a big black hole that the patients disappeared into. Sometimes, they re-emerged days later, sometimes they never came out.
The bible for junior doctors across the land is the Oxford Handbook of medicine. If you read the sections on treating critically ill people, regardless of the condition, it’ll say something like “do X then Y then Z and if that still doesn’t work, call ICU.” Rarely, do you get any more details and, as a result, I was always more than a little mystified about what went on behind those locked double doors. It’s been a real revelation working on the intensive care unit and seeing things from the other side.
To be honest with you, I was a little underwhelmed when I found out the truth. Aside from mechanical ventilation, nothing particularly special or profound happens in intensive care. Intensive care is based around meticulous attention to detail. It’s based around being focused on every aspect of your patient’s wellbeing. Closely monitoring ALL of their organ systems and intervening quickly and appropriately to try to correct anything that is drifting awry.
I’d say the single biggest difference between ICU and a normal medical or surgical ward is the nursing staff. I’m not saying that the nurses are better on ICU, it’s just that there are many more of them. We get one nurse for every patient. It’s great. It means you have so much more scope to do things. For example, we can confidently put a patient on an infusion of midazolam with the knowledge that they’ll be someone around to turn it off if the patient stops breathing.
It’s also made me realise that it’s often the simplest of things, done early, that make the biggest difference to critically unwell patients. Things like giving oxygen or fluids or adequate pain relief. I honestly believe that every doctor working in an acute specialty should spend some time working in intensive care at some point. Intensive care is based around simple things done well. Good medical care is based around simple things done well, and this is what I’ve seen again and again over the last few months.