Hey Mufreir Podcast_Mark Whiteley_Part1: Audio automatically transcribed by Sonix

Hey Mufreir Podcast_Mark Whiteley_Part1: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Brian Sapp:
Hey Mufreir! Want to know more about vein disease, but not be bored to death? Well, you've come to the right place! Join us as we talk about all kinds of things, including vascular disease, advice, comedy, and, of course, business growth. I'm your host, Brian Sapp.

Brian Sapp:
Hey, Mufreir! This is Brian Sapp from the Hey Mufreir Podcast, this episode is brought to you by Doc2Doc Lending. Doc2Doc Lending provides personal loans to physicians and dentists at rates that make sense. Apply in under 5 minutes at Doc2DocLending.com.

Brian Sapp:
Hi, this is Brian Sapp, with the Hey Mufreir Podcast, it is my pleasure to present Professor Mark Whiteley, he is a venous surgeon in the UK, he introduced endovenous ablation surgery to the UK in 1999 and set up the internationally renowned The Whitely Clinic in 2001. He now has three clinics in the UK, is opening a fourth in April of 2022. Mark invented the TRLOP procedure for incompetent perforating veins in 2000 and introduced endovenous microwave and high intensity focused ultrasound or HIFU to the UK in 2019. Mark set up the College of Phlebology in 2011 and now runs training courses and fellowships as well as the College of Phlebology International Vein Registry. He sits on the editorial board of the Journal of Vascular Surgery, Venous and Lymphatic Disorders and has won multiple international prizes for his work, and has over 146 peer-reviewed publications. He has written three books on venous disease, including the first one featured on Amazon on the venous causes for Pelvic Congestion Syndrome. To say that we have a privilege of talking to Dr. Mark Whiteley is an understatement, I've been following his career for 20 years, and he is a force to be reckoned with in the Venious industry. It is extreme pleasure for me to have a casual conversation with this giant in the international vein disease, doctor, professor Mark Whiteley. Hey, Mark, how are you doing? Can you tell me, like what, how you, through your medical journey, what made you choose veins?

Mark Whiteley:
Thanks, Brian, it's great and thanks so much for inviting me to be part of this! Yeah, veins is really interesting. I started life as a general surgeon, I had no medicine in my family at all, and I just basically loved biology at school and ended up being told, I thought I was pretty thick at school, I didn't think I was very clever, and I got told at a careers fair that although it's like, wasn't that great, you know, my grades were, they wanted all-rounders. And as I played a lot of rugby and I sort of did, I got into medicine, went through medicine and just fell in love with the subject, absolutely, I had a fantastic time in medical school. But the funny thing is, right from, I remember as a first-year medical student at 18 years old, just asking a doctor how veins actually work because they were telling us about valves and things. And it was very, very clear that the doctor didn't have a clue how they actually worked. So I thought, fine, and then as I went through and became a junior doctor and we were ripping out veins and some doctors and some hospitals said, no, you only have to tie the top, and it would thrombosis away, and other people were saying, no, you have to strip them, I realized that they had no idea what they were doing at all. And I'm old enough to remember that the handheld Doppler sort of then came in before Duplex and everyone thought that was revolutionary. And then we had Duplex, but they sort of said, well, you only really need it for complex veins. And I was going through all of this as a junior doctor and junior surgeon, and I just got more and more fascinated because in those days as a trainee, I was doing cancers, I was doing the oncology side, I was going through my different sections in urology, as you do as a rotation. And then first of all, quite broad, so you do orthopedics as well and then you come down into general surgery and it sort of ..... The one thing I found is vein surgery, firstly, there's not an awful lot of people have got it. Secondly, there's virtually nobody who understands it, who or who cares about it, so there's a wide open market as such. Thirdly, it is absolutely fascinating. The more you get into it, the more you realize that there's research that needs to be done because people don't understand it. But fourthly, and what really drives me more than anything is I've never found a condition in medicine where patients and doctors expect a bad result and do nothing about it, and this is utterly normal. And you say to patients, oh, your veins have come back because you've had them done five times before. And they go, yeah, well, the doctor told me they'd come back and everybody says, so fine. Imagine that if it was anything else, you'd be down to the local solicitor, you'd be issuing writs, you'd be complaining. Veins, it's just, they said, and the more you understand it, the more you realize that, in fact, veins shouldn't come back if you treat them properly. Apart from the natural deterioration, which you know from the Framingham Studies 3% to 4.5% per year, apart from that, anyone whose recurrence rate is higher than that is doing something wrong. And, you know, I thought it would take me six months to convince the world, and 20 years later, I'm still trying to convince my colleagues!

Brian Sapp:
No. So, man, you spoke so much truth there. And man, that's, that is so profound, I would say one-third, ao one of the reasons why I left my old employer is he failed to understand the deep venous component, he failed to understand the root cause for a lot of reoccurrence, you know, and I was just a sonographer, but I got to see it because I was seeing patients at the beginning, I was seeing them through the journey, I was seeing them at the end, and I was just like getting crushed. I took it very personal when somebody would have failed treatment and like you would say, so I always, so I rarely go to vein conferences, Mark, and what, and people ask me all the time, they're like, why don't you go to vein conferences? And I'm like, They're all, besides yourself, you're an innovator, you think outside the box and you push the envelope, but most of the other guys just regurgitate the same information and they haven't even thought about why. You know, one of the funny things is like after endovenous ablation, they'll go, well, like the patient for a long time, people would, would have treatment from the knee, you know, proximal calf up, and the patient would come back and they'd have a bunch of dilated varicose veins in the lower leg. And the doctors would be like, well, you know, the veins have to reroute themselves and give it time, and it's like, no. And even now, like in American Insurance, I think Blue Cross Blue Shield makes us wait six weeks to see a vein shut, like, I've never done it, we've never done an ablation of the GSV, and six, six weeks later, the anterior accessory, which was reflexively at the beginning, suddenly shuts down, it never happens, yet that's their policy. And again, this because of people's, somebody at an academic who really didn't understand veins went through this whole policy and created this, but go ahead, I'm sorry.

Mark Whiteley:
And though, this is, what you say is absolutely right, because we have the same problem in the UK, where the ... top vein surgeons, the ones that the government listen to, are vascular surgeons who happen to do some veins. So of course, if you block off an artery, you do find another way around, you do, you collateralize, and so that's in their brains. But of course, when you're stopping reflux, you're actually plugging the hole, you're stopping the falling down so the blood doesn't have to find another way around, you stopped it going the wrong way. And it's a totally different concept and it took me years to understand that, but once you do it, it's like, you know, it's like a road to Damascus sort of time. You say, oh my gosh, it's so obvious! And, you know, basic, there is no ..., One of the things I always say to people, as I say, if they go to a doctor for veins and the doctor does their own scan and they don't work in a team with a proper vascular scientist, walk out, number 1. Second time, if you talk to a doctor, you say, what happens when I take away or a bleed to vein? If it says it finds another way, you walk out as well. Because those are two really big things that your doctor doesn't know what they're talking about.

Brian Sapp:
Oh, I agree, 100%. Now, for my American audience in the UK, a vascular sonographer is a vascular scientist. They, they have much higher regard for their sonographers than we do in the United States, they give them this fancy title. I actually joined the European Society for Vascular just because I wanted, I was hoping I could get somehow get a title of a vascular scientist, if I ever, no it didn't happen, but I donated my money to them. But I wanted to clarify that for Americans, again, it's a, it's a registered vascular sonographer. And we're very, at my clinic, we're very sonographer forward. If we get it wrong, the doctor is going to get it wrong, most times. How do you feel about that? I know you have a great vascular scientist on your team, you have probably had a whole bunch of them.

Mark Whiteley:
I would say that my whole career has been based totally and utterly because I've managed to work with some geniuses. And one of them is Judy Holdstock the vascular technologist or scientists that I work with, and I think that most doctors don't talk to the people around them, they think that they're the only important person. And I used to go I mean, right from the beginning when I first met Judy, I looked over her shoulder once, saw her scanning someone, I went, I've got to work with you because she was seeing things I'd never seen. But then one of the first conversations I had said to her, I said, you know, I said, Judy, and this was right back in 1999, they said, Judy, I said, what's really weird is when I scan patients who have got great .... vein reflux, so reflux down from the groin to the ankle. I said, sometimes I find people who aren't refluxing at the groin, but the refluxing below that. And I said, but you know, what everybody says is you, you get your great .... vein reflux because of pressure from the, from above, which means the top valve has to come first. So I said, okay. And she said, oh, we see that all the time. She said, all the time. I said, well, why don't you? Why don't you tell us? She said, oh, because you doctors never listen, and our greatest, our greatest research and the things that have come out, the TRLOP technique, the ascending reflux, the pelvic veins, everything, is because we have the same regard for our other doctors, whether they're interventional radiology, dermatologists, venous surgeons, as we do, our RVTs, our vascular scientists on this, and what we do is anyone who says, hey, isn't this interesting? We listen to and we go and we look at it. And because of that, we discover the power of a tissue, you know, all of these different things we've published is purely and simply that we listen to people who know what they're talking about, and I personally don't mind what the title is as long as you're expert at your job and you have to be listened to and I mean, thank God I did with Judy because it's made my career.

Brian Sapp:
No, that's, that's awesome, that is so awesome to hear. And you've, you know, I know that you've developed, you were the first to do endovenous ablation, like we've talked about. You've developed the TRLOP procedure for perforating veins, what other, I mean, I know you've worked with, you're the lead investigator with the new HIFU ultrasound, I know today we were going to talk about pelvic congestion, but I mean, for, for my audience, they may not know, I mean, what are the things you see exciting that you've worked on in the past or working on the future? And then let's talk about a little bit about the pelvic congestion, how you, your beliefs on it, and the deficiencies you see.

Mark Whiteley:
So I think, I think when we're talking about leg varicose veins now, if people keep up to date with what is going on and they're doing good endovenous ablation with the right techniques and they use the right powers and they also accept and understand, I know it's too controversial, but the perforated veins and the pelvic reflux into the legs, as long as you understand that, I think legs now, we should be able to everybody up to a fairly good standard. So looking forward, what are the exciting things? Well, the first most exciting is pelvic congestion syndrome and pelvic congestion syndrome, we know that one in six women who have leg varicose veins and one in 30 men who have leg varicose veins have them predominantly or a major be coming from pelvic veins. And it just shocks me that doctors will, they will know that venous blood goes from your big toe to your heart, and they only look for deficiencies of that circulation up to the groin. So anywhere that it falls out into the veins, up to the groin is varicose veins. But above that, it just doesn't happen. Unless, of course, you're a boy, and if you're a boy, then you can get varicose veins on your testicle because you can see it. And that's got a very good seal, but when you go to these conferences, you see world experts on pelvic congestion, they'll tell you it's females only. And I always stand up and say, so you don't see boys with varicose ... and they get very embarrassed and they go as Whitely talking again and, you know, basically pelvic congestion, simply, if we just called it varicose veins of the pelvis, then I think it would be a lot easier. But we have to now call it pelvic venous disorders because people want to give it a sexy title, but it really is varicose veins of the pelvis and it can come from because of the valves not working and reflux or it can come because of obstruction. And as you all know, there's a huge amount of arguments as to which is more important and how we should treat it, and that's an academic thing, but it is phenomenal. But the most important thing is in the UK and we've got a much smaller population than yours, but in the UK, we know there's about a million women who have chronic pain in their pelvis, whose lives are disturbed by it, and they go to gynecologists and they get told, you know, we're going to look for endometriosis, we look for adhesions, they don't, they come out at the end, and they say, there's nothing wrong with you, you have to see a psychiatrist, you're mads, they've paid for lots of investigations, they've had invasive things like laparoscopy and nobody picked up they've got varicose veins in the pelvis causing it, and that's shocking, shocking.

Brian Sapp:
So it is, it is so shocking, and I see it all the time. I've been, I've been scanning pelvic and iliac and pelvic veins for... For about 15 years. I had a family member who I scanned because they were going to go on birth control, and I have seen enough women, young women who've had DVT after starting birth control, that has said, hey, I want to look at your iliacs, and I did, iliacs were beautiful but their pelvic her pelvis was just engorged, and this was a 20-year-old relative of mine. And so I, she was going to the OB-GYN like the next week, and so we wrote up the report, we said that she had pelvic congestion and I didn't want to be the, you know, it's weird whenever you're dealing with family, you don't want to be the only person. So I was looking, I just wanted confirmation. So we requested a transvaginal ultrasound and she went and they go, you should go see a vascular doctor, we don't do this. So I called and I'm like, listen, what do you mean you don't do this? Like, I just want you to look for varicoses across the myometrium, I want you to prepare uterine vein, like these are obvious, I can see them with the transabdominal, but you should have no problems. I get a report back, that was normal.

Mark Whiteley:
Oh, yeah.

Brian Sapp:
And I wrote a letter to the doctor and I just blast it, I just gave her all the information. And the thing is, the doctor gave me, the OB-GYN, gave me a callback, and she said, you know, you came and talk to me about a couple of years and I want to apologize and this and that, and it turns out her sonographer, the, the OB-GYN's sonographer ended up coming and becoming a patient of mine. And she had public congestion, but it is so widely unrecognized.

Mark Whiteley:
Yeah. I'll tell you two little anecdotes of mine as well, because it really, one is, one of my best friends is a gynecologist in the U.K. She's absolutely brilliant, she, she's very, very good at what she does in the menopause area. And one day I was talking to her about this and I said, you know, it's amazing. We don't ever get any referrals from gynecologists, we only pick them up because patients read my book or, you know, they've sort of seen the website. And I said and they're really upset because they've spent so long looking for an answer. And I said, you know, at laparoscopy, surely sometimes I know the veins are deep inside. But I said, sometimes you must see varicose, and she said, oh, yeah, they all have them. I said, I said, I said, so all your women with pelvic pain that you don't find another cause you see these big veins. She said, yeah, if you, if you get the endometrium, you get big bulging veins. I said, you don't think that's a problem? She went, no, you know, you see it all the time and they're seeing the problem, but because nobody's educated them that that's pelvic congestion. They just say normal, just a bit veiny. The second one I must say about is, for many years, when I, when I was sort of standing up at conferences and going in the newspapers in the UK and saying, look, we can now cure leg ulcers, we can, you know, pelvic veins. And I was trying to bring people up into the 21st century about veins. And one of my big detractors over here, there's a very famous doctor into veins, and he was asked all the time whenever the, because newspapers always try to have the other side, and they would have some, they'd go to him, and he was often the person who'd say, oh, you know, it's not right, it's not true. And he was really horrible. And that meeting to be absolutely, very, very horrible to our research. And then out of the blue, I got a phone call from him and said, my daughter has just got, got married and she's having so much discomfort in her pelvis during, during and after sexual intercourse deep inside. And she's been to see the gynecologist, two different ones, very well respected, that he had managed to bring in the medical profession, who'd gotten very good referrals, they'd said there's nothing wrong with her. And she ended up under a psychiatrist. And he said, and his words were, he said, I don't believe anything that you say, but would you mind scanning her? So, so we sent it to Judy Hornstock, who is expert, who did the, design the, the transvaginal duplex and the criteria that we do with Charmaine Harrison, and she found that all four veins, both ovarian and both internal illiac, absolute hosing, huge. No, no compressions, no crack and nothing else. Nice easy one to do. We coiled and blazed it all, completely in utterly, you know, you had to use a bit of post-operative discomfort because you've thrombosis, a couple of, a couple of months later absolutely pain free, seven months later, pregnant and with no trouble at all. And you know, he's never even, I've meet him since, he never even acknowledges me, never thanks, never, even comes up and says, actually, you know, you're, still speaks out against pelvic congestion. Unbelievable, isn't it?

Brian Sapp:
It's unbelievable. I, it's, it's so sad. So, I mean, I, so it bothered me so much, I told you, my previous employer, I was over from 2006 to 2010, I was finding all these indications for patients with pelvic and, and iliac vein disease, and he just didn't understand it. He thought I was taking, he thought I was taking ablations away from him. Instead, I was like, no, I'm finding the root cause. And I would have so many women who would cry, they would start crying. And it would and it's, it's almost magical because I would ask, I would see something on the ultrasound that would indicate pelvic involvement, and I swear they would think I was like an astrologist because I could sit there and go, you know, you have, you have low back pain, you have pain during intercourse, and they would start crying because they had been to doctor after doctor after doctor. It's very, I will say it's very rewarding, and I think with vein disease and maybe, I hope you have the same result, I think it's more life changing than any other vascular, you know, you can, it's crazy, you can find a critical carotid on somebody, you can treat it. And the patient lives a little bit. And they, they're not going to bring you a basket of fruit when we find somebody's problem that they've searched for 15 years, and they have taken anti-psychotics and you relieve that pain, oh my god, they ended up being like a disciple and telling the whole world about you, and it's amazing, very rewarding.

Mark Whiteley:
And only, you get exactly the same thing with venous leg ulcers, who have been told for years that you have to have manuka honey or compression and stuff, and one day they suddenly find out that actually you can treat the underlying cause, the veins. And 18 weeks later, on average, they, disapp... the ulcer disappears, and they didn't even have to wear compression material at the time. And it is, it's lovely we've even had a couple of patients start to sue the NHS because they were never told, and of course, over here, we've got to think of the nice guidelines, the National Institute of Health and Care Excellence guidelines, and even though those guidelines, which it was made to follow, say if you have a venous leg ulcer or severe varicose veins, you should have a duplex scan and treatment, they were written by English doctors on English, English, or as I should've say, UK doctors by randomised controlled studies paid for by the UK Tax Office, and still those same doctors have, once they've got their names on the papers, go back to not treating them. It is utterly ridiculous that you know, you have a country that pays for the research and other research, and very clever fellow John Michaels, up from, who's now a health, he's a doctor, but he also does a lot of health economics up in Sheffield and he showed many years ago there's a study called the Active Study. And just even if you talk about leg varicose veins even away from pelvic varicose veins, but just leg varicose vaccines per pound spent, you actually get more improvement for longer, so what sort of quality of life ..., for each pound you spend than you do for almost any other disease, than cancers, arterial surgery or anything, because you not only relieve the problem now, but you prevent the problems in the future. And you're doing it on patients who have got decades to live, who aren't at the other end of life. And venous disease should be right up there, it should be the thing people are talking about, but it's just not sexy, people don't talk about it.

Brian Sapp:
No. And it's so, so this is the most frustrating for me, and the public doesn't understand this. Your doctor doesn't know anything about vein disease, and chances are you're a vascular surgeon, and I know this is very controversial to say, but they don't know shit either, and I'll give you an example, Mark, I told somebody the other day, I find it crazy, there's this group of vascular surgeons, they have 19 vascular surgeons in their group and they're marketing varicose veins to the public, okay? They're spending money marketing varicose veins, and I sat down and I was talking to a friend and I said, listen, varicose venous disease is 15 times more prevalent than arterial disease. So think about this, you have 19 surgeons, vascular surgeons, almost all of their patients are Medicare, 65 years old or older, probably 80% of them, and they're doing all this arterial work and they have all this venous work walking through their own clinic. And yet they're advertising for a 32-year-old girl with spider veins and the patient with venous stage four or venous disease is walking through their clinic and they don't even recognize it, it's crazy to me.

Mark Whiteley:
It is. We have a problem. I mean, as an academic, I was chairman of a session in a Paris meeting in about just before COVID, about end of 2018, and it just struck me I was on the table, on the sort of thing, and there were a couple of American colleagues there as well, but mainly was a European meeting. Somebody from the audience just started the conversation, they said, why is it that venous disease is so abysmally looked after and looked at? And I said, I can't speak for any other one, but in England, what happens is we have the National Health Service, which has a monopoly on, on jobs and training, and people who do private practice have trained in the NHS and then do some private work. And our difficulty is, is if the NHS doesn't recognize the condition and doesn't train people for it, it doesn't occur. So we don't have consultant vein surgeons and unfortunately, the public and everyone else thinks vascular means veins, they don't realize it means arteries and we should call, vascular should be renamed arterial and venous should be venous. And that way people would understand that we don't have any venous consultants in the UK, in the NHS and because of that there is no training because nobody trains if there isn't a job there. And of course, the medical schools don't train if there's not a job either. So I had a patient the other day who came to see me about two years ago, now, and she was a research fellow of mine, and I do these research fellowships for people who want to be medical students, and I give them a summer, and I get them to publish some papers and it helps them in their career. And she had come, I've done this, got a place in a medical school, gone through, her medical school was up in Manchester and she came back as a junior doctor for me to do her veins. And I said, well, it's very kind of you, but, you know, it's a few hundred miles, why didn't do it if England's a long way and I said, I said, you know why didn't you haven't done in Manchester? She said well number one, if you saw what they were doing there you wouldn't have it done, she said, but number two, she said, in my five years of training, she said, I had one-hour training on varicose veins. And when I went to that lecture, I went in there and this was down as the veins and varicose veins lecture, one hour in five years, and she said that the consultant didn't turn up and sent their registrar instead because they weren't going to waste their time teaching varicose veins. The registrar turned up and said, and it's only a couple of years ago, and said, I don't really know much about veins, the boss told me to come along, but if they're bald then you should strip them out, do you have any questions? And that, she knew different because she'd worked in my unit, but do you know all those other people? They're going to be the GPs and the family doctors of five years time and that's another generation of doctors who are going to go through still think venous diseases, a bit cosmetically, a bit peripheral. And it is a huge uphill battle to explain that 30% of the population have a problem that deteriorates and you leave it long enough and it becomes a medical problem. And that's before you get to the pelvic congestion, everything else, that's just, you know, that's just your leg veins.

Brian Sapp:
Yep. No, I agree. I mean, so in the United States, a lot of the large hospital institutions, they won't allow you because of the drug reps in the past, they won't let you do lunch and learns anymore, and so it's very hard to educate somebody. And what we found, my experience is if somebody comes in for leg pain, the doctor will send them to orthopedics first, the Orthopedics, they'll clear them, they come back and then they'll send them to pain management. So I think Harvard and Stanford and Stanford both did a study and they found one in four people with ridicule-apathy nerve pain or pain in the legs had undiagnosed chronic venous insufficiency.

Mark Whiteley:
Wow. .....

Brian Sapp:
And so but the problem is it's how do you reach those people? In our clinic, you have to reach them like you do through social media. And that's what's crazy is, we finally, it takes probably about ten patients who come back to their doctor and go, why? Why didn't you tell us about this before? Now, I have one great referral group out of Tyrone, Georgia, and I actually have a nurse practitioner there, I can't think of her name, but she is amazing. She actually sends us patients and she'll actually write the order to check for pelvic congestion. She, she understands it so well, and this is just somebody who is willing to listen, take an hour or two to listen, and then, as she's heard, more patients, more patients, she's become one of our best referrals. But it's like speaking to the, to the, to the deaf as far as trying to communicate to people. And then, of course, with pelvic venous disease, a lot of the GYN docs, they solve it by taking out the, the uterus.

Mark Whiteley:
Oh, wow.

Brian Sapp:
And when they take out the uterus, they take out all the, the engorgement, engorged veins and there is some symptom relief, but then the patient develops hormonal dysfunction and gets, gains weight and all these side effects that are bad.

Mark Whiteley:
I've just actually commented on social media, I don't know if I'll get into trouble because in last, last week I think it is in Canada, there's a doctor who took out somebody's fallopian tube for pelvic congestion. And when he was in there, took out the other one, so made her sterile and she's turned around and sued him for making her sterile, and he's countersuing her for trying to ruin his reputation because she consented and everything. And I wrote and said, it's irrelevant, if it's true, unless the reporters got it wrong, if it was congestion, what was he doing touching a fallopian tube, was in any case? ..... It's a vein problem. Don't touch, don't touch her reproductive organs. You know, it's just, it's it's unbelievable. But it's, what I would say is, you're, I can tell your frustration, but it's even worse in the UK because what we found in the US at least most of your patients do their research. And what I found is on my, with the books I've written, with my YouTube video, with my papers, with a website, we get so many more questions from people in the States than we do in the UK, even though we're a UK-based company, because the UK patients, there are still got this thing in the UK that if my GP says it, then they must know and they don't question it and they don't think, does my GP actually know the leastest advances in OB-GYN, ENT, neurosurgery? You know, they don't realise that it's a very generalist opinion, so we have the problems, I wrote something up about, you probably know, the 2012 guidelines showing that if you have thrombosis in your great ... vein or small ... vein. So what they used to call phlebitis or chronic venous thrombophebitis, so people call it phlebitis. We now know that that, if the clot in the end of that gets close to the deep veins, you've got a 1% chance of a pulmonary embolism. So everyone who gets diagnosed with phlebitis must have a duplex ultrasound scan and if it's close to the junction should be anticoagulated, guidelines for the USA, guidelines from the UK 2012. So I wrote up in Facebook to everyone, watch out for this, if they're told you've got phlebitis, please follow these guidelines. And of course what happens, absolutely loads of GP's writing, this is disgusting, these all get better with antibiotics, it's not, not having an ultrasound scan but not having even the right treatment! But because it's hot and red, there must be infection and that is still going on. The number of people who get referred for a scan with phlebitis is, I wouldn't say zero, but it's close on zero, even though the guidelines are now ten years out there. And then when people turn up to the ER and they've got a clot in their lungs, it's oh, I wonder where that came from. It's, you know, venous disease, oh as I could go for hours but it's just so, so frustrating.

Brian Sapp:
No, I agree. So, so I'm working on a couple of book chapters myself and I just had shoulder surgery two weeks ago, I'm supposed to be wearing a harness, but I'm not because it doesn't look good. And so I hired a girl off Facebook and she's been typing for me, and literally my thermostat, in my upstairs went out and I had an air conditioning guy, this was three days ago, he was walking up and down my attic stairs, right outside my office and he was groaning. And I started talking to him and he's like, oh, I had arthroscopic knee surgery three weeks ago. And I was like, do you, do you feel like you have a muscle cramp that won't go away? And he's like, ph yeah, for the last three days, and I was like, you got to go to my office! And he ended up having two out of two, two gastrocnemius veins that were really dilated, thrombosis, his little sinus was thrombosed, and he had been coughing and a little short of breath, and it's like he had went to the orthopedics and didn't see anything. And even in the United States, I have a, so I wrote a paper in 2014, I still cannot get, I see to require muscular caffeine imaging of gastrocnemius veins, and you know as well when you're looking at gastric perforations play a role in venous insufficiency, but there's still like this, just constant fight over things that should be relatively for people that are deep into the venous world are simple.

Mark Whiteley:
You know, I mean, it is frightening. Some of the statistics that come out there was, there was a study that was done which I, even I was totally shocked showing that if you get, if you look at people who get off airplanes, who have flown for more than 7 hours, 1 in 12 have a small DVT. And most of those people, of course, we don't scan 1 in 12, and luckily, most of those people will get better and they'll say, oh, I don't know why, but I had a was swelling on that flight, you know that, but all of these things, you know, you sort of see around, you at least should know about it and have it because even if all you do is have a scan check, it doesn't grow in the second scan either three days or a week later, depending on your protocol, you know, it would be so much safer to actually know in the knowledge and just sort of wait for the disaster. And then everyone goes, gosh, you know, isn't it terrible what can happen? Yes.

Brian Sapp:
No, it's amazing. So listen, Mark, Mark, man, you're amazing. I could talk to you for as literally all day. I know, would you be open, open to having another discussion at another time?

Mark Whiteley:
Always. If it's about veins, I can talk as long as you like!

Brian Sapp:
Thanks for listening to the Hey Mufreir! Podcast. For the show notes, transcripts, and downloads of the things that we've covered, visit HeyMufreirPodcast.com.

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