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Yeah. Ok. What about now? You know, so I, ok, perfect. Ok. It's like two. Ok. Yeah, we can probably make a stop. Ok, good evening, everyone. Thank you for coming and thank you for those who have joined online and I'll just briefly introduce myself. My name is Hiba with the primary medical student, very interest in pediatric surgery. Um, and now you've got three amazing speakers with us today. We've got Mr Doctor. And, um, and so they'll basically give you an insight into pediatric surgery itself and then if you have any questions at the end, you can, you know, ask them, find out more so on stage for them. Thank you. So, is it now? Yeah, my screen. Yeah, I'm tired. Mhm. Hopefully everybody at home can also hear this. Uh, my name is Ap and this is one of the, yeah, both pediatric surgical registrars here at ST George's. Um, and we'd like to share our ideal day in the life of a pediatric surgical registrar at work. Um, your previous talk is a bit about our pseudo reality and what we do, what we see, um, our reasons for doing pediatric surgery. Um, and some recommendations and tips and tricks. Um, do stop us if you have any questions. So imagine this, it's eight o'clock, you've come into work and um, you're asked to go, you know, you get the bleep, you're on call. And the first thing you see is this, uh, which is a baby that you've been asked to see in the neonatal unit. Um, they've been born, all of their intestines are out. What do you do as a pediatric surgical registrar? It may be your job to go down and see this baby first with the neonatal team, go and assess them, go and do the first treatment, which is putting all of this bowel back in a bag and trying to keep the baby safe and warm and resuscitated and also to speak to the parents. You've done that an hour has passed. It's now nine o'clock. So this would be a scenario where you find a child in um uh in A&E with what we call an acute scrotum. Um And the big differential diagnosis would be testicular torsion. Uh So as you can see the left this of this child is uh black in color. Um you have a short window between the time of the start of the symptoms, usually about 6 to 8 hours uh to take the child to theater potentially untwist and save the test, sorry. Um exciting uh something for, for us in a and hopefully see a testis for a child many more lives to come. So next it's 10 o'clock, you've got out of theater, you get a phone call from a DGH to say, oh no, they've got a, another tiny baby with a big belly and they've done an X ray and they think it's a bit abnormal and lo and behold, this baby has got a massive pneumoperitoneum. So there's air where it shouldn't be. You organize the transfer, you see them in, see them in the neonatal unit. Again, with your colleagues, you speak to the anesthesist, you stabilize this baby and then you tee them up for theater. You go in, you find this 24 weer who's 600 g in this case has got a little hole in their bowel, you close it up, you get the baby better and then it's 11 o'clock, you're exhausted. So such a quick Laroy. Um So again, uh I take um yeah, II love seeing things like that in A&E and trying to sort in a child in A&E even before going to theater. So for example, this baby has got swelling that looks like inguinoscrotal coming to any a bit of pain, maybe a bit of vomiting and uh out of differential, he would be an incarcerated inguinal hernia. Um And again, a lot of um a lot of thought comes uh to managing a child like that in A&E because um uh you're you in the first instance, you want to reduce a hernia to save them an emergency surgery, uh, to, um, and also protect the bowel that's potentially incarcerated inside it. You've got a baby who's uncomfortable even with you touching the area. So you have to think about excellent pain relief again, managing and speaking to parents assuring them and getting them to agree with you that the right thing for this child is actually give him good pain relief and try and reduce incarcerated hernia that would save the bowel and see them need him. Uh, an emergency surgery. 12 o'clock, 12 o'clock comes, you're still so busy. Gosh, and the trauma bleed goes off. You're asked to go down and see a 15 year old boy who's been attacked by a machete, he stuck his hand out. He's bleeding from everywhere. They can't get control of the blood. You're the person to put on the tourniquet. You may not be the person to do this operation. I certainly wouldn't be, I don't think Mr M would be either. But, um, you know, you're, you're there, you're the first person seeing this patient and delivering emergency care and it, you know, the plastic surgeons come down, the trauma surgeons come down, the vascular surgeons come down and you're still there holding this hand while chaos ensues around you. It's one o'clock finally, uh, a break. If we get there, we get to get some food and stuff two o'clock, two o'clock. Yeah. And we have, uh, another trauma scenario. Um, quite extreme, but, uh, very rarely, you may end up needing to do a thoracotomy. Usually that's something that is done uh unseen in a trauma with cardiac arrest and possibly bleeding, uh in the thoracic cavity or in, in A&E you're doing a, a trauma thoracotomy clamshell. Uh You're probably got a heart that has stopped you evacuating a hematoma, potentially around the heart, potentially, uh leaving a finger as the surgeon is doing to stop potentially a called bleeding. And if you're lucky, you're gonna try and massage the heart and get the child back to life. Three o'clock, you've saved your life. Now, you've got another test to open this time. It's a 1.5 kg baby. He's been born with a congenital esophageal atresia. This, you've gone from a 15 year old, 90 kg to a 1.5 kg one day old baby whose ends of the esophagus haven't met. And there's an abnormal connection to the tia just to highlight the variety in what we do as pediatric surgeons. So let me four o'clock. Um, gay child presents into any um acute abdomen, what we call peritonitis, distended, wanting green, shocked, you're doing your best to resuscitate. Um uh thinking of a differential diagnosis. Most of the time when you're faced with peritonitis, you're heading towards laparotomy. And in this case, this child who was about six or seven had what we call a segmental VV of the bowel. So part of the bowel has twisted against a narrower area of the mesentery, cutting the blood supply. And, um, um, this child in particular ended up with, uh, resection a stoma and later on joined about together and they're leading now a normal life. It's five o'clock. It's the end of your attending shift. You're exhausted, but you're excited. You've had a great day. So, obviously, this is a bit flippant, but pediatric surgery is incredibly varied. And those pictures and those little case vignettes are just to demonstrate that I think, I think as I think so, two of the boys wouldn't be here, but it's also an incredibly satisfying profession and that's what we're here to talk to you about. So, um why did Osama want to say? So, some of the things that uh I thought of when uh asked me the question was, um, uh again, something that perhaps you need to be a surgery compared to say other surgeries, the con um you get big variety of conditions that uh you deal with, such as Atresia, uh gastroschisis, um all sorts of uh different anomalies that we deal with. And um, if you think about it, when you correct this anomaly, uh very early on in life, you hopefully, um lead to a child who can live long, healthy life. Um, afterwards, um I like the acuity uh of the conditions that you can. So if someone comes unwell, you manage them well, you do your surgery and then they're fixed. It's satisfying that way. Um, big variety and variation in the physiology between, as you said, the premature 600 g to a 1617 year old who essentially is an adult. Uh, and you have to have awareness of very, very small blood volume in say a small baby compared to an adult. Um, the numbers, the heart rates, the everything else that you need to be aware of. Um you are uh a traditional surgeon compared to adults where perhaps they're uh leaning more towards subspecialisation. Um So we luckily we get to do big proactive surgeries. Um We talked about babies versus older people, lots of research opportunities again. Um And ever evolving uh surgery as Mr will talk to us about uh some innovations and so on. Um uh So plenty of room for people who want to uh be excellent. And I asked, I share the same question. So there's obviously some overlap. Um The thing I said was that I think pediatric surgery gives you lots of varied operating as the farmer says. And as we've seen, there's a lot to do. You can and you, you, you get to operate on almost every bit of the body. This sounds stupid, but it's actually probably the main reason for me is that you get to be silly, you get to have fun, you get to interact with wonderful Children, wonderful parents. And you know, it's, that is a pleasure and a joy really. The anatomy is beautiful. I can still remember the first neonatal or baby laparotomy that I saw, seeing the bowel and seeing it the way it's meant to be. Um, and it, you know, there's nothing, nothing really quite compared to that. Um, and it's interesting anatomy and interesting anomalies. And I think, you know, at, at heart of hearts, we are anatomists and surgeons and I really enjoyed that. The true general surgeons, as a Simon said, I also think it's a really supportive small specialty which has its benefits. There's, I think 304 100 pediatric surgical consultants in the country, there's about 40 peed surgical trainees in our region. I know most of them. I'm friends with a lot of them. Um, and actually I've met the most amazing people in pediatric surgery, both trainees and consultants who are really good friends. And it sounds silly. I was talking to somebody on my way in, you find your tribe in medicine and pediatric surgery is a really nice tribe of people. The last thing is that Children want to get better. Um And that, and again, there's lots to be said for that. As opposed to in adults, some people faster and faster on the ward, Children want to get up, they want to play and, you know, a couple of hours after an operation, they might be up and playing again and there's nothing more satisfying than that. What are the and so obviously, there are flip sides to every, you know, not everything is rose colored loveliness. There are challenges associated with pediatric surgery and these are things that we came up with currently, I think. Um um so, so it's there are obviously conditions that are rare and a lot of the countries with enemies, for example, can be quite rare. So sometimes you don't get to see them that much and that uh creates some challenges in training. Pediatric surgery is a small specialty. I think there's 22 hospitals that do pediatric surgery in the country, which means that your regions that you are um sent to for training are quite vast. So London is from Norwich to Southampton. Um and you have to be prepared to move, there are obviously smaller, smaller sceneries. Um But I mean, it gives you vast opportunities for exposure to different places and different ways of doing things. Um I guess I'll talk about this as well. I haven't been a call all day, but you know, safeguarding comes into things. Um And you are occasionally encountered with very challenging cases which are very heartbreaking. But ultimately, I mean, the flip side to this is that you're always trying to do the best for the child and putting the child first. And again, that's incredibly satisfying some regular uncles. Um II think it's part of uh most of the acute specialities. Um Again, um I like the uncles. I like the acuity of the conditions, but you just have to accept that there'll be some night shifts and so on. And I think that this continues into consultancy, which is a point. I think why we put this in is that you're likely to be called in all the way through your career, which is satisfying and fun. But it is also, I think at a point quite tiring. Um, we talked about the fact that communication can be complex because you've not only got the patient but you've got the parents, you've occasionally got the grandparents and you've occasionally got the uncles and aunties as well. And again, I think that's quite fun. I enjoy that challenge, but it can occasionally pose an extra degree of challenge, um, competitive at the beginning. I mean, um it's, uh we will talk about some numbers in a bit but there is a degree of competition and what I would always say. Um I remember much the sounds of it. Um But what I would, what, what I was always said to people, you know, think about it this way. If, if you want to do something, just go for it regardless of the amount of job. I don't think that matters much. If you want to do PX surgery. Don't worry too much about how many people or how many jobs if you want to do it, just go for it, you'll get it, you will get it. So, um, um, uh as long as you put in the effort and, and so on, um, there is a degree of competition but it's doable. The other thing to say is that it's still competitive at the end. So there, there's limited places limit, limited places that do pediatric surgery, limited number of consultant jobs. Um, so you can get to the end of your training and still find yourself trying to get something somewhere to work. Um But again, there's, as a farmer says, you only need one job and there's only one of you. So that's, that's fine. Um Just a little bit on the pathway. So sorry to jump a bit. But um for pediatric surgery training and any of the surgical specialties training. So, um most of you will finish medical school, do your F one and F two years and then apply for core surgical training. And actually for most of the surgical specialties, if that's the correct pathway, if you want to do cardiothoracic or neurosurgery, there are some run through job speed surgeries is very much so part of the standard pathway. So you apply for your core surgical training jobs. Um try and apply for something with some pediatric surgery in it because it counts towards your ST three application and try to apply something with some general surgery in it because again, it counts towards your pediatric surgery application. You get your MRCS exam and then you apply for your ST three training number and you go from ST 3 to 8. Um, and then you get your CCT at the end and do your FRCS P surgery exam at some point in the middle of all of that. Um, I'll talk a bit about surgical training, please. I did it a bit quite a while ago. Now, the application process has changed recently and you will have to do the M SRA not the MRSA as I keep calling it, but it's essentially a multispecialty exam that you have to do and reach a certain number to get. And our lovely everyone who's currently stressing about his co surgical training application assures me that you need to go and pass test and pass medicine to do to pass this. Um What I would say is to read the person specific investigation, which is what the QR code is on there and start reading it earlier rather than later. Because actually, if you get all your audits and bits done in medical school and through your F one and F two, you're more likely to not be stressed out when it comes to applying for your core training application. Um and also thinking about papers and publications. This book is incredibly useful at every juncture. So at core training and registrar training and any other interview you ever have to go to, I would 100% recommend it. I did not write it, but this is very, it's very good. Yes, for all interviews. Um The, the one thing to say about it is uh don't memorize the answers um because everyone else would have done. Yeah. So uh get the, the main ideas from the book and make it your answer personalize it. Uh It's a three application. So again, a person specifications, things that would make you score. Well, um so if you can um uh do your best to get you new to experience um pedia intensive care experience. Uh If you can, you will need obviously the, the audits, the uh courses and all the rest of it. But again, the QR code should take you to the website where the person is. Um uh you apply and then you have to score above a certain number before you're uh sorry, you're invited to an interview. And then the interview format is about half an hour, 10 minutes each uh free station. Um and it's sort of half interview, half quick examination. Uh So I think you get ranked and if you rank high enough, um you get a shot. Other things that I would suggest to kind of gain exposure and experience to repeat surgery is going to the conferences. So the BA S conference is held every year. There's a evening once a week in London called CS, which is what I was encouraged to go to is an F one where they were pediatric surgical um centers from different areas in the region come and present some of their work. And certainly, historically, it's always been a really great opportunity to meet people and to network. Um and even as an F one or a medical student, you're more than welcome to come along. In fact, our medical student presented on our behalf last week. Um So if you get involved in the department, there's always opportunities for you to present. Um you should try and deliver your own teaching, I think. Sorry, that's what I meant to say in this ST three application bit. But actually any evidence of teaching always helps with your application. And if you go on the BS website, there's a link to trips, which is a trainee group. Um, if you message them, they will always send you um, newsletters and so on and so forth, which is always helpful for when you're thinking about applying for repeat surgery, which hopefully you will do, um, a little bit on the numbers not to scare you. We're certainly not the worst in terms of ranking, but there's always kind of between 10 and 20 jobs a year. This year was a bit, there was loads of jobs that came up all of a sudden. And when I applied, there were 12 jobs and when the arm applied, there were 11 jobs. So, you know, it's kind of about right, which sounds like not many, but actually, you know, and what I would say is most people don't get in the first time. So don't be disheartened. I certainly didn't get in the first time Osama didn't get in the first time. Most people I know didn't get in the first time. So, if you don't, if, if at first you don't succeed, please try again. Um, so to summarize pediatric surgery is a busy specialty. It's very varied. You meet amazing Children and families, you get to see some pretty interesting operating, which is important. You can say that one again. Uh Nothing is ever the same. And again, that's a great perk of coming to work and doing pediatric surgery. It's great opportunities, great colleagues. Um And it's a specialty. So I'd recommend you will do it. Thank you. Uh If you've got any questions, please email us, please, uh ask any questions now. But um yeah, it's only less specific for pediatrics, but just surgery. And you said you guys get, what did you do after your CT two? Um So after my CT two, I actually got into general surgery as a trainee first time around. I was in the middle of COVID um and had kind of enjoyed both p surgery and general surgery. I'd always thought I wanted to do surgery but put in an application for both. Um and got a general surgical training number. I think if I hadn't got that, I would have replied, probably in hindsight, should have maybe applied for a neonatal fellowship and done six months of neonates and six months of pediatric intensive care because that would have been helpful. Um People do registrar, fellow jobs and it's really not uncommon for people not to get in the first time. There's loads of opportunities out there. So people do anatomy demonstrating for a year, which is again, helpful. People get ready our fellow jobs and all of that, even if it feels like it's not following your trajectory, your career path, it's always helpful and everything you learn in a year, nobody takes that away from you. You get it to take it with you. And there's lots to be said, sorry, I'm talking a lot, lots to be said, um having experience as a registrar without being a trainee. So I feel that my experience as a general surgical registrar meant that I got to my interview a lot more confident because I had experience of managing an on call take. And I was confident in the way that I gave my decision making. And it then meant that when I came to p surgery again, I wasn't fazed by having to make decisions all the time. And I found that a lot easier. So, you know, all experience is valuable, I think. Yeah, definitely. Uh Same thought. So, um don't worry about not following the exact pathway from CT one ct two to ST three and so on. Even if you have to uh do things in between. Um my uh pathway was a bit different because I did my med school in Egypt. Uh so I came and did sort of sho level job to start with. Um having done my MRC S. But as I said, when I first applied, um I didn't get the correct score to go to the interview. Um what I did uh is again, II did um about five months in NICU, about three or four months in Nicu worked on all the other bits in the person specific medication. And as I said, it, all experience is very, very valid, you very important and you will, it will come to a benefit for, for example, Nicu was perhaps too medical for me when I did it. But um after I finished the five month, I found myself way more comfortable in assisting. And a it even for a surgical aspect compared to my colleagues, perhaps who uh most of their training were purely uh surgical. So all experience add up, add up to you. And uh as I was speaking to your colleagues earlier, um it's important in the beginning of your career as one of my consultants used to say is to keep as uh wide for especially in the F one F two as possible. Do don't have everything in F one F two surgically themed. You need the general medicine, the A and the pediatrics. Um and then a bit of a bit bit of uh surgery, of course, but then uh you need that basic wide knowledge to start with. Um And yeah, just uh um have the person specification always ahead of you and try and score as best as you can. And don't worry about, you know, needing an extra year in between to rebuild more screens. Any other questions? Yeah, and how do you deal with the emotional challenges in Children sometimes you have so, you know, oh good question. Um The way I would answer that, um you, I think, as I was saying, I think to, to do pediatrics, you, you, you usually is a person who care a lot about your patients. II would say that in general. Um But uh to, after a bit of experience, you learn to uh sort of put boundaries about uh around your emotions and especially in these tough situations and you try your best to uh when you're managing difficult um um patients and in a, in a difficult scenario where perhaps an passes away or so. So um obviously deal with that case. Uh and with 100% you caring, but then don't carry the emotions too far away from uh the case and, and your working hours otherwise it can affect you in the rest of your life. Um So it's about, I think uh having a bit of control on your sort of feelings and emotions and try and have that in the scenario if you managing the patient, but then um keep it in that sort of boundary. I would say I'm maybe a bit different. Um, I II still get really upset by cases. Uh, and I think that's normal and, um, I would say that I talked about my tribe and I have a really good network of, um, friends in pediatric surgery and in medicine who are an excellent support structure. And I rely on my family a lot to provide me structure. And I'd say that's the key is that I've got a very supportive partner who understands when I'm really snappy. It's because I had a terrible day at work or something awful happened and I do other things. So I go and play tennis and I find hitting a tennis very hard against. Nobody helps me relax and helps me kind of vent my frustrations and kind of get rid of some of my upset. And I find that to be a helpful thing, I think it's really natural to be emotionally invested in your patients. And I think the degree of that, as also said is key to succeeding as a pediatric surgeon because you, you are the person for a extent. Um But you build your network of kind of you build your support around you and through friends, family, other activities, your colleagues, your bosses. Because actually that's the reason for doing pediatric surgery is that you've got people to help you and to guide you along the way because they're all going through it too. I just have one question at this time. Um You mentioned that, for example, cos it's such a small specialty, you know, you might be training in really large areas. How, how do you practically manage that in terms of like living and commuting and keeping, you know, having a strong support network with your family or friends? But how does that have you? I mean, I'm sure it's difficult, but is there any advice that you have for people? Um So again, it is challenging. So the network, the kind of the regions or consortiums just to briefly break them down as Scotland, which is actually an excellent scenery because it's only Glasgow and Edinburgh. So actually you can live between either and it's only 45 minutes away. Uh There's Manchester Liverpool, which is a game excellent because it's only about an hour away from each other. So you can live in one commute to the other. And the deaneries are quite understanding in that you probably get split three years, three years and you get to choose where you want to go. Um The northeast of England is a bit tricky, I'd say. Do you think that's fair geography, Newcastle to le and again, you, in theory, you're north and north and south people struggle a little bit. But I think actually they only end up in two Jan for most of their two places, for most of their training. So three years in each. Um it's Bristol Birmingham Cardiff, which again is not bad. You can kind of commute between the two people love going there. So they kind of make up for the fact that they have to move a bit. Um And then London again, we're meant to be north and south of the river and actually, you know, the training program directors understand that we're human. Um And then we've got families, we've got to settle. Um And most people move for, for a period of time and you get, most people have two years out, four years in or two years in four years out. So they kind of work out where they want to be. You can kind of move around that. It, it is tough and I, II don't, I think it would be amiss of me to say it's not, it's not tough. Uh, and certainly one of my decisions in swapping from, from general surgery to ped surgery was at a northeast of London General Surgical number. I wouldn't have had to move ever. I wouldn't have even had to think, thought about moving. But actually the, the pull of pediatric surgery was so great that I said, well, you know what? So if I have to move for two years, it's only two years. Um, and you know, if it means two years away I can still come home on the weekends. Um, which is not, it's not perfect but it, it does work. Um, no, I think the thing as well to say is that things are changing. And for example, this split between north and south of London to try and limit people moving around is a new thing. So who knows in the next few years? And part of that, I am sure came from people actually raising concerns about moving too much. So perhaps there's room for things to get even better. Um Usually you get support, say, for example, if you've got a property that you already own and you wanna buy a property closer to your new hospital, got some criteria for it, but they can support you in that course of say, buy a new property and so on. Um Oh yeah, I um having said all of that, I think there is still great benefit from working in multiple places because that, that it's, it all comes to the experience of the consultants that you work with. And um if you move around and you meet great consultants and you learn from them, that's what you need. It's only six years in the scheme of 20 years of career or 40 years of career. So people make it work. That's not a perfect answer. I'm sorry. Anybody else? Is there anybody online? That's good question. Yeah. Yeah. There are a lot of people online. So if we don't have priority for in person questions, but there is plenty of people online. So they have asked some questions. So if I asked. So you sort of commented on it as well. I have um either you start your own families if so how do you manage family that is working and trading? Got two sons. Uh Almost five and three. Sorry. Yeah, probably no something else. Um, um I II actually had my first one before I got my number and people were like a bit shocked. What are you, what are you doing with your life? So you need your number first. But um uh I think it's, it's important to maintain that perspective of um as much as possible. You wanna balance your work, your family and then your personal time activities. Um And it, it is definitely doable. Uh I do the on call, I do everything and when I'm at work, I do my best to be uh as, as good as far as I can be. And then when I go home, you know, I spend my time with my kids as much as possible, take them out and all that. So it, it's definitely doable. Um um Is there more to say about that? Um I haven't came to a point yet where I was like, there is, you know, a big conflict between the two, not all. Um I think part of it is I said earlier, uh um having people around you who understand your career and the challenges that you face and your uncles and things like that and that sometimes the bad days and, and things that make a big difference. And although I haven't started in my own family, I'd say that pediatric surgery has got, um, I think the most number of female consultants as a proportion um of the surgical specialties. Um, and actually when I look at most of the, the female consultants, most of them have got families as well. Um, and, you know, it is a supportive specialty. Um And there's scope for less than full time work through training and most of my colleagues or quite a lot of colleagues, even male and female are being supported to take less than full time work for whatever reason. So don't, don't, don't, don't let that put you off if you want to have a family and want to do surgery, it's the world is changing. Um female surgeons are safer according to all the research that's out there. So people need female surgeons as well. Um And another question um from the um is asking, what would you uh what would, what would you like to say about the future of pediatric surgery? I worry that it has no future with overdeveloping technology. Yeah, is probably the best city to answer. Um I mean, I think the technology is improving and I think it's an adjunct really, it helps us um in a way, the technical skill in the art still trumps everything though. And I think there will come a time when this guy will be me in, in a wheelchair when there's, you know, they failed that they're a robot or they're like surgery and they need, um, that, that those old school skills, so new skills to master. And II think those innovations really are quite exciting, to be honest. And, you know, II think they'll just help improve things. Kind of a follow up question from that I was gonna ask, are most of the surgeries that you both to be open rather than laparoscopic or probably more open surgery than there is in the adult world. Certainly, the urologists that come and occasionally dabble with us in pediatric urology are always surprised by seeing a kidney in real life. Um You know, they, they do everything robotically or laparoscopically and, you know, it's nice to be able to touch and feel things and see what things feel like so that it's a balance. And obviously, um you kind of went through a, a lot of different um systems that you operate on as you approach towards the end of your training. Um Do you start yourself specialized like in other surgeons as well or are you, as you mentioned, just a general, general surgeon, to some extent you do. But when you're on call, you may say anything. So you need to be a master of all of it. It's cool. I would say the good thing about it is um although there is more talk about subspecialisation, you still have the opportunity to develop a big variety of surgery and any skill that you develop in any speciality. Well, um will be transferable skills that you will use in whatever surgery that you use. So even if you don't end up being a urologist that uh or a say plastic surgeon or whatever, but any skill that you pick from uh training in these, um perhaps or sorry, will benefit you in doing any other surgery that you do and you have, you have the opportunity definitely during training to be as general and wide as you can. Uh And then perhaps later on if you want, you can do subspeciation perhaps uh with a fellowship. Also any other questions from the chat? There are, yes, that's fine. Well, then we can, yeah, ask those questions. So I was asking is how would you compare to the end of surgery here to that of abroad if you have practice abroad? I haven't actually done p surgery back in Egypt. Um I've spoke, I've got many colleagues who practice it back home. And um what I would say is that um the, the, so for example, you could say that in Egypt they get um higher numbers and um which translates perhaps to um more opportunity for training and improving um surgical skills. However, um in a, in A NHS and the training that we have, you have so many different systems and ways that means that you practice medicine and you practice surgery and you train in surgery, um, while, um, being safe, you're provi and providing the best care to your patients. So I just sure thought I haven't had any experience of abroad. Um, yeah. No, I can't, I can't really help with that one and I don't, I think has done quite a lot of work in the developing world and I'm sure he'll touch on that in his talk. hopefully. Yeah, and you as well in your asking, can you please also advise how we could participate during med school to build up our profile, to repeat surgery? So my recommendation would be to come and find us. Uh We are always here every day pretty much all the time. Um But if you are interested, if you contact us, email us, our emails were on the slide. Um There's always projects you can get involved with, you can always come and join us in theater. We're always looking for people that are enthusiastic. Um I would really recommend coming along to the conferences and trying to get things presented. We're very welcome to medical student presenters and it's a friendly environment. Um and it's good for your CV. So if you can get yourself involved in some projects, you can get presenting, get yourself some points towards your applications. Um And also what I would say is that pediatric surgery, you need to see it. So you need to have gained some exposure to it before you make a decision, you need to have spoken to lots of people because it is a difficult specialty. It's um, as all surgical specialties are, but it's, um, you know, from a lifestyle perspective, it, it is a lifestyle, um, and one that you need to be fully subscribed to. Yeah. Um, should we let Mr do his talk? Oh, yeah. Yeah. Um, you mentioned quite a lot that, um, experience in and is helpful. I was wondering if each surgery is specialty where uh after care is done by mostly done by you or do you discharge the patients to make you you after surgery jointly managed? I would say so um a baby say within the neonatal unit, a neonate um that needs an operation, medical care. You know, we work in close conjunction as one team with the neonatologists and the intensivist to manage their, manage your child postoperatively and sometimes preoperatively. Um And you know, again, that's quite a nice thing. You develop good relationships with other specialties and other and work out other thought processes and other ways of tackling problems to see it from other people's sides. So I quite like that element of care. So it's not do the operation give the patient to the orthopedia, for example, it's not quite like that. Cool. So you let me up to. So I just scroll on the thing or please, please? Ok. Oh, good evening. Uh So I'm Mokhtar, I've been a consultant at Saint George's for 16 years now. So I thought I'd talk to you a bit more about surgery in general. Um, you're all at the beginning of, you know, the fact that you're here tonight, I am, I assume you're all interested in surgery and it's going to be very varied where you end up. So, II thought I'd give you a bit of a, um, talk about things that you can do now to work on becoming really good surgeons rather than adequate surgeons. And then we'll go through a few of our sort of more interesting cases that we've had over the years. So when I uh when we get medical students coming through our firms and we do the, their assessment, um, the top mark that I can give any of you is acceptable. Um And irks me a bit because really to be a good, even a physician or a surgeon, you need to be exceptional. Really, that's what your patients would expect. Um So, you know, the training system at the moment, really, it's scared to make you AAA good enough surgeon. Um What do you need? You need adequate exposure to surgery and the rotations and the experience you need to finish your training, you need to read the books, pass the exams and actually, then you'll, you'll be a good enough surgeon and you'll get reasonable outcomes for your patients. Nature is very forgiving. You know, our job is often to put parts of the body in the right place, put some sutures to hold it there for nature to heal it and fix it. So you end up, um, even as a good enough surgeon getting pretty good results. But, you know, to me that's not, you know, you need to be, uh, from now you can work on things, um, to make yourself even better. It's far more difficult to achieve that little few percent extra. Um to get the best outcome for your patients, you need to become quite obsessive with the craft of the surgery. Through your training, you can, you can learn the knowledge, you can learn how to assess patients. But until you become a master of the craft of surgery, really, you're not a proper surgeon. And that's, that's, that's the challenge really. And you know, I'd encourage you to really focus on that craft of surgery so that your life is much easier. You know, you go through your 68 years of training and at the end of it, if you've not become really good at the craft, your life is going to be really difficult, you're going to be quite stressed about every operation. It's going to be a real challenge for you. Things you can do, seek out the best mentors. You know, I, you know, my talk today is based on observing some of the best people that I learned from. Um and also a holistic approach to your personal development. So I'm gonna talk, talk about some quite left field things that today that, that will help you become a better surgeon. Um and hopefully get better outcomes for your patients. Uh It's the first thing they're, they're all sort of ideas and observations of mine. Um So to me, the best surgeons will, it's the magic happens in the very subtle movements in their hands and instruments that happen in response to what they're feeling. So you can, you can train yourself from now to start actually being very conscious of what your hands and fingers are feeling. When you're opening the door, feel the temperature of that doorknob, feel the surface of it. And when you open that door, try and imagine what is happening to the mechanism of the, the hinge on the insi you know, the lever on the inside and that, that, that will get you more and more attuned to what's happening in your fingers and you will then subconsciously react to what you're feeling. And that's, that's pro I read something on here to, to remind me, I don't know if any of, you know, um the isle of man tt it's, it's a, it's a uh motorcycle race. I think it's about 30 odd miles around the isle of man on normal roads. It's the most dangerous race in the world. They're doing an excess of 200 miles an hour on those roads and they're normal roads. With roundabouts, trees leaves that can be wet. And I saw an interview of one of the, uh, I mean, you, you should watch, you know, a AAA camera view from one of the motorcycles and it's so fast, it's un perceptible what they're doing. You know, it's just incredible night. I watched an interview and the interviewer said after the, the rider, he said, you know, when you're riding your motorbike, you must be holding on for dear life when you're going at those speeds. And he said, actually, it's completely the opposite. I'm holding the handlebars as so they're eggshells because what I want to do, I want to be feeling what that little patch where the, the tire is touching the road. I need to be feeling that through the forks through my hands and then I'll make very imperceptible tiny reactive movements in response to that. And that's what's gonna get me through those crazy corners. So it's, it's, that's what I mean by appropriate reception. And when we're operating, you're, you, you've gotta feel what's happening through your fingers. Even through, uh, laparoscopic surgery, you need to be able to feel what's happening at the tip of that laparoscopic instrument and then you'll do subtle movements without even knowing which will, um, make your operation better and easier, sorry, um, master your own physiology. So I, you know, sometimes we're operating in real crisis moments just, um, yesterday evening, we were operating on a 24 week gestation, 500 grand baby who had a cardiac arrest midway through the operation. And in those times when your natural response is, you know, adrenaline release tachycardia, your brain goes hazy. You're shaking and if you get into that cycle you've actually lost the game and you've lost your operation and the child probably won't make it. So this is something you can work on now is to make yourself so calm that your heart rate's running at 60 for example. And when, ah, crisis hits and everyone around you is in panic, you're the one who's going to take the leadership role and change things. Ok? You allow your heart rate to go up to 70 but not to lose the situation, you can't faint, you can't go hazy. You have to be in control of your physiology and that will help you to become a more exceptional surgeon. Um, damage control. This is a concept, um, that has been around for a long time now. It came from war surgery, um, and trauma surgery. And it's basically, if we understand that surgery itself is, has a, is a big insult on the patient. It really affects their physiology in a very negative way. So if you've got a already sick patient who's, um, physiologically in, in, in crisis, and you then inflict a big operation on them, their chances of survival are, are, are diminished. And the concept of damage control is to do very focused, very abbreviated surgery. That doesn't take so much time. So, and that applies, you know, to every surgery you do. So, when we talk about very sick neonatal operations, we're doing a laparotomy. This is not gonna be a thoughtful methodical three hour operation. It's gonna be, is the anus happy. Are you stable? It's ready. Steady, go. And you've got 20 minutes to do that laparotomy to do the least that you can to get that child stable. Think of it as part of your resuscitation, think of the operation as part of the medical treatment um concept to, you know, you can read about this. Um I can remember a few years ago, I was, I had, had an illness and I hadn't operated for three months or so. So my first few operations that I did, I kept them very simple. And I can remember doing a hernia and I thought, ok, I'm going to really concentrate on this and concentrate on each thing that I do and it was so clunky each step. I found it really difficult. Um And it's because I was trying to use my conscious brain to, to achieve it and, and actually difficult things like, you know, the best paintings or, you know, amazing dancers or sportsmen or surgery, you know, your conscious brain just cannot achieve um that level of sort of quality for that to happen. You have to tap into your subconscious brain. That's where the skill really lies. Um And this con concept of flow is, is allowing your subconscious to express itself to, to, to be able to do those things. So you have to let the conscience move out of the way. Um This is a quote from Bruce Lee, be like water, my friend. So movement, you know, creates that flow. You can't, you can't do step by step. If you're going to do exceptional surgery, you need to be in it focused. And just if you hit difficult parts of the operation, move around them and you'll find that just like if you're doing an exam, you go and do all the easy questions and then you come back to the harder ones and somehow the harder ones become easier. Um And that's the same in surgery, just go do all the easy bits and then the difficult bits will, will, you know, be easier as you go along. Um Now gymnasts, so if a gymnast has to do a new move, say they're doing Olympic gymnast, doing a triple flip and onto a horse and some kind of really crazy move, it's potentially quite dangerous the first time that they've ever done it and the way they do it is their trainers, they will talk through what they're going to do and they'll make them visualize what they're going to do in that and for that movement they're doing and they'll go over it in their head and by doing that they create neural pathways so that when they do the jump, they're far more likely to achieve it. And actually I watched the best surgeons and as they prepare for an operation you'll see them go silent. They'll go and do their scrub and they'll take ages doing their scrub and won't be tired if anyone disturbs them. Because what they're doing is they are going through that operation in their mind, they're going through each step. So when they then come to the table half the work's already done, they know what they're going to do. They've already done it in their mind and it becomes much easier. Um Stoic philosophy, this is based on the teachings of the Roman Emperor Marx Arulius. And it goes back to some of the things that you guys were talking about, about your emotions. And when I was back in the day, when I was a medical student, we were taught by some people that actually you need to disconnect your feelings. You need to be able to treat your patient objectively and don't feel, I don't, I don't buy into that because to really do the best for your patient to really give them everything you can, you have to feel, you have to have that emotion and then you'll do the best for them, but be aware of the emotion and observe it and then put it aside. Don't let it overwhelm you because that emotion can overwhelm you and you can't then function as well as you need to. So what do I think? So, there's a stimulus, highly charged stimulus, be it? Um emotion or trauma, observe it but don't let it affect your inner peace, you need to maintain your inner self. Um And between that stimulus and, and your response, your response shouldn't be the immediate response to the trauma. Um in that space you'll find your power and that's, that's, that's really, you know, something that you can really work on. It takes a long time. Um And all your actions should come from a place of stillness. Uh Well, I've put here practice your spiritual fitness. I know a lot of um good surgeons who pray because some of the things that, you know, Aa and Osama talked about, they're just so mind bendingly difficult that as, you know, I II can't believe that we actually do them each day. Um And you need all the help you can get. So, yeah, I II would pray. Um, another thing that can help you improve your surgery, take yourself out of your comfort zone. So, over the years, I've been quite lucky. I've worked in Nepal for, um with our team for a lot of years and this was one of my experiences was in the, in the earthquake in Pakistan. And uh you had 100s of very, very um damaged people coming out from the mountains that we were treating in sort of makeshift er um theaters, this chat with the telephone, this is a satellite telephone that's um Shakil Qureshi, he's a professor at the Evelina Hospital and he's talking to the Health Minister of Pakistan. And, and that's, you know, these are other skills that you need to develop leadership and communication. So he was able to get out, we're in the middle of nowhere in the mountains. But, but he was able to make those calls and have that charisma and leadership to get us all the equipment and help that we needed in the middle of nowhere. And these were the operating FS that we worked on in back of sort of ambulances. And your operating table is, you know, not the best. Your lighting is very poor. Anesthesia is usually Ketamine. So the patient's not asleep, they're moving around. So if you can work in that kind of environment with poor lighting, a moving patient when you come back to Saint George's, everything seems so easy. It, your skills are just at, at another level. Um So I'll just talk through a few of the interesting cases we've had over the years. So this is um what was her name? Isabel Dalby. Ok. So she was um appendicitis, you all know about appendicitis, very, very common. Um But it's very, very rare in newborn babies. It's rare and exceptionally dangerous. So it has a greater than 50% mortality. Why is that? I, you know, I think there's probably a delay in diagnosis. Um The treatment, they end up with a big laparotomy. So, laparotomy with sepsis equals very high mortality. So, Isabel present as a neonate with a acute abdomen didn't quite fit any of the more common neonatal conditions. So we treated her, we didn't know what we were doing. So we, we did a laparoscopy. We've got at that time just got some new three millimeter sets. Um It's a tiny, tiny camera, tiny instruments and we went into her tummy and found that she had appendicitis. We did her appendicectomy. Uh I think she was three or four weeks old at that stage and she made a good recovery because she didn't have the trauma of a laparotomy. Um And at that time, she was the youngest child to have ever had a laparoscopic appendicectomy. Um Osama showed you something about uh uh Volvulus. So this is um a picture of midgut vvs. So this happens in Children who are born with an underlying abnormality of the intestine where they have something called a malrotation which makes them susceptible to a midgut valvular. And it's one of the most devastating and catastrophic conditions because you lose all of your midgut, you lose your small bowel and that really isn't compatible with life. Um And like I said, you know, the good surgeon will read his books and the books. What, what are we taught? How do we deal with a child that has completely black dead mid up, we're taught either to remove it all. You know, if you're not particularly brave, you, you take it all out and you hand back the child to the parents in on the net unit and then they're subjected to a life of parenteral nutrition, parenteral nutrition, you know, has its own problems. And after a few years that child will get cholestasis and liver damage and they may be a candidate for intestinal transplant or liver transplant. But the outcomes are not great. Um A braver surgeon might just close the, leave everything there, close the abdomen and um not resuscitate the child and hand it back to the parents and say, you know, this isn't compatible with life, you gotta let them die. And this is, this is, this is basically what books taught us. Um So this many years ago, this is a, a little boy called Alfie Pettingill. One night, he presented to us with an acute midgut volvulus. Um He was a term baby otherwise well and strong and had findings of totally black midgut II didn't want to remove all his bowel and I didn't want to let him die either. Um You know, we're, we're taught that if you have a gangrenous foot, it has to be cut off. If you have dead organs or dead tissue inside you, it has to be removed. And that's, it's a sort of basic teaching and that, you know, the way we treated him was, you have to flip that on its head. So we basically left his intestine in, um, sent him back to the neonatal unit, but we gave, gave him full resuscitation. We gave him antibiotics and we helped him to live. But with this dead bow inside him and he survived, he didn't die. We then went back into his abdomen and found um, like lots of fibrosed scar tissue. But within that fibro scar tissue, there were little sausages of intestine that had survived. So I did another operation to try and pick those bits out and try and join them all up chain of anastomoses. Um, but it wasn't of great quality. And so, um, after that operation, he developed bowel obstruction, didn't really progress. So we did another operation and I found a lot of those joints had strictured. Um, at that point, you know, we thought about how can we stop all these sausages from stricturing. So we, we stented it. We put a tube through all of his intestine that would sort of connected up. And, uh, he, he, he survived all those little sausages came together to produce enough intestine for him to, he, he was in the hospital for nine months. So, so he had parenteral nutrition, but then we gradually built up his feeds. Um, and that's him at that this last Christmas, the parents sent me, uh, this picture. He's tall, he eats normally and you wouldn't know, uh, that he'd ever been through that kind of trauma. Now, what we learnt from Alfie, um we've then applied to Children subsequently. So now when the child has a midgut ULV less and dead bowel, we don't remove it, we don't just put it back to fibrose. We stent it from day one. So it's AAA special tube that goes into the stomach through all the, the dead in what we believe to be dead intestine. Um And into the colon, we then start feeding into that tube from day one and it's fenestrated. So you're feeding along the what is thought to be dead bowel but also into the colon. And what, what we think happens is that yes, some of that bowel dies but it dies as a fibrotic tube around your stent and as the child's growing, these are babies, remember? So their intestine is gonna, they're going through lots of changes. We think that some of the mucosa migrates into that fibrotic tube also where you're feeding milk or feed into the colon, which is not designed to absorb that kind of, you know, nutrition. Uh at a microscopic level, it starts forming gli similar to the small intestine and, and a a process of adaptation starts. So the, the colon starts doing some of the work of the small intestine. Um And this is, this is one of our, um she was born last year and a couple of weeks of age. She had an acute midgut volvulus and that's what we did for her. So she had dead black midgut. We stented it all and she's now completely recovered. She didn't have to, she stayed in the hospital for three months because she didn't go through those chains of operations that you did. Um And she's now um fully fed and healthy. Um This is um Abby. So Abby was born at 23 weeks, gestation and developed something called necrotizing enterocolitis. It's a uh inflammatory infective interspinal condition that happens mostly in very premature babies. She'd, you know, ruptured her intestine become septic. She was tiny. I mean, at 23 weeks, gestation, they're just, their skin is transparent. They're very much like jelly. And as a team operated on babies 2625 weeks and got them through their surgery. But 23 weeks, if you think about it, it's below the, the uh age that you're allowed to uh um um terminate your pregnancy. So, um as a team, we decided to, to pro proceed with a laparotomy for her. It's, this is the sort of case where all those things that I talked about come into play. You know, you have to have a team that's ready to go beyond what's achievable to try and get these kind of kids through and she had a major laparotomy at 23 weeks. Gestation. God knows how we did it and she survived and, and is now now now a, a healthy, thriving five year old. Oh, I didn't have a picture of this one but this is another thing that's not in the books. So, um, some years ago I was, you know, it was a weekend, um, I was a five year old boy somewhere out in Kent and he'd gone to the park with his parents. He'd asked for an ice cream and they, they decided not to give him an, let him buy him an ice cream. So he had a tantrum. He started screaming and jumping up and down and going mental and he was swallowing a lot of air. And while he was doing that, he suddenly started getting breathing difficulties and collapsed. An ambulance was called, he was taken to his local hospital, deteriorated, got ventilated, intubated and ventilated and transferred to the ITP ICU at Saint George's. So we got called to see him on P ICU. And uh basically this boy had an undiagnosed diaphragmatic hernia. So he'd had it since he was a baby, but it not affected him in any way. But on that day when he had jumped around and had had his tantrum, he'd flipped his stomach up into his chest through that little hole. And when he was bagged and ventilated, basically, he was filling up his stomach with more and more gas which was up in his chest. And so I saw him on the P ICU realized, ok, he's got a diaphragmatic hernia. I can see something up in his chest there. But as you know, he just kept deteriorating and I couldn't make sense of why, why would a child with an undiagnosed, diaphragmatic? And he's never had trouble. He's got good lungs. Why is he just deteriorating? We put an NG tube down. It just wouldn't go anywhere because it, you know, such a sharp kink up into his chest. And as we were talking, I was phoned, a couple of my colleagues to ask them what could be happening. Um P ICU doctors were very concerned as we were talking, essentially, what happened was that his stomach filled up more and more and more. And at some point, his media mediastinum shifted right across his cardiac output stopped and he went into cardiac arrest. So in front of us, he's in cardiac arrest and I'd, I'd never been taught what to do. I'd never seen a child do this. I'd never read about it in any books. Um But we decided, ok, if we're gonna do something, we gotta do something. Now, let's take him to theater. So we took him to theater with the IP ICU on, on his bed giving compressions. Um We got to the theater, luckily there was a very um very, very senior pediatric anesthetist that day who was already in theater, he got him onto the table and said, so if you're gonna do something do something now cos there's, I've got no output since this is um So I went to scrub. He said, don't scrub, just get your gloves on and do something. One of the nurses said, wait, wait, stop everybody. We need to do the wh O checklist. He said, pop checklist, do something, whatever you're gonna do, do it now. So what did I do? I opened his abdomen not knowing what I'm actually trying to achieve or why this is happening. Opened his abdomen. He had a very tight hole in his diaphragm, put my fingers up there and just gradually yanked his stomach back into his abdomen from the chest. And as I did that, um the mediastinum came back into like, I mean, the when I cut his abdomen open, there was, it was like uh like doing a post mortem, there was no bleeding, there was this just blood was starting to clot in his veins. Um But as soon as his heart came back into, into central, he got an output and, and we got a heartbeat and uh yeah, so and then he survived. He, you know, he went to back to P ICU and I saw him in clinic four weeks later running. Um and you know, it's one of those things that's not in the books. Then, of course, I searched the internet and there are few cases reported all around the world, but again, really high mortality because it's just not seen and not recognized. So we then thought about how do you treat this condition and, um, wrote this paper and it's essentially, you, you, you try a nasogastric tube, um, first to try and decompress that stomach. And, uh, next step would be to put a chest drain in, but that chest drain has to go through the chest and pierce the stomach within the chest to try and decompress it. So that's your, that's, you know, that would be part, part of your pathway and, and then, then surgery. But, you know, to, to really look out for it cos, you know, as a pediatric surgeon, you're probably gonna see it once or twice in your lifetime, maybe. All right. Um, this is a, uh, a line from a poem from by Dylan Thomas and it's about old age, um, rage against the dying of the light. And II think it applies to, to us in many ways because in pediatric surgery, a lot of our work is selective, but then a lot of it is the emergencies. Um, and some of them die and it's very difficult as you said, Aisha. And you may do 100s of really good operations and they're all fine. They go away. You never remember them. It's the ones that don't make it, you carry them with you for the rest of your life. So I would say, you know, although I said to you have that stillness and calmness and that's where you get your power. That's where you get your focus at the same time you need to have this rage to do the best for that patient. And if you have that, that's what's going to get you the results, you know, get them through when, when you wouldn't expect to, I'll leave it there. Any questions, checking the online. Oh, very good. The question about the last case you before. But um I was just looking at the Yes. Are there guidelines now in terms of what to do? I think our paper is the guidelines for it. Yeah. Um So that paper was written by Jess who was here like you one of our medical students at the time and she's now uh ST eight. Yeah. About to be a consultant, pediatric surgeon. Yeah, sorry you mentioned earlier about kind of mastering your own physiology. I'm assuming with a case like this from the description, it's even for someone who's been a consultant for a long time or seen a lot of things, what tips have you got for doing that or is it just experience or are there certain things? I think part of it is awareness, awareness that you've got, you know, this is your physiology, this is your mental state and you know, in your times where you're not in a difficult scenario, that's when you can concentrate and work on your physiology and your day to day life. If someone's winding you up or you know, you're in a traumatic situation, step back and think. Ok, let the noise happen, but I'm not going to let it affect me. I'm not going to let it come beyond my borders and I'll observe it, park it and then react in a very calm way. Yeah. And you know, your physiology, I guess against it so many different ways to do it. Isn't there meditation or, or uh yoga, whatever, you know, you, you choose, mm for something as complicated as this and as normal as this, how do you come up with the algorithm for something that hasn't been heard before? Because obviously the thing that you did very young, obviously, that was more desperation to do anything to kind of decompress the stomach as opposed. Will you be able to kind of explain your summary of the thought process in terms of doing a? Yeah, I mean, I think when we did a search, we found that people had tried to decompress these with chest drains. The problem is that you can get the chest drain into the chest cavity. You may not perforate the balloon of the stomach. So, um you know, it, it seems to be a logical thing that that's what is causing. It's like a tension pneumothorax, isn't it? Basically? So, uh you've got to try and do your best to deflate that stomach as quickly as you can. Mhm. Did she still do pediatric surgery? Yeah. Yeah, definitely. Yeah. No, no, I feel very blessed to have been able to do this and to impact people's lives in such a profound way. And, you know, you mentioned, I share the old calls and at your stage they're very grueling as a consultant. You're on call, but you're at home and if you come in, it's for something so exciting. You come in two or three hours, you're gonna do something so otherworldly and then go back home. It's just like no other job does that for you? Yeah. And you know, II don't think I'd be able to wake up for anything else. But you know, if Osama calls me three o'clock in the morning, yeah, I'm there. Um There's one question from Charlotte from online. So she asks, do you have any experience of pediatric surgical oncology? If so, what advice would you give to an interested medical student? Uh Yeah. So um solid tumor oncology in, in, you know, is, is they're quite rare tumors. So you have to develop a real expertise and there's more and more evidence that the brilliance of your surgery is what gets the good outcomes. And this is, this is very difficult because you, you can be a pediatric oncology surgeon. You may, you know, something like a neuroblastoma. These are very hard tumors wrapped and welded onto vital organs and blood vessels and you've got to try and carve them off without damaging the good tissue but removing as much as you can. So that takes extreme levels, levels of skill. But um, nobody knows that what you've done really in that operation. And, uh, you know, we've had patients sent over from other parts of the world where they've had their surgery but huge parts of the tumor are still there or they've just deemed them inoperable. Um, so for a pediatric oncology surgeon, your level of technical skill has to be really high level, you know, and you can be forgiven for being a miserable bugger. As long as you can do the, do the skill, you know, do the surgery. That's, that's, that's where it's at. It doesn't matter if your communication skills or your empathy are great. I, you know, that's, that's when you want the really obsessed meticulous surgeon that area. Fun. Anything else? Yeah. All right. Live good, good, good. Thank you for turning up. Thank you too. One second one. Ok. I would say, I think it's more. I know. I always think you should give me and you want that now, 10 years later I should have paid attention to it. Oh, yeah. No, II need my, don't wanna help you. Have a good luck with your return. Thank you so much and let, let us know. Yeah, if you need anything. Yeah, I'll see you. Thank you very much looking surgeries. You just for your name and back of my mind. II know I can sit exam.