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Um We're now gonna move on to our anesthetics and itu in the low resource sector. So we've got two speakers for the next session and we have got rich then he's a consultant anesthetist and intensivist within the University Hospital of Sussex Foundation Trust. He's involved with the solutions in looking at antics in low resource settings. He's worked in and other low and middle income countries and is interested in developing critical care capacity of these doctor as a consultant in pediatric care and his overseas work has been in service education and hospital program support for district hospital health workers in Nepal and elsewhere. He's worked with the Associate of Anesthetists, the International of the Red Cross NF and Party Alliance in Ukraine and the Royal College Gap and Child Health Global in Nepal. Thank you. Thanks. Thanks very much for the introduction. Can you hear me at the back? Yeah, the voice is strong enough. Good. Uh Thanks to the organizers, um great conference. I've been listening to quite a bit. I mean a lot. So, thank you very much and great to be talking with Ollie. So, Ollie and I were registrars together at ST George Hospital a long time ago, they called gray hair and a and actually, this is probably the first time we talked again since actually. Um so Ollie very much went in the pediatric intensive care way and, and the poor, I went in the adult intensive care way in Sub Saharan Africa. So II would say I'm talking about safe because I think it's uh a great educational tool. Um I'm sort of an individual who works in collaboration with um other colleagues from around the world Europe America, Canada. So I'm not working for an NGO or an organization. I don't know anything about conflict and I don't know any, anything about humanitarian disasters. So, so don't ask me right. There have been lots of other speakers, you know all about that. So um I'm gonna really just talk about education really because most of what I do is about anesthesia and critical illness education and very much focused on Sub Saharan Africa stroke. So let's talk about safe. So safe is a collaboration between the Association of Anus and W sa the World Federation Society of Anesthesiologists. Um And I just would like to say thank you to Jolly Moore whose slides I've nicked because I'm not um I'm not uh part of the Safe sty group, but I obviously do enjoy nicking all their material and teaching it very good material for teaching in low resource settings. So we had a lot of chat about anesthesia and surgical related mortality. This is another slide, particularly focus on anesthesia related mortality. So, what I'm talking about is if you're doing a spinal anesthesia, which is a common uh anesthetic approach for cesarean sections, if that, if that spine goes too high and you have a respiratory and cardiovascular collapse and you then die from that or is an anesthesia related mortality. And unfortunately, you know, it is still a big problem. I was um talking at a conference in Tanzania two weeks ago, which is a non physician, Anestis. And II asked how many have experienced a high a total spinal, so total spinal mean cardiovascular respiratory arrest in the last year, 30% of the audience put their hands up. If you are that in an anesthesia audience in the UK, you probably wouldn't get anybody to put their hands up. So it's something really that needs that in managing that anyhow. So we know that anesthesia mortality in high resource setting has dramatically increased, but the problem is still in low resource settings. And the other problem is training. So we know there's a global shortage of physicians Anestis which is particularly focused in Sub Saharan Africa and Southeast Asia. And the background of trainer or providers is variable, very few anesthesiologists in Sub Saharan Africa. And the other problem is limited or no access to continued medical education. So you may have a very short and not great anesthesia training, you're then sent to a rural hospital where you may be the only provider there and you'll never get any more learning for the rest of your life. And there's a real problem with, um, with learning. And if you look at Africa, there are 30 distinct training pathways. Um, majority of them are for non physician, um, anesthetic providers. Um, and then the duration varies. There's no, um, in, in Tanzania, for example, where I spend most of the time, there's no national curriculum for uh non physician anesthesia providers. Apart from a BSC in anesthesia, which three years and very few people um are trained in. So everybody sets their own curriculum and when you decide who's gonna go and uh be taught that curriculum, um there's no um admission exam. It's basically where your hospital can fund you to go to that course. So, um variety of uh academic um achievements people do in these courses so safe. Um As I said was this initiative launched in 2011 and was very much involved in it when it started. And a lot of the training materials that was involved in is still on the uh on the website. Um And it really was focusing on the common causes of mortality, particularly um with obstetrics and pediatrics, which are the big killers um in uh in low resource settings. Um trying to improve confidence in those who are already working in the field and try and get some a medical education and professional type training for those that are working there. So, the flagship safe courses are safe obstetrics and safe pediatrics. Um, there are some newer safe courses, um, which I haven't, um, been involved in operating room is very much an MDT approach to try and get surgeons and this and, and nursing staff to work together, um, things like the checklist and then some newer safe developments such as refresher training. Um, And that's statement that I've been involved in, in two, regions in Tanzania to try and give rural Easters. You haven't had any education since they trained to give them some um refresher in some of the, er, training they already had. Um everybody says about critical care. So, um at the moment, uh the problem with the legacy of COVID is um politicians like producing lots of ventilators. Um and even in this country, you know, we had a lot of ventilators. Um we use ventilators that didn't work very well. So we caused a lot of harm by ventilating people badly and also reporting a lot of people who hadn't had experience with ventilation. So, um they weren't training and that was even in this country. So a lot of the harm was from us ventilating people on poor ventilators. What's happened in low resource settings is since caning, there's a lot of infrastructure going into building intensive can um machines that um ventilators, machines go ping, but there's actually no training going on at all. So what we've created is a infrastructure of ventilators which are just basically killing the patients. So, um critical care education is um key to moving forward and, and safe is looking at developing it. We're not there at the moment, we really started early taught, but it is somewhere where um safe would like to go. So a typical safe course lasts about three days and involves um 32 participants with quite heavy um faculty. So it's quite um it's quite a heavy person centered course. Um sort of modular format mi mixed with lectures, lots of breakout sessions, interactive and hands on. So a lot of practical as well as lectures. Um there's a one day training training so that we can then obviously pass on that knowledge to, to a local faculty and it, and it looking at the pre the interim, the post care. So the three day course I've always quite struggled to get people to come for three days when, especially when they're in a rural practice. And there are perhaps one or two people trying to get people to come for three days hasn't been very practical. So the beauty of a safe course being in modular format is we can take modules and we can do it, for example, in training for students, we can do it over a two year, two week period. And um what I've been doing is also um teaching some safe life courses. We're taking a few modules at a time and, and teaching them and safe, you know, has reached 51 countries over 1000 trainers. Um, you know, it's really far reaching, not just in Sub Saharan Africa where I've been working. So that's safe if I focus a bit on safe obstetrics cos, that's, um, one of the main teaching focuses that I do at the moment. Why safe obstetrics. And I think we've heard all this before. Um I think from an anesthetic and obstetric per perspective, remember that C section is the commonest um surgery performed globally. And if you're in a small rural hospital, it's perhaps the only surgery you're doing. So. So, um, you know, obstetrics um is a real big focus for, for anesthesia. And I think we've seen this, we recognize that 95% of the global maternal deaths have low and middle income second and particularly 87% in Sub Saharan Africa and Southern Asia. So, you know, big problem with maternal mortality. So what is safe for anesthesia? So it's um these modules which basically cover um uh intra or pre intra and postpartum care and actually pretty relevant for all general anesthesia. Um, similar sort of problems going through any sort of emergency anesthesia. There's also um a section on uh neonatal resuscitation, um because it's recognized that that may be what the anesthetic provider has to be involved in as well. So usually I won't go through them in detail. But as you can see the big killers, sepsis, eclampsia, obstetric hemorrhage, those are the key focuses of Saint obstetrics. And then what's relatively new, it certainly came about over COVID is, is safe online. And II think it's just quite a game changer in trying to really move uh education to a wider audience. Um The safe online is also accessible offline so you can download a, an app onto your mobile phone and have the whole course on your phone, which is obviously an issue when you don't, which is great when you don't have um internet access. Um and it's basically uh narrated lectures, but also with videos, drop down assessments, algorithms, animation scenarios, you know, interesting learning, which actually um you need to um educate uh certainly uh in Tanzania, they, they very much er whole way through school and training if they did Didactic type training. So if they have to sort of guide them through this and work with them, but it's not training they've ever really experienced before, we may think it's, you know, that's the way we do our training in the UK and in Sub Saharan Africa, that's not the case. And then the beauty is that you can, you can um do online discussions with it as well. So I can, you know, get a group to do some of the online stuff and I can then talk to them from the UK and then when I go out there, I can do some refresher, um, some practical training with him. So I think it will mean that we perhaps won't have to have three day courses, which is, which is quite difficult to get people to. Um, and we can have that sort of hybrid course where we've got an online version, um, with some practical, um, uh, with some discussions and some practical sessions. And then the one thing I would say is about online courses, I mean, you know, they may seem amazing but often you send them out and maybe does the online course. So you need to, you need to manage that well and that maybe you need to manage that an initially by doing it with the person. But I think it's a, it's a, it's a game changer in terms of how we uh do our education. And so, um so I sort of said most of this, it gives us increased access and you don't have to spend as much money, um use it privately as an accompaniment to face to face. Um and yeah, institutional national curriculum. So one of the things that we're just starting at the hospital, I work in northern Tanzania. It's a university hospital is actually integrating the curriculum. So as I said, there aren't curriculums, there aren't national curriculums for nurse and who are sort of over 90% of the anesthesia providers in Sub Saharan Africa. So if we can integrate these in these online courses with practical sessions into the curriculum. Um That would be uh you know, a great, great achievement. Um And it also means we can use um uh safe training updates as well. So that's safe and that's very much a product of the association of a system that we have to say, um greater learning tools. Um And as I said, hopefully developing um an itu learning tool as well. Um I know somebody will ask you about impact. Does it work? I'm not an educationist. These are my slides and I don't really understand all this evaluation and stuff, but there's been a lot of work done and safe uh a lot of good work. Um And I think a lot of the work looking at impact knowledge, skills, looking at organizational change, looking at behavioral change, there's some good evidence that it does make a difference. Um I'm not gonna go in this detail just for time reasons. But for example, if you look at, I talked about um spine and I worry about these uh total spinals. If you use this sort of behavior, measuring the block for how high the spinal anesthesia is going, that's often why um unexpected um high total spins happened. So just by doing a um training module to observe behavior improved, so that's state. Um I hope so. Um And say that's sort of very much about anesthesia training, what I thought I would just move on to a little bit about intensive care. Um And the question I think was asked, what does itu look like in a, in a low resource setting? And I think uh the answer to me is I talked to you about the problem with COVID and ventilators. We've got lots of all our regional hospitals in Tania now have an itu with ventilators and all we're doing is ventilating people very badly and we have high mortality. So it's not great for the staff morale for starters and we certainly not great for patients. So I think it really mean depends on what you mean by critical illness. Um And part of the, the issue with uh traditional medicine is we think about medicine, we think about obstetric care, cardiology, care, respiratory care. It's all very um pathways um or are treatments, infections, diseases, treatments are very vertical pathways. And the trouble is that it doesn't really work for critical illness. There's all these vertical pathways. They have sick patients at some stage, they have critically ill patients. So these are patients who are sick, these patients who have organ dysfunction and these patients who are potentially quickly going up. So all those vertical pathways will have patients like that. So we really need to look horizontally to try and do something about critical illness outside the intensive age max watch. Oops, that's what E ECC is, which I'll going to advertise a little bit. Um Very grateful we've got Ryan Ellis at the back in the audience. He's very much spear leaving this in the UK. So if you're interested in supporting this talk to Ryan, please. So E ECC is basically the care that we should provide to all critically ill patients in all hospitals in the world. This applies to low and high resource settings. Very much the baby of um F Tim Baker who's a UK intensive in Sweden and now works in Barcelo. Um And it's not about intensive care units. And that's whenever you talk to policy makers and you talk about critically ill, you talk about intensive care units and this isn't about intensive care unit. This is about patients who are outside the intensive care. You know, there's a large, big little burner down there. So, you know, in the emergency units where you work one in 10 of your patients, you see are critically ill, but they're not in a if you do point prevalence studies and this has been done in Sweden. It's been done in Malawi, it's been done in other countries as well. If you look for patients who are critically ill and you can find that by looking for danger signs in their physiology. So they're vital signs. We find there's a prevalence of up to one in five patients out in our hospitals are critically ill and you'll find that in the UK as well. We've had a big focus on that over the last 15 years focusing on the deteriorating patient. We've developed outreach teams, we've got early warning systems. Um So actually, I'd say UK is probably well ahead of the rest of the world in that sort of concept. It's been slow to move it um out of the UK. But we know there's a big critic on this. And the problem is, as I say, when we talk about critical illness, everybody thinks about intensive care, But 90% of critically ill patients are outside the itu. Ok. So that's probably where we need to influence policy. And that's what the ECC is trying to do. If we look at COVID talked about COVID in intensive care units. Actually, there was a huge number of patients who are critically ill who were in intensive care units. And even a lot of women would be looking after them. They will have option therapies, they had abnormal vital signs and they weren't in intensive care units. The critical illness is not about intensive care units, but it does need recognizing it does need managing and this is the problem. These patients are outside the itu and anticipating it, they're not recognized. Therefore, people don't respond and therefore patients aren't rescued in a, in a timely manner and therefore reversible. Um pathology becomes irreversible. And then it doesn't really matter whether they go to intensive care cos they're not gonna survive anyhow, we know the more organ dysfunction you have in intensive care, you the higher you are likely to go. So we wanna really get this early and reverse the problems. So we don't have patients come to intensive care as they've got better or if they do, do they come in any timely fashion. And so the consensus del consensus um were set out to define what EEC would look like. Um And involved 269 experts of which 67% were from low resource settings. So a lot of my colleagues in Tanzania were involved in this. Um and the idea was to define what E ECC would look like. And it's really about identification which you're all familiar with, with vital signs and early warning systems and the care, the ABCD approach of our critically ill patients. So it's nothing new. This isn't rocket science, but it's just not being done. Ok? And it needs a, it's a game changer in terms of saving lives. Modeling shows we do this to save a million lives. You have to have a number like that to tell policymakers, right? But that's what the ECC um is uh um identified as and then these experts came out with 40 clinical processes and 67 hospital read readiness requirements so that you could manage patients with critical illness in every hospital in the world. So for example, a clinical process would be you do your wife and sons, you know your BP, your heart, post Optim hospital readiness would be, the hospital needs to have a pulse in it, to, to be able to measure those er signs, a hospital needs to have some training so that the person understands what a low oxygen saturation me. Uh reading is a hospital access and training to understand what to do when you have uh a low pulse ox ox. This may seem really obvious to you all but it's not happening. And all of our studies show that it's not happening. Children are out there on wards, hypoxic, very few of them are having oxygen, really basic, simple therapies and it's not really because of access. So we've done quite a lot of work looking at access. Um hospitals do have this equipment and this certainly in, in Sub Saharan Africa. The problem is it's not available immediately for the critical ill patients. So it may be locked in a cupboard. Um It may be in the pharmacy as a drug. So it's not there ready to be used. Um You on some uh economics which is another way to include uh policy makers and provide c costs about $17 a day. So it's on a par with emergency obstetric care. Um and um um let's say uh HIV screen. So it, and, and it's very cost effective if you look at um uh Tanzania um threshold to pay, it is about $100 a day. So it's well below uh what, what people were prepared to pay but of course, um he does need some training as well, so similar to safe, um which is, you know, the Collaboration Association or a World Federation. Um And I course at Stanford University and a and a group of us have been developing materials for education in uh E ECC. Uh And again, it's a um interactive tool, it's downloadable. So you can look at it offline, it's modular, so you can use it in, in a bit and you can also um reflect and, and feedback um and it's interacted. So at the end of it, you, you know, do some quizzes and also the uh the supervisors looking after um the learning will know that you've done uh how well you've done when you've done well. There again, as I said, there's no point introducing um online learning without you making sure it is actually happening. One that, you know, a lot of issues we were having set out in Africa was send out online learning, but it wasn't being done. And that's because it wasn't the time or the understanding of how to do this sort of learning. That's sort of an example of a training menu. So it's a mixture of classroom content, acting, skills and assessment, um case based discussion simulation. All this can be used in your ee um uh training. And what's exciting is that the um Ministry of Health uh in Tanzania has adopted this um as uh the way forward So they um are now collaborating with UNICEF and they're about to start an implementation project uh across five regions in, in Tanzania um to actually learn how to implement this sort of training um uh across Tanzania. So the idea is that 18 months, they'll implement it, they get it wrong, you'll, they'll do something a little bit different and then it'll be maybe rolled out elsewhere. So exciting with a country like this is taking on this war because I, we recognize um that it's cost effective and also t to save all live. And finally, really just to say, you know, you asked about what the en is. Um and the barriers to change in this sort of context, people focus on equipment and staffing equipment is a separate tool. But we are looking at ways of making more sustainable uh reasonable equipment. But I think when it comes to staffing, um I think I want to focus on teachers and that's one of the things that's really lacking. And the reason I'm telling you that in this audience, because I think if you are interested um as doctors in training in being involved in low resource settings, this is a good place to start. I take training with me who I expect if they are AMNE this to have had just done some six months of obstetric experience. Cos I need to understand about obstetrics if they're interested in helping with intensive care physicians or anesthetist but I II feel they should have done six months in an acute setting, whether that's acute medical unit or an intensive care setting. So, I don't think it needs a lot of experience. Um, we're not, you know, not, people aren't coming out to practice in conflict areas or disasters, but I think there's a lot of opportunities, uh, for trainees for teaching. Um, certainly in Sub Saharan Africa, um, to improve outcomes of patients. Um and uh and save lives. So I'm not gonna hand them over to Holly, just go over and then uh we can chat with him. Hello. Uh Can you hear me at the back? No, I can't hear you. It's a idiotic way to ask, isn't it? You know what I'm Ollie, I'm um not gonna talk about P RC on at all about this. So I started off by talk by apologizing. You should never do. But anyway, um I am Apr C consultant. I've done anesthesia as well and or do it. I used to work with uh the Nick Simons P in the fall for a long time. And uh I'm now a consultant advisor to RCA PC. Anyway, uh which is there you go. So I've been out in the pool for about 16 years. This photo was taken about 12 years ago when they did a six month work surveying lots of hospitals. This is Raj Raj Rashmi. So Rashmi work with us on the, on the R CPC H program. So you'll probably hear later anyway, this is what it used to be like. It's a lot better than that now. But this is a woman who's, I don't know if you can see, this is a 45 kg woman. She's about 30 years old. She's got a dead baby, baby's dead. You can see its foot in breech. It's hard to hear me. Oh, yeah. Is there a microphone? Right? OK. I'll stop looking because I noticed with one of the speakers, if you look that way, you can't hear me. Can you hear me now? Yeah, Kim. Yeah. Can you try to? OK. Good. That's better, right. Good. Too close to it down. OK. Right. How's that? Exactly halfway between. Yeah. OK. I'll try to get right. Anyway, so anyway, so this woman, this baby's thought this baby had died at some point in trying to, we're not trying to illustrate in this photo. You've heard about maternity care. I think yesterday. Is that right? And you know, obviously from Richard as well, you can see a heater and the pool's not always warm. This woman on her left is called, she's an anesthesia provider, anesthesia assistant as they're called, but she tells you everything about their hierarchy in terms of down there not looked after, not respected this woman. This woman's baby has died and she's having a life saving Cesarean section. This is not saving the life of the baby. This is saving the life of the mother. And this is a fundamental thing about different hospitals in Nepal and across the world. This is the number one thing that every hospital needs to be able to do and it's still not doing adequately or in great enough numbers. So this is Nepal. Um I should say I, we meant to say at the beginning, I'm very obviously not on Neal. You know, I shouldn't really be talk talking to you about Nepal. I've been going, I've gone there a lot about 50 times. I speak of smattering of pathetic Nepali. Um But uh you know, I'm not Nepa, I'm speaking for this country from the people that are working there entirely from the position of being a consultant in Southampton. So let's just put that caveat in anyway. Here it is. Um you obviously Himalayas and obviously the blue, the the brown, sorry, the darker bits are where not many people live and the pink bits, the Tora flat bits border India, its where most population, population in the country is around 30 million, most of the population 17 8 and 20 million given the flat bits. And on the right hand corner is the provincial structure now and where the OP th program which is pediatric is of the elevator products too. So it's a very diverse country, you know, some heavy areas like this. It's up near Everest. Um There's all my photos, this is right outside hospital in began. Do you remember that? What do you mean? I know you're on the other side, but it's obviously a Buddhist country. Mostly Hindu. Actually, it's got very diverse populations. And what I'm trying to sort of set here is a little bit of the context of where somewhere like Richard's work and the safe work we've done in the before too actually would fit in. So here on the right, the blue buildings, blue roof buildings is calico in the far west, very remote area here on the left. This is um I think h so outside one of the hospitals very busy, looks completely different population, completely different access, completely different world is completely different. So vastly different kind of access to the population for the healthcare rush me wears that. Recognize that. Ok, that's zero mile which is a famous Coronary gene we r but basically this is a woman, ok, walking around by the bus station, it's just this anesthesia is really only about women overseas. It's obviously about many things and about surgery and all that kind of thing. But the one thing it should be about in the global health really should be about women first, right? And this woman is a woman that's, you know, I don't know anything about this particular woman, of course, but she's likely to be a woman from a disenfranchised card or ca she's likely to be, have very little agency in her own family, let alone when she approaches the hospital, she's likely to not have very much money. She's likely to be faced with a plethora of choices about where she goes, including an explosion in private healthcare which inevitably costs more money. So not necessarily government hospitals, this is go hospital where women are looking in where people are having recovering from Cesarean section. And this hospital nonetheless is ur in the far west very remote hospital that's in the middle of the day. There's not a lot happening in that hospital. I mean, this was some years ago. But even so the concept still holds value. These different hospitals are not bus, they're not like I've been to a a bit and you know, in Chad, I work with them and you're talking about a big regional hospital, 2 300 beds, something like that. This is a hospital of 15, 15 beds, that is the only hospital in a district of 200,000 people. That's the deficit that there is so Richard Haton, I'm sure you read the last, it said this some years ago, there's a sort of ho trinity or a trinity really of how we define where we should be coming from, really become a global concept of global justice, the rule of law you hope exist and it doesn't in so many places, basic context of human rights and equity that should be driving every healthcare intervention that we think about. So this hos this photo is taken outside Tanz Mission Hospital again in the west of Nepool. And it just sort of shows who's doing all the work. You know, there's all women, there, there aren't any men there doing any work just in the middle of the day, the women are collecting water. Tanz is not particularly in part of the pool actually relatively increasing. As you know, there's now push for the sustainable Development goals to make universal health coverage. Absolutely fundamental and surgery rather like critical care. And obviously anesthesia by proxy has been very neglected. It's about to be an expensive thing. It's about to be, it's about to be ines essential. And so now there's been lots of pushes started and boosted by the Lancet Commission, which is now nearly nine years ago, uh for universal coverage of essential surgery. So for women having Cesarean sections, that's the number one thing to remember really? So here's a woman somewhere on the road or younger. I don't know how old she is. She's probably only about 40. She looks about 60. She's doing all the work and this little boy out there messing around and some other young lads who are doing nothing contributing. She's doing all the work in the middle of the day. These are the sort of domains of universal access and I'm sure you've heard these kind of things before and many other talks. But when we're thinking about a health facility that we're going to work in or a health facility that we're trying to understand or a district hospital if we, if we say in, in Nepal, these are the things that fundamentally need to be available. So availability, it needs to physically be there. It needs to be open 24 7. It needs to be accessible. Obviously, in Nepal, that means can you actually physically get there? It's hard and it's expensive and it might take you 10 hours to get to a hospital. Literally, we also have to have agency in terms of getting there. Are you the person making the choice if you're having a Cesarean section and you're obstructive in labor, which is very, very common um to avoid having a uterine rupture or dying or the baby's certainly dying. You need to be able to advocate for you getting there and when you get there, you need to be listened to when you get there. And like that woman where I showed you the picture of the baby who was already dead. What age is that woman have in that kind of scenario? It needs to be affordable. So, you know, universal health coverage means universal free healthcare. You know, we're in a phase where the NHS has been squeezed. I've been working as a doctor for 35 years. So I have seen that it's, it's more pressured now probably than it ever has been, but it's still a wonderful thing. It's a wonderful thing that we have free at the point of access healthcare. That is not true in so many parts of the world. It's increasingly true in the past, but not for lots of different things and may not be for a woman that can't choose it. Um, and it needs to be acceptable by that means, be any good. Right. You need to go there. And when, when we did some of the surveys, when we first started that program in, in, um, in aspiration and South, we asked patients what they said about the hospital. And the first thing they said it's much cleaner than it used to be. Oh, that's great. Right. But it ought to be, that ought to be the most entry level thing. And they ought to, they wanna say I want to bring my family here because they have really good care. One of the, I think the successes of our program due to harassment in others is that patients now want to come to the hospital. They believe that it's a better place. They believe they're gonna get better care. And of course, it has to be adequate. And that means that the people have to be trained, there has to be enough staff there, there has to be enough equipment, there has to be blood available, um, and all that kind of stuff. So for surgery, just again, a quick recap, the Lancet publishes commission, there are many commissions in the Lancet. This is 2015 outlining the targets that should be got to for surgery. And I'll show you towards the end of the study that we did in the pool, which shows how far behind everything really is. Despite the great achievement, an essential surgery was DCP three, I think it was, which basically outlined much the same thing. So this all, there was a big push to do this and the wh O took it on as a, as a, as a kind of, well, one aspect of it. And so there was kind of moves to kind of recognize the inadequacy and lack of surgery everywhere a lot. Ok. Yeah. Oh, sorry, I don't have that my last name to cut up. Uh, that's a bit unfortunate. Well, I'll tell, I'll tell you about the effects of recovery before this thing appears because that's relevant to that. Actually, that's very disappointing. Anyway, some years ago I was trying to get a handle on this. So I started off, you know, I worked for many years ago and I started doing some work and I did all the safe stuff and I thought, ok, thank you. Um, and I learned trying to get a handle on what these hospitals were all about. So the concept of effective coverage was defined by a girl called Ta Has in the seventies. And it's really about the idea of the greatest facility, the best facility for those who need it. So, providing coverage that's most effective. Um, And um unfortunately, what the slide doesn't actually show is the various components of that which have to do with accessibility, affordability and add a bristle. And the, the organization I worked with in the for quite a long time, about 15 years was the next time Institute American funded who work with government to support uh hospitals and they defined affected coverage, didn't call it that. But basically saying that what you need to do in these hospitals is to put an mu TP like this guy in the middle and he was to build a team around him and he provide facilities, communication, referral pathways, essential equipment, capital items, cm E continue medical education and you need to um do that for district hospitals. So making the hub. So we've talked about maternity and pediatrics and anesthesia and trauma and and you know, gladly talk about ultrasound and all these things, but they have to function within the whole of a functional district hospital which very few agencies actually support. So it's about supporting these stuff. This is this is a general surgeon, this is an anesthesia assistant and this is a theater nurse doing basically all a very healthy screening child. Um and it's about supporting these working within their health and that's providing effective coverage at this hospital. So as Richard alluded to you at the time that this I made this slide like 10 years ago, I worked in Southampton Hospital, there are now 100 and 60% of in our hospital. Imagine that at this time there were no zero anesthesiologist in any of these districts. There are 75 districts in Nepal. Sure. They were in Kathmandu. They're in some of the bigger cities in the south, but there were none even now in 2024 in the hospitals that we work with in the south. And that's pediatric. But I keep an eye on the anesthesia. There's like one in each of these hospitals, one for a population of 500,000. And that's mentally low, isn't it? That's because nobody wants to work there funnily enough because there's no money to be made privately and various other things, you know, and the problem is that good people are not dis them, not wanting money. But the basic fact is there's no incentive to go there and you talk about learning, you've got to incentivize people to learn, that's what it's giving it to them. So again, um as, as richer and negative to generally in low income countries, attitude and mortality is bad. It's not all to do with skill. It's sometimes late presentation. If you're presenting a woman with u imminent uterine rupture is quite a lot sicker than many of the mothers that we have. But essentially low outcomes, sorry, worse outcomes generally due to low experience to train but not only and so, but, but there are no anesthesiologists. So what do you do? You treat treat somebody like being a given to me in that setting. What do you need for effective coverage for knee? This is taking a long time ago. I read Great Hair. Now you need basically good for training. You need updated stuff. You need enough cases, you need an enabled environment, you need supervision and you need continuous learning. And the other thing that learning does that helps people stay in remote areas. It's quite interesting word to show that if you, if you, um if you train people in a remote area, they're more likely to stay there, more incentivized to do it. We just didn't work on this in the pool. We published some papers. One of the things that we did is that we did on a hybrid learning thing over a year to engage and incentivize people and give them a qualification. And if you're interested, I can send you those papers. And we also showed that kind of anesthesia providers are just as stable as anyone else is proving what they do is good. So they provided 4000 logbook cases if we didn't want tablets. This is 10 years ago. This has not been as in, you know, much internet and all that kind of stuff. This is back in the anti time when table were Frank New. So surgery, these are the outcomes that last commission um said that we should be aiming for and this is what we did when we did a big surgery study about five years ago in the full, um, half be as we published a year ago and use it to lobby government to improve surgical plan for the country. So, here's a target 5000, which is based on New Zealand. By the way, if anyone's either from here or there, that's apparently the best surgical service in the world. This is, this is by disparate crumbling around the bottom. What that actually tells you is much more, what is there than what isn't there. As everyone talking about a country that my work was in part, I wanted to find out what is being done, not what isn't being done, but essentially, you know, close treatment of fracture, fracture was being done. You know, anyways and Cesarean sections, you know, some districts were no Cesarean sections were being done at all. But what we wanted to show is we wanted to show that generalist teams ie not specialist team will be delivering stuff. And this is very controversial in the UK at the moment to do with anesthesia associates. And I haven't lost to that debate. Cos I'm too, too near the end of too near retirement. I don't want to have a fight with anybody anymore. But basically what we showed in Nepal is doctors like this generalist doctor and anesthesia assistants. The time is you get 20 per 100,000. They're nowhere near that in most parts of Nepal. This is an arbitrary target that just shows that uh sorry the outcomes improve. If you get to that target, we show that a general and surgical team and the GPS who do the surgery and that the assistant are in density eight times specialist. Um And so what we were advocating for was that this model of supporting journalists. And this is again, what we do in our, I'm always banging on much as I love pediatricians, always banging on about how most of the pediatrics in district hospitals are done by non pediatricians. And therefore we need to support them in our work as much as we can. So that certainly here and this is a graph that I actually never made it into the paper. You know, I love it because it obviously very part of that. If you show them the met me, it's all about where you're delivering what you need to deliver. So the Met need, you can work out 5% of all of all deliveries. Generally go the wh O generally go to section obviously in urban areas. That's a lot higher in some rural areas that they've already got a scar. They don't know any scar, don't have labor, that kind of thing. But generally the Met need being in, in blue and we show them in some districts that met, needs being met by a general surgical team. But in others, nowhere near being met again. This is five or six years ago. It's probably out of date already. So to deliver basic surgery, mean hospital functionality, we're aiming for effective coverage, an enabled environment, an individual, an individual MDG P who's competent and supported, competent team. You need management skills and management power and need to lower and understand the risk of the procedure. Nobody wants to do laparotomies in district hospitals because the risk is enormous. The patients like to go, it's much easier to go, just go down the road even if it's three hours, it's not your problem anymore. You can understand understanding that factor. Um Again, sorry that I get it, but essentially just summarizing what, what I'm trying to talk about is district hospitals are a key hub for providing effective coverage for people in rural areas, but also urban poor who are often very disenfranchised and unable to access services by having general surgeons doing what would be considered specialists in other places and using kind of people like these guys who have 2030 years have been working for as he in the right. Right. And so um so functional district hospitals and there was a lovely photo at the end I don anyway, functional district hospitals gives you effective surgical coverage with the other stuff that we talked about. Thanks. It's funny cause I may not, you know, um Thank you so much for that session. Um And we're in the interest of time. We're gonna keep this one question actually and you can answer your questions. Um, maybe on the other side, is there anyone who wants to ask the question? It's for, um, on the fine. Yeah. II think I was just wondering and given the, and sort of the lack of, um, of trained providers and, and the increase ultrasound, whether or not you've noticed or predict an increase in regional ultrasound. So blocks being used as a safe and perhaps, and in some social settings. So, um yeah, it depends on what we're talking about, whether we're talking about um university settings, regional settings or, or rural settings. And certainly, uh at the University Hospital, you know, access to a generally throughout the hospital now and regional blocks is certainly um something that, you know, is, is a focus. Um, you remember though that um most of uh anesthesia in, but it's for anesthesia in, in rural settings, this section. So you could use it for postop um analgesia, I suppose. But remember you gotta have the thing about Alzheimer's, you need to have that training. You. So ely had no, they can require a lot of it if you're doing um, you know, one C section a day and that's the entirety of your anesthesia. Then it's probably not AAA place to go and do your ultrasound. But certainly in um the university hospital, it has been taught and been used by the anesthesiologists who uh are few and far between. So where I work, um, the case was here in the north, up until three years ago, there were zero anesthesiologists in a university teaching hospital with 1000 beds. Um, unfortunately when I three, but, you know, like six months ago, one was on maternity leave, one was doing some cardio thoracic training in India. And so we're down to one again. So, so, um, I think, you know, um, we've probably got to do a lot, a lot of walking before, before we run into doing. What's that? Don't know what I can hold. I know you say you don't need ultrasounds that you got those guys. I show you that are unbelievable. They can drop anything. You can put spinals in anybody. And so that's so fine. I have to in terms of that and, you know, even at home now, isn't it? But basically you can do it on your own and you can see here and let you know, but safer much more. Yeah, basically you probably should never ask too old near me. Retiring. Thank you so much for the time.