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Is the EGM, uh which is really just to rubber stamping what your hardworking committee does all the time and letting you know what's happening. Uh The committee is uh both the people elected and also who have been uh brought on to the committee as futures and ve commerce contributors, made up of consultants, but also made up very importantly of our trainees and representatives of our trainees subcommittee, uh who contribute huge amount, especially the, it and the, the pro on the social media of our act. Um, so I'll just give you the bits and pieces from, er, the, er, the committee meeting this morning, which is important, um, continuing what we're doing. Um, I'll win Abraham who, you know, as a secretary, uh has stood for election as chair elect. No, he is his treasurer but he stood for uh, election, sorry, as chair elect and was elected unopposed. So, congratulations. Uh, and, and, you know, it's just gonna be good to combining that with TPD and, um, that will cause you a problem. We need to have expressions of interest which will be invited to uh both uh whatsapp and email expressions of interest as next treasurer, uh, is willing to teach you how to the inland revenue and how to do all the accountancy and invest and everything else. He would like to not be treasurer and chairman at the same time, they kill you. Uh, so think about that. Uh, if anybody's interested, uh, one of the questions that will come out to the committee and to the bo of committee is about next year's, uh, annual meeting planning to have it either on Friday or Saturday. I have a poll to see what, what people want to do in terms of location and date. Uh It really has to be for a variety of reasons that first week of June. Um The other bits and pieces are, the finances are relatively healthy. It's important that when you're approached by trainees, that you make sure that they're aware that they can access funds for traveling and be involved in limit projects. There's funds, short amounts of money available for short trips and then there's the fellowships which classically are not heavily subscribed so in and not just trainees, but also your pa s your physiotherapists, your theater staff because there are opportunities for our paramedical staff to be involved in what we do. Uh Just talking to the guys in the I and they'd love to have somebody to set up and in and out into some sort of order all equipment they've got. Um so spread the word is really, really important Uh And that's really the only important thing is to, to highlight um looking you ready? Ok. So uh any questions from the floor about uh from the A GM? Are you happy for your committee to continue thing? Uh What causes to see if anybody wants to get involved? Please get involved. Really? Thanks to our membership has a lot of work, especially it, which we're completely unable to deal with. Um The other thing is uh every year we used to give the Poder Medal and after some discussion, it's now become the walk meal, which is awarded to somebody who's done something special for orthopedics in a global sense. And after a short vote, awarded Lose Circle. So those of you who are involved in trauma will know that New Circle is a guy set up 25 years ago, we set up sign and that has done over 400,000 free im nailings across the world. Those of us work in Africa and are used to know the value you put in a sign nail without any image intensifier. A foot and ankle surgeon like Ashton can still put one in. I think it's very prosthetic. He said I can use it. I thought it must be. But lou is celebrating 25 years of this project who manufactures screws, everything supported by local business, originally by ACUMA, but now self funded implant is basically funded by charitable donations, individual charitable project. And he was uh awarded the first uh walk UK medal, just Walk UK medal. So um obviously Louis isn't here. So I'm gonna pass this over to Alberta to give to him and do this, please. He is uh is he on record this from the world orthopedic concern in UK for the past 25 years. Signs mission is to bring a quality of fracture care throughout the world. We stand with you in this goal, the success of Sign can be attributed to the quality of the sign surgeons. They are as good as any surgeons in the world. I review their cases on the database every day and their surgeries are very good. Marcel Pro said the real Voyage of Discovery consists not in seeking new landscapes but in having new eyes. This is important because as surgeons, we must always be looking at different problems with new eyes and find solutions to better treat our patients. Thank you for this award. I am grateful and I see a lot of synergy between our two organizations. Thank you. Thanks. I think he's really touched by it. He's really touched that somebody on the other side of the world just across Atlantic recognizes his work. But all of us who've done sign nails and have seen the results and the benefits from Ukraine to Zambia, to Malawi and uh Uganda Burma know the value of what he's done. Thank you very much on behalf of the group. Yes, you're OK. So no other comments, no other questions. Right. So Simon and Alice take the floor. So I sure that both is part of walk in many ways. Um Have a Oh no, yeah, that's your job. Uh So officially the handler of the chairmanship goes at the M I completely forgot that no one to give it away. You see. Uh and uh it's up to uh Ashton now to take over as chair uh and be supported by all of you in, in working harder at the creating the relationships that we need to create with both and her B ssh. But also people like bas and B Mr s, we need to do that. So it goes over to you to do some hard work now and look at the eyes at the end of a phone. You always are and I will be picking that up more often than you hope. Um I just wanna say thank you and I want, you know, credit you for all the hard work you've done in your three years as chairman, you know, taken over from very hot shoes yourself like deeper and carried on that um that out, you know, um were about walked us and kept us as a high profile organization with lots of recognition among our peers. So, uh I can only hope to, we were able to emulate that in, in my tenure here. I thank you also for uh you know, staying on for a little bit longer to allow me to kind of warm up to the role considering I'm coming in at sort of an early stage of my career here. So, so I look forward to the challenges ahead. We've got a vision, a mission to achieve and hopefully hand over to another big man coming after me. So I OK. OK, in everyone. So there's two of us, there's no answer but it should come up. But, yeah. Ok. Good. The reason why there's, there's no power point is so what we're gonna do today? So I'm Simon, I'm a li construction surgeon from Liverpool and a master and associate professor in Global Trauma at Oxford. Um, and, um, yourself, I'm, er, five in the 17 and I'm the global surgery rep for voter and the walk training right here. We thought everyone might be a bit powerpoint out. Um, so we're gonna do a question and answer session where Alice is gonna ask me some questions. Hopefully she's top, saw the top and what she's gonna ask, there's gonna be some curveballs maybe in there. And it's also, and anyone can ask a question. So we're gonna focus on research and the reason why we're doing that is that's what I do on a day to day, day to day basis. So we'll start with set up these beautiful, er, chairs. I feel like I'm giving a ted talk. Um, we might have moving forward. Does that work? Yeah. But it's not our base then is it? Um So I don't need that. Do I, do we have to do a dramatic spin? Yeah. Dramatic. W we go right. I'm gonna channel my best Jeremy Paxman vibes, I think practice aren't gonna sit. I feel a bit odd. Um So how did you get involved with global surgery research? Uh So I II basically finished, I finished medical school. I messed around a long time in medical school and realized that I basically wanted to be an orthopedic surgeon. Um And I needed to get my head together. So I thought, well, you know, I needed to be different. So I found the one person in the hospital who was doing something different and that was a professor who was a press who was a Greek guy um in Leeds. He wasn't pro G, it was a guy called Proet and he was doing lots and lots of research and I sort of realized that I'm gonna become an orthopedic surgeon. I need to be different. So I went to him and said, listen, this is my situation and he helped me out a lot. He was a mentor and that's when I started to get involved in research. Um And I've always liked adventure. I've always liked traveling and I've always planned to go and, and do something abroad. Um So I got a bit of funding, started my research up and I went and worked in Malawi for a period of time. And as I was there quite, quite quickly, actually, I sort of realized that I wasn't, I wasn't really needed. Um, I didn't go there with grand hopes but I think it's quite, it's quite obvious that basically I was just there just to, to, to help. But in a way, you know, equally me, not being, there wasn't, wasn't particularly me being there wasn't particularly useful. Um, with my background and research, I sort of saw there was some unanswered questions. Um And I saw the impact that basically research research could have, which essentially I couldn't have operating. It doesn't matter. We know that we could operate all day long and, you know, we're never gonna, we're never gonna fix all these challenges that are presented throughout low resource settings, but no one at this point was doing research in that area. So global surgery wasn't, wasn't a word. Um There wasn't really people doing research in that area. Um So, uh I'll go back to the UK and I and II sort of had this idea where I wanted to answer a question about HIV. At the time, lots of people um thought that HIV was a huge problem uh with regards to fracture related infection and also fracture healing. And it seems a bit odd now because we, we sort of know now that there isn't really an increased risk of infection, there isn't really an increased risk of problems with healing back then. It, it, it was a, it was a big deal. There was lots and lots of papers on it. So I applied to get some money, got some money answered the question finished as a consultant. And eventually, um my costa approached me and said, listen in Oxford was sort of bo the bored of comparing a screw versus a plate. Um and slightly selfishly and no one really admit this. But the, the, the group saw that they could only get a certain amount of funding to do what they wanted to do in the UK. And it's a huge part of funding in global health cos suddenly it was like global surgery, global health and all the money who was getting poured into it. So I was asked to go and join the group. Um and that was about two years ago and the last two years we've raised about 8 million lbs worth of funding. We work in, in Asia, do work in Sub Saharan Africa and, and now I'm here, we've already gone. So off peace from what we obviously was it. I don't know what we were. No, that was, that wasn't what you said when I asked you that question. That was much more interesting. Was it? Ok. Right. Um So now you're a li consult with a kind of 5050. So, yeah, so it's just so basically how my job works and some people will understand this and some people won't understand it. So, an academic surgeon, I, I'm paid by the university, the university pays my salary. I work for the NHS free almost. Um So the, the MRC mrc pay Oxford Oxford pay me and the NHS get me for free. Um So I do about, I used to do about 5050 probably is about 5070. So I 20% and in theory is 5050. What advice would you give to a enthusiastic UK based trainee who wants to do what you're doing? I think the, the, that's a good question. So I think about what I what, OK, and how, how, how I did it, I think it's quite important to, to know why you're doing it and, and it's quite difficult to admit this, but I did it for quite a selfish reason. It's great to say you wanna help everyone, which is really good. Um But that only gets you so far. The reason realistically II did what I did and it is good now that I get to help people is that I liked people. I like going to cool places and I liked adventure. Um And eventually that's growing into something where I can help a lot of people. So as a trainee, you've gotta think about very first thing I think about is why are you doing it and why do you wanna do it? Um And be honest with yourself. Um Once you know why you wanna get into research is, is do what I did and find someone who can potentially help you. It's a bit like if you're gonna design a dress, you want it to be shown at London Fashion Week, you gotta go find someone s dress and put it on, on the fashion Week. So you find that person. It doesn't have to be an orthopedic surgeon. It might be, it might be someone else to basically guide you and they're not gonna do it for you. They can act as a mentor. If you wanna do global health research to a degree, you live it. So you don't have to go and work in a, in a low resource setting. But you've gotta, I think it's important to at least visit it, know what the problems are. And um you've got to come to an individual, me or someone else and they're not, it's changing the way research has been done. So people aren't just giving you the work. You've gotta come with a problem that you see and a way to fix it. Um So what I'd say to a trainee is think about why you want to do it, try and find someone who's done it or doing it in that area to, to guide you. They're not gonna, they're not gonna do it for you. Um Try and think about what problems need addressing how you can do that through research and a really good way to do that as a trainee it, systematic reviews are really good. OK. Cos there are lots of pro you can find out what all the problems are, you can review it in the paper, you know, lots of skills and you can get it published. Um So that's, that's essentially what II did and that's what a lot of people are doing. Now, another thing is there's lots of collaborative research, there's the global Surgery units, there's lots of international collaborations that you can get involved with to get you the exposure to research. Um Soon there's gonna be a Global Injury group starting at Oxford. So things like that where you're collaborating with people and also, you know, you don't training, you don't have to do search, you know, it's not, it's, it's not a um compulsory, it's not compulsory. Yeah. Um and it is um hard. Um you don't get paid uh to do it, you'll be working weekends, you're working nights. So I'm not saying don't do it. I just think you need to know why you, why you want to do it. We talked earlier about how we probably don't have time to cover, we can ask a question, but I really want to really falls. This question is so easy to ask. Now, a huge the whole area of global surgery now is thinking about actually local authors should be writing about local issues from local audience. And so the idea of globalization versus the of global surgery is something that is in everyone's mind whilst they're doing research and global surgery. So high income trainees are obviously not the local authors writing about local issues. What would your advice be for? Oh, that could take either way it could either be. How do high income trainees help negotiate that issue? Well, I think the better question is for our kind of global audience online, how can local trainees local to the global South, which is obviously a very large area, get involved with research. And so I think that what's happening now is that I think in 10, maybe 15 years, someone like me won't exist, my job II won't have a job, but I'll have to do something else. And the reason why it's happening quite rapidly is, is fund is now um moving away from funding UK based individuals. Well, how the N hr used to work is that if you, if you were a person working in a in South Africa and you wanted to apply to one of their big grants if you had to find someone in the UK with. So just last week that's now stopped. Basically, you can, you can be in Sub Saharan Africa and you can apply for whatever you like from N hr and you'll be put on an equal setting. So someone in the UK, in fact, they're actually pushing people more from, from a low income setting to be involved. Um So I think for people who, who are actually, you know, living and working in, in lower middle income countries, the advice with regards to find out why you want to do it by someone who's done it in the past. And that might not be a part of the surgeon. Um, and look at what the problems are and ways to address them, applies to them. Think what they need to, to, to and what we need to realize as well is, is that's the future. It may even be less than, than, than 10 years. But I think I won't be doing what I'm doing because it will be all, well, the south, it won't be in the global north. So they actually are the first people to do it. Um, Malcolm already do it. So they, they fund people that in the UK based setting and soon MRC will be doing it. So I think that's, that's what the future is gonna be. And I think realistically as an organization, um, it's gonna happen with education, it's gonna happen with what we do. Uh, so, and that's a good thing. The, I guess the ideal surgery to something that works itself out, it's up to you. Thank you very much for those questions. That's actually time. So, uh, yeah. Does anyone have any add or any other questions then? Um, one of the things I found is it's really difficult to immobilize the local clinicians to try and actually get actively involved in research because there's not essentially a financial benefit to it and it's not a uh an environment by which they can gain additional practice from having research papers because the local population either don't know or aren't interested. I don't know really. Which so well, I did two papers when I was there, but I'm the author, I did all the work for it. And every time I asked people to try and help me with that, there was like, well, well, what if that makes sense? Did you have any success in sort of mobilizing the local clinics to have a, a hunger for that knowledge? Because I do think like the pathology is different in Cambodia to what it is here. The patient's course is different because there's some things about the local population that are just a bit different to how the, the, the treatments respond in the UK. And there's definitely a need for that to be in the literature so that when people go there, they don't just do what we normally do in the Western have problems. So how do you, how do you get people doing? Cos I failed completely. So I think it, I think it comes, it's cultural, isn't it? So it's cultural about how, how their, their, their job and how their lives are, are funded. Cos let's be honest, it's all about money uh doing things out of goodwill and get you so far. So the way our research set up is all driven by money. Universities aren't there for goodwill. They, they, they get, they get money from the government. The way they get money from the government is to produce high, high input impact research that gets published in high impact journals. And that means they get a score and the higher your score, the more money you get. Um and then, and then we get funded as academics to do the research, to make them get high impact papers. And it's like this big circle um which no one talks about, it's like the big elephant in the room but, but in, in, in sort of a low and middle income setting that doesn't exist so that the money aspect doesn't exist. Um which I think is why the funders are now changed. So listen, this is the only way things are gonna get changed where the local universities have the money and the infrastructure to fund individuals to physically do the research and then as cultures change, hopefully things will then develop to be slightly more as they are in the UK. And that's things like what the N hr are doing. That's why I think they're thinking on a higher level to, to try and address things like that. Why would you, I mean, if they're busy enough, you're not gonna, why would you do it for free? Thanks so much for your uh interactive er session. They are very uh engaging as well, similar, similar themed question, right? So a bit of an ethical conundrum this one. So you do the research out there, but you're out there to try and empower the local population and the local clinicians who don't have access as much as you have to the Western papers, you know, and uh and the, the technology and stuff. And so what do you think about? Right. Ok. Inviting a lot of people on board as coauthors with a paper for probably a bit less involvement than would normally get somebody, a dad to a paper. But ultimately relinquishing the first over title to them because the work we put is towards that publication, even if, even if it's less than yours is still quite high for their setting to, to earn that title and I know that some papers actually waive publication fees, even the other. Er, er, so some, well, if, if, if you like open access, er, kind of basis, er, for publication, you, you, you, you get an advantage from that point, what, what do you think of your ethical? So, so it has changed a lot even over the last sort of five years. And now, so we've just got, er, so we got 3 million from a chart to set up like a global injury group. So, the same way that burning up a global surgery group and the way of set up the, the, the, the project is, um, we have people in, in, in three different countries and the money's raised from the N hr but actually, um we give individuals in Malawi, Tanzania and South Africa the money and, and I'm not gonna do anything, the, the individuals on the ground, it's up to them to make it work. If it works great. If it doesn't work, then that's just, that's just life. So they're basically gonna have the money, they're gonna run the projects. Um So hopefully the infrastructure from on the ground will, will be built with guidance and then with regards to the au authorship, um there's no first author, there's no last author. Everyone's published has a massive long list which the journals hate in the appendix and it's published under say the Global Injury Group. And that's, that's what most people now, if you look at a lot of the global Surgery papers, it's just like N hr Global Surgery and 6000 names like Global Burden Disease is probably the biggest one. They rely on thousands of people and they just publish it under the Global Burn Disease and all these people are authors. Um Does that answer your question? Yeah, that does actually. And I think it's a good model. Um Yeah. No. OK. The, the, the reason why the authorship is, is, is, is important as an academic is because um you basically have to go to university. Um you know, it says after five years, give me your five star papers published in the Lancet. And it doesn't matter if you're first or if you're last, if you're one of 6000. Ok. You can go on a paper if you're there. It still counts. How can you feed that message back to our training institutions? Deaneries in terms of their criteria for trainees to? It's come out. That's class. Oh, yeah, it's come out. You have to be first or second author, didn't you? I'm living in this age. Oh, no, I good question. Very interesting topic. Um We, I was fortunate enough to link up with the N A and W a few years ago. Um And so II helped with the faculty on that with these breakout groups. And we had this lovely opportunity of hearing some research ideas from in each of the groups and then they presented them all at the end and II may be wrong, but I seem to remember 90% of the ideas that came up were from really young um trainees or medical students. And their main research aim was to write was to research on infected implants, trauma implants, basically infected plates, infected nails and things like that. Cos obviously, if you link to the ST GS and open fractures and the huge trauma burden that, that the LL MIT has really face the these guys you asking about how do they work out, how do you stimulate them and do the research these guys are seeing something that isn't right. They're seeing medical treatment and orthopedic treatment that's going wrong and they don't understand it and they can't, they wanna be able to understand it and how to treat it. So, I think, I think these, these, uh, it's, it's feel it live it and see what comes to you. Um, but surely I would have thought with the global, um, the buffers that you're involved with that, I would hope that it was involved with ST GS but also with the most troublesome problems which is infected former cases or, you know, open factors and poor suboptimal treatment. The only way, the only way you get money. So the, the, it's a bit of a learning process that you go to an individual who's got loads and loads of cash that N hr and the first thing we wanna know is what the patients think. How do you know it's a problem. So that's why all these surveys on, uh, prioritization of research in gi surgery, global surgery, orthopedic surgery. The reason why they're all over the internet and everyone's doing them now is because you, you have to show that basically it's a priority on the ground. So if we, we did one throughout Sub Southern Africa and it's crazy what's top like infection is, is, is high up, but rehab is like really high up. Um It's a bizarre one but, but the, but you have to show that otherwise you, you, you you, you can't get the, the money. And also you've got to show what the patients think is important. So on the higher level of funding that does happen, you say to the medical student, he said II want to do a research paper in invented trauma implants. So you gotta, you just gotta do it like no one's gonna do it for you. That the, the, the problem is as a junior is you think that like this is how I feel? You thought that everyone else knows what they're doing and you think that everyone's like, super clever. And you think that for example, the, the question with HIV and getting and, and fracture healing and infection, I just thought that everyone knew better than me. I was like, I'm just like a registrar. You know, everyone knows way better than me. But actually you soon realize that basically they don't, they're just winging it everyone. So for the, for the, for the, for the medical students in, in that setting, it's just about trying to find an individual who's done it and then putting your um question into a, into a fundable way and then approaching the funder because then you have the support to then go on and change what you wanna do. I think we might have to move on. Thank you very much and that's fine. Well, um, so who have you got next? Next? We've got um we who um a couple of years ago. Um and unfortunately, video of this present that he sent in and then he will be available online for questions after. Um Good afternoon. My name is Caesar. We and I'm a consultant of trauma and orthopedic surgeon at Dorset County Hospital. I used my work Bursary to organize a clinical visit to Juba Teaching Hospital in South Sudan in December. 2022 I used the walk Bursary. I was awarded to support clinical services at Teaching Hospital and also to learn about the challenges faced. South Sudan is the newest country in the world. It has a population of 10 million people in the capital city is in Juba. Um Shortly following its inception, there was a civil war between 2014 and 2020. The healthcare system comprises of both government and private hospitals with one tertiary referral center which is Tuba Teaching Hospital and there are numerous challenges including equipment, training and personnel. Juba Teaching Hospital is the only referral hospital in South Sudan. There are 580 beds which could rise to 800 with bed sharing and full time orthopedic consultants at Ju Teaching Hospital. And this is a team I work with. This is myself here in the middle and this is Doctor Brian Madison who hosted and supported me. I also visited and worked with the South Sudan orthopedics and Trauma Society which were only formed three years ago. But in that time they've managed to organize flying visits around the country in rural areas. Seeing a high volume of patients. On Mondays, there were grand rounds which comprised medical students, orthopedic residents. In addition to consultants, these were pictures of the theater stores. This is the equipment we used to sterilize uh surgical instruments. And these were the operating theaters which were also shared with the general surgical teams, which meant that procedures such as hemiarthroplasties could not be performed one side. Some of the challenges we face when performing trauma surgery, there were often times when the generators would fail. And um we would require a temporary lighting to finish procedures. And for long bone fractures, we used the sc nail, this is the scrubbing area and the, the corridors. And again, these are the gowns, drapes and, and some of the kit we used. And luckily the generators came back on just before we were about to start that tibial nailing. These are some of the widespread challenges that the hospital face as a whole. The first I in the country was opened on the 20th of December with a total of nine beds for the whole country. There are also challenges from the private sector and this is one of the units I attended and the doctors working in this unit are often paid $1000 per procedure. Whereas in the government hospitals, they are paid $10 a month. In terms of training, there are no formal residency programs. Surgeons often have to train abroad and fund their own training and their salaries are often still fairly low while doing so. What did I learn from this experience? Well, firstly, at 6 ft five, I was not always the tallest person in the room and I was often dwarfed by people. So II also had the opportunity to learn a great deal about some of the challenges faced um in attaining their training by the surgeons as well as the challenges they faced in their day to day lives in order to provide a safe service for the residents in Juba. So to help address some of these challenges, I have been collecting kit from my unit with the aim and and the goal for it to be sent to Juba Teaching Hospital with a focal contact in in South Sudan. And I've also explored the option of organizing virtual workshops in terms, but I feel that the training works better face to face due to problems with Wi Fi connectivity and hopefully it'll help to organize some of these training workshops during my next visit to Juba. So in the current region that I work, one of the nearby hospitals, Paul Hospital founded a link between their hospital and my hospital. The aim was to build a 400 bed hospital. Unfortunately, the plans were abandoned after the civil war. However, the hospital staff continued to do a lot of good in that hospital. And in that region. Um A lot of work and support was provided in supporting the maternity services um as well as helping to provide pediatric services to various local villages. So my next steps would be to continue to develop further links between the hospital and to um continue to send the confinement of kit um to the unit. I will organize another visit to the hospital to further provide orthopedic services and you to raise awareness in the long term. I hope to be in a position to organize an international fellowship or a visitation. As I feel this would help to support the surgeons there and give them another outlet, another avenue to further progress to their orthopedic surgeon. Because a lot of the surgeons there are are very keen to further develop their training. It's simply about fostering good links. Uh And this will enable them to help to practice and continue the development of Juba in South Sudan. Thank you very much for listening. Um Happy to answer any questions. Oh, great. I can see Susa. Um Welcome. Thank you so much for that. Uh talk. Uh Does anyone have any questions? Uh So thanks for that. Uh your, your visit. What did you feel the security situation was like uh in terms of safety of traveling out of Juba? Um Well, again, look, firstly, thanks, I just wanted to thank the the world orthopedic concerned for providing the Bursary. II really wanted to be there. In person, but I, unfortunately I had some last minute car trouble. So I really did want to present that in person. And in terms of the security situation, it, it is still, it is still quite tense in terms of um y you require a special license if you're an NGO, I think I was fortunate in that um I have family members who worked within the government itself, so I did have that security provided. But in terms of the security situation itself, it's really been quite tense over the last year or so because South Sudan are due to hold elections. And I think once those elections are finally held, there will be a period of stability. Ok. Thanks very much. It's a very interesting talk. What kind of problems are there with brain drain uh issues in South Sudan because you said that there's no opportunities for training in orthopedics and people having to go abroad. Isn't there a risk that when people go to do their training abroad, they just are going to come back if they're going to be paid $10 per month. And, and you, you're absolutely right. I think so there are no four more residency training programs, the especially the adjacent or the nearest um countries would be Ethiopia and Sudan where a lot of surgeons go to train. But I do think, I suppose because of a lot of connections to South Sudan itself and in South Sudan for example, the private sector would pay surgeons about $1000 for doing a trauma procedure. So they're not poorly remunerated. But what that means is that even within the country itself, it takes the focus away really from the government hospitals or the public hospitals. And it tends, and there tends to be a focus towards more of the private setting in, in terms of brain day, that there certainly is a risk. But I think in terms of training, there's always gotta be an understanding if I do set up a training program in the future that whoever participates will return and to continue to develop themselves. Got you and I've got a question and Caesar you went to um you were in GT, it was very, it was the very end of your training. Was it? I think it was just after your fellowship and before consultancy, did you learn anything new that from the team out there that you found useful within you? Y yes, I did actually, I think in, I learned, I learned a lot of operating with them for two weeks. Firstly, that personally, II used to take too many X rays and, and, but also the challenge is that a lot of the surgeons um certainly had to cope with. I think one of the surgeons I work with, he told me when he, he started working, he had to effectively buy his own sutures. Because sometimes again, that would not be available and, and there are also lots of challenges as well. Cos a lot, a lot of, a lot of things have been donated to South Suan, but it's about ensuring that equipment such as image intensifier are maintained as well. So, so II learned a lot and the surgeons there are certainly quite, quite skilled and it kind of feels as if they are certainly, you know, treading water against the su tsunami themselves. But I think those are some of the things that I learned just from being there. And I'm very keen and motivated certainly as a consultant just to go back there. And I just see this as a, as a start of my ongoing involvement. Thank you very much. Um Yeah, so can I just have one question? I don't know if you were watching this for me, but uh uh there was sort of ius about whether getting involved in management was a good idea clearly in South Sudan, you're not just a, a clinician, you're also a clinical leader and I suppose you're also a manager as well. Um Because I encouraged you to go into management in the UK. Um Well, manage is often is often thrust on you. I mean, I've, I've been nominated to be trauma leader of my trust. Um So I think I, you know, certainly getting involved from the, from that management aspect has helped me to speak to the appropriate kit suppliers and, and to speak to them about sending kit to South Sudan. So I think it's the thing being in management certainly gives you, gives you certainly more of a say and helps you to try and direct resources where appropriate, where they are needed. So I think, I think that aspect has, has helped as well. That's the thing with my. Thank you very much. Yeah, we, we're gonna move on now, but thank you so much. I'm so glad that you could tune in. Not at all. Thank you, Alice. I think up next is, is um, so he's gonna talk about the e evolution of postoperative follow up, fractured through the period. Mm. Hello, everyone. Pleasure to be here. Um, er, like Simon said, I'm gonna um present some stuff, er, about our feet first trips over the past few years and how we've tried to capture follow up data and how that process has evolved over that time. I went on a trip, trip in October with camp, who you all know. Um And uh yeah, it's a pleasure to be here talking to you about it today. And that's a really thanks to Wam Bota for giving me the, um, traveling, traveling Bursary last year without that, er, or a struggle to make that trip also to feed first charity for having me and to ash as well for his relentless fundraising. We won at the end. So, er, Ros actually spoke about feet, feet first trips earlier. So going since 2004 typically involves a trip involves two, visiting two district hospitals over two weeks. It happens up to four times per year. The trips are heavily heavily supported by the orthopedic clinical officers or OC OS who organize the visits whilst we're there, set up the clinics and will see the follow ups in person after the UK surgeons leave. We found that it's been very difficult to offer, uh, in person follow up, uh, on subsequent feet, first trips for the patients that are operating on just because of the changing, er, frequency of the trips of who goes on them and where they are. Uh, we've spoken about Malawi a lot today but it's a, uh, an African country of about 2 20 million people with a very stretched healthcare system. I looked at some data from, it's a while ago now, about 2008 and there were only nine orthopedic surgeons in the whole country. Um, and I've worked at DG HS with, with, um, like I say, some, the, the most of the work workload is done by, er, O CTO S, they want to follow up. So why, why do we follow up patients? Um, we all operate on patients who are involved in surgery and follow them up for various reasons. You have to ask yourself a question. Would you, would you be happy to operate on someone and never see them again or do not. And you assume that everything's fine with a patient that's been operated on unless they come back with a problem. Are you happy as the surgeon to, uh, to say you've done a good job unless you see it for yourself. Are you happy that what you're doing is working if you're not seeing these patients? So, since 2020 to 2021 ft first has developed a, a follow up strategy for trying to follow up these patients. And er, we've, this has evolved over the last few years and I'll, I'll, I'll touch on it now. Essentially, er, er, the crux of it is building a clear follow up schedule for all the patients that are seen on a trip and, and then giving this to the OC Os who are gonna see them in person afterwards. Our patients generally are followed up with a combination of two weeks, about 6 to 8 weeks or 3 to 4 months. All the clinical information that we asked for. So that might be a clinical summary, an X ray, a clinical photograph, a video. Um This is all sent on dedicated whatsapp groups which are encrypted um from the OT Os to the UK surgeons at home. And these, these whatsapp groups also act as a channel creating any ad hoc concerns that they might have. So this is the trip I went on that Roser, he spoke to you earlier was on as well. So we went to two hospitals in October. So Kasungu and Maimer, uh this is a picture of one of the morning clinics cos you can see how busy this is. And I put this in here to sort of illustrate how chaotic these clinics can be and how many people are there are and to illustrate how difficult it might be to maintain data on these patients. This is our trip ros went into more detail than I did earlier but saw over 200 patients in clinic performed 47 operations as well as lots of injections and a mixture of indications and operations that we did. So since we started trying to follow up these, these patients with this project, there were some early challenges that we recognize and some of these are ongoing. The first thing that this is difficult to follow patients up uh remotely and in, in a setting like Malawi, um we found that there were a number of feet first surgeons and it was very difficult for surgeons who hadn't been on that trip to be in the whatsapp group and to follow up someone else's cases. Language and spelling is an ongoing issue. Er English isn't a lot of Malawians first language and we're trying to collect a lot of data and that involves names, phone numbers, er clinical histories and all this sort of stuff. So doing that in a different language or as a second language can be very, very difficult maintaining data quality as a result of that in these chaotic clinic and er, and theater lists is very, very difficult and, er, when you're there, there's a lot of data being recorded in different places and consolidating this can be really difficult. So when you're in clinic, for example, there might be four books with people scribbling things down, handwritten many phones, taking pictures of patients and x rays, cameras all over the place and getting that into one well organized place is, is really, really difficult and then we go to different places and there is varying engagement from local teams, you for a number of different groups. So over the last few years, we have developed some solutions and tried to improve things. So we've built performers that we gradually refined over time. We tried to make sure, especially on this last trip that we had a single point of data entry. So within the clinic or in the evening or within, er, we would have one laptop and one file and all the data would go in there and it'd be double checked to make sure that it was all correct. Historically, there's been lots of problems getting hold of patients afterwards. A lot of this is done by phone and, er, in Malawi and I guess in, in lots of places, phone numbers change all the time, people lose that phone, they lose that number. And so we make, made sure that we, we get multiple numbers of patients for them. Maybe they, if they have a second number or a family member or someone in the village, um who we could contact as well. Having dedicated whatsapp groups for each site was also really important. There's lots of uh lots of messages getting sent around in lots of different groups and things get lost. So dedicated whatsapp groups, regular scheduled chasing by the operating surgeon. So say on a weekly basis, um using the information from the database, we can contact them and say we need to know about this patient, this patient and this patient at certain time frames. And then there's the uh the sort of incentivizing participation. So this is a difficult one but there were times where we've sent, for example, air time and things like that to people to try and encourage them to send us back. This is an example of one of the databases that we built on this last trip you can see here, this self reg goes on for miles. But it's obviously there's a lot of data in there. It's to illustrate how difficult it is to keep this all corrected in one place, using that information. This is a list from one site of all the patients we operated on and this is what we sent to the OC O. So this includes all the different time points after. So at two weeks, six weeks, what we would like from them. So it would be that a photo or an X ray and that's what we send for them to look at electronically or to print off. Here's some data for you. So since 2021 I highlight these, these are the first attendance, follow up rates generally between about 50 80% which isn't bad and is an improvement before we um started the uh the project we look here, you can see it is important that the first clinic appointment is always the best attended and then it nails off. So what can we say about the projects and about our follow up. So throughout the time, base quality has improved and that's required a lot of energy and effort at the time. As very energy intensive, we've seen a stable follow up rate. And over time, I think as ros mentioned, the number of patients we've seen on these on these trips has increased. So we're seeing, we're seeing the same percentage we're getting follow up from more patients. We also found that issues uh that have occurred have been raised early by the OC Os and uh we've been able to act on them remotely effectively. This is obviously a work in progress and I think um relationships are being built up in places that we're going back to. Um But uh we have seen variable follow up between sites. The numbers I showed you earlier are amalgamated generally between two sites so some sites do perform better than others and might bring down or bring up the average er follow up. It does require a lot of time and energy this er in the chasing of uh of the data. We're all busy here in the UK as well. So there's a lot of energy and time goes into this and we saw fading engagement follow up and we don't see the follow up rate improving above 80% are important lessons that we've learned. So I mentioned before, the first visit is always the most attended. I think that's important to remember because you should pick wisely. Um It might be good to catch problems early at two weeks, wound problems and things. But perhaps if you're looking for something like a non union, I think that your first time you see a patient a bit later and there is a high chance that people aren't gonna turn up to follow up. And I think you need to carefully if uh if you're doing something where if they didn't occur, would that be really? Really? And you have to be comfortable trusting other people? Um So you'll get a lot of messages when you say, oh, how is Xy and Z doing? You'll get a lot of messages back saying, oh yeah, they're absolutely fine. Nothing to worry about. Don't swear. And you have to be comfortable taking people at their word for that power outages. I mean, this is Africa power outages are, uh, are everywhere. Um, and they cause lots and lots of problems so people can't charge their phones. Um, they can't, er, send messages. The X ray machine barely works and that's a problem. We're not gonna, we're not gonna solve, er, easily, a lack of air time as well. So getting information from there to here is very difficult and a lack of air time for the patients to being contacted. But then I suppose we think maybe no news is good news. If you're um from Malawi and getting to the hospital that time and money, subjectively, you think the operation has gone. Well, the problem has been resolved if you bother turning up probably the same in the UK to be honest. Um moving forward. So there's a lot of challenges with something like this longer term follow up is problematic um for a number of reasons and things moving forward, a lot of administration with this. So further secretarial support, improve pathways and electronic solutions. There's always paying people the OC OS more to try and improve it. Uh Take some questions, but this is Ash's QR code, an Iron Man. So for his knees, he should, he should hopefully er pay some money. It's very good. Then I II thought other questions not fused for Ash. I don't care what data protection wise. There's lots and lots and lots, lots of, yeah, from a whatsapp perspective. Uh Yeah, I think I think, I think it's, it's really good. I think if you, if you, if it's, if it's gonna continue and it's gonna be a model for, for other ways of doing it, you'll have to speak to someone who's, um, a data manager. There's a lot, there's lots of problems with a lot of the stuff you're collecting data protection. It's crazy what you can and can't, can't, I can't collect II II was the same as you where I was like, oh, of course, we can collect someone's name and, and their phone number. You just can, you can even collect that. You can't even collect the day they were operated on. People can then link it, go to the hospital, find out what and, and then they can find out who it is. So II just think it's great what's happening but just, just, just be aware. But is it the data law of the country? So we, we, we did have permission with the uh ministry to, to actually collect the data because when, when, when I wrote to them, I said that that's what I'm gonna do. I, I've heard them that as an assurance that, you know, I'm doing things with an element of governance and they took that as a like, right? OK. But you're gonna have to collect that data. But I know that moving forward is a model that we're gonna promote, that has to be thought about and maybe developing a more, you know, encrypted kind of communication. Yeah. I mean, you know, you have the only person we're doing, we do it in the NHS every day with like, oh, audits with our research and everything that we do in the, we, we do incorrectly just as the evolution of data protection continues to get, evolve, a data protection rules mean, I can see Alex. Alex, you know, a lot about it and I, it is actually slightly more stripped. Yeah, when I was there, I mean, as you say, we all use whatsapp and various reasons, we've been looking for something else, not actually for our charity. I don't know anything about it, but it's been suggested to me that you can have like a discussion group regarding discussing case. There's something called, it's called. Yeah. Yeah. And I mean, I have no experience of it but I don't know whether that's any safer with. Um, the discussion is not the discussion on what is not an issue. The issue with the data protection is that, is being able to identify an individual. It sounds crazy. But like, you know, it's the, it's the name, the, the first name, the second and the date of birth where they had their operation, what day they had their operation, all those things, there's, there's strict laws around what you're allowed to actually physically and what you're not allowed to correct. So if the discussion around complications is all fine, even the outcomes actually is fine if you can't trace it back to an individual. The issue is around your, your data because it belongs to you. Someone being able to, you can have someone's data. If you can't identify it, there's a way for someone to identify you. Would you, would you get them all to sign a consent form? Um You know, um but I wonder whether we can modify the consent form and say, you know, just so many people, a unique identifier on your data. So even a unique identifier and you know what operation they had and you know what day they had their operation, you can't, you just can't do that. It's crazy but we do it in the NHS to look after our own patients. That's how we, it's the, is an issue in the NHS that we can't, we can't do that, isn't it? So you haven't got that, but that is self defeating because if you regulate what you're doing is you're causing harm to the patients. II, I'm not making the day not rule it. Just that, that, that, that because this is getting to like high level stuff where they're doing good work and getting outcoming it and want to be sustainable. And if it, if it, if you move on to that level of sustainability, you have to follow what the NGO S use it as an excuse not to out to other people. So you then have two different groups looking after patients and then other no names mentioned will not um will not collaborate with you to be able to give you the information as to what, what um operation and treatment they've had before and they're just using GDPR as an excuse to keep their updated within themselves without sharing it. But that is harming patients. It's where there are, there are ways to do it. It just gets very, not an expert at all. It's just what, there's just ways to, ways to do it. So you, you're right, you're right to, to raise and to just put that mark on. And we've been trashing this around with a line project because at one stage we had lots of trainees and consultants keeping stuff on the databases. And I said, oh no, no, no, no. We, we basically thought, oh, come on, we need to just get this under control, but we ended up liaising with our hospital director. Um and uh um we came up with a pragmatic solution which basically is a hospital computer which is given to the BH which is in the office. Um And so they keep a database in the room, in the hospital where all the treatments done. I know you can't do that with the visiting CS, you, so you were under their governance. Um And then you chop out all the other. I've got my own database. I've got this er, or anything else that deleted, we had to clamp down quite quickly on that, but it's just what it looks like you've got to try and work out. So when you look back as you say, what does it look like? You know, no one is gonna go to prison, you know, things are done in. It's just like it's, it's just, it's just gotta be done in the, in the, in the correct manner perhaps. Has anyone else got any questions? I couldn't agree with Simon Moore. It's really frustrating doing this in Malawi, but I mean, it's, it's great stuff, but it would be quite nice for you to kind of share the findings beyond this room and which will involve publishing it with ethical approval and in to get ethical approval, you kind of talked about patient in incentives. It's clearly stipulated in kind of like the Malawi. So whether you like it or not, we're just gonna have to kind of figure it out somehow so that we can kind of share these this great stuff on this room and it's frustrating. It's long, it's expensive, but it's, it's not sense. It. Thank you very much. So we're talking a bit session. I think we're gonna have a break. So the break is now eight minutes. Is that still ok? It's in everybody's interest so we can get away a bit early, at least. Yeah, there is