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So we left a little bit of a, a little hiatus to see if there's any questions that came up from the chat room that we were caught up, just gives us some uh glitches with the V but there haven't been any so far, touch wood. Um Traditionally, we've always involved our trainees in uh what botha does and more and more that uh the old days of having a lot of what I'll call old farts in the room who had retired 20 years before and saying, you know, it's a good thing it was to have uh involvement overseas. It's actually the future is in the hands of the youngsters. You know, it's got to be you guys that take it on and move it forward, build these relationships. And, you know, I'm heartened when I see what's happened in Leicester in Bristol and how these links have just developed rapidly, what I would call long lasting friendships. It's not just professional collaboration, it's much more than that. And the same is happening in Zimbabwe now is saying, hopefully will happen in the zoo, zoo and the long way. So without much further, I do, I'm going to ask Alice to actually chair the next session and she did a lot of work cajoling people, I think to get things in, in time. Thank you very much, Alice. Thank you very much. Um Mhm. Right. Hi, everyone. My name's Alice Campion. I'm in ST for, uh, you know, register in 17 Ary. Um, and, um, I am really looking forward to introducing our next four speakers. Um, and, um, I'm really grateful that two of them could be here today and two of them are two ning in from um uh Uganda and South Stan. Um uh Doctor Brian Madison is in fact, orthopedic consultant and um Liz is just on the brink of becoming a consultant as well, but I'm still going to claim them as trainees in this session. Um But first, I'm just gonna hijack it for a couple of minutes to um talk about a project that I've been really excited to be involved with in the last three years. And that's a collaborative trainee project between Gas Arc, which is the Global Anesthesia Surgical obstetric Collaboration. Um Cathexis at the College of Surgeons, East Central and South Africa, and the Royal College of Surgeons in Ireland. Um And this was a project to assess the surgical workforce in the Kosek PSA region. So, a couple of things to mention before I tell you about it is it is weird that as a British based trainee, I have been involved in a project counting surgeons. And I think we as British trainees and surgeons would find it strange if a different country and was responsible for that project. And so what's been really nice about this project is it's slowly morphing into a project that is owned and led by Kosek PSA rather than a British based organization. Um So, um I have to acknowledge my team of 14 people. Um Our senior authors, Prof Bekele in Boston who um obviously qualified consultants, um MS Mangwon, who works for the Royal College of Surgeons in Ireland. And um everybody else on this list is a trainee based across five different countries in four different time zones. So it was, it took a long time, three years to just do a survey is a really long time. And actually, when I try to compare it to how many orthopedic consultants are in the UK, it does take a little bit of digging and you come across with some different figures. Um If you just Google it 5, 10 days ago, this is the first um piece of information you come across which says there are 2654. And if you look on the Royal College of Surgeons, they'll say there are 5071. Um So if I just use the big number to make it more dramatic comparison that works out as 9.3 orthopedic consultants per 100,000 individuals. And um the Lancet Commission of global surgery. When trying to work out how many healthcare professionals are needed per 100,000. They use a figure of 20 but 20 counts is uh surgeons, obstetricians, and anesthetists. But 20 of these individuals are needed per 100,000. We were trying to work out how many specialist surgeons were in these countries. And we had lots of meetings to discuss what we would count as a specialist surgeon. Um because is widely known that it's not just people who have gone to medical school and passed certain exams that providing the majority of the care as rose points out in her talk, there are a lot of allied healthcare professionals fulfilling the role of surgeons. But we decided to start with this project, we would just count people who have qualifications that we would recognize here as consultant qualifications in the UK. And we also did a survey which we published through social media. Um and we contacted all sorts of organizations, we looked through all sorts of medical records and we started with a conceptual capsule database that um record the amount of special surgeons. Um And after a lot of cross checking, a lot of verifying um the number of um consultant orthopedic surgeons, which is a small number of the people we collected across these countries is 490 for um broken down that works out as not 4900.12 per 100,000. So um as we all know already there aren't very many consultant orthopedic surgeons working in these regions. Um And also this data is immediately out of date the moment you can't counter it, it no longer it's already in the past. So this is in 2022. Um And um throughout the talks today, people have quoted different numbers of surgeons for different countries. Um So, yeah, I think it's, it's an ongoing battle and what's really great is hearing about all the people here and uh in collaboration with walk and otherwise that are trying to help fill these huge gaps in surgical workforce. Um So, um I can now introduce my first speaker of the session, which is um Mike Stoddart who is a good friend and also an orthopedic registrar in 73. So, uh good afternoon, I'm Mike, um one of the ST sixes in seven and I'm one of the people that Anna scheduled to uh to come and give a talk this afternoon. Um She's given me this title of uplifting training in South Africa. And I think what she means by this is come and talk to you about the time that I spent after my core training. Um uh when I went and worked at Bedford Orthopedic Hospital for a year which is in the eastern cape of South Africa. Um So my uh my story is that I went to medical school, I got a, went into foundation program. I went straight away into a orthopedic themed course surgical post in a major trauma center. Um And I felt that I wanted to step off that conveyor belt for a year. I've been to South Africa as a medical student for my medical elective. I was really keen to get back out there and had an amazing time. Um So I applied for a medical officer job in um to, to which is in the eastern cape of South Africa. Now, this is a really diverse region in South Africa has um what Elizabeth, which is at the end of the garden route, which is a real tourist place and goes all the way up to um um to, to amount prayer which we have a nice photo of the taxi riots, which happened the year before I went there. Um And the diversity in the healthcare is all stems back essentially to apartheid. Uh This is a region that was an independent homeland during the apartheid period despite Nelson Mandela being born just down the road from them to, to uh it wasn't, the trans guy wasn't recognized as a, a member of the of South Africans of the mid nineties. Um And so I sort of was pretty wet behind the ears and landed in uh the Eastern Cape and was really excited to see how they dealt with trauma. So um Bedford orthopedic Hospital um as I say is Alimta to and it uh serves a region of the trans chi which is essentially between two rivers in the Eastern cape. Um And uh they have a population or server population between 4 to 6 million people. And the only hospital that offers orthopedic care in this region, um The referral pathways come through uh district, regional hospitals quite similar to what we've heard in Malawi. Um uh And the hospital itself is based into a traditional firm structure with upper limb pediatrics, lower limb um spines. Uh and then a sort of on a Friday Friday team was known as a tumor in sepsis and that's essentially everything else. Um And so as we've already spoken about, you know, the things that I saw out there is, you know, pathology that you just don't see in the UK, you know, neglected trauma, um, extra primary TB in kids in uh immunocompromised adults, um uh malignancies and then fractures related to that. It was, you know, it was just like nothing you would see at home. Um And I was employed as a, as a medical officer there, which meant I was on their own call rotor and I was part of the team. Um, and I very quickly found out what it was like to be on call on payday on public holidays. Um, we had a road traffic accidents was the bread and butter and that was either between other vehicles, pedestrians or local wildlife. Um I worked for the upper limb unit for about six months and we spent a lot of time putting tendons back together after Panga or Bush knife injuries, um and gunshots. Uh and the results of that were incredibly common and the team, there have been credible experience of how to manage these sorts of injuries without the need for excessive do bribe mints. Um You might have at home. Um, outpatients was always a busy day. Um And the pressures uh similar to the UK, but obviously at the extreme end of that spectrum, um you know, easily see 100 patient's in outpatients in a day. Um and we had really uh pressures with on bed numbers and you would always hold a bed back for the end of the clinic. As you knew that the last patient section that you'd see either be an infected open fracture or receptive patient or something. So it was a real chance to try and manage the uh the each firm would have to sort of real juggle the difference between managing the patient that they had in front of them in their clinic room versus how to manage that population that they have as a whole. Um So, yeah, as I said, I went out there really thought that I was going to be, you know, think chest reigns in people nailing femurs and I did all of that. But I think what I really got out of it was I met the most in credible colleagues and clinicians out there. These are people who have uh found their niche and are able to work in an environment and have developed a service that works there. Um For example, one of the other medical officers um had learned how to do ultrasound blocks that meant that we could open up an extra theater to do upper limb cases when uh and it's just eventually, you know, inevitably got called away to go and help in the obstetric unit down the road or something like that. So it just allowed um things to continue. Um I learned a lot of the lost art of orthopedics. Uh You know how to wedge uh wedge a cast um and how to treat patient's in traction, um how to plan a list so that when you know that you've got a bony procedure and you've got, then got to wait for your kid to be sterilized that you would put a soft tissue procedure in between. Um what to do when the power goes out in the tourniquet, deflates. Um You know what to do when there's no water. We've already heard that today. Um We had a week where we had no water and we ended up using irrigation fluid from a donated um uh arthroscopy stack that had been sat in the corner for quite a while. Um The, you know, cheap plates work just as well as the expense of locking plates that we use at home. Um You know, a if you don't have a retrograde femoral nail, you can use a tibial nail backwards. Um And it was just lots of stuff. Um But I met some incredible people and had a great time. I saw fantastic countryside and had, I think what um what I've learned out there I brought back with me. Um And I think it's probably defined how I work at the moment at home. A lot of those skills have been brought back with me. Um uh So I'll give you sort of a very brief overview of what my story is. Um And the challenges they really face are they, I've experienced firsthand the day to day struggles that they have with their lack of infrastructure. Uh The in the sheer volume of cases they have to get through. Um And I've brought some of that back with me and I've been back a couple of times now even with the pandemic. And it was by far the best thing I've done and I would really encourage people who are thinking about doing similar things. This is slightly different to what was just discussed. This was a year out before I took a registrar post. But if you have any opportunity to, then I would definitely, definitely do it. So, in cozy and thank you, does anyone have any questions for Mike um question? I'm often asked my trainees, did you have your registrar number before you went out? No. Did you think or were you told that it would be, um, an impediment to getting a registrar number before you went. So I, I'd always wanted to go back. And so I thought the best time for me to go would be too, would be at that point because I would have learned some basic surgical skills during my training. Um, but then I then came back for the interviews, got my number finished my year out there. But I don't think if you had a number, it would really change the way that you approach other than trying to get the time out of training in order to, to get that, which it sounds like it's now not an issue. Thank you. I've got so many questions but only one thing I would ask was uh were you able to integrate your experience down to applications and e portfolio? Nice CP things. And if you did, how, how did you integrated into? So I kept a log book that the South African trainees you. So I've got a South African log book but in terms of I C P and W V A s, I didn't do that. But, but if you went out um in training, then yes, that would be something that you could do. Great, very interesting talk. Thank you very much. Um Do you think there is a point in training from what your experience has been there is optimal to go? You went before registrar just after S H O years. So quite junior is it would have used that a really good time to get the best experience or later on. What is the best point do you think to get out and get the most out of it and give the post? I think that's a really good question. Um, it is that balance of, you need to go out with some skills and, you know, with some, you have to be able to have to have some surgical hands to go out there. But I think by going out quite early, I hadn't been fully indoctrinated in terms of the UK training system. This is how this is done and actually allowed me to go out with really open eyes to see how things can be done. And then what, what's happened is I've come back home, seen how, you know, the security of some of this neglected trauma is dealt with at home. And I can really compare contrast what I've seen out there and it, you can almost challenge some of the dogma that we do here because I've seen it done elsewhere and it works for them. It might not work here for us, but it works for them. And I think that's why it's important not to um really uh compare different health care systems because as I said, you know, the whole infrastructure is completely different. You know, you'd have a transfer that comes four days afterwards and things. So it's unfair to compare the two. But, um, but yeah, so I went off on a tangent there. We have a question from Steve Martin online. Um, and he's asking how easy was it to get medical registration and to arrange a job in South Africa in my day brackets? 1994. It was easy. But I hear it's much more difficult now. Yeah. So I think the whole process probably took about nine months. Um, uh, from the day that I thought I wanted to go to me landing in Johannesburg. Yeah. So it took, it required a lot of rubber stamps and lots of waiting. Even when I arrived, there was lots of waiting outside people's officers um, for the right person to come with the correct stamp and paperwork, but that's the nature of the beast and I thought it was worth worth every moment. I sat outside those officers pulling my hair out, but great. Thank you so much, Mike. Okay. Um So another way that trainees could get involved maybe for short distance of times is via P T C which has primary trauma care when I was trying to think of something that I want to get involved with. I, somebody said, oh, have you spoken to Nigel roster? And I was like, who's that? Uh, quickly found out who he was. And, um, uh I had the pleasure of teaching PTC in Uganda and absolute pleasure of meeting, um, a fantastic pre oh, sorry, I've gone it's a different one. Uh I think Eric snacks um could just change it. Angel. Yeah, because he's nodding in the back from the guys gripped. Thank you. Um So I had the absolute pleasure of meeting Eric who is a pre intern doctor in Uganda waiting for his internship to start having qualified as a doctor last year. Uh Well, uh I'm so delighted and excited to be part of uh the world orthopedic conference today. Uh My name is Eric seen on um an intern doctor, a PTC instructor, as well as the simulation trainer, working with Google University, uh simulation training center in Northern Uganda. I'm so happy today to be presenting about a primary form, a training program in Uganda. And this will be our out trend for nice discussion. Uh Well, talking about trauma, I must say is actually silent, ongoing pandemic that has been forgotten uh for many years, uh the trauma Moby deteriorates, for example, have outwait uh mobility that is caused by many other infectious diseases. Uh As you can see TB HIV, even when you combined. So trauma is still uh so bad in full and needs our full attention in Uganda. Uh still trauma stands as the leading cause of one of the leading causes of morbidity and mortality. And uh the recent rate which shows that actually young people are highly you know, affected and that the most common cause of uh injuries or trauma is actually motorcycle accidents and now uh talking about primary trauma training program in Uganda, this is the course that has was first delivered in 2010 back in the days just so you can see uh Mr Nigel in the picture, the cost was conducted in uh Mingo Hospital and several instructors and PTC providers were trained uh following that in uh year 2012 to 2014, that was under the coal project, the uh Dexa Oxford Autho Pedic Link project. Um This PTC training was carried out in eight regional referral hospitals and I must say it was so fruitful uh that uh several instructors and again, providers of PTC were trained. And as you can see, uh since after that, there was actually LAG and it almost uh went off people's mind that PTC exists in Uganda, but likely enough has been devitalized just last year uh with funding it. And that led to the creation of uh primary trauma care uh program in Northern Uganda, call it the Northern Uganda chapter. So, uh we conducted uh primary trauma trainings in the four regional faour. Spitaels are using the cascading model, which is uh which is the, the adopted model from the double I mean A from the PT see uh foundation and uh as highlighted in the first regional referral hospitals, we had visiting faculty from UK who mentored and you know, trained local uh people to be antonius providers, but also instructors that helped us create a pool of local instructors that subsequently uh road out the cost to um be regional referral hospital. So in total, we've trained 198 PTC providers and uh one, I mean, uh 40 instructors. And uh following each of these trainings, we have registered significant improvement in uh knowledge and the skills and the confidence necessarily to resist state adequately results, state the trauma patient's and uh still from the reports that you've received um these improvement in the overall trauma uh system. And then uh I must mention that during the um be PTC training, we had uh a team of surgeons from Sudan who joined the team and we're trained ear's also instructors and hopefully there will be now conducting more trainings in South Sudan that uh actually lows out the training too done. Uh during all these training that our strength has been uh the freely available materials on the primary trauma foundation website. And now we've added on the fact that we've created a pool of local instructors who are enthusiastic, you know, azaleas and very committed to loading out this program. We've also had uh institutionally buy in's and in video interest in having this program carried on. Um However, we've been limited by the issue of funds. So uh we think one of the possible solutions could be having this program incorporated into the minutes of healthy uh training programs and then also uh having more funds just like we had uh from third, having more funders come on board and you know, support the program. Uh we look forward to establish a committee that would be fundamental uh keen rolling out this not only in the country but also to the neighboring countries. And also we're looking at establishing a modular online course uh to help train more people, but also act as a refresher, you know, program for those that have undergone a physical training, But then also further uh follow up studies and further studies needs to be done so that we continuously assess they gain, encourage uh skills and confidence as well as their retention. Uh Well, I wouldn't, I love to go man. I was talking about my personal experience and I must uh say that it has been so a nice has been Mavericks participating in the PT see, uh grown professionally. I've, I've, you know, moved both outside the country to mention hours in the Leone uh just a few months back at any day average or conference on trauma, but as well in my own country have been able to move to different areas that I've not had not reached before. So I look for is participating in more PTC training than having more fun. Uh how symbolized by telling us that from primary trauma care has improved, not only the care for the injured patient's, but the overall, you know, trauma care systems in Uganda and we aim at cascading each further are beyond even the boundaries of Uganda, but still put more emphasis on generating evidence for its clinical impact as a way of uh you know, having um uh more papers published uh about the program and having more uh evidence of its impact. So, uh we're so delighted and I'm so happy privilege that are presented to you. Uh Thank you so much. Brilliant. Thank you so much, Eric. Um Does anybody have any questions uh Eric? Do you, can you just recap? So you were recently invited by the W H O to talk about this? And um one of their conferences. Can you just explain what that was again? Oh, yes. Uh Thank you, Alex. Uh That was uh delegate all program that was always trying to develop a similar uh from a train that uh we want to uh separate global. Uh So uh PTC instructor were invited through the PT CT a person uh you know, to participate in the development of uh the, the program content. So we had a one month, you know, online discussion and then rubbed up with, you know, a physical meeting in New York. Uh uh some of everything brilliant. Um um Coffee Sweet. I might, my name is Deborah Eastwood. I'm probably ignorant about this system. But what sorts of people are you training with this course? What sorts of people? Well, thank you so much. We, we train major uh frontline, its workers uh in large source countries. Uh you must appreciate that we actually don't have many of specials is uh denounces, you know, even midwives will not be surprised in the midwives, you know, putting uh stabilized uh patient with trauma. Uh so midwives, uh clinical officers, medical officers, those are the main budget groups as well as you know, uh the medical students, right? But, but everyone's already got a little bit of medical or nursing training. Yeah, very true, Very true. Thank you. Thank you so much, Eric. That was brilliant. Um So it's an absolute pleasure is now introduce um uh MS Elizabeth Testing. Um She is the lead for the Kings Kongo Central Partnership. Um And I'm really excited to hear her talk. Thank. Thank you. Everyone. Really great to see faces. I recognize in the room and some faces. I don't if you've heard bits of this before. My apologies, if this is all new to you. Hopefully, there's something that resonates with you. Um So yes, I'm uh orthopedic surgeon soon to be a Limerick construction consultant starting at Stanmore. Um But I've been involved with the work in the DRC um since 2013. So I started my involvement as a corps trainee and have continued and will continue into my consultant career. The reasons why I've called this talk. Second, crutches will become clear towards the end. I want to start with talking about Congo Central. So the Kingdom of the Congo with A K uh spans what is currently Angola, the D R C. Um And a bit of Congo, Brazzaville, French Congo. Um and it's the region of Congo that we've been involved with. So it was a magnificent, enormous kingdom, very wealthy. Uh And the Portuguese first came into contact with it in 14 92. And that's a picture there of the Congo River meeting the Atlantic Ocean. So there was a period of trade that started and then really a sequence of catastrophes and terrible Western involvement with, with the Kongo Kingdom. So mixed picture in terms of its leadership over the course of it's history. I don't think any country is unique in that. Uh I think what's particular about the Democratic Republic of Congo is how the Western world has interacted with it and the catastrophe that that has led to uh and the fact that it's not a state that's ever really functioned. So we talk about places that are post conflict or places that have known a period of where things worked. Congo is not one of those. It's never really had a functioning state unless you go back probably to the Kongo Kingdom. This is the Ministry of Health map for the for the province that we're in. So this is population of six million people. Um And what it highlights to me is the Incredibles resourcefulness and the intelligence of the individuals that you will meet in places like this. But the really catastrophic lack of uh infrastructure and appropriate systems for delivering healthcare. So this is the way that they are planning their healthcare delivery for a population of six million and they're faced with this. The province connects to port towns, Bowman, Matadi with the capital, Kinshasa boats can make it to Matadi with their big containers. They then have to do the remaining 350 kilometers by road. This is what happens on that road, terrible drivers unregulated, they drink uh container trucks, not adequately controlled, you know, no maintenance when you uh will have to take my word for it. But there's a vehicle just here, unsurvivable. Polytrauma is what happens. There are also the motor bikes and the motorbikes lead to the other big uh pandemic. I would say open tibia fractures, open tibia requires resource to managed well. Uh And that is something that they don't have. So this is the reality of the way the open tibia presents uh cardboard acting as the splint, somebody's probably put a couple of stitches in through the dirt and left it at that. If they're lucky, eventually, this is the sort of treatment that you can uh provide. And that's kind of best case scenario for most of this province. What do you do with a situation like that? How do you make trauma care better for this sort of system? This sort of environment? One approach would be to fly on a regular basis and fix all the open tibias you can find, I, I don't think that's the way forward. Um And I very much had a strong sense when I started as a trainee that I wanted to be involved in something sustainable and long term. And that came alongside people who are already working in these environments. So I got involved with Kings, global health partnerships. Uh It is an initiative based out of King's College London, which is the university, but then also Kings HealthPartners, which is the NHS Trust that make up the academic center. And uh partnership work is really about collaborating with people who are already in that country, in that environment. It it you know, it's their country, it's their population, they are the experts in this environment and we simply come alongside and support where we can. So there are four partnerships at the moment that Kings works with the long, the longest standing one is in Somaliland, there's also one in Zambia, one in Sierra Leone, and the one in the DRC since uh 2013 was the first visit. But real work started in 2015. And the approach is really to strengthen the whole health system. So the partnerships work across the spectrum of healthcare, healthcare delivery, but also higher education institutions. So it's not just about we're going to make operations better, but about the whole system. How do you strengthen the whole system to deliver high quality healthcare? And that's about strengthening education and training. Uh and it's also about strengthening the quality of the service that's delivered. How do you, how do you improve quality of healthcare? So the approach is to work with local public sector partners. We work by invitation. So the reason why we're in that province in Congo is that's where the Congolese diaspora invited us to were embedded within the organization. So we don't sit separate from the organization that's there. We engage as peers and we're responsive to what they're saying. So I don't come and say, I'd like to do this project. They say, Liz, we need help with this. And I say, let me see what I can do what we can contribute and uh for those reasons were trusted and we really work very hard at that to be a trusted partner and to work about, you know, it's about mutual benefit deeper, had that lovely slide of, you know, UK and what happens uh in the places where we work, this is about collaboration both ways. It's not just north to south, it's south to north and it's south, south and we're committed for the long term. So we work with institutions and these are the institutions that were working with in the Congo Central province. So there's the Ministry of Health, which is the political element of what delivers healthcare. And I've now had the privilege of meeting the sixth Minister of Health since I've been involved. Um And they don't always have a healthcare background is more a political appointment, but they provide some strategy and then we work with the division of health, which is this one here. Um And they're really the technical branch of you know, healthcare delivery. So how many doctors go, where, who does, what, how do we implement this program? And that's really who we implement our programs through? These are the two main institutions that we work with. So there's the main referral hospital, King Conda, which is in the capital of the province, Matadi and then also with the university which is in Boma. But really crucially, it's about working with the systems and the institutions, but it's about the people. Uh and we would be nowhere if we weren't working with people. Um And these are just wonderful friends and wonderful colleagues. I won't name them all. Um But top right hand corner are the two Congolese diaspora doctors who first invited us to be involved, you know, a long time ago. And we've built relationships with people since then. So we're now working across 10, 10 sites. And I mentioned before that road that runs from the port towns, Bowman, Matadi up to the capital and capital just beyond number five, Kinshasa. And so it's a, it's a sequence of hospitals and centres all along that road that cover the kind of geographical expanse of the province. And we're working across four areas, training research, clinical care and trauma system development research. I've put there is a separate thing because we do focus on increasing research capacity, but it really underpins everything else we do. I won't go into too much detail about Trump primary trauma care because I think that's really eloquently been spoken to by Eric. Um but this was really an early way in for us into working with the Ministry of Health. So there's an express need, we need training for our clinic to know what to do with trauma. We are so overwhelmed with trauma. Our clinicians are scared, they don't know what to do. What can we do with the resources available to us. So I went and did a primary trauma care course in Madagascar. So I was trained by Malagasy doctors to deliver PTC because it needed to be in French. Um and ran the first course in 2016 with a group of UK volunteers, trained Congolese instructors. Um And we've now trained 420 40 Congolese instructors. Um And after that first training course, we were no longer needed to run any more courses. And that's the whole point of PT see you, you know, you deliver it and then you move on. Um and a reef, you really crucial things have come out of that. Number one is that this program has now been adopted by the program Nationalization. Eugene's, you monitor uh new uh which is the National um Ministry of Health Body that organizes or that coordinates emergency preparedness and response. Uh And so the primary trauma care now sits within their remit uh for governance for financing for what's what's delivered. The other really brilliant thing is that our Congolese instructors traveled to Burundi and ran the first Burundi PTC uh last year, which to me, I think is the way forward, you know, uh Congolese instructors delivering a Burundi PTC is 100% the way we should be going and for us to be supporting initiatives like those um part of that work then I've already mentioned newer. But the other thing that happened was that the W H O was interested to see what we were doing around emergency care. Uh And I kept wanting to come back to orthopedics because I think well, orthopedics is my skill set. I want to teach people how to do frames, but we're not at that stage and that's not what I've been asked to do. Um what we've been asked to do is to support emergency care and really a much, you know, more basic level of, of training. And so that's what we've done. And this is a collaboration with the W H O also with the Emergency Association of the DRC um to expand primary trauma care and also to support their next conference which will be in Kinshasa in August, which is around emergency care. And then the other initiative was safe, surgery saves lives. This isn't something I made up as the W H O um initiative, safe surgery saves lives. But it's true and you can't talk about quality of care if it's not safe, you know, safety is kind of one of the fundamentals of delivering high quality care. So I initially had this vision of delivering a kind of a basic surgical skills course. So in 2016, with the UK volunteer James Berwyn, who some of you may know we uh we ran a basic surgical skills course. And afterwards I thought it's not right, it's not what's needed. It's not the right context we needed, like take it totally many steps back and think more strategically. Uh And so out of that was born, this initiative safe surgery saves lives uh where we train the anesthetic care provider, uh usually a nurse or technician, the scrub team or nurses with the surgical nurses and then the surgeons that are there. So it's multidisciplinary. We involve everybody break down barriers, teamwork, all of that kind of stuff. Um And then the W H O has this program which is 10 pillars to make surgery. So safer, wash your hands, infection prevention control, really basic count swabs, count them in, count them out, know what you're doing with your swabs, uh patient monitoring, how to use the SATS probe, how to check a heart rate every now and then, make sure your patient's, you know, being monitored. Um and the W H O checklist uh and informed consent, all of those things have been revolutionary. Uh Probably 90% of the people that we've trained that we've spoken to have not had any of this kind of training before. Uh And they absolutely love it that like, wow. I mean, can you imagine telling somebody for the first time ever that there's a system to do a swab count so that you no longer have retained swabs. It's revolutionary. Um So that's been very exciting. We started with a team of the four main hospitals in 2018. Uh got some more funding and have expanded that out. So we're now in 10, 10 sites we've delivered, you know, cascaded the training. Um and they're currently doing a 10 week mentoring program. So, clinicians from the uh four big hospitals are mentors for another six smaller sites. Um And we've coupled this safety training with quality improvement methodology. So you don't do swab counts. Why don't you do swab counts? Root cause analysis transpires that you have to cut your swabs because you buy them in a big role. So they don't come as a neatly packaged. Five say, well, you know, how can you do that? Well, instead of cutting them into four, why don't you standardize it and always cut them into five simple things like that. But the the coupling of quality improvement work with safe surgery, I think has been really um really key to making sure that you don't just tell people something but that it actually gets embedded into practice. Uh And I mentioned before certain research really cross cutting and I haven't put up all the various publications, but I did want to highlight a publication around Cobalt because deeper mentioned that. And so there's a publication and then a presentation we'll publication in the Lancet Planetary Health and then a presentation at the B O A last year by John um looking at Cobalt in the supply chain. Uh And this was a UK trainee who had had this idea for a paper, wanted to explore Cobalt in the orthopedic world. Uh and the ethical implications there of uh he and I got talking, he said, oh, you actually know about the Congo. And I said, yes. And I said, well, you know, should we collaborate? And so we then got input from our Congolese colleagues about the paper and that really helped change the tone of the paper um and gave a bit more. Um Yeah, change the tone of it. And we had more of a discussion about what it also means for the fact that you can't get a hip replacement in Congo if you need one. So all the Cobalt goes elsewhere and it doesn't make it, you know, Congolese patient's don't have access to it. Um So I come back to the title of my talk, which was second crutches. Um And this was a patient who I treated when I lived in Congo. Um and he had a, an ankle fracture that I'd uh fixed with what I had available to me. Um, and it wasn't a robust fixation. So it really needed the benefit of this cast and it needed the benefit of him not walking on it. So he was quite a young chap and I thought it would be fine. You know, you'll be able to get up and get going with his crutches. Anyway, I see him one day with this one crutch and I was like, oh, no, it's all going to fall apart. Disaster mess. And I said, what are you doing? Well, you know, I told you, you can't put weight on that leg. And why have you only got one crutch? Like it's not that hard, you know, it's not a hard concept to crutches. And he said, I'm very sorry, doctor, but I've only got money for one crutch, you know, to buy two crutches was going to cost me this much and I've only got money for one crutch. So this, my friend here is helping me. So my friend is making sure that I don't put weight on my leg. He's my second crutch until I've got enough money to buy two. And that for me has been my experience of this work. Is it a, you think you've got it figured out and you're nowhere, you haven't got a clue because people's reality is so very different from what you might imagine. Um, and the second thing is we, we all need second crutches. We all need a new way of looking at stuff and we all need help and support. And it's really on us to be humble and honest and to work together because we're facing a huge challenge. You know, if you look at orthopedics across the world and if you're looking at what good quality care is for limbs, it's, it's a huge challenge, you know, when we've barely scratched the surface. Uh And so it's going to take some second crutches um to help improve care for the people who really, really need it. Um I'll leave it at that. I know there might be some trainees who want to have a bit of a discussion about, you know, how you get involved and I'm happy to take those questions after, um or feel free to write to me. Yeah. Thank you. Thank you so much, Liz. It's absolutely fantastic. Does anybody have any questions? Thank you very much for that to talk quick question about the funding and where it goes to. So, uh quote me, if I'm wrong, it sounds like the most of funding goes to teaching trauma care, uh perhaps pre hospital setting in a bit more. Where, where do you find yourself putting most of the funding to which aspects of that? Uh So our maybe first just to explain about where the funding comes from. So we, we are uh as uh as an organization. So Kings Global Health Partnerships receives funding from King's College London, so from the University um and also from King's Health Partners. So there's a kind of a court bit of funding that helps support um some of the work and particularly what gets done in London. And then we are dependent on grants for delivering programs. So the current program of Safe Surgery is being funded by E K F S which is a German um grant making charity. Uh And that funding really goes to implementing the program. So that's over the course of two years and that's to run the training programs. Um It's to run support the mentoring program at the moment. So for example, we give mentors and mentees a bit of money so that they can make whatsapp calls to each other. Um And then there's some support for uh the division of health. We don't uh send money directly into government bodies usually. Uh but there's an agreed budget together because it's um yeah, part partnership work. You know, if you really want to know if you're working together, you've got a shared budget. You know, if uh you may have some agreed objectives together, but if all the money goes here or this person decides where all the money is, uh there is all, you know, there's a power imbalance. Yeah, thank you. Anyone else. Um I was interested to see that the safe surgery has been rolled out that one of the concerns I have and I keep facing it is the safe surgery programs. Checklist programs have come, they've been adopted in very commas often on a pair DM basis where somebody comes to the conference, uh, and the program and they get the 22 days worth of peridiums enthusiasm for six months. And then the frustration is that I see these lists lying everywhere unused. Uh, they've often fallen off the anesthetic machine and they're actually filed at the bottom or actually cover the hole in the anesthetic machine drawers so that the dogs don't fall out. And it's that sustainability of the checklist, for example, is very difficult. And some hospitals I go to a year later, it's gone and then you go to another hospital where they've had no training and enthusiastic. And the sternest actually chirps up and starts right before we start. And often one of the things is seeing a prayer and then doing the checklist, which I find very sort of uh surprising, but it worked. But it's just that how do we sustain this because this is a problem that actually happens in UK as well. You know, the checklist doesn't always happen in the UK as you know. Um So I'm, I'm always really mindful that I tell my Congolese they have this notion, you know, that in the UK, you know, people are really diligent. So I try and dispel that notion, you know, we wouldn't be doing the checklist if it was up to us. You know, we just wouldn't, you might find a few people but we wouldn't. So, it's, it's about making a system that works. Right. Because you can't always rely on the goodwill of people. So, um, we, we do not do per Diems that we do not pay anybody to attend training. We pay nobody to do anything. I have joked about it. I said, you know, if I gave everybody a dollar to fill in a checklist, I'm pretty sure I'd have many checklists. Um, and we also haven't adopted a paper approach because in my experience, every program that relies on a printer, a cartridge and paper in a system that has zero money is doomed to fail. So, what we've actually done is we've had them printed as a flag. So it's fabric, not paper and really, really big and so people can do the checklist from the wall. So it's visible for everybody and you do it from the wall and you haven't got reams of paper also. We shouldn't be having reams of paper. Um, so that, that's how we've, uh, that's been our experience with working around that. I mean, you know, this, we're half were a year into a two year program for all 10 sites at the moment. So we'll see how, you know how well that goes, but we've purposely tried to move away from the paper issue because uh not sustainable. Uh So do you have it on a wall inside the inside, inside the operating room? You just fold it away. Uh No, it stays up on the wall, so it's permanent, it stays up on the wall. Yeah, thank you, Liz. I mean, that's fantastic. Uh Just wanted to pick your brains on, you know, you, you mentioned you've been talking to some government officials and what has generally been the experience? The reason I ask that question is we are doing some sort of global uh Sarcoma project set up in Kenya, especially in Kenya. I understand must be probably better than DRC. Uh But I think we've been, we've followed your model, which is, you know, so far I was looking at very keenly and we were following the same guidelines. So we want to make sure that basics I addressed first in terms of, you know, having some guidance in place for referrals and, you know, everybody should not be getting into Sarcoma because there is life threatening cases on most occasions. So, I mean, what at what level should you integrate and what were you able to get out of them? Because I understand it's a moving target as well. Um I think so. I haven't got uh can I, can I show um one of the, yeah, this lady here, her name's Puff there is Mom Boo and she was the very first provincial Minister of Health that I met. So in 2013, we arrived Congolese diaspora with us. A few other people, some junior doctors, uh, a meeting had been arranged with her. Anyway, we walked in and she literally looked me up and down and she looked all of us up and down and she didn't say it in exactly those words. But her look was, who are you? What are you doing here? What exactly have you got to offer? And we had a British surgeon with us. He didn't speak French and that was just the ultimate insult. And she said, and this guy doesn't even speak French, you know. You know, and I, uh, in that moment I thought, I really like this lady. Uh, I also thought this is brilliant and this is what should happen, you know, we should be just shown the door. Like, who do you think you are rocking up here and thinking you're just gonna do stuff? Um, and so that was the start of a really brilliant relationship. So she didn't give us the time of day. She really wasn't interested. And I think she probably thought, well, if they ever come back I might, you know. So anyway, I came back on my own the following year and I went, and I knocked on her door again. I said, you know, I'm really sorry, but, you know, is, you know, is there anything I can do? And I think at that moment she thought, well, maybe there is a bit of serious here and she's actually been an in credible supporter. She's unfortunate, she's too good, basically. So, you know, people who are good at their jobs don't stay in political post for very long in my experience. Um, but she's been a tremendous ally and advocate. Um, so I think that, you know, it's a lot of, it depends on the people you meet and the relationships that you build and sometimes you might meet someone and you think this isn't going to go anywhere and sometimes, you know, it works out and yes, there is a lot of, you know, political change over but you find the people who stay on the ground. So for us that's the division of health who are the technical people. Um And Doctor Kim Food has been there now for, you know, for decades. So there will be people in my experience anyway, on the technical side who stay there and the politicians come and go and you find the ones that you can work with and the ones that don't. Well, you know, but I think always come with the humility and with the recognition that they are the experts and it's their country. You know, you're, you're a guest, you might have something to offer, you might have something brilliant to offer if they don't want it. You know, that that's, that's on them, you know, I think, yeah. Uh Liz, can I just echo a question we had early from one of the colleagues in the bathroom here, uh who asked Mike when the best time to get involved with this sort of thing is um and did you say you went as a CT one the first time? Um If you were kind of going through your training again, would you've done the same or would you, I, I think it depends a little bit on how you want to get involved and what you want to do. So, if you're going with the notion that you want to do some operations, well, then you better go when you can do them and do them well, and you'd be expected to do them in the UK, otherwise, you know, don't do it. Um I think if you want to go and contribute and be involved in a meaningful way anytime is fine. You know, I, I wasn't initially going to do operations. So, you know, I went to meet with people to say what skill set do I have. Like, yes, I can teach a PTC course, you know, well, even that I didn't, you know, I went to Madagascar and I talked, talked myself. Um so I think just be really mindful and when I went, so I went, after I went between S T five and S T six when I went to work clinically. Uh and I felt there were a few things that were important for me. Number one was I wasn't going to do anything there that I wouldn't, that I wouldn't be expected to do unsupervised and on my own in the UK, because that was important for me. Number two, I didn't do any procedures or any clinical work without my Congolese colleagues. So we worked as a team and I worked with a senior person who had no orthopedic training but was the expert in that environment. So he and I worked really well together and I was registered with the Congo Medical Council, which might have been marginally more difficult than the South African Medical Council because the process was very opaque and in the UN just involved a very large envelope. Um but I am registered with the Congolese Medical Council and that was also important for me. I think the other really key thing to say about partnership work is that if you become involved in a partnership, you're contributing to something. So you personally don't have to be the long term commitment, but you can contribute to something that is the long term commitment. So, you know, we take volunteers for two weeks, we take volunteers for a week because you're contributing to a piece of work that fits within a long term commitment. So don't feel like you have to, you know, dedicate the rest of your life to something or go for a year or whatever, find something that's already long term and that's already going and contribute to that. And you can contribute to that at any stage really. Um, so I think, don't, don't be, don't be put off and, and oftentimes actually the best time is the best, best time when it's the best time for you. You know, I don't know, you're having a baby, you're getting married, you're doing a job, be particularly like, or don't like where you're having to move or you just need a break. You know, there's all sorts of reasons why people go and do something different, so do it when it's right for you, I think. Yeah, brilliant. Thank you so much. Okay. Um, so, um, the final speaker today unfortunately was going to be available for questions afterwards but had to be called away to an emergency, but he did pre record his talk. Um, and it's um, uh, he's an orthopedic consultant, um, and head of the South Sudan Trauma Society and his name is Brian Madison. I had the pleasure of meeting Brian when we did the diploma of tropical medicine together, um, the East African partnership with the London School of Hygiene Tropical Medicine. Um, and um, he's very keen to be contacted by any trainees or any consultants who would like to, um, support him into Afghanistan. Um, and um, uh, please contact me or I think his, uh email dress might be at the end of the presentation if you would like to get involved. Um, so if we could just start his present presentation then. That would be great. Thank you. Good morning everyone. Um My name is Doctor Brian Madison, uh uh um my orthopedic surgeon from South Sudan, uh and I'm the President's South Sudan Orthopedics and Trauma Society. Um I'll be giving you a talk on, uh just an introduction to the South Sudan Orthopedics and Trauma Society as well as uh this article comes that we've been conducting uh in South Sudan. So just a brief about our society. Uh This is a society which was uh established in 2021. It's uh the professional association that brings together uh orthopedic surgeons, orthopedic surgery, trainees and diverse medical professionals with interest in the field. Uh We are and not for profit organization that focuses on unifying all these roles towards the common goal of uh and enhance patient care. Um uh you know, uh healthcare professionals, welfare, as well as transformed lives. Um Our society considers access to a propublica as a basic human, right? And that's uh that's about uh what our society is based on. Uh That's a core principle of our society and we're leading a strategic endeavor uh to place ourselves at the center of these ambitious right now. Uh As a background, as I mentioned, the society was established in June 2021 as a brainchild of very small global for therapeutics urgency um uh South Sudan as a country and range from a protracted conflict. That last is for last for about half a century, studied in the uh 1955 with the, with the independence of Sudan, South Sudan decided that they don't want to be part of Sudan. So a rebellion ensued in that part of the country. And since then, uh there was zero infrastructure in that uh in South Sudan a Syrian and by infrastructure, I mean, everything from electricity, clean water, both networks uh and health care. So the country gained independence in 2021. Uh And right after the independence from foreign trade, uh South underneath orthopedic surgeons decided that they wanted to go back to come back to South Sudan. Um and they started uh sort of established the practice in the country. So the number, the number increased to 2, 11 orthopedic surgeons in 2021. And this is actually the group that came together and said, okay, uh we have to form a body that, you know, brings uh orthopedic surgeons together South Sudan, uh to be able to unite and, you know, do something for the country. Uh And as we speak at the moment, the whole country has uh 13 orthopedic surgeons and we have the good news is we have four residents who are currently under training. So I expect the number to increase over the next few years. Um So this group was brought together by a common understanding of the problem uh orthopedic care in the country. Uh And the desire to find ways to solve uh these issues. So the Southern an orthopedic and trauma society is a registered charitable organization in South Sudan. We decided that we wanted to be in the thick of uh you know, uh in the thick of Axion, you know. Uh so we don't only uh like as an NGO, we have, we have more powers to transition projects and go out on Africa. So that's how we registered uh our society to be more of a proactive uh body. So I'll talk a little bit about surgical artery camps in South Sudan. So, you know, the country has only 13 orthopedic seconds for the population of about 12 million uh which is a very, very small number and all these 13 orthopedic surgeons practicing uh in the capital city of Yuba. The reason behind that is uh this is the only, the only city that, you know, has facilities for, for orthopedic surgeries. And by that, I mean, uh surgical uh operating theaters and uh orthopedic equipment, tools and implants. Uh um So Juba, uh Juba Sec had uh population of about 500,000 and at least 13 orthopedic surgeons. Uh as I said, they all work in, in Juba. So they have multiple offices uh spread all over uh the city. Uh But there are only three hospitals within Juba uh that uh ready to conduct orthopedic surgeries. And these three hospitals, the government hospital and two private hospitals and the bad news is that the government hospital is not uh well equipped. So, uh I would say that uh the big chunk of our practice is actually uh private, which is counting really because uh orthopedic uh to be specific trauma problems are usually problems of the poor. So I don't, I don't feel like we're doing a lot, but at least we're doing something. And the reason is that the country doesn't have a national hence Assurance uh scheme. So approximately about 10 to 20% of the population of Juba, the capital uh have uh you know, health insurance coverage, private health insurance coverage. So we can say that uh 80 to 90% of the population do not have access posturepedic care and this is a big problem. Um So as I said, majority of the population uh of South Sudan, only 500,009 in Juba, the biggest majority are outside Juba. And as we can, we can say that Buba is the only urban uh center in South Sudan, the other two main uh cities. Uh No, but they're more or less, you know, Ruhr Away. Uh in a sense, uh you know, they don't have enough infrastructure, uh they don't have enough hospitals, they don't have health coverage and all this kind of stuff. So um the majority of the population do not have access to conventional health services. And South Sudan could be the true embodiment of the three delays of uh model of global surgery. Uh First, there is the delay uh of the decision to uh to seek care. Uh South Sudanese majority of South Sudanese population actually, uh in their whole lifetime did not get access to medical care. So that means uh they rely more on traditional bond setters and their decision making in terms of decision to seek healthcare is very poor because they believe that they're not, you know, they're not hospitals out there for them to go. So uh we have a problem with the first delay. And for this, for the minority who decide to seek care, it's very difficult for them to reach healthcare facilities. We don't have health care facilities spread all over the country. Uh So for you to get health proper, also Medicare, let me say you have to travel all the way to the capital city of liver. And this is sometimes handled with a lot of problems including poor road networks. And the other problem as I mentioned, for example, the government hospital does not have enough human resources for health. So when they reach uh these hospitals, they experienced the third delay. And you know, when you, when you have these uh situation of uh scarcity, there has to be a plan. So this is where traditional bone setter uh stepped in at least over the past years, where there is no conventional healthcare uh services in the country, traditional bone setter took over and they were managing you know, uh cases of injuries. So I just want you to see this video. It's not from South Sudan, but perhaps it sheds a light on the problem of traditional bonesetter's. Uh I think maybe dislocation, it was very painful. Uh It's a funny video but I just decided to put it on here uh because it changed the light on, on the problem. So surgical outreach comes in Juba. What our experience is the first outbreak cam was conducted in September 2021. And this coincided with the establishment establishment of the society, we wanted to paint a picture that we are proactively go out there in the population and do stuff. So we conducted this outreach within Juba. So it's technically an inr each. Uh it was done in the military hospital and we saw it was a one day program and we saw 337 patient's, most of them, uh with regards to orthopedic problems, most of them had knee osteoarthritis and mechanical low back pain. And with regards of coma problems, you know, the the regular problems we uh that we see in areas that do not have access to healthcare that is non union. Uh malunion chronic posttraumatic uh osteomyelitis. Um So during that one day surgical camp, we did 68 years and it was a success, a lot of people showed up and uh you know, uh they were happy that uh they could see that, you know, orthopedic care could be available free of charge because most of these people would have, you would have needed to go to a private facility. But now we brought the services to them. So that was a good thing. So this is the team that did the surgeries. I mean, the, the camp and uh me myself in the middle there with a few, uh, partners and this is one of the surgery's going on. Uh And we can see here an image where we, we have a lot of uh patient's waiting to receive care. And uh the advantage of these camps is that the mainly targeting the poor, the poor and undeserved people who do not uh otherwise have access to healthcare. And we publish the summary or the report of these uh trade activity with the South Sudan medical journal. And you guys are free to, to have a look at the uh this paper. Um So we did the second, the second outreach uh in March 2022 there was, there was a long luck time between the two outbreaks. The main reason for that is uh you know, this outreach needed a lot of money. And as a society, we we, we had to run up and down to make sure that we get the funds needed to conduct this outreach. Uh So that was the reason behind it today. And again, we're, we were still a very, very new society. So we still travel with, you know, getting to know uh our strength and witnesses and so forth. So we did the second outbreak in, wow. Uh this is uh one of the major cities uh in South Sudan. Uh and it was in March 2022. And the objectives were provision of orthopedic care, outpatient services, uh three medications and surgeries because as I say, most of these people are undeserved, they don't have access to healthcare. And uh because we believe that uh treating and teaching should go in hand. We took advantage of the situation and uh provided health education on orthopedic conditions, um you know, to the people out there. But at the same time, also, there is a medical, there is a medical school um in, in, in, wow, that's the Universal Western barrels. Also, we, we took that opportunity to take the students, you know, the orthopedic model. Otherwise they usually don't, don't have access to that. So the team was composed of four seconds, one orthopedic um medical officer and to scrap nurses and the hospitality with while teaching hospital provided uh the anesthesiologist and other supportive staff. Um So big support came from side international. Uh they provided nails and uh external fixators. Uh Zane Telecom, a local telecom company provided for us tickets and uh medications were sourced from uh you know, pharmaceutical partner, pharmaceutical companies. So we did um uh over six days, we saw 15 40 patient's most knee osteoarthritis, low back pain, again, neglected fractures, late union and malunion were the main trauma conditions and we did 33 surgeries that was over the course of five days. So it was a success. And this is the team that did the outreach. In this picture, we can see uh one of the team, one of the, one of the surgeons conducting a consultation and the medical students were around trying to learn from this experience. So that, that brings our principles of principle of teaching while at the same time uh treating patient's. Uh and on the picture on the right, you can see that that was uh we conducted uh teaching to medical students in, in uh University of Bihar Rosel. These are underground with medical students. So we were able to cover with them, they're orthopedics uh module. Uh another picture of a consultation which was going on and you can see the crowd is a little bit bigger. So that's one of the days. And we can see that actually, I don't know why, but majority of those who came for the outbreak where women. So you can see that this picture shows that, you know, um is there really undeserved, you know, they're really undeserved. Um two pictures showing uh the picture on the left one uh ongoing surgery. I know the conditions are not good because the number of uh stuff in the room is should have been limited, but we had to teach and the picture on the right is as cutting schools because we don't have the luxury of having, you know, the variety of schools out there. And then over here you can see we're trying to get a patient moving for surgery. We had a lot of challenges. What this is one of the big challenges a patient who presented with the knee swelling was diagnosed with osteosarcoma, but it was too late and we could not do anything in the patient was moving from one traditional bone setter to the other, could not get healthcare. We could not get, you know, proper uh medical care. So these are the patient's that we target and these are the patient's that will benefit that benefit from our problem. You can see this one is uh you know, uh and expose stevia. So we don't have access to plastic surgeons, but we do rotation flaps. So that's, that's of help. And over here is uh old uh elbow fracture which presented plate elbow dislocation. Again, nothing could be done. So, uh and Brian asked us to actually turn the volume down for the last bit because it's um mainly what he wants to say is drowned out by the patient screaming as the traditional bone setter is hitting his leg with a hammer. So um he his final sentence was just thank you very much for inviting him to this conference. Um And yeah, unfortunately, he's not available to ask questions. I was just wondering if anybody had any thoughts really or when we wanted to start anything as a discussion point. I just, I just wondered it, it's still, it's still fairly dangerous to go to south. So I wonder what it's like. So it isn't that dangerous? Um, it's still red on the F C O I think website. But one of our, what Boater Fellowships went to Caesar Wek who's a currently hip fellow inboard meth who couldn't present today because he's getting married. So I let him off. But he, and yeah, he was in South Sudan a few months ago and I felt very safe, comfortable though. Uh Obviously, it's a very new uh community, isn't it? Yeah. Um You know, it's uh considering that they're newly formed society. It looks as though they've achieved quite a lot in a really short period of time. Yeah. Well, that country has been read on the F C O. Indeed. Um So it's really quite remarkable and they should be congratulated for what they've achieved. Yeah, absolutely. Um Is there any input from walk that they might need? Um Well, I think Cesar really appreciate. Uh Seizers report is available and he talked about really wanting to just provide resources. And as you heard, see as you heard, Brian talking about the they want to do outreach within their own country, but I just don't have any money. And sometimes I think, okay, how many, how much money have I spent on flights to various places, doing various things and with that money be better redirected. Um I think a lot of, um, a lot of today has been in the background, thinking about capacity building and workforce issues. Um, and you mentioned how you've got clinical work, but you've got advocacy, research and education. Um I definitely think in my career now I step more into a research, advocacy, education side of things. But that, that's because I've had these amazing adventures and opportunities and um I've been able to go to meet people and build that kind of network and relationship. So I think you still need some of that input. But um yeah, you're absolutely right that some of the like a room for a trainee collaborative. I hope so. Absolutely. Yeah, definitely. Yeah, I've been talking to Brian and actually, um uh Cesar and Brian have started having that discussion as well. Um So I think my hand back over to uh thank you very much for arranging that. That was very, very good. So it forced me, it is too close the conference. Um It's been an experiment, I think judging from what's happened and what people have done from abroad and the interaction and also engagement for our speaker's. This has been a lot of work and some of them have really gone out of their way to get the talks prepared, get everything prepared in terms of uh organizing, recording the trainees and Zambia. Actually, we're the ones that got the talk all organized. Professor Jealous. You know, so people have been involved throughout and I have to thank them all for doing that and for everybody here that's made it possible. I think the individual team have done a great job and I really thank them from the professionalism, uh, medal. I mean, I must say thank you very much to medal and fill for what they've done because it's actually allowed it to happen. You know, we were, I think reticent when we discussed it being hybrid and uh probably the best description was being orthopedic surgeons. We're risk averse. So we thought, well, we wouldn't do it this time. We'll wait, wait, wait till later. But it's been a great success and I hope to repeat it in the next conference. And with that, thank you to the be away for supporting us to just in here who's done a lot of the background, panic, panic answers and organization. Uh and to all the speakers who made a big effort to come even in between cases. I mean, how, how is that getting a plastic surgeon to come out to help and give a talk to the orthopedic conference that's got to be a first time. Uh So thank you very much. All for coming evaluations. Please do the evaluations that's really important to get your CPD points. But also if you have thoughts and positive, what did we do? Well, what can we do better for next time? How more can we involve the diaspora of orthopedics worldwide? Thank you very much. Um And we also just say thank you so much to you as well. Alberto for putting on a fantastic day and actually maps got something for you just to say thank you from us. It's the book I will be able to see. Okay. Thank you very much.