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Okay. Mhm. Hello everyone. I hope that you can see me and that you can hear me. Please do let me know if you have any problems. Um Thank you for joining me and um everyone else for our fourth talk in the Widening Participation Plastic Series. Um I just wanna say that we have a really exciting talk today. Um And before we get into that, I just wanna um pass over to our sponsor Jonathan from mps. Um and he'll give us a few minutes to talk about mps. That's all right. Um Thank you. Thank you, Lewis. So, hello, everyone. We are proud sponsors of the Widening Medics Partnership Network and we're happy and delighted to sponsor today's session. So I just want to give you a quick introduction to myself and what medical protection, formally known as MPS do and support how we support our doctors and students. So we were found in, in 18 92. So we've been around for a long time and we're the world's leading medical, medical defense, June and Medical defense organization. Um What medical defense means is that we're assisting members with a wide range of legal and ethical problems that can arise from their professional practice. This can include assistance with clinical negligence claims, indemnity claims compensation claims for patient's dealing with patient complaints, medical council inquiries, legal and ethical dilemma. So that could be um asking for medical legal advice um using our 24 hours a day, seven days a week, medical legal helpline disciplinary proceedings or inquests and fatal accident inquiries. So we're here and we support doctors and dentists when things go wrong. But we also do a lot of work to prevent issues arising in the first place. So as you maybe aware in the UK is a G M C and legal requirement to have adequate and appropriate medical indemnity. Um So that's for a medical defense organization, that's how you can have your indemnity coverage if you do need that. Um Whilst working for the NHS, you do have co value at the recent called NHS Indemnity, but really, really realistically, that's only there too. So protect the patient if they need a monetary amount such as compensation. Um if they have been disadvantaged by a procedure or treatment at a hospital and it just indemnity doesn't really look after the doctor as you can see on the grid. So having that additional protection for a medal from a medical defense organization gives you the right to request support with regards to GM see investigations, helping disciplinary proceedings, representation and legal advice. With regards to commandeer inquests. We also help respond to patient complaints. You've got access to a medical legal advice during 24 hours, seven days a week. And another big one that I always like to talk about is protection for good Samaritans Act worldwide. Um Was you're a doctor and you do have a professional obligation to support an emergency, whether that's on the roadside, on a plane in a restaurant, but you aren't covered by the NHS if a claim was to come from that act of being a good Samaritan, but you do have the right to request by indemnity from ourselves. Um Just from the case files. On average, we see doctors having at least two clinical negligence claims over a typical career lymph, those aren't actually successful claims. Um So it is really important to make sure that you do have a medical defense organization membership even if you're covered by the NHS. And what makes us different is that we, we are the world's largest and we support 100 and 40,000 members working in the UK. Um 100,000 of them being doctors. Um So we are the provider of choice um and join us today by that QR code F Y membership is completely free. F two memberships only 20 lbs and we are the most competitive crosstable training. But thank you so much for your time and your attention. I'll pass on now to the lovely speaker. Um And now like to introduce our speaker for this evening. So tonight we have MS Elizabeth Chip. Miss Chip is currently the training program direct there and the plastic surgery training, health education West Midlands. She qualified from the University of Birmingham in 2004 and completed plaque surgery training in the West Midlands. She specialized in in management of acute burns and reconstruction. Her interests are microsurgery, medical education and mischief is involved with a regular complex scar clinic which provides multidisciplinary assessment of patient's with scars and provides access to a range of surgical and non surgical interventions. So I'd now like to hand over to our speaker tonight. Thank you very much live for that very kind introduction. Welcome everybody and thank you for giving up your time in your evening to come and hear a bit about burn surgery. Hopefully I'm going to give you some information that you'll find interesting. I'm just going to share my screen. Okay. So hopefully you can see my slides. So as live mentioned, I'm a consultant, plastic surgeon specializing in burns. I work at these two hospitals here. So top left is the Queen Elizabeth Hospital in Birmingham. Uh bottom left is Birmingham Children's Hospital in the city center. Uh That's not me. I'm afraid that's just a generic picture of a glamorous female surgeon. Um Now that I'm showing my slides, I can't see the chat box. So if anybody's got any burning questions, please feel free to amuse yourself and shout out. But otherwise we'll take any questions at the end if that's okay. So, what we're going to talk about this evening? So I like to talk about plastic surgery and what it is and, and more importantly what it isn't because I think there's a lot of misconceptions about that. Hopefully, I'm preaching to the converted, the fact that you all here this evening means that you've got some idea about plastic surgery. And I know this is the fourth webinar. So you've already heard some of my colleagues already. I'm gonna talk a little bit about burn surgery. That's a huge topic. I could spend hours and days and weeks talking about it. So we'll just give a bit of an overview of some principles of burn surgery. And then I'd like to introduce you to a patient of mine that changed our practice. A really inspiring lady. Um, well, then talk a little bit about sort of life as a plastic surgeon. Life is a burns surgeon, the training pathway, what I do in my typical day and week and then plenty of time for questions at the end. So, what is plastic surgery? Okay? Is this plastic surgery? So if you ask the man on the street or the lady on the street, what's plastic surgery? This is what a lot of people think about, I think nose jobs, boob jobs, liposuction, Kardashians, you know, all these kind of things, as I say, I'm hoping that this won't come as a surprise to you. Um, also is this plastic surgery? Is it about making loads of money? Um, sadly not, I mean, you know, yes, none of us are, uh, you know, we all have a nice secure job and, you know, we're all well paid. But actually if you go into it just for the money, there are easier ways I think to make more money. So, don't do plastic surgery just for the money. So this is what plastic surgery is really about a whole manner of things. So Children with craniofacial conditions, babies with cleft lip and palate patient's with hand trauma, patient having breast reconstruction after breast cancer, patient's with soft tissue infections such as necrotizing fasciitis, complications of other surgery. So this is a sternal wound dehiscence after a cardiac procedure, lower limb trauma, sorry, I should have apologized the beginning. Some gory photos, lower limb trauma with the glory photo, various types of scars. This shows a keloid scar, but all sorts of troublesome scars, congenital hand disorders. Um This is an interesting on this picture shows a childhood, prominent ears and this really shows the sort of overlap between what we would call what some people would call cosmetic. Um so things like kind of capacity treatment, prominent, hears things like that. Uh skin cancers, head and neck cancers, uh skin loss conditions apart from burn. So this is toxic, epidermal necrolysis, Children and adults with vascular anomalies, facial trauma, acquired hand conditions. So it was rheumatoid arthritis but things like jupiter and osteoarthritis as well. Hypospadias and genital urinary conditions, facial palsy abdominal wall surgery, hernias, reconstruction. And then what we're here to talk about tonight, which obviously is the most important and interesting all these topics. So, burn surgery. So this is what plastic surgery is all about. So, what do we know about burns? You're probably all far too young to know any of the people across the top. I always feel very old and show my age when I'm putting up this slide. So uh these are some sort of famous people along the top who've had burn injuries. You might recognize um Katie Piper, they're sort of third from the left who's probably the most recent uh she was a victim of an acid attack. But these are all people who've had famous are famous for having burn injuries in the past. So about 250,000 burn injuries happen every year in the UK, but it only makes up about 1% of any attendances. So it's not that common. Uh in terms of anything that walks through the door into a and e uh men get burnt more often than women. And we know that there are certain predisposing factors such as elderly patient's people who've got pre existing medical conditions. Uh those who misuse drugs and alcohol and actually just downright carelessness accounts for a lot of our work. So people doing things that, you know, they wish they hadn't done. In hindsight, there's lots of different types of burns and flame and skull burns are the ones that we see most commonly. Uh, so it says at the top there. So skull burns, particularly in Children. Um, scolds are by far the most common type of injury and flame burns more common in adults. But we also see types of burns, flash burns, contact burns, chemical electrical burns and friction burns. So a little bit of anatomy won't do too much this evening, but this is a cross section of the skin. So the skin is the largest organ in your body. And you can see from this diagram, it's got lots and lots of functions. It's there to protect you from the outside world. It stops everything on the outside world getting in and all of your blood and or fluid in your temperature from getting out. So it's involved in homeostasis. It's protective. It's important in your immune function in temperature control, in metabolism. And of course, you know, not least is the aesthetic appearance your, the way that the world sees you. Um depends on how your skin looks, what color it is, whether you've got scars, whether you've got blemishes, what skin tone you've got, what your skin texture is like. Do you have wrinkles? You have sun damage? So, aesthetic appearance is a very important function of the skin. And when you have a major burn all of those functions are wiped out in one go. So we as burn surgeons need to see what we can do to try and replace all of those functions at one, at a time. The other thing that happens with a major burn is you get a systemic response and it affects every other single organ. So as well as the skin being affected, it affects your respiratory system, your cardiovascular system, your digestive system, your metabolic system and your immune system and patient's with major burn injuries become profoundly immunosuppressed. So again, when you have a major burn, this is just to emphasize, this affects all of your body organs and systems, not just the skin that you can see on the outside, but everything else as well. So first aid, if you go away from tonight, knowing nothing more than this slide, then I think that will still be useful. It's amazing how uh how many different types of first aid we see with patient's who've got burns even amongst medical professionals. So we see people who've applied toothpaste. That's quite a common one. Um flour, eggs, butter, turmeric. I saw that a child recently whose parents had reached into the fridge and got a loaf of sourdough bread that was proving in the fridge and put that on. So we don't want any of that. Okay. The main thing to do if you have a burn injury or you're with somebody who's unfortunately have to have a burn injury is first of all, stop the burning process. So take them away from whatever it is. Put the stop drop and roll. Put the flames out, take away the hot clothes. If you spilled hot water on yourself, remove yourself from the burning process and then you want to cool the burn whilst keeping the patient warm. So the best first aid is cool running water for 20 minutes. So cool running water is better than a wet towel than an ice pack than than something that's just cold. Cool running water helps to dissipate the temperature and it's effective any time in the first three hours after the burn injury. So even if you don't do it straight away, even if you see a patient in hospital sometime after the burn injury, that's still worth doing. And then the next thing is to cover the burn cling film. Here is as good as anything. It's virtually sterile. Once you cover the burn with just a light dressing, you'll find the patient is a lot more comfortable because the nerve endings aren't exposed, it helps prevent temperature loss and it just helps to keep that wound clean and reduce the risk of infection. And whilst you're doing all this, you need to keep yourself or the patient warm because particularly Children, if your cooling the burn with cool running water, it's very easy for them to actually lose temperature and become hypothermic. So cool the burn. But keep the patient warm. Okay. So another gory photo apologize to this. This is a sort of deliberately shocking photograph of a young child with a burn injury. And this just talks about how we assess burn. So if we're faced with a child like this, who's going to be very upset and distressed and the parents are gonna be very upset and distressed. We need to have a systematic approach of how we're going to assess this burn injury. So we talk about an ABC approach and, and that will be familiar to you if you've done any kind of trauma training, a TLS, that sort of thing. So it focuses on the concept that problems with the airway are immediately life threatening. And if you're going to die from a trauma from a burn injury, then it's an airway problem that will kill you first. The next most important thing is a breathing problem. And after that, we come to look at a circulation problem. So a burn is just a form of trauma like any other trauma. So we follow that same ABC approach and it's really important to focus on that and try not to get distracted by the fact that, you know, burns are horrible distressing wounds, they're smelly there, you know, they look horrible and patient's and relatives and family members will always be very, very distressed. So you've got to focus on the ABC approach when you've done that and you've excluded any life threatening injuries that are immediately life threatening. Then we want to look at the size of the burn and then try and assess the depth of the burn and then finally making sure that we are not forgetting to exclude any other injuries. So sometimes patient's will just have an isolated burn injury, but sometimes it may be associated with other trauma as well. This photograph again is just to highlight that, you know, I think you can't emphasize this enough, this ABC approach. So don't get distracted by the burn. So if this patient comes in, it's very easy to think. Oh my goodness. Look at this burn. How big is it? How deep is it? Is it third degree? Is it this is it that, but actually this is a gentleman who was involved in a house fire jumped out of Hearst floor window. Um He may well have a C spine injury. He is very likely to have an inhalation injury. He may have a threatened airway. He's almost certainly gotta be problem. He might have got internal injuries, he might have a pelvic fracture or internal bleeding. So he may well have an a problem, a be problem and a C problem which are all going to be life threatening far quicker than the burns are major burn injuries are indeed life threatening, but they don't kill you very quickly. Whereas these other things do. So, ABC approach and, and try and put aside the sort of distressing, unpleasant sight and smell and sounds of the burn wound. So how do we calculate size of burns? This is something that comes with practice. Okay. It needs a bit of practice. It can be quite tricky. We talk about burns in terms of percentage. So the percent of your total body surface area. So out of your whole body, how much of it is burnt. Um The reason that's important is it affects how we treat patient's, but it also affects their outcome. We know that if you add the size of the burn and add your age and the patient's age and then if they have an inhalation injury, they also score an extra 17 points that, that gives you an estimate of their risk of mortality. Uh So as an example, if you are 50 years old and you've got a 50% burn plus an inhalation injury that gives you a, it's called a revised bow school. A revised low score of 100 and 17. So you have 100 and 17% chance of dying. Now, in when this uh school was established, that was quite an accurate predictor of mortality. Nowadays, as burn care has got better and patient survival is expected to be better, then we would expect certainly in our unit in Burma and we'd expect a patient with a revised both score up to about 100 and 30 to be able to survive. Um So we would, we would treat anybody up to revise both school about 100 and 30 above that. Then, then really, we're still looking into that being a non survivable injury. So how do we calculate the size of the burn? There's a few different ways of doing it. So, again, this is a slightly old fashioned way of doing. This is the rule of nines and this was invented by somebody called Wallace who was actually a burn surgeon here in Birmingham. And this gives us an estimate. It's, it's quite approximate, it's not terribly precise and it's more accurate in adults than Children. The reason being that the proportions of your body change with age. So Children have relatively big heads and small legs compared to adults. And as you grow, your head gets relatively smaller. So you can see that in an adult, the front of the chest uh accounts for about 18% of the body as does the back, the head is about 9%. Each arm is about 9% and each leg is about 18%. So the whole body is built into multiples of 9%. A more accurate way of calculating the size of a burn. There is with this chart which is called the London Browder chart. And you can see here that instead of the chest and abdomen being 18% it's now 13%. And the head and legs are given different values depending on the age of the patient. So this is a more accurate way, particularly Children. And this is how we would expect referring hospitals to be able to describe the size of a burn to us. And essentially what you do is you shade in part of the body that's burnt and then you add it all up. You look at the little chart at the bottom here and work out the percentage that's um accounted for by the head and the leg at various different ages. And you taught it all up in the table on the right hand side to give you a total. Um An easier way of doing this for patient's particularly, you've got small burns or patchy burns is to use the palm of the patient's hand. And the palm of the patient's hand accounts for about 1% of their body. If we go back to this diagram here, patient's very rarely get burned in a sort of nice anatomical area. So it's very unusual that somebody comes in having burnt all of one leg but nothing else. So it's often quite patchy. Um And uh as I say, an easier way to deal with these smaller Apache burns is to sort of plot out each part of the patient's hand being about 1%. So when we looked at the size of the burn, the next thing we need to do is work out the depth of the burn. And again, there are different ways that we can do this. The first way is just by looking at the burn and looking at the clinical features. What does it look like in terms of its color? Is it wet? Is it dry? Is it blistered? Is it charred and leathery? Is it white and waxy? Does it look red and very wet? Has it got sensation? So this is quite a soft sign and not one that I'm particularly keen on, to be honest, but people will talk about deep burns, full thickness burns being insensate and not having sensation. Whereas more superficial burns tend to be very sensitive and then we can look for capillary refill. So press down on the burn wound and see whether it blanches and refills. And that can give us some idea about the depth of the burn. But we know that even with experience burns, consultants who have been doing this for a long time, clinical examination is only reliable in about three quarters of cases. So we need some other adjuncts to help us get it right more often. Um And we can use various things. We can use laser scans, we can use ultrasound. The gold standard is to take a biopsy, but obviously, that's quite invasive. So we tend to rely on things like laser and thermal imaging as well as our clinical examination. And the diagram on the right here just shows you some of the terminology that we use. So you may be familiar with things like first degree, second degree, third degree burns, which is still used in the States. But here in the UK, we've moved away from that terminology now really. And we described the burn in terms of the anatomical layer that it effects. So the first layer of the skin, the epidermis, if it's just in the epidermis, and that's a superficial burn. And actually, um that would be expected to heal without any scarring. And we don't actually include that in our percentage calculation. Once the burn goes into the dermis, we can talk about it being in the superficial layers of the dermis, the deep layers of the dermis, or if it goes all the way through into the subcutaneous fat, then it's a full thickness burn. So these are the kind of terms we use and because we're describing it in terms of the anatomy, it gives you some idea of which parts of the skin have been injured. So, erythema, so this is our superficial burn that just affects the epidermis. So for example, sunburn, we probably all experienced this ourselves. It's bright red, it blanches, it's very painful. But the good news is it heals rapidly without scarring because the dermis hasn't been breached. So we don't actually include that within our TBS A calculations, although it's very painful and sore, we don't generally need to treat it with things like fluid that we would give to another big burn. And as we progress down into the layers of the skin, the next uh depth, the next thicknesses, a superficial partial thickness burn. And here we see that there's some blistering. And when those blisters burst, we see skin loss and the burn underneath is very red and wet and leaking a lot of fluid. And again, we'd expect this to be painful and it blanches with pressure. So if we press down on it, it blanches and refills rapidly because it's got a good blood supply. And we'd expect this to heal well on its own with dressings without needing any surgery or special treatment as we get a bit deeper. So deep partial thickness or deep dermal burns, these tend to be a little bit dryer and paler. They have a classic cherry red appearance with fixed staining and that's because the small capillaries are thrombosed. So as you press down on the burn, you either don't see any capillary refill or you may just see very slow, very sluggish capillary refill and here sensation maybe reduced. But as I say, that's not a terribly reliable sign because you can imagine this is still a very painful injury and it's quite a subjective thing to try and work out which areas have got more or less sensation. So I don't find that terribly useful. So full thickness, you don't need to be a medical expert to see this is a full thickness burn. It's black and charred and leathery and appearance. Um There's clearly gonna be know capillary refill here if you press down on this and I've put painless and inverted commas because yes, the very deep pair of the burn probably is painless, but the bit around the edges, which is not quite so deep is almost certainly still very painful. And hopefully, nobody would argue that this patient wouldn't require some pain relief. So, assessing the depth of the burn, it's quite easy when it's clearly very superficial, very deep. What's more tricky is when it's in between or when it's mixed. So this picture here of this patient has burnt their legs. You can see there are some areas that are bright red, some that are a bit darker, read, some that are quite white and waxy and and uh an area on the right anterior thigh that looks quite leathery. So this is quite typical of a patient who's got some areas which are deeper than others, some areas that we would expect to heal with dressings, whereas some areas will need potentially some surgery, some skin graft to get them to heal. And the other thing that complicates it is that burns actually progress over the 1st 48 hours. So if you look at a burn injury when it first happens and then you dress it and you look at it again in two days time, it's often changed quite significantly. And uh you can sometimes get caught out and look a bit daft when you confidently tell a patient that's going to heal fine and then you look at it in two days time and it's clearly deeper. So these are all reasons why it needs, you know, a lot of experience looking at burn wounds before you can quite confidently say how deep they are and how big they are. So, one of the things we said that the skin does is to stop fluid leaking out when you've lost your skin because you had a burn, you lose a lot of fluid and we need to start replacing that fluid and also electrolytes, the patient will be losing. So we do that for any adults, you've got to burn greater than 15% and Children who've got to burn greater than about 10% and Children also need maintenance fluid as well. Uh There's lots of different formula. You don't need to learn it tonight. Certainly. But this is just an example of the most commonly used formula called the Parkland formula. And what this does is it works out how much fluid you need in 24 hours by multiplying four by the weight of the patient, by the size of the burning percent. And we split that in half, we give half in eight hours and the rest in the next 16 hours. And we need to calculate that from the time of the burn, not the time of arrival in hospital, which might be quite a bit later. So just to give an example of what that looks like. So if you take your sort of typical 70 kg man who's got a 45% burn in 24 hours, he needs 12.5 liters of fluid. So a huge amount of fluid and that just shows how much fluid is being continuously lost from that burn wound. So that works out at about 800 miles an hour for the first eight hours and about 400 miles an hour for the next 16 hours. So it's really important that we get this fluid resuscitation, we get it calculated correctly started promptly because you can see that once we get behind with this sort of volume of fluid, patient's are very prone to getting dehydrated, going into renal failure, so on and so forth. Okay. So management of burns, I think we just got one slide on this. And again, people have written entire textbook. So I don't propose to, to tell you how to manage a burn, but just to give you some general principles. Um as we've said already, it depends on the size of the burn and the depth of the burn. So burns that are small or superficial, we would generally expect to heal with dressings alone. The picture on the right shows somebody who's got to burn to their hands that's being managed in a with some ointment in a bag. But actually, we tend to keep burns kind of wrapped up in bandages. Now, if burns are very big or very deep, then actually, we might need to excite them to get them to heal. And generally, we use skin grafts then to reconstruct the defect. And we know that bones that take longer to heal are more likely to leave troublesome scars. So like the scar again that you can see on the right hand side on this patient's chest, this is a hypertrophic scar. This is a scar which is red, it's raised, it's thick, they're uncomfortable, they're itchy, they're unsightly. So if we know by looking to burn that it's likely to take more than two or three weeks to heal, then we're more likely to operate on that to increase the chance of them having. They'll still have a scar, unfortunately, but we're aiming to give them the best possible scar. So this is one of the things that I love about being a burns surgeon. So you have heard from other, other plastic surgery colleagues and different specialties within this series. So, you know, why, why am I here to persuade you that burns is the best. Well, I think burns is one of the best examples of multidisciplinary working. Uh This is a photograph of the M D T at the burn center in Charleston where I did my fellowship. And these are all people who play an absolutely vital role in looking after a burns patient. So as a burns surgeon, I like to think I'm quite important, but actually, we're probably one of the least important people really in this whole team. Um The other people who play an important part, our uh anesthetists intensive ists, nurses obviously who take care of these patient's all the time. Our therapy team are really important. So, physiotherapists, occupational therapists, dietitians, speech therapists, um psychology is a huge part of looking after patient's with burns. So the psychological recovery from a burn injury is even more important. I would argue than the physical recovery microbiologists are really important. So these patient's are hugely immuno suppressed and prone to all kind of weird and wonderful infections. So, a microbiologists are really important to guide our antibiotic treatment. Uh When we've got Children, then obviously people like play specialists and nursery nurses are important dietitian because we need to feed uh patient with major burns, need massive amounts of nutrition and huge amounts of calories to get them to heal social workers, to help people get back to back to their accommodation, back to their job, back to their normal life and then right down the bottom of surgeons. But all of these people work every day to look after these patient's. And it's one of the things I really love about burns. The other thing I really love is being quite a medical surgeon. So this is a picture. This is a stock picture off the internet is not one of my patient's, but this is a quite a typical appearance of a burns patient on I T you. So you can see they're all wrapped up in dressings and they're attached to lots of different machines. So this patient is on a ventilator, their, on their having feed through a nasogastric tube, they're having fluid through an intravenous line. Very commonly, they'll be on medication to support their BP. They're quite often on renal replacement therapy to support their kidneys. Um This is something that perhaps some other areas of surgery and certainly some other areas of plastic surgery don't see that much of. So as a burn surgeon, I can be expected to go onto I T U and talk to my I T U colleagues, you know, showing the same language about all the organ support that my patient's need. Uh when a major burn patient is admitted, they are critically ill, they've got a life threatening injury and what we do in those first few hours and first few days depends on, makes a difference to whether they will survive or not. So I, I think that's fantastic there. Would you say not many other areas of plastic surgery that, that have this um that have such critically unwell patient's and really the chance to be quite a medical surgeon. So we're expected to have some knowledge about inhalation injury, about ventilation, about managing BP, about managing renal failure. And I think that's really interesting. And then even when they discharged from I two and come to the ward. A lot of our patient's have coexisting medical problems. Um, either an coexisting co morbidity or drug and alcohol use or medical problems that they've developed as a result of their burn. Um, and it's important that we can manage all of those as well. Despite being a surgeon, we have to be able to manage the medical side as well, which is really challenging. And then the other thing about burn surgery, which is um maybe not unique but quite unusual within surgery and plastic surgery is the chance to build a long term relationship with your patient's. So some of the patient's I treat who are very young Children. I will potentially be looking after them and their family for years and decades to come. Okay. So this is not like a patient who has a hernia and you do a hernia repair and discharge them and never see them again. These are patient's that will be seeing potentially for many years to come to deal with their scars, uh to try and improve their function, to try and improve their appearance. They're likely to need long term psychological support. And for example, Children who've been burnt might have the chance to go to camps and meet other Children who've been burnt. And once they become adults, they're usually still undergoing treatment as they as they move to the adult service. Uh And I think that chance to build up that long term management is absolutely brilliant. So we've got all the acute life threatening stuff when they're in I T U. And then later on they maybe 5, 10, 20 years down the line were able to use a whole range of reconstructive options to try and deal with their scars and, and improve their life in terms of their appearance and function as much as possible. It's incredibly rewarding. So that's a whistle stop tour of burns, burns as a subject before I just move on to the patient that changed my life. Any burning questions, feel free to share it out. Otherwise we'll take them at the end. Okay. We'll move on. So I'd like to introduce you to a lady called Lisa Chapman. So she's given her permission for these photographs to be used. But if I could ask that that nobody takes any screenshots or anything where she's happy for them to use for teaching. But obviously, you know, they are clinical photographs. So we just treat those with a bit of respect. So this is a lady who was home one day she finished work, she came home um fed her dog, went to turn on the gas cooker and her house exploded and collapsed around her. And she, her last memory um was that she remembers the walls falling in and she remembers this sort of triangle that was forming around her. And the next thing she knew she woke up on her garden and her lawn outside essentially surrounded by this collapsed building being rescued by the fire brigade. So she was brought into us um into A and E and we did our initial ABC assessment. So she was actually awake. She was talking to us. Um we worked out her age. She was about 40 from memory at the time of her burn, the size of her burn, which was 65% and she had an inhalation injury. So she scored an extra 17. So her revised bow score was 100 and 29 right on that cusp of what we would consider to be a survivable injury. And actually, I remember this was about four or five years ago. Now remember Lisa saying to us, here's my mobile phone. She said please switch it off and only switch it on if I die to call my family. Uh you know, she knew when she came in just what the odds were. So we started some fluid resuscitation as we just talked about, we took her straight to theater and actually she needed multiple theater trips, which we'll we'll discuss in a minute. She had her burn injuries, excised and treated with some skin grafts of her own skin, various different skin substitutes as well. So this is her when she came in. These are some pictures of the burns on her back. You see the sort of white and leathery, they're all full thickness. This was the burn to her face. This was her when she had some of her surgery. So this is her own skin covered with donated skin over the top, what we call allograft. So when people die and donate their organs and donate their skin, this is how we use it. So this is allograft over her own skin. These are some slightly later photographs showing some skin grafts to her arms. They've started to heal and take so they're looking a bit more pink. Um And this is a relatively new technique that we use on one of her arms, which is slightly different way of doing skin grafting. Um on her abdomen. Here, she's actually got a skin substitute we use, that's called integra because she didn't have enough skin of her own to use a skin graft. So we had to use an artificial skin until some of her own skin heals. So she really is quite a good example of some of the different reconstructive options that we've got and then disaster struck. So one day when she was in theater, we noticed that her left foot was becoming discolored and modeled. We got the vascular surgeons in and they did some investigations and an angiogram and she basically developed an acute year scheme at left leg which was a complication from an arterial line that she had in her femoral artery. Um At this point, Lisa was really very unwell. So she was on intensive care. She was in multi organ failure. Um She was on very high amounts of oxygen, very high amounts of BP support. And again, I remember vividly one weekend calling her family and she had a big family who all came in and we had to tell them that we didn't think she was going to survive the weekend, but she managed to pull through and sort of rally a bit. Um And as she improved, unfortunately, had to amputate her leg. Um I don't expect you to read this. This text is small, but this is just to show this is our electronic patient record that we use in Birmingham. And this is a list of all of the operations that Lisa had while she was with us. So a huge number of of procedures, changing dressings, doing surgery, inserting lines, amputating her leg, having to revise her amputation, stump. So this is a sort of example of the kind of things that patient's with major burns go through. So later on when she got out of I T U, the process of rehabilitation start. So lots of physiotherapy occupational therapy, thinking about fitting a limb um following her amputation, psychology, obviously hugely important speech and language therapy. And she really had a big long list of complication. She had a pulmonary embolus as well as her amputation. She had pneumonia, she had a R D S. So very bad respiratory failure, severe sepsis and of course psychological problems, you know, she came home one day and when she woke up on I T U, she'd lost her leg. We had to tell her she lost her leg and that she got 65% burns. Lisa was incredibly strong lady. She got through all of this really without batting an eyelid, made it out of hospital in record time. So it was, you know, eventually time to go home. But where was she going to go? Her house was destroyed. So we have to start thinking about that again quite early. What's our discharge plan? Where are people going to go to? What adaptations is she going to need at home now that she's an amputee and we, we aim for patient's um to have about one day in hospital for every percent burn. So 65% burned, she was in hospital for about 70 days. So actually that that's pretty good. Uh And she is to say she was very, very positive and determined and made an amazing recovery. This is her when she left the day that she left with some of her family and me and a medical student. She got a big smile on her face and that's typical of, of Lisa. She's an absolutely inspiring amazing woman. So despite the fact, she lost her leg essentially as a result of a medical complication, uh she's still got a beaming smile on her face and she very kindly um spent some time speaking to this medical student who's on this photograph. And he actually produced a poster for one of the burns conferences. So she described what she could remember in I T U and, and what happened during her patient journey, really interesting. Um He took the time really to, to speak to a lot more than we ever have the chance to, to do often for these patient's. And she talked about things like when she woke up in I T U, she felt she was drowning in Quicksand. And you know, she felt she was trying to get out and people are pushing her back down. And she has quite a vivid memory that when she woke up, she said, if there were two buttons on the wall and one said, stay and survive. And the other said, go and die should have chosen the button to die because she was in so much pain and felt so distressed. But now she's really pleased that she survived and she got through. Um So later still after she left hospital, we have to think about reconstruction. So trying to improve her function, trying to improve the way that her scars looked. I've built up a great relationship with Lisa and she's going to be a patient of mine for many years to come. I hope she's an absolutely amazing woman. And here we need to think about, do we use our reconstructive ladder or a reconstructive toolbox? So which of the kind of reconstructive options. Do we use skin grafts, flat skin substitutes, tissue expanders, all sorts of different things. Where do we start? So, this is Lisa now, she's actually a patient advocate for the what used to be called the Healing Foundation. It's now called the Scar Free Foundation. She has essentially volunteered to be involved in all sorts of research projects. Um She actually lives in Derby now but she travels regularly from Derby to Birmingham to come and help us out with all kind of research project. She speaks to other patient's who've been injured. She's an absolute inspiration. And if I look down my clinic list and see that lease is coming to visit me, it absolutely makes my day. She comes in, she now runs, she walks, she swims, she drives, she gets on with everything with her prosthetic limb. She's incredibly positive. And I think as an example of whining would want to do burn surgery. I think she's an absolutely perfect example. So I think I've been talking quite a while already. So I'm just going to talk briefly a little bit about what a career in burn surgery involved. So what do I do? I look after adults and Children. Uh most burns are small. Okay, luckily some are major like Lisa and other patient's like that and some are fatal. Sadly, we do have some patients who don't survive the burn injuries. I'm involved in their acute cares when they first come in but also the long term reconstruction and as burn surgeons were also involved in looking after patient's who have skin loss from other reasons as well. So things like staphylococcal scolded skin, toxic epidermal necrolysis and necrotizing fasciitis, so called flesh eating bugs. Another big part of what we do is dealing with scars. The scars of all types actually doesn't just have to be burns, but people with scars that are painful or contracted or itchy or limiting their function. And we have lots of different ways of dealing with those. And then uh myself and all of my colleagues also have some other interests as well. So a bit of general plastic surgery, mainly skin cancer and other things like that. But we all have some other sub specialty interest because just dealing with burns all the time is um can be quite draining. So I'm assuming you're all here because you think at least you think you might want to do plastic surgery. Um And I would highly recommend it. Why is it so good? So it's varied and challenging the slide at the beginning shows just how varied plastic surgery is. If I can't convince you that burns is the best subspecialty, there are lots of other really uh challenging, interesting, fascinating and rewarding subspecialties. You've got the chance to do clinical work, but also academic work, training and education. Obviously, you can't really talk about plastic surgery without talking about private practice. So there is that opportunity. If that's something that's important to you, there's also the chance to work overseas to do charitable work. And as I mentioned already, it's truly multidisciplinary. So as a plastic surgeon, particularly burn surgeon, you work with all different specialties. Um It's a specialty where you can be quite artistic. If you're a sort of artistic person, you definitely have a chance to, to use that. And many of our patient's are very complex, very challenging. There's definitely never a dull day. Um And never a boring case. So, you know, many of our patient's, you think you've seen it all? And then something else comes along. Um I had a gentleman who was admitted on New Year's Eve who've been to a party, got a bit drunk with some friends and they decided to put a firework up his rectum and set fire to it and he came in with a very complex burn to his rectum and his perineum who needed a colostomy and really complex reconstruction. So I've never seen that before. Probably never see it again, but it just goes to show that every day is different. And as I mentioned is the opportunity for lifelong care. So some of these patient's, you can, you can look after them for their whole life and of course, not just them but their families as well. So, what's life like as a plastic surgeon? Um two different parts really? So, life is a trainee. Uh So the picture on the left, this is you trying to climb the mountain. There are definitely, um, it's quite, you know, quite a tough life being a trainee in anything, I suppose, but particularly plastics, you often have to move around the country for different training posts. Um, so potentially you're moving house and moving jobs quite often. You don't yet have that long term job security. And then the main downside, of course is the dreaded exams. There's a bit of a tick box mentality being a trainee. So you've got to do certain assessment, you've got to do a certain number of procedures. You've got to do a certain number of audits and write a, a certain number of papers. So you kind of can often feel that you're going through your training, ticking off those boxes and there's a little bit less flexibility in your job plan as a trainee. So you get told, you know, on a Monday you're working with Mr so and so on a Tuesday, you might be in clinic with MS is so and so, but you don't have too much say in your job plan. Um And you've, you know, you've gone on call Rotas as well, so not to say, it's not enjoyable. I thoroughly enjoyed my time as a trainee, but I have to say that life as a consultant is much, much better. So once you get your consultant post, you've got a lot more long term job security and this is the time and you can really settle in one place. You've reached the top of this hill with this mountain, um, and potentially no more exams unless you choose to do any little bit of tick box mentality. So you've still got to have your appraisal and, and meet certain targets and things as a consultant. But the main thing that I find that, you know, is really rewarding is you've got a lot more flexibility in your job plan and what other interests you can take on. So, um I'll show you on a slide in a minute, what my week involved. So a lot of people and I, I did as well when I was a trainee, think that if you're a surgeon, you're doing lots of surgery. Okay. And actually that's not the case. So this is my typical week. Um Monday is my NON NHS day where I tend to do some educational work, some training work. I might do a little bit of private practice. Uh And I go and ride my horse. So Mondays are my NON NHS day outside of work. Tuesdays are S P A which is supporting professional activities. So going on courses, doing mandatory training, reading journal articles, looking after my trainees, all those sorts of things that are non clinical Wednesdays, I'm either doing a peripheral plastic surgery clinic or I'm working at the children's hospital. And then Thursday's is when I get to do my main operating list. So actually one day in the week I'm operating Friday, we have our pediatric M D T and I have a clinic and then I'm on call one in every six weeks for both adults and Children. So, quite a varied week, say no, two days are the same, but actually quite a small amount of operating. So, what do I do if I'm not operating again? This is something I think I was never told as a trainee. But actually there's a huge amount of things that you can do and you can really mold your job plan depending on what you enjoy. So I do ward rounds and I do clinics. I do theater list. I have to be on call certain amount of time. Um But actually, I also have an educational role as training program director. So I do a lot of teaching and training and supervising our trainees. Excuse me, I do a bit of audit and quality improvement and certainly supervised trainees to do that as well. But I also have some other interest which I really enjoy. So I'm deputy chair of our Clinical Ethics Group. I have an interest in intensive care, having worked in intensive care during COVID. Um and I do a little bit of anesthetics intensive care. I work on the investigations team for the trust and I've also just started some prehospital work as well doing equestrian work. So my week is really quite varied. Um, and, you know, actually operating as a relatively small part of that. So, what about life outside of work? People say, well, how do you balance being a surgeon? You know, do you have time to do anything else? And I would say it, you know, it does need a bit of careful juggling. But yeah, this is how I choose to spend my time outside of work. If I can, looking through the years, my horse preferably on a nice sunny day. Not always. Um, I like to run. I don't do it quite as often as I should these days, but this is me and a friend of mine who's a nurse in the burns unit running the Birmingham half marathon. And I've got two young Children who also take up quite a lot of time. So it's certainly possible to balance all these things. You just need to be quite organized and do a bit of juggling. But it's absolutely possible to be a surgeon, a plastic surgeon, a burns surgeon and maintain other interests outside of work. So, how do you get there? Um, I'm not sure what stage you're all at today, but probably a lot of you are still at the first stage here in medical school. When you qualify, you're going to join the foundation program for two years. And then if you want to be a plastic surgeon, you would then aim to enter court surgical training for another two years after you've done your mrcs exam, you would then apply for higher surgical training. So getting what we call a training number, which is generally about six years. Although there's a move to being a competency based rather than a time based program now, so it might be that people can do that in slightly shorter time and again, some more exams before you become a consultant and you're a consultant for a long time, certainly feels like it. It feels like a long time since I was in that first medical school box on the left. And I've got a long time ahead of me as a consultant all being well. So a couple of exams along the way, your mrcs exam is sort of the gate between court and higher surgical training and the national selection. Um Some people choose to do a higher degree. It's probably less common now than it used to be. Most people will do, still do a fellowship. So at some point you decide what subspecialty interest you have and you go off somewhere else to be trained in that, whether that's where else in this country or overseas. And then you need to do your F R C S plaster your plastic surgery exam before you get to be a consultant. So there's a few little hurdles along the way. So how do you get there? So the people who are listening, if this is something that you still think you might like to do, it's never too early to start building a surgical portfolio. So, you know, try and get involved in any audits or projects that are going in the hospital where you're working, try and get to theater and start to develop a log book. You know, even if you're just helping to stitch a wound or put a dressing on, you know, write it all down and try and develop a log book, perhaps, try and get some taste today's or taste a week's, make contact with the department where you like to go and see a bit about what they do and see what it's really like on the ground. Um, try and find the opportunities in all placements. So I did an A and E job as an S H O which I hated, I really hated any, but I managed to try and look at the burns patient's coming into any. And I did a project which I managed to publish and present. And so, you know, even within a job that perhaps wasn't my long term career plan, I managed to find some opportunities. So, you know, whatever job you're doing, you can almost certainly find something related to plastic surgery if that's where your interest lies. But having said that keep an open mind, there are lots of different specialties out there. It might be that even perhaps surgery isn't for you, maybe you try it and you, you decide that it's not for you medicine. You know, the beauty of medicine is there are loads of different specialties and loads of different paths you can take. So keep an open mind. Um and it's never too early to start building a portfolio. As I say, surgical experience and log book, you will need to start to develop some of these things. So publications presentations, try and make a start when you can if somebody's got a research project going on. So if you can get involved, if you can help them collect some data and get your name involved in that prizes and awards obviously are nice to have. Not everybody has them by any means. So don't feel, you know, don't feel down heartened if you, if you haven't got one, but it does start to score some extra points when you go into National Selection audits and quality improvement. So there's always somebody doing an audit. So if you haven't got one yourself, see if you can join in with one that's happening, maybe somebody's done an audit and they need it to be re audited. So you can get involved with that. So see what's going on around you and uh and make us start with that. So audit is important teaching, you might have the chance to, to teach either some medical student peers, maybe you're gonna teach some nurses do a little bit of local teaching on the ward, maybe in a more formal post So perhaps you're going to be a clinical lecturer or an anatomy demonstrator management and leadership as well. So when you're building your portfolio and your job applications bit later on, you'll find that all of these areas score points and what your ideally want to do is is get something in each box so that you're scoring a point for each area. So maybe, maybe you captain your sports team at med school, maybe you sit on a committee, maybe you've run the rotor in one of your jobs. All these things count towards demonstrating some experience in management and leadership. And then finally, when you've done all of these things, if you've got any time and effort and energy left, you want to try and develop some hobbies and interests outside of medicine. That's not just for your application form, but actually, just to make sure that you stay a well rounded individual, you're less likely to burn out, you know, medicine, surgery, plastic surgery can be very challenging. It can be, um you know, quite draining. So make sure you try and maintain those hobbies and interests outside of medicines, you've got something to, to switch off at the end of the day and uh and relax application process is probably still a little bit far ahead for, for most of you. But essentially every year, it's an annual process coordinated by the London Dean Ary. And people apply uh for a higher surgical training post and you can actually rank which denies you want to work in. You then get long listed and shortlisted for an interview and the interview is made up of lots of different stations. So you get score for your portfolio, you ask some clinical questions, you have to do a presentation, your score on your communication skills. And so depending on your score, you'll then get put into a table a little bit like you casting, applying for university. So depending on where you rank, depends on whether you'll get your first choice of Dean Aree and it is very competitive. So it's worth having a plan B. But I would say, you know, if you don't go for it, you definitely won't get it. And actually, if you really want it, there's no reason at all why you shouldn't go for it. So just because it's competitive doesn't mean it's not the right thing to do, but maybe worth having a backup plan as well, even if that backup plan is that you might locum for a year or travel for a year and then try again. So hopefully by now, you still want to be a plastic surgeon. I think I've definitely taken up more than enough time. Thank you very much for listening. My email address is here. I'm happy for anyone to contact me by email or pass on any questions or comments to the organizers or any questions or comments happy to take. Now, either in the chat box or by um muting yourself and shouting out. Thank you very much. Thank you so much for the talk. It was, that was a really, really, really great talk. Thank you so much for giving that over your whistle. Stop talking quite a big subject. So, apologies if I've taken up too much time but very happy to take any questions. No, I thought that was great. Like the patient story and the important advice at the end was really useful as well. I can see there's a question in the chat already. So it's um how can noninvasive cosmetology procedures help in dealing with burns or scars left after? I didn't see, sorry if I skipped something that the cosmetic procedures listed as a team work. Um Okay. So basically asking about the cosmetic procedures afterwards. Yeah. So I think we talked about scar management. That's definitely a big part of what we do in a big part of what the team doing. And actually the occupational therapists and physiotherapists are people who are heavily involved with scar management. So that's where that kind of fits into the multidisciplinary team work. I think it's always difficult when you're talking about cosmetic because actually, you know, people to write cosmetic, think you might think about Botox and fillers and things that are truly cosmetic if you like to improve somebody's appearance. Whereas if we're talking about improving burns scarring, um that's probably more functional rather than perhaps cosmetic. So there are lots of different things we can do. Absolutely. And as I say, we can't unfortunately cover all aspects of burns in a short talk. But some of the things that we do for patients with burn scars are so scar massage, they will often have a pressure garment made a very tightly fitting elastic garment that's made to measure, to help put pressure on the scars. We use things like silicon, topical silicon. We often inject scars with steroids to some of the pictures I showed earlier of those big thick red lumpy scars. We often deal with those with steroid injections. Um we may need to do some surgery to improve. So cars, so if scars are tight and contracted or causing functional problems, they may need surgical release. So an example of that is if somebody has a burn around their mouth and they can't open their mouth or they have a scar to their cheek which pulls down there, eyelid, for example, they need dealing with with surgery potentially or if you've got a scar that crosses a joint to makes it difficult to extend or flex that joint. Um And then we do to, you know, once we've dealt with the functional problems, we come to look more about the appearance. So uh we might try some laser treatment. Um Some of my colleagues do laser treatment, we might try things like cosmetic camouflage. So essentially a medical grade makeup to try and disguise scars and help them blend in. We might do things like micro needling, which is perhaps a bit more overlap with the truly cosmetic procedures, all sorts of things we do. Um And occasionally we'll even try and take away those scars and start again and resurface them with some of the newer skin substitutes that we've coming out. So there are dozens and dozens of techniques. And what we're trying to in Birmingham is we run a complex scar clinic once a month where we have several burn surgeons. We have our burns therapists, we have our psychologists have some of our research team, uh seeing patient's and actually spending quite a lot of time with the patient's to see what we can do to improve the scars. And I think some of those techniques would probably fall under what you would class as cosmetic, but it is still a, a team effort. Absolutely. Uh I was just wondering myself, what's, what's the most important sort of management or thing that you need to do to prevent or like improve the outcomes of like scar contractors and things from burns. So, the most important thing actually is good first aid. Okay. So the when when you have a burn, the depth of the burn determines what will happen after that. So how deep the burn is, will depend how long it takes to heal, the longer it takes to heal the worst, the scarring is likely to be generally, there are some things we can't change. So we can't change somebody's ethnicity. We can't change their genetic predisposition to form abnormal scars. Um But actually, first aid is proven to reduce the time to healing, reduce the need for skin graft, um and potentially reduce the depth of the burn. So, actually good first aid is something anybody can do. You know people at home as, as a first aider, as somebody in A and E and that's actually the most important thing we can do after that, we are left as burn surgeons. We've got a burn wound, which is, you know, we, we can't check if a burn is full thickness. We can't change the fact that it's full thing as what we can do then to improve scarring is to try and get that burn healed as quickly as possible. So, you know, burn management used to be quite conservative. We used to say, well, we'll leave it for three weeks and we'll manage it with dressings and anything that hasn't healed after three weeks, then we'll graft it. But now we know a lot more that actually people, um even people who heal quicker than that can get bad scars, and we know that it's more common on certain parts of the body and in certain ethnic groups. So we might actually decide to graft a burn much earlier to get it healed as quickly as possible. And then once it's healed, then that's when the rest of the multidisciplinary team come in. So really early burn scar management. So getting them to see the burns therapists starting scar massage, getting them into a pressure garment, using silicon. It's lots of different things then together. But once you've got a scar, that scar is permanent, the best thing to do is to try and prevent that scar in the first place. So obviously either right at the beginning is burn prevention. So stopping people getting burnt in the first place and then making sure that they're getting the right first aid and then getting them healed as quickly as possible. Okay, thank you for that answer. There's someone else that's asked regarding the burns that evolve over 48 hours. Do they ever improve over that time or do they only get worse than expected? That's a good question. Um usually worse. So the reason for that is that there's ongoing inflammation. So when you have a burn, you get lots of inflammatory mediators that are released and it tends to progress and get deeper again. We know that good first aid and good initial management will help. So if somebody has good first aid and we give them the right amount of resuscitation fluid, we keep them nice and warm, then we are trying to at least preserve uh didn't show the diagram but that there's a, a theory of burns that talks about being in zones, the middle zone is damaged and you can't really, you can't save that. There's then an outer zone. If you imagine like uh the peripheries of the burn is what's called the zone of stasis. And the potentially the zone of stasis can be saved. So the things we can do then are good. First aid. Again, given the right amount of fluid. If we give too much fluid or not enough fluid, then that zone of stasis can progress. If we let the patient get very cold or if they end up on lots of inotropes in I T U, then all those things can make the zone of stasis get worse. And that's why the burn looks worse than 48 hours. But in theory, if we keep them nice and warm and well hydrated and do all the right things and use the right dressings, we can at least preserve that zone of stasis. So it probably doesn't look any better. Um, but hopefully it won't look any worse. And hopefully that answered your question. A lot of people saying, thank you for the talk, by the way, um, someone asked, asked, could you give me any examples of new innovation slash research that could change the future of burns care? For example, biological stem cell research? Yeah, absolutely. So there's loads of research going on in burns at the moment. It's, it's really quite exciting. Uh, potentially there'll be dressings in the future that prevent scarring. Okay. So there's lots of research into dressings actually have things impregnated in them to try and improve wound healing and prevent scarring. Uh Definitely, we've already got some interesting skin substitute but actually moving towards uh culturing skin. So we were already able to culture the top layer of the skin, the epidermis, but potentially, in fact, it is already happening and we treated a child a few years ago who had a 98% burn. Um So if you have 98% burn, clearly, you've got very, very little skin left to use a skin graft. So there's a, a team in Switzerland who are working on a full thickness cultured skin. So we took a tiny biopsy and sent it to Switzerland and they basically cultured that and grew it and presented us with sheets of his skin. So genetically his skin, both the epidermis and the dermis to use as a skin graft. Absolutely brilliant. Sadly, the child didn't survive. He had lots of other complications, but actually his wounds were healing and the skin was, was working. So I think that's a big area. Um Things like face transplants, I think potentially will change the outcome of burns. Patient's with major burns who got very significant facial scarring. Obviously, people are doing face transplants and it is an increasing area, but it's not yet the very frequently done in burns. And I think perhaps in the future, that's something that will become more common. So, yeah, I think there are definitely lots of things on the horizon. And um as I say, there's a charity called, it used to called the Healing Foundation. It's now called the Scar Free Foundation. And their aim is that people uh they will eliminate scars, people will get injured and never scar. Now, whether that's actually realistic, I don't know, but there's certainly lots of things. I think that will come in the next uh a couple of decades and perhaps, you know, within my career that will reduce scarring and improve function and improve outcome. Okay, thank you very much. That's a really detailed answer. Uh Someone asked, um, is it absolutely your choice to operate only one day a week? And do you wish that you did more? Given that you, that was your choice of career? Yeah, that's a good question. Um, kind of, and I suppose actually my, my main operating days on Thursday to be fair. I do some, I do a little bit of operating at the children's hospital as well. And when I'm on call, I do more operating. So it's not to say that I only ever do one day a week. I think the difficulty is when you start as a consultant to say, you expect you're gonna be operating all the time, but actually, you can't operate all the times you have to do clinics because otherwise you never have any patient's to operate on. Um, you have to then do clinics to follow them up, you have to do on calls and some of that will be operating that some of that will just be, you know, looking after patients who are being admitted, you have to do um continuing professional development. So, you know, I, I have to do reading and studying and things that keep me up to date and make sure that my, my skills are maintained. You have to do some admin, you have to do things like dealing with complaints, writing guidelines. Um You know, we've got an M R S A small MRSA outbreak on our ward at the moment. So, you know, the consultant who's responsible for those cases will get called to a meeting with infection control. Uh We have a meeting tomorrow, we've got a consultant meeting tomorrow and then we've got a meeting between the burns and the I T U staff where we discuss guidelines and protocols and clinical management. So you have to fit all of this into a week. Um You know, you might then want to do some audit, you might want to do some research. Uh you know, as much as you, as much as we all like to operate because the surgeons, you know, there's a limit to actually how much you can fit in a week and some people will operate more than others. So not to say that that's all anybody does. It will depend a little bit on what your other subspecialty interests are so because I have a role in education and in ethics and intensive care. Some of my week is spent doing some of those things where some of my colleagues will, will perhaps do a bit more operating. But the beauty of being consultant is that your job plan is a bit flexible and it changes with time. So my job plan now is quite different when I started as a consultant nine years ago and I think it will change again over the next few years. So you can mould your job plan and how your wheat looks depending on what your interests are. Um Alex Sharp has asked what aspects of your management plan and the use of novel therapies are restricted by the hospital by what the hospital allows. For example, you mentioned integra, would the hospital allow the use of different um dermal substitutes such as Metro Derm or the use of other more novel techniques such negative pressure therapy? My my daughters come to join in. This is the uh uh um you have to be quiet. So yeah, that's a good question. Um Yeah, obviously, cost comes into things definitely burn. Surgery is quite expensive. The way that it's funded means that we get a block payment um to the C C G or however, pay us a certain amount of money every year, no matter what we use to some extent. So we have a bit of flexibility. Hey, stop it we have a bit of flexibility in what we use. But at the same time, obviously, the people, you know, the managers will be saying, well, where can we save money? Where can we improve things? So, um yeah, if I want to use Integra, that's fine. We use may trade. Um All the Metro is not as good. We use a new skin substitute called BTM. Um And you know, within reason will be allowed to use that quite freely. Uh Negative pressure therapy is widely used actually. And yet we do use that a lot, I suppose it's, it's not so much what the hospital allows, it's actually a bigger levels. It's more of a regional or national level. So there are procedures which are no longer funded and things that are no long funded. So for example, if you have a keloid scar because you've had your ear pierced, uh we used to treat that with surgery or with steroids or whatever and, and now that's not funded and that's not a hospital decision, that's a regional decision. But for people who've got scars from burns were still able to treat them, so sometimes they'll be guidelines that are kind of imposed on us. But within the department, yeah, we've got quite a bit of flexibility as to what we use within reason. Um You know, well, sometimes have to put in a business case. So we, we started using something called Next Brid fairly recently, which is an enzyme that debrides burns. Um, and that was a new treatment that's quite expensive. And we have to put in a business case and say, well, why should we use it? Well, actually, because we do take patient's to theater less, they need less time in hospital, fewer blood transfusions, fewer dressings, for example. And you have to sort of show how you can justify the expense. Um, luckily, you know, as a clinician, you don't have too much of that to do day today. You know, you get a bit of freedom really to use what you think is clinically necessary. Um And then, you know, your clinical lead and the managers and things will have to sit down and talk about where, where perhaps we can save some money. We use a lot of silver dressings, for example. So they're pretty expensive, but we can show that that reduces infection which in turn improves outcome and so you can justify what you do. Yeah, fair enough. I mean, there's some of those um different technique like new technologies and things sound like really interesting like you mentioned the enzyme and the skin culturing. Um Looking forward to seeing some of that thing, some of those things as I progressed in my career as well. Um If anyone else has any other questions, please feel free to, to put them in the chat now. Um um otherwise I think if no one else has any other questions I think we can end it there. And I just want to say thank you again, that was a really, really brilliant talk. So, and we appreciate you giving up your time to speak for our audience. Um, very much for the invitation. I really appreciate it. And they say I'm happy if anybody has any other questions, any advice for attempting to get electives and plastic surgery. Uh Yes, it depends whether you want to be in this country or abroad. I think that's the first thing to think about and if there's any particular areas you want to look in, um, certainly our medical school had a big list of elective, you know, places that you could contact. But generally I start off by thinking that either which area want to focus on geographically or which, which part of plastic surgery and then see if you can find some contact. So, you know, within this country, that's relatively easy. Um, if you wanted to go overseas, you probably need to find a local consultant and, you know, find something with contact who can, who can put you in touch. You know, definitely that one of the benefits of plastic surgeries, you can go anywhere in the world. You know, you could literally be operating on, you know, Children with Cleft in the third world or, you know, polytrauma in a trauma hospital in South Africa or skin cancer in Australia. You know, it's, it's the world is your oyster. Really? It, yeah, I mean, there were loads of options. Um, I personally couldn't go abroad because of COVID, but I managed to do a little bit at gosh, at Great Ormond Street, which really, really gets, um, um, but yeah, I think lots of people are saying thank you again. So, yeah, thank you so much for giving up your time and just so let's no. Well, we are planning for more talks in this series and we'll release them soon which speakers they will be. But we're looking to cover things like head and neck, a little bit more, some pediatric plastic surgery and a little bit more into how you actually get into plastic surgery. Um, so do follow us on those social media that I've put in the chat there so that you can keep up to date and, um, make sure you join us for those future events. Thank you again. I'll, um, I'll just hang about here for if there's any other questions at all, but otherwise we'll end the talk there. Thank you again. Bye bye bye bye. Goodnight. Yeah.