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GASOC September Journal Club (Technical issue- sound starts 02:24)

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Summary

This online teaching session will go through Scalpel Manchester Surgical Society's call for medical professionals in Manchester to help with their medical education events, as well as organizations like Global Anesthesia Surgery and Obstetric Collaboration, who are attempting to tackle global surgery issues. Some of the topics discussed include the importance of access, safety, and quality of surgery; inequality of surgery in different countries; and the importance of reporting outcomes. The speaker Brian Suad will present his experience of overseas surgical collaborations in order to bridge the gap sustainably. Don't miss the chance to get an in-depth look and knowledge on the topics discussed.
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Description

Welcome to GASOC September Journal Club!

This months journal club will feature two renowned plastic surgeons discussing their research and experiences of overseas surgical collaborations. We are excited to be running this journal club as a hybrid event with the face to face aspect being held in Manchester at the Undergraduate Centre, Manchester Royal Infirmary. The in-person aspect of the event will start with a reception at 1830 followed by talks beginning at 1900 BST

Mr Brian Sommerlad, a Consultant Plastic Surgeon, St Andrew’s Centre, Broomfield Hospital, Chelmsford and Honorary Consultant Plastic Surgeon at Great Ormond Street Hospital for Children, London. He is the co-founder and Chairman of the charity “CLEFT” (www.cleft.org.uk). Mr Sommerlad was previously President of the Craniofacial Society of Great Britain and Ireland (1996) and of the British Association of Plastic Surgeons (1998) and previously member of the Clinical Standards Advisory Board (CSAG) on Cleft Lip and Palate and the CSAG Implementation Group. He regularly works with surgeons in Bangladesh, Sri Lanka, Uganda, Iran, Egypt and the autonomous Kurdistan region of Iraq. He has published extensively, particularly on palate surgery and function. He will be discussing the paper 'The governance of overseas surgical collaborations – BFIRST/BSSH'.

Link: https://pubmed.ncbi.nlm.nih.gov/33051175/

Mr Kiran Nakarmi, MD, MCh, is Head of the Department of Burns, Plastic and Reconstructive Surgery at Kirtipur Hospital, Kathmandu, Nepal. He is an associate professor of plastic surgery at National Academy of Medical Science in Nepal and faculty of the hand and microsurgery fellowship program at Kirtipur Hospital. Mr Nakarmi will be discussing his work on free flaps in developing countries 'Review of the First 108 Free Flaps at Public Health Concern Trust-NEPAL Hospitals: Challenges and Opportunities in Developing Countries'.

Link: https://pubmed.ncbi.nlm.nih.gov/30161043/

*Disclaimer: This session is recorded for those who are not able to attend to watch at a later date. If you are not happy with pictures/video being taken and shared on social media please email gasocuk@gmail.com or to speak to a GASOC committee member at the event*

Learning objectives

Learning Objectives: 1. Identify the inequalities in access to surgical care that exist across countries and between individuals within countries. 2. Discern differences in safety and quality of surgical care between countries. 3. Evaluate the mechanisms in place to measure the quality of surgical care, such as the Independent Blind Assessment. 4. Analyze the effects of the Clinical Standards Advisory Group in the UK on the quantity and quality of surgical care. 5. Analyze methods of sustaining overseas surgical collaborations, such as those supported by Cleft and the Global Anesthesia, Surgery, and Obstetric Collaboration.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi Henry. Sorry to interrupt, but I think you're muted for the online people. No, we can't hear you. Can you guys hear me now? Yes, we can hear you now. All sorted like a video. Ok. Can, can, can you still hear me? Perfect. Ok. Can you see the, can you see the presentation? Yes, sorry about that. Everyone is the presentation moving. Yeah, I can see what it is. Perfect. So I'm gonna zip through so that we can get on with the real me of, of everything. Um, Evelyn who you won't have heard from Scalpel Manchester Surgical Society has just promoted um asking for people who are based in Manchester all around to help with their medical education events. So if you get in touch with scalpel Manchester, if you're interested in helping out um Gasso, who is the other host of this event, the Global Anesthesia Surgery and obstetric Collaboration was set up as a bunch of trainees set up in 2015 in response to the Lancet Commission of Global Surgery um in order to try and have a meaningful input from trainees across anesthesia surgery and obstetrics um to try and tackle these problems, the middle countries accounting for the a large proportion of the world population and a low proportion of surgical procedures and a high, high proportion of the global disease burden caused by surgically treated pathology. And yet it's probably true that surgery has been neglected part of global health interventions previously. So, um I'll just zip through this. Um Just to let you know what we're up to. We have regular journal clubs. Um We frequently collaborate with other societies to have things like hack hackathons. We're involved in the virtual reality and me and surgery um organization which looks at providing extended reality training sessions to trainees in a range of countries using cadaveric dissections undertaken in Brighton under the supervision of a maxillofacial surgeon by the name of Jack Dander, who's a very inspiring character. He'll be speaking at our conference and this provides free surgical and now of late anesthetic simulation experience to uh students and professionals in countries where they are not receiving that locally or to augment what they're receiving locally. We have set up on the Med app alongside a number of different stakeholders, the Global Frugal Innovation Skills course, which is an eight module um course which is freely available. And we're currently on module five. And the, it's from a range of different groups including the Med Tech Foundation, um the um medical um engineering department in Leeds A SI T and a number of different groups. And it's really fantastic and it's going to be available online for a long time and that's supported by the Royal College of Surgeons. We provide funding to people who want to gain experience um volunteering abroad. And finally, we have a conference every year and this year it's in Oxford on the 23rd of September in two weeks time, you can still sign up and that's going to be really interesting. So you're not here to listen to me. Um I'm gonna stop show my slides and invite our first speaker who is Mr Brian Suad. Um He is the er exp president of the craniofacial Society of Great Britain Ireland and back Pras, he's an extremely experienced, er, cleft surgeon. He's an honorary consultant at the er Great Ormond Street Hospital as well as a consultant at Chelmsford. He um has been engaged with um international surgical surgical collaborations for a very long time and he's co-founder and chairman of the charity Cleft. So um I'm going to hand over to Mr Brian Summer. Just this was on your slides. Let me get you the slides here. That doctor. Well, thank you very much. Uh very nice to, to be here. Um an amazing collection of, oh I up on the screen, um an amazing collection of organizations um that I hadn't heard of actually. Um So I was asked to speak about the governance of overseas surgical collaborations, er, and particularly um my, my experience of, of such collaborations and I've added the, the subtitle of bridging the gap sustainably uh for reasons that will become obvious. Uh And it was intended to be linked with be first and BS. Uh, can you hear me? Ok. Am I talking in the right place? Um, I think be first is a great organization. We had a very good meeting quite a few years ago now, er, linked with B SSH. My special area of interest is Cleft and palate and because Clefts are not just surgical because there are lots of other, because lots of other specialists are involved, it's not really very appropriate uh direct link with be with, be first, for example, um and not much linked with B SSH. Er, so I'm, I'm really going to talk more as in my role as, as chair of, of the charity Cleft, the um uh step line of which is bridging the gap, which is what's doing, how is that happening? Yeah, sorry. And what have I done wrong? It might end up with that. Um That little thing that, yeah, I'm afraid. So it's going to stick there, is it? Well, unless there we go. Ok. That, so as Henry said, I, I uh still do quite a lot of operating. Um I'm an honorary consultant at the street and I, I was recently one of the old, perhaps the oldest new appointment for the NHS in an adit um job in, in um I, I think you, this is very frequently shown slide and, and it's variations about inequality in, in surgery. I quite like the, the, the, the, the one on the right, which, er, uh, which is the reality, um, that many people are going to have no chance of, of, of, um, equality and some have huge opportunities. So there's inequality of safety, of surgery, of access and, and of quality. And I'm going to just mention e each one of those safety, some whose lives are unnecessarily lost. And that happens in every country. But it's much more common in, in less well off, less endowed societies. Some do not have the opportunity of surgery. So in many countries in the world, for example, we find adults with unrepaired clefts, but there's also the issue of quality. Some would actually be better off if they, if they hadn't had surgery and regrettably in, in my travels around the world. I've seen a huge number of those problems where Tim good, uh who's the chair of our um international Student committee and I are going to uh Gaza in um in October. And um we've heard reports from there, for example of one surgeon who's dominated cleft care in cleft surgery in Gaza and has produced a whole array of cleft cripples basically. And, and that happens in, in, in many countries. So all each of those is important, you need access, but you need quality and of course, you need to have a safe uh operation and there is inequality both within countries and between countries within countries. The main issue is quality. Generally, safety is not an issue. Generally access is not a huge problem. Although following COVID, it's become more difficult in, in probably many countries, certainly in the UK. But the big issue is quality. Um, you all know about the Bristol heart scandal where a lot of Children died in, in Bristol children's hospital who would have survived elsewhere was the subject of a big um uh review. Uh and the message that came out of it was that this surgeon was a very honorable man. He was really trying to do his best. He believed that he was doing the right thing for his patients. But the message is that it's no longer good enough to do your best. Of course, not everybody can be the best, but everybody has, there has to be a way of, of, of, of stopping the people who are way down the bottom of that uh of that skill set. And one of the great changes, certainly in Cleft and pallet, but in other spec subspecialties as well has been the reporting of outcomes. So in, in Clefts, it's, that's now very well established that each center uh rep reports its own outcomes. Initially, these reports were anonymous, then the re the reports were just issued to the surgeon. Now available to everyone, for example. And one of the pioneers in this was the Society for Cardio Cardiothoracic Surgery in, in Great Britain and Ireland um where they make a, the, their data available to everybody. The U in Cleft in the Euro study was, was uh first big study comparing outcomes and this was the outcomes in relation to maxillary growth between six centers, two in the UK and four elsewhere. And rightly or wrongly, um the two worst centers were in the UK and so that we all all feel guilt equally guilty. The two, those two centers were Manchester and Great Street. Um I think a little unfair, but nevertheless, that was rightly or wrongly, those and they were based on very small numbers of, of, of patients around about 20 or 30 patients. But rightly or wrongly, that was the stimulus to a big change in the UK, which resulted in the Clinical Standards Advisory Group and then um rationalizing collect centers, reducing the numbers from 57 I think down to whatever 11. Now other countries saw Euro Cleft and I particularly remember talking to Americans. Well, you know, that's terrible. What you're doing in Amer, what you're doing in Europe is terrible. You know, our results are bad. So this was a comparison of the Merri Cleft uh versus um Euro and actually, uh a Merri Cleft to the uh the green so good at the top, bad at the bottom. Actually, uh they were as bad and possibly worse than uh than Europe. So they certainly had nothing to be very proud of the gold standard in, in looking at outcomes is independent blind assessment. And we are sort of going that direction, that direction in, in in Clefts. It's a lot of work. Um But to have someone from outside looking at your outcomes is really very important. But the greatest inequality is not within countries but between countries and Henry mentioned um that the Lancet Commission. So th the these are the figures of um current health expenditure per capita in dollars. United States, 10 $10,000 a year, low income countries, 100 and $6 a year hugely unequal. And so the the low and middle income countries way down the bottom of, of health expenditure. And this was the Lancet Commission looking at um the proportion of the population without access to affordable surgery and anesthesia um where dark is 100% and, and so on. And you can see that the a lot of Africa, a great amount of a great er area in Africa and Asia, uh particularly India Pakistan, um Myanmar Bangladesh all way, way below. Um the rest and the, and John Mirra who's plastic surgeon in, in Boston was the, the, the, the key author, the um principal author of the, of the Lancet Commission. And um this was another one of their, of their findings that um looking at the n the the increase needed to produce a bare minimum, I think of 20 surgeons, anesthetists and obstetricians, er, per 100,000. Uh um So red means they were almost not there. They had to go from less than one up to 20. Um Orange is the next worst, which includes, for example, Bangladesh and Myanmar as well as a lot of Africa and so on. So there's this huge gap in, in just numbers of, of, of um specialists. So the big problem in low and middle income countries is access, but it's also quality as I've shown in that point slide and it's also safety. So a little about my personal experience in clefts because that's what I've done in other countries. Um I I started off as a, as a pretty general plastic surgeon and sort of gradually became more and more specialized in in cleft lip and palate. And I've been very lucky to have operated on, on cleft patients and I think it's now 26 countries around the world, but to, to operate many times more than more than two or three times in about seven countries. That's just Iran and Iraq, which are two of the places that I've been been involved with. Um in recent years. Um These are some of the problems in, in, in Cleft care globally. There's the problem of, of poverty um mm being made worse and will be made hugely worse by climate change. The issue of numbers of surgeons, as we've just seen from the Lancet Commission, the training of surgeons, um, which varies very much in different countries. There are, there are some highly developed countries where the training is terrible. Um, II, I better not mention a country but I'm going to one in southern Europe in a couple of weeks time where sur surgical trainees get no surgery. Basically they get to the end of their training. And, um, and really haven't done much of much surgery. There's the problem of, of special or not the problem, the need for specialization, but the problem of dabbling and that's a problem in many countries and, and it was in the UK, uh, um, that's why there were 57 craft centers in the UK with, er, with some surgeons doing, you know, five a year. There's the problem of follow up of actually seeing your patients again and learning from your outcomes, difficulties in facilities and equipment deficiencies in anesthesia. American spelling, um, problemss in many countries of conflict and war sanctions. Um, a problem in, in, in several countries such as Iran, the law of private practice. And that's a big problem and it's uh, totally understandable. But if you have a, an exportable skill such as surgery and someone's gonna pay you 100 times more than you get paid in your own country, it's fully understandable that people want to do that. And the UK has been very guilty of this because they have actually depended on, on people who have been trained in other countries supporting some specialties where recruitment has been difficult and still continue to do. So. There's interdisciplinary fighting and that's been a problem in the UK. But it's, it's a problem in many countries and there's a problem of NGOS and charities which I'll come back to. And there's a problem because governments have not been involved in collective and palli care in many countries. So, uh there are a lot of cleft babies born every year, perhaps 200,000 quarter of a million estimated numbers on that slide. Um possibly um uh 40,000 in India and so on fewer in China. Uh because of the one child policy, um a lot in Bangladesh uh which I'm gonna mention and about 1000 in the UK. So round about 200,000 and the great majority of them born in, in developing or least developed countries, low and middle income countries. So just to look at a couple of countries, China, perhaps 25,000 a year. And in China, there's this great contrast between the, the modern and the, the uh the wealthy and, and the poor side by side. And I in that archetypal communist country, patients still have to pay parents still have to pay to have a cleft operation, maybe $600. NGO. For that reason, NGO S have got very involved, small train is very involved, for example, in in China, India, more pay more cleft babies per year. Again, this contrast between the, the very beautiful of uh the Taj Mahal and still a lot of poverty despite uh sending a um a mission to the Moon. Um and some excellent centers. But again, NGOS have been a problem. I visited Baras in 2009 that I was involved with smart train. I'm not now um the reasons that will become obvious, I think um and uh this surgeon had done 1876 cleft operations or claimed to have done in one year, uh plus a, a few others. And that's six a day without uh for every day of the year. And, um, if you don't believe it, but that's what he claimed, few secondary procedures, limited follow up. He had no time if he was doing those sort of numbers. Whereas in the nearby government hospital, the Banaras Hindu University and here's the, the head of that department, one cleft that they were doing one cleft a month in 2008. Why? Because it was profitable to do them in privately in a private hospital and be paid by, by smart train. And that meant that trainees had no exposure to cleft surgery. We, we talked uh about, um, so as I was coming in, um, in southern Egypt, uh upper Egypt, um very poor and amazingly poor. Really not. We don't think of Egypt as being a particularly poor country, but certainly Upper Egypt is. So this is somewhere between, it's sort of north of the, the tourist, uh, Nile River trips but south of the, the capital. So there's, there's not much money. Um, seeps Saha. So when I first went there, very few centers, very poor, er, government hospitals at that time in upper Egypt doctors earning very little. Um, and for that reason, medical immigration and in fact, the man who, who got me involved in Saha is working in Saudi. I don't blame him, but it's tragic, isn't it? Iran? Um, very beautiful country. Uh, really most people who go to love it and, uh, the people are wonderful but as you know, a, a regime which is, er, well, more and more, um, authoritarian and, and difficult, this is Isfahan on the right, a beautiful city and, um, it's, it's not what it, it's not what it, what it feels like. Um, all these ladies, these are all speech and language therapists and they all have to wear their, their, the black in the hospital or because that's a, a government institution, but they certainly don't wear that all the time. Um, and as you know, they're gradually sort of pulling back the headscarf. Um, and, you know, it's not what it seems. So this is actually a bottle of Shiraz in Shiraz, um, brewed in a room upstairs and, um, uh, of course not legal but, um, it's a fascinating country surgery for Clefts in Iran, mainly by pediatric and plastic surgeons. But anyone has to go. This is the problem. So the problem is not access but quality in in Iran, there has in the past been poor multidisciplinary care. There still is, except for for I think this one center in Isfahan and here's a meeting in Isfahan. Um The multidisciplinary team working has largely been pushed by the speech and language therapists. In fact, um carrying reluctant surgeons along with them, I would say results have been poor. Uh lots of, lots of what we call cleft cripples. Um because of this, everyone has to go sort of policy. They actually published their results which showed 75% of the patients after pellet repair had had hyper significant hypo, moderate or severe hyponasal. Um pretty brave to publish it. Er, they pub, they republished a few years later. Um and if that percentage come down to 40 which is a big improvement. So they've been very keen to improve and that's, that's why I was invited to go there. Sanctions have been a problem um because they're, they, they, it's so difficult for them to, to go anywhere to get to meetings and to keep up to date. The, the, the, a semi autonomous region of Kurdistan. This is Suliman um where uh I'll be going in um in November. Um a, a hospital built by Italians. This is a government hospital called the emergency hospital. The big problem in Iraq has been, especially in Kurdistan has been conflict until a few years ago. There have been 50 years of constant conflict with Iran then with Saddam Hussein. And it, it, it, it's just gone on forever. On the right is Halabjah, Halabja is, uh, up here near the Iran border. And, um, uh, this is on the right, the museum in, in a laja. And the, the exhibit, the rope is actually the rope they used to hang chemical Ali who was Saddam's um, cousin, I think, wasn't he, um, following the chemical bombing of, of AJA? It's quite amazing museum where they sort of imagine what it was like when this, when the chemical weapons arrived. Uganda. Very beautiful country. Not many surgeons because of big distances, they need camps. They, they need to, people need to come long distances and the infrastructure's pretty grim. So this is Robertson Tongo, the who was the senior surgeon in, um, Malago hospital, frequent power, power cuts. His solution was just to operate during the day and pull the table over to the window. This is Malago hospital number one teaching hospital in, in Uganda, in Kampala 2008. When I was there, the door into the main recovery room was hanging on one hinge. Two years later, they'd solved that problem and the other door was hanging on one hinge. And the reason I show that is that it's very soul destroying, to work in that environment, to work with that limited support. You know, we complain in this country but we just don't know, we're born and I, I know, I know that those surgeons are, have, have, are discouraged, have, uh, you know, it's very difficult to keep going in that situation. This is Rwanda in 2006. Uh, er, I went there with, er, is Israel Walker at one of the anesthetic colleagues from the street. She was using an oxygen concentrator because there wasn't gas, there wasn't er, um gas, there weren't gas cylinders, er, and er, it wasn't working and that was the reason there were, there was a litter of mice in the uh in the middle of the uh oxygen concentrator. Sri Lanka again, a very beautiful country, relatively high quality medical services. Um This is er Romesh Sara who has been a friend for a long time. This is uh candy in uh in um Sri Lanka. There has been a lot of input. It's a, the nicer the country, the more Western visitors there are going to be. Um, and you know, everyone loves going to Sri Lanka. There, there are some multidisciplinary teams but there are only three sort of major centers. And so this is actually a, an anti a, a postnatal class for mums teaching about feeding to a group. And there's been this long standing, there was this longstanding conflict in, in the Tamil area in the north. This is um the teaching hospital in Jaffna, uh South America. Um this is Peru. There's a, a tradition in South America of internal charitable foundations. So foundations which work within their own country. I think that's very different. So they talk about missions, but these are in country missions very different from overseas, sometimes called parachute missions, which I'm going to mention problems in a lot of South America as accessibility. So the Andes are a, a significant hurdle altitude is a problem. I I operated um once in L Alto in Bolivia at a, at an altitude of 4200 m. And I went into the recovery room and was a bit worried because the uh the baby had an oxygen saturation of 86. Um M oh no, 88 down mine mine was 86. So, but it's interesting actually, you know, you do get really quite short of breath, even, even operating, which is not exactly hard physical activity. Bangladesh is a country that I've really had most involvement with. Um the it's still expensive to have a government operation in Bangladesh perhaps nine month salary for, for the, for one of these parents who works in a, a garment factory, making the clothes that probably many of you have uh have have worn. And we, I went to visit that family and this was the room they lived in, shared cooking, shared, dining in a, in a um a sort of apartment blocker. You really couldn't call it that um shared toilet. And yet the family looking spotless, always remarkable. So perhaps 100 and 80 million people. Lots of difficult cases, lots of craniofacial clefts. We've done a research project there looking at 100 and 25 TC A cio craniofacial clefts, huge workload of lots of things, especially burns. Actually, I mean for, for plastic surgeons, burns are a massive challenge. There was virtually no multidisciplinary care in Bangladesh and most of the clefts are treated by Ngos. The great majority by a smile track where surgeons are paid. So smart train will pay 250 to $350 per case to the hospital. But a percentage goes to the surgeon. There are so so many other priorities for, for, for surgeons, for plastic surgeons. Anyway, working in Bangladesh, the the little boy up in the top left w uh he was given some cos soda by his aunt to drink because she was trying to kill him because that would have meant that her son is the next oldest male, would have inherited the family uh fortune or not fortune. Um So I did some work on his palate but he had lots of other problems, malnutrition um and typical burns contractures. And the problem is that the government has been able to take little responsibility because uh an overseas NGO has or o overseas NGO S not just my train, others as well have taken the load and done these operations in private hospitals, it means that there's really no great incentive for the government to, to get involved and that's not a sustainable solution. So finally, some suggestions how we can help those of us in high income countries uh can help those working in low and middle income countries. I, I have some personal role models. I I was actually a, a training surgeon uh when it, during the Vietnam war and I went to uh with an Australian er aid team working in a, in a, a government hospital in Vietnam in 71. Um and uh but while I was there, I visited the BASK unit which was set up by, by Arthur Bask, a New York um plastic surgeon in Saigon as it was then called uh which was very impressive Paul Brand um surgeon in the Christian Medical College in Galore. Er, he showed that the reason for digit for loss of digits in leprosy. I had a very enjoyable evening which I'll never forget when Peter Randall, late great surgeon from um Philadelphia invited me to go to the American Society of Plastic Gs and I sat at the table with Paul Brandon and Peter Randall and he told me that the, the, the the story of the take home cat, do you know what that's all about? So, the the leprosy patients when they same time were sent home with ac why to kill the rats that ate the anesthetic fingers while patients were asleep that Jack Ma and the, the the project, the, the Glasgow inspired project in Accra Ghana also moving into uh Sierra Leone to some extent, a really great model that that's been AAA great twinning arrangement where er n numerous surgeons have gone from canni burn to Accra, but also surgeons who have come back for a year to canni for training. I think a really a really good model Sam Nordoff in uh in Taiwan, Taiwan Chang Hospital. And the great thing about Sam Nordoff was that um he recognized he went as a missionary surgeon, actually realized that this wasn't going to cope with the scale, the cope with the the the scale of the problem and got involved with the shipping magnate, Shang Gu and set up that amazing plastic surgery unit. And most importantly, he trained a generation of people who took over um uh chan very famous surgeons Philip Chen has now left Chang for reasons that I'm not totally clear about and we're going to hear from Nepal in a moment. But uh I I he's one of my inspirations as well, Shankar Ry, um who um single handedly has, has developed uh plastic surgery um and particularly interested in in cleft surgery in Nepal. And incidentally, he does work with Smart Train, but all the money from smart train goes into his center, not into his pocket. So uh we've been through some of the challenges um and we have to somehow help with, with, with all of those challenges. And NGO S have not, as I've explained, not always been helpful in some places they actually cause the problem. So long term sustainable solutions, not international missions. I hate the word missions because it's got this sort of evangelical overturn. Uh I I rather would call visits so no international missions unless there's no alternative, there are places where there is no alternative. Um and, and that is reasonable. But parachute missions often inexperienced surgeons from overseas, you know, the the face lifting surgeon from Miami going to Guatemala for a week, a a year, putting it on his website to show what a great guy he is. Uh and that, you know, that's still happening undoubtedly often, no liaison with local clinicians. I I've been on one what I would call a parachute mission. It was with an Italian team to Myanmar and the they brought the whole team, nurses and anesthetists and the local team sat drinking coffee in the coffee room while this team took over two of their three operating theaters for a week. And often they leave nothing behind except disasters and they don't understand local problems and maybe unaware of local customs, un unable to cope with malnourished babies, which they're not used to seeing in their own countries, not being aware of local custom eating customs, for example. And also they are patronizing they are neo colonialist. You know, it it is, you know, we we're coming along, we're going to do it because we're better than you. And sadly, the people in many of these countries, um, believe that and you have inexperienced, I've seen it in many places, inexperienced surgeons. People never do cleft surgery in their own country. Going to a place where there are very well established surgeons who do a very good job. But the local population believe that because they're from the West, they must be better. Uh a lot of that happening. So not international missions and not paying local surgeons per case, which distorts the local health economy enormously. Um you know, it must make the hypospadias surgeon pretty sick to see the cleft surgeon cremi. It but you can't show pretty pictures of how this radio operations. It discourages governments from becoming involved, as I've said. And that's a major problem. We are trying in Bangladesh to work with the government but of course governments change all the time. There's an election in Bangladesh in about three months. The whole thing may, may turn over and the people we've been trying to work with may have may be gone. It discourages surgeons from working in government hospitals. So in the hospital we work in, in Bangladesh, there are a couple of surgeons who are really not keen. So we we've built, we've built up a, a cleft, a multidisciplinary cleft center in the go in the main government hospital in, in Dhaka. But there are a number of surgeons in that center who have small trained partnerships outside. They don't want to develop a government center. They, they're, they're actively uh they o many of them are actively discouraging it. And the problem about paying per patient is that it encourages quantity, not quality, obviously, for obvious reasons. And what happens when that NGO leaves? I, I just wonder what would happen in many of these countries if these major international charities suddenly stopped working. So just a few suggestions and this is what we tried to do in in our charity cleft, keep the costs low. The the visiting clinicians, visitors, guests, they're not, they're not there to primary to operate, they're there as guests of the local surgeons and the local team set the agenda. The visitors work with the team don't take over no big missions except for teaching. So we do have some big groups of multidisciplinary uh teams but just for teaching and these centers should be in training centers. Ideally, government hospitals, multidisciplinary team care is priority support the development of pediatric anesthesia. That's a major part of our work, encourage longterm care, support outcome measurement. So people start looking at their own outcomes training as a priority help to provide equipment which we have done and facilities encourage collaborative research. And this is not us going out to do our research, but this is encouraging them to do their research and aiming for independence. We said five years if if possible in some places, I think it can be, but in others it can't and um try to get government involved. So we need longterm sustainable solutions to improve access, also, quality, also safety. We can all help to bridge the gap. Thank you. Thank you very much. That was um very inspiring and um I'm just very grateful that you've made the effort to come up here as well because I think having in the room with people here really helps to spark people's engagement with these topics which are so important, we're gonna actually make a difference. Um We'll wait for questions at the end if that's OK. Just um as I know that Mr mccay will be um ready to present now and we can have a quick discussion before we get back to London. So Mr um Mr NAMI, are you on the line now? Yes. Yes. Would you like to share your slides? Ok. Thank you both. Um Just briefly, the slides are being um shared. Um Ki Mkay is um the head of burns plastic surgery at um hospital in Nepal. Um I first encountered MS Mkay when um undertaking some, some research into micro surgery on National Surgical Collaborations and he was extremely helpful and evidently extremely passionate. So this is having him talk at a gas journal club has been something we've been trying has been in the pipeline for a little while now. So I'm really grateful that he's er, joined us. So, thanks very much and without further ado er Mister K NAMI, thank you Henry. Ah Good evening everyone. Uh This is our short experience of microsurgery in Nepal. I'll be talking about the country in a short detail and then that will be followed by our healthcare system. And uh in the end, I'll be talking about micros experience at our center. So as you know, uh sorry, it's taking long time. Uh Nepal is a country known to be the bud. Uh And uh it's also known as a country of mountains. It's a very small country. Uh And in the north, there are high mountains and in the south there there is a plain area. And uh as you know, 10 out of 14 highest mountains in the world are located in this small country that makes the country very, very geographically challenging. And this is specifically difficult for the patient, for the for them to access the health care because most of the healthcare facilities are located in the cities and these difficult places do not have any roads so many, many a times they need to be carried. So Nepal has got 30 million people and only 30 plastic surgeons and around 15 hand surgeons in the whole country. So basic health care is uh like not available in all the parts of the country. So we are not uh if you are talking about plastic surgery, that's basically luxury and it's a available only in the capital city and there is almost nonexistent existent health insurance. So patients are usually most of the time they are paying out of their pocket. Uh The provision of free health is very insignificant although it's there in the constitution of the country. Uh there has been some improvement in the survival in terms of communicable diseases. But noncommunicable diseases are they are ignored and they are on rise. So if you look at the status of Nepal in the health Olympics, this is not a very recent data, but it could be similar to uh present data. So Nepal stands at 150 out of more than 200 countries. So uh these data, I want to emphasize that surgical conditions, they have not been given much attention even by wo until recently. But uh it has been found that up to one third of the like global uh disability adjusted life years are contributed by surgical conditions and there are around 5 billion people with no access to basic surgical services and most of them are from developing countries. And if you talk about plastic surgery, it is still in infancy in most of the developing countries. And uh it is in the the scarcity is even more star if we are talking about plastic surgery. So another fact is that plastic surgical conditions disproportionately affect the people from lower social stratum such as cleft and other conditions. They are much more common in our part of the world and because we do not have enough people to take care of these conditions and the disease load is very high. We often uh depend on the teams from outside. So uh I'll be talking about how it is uh the most cost effective way to uh train the local surgeons to develop a sustainable model. Now, let's talk about our hospital. We started in Kathmandu model hospital, which is uh it's a non not for profit go no NG Hospital. Uh It runs under a trust known as Public Health Concern Trust Nepal. And we started with Research International which is uh uh not for profit. Uh NGO from, from the USA uh as uh Brian already mentioned, uh Doctor Ray was my mentor and I joined him in 2000 to start the department in this small hospital. And now it has grown uh uh bigger and we have moved to uh another hospital which is 100 bed hospital. Uh It's a multispecialty hospital and we occupy almost half of this hospital. And we have around uh we have 11 reconstructive surgeons out of whom six are plastic surgeons, two are orthopedic hand surgeon, three maxillofacial surgeons and out of 11, 3 of them are females. So these are the units, the unit division in the department, we have four units and surgery uh burns gen plastics and cleft. So if you are talking about a facial cleft, we are doing trying to do comprehensive cleft care and it may not be as good as in the developed countries. But we are trying to include all the aspects of cleft care. And we are operating not only in Kathmandu but also in five out centers around the country. We go to these centers every month to do cleft surgery and we have locally uh employed staff, they are full time, full time staff who are not only screen the patient, but they also provide the perioperative care, speech therapy also. And dental care is also being provided out of Karu. And we are also doing speech therapy throughout the country in the in the villages. And the burn is a big problem in Nepal because we have the government data mentions that we see around 55,000 incidences of burn in the whole country at K hospital. We receive large chunk of these patients. Actually, the hospital is the largest burn center in Nepal. Uh We are doing acute wound care in Kathmandu, but we are planning to extend it outside of Kathmandu also in the eastern part of the country. However, we have been doing burned reconstruction in our two centers as well. So if you look at this uh graph, you can see that the number of burn cases have been increasing every year. We started in 2013. And if you look at the data of admitted burn patients, it's going up every every year and uh last year it was 661 admissions. Uh In that year, this year it has like, this is the 444 is the data from the first six months. And uh we have 40 beds allocated for the burn patients out of which eight are ICU beds. And there are two dedicated burn theaters which run six days a week and burn is a big problem in Nepal because of the deadly combination combination is what I'd like to say. Like there are 33 deadly combination. One of them is the high disease load, but the physical face and manpower is lacking. The second is unsafe environment. We are using open fire to light our house to cook and to keep ourselves warm. But safety precautions are not there. And then other thing is other other, the combination is because this is the disease are poor, mostly the poor people are involved and care is very expensive. So all of these contribute to make it a big problem, big health problem in. And uh there is not a single government facility for these patients to go to. Uh So we started our uh burn service in 2013. There is no government support or policy for the burn patients. There is not a single hospital in the country with burn u until we started in our hospital. And there are not many burn care professionals as you saw that the number of plastic surgeons is very less and not many of them are interested in taking care of the burn because of the poor outcome and the poor financial return. We have a dedicated hand unit. As you saw, we have three hand surgeons including myself and we have been conducting hand surgery fellowship at our center. It's a one year fellowship recognized by the Medical Council of Nepal. And the thing is that the spectrum of cases are limited um mostly to trauma and burn. We do see some congenital uh uh hand hand cases. And we have also started to do uh peripheral nerve surgery including brachial pictures and but most of the patients like uh cleft and other patients, uh the patients are very poor and most of them have to pay by themselves. So now coming to microsurgery, so I got this paper published in 2018. Uh this was based on our work. So which actually started in 2003. Uh This was right after I finished my fellowship in hand surgery, I came back from Nepal and we conducted several uh microsurgery workshops and we included many uh reconstructive surgeon, surgeons, uh not only plastic surgeons, but also orthopedic surgeons, gynecologist, cardiac surgeons and neurosurgeons. Many of these gynecologist uh gynecologists, they have started to do uh recanalization, cardiac surgeons, they have started to do CPG operations. So we, we try to include each and every specialty uh to uh into microsurgery. But we had very low resources. So we were dependent on the loops and uh chicken legs uh for the training. And in 2007, uh we came across inter class Australia and New Zealand. Uh So they have been coming to our center every year since then and they have been supporting to do around 15 cases every year uh by, by the local surgeons in during the big earthquake of 2015, we had collaboration, we started collaboration with other organizations to do micro surgery such as paper first and research, international. Research International has been helping us do cleft surgery and bone reconstruction surgery since 1999. But they also started to help us with microsurgery since after earthquake. So from 2007 to 2017, uh we uh conducted these works ups in three centers, actually uh two of these centers, Fe Nepal Ka Hospital and they, they belong to Nepal. And then we also went to a government hospital which is known as National Trauma Center where we did four cases. And uh uh most of the other cases were done at the F Nepal hospitals. So if you look at this chart, you can see that in 2013 and 2014, we didn't get any uh expatriate uh teams coming to Kathmandu and uh after 2017, uh inter plus Australia in New Zealand had they have stopped coming to Nepal, but they have been supporting us to do the cases However, research international has been sending a team every year to Nepal. It's a small team consisting of two surgeons, sometimes no anesthetic and two nurses, they come to Nepal, they spend a week with us and we do a few cases with them. So uh we started our micro surgical adventure with Inter Australia and New Zealand. Uh We would do a screening of the cases before the team actually arrived in Nepal. We would do email consult. Uh And uh depending on the discussion, we would even do a special test like angiography for for the patient that uh they are, they were indicated. And then after that, when they arrived to Nepal, then we would see the patients together, we would plan together and we will plan it in such a way that we were doing easiest flap to start with. Actually, we were doing radio artery for flaps in the initial uh workshops. And then uh our intention was to try to focus on one flap at a time. For example, in the first few flaps, few flap works up doing radio for. And the next flap we took on was uh free fibula because we had a like a lot of referral of oral cancers in our, our our hospital. So the third flap we took on was a flap, a flap. That's how we build on and gradually build up on uh different and more difficult flaps depending on the uh case load. And uh type of problem we came across and then we were also involved in preoperative preparation and anesthesia evaluation. So, uh the main aim was to involve the local surgeons as much as possible. Uh Each actually, the inter class Australia team used to have two macros surgeons and 11 of the surgeons was Stagg with uh one of the local surgeon. Actually that at that time, we aar and I was doing the most of the surgeries and we, we were trying to learn as much as possible so that we could transfer the skill to the younger surgeons. And the micro part was done by both the local surgeons. We uh were trying to focus on one technique. One and uh that technique was posterior wall first technique and uh which we are still practicing and find it very useful compared to many other different techniques. And we would always try to do two veins as much as possible. And most of our cases had uh general anesthesia and uh some of them have epidural anesthesia specifically when the uh recipient and donor sites were uh the lower proximity. And uh some of them even had general anesthesia because the operative time was uh long. Uh and uh mo uh in most of the cases where we have uh epidural catheter, uh the catheter were late for the postoperative pain relief. So this is the picture you can see uh the local and uh expectorate surgeons working together and there are many residents you can see watching and uh you can also notice that there are no monitors to, for the residents to uh look at. So sometimes they would uh look uh into the eye pieces themselves. So initially, we were, we were using uh operating loops because we didn't have microscope. So until uh may 2008 and uh uh up up to weeks time, we had done already done eight cases. Uh we were doing it only with loops. But uh after that in the class Australia, I donated a microscope. So after that, we started to do under the microscope. So most of the cases, we needed more than 12 hours of surgery. They, they had under overnight intubation and they were transferred to the ICU. But the rest of the cases they were extubated and put in the postoperative ward and post operative ward. The nurse patient ratio was around four is to one and flap monitoring was done uh which included color temperature capillary refill and Doppler Doppler monitoring. And you can, if you look at this chart uh which we uh locally use, you can see this uh area encircled with a yellow um line. Uh Actually some of the nurses, they were, they were taking the cool uh the the reporting the flap to be cool when they, they thought that the flap was actually cool. Actually, they didn't know that the cool flap was a bad flap. So they had to do it again to say that it's warm, it will not cool. So uh our dopplers uh were used for preoperative mapping of the ilter and also for the postoperative uh monitoring. But uh as you know, uh regular Doppler monitoring is not very reliable because sometimes it is difficult to localize the peril with just the Doppler. We have never done uh A CT angiogram to look uh localize the ter. Our aim to do CT angiogram is to see the status of other blood vessels when we are taking uh the flap based on the measure uh BP. And uh uh I if uh the probe is placed near by the mes major vessels, uh especially in the neck area, you may have false positive results. And same thing can happen if the probe is placed proximal to anastomosis and then uh that can lead to delayed action and flap loss. So we have this uh postoperative uh flap monitoring protocol and then the feeding is started next morning with sis except in tube patients. Uh They start only after 3 to 5 days, especially when uh the operation was done in the oral cavity. So most of the oral patient, oral cancer patient, uh when they have mandibular reconstruction, they usually have tracheostomy uh for about a week uh and it was removed after the plugging trial. And most of them uh received the anticoagulation uh uh with uh heparin uh initially, we were using heparin, but nowadays, we have started to use the lower low molecular weight uh uh heparin. And uh after a week, uh we give them uh low dose aspirin for a month. And uh when there is no further need for flap monitoring, uh when there is no flap swelling, when all the tubes are removed, when the patient has already started to take uh orally and when they can move uh independently, that's the, that's the time we discharge the patient. So if you look at this uh chart here, uh I had tried to compare the complications uh during and uh outside of works up, outside of works up means that the cases uh the local team was doing and inside works up means uh these are the cases done with the expectorate team. If you see the rate of infection is almost similar complex. Uh flap loss was uh a little bit more with the expect uh uh uh when we are doing it ourselves and then partial flap loss was slightly more with uh uh uh inside the workshop. Hematoma is almost similar. Chest infection was more common with inside works. So, because some of the cases we took took and they had a very bad case and they had oral cancer. So I think the preoperative situation, the morbidity lead to the higher chest infection postoperatively. And same thing applies to the date the mortality. Also, uh we were taking more complicated cases when uh the team was in Nepal. Some of them are, were very, very uh malnourished and they had the cancer for a long time. So, reconstructive macros surgery is very vital but it's under utilized skill in developing countries because of many reasons, it's not available, training is not available. Resources are not available in Nepal. We have started to do these cases in increasing numbers. Uh initially, uh it was ciliated by, by the expectorate team, but now the local team is doing it in increase increasing number. And we have also started to take on larger variety of flaps. So, indications and outcomes are similar to other developing countries. Uh So, trauma, tumor and burns were the m major indications. And uh uh when we are talking about burns, um most of them were post burn contracture rather than the acute burn. But however, we have done uh free flash for the some of the acute burns, especially with the uh electric burns and the epileptic uh burns and outcome has been uh uh like uh slightly more than 91%. So this picture, uh this picture actually this page. So three sets of uh patients uh like uh the top one had a squamous cell carcinoma, uh following burn injury. So we excited. This is the, the the part that's son, son with the ulcer is the actually the heel of the patient. His toes were already uh amputated at the time. Of injury. And we did a radio art for and flap for this one. And the second one is a post traumatic injury. Uh sorry, this was a squamous cell carcinoma again in a leprotic patient. And we did a contralateral uh medial plantar artery flap. And the third one is a de lobbing injury of the heel where we did the rectus uh uh abdomen is flap. Uh the, the third one, third patient didn't show up for the follow up. So we don't know what happened to him, but the first patient was doing well. Uh even after five years of uh surgery and the second patient uh with the squamous cell carcinoma, the heel, he had a recurrence of the cancer, um and he didn't show up afterwards. So this lady young lady had a avulsion injury uh of the scalp in a ve belt up of uh rice mill. And we did the later side flap with skin grafting. Normally we would do a burr hole and uh uh uh wait for the tissue to develop and then graft uh that takes a long time. And that also uh provides a very poor uh quality coverage. So this is how the team is sitting together with the local, you see lots of residents around and the expectorate team patient there, the photographers, everyone is there during the screening. So the challenge is and uh there is a lack of awareness among the people and also among the health providers. Initially, when we were doing the free flaps, even the like on onco surgeons, they were not referring the patient. But one, only after a few uh such uh uh workshops, they started to send the patients. And uh as I mentioned earlier, there are not many plastic surgeons in the country. And uh uh most of them are uh uh in Kathmandu and those who are outside, they are not in teams, they, they work alone. Uh And so microsurgery not for the people who work alone. And the plastic surgery residency started in Nepal only in 2009. And every year we get 2 to 3 residents. Uh So the number is still growing very slowly which is in star uh like it, it's quite different from Bangladesh. Uh I remember going to Bangladesh in 2005 when there were very few plastic surgeons. Now they have hundreds of plastic surgeons. That training program is really big. It's not like that in Nepal. And the caseload is also not very big in Nepal as compared to Bangladesh because the uh the size of the country is similar uh Nepal and Bangladesh, the surface area is equal, but the population is about eight times less in Nepal. So none of the cancer hospitals have plastic surgeon. That's another uh uh problem. Um There are two government uh run uh cancer. So none of them have plastic surgeons. So whenever they uh need some reconstruction, they do all kinds of uh local flaps and uh uh sometimes it works, sometimes it doesn't work. And when it doesn't work, only the only then the patient come to us and there is no culture of ors collaboration. Actually, in case of acute uh extremity uh injuries, uh orthopedic surgeon, they try to do everything by themselves. And only when they have bone exposed and uh infected, then we get to see the patient. So that makes it very difficult for the patients. And uh to ourselves also to the plastic surgeon, it's also very challenging and uh anesthesia. Uh Also, uh there are not many anesthesiologists in the country. Uh We have four full time anesthesiologists in the whole hospital. They have to take care of all those specialties. And uh when we are planning to do to do the micro surgery, we have to really think about it because it takes 6 to 8 hours and it takes up the, it takes up 11 theater room for the whole day. Uh So we have to really think and uh plan well ahead of time and uh sometimes the other specialty surgeon, they may not like the idea of occupying the room for the whole day. And the other thing is the lack of frozen section biopsy in, in the co in the country. Uh So we have uh had some recurrences because of this uh this situation. So the training resources are also lacking such as fund. There are no training lab, uh no training microscope or instruments, even sutures are more um very expensive. So we have not been able to uh you buy the suture, sometimes we get donated sutures and then we, we can use it for the training, but they are, they are very precious for us and we do not have display monitor. So the, so the the trainees have to look down into the I piece. They, they cannot look, look into the display monitor and we do not have animal farm. So we use chicken leg model most of the time. And carvers are not also available for flab dish shaking because in most of the caregivers they are preserved in for and it's not very good for dissection. And the cost is very high for this type, this type of surgeries. And because our our a pretty poor country, there is no insurance to cover the cost in the class Australia. And New Zealand has been covering 15 flaps per year now. They are, they are decreasing it every year. And uh fortunately, we have been getting some of the patients who are paid by the third party, for example, somebody involved in a work related injury or somebody involved in the traffic accident, they are paid by the third party. So we can uh we can do a few flaps um uh without their help as well. And uh when the surgery is being covered by interplay. And Newland, the cost does not cover for the failures, secondary procedures. So uh it's very difficult for us to uh manage that way, uh especially when it's being covered by the donor organization. So what we do is we try when the and C or flaps for these kind of cases. So, uh in conclusion, free flap is a uh microsurgery is a very uh important and uh uh necessary uh tool for the reconstructive surgeons because we can take care of most of the challenging uh tissue defects with this technique. And uh there are several challenges to that. And in Nepal training and support of local health personnel, it has increased local capacity to far from microsurgeon reconstruction. And uh it's an important step in creating a sustainable model. Thank you. There we go. Thank you very much. That was a fantastic talk. Um I hope you manage to hear some of the clapping through that feedback and I'm conscious it's very late at night where you are and um I'm muted. AM II I think you guys can hear me still, can't you? Yeah, I'm mute on the main screen. Yes, we can hear you. This is some of that laptop I think. Can you hear me? Yeah, great, thanks. Um So uh we just have time. Um And Mr Suard also needs to get back to London. So just have time for maybe a few quick questions and a short discussion. Um Anyone in the room. Do you have any questions for Mr Sula or Mr mccarney about what we've heard? Um Matthew's got his hand up there. Uh So in your practice, you have the talk to me about, I think your practice in regards. So I'll just repeat the question for those online. The question um in the room was, has have either either of you, I think Mr, I could take the answer first and then Mr, but has there been any teaching from low resource environment to high resource environment? And um that has resulted in a change of practice maybe. Yes. Well, I'll, I'll, I'll answer from uh from my experience. Um The answer is we use stuff, you know, we, we um we waste so much stuff and we, I, I just think be this month ago and we took some ra tubes, some endotracheal tubes. They reused them over and over and over again until they, you know, they sterilize them and they reused them. We're, we're, we're, we're very wasteful, aren't we? With, with more and more disposable stuff? I mean, for a long time, I collected disposable sets in the private hospital in Chomps where I do some work and took them to Bangladesh, not allowed to do that anymore because you, you can't use dis, you can't reuse disposable equipment. I feel this is being powered by the companies that make the disposable instruments. But interesting to hear about, about Nepal and that was a very nice talk. Thank you very much. Thank you some summer. It was very nice speaking besides you, I've heard a lot about you from Dr Ray. I have not been fortunate enough to meet you. Um So same thing in Nepal also, we try to use the resources as much as possible because everything costs a lot. Um And uh we, we try to buy the things locally. Some of them are not available. We depend on the donated stuff, for example, uh dopplers were donated by the uh different organizations. We have donated microscopes and we, we also got uh donated uh operating loops from the, there is an organization called uh Loops around the world and I don't know whether you have heard about that. Uh and uh that uh organization actually see you the uh number of like whatever number of loops you need, actually, you have to justify your need. Shank about Shaka, right? Um I actually first met him in Bangladesh because he, there was no plastic surgical accredited training in Nepal. So what did he do? He moved to Bangladesh for three years, I think, er and trained in, in DKA in plastic surgery. So there was a training program. It just gives an idea of the dedication of the guy. He's, he's remarkable. Um And you mentioned about how there are hundreds of, of plastic surgeons in uh in Bangladesh, but they're all in darker and that's a big problem. You know, the, the, they're actually um uh I think there are two in, there's Korean Chip Gong, you know. Yeah, there's a lot but they, they all want to stay in the big smoke. That's another problem in lots of countries. They want to stay in the big city. Sorry, digression. Thank you. Um Have you got any questions on the online event or any more in the room? Uh Yes. Ok. Um So just to repeat the question um from Mr Bill, the local Cleft surgeon in Manchester. Um it was, has there, have you had any trouble um obtaining registration in the countries in which you're um collaborating with both from the summer perspective? Or if Mr mca's had to assist the surgeons in, in getting, getting that registration with the government and have to be cooperative. I can comment about um from my friends. So we do get reco in Bangladesh, for example, we do get registration um at least the surgeons um with the Bangladesh Medical and Dental Council. Um I think that's important, you know, I think it's uh it's all part of being part of the place and um even if it's not legally necessary, I think if it's possible we should do it. Let me tell a little bit about this because in Nepal, it's legally necessary to get registered. Otherwise there have been incidences where the doctors have been in jail. Uh But like initially, it was very easy to get it registered, but later for a few years, they made it mandatory for the surgeon to get a working visa even for a short time. Now they have changed it in such a way that the doctors, if they come here for less than one week mission, they can uh work with the permission from the Nepal Medical Council under the tourist visa. So that's, that's something that has changed recently. But no. Um yeah, just again for those online. Um as we were saying that it's, it's becoming a bit her experience is it's becoming a bit harder for visiting surgeons to obtain the relevant um registrations. Yeah, II I don't know about um I go to other countries where I don't get where I'm not registered, to be honest, but I think the key thing is that these are still the patients of the local team. Um and you know, you may be assisting them to do cases or, but they're not my patients. That that's the, that's the big difference between what I would call a teaching visit and a parachute mission. You know, the, the big, the big groups, the 20 or 30 people sort of flying in for a week, taking the the team pictures at the end and you know that that's the scene I think has to stop. Um And you know, it's, as I said, in my chat, we we we're the guests, they, they, they're in charge. Um But if you can get registered. Yeah. And, and so, uh and by the way, um we, we cla is a team from Newcastle funded by Cleft, er, are often Neall in a, in a few months, in about three or four months. You, uh you've, you've already had a visit from David Sainsbury, from, from um Newcastle and that a team is on its way, but specifically to help with areas that, that, that you have identified um er Doctor Maka in, in Nepal, particularly, for example, to help develop um orthognathic surgery, um bone graft surgery. That's the idea, the 20 arrangements. Great. If you, if you can, if you can have a uh a a team that kind of adopts and works with uh another center. Uh It's a very mutually beneficial arrangement. Thank you any more questions here. So, um so all that's remained is for me to thank Mr NAMI and Mr Simla for um speaking, sharing their experiences. Hopefully, we will learn a lot. Um Thank you to everyone who's attended today and hopefully you'll come away, inspired and motivated to, to read a bit more and, and, and find out um about what's open to you guys. Um If you're a surgical trainee or a surgeon, please do get in touch with scalpel to help them run their teaching events, recruit the next generation of surgeons. And if you want to check out what's going on with gas oc, just find us on Twitter, uh go to our website. Um I just have a small token of our phone coming all the way, but, um, I also don't want you to miss your train. So I think we should round up there. So, just a quick round of applause and then, ok. Ok. Thanks everyone and look out for the next Journal club at nine.