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Um as well. So please please do jump in as we go through and ask any questions either in the chat and James or I'm sure stop me and stuff. I don't think I can see the chat at the same time as presenting, but James, I'm sure stop me. Um or, or just jump in and unmute yourself and ask a question any time. Um I'm just going to try to share my screen under the wax. Always the moment of truth. Um Great and hopefully we can see that again, James. Is that alright? That's all good. Perfect. All right. So, um yeah, so as James says, so I've done sort of a number of missions with MSF and also the Royal College of Pediatrics and my main, main places I've been have been Myanmar Iraq, Sudan ***, South Sudan. Um and Chad and then, yeah, bits in Nepal in between and sort of little bits elsewhere. Um But this talk was sort of low settings and austere environments. And so I thought I'd just try to give you a flavor of some of my missions and hopefully they're vaguely useful and just, and just sort of link on to some wider topics. So I guess like, first of all, just thinking about austere environments, um just to think about, you know, we think about working in austere environments, but obviously, actually the most important people are the people who are, who are living there and who are actually trying to access the health care in the first place. So I guess what, we're trying to set the scene of, you know, maybe, maybe what that entails. I'm sure you, you know, you already know a lot about this but just thinking there's a 2.5 year old child in that, in that two call, this is in South Sudan. It was actually just on the border between Sudan and South Sudan in a go and who's who's fit and has been fitting for 24 hours um on and off. Um And the family are just making the decision about whether to go to hospital or not. Um It's 14 people who live in that too, all from the same family that's grandma in front in the, in the, in the pink. And just to say all the people who are in these photographs have, have given consent or the main caregiver to give consent for any pictures you used today. Um Just out of interest, I don't know whether to just warm up kind of thing like uh any, any, any sort of take us for what kind of challenges this, this two year old and this family might face in getting to hospital in this, in this austere environment. You don't want to just volunteer any, any little, er, suggestions. It's always tough, isn't it? When you're not expecting it to be a participator, participator sport? That's, uh, any, any, any, any, any thoughts. So, um, Morgan's putting the chat distance and then ahmed's, um, saying finances. Absolutely. Absolutely. Both are really important things. So I can't see much infrastructure there in the background here. There's some, some telephone poles or maybe electricity poles in the background, but there's not a road to see is there and there's definitely not a lot of infrastructure to be seen. So distance is going to be a big thing. And then, yeah, finance wise, it doesn't look like finances are going to be particularly healthy to get a bus or to get any other taxi or, or other help to get to the hospital, one else. And then, um, few people are saying transport as well. Absolutely. Yeah. So either personal transport. So again, can't see a motorbike in that picture and can't see a, you know, a van or anything. So, um, you know, they might struggle to get there themselves and then as you say, they might struggle to pay to get to the hospital as well and then they might be asked for money out of the hospital clearly. And Ellie's saying, um, balancing working with alongside accessing healthcare. Absolutely. That's the thing. Isn't it? So grandma takes that child in, then you can see at least four or five other Children there who's looking after them and who's, who's being able to keep the family, you know, to keep the rest of the family alive in the meantime and care for them whilst they're in the hospital. So, so, yeah, so you're absolutely, you know, you're on points with all of this. So location wise, as you say, 75% of people in the whole of South Sudan live more than one hour from a healthcare facility. And this family lived about 35 miles from the MSF facility. But actually to get to a local facility would have been much further than that. And that's why the MSF facility was, was put there. Um education just even to know to go to hospital in the first place I think is one of the one of the really big things and you know, thinking about silver bullets in these austere environments and we know that um female education is, is, is one of the most powerful things in the world and one of the most important. And in 2013, obviously going back 10 years now, only 500 girl graduated secondary school in the entirety of South Sudan. And now only 10% get a primary education that's across the entire country. Um And South Sudan is obviously the the the the world's newest country. So they formed in 2013 when it split away from North Sudan, North Sudan. Um, but, you know, if you don't, if you haven't had r dementia education and you don't know that facilities exist or when to go to hospital, then clearly that's going to be a big, a big problem as well. And then clearly acceptance. So the vaccination rate in South Sudan, um, in general is 24%. Um, and that's obviously multifactorial thinking about, um, you know, logistics and, um, cold chains and finances and availability and stuff, but also very much the acceptance of, of medicine. That's, you know, not a traditional medicine, which is just down the road, like you might just go into your village and get a traditional medicine, um, sort of appointment or, you know, to get someone to see who you trust, who, who has the same values you do. Um, but then to accept, you know, help from a more sort of Western style healthcare system again, is sort of between that acceptance and education, I guess other things. So family circumstances exactly as you said in the chat there. So the average number of Children per female is 4.6 in the whole of South Suat. And that, you know, that's the number of families who are 89, 10 Children probably. And then again, if mum has to go and spend maybe two weeks in the hospital with a fitting child, then who's looking after the other 3.62 in this case, obviously, that's an average and then personal logistics, as you say, like trying to actually get there, you know, physically yourself, regional logistics. Um you know, so actually the infrastructure of getting to a healthcare facility like roads, um you know, network of transport in general. Um This is, this is where this person lives in, in Abbie um on the right on the border between Sudan and South Sudan. Um, and, um, it's in a complete vacuum really because, um, nine, it's its own autonomous region, um, which is only about 20 kilometers square, probably, well, 100 kilometers, 100 square kilometers, maybe. So, er, 10 by 10, something like that. Um, where neither Sudan nor South Sudan take administrative responsibility. So it's just this kind of vacuum of an austere environment, I guess. Um, it's very beautiful as I can show you that. Um, but also security. So given that it's, you know, between those two, there's quite a few factions who are, weren't at war at the time that I was there, but literally within two weeks of me leaving, there was an outbreak of war between these two, ethnically different factions. And so, you know, going across front lines or maybe in two areas which are run by traditionally opposition groups and we don't have to look too far into the news at the moment to think about the difficulties of within the same country. Or within the same region, walking, going across very dangerous borders and having very different cultural cultural groups living in uh intention. So lots and lots of, lots and lots of difficulties for those who are accessing care. And so I guess like the, the, the thought process which I was sort of going through from that was like, what sort of care do you offer to that, to that child? So that was an actual child who was um who had TB meningitis, it turned out. Um But they're probably gonna have to spend 12 hours of getting to the hospital and then when they do get to the hospital, what are they, what are they going to find? Um And this guy, I guess comes from the, the MSF perspective of thinking, well, what, what sort of facilities do you put in, in these, in, in relative environments? And does that help or can that have a double edged sword sometimes? And, and how, how, how can that work out? So, I just wanted to think about a few different models that I've experienced and there's probably many more, but it's just easy to talk from sort of personal experience, I guess. So. Um I worked in *** um for a little while a few years ago. So about four months then, um and I'm calling this one the factory. So this is a, this was a 800 bed pediatric hospital. Um *** at the time was the lowest, it was the country with the lowest un developmental index. So it was 100 and 86 out of 100 and 86 in the development index in the world and in the east of the country. So the capital is kind of west. But in the east of the country, there are just huge waves with very little infrastructure whatsoever. And the people who lived in this area lived probably four hours drive from any healthcare facility at all, close to the border with Nigeria, close to kind of Boko Haram territory. So again, difficult area. And what normally happens is you will be aware is sort of towards August every year in large belts of Sub Saharan Africa. And you have kind of a double whammy where you get the basically the crops have run out and you know, there's a kind of a drought and then the crops are kind of finishing. So there's a, there's a famine and then the monsoon season starts like just then and that roughly revisal sizes the crops, but it also has lots of standing water for mosquitoes to breed. So you're just at the time when malnutrition is at its peak, but then you get a malaria peak at the same time and this is what this hospital has been dealing with for probably 20 years. It's had an emergency every year with multiple, multiple, multiple people coming in. And so this is the, this is a dry slide but um looking at the graphs. So when you walk into the hospital, these are the graphs of the admissions and the deaths. So if you look at the um at the um the one sort of down here at the bottom, right, um you'll see that um the admission and so this is the deaths in the whole hospital. This was 2018. And you can see that you kind of go along January, February March, April June, sort of, you know, a little bit rising and then the peak up there, we're looking at 96 Children dying a week, um, in this hospital, er, during sort of first week of September and then tailing back off towards December. And you can see at the top there are admissions to, to the pediatric unit alone. Um, so in one week in September, there were 650 admissions to the, to the pediatric department. And on the left hand side, there are about 400 to the, um, to the nutrition department. So we're talking over 1000 admissions a week, um, to this huge, huge, huge hospital and this is kind of what it looks like. Um, so, um, this is, this is the intensive care unit, um, for the nutrition. So there's one for the pediatrics and one for the nutrition and these are genuinely the sickest Children in the world. I don't believe that there are sicker Children in the world than these patients. And um this end particularly was the, was the sort of higher dependency care. But you can see it's pretty rudimentary. So there's a couple of oxygen cylinders around, there's a concentrators, sorry, there's a weight scale there in the back, there's one nursing station towards the end. And for this entire room of, let's say 32 patients, 36 patients, there's, there's 22 to 3 nurses. So there's three nurses in white and then there's two healthcare assistants who are, who are in yellow. And basically what happens is you kind of you do a ward round and it's just very pragmatic. So you basically pin up the, the orders for the day. So the prescriptions and the fluids that you want and whether you want plan a Plan B, plan C, which is how you rehydrate Children. And so plan A is just you give them fluid when they have a diarrhea or a vomit. Plan B is you give them a certain amount. So 75 mils per kilo over four hours. And plan C as you push very hard on their, on their rehydration and you'd pin that up. And then the nurses and the nutrition assistants would just be doing around the whole day. It's like painting the bridge that you get to one end and then you need the painting and you go back to the other one just enex the plan and then taking the thing down shoving it in the notes and move on. What's next? And this was just a real factory of malnutrition. And what the, er, nu nutrition assistants do in, in yellow is, um, they go round with a massive bucket of milk every three hours or sometimes every two hours and they ask the mum for right. Where's your card? Um, that says how much milk you get? Right. You get 65 mils every three hours, right. Here's a, here's a, here's a, here's a massive syringe, 65 mils into your cup, right? Feed your child through the NG tube, through the, through the mouth if possible. And and it just keeps going 24 hours a day like that round and round and round. And um I think this is, this is kind of like the the initial kind of response to overwhelming pressures in low resource settings is that you have a low resource hospital, but you work on capacity. So you try to be in a position to treat as many Children as possible with predictable things. So with malnutrition, you know that they're going to be septic like so they have basically no immune system. So they are going to be septic. So you're gonna give antibiotics to everybody. Literally everybody has to get five days of antibiotics. Um You know, you're gonna give milk. So you give f 75 the low calorie milk to every single non nourished patient when they come in, at the same amount. So 100 and 35 mils per kilo per day, um, you know, that you're going to have to probably give themselves fluid for, for, for, for, for rehydration. Um, and then, you know, you're probably going to have to give most of the antimalarials. And so you're kind of doing a factory base, which says, well, we're not sure about you as an individual, but we're just gonna blanket treat you and most of you will get better and unfortunately, quite a few of you will die. But if we're getting 90% of you better, then we're doing a cracking job. And that's kind of, that's the factory model that you kind of put in place low resources. But the stuff that you can do with fluids, oxygen milk, antibiotics and antimalarials. Five simple, relatively cost effective things you can treat 90% of the world's sickest Children like this. I think that's something that's actually really, really reassuring, particularly in a, in a, in a, in a place like this, but you've got to get the organization right and get the staff, right. Um And so that was what was really interesting about this project, just huge numbers but low, low ability. Um But with simple, simple, simple things, um getting a lot of Children better. Uh and not just Children, sometimes sometimes other patients take on beds. And I think that brings me on in some ways to just thinking about dealing with the bigger picture. And I'm going to try to sort of inter intersperse, thinking about the actual medicine in this talk. But then also thinking about how you deal with it, maybe just as an individual as well. And um I think I know this project. It's in Magaria, in ***. It's famous for being a sort of destroyer of humanitarians, both national staff and international staff. Um because seeing 95 Children die a week is significant, right? Like that's, that's tough. And the way most of them were dying, prepare yourself for sad story. But, but the way that most of them are dying is, is really, is really quite dramatic. Um These are Children who for the want of three extra bags of rice a year would survive but who who don't have enough protein to a clear their skin to their body and so their skin is just falling off with Koko and, and, and, and then infection on top of it. And so when someone is deteriorating, you're doing CPR on them, you know, their skin is just coming off in your hands. Um And you do 10 minutes, you give them fluid bolus, you give them, you correct their sugar, you give them like at least one adrenaline and at 10 minutes you say I'm really sorry, like we, we tried everything. I, you know, I can't imagine how you're feeling. Um And we're so so sorry and the mum sort of elbows you in, you know, in the face and says, are you not finished yet? Get out of the way and then slings this dead baby on her back and then walks in 24 hours home to her to call. Um, because she's known all along this baby was gonna die. Um, and you've had the hope that you might be able to do something about it and you can't, um, in at least 10% of the cases. Um and that's really challenging because you start seeing a lot of those throughout a week and then you start thinking you're doing nothing and the project's doing nothing and it's quite traumatizing for everyone involved. Um But I think in an austere environment, a lot of the time you've got to, you've got to keep hold of the bigger picture and the bigger picture is that we have a model which works for 90% of the patients and we're seeing the 10% that are passing away, unfortunately, but they never had a chance, like with, er, in, in, in the way that they were the severity of the illness with which they came to us. Um and the, and the resources that were available and this is this child is a good one just to just remember. So these are, these are the notes, er, this is kind of the daily note sheet. So you do a daily summary and then a daily second visit in the afternoon and, er, it's in some of my and my partner's very bad French. Um, but basically it says, um, in a, in a, in a state of shock, um, um, you move to the white beds, which is the resuscitation beds. Um, gasping, which is kind of that last terminal breathing when you're just gasping for air and it's very much brainstem, um, pulse is not great. Put them on 100 and 50% maintenance. Fluids start these antibiotics. They're in a state of shock. And so I was looking at this, like reading back through the notes and then in front, this was probably 48 hours afterwards. And in front of me was this child, um, who's now sitting up drinking, you know, by themselves, obviously malnourished, um, but active alert and happy and you lose sight of this. Um, when you're, when you're dealing in the big numbers. So actually this one patient we'd probably seen the day before on the, you know, or two days before on that, on that table with very few resources, but for the right amount of fluid, for the right antibiotics for a bit of oxygen and crucially for the care of the nurses who would, you know, do the observations recognize when something was wrong, give the right medications recannulate the patient, keep their sugar up in just a couple of days with very simple stuff. We've gone from gasping and peri arrest to sitting up drinking milk with a smiling mum and, and I think it's holding on to those individual cases that that's the majority. Um, but in a factory like that you just don't get to see that anymore. And, er, it was always, I always found it funny that when we were in this, um, in this room, er, just to go back to this picture. And if you said right. So malnutrition you may know is it comes in phases. So you do a, a phase one, which is your low calorie milk and you're trying to stabilize them from a sepsis perspective. And then you go into transition phase where they start taking the plumping out for the first time and it's like the nicest thing in the world to see like a child who's not eating any solids basically for however many months. Um, and has just, you know, has been poked and prodded and cannulated and had a really traumatic time and you offer them this peanut butter salty deliciousness, which is like some of the doctors actually steal just to put on pancakes. It's like really good. Um, and they, they take one bite and they're not, they're expecting to hate it and then like, oh, oh, that's nice. And then, and then they, you know, they start munching and then they have another one and then they have another one and then they have another one and then anyway, they go into the transition phase and if they've got an appetite positive, they then go into phase two. and that's when they're discharged when they're just taking the plumping up and uh when you're in this room, the, the intensive care room as part of the factory, you say. Right. Well, I think this child's now ready for, um, for, for, for transition phase and literally within 15 seconds of you saying that one of those guys in yellow will just run over and be like transition, transition and just scoop the baby up with all of the um with all of the er the mat and the, you know, the um the any equipment that's there with a blanket with like, you know, half the milk, you know, with cannula tring sort of down the thing and just scoot them up, pick them up, take them to a new tent and then they go into phase one tent and then they go into transition tent and this happens multiple times a day with the mum kind of like, you know, running after them to see where they're going. Um And it means that you lose track of the individual but you hopefully are part of the whole and this is one of the missions that I was proud to be part of, even though I felt completely useless in this, most of the time because I wasn't very experiencing in malnutrition at the time. Um But the project did incredible stuff just for being there. So that's kind of 11 blueprint of working in a relatively austere environment. So doing the lea doing sort of the least for the most if you know what I mean. Um, this is another one. So I was in Iraq and, um, back in 2018 in Mosul and, um, sort of out towards the Syrian border. And, um, this was, um, this was in response to the ISIS, um, occupations ever been there for a while. And Isis would have announced MO in 2017. And, and so a big kind of cut had been made across the country, um, where lots of people couldn't access health care because they couldn't get across the front lines with, with Isis. Um, but, you know, um, Iraq is a, you know, a middle income country, um, and are used to a high level of healthcare and, and the numbers in the population are less there. There's, there's, um, fewer cases of malaria. Clearly, there's fewer cases of malnutrition. So actually the, the offering here for, you know, the same, the same section of MSF is this, which looks a lot more like something you'd recognize in the Bristol Children's Hospital or, you know, in any hospital that you work in and, you know, you'd recognize a dynap machine there, you'd recognize like everyone's in scrubs. Um, and, you know, we're in a natural building with walls and fair enough bullet holes on the ceiling. But whatever. Um And um and then, you know, a reco this is the recess area at the bottom which again, Russ trolley diner map, um clocks on the wall ABCD kind of thing. Um You could imagine this in the UK and I actually had some problems thinking about this is an austere environment for a different reason for, for a war zone basically. Um But into that, you kind of drop more of a Western blueprint where you say, right, we're going to try to give a more Western style of the hospital here and, and try to give a high level of care to the fewer numbers of people who come here because we have the capacity to do that. And so you can drop in a more Western model into austere environments if felt appropriate, but I always felt quite bad for the people in the beneficiaries in subs Southern Africa when I was like, well, why are we not giving them the same, the same standard? And it's because it's a lot more people and a lot and a lot more price. Um And then there's kind of a hybrid model which I was kind of part of in South Sudan and recently in Chad, I got back about two months ago from Chad and very much there. They've got a, they've got, this is an H GU in South Sudan, which is rudimentary, but nursing numbers are a lot higher. So you've kind of got the rudimentary care, but with much higher nurses, much higher numbers of nursing that also has surgical provision, maternity provision. And it's kind of like a more of a one stop shop there isn't just sticking a plaster over stuff. It's actually kind of doing more capacity and, and some capacity building as well with the team there as well. So for me, this is, this is more of a not just keeping your heads above water, which it wasn't in the chair, just putting a sticking plaster over a horrendous horrendous er environment. Um but trying to do a bit of a hybrid between giving a western standard of nursing care and surgical care and not having to refer out. Um but also making it kind of culturally appropriate in the in what was offered and still prioritizing the simple things and the amount of wildlife in this hospital just to put it out there. Like, obviously you can see a cat there on the on the left, there were hedgehogs in this hospital all the time. You couldn't at night. If you went in, you'd see five hedgehogs just wandering around the wards and who knew they were c these hedgehogs and that's, that's a goat in the in the emergency department just who's hiding under that, that cubicle in there, um which was always fun, there was there and then about 25 kittens and various one scorpion. Um and I think a snake at one stage there were all sorts of wildlife and just to kind of emphasize that this kind of hybrid was, you know, this is a well established hospital. This is where the child who was in the t at the beginning, um, came to with a pediatric ward there with, you know, a roof which always helps, um, and, you know, an operating theater, which we managed to ventilate a couple of patients in overnight to try to bridge them to, to the morning when they were super sick. So I thought, I thought I'd do a couple of just kind of case studies. I hope that's sort of giving an overview of maybe the, the actual types of intervention and some of maybe some of the reasons why those interventions are there. Um And it's always, it's always funny when you do these kind of talks, it it's never, never clear exactly what to cover. So I hope it's vaguely interesting and useful for you. But um obviously do shout if I'm saying stuff that's completely useless and you want me to talk about other things, I'd be very happy to. Um I was going to talk about some, some of the challenges just in practicalities and sort of move to, to Sudan this time. So this is um like Sudan um in a neonatal unit where we were setting up a neonatal unit just for, we had two beds when we started and we basically just stole a few extra beds and sort of tried to build capacity over time. And uh this little baby who was brought in on day five of life, uh saturations of 22%. Um blue heart rate of, I think 62 or something like that. Um Neither CPR um had this, this family had walked for about 24 hours to get to us. And I said, like, how, how do you manage that? Do you just sleep under the stars or do you, you know, do you, what happens with that? Do you take turns? And they were like, no, no. So you go, so you start walking and then you, you go in the right general direction and you get to a village and then um you just knock on the door of a village and say we're on our way to hospital. Would anyone mind keep um putting us up? Um And then almost, almost, almost always. So, um the first person says, yeah, sure come and sleep on our floor. Can we, can we make you some food? Can we, you know, it is from, you know, for people who have extremely limited resources. Um The community ethos is, is normally extremely positive and extremely overwhelming. And so they just stayed at multiple houses on the way, been fed by locals um who they didn't know. Um And then made its hospital with this extremely sick baby. Um He was also having seizures. Um And so anyway, got antibiotics, got fluids, got oxygen, you can see in there and then we had a decision to make whether we were going to try to transfer this baby. So there was another hospital that was a government hospital with a neonatal unit about two hours away. And so um the doctors who were, there weren't very experienced in neonates and they were like, they were like just we have to transfer this baby like they're super sick, we need to transfer them um and you have to get an ambulance. So we said sure um we tried to get an ambulance then so we called the local ambulance which turned out to be a Toyota pickup truck um with no signs um and they turned up and they said, well we can take the baby but you're gonna have to pay, you're gonna have to give us petrol first. And um it turns out that the Sudanese word, the Sudanese Arabic word for petrol and diesel is the same word um where it was in this area. And so MSF cheerfully filled them up with diesel um and broke the car. Er so they had to siphon that out and someone had to drive to another town to pick up petrol to then put it in this, in this ambulance and um then this ambulance comes and we get the baby in it and um this baby is um basically needing CPAP by this stage. So I don't know if you've come across much CPAP before. But, um, CPAP is where you, you breathe out against pressure and it just splints open the airways, so to stop your airways, collapsing at the end of breathing out, basically. And, um, you can do that with a CPAP machine or you can do what we call bubble CPAP. Um, which is where you get, if you get a nasal cannula set and you cut one end and then you put the nasal cannula under water, then the baby breathes out. So you've got oxygen coming in one way and then when the baby breathes out, if it's bubbling, the baby's breathing out under water and all CPAP is measured in centimeters of water. So you just go up and down, depending on your, um depending on how much pressure you want them to have. So we'd worked for this with baby and the baby had sort of desaturated that night to kind of again, 60 50% 60%. And we thought they were about to pass away, but we thought we would try the CPAP. So we kind of improvised and you can see this is the CPAP here in the, in the ambulance. So we ended up sticking this baby to this, to this, to this ambulance um bench with our only SATS probe and, and um and then kind of putting er some sellotape around this, this this jar of water that you can see there, which is the where the cpap's going into. And anyway, so this, the nurse there called a who was amazing, um takes this baby, you know, on this two hour journey. But we get a call about five minutes later saying, I think, I think this baby's um, this baby's really sick. Like, do you mind coming and having a look at them? And they were at the MSF office? I said, why do you think they're very sick? And she said, I think they've arrested. I was like, that sounds, that sounds pretty sick. Um, and so she was doing CPR and it turns out that they'd gone to the MSF office and the, er, the, the, the ambulance has said we'll take them but you need to pay us $50. Um, because it's, it's, it's a long way and, you know, this is our job and stuff. Er, and so whilst they negotiated the fee, they turned off the engine which had turned off the oxygen supply to the baby and the baby had desaturated and rested. So we managed to turn this baby back around, get them to, back to our hospital, get them back on the CPAP in, you know, so as soon as they got back on the oxygen sats came up again, started, started breathing again and we said, right, we're not sending you anywhere. We're just gonna keep you here. This was our entire unit here. Just kind of like this when we got sort of five or six beds in them in a quite a small room. And, um, I said right to the, to the parents, I was like, right, we are keeping you here. You're safer here. It is dangerous to transfer and we're just gonna ride it out of here and see what happens. And within about seven minutes of me saying that their power went off and we only had one battery operated, um, p um oxygen concentrator and one SATS probe and we had three babies who needed oxygen. So we put the SATS probe on one and then the oxygen on another. And then when the SATS got to 70% on that baby, we switched the oxygen over to them and switched the SATS probe over to the third one. And then as soon as the, the saturated in has got to 70% on that one, then switched the ox to that one and just keep moving around in a kind of circle like that. Um And, you know, 45 minutes past and then the oxygen is starting to go down and it's, it's on its last battery. And then thankfully, the hospital director came and, and switched on the generator for us. Um But we were just about to run with this baby to the uh to the MSF office which was halfway across town to try to get reliable electricity down. But anyway, this baby had then, you know, the, through the austere environment of a making its a in the first place through various villages in 45 degree heat having been born at home, you know, with no sepsis control with no birth at tenant um with a mum who obviously has no form of education, et cetera, et cetera. And then get to the hospital to then survive with very limited antibiotics, um fluids, oxygen with a little bit of pressured oxygen to then try to transfer and fail to then survive having a massive power cut. Then this baby was discharged home. Two weeks later, look, looking neurologically intact, gaining weight, breastfeeding, well sucking, well, um and wearing a strangely oversized dress, um, as you can see. But, um, it's incredible that in those kind of austere environments, the resilience of both people and their Children is absolutely phenomenal. And, you know, this mum never, never asked for anything, never, never complained, never put any pressure on the, on the team at all. And just sort of obviously puts into perspective sometimes when you're particularly in A&E and people are saying I've been waiting for 26 minutes. Uh How dare you not see my child um and stuff, but it's the resilience of people is absolutely phenomenal and that's where you derive a lot of hope from in them, in those environments. Um So that, that, that's kind of just like, I guess an illustrative, one of one particular one that kind of stood out and fortunately had a good outcome. Just think about a few clinical things in, in sort of more austere environments. So I think you, you end up managing a lot, this is kind of more personal kind of reflections, I guess you, you end up managing a lot of uncertainty. So quite often with MSF, particularly, you're sort of, you're leading a team who have got maybe 10 junior doctors from, from, from the local sort of environment. Um and you have to manage a lot of uncertainty for severe TB, severe HIV, severe um malnutrition, which the first time you do it, you don't really know much about. And I think in those environments, there's a lot of managing that uncertainty and just trying to be pragmatic and being collaborative and um I think sort of trying to find other people who know stuff um and then coming up with a plan together and I think in some ways trusting what you bring to the team a lot of the time, that's not necessarily clinical knowledge about a lot of the conditions. It's a pragmatism and the systems approach that um means that you may not know exactly how to manage this, but you know how to find out how to do it and you know how to manage ABCD, er, and you know how to do things in a structured way and how long to give antibiotics for and how to avoid super infections in other ways and how to prevent seizures and how to give good nursing care and do good glycemic control and that kind of stuff. And actually, as we've said already, all that simple stuff is 90% of the battle and then the kind of the actual diagnosis and the actual kind of specific stuff for different Children is, is uh is the last 10% in some ways. Um But you get very quickly into a state of not knowing what you're doing a lot of the times and realizing that that's ok and that you do have skills that you contribute to a team and that you'll figure something out together, um which is sometimes quite liberating. Um And in some ways that uncertainty is limited by the amount of choice that you actually have of what you can do. So, you know, there aren't a lot of, there are only about five antibiotics in most places. So in Chad where I just come back from, we had Ketrax which everyone gets, it's like water, you just kind of Sprinkle it on them. Um And um Gentamicin, metroNIDAZOLE, Ampicillin and Clindamycin pretty much. Um And so you've only got five options. So you start with two maybe, or you start with one, then you add another one if you think, you know, you've narrowed it down somewhere else and then you add another one maybe and then you start anti TB therapy. Um And investigation wise, you've got a hemoglobin, you've got um a blood sugar. Um, and you've got a malaria test and so those are your basics and in some ways you're wondering why I've put this menu up there. But it, it feels like being vegetarian in, in restaurants, which I really appreciate. I don't know if anyone else is vegetarian or vegan on the, um, on the call. But, like, you know, it really limits your choice, doesn't it? And like, you know, it, it's quite unnerving when the waiter comes to the table and says, right, what are you gonna have then? And you've got to look down the entire menu and then actually, if you're a vegetarian, you've only got two options or vegan, you've probably got one. and you're like, oh, I'll have that one then please. And, uh, you can make decisions a lot quicker and it takes a lot of the pressure away from you and making them. Um, and I think that's, that's actually a really liberating thing working in an O environment because you've only got so much you can do. So as long as you do what you've got and you do it in a sensible, logical way. Um, and you think around it and you get advice then actually, that's a really liberating thing. I think I've really come to appreciate that. And I think one of the other things personally and particularly coming from the NHS is that, um, you realize that lots of mistakes are made in medicine and you realize just how good the care is in the NHS and in sort of, you know, more resource rich environments in general. And, you know, you see some of the data that come in the, the incident reports, like, oh, this person was given an antibiotic 10 minutes late and, you know, someone didn't check if it was at the right temperature or something. You know, whereas like the problems that are going on here are someone, someone refused to give insulin or gave 17 times too much insulin on a regular basis because they don't know, like what numbers are like the numbers in English, for example, like which is completely understandable if you've never been taught it. Um So I think being able to roll with the, to roll with a very um variable standard of medicine and just think that every day everything that goes wrong, we're just going to try to improve gently and in a culturally appropriate way and in a, in a gentle and a positive way and the doctors that I've seen in austere environments who had the hardest times and have had the most difficulties with personal wellbeing, mental health and that kind of stuff have been the ones who have gone over and, and assumed, well, we're going to do everything like we do in the U A and we're only going to accept a naught 0.2% mortality because that's what Children do like they don't die and what do you mean this was given at this time? And what do you mean like you've missed this and how dare you not do this and that, that's really, really naive and really dangerous way of thinking about austere environments. It's, it's rolling, it's rolling with the punches and it's trying to gradually improve things with the content and the collaboration of everyone who's there. Um And one example when I first went out was uh my first MSF mission was in Iraq and um a a baby overnight. So a premature baby to be fair had been given three times the dose of gentamicin. So the one person had given it twice for some reason and then another person had come and give them a third dose all within about half an hour. Um I said, look, this is, this is a, you know, just a myok for um for pediatric membership. It's like, well, this is a, this is kind of a never event and like, you know, we, we, we need to be honest, it is a duty of candor. We need to speak to the parents and we need to tell them what's happened to start first to wash out the kidneys. We need to do some um some, some, some using these and then, you know, we need to speak to the, the nurse who did this and, and just sort of just in a gentle way, sort of say, why, why did this happen? Like, what do we think about this? What could be the problems and stuff? And, but I went to the supervisor, I said, look, this is, this isn't really on this. This is quite, this is a difficult, this shouldn't have happened. Can, can you help me sort of sort this? And he marched over to them and it was a female nurse in Iraq and he rang their husband immediately because he didn't want to deal with them. And he said your, your wife is killing, is killing small babies. Is that what you expect from her? Like, how dare she, like, have you not trained her? Like, why is she killing babies? Like, I can't be having this in my unit come and take her home and, um, that was completely unexpected and obviously, absolutely horrendous and who knows the home situation and whether there's a risk of violence there and all this kind of stuff. Um, and that was kind of a real lesson for me about how to go about things in a, let's just let's just go really, really soft and really try to understand the cultural kind of sensitivities, um, before sort of really escalating any of these, any of these mistakes. Let's just try to make care, better, make Children safe and deal with the wrestling team. And I just wanted to touch on t so in the last 10 minutes, we'll probably just talk a few about a few other topics if that's ok. Um, and teamwork is one of them and I think when you're working as a UK medic in an austere environment, you're always in a, you're always in a team and it's always really important to figure out your place in that team as a, you know, clich, but, you know, do you know your position within a team? And, um, this was the team in South Sudan who were an incredible group of humans. Um And, er, were so enthusiastic and just wanted to learn, wanted to do the best thing for every patient wanted to discuss, wanted to teach me about the stuff I didn't know, wanted to learn from me, the stuff that I did know, which maybe they hadn't come across before. No pediatric um specialists. They were kind of like junior doctors, adult doctors. Um and it was a really, really positive collaborating kind of environment and I was super lucky to be there, but equally, I felt like I'd done three or four missions by that time and I felt like I understood how that communication works and how collaboration works a little bit more. And I've been really burnt in um in *** where the local team were just traumatized and they didn't want to have anything to do with the expats and they wanted to do about 45 minutes of work a day and sleep for the rest of the time and then went on strike when someone suggested they should do a bit more. So you're a little bit dependent on your team um for what care you can give and how your experience is. Um I've been very lucky in the vast majority of my missions. It was only the initial where things were very difficult. And I don't know if you come across this concept before. But um I remember the first course I went on for a global health. I think it was a or something at the R CPC H. And someone said, um the chicken, the chicken theory where whenever you get to a new environment, like a sort of particular a environment, um you do a chicken where a chicken puts 1 ft down and then lift the other foot up and then looks around and is like, right, what do I do next? I'm not putting my foot down until I've, I've understood the situation, like, what am I doing? Um And um that's very much like what you, what you end up doing in austere environments. You kind of like you take your first step in a completely nonjudgmental way. Ideally, you say I'm not really sure I'm doing it. Please tell me things and let's work this out together and then you try to figure out where your next step is and you try not to make too many missteps if you can, but you wait and you take things slowly and you never ever assume that you know, anything until you're able to collaborate with people and understand what they know and what they want from you. And again, some of the big pitfalls are working in steer environments are assuming that you're gonna do the same role that you are in the UK cos it's not the same role I was just going to put on this as well that um obviously, whenever your team working in, in, in areas and environments, there's, there's an ethical kind of question there as well. Um Which I get asked occasionally um sometimes during these talks about clearly, you know, there's two white faces in that, in that picture. And is it, you know, yes, there are there downsides to, to people going from resource rich environments to resource poor environments. And yes, there definitely are and yes, there are colonial overtones and yes, there are difficulties. My normal response to that is a working in a diverse team is always a positive thing and we really appreciate that in the NHS. So if anyone comes from Sudan in the NHS, we really appreciate their perspective and their ethics and their work ethic and the things that we can learn from them. And we think we give better patient care by having a team that has one person from the UK, one person from Sudan, one person from India, one person from Portugal, one person from Brazil, we think that gives really good care. So why are we saying that in Chad or in South or in South Sudan, it has to be completely homogenous and actually people from around the world aren't welcome, um, to you, you know, don't, we, don't, we celebrate a diverse team and isn't that strong game. And, um, secondly, I think sometimes we lose sight of who's the most important person here and it's the people, it's that child in that too, right from the very beginning of, of this, um this presentation. And um if you ask them and their family, do you mind if you're treated by someone from this area or someone local or someone wherever? I think they'd be more interested in the outcome rather than, rather than necessarily who's treating them and what potential previous things may have been done 100 years ago by their country that they come from. Um And so there are lots of nuances there as well, which I don't quite have time to go into, but I always happy, always happy to discuss and very cognizant that um there's a lot of bad things that have happened and on and do continue to happen by aid being applied in the wrong ways and very, very cognizant of that. But when you're with people and you're working in a team, lots of that actually dissipates and that's all very theoretical. Um But practically you get on and you do it, uh just a few last slides just thinking about actually life in the field, um, with MSF actually is variable but normally there are some niceties. There's lots of people who works in MSF for a long time who know how to make life a little bit easier. Top left there is my first room in MSF in a little, um, basically a camper van. It was almost like a thing on wheels outside. This, this, which got lots of, er, this top right one which was the main building which got lots of bull holes on the top um, where it was absolutely freezing. I thought Iraq was really hot but it turns out it's flipping freezing over the winter, particularly at night, but quite often there's a real camaraderie, there's, this was *** on the bottom left with a table tennis, table pool, table, some little competitions going on and then everyone's played ticket to ride, introduced ticket to ride in Jungle speed to Sudan and that, that took off like wildfire, which was great. Um This is a, this is like a, an elder in one of the villages who came to have a cultural kind of briefing but absolutely loved jungle speed. Um, and, er, and he'd come a few times and then he'd be like, we'd always have this like this 60 year old, you know, Susan elder guy holding this plastic trophy of jungle speed in his hand, you know. Um can be like a really beautiful environment this, for South Sudan, a really good atmosphere. Um and some, some opportunities to get involved in the culture, no matter where you are even in quite austere environments. So have the opportunity to join a band in, in ***, which played for the, for the malnourished Children uh to join a football team in um in, in Sudan. And then get invited to quite a few Christenings in, in Sudan as well um of the babies who came through the unit, um which was really a real privilege to be sort of to have an opportunity to understand a little bit of the culture. And then lastly, I think the question is when you're working in an austere environment, obviously, you're there to try to be useful if you possibly can and that's the most important thing, but you can reflect that a little bit selfishly sometimes and say, well, what does it do for you personally? And how does that reflect back on your life in the UK or wherever you work? And just a few of my reflections are that I definitely know what a sick child looks like from having been abroad. And it makes me sometimes sometimes too relaxed, maybe some of my colleagues may say, I don't know behind my back. But um I'm very relaxed in most acute situations in PDD, even if you've got a super sick child with the amount of resources that you have, the amount of time that you have, which you don't realize and the amount of people, you have to help you in the UK is overwhelming sometimes. So definitely know what a sick patient looks like. You get. You do get the opportunity to see a number of clinical signs, symptoms presentations, which you wouldn't do in non austere environments and you make clinical decisions, you don't make number decisions. I think that's a really, really important concept in medicine that we've kind of lost and we do a lot of investigations without really thinking about why. Um And then we have to act on things which we never really wanted to know about a lot of the time. Whereas in an austere environment you have, you have yourself, you have a patient, you have a parent and you just have to figure something out about what's the best thing to treat them with and what's the worst thing that could be happening and how to prevent that. And I think again, that's a really liberating thing. I think personally it gives you a lot of resilience and confidence and a lot of perspective, you end up, you end up knowing yourself a lot better about how you, how you behave under pressure, how you behave in isolation in some ways, like how you behave away from family and friends, how you behave in chad. I was working 14 hours every day for 2.5 months in 45 degree heat. Speaking very bad French. Um and I was knackered. Um, but you end up knowing what you're capable of doing and what you're not, it was you end up knowing your limitations and trying to sort of mitigate them. Um, and I think the last thing there is a really, is a really important concept is like, well, I've done that. If I've done that, then I can cope with anything. And I think there's a degree of working in a environments and I've definitely not worked in the most austere or the most, er, insecure, but even just from the little bits that I've done it kind of feels like, well, you know, you, you see 70 people in PDD, you think? Well, you know, there were 800 people in that *** Hospital and they were a hell of a lot sicker than they are today here. So, if we've dealt with that, I can, I can probably figure our, our way through this. And I think that's a really positive, powerful kind of thing to have at the back of your head. And I also, I think some of the really positive things about being in a environments are that there's a really fast turnaround for quality improvement work and it actually works. So, you know, we create an HD U in Chad um for the, for the, um, malnourished patients and we said one day, should we do an HD U? And we know we talked to the lead nurse and we talked to the local staff and everyone thought that was a good idea. And we thought, should we do obs every two hours, every three hours? Obs every, every one hour, let's do every one hour. Should we make some signs? Ok. Can you get this a carpenter? Um, who's just, who works in town? Um Can you just ask him to make some signs and literally 24 hours, we had an HD U um just made up of moving that equipment around a little bit, making some signs, getting all the, all the staff on board. And if you try to do that in, in Bristol, that would be a three year uphill battle of probably 700 meetings or something. It's just, you know, if you want to do a bit of quality improvement and you have a good idea or someone else has a good idea that you can agree with, then it actually happens. I think that's a really special thing as well. You do a lot of managing your teams and you don't have your sort of seniors around a lot of the time as well because you are the senior person. Um So you get a lot of management skills like doing rotors, like managing risk with um with juniors. Um And you have to be really innovative to work with what you've got. So making that CPAP out of bubbles, for example, scalping on sometimes um oxygen circuits to be able to get three people on the same oxygen at one time, that kind of stuff and you get a lot of stories and situations for applications which stand out. So all of my applications to grid PDD and then for consultancy and then even for other things, outside of me, a lot of my experience comes from situations which are outside the norm of what people would normally do in the UK. Um And so that's been quite a powerful thing, I think for me, it is very, very selfish. It's not the reason why you're there obviously, but just to reflect it back, it is a helpful thing. Uh Let's skip through this and just say that the last challenge normally of um of working every austere environment is coming home again and I got back on the sixth of November and I'm still just about just about getting there from um I started feeling myself again literally yesterday actually, or over the weekend, I was covering nights for the strikes. I started feeling like, oh, I'm back, I'm back in Western medicine again and it's taken me over two months to kind of to really get back. And that was only from a two month mission. And actually they say you normally take as long to get back into stuff as you were out. So that actually makes sense. I haven't thought of that before. Um But some of the things which, which, which are always kind of tricky for me is standing in front of a butter um aisle in the supermarket is like, how do I possibly know? How do I make a decision between Flora or Ley Butley or Anchors? What is the difference? Why is it all so expensive? This is mental and I just get paralyzed by trying to make decisions. You've always got the sofa or the fridge or the curtain test where um I got back from Iraq and my mum said, right, we've been waiting for you to get back so that we can ask you, do we get strips on the couch and do we get them horizontally or do we get them vertically? I was like mum, I don't know, I mean, vertical sounds good, but will that not make it too long? It might make it look long if it's vertical, whereas horizontal might, you know, that might be better. It's like mum, I don't care. I've been making different decisions for the last like six months. I can't, I can't do this. Um And it's just an interesting kind of like you do have a reintegration kind of thing. And then you've got all these tests in the hospital which are expected of you. And it always takes me a good few weeks to get back to actually requesting tests and thinking I need them. Um And that's a really interesting thing because I think we do need a lot fewer than we actually do anyway. Sorry, I've whistled on there for quite a long time. Um So, um I hope that's sort of a little bit of a flavor just to some of the experiences that I've had, as I say, you know, it, it, it's a bit of a jungle um healthcare abroad. So you'll find lots of people with different experiences and different thoughts and who are far more expert than I am. Um But hopefully it's been useful as a bit of an overview and a little bit of a, a flavor of things. Um Very happy to take any questions and you're very welcome to email me any time on, on that email. It does have AK in the middle. Otherwise you get a hold of a doctor in the US who's very nice and normally forwards on stuff to me. Um But everyone wants to email you very welcome if you have any questions that you don't want to ask in front of everyone else, but thank you very much for your attention. Um If you want to type in questions in the chat as well. Um If you just wanna ask on that, um I'll, I'll start things off actually, if that's all right, Michael, I wanted to ask when, when you've been out on all these missions. Have you ever found that there's sort of been a bit of friction between um different aid groups in the same area with sort of competing um objectives? Yeah, I think so. Um I've, I've never been senior enough to find that in some ways because uh it's normally kind of like the the big bosses kind of who are, who are liaising with different um different NGO S and MSF is an interesting one because as you probably know, um MSF is uh is completely independent, so it's fiercely independent, it gets 95% of all of its $2 billion a year funding from individual donors. So it's not related to any other NGO. It's not related to any um government organization, Eu Pharmaceutical, anything like that. And if you go to the like the health cluster, which you normally get after a um after an like in an emergency, an earthquake or something like that, it's a health cluster where all the NGO S get together and plan what they're gonna do. An MSF sort of vehemently either doesn't go to it or goes and stands in the back, but it refuses to cooperate um because they want to be independent, they don't want to be associated with a, a faith organization or a government or a, a military operation. So MSF always has a little bit of friction from that perspective. But I think the other thing with MSF is that they're quite often operating in areas where there aren't very many NGO S and that's the whole point of being there. So generally speaking, I haven't seen much, much conflict at all. Um There's more conflict within MSF than there is without it in some ways. Um, but no, I mean, hopefully more systems exist now thinking about wh o clusters, particularly for big emergencies to try to make sure everyone's doing useful things that potentiate each other rather than conflict. Yes. Any questions for anyone else she popping in the chat or if you're feeling brave, you can unmute yourselves. Um, Morgan's just asking, has working in these environments changed the way you work here in the UK. Absolutely. Right. Absolutely. And I think, I think it's a pragmatism and I think it's a, it's a risk holding thing. So you'll find out, I obviously don't know what, what level one is, but particularly for those who are a bit more junior maybe. And students that, like a lot of our work in the UK is, is balancing risk and it's about saying, right, you can go home and there's a risk to anyone going home and there's a risk to do any procedure and that kind of stuff. Whereas, like the perspective that if I send a child home from A&E, there's probably only a 1% chance that I haven't realized that they're really sick if they're really sick and then if they get home, there's probably only 1% chance that their family won't realize that they're really sick and bring them back. And then if they do that, there's probably only 1% chance that they won't be able to get back to hospital in time by calling an ambulance or by getting a taxi or whatever. So you're talking multiples of, you know, 1%. Whereas, you know, there you're managing huge risk where you're saying you've got one shot at this and if you don't get this right, then there are no other resources, there are no other options and they're not going to be able to come back because they live, you know, miles away. So I think that realization of risk makes you a lot less anxious in the UK and means that you can be a lot more pragmatic, you can do fewer investigations and you can just try to do what's best for patients rather than sort of thinking about your, you know, very defensive medicine all the time. So I think that's quite helpful. Um, and then, yeah, I think it is that just, you just feel like you can cope with things. I think me personally, you know, I feel like I've drawn those experiences a lot to think. Oh God, you know, I've worked 14 hours a day for two months in a row. Like I've done, I've just done two night shifts. I can definitely do another one or I can, you know, this is really bad. So everyone is really stress. But guys, we're gonna get through this, like we're definitely gonna get through this as a team because we know we can, and I think it makes you more positive about a lot of the stuff you do in the UK as well. Um, we're all coming in now. So, um, Steel's asking, um, how can you get involved in humanitarian medicine as a medical student? And then sort of Sam's asked something similar where, um, what are his options of getting involved if you're qualifying for something other than a doctor? Yeah. Really good questions. So, from a medical student first, um, so even just coming to this talk, even having any idea that you might be involved in global health in the future is your first step. So keeping that little flame, burning somewhere in your brain that says, oh yeah, I'm interested in global health. I'm interested in austere environments, that kind of thing. That is the most important thing to have because if you don't have that you never see the opportunities, but as soon as you have that you start seeing opportunities all over the place. So opportunities in the UK might involve. Um, so MSF definitely has a number of campaigns. One is um trying to support the preventing migrants going to um Rwanda. Um Another is like making affordable medications. Another is, er, care for Calais and for sort of um those migrating through Calais and then settling migrants in the UK as well. So there's lots of kind of advocacy things that you can do as a student, um which is, which is really powerful. Um You can be involved in some ID stuff as a medical students, like, if you're interested in doing this and you want to learn more about TB HIV, um, other random infections. You can go to your ID team in your hospital and say I'm interested in doing. Have you got an audit or something? Have you got a research bit that I could get involved with? You? Think about any courses that you can go on. So, like one day courses or even more than that to sort of get more experience in life abroad. And then from the actual going abroad, I think number one is visiting relatively austere environments. So thinking about if you're going on holiday somewhere, even can you safely go to somewhere that's maybe a little bit more remote. And can you start experiencing some of those cultures? Can you think about working with care for Calais, for example, or other other organizations which deal with um with migrant health or with um Austrian environments in Western Europe? Um And then can you, can you do your elective somewhere like that? Can you, so I did my elective in Tanzania? And that was a real eye opener for me that was really helpful. Um And then can you find a charity which or an NGO which suits you? And you think is useful, isn't asking you to spend 2500 lbs to go? Cos that's always a red flag. Um And is doing something which you think is beneficial, whether that's a vaccination campaign, whether that's an educational thing, but trying to make sure it's sustainable, trying to make sure it benefits the people who are actually there. Um and try to make sure it isn't tourism. But I think there's a lot of options to do in the UK without doing that. And then taking your first steps, at least experiencing those kind of more remote environments is quite helpful as a medical student and then as a nonmedical student, you've got buckets of options. So in my last projects in Chad, for example, and I'm mainly MSF centric because that's most of my experience. But I think there were 50 expats and only four of us were doctors. Um So, you know, 46 people are not doing are not doctors. So that's nurses, that's health promotion staff, that's um nursing assistants, physios, um finance, admin logistics, water sanitation, just project management um to be like field that kind of stuff. So huge numbers of power, medical options and huge numbers of administration, finance, logistical kind of options as well. Um And that's actually most of the time more important than the doctors like that. Setting doctors do the last 5% of it, but 95% of the project is the non doctors. Um And then Danny is asking um if you could pinpoint one issue with liaising with host countries. Um What, what would it be? So ie political cultural essential. Um That's a very good question. Oh God, I mean, it, it's the collaboration, like it's, it's really the, it, it's having the humility to, to just say, how am I best useful to you? How can I learn and how can I help? And I think that's the, that's the thing and it's getting that balance right. A little bit because in some places they'll expect you to be coming in as someone from the UK, who is, or from anywhere in sort of Western healthcare, who knows better or who thinks they know better. And, you know, we don't, we just have different skills, right? Like which are hopefully useful. Um And the guy like the people who work in that environment every day have incredible skills which are also useful. So it's really the question of getting your attitude, right? I think before you go in and I'm not saying I have got my attitude right at all and I'm very much still learning. Um But it's about looking at this as we are, you know, there is a meeting of everybody has so much to give and how can we assimilate that and communicate that together? And how can we put the patient at the absolute center of that? I'm not sure if that's all that answers your question or not, but it's, it's, it's somewhere in that collaboration, hu humility sort of vibe. Yeah, there's an answer apparently perfect. Um But so we'll go for the final question. Um Would you say working in these environments is a fundamental step for working in health care in the UK. Um I would use sort of recommend doing this. Um I like how you just dodged, dodged saying pronouncing that II think that's, that's KFA. Hopefully. Um I love the name KFA. I think it's, I think it's one of my favorite names ever. Um But um yeah, sorry a um so um we say working in these environments is set for working in health care in the UK. Er, yes, I would 100% recommend doing it. Um I really would, it's absolutely not a fundamental step as you know, clearly you don't have to cos most people don't and the amount of people you meet on ward rounds, like when I was a reg like these consultants and you say, oh, I had just come back from wherever and they'll be like, what were you doing there? Why, why would you, why would you want to go there? Like what's I don't get it? I don't get it. And you, you'd be surprised the number of people who don't get it, but medicine is about pattern recognition. Medicine is about experience and medicine is about confidence. Like that's what, that's what it's really about and you can't get that by working in a silo, like, you know, working in a single environment, your whole career. Um because you don't get that breadth of experience at all. So even if not working abroad, like having, you know, working in different areas and different specialties in, you know, in more difficult. So DG HS in more difficult areas, maybe with high rates of um of, of, of poverty and need in the UK is I think really, really important and then you extrapolate that one step further and then that's maybe in Europe and one step further is in, you know, in lower resource environments. So I think it's hugely helpful and I think it's definitely made me a better doctor. I hope um and I would recommend it to anyone, but I'd make sure you're getting into it for the right reasons that you know, what sort of stuff you want to do. So do you want to do more quality improvement stuff like in them, Myanmar, it was more like bringing in systems of hand washing and um you know, um Dengue clinic and flow through the hospital sort of stuff and not actually touching patients M SFA lot of the time it's actually hands on or do you want to get more involved in policy work and that kind of stuff which is obviously great from a managerial prospective work in the UK too. So choose what you think is the most useful for you and that you are most useful at and trying to broaden your horizons, dip your toe in somewhere. Um If you haven't already and then reassess and think every time I dip my toe somewhere. I have a period of reflection and reassessment. What went well, what didn't do I want to do more of this? Do I want to do less of this? And how has it impacted me impacted me? And I think just being self aware each time is, is a really helpful way to build a career like that and then use those skills when you're back as well. Well, thanks everyone for asking such um interesting and type of questions and I'd just like to say thank you to Michael for taking the time out to um be with us and give us this amazing talk on everything. Um So yeah, thank you so much for everyone involved, especially Michael any time. Thank you so much James for organizing, fantastic job with organizing. Thank you so much for giving up your, your evenings, everyone who's uh who's been incredibly patient and, and listened and actually made it to the end. So thank you for that. Um Make sure to go give the College of Medicine a follow on Instagram for those who are still here. We'll be promoting more sort of stuff and just like putting little snippets of um webinars we put out um on Instagram. So we're reacting on there if you wanna just all give that a follow. Cool. Alright, thanks guys. Um Cheers Michael. I really, really appreciate taking the time to do this. Um Hopefully see you um in the hospital soon. I need to work some um, H A shifts after, er, that shift. Yeah, I imagine. Well, we'll look forward to seeing you then, right? Thanks m have a lovely rest of your evening. You take all the best guys. Thanks guys. See you.