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OK. So our next uh speaker is Mr Hasan in trauma and orthopedic Clinical Fellow at University Hospitals, Dorset. Mr Intes will discuss improvised surgical techniques adapting to resource constraint, highlighting the innovation and adaptability required to deliver surgical care in resource limited environments. Please join me in welcoming M NTS. Thank you. My name is Joan. Uh my colleagues already introduced me. So um my experience of this isn't on the uh battlefield but um it's going to tackle the issues of surgical techniques that have been improvised over time uh based on unfortunate experiences during world wars and how we've adapted to restore constraints, constraints. So the first thing that we need to identify is obviously the nature of conflict injuries is different to routine injuries that we see on a trauma and orthopedic ward. Um So just to put it into perspective, there's a large review that was done in 2020 49 studies were evaluated in 18 different countries and they basically uh evaluated the nature of trauma, the cause and the people affected. So, out of these, we had around 58,000 pe uh patients that were evaluated. So 79.3% were males and predominantly. Um so one third of the population was under 18 years of age. Um the most common mechanism of injury was blast injury. So half of them sustained injuries through blasts and extremity trauma accounted for 33.5%. So because extremity trauma was the most common injury sustained, uh our talk will mostly be uh focused on trauma and orthopedics. So these type of injuries, the study also evaluated where these these were managed. So the top, so one third of these injuries were managed at military facilities, uh only 20 per 20% were managed at local health centers and 16% at government public hospitals a large majority. So 12.2% were managed by humanitarian organizations which have seen an increase over the past few years. So this is just um a graph which was from the same study. So don't get uh mixed with the colors so important uh colors to see are the purples. So light purple and dark purple. They basically mentioned the mechanism of injury most common was a blast followed by uh gun short wounds and the red basically as you can see from a distance and the orange underneath, it mentions that the most common injuries were uh extremity injuries followed by head and neck injuries. So surgery complicated. How does it differ from surgery that we uh seen noncomplicated like the UK? So there's special features of practice of surgery. And time before. So obviously, there's a specific epidemiology of ward ones just as we discussed, uh most of them are blast injuries, gunshot wounds, which will you would not routinely see in a hospital setting in nonconflict areas. There is very limited resource limited uh technical environment. You can see the picture that's an operating room. So it's vastly different from what we are used to see hostilities and quiet environment, obviously. Um as we discussed earlier and we've seen from uh the speakers who mentioned that the healthcare staff in Gaza and healthcare staff in Myanmar, um they're not safe from attacks. So a hostile violent environment also is an added constraint. There's mass casualties. So we used to the triage system in emergency departments, but this is the proper application of triage where there is mass casualties and you have to prioritize within time to save life life, live or save resource. Uh outcome of hospital patient care is a function of the efficiency of what the care is delivered to patients before they reach the hospital. So ADLs protocols, basic life supports, uh advanced life support. There is a specific wound pathology that needs to be studied. Uh So because most wounds are bullet wounds forms blast, so there's something called decapitation effect from bullets that needs to be evaluated. So a bullet might have a small entry, a small exit, but the damage it's done in those between those areas is massive. So there's specific wound pathology that surgeons need to be aware of. And there are specific techniques appropriate to the context and pathology specifically saying that 99% I can say the confidence of these injuries are septic wounds. So they're not clean wounds and then therefore, they cannot be closed primarily. And there's no role for internal fixation, they usually manage with external fixation. So this brings to us to humanitarian surgery. So it is basically like um I miss uh I think describe surgery for ERD populations in a variety of settings, mostly either run by charitable organizations or disease specific surgical missions, emergency or disaster conflict settings that we have basically focused on like us. And uh Myanmar um it should be governed by the International Humanitarian Law, which was based on the Geneva 1949 conventions. Basically, it says uh people who are not actively involved in bo should be safe, which involves civilians, medics, aid workers, wounded troops, sick, troops, prison of wars, uh and ship like troops. But unfortunately, no one follows these. Uh It's just a paper that's been published in uh the challenges of humanity is obviously are a lack of infrastructure, lack of diagnostic imaging. You won't even have x-rays sometimes. So it's mostly the real clinical findings that you base your decisions on uh difficulty to get patient follow ups. The only opportunity you have to manage a patient is when he is with you, there's a very low likelihood that you'll be able to follow up a patient. So your decisions have to be it, keeping this in mind. And as as I mentioned previously, the wounds are usually septic. So primary closure is not an option. We'll give them infection. Internal fixation is not an option because you need the wounds to heal before you can perform internal fixation. So there's a brief history of surgical innovations and improvisation. So I'll take you through how we went, how we came to develop the healthcare system based on the calamities that happened to our ancestors. So the first uh medical innovation or improvisation was a surgical ligature. So a FP and he was sent as the chief surgeon to the siege of so obviously wasn't qualified. So he was so horrified by the injuries. Patient patients would basically bleed to death. So he found a very simple procedure. So he said we clamp the bleeding ends, put a stitch to it. He used silk threads and basically once the silk threads maintained continuity of the vessels, he used to unclamp them. So made a huge difference. Uh The next big improvement comes from 1792. So Dominic Larry, he was a surgeon in chief to Napoleon's army. Uh He noticed that the French were very good in moving cannons. So we were very good at killing people and they would basically manage high speed uh maneuvers so they could um get cannons from one place to another with horse drawn carriages. But unfortunately, the only method of transporting patients was on the shoulders of soldier. So he introduced the idea of flying ambulances. Basically these the same principle of carrying a cannon. He used it for patients. So he basically devised that small um carriage that you see underneath in the black and white picture. So it used to carry around 10 to 12 patients. Uh So that was one of the first um breakthroughs of managing patients at work. Uh He also introduced the concept of triad. So rather than managing patients as per their rank, we were managing patients as per the severity of injury. So then came World War One. obviously, with time, we've become more destructive. So 9 million military deaths and 23 million wounded. So this was unprecedented in the previous wars. The major cause of death wasn't the artery or the damage sustained wall itself. The major cause of death was disease because we weren't very good at managing infections and we weren't very good at managing wounds. We wouldn't deprive them, they would get infected, but it was a turnover this time. So World War One, most of the fatalities were due to enemy fire. So it and the first use of poison gas. So what's the impact of the World War? So as a result of necessity, we thought about something called a casualty caring station. So basically patients would come in and then the ones who could be managed were managed immediately and sent back to uh fight in the board. So it basically served as a triad and a quick uh service for patient management. So you can see on the top right, that's um for a picture of what would be attempted accommodation, serving as a casualty caring center, uh portable x-rays. So Marie Curie also uh contributed to the development of portable x rays. So we could identify the nature of injury and then determine what needs to be done. Uh The Royal Medical Army Corps established um that more doctors should be given ranks in the military because previously, they were perceived as being uh a hindrance to the war itself. So by 1918, which was the World War One, half of Britain's doctors were on active duty. S solution is also something which was very critical. Uh It was a solution which was derived to uh disinfect wounds until they healed. So it was basically putting a tube through the wound, putting in solution which is sodium hyloride until the wounds have basically managed. And Thomas Splint, it was uh promoted by Mr Robert Jones, whose uh name is uh there's a hospital named as well in a street under him for stabilization and transportation of injured lower immune patients so that they can be triaged and taken to casualty stations. Uh Similarly, World War Two saw the campaign for Blood for Britain. So Dr Charles Drew, he was the pioneer of development of blood plasma. He was recruited by the British armies and then uh he managed to get 5000 L of plasma to British soldiers to save a lot of lights and also blood mobiles, basically mobile um uh carriages where patients could give blood. And then these were taken to the military offices. We this was the first time penicillin were used on a large scale. So it prevented a lot of uh wound infections, mobile arteries, surgical hospitals. So the previous caring stations now became military army surgical hospitals, mobile and amputation techniques and prosthetics improved because obviously World War One saw a lot of uh difficult injuries. So the lessons we learned from the collaborative efforts were obviously the uh formation of the International Committee of Red Cross. So a Swiss businessman Henry do, he visited following the battle of so freedom. And then he saw the horrors of war. And he basically wrote a book which became the foundations of the ICR C founded in 1863 generic conventions we've already discussed and they were brought about to prevent more harm to uh people who are not actively fighting and the emblems, the cross, the red Crescent and the crystal basically identified people who are not to be targeted. Obviously, no one has followed these in recent times and the N SF which is borders, uh Doctors without borders were formed in 1968 in the Parisian HS. And um as a result since 1968 last year, they've published a report saying that they've managed one around one like 25,000 patients uh giving surgical care under. So that's a huge achievement. So what we've learned from the first World War up to now is that ICI C was established, they've basically given aid in a lot of centers. So you can see there's two different settings. So the our first one is a makeshift operation. The the one at the bottom is obviously an advance center. So what they've come out, um in terms of the principles of war surgery is that this needs to be a surgical mo thing which can be active at any time and there is a disaster. Um So it usually involves surgeon, anesthetic or nurse, ward, nurse and physio therapist, but mostly the surgeon does it all, mostly it's an orthopedic surgeon because as we discussed previously, mostly these are extremity injuries. The principle is generous wound debridement, delayed primary closure because these wounds are again septic wounds, not amenable to primary closure or internal fixations and you stabilize these wounds either as a back up a fixator or fracture and non weapon injuries. Um The I've highlighted these because these are some injuries or some presentations which the trauma surgeon or was working in a war environment should be able to cope with. So these include an emergency sedation, appendicectomy, strangulated hernias, et cetera. So some recent innovations, obviously, these are not innovations as such. These are improvisations. So Iran Iraq war saw that there was a shortage of Thomas Splints. So they made their own splints called the Elder Sheet Sprint. They had lower rates of skin excoriation. They were much cheaper to produce and it basically reduced the cost of managing patients. Similarly, they made an Elder Sheet externally fixated as you can see. Uh it's quite different from what you see on a routine orthopedic board. It's based on a click bar system. It's extremely cheap and it was very sustainable as well. So some more recent innovations are that until recently, ICRC focused on management of fresh injuries and delayed primary closure but not on the uh long term management. But because there's been so many injuries in the past world wars, uh the postconflict surgeries have um are mostly presenting with chronic lymph pathologies. So it could either be malunion, chronic osteomyelitis, poorly done amputations or nerve injuries. So, this led to the development of CRC limb reconstruction project which was started in 2014 in Libya and they trained six national surgeons. The aim is to become a regional center of expertise and train more, more surgeons so that they can manage these complications. So from what we've gone through, so uh we basically gone through a brief history of time. So initially, wounds were managed very in very basic fashion. Then we innovated, we got antibiotics, we got better wound management strategies, then we improvised by cutting down the cost. The unmet needs of the current time is that the more than other surgeons are trained in subspecialty. So if you see a trauma surgeon nowadays, he would not be able to manage a general surgery emergency, a gynecological emergency. So any war surgeon cannot be equivalent to a trauma surgeon. So war surgeons need particular training especially to cover a broad spectrum of uh emergencies. So the following initiatives uh focus on the development of expertise in this area. So IRC surgical learning hub and the global network for weapon uh wounded care. So they basically elaborated and trained 16 participants at uh in Congo uh earlier this year with the aim that we train war surgeons so that they can tackle these uh difficult situations. Um In the next month in Geneva, there is going to be the first conference of Weapon Wounded Care held by the C RC. David. Not, he's a very well renowned surgeon in the UK. And he also is the pioneer of the surgical training in at a environment program and the D RC. So he has trained 704,007 doctors up to now in conflict areas who can now confidently manage worse um worse surgeries and the Harvard Global Surgery Collaborative. Um So some of the slides that I've taken are from their platform on youtube. They basically operate like what you're doing with minor doctors. So they increase awareness through online webinars. They invite more surgeons like mi you invited Mr Cope every morning. Um So it's a similar platform and they've also reached a lot of people increasing awareness. So this is just a recent article that's been published in Lancet. So trauma case reported to global telemedicine. Uh it was an initiative on the Gaza Strip. So although it's well intentioned, it's obviously deemed to fail because the, so there was a case series of 12 patients, five with gunshots, five with six with pregnant injury. Um So the only functioning hospital left was NASR hospital, but that's been nonfunctional since February. So even this well intentioned global telemedicine approach wouldn't be uh enough because there's understaffing, underserved and the hospitals undersea. So telemedicine unfortunately loses its impact although it's a good initiative. So what are the telecom messages? So obviously, we've discussed how we've come to this stage. Uh What advancements we've gone through in surgery but unfortunately, humanitarian surgery is still in infancy. The demand isn't met by the supplier. Um The biggest challenge obviously is lack of adequately trained personnel. Previously, the challenges were managing infections, managing wounds, managing um resources, but the most important resources, adequately trained personnel for war surgeries. So the need of the r overseas, increased capacity for training programs and for local and international surgeons uh who can basically manage humanitian surgery. So as discussed earlier, um the medics at Plaza and medics at Myanmar are being targeted So obviously this discourages anyone who wants to help to come from abroad. So I foresee that mm less and less people would be inclined to go to AA because it's going to be a suicide mission because there's no international humanitarian law. So the need of the r is we need to train the people who are on ground so that they can manage much better. Thank you.