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Insights into Orthopaedics - Talk 3 - Life as a hip surgeon & basics of hip fractures

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Summary

In this on-demand teaching session, medical professionals learn to confidently identify and describe fractures in the hip joint and plan the appropriate treatment, be it fixation or arthroplasty. The session delves into the anatomy and clinical presentations of hip fractures, studying in great detail the different radiological landmarks that are vital knowledge. Attendees will also learn to understand the implications of the anatomy of the hip joint's capsule on hip injuries and their treatment. This training, which is relevant for med students and foundation doctors, provides insight on the prevalence, causes, and impact of hip fractures using the UK's National Hip Fracture Database as a reference. In addition, attendees are equipped to accurately interpret X-rays with a specific focus on intracapsular and extracapsular fractures, learning valuable frameworks such as the Garden classification system.
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Description

Mr Sarkhell Radha is a fellowship trained, multiple award winning, Consultant Trauma and Orthopaedic Surgeon. Mr Radha is the Clinical Lead of the Trauma and Orthopaedic Department in Croydon University Hospital.

He has over 30 peer-reviewed publications and holds an MSc in Evidence Based Medicine as well as an MBA. Mr Radha is also the lead for the 1st international Best Practice Guideline project in arthroscopic management of Femoral Acetabular Impingement syndrome (FAI) as part of The Hip Preservation Society. In his spare time, he travels across the globe to operate for charity for the Swisscross Foundation.

His talk will focus on his day to day life as a hip surgeon and explore the basics of hip fractures.

Learning objectives

1. Understand how to confidently describe a fracture, discerning whether it requires a fixation or arthroplasty for its management. 2. Identify different radiological landmarks relevant to fractures, which are significant for both foundation doctors and medical students. 3. Comprehend the clinical anatomy of the hip joint, its relevance to fractures and its implications for treatment, with emphasis on the capsule of the hip joint and its three ligaments. 4. Become familiar with the circumstances surrounding hip fractures, their epidemiology in the United Kingdom, and their commonly associated patient presentations. 5. Comprehend the process of diagnosing a hip fracture, including typical X-ray presentations, as well as understanding the Garden Classification of fractures and its implications for treatment options.
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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.

Today's session should be that you should be able to describe this fracture uh with confidence with uh with conviction that this needs either a fixation or an arthroplasty in terms of management. And uh we're just gonna see uh the different radiological uh kind of landmarks that you kind of need to know as, as a foundation doctor, even as a med student for your exams. Uh Yeah, move on to the next slide. Uh If if anyone has access to camera phones, obviously, if you can just scan this QR code, this is something new that you can um if you feel shy that you're, you're responding in in the here, you can send individual texts to uh these questions as you can uh scan the QR code along. Um Obviously, how do you diagnose is, is quite uh straightforward with the X ray but otherwise any clinical findings that you can think of, please put it in the chat box as well. Uh Yeah, next lay down and yeah, just uh just a quick refreshment of memory or if you don't know of classification systems that you'd find. Yeah, it comes on to my phone where I'm uh keeping the pole light. Yep. One uh coming to the clinical anatomy of the hip joint. Um I need pictures with you. Yeah. Um I'm not going into very uh specific flexors and muscle attachments, but uh quite relevant to what we're going to talk about after. Uh this is that the capsule of the hip joint, it's made of three ligaments as we all know, iliofemoral, pubofemoral femoral ligament. Uh if you can see here that anteriorly the the ligament, the capsule kind of stretches from the uh greater trachaner to the less trachaner. Um But posteriorly, it's a bit deficient or or otherwise it, it ends more approximately um at the inter crest. Yeah, the next slide. No, I need this one. Yeah, just go as I'm talking. I mean, like I'm just saying as I'm talking, just click once so that I'm I'm able to talk through the images as well. Um Just a Caria image on the right showing uh the ligament in, in a human specimen. Uh The next picture, please. And uh just even more explanation that posteriorly it's deficient um at the intertrochanteric crest. So uh that's the end point. So anteriorly, it extends a bit more posteriorly, it it ends uh at the c um the crest. Yeah, blood supply is the calcium. I think this is quite important uh in terms of managing an injury. Uh This is what we uh kind of think about when, when we're kind of uh managing a hip fracture. Uh if the blood supply to the head gets cut off because of the lateral circumflex, having um retrograde flow into the head, then we need to kind of replace the joint. Um In simpler terms, if the fracture is at this point, you can logically see that the the artery arterial supply to the head gets cut off. Yeah, the next image uh would show a very similar picture just along with the ligament discovery. You can see that uh when, when the capsule is, you know, the fracture is through the capsule, uh the blood supply to the head gets compromised and that forms the basis of, of treating uh these injuries. Next sleep, please. So, uh epidemiology or, or the importance of what we're talking about today. Um This is the National Hip Frac Fracture Database. Uh This is the latest report that we have uh as you can see, it's a, it's a nationwide countrywide thing that uh we collect data on each hip fracture that comes into uh the UK hospitals. It's a huge burden. Um If you can click on the next slide, there's um there's a graph which shows the latest data uh in 2022. Uh almost um 72,000, more than 72,000 people suffered hip fractures in, in uh uh in the United Kingdom. And uh it's quite interesting to know that 7000 of it was, was in December probably going to uh weather patterns and uh Christmas drinking culture. But, um, it, it, it is quite interesting that it keeps, it keeps adding on each year. There's, there's no respite uh from the fact that there is uh ever so much he practice uh day in and day out. Um It makes me presentation wise, you can uh keep clicking through. This is just a very uh typical um patient presentation with uh a shortened and externally rotated um uh fe uh kind of lower limb after suffering a neck femur fracture. Uh usually it's a, it's an elderly osteoporotic bone. Um It's, it's caused by a fall, trivial uh trivial for low energy mechanism. Um But in terms of uh you know, variation, if you see it in a very young individual, it, it, it, it, it doesn't, it doesn't mean the same. Uh it could be probably because of a high energy injury, but the, the most probable um or the, the most common uh individuals who suffer these are elderly individuals who have a severity one. It's important to rule out other injuries, especially when the elderly and demented uh a head injury would always be masked by other, other signs. Um You need to know their past medical problems, especially their drug history, uh whether they're diabetic because that kind of helps um in deciding about wound healing and things like that. Uh social history is again an important part of, of uh our treatment plan because it forms the basis of whether to uh go in for a hemiarthroplasty versus a total hip replacement as I be talking in the next few days. What? So that's uh a clear picture of normal X ray of um in an ap view of a hip. Um just in terms of identification, um the next line would, would give you a clear idea of, of what you should be looking for. Um Go on. Yeah, that's the normal line which um comes from the inferior border of the superior pubic quam and extends along the inferior border of the femoral leg uh all along the cancer. So uh this is usually the line that we are really concerned about in, in um uh hip fracture, especially in the p view of the uh pelvis go and when you see a lab review, um sometimes it's, it's quite new for my students to see this. And uh you know, we're not really taught in depth about these things, but as a foundation doctor, when you start your training, uh you are expected to know these and sometimes I've seen a few uh a few f one doctors who start the, the rotation, you know, they, they don't even know what they're looking at. So the next picture quite uh explains it in detail that uh this is the head and it's quite self explanatory, the neck shaft of the femur. Um This would be the ECU tuberosity. And this is really, really important when you don't have an obvious structure pattern on the AP view that you need to see the la to kind of really know how the fracture is displaced. One. There's another um informative x-ray about uh how you can kind of define the capsule. Um Even recently, I remember one of uh of our co trainees were, were getting quizzed on uh during, during the meeting about uh how you would exactly define an extra capsule as an intracapsular effect. And I think uh this slide isn't really um exactly true as in, you know, there's no fixed capsule or margins, but you can get an idea by seeing this. And if you click on the next picture, you know, um that gives you a completely full idea about uh how you can broadly classify these fractures. Um intracapsular is again at, at a very uh fine limit student or, you know, at an F one level when you know these things, it, it really impresses um consultants, I think and, and it really gives a good picture that, you know, your stuff, especially with hip fractures. Um Obviously the the head, the capitis, you, you get that uh line over there, it's an intracapsular fracture, but again subdued into subcapsule trans which goes through the neck and then Bale which is at the base of the neck. Um That's it with the intracapsular. But when you come into extracapsular fractures, you have in intertrochanter and subtrochanteric. It's quite self-explanatory with the, with the great and, and then moving on um just dealing with the intracapsular neck of femur fracture from now, um this is just an X ray with uh an obvious intercapsular fracture. Um P Do you, do you wanna have a, have a go about uh just describing, you know, uh whatever you see in the sense we've, we've talked about the things that I do. You think it's, it's incontinuity? Mm Sorry. I think I was gonna say it's in, in continuity. Yeah, I think that I think it a little bit rough. OK. Uh So, I mean, the inferior border of the superior pubic ramus in line with um the inferior border of the neck feur, you still think it's um I wanna change. Yeah. The next picture kind of uh puts this into place. So there is that tiny loss of line, I think it's, it's, it's difficult when you just see one x- but as you keep seeing more and more, I think it, it becomes a bit more obvious. Um Yeah, this, this is a quite typical example of the loss of line. There's um there's a bony overlap uh over, you know, the fractures, there's uh obvious fem neck shortening and it would really help. Usually with the, with the pelvis view you have um you have the other hip to compare and it's uh really obvious on, on the Ap Yeah, only one garden classification is uh is again something really basic. Um This is this is really useful in terms of choosing treatment options. Uh If you think of uh BCD, um Gard is usually the valgus impacted fractures, uh these where it's, it's not the fracture pattern is incomplete. So you still have a bit of uh cortex in impact. Uh The third is where there's, there's quite a bit of uh quite a bit of uh displacement. Um And garden floor is is where the head and the neck is completely displaced if you click through the pictures. Yeah, this is, this is quite a good slide to kind of remember easily. Um The the fracture patterns. As I was saying, the valgus impacted nerve would, would obviously be just a just a line through the cortex. Uh but the the impacted fragment goes into vis and, and hence the name um Garden two is, is a complete break in the cortex, but it's still undisplaced. Three is where it starts to get displaced, but still there's 50% contact. And then four, you have almost complete displacement. The treatment of these fractures depends, I mean the treatment of these fractures depends on this classification as such. But in, in a more broad sense, it depends on whether the you you're able to s salvage the head or not. And on the next slide, you'll um you'll be able to see options for arthroplasty. As I was saying, So on the left, you have very uh obvious displaced uh neck femur fracture where there's uh um where there is complete displacement of the head with the neck. And on the next two images that you can see uh is what you call a hemiarthroplasty on a thr this is usually guided by uh nice guidelines. Um Usually when, when you have a patient who's fit um fit enough for the procedure, um he's, he's cognitively intact, he's, he's able to walk outside, but no more than no more than a stick. Um That's when you, you would advocate the thr and obviously you, you need a hip surgeon to do a thr because of the cup. Uh But for people who are demented in a, in a, in a kind of question frame that we had who was in a care home, she's not really mobilizing. Well, she's, she's on multiple drugs for, if she's not someone who would uh tolerate a procedure. Um And for her, for someone like her, we'd go in with a hemiarthroplasty. Great. And then uh moving on you, intertrochanteric is uh again, quite self explanatory. It's, it's, it's a fracture pattern that I was um earlier mentioning outside the capsule. So you can still salvage the native joint, you don't have to replace the head. Um Options for fixation depends on, on how the fracture pattern is. Um It's a very simple uh classification of events where it, it, it broadly divides the fractures into two or three part fractures, um detail into type one, type two, type three. A as far as I've seen, I've, I've not noticed uh people really fussing about it, but it's just that um if there's a break in the cortex and then you're able to reduce it quite well. A DHS would stick. Uh Obviously, there's, there's uh a part of the lateral wall um of the female that, that needs to be intact for the DHS to stick. But otherwise, if it's a com community pattern or fracture, um A nail is being propagated these days uh across the UK as well. Um The next slide would show a few X rays about uh intertrochanter fractures where you can see a clear uh pattern of uh of kind of um fracture line extending from the great to the left. And uh it's almost as if it's community and, and broken into so many uh fragments. Yeah. Go on surgical options. As I was uh saying, uh P FN and DHS is, is um usually advocated. Uh I think there's, there's even new evidence in, in January 2023 when I published a sort of guideline where we can um attempt to DHS as um when you have the lateral cortex intact. Um If I'm not wrong mister, I think uh it's less than if, if 10 millimeters of lateral cortex, then you would opt for an IM uh But I think if if you have a good lateral wall, um you have a very stable reducible fracture pattern DHS is uh is still preferred in most centers. Um I think we're at the end of um a sl show, um just going back to these questions, then I think if, if you've um listened throughout the lecture about um uh patterns of uh patterns of injury and then uh the principles of treatment, I think at this point um in terms of reading x rays, um classification systems and uh management, depending on the fracture pattern and nice guidelines. Um If you scan that QR code, you, you would be able to just pop in a few lines about these questions. And yeah, if, if you're and II think we've, we've had a few uh answers from uh from the audience on the, on the Q and A as well. And uh I think I'll, I'll leave it to mister after this, please. Uh I mean your valuable input and your opinion on on these uh fractures and of course your life as a hip surgeon, I think it's really interesting to me. Can you see my Yeah. OK. Yes, there we go. No. But can you see now uh we can currently just see me? We can't see a slide yet. I got no idea. So stop sharing. OK, let's stop. So when I click here, share, OK. Entire window. Watch your step. No, no. Yeah. Yeah. And they said all Yes. Yes. Ok. Uh, I don't see any of you now, when I share it for some reason, which is very strange. I'd normally like to see my audience. Dira. Excellent, thanks very much. And, uh, thanks all of you for taking time. First of all, to attend. Knows we're very keen to support especially medical student, uh, regardless of where they are, whether nationally or internationally. So, I'm grateful for your time first. I think I'm not going to, I covered all the clinical topic uh very well as much as what you need to know and what expected for your day one, fy one. So I'm going to just basically also sort of cover some insight as to how I got here. Uh Hopefully that will encourage you and stimulate you to sort of pursue car in orthopedic surgery. Obviously, I want all of you to become an orthopedic surgeon. So I'm, I'm sorry, I'm consultant orthopedic surgeon. I work at Croydon and seven I work for multiple other organizations including Swiss Cross, which I do my work. And I also sort of actively involving teaching and training uh student from Saint George's King's College and Croydon. Uh So I'm going to cover a bit about my journey, uh just to make you sort of make you aware that nothing is impossible. Um Everybody can be an orthopedic surgeon, uh which is, which is, which is great. Uh Because I do know, uh once you start in sort of your job or any placement. I keep telling you this is very competitive specialty, you know. So there are surgeons colleagues, uh even other subspecialties to try. Pretty much put negative comment that puts you off. And from my experience, if I can do it, I think all of you can do it. Uh hip fracture is covered and more some tips on my limited life experience. That's me. I don't think I've changed much. Have I put? I think as far as the uh, can you hear me? Yeah. Uh Yes. Yes, you can still hear too. So as far as the look is concerned, I don't think I've changed much and arguably my behavior has still been, uh I still behave quite young and childish and that help because, uh the, you know, you, when you're a child, you, you've got a lot of dreams, you know, you might want to be a teacher, singer police officer. So we all have this uh uh multiple dreams in our head. Uh The one in the middle, that's what I want it to be. So mechanic and there's a reason for it. Then the reason we, my dad, this is my dad that was back in 1986. He came to London to treat my sister's eye needed a corneal graft at the time. So this guy never. Well, he went to school five days but he could read and write Kurdish. He was, he was very good in Arabic. Well, he used to pretend that he knows very good English. But I found out later once, once I learn English myself, I found out he was just quite basics. Uh And he used to also think he knows a bit of Germany because he used to supervise the German workers. They used to build the road in Iraq. Uh Believe it or not. Uh So my dad used to be their supervisor and he was very much into car. He used to sell, car, buy, car, had a car shop. And then you can imagine as a child, he always wants to be around him. Have a go at driving a car, sometimes dismantling the engines and uh pulling screws here and there, uh which I did it on numerous occasions. So I always wanted to become a mechanic, to be honest, uh close to a level, I have a eldest brother. He was, he, he's much more clever and smarter than me. He was you sort of top gold medal in the whole country for 18 years. So he used to wind me up saying you're going to be a mechanic. Uh not been disrespectful to the mechanic as the, as the, as a profession, but in my culture, sort of being a mechanic and a doctor is quite different and look at your elder brother, he's going to be a, a doctor and you're gonna regret it in the long term. So, partly to sort of please them. Actually I say, ok, well, I can do it. I can be a doctor. Uh, anyway. So I don't know why you're so obsessed that my brother can do and I cannot do myself. So I then worked hard and my, a level decided that I'm, I'm going to be a doctor. So right now I'm orthopedic surgeon, not just a doctor. Uh, and then I engage in research and I'm very keen educator and, and at the same time I've always kept my humanitarian work and I've always sort of remember, you know, to be a surgeon, you've got to have a number of attributes. It's not just, you study hard, you get a good mark and that's it. You go, you do well with the interview because it, it does bite you back at the end. If you don't have skills and expertise required to provide a deeper care to your patient, it's not just technical skills, it's not just precision in what you do. You have to have that level of connection with your patient and you've got to understand your patient. And more importantly, you got to treat each uh sort of patient as the whole entity. And you've got to know when you're going to operate or when you're not going to operate and what sort of treatment you prefer, sort of individualized, pretty much customized to that patient. And that requires you to have a more deeper sort of engagement and understanding with your patient. So this is the answer for some other subspecialty. They think orthopedics, they don't really need to talk to the patients. Uh They're just there with their hammers screwdrivers. And uh that's it, it's actually exactly opposite to be able to get the trust of the patient that you're going to operate on and you are directly responsible for the life and death and disability of that patient or to make them better to bring them from disability back to normal day to day life. And that require a lot of confidence and which is basically means you got to engage with your patient right from the beginning. So then say all of us could be an orthopedic surgeon. So there, there are challenges, all of us have got stories to tell and I'm pretty much sure mine is not unique, but then you got to be able to get out of your comfort zone and overcome challenges in your day to day personal life and that will make you stronger. I came to this country as an asylum seeker uh back in 2002. Uh I'm glad Ro soak and the current government were not in the power. I know uh go to what I am now. Uh But then, so you did that involve walking, taking illegal roads arriving in the country illegally, which is uh then it was a shock to my system because I had no sort of issue apart from political issues back in my country, I had a very comfortable living, a very nice decent big family. But then you suddenly, and, and I was fully qualified as a doctor. So you suddenly learned somewhere, then you got to be treated while you feel you will be treated as a second class. In fact, I got detained for a week when I arrived because they wanted to check, I'm not a terrorist. So it was a part of terrorist screen they had at the time. So I got detained. There was a place in a detention center near Cambridge. I still remember then, uh it, it really hasn't stopped there. Then I got a sort of put in a sort of a group accommodation north of England. Uh no paperwork to work and uh at the same time, no uh facilities to, to read or study and no opportunities. So you kind of feel lost to say, ok, well, I was a doctor who had a, a lot of dream but then now suddenly I'm having to wait for the home office or a or a just to basically real sort of decide on your future, which means you can actually just access, sort of, uh you could, you could be allowed to study and reify and get a GC REG registration. So I was one of those lucky ones managed to get uh my applications uh uh sort of approved by the home office. Well, in fact it wasn't by home office, you had to go to the court. Uh then uh I formally became a refugee and I think some of you may be too young to remember back in 2003, uh being a refugee wasn't a very good attribute because there was a lot of, sort of negative uh media. So you almost wanted sort of hide yourself and try to pretend you're, you're here for other reason and you're not refugees and you're here as a tourist or pay, you pay the country to study. So it was almost, it's all almost stigma. Uh Luckily nowadays, much better. So imagine then that you got you face socially, the stigma would be a refugee in a country which is uh not your own at the time. And then at the same time, you've got all of this worry, you left your family, uh you got to restart your life again here. Uh You, your family wanted you to be a doctor, you basically uh uh build all your dream and you want you to be a mechanic. The closest to my, my speciality has was orthopedics and you can imagine why uh I wanted to play and work with my tool and make my patient better and see them uh to sort of better day one. So and suddenly now you're a refugee and then you start to think, how am I, how am I going to sort of fit in So then I did a recalification exam. It was a 12, II realized I was uh among one of the uh only refugees to do to have done the three exam, first trial. At that time, B they published a big article on me personally thinking I've done such a great achievement and it was a major achievement just to reify and to be sort of uh eligible for provisional GMC registration, not even the full one. And there was uh an article about me again at uh is a uh new newspaper there uh journal which basically it, it's, it's, it just mine, as I said, II, mine may not be, I've not had much struggle than many others, but it is, I had a fair share of my struggle, which is basically made me feel stronger and also thinking to get to where you want and you got to come out of your comfort zone. And we can say it's tough run. I do feel asleep on sofas whenever I want and I sleep very easily. Actually. Then I managed then going through the system just like all of you. At first, I was uh uh I got, I managed to get a clinical attachment. I got, I had five days in pediatric. Then followed by I was lucky, I managed to get four weeks or 4 to 6 weeks in orthopedics. And I went to my first interview to get a job. Uh So remember I got asked the, the consultant who asked me that question. He's a very good colleague of mine. He is, uh we do discuss complex cases together now, uh in the northeast, he asked me, he said, ok, what do you wanna do in the long term? First question? I said, well, I want to become orthopedic surgeon and innocently, I didn't think of much, much of it. And still, I don't, he's probably good. This gentleman has no racial racist bone in his, in his body. So innocently, he said, ok, you're from Iraq, you've got three gaps in your CV. By then I had because I had to wait for asylum, then go through exam. And I said, do you know how difficult to become orthopedic surgeon? So, um I, to be honest, I didn't practice interviews, so I didn't really know what to say. And I didn't know the audit research, by the way, we didn't have that work at the time. So I looked at him and said, uh Mr So and so what's your job? And let's see. So he told me uh I'm consultant Ortho orthopedic surgeon. Uh innocently, I said, well, if you can do it, why do you, do you think I cannot do it today? The same consultant when, when he sees me, uh sort of brings that as a uh as a said that you did that in your interview. So we terminated your interview. My interview was terminated. They didn't ask me any question because understandably he was very upset. Then I was lucky because the parts of the hr and management there's always there. Are you, you get to the interview somewhere, somebody likes you for a different reason. The hr and management, they seems to quite like my comment because it was me just being myself and honest and your knows me, I am a blunt and honest. There's no barriers when I speak. Uh They, the management says, no, we'll give him a job. I got a phone call uh and says, well, Mr So and so I wasn't very pleased, but we're happy to give you a job. That's where I started, that was in Northeast. Then regar opportunity came up there used to be national. Uh So course I got it. Then after 1.5 years, then I applied nationally for Regar. II did come amongst the top, I think 10 in the country and managed to get Northwest London uh rotation. I completed that. I still keep in touch with all my mentor. I still use them as uh not just a body of clinical expertise to share practice with and to learn from them still. But it is more the the the network you feel you're in debt to them and you got to respect them. And at the same time, it brings you comfort. So I have always sort of maintained uh that relationship with my previous consultant and mentors. Then I managed to get a fellowship at uh South West London and now uh got a consultant job. Well, I have been for the past uh four years. So going back to the, what we, we said in childhood, you, you, we all have different dreams actually. Yes, the dream might not work but actually it, it, you got to do the, the, the, the work for it and nothing is impossible. Then there are a lot of nowadays. I mean, previously, we didn't have much. I uh remember II hope setting up the first uh refugee health worker program in the northeast of England because we really didn't have much support. Nowadays, you got most of the website, most of the association, they are excellent and you should, you should use them. And I've got to, I think, done reasonably well. Uh apart from, I mean, a consultant which I always wanted to be consultant orthopedic surgeon uh within the first few months, almost less than a year of my practice uh as a consultant, I got uh appointed. In fact, I got uh voted by the whole department consultant as their clinical lead. And at the time I was, I think myself and ravi manner was the most junior one. Then I got up uh surgically for education and training, looking after King's College and uh Saint George's and uh also actively engaged in research uh through NIH R studies and started then uh take one step further. He was the education and training supervisor, but then started to formally provide fellowship uh at year three as a consultant. So then you always question yourself. How do I manage everything? Uh Everything? Am I, am I so special? Am I unique? And what is good about me? Which is uh you always feel, feel that we and, and it is, it is valid. You've got to feel important, you've got to feel, to sort of love yourself. Uh But then actually I've done nothing more than anybody else could do. It's, it's not nothing special uh that I've done that. None of as of any of you can cannot do it is it is about your time management and getting your priority, right? And also uh imagine so, so going back to your dreams, so making sure you're not gonna leave your dream alone, you just, you got to push hard and you will get it and you might feel some isolated uh uh socially mentally uh sort of uh uh but there's always help and support out there. It just takes one smile from one of your consultant and one of your mentor or sort of one of your friend, uh just your days, just get better and better and better and you'll be able to achieve more. And that's exactly what, what I thought, what happened in my case. So good planning. Uh it comes and then you got to be organized, you need to be focused and exactly uh know uh where to start and where to end up and that will just gives you less stress. The last thing you want to have stress with that's at work at home. Uh So the way to tackle this, you got to plan all your journey all your day to day as much as possible, then I'm sure you've, you've probably seen this uh everywhere and it is true. This always worked for me and this is, it's a nicer er sort of er matrix for me. If you've got an important and urgent work, you've got to do it. Now. It's same clinically. If you've got somebody overnight, turn up with septic arthritis of a joint before 12 o'clock, your outcome is better if you intervene early, somebody with a massive open fracture which is dirty wound, uh neurovascular damage, the outcome will be better if you do it. You've got to do them now. So this, this can, this has to take priority and this reflected also in your yourself because as I said, remember you are the most important person. So you got to love yourself and look after yourself and then plan your day, your journey. So what you got in your head for your career, uh you, you, you, you sort of, you plan your foundation program, you got to do what urgent requirement now course surgically uh training same and there are things you, you know, it, it's it's, it is important but it's not that urgent. So you, you know, I don't, I'm not sort of suggesting you should plan uh working into your, your ST three. Of course, if you can do it's better, but there's, you've got ample time. You got 45 years and obviously please don't waste your time with, with task with conversations with placement, which is not important and not urgent, just eliminate them early. Just don't try to please people around you. But because you just want to sort of be mister or missus nice person because it is not worth it, you're not gonna be useful for yourself or for your surrounding. So from day one, what I suggest whatever you want to do urgently are important, do it now and whatever you don't want to do and they're not important and not urgent, just read them from your system. Then there are, you're not working them and, and this is what's fun about orthopedics, er and working as orthopedics. Er you got to have that family sort of relationship with your team and you got to make sure you respect and value individual member of your team. And more importantly, you need to empower them. Everybody has to have a say in what you do. And it's really important because at the end of the day, you want your journey to run smoothly, which is basically compatible with your patient journey. Because if your journey runs smoothly, you come to work with, with a sort of strong motivation and a good attitude that you're going to do your trauma list today and you're going to do deliver that number of patients. Uh It is good for your patient. It's good for yourself because that's what your target is. But the only way this work is actually if you have a team around you, they're happy, they feel ha they have a say in what you do and they're empowered to do so. And these two pictures taken in two separate occasions, both both marks uh significant milestone which my team uh helped me to do. One of them is the trauma list which is finished quarter to five. We did a maximum number that could be possible in the whole UK and the other side of the triple list uh or the triple operating list. Uh We managed to do 12 hip and joint replacement starting eight o'clock, finishing at 420. So that's not me. That's the whole thing. Then don't leave the academic side of things because trust me, it's not boring. I know when you, when I started II brought up and trained in the country, we I didn't even know the audit and quality improvement project. So it was really difficult for me to start in the beginning uh how to get my head around even reading papers. Uh Remember there was a website, critical appraisal of papers. We used to read this and I was thinking, what's p value? What's this? It was, it was really difficult but you got to push yourself because uh you, once you do this, you have your first case report or first your paper published it just, it, it's such a, such fine, it's really, really nice thing. You just feel, you feel so important. Uh And you can progress further so far. I've done, I've, I've, I've led and published three guidelines. Uh the hip arthroscopy guideline, we had uh a colleague and coauthors, more than 70 countries in the whole world, more than 2, 260 coauthors. And it's the first one in the whole world. So it's, it's, it's something to be proud of these will stay, whether I'm gonna be around 1015 years, whatever or 50 years to, to stay for generation uh then get involved in, in, in, in giving back to your colleagues and your communities. Uh Whether that is a faculty member of the research course or any other association, I think it's, it's, you know, it's important because once you feel that you can, you have got some skills uh that you II, I've never imagined I could actually publish a paper after my foundation program. So now that I, you know, it, it is good. II would like to support. So I like to get involved in, in, in areas which uh I can spread at least a positive energy to my, my students. And and the junior colleagues then management, it is important. And this is where I got my MBA. And again, at the time when I did my MBA, uh even my colleague, they sort sort of raised questions. So why do you wanna do, are you going to be a manager? Why do you wanna do MBA S? But I just find there is a merit into it because you look uh from a small team, right to the whole wider surgical team, clinician. Uh you're assumed as a person who manage and lead the team. So what about if you formally sort of go and study and, and learn how to actually run the team and manage the team properly? Uh There are multiple good, good sort of management courses and, and, and uh MBA equivalent or, you know, in our universities. And I think it's good, you got to, you know, you got to think about this from now because again, for me, your impact on a wider community, on your colleagues uh on your staff, you know, you got to be able to support them and support them in a structures professional way, which I think there's, you know, you learn a lot from doing these courses and MBA S or PG certificate in management uh to how to deal with the day to day management. And again, it helps you how to have a difficult conversation uh uh with, with the colleagues with a member of the team which they may not perform to the standards you think, uh or the trust things that require and it's, it, it's gonna give you, give you skills to deal with those. I was lucky my first year as a uh trainer in the region during COVID, I got a trainer of the year award again, very sort of nice, uh very motivating. So it pushed me to carry on uh to do more. But at the same time, I also uh sort of take, took training a step further. So when I go to Iraq or other countries for a charity work, I always find a time whether it's an hour or two to basically treat the treat, the teach the local team what we do here because I do II do, I do sort of, I do a lot of charity work but I do uh uh support teaching and training the locals to do what you do here because a week of me or two weeks of me, we might think we, we do a major impact but actually the impact of teaching and training local, they, they're gonna be there 365 day a year. So that's where then I do a lot of humanitarian work. I work with Swiss Cross. Prior to this, I used to work uh I was founder of Newcastle Gates at medical volunteer when we did the first trip to Iraq. Uh And I went back also at the time of ISIS dealing with the wound. Uh We were sort of heavily wounded and, and war torn victims. Uh And then again, for yourself, your skill is gonna be better. You, you will work in an environment with very limited resource, with the team, uh which is struggling with basics and with the implant and instrument that uh you sort of, you've never come across here in the UK. This is a, a young guy. Uh He was one of the first sort of freedom fighter at the time who had a massive Osteomyelitis femur. Then at that time, II looked around everywhere. I couldn't find anything to treat this guy. I found this fusion now in Germany, uh which is then uh uh collected money uh and managed to sort of treat him with this, that was the preoperative X rays. Uh Then there's a video here. He's six weeks after the surgery. He's, he's come back to walk in and he's sending me hello in a minute. So that's what so that you, you are changing the life of people and please please, please, whatever you do, uh whatever subspecialty you're going to end up working in, do give back to your community, do give back to the poor people and do give back to people who are less fortunate than us. Because to be honest, that is, you know, that keeps you going, that motivates you and that makes you feel like you are existing and I do a lot of work with the uh the Children organization as well, uh dealing with some uh basic issues. Uh again, if areas were out of my depth and uh then I reach out to a pediatric surgeon across the whole world, we've got from sort of Canada to Switzerland. Uh and, and we managed to get to sort of arrange funding and get everything sorted so that little kid will at least have a heart and we can, we can uh sort of treat some aspect of their care. And you will be surprised there are kids which are struggling with just uh spasticity around the achilles stent. Nothing else. That's the major problem. And it's in that, in that age group when that kid goes to the school and limp and everybody else try start to comment and bully that kid. Well, all, all you, you, you need to do, you might need to just inject buttocks or do a little uh sort of tendon release you, you basically bring back that kid to the school as normal as it could be. So, please do give back to your community and it's really important. Uh Again, nothing is easy. Yeah, it is nothing but, but, but trust me, once you, you, you've done it, it, it's, it's gonna be worth it then I was, I, I've, I've been very lucky. And again, your, your work, we always have this sort of uh try to have that feeling ok. Well, I mean, nobody cares why doing this, why should I work this hard? Why should I do charity work? I mean, why should I speak to you? So, and so why should I get on well with management? Because nobody cares, the system is in disasters and yeah, at the end of the day we are just numbers but it's not right. Actually because you get, you get appreciated. Might not be just now I was doctor over there at Chelsea Westminster and Westminster Sex back in 2017. Probably that was the the first time II felt so happy. This is all the work I've done. Now said to me, I'm not just a doctor. I'm a doctor over there for the whole trust uh employer months that leading by example award. So there's there's multiple thi this this one keeps you going and you will get rewarded when the time comes. And I think the most important reward for me is, is my patient and uh the the the letter you get from your patient. It it it it brings to date, it brings uh tears in my eyes and I have, I've literally got an email today from one of my patients. It's made me tearful and it's really nice because it feels like what you dreamed of during childhood and what you did, even if that was for your parents, they want you to be a doctor. Now it's the effect and much, much further than that. It's, uh, you're making people lives better and they are truly grateful. And again, these are just patient. You've done the surgery, they're happy that they just, they just want to have a picture with you and it's really rewarding and it's nice. Then you've got to have a work life balance. I'm not, I have to admit I'm not very good in giving this advice. Uh, but, uh, remember you got to look after yourself and then find a hobby, find something that you can sort of entertain yourself. I'll visit you, the arm done here. OK. Thank you. Thank you, Mister A. That's, uh, I know I went a few minutes uh off the line but no, not at all. I think we, we started quite late. Um So we're right on time. Thank you. Thank you, Mister A. I think personally II II wanna clap and, and give, give an ovation because, um I've never had so much insight into Ortho uh from a consultant's perspective. And I think, uh I had a few questions, but at, at, at one point you've, you've given all the answers for, um, lots of, lots of things that you've done and I think it's really inspiring. Um Not, not just for me, I think it even for the, for the med students. Um, anyone, anyone listening, I think this is being recorded as well. So, um it's, uh it's, it's really inspiring insight. Uh from, from where you were and how difficult it was to get to where you are at this point. Then the key is, as I said, it is nothing. We, we are all human beings are strong. You all do things which later on you realize you think am I special? I go through this but actually not look around you. There's everybody, there are people who has gone through much tougher time uh than, than I have been. They just, they might not be as open as me. And I think that's very important. You've got to sort of to be open to your society because now a lot of people, they have got stories to tell and unless they share it, you know, people get so anxious about it. Say when I was a refugee, I, you know, it was, it was almost a stigma to say I was sort a fidget but I was saying it everywhere. At, at that point. Did you, did you think of giving back in the sense of I II know you had to go through training and everything but you, you always had this idea of swiss course of doing charity work even at that point when you were 100%. So I used to go around to several hospital and collect external fixators. I've sent some to Guinea Sierra Leone and then Iraq, it was just a simple things like people, I went to Guinea, I was shocked people are desperate for some basic stuff. And then II work as an F it was F two here at that time. It was F two thinking, OK, we, we, we throw more waste here, we throw, we can run a hospital in a little village somewhere and just the little things you do. So you start collecting, you start sending things and it works absolutely right. They, they, they get, they, they get where, where it should be. That's, that's really interesting. Um II would have never thought of that actually at, at and at an F two stage uh sending implants and you did mention that you, you did a fusion nail for the, for the Osteomyelitis. Yeah. And you, you keep doing these things as, as time goes in a sense like yeah, 100% 100%. So I II do, I do. So I spend at least two week of my annual leave every year uh on a charity trip. So my next one is in June. So that definitely two weeks, sometimes 3 to 4 weeks. Uh And uh as I said, that that breaks me. It, it's, it's worth more than money. It's, it's, it, you know, it brings mental and physical comfort and wellbeing for you, which is, which is really, really nice. Thank you. Thank you so much mister um a any, any input case, anything that you want to ask? Um Actually I like to ask a question just in terms of from a medical student perspective, obviously, if you're interested in doing humanitarian work, electronic surgeons, is there any kind of things that you recommend almost trying to learn now or can I develop the skills? So when we have the adequate surgical skills we use in the humanitarian context, a very good question. Again, when I talk to a medical student, the first thing, they think they think they, they need to be a surgeon on sort of or, or a proper qualified medical consultant to go too much work. It's not actually. And I, when II went with the team, we, we set up the first theater compound and the first theater in Iraq, I was, we were not doing the doctor's job. We were basically cleaning the floor, getting all those sort of instruments set and stuff ready. So it, there are a lot of opportunities. It's not, you don't need to go there and operate on, on patients. As I said, it's, it's uh every time I go, II give an hour or two of training or lectures, it is, it is teaching them how the, the health system here works, how you pass through your, your medical exam, how you, you do your audit. So things like that you don't need to physically operate on people. And there are a lot of opportunities I know some organizations like I work with. Well, I visited MSF. Uh they might want you to do a putative vocational training or a certificate and stuff. But then equally there are others, all they might need you to do, collect some of their instruments near expiry expired, whatever it and, and support them in that way. So you start the feeling of comfort you get, you don't physically need to be there and, and operate. You just need to contribute and, and know that your contribution goes too far, especially you're not giving money, you're given the instrument an implant, which is not used to anyway. Anything from you. Huh? No, first and foremost, thank you very much for giving the talk. It was excellent. I really enjoyed it and I'm happy to see that you've, you've had, you've shown your like sort of whole life journey from your image at the start all the way to the end. And II really was fascinated by humanitarian work, but just a bit more regarding sort of your thought on the orthopedic pathway and journey of a student. From our perspective. How do you think we best go about things from our point of view? Because I know there are a few students in the call at the moment. So I think that they'd probably be interested in knowing your thoughts regarding what students could be doing now if they were interested in. Yeah, I think so. Imagine by the time uh you qualify, you all have M BBS equivalent and I think MP will have be at the same time which basically personally, uh you will, you will have no issues as far as most of your B AC seems to be management oriented. You'll have a project in management that could easily cover that. I think what, what's now become more relevant and relevant formal experience and qualification in teaching, which is, which seems to be to become, has become a norm. Now, then that will, as far as your academic post uh medical student uh degrees is concerned, then you need to, you got to have a presentation which is gonna be minimum national or international and you got to have a publication. These are the two areas which has increasingly become difficult because you go to every single interview, there is a requirement to do that many numbers. So you can imagine that every single student will, will try to present or publish one and sometimes you, you go to a journal and they pay thousands of pounds for it. So to do this, you got to start this early, at least to link up with, with the might be a taster week somewhere with a consultant who are interested in sort of supporting student. Give an audit link up with them early and get your presentation and papers early on and don't wait it because you look at all the requirement from core surgical training on work. You got to have publication, you got to have presentation. Now you got to have at least 22 cycle completed audit and I'm not worried about the, the, the academic side and the degrees because as I said, uh, uh, most of the universities they will offer the management side of it. And then the teaching, it's easy to get PD certificate in medical education. It's, it's become much, much easier, more friendlier now. But your paper presentation of the three has to start early. Ok. Right. Uh, I think any, any questions from, uh, about things even now, can we get an opportunity to enter training if we do what you said 100%? And I think there are, you know, from your experience at the, er, we are very everybody friendly, including international medical graduate. Uh, I think apart from one, uh, which there was a reason that was not able to, to get to a training, everybody else we had past three years, uh, we gave them exactly the same opportunity as a training. Uh, and then it's up to them. If you work hard for it, then now it's the M sra, I can't help with the M SRA, but we can help with the audit with your paper, with your presentation, with your management, with your teaching. So everything that a trainee expect from us, we open the same opportunity for no trainee. And in fact, even the educational days and zero days they call these guys, we give them the equal numbers because you've got to think about every, you know, where we, you know, yes, you can graduate every everybody but everybody else needs to get, get, giving a fair chance because that's the only way to have that sort of diverse workforce that, you know, it can, it can benefit your patient. I think your system better in the long term and there is always space for everyone. Trust me, you know, the competition ratio, all of those II would ignore that if you want align yourself with a subspecialty, you will get it. You might not get it straight from every year F two, but you'll get it. You might have to, to do one year of F three equivalent and get it. It's, you know, you just need, need a bit of hard work on your side. Definitely. Thank you. Thank you so much. Once again, I'm, I'm quite humbled by your presence. I mean, it's, it's almost half eight and you're, you're still in. Um Thank you. Thank you so much. No worries. Thank you for you guys. I'm, I'm sorry, I have to stay till almost not at all. Not at all. I think it is there. I I'm very happy to support anything else in the long term. As I said, it's uh it's a privilege to be here and well done and the rest of the team. Thank you very much. It was a privilege. Thank you and thank you to everyone who attended as well. Please do fill in the feedback from thanks. Guys. Thank you. All right, thank you. It's just us b uh Yeah, I think I'll just stop going live now and then. Yeah, I think, yeah, that's all. But yeah, we'll see you guys next week for next talk then. Thanks. Thanks. Be both. I I'll catch up with you man. Take care, take care. Bye, take care. Bye Pish.