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  • Introduction to the A–E assessment in an LMIC setting by Dr Sylviane Defres, Infectious Diseases and Tropical Medicine Consultant/Mersey Programme Director for Infectious Diseases, London School of Tropical Medicine

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Speaker is doctor who is the nursing program director for Infectious Diseases and the N Consult in and Infectious Diseases and the clinical lead to the Neurological Infection Service in Liverpool University Hospital. And he is a senior in the Clinical Master's program in Tropical Infectious Diseases at the Medicine and an associate professor. It also in a Infection and India and the European Society of Clinical Microbiology. OK, like a neck trying to do this and thank you for inviting me to the conference and thanks and Lisa for um bringing me here. It's been really, really good listening to a lot of talks. Um We had a great catch up yesterday and I'm really pleased to hear that. Um I teach you on neurological infections, had such a lasting impact on you because most people hate neurological infections unless you're a neurologist. Um So, um I was really pleased to hear that, that someone has remembered something I've thought. Um But thank you for giving me this title. What else am I gonna do with this title? Um So uh someone mentioned yesterday about ID Physicians and not everything is about infectious diseases. Um It's not but a lot of ID doctors also do general internal medicine. Um And I mean, hands up who has done an A LS course at LSB LS pa LSN LS. Yeah. Ok. So you know A to E already so I can just sit down and I talks over it. Yeah. Right. The other challenge you gave me was LM IC settings which um this talk could either be very short or it could be exceedingly long. Um And we already heard from um Elizabeth earlier on about the problems with the definition of LM IC settings. Um This, these are just definitions from um the World Bank to classify countries. Um but it doesn't tell you exactly what's going on in the countries and it's more than just resources. It's more about um the geography, the climate, um people, the infrastructures, what um equipment you've got, how do you get that equipment to people who need it? And then of course, all goes completely pear shaped when you have political unrest, wars and natural disasters. Um I can put lots of photographs on here. So a talk on at E assessment in LM IC sessions is not going to cover everything. So the crucial bit in the title was introduction. Ok. I'm only going to touch you on some things, not everything. Um But I'm gonna try and it was a little bit of evidence and the, and the literature research um in, in certain areas and try to kind of apply some of the issues of at E assessment of the challenges and how people have adapted um when they don't have everything to their availability. If you know a to E you know what it stands for, you probably also know it's the beginning of all CPR and simulation scenarios by the recess Council. What you may not know is that the evidence behind the at E assessment comes from high income setting research and all the documents have been written for high income settings, not no resource settings at all. Um And everyone who's on all these councils are all from high income settings. So there's a question about the applicability in the low resource um setting and which is this and council and all these resuscitation councils together have recognized that there's a flaw in this. Um And they have come up with um their first statement which you can read in in the likes of global health and highlight some of problems with and the resuscitation guidelines and how they want to incorporate the voice of people who are working in low research settings in order to create guidelines that are applicable in those settings. Um But they're not there to redesign everything. And so they do acknowledge that um there are some programs that are already up and running that are really good. And you've heard some examples of these today and I guess a lot of this conference is also about seeing how we all work together and how things overlap. Um, and we're not in these individual silos. Ph of mine is these individual silos. Um, and you'll also, it's another thing they talk about, which again is a new, um, uh, sort of topic is this chain mail of survival. You've probably all heard about the chain of survival, which has been sort of ingrained into us through all of our CPR simulations that we've all done, you break one link and the whole chain falls apart and you go by the outcome for your patients. Um Well, the tune mail is in the settings where you may not necessarily have everything to your disposal. Well, your whole chain is not gonna completely collapse. OK? So it's not gonna be perfect outcomes, but you have some sort of outcome and some sort of improvement in care. Um So I'm just gonna touch on a couple of the examples and in terms of the resuscitation Council, but they acknowledge the good work that's already happened. Um And one of these is helping babies breathe campaign. I'm an adult physician. I am not a pediatrician, ok? But I'm married to one. And it's really you good to look at the examples of, of other specialities and how they've done something. Well, so one of the challenges with N Ls for these big meaty documents all written in English and people in low income settings didn't necessarily understand all of it. It takes a lot of time to actually read these he documents and you have to take two or three days out if you're working to go and do the course, et cetera. And all helping really breath program has done is make this simple and straightforward, take the basics of it and make it an easy program for people to join in on put it into their own language. A flip charts that they can use, they modify their program as they've gone along. So it's not one size fits all. So some places said we can't afford to leave um, work for two days. So we want only one day fine. Ok. Hm. Actually, there's too much content for one day. We need a bit longer acknowledging that they actually have to factor this into um the working lives of people. Um And it works. So yesterday, there was a comment about education not being good strategies for quality improvement programs. That's not true. They do work, they're short lived and that's the problem. Ok. They have to be repeatedly repeated repeated. Hence why we all have to be certified every four years with our, our ATL S or ATL S et cetera. Ok. Or why we have to do our B LS courses every year to show that we still have the competencies. And this is where this falls down. A lot of um low income settings where you don't actually have the resources to release people to go off and do that continual training. But another p about on this program was how they really engaged with the people on the ground and empowered them and showed them how it was making a difference. So there, there are lots of papers that have shown neonatal deaths have gone down with this program and that is within the limitations of not good data collection of neonatal deaths. OK? So I put that caveat there and they acknowledge that but there, there are countless um evidence it works. They've also looked at it into a little bit more detail and there are also challenges. But what they have done is they modify and they listen to people who are doing the program and they modify it to incorporate those challenges and certain things that we maybe don't think of because we're all used to be watched as we do our clinical practice work based assessments, a cat, et cetera, et cetera stimulation. We're really used to that. A lot of people aren't, this is really alien to them to be having somebody watching them and being given a debrief, feels like a criticism. Um And they, they don't like it. OK. So actually being able to say this is a good thing to kind of help you to improve and show the data. Then they see the effect of it. Now they want to come back and do it more. Now they want to reengage in this training program and training others in the program. This is why this has been a good example. Um And this is just one of the quotes from um the document. And I think it, it's the key that is at the beginning, simplicity and clarity um to make this work. Um But then the monitoring data, we've heard about data collection so many times in all of the different talks. Um And it's really important to make data collection routine. Um And I'm gonna come back to data in a second and I am gonna get to at e in a moment, I promise sure has also come up with loads of toolkits and what they've also um come up with this framework that focuses not just on CPR, so not just the assessment of the patient that we see in front of us, which is main topic of, of the topic of this talk, but also what happens before they even come in. So we heard about trauma care and actually going and getting people at the site of accidents. Um So that this this framework helps policy makers decide in which part of the country do they want to put their efforts into, to hospital care, into the emergency care, into the, the admissions part of it, the clinic part of it. So this is not a tool for individual hospitals, but more for policy makers. Um And I just bring this up because this is um this is a level three facility up in Northwest, um, Kenya. Um, and they have a lovely, beautiful ambulance sitting outside. It doesn't get used for picking up patients. Ok. It's used occasionally for taking a patient from their facility to a tertiary center if needed or when they run out of oxygen cylinders and they have to go a few 100 miles to go and get some more. Ok. So they're not actually there for getting patients to come to the facility. No, they walk, they walk, they cycle, they get onto a picky picky. Um favorite past time of mine is uh counting how many people you can get on the back of a picky picky. Um I counted up to six at the maximum. Um Obviously, you know, road safety out the window. Hence why there's a problem with, with trauma et cetera, but people are walking to get to um hospitals and healthcare facilities. Um This is a sad story. Um Marianne who walked while she was in labor um in Sierra Leone to get to her healthcare facility, you can see that the terraine is not easy to get there. Um And shortly after she arrived, her baby died. So people present late and hence when we come to the e to E assessment, they're obviously in extremist by the time that they get there. Um I will never complain about potholes ever again. Um In the UK um on the only two roads that actually have tarmac in Kenya, the potholes are amazing. Um, but, uh, most of the roads are dirt tracks. Then I had to, that climate change again. Another topic you heard about yesterday. Um, and all sorts of disasters that happened again. This is a very sad instance that, that happened shortly after I left Kenya a few weeks ago. Um, and this just completely brings things to a stand for people. So I'm not gonna talk more about the prehospital aspect, but you'll see that there's tons of data from about um data sets about uh toolkits and guidelines. They're producing a lot of information and now we're getting to at eat. E is all one of those toolkits. OK? So they're producing all this stuff and now we need to kind of get this into routine practice. So here we've got a nice um three hour center. It's got its protocols up on place. We've got an emergency trolley all prepared. Wonderful. This is what we should be aiming for. Um This is the same hospital that I showed you. This is the triage room, the emergency department, the clinical assessment room, all in one. It's not doing too bad. It's got some kit in the room, it's got some protocols on the wall, but it's not ideal. OK? And people come in on this on a first come first serve basis um sitting out in a queue. So there isn't really a proper triage system in place. And I can't say triage beside thinking about safety, you're safety and healthcare professionals, safety. Um and obviously Ebola COVID that changes how we assess people and then try to do at E assessment wearing all of that on. Ok, believe me, it gets very hot and sweaty inside those things. All right, it's not fun trying to assess your patients dressed up like that right now. We're on to 80 E. Um you know that having um a clear airway is critical, there's no point going on to BCD if you haven't got a, a clear airway. Um And we want to make sure that it's potent. Um But you may not have all of the equipment that you would like. Um you may not have the personnel that you would like. And as you've heard in one of the other talks from your critical care team, um Certainly, it's a bad thing to be trying to intubate if you're not skilled or if you're not maintaining those skills, you're not being supervised, et cetera. So you'd be far better focusing on the basic skills. And there are plenty of literature evidence that shows that doing the simple techniques works well. So making sure that people are training the first responders, the first healthcare workers, medical officers, not necessarily the doctors, but those that are seeing patients at the first, at the very beginning to do the basic techniques first. So I can't emphasize that enough. Obviously, we assess breathing um because we want to identify if there's any respiratory distress um and be able to treat that immediately. Um So obviously the chest or if there's tension in the thor, we're gonna treat that immediately. Um And, and be able to know how to recognize those things looking for respiratory effort. Thinking, could they be hypoxic? I mean, we all know somebody looks like we stress, what do you need to do? Get some oxygen? Well, they may not have world oxygen in your hospital. It may be just cylinders that you have and you might only have a few cylinders in the hospital that are sitting in the operating room, not where you might need them. So you have to think about the logistics about where you put your oxygen cylinders. You certainly probably won't have any ventilators and certainly in this facility that I showed you earlier, there are no ventilators and then throwing to actually get any issues with like just a day, you have power outages. That would be a nightmare. Um In terms of running out of oxygen, you have to think, well, where are you going to go? Get your next oxygen and fill, fill back up again? So these are some of the challenges that you have to think of in advance and sometimes it is a choice of who needs the oxygen the most if you only have a limited supply and the ambulance has already gone down the road for a two hour trip to get the oxygen filter filled back up again. In terms of how you assess, um, we've got lots of fancy equipment, um, to assess oximetry. For example, um, these little ones that came out big drugs during COVID pandemic, these have really made things a lot easier cos they're, they're small battery powered, not needing to be plugged into the wall. Fantastic. They're not all very accurate, which is one floor, but it's better than nothing. Um You certainly probably won't have a blood gas ma um machine to be able to, to assess um blood gasses and you might have chest x ray facilities. I would like to hope that clinical examination will pick up what's wrong with this patient rather than the chest x-ray. And I think clinical examination is the thing that really need to emphasize us. We've become too reliant on investigations in this hospital a lot or in hospital in this country. A lot of my trainees will go immediately to the big long list of investigations. No, we need to think about actual clinical assessment and the more you clinical exam. And in fact, I think it was mentioned yesterday as well about how much we can learn when we go over on these trips of the clinical signs and pick up um a lot of these clinical techniques. Um you might have some point of care tests. Um and, and they have revolutionized um a lot of, of clinical practice. Um sometimes they're very expensive so that can be an issue and sometimes the sensitivities and aren't perfect. Um HIV Kits Great cos they're free. Um And so doing a point of care test is good. Um in the setting of, for example, somebody who's got respiratory distress, it opens up the differentials of what could be causing that respiratory distress. TB um In a lot of countries, you may not necessarily have your chest X ray. You may not be able to get a sputum sample. A smear the gene expert machine might be at a different hospital, but you might be able to do a um a urinary lab test and that's been shown in evidence um literature at time and time again in different settings to be really useful and in your sick TB patient, regardless of whether or not you're HIV positive or HIV negative. So there are at some point of protests that may be useful. Um Things that they can do for um adapting uh in these situations, you don't have oxygen while having a good logistics to know what your supply of oxygen is, where to go to get your oxygen fers. And there's these concentrators, oxygen concentrators, which are really useful. Um They are about uh powered um but they do have a backup battery pack so that if the electricity goes down, you still have a battery pack that will keep going until the electricity comes back up again. And most of the hospitals that I've been to have solar cars, they have um generators for those problems of, of backup um in an emergency situation. What we're not often very good at teaching everybody is, is about the use the judicial use of oxygen. So it's not just about banging on the oxygen, but actually titr it to the knees so that you're actually then not using up all your cylinders unnecessarily um and causing damage by over oxygen. So actually educating um our medical officers in terms of which venturia mask, what um level of oxygen flow should we be using? And these are very helpful techniques. And there have been cases of uh patients in hospitals where there are ventilators, toxin, mediated, not being able to breathe. For example, when people, family members have been bagging and masking and for hours on and hours on end or even days until have cleared out. Um and loads of people, I've just picked two pictures of, of created novel techniques of um creating machines that will do that for you because obviously it's very time consuming doing this for a few days in a row round the clock uh to try and save your loved one. Um And there's even engineering companies that, that assess kind of the weight, the pressure to make sure that it's it's good and not causing any viral trauma. And this was a big during COVID when there was a big problem or, or question about ventilation and across low income income settings and not being able to give ventilators. Um I don't see a lot of that in practice, but it's, it's a technique. Um training, we've heard a lot about training, ok, training, training, training, um and education really important. So this is um some of my students who were training on the, the bubble CPAP. Um We've never used this before and then we can then take that back to their home country. Um And they are here in Kenya in the ho in the hospital where I was at just a few weeks ago. Um This little three term baby um in respiratory distress, there is no surfactant. Um It's too costly, it's too expensive. You can't give that, you can put on the bubble CPAP and help support the breathing. Um And this little baby did really well. Um and learning even more about the adaptations that people can do when you don't have resources. And there are little youtube clips about how to make um uh bubble CPAP just using three cannulas, OK? Or using a bottle of water and how that can kind of when you don't have the equipment. So people are very ingenious um when they have lack of resources. So we can do a lot to learn from our colleagues overseas circulation. Well, we all know about um identifying shock and cardiovascular compromise. Um flu resuscitation being the cornerstone of this and how we assess it but also how you need to be investigating it and treating the cause as you go along. IV. Access might be a challenge. You can see a couple of examples there as to why that might be the case and a lot of use of intraosseous um uh IV or intraosseous fluids. Um Certainly there's gonna be a lack of monitoring equipment. You're not gonna be doing any CVP monitoring. Um But doing the simplest things well is what's going to matter, giving a bolus of fluid reassessing that BP and further fluids of sleeping. Um There's a lot of focus on prevention and education um in the in the community care. So preventing the need to get to the point of having to give intravenous and intraosseous fields. So that Children with diarrheal illnesses, teaching them about how to give um oral rehydration fluids instead and even teaching them how to make it up themselves rather than relying on little sachets and having to go to collect those sessions. And that has been shown to be effective at preventing admissions. Um Obviously, trauma surgery, that's a whole other question. I'm not a surgeon. Um And then the other, I'm gonna talk about the main big threes, the sepsis, trauma and post partum hemorrhage obviously are the big ones in terms of the causes of shock. And so we're gonna have to um deal with those. I put snake bite in there. I've come from Liverpool. We've got a big snake bite unit. And so I have to talk about snake bites. But also II picked the, because some of the research papers I'm about to show you next are actually research that have been done in the countries where these are a problem and have shown and RCT S what treatment should be used and they really good evidence of, of research. That's why I picked them as examples. And so I'm gonna start with sepsis. Um This is a public health campaign from Scotland when I first qualified people weren't really that aware of sepsis and sepsis was not well managed in the UK. Um It's become a big, big focus. People now come in. I had sepsis and not really understanding what does sepsis mean. And we've now swung the other way in over treating um people with sepsis, but the public are aware of sepsis because of the big public health campaigns. People are not aware of sepsis in many low and middle income settings. So that's probably number one. And we've got a lot of um work that has gone into training healthcare professionals in how to recognize sepsis. And with the evidence of various papers like the, the six level six and, and, and getting um treatment rapidly within one hour, we know that improves outcomes. So we've done a lot to improve sepsis outcomes in the western setting and high income settings. It's not so well done across the world. This is a nice paper, a nice simple intervention about how they've just done an education package using technology to health frontline healthcare workers in teaching them how to recognize and manage sepsis. I have improved the outcomes of of sepsis mortality in this setting in Nigeria. Um Diagnostics, I was asked to mention something about diagnostics. Um Obviously this has got CSF in the middle, it could be also blood as well, but there are simple basic tests. There's also very complex tests. Having a microbiology lab involves a lot of um training and technology and hence why it's not involved in a lot of an awful lot of places and why we need more and more of these point of care tests. Um which is good. I think someone mentioned yesterday about how there's more and more multiplex PCR S et cetera and they're simple and easier to use. They're not all perfect either. Um And they do lose some of the sensitivity and specificity for some of the infections. So many of these parts of care tests are not as good as the laboratory tests when they're compared to those. But if you have nothing, it might be better than, than that. So obviously, this is um a number of high income laboratories and what they look like. This is the one in it's not bad. They can do basic microscopy, they can do some basic tests, they do have a hood to be able to do um TB smears, but they have to send that sample off to another hospital if they want a gene expert, if it's smear negative, OK. That adds a huge extra delay and actually get the results. They can't do blood cultures, they won't know anything about sensitivities um of, of antimicrobial. Um So there's been a lot of talk about point of care crp testing because ants in a MR is a big thing um across the world, not just in high income settings. Um and trying to be judicious with our use of antibiotics. So people are thinking work on the use point of care testing for C RP to kind of guide who's got a bacterial infection, who hasn't. But when you look at this in the low resource setting, the evidence is is not great. And this review and that looks at all of the evidence that that, that there is currently says it might be beneficial, but it doesn't have a good enough positive predictive value to be used as a single tool. So you're still gonna have to use a whole pile of other tools to kind of make those decision making processes. And the picture that I put on the right is the price list for the investigations that the patient has to pay when they come into the hospital. So you have to choose very carefully which test you're going to do to help guide the management of the patient. Ok. You've heard that time and time again patients have to pay or get the relatives to come in, um, and pay. Um, this is a nice study. Um, so we know that tram acid is good in, in trauma. Um, and this group wants to have a look to see. Well, does it help in postpartum hemorrhage? It's the leading cause of, of death, um, maternal death worldwide and, and you can see there what the mortality rates are like for women in low resource settings. Um And this trial uh decided to look at tram acid to see if that would improve the outcomes. And it did, it reduced the the deaths by about a third, but it didn't reduce it as much as to the levels of high income settings. And that's because of the use and need of blood transfusion and the scarcity of blood. They also did something. Um it was a a difficult study to do. They also interviewed the families of the woman that died. Um And you can read some of these quotes but the lack of blood um was a big big factor. Women waiting for a bag of blood to come. The hospital I was in when I was there, there was three bags of blood sitting in the fridge, ok. Uh And there was constantly this request for giving blood. In fact, the hospital even has a policy that says we'll give you blood if you need it. But when you leave, could you please give us some back. Ok. That might shock some people. But there is a big campaign um across many countries to kind of get people to donate blood giving blood is a whole different topic on its own, right? And in terms of people being paid to give blood, having family members give blood the whole screening of blood. That's a whole other lecture in its own right? But there is more and more of a push to get people to donate blood because blood is absolutely crucial. Um In these situations, snake bite um can cause lots of different things. Uh Obviously, I I'll give it some examples there. But the, the research paper that I wanted just to highlight um was a group in Sri Lanka, they decided to um do this trial um on the Russell biker which only exists in, in Southeast Asia. Um and they looked at the evidence of other RCT S of how to treat snack bites in other countries, Australia, for example. Um and uh some really good evidence there about how to treat other snakes, but this particular snake has had no investigation about what is the optimum amount of anti venom should you give F FP? Should you not? So this causes a, a consumptive coagulopathy. Um and they want to try and predict who's gonna get that coagulopathy and treat it quickly. And so obviously, that's the end result when they get the coagulopathy, you're um bleeding from everywhere you can have strokes and the fact that's the major cause of death. Um, either hemorrhagic or ischemic strokes and how they try to investigate it. Well, an I NR would be brilliant but they can't afford it and they don't have the skills to do them. So instead the technical blood, um, something and do a 20 minute coagulation test and try to estimate whether or not someone might be headed towards coagulopathy. So a very crude measure, but it's what they have. Um And they set up this study because there was a bit of controversy, we give 20 units to get 10 units of antivenom. Does F FP work, does it not work? And it was a really lovely, well designed study by people in low income settings running the whole thing. Um And except for David L who obviously comes and for everybody else um from the set and they showed that there was no difference between the two treatment arms. This made a big difference to the national guidelines. So now they only give 10 units instead of 20 units. And it showed that F FP doesn't make any difference to it quite properly. So they don't waste their resources and trying to get F FP, which is very costly. So I just wanted to get some examples of good research happening in these settings for the problems of these settings um onto D for disability. Um So obviously, II mentioned about neurology um most people don't like neurology. Um But simple tools like a V pu or to treat. Ok. Um They're either alert and verbal um or they're not or they're groaning or they're unconscious. That's simple doing glas coma scales isn't always easy and straightforward. OK. Remember it was, it was developed for drunk glaswegians and head trauma. It's not good for other causes um of, of decrea decreased conscious level. Um but in certain countries, they have translated it, they have um diagrams to kind of help people know how to do it. And this pediatric version um the bla one is developed for infection, it's developed for malaria. Um and it's simple. So there are techniques, simple techniques of assessing conscious level. Um And you don't need to do fancy neurological um investigations. You're looking for um gross and crude markers of neurological dysfunction and it's not really part of the ABCD, but I thought it was quite fun. Um We, we think about assessing people's eyes and their, their, their vision. Completely pointless to ask somebody who's illiterate to look at the letters and say the letters. So I observe people coming in just pointing to the line, ladies pointing to the line and they're going hm to say which sl we've got to really prove simple techniques but just modifying the things that we do to the setting that is per to those countries. And so management, obviously, hyperglycemia, we need to make sure that we've got glucometers, not everywhere do we have that? And so given glucose where necessary controlling seizures that to us is, is, is obvious. But that can be quite a challenge when culturally, there's a lot of myths around seizures. Um, and, uh, also whether or not you've got accessibility to medications and an awful lot of the medications that are available are the older antiepileptics with a lot of side effects. Um, aren't very nice to be given. Um, so wh O make big movements in that area in terms of the, the, um, wh O drug list as well. So that's making a change. But there's still a lot of seizure activity, managing endocranial pressure, simple techniques like 30 degree up on the bed. It does make a difference. You don't have to have ICP monitoring. Um, in terms of investigations, you may not necessarily have a CT scanner. Um, you might have a CT scanner but you might not have anybody to report it. So this is one of my stars, um, who was in a small district hospital and they did have a CT scanner. He didn't have a, um, anyone to report it. And somebody said we think it's normal and he whatsapp to me, he says, I don't think this is normal. What do you think that? So he sent me a snapshot and then sent me the whole thing just for doing it. So he's out in, in Sub Saharan Africa, sending me a whatsapp link to the patients and CT scan. We've gone on um a bit further than that. Um So, er worldwide radiology um in production of Collective Minds, radiology have created this platform where people across the world can actually tap in to this platform, this network of radiologists to be able to get guidance about scans. I'm sure my TS will still send me images um when they're abroad, but that's fine because I had brain infections. I'm so a bit nerdy that way. Um I also really like MRI scans. So anybody who knows me will always say that I want an MRI scan. Well, you're not going to get that in very many um areas in, in no resource settings and there has been some work around portable MRI S. Um They are expensive and they haven't been trials in low resource settings. Um And they're not as good as a main MRI in terms of the sensitivity of the images. So it's great. It's not perfect um More in the the, but it does exist. We had a fantastic talk earlier on about point of care and course, and that really has been a big shift in, in a lot of patients in resource settings and not all the things that I think for else and I'm not going to cover anything else because it will be awful lot. Obviously, patients exam, all of the rest of the body are important. Um And I just wanted to kind of bring up this particular example at the bottom. Um Obviously, the skin, see what we find. Um The the treatment would be um to my. Um But here we got some different place that actually can help the the skin there, specific type of that got an and, and properties. I know that if we have you listening to our, obviously, you can do that this kind of practice, so you can learn from other techniques. So I hope that in um all of this, I've given you the importance of the assessment. Um The structure is exactly the same as what we do here. Um But you might have to adapt it according to the resources and what you've got, it's absolutely crucial um to triage people using this to accurately diagnose people. Um And it is the basic first of emergency care. There's plenty of evidence that this works and improve because we don't want to be care and we don't have it. And, but in the set, we have lots of problems, there's lots of infrastructure issues. Um And that's bigger than us. Sometimes we're working on the ground, but we are here to be advocates for some of these issues and try to raise the topic above us. And then I'd like to bring on education something that time and that we can incorporate overseas to help equip others for them to learn. But then then to also teach other. It's very important that we train people overseas to be looking after their own healthcare systems and training the next generation as well. Um We can use technology, technology can be useful as long as we're using it carefully. Um And it isn't the answer to everything. Um Certainly it has classifications of electric, et cetera, but it can be helpful. You heard that again, time to time to get through some of these. So I will end it there. Um Oh no, I do have a plug because everybody else gives a plug. So um we also have courses on LSD, have masters courses. Um And in fact, some of you are coming to the LSD to get your masters for us as well. I look forward to seeing somebody then um but if there is another plug, you have seen other night, if you've been with us last weekend. Um It was absolutely. Thank you so much, Doctor. Um I'm gonna start with a few questions that are online first. So please put your hand up like to ask some questions in the room because we do have um questions. So um online limit of point of care test allowed in low income and resource settings. How do you balance out management after your assessment versus capabilities? Which do you prioritize, especially when you are taught so differently invested in training. So I think um what's important is going back to assessment and, and thinking very carefully for what you think the differential diagnosis is choosing the um II said it earlier on. But I think in um Western system, we have become two years as a matter of like actually thinking about why we're requesting the test that we're requesting. But when you have to realize that the patients to be paying for those tests, we actually want to make sure that you are constant at least. Um And I think that you have to use some people who are aware of the specific and sensitivities of the tests because a lot of people who think that multiplex PCR S are the answer to everything. Um I'm and they are not very happy with us because we just um the multi pr um for, for infections because PCR S are better now that's in the, in, it's not knowing how much of these viruses necessarily are causing certain CMS infections. And at the end of the day, which ones can be treat, which ones can treat. Um So you're going to focus on what's prevalent in this area, what's most likely to be the cause, what treatment have I got? Um And there'll be others that you don't have any treatment for and that's it. So you have to use your resources wisely. Thank you. Any questions in the room, you can put your hands straight up. B is ad E otherwise I'll continue to the one that we have before the conference. So one is adapting history to your opinion, talk of language. Are there any other ways or things that you need to take into account mysteries, whether it's local sales or idioms? And I think you've heard from a number of people how relationships is really important and, and, you know, not being a person who just goes out there to do some work and, you know, you will be able to do it all but actually being respected, um, comes with time um and understanding their culture, you may not necessarily know um when you go there, even if you do learn the language, you may not know the implications of certain choices, how that may be offensive or it may be a completely different meaning. So I would say that when you first go out, you're going to really observe, get to know people, listen to the people who are on the ground and learn from them first. Um and use people who are there to help you with what people are saying. Um But clinical observation just watch, you can pick up so many clinical sign by just looking, even if you don't necessarily understand all of the language in terms of the history. But yes, 80% of your clinical act, you manage your history and your examination, the rest of investigations is that it to confirm what you actually think? Thank you. Any other questions from anyone in the audience? I think that's it for now. Can I give you some lab?