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Good evening, everybody. And welcome to the 10th Webinar for the Faculty of Medical Leadership and Management Trainee Steering Group. And this evening, we've got a special webinar for you in conjunction with the Southwest Regional Defense Medical Leadership Network. Um, you're gonna here shortly a little bit about FML, m t s d. And the speakers that we've got lined up for you this evening. But just to let you know a little bit about the region Defense medical leadership networks These are new networks that have been brought in over the last year to bring together like minded people who have an interest in leadership and, uh, an opportunity for people to be able to share their views and their ideas to ensure that we deliver really quality healthcare across across defense. So you're gonna hear from three really exciting defense speakers. Um, but hopefully with lots of linking to whatever you do in your role way, whether you're here as an NHS trainee, whether you're a member of the Defense Medical Services, I'm sure you're going to find this evening a really interesting event. So my name is a genetic commander, Laura Kati. And I'm the vice chair of the Faculty of Medical Leadership and Management Trainee Steering Group and also the lead for the Southwest Regional Defense Leadership Network. And I'm going to hand over now to my other co chair as well. Good evening. Oh, and my name is Megan Chamberlain. I am the armed Forces wrap of the TSG and welcome to the tent session in the FML M Training Training stadium groups Introduction to Leadership Webinar series, which has now been running for over a year. And it's been quite successful. The T S D works to generally improve leadership training across the UK, mainly for trainee doctors, but we were to support trainees in all in all areas and all over the region's from Scotland, Ireland, Wales and England. And we are we're except trainees than the FML m itself. Tonight we invite speakers across the Defense medical services as mentioned by by Laura, and we're really excited to discuss sort of leading challenge leading and challenging in osteo environments across the world. These presentational broadly linked to the FML M standards of teams and organization and system leadership. As we discuss aspects of leadership that can be transferred between the routine NHS care that we all deal with every day and defense healthcare. We've got three excellent speakers with us today, Uh, and we plan for a panel discussion at the end. So after each presentation, we'll have time for one or two questions quite specific to their presentation, which we ask you to put in in the Q and a box with the majority of questions aimed for the end. So please throughout the evening, please put your questions in and we'll hope, hopefully get them all together for the end to have a really nice conversation about different experiences and what we think about leading in such challenging environments and how we can relate that to our time in in the NHS and in the UK. So joining us today, we've got three speakers as mentioned. So first of all, we've got Surge Commander Will Sharp, who is the current principal medical officer, or the senior doctor aboard the HMS Queen Elizabeth aircraft carrier. Following we've got the Lieutenant Colonel, Nicola Macleod, who is the senior medical officer, G p by trade, um at shape, which stands for the Supreme Headquarters Allied Powers in Europe, which is also related to NATO. And we've got Lieutenant Commander Steve Andrews, who is a Royal Marine by background turned radiographer turned medical support officer. So he works with medical operations and logistical, uh, logistics. And we'll be telling us about his experiences in do, Of course. So starting off of this just now, we've got a highlight. Handover to search commander will sharp to to take her into the first part of the presentations. Thank you very much so? Well, thanks, Megan. Good evening, everybody. I'll just get my screen up so we have something to look at. Cool. So hopefully sure we have to see that. So good evening, everybody. Thanks for inviting me to speak to you tonight. I'm will sharp. I'm a g p. A specialist in aviation medicine. And I'm currently the commander, medical and principal medical officer of HMS Queen Elizabeth, our nation's flagship. Um, so I look after a team at the moment between 16 and 45 people, plus any ships. We put out the door as part of a task group providing the sort of medical care. But what I'm going to do tonight is talk to you about my experiences of delivering migrant care in the Mediterranean back in 2016. And you might think, How is this relevant to us today? Well, you only have to look at what's happening both in the Mediterranean and the English Channel to know that the problem of migrant migration people putting themselves at risk and C hasn't gone away. And hopefully what we'll do is just reflect. Reflect on that tonight. And I always start this presentation with a little bit of a warning. And that warning is that this is a real experience. This is something I did on deployment. I won't sugarcoat it for the audience. Um, I'll talk about what had happened. What has happened? Um, so there are some slightly distressing bits of content that we may come across tonight, but I just want to take you to the August bank holiday. Back in 2016. Many of you won't remember what you were doing, but I certainly do. Um, it was my It was 6. 30 in the morning. It was my birthday. And a general alarm goes off on the ships and we spotted a boat on the horizon. I'm four weeks post C c t as a G p. So this is my first sort of big rescue experience. So what you'll see in the footage is us rescuing migrants off north of Libya, bringing them a across into a boat to get them up onto the side of the ship on the left hand side. Um, one of the ship's company, dressed in white overalls, has jumped into boats because they've reported a casualty. Um, and my colleague is just getting an assessment before they called down for both myself as a medical officer and one of my medical assistance to come and assist with the casualty. We enter that boat not knowing quite what we're going to be confronted with and end up doing a rapid bit of triage. Um, finding one person who's who's clearly deceased and undergoing CPR on another and bear in mind, this is sort of Mediterranean heat 35 40 degrees, much like it is today around around the South Coast, if not a little bit hotter. We're sort of knee and ankle deep in fluid seawater fuel bodily fluids, and these people have been at sea for at least a good 14 hours, many of whom won't have had any fluids or food since. And unfortunately on that that morning, that second rescue of the day, we declared six people dead. Uh, sorry. Not six people dead, two people dead. But that was the start of the day by way of a little bit of background. I was kind of reflecting on on leadership and and how my sort of leadership journey started. And I think for many of us, um, we start becoming leaders from childhood, whether that be with siblings or other family members. But for me, I did a few. I would say formative thing in my life. And that was becoming a police officer for Greater Manchester Police 4.5 years experiencing what life on the streets was like in South Manchester, dealing with stressful situations, dealing with difficult individuals, um, and and living that experience in conjunction with while while I was doing medical school and then I kind of brew as a leader both in my f one f two years, you know, responding to those things like the cardiac arrest you've never been to before finding yourself in a stressful situation, which over time, you get used to and I was lucky enough to be sponsored by the Navy. So I found myself doing a few operational tours in the in the Arabian Gulf, helping at the 2012 Olympics, um, and supplying medical care on board a number of different platforms. And that was before I came back and started my GP training in in Portsmouth in the mid Sussex. And then I I took over on this deployment that you've just seen, but we'll go back to that in a minute. I found myself sort of leading teams at air stations, um, instructing individuals in aviation medicine which I specialized in, and and leading other other teams at other medical centers and then finding myself in Navy command, leading an even smaller team, looking at how we did some strategic change for the Navy. And now I find myself in that kind of environment where I've got an even bigger team, a task group where I'm where I've got a lot of medical responsibility. So I think throughout those experiences there were sort of lots of leadership experiences, um, that we sort of develop on. We hone our skills, know what works, what doesn't work, but leading in a maritime environments an interesting place because it's pretty hostile and often what you experienced back in the UK with the ability to pick up the phone, call an ambulance, which you hope will turn up within eight minutes for a priority. One. Uh, getting up. Getting a patient hospital is often the first step, but the maritime environment can be incredibly hostile. It can be hostile. If you can't achieve reach back, it can be hostile with the sea state. It can be hostile if you're in the middle of the Atlantic Mediterranean Pacific, when you're dealing with somebody who's sick, ill or injured, and there can be many operational challenges sort of overlaid with that. And that might be. You've got somebody who's injured themselves fast roping or you're doing counterterrorism or counter piracy ops. So there's potential for an increased level of risk and medical challenges aren't far away. Uh, this was a patient I saw, uh, they came in with a bit of heat stroke, and I found them to be, uh, in complete heart block, purely incidentally, because I wasn't happy with the bradycardia of someone who was age 49 and we were 48 hours away from anywhere. So how are you going to deal with that? How are you going to manage your team to respond to this patient in the middle of the night when you need to get some rest? And that's the sort of scenario I found myself in. But those kind of scenarios were not that uncommon at seat, and the evacuation chain can be more complex. We're used to in general practice in the UK, picking up a phone, calling for an ambulance and hoping it will turn up on time. But at the moment, we're currently in positions were often finding ourselves holding patient's without all the resources we might want that are in the emergency department. But when you're in a maritime environment, that evacuation chain can be extended. Can be many days, particularly if you're at one of the polar ends, Um, or if you're in the middle of an ocean, um, and you may find yourself moving from platform to platform to platform with a casualty as part of their evacuation process, which can just make things a bit more complex and a bit more stressful. And let's go back to the sort of migrant rescue. So when you're when I knew I was taking over a team who had been on the task for a few months, I need to understand the context of what had been going on. And that context was really important for me to set the scene in terms of what I needed to do to prepare myself to go out, but also what I needed to take with me both from an educational point of view for the team, but also the kind of skills I needed to broaden myself out with to be prepared. And the migrant um rescue seen changed in 2015 when this little Syrian boy washes up on the coast as a result of of his death and his image on the newspapers. We found ourselves in a position where the EU responded by putting a task force together, um, to go out the door to deal with migrant rescue, and it was really important to understand the environment you're operating in because we saw the Mediterranean environment move significant numbers of migrants at the back end of 2015 and into 2016 and in fact, when I ended up deploying, we had the busiest suburb of migrant movement we had seen in a generation with up to 10,000 people put to see on a daily basis when the level the weather, uh, and the conditions permitted, which meant you could have mask you massive rescue operations. And it was really important to understand who were going to be treating because people were coming from multiple countries, which brings potential multiple pathologies with them. Different complexities have been traveling for weeks to months. Two days, Um, and many of them been trafficked and often put to see against their will in quite perilous sort of conditions with with with some nasty injuries. So for me going out fresh out the box as a as a as a GP. Having done my training within the NHS, I found myself with a small team of medical assistance, either three or four of them, but also a bigger ships coming who were all first aid trained, um, and would provide some backup if we ever needed it. And how do you prepare a team when you're going out? And you're potentially pulling people out of boats potentially bodies out of boats, Uh, in the middle of the Mediterranean. What skill set you need for that? And I recognize pretty quickly that for me, my biggest anxieties kind of sat around pediatrics and obstetrics. You know, what am I going to do if it's only me delivering that pediatric care or that obstetric care without cassava option? And that for me was where I had to push hard on my sort of training, um, and and get through the door on some courses to build up that sort of skill set to prepare myself. And it was really important when you take over a team, or certainly as I took over a team who hadn't had any of these really big rescues to think about how you're gonna manage the scenarios that you're potentially going to face. And for us, it was about planning, practicing moulage ing and executing, um, smaller rescues if we had the opportunity to do them to understand what did and didn't work as a group, but also reflect on what they had already been doing, Um, and think about worst case scenarios, because for us, this was a good scenario. This is a boat laden with between 100 and 2100 and 30 people put to see when the weather permission is permitted. However, what you can see here is a high risk scenario, and this is a scenario where we've potentially got 6 to 800 people on a boat. The people who would pay the least money would be inside the boat, um, sort of below decks. And you can imagine the risk of this capsizing like shown here, because my biggest worry was How are we going to manage this scenario if we have a mass capsize? We have hundreds of people in the water and potentially tens, if not hundreds of people drowning in front of us where we're doing our best. But we can't completely control the situation because that for us, is a mass cow. So what we would find ourselves doing is we would intercept these boats. We'd reassure the people, and that was so critical by keeping them calm, we could mitigate some of that risk of that boat flipping because the moment they want to get out or move to one side potential. We've got a mass casualty on our hands, and this was really high risk for us if we got this right. We were pretty pretty happy with what could happen next. And then we find ourselves rescuing, reassuring and triaging the people. What you can see there is that fluid. I talked about the bolts sticking up from those wooden beams, and we'd use the pilot ladder on the left hand side, where you can see the chat climbing almost as a triage tool for us. If they could get up there, that was pretty reassuring. If they couldn't, we give them some water. We'd give them some glucose tablets. We'd see what they were like 5, 10 minutes later and then repeat the process. And then we find ourselves often in scenarios where we ended up treating people in the boats. And you can see me here having called a couple of people out. But actually there's a concern about casualties within, within the boat we've just seen. And for us, for me, jumping in there is a risky, risky manoeuvre. Don't quite know what we're going to get, Um, so it's really important to understand the sort of the environment you're operating in, what the risks are to both yourself and your team and whether you're going to take those risks knowing that you've got hundreds of other casualties to deal with. And we also find ourselves sort of recovering any deceased we needed to at the end of the sort of operations as we needed to. We're looking after young to old, vulnerable people, people who had often been trafficked people without family. So some really difficult and harrowing sort of circumstances, so looking after them was really important. And then we'd find ourselves delivering care 24 7 for up to about 60 hours. And with a team of four or five of you with only one of me, that can be quite challenging to, um, and my biggest worry was sort of that period of time where we're going to be outside of the range of the, uh, hello, because if I can't get someone off safely, that's that's really difficult. Um, and I've got to work out who I'm going to send off if I can send them off and when I can send them off to get them to safety. And this is what 710 people look like on the back end of the ship now better than the boats they're in, but still cramped but safer conditions and managing the expectation of 700 people can always be a bit of a challenge. And just just below the sort of image here is where we were set up as a medical area. And this was our medical area where the T we'd often have a sort of Q of patient's. The team would see triage and treat. Um, what was coming in? Um, and we had about five or six camp beds, set up a couple of beds effectively as our sort of mini recess or, uh, trauma sort of area where we could deliver the best care we could. And it was really important for us to sort of treat individuals as they came through, offer them care and compassion within the space that we had. And you can see people double bunking. You know, we've got probably about 10 people you can't see within this image, but this is our sort of act capacity, doing the best with what we've got in the landscape we're operating in, which is in the middle of the Mediterranean. And we'd look after them sort of day and night feed and water them. And you know, often when we had the opportunity to bring in little ones, we would do So this was a 14 day old who I think was the youngest migrant we rescued. Um, so we just brought the the child in for a bit of a bit of nursing, sort of in the show with Mom when we could and would often do that with the families or pregnant women as we could to keep them safe, We'll transfer them on our passage and offload them to the Red Cross. Uh, the move. Move any of the deceased off to the local authorities. And then what we do in the next 48 hours is we'd transit back. Were transit back to the operational area. We do a reset as a team. We did a debrief. We'd report back to HQ and we'd sleep. And the debriefing as a group, looking at what was good, what wasn't so good and what we could do better next time was absolutely critical. While also share ing that lived experience that we we we felt while we were there and then What I want to do is I just want to come back to a couple of rescues. So the rescue you saw on the video we ended up recovering a mix of men, women and Children and the two deceased you saw and that boat boat number two was sort of the difficult starts the day. Really. Boat number one was pretty pretty easy going. But then we ended up with a challenging scenario. So towards the latter part of the day, we rescued a boat number six and boat number six was full of women and Children. And we came across a baby whose mother had collapsed at the top of the ladder who had not fed for 24 hours. This was an eight week old baby weighing only 4.5 kg. Floppy and pyrexic, now stripping, stripping him down to change his clothing, Find his to keep anemic, tachycardic, hypertensive, my sat's probes. Not working. He's got increased work of breathing a sunken fontanel. So this is all sort of red flag e stuff to the GPS in the room and something. We probably want to get up to the hospital for an assessment, but Unfortunately, I don't have that luxury. So I end up trying and failing to get in some IV access. Um, he's fairly periphery shut down. But I did get enough access to get me one drop of blood back to tell me he was hypoglycemic as well. So I end up sticking an easy I Oh, in his tibia fluid bonus seeing him, giving him some stat antibiotics and looking at how we're gonna, uh, cosy vacuum to the nearest nearest boat. And that was an Italian aircraft carrier, the Giuseppe Garibaldi. Um and we did a perilous boat transfer, sort of at nine PM at night, in the pitch, black with this high. See? Swell. And I remember sitting with his mother, who we had also fluid resuscitated that day and, um, sorted out sitting with her while we're caught in the downdraft of a Huey in a Merlin. Worried about losing this baby over the side, knowing that he needed to get some help in the hospital. Um, but I'm pleased to say we sort of stabilized him before the transfer. And I must say, after the the difficult morning start, you know, having a baby who's taken a couple of bottles, had a couple of wet nappies, Um, and has, um, you know, sort of come around. And actually, his mom's pretty happy with him was really rewarding. And this was us the sort of next morning with the team high morale, Busy day, busy night. But we were still going at it and just cracking on with what we had to do. And it was difficult dealing with patient's throughout the night. As we all know, dealing with a Q of patient's always at the door can be really difficult, and by the end of that sort of 60 hour period were treated over 50 people. Both the deceased, the eight week old eight pregnant women with abdominal pain, multiple burns and wounds, soft tissue injuries, multiple cases of dehydration, collapse and even a sort of asthma exacerbation requiring NEBs and a bit of monitoring before we offloaded them. So really busy tea time for for our small team, and then things didn't kind of stop. And actually, if I reflect back on the probably the harder rescue we had, we had one, um, at the end of October, where we rescued 619 people. We treated 65 people during during that sort of 60 hour or so rescue chest sepsis, multiple pyrexia is coming in. Some were P. U O S from people who had often originated from sub Saharan Africa. So that immediately put my sort of G p anxiety up multiple pregnant women who have been crushed in boats. We, unfortunately, had a patient who had been raped, and we found out to be pregnant. We had multiple soft tissue injuries, UTIs, gastritis and even a few cases of seasickness. Human bites, dehydration, collapses and, unfortunately, a few more body recovery's. But I kind of just wanna come to sort of my closing. And for us as a team, it was really important, um, for us to have some morale and the morale often came in the face. Uh, the morale was sort of focused often around the the Children we had rescued because they provided, uh, some great entertainment. And we'd often have the family's super close to us in the medical area. And these are just a few of the Children we picked up one day. The boy in the bottom right is a little boy called Destiny. who spent 48 hours doing his maths and telling us all about his time to tables and showing us how to add and subtract things. Uh, while his other siblings were fighting over who got sort of bigger, um, inflated, Uh, examination gloves. And, you know, you look at this image now and you think, Oh, kids are wearing masks. That's not uncommon with covid. But actually having these guys close to us, um, for when we had tougher times to just go out and chat to and smile at was really good and rewarding, and I just kind of want to end on a couple of thoughts. Really? Um, a steer medicine can be tough and challenging, but if you know where you're going and you think about what you can face, you can often prepare yourself and your team, and that's critical to help you build resilience. And for us, it was really important to focus on the winds, the small but important things that would keep us going. And what's really important to is not to ignore the difficult days, however tough, challenging and fatiguing. They are because if you communicate and talk to each other as a team, you can really move forward and and make the best of what you've got. And what I found absolutely essential was that debriefing element really important to debrief with the team to talk through what that shared experience was like. And for me, as the clinician, the solo clinician, I found it was really important to reach back into an ally, to have a chat, to have an offload, to talk about my experience. Because actually, we need to look after ourselves when we're out there, and what I'm gonna do is just kind of leave you with that. But I'm gonna welcome sort of questions at the end of the talk. And I'm sorry my slides were darting all over the place. I wasn't clicking anything, but I'm not sure what my power points been doing. Whether it's stuck a few times on, um So let me end there and I'll pick things up in a bit. Thank you. Thank you very much. So it was a fantastic presentation. It's the second time I've I've heard it and it still hits home to me. How the importance of communication just reassuring patient's and providing basic care can make such a difference in such a difficult scenario. Um, I had one question for you. So you mentioned the importance of regular team briefs, maintain the resilience of the team and you mentioned a few times throughout your presentation. I wonder if you had any particularly challenging times amongst the team itself, that whether there was any fracturing of the team and how you manage that with dealing with everything else of all the clinical duties, you're doing all the other duties as a medical officer on board and how you balanced that and mended that team together or supported the mending of that team during your time out in the med. Yeah, that Thanks, Meghan. I think that's a That's a really good question, and I'll pull out a couple of sort of examples there. So when I joined the team, they had already been on task for quite a few months. A number of them, so they had already been in that environment, so there was sort of not an apathy. I wouldn't use that word, but, uh, a they they thought they knew a lot of what they needed to know about the environment. They were going into and what that rescue in August showed us was actually, you know, they they hadn't had CPR in boats before. They hadn't had the volume or complexity of casualties before. And I'd already used the weeks before to do a bit of a reset, Um, for us, because you kind of can become a little bit emotionally unattached. Two scenarios if you're dealing with patient's day in, day out or, you know, in this case, migrants day in, day out. And for me, it was really important to just bring the focus back to the individuals, as in the individual patient's, um, to get that kind of reset in and get the videos up of, you know how we're going to deal with the difficult delivery. How are we going to deal with a breach? You know, how are we going to deal with, you know, uh, a cardiac arrest in an infant, that kind of thing. To refocus minds beyond what we were doing. And the second thing there was knowing your team. Now we all have strengths and weaknesses, and I think, um, there are, uh, individuals who will be strong in some areas and less strong than others and making sure the skills mix was right because we were providing care for, you know, 60 our blocks when we were doing it. And the intensity was is huge. You know, we were going often from sort of 67 in the morning, through to whatever time in the middle of the night in terms of Q outside the door and people needing to be seen. And often people don't realize that they're terribly sick until they've realized they've got a resource they can go to as well. Um, so So that Q was pretty unrelated relenting after we got them into the boats. Um, So knowing your people, I think, and knowing what their skills are is absolutely critical, Um, and and pairing up the strength the stronger, weaker team members was was really important for us. Um, and also coaching, you know, just just spending time doing moulage is, you know, how do you deal with an asthma exacerbation? How are you going to deal with someone having a fit? All of that stuff was was really important to firstly for me to identify where people strengths and weaknesses lied in acute management but also to help bond us as a team and how we're going to manage something for real. You know, we did have someone fitting. We did have someone with sepsis. We did have an asthma exacerbation. It's not all battlefield medicine, which were often teaching our teaching our team. So so it might not be a catastrophic hemorrhage, but it might be a medical emergency. So it's kind of having that reset and getting getting people focused. Thank you, thank you. So we've got some, uh, fantastic questions in the Q and A. Some of those that will leave for you to probably type an answer if if that's OK, there's some quite specific ones, and there's some general ones which will pull into the panel. But there's one that I think leads on quite nicely to what you've just been talking about. So there's been a lot of talk about trauma amongst health professionals lately. How do the Navy mitigate this? And what do you think? We can learn from the Navy that can be applied to those in the NHS environments. So presumably by trauma, we're not talking about physical. We're probably talking about mental mental trauma as in, You know, I mean, if I look at my colleagues who have many of whom have worked through the covid pandemic in hospital, you know, that's sort of level of, you know, that that that can be very difficult. So how how do we how do we mitigate against it, or how does the Navy mitigate against it? Well, we we we have a thing called trim, which is, um, which affected is trauma sort of post trauma management, which provides, uh, ability. And we would have done this with the ship's company. Certainly those involved in some of the more difficult times, like body recovery and stuff, um, to debrief them and provide them with points and access to do that. Um, I think as healthcare providers within, within the military, um, one of the things I learned And before I went out the door, I spoke to a good friend who's a consultant psychiatrist. Um, and we talked about resilience building, and I think if you go into a scenario that you were never expecting and you never even thought about, you're going to be on the back foot. But if you go into a scenario where you've done some table topping, you've done some moolah. Jing practicing You put yourself in a position where at least you thought about what you might be confronted with. It's never the same as the real thing, but it does set you up better. And I often think, as the sort of military or as the Navy, we, we we will often do that knowing where we're going, Um, and while it's not always perfect, you know, it's it's a good opportunity. Um and yeah, I think I think if I was to reflect that back on the NHS environment and reflecting back onto my time as a as a junior junior doctor in hospital, I think sometimes you need a bit of time. Uh, and that's a little bit of time in between shifts or on a shift where you can meet with colleagues, have a bit of a download with colleagues. Just talk about that day that you've just had, because it's difficult. If you've been busy and it's been nonstop and you've not had that opportunity, you might find yourself in a position where you've not found anybody you can speak to and and and have that download and that is so critical, I think, to be able to deliver healthcare in a way that both protects you as a clinician but also the colleagues around you. So I I guess I'd reflect, you know, take some time out if you've got an opportunity, if you're in your your environment, if it's difficult, or even if it's not difficult to know your people talk about your experiences and kind of share that experience to to protect yourselves, but also help spot the people who might be struggling a bit and think about how you're going to mitigate that. That's brilliant. Thank you very much. Thank you for your wonderful doc. Thank you very much. So I think we'll move on to our next week, if that's ok. Um, so I'd like to invite the senate Colonel Nicola McLeod's mom if you'd like to take the stage for a presentation. Um, lovely to hear what you are going to talk about next. Thank you very much. Mom, are you to Oline? Thank you. Thanks. So, I mean, what a wonderful account of, uh, some truly, uh, unusual navy experience is I think I'm the army. Bit of this Navy sandwich, and I'm very grateful for the invite to speak this evening. I'm Nicola McLeod. Um my natural instinct is for crawling around in the grass. It felt like an interesting thing to do at work and, of course, are interested in carrying a resource facility in the back of a Land Rover or a pre hospital care berg and on foot, um needs a bit of flexibility in the way that we do medicine and the way that we lead, um, medics and others. So I I thought I'd draw a few ideas on leadership from some of my more formative experiences a military doctor and I think many of them, while not not identical in anyway, will echo a lot of things that that will has talked about already. And I hope that a lot of them will be quite relatable to you because one of the particular themes, of course, which we all benefit from is that training is such a big part of it. Training together is a big part of it, whether it's in medicine or in the military, and that really enables an effective leader, uh, to do their job in the most austere or difficult of circumstances. I think it's worth mentioning where I am now. Um, I have a very grand title, which isn't justified by roll necessarily. But the Supreme Headquarters of the Allied Powers in Europe, of course, is a is a big strategic headquarter of NATO. What much of my job at the moment is fairly sub tactical. So it's primary care in a very typical practice that looks after Children and families and actually quite relatively aged officers that, um, and the service people of various forms. Um, we're closely but not directly linked to NATO. And you can see that apart from the 19 sixties, less than supreme architecture is far from austere. At the moment, Um, the other part, which is arguably more complicated and and calls for more, I think, in the way of leadership and teamwork is corralling together the care of the defense diaspora in European turkey. So you can see they're a little picture of what the European Joint Support Unit does, with some 100 odd supported locations across many countries around 30 with a fair scattering of, um, start officers who, of course, have a keen interest in the health of people across Europe. So the jobs here involve lots and lots of liaison with national healthcare providers and all of those countries, uh, the various services, all of our chains of command, our own network of defense consultants and GPS and other healthcare providers and communication, of course, at the core of everything that we do. So this is about austerity, and that's not austere. But I think it's nice to know where where people are coming from when they're when they're speaking. Um, this is our our area of interest at the moment, which is larger than the Roman Empire. Um, but but back to back to basics, um, the more natural habitat, perhaps, of an army doctor. And I think anyone that's ever put Cabinet up in the dark in the thorny bushes of Kenya will know that teamwork is forged in training and leadership demands really become more taxing than this. Also, that sometimes it's important to know simply that you're just not the leader for the job, but really, what the military does offer is a vast amount of generic team training, whether it's planning or aqsa logistics. That really generic scenario allows for the respective seems to work under or with effective leaders. So and one of the big things that I think is is true for preparing for operations, which will brought out so beautifully was that things need to be resource constrained and non permissive to gain realism. Um, and you know, he talked about mu lodging. It's to allow clear things to happen in the pressure of the moment. If you've done it before in some form, uh, makes things easier later when you come to do the more important stuff. And, of course, the other aspect, which is really fundamental to military way of doing leadership, is ensuring that others understand your vision. So here it's fairly simple, and I wasn't involved, but often telling people what you're aiming for. You know, we call it Mission Command and some context, um, telling people what your vision is, need to work and eats orders, and it's explanations often needs an individual approach. So with vision and a few drills, a lot of the groundwork is done. So a few months after pushing the Land Rover up, that plank here is the same team short time later in Kabul were responding early in a tour to bomb that was targeting contractors. This is an infantry quick reaction force, and it's a BBC picture. The media are out. This is multi agency, it's joined. It's stressful. And it's a non permissive scenario. The infantry are perfectly doing their thing. They're cordoning and controlling, and they're allowing the medics the space to operate. That's the scene. We all know what we're doing. We've millage did it. We know how to deal with it. Uh, what, Of course you need the flexibility for, though is working out how you're going to move the car to get the kid out from underneath it So we don't We haven't planned for that. We haven't necessarily trained that scenario, but we do know the local people and have done our groundwork in terms of meeting the local leaders and knowing who to speak to and getting on with the police. So they called in more the local skip operator who was able to do the heavy lifting which allowed us then to extricate a young boy, package him off the hospital, and that wasn't it. I guess the big thing is that there's a lot of learning comes from every experience isn't there? So while we drilled all the kind of major incident principles, um, we work very closely in this scenario with a US team, in fact, directly with them. So we looked at what went not as well in this scenario and took it forward, um, and did a bit more work with all of the teams involved, whether they be us or UK walked through, talk through. We brought in the very responsive but less experienced embassy teams. There was lots of diplomacy, communication and the A's on. Um, and getting to know the people that we were planning to or thought we might have to work with was a big part of making sure we were prepared for the next big event. Defining leadership was really important, so establishing, who in fact had the control when everything happens, because I think that the big thing that underpins just about everything we do is getting the command and control to the leadership right in the first place. And then, of course, bringing together disparate teams in whatever way that took, whether it's all wearing the same badge or all using the same communications method. Um, you know, sending out Motorola's to to do something useful. This is the next scenario, then. So So that all that work over a couple of months really paid off when the plan was put the test. So this one was messy. We stood, too, in the ops room, it was dark. Things smell petroleum, dead people everywhere. Five people need to dig out different agencies, but a fairly simple vision. And And it was reasonably simple because there weren't that many hospitals that we would be using. Basically, one with not many beds, um, clear options to get back people back to those limb hospital resources despite perilous communications methods. You know, headsets that didn't fit under different nations. Helmets, etcetera, and understanding of the end game meant that about 52 people were extracted by helicopter or road in this scenario. So the big things I thought were worth drawing out of that was just that the stability of the team was really useful and important that that training for flexibility, um, we're very good at that in the British military, trained for the war, but also for a war. Um, knowing the vision or or indeed, Mission Command, depending on how how military you're feeling at the time and then having the underlying drills to be able to deal with anything that needs dealt with is is super important in all of the scenarios that I've encountered that I find challenging in my time, even when it doesn't involve trauma or big holes in the ground. And the other big thing that I often think about when I'm thinking about leadership in medicine is that we're often not in charge. So we are responding, particularly that you're responding to other commanders in support of them. And I think one of the big things that that I've thought through has been, um, leadership by influence. So making sure that you have the right relationships with the right people in order that you can, your voice is heard, you have a seat at the table, and so getting those things right in many of our shoes will will be an important part of of working with and for the military. And, of course, all those lessons trans well to translate well to medicine as well. One of it's one of the great careers that offers the coalface experience. Everyone does an apprenticeship. We're all mentored. All levels of responsibility. Um, we don't. We don't select our clinical leaders from all graduates. We treat we, we select them from people that have gone through the same experience as us. So to use a bit of an Army theme they've served to lead, you know, whether it's on the ward in the theaters, Um, they've got the flexibility of mind, whether it's from putting up cam nets in Kenya or the two AM cesarean. They know the team. People work in places. Granted, not all four month jobs lend themselves to this. But you generally work in a team for a few years and often come back to it in your consultancy, understanding that everything you can do to make things less austere even in the most austere of environments is really important. So more comms, more transport, better systems, better relationships and team bonding all very important. So to get us out of that particular whole, um, I I think this, um this sort of emphasize is some of the some of the same sort of messages I couldn't get through a presentation without putting a few parachutes and just to counteract all the ships. Um, in this scenario, we're setting up a 60 person or so medical team to respond to a non event so far, but there are lots of people landing on quite rough ground. So I think examples of how to do this Well, we're just planning handover cards and keeping everything in English and French just taking away every friction that we could wrecking things, looking in advance, um, preparation, preventing for performance and all that sort of thing. And it That brings me back then, perhaps to the the most austere thing I've done in the last in this job, which, of course, was at the point where everybody and we were wanted the covid immunization at the same time as the UK who was ahead of the game. Um, we were sort of I don't want to say forced into, But we were in a position where we wanted to be able to honor that demand, whether it was in the embassies or among our own m o D cohort. So it was, I think, um, to to some extent, um, Mission command or somebody else's vision that allowed us all the freedom that we needed to take a couple of cold boxes, make sure that everything was safe and and sort out the logistics to get round a number of these sites. Um, too, to put things in place. And that's just an example of how osteo the whole thing was. So I think the flexibility of logistics, the network that comes and they're working with these people do today All Echo's back. So while this is a little bit of a, uh, the less austere in, perhaps of what the the army, um, ask us to do the all the same lessons come to the fore. I'll stop there on the on a double chandelier in the ballroom of the Istanbul concert. Um, hand back. Thank you very much, ma'am. Thank you for your talk. Um, it's really interesting to hear about the how the army, how the army managed some difficult situations and the training that's involved, and I wonder whether you be able to tell us a little bit about what your thoughts are. So I know at the moment where you're working, it is It's yes, on the less austere end of the spectrum. Um, but I wonder whether you'd be able to tell us a little bit about what you think. Thinking back to your training days, thinking back to when you were a GP trainee or a foundation doctor. Uh, what do you think you could have done differently or what opportunities that you may have come across now that you didn't know about? Then, um would you have taken up on, uh, to to sort of prepare yourself slightly better or thinking about our other colleagues that are watching this watching this? What presentation? Any advice you'd give to them to help support with leadership development and being a bit more better prepared for difficult situations in the future. I think one of the big things that, as I mentioned apprenticeship and and being mentored at every level is such a valuable part of what we get in our profession. Um, so making the most of that in training is something that I would I might review how had approached it. Um, so you know, I mentioned the two AM Cesarean. It's putting yourself in the place to gain a really huge breadth of experience from superbly experienced people before you're in a position where you're doing these things on your own. So having experienced something once isn't everything but having a good broad grounding in all manner of experiences. I think it's a super opportunity that shouldn't be missed through the early years of our training. And we're lucky in the military and, um, with our civilian colleagues to have exposure to all all manner of different training opportunities that probably aren't available in all walks of life. Whether it's, um, you know, elements of prehospital care if that's your interest or the aviation medicine side of things which many of us take an interest in or or whether it's occupation medicine, it's about broad exposure. And then perhaps, um, taking the opportunity. A lot of us in this cool have, you know, general duties time. So time before you have the real responsibility of being being out there solo and in charge, um, to hone your skills and drills so that when you become a leader, you're able to, you know, train those into others. That's great. And I think we've got 11 question in the Corona box. Laura Eadie. Yeah, so thank you, Tom. So how do you find the balance of leadership between clinical leadership and logistical military leadership, which may or may not have direct clinical consequences. So if I if I think about it's not, I suppose there's logistic leadership. And then there's broader aspects of the kind of the command side of things, whether it's planning, etcetera, I think striking the right balance is tricky at times. Um, clinical leadership, of course, is such a broad spectrum statement. You know, it covers everything from master of your craft and being good at what you do and mentoring your juniors and doing training, um, to standing at the end of the bed in in the event of a trauma if you're the e. D. Red or consultant. So I think it it depends on what role you have at the time. Mine's very evenly split between, um, sort of policy and command and thinking about logistics, of vaccinations and things to doing general practice and seeing real humans and trying to treat them in the best way anyhow. And remember, you know what to do with the types of people that weren't in my 30 to 40 year old, mainly male practice, um, five years ago, Um and, of course, the the challenges of of communication in the European environment. So talking to other providers in other countries. So I think that that the balance is hard to strike and that that that's the value in, uh, and making sure you thought through your job plan before you embark upon it. So you're not working Saturdays and Sundays. I think that's worth saying as well and taking the time that will mentions to think about things in between events. Thank you. Thank you very much, ma'am. Thank you. Your presentation. Um, I think we'll move on to our final presentation, which is coming from Lieutenant Commander Steve Andrews. He's going to give us an insight into, um, the setting up of the medical logistics and the medical capability in Norway. So over to you, sir. Thank you very much. Can you hear me? Okay. Yeah. Um, so Good evening, everyone. My name's Steve Andrews and a bit of background on myself. Been in the military 26 years. Start off. My military career is a roll marine. Then I got bitten by the medical bug about three years in sided, Specialized as a medical assistant. Certainly specialized as a radiographer and a sonographer and then around about 10 years ago, took a commission, and now I'm a medical services. Also just posed the NHS equivalent would be something like a, uh, an NHS operations manager or something like that. Um, So I'm going to talk to you about basically leading a change project, which is all about developing a medical force able to operate in extreme cold weather environment. Um, I'm happy to take any questions about wider leadership matters have finished four years in Commander the Commando Medical Squadron, Uh, which up to 100 and 50 people who did everything from, uh, single to medical medical assistance, right? The way up to deployable surgical teams. So I'm happy to take any questions on that. So I'm just gonna see if I get this presentation up. I'm just going to switch my camera off when I do this, because I have terrible Internet in Little Devil. Uh huh. Brilliant. We can see that. You can see that. Okay. Uh, so hopefully you could both see and hear that short slide, that short video. But the aim of my presentation is to give you a broad overview of of a change project which we looked at, which was developing world class military medical force. Able to operate effectively in the extreme cold weather environment. The project covers all aspects of what is known as the operational patient care pathway. But this presentation mainly focuses on the developments within the role to space. And for those of you that don't speak military, that's the sort of deployed hospital care space where you could see things like an emergency department. Uh, damage control, surgery, intensive care sexually. Um, so I'm going to cover. Firstly, why did this change project come about? Uh, what we've done about it? Two dates right away from late 2018, right? The way up to just a few weeks ago. And what's happening next? So, looking at some of the global strategic factors, why this change project that's been brought about? Um, the high North is changing. Uh, global warming is bringing about access to what's probably going to be an all around your shipping route. Uh, so think of a second Suez Canal. Um, And as the ice sheets melt, there's minerals that become available energy. Marine liberals, uh, Marine resources. And this, combined with a revitalized, aggressive Russia, is seeing a change both in the environmental aspect of this, uh, this region, but also the military aspect of this region. I'm conscious of the, uh, the level we're talking about, so I'm not going to go into too much depth over certain things. I'll be deliberately vague more than that. So that is a strategic level. Then we can look at some of the national strategic level about why this change project is needed. Is this something called project time? Go. Uh, this is all available and open source, and it was first signed off in September of 2018. And this is a bilateral defense agreement between the British and Norwegian government's, and it basically says that, uh, the the High North will become one of the key parts of the the UK's defense strategery, and this was reinforced by further publication in March of 2022. The Royal Marines are the UK's Arctic Specialist Force, uh, Met Squadron, which I used to be in charge of until a few weeks ago, provided the majority of medical support to the role Marines hence from a medical change point of view why I was brought into it. And then if we take it down to sort of tactical level, why we need to bring about this change project well, the Royal Marines and Med Squadron and really the rest of the UK military had decades of experience of operating in the hot and temperate environments. So think of Iraq, Afghanistan, places like that. And prior to 2020 the last time a large medical force deployed into the Arctic Circle 15 years previous. Now people move around a lot in the military. And if you stop doing something for 15 years and this is equal applicable to the civilian sector very quickly, you'll find that the, uh, the collective knowledge and memory of the organization goes and things that would have been very, very routine, and people would have been all over it. Those, uh, those skills, actually quite quickly operating in minus 30 is extremely challenging. And both personal and team schools need to be developed to, uh, thrive in this environment. Uh, just remember, bit of research it If you're thinking, uh, well, basically, I googled the optimum temperature to do surgery, and it's between 18 and 21 degrees. Now, if you're trying to do surgery in that temperature inside a tent, when the outside temperature is, say minus 30 the logistical challenges of maintaining that 50 degree temperature difference can be quite a challenge. So we needed to start thinking about how we're going to do this sort of stuff. So what happened today and this is basically a journey I'm going to take you on now. So I was notified of a project tangled in November of 2018. Talk about a month to sort of filter down the military chain. Um, I knew that we had a problem. What I didn't know was the size, scale, taste, color of that problem. So, uh, the think of us, we could either go to the Arctic, spend five years, maybe 10 years, making mistakes, learning from those mistakes, and we're finding that way. Or we could just look for an organization that was pretty good at operating medically in extreme called Web environment. Perhaps not surprisingly, if you're looking for a force that's good in operating in the far north of Norway, well, the Norwegians is probably a good place to start. So, um, myself and four others of my team, we basically embedded ourselves within the Norwegians, uh, for one of their major medical exercises. And we look both both in the deployed hospital care space, but also forward into their role one space. And we followed them for about five weeks and we came back with a report, and this report was where I graded we were, as in med Squadron. If we have to deploy medical facilities into the extreme cold weather environments at that time, and it's graded on five function's really how we would validate the facility. So Commander Control, deploying, established treat, maneuver and sustain. Um, and it's rag scored. So green is good, red is bad, and you can see there that things were looking too great. You know, we we needed to do a bit of work here, and from that came nine recommendations. We've just seen that Let's go through a couple of these. So first, almost about infrastructure. The top right of this slide, you can see the tentage we were using at the time, which was a canvas tent with metal poles on the inside which works perfectly well in the temperate environment and the warm environment. And it worked pretty well well in the art environments. Once you had a heater in there, the problem is, is intensive, designed to be moved and so snow would land on the tent. The tent was warm, snow would melt and the canvas would be wet but not leaking. You come to move, you turn your heater off your canvas as then frozen solid within a few minutes. It's just like trying to fold up corrugated iron. And also the metal poles inside would have all frozen together surround to boil kettles when we're doing this temperature trial to to separate the metal poles. So this this wasn't really the Norwegian issues inflatable tents for a reason in this environment. So we looked at that model. We looked at different types of tents and we decided on a on one we've just seen on the bottom left of the slide, which is a German type tent. Another example here is how we move large amounts of medical kit in the, uh so basically, this picture on the bottom left is how we would move basically surgical facilities So they go in these things. For isil containers, you can have things called reefers, which are ice containers that can maintain a temperature with through that story of conditioning or heating. But we didn't have a method at the time. Uh, if we were transiting from A to B to maintain an active heating on that kit. So normally this isn't too much of an issue. But if you think this is full of all the stuff, you would need to deploy a hospital into the fields or anything fluids too electro med equipments to plastics. Well, if you're driving from me to be and you get to the far end and you open up your container and everything is now at minus 30 you've just written off all that kit because all the drugs have run out of temperature range your fluids of all frozen. All the batteries in your medical devices would have all died. And so, uh, we come up with a method of clipping a generator onto the side of these containers so we can maintain the temperature during transit. Another one was introduction of a pan. CMG stands for commando medical group, cold weather warfare medical training package now to operate in extreme cold weather environments. There's a course for absolutely everything. Card and go outside of wire the camp until you've done your five day survival course. Can't drive a car until you don't know when I was driving course, but never since the late sixties of when the Marines first started going to Norway. Have you actually developed a course? The talk medics to be medics in that environment by the term. Medically, I'm using everything that covers everything from medical assistance right the way to a consultant surgeon. So we decided to develop a course. It's gonna be in two parts. There's gonna be a weekend to day package during the pre deployment training and then a five day package in the snow. And it was designed to basically cover three things. So, firstly, the changes we need to bring back to the way we normally talk to do our business to deal with trauma casualty In the extreme cold weather environment, we start stripping after casualty, and it's, uh minus 30. Just killed your casualty. More training on cold weather injuries. So things like hypothermia, frostbit, things like that and then injuries associated with cold weather. So stuff like carbon monoxide poisoning or respiratory illnesses. Another recommendation was a compulsory pre deployment package. So we could get the teams together before we, uh, deployed out to Norway and developing that really important, uh, team skills, individual skills developing the robustness, um, some medical training and also hands on the kits. They're going to be using it for the first time they put the facility at. It's not a minus 30. They get to do it in the, uh, the cold wet of Dartmoor before they do it in the extreme cold of normal. Another recommendation was tailored three week, uh, cold weather warfare package. So the top part of that that slide there, that shows the generic three week package. So there's a survival phase. There's a mobility face where the troops have learned how to skip. And then there's a tactical phase there where the whole thing's fall together and there's a tactical element to it. And then there'd be continuation training on the back. And now, now my thinking was here we should use this time more applicable to what the job or will actually is of the medical person I love their Whether that be the consult decision, the dentist, the GP, etcetera. So the first phase it was exactly the same as the generic phrase the, uh the five day cold weather survival cause we then brought in a phase where, um facilities were set up and people got used to doing their role in extreme cold environment, but without the tactical element to it. And then we brought in the tackle element to it, which covered things like, uh, defensive positions. Recchi inciting the facilities, etcetera, and then medical training from the Cold Weather Medical Course, which I just briefly spoke about. Uh, and perhaps the most important of the nine recommendations was improved coordination with the Norwegian medical elements for future deployments in order to facilitate a coalition patient capital. Um, and this is all about, um, developing the skills, the relationships. So if we are doing this for real, we're able to seamlessly transfer casualties into, uh into each each other's healthcare systems. And I'll talk more about this in a bit so you can see the the initial team that went in there from the picture on the bottom. Right. Um, I lead the team. When I looked at the sort of overall commander control of how the Norwegians did their business person on the far left of that picture, he's a row Marie Mountain leader and he he's basically an expert in, um, from a British perspective, the wrong perspective, how we operate an extreme cold weather environment. So he he was brought in to really look how we would map the medical elements or the proposed medical way of doing things across to the standard military. Right? There was a guy looking at the G four aspects. Uh, there was a consultant TD consult important, who was looking at the clinical aspects, more sort of outside of the tent and then a an o d. P to look at the the equipment and the procedures inside the tent. So we came back from that we went and then into a period of resource in refining where, um uh probably change project point of view. We basically beg, borrow, stole, lobbied anything to get the resources and funding we needed to, uh, to realize this ambition prior to deployment on after deployment 22,020 which is a is an exercise really in the deployment, which spans from early November 19, regulated up through April 2020. So we're running that deployment and there was a a structured eight phase pathway to reach what's called IOC or interim operating capability. So, uh, one of those chemical exercise snowflake, which is a multinational, uh, medical exercise, uh, which had the theme of patient care in the extreme cold weather. Right The way throat we ran into that, um called weather warfare phase, which was the survival phase. The nontaxable phase in a tactical phase. A cold weather medical course that you can see down there, um ability, face and interoperability face and then finished on Cold Response 2020 which unfortunately, was brought to a close early because of something called covid 19. Um, when I was talking earlier about a collective memory of an organization and showing draw your attention to the picture on the, uh, the bottom left of this slide. And what this picture basically shows is there's a, uh, a Land Rover with the trailer on the back of that trailer is generator another back that generate you got some power leads which are going across the term across. And then just after the right of that picture, there is a surgical 30 and those, uh, generate, it's placed in power in Electromatic and inside that facility. Now, this is really low level business. When it comes to running these type facilities, it's more sort of that the corporal business, maybe Sergeant business, maybe private business. But, uh, these power leads when they have power, go through them. He to that sits on permafrost, permafrost will melt, and these power leads will basically sit in a kind of gully of water, which is fine as long as there's, um, power going through them. The problem is that minus 30 you switch that generator off very quickly. Your power lead is frozen into the permafrost, so things like matting being put down on the floor to raise power leads off so it wouldn't melt into permafrost. You could move your facility when you wanted to. That sort of low level, uh, memory need to be built into the organization. Uh, and the picture on the bottom right of that slide is, uh is Laura's husband grabs. So we came back from our deployment 2020. Uh, we started it with nine recommendations. We came back with 19 recommendations, as you can see there, but we achieve the aim and we were IOC. We were safe to deploy medical facilities into that extreme cold weather environment. But there's always more work to be done. As I said, the final exercise, the large nature excise, got cut short because of COVID 19 and, uh, the winter deployment in 2021 weeks. The Royal Marines will go to Norway on last every single year. That always had modern, moderate aspirations compared to 20 and 22. Um, but it really from a medical point of view, there was very little training. There was all real life support, um, trying to get a grip of covid 19 amongst the population and trying to avoid any sort of reputational damage. There was no large NATO exercise at the end of 2021 but I think us losing out a lot of deployments probably delayed fo see somewhere between 12 and 24 months. I think that's probably quite a bit say across a lot of organizations from Covid um, the summer cane of 2021 copay was left in in the I think starters operating again. There was a large Norwegian medical exercise far north of Norway, and we embedded a small UK team into the Norwegian operation here. Cash way. Uh, I had in probability and defense engagement throughout and that that picture there is taken in the very far north of Norway. Uh, and that picture is actually taken at midnight. You can see it really is the land of the never setting sun of that time of year. We then ran winter serpents, uh, which is the pre deployment package, which I spoke about earlier in, uh so over November 21. So phase one, get all the teams in, you administer them. You make sure Evans got the right kit. They're all issued with the right extreme cold weather equipment. There was a a military skills package which had two fold. Really. One was to develop their military skills, but the second part that was developing the teamwork required for operating the extreme cold weather. And then there's part of the cold weather medical course, and it really operated as a safety check. So, uh, myself, as they were seeking, identify anyone who was really spreading it earlier so they could be afforded that extra support prior to deployment. So pre Christmas there was activity between November uh, December 2021. So various cold weather survival courses, cold weather both, of course, is called weather Medical course has been delivered. And we established the M. R. S. So think a GP led primary healthcare facility in the main bridge based in part of Costa and part of the, uh, the base in town from Northern Normal that we removed to a different location. Um, at the end of December, prior to the, uh the new year where the exercise started proper, uh, there was a NATO Cold weather operational conference which had a large medical element to it, which babies which people attended and spoke up and also attended by all the different sort of natures. Natures. Um, an interesting to see is it's not just us as the bricks that realizing, you know, we've taken the I up our ball of operating extreme cold weather environments. This this is shared across all of NATO. And there was a NATO cold weather medical instructor's course pile, of course, delivered in November and early December, which I think I've got Victor. Yeah, picture of them. So it focused on, um, medical care forward of the, uh, the hospital space. And they're very much focused on you, keeping casualties warm. The best methods to do that prolonged field care, the sort of considerations you need to think about when you're operating out of the tent. Um, the best ways of carrying medical kids. And it was really designed to teach these medical instructors to then go out to their various different units, whatever nation they may be and deliver this trading very good course. Post Christmas. Then, uh, we had very similar 2020 and eight phase package to be delivered. Uh, I still flick tailored course Cold weather medical course in probability exercise with the Norwegians and the USMC, um, prior to building up to what was going to be exercise cold response 2022. Mm. We have combating that throughout. We still have to do at that stage nonsymptomatic testing. So anyone moment anyone could be taken out and put into quarantine The principal believe instructor of Cold Weather medical course, uh, got taken out around about 12 hours before he was start to deliver his first lecture. So, um, from a leadership point of view, you have to really have some resilience in your plan when anyone gets taken out in a moment. Stories. Uh, there was also this guy as well. He messed with with our plans, and large elements of the squadron were called from Norway and had to go on operations in, uh, Eastern Europe. However, the face plant did roll ahead. Exercise Snowflake did still happen. Um, and you can see from from the picture on the top left of this slide when you're delivering medical care in this sort of environment, the sort of things you need to consider so you can see this is inside the tent. There's some palates which is raising the casualty off the floor, which is then the stretcher with a roll mat on the stretcher with what's called a a blizzard blanket, which is a really good bit of kit where you can put your casualty inside this. And if you want to check a pedal pulse, it basically has. It's a little bit so you can unzip the, uh to gain access to the patient street et cetera. So this is some of the sort of specialist kidney cancer called worth 12, Of course. Uh, so, basically two days in the classroom, a night how to operate and live in a 10 man tent just top left a four man tent and then a survival night in a snow whole Prior to it, everyone doing the, uh, famous icebreaking throws setting up the facility in the non tactical environment, you can see you picked on the top, right? That is a put of the surge facility there, slightly bigger than what you see in the UK, because whilst in the temperate environment or in the warm environment circumstance, you can do your triage outside. You can't do that. You need a heated area to, uh, to try as patient's can't do that outside the town. Then we brought tactics into it. So considerations of Recchi citing camouflage, different types of work routines. Um, exactly called weather medical course, uh, which was Norwegian and British delivered, and students from, uh, the UK Norwegians and mountains tackle mobility phase. I've got this down as a phase six, but really, this sort of happened throughout where the drivers in the squadron are very good at driving that sort of environment, seen on the top right of the slide, that considerations of driving in those sort of conditions we see on the left hand slides need to be practiced and rehearsed. There was a big improbability medical exercise with the Norwegians and U. S allies, and this worked on a a three phase plan. So Phase one, because we'll go to this location and we all set up our facilities quite close to each other and you can walk around. You can see where the Norwegian Norwegian city looks like. You can play with their care. They can do that at the American facility, etcetera. Phase two then was practicing the the implications and the feasibility of moving patient's between each other's facilities. So what's the So what of a Norwegian patient's go into a US roll one. So a US forward medical nodes then say British role to to the end a American tacky back taking the castle further down the chain to a say Norwegian roll through that stuff is practiced. Um, and this this low level stuff is important. So does the American Toobin fit on the British ventilator. Does the Norwegian stretcher fit on the British? Pressel's things like that and then Phase three was mixing the teams up so I can. What's the So what's of taking the Norwegian surgeon to put in the British facility the British Medical Stick them back Norwegian ambulance, the American Edie consultants and put in charge of a British and Norwegian t working off British kit. Things like that? Well, that was going on. There's also a Arctic hems course delivered, and finally, then it finished with poor response 2022. But this was lesser in its ambition, because large elements of the of the force of the cold preparations uh, so likely future requirements. Then I've separate this out the 1 to 2 years spaced 3 to 6 year space and the 7 to 10 year space. Uh, this isn't, um, defense policy or, uh, well, the party. This is just the world called the sleeve bandage. So I think the ones to your space that medical course needs to be piece that compliance. Um, Norwegian attendance of various British exercises into 3 to 6 year space. I think we need to be validated facilities in the extreme cold weather. It's all very good validating the temperate environment to be taking good to go there. Are they really good to go in that environment? Um, some additions to some of our medical modules. So a fiber one module has primary help. Their modules. So what sort of, uh, consumables and medicines do we use more of in the extreme cold weather around? Uh, 3 70 module is the role to module. And so things like this would be if we're doing a casualty transfer, Uh, post surgery further down the chain. Um, we'll need more batteries for all the different electro med. Because batteries don't last as long in extreme cold weather. Clinical placements in the optic roll, three in trams. Oh, and then longer term things like foreign service exchange assignments. So Norwegian working in, uh, met squadron and, uh, World Navy medic or Omary medic working in Norwegian Med Italia, uh, language courses in a permanent store of VH. Our medical kicked in the, uh I know in summary. Then I spoke about why this change project was brought about from a national and global strategic reasons and the low level tactical reasons. What's been done to date, right the way through from product time. They'll drop it on our lap in November 2018. Right the way through. Too often. Deployment 2022 which just finished in April. And then, uh, what we're doing next, both in the near middle. Uh, there's a couple of references. All right, that concludes the presentation. Okay. Okay. Thank you. Thank you very much, sir. Thank you. Your presentation. It's really interesting to hear about the challenges that you have. Um, developing such a such a course in such an exercise over the past few years and how it's more often changed as the exercises has moved from one place to the other. And I wonder what the thinking back on, what you have have done over the past few years, what the team have done. How do you make sure that how did you make sure that you have covered all aspects prior to going away to Norway for the first time? And and did you reflect and evaluate on each part of the plan and change it accordingly? Um, yes. There was a lot of reflecting and evaluating after each phase because, uh, certainly in 2020 is the first time any of us that had done it before. So we were there. We had a plan, but the plan did change. Um, and beer and hold as we were, we were delivering it in the execution of things. Um, just repeat the first part of your question again. So, uh, so I said, how did you make sure that you had Coverdell aspect so of the exercise prior to going away? So how did you make sure that every aspect of the exercise were covered when you when you went away? Uh, so a lot of it was I was planning we brought in. Um, So you basically look at the team and you look for, uh, previous knowledge, Um, stuff like that. So, um, what I would say is, when it comes to planning this sort of thing, it's a It's definitely a team sport. You know, as many people in on what? In the military, we call it the estimate, how you're going to do it as possible. Um, and also that has another added advantage of people are brought in, uh, irrespective of what rank beyond the military. They then feel some ownership towards the problem. So that was That was really, really good. And given that the there was a lack of experience that working in the cold weather environment from the British from Britain's military, did you think about accessing or did you access? Because I know that I'm sure a lot of us know about. There's lots, of course, is available through, for example, through when through the Wilderness Wilderness. And, uh, what's the word called, uh or lost it So wilderness training that is available. There's lots of packages about polar medicine, etcetera. Do you ever think about experience and medical care and those respects at all when making when you're planning and taking on advice from from outside agencies at all? Yes, certainly people with previous experience of going to the South Pole or something. But they were. They were intra mental in some of the shape, nearly shape of the cold weather medical course, Um, and also the memory. Earlier I spoke about the role Marine Mountain Leader Um, he was really useful as well. Well, what's not medical was able to sort of transfer the the bricks, the previous British tea GPS operated night environment and put it in a medical spin on it. So that was that was it? Um, Laura, do we have any questions from the from the chest home? Yeah. So we've got one from the majority of medics that were involved with sex. Eyes were embedded in the NHS. Well, will they be able to take away from the course when returning to day to day work and UK hostels? And how will they be supported in maintaining these hard won skills? Yeah, it's a really good question. Um, I'll answer that question back to front. So maintaining these hard won skills, obviously that eight phase package there, that's not including the final exercise. That's 10 weeks. You're asking if someone's life even before you consider two Weeks PDT. So one thing we did try to do is once someone has received that training, we we tried to hang on to them. They were a a valuable asset, and part of that is making sure that the training they do receive is, uh is applicable to them. And it's enjoyable as well challenging, but enjoyable because you want them to come back. You want them to come out in the next Norway and feel part of the team and developing that really, really important TV bus, Um, take with my cohost and returned the day to day work. I think one thing that was ever that certainly from the the early part of the training was a lot of people said it was the hardest thing they've ever done. Um, the cold, wet survival course and things like that. So I think it's helped develop the robustness, which I think they'll be able to take back to the, uh to the UK Whilst you know, we don't expect out of hospital to be at minus 30. Um, some of the the challenge is I think that they faced in the outcome would help them back in the energy. Just, um and I think the relationships have developed as well. Reject were really important. That's great. Thank you very much. So thank you for your presentation. Um, so I think we'll just move on if m if all the presenters with my interest pending on their cameras and I know that it's a bit a bit type of time starting to overrun. So I think what we'll do is, I'll just ask a general question to you all that hopefully you might all have some interesting thoughts about moving forward. Uh, and if anyone has got any questions for any of Panelists or any questions, particularly about defense medicine at all, then feel free to put in the box while while we're discussing this question. So I think I'm going to open with just a very generic question of thinking back on your experiences. So as as a leader through recent times and more senior leadership and earlier on through training and through, um, even right back to medical school. Is there anything that you would change or that you would do differently? Uh, thinking back on your experiences when, for example, if you're talking to trees or talking to other colleagues about supporting and about encouraging, um, their skills and development over their careers as a clinician. So anyone is willing to start. Should I should I jump in there? Megan, I think I think, um, one thing I reflect on, um, is reflection. Actually, that sort of personal reflection, I think certainly when when I was a junior, I was very much jumping through this sort of academic hoops of getting to where I needed to go, but actually one of the really powerful things I've sort of noticed. And I know we talked a lot about reflection general practice. But I also did some some work on a course where I was sort of given a coach, um, for a few few hours over the course of a few months. Uh, sort of professional coach is actually, it's incredibly powerful. And just taking some time to think about who you are and what you're doing. And what you want to achieve is hugely beneficial and rewarding. And although I haven't done it yet, I mean, if you can find a sort of mentor, I think in a professional environment, um, as part of a sort of mentorship program that's probably incredibly beneficial. Find those kind of peers who you aspire to be like, and you can take stuff away from, I think is probably the advice I give to my younger self, not just go for those hoops, but kind of step back a bit and think about who you want to be and how you want to perform. Thank you, sir. I am. I mean my my thoughts echo wills in terms of finding a mentor or people that inspire you, Um, and then making sure that they know where they're able to impart the bits of them that that you respect on you by putting yourself in a position to speak to them and and learn from them. But another aspect of things is perhaps, um, this is a good lesson in it here, um, being able to get your message across. So I don't know that we do a lot of communication training one on one, don't we? But I think part of being a leader is being able to impart what you want to happen and to communicate well to peers. To seniors, the junior is to whomever you're talking to. So I don't think that's something we train at very well, and it's something that is certainly worth considering. And then the other bit that I find myself doing a lot of with virtually no training, um, is sort of project managing. So Steve's presentations lovely in that regard, you know, it's a country through how to how to manage a project and how to take things from an idea to actual facts. Um, so So doing a bit of work on that perhaps a little bit earlier in my career would have been something I might have changed. Thank you. Um, I'd probably say I'd give myself younger self two pieces of advice when I say my younger self, I'm probably going to myself about five years ago. Not the, uh, younger Steve Andrews. Many, many years ago. Um, the first one is when you're leaving, the team is and the military terrible. This we take a lot of things for granted. Take a lot of other people for granted. So because everyone's doing a, I don't know, an 18 hour day or something like that. You assume that's normal. And so one thing I would say is I would sing the praises of my teams. People have worked with more than I, uh, more than I did at the time. Uh, the second one is is look for enjoyment and have fun because those sort of unique, uh, situations will find ourselves in throughout our careers. They They've gone very fast before. You know it to sit down the best. Yeah, Absolutely. No, that's great. Thank you for your for your for your thoughts. And I think, uh, Laura, do you have any any other questions or any thoughts or or speakers? Yes. We haven't any other questions. Last call for any questions on the on the on the Q and A, um, quickly. So there is some one that asked about thought processes. So perhaps when you're dealing with some of these difficult situations, how do you have you got? Have have any of you got a mechanism for how you kind of process process those those challenging thoughts? I'm a massive fan of something called tepid oil. Uh, explain what that is so tepid. Oil is in your monitor. So if you're presented with a problem, um, you write down tepid oil on a bit of paper. So tea is training. He is equipment, peers, personnel. I is information. So I think comes. He is doctrine. Oh, is organization second eyes infrastructure in the final hours? Logistics. Is there any problem you come across? If you break it down by type of oil, you're probably going to get around about 90% of the answers or you'll consider 90% of the facts. Um, there's also a tepid coil. If you're a punishment, you want a clinical aspect of it. Fantastic. A brilliant, brilliant take. Take away for people, people there, I think another audience member I did have thought I I quite like a bit of tepid oil myself when it's big and complex when it's small and complicated. Um simple, simple know Monix have served well, you know, whether it's CS Catman Control, Safety Kam Sestriere Get those sorts of things have just been a really good handrail in some in some otherwise very difficult to handle situations. Yeah, thank you. Yeah, I would I would absolutely sort of echo that. I think you know, I was thinking the other the other day about sort of anchoring, which can lead to sort of cognitive bias and stuff. But actually, if you can find something, that's the familiar thing in the scenario that you're facing, whatever that is, whether that's you taking a step back at the end of the bed to look at what's going on, whether that's that familiar bit of kit or that familiar kind of patient presentation just finding that that commonality that you've all that experience that you you might have had some familiarity with before can be quite, I think, important in terms of understanding where you're at so that you can sort of take a big breath, think about what you're about to do and then crack on. I'd like to I think we're gonna bring it to close Now that we've run over a little bit, I'd like to thank all of us speakers very grateful for your time. And we're all different time zones as well. So thank you very much for taking part. We really appreciate your your thoughts. Um, your time that you put into the presentation and and listening to your stories, um like to thank the all the attendees for coming to the webinar. It's lovely to have a good turnout and thank you for your questions throughout, the webinar will be recorded as being recorded. So hopefully we'll be up on the website soon for you to share or to watch back again. Um, and I just like to mention again that if you're interested in learning more about the training steering group or about the faculty of medical leadership and management, there's lots of resources on the website. Um, and lots of useful information to help with learning and learning about leadership training throughout throughout your career. Um, thank you again to everybody. So, uh, just be clothing off now and, uh, signing off. But thank you again for coming and hope you have a lovely evening.