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Hi, everyone. Uh Thank you so much for coming to the um extreme surgery session. You're all very welcome. Um So we've got two speakers today. Um I'll be inducing Miss Clara Owen Vila. Uh So Clara is a trauma and orthopedic ST seven based in Liverpool with an interest in major trauma and limb construction, reconstruction, surgery, and humanitarian orthopedics. She has a wealth of experience in the field of expedition medicine and having covered expeditions across the world. Um And today she'll be talking to us about her work. You ran close to throw the hi, everyone. Thanks for having me. First of all, I just want you to have a think about a question. So, what would you do if someone told you that you could have six months or a year out of training or for being a consultant and you could do anything you wanted. It doesn't have to be to do with medicine, but you could do anything. So, just have a think for a second. What would you do? Because that's not often a question that we ask ourselves. Um And uh if you want to come and discuss that with me afterwards it'd be, I'd look forward to hearing from you. Um, so I've already been introduced, but yes, I'm ast seven orthopedics up in Liverpool, um, and an expedition doctor as well. And, uh, hopefully today I will dispel the myth about taking time off training. Um, and also hopefully show you that doing things slightly differently is a good thing and should be encouraged. So I'm just showing you my training timeline just because on paper, I look like I've gone through step after step without taking time out. But actually, as you will see, I have had time out training to do lots of different things. So it's possible and there's lots of different routes to doing that. So I er studied in London and then I did my foundation years up in Newcastle and then I was a uh firmly converted to the North, but I switched sides and I did my uh core training in Mersey and this was the first opportunity that I had to do something slightly different. So when I got my T three number, I deferred my entry by six months and I decided to go and live in Mozambique, working as a diver and as a dive medicine doctor. So this is one of my photos. The guy on the left was my neighbor and these guys had just caught this big Marlin. They're about three K from land and they were high on life at this stage. But being in Mozambique it was the first time that I'd been in Africa and this experience had a huge impact on the trajectory of my life and also the trajectory of my career. Um It was the first time I had experienced such a different culture and these guys are just catching their version of the bus and obviously much lower resource area compared to what we're used to. It was the first time that I had experienced the handling of major trauma pre hospital and seeing that there was obviously significant differences into how we deal with stuff here. What I was exposed to was lack of scoop ambulance services and also just the management of general conditions, the neck of femurs being managed as outpatients and the open fractures being treated extremely differently to what we used to hear. But all in all being in Mozambique and living there for six months was something that very firmly made me realize that I wanted to incorporate humanitarian work into my career. And it's not something that I would have thought of had I not had that opportunity to go and do something different. So returning to training, a lot of people worry about your commitment to surgery and this is what a lot of people come and ask me. But actually being away, you realize, oh, I realize that I love my job. And so it really gave me aba new burst of life when I came back to training as an ST three throughout my work as an NHS doctor, I've been involved in expedition medicine and the things that I particularly am involved in are mountaineering diving and marine research. And then I cover some sports medicine as well within the UK. I'm one of the GB judo team doctors and I cover things like London Marathon and various ultra marathons, etc. So, why expedition medicine? Well, for me, I love being outdoors. I'm very sporty. Um, so it's a win win situation but it's something where you get, you can't get anything like it working in the NHS, it gives you a lease of life every time you go away and it just brings something different to you as a person. This is one of my colleagues. We worked together many times in Kilimanjaro or in Kilimanjaro. Has anyone ever been there been up? Ki? No. Uh, so that, that's one of the landscapes that you see when you're, when you're climbing up. But yeah, you get to meet lots of different people, travel to lots of different places and it's a pretty special, er, and privileged position to be in. So, is it easy if you do it properly? Not always, there's lots of things to consider. It's quite a big responsibility and it's very different working in the, we used to having lots of people around us as part of our team, but when you are the sole expedition doctor, you're very much on your own and it's a very different way of working. You have to make some quite difficult decisions depending on what kind of expeditions you're working on. Some people would have been training for this event for years. And sometimes you have to be the person that ends up pulling them back at the end. If for whatever reason, you don't feel that they are fit to continue. So it's some difficult decisions and some difficult situations. And also it's the kind of environment where everything's fine until it's not. And then you have to be prepared to deal with whatever it is that happens. So what skills do you need? Well, depending on what you're going to do, you need to just be proficient in whatever it is. So if you want to be involved in mountaineering, you have to have experience in mountaineering. If you want to be a dive medicine, you have to be a pretty proficient diver to make sure that everyone that you're with stays safe. But what I wanted to show you was this. So these are the things that I think you need to be a good expedition doctor. And I think you'll all agree that these are all things that you'll probably see if you are looking at a surgical desirable criteria section of an application form. So there's a lot of transferrable skills that are required in both expedition and surgical jobs and you have uh but yeah, lots of transferrable skills. So what does it entail. So for me, pre expedition is the most important part of the expedition. All of your work happens at this point and if you neglect it, you will pay for it when you're on expedition. Um So as you can see, medical kit list depends where you're going to be. Um But you have to try and pre empt the kind of problems that you're going to be dealt with. So, are you dealing with high altitudes? Are you going to be in a jungle environment where infectious diseases is probably going to be the thing that you need to think of hyperthermia, hyperthermia, and altitude sickness, et cetera. So you need to make sure that you're taking everything you need. But at the same time, most of the time you'll be carrying everything with you. So you have to be selective. What does it entail? So the thing that I love most about expedition medicine is the planning in case something goes wrong. So when you're doing pre op plans for surgery, you normally have a plan A B and C and the same is, is for this as well. Can often be on expedition, especially if you're on the longer expeditions where you may have good access to health care for the first couple of days. But then by the time you get five days in or a couple of weeks in, you have no access to roads and then you have to start thinking about whether or not you can get helicopters in to evacuate if you need it. You have to start thinking whether or not you have phone signal. Do you need satellite phones and having a plan for every eventuality at every point in the expedition? And like I said, if you don't do this, then you'll find yourself in a situation where shit's hit the fan basically. And you have to be thinking about logistical stuff, which isn't really what you, what you want to be doing at that point in time. So knowing your team and knowing your clients is obviously very, very important and knowing this before you go away, um you need to make sure that you know about their physical past medical history. But mental health is, is a really important thing to know about before you go on expedition. Obviously, having a mental health problem does not exclude you from expeditions, but these conditions can be exacerbated in stressful situations. And it's something that again you do need to be aware of. So you can support whoever it is that you're with. And uh so my best advice to you is prepare as much as you can so that you can then relax when you're on expedition. And don't let this be something that you hear when you're halfway up a mountain. Because luckily for me, I heard this eight weeks pre expedition from someone who was planning on taking their CPAP machine up to 5000 M, so speak to your clients first because they will also fill out medical forms and say that they've got no problems and then you find that they do so out of program experience. Has anyone heard of s before? Yeah. So if you're a trainee, these are really incredible opportunities to do something different and know that your job is there. When you come back between ST four and T five. I was very, very lucky to be granted in that program experience for a year where my husband and I decided that we were going to cycle from Australia to the UK. Um We planned on doing this unsupported so just carrying all of our stuff with us. Um and uh we decided as an extra challenge that we weren't going to spend any money on hotels or accommodation. And that's me in some sort of shelter before it got too hot when I cut my hair off. Um So we cycled 3000 miles across Australia, uh going through the Nulla Desert and these were some of the views that we were party to pretty much every night as we cycled West. This is the breakfast of champions that got us through uh porridge banana and nutella. And this was a common occurrence of our cycling at night because it started getting too hot in the desert to cycle during the day. And so we, we cycled all the way essentially to the Chinese border. Between China and Vietnam. But then a little something called COVID started ringing in our ears and at that point, we flipped it off and thought, oh, it'll be gone in a few weeks. So we decided that we would re route and go back through Southeast Asia. But then by the time we got to New Delhi, it was very much not going away. And so we decided to call it a day there and fly back. But we ended up cycling 9500 miles and we had an incredible experience. So a lot of people, this is the question that they ask, how on earth did they let you go and do that? And I think the big thing is that I actually asked so many people said, don't even bother asking, they're not gonna let you go. But if you don't ask, you don't get, I had a plan, I knew what I wanted to do and I fought my corner and I said, if you let me go, I think I'll have this, this, this and this experience and this is what I can bring back to the training program. Um I also had a very er supportive TPD who got it and uh he supported me uh to go and also when I came back as well. So that's something that's really important if you're planning on doing anything like that. Um, make sure that you're just open and honest about it. Uh and did people judge you? And that's a big thing. I think that's a huge thing that puts people off doing this. People worry that you're not dedicated or that people are gonna think you're lazy or lots of things, but people don't judge you in it. If anything, if people judge you, it's in a positive way, only good things have come out of these kind of trips for me and lucky enough to come and chat to all of you guys about it. So people don't judge you and just don't let that be a reason to not do something. So my take home messages for you are shy Benz getting out. If you don't ask, you don't get utilize the opportunities available to you. If you haven't heard of the Gold Guide, have a look at it. There's lots of program, career breaks, things for fellowships and things related to medicine as well. And it means that you can take six months or a year out of training and go and do something different. Whether that be leadership, whether that be something completely unrelated, but there are opportunities there. So make sure that you have a look at that if you want to do something different, do it. Don't listen to people telling you that you can't, you can. And variety is the spice of life in a day and age where lots of people are burning out. There's lots of pressures within our profession, having variety gives you a bit of a lease of life and helps you get through. So, and let's see if this works and this is a picture of one of the giant manors that used to come and see us, one of our, all of our dives at this particular site. So thank you for being attentive audience coming to the front, making me feel very welcome. If anyone wants to talk about anything to do with my talk, then I'll be around and just come and grab me. I'll be more than happy to answer questions. So thank you. Uh Mom's the next person. Thank you, Clara. That was very, very inspirational. Um I'm just going to open up to the audience. Does anyone have any questions? Yeah. Yeah. No. Um annual leave sometimes you can be clever with annual leave and again, if you're open with bosses and you move things around, so you have nights and then you're off and then you have a bit of annual leave. Again. I've been very lucky that I've got bosses that have been very amenable to that. So yeah, that's all I can say. Be open and yeah, you can be clever with how you use your leave. Yes, most probably in Mozambique. And I guess it's probably because I was there for quite a reasonable amount of time. I'm not sure that was specifically to do with the expedition itself. So we had a couple of nasty spinal injuries from guys that were actually surfing just nearby. So nothing to do with diving. But I think the most, the thing that I noticed the most when we had those quite significant injuries, being able to get an ambulance in and transferring people to healthcare was extremely difficult. And often you'd have to just put someone in a bus and driving yourself for a few hours. So that was quite extreme. But a lot of the mountaineering stuff, it, it's like I said, it's either it's n 99% of the time nothing will happen. People will have some blisters and whatever. But when, if someone falls, if you're on a climbing exhibition and someone falls, then obviously that's going to completely change everything for you. So it's literally a bit like an anesthetist there. You'll be sitting there chilling, enjoying yourself and then something just happens and then there you go. But yeah, planning keeps everything relatively calm. Any other questions? Yes. Yeah. Yes. Well, I think you're going to be talking about stuff actually, what I was going to say that it might be that we let Mr talk about his stuff next and then do some more questions at the end because I'm just conscious that we will have time for lots of questions. So if I could introduce Mr Misra is a general surgery and trauma surgeon from Aintree Hospital amongst saving lives in the hospital. He's actually founded the Knife Savers, not for profit organization. Which is educating people within the community and how to act and how to save lives with significant bleeding in a pre hospital setting. So over to you, thank you very much for that fantastic introduction. Really humbled to be invited to talk as this is the first time used to come in many years ago when I was sat in your seat when I had hair and didn't have a white beard. So really appreciate the invitation of the council and the president. Thank you very much. So, my name's Nick Misra. I'm a general and trauma surgeon from the emergency and trauma surgery units in Liverpool at a hospital. And this is essentially a talk about the surgical fight back against the epidemic of knife crime that's hit us in waves in merseyside over the recent years. So this is where we were and this is where we kind of are now. This is police data from the darker, the color, the worse the picture. These are rates of offenses per 100,000. And if you look at about 14 years ago, 1314 years ago, the top graph, the top image, sorry, it was London and the East Midlands were the highest volumes of knife offenses that related to them to these patients. Then coming in hitting us in the healthcare settings and the hospitals were busier with knife trauma with fatalities from knife crime. Now fast forward 10 years look how the picture has changed across the country. You've got a very, very big band of dark going across from the north from where I am in Merseyside, across Greater Manchester Yorkshire across to Newcastle. Um You've got London and spreading out to around the sort of East Anglia Cambridgeshire area as well and East Midlands, but everywhere has got darker. The picture has got worse when it comes to the police data and the health care data actually mirrors this as well. Now we had a dip because of the pandemic. Er people were staying at home, they weren't going out, they weren't socializing, they weren't having arguments that escalated to violence. But then when lockdowns got released and the world kind of got back to normal things started to get worse. And in fact, last year this was buried, we had the highest recorded number of knife related fatalities since records began. And you know what, this was buried. Why was this buried? Because this makes terrible news about a year beforehand. The government came out and said we've got the lowest rate of fatalities from the year before because we were in lockdown. And then when we came out and society started interacting, knife incidents started going up and fatality started to increase. Now these numbers have stories and these stories are people and in Liverpool, it's quite sadly, we have our local newspaper Liverpool, E has this once a month, at least July 2018, this young lad Daniel G Jamieson had a fight organized by WhatsApp in Liverpool. They call it a straightener, uh, something that a fight that culminates from an argument. So a straightener was organized in a field, um, in an area called Belle Vale. Er, this young lad came over with his mates, the, er, er, er, er, his, his opponents came with their friends, a knife was pulled and Daniel had a single stab injury to his left groin. He came into the trauma center at entry and I was the trauma surgeon on duty that night and I couldn't save his life. He exsanguinated. He came in in traumatic cardiac arrest and had a very aggressive trauma resuscitation. Full team were involved. The vascular surgical team were involved. It was a on re reviewing the case time after time after time, there isn't really anything we could have done that was better. And I took this picture about half an hour after talking to Daniel's dad to remind me of the bleakness of the situation that we were facing. This is 2018 and this was our third, er, mortality from a knife wound in common in succession of the summer of 2018. And essentially, we'd had enough. I'd had enough and we couldn't keep having this conversation with mums and dads, uh, about their younger, their young sons or daughters, not coming home again. We, we, we'd had enough. So what I wanted to do I had a long, it was a cathartic moment in my career, I have to say one of those times where things had to get better. So I needed to make them better and what do we do as surgeons? We find a problem and we make it better. So I wanted to take our knowledge of what we are, having our lived experience with knives and knife wounds, bleeding and the time criticality of the needing to stop bleeding into these streets just outside of our hospital, into North Liverpool. I wanted to take the knowledge and the skill set of doctors of surgeons into our communities. So I came up with this idea and we called, it was called knife saver and we came together with some emergency, do er, emergency care, uh practitioners, er emergency physicians and basically a big gang in the hospital who'd gone through these horrendous incidents in 2018 and thought, you know what collectively we wanna make this better. No, it had a single aim. It still does have a single aim. We aim to educate and empower literally anyone and everyone how to control bleeding from knife wounds. And actually I'm gonna change that. Oh, it's going to change to not just controlling bleeding from knife wounds, but controlling bleeding, two parts to the campaign education and in the education we talk about bleeding. What is bleeding, why, why is it so time critical? How long does it take for someone to bleed out? How long does it take for an ambulance to turn up and to give that knowledge to, to the people who we're teaching. I wrapped up inside. There is a preventative message about the dangers of a single knife wound. Because time and time again, the incidence of the patients that I operate on our team operates on is a escalated argument where the er, where the victim who was stabbed often says, and in fact, on, once their assailant is, is apprehended as well. Hear it time and time again. It, it was just a wound. I didn't mean to kill them. I didn't mean to try to kill them. It was just a wound and we want to try and smash that um perception and kits as well. Bleeding control packs and cabinets. I'll come to that in a bit. We teach the education of bleeding and bleeding control. Three letters really simple. ABC. Anywhere we go, schools, colleges, um the night time economy, same thing ABC be alert. Make sure you're alert. Get on the telephone alert. 999, the authorities, where's the bleeding coming from? Compress the control, the bleeding control kits that we helped design in 2018 contain three things. Mainly procoagulant gauze either um Celox or Kyo Gauze, um an elasticated compressible bandage and a tourniquet as well. We then lobbied, I wanted these accessible uh similar to defib basically to put them in these bright red boxes around the city center of Liverpool, around the region and we were told no time and time again. We had to campaign long and hard. It sounds strange. It's in intuitive. You want to put first aid kit around cities to make things better. But we were told no, because that looks bad in a city center. We've got visitors coming to Liverpool and I was told that they don't want to come and look at the word bleeding and knives. So, no, you're not gonna have this done. But what are we as surgeons? We're persistent, aren't we? We have a goal and we go for it. So journey so far we started in 2019. That was our first big event and we brought together around 50 to 60 bars in the night time economy of Liverpool, around 80 to 90 of the staff and it was like a conveyor belt of bleeding control education. We raised about 20,000 lbs to get bleeding control packs for each of those establishments. So we now know that these bars of this particular area of Liverpool City Center have a pack and have been trained by us. Then I thought, ok, it's all very well having static points. What about mobile bleeding control points? How can we get bleeding control packs to areas if they're required quickly? So I thought, you know what taxis, why not? I thought I approached the taxi companies, one of the big taxi companies expecting them to be laughed out of the room. But they said yes, we managed to convince a large um hospitality group called pub invest to fund more packs for the taxi cabs. And again, another big event, we ran around 50 just over 50 taxi cab drivers, we train them up and they currently, their pack is the city center. They've been trained by us. They've got a pack inside the cab as well. A couple of weeks after that, we started getting into schools. This is 2020 of the pandemic pre pandemic, isn't it like days before? Um, so the um we went to a school in a part of Liverpool Mersey Cycle Holton. We taught their, their, their teachers and their head teachers. They said, look, we want to be taught up on this thing that we hear about bleeding control. Ok, we'll do it. We're not really reaching the demographic we want to, which is the young people will do it anyway. Two weeks later, two of their students were involved in a fight outside the school and were stabbed. The teachers on automatic mode came out, brought that pack shoved the wound, the um the kit go into the wound and used their essentially quite rudimentary knowledge that we think is rudimentary surgeons as doctors and they were on automatic mood cool as a cucumber. The feedback we got was amazing. These two young lads got air left it to us in the trauma center and made an excellent recovery. Do a lot of work with Liverpool football club and now starting to do some with Everton football club. I wanted to engage the sports clubs of the region because that's the demographic that they appeal to is the demographic I want to appeal to. And so we've done a lot of work with Liverpool football club. A number of events with them on these events. It's a brilliant day, a single day where they organize for around 8 to 9 schools to bring in a select number of their students. Around 101 120 students in your child in, in, in through the day, two halves of the day. And again, it's like a conveyor belt of bleeding control education um and wrapped up inside. That is a very, um there's a very clear message about the dangers of a single knife wound and they are brilliant days, honestly, have so much fun, just laugh all day, such such cheeky chat, get some good feedback as well. We'll get some excellent feedback among the absolutely brilliant feedback about some of the people that are involved in our sessions have used our skills to stop people bleeding. And what's very clear from that. And this is what we thought when we started the campaign. It ought to be health professionals with a lived experience of dealing with bleeding, delivering this education. Around 90 of, well, last time we surveyed them around 98% of people. Um after the training, felt prepared or very prepared to deal with the bleeding wound versus 28% before I'm gonna pause here. This is a chap called Alan Walsh. Now, one of the things about doing knife savers and trying to fight back against this epidemic of knife crime is the connections I make and that we make. Now, Alan's become a good friend, Alan's an ex, an ex convict. So he got done for armed robbery. How many, how many surgeons can say? They've got a good friend who's an armed robber. Basically, I didn't intend to say that when I was training, I have to say, but we speak a lot about how we're going to make this better in our city. He teaches a cohort of young people to try to give them a focus via boxing. This is what he says, people, the culture it safe to carry a knife. They've also created a fashion accessory that's become like the mobile phone. As soon as you leave your house, it's your phone and the knife that goes along quicker. So we get a lot of detailed, I get a lot of detailed information from Alan. Why is this happening? And people like him, the youth workers that it's become a culture where young people in the city and I have no doubt this occurs around the country where they go out with a knife, wallet, keys, phone. I mean, when did that happen? We get a lot of press. Um We've managed to get ourselves onto the red sofa to, to talk about our campaign. And based on that, we got invited down to Westminster to, to present our work to the parliamentary group um on knife crime to tell them what we're doing emerges how to try to make this better. So I wanna talk about where we're gonna go from. Now, firstly, during the pandemic, we had to, we were forced to innovate, we couldn't be everywhere. So we started to do run at live webinars. We then started to think, well, we can't be everywhere anyway, because we've got a day job in the National Health Service. So we then started to think about exporting this education we're giving online and also we've done it. We've created an e learning package for young people and this is gonna go live to uh uh uh I gonna go beta testing in the summer term. Um Get some evaluation back from the schools that we're gonna run it with, with a view to open it up to every school and college in the region or help help someone with bleeding and injury. This can be a frightening experience but have confidence of these simple steps that you can help anyone without any special equip. So we're very excited about this to actually get our, our, our, this um all our of our contents from um all of the stuff that we've taught over the years online we've done it now. Um, to and hope we may be able to get into many, many more hearts and minds than we would have done if we would have done, um, done it. Um, live as well. Secondly, the cabinets. So we've got them up after years of being told no, by the councils and by various authorities, we, we went the right way and we got them up. We didn't just like do a gorilla job and put them up overnight. We have permissions to put them up and oh my word, it took us a long time to do that. Around 25 cabinets around the region. Now around 15, around the city center, that sort of area around the night time economy is the highest risk. You ring 999 you get the code to open the cabinet, you open the cabinet and the trauma kits are inside. We used intel, we use police intelligence to work out the hot spots to where to put them as well as human intelligence as well. We asked the people around the night time economy. Well, listen, where are these dodgy areas? These dark corners where you think we need to put them up? We correlated to the police data which we, we work very close with as well. And we're going to log these online, going to geo these the cabinets and not, we are going to, we are via a website called pack map. So watch this space thirdly again, another summer in the pandemic patient of mine comes in Saturday afternoon on Thorn Beach. Very nice. Uh, any of, you know, merseyside, very nice affluent area. Um, you know, footballers and orthopedic surgeons live there basically. And Saturday afternoon and two young lads are involved in a fight on a sand dune. They get stabbed. It took 51 minutes from the 999 call till the first healthcare professional turned up because the police had to clear the area and there's a long, long line of coastline there. The two lads came in to, to the trauma center, one had a thoracotomy, the other had a laparotomy. They were actually due to in a mis costal vessel that was bleeding and an abdominal wall vessel that was bleeding as well compressed really well by their friends. But it made me think, you know, what can we get the kit if required if it's helpful to situations like this quicker drones? Why not? I mean, who doesn't love drones? Drones are so cool. So we approached the drone company down in London. Um And at every, any point I expected to hear now this is ridiculous. It's not gonna work and I never heard that. They kept saying yes. So we're gonna give it a go. We're gonna trial it. I don't know where this is gonna go, but it'll be great fun. We finally had a really good meeting. With Everton football club yesterday. They mm managed to get a uh 20,000 lb grant to work on a virtual reality um immersive film for schools. We're gonna get a mobile unit, not, we're going to, they have bought the kit and we are, we, I am helping to write the narrative for a, an immersive film for young people to take them through a journey involving uh uh an in a stabbing but in a trauma informed way, not triggering. But actually, it's about choices we want to show them that there are choices that can be made. At the end. We're going to give an alternative scenario where it shows bleeding control and action as it were again watch this space. So I think I probably ran over time massively in a conclusion. We have gone live since 2019, trained around 8000 people and counting around 1700 bleeding control packs available now around Merseyside and 25 cabinets and counting as well. And we have five case reports of successful hemorrhage control chelating. And we'll write up last year, the rates of knife crime by police force area was published and it showed that Merseyside had the second biggest decrease in knife crime offenses in the region in the country. Sorry. So it says smallest percentage increase, typical government then they can't say as it is, this is this is the second highest decrease 18 per cent down from previous years. And this is a collaborative effort, but I II kind of hope that we have played some small part in that and all, all of that kind of cool stuff and the e learning and the, and the drones and the VR actually just that's almost adjunct and it boils down to this these days that we educate, we teach, we go to schools are amazing and you know what, it's probably the best thing I've done since being a consultant. And that sounds mad, doesn't it? But we learn our true value when we step out the people listen to us. It's not just about being listened to, but actually you realize how much we are valued and that does mean a lot. Thank you. I'd like to say a big thank you to Mr Misra for that talk and for educating us about what's going on in Liverpool with their response to knife crime. I'm hoping that you're all feeling pretty inspired between Mr and Mr Misra. They've shown you that adventures and experiences outside of the can massively improve your training and your quality of life and knowledge of what's out there. So I encourage you now for five minutes to think of some really good questions to say any queries you might have as to how you might do something like one of these two inspirational people and that they can answer any questions for you. So I open the floor to questions. Yes, Italy. Um obviously it's unfortunately really useful and necessary to have that knife crime information and how to provide that first aid. Is that staying just within Merseyside or have you got plans to try and expand that elsewhere? Because I'm in the Midlands and there just seems to be the same trend everywhere. Yeah. So um no, everywhere, the, the vision that I had when I started this off, this would be national, but I have more control over Merseyside. So as in we, I can change things and alter things. Um So with franchised, if that's the right word to blackpool, just up North Lancashire the coast, they've approached us and we've fundraising for them to buy kit, give them all our training materials as well. We had a large group of really engaged trauma nurse practitioners from the trauma center in Sheffield, come to us as well. Again, the same thing, train them up to try to grow a similar campaign where they are. So, no, this is exportable. Honestly, our value surgeons I have to say is really we undervalue that value and for us to give that message, speaks hugely resonates hugely. So this could work anywhere to be honest, maybe meet me after we can sort something out questions. So in the interim, whilst we're waiting, I've got a question from. So a lot of your expedition medicine, I'm thinking as a surgical trainee as you are, do I need any pre hospital qualifications to embark on this sort of journey and to provide that medical care. And if so how do I go about that? So when I started doing expedition medicine, it was still very um ad hoc and it was, you got into it because uh you fell into it because you, you used to like, I used to climb as a climber and then I became a doctor and then it became one of those things where they'd be like, oh, well, now you're a doctor. So now you can come with us and be a climber and a doctor at the same time. But it's obviously quite different now because you have the prehospital um uh routes of training. Um So, uh I think having having some pre hospital experience is will help. Um I think you can get airway experience within hospital training. Um And there are, you may know him, but there are a couple of people that I work with that are orthopedic surgeons, but they have had uh airway training and they have on their pre hospital exams as well and they do a lot of pre hospital stuff. So you, you don't need to go to that extent for expedition medicine, you do need to be comfortable with airway. So whether you're happy just putting simple airways in, if you've got experience and you're happy to chew, but I mean, it's not really necessary, but as much experience as you can get, I would, in terms of courses. There are lots of expedition courses that will have some airway stuff in it and also specific pre hospital medicine courses as well. The RC C Edinburgh definitely have a long list of expedition courses and I'm sure the RCs England does as well. So just have a look on their website because there is now a faculty for pre hospital and expedition medicine. So it's very easy to access online. I just, I had a quick question for both of our speakers. Um What, what if, what if you encountered as your biggest challenge throughout your journeys? If you don't mind just talking about it briefly in, in terms of one developing your, your uh program and, and in terms of your journey in expedition medicine, biggest challenges. So I think early on the challenge of being headstrong enough to essentially ignore what everyone told me. Um and uh just go for it, what it was that I wanted. Um So, and having done that once and you probably have the same uh once you do it once and you get your way, you kind of just you keep, you keep doing it. Obviously, you don't want to push boundaries too much. But um you, yeah, I think the the challenges early on trying to do something slightly differently was, was quite big at the time. But I think things are changing now. So I would encourage everyone to ignore what people tell them if they say that you shouldn't be doing this because a surgeon needs to be 100% or everything in your life is surgery. That's, I don't believe that, I believe that you are very unique specimens and you have to have lots of other skills to be a good surgeon other than what you learn in hospital and you're more valuable having good life experiences than just being in a very closed environment in the NHS. So, yeah, 100 per cent echo that actually I'm glad I let you go first to steal your answer. So exactly that just we heard. That's a really good question, by the way, heard. No, a lot. When I was starting this off, even at the conceptual stage, the planning stage, this will never work. This is mad. The buying pack stage. No, no, no. And it's I'm not saying ignore no. But you know, we're surgeons, we are resilient, we are persistent, we have a goal, we are task focused and we get that task done. This is why, you know, we are the best people in the hospitals. Can I say that? You know what I'm saying? That well, we are so you know, it is that I think especially, you know, listen, Clara's brilliant talk as well. It's exactly the same. You've got to focus, you want to do something for the good of yourself and for the greater good as well. What's really important as well is fostering this mentality about a portfolio career because I was never taught that when I was your stage, it's exactly that tunnel vision. Do your BST, do your higher surgical training, go away for a little bit, do a degree and then it spits you out the other end train like that. So therefore to come out that we then focus for the rest of our careers with that sort of narrow tunnel vision. And actually what's I learned early on from one of my mentors in, I was trained as an HP surgeon was to have that portfolio mentality as in do something in your career. That isn't surgery, whether that be medico legal, whether that be a variety of expedition meds and a variety of other things. But to actually have it as part of your career, it's not a hobby. So when someone says to you, where are you? Well, I'm running a bleeding control event today. No one said in the last four years. Well, you can't do that. It's not part of your job plan. I'm sure they did. And when I said no, they ignored that and then you crack on and that becomes part of you and what you deliver as a surgeon. Basically, thank you. I'm going to bring the session to a close but the remarks I want to leave you with just that we've just had a talk prior to this on the fact that you're the next generation of surgeons and like Mr Bira just said, it's not necessarily about concentrating on the destination, although that's important, enjoy the journey and take the experiences as they present themselves and go out and find them. So whether it be extreme remote expedition or letting your practice influence the community around you take the opportunities because you testing your own limits and getting some life experience is only going to make you a better surgeon. So with that note, thank you for listening and please say a big thank you to our speakers.