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still working. So setting up. Good morning, Joe. We should now be live. The any you meeting 2020 to the play button is just come up so people will be pressing that. And so his chair of the first session. I'm just gonna hand over the meeting to you on. We can get going. Great. Thanks very much. Change. Good morning. We're delighted to welcome you to the North Amitiza updates 2022 on thank you to all he registered and joined our virtual meeting this year on behalf of the M AU organizing Committee. We would like to thank Medal for hosting this conference where they're virtually platform as well as our main sponsors, Drakkar and Medi Plus. Over the day, in four main sessions, we will be bringing these speakers on a variety of topics. The one he Patel, training price presentations and ending with a lively or a short a volatile debate on nitrous oxide. He's in anesthetic practice throughout the day. There is theophylline to lose tease, live chat function to the right off the presentation screen. Please. Do you ride your comments and questions there to make the day is interactive as possible. During each of the sessions, the chair will monitor the live chat feed. Impose your questions to the speakers when they return to the screen for the Q and A discussion at the end of all three presentations. There's also the virtual poster hall, which she should be able to access from a link at the top of the chat feed. Feel free to view and interact with these posters at any point during the day. The recording off today's conference will be available soon. Have catch up doing she gave the automatic certification of attendance from metal. Please do remember to refresh your screen between talks to allow any updates or information on the live chats appear in your home screen. Finally, if you have any technical issues during the day, please email nourished anesthesia. Update any new h dot any chest dot UK, which is also linked in the chat. This email account will be monitored throughout the day, and there's also the help function on metal at the bottom right off your screen. I am now delighted to welcome our first speaker off the date or Jeana Singleton. So Georgina completed call medical training before commencing her anesthetics training here in the east of England. Diener E. Under ST six. She took time of program for research and is currently in her second year off a HS Are See Fellowship in London. During her fellowship, she has worked on several national projects, but mainly on the Peri Operative Corti Improvement program or Pee Quit. Georgina has kindly on. It's kind of going to talk to us. This'll warning about the recently with these guidelines in Perioperative Medicine on her work with Peak Whip Welcome Doreena. Thank you, Doctor will care for the introduction. I'm thank you for the invitation to speak here nor a Champ Stains in rock dates. As you just heard. My name is Georgine a Singleton. From February 2020 I have been out of anesthetics training on Antarctica Program Research Coast or you Are I'm just Coming to the End of Fellowship with Health Services Research Center, which is based on the Royal College beneath protests in conjunction with the UC Else Surgical Outcomes Research Center. The national project, which I was linked with drawing my fellowship with the Peri Operative Quality Improvement Program for people Time Till I was given for today's talk was watching um perioperative medicine. However, one of the things I've learned over the last couple of years is that in many areas of perioperative medicine, we have a good understanding of what works and what doesn't. And we have a good understanding of what we should be doing. But that could be many challenges. Associate it with the implementation off. Best practice at the time of the NHS is under considerable pressure. It seems that perhaps we need to focus our attention on trying to do well the things that we know work. In other words, we need to the structures and decisions on work out how best we can deliver the service. Having spent the last two years as a people, fellow people is important to me. So I will talk about this first with reference to just to what I just said about focusing on doing what we know works and doing it well, then I'm going to talk about dreaming, drinking, eating, on mobilizing after surgery. Well, then we want to talk about two new guidelines, the first of which is the preoperative assessment on optimization guideline. And the second is the guideline for establishing enhanced perioperative cast offices. Finally, I hope to be able to tile this together by considering the management of change. I know that many of you are familiar with sleep it, but for those of you who are not people, is a multi disciplinary initiative to evaluate the quality of care and outcomes of patients undergoing major surgery in the NHS. It's a perspective observation ulcus oh port Study, which recruits adults undergoing elective major noncardiac surgery, measures complications, failure to rescue on patient reported outcomes as well as collecting data for research on a national level. Pee Quit seeks to provide local collaborators with data to support local quality improvement. In addition to the collection around analysis off onto tasted data pee quit seats. Qualitative data on the process is surrounding implementation and if it's the costuming, had to remind us of the difference between different types of research. One stated research is new miracle and can be measured in analyzed based on numbers. I was qualitative research uses know numerical data to understand concepts, opinions or experiences. Well, those people is never officially suspended during the covert 19 lb emmick, the lack of elective operating a heavy covert related to nickel workload. Redeployment of stuff on the prioritization, off covert 19 studies recruitment. Understand that he fell. However, despite this, and thanks to the huge efforts of many of our local collaborators, we were able to recruit just over 9000 patients between all this 2019 on July 2021 when we produced our third Pee Quit reports in September 2021 in line with previous units. Peek quick past identified. It stopped five priorities for the coming year, and the one which I would like to focus on is the concept of dreaming, drinking, eating and mobilizing after major surgery on Peek Quick State, or is based on patients achieving this within 24 hours of surgery. Now people is not a new concept. It was written about back in 2000 and 16, and there's also being possible. Cheers Dream Campaign for a number of years, dreaming has its origins in the enhanced recovery model of care on Does I'm sure you will know enhance trick covering It was a model of care that was developed in the 19 nineties, and it was supposed to have been the new standard of care in the UK since 2020 2012. Despite this, there remains wide variations in practice is both in terms of a difference to pathways and also in terms of the pathways themselves. And it only takes a quick slept on the Internet to see that there are many, many enhanced coverage, particularly around a paper by Joseph's and published a few years ago now showed that increased compliance with enhanced recovery halfways had association with a shorter length of stay. However, another consideration is that pathways with fewer elements are more likely to be a day too thin. Those with many elements and a scoping review published in 2000 and 19 agreed with this finding a small number Simple measures are much more likely to be implemented and followed by the clinical tea, then more complex pathways. I'm with this in mind, Peek quick, decided to pilots, tells dreaming on dreaming, is considered to something cleaner, reflect the cool concepts off and hunt recovery getting conditions, but to the basics of enhanced recovery pathways. In putting an explicit goals for patients. Other areas of enhancement covering a naturally adopted other areas, such as the reduction of intravenous opiates on the removal of catheters and drains now to be quits. Data on dreaming on this analysis has been led by my colleague doctor matter on. We hope to see her paper published very shortly. The key findings from Pique rips data our first, that there is considerable variation between hospitals in the number of patients dreaming at 24 hours and towards, um, numbers to this. A subgroup analysis off just over 7000 colorectal patients across 113 different hospitals revealed that 60% of patients were dreaming at 24 hours, but that the intercourse I'll arrange was 37 to 73% depending on the hospital. The second keep finding is it. There was an association between dreaming a 24 hours on blend the hospital stay that's his Patients who are dreaming at 24 hours had a shorter trips day on. We saw that this association was preserved even after correcting for complications on this data doesn't allow us to comment on the course on defect, but given that dreaming is a low cost, low risk on relatively simple measure and certainly with the current covert related pressures on beds and we think that this is a very good place for teams to start when we consider it to be especially important for those teams that might be struggling to adopt other enhance recovery protocols. However, what the quantitative data doesn't tell us is why there's such huge variation between hospitals and why some hospitals are very successful in getting their patients to be drinking, eating and mobilizing within 24 hours on why some hospitals or not. And this is where people it qualitative research becomes important. The qualitative research team aimed to get a better understanding of just this. So there was a qualitative research team aimed to describe and examine healthcare professionals. Perceptions, often able, is, um, barriers to delivering peak quits. Inhance recovery process is on a focus of this study was delivering dreaming. The methodology involved inducting some instructors, interviews with staff who were working in perioperative care and also who worked with people. Some instructed interviews were chosen because it's allowed the researcher to gain information on court topics in a standardized way, but they but without being too restrictive, we focused on colorectal surgery on Dinora to obtain a representative sample, we identified sites that had recruited more you 30 colorectal patients per year for the three years of people. We then looked at trends across the three is to identify sites that had consistently achieved people Smell Tricks site which had improved over time and site, which we're not achieving people, it metrics. We recruited eight different sites to achieve diversity across the following domains geographical location, academic status on solids. Interviews were audio recorded on but subsequently transcribed. The transcripts were then are analyzed to find things Onda. Our data told us that the complex into play off factors as to whether chemo jitters were implemented on these factors were related to stuff patients on do also organisations and within that we found common facilitators. What team work the presence of local champions on do their support off the organization barriers where lack of stuff time, lack of stuff, resources, lack of consistent protocols on also perceived resistant to change resistance to change and I wonder if any of these barriers sound familiar to you. These interviews also enabled us to obtain examples of good practice and how some sites had overcome common barriers, and this was important to share with the Pee quit team on do also, all of people. It's a local collaborators, and here's some of the examples that we used in the most recent people, it report. One example is a hospital that bought a fridge to store supplement drinks in on the ward and made this accessible to patients. And then that way they promoted both drinking on mobilization. Another example is one surgeon who frequently documented in his post operative note. If a cup of tea in recovery was appropriate for his patients on this, allowed patients to begin their journey towards recovery very early on this qualitative work stream. Not only helps is to interpret are quantitative data but helps by identifying challenges that site space when implementing peek what metrics and this can help us direct or quality improvement, quality improvement work from a national level. I think we don't recognize changes difficult on something, the more amenable to change, then others. And this is where we hope that peek quick data consider port local teams to look at the local context on the resources and support it is available to them. The second topic, which I want to discuss, is the redesign of the surgical pathway. And there are numerous examples of redesigning the surgical pathway on Covert 19 has been a catalyst for this one area that has been greatly impacted by Kobe. 19 is the preoperative assessment process. I don't know that many of you will have experience off this. Many trusts already have robust preoperative assessment processes in place, but some do not. And so I'm going to use this opportunity to highlight the key features of the new guideline, published in 2024. Peri Operative Medicine is a growing subspecialty, which has been driven by more complex surgical patients in combination with advancing surgical under anesthetic techniques. And I think we're all aware that we're moving away from the traditional model of Cara, where the anesthetist was involved late in surgical pathway to the Peri Operative Model of care, which starts from the moment of contemplation of surgery and continues until the patient has made a full coverage. I'll not talk through some of the key recommendations from the guideline. The guidelines suggests early involvement with preoperative assessment teams with early completion off self assessment question is on. Ideally, this would be done digitally. There's attention drawn to the assessment off mental health from cognition. The assessment of nutrition on the assessment. All Francie The guideline recommends a functional capacity assessment to evaluate what the patient could do and suggest choosing the Duke Activity Status Index six minute walk test for the six to standing more minute assessment on here. I'd like to remind you that snapped three, which is the next Sprint National and it's anesthesia project is taking place in March 2022. It will examine frailty delirium under the older surgical patient. The next recommendation is for early identification, off specific conditions and co morbidities on Do. The guidelines suggests that conditions are managed as per standardized guns like guidelines such a CPA guideline on diabetes. The other specific condition which of course, is mentioned is cov 19 on Did they suggest caution in the first seven weeks or when steroids? More biological agents have been used? The term optimization is frequently talked about, but I think it is increasingly recognized that there are a finite number of areas where optimization improves results, and it's been suggested that these areas are smoking, exercise, nutrition, psychological preparedness, on medication use by all members of the multi disciplinary team targeting the steps at all stages of the patients. Perioperative care. This is perhaps where we can make the biggest difference, and we also being encouraged to be waiting lists as preparation lists and to get our patients to do the same on this will allow us to focus on those key areas where optimization makes a difference. Risk assessment. Individualized care on shared decision making are increasingly becoming the focus off modern medicine, and the guy find calls for the standardization of pathways and protocols when thinking about individualized care. This may sound country intuitive, but the guidelines suggest that by doing this we will flag up areas where care should be individualized on. We'll be able to filter out lower risk patients and allocate resources to those who are at a higher risk. As well as being a requirement by your individualized risk assessment allows us to communicate and discuss risk with colleagues and patients On also allows us to plan the perioperative care pathway. Many risk assessment tools are available on the one suggested by people, and also by the new guideline. It's the sort clinical judgment models, and this time they found, or nine since the sort was originally published, several papers have reevaluated it for different code warts. I'm just on the most recent large scale update revealed that the new sort clinical judgment model is more accurate than the original sort Modern. It found that combining subjective under objective measurement of the patient risk allowed for a more accurate rest estimation of risk. On day, I would suggest that there's no point in calculating risk unless we use the information effectively. And as I previously mentioned, risk assessment can be used to help go the allocation of resources on the postoperative care destination for patients. And this brings me on to my next guideline, which is the guideline for delivering and 100 Cats services. This guy's I was published by the faculty off intensive care minutes and in May 2020. Work on this guideline, however, started several years before, but with the code from 19, pandemic, it's released has been very timely. Inhance Care is described as a service provided to adults in an area identified. It's capable of providing high level level observation, monitoring on interventions, then a general ward, but not requiring organ support. You got time makes recommendations for planning delivery on governance, off inhance care services. It the X Cried and hands Care is offering a bridging clinical care between the ward hand critical care aunt. It shut. It suggests that it's use may be able to reduce the man for on release capacity of critical care fence so that they are available for the most critically ill patients who need the most. It stresses the need for enhance care to be part of a continuum of care, from ward to intensive care. But it shouldn't negatively impact one level to care. The guideline notes the key principles off personalized care, governance service models, um, patient pathways. And it acknowledges they're into relationship in terms of improving patient care and also improving patient. So it recognizes. These services are likely to the different in different institutions, largely depending on the resources available on that includes the staff on buffing levels on do the skill mix. And so this is not about new advances in perioperative medicine, but it's about developing services which allow us to provide the right care for the right patients in the right setting on by the right people and finally a common theme running through my talk is the management of change on DCI Angel. Medicine is extremely important and much change was proved to be necessary over the last two years. Some of the qualitative research I undertook during my fellowship was evaluating the changes that we made during the Kobe 19 pandemic to elective surgical services. On the paper you can see here was published in 2021. A brief summary of the report is his follows. Success in the rapid reorganization of services can be attributed to the flexibility on the adopt ability of staff conditions being involved in decision making, on motivation, on teamwork to drive the change process food. And I think these concepts I'm not just applicable to the surgical service, but also more widely within your hs. So to conclude, I hope that this could talk has illustrated some of the recent updates in perioperative care, but also how we need to focus on adopting services to lack to allow us to do what we know. I hope I've encourage you to consider the chain the change process and acknowledged that some of the associative some of the associated difficulties with change, but also I hoped. I've helped you identify several factors which may be important to make change more likely to be successful and sustainable. I also hope that this talk is giving you an idea. Some of the work that my fellowship has given me the opportunity to be involved with. Thank you for listening on. I'm going to know leave you with Einstein on here, or some acknowledgements. I look forward to answering questions later on this morning. Thank you for listening. Thank you so much, Georgina, for this really interesting and thought provoking presentation, I concede there are one or two questions appearing on the chat, which we could put you at the end of the session. So our second speaker this morning is Dr Aidan Devil in 18 is a consultant. Anything tests working in King's College Hospital in London, and he trained at the University of Edinburgh and leave to London for specialty training. A few years back, he has interest in about two biliary vascular and regional anesthesia as well as medical education. He works at the Royal College of Beneath Test is Education for a while, still training, and his report on the 2010 curriculum helped to go at the development off the 2021 curriculum. He was a member off the group that wrote the 2021 Quick lump on. He now sits on the quick lung development on a sure in script at the Royal College beneath the tests. Thank you so much for joining us today, Aiden. And we're delighted I had e and talk to us about the raw college 2021 curriculum and what has changed. Welcome, Aiden. Yeah. Hi, everyone. My name's eight and Devin I'm a consultant in East east at King's College Hospital in London on dive. Been involved in development off the 2021 curriculum. Uh, Roy, culturally cysts on I sit on the group that's monitoring the implementation off the curriculum. So I've been asked to talk to your state by George Walker, who I studied with in Edinburgh few years ago. So I was delighted to hear from Joe on very pleased, able to come and talk to you today on, but I have to give some credit. Todo Lipton, who's a consult with the cyst at guys and some Thomas, is he The's are his slides, and I adopted them for this meeting, so thank you very much to him. So I'm going to talk about about assessment and 2021 curriculum on going to give you a little bit of the background to the curriculum on going to go through a little bit of the terminology cause some of it is new. I'll take you through some of the new assessment tools on. Then I'll talk about where we use this assessment tools and how they're critical progression. Points in the curriculum are working. So just to go back a little bit at the GMC asked all of the medical royal colleges to redesign there curricula because they were finding they were having a lot of problems with new consultants being referred to them on. It wasn't so much the clinical knowledge or their skills that we're in question, and they were often finding that there were problems with professionalism, communication team working those sorts of things that were leading to these fitness to practice hearings on day had a look at the medical curricula at the time, and they they asked all the royal colleges to redesign their curriculum to incorporate on greater focus on on those kind of skills and the professionalism aspect of being a doctor. That's what this and document excellence by design was aimed out. So all the Royal College is every written there curricula in recent times. One thing that they also asked for is that there were fewer high level generic outcomes so that our curriculum previously was very detailed on. But it had a lot of a lot of content in it, and they thought that was actually a bit of a problem for trainings trying to navigate the curriculum. They asked us to simplify by being clearer about exactly what we wanted trainings to do and to have less detail on. We hope we've done that. They also, um, released this document called the Generic Professional Capabilities Framework on. Basically, it's all the things you want to go, doctor to be able to do so you want them to have some leadership skills to be able to work in a team, to have patient safety at the forefront of their mind on, to be trained in safeguarding on, to be able to teach and train on. Dave asked us and to put these and all of these qualities into the curriculum and very explicit way and to assess, um, robustly on do these things were there in the previous curriculum, but on I think they were more of ah, afterthought rather than the scene is being the meat of the curriculum. So we tried to address that and with the 2021 curriculum, and another thing they asked us to do was to bring in a range of assessments so that we could make a global judgment about the trainees performance on I think with the previous. And if you're a shin of the curriculum, it was brought in around the time that competency based medical education WAAS in Vogue on the workplace basis essence were quite new. I think over time the use of the workplace based assessments probably became corrupted and that they were designed this feet. But vehicles for feedback or or formative tools way sort of ended up using them on a summit of twos, which means that we were using them as a test of knowledge or test of skill rather than and what they were designed for. And I think the GMC realized this and they asked us to create a new Testament program on DTIC. More rounded view off the trainee on also, and looked at the non clinical aspect of it more closely. So I'm sure a lot of you know this already, but and just thio and go over the new structure of training. So currently and we have core intermediate and higher on day two years, a core two years intermediate on three years prior and advanced. And what we find previously is that there were a lot of training is that were dropping out of training and between core and intermediate big print, mainly because they haven't managed to pass the primary FRC A on I was felt that if we managed to keep trainees in training for longer, that the chances of passing the exam would be much higher on the chances of actually progressing onto the stage two or intermediate training and would therefore be higher on. It would cause a lot less disruption to people's lives. So we've changed the structure somewhat in that stage one. The first stage of training is no three years on. Then trainings reapply tost four instead of instead of applying to ST three under the old system. This gives the training is another year to get their primary FRC, and it gives them time to get some more general experience on, particularly in places like obstetrics, where they're expected to be an independently able to practice by the end. Stage one, then Stage two is predominately made off specialty areas on that more consolidation practice, and Stage three is on preparation for a consultant practice where the trainee can and take more responsibility, develop their normal clinical skills and also on take on a special interest area. So how did we, uh, then write the curriculum so that we could incorporate these non clinical aspects into it? Well, it's maintaining a kind of robust assessment feature. Will we manage to split the whole anesthesia into 14 domains on? Did take a while to do this on the Xarelto, the demeans that we came up with so you can see on on the top of this that the first seven are the non clinical and aspects of the GMC asked us to look at that. That's deliberate because we wanted to show that we were emphasizing those in the curriculum. And so these are things like professional behavior Team working, safeguarding those sorts of things. Onda last seven are the clinical practice of anesthesia, as we would assume it would all recognize it. You'll notice here that on things a group together by type anesthesia rather than by type of surgery, and that that was deliberate because it was felt and the old way that we had previously organized the curriculum didn't allow for transferrable skills and to be assessed in different areas of the curriculum. For instance, if you were on to explain the surgery and you needed to double even chew, then that didn't really seem to fit on only really seem to fit in thoracic module. So we've tried. Teo. We've tried to keep things together by type, funnest, easier rather than by type of surgery. You'll also see that, and general anesthesia is is one domain. But so is resuscitation and transfer, and I'm clearly the two are not equivalent in terms of content. General anesthesia is by far the biggest domain that we have in the in the curriculum on, so that the domains are not equal on. But it doesn't mean that just because they're 14 of them that they're all equal. So so there's different numbers, amount of content in the different domains. So we were just to look at one domain, which is general anesthesia, just to see how it training progresses through the curriculum at Stage one in the general anesthesia domain, we would expect them to be able at the end of stage one to anesthetized a, say 123 patients who are going non complex elective on emergency surgery within a general theater setting. So that's what would expect for general anesthesia. And then you can see, by the end of training, we'd expect trainees on who are almost ready to be consultants to be able to exercise any patient for non specialist surgery in any area. Uh, any area of the hospital Onda, also that they have developed, practiced within a defined area specialist interest. So I think that's probably what you'd expect a consultant for the start of the consultant practice to be able to do so. What's new in assessment on? I'll just go back to what we used to do. So if you previously under the old curriculum had one beach type of assessment on dude hard, some clinical exposure and you had a few cases in your log book, you could legitimately go to your supervisor and say, Please, can you sign me off? I've got one of each on. Dad worked for a while, and what we're trying to do now is to DMV for size the workplace based assessments as the only source off on a valid information. There are lots of things that we can look at that give us information about how well training is progressing on be under the new curriculum. All of these are violent sources of information that could show that someone's progressing got the voice of the assessment property. So that's trainers through and the most multiple training report, which we'll talk about it later. So trainers opinions are important and the use of simulation can be used. Teo I'd on decisions, and whether trainees have moved forward have progressed, and experience in the form of local cases is also quite important. It should be taken into consideration on then it says, here s L E C. And this is a new term for the workplace based assessments. As I said earlier, we're trying to get away from and the idea that the workplace that these tools, our assessments, they're actually vehicles for feedback or a document, often educational and hunter. So SLE stands for supervised learning event on I think that probably is a better name for what are these? Two should be used rather than a pass fail mentality or a satisfactory on satisfactory idea. So the idea is that you could do an SLE, which and which shows that actually was lots of scope for improvement. And that's not necessarily a bad thing on personal activities were talking about things like reading a Journal article doing an online module, learning more Jewell and all of those things are and can be put into their lifelong learning platform and can be used to show that training has progressed on. Reflections are also on difficult cases or an interesting cases, and are also valid ways processing progress under the new curriculum. So when we come to the assessment tools that we have and a lot of them, as I mentioned before, there have been rebranded a supervised learning events and the first four will be familiar to all of you on the docks can attack CBD and all nuts. They're more or less unchanged with one with one difference that I'll go into a little bit later on. There's one of the bottom here that you might not recognize. Add a Q I pat on that stands for anesthesia. A quarter improvement project assessment, too, on that is to be used to assess any. Q. I projects that the training does. It's it allows them to give evidence to create evidence Teo towards a lot of the domains. And once that tools used, um, the college has its quality in Penn Improvement Compendium on which is to back up this acute pot form. And so there's some useful stuff in there if you're if you want to get more information about you. So one thing that you and may have noticed already on is that we've introduced some supervision scales to work to the what we used to call the workplace basis essence somewhat, and I called SLE. So this is like a little bit of confusion on bein Lee people. Not really, no, I understand. Not really, and knowing whether it's okay to say level three your level for when they've actually been in the hospital or when they've been in the room observing, observing the training. The idea behind the supervision scale is asking if this training was to do the same procedure or the same case again and under the same circumstances. What level of supervision do you think they would need to be safe? So if you think actually I could have been in the coffee room for that case, then you could say that patient there that to training is doing that case that level to a. But if you think actually I could have been a bit further away, I could have had my lunch in the department. Then you could say that that was done it to be. If you think I was on call, I could have left. I could have gone home and left training to do the case. Then that's level three on. If you think they're working at a consultant level then or the equivalent, then you can say that was level for So it's It's not saying that every train that that the trainee can do that kind of case forever. It's not a license for them to practice independently. It's just saying what you observed on the on the level of supervision you thought they needed for that case. So, for example, you might have a trainee who does straightforward appendix on, do you think? Actually, that was level three on Dyken. Be a home quite easily for the training to do that case. But then you might get a patient who's a much more frail, much sicker on about the same kind of case. And you, you might think for that sort of case. Actually, it's two a. And so that just goes to show you the supervision scale is dynamic on. But as Thedetroitbureau eloped, they'll take on more complex cases on the supervision scale that they receive in their assessment should start increase. I'm I think that's something that we all do quite naturally, a supervisors. We we sized things up when we say, Well, I think I don't need to be here. Or actually I need to be here because this patient sick or this training is not quite where we want it to be. To manage this case safely on displaced on the work of Jenny Well, Er, who is from New Zealand on, has done quite a lot of work on work, place, place assessments or SLE. He's in anesthesia on. They find that when we they introduced this sort of scale, that's kind of supervision scale, that it gave a lot more robustness on a lot more. It was a lot more discriminating Onda ast compared to the previous and use the word often of these assessment tools. So that's what it's based on. Okay, so we've not have another and another new. This is one of the new tools that we have called multiple Trainer report on dissension. The This is quite similar to what lots of you have been doing with giving consultant feet, but and what we've done is we formalized the process of consultant feedback, and it's been integrated into the lifelong learning platform on. But it's it's not a replacement for the multi source feedback. It has a few differences, so the it's generated. It's generated by the supervisor about the college student on day. Send a request for feedback two trainers that have been working without training on, but it's not a multi disciplinary, and to like the MSF, it's just for trainers, so consultant and create great and trainers on. But the choice is not the trainees choices, the trainers choice so you can see that it might throw up some and different results. Then you may get from the MSF, where that training is naturally likely to choose to send the assessment to people that they get on with, um, people that they think we'll give them my street backwards, that this could be sent to people who are known to give challenging feedback or or or potential hawks rather than dogs, so it might get slightly better, slightly and different. Angle on on the train is progression, I think, and where we anticipate this being used is that critical progression points in the in the trainees career. So things like at the end of the normal period at the end of a year at the end of a stage of training and we've received this a multiple trainer report being used in know sorts, various. So just to remind you off the stages of training Stage one is three years stage 22 years on stage through the another two years on these of the 14 domains that are need to be assessed on these domains, Aricept at every stage of training, so up three points during during training at the end of CT three at the end of ST. If I've been at the end of ST seven, these domains are assessed and separately on the way that we assess these domains is by using this form, which is called Halo form Holistic assessment off learning outcome. Uh, it's completed at the end of each stage, and you have one halo for each domain on bits. Not that you're getting your weight till you get to the end of this stage. And then suddenly the trainee puts a lot of information together to try and show that they and reached they progressed. As the training starts a stage of training from day one, they should be allocating items to end to the halo form so that at the end of CT one, for example, the trainee you Sorry. I'll just go back at the end of CT one. You could be looking at the trainees halo forms on. It would be after it should be a third full. You won't be able to sign it off because they still got two more years to do in that stage. But at the end of CT to you'd want to see some more progress so that there isn't a panic in CT three to gather all the evidence for that stage of training. So training should be allocating things as they go along. So that and so that there's a study on be evidence of progress as they moved through our training. So what kind of evidence do they need to be collecting to have this halo form signed off? Well, the super light supervised learning events, the essay least, are important personal activities. Person reflections on the log book is also important on as they as they link each piece of evidence into the L0. P. They should link. They should link to water called key capabilities. And I'll show you what those are a little bit later. So you probably had a look at the other domains that we talked about earlier on. Do you can see one is perioperative medicine General anesthesia here, regional anesthesia resuscitation and transfer procedural sedation, pain and intensive care. And being familiar with the old curriculum, you're likely to say, Well, worst cardiac worse neuro I don't see obstetrics in there on day. Everything is in there, but it is, and it's just packaged in a different way. So for obstetrics, for example, there's some regional anesthesia. There's some general on this easier on there, some peri operative medicine on some of these areas that were talking about our our specialist areas under generally signed off by specialists and Easter's to work in those areas. So in order to support the sign off of those areas, this form is being has Bean created, called C C C form. It's got a very worthy title, which is completion of capability Cluster form. But see, see see is a lot easier to say, and it's basically used to assess progress in a few specialists areas, and it's completed by and designated trainers on. But once those once the C C. C form for cardiac has been signed off and that goes into the halo form and it can be used as evidence for completing the halo, so this'll slide just shows a little bit about how it works. So the example I gave off obstetrics. There is some capabilities in the G a section, some in the regional section, on some in the perioperative medicine section. But once the obstetric anesthetist signs off the CC see form that will pull together all of those capabilities, and they will show up on the lifelong learning as being completed as having been signed off. So it gives the person who then comes to the air comes to sign off the stage one halo for G A. That they have confidence that the obstetric capabilities have been met on Go. It's to get around the problem off off the way that was packaged the curriculum. So if you come to sign a trading off for general anesthesia, how does it look? And, well, I haven't deliberately haven't shown you the lifelong learning platform, because I think that's a whole other talking itself, and I'll talk a little bit more at the end about that. But you'll see the high level learning outcome, which, which is the sort of description of what they should be able to do. So we said that they should be able thio and exercise, say, 123 patients for non complex elective, an emergency surgery in theaters. This is then further broken down into some key capabilities, and these are the things that the trainees can link there evidence to so they can link there evidence to and doing a check of the anesthetic machine on to planning recovery care and managing on managing recovery so they can link evidence to these key capabilities of once you've done that, then the on Ben the area could be signed off. The domain can be signed off in the halo on it doesn't have to be just as a lease. As I said before, it could be log book could be some personal activities or reflections as well. So when you come to the lifelong learning platform, you'll see something that looks a bit like this, which looks a bit sort of mind blowing at the start. But what what I would focus on is the this column, which is the supervision level. So for each halo, it will say the supervision that level that's expected and for the training to be able to sign to be signed off for that area and you can just scan down and see actually yet on day was ah, lap appendix, and that was to be so that's good. And then anesthetic machine check also to be so you can see that the patient or the the training is reached the level that you're expecting. So this and table is just a summary. It's quite a lot on here, but it's a summary of all the different forms of assessments that there are in the curriculum, so I won't go through everything. But one of the main things I wanted to point out is that we don't have a minimum number off S L Easy anymore. So we used to say, for a much unit of training, we want it at least one of each type off work place based assessment. We're not stipulating that anymore. Eso There's no minimum. We want to encourage their uses educational twos on get away from them, being used as pass fail type assessments. So that's thinking behind that. That said, if someone doesn't have any of them, it will be difficult to get the unit signed off. So you'll let least need 11 of each to have Ah, Halo form signed off on a particular area, especially as we're talking about some, you know, potentially three years worth of work. So I would we would expect through to be several and several of each kind on, but we encourage the trainees as their submitting needs to think about linking them to all of the areas that are relevant on we're not. We understand that there is quite a burden of assessment on trainers on Do want to keep a synonym a list possible. And if there is a case, for example, let's say and trauma patient that fracture neck femur, who's delirious or has dementia or some other and payment of the capacity then there could be a safe guarding on day could link. That's the safeguarding issue that could be something to do with pre op preparation, which could be preoperative. Medicine could be regional on. It's easier with spinal, and there could be a number off things that they could link to. And that's appropriate if it's relevant to that case. So we encourage trainings to link on do several items if it's appropriate on do some other things to note. The primary Farxiga, as I mentioned, is pushed to the end of CT three instead of CT too. On final, FRC is invested five on. They'll still be a yearly e s s r a Z as ah, there is a the moment, so it's sort of reasonably clear how we would assess a clinical capabilities or clinical domains. But how do we go about Cecil in these generic professional capabilities that the GMC is entrusted in? Well, I think some of them, as I just mentioned, will actually form part of everyday clinical practice. But others are a bit less obvious. How you would integrate that into a list and so research is is probably an obvious one. Unless you recruited a patient into a study or your and reading a journal or discussing a journal article during the case with a trainee, it's difficult to see how you would, um, how you would incorporate and research the whole of research and into clinical practice or into a clinical list. So this is this slide is just to demonstrate that on D, although you might be doing a clinical nodule, you can incorporate some of the non clinical things so and safety and Q I mean obvious one on defecation. Behaviors are definitely easily observable in the clinical areas, and I would encourage you if you have concerns about the professionalism or the professional behavior of the training, please do note that on their assessments because it's and it's ah, it's really important that we get that feedback. Otherwise, it is difficult Teo to address that and help them support them to develop in that way. So one of the ones which probably doesn't fit quite so easily into clinical practice is education and training. And I've just pull this out from the curriculum on the college website just to give you on example off how this could be assessed. And so, for example, if you observe someone supervising more junior college, you could do in SLE for them. If they attend a course, then they can submit that as a personal activity that certificate can be uploaded on. That's very valid evidence and teaching and simulation courses on development, off patient information or educational material for patients, and four and being involved with departmental teaching programs so you can see that these are all things that people would do anyway on we're just asking that they put a bit of evidence of that into their portfolio, and we're not trying to. We're not trying to force things that don't really fit into S l Easy, because it doesn't really make sense to do that. But if if the evidence is, they're on it and it makes sense of the trainee has has been developing your skills and education and training, then you can happily and sign off the little form for them. So coming close to the end, and I realized that there's been a lot of acronyms a lot of new things on, but just to sort of summarize a little bit on. But workplace based assessments are no cold supervised learning events or S. L East. What used to be consultant feedback is now The multiple trainer report, or MTR, on the old Cup form is now either the C C C form for things like cardiac neuro statics and or the halo form, which is done at the end of a stage of training. We have 14 domains in the new curriculum. Seven clinical and seven non clinical on each one needs are halo form at the end of each stage of trainings or not every year, but at each stage I want to see a range of evidence on. We want to see consistent progress towards these halo forms throughout the throughout the trainees career. Ah, what I would encourage you to do is to is to remind trainees to evidence the non clinical domains as we go along. And if you especially if you see that you're involved in a case where it it could provide some good evidence, please encourage the treaty to submit an assessment on SLE on Do get them to link to that to the appropriate areas because it will be tricky and evidence those sorts of things at the last minute on a little bit of background. And I know there are lots of teething problems with a lifelong learning platform of the moment, and I do expect to get questions about that tomorrow on Apologize about that. The background to that is that the GMC gave us approval for the correct one in May last year. We then hard, not very long to publicize, teach everyone about the new curriculum on, developed the whole lifelong learning platform into the new system of assessment in a very quick time s so that it was ready to actually launch in August. So there are bugs on D colleges aware of thumb, and they're working through them as best they can If something If you pick up a bug, please do report it so the it can be it can be added to the list on green. Oh, there were problems with it on, but we're just grateful for your patients on, and they will be sorted out on in due time. And they have a list of off bugs that they're working on. That the moment you want some more information? The about what I talked about, everything I've discussed today is backed up by the information at the college Web page, and I'll just do that now just to show you what's there. Um, here we are. So if you go to college Web page, click on training and careers and then click down to 2021 curriculum, there is an assessment page there on down there is everything we've talked about today. There's the assessment guidance document, which goes into a bit more detail on what I've talked about. It's also got an explanation of the new terminology Halo form the triple see form all of those sorts of things, and there's a little there's a couple of podcasts which talk about, and if you're really interested in that sort of thing takes you into the philosophy of the assessment on Do another document about the assessment strategy. And if you get stuck with all the acronym is, there's a little decoder there for you as well, so I'd encourage you to go and have a look there if you want to get more information. Onda. That's it. Thank you very much for having me. I'll be in the panel a little bit later, so I'll be ready to answer your questions. Thank you. Thank you, Aidan. Things really informative and lovely summary of the knee assessments and the change is just a viral, putting the new quickly and into practice on the podcast you mentioned at the end. There a swell on the Royal College Websites are really useful to tell them to five or 10 minutes and soundbite about each of the assessments to please do. Put your questions for Doctor Devlin into the live chat, and we will answer them at the end off the session. We're running slightly ahead of time just by a few minutes, but I think we'll roll on our third speaker this morning is Dr GMO Martin. It's a cardiothoracic anything just on the clinical lead for theaters at Royal Papworth Hospital. Doctor Martin is clinical. Interests include blooming hypertension, inter operative at T o E heart and lung transplantation, as well as a pulmonary thromboangiitis. To me. He's also the anesthetic lead for the A water working grip and were absolutely delighted to welcome him. Welcome him this morning to talk to us about managing pulmonary hypertension in patients undergoing non cardiac surgery at welcome. Gimme Martinez. We're going to review something constant level. Well, you have retention that hopefully will kill you to money. This patient is safely provide the best possible care. Let me really use the screen a little bit. Right? So, um, why is that? I have attention. Important with it's a Y c and diagnose. If we don't understand, my habitation probably would miss a appropriately probability. We're counting the majority of the patients that are emerging diseases that will okay kill you to money. Displaces is safely on. Provide the best possible. Okay, let me be used this cream little bit, right? So why haven't changed important? Well, he's a y c and diagnose if we don't understand from a habitation probably would miss a a property preoperative. We're counting much of the other patients that are imagine diseases that will make it more prevalent eventually, like crawling from about it. This is more and more people are having needs to keep replacements on. But remember, this is is is very common in those questions. Eventually, some of them will develop more of a bitch is what you have in mind. Our cardiologists have no experience diabetic care. So you were sick. Advice from the color is just double. It is the cost or the It's a very little repetition, but you will have to have a management plan to monitor it safely on a enable it is surgery in those patients on your other thing would be eventually getting with the complications off that month. They should. We gonna have retention. Well, the mortality is up to triple three times there in comparison with a number manipulation of places, and they're going keeps on the replacement. For example, it's important to reminder orthopedic is really one of the key. A high risk surgery for this type of three cc's will see that later. If you look at the mortality associative the little mortality in places and they're going numb. Correct surgery if they have, um, I have prevention. It varies a lot between 18 to 20% which is one in 5 to 1% money, hundreds on. The reason for that is that him a permanent have potentially is merely a chemo dynamic states. So up until we can identify a labeled the costs on the name and the part of the issue or is it a potential? We're not saying much, really. So everyone with the meeting arterial pulmonary pressures 25 or above could be labeled someone with attention. If you want, you got some more fresh. With that definition, you'd say that those with a PVR more than 249 are have pulmonary vascular disease, so you might have potential second mode. Anamika State, Do you have to marry faster? The cheese units you have BV are about 240 on when we look at the time. But the classifications from hypertension There are some groups that we know very well under I grooves are released bit less familiar. We will concentrate the ones that you're less familiar with it because those are the ones who have the, I guess, mortality. So when we divide, they're grouping more time between 1% on 20%. Probably the group in the 20% of those other species that doing involved vascular disease. So in the Group one, you got the particle minor artery. A pressure would used to be called primary, but now it was going away from the poster. The Group two is the left scrotal cyst we're gonna talk about. This is because most of your experts in managing the left heart disease the trick Rubies. Landis's is very uncommon. That basic with COPD, the fellow severe severe hypertension of the bone that will make a put the right ventricle or they're a life addressed. So we're gonna explode, Got grandchildren were end up with dreaming. Lose your party one that I just mentioned on the growing from a call it disease that is the one that is a marriage. And now we need to be aware off. And there's another group that will develop some Buster. This is there is no clear the pathophysiology people we could make a teacher sees people with, um circle. Those is another another things a obesity. Maybe mention special group because it's coming multifactorial. You could basically, with sleep a player that we know that dude event vascular disease full time they could have also COPD they could have left are the city. It's somebody who have attention related to that one. Of course, they are kind of group to have chronic trouble bowling disease. So when a patient with obesity have a chronic hypertension as taking anatomy, measurements very rarely need to send them to other way off the respiratory physician or cardiologist specializing in a capitation. To put it with more fresh of the bone, establish exactly what the problem is on the issues off. You might have retention with Know it's related to the issues with the Reverend. I wasn't very with the Reverend. Well, first of shape is a role in shape. You look at the L V, for example, they'll be is shaping a very common way on it have three layers, one that is actually 100 jittery. Now I'm one oblique. So when did ventricle contracts? You contracted a very sinker. Anyway, that the same, would you manage a pressure on volume overload? Very well on the telemetry regulation that you're very familiar with with the fungus Stalin love. Maybe this ventricle. Very adaptable to those acute changes in pressure. I'm volume overload. How are you? Look at the RV. Right then it come. It is more like cube. The body goes through a tricuspid bar close with Dr In. Tickle on comes out on the other side with everybody on. Also, it's missing oblique layer in the middle. We make this ventricle better vulnerable to a kid. Changes in pressure and folate, particularly changes in breath on be given the changes in volume on its own. Given that the company function is so a couple of lungs, a hospital bed in the lungs is so wide it can come with huge amount of volume. We should happen. Obesity, for example. They can have a cutter, uh, put off 15 or 18 m on the State Cup. Marginal. Increasing the pulmonary pressure. However, changes in pressure and all that. Well, did you look at the echo when you want to talk about his rent? Agrees. Also be difficult. You look at some pictures. So these four chamber beat on the left side. The screen He looked like a lead shaped like but you look at the other views on the right side of the screen, it looked like a banana or across son in the bottom of the screen. So she gave me that. You have a company lung, which you say how good is they are really in the space on that is a problem for everyone, not only for a niece, that is about four cardiologists, uh, prospective position, talking about numbers with driving. And it has to be more difficult on sometimes needed MRI and other devices. Another is studies to establish just things. So when you double the work out for the space in, the first thing that will happen is probably a fantastic this's transesophageal echo. But it's a four chambers very similar to the ones you're used to see in your practice. For example, look at this place and have a systolic pressure is 63. We put him in the what is severe form a habitation. However, if you look at the left side off this train in the bottle does the right ventricle and this one here Did you look at it? The function off the analysts. This is a trick custody on how much is going up and down. It's just a cyst cyst Still in Systole systole. The actual countries also good sister sister in Systole, so they find this woman have potentially severe. They've been fine. She's good. The right ventricle, is it. Being dilated is a big help atropic, but it's moving well. This is a couple with the pulmonary artery and unable to the library. The stroke volume on the cutting out require to go through a stressful situation such as a laparotomy. Let's say so. We're doing the lowest severe is moving all right, recommend you get familiar to look in the back of your son. Remember that some of the technicians that not that familiar with my heart disease, so we only pay attention to the left side. So if you go, there is risk factor to basic risk factor to happen in a habitation. You may want to bring a cartilage next to you or Technician said, Listen, can you look at the area for me and show me the artery? Is it moving? Well is in dilated. If you have a traffic look at this side of sample, for example, we were the severe bone happened tension. But look how different arriving two products. It's also related it. It's happened traffic, but you look at this right here. The actual function is almost none on the lungs. You know, your functional the analysts is very little. You don't need to be an expert, but it's good that you go on, see for this disease yourself because maybe even in the Caribbean with no dimensional to drive into so that will be a preliminary state on. But any issue very well have been totally initial there. Every and if you have a look at the Red Square there, it's a hyper V. Are we being professional? Load our relation? Increase of our reward stress reused, right, right profusion on eventually will be a model of driving people is teeny. So when the patient country table, even before the surgery star that are we in those with severe form of irritation and poor function will be through the cycle off proficient skin, their profession ischemia, similar to what happened on l. B. But L B is naturally a skilled for management managing these things, but they are reasonable. And of course, this is chemo will let you dilation from cancer regurgitation mobile. You know, overload. I said, Consequence. The left side will be a big empty because the right size of pumping enough So you have local er that locally up will have less pressure on the aortic route on the Lopressor they want to do we have more estimate on there. Are we on that loop will be persistent, and we'll let to base in the generation over the years, Um, uneven in minutes when there is other insult to this thing. I look at the right side of the street here. How empty that he's on an interest testing and cook. Another affair that's covered a study. A lot of steps is maybe inclined to give one little Hartman to this. I'll be trying to feeling it more. But if you look at the right side of the right side is really dilated, there is no concern function on a little. Harmon probably would make this patient either arrest or producing a severe increases right, your pressure, liver congestion and and only complete the complication of driving to great faith. So most cases, So if they get a tablet to have vascular disease with me is not the policies is no soap. Really related is Tyler Idiopathic connected tissue list is related or grounded from, um, Bolic. They will be suitable to have a pulmonary vessels. I later trying to reduce it from generation. We shaved the right ventricle to prove the function on our increases. Survival. This patient's undertake my station family case will be key to go through any non correct surgery. First is the disease Lengel. Secondly, this is treated if if it is pretty, is the basin optimized it's in. The best possible condition on this is when you want to engage the pulmonary hospital system. That's probably the reason represented in your hospital, but they're six units in the country that come a prescribe on drink and bases with these drugs and the common ones that may be familiar to you still don't feel a lot of field, which are 44, 17 inhibitors real see what state and then I'm presented in. Some of them will have a personal with prostaglandin infusion. You dropped the pressure, probably those kind of high risk group, but most recent, we haven't really sure this drug to be able to control the pulmonary Vascular. This is okay. Um, and there are other group with people with growing from a building. This is Look at this gentleman. He said 22 years old chap who waas scheduled for release surgery in the way of assessment. If he mentioned that, sometimes you feel breathless when he exercise. So they did an echo. I look at the RV. This is the ankle here. Massive dilation of the right ventricle almost knocks her function. If the space should have goes through the central breo that arrested on the table when they released a tourniquet, for example, when they put pressure on the cement of the family And so this place it was sent to a period physician, the diagnosis chronic, probably the city's he kind of history will be on a close interrogation. It appeared that you got to be five years ago, but after that, he was fine on, So he went to popularity. Had a chronic trouble in that directory. The removal, these material from the pulmonary arteries, the pulmonary pressure dropped to almost normal values, going back to his normal life. And look at the right ventricle. Six mile like totally remodeled. So now you can save the fact his knee surgery without putting his I've a risk, the it with the non diagnosed with non treated pulmonary hypertension. I look at the elevation in the bottom because this this shape before they from when the director me on six months ladies total remoter is much better feeling of their be on everything's better. So being a white woman have her dangerous label e treating with. Put this facing the much better position. But what happened with those faces are label untreated on they don't need no connects it on. Then you say What's okay? Which one we can drink out with something your hospital, which one you need to send your place like up for samples or we need the assistance of the prostate. It didn't for sure. All of them, no matter where they haven't said really a chewable. They're bussed quick pulmonary vascular resistance thing, especially people who are prevention because they will maybe repeat the record catheter. Maybe increasing medication may be related with the disease and find out that is no treatable on or find that there's another have patients that just you know so for example, um, under the difficult group, there are some places that they don't know. They go from a habitation. The functional class is normal. Those are easy because you provide know Michael. They do well. There are a group of that is very, very sick. Obviously, they need to go to a special center, but the majority are somewhere in the middle. In the place where the pulmonary vascular is going down, the pressure's going up. The RV and exercise currents are going down. But there's somebody in a minute. We're still have surgery, but we don't know I was sick. They are under two pension classes. Everything that's happened, we left. Hardly. She's I am the who. Classification is key to establish which one? Another low risk countries. And I gotta give you some examples about merging, living with the woman habitation, the insult expected with the surgery on the very preventative management of this place. This is a 43 years old woman with you have a facial related to protective, actually, cyst. I think she had, um, a scare there, man. She got the Internet, um, acetaminophen, which is one of the A and doctor receptors treated meters, so she wasn't a sentence. And then I feed to brought is very common on. There's something for he for her connective tissue disease. So she needs you have a nasal polypectomy repetitive, no nasal. Believing the initial advise from the physician is always usually come in a brace. But some patients they this is effectively quality of life so much. Uh, they said, Listen, I need to have this operation because I can't live like this or the repetitive complications. Such a nice or bleeding need more hospital admissions. It's stopping. Don't think population. Some of these places will be on public it, and that could be put them a risk for a lot of problems. Yeah, so you're constantly class was June. You're laughing was no more. Most of these basic of normal lung function hear any problem be was 168 which is love. That's a very good mark it off compensation of heart failure on the card again. This was 2.75 but more importantly, she did a mini walking test six minute, and she managed to do 494 meters. So when the anus it is contact me from this local hospital. Regional hospital. I said she can probably safely, uh, surgery. You can look at hospital, ensure that they and medication is optimized. Cover for go with the pulmonary was for the system to see. They need to repeat it right now. Catheter and she can go through when you look at their coat before surgery that we have a good feeling terribly was dilated traffic as the majority of them I was still a couple was still moving on. Her friend's stomach. Class was good. So she got surgery in the local hospital and everything was fine. I look at this time, basically Temple, 52 years old lady. She got a medical body insist. Okay, Pulmonary pressure was 86/32 associated to it. Very humor Attic until injectors is low functional. Class 34. She's on two drugs. Restrictive lung disease accumulation live another bit. But in this particular case, she was advised not have surgery because the cyst was benign. She was coming repetitive punchers. On one day you can see here the pictures she said I can't keep car in this in me. I'd rather die live like this. Okay, so let's prepare for surgery. I'm present on a seasonal. Feel it. You know, we mentioned many well conditioned it only 184 m. So the index and everything was reading the low side and we decided to have surgery. A couple with local strong guns on these, you can see with the yellow line. The pressure was 160 over 60 in the community, The artery, it was super systemic. Although the cvb waas 10 she was very well compensated. If I do two oxygen was 90 on the saturation was just 90. True. So it's very common to have a senior when people say, Boy, I haven't seen hypercapnia ago It's a good thing to do in this place is but most of it's are exactly when they're high virus. So if your tragedy with based on the only boy in that doesn't no good enough, you need to be the person is going to keep this by say so. This lady did well expend a couple of days and I see you with your, uh, cpap eventually went home. Luckily, both surgeries a cyst on the pull it back to me are surgeries that you're not respective major. Install during century, apart from the genetic thing. Any decision, Bull? A cement, Tony Kids, Maybe laparoscopy, but not necessarily, or things that will accurately cause hypertension or increase the pulmonary pressure. Those will put those places are very, very virus on. You need to anticipate to all these things. Look at this lady. 41 years old weapon habitation due to a congenital abnormal absence. All right, You know the artery you can see here on the right side, there's no scar tissue in the lung. So with the issue of mellows to be a habitation, it was for a mastectomy. And I thought we could manage running the local hospital. We did a little mini. What? Congestion is Tony 175. We did it at upward. I thought maybe we all were doing this. You could be managed. It is not like a hospital in the middle of the case that they tremendous bradycardia they can help with drop. We had to resuscitate here, didn't arrested but closely. Bit of Nora bit off adrenaline on a journey infusion and she went through. She spent a couple of patients, you know, triggering on. Then went to the water and went home, so she did well. But it was so funny, toble that whatever happened during that astasia doing the surgery, even if it was a big insult make these are reaching, start failing very quick. So the function because to me, is everything off course. The shape on the front or the ARB will be very good markers on the cardiac index in the right hand out that there is another other information, but they cannot walk more than 253 100 m. Definitely this guy should be managed, especially center. But those who can do 3 5400 m and I'm having almost a normal daily life. You could safely operate off almost everything. So for the Humira Anomic management, avoid pre medication because it's a patient. Get feeling sleepy and retains your two in the world. You already put in the RV a stray on a stress. Give this history professional induction close to whatever they go in there awake. So many reviews mentioned that they were impressive to be about 60 but you're so independent. That very sick lady mean 60 wasn't enough. So you need to keep the systolic pressure off the mean pressure the system impressed or wherever it is with the braces to wait because we know that in those conditions they are is working well. But at least enough to produce a decent use. The drugs that you normally use Just your thing y sleep. If you're gonna give it a problem for you probably want to be ahead of the game with a muscle. Contracting with a Romina lord Phenylephrine to compensate for the drop in the vascular resistance is final 100 studies, not contraindicated, but again, you're gonna do a spinal. Be sure that the systolic pressure is maintained the whole time. You cannot wait to see it going down to do some skin off. You need to take it again. But it's not absolute contraindication. For example, someone with a risk for file like this lady for the polypectomy will be someone suitable to do it. It's finally we did it more business. Are you put in our tail lining every patient? Okay, No, because it's said regard be, I think, a rescue. But because you want to be aware of any changes very, very earlier, start treating all time, most of these places and respond to treatment they're not, is no. Magic is just fish allergy they do respond to in our adrenaline. Mitterrand mean off and left. Three I'm troops is fine. The king's to start the start a peaceful, timely on Avoid the RV to get more risque. Me more hyper refused to start failing because being in them back from that situation is difficult. You need to come enough experience with dissipated problems that we'll put that are be a trailer stress. For example, bone marrow in Melissa Unisom end. Remember that every place in cover bit off a cement syndrome, even if the the weather, it's just that most places are healthy and we don't know it is but every patient with perhaps some degree of microembolus age. But those people with pulmonary hypertension and Araby problems will be particularly vulnerable to have came in on me impact out of these problems fat I'm not truly the air pneumoperitoneum and pretend Look at this lady. She was really sick. We did that other books on. I went to kept me the TV. She had reduced the diuretic because was very hot summer. By the time she was having surgery. After two cancellations, She was born in lower load. That was before this, um, in the RV. Wasn't moving. Break. We started with Nora. I would happen after guesstimate. Look, this storm, this white stuff. So she tried to rest at the bowling. Very low pressure require to fire six millions off metaraminol bullet cyst in there in less than a minute to bring the pressure up there trying to go down all the time. Then, with the she got a race of Northern and running. I think we started some kind of jobs. But once they don't past, then we start to recover again. We give some furosemide before the cement you off low there. Be so it does require some specialized management. Is she didn't well, in a minute walking test, which was high race. We did it at all. Um, because from the diabetic perspective, for our computer management, everything was easier there. So we went to support the our colleagues. There was a lovely case. She did well, but she's staying constipated a couple of weeks in here. Him and he did require a lot of people from the pulmonary hypertension specialists was difficult but another night hospital. Um so they dropped that you can use whatever you're familiar with us. And long as you know, the effect the beauty mean dopamine, epinephrine, all them with help. They are the function to have some marginal improvement on the function on any of us are convicted. Do more adrenalin. Three left really love those 88 protease favor because of the less effective implement circulation. But all the others have not contraindicated. The reviews are very strict on that, but in reality, we use the every day they do fine the pulmonary vessels later that it would always ask me 90 go outside in case iloprost they are great, but they're more for specialized centers. Is difficult to use All the steam theaters are degree of you were in the center that the monitor space it regularly, so I don't know. Based on my strategy pulmonary muscle related then the effects of these I later is is is a Some limitation is no magic. So if you think that you will definitely need some more advanced like this, you probably want to Money is pacing the especially senator. Um so in summary, you have to sing in a habitation, you have to pay attention on the pulmonary artery pressures, and they are being performance. They working in partnership if you can, not singing one without looking at the island. This basically common hypertension high as they are doing it to that question. Come together. You cannot think of the nice elation. Basically, you have a danger. When I do. Baby, you don't ask. How is it? Every you only have a couple questions? Guided Echocardiographic A. Says, because you born articulately finger center ignition. Not familiar to look for the MRI as a specific question, and you tell me, how is our be? Is that triggers for the presentation? Was the actual function on off course sick expert opinion from the pulmonary hypertension specialists that they must be realities or a position? Your hospital? Who is a link with the specialist centers? You need your loved anesthetic to the Bonneville in during surgery? Invasive monetary support temporarily central standard extent, but definitely they're They're line for this patient and even the the surgeries and Know race. You want to be ahead of the game to treat any eventuality and considering cutting on Easter days stomach. You have a lot of experience in. It's in this place in particular those who are tricks. But you feel that you need support from a Those who do this more regularly is fine, but it's stuff, he said. Within your recent statement, You know what you can kind of manage. I don't think we should be prescriptive. Who should do this? Some people go different views, but I mean your liver on that sense, I think you're good at what you do. You know what you're doing on you got the knowledge on this kills. I don't see where you kind of money one of these faces, but he's very, very, very high risk group. You probably want to send them to know on. You need to discuss the possibility plan. Everyone, we need 24 to 48 hours. I see you even need to do extremely well. But any fluid shift, any pain control with this tablet displaced. So I mean, you know, have to see about it. And I see you, which now, with the current pressure is difficult because if they do with their friends night, okay, go to the war. But is the water it It, um with this kills Sunday observations that close enough to be sure the space through. Well, sometimes it's a hit. And Miss kids on sentence where you need to know what's gonna happen with the basic like to walk. Let's take This is a big cyst removed this light issue. Well, she died the after stopping hypertension a couple years later. But Alicia could have the last years off your life without the speak mass current this big muscle everywhere. Great. Thank you much. I hope you enjoy the session that you were going to stop here because every day about the time having today, thank you very much. A gmo for that talking, very challenging topic. I know. I'm I certainly has worried when I see pulmonary hypertension on a on a echo report on D. I'd like to welcome more speakers back to that screen for the question. That's a discussion. Thank you all so much for joining us this morning. It's not sweet. Pleasure to have the I love you. Thank you was like I could bring the right place in the right button. Yes, I'm in the right place. Yes. Yeah, absolutely. Welcome. back on. So we have, ah, number of questions that's been appearing on the chat feed that I've been trying to field as I've been listening to your talks this morning and so, thank you to the delegates that have put forward these questions. Keep them coming. I'll keep an eye on the chat. A sweet talk through some of those questions just now. And so, uh, if we could start maybe first of a lot with Georgina on down, One of the first questions is, uh, what advice would you give to someone? He says that they think more of their patients should be dreaming. Where should they start? And do you have any tips? Okay, So first. Well, I think I'd say it's brilliant that they have recognized that this is something that they want Teo divert their attention to on. I think the key thing is to just start. It's likely to be a process, and it may take several literation is to get. The outcome that's required that started, is, is the main thing. I think that I would then I'd be advised people to look at the local context, so to see what resources and what supporter available. I would then say it's really important to build up a team of people on within that team. As I spoke about in the talk, then having somebody who really champions, what you're trying to do on it is visible in a place that you're trying to do that is really important. Um, I think next I'd think about communication both within the team and also more widely that so just to the people who you are trying to introduce the new new concept to, um on we found with some of the work that we've done that actually mixing up different types of communication has been really effective. So posters and emails and local communication groups, as well as speaking frequently at department meetings or wider hospital meetings, Um, the next thing, I'd say is to then collect some data on be evaluate great thank you know you know, is challenging in many aspects. And another question that's come in has seen you mentioned what you talk about. A patient related factors influenced whether peek quick metrics were achieved could use a bit bit more about this. Yes, so that's really in relation to the concept of inhance recovery and specifically looking at dreaming. So drinking, eating and mobilizing. And we found that early communication with patients from the whole of the DT really helped patients to know what to expect in terms of their recovery. I'm certainly from my experience, then some patient. You see them on Day one. After that major surgery, it might be quite surprised that you're asking them to get out of bed or to walk or to eat on. I think only on in the process. If we consents staged goals, then it really helps patients increase their confidence in the recovery journey. I'm just gonna it now. It's speakers D set stage. Go through your patients after after surgery or do you leave? But more to this surgical or surgical colleagues, I think about where I see a team. Most of our basic go tries to you, so it's money on. This is very much surgically driven, the possibility care. Unfortunately, I I think the opportunities for persuading patients out of bed doesn't any Cysts are limited if you meet them on the day of surgery. But I think it's nice to just plan to see when you see them for the pre op assessment and say, Well, of course, tomorrow you'll be sitting out in the chair and on You might get it for a walk down the ward, and you can at least plant a seed because you don't know what they've been told necessarily beforehand. What I notice is, if the pain if our high risk bill, your patients, for example, go to the the normal postop level to area where they receive POSTOP patients every day, they progress quickly. But if there's something that goes wrong where they don't have a bed there and they go to the general, I see you whether used to very sick patients, they tend to stagnate a bit and because the expectation is it the same? So eh, so that's something that I have noticed that if you the expectation is that the patients will get out and get going, then that's what happens. And it's not the expectation, because they're actually the well is the patient in that I see you then and that tends to be they. They tend to don't get the same focus as the other patients who are much sicker than that. Well, I think you highlighted some key points that it's about, um, a multi disciplinary approach on actually talking to the whole team on DCI Angel, Perhaps sometimes the culture of what's expected so that we may not need to wait for physiotherapists to get patients out of bed on Day one on day. I think it's really important to involve the whole team and as you mentioned, some wards and postoperative units and more set up to doing that. And that's where protocal eyes care could be really important and really beneficial, and certainly to those low risk patients who you would expect would move through the through through the pathway on without any problems. I don't think certainly aid what you mentioned there, but discussing it it's obviously a multidisciplinary goal. But mentioning at the pre op assessment and setting those expectations when they're, well, pre op, Certainly probably something very helpful and in getting them out of bed sooner and you've also, Georgina mentioned dreaming. It's important you mentioned particularly about doing being important for colorectal patients. It is obviously this is something we should aim for in other patients. Is there any other data that you could talk about on that. Yes. Okay, Prep. Is it two at a number of surgical specialties on, actually, the vast majority of patients. We should certainly be considering dreaming then maybe a few cases in a few specialties where this isn't appropriate. So perhaps Upper GI I surgery on, but there might be concerned about the anastomosis or her possibility surgery, for example. But I think if we consider it and it really helps us focus on the key goals of inhance recovery, which is the restoration to normal physiological function on getting patients back to normal function to enable them to recover it and be discharged as early as possible. So other said before, I think it's important to talk to the surgeons on DCA ncidod and consider whether it's appropriate early on in the in the pathway. But I would suggest that having looks at Eclipse Data, then there are many patients, but the majority of patients we should be considering this, and there are only a few executions, right? Thank you very much. Estrogen A. I'm just scrolling through the chat to make sure there's no more questions coming in. And if we might leave on T ask Aidan a few questions, even is absolutely lovely to see you after so long. And thank you so much for coming. Start us in virtually in Norwich and that some of the questions posed are, um, are there any new recommendations on high frequency training? Should be meeting with their educational supervisor off the back of the new curriculum? Uh, no, we haven't. We haven't specifically mandated that. And I would say that with the new curriculum, there's definitely some settling in and some teething problems on day for the for the next year or so. I think we probably need to be having more frequent meetings with our trainees because and supervisors, we're getting to know what what's needed. And the trainees air also getting their head around it a swell. So rather than discovering a problem quite later on in the year, it's probably wise to just check in with Training is a little bit more frequently but way haven't mandated that. I think Oh, it's a good agent with the supervisor to, um to use a judgement to just side up lately. Yeah, and that someone has asked, uh, what is the change in the domain for 18. Quick. I think that's a question about the quality improvement, too. So there was quality improvement in the previous curriculum, but it wasn't really assessed on. It was unclear it didn't on the E portfolio before. We had a lot of pee. It wasn't really clear where that and that it in, and even now, on the on the lifelong, learning with the old curriculum, it it There's no rule bus criteria for how we assess it. So we knew that there was good stuff happening around the country. But it wasn't on consistent around the country, and it wasn't it wasn't being done in the same way everywhere, so we just tried to make it a bit more consistent. So it's probably nothing new there if you're already doing this, but and we've tried, what we've done is just to formalize it so that it is there and it can be avoided. So in certain areas, trainings could sort of and read a lot of it a little bit, whereas that's not really possible anymore. So in the new curriculum, you still need to know the same things to be a consultant as you did in the old one is just It's packaged in a different way, and we've We've put more explicit things in there around things like research, education and professionalism, so that if there are deficiencies there that needs to be dealt with that we have, Ah, I mean's to do it. And also, if there's a trainee that's not meeting those standards, we have means of actually giving them some extra time, which wasn't really that easy to do in the old curriculum because focus so heavily on the clinical aspects. Thank you. I'm just feeling the questions here is we go So and then the question come in saying, Do trainees have to do ah que I pee for every Jermaine? Or is this just another form of evidence but not essential to get signed off? And no, you don't have to do a cute call the improvement project for every domain, because that would mean that have to do 14 projects for each state of training, which is too much. And it's just it's just to formalize the assessment off a Q I project training might do. They have been doing for years. We, you know, we often are at a recipe. We wanted to see some former your activity going on. So it's to formalize that if you go into the blueprint in the College on college website in the assessment guidance, it shows that the Q and A Q I tools for assessing a bipap can actually be used to demonstrate lots of things. So research is one that it can take a box of that's relevant team working but of leadership and safety. Quality improvement is the obvious one, so we can actually take quite a lot of boxes on just by doing one. Q I project. So that's something to look out for. If you're doing an assessment for ah trainee, just think, actually, does this take some of the non clinical domains? Because those are the things that aren't so obvious to to find evidence for and you don't come to the end of stage of training. I think I got nothing for leadership or nothing about communication where actually did all that stuff, but you just haven't recorded it. And so it's it's to try and make it easier for training is to demonstrate what they're already doing. And that's something I suppose. It's educational supervisors we can do when we meet just to remind trainees to be looking at the non clinical domains as well, and to be right when they're doing their workplace assessment. Some projects to look at what they could fulfill through that. Yeah, so I think that this stuff that we've formalized in the new curriculum and non clinical stuff it actually was there in the old curriculum, but we didn't have a way of assessing it. And they're certainly wasn't a way to hold a trainee back. For example, if there was a problem with their team working or their communication, there was no way to, um, there's no way to say actually need a bit of extra time to work on this because they could quite generally say, Well, I've met all the requirements of the curriculum So on, And conflicts of the Converse is that is that the training who is doing really well needs to be reminded. You need to show that you're doing really well by collecting this evidence that go along, so that will just take a little bit off reminding and prompting for the next year or two until it also was done I apologize. I think we're about to breach into LLP here, Aiden. But there's been a a question come up asking about the inability to modify the MTR feedback on. But I don't know with that cellapy or if it's the form. But do you know this is ah, current problem? Um, so it's no that that's I did see that on a chat on. That is a good point. I'll take up back to the college at our next meeting and see if we can and put that facility. And there I have to say I've approved a few MTR and I haven't noticed up because all the comments were fine. But I think that's important that that the trainers were able to do that on. I saw that that also written that there was no option to say that we couldn't comment because of not not knowing the training or nothing worked with him recently so that that could be that that might be something else that we need to put in. So, as I said in the talk, there are numerous teething problems. We really wanted to delay the implement implementation of the curriculum because of exam problems coverted the recruitment issues on everything else that was going on and but the GMC and said, No, it has. It has to be implemented in August. So ideally, we would have had a year or so to prepare for all these things and we wouldn't have had so many teething problems. But But we are, We are, we are. So they are, You know that there are a lot of bugs and we're trying to work through them. That's great. And I'm amazed that there are not a battery off questions relating that I'm just looking through the live chat of just updated it. I'm just gonna just do one final check that there's no more questions for you. And thank you so much for coming to see you on this morning. It's been fantastic. Toe. Have you experienced Teo quickly You to, um um so and the g m r. I leave on them to talk on the do you feel with the questions that we've seen today And thank you again. So much for coming. Bring your expertise, Teo North North for actual meeting. And quite often, the echoes. One of the questions that come in and I would totally agree with this question quite often. The echoes and the preop assessments say this ability or some pulmonary hypertension, but but it's not quantified. Is there something that we need to worry about when we see patients? Preoperatively with the echo is a screening method, and you're right. It always create a bit of alarm on which other you ignore because he's so repetitive There something, or you take it too seriously. And then you capture the laser surgery, which is not always the best for the patient. Yeah, I would say if they said Sign up on my attention, you have to go back to technician and say, Can you quantify this? But also, let's say that in general, most patient, that's a COPD sort of it'll record. This is got mild to moderate from a habitation than you think. What do I do in general? Those basic have a normal RV. So you look at the right ventricle. Second new formula, all the right ventricle. I said at the end of the job that the session that the questions come together woman, hypertension, for is there a way that have real Timoptic for today? is your how is everybody? Because that is not always answered. The report. There is no dilate is moving well, you can almost ignore it. It doesn't mean that doesn't happen with hypertension, but it's exceedingly likely that will cost very productive problems. It's a lot of people living all day with my mom or my habitation. They never had a problem in their life. Either Be swine. But I think if you happen, that they are very eats dilated or is no moving. Well, in that case, you have to send it to the physician part way to further investigation, to label treat it on all the things that we discussed. Okay, so so really to go back. If you got any concerns about the right ventricle, go back to the technician and quantify. And what if I What do you mean with the MRI of my attention? Is it mine more than you need the number on description of the driving? Great. Thank you. Another. A question has come through and looking, talking about particular with P dexa and hip and knee candidates on many of the neck of femur fractures that we see a lot off in Norwich on have limited mobility anyway. What would alert you to a patient with preliminary hypertension or V failure, especially they They often have mixed co morbidities accurate. All these patients is impractical. Do you have any tips or suggestions? Well, I think we know that neck from a fractured meet a herding care within 24 hours. It possible. But I think you have to have it in an emergency echo. You have to have an echo because even if you're not going to delay surgery, you can have a response file about how much you need to keep up your anesthetic. Let's say the echo shows of the ventricle is elated that are some Sinus to be a problem. Hypertension. The patient cannot exercise because they've been in house bone for a while. Then you have to gear up because you know that any insult in surgery may put this patient a classic hip fracture that arrested after it's mostly related to a small and a listen on someone with him or her potential, because we know almost everyone cut some degree of embolism, so you have to have an echo before doing it. If your heart is not getting to that. You have to put pressure on that because for other surgeries, they could always do echoes when some having a heart failure or an m I. So that basically being a similar category, um And then if you see that the right ventricle is struggling honesty, you think the basic will benefit from surgery you can put in our line, you can start on infusions. So this dogma that we always learned a strain is what you're gonna do with echo. You're gonna lose anyway. Yes, you can do things with the echo because you can master your technique adopted to the recent echo. So you know what, black or why you do the surgery you don't, is how you set up your anesthetic and I think we have to be more. Yeah, a strong in requesting an echo within 24 hours. Yeah, I think there's definitely a quite a distinct line, I suppose, between elective hip and knee orthopedic surgeries, limited mobility on my special threshold could be quite low for doing an echo in those patients on down. If the hospital has capacity to do that in the time frame, I know certainly we're seeing are pretty assessments only a week, really, sometimes before elective surgery at the moment because of the backlog of CO there, so that makes it challenging. But I think with the neck of femur fractures, it is even more challenging to get echoes in the time window on be. Quite often, I think a lot of people end up putting in our lines and running on a trip pre emptively, assuming that there is some pathology but no having it quantified, that would be a good compromise. But ideally, yes, we had to push me cards for images, and we know that the hospital, most of them got capacity to the urgent Echo is just the It's up to us to start pushing the standards to what the surgeon I need to happen. Um certainly opens the that it's quite thought provoking in that perhaps, if there's a busting trauma regularly should be looking at doing being able to do a quick echo to see if the right ventricle is grossly abnormal and then and then using that, because the reality is that most places when they go from fractured would do well, no matter what we do but we know that they say for rain, urgent operation is kind of high mortality, and most of the people that die is usually associated with underneath it. Cardiac disease, um pulmon help attention. So if we can pick up those patients off by a better care, maybe we could dramatic changes in the in the preoperative mortality. Yeah, and the risk prefer? There's another question here, in terms of anesthetic techniques. Are there any difference in it? Comes with TV versus volatile in suspected plenty hyper taste attention cases. You read all reviews. Oh, are they the pharmacology of the Bala tight that said that the press correct function are they myocyte level from the clinic as perspective usually relevant so you can use whatever you feel comfortable with. That's the matter, is not is not gonna affect the heart enough to put the basin or risk whatever you use. Great and thank you very much for your homemade tips. I've taken a screenshot of those You've mentioned the number of troops that can be used on, but what's your on a trip of choice in the contact Supplement Hypertension? Well, I love to start, nor are very early Although it's a Vaseline tricked er, they have some beat effects, so they are people for months will improve marginally. But more importantly, we maintained route pressure in the right coronary artery because he scheme years was started cycle off the PA pressure goes up low flow in the corner. In the right, carotid goes down. They are They become more ischemic. After being off many years, suffering on then, brother cardiac arrest. This is the usual cycle. So no generally will give a nice standard to prevent or minimize the risk of that. Eventually cool the silent dropping The karate pressure are very distant, further patient arrest. But if I run in nor the high level on, I needed second bit more aggressive for the RV performance. Probably adrenalin be. My option is in every couple weeks around dopamine. I know people is nobody a a find a dopamine, but dopamine adrenaline. My second daughter will be any one of them. Excellent. And I've just quit and have one last quick scroll through the live feed. But I think, um, there are no more questions that I can see coming up, and so I think we'll and joy it to a close and say thank you so much for all of you for joining us this morning on giving us some really informative and thought provoking talks. Absolutely taken some tips away. So and there'll be a half our coffee break with the video from our sponsor, Medi Plus. So please take the ocean you to have a coffee and view the posters and, well, welcome you back 11 30 for the training presentations for the runny Patel prize on. That will be terribly, Doctor. Caroline. Really? And thank you all for joining the first session off any U 2022. Thank you very much. Probably day, everyone. Thank you so briefly just before we go to the break. I'm just gonna introduced Sherry Crispy. He was one of our sponsors, um, from a medical office, and he should be joining me now. Um, I just asked him to start his video on, but hopefully he can tell us a little bit about medical us. Good morning, treat. Morning, James. Thank you very much. Thank you. Uh, thanks for having me. Thanks for introduction, James. My name is Sherrick. I'm the Rep for many. Plus full. The South on East Anglia, which, of course, includes Norfolk in Norwich. You've been a longstanding customer of hours. So the last time I had any interaction with Norfolk in Norwich Waas it was the audit day back in March 2020 which waas matter of days before we first lock down on. So I guess the fact that we're all doing this event online is testament to how we're not quite back to normality yet. But it's lovely to be back in interaction with you guys and to be able to to listen to some of the talks today is, well, it's been very informative so far on so many. Plus, who are we? I'm hoping that some of you, if not most of you will already be familiar with the name. You might well have seen us on packets lying around in the theaters, in the store rooms. So we are great British manufacturer off medical devices, a large products made here in the UK and then distributed Teo UK hospitals. NHS private included a swell, so you will hopefully be familiar with our TV set, which looks a little bit like this, which I know that you guys use um, personal three way and a full way sets the's also used in surrounding trust. So those of you don't belong to Norfolk under it should also be familiar, which is get eso actually a G by guidelines for how TV sets should be are in fact model done our sets. So we've got a variation of different sets with different levels of integrative valves on length. But we are used as an example in terms of how TV sets should be set out on. So there are a couple of products on a couple of things I wanted to just touch on this morning very briefly. The first product I wanted to show you guys which hasn't actually been seen by more for concurrent so far is our dedicated capnographer months, which I'm just gonna hold up like this here. Now we've been inundated with enquiries for this particular mask, I would say, probably in the last 6 to 8 months on, but I think over will have played a part in that. But generally what we've noticed is a trend across hospitals and trust in a minute who aren't sort of in line with guidelines when it comes to capnographer hasn't been that much attention placed on it. A lot of people are using a sort of D i Y method poking you can, you know if you decide which I won't go into detail on but having a dedicated capnographer mascots. Some has been something that a lot of hospitals have picked upon. They wanted to try and take on board. So this is our mask. It has a centrally position. So to something, line just there, which last for the most sort of accurate readings on event, tired or so to it's made from a very high quality PVC, which is very soft on the face, doesn't tend to leave any marks, even if it's been on for a good few hours on it's vanilla scented, which there's been papers release, which suggests that the liver is of a calming influence. So hopefully all like this man of vanilla you have your patient is on balsa. The mask is Venable in um, it's been made compatible for both sides stream on micro stream machines. So this little connect a piece here would go into any kind of microsyringe a sheen which, for example, would be or Philip. So you're getting the machines way also have it with a standard mail Luke, which would be available for most other machines as well. And it would be compatible. Andi, other product or rather, range I was going to touch on what? Our connectors. Uh, so we have a range of peripheral IV connectors. This one here is our high flow. Why collector? As you could see, the green valves, there are anti reflux valves. So that's a very simple, straight forward connected piece there, which is useful in a lot of situations, but almost sort of sort after connector, if you like, is this's This is our We named it the Carpentry connector because it was made in conjunction where the group of any statistical commentary you came to us and said, We have a very specific need. Could you help us create something on be have done? And now it goes far beyond Coventry to the reaches of the world, actually, where this is exported. So as you can see here, a central gravity IV line here with an anti reflux valve on two anti siphoned valve ports here, of course, the green bridge and the tubing itself is anti kink. So it really is a nice piece of get to keep everything streamlined on delouse for sort of very small dead space as well for fluids to mix before it goes into the cannula. Um, now, if either of these have sparked your interest, the capital, a mask or any of the connectors, I do believe my details are on the poster page. James also has them, if needed, but he might put them into the chatters. Well, if needed. Do feel free to get in touch. Even if you have any remarks on our TV sets, any comments, anything you'd like to say, Any ideas you've got? Do you feel free to get in touch? Were always on the lookout for product feedback. We love to hear from you guys about what, what else? We can do anything that's good. Anything that could be with improving do feel free to get in touch on now, just briefly on the environment I wanted to touch on. Now TVA is sort of regarded as the morgue environmentally friendly method of anesthesia and compared to sort of volatile gases. But of course, we're level with the criticism back about our single use plastics. You know, the packaging that that these come in on these are disposed of. Ultimately, there are plastic, um, now, in terms of a wider solution for this problem, when it comes to hospitals, we are at the forefront of trying to do something about this on and we are exploring different avenues. We're aware of certain projects that are taking place where by these single use plastics can be removed and safely recycled. There's lots of regulate tree requirements in the background. There's lots of things we have to be careful off. But the environment is something that many pills takes very seriously, and we are looking at ways of sort of getting around that problem on become pany, we offset or remissions. We plant thousands of trees every year. We also involved with a project called Project See Grass which involves and cleaning up our oceans. So we contribute to that quite heavily. Eso as a company, we do what we come on because being British in this country means that technically, the products you buy have a lower carbon footprint. If that makes any sense. So yeah, we do what we can attempt any in terms of helping the environment on the final thing I wanted to touch on on. I hope that some of you would be interested in something like this is medical Is's study dates. Now we is a company. We try to run 2 to 3 study days based solely on TV every year. Now, in the last couple of years, Dutilleux always see the situation with the pandemic. We haven't been able to conduct as many as we've liked on the ones we have conducted have been virtual and that is a plan for this year is well on. We do have two coming up. One will be up in Scotland. If any of you fancy a good, what 67 hour drive from from Norwich. You're more than welcome to attend. But I myself from planning one for East Anglia, and that would hopefully take place in sort of late spring. I'm talking May. Perhaps June it might trickle into on this one will be virtual Now. What we tend to do on these days is we invite speakers from around the region around the country who are particularly knowledgeable in a certain area of TV so TV of the talks will have a section on the environment will go through the age guidelines. We can also sort of make it a little bit mawr. We can go into quite a bit of depth and touch on pharmacokinetic side as well, so we sort of dedicate four or five hours. Two different topics of TV these days would get you a They would get your sea pretty points a swell on def. If it is an impersonal, then we would try to for sure have those sort of in an external venue. So these are the kind of things were hoping to do that will be one this year, a set in the first half of this year, any Stanley or somewhere. So I will most definitely get the details out to you guys and make sure that should have sent out to everybody who might be interested. So do do look out for something like that, but we are always going to work me trust and sort of increase the awareness of TV on education if it's if it's needed, because often it's difficult for ah hospital or a trust particularly focus on one area so we're happy to do that on just finally the As I mentioned the carpentry connector, a team of guys came from Coventry to us and said, We got an idea. Help us develop it. If any of you didn't quite fancy going on the Apprentice this year or dragons den wasn't quite ready at that stage. Then you can come to us on on will help you develop something. If you've got a particular idea or refused noticed on, do that. There is space for something and you want to explore Do come to us Do drop me a line were always on the lookout for new products. We do have a new product development team who are working on things that the minute that I cannot reveal. But do you come to us were always on the lookout. So as I said, my details on the poster anybody if you'd like to get in touch about anything I've touched on today any sort of general comments, any questions you've got? Please do drop me a line and I would love to hear from you on on that. No, I wish you a very successful afternoon. Make it very much Ames on down. I look forward to seeing some of you in person and then it the coming months and years. Thanks very much. Great. Thank you very much for your time shriek. We'll just let people have a little bit of a break now on. Don't see them back a bit later. Thanks again. She can have a good day. Thank you.