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Summary

In this installment of their "Keep Light" series, medical professionals John da Series and Diego provide a deep dive into orthopedics, with special attention given to referrals, anecdotal experiences, and best practices. They meticulously dissect a case study of a 40-year-old male with worsening back pain, offering tips for efficiently communicating details in referrals. Stressing the importance of precision and empathy when presenting cases, they share a helpful mnemonic aid, "TIT," to guide medics in identifying and ruling out potential trauma, infections, and tumors. Attendees can look forward to learning practical skills and gaining a nuanced understanding of orthopedics to enhance their own practice and referral procedures.

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Learning objectives

  1. By the end of this session, learners will be able to identify the primary learning areas in orthopedics and gain increased insight into the specialties' nuances and specialties.

  2. Learners will be able to understand the process of referrals in medicine and will learn strategies to improve the efficacy and efficiency of their referrals.

  3. Learners will gain practical tips for dealing with a variety of common orthopedic conditions and scenarios, assisting in improving the management of patient care.

  4. Participants will learn the importance of being adept at communication between healthcare providers, and the key components that make a successful and efficient referral.

  5. Learners will be able to apply the SBAR (Situation, Background, Assessment, Recommendation) process in their interactions with fellow healthcare providers, and in emergency situations, to share patients' information more effectively.

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Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

And welcome to our fourth episode of our series called Keep Light. Um My name is John da series. I'm one of the Aes H OS currently working in Queen Alexandra Ports Smith um UK and I'm here with my friend and colleague who will allow, allow to introduce himself. So, uh my name is Diego. I am currently uh orthopedic ST four registrar level at KSS currently working Ashton Saint Peter's. Um looking forward to this, this, these 30 minutes is going through some orthopedic stuff and getting, giving you some tips on how to make things feel easy between A and, and Tina. Cool. How are you, how are you feeling today? Right. Good, good Monday afternoon. Get P as time of the day and the week. Yes, that time, right? So, you know, those who, who are with us today and those who are, you know, watching this video. Um This is literally as the title suggests, it's literally keep it light. Um And our objectives for this episode is we're going to talk about orthopedics, hence why, you know, our orthopedic registrar J. Um And you know, we're not going to talk about all of the the million types of orthopedic conditions, um, that we would discuss in a specific or type of referral. But we're going to kind of talk about specific cases and go through the ins and outs of referrals, going through nuances and just things that we've just encountered with our experience. And hopefully, you know, after this quick 30 minute session, you get to learn a thing or two and that just helps you with your own practice and the referrals that you do. All right. Um I just have a quick slide and I always use this to all of my um all the episodes and I just kind of change the SB a bit. Um But I think SBAR process is kind of similar to kind of enzymes. Um because I'm a nerd, um um I think SBAR is kind of lock and key. You know, if you speak to the right person, you give them the right information, then potentially you unlock, there's their wisdom, there's specialist input and you, you have that j and that work for um process. Um It works sometimes but I wouldn't say all the time. Um because I think um referrals are more kind of like an induced fit, like you don't know who you're speaking with, what his background is, what his habits are and how he generally he or she likes to receive referrals. So it may not, might not necessarily work all the time. So I feel like with experience. I feel like it's more of an induced fifth the, where you actually have to adjust and see what types of referrals actually work, depending on who you're speaking with. What type of day or what time, what time in the day. Like, if you're referring to someone, I was calling you go at 3 a.m. in the morning, you definitely don't want me to start with. I have a 73 year old person who was walking and blah, blah, blah, blah, blah, blah. So it really depends on the timing and who you're speaking with. So and I just want to add as well like sbar is, it's an art, the more you do, the more you realize that you can, it's like essentially how can I get this person's attention about a patient. So if you go back to your previous life, John. Yeah. So like that's really good. I think that's key. Like people don't do this enough, please introduce, please introduce who you are, where you are, what you're doing and what you're doing. Exactly. Because there's like start off with like a reason like like situation um you do, you can even, you can even like, like I would like to refer a patient who I think has to call for syndrome. Exactly. Yeah. And back to the conversation about if you were calling someone who's at home three a useful thing to do just to orientate someone because I would be when I'm asleep. Say hi. Like if, if you call me up, hi, I'm John. I'm the A DH I'm calling you up from, from the ad department at three in the morning. So the person on the phone is kind of waking up and going 3 a.m. recess. So you're 3 a.m. recess? Ok. He's, I would have to wake up. I very quickly now just to figure out what's going on. So, exactly. situation, which is also later environment within reason, depending on the time is. Yeah, exactly. And yeah, just as I mentioned, that takes experience. Um as but as again, it's always good to be human and introduce yourself and ask them if they're actually free to accept your referral because and emergencies are always happening in the emergency department, but they could also be handling some emergency in their ward or they might be in cpod or something like that. So always ask and be human about it. Um Sure. So we'll go just casually through the cases and you know, just kind of casually talk about it and just see how this referral works for you and Jego and then obviously you will go through the, what you think is actually the proper way, at least in your experience and then just go through the different things specific to this case. All right. So just for everyone, um who's with us today, um First case is going to be a 40 year old male came in due to longstanding back pain for about a year. Mentions that the past two weeks it has been worsening. So, um, he adds that he's been having, you know, intermittent paresthesia on all of his limbs. Um, occasionally has like an electric light sensation going down from the base of his spine going downwards. He didn't mention any kind of bowel and bladder incontinence, incontinence. Um, ob observations that we've done were all OK. His bloods and in, and his urine dip was actually fine, didn't really see any kind of particular reason as to why he's feeling. This is the way he is, um, on, on just more specific assessments. We've noted that he's having active paresthesia. He did mention it's kind of intermittent, it's not always there but does come in waves. Um, he mentions he's a bit having some numbness from the shoulders down. Um, he has four out of five muscle strength on all lives. Um, didn't really do a reflex test, but, um, did mention he does kind of feel that way as far as the assessment goes and based on just looking at him or inspecting you do see some muscle wastage from there. Um So if I were just quickly sample my referral and call you at, let's say 2 a.m. which is normally, um, the favorite time for A&E people to go orthopedics, just like just reading this, just these two, the, the, the information of this slide. If I were just to just refer you as is with these words here. How do you, what do you feel with these, just random bits of stuff on there? Uh, well, I mean, like no one likes, honestly, no one really likes back pain. I think about the best way of moving forward for this. The only thing that would catch me is that acute, like worsening over two weeks having, um, let me just see. Well, you possible bila bilateral sciatica that to that's already I'm like, I need to think like, what are you trying to, what do I need to rule out here? Is it a cord compression? Is it a syndrome you need to think about when, when patients come into what I usually tell patients when I get to get it further on to me is we need to make sure that we rule out the thing that will cause, you know, life altering things. So for anyone coming in, it's called a equina syndrome or Ecuador cord compression until otherwise so or it could, you know, this could even be, you know, this got for all for all I know. So it's, it's, it's, it could be anything at this point in time. Um And yeah, yeah. And I just wonder like what's your general feeling like if someone were just to just give you information and um nothing just turning in his mind and just leaves you that information. Like, what do you think what should I do? I just backward. What do you think is I usually fire back with, what do you think is going on? Exactly. Yeah. Exactly. And it's to be, you know, to be fair just for everyone listening. It doesn't, it doesn't become a productive conversation because obviously you just giving him all of this information and you left it with the specialist and you're like, you're now let him think all about it and it doesn't become productive if that makes sense. Um As um J goes mentioned, you know, nobody likes chronic back pain, you know, your acute worsening back pain, especially seeing that in the A&E but in terms of ruling out the big things, as mentioned, you're looking at CO Q, you're looking at potential new focal neurology. So if I were to like convert this whole entire um block of information here, I would just normally say, you know, I have a 40 year old male and we're potentially ruling out KJ kna. Um He did mention there were some worsening um symptoms such as weakness and bilateral paresthesia from the neck down. Um He would have some kind of learn type phenomenon where he would bend his neck and this electric shock coming down. He didn't mention any bowel or bladder um incontinence, but we're doing a bladder scan anyway, just to see if there's actually any um retention. Um obviously depends on who you're speaking with. But apr exam is debatable um, and, um, II would pr everyone with back pain to be absolutely honest. Sure. Um, and even then, like, um, I just in orthopedics it, every, if anyone has any sort of pain, joint pain, limb pain, whatever pain. But, you know, we're orthoptic, like simple, you know. Um, there's a saying I always think to myself another don't be ati t what is ti t think about trauma, think about infections, think about tumors for life. This could well be, you know, myeloma or something like that. Sure. Sure, sure. You think about, if you think about, if you think about, if anyone comes in any joint pain in A&E think of those three things and you can go wrong, it helps you. It's a, it's a surgical sympathy there. What is it, what is it called? Ti Yeah. Don't be at so trauma, trauma, infection, tumors. Hm. It's actually quite good. And because obviously there was some atrophy noted, obviously, it could have been because of the muscle wastage. Yeah. Could be a sign of tumors as well because if he was losing weight. Exactly. So, you know, so he's really difficult to say. Exactly. So, you know, um pr or no pr but you know, sometimes they will ask, you will ask the patient, do you have any saddle anesthesia or like just numbness in the groin? Um But II do agree, I think just having that pr gives you a bit more of objective evidence and it actually helps. And, um, just a pet peeve that I've picked up is that, you know, when you do pr everyone's, when you do apr examination and you come in tone, everyone's tone is different. What I like obviously do, you can do it just to have it down. But what's more, what's I think is, gives a bit more is that sounds as paraesthesia? So I would get, I would get like a cannula or blood sharp needle where you draw, you know, fluids from and then you start to tap around the anal region. And if they can't feel that sharp sensation, then that tells, that would tell me more than apr examination. So I would do both. Right. It's worth your time getting uh getting like a, a blunt needle and, and seeing if they can feel that sensation around that perineal region. Right. So it's a bit more objective. Absolutely. Yeah. Hm. Right. That actually makes sense because, you know, if you do around your entire finger pr then obviously they'll feel some sort of thing either intrarectally or, yeah, I mean, what, what's like? Do you know, do you, what do you know what abnormal anal tone feels like? I mean, ii like everyone's anal tone is different. So. Right. I don't know if someone's, oh, I may have lax anal tone and that might be abnormal, but a patient can tell you whether a sharp thing does not feel sharp and sure that's, that, that to me gives you more. Sure. Yeah. Right. Um How do you feel about the age criteria? Do you actually use it a lot? Like, do you actually have referrals where you'll say specific dermato myotome or is it enough just to say from a specific region of the body? I think, I think, I think an Asia chart is a beautiful tool. I think anyone comes in with. I know query called the syndrome or query. Um query, you know, spinal trauma and Asia chart is, it's awesome. Look, it, it's literally, it, it, it may be a lot of work, but look, it's, it allows a to get a baseline of what someone was at the time of your combination and it's and when you, when and and subsequent reviews, you can refer back to that and see if things progressed or progressed, gotten worse, gotten better, stayed the same. It's, it's a very, very useful to, I mean, I do get it sometimes you do a quick exam. I mean, that could be more for uh that could be more for the Ortho sho taking the referral. But obviously, I do appreciate you guys in a and you have a lot of patients. If you have time to, if you have time to do an Asia chart, then that would really help us out. But sure, I would expect someone from our end in orthopedics to do this to do this. If not, if not, my S ari would do it myself personally. Um Make sure it's and make sure these are done um at intervals to see if there's any change at all. Sure. So it's a good kind of monitoring, kind of, kind of like a baseline neurology just to see where we're at. It's also easy to follow as well because you have mobile as charts and you can like sure the documentation guides there as well. Yeah. Um Yeah, but I definitely agree, you know, it's really busy in the A and um but I think systematically, you know, if you actually see one bit, I mean, I think as far as the people who are in A&E, um you can actually, once you find that localization, you don't necessarily have to go all the way down because normally a or the spine, the way it works, once you kind of see that level, maybe go two or three and then once you get that done, that kind of just tells you roughly where it is. Um But yeah, you know, giving regions are always good um just to help orthopedic and A&E doctors just to talk about it. Um So just for the listeners as well. AJ is actually good. But if you're actually struggling in terms of, in terms of what to do or what red flags that you have to pick up or what sort of work ups you have to do, if particularly in the A&E or primary care. It is a very helpful link that I've just put on the slide here. It's called the JG IR FT or to get it right the first time. Um It's a good, great, simple interactive pathway and you literally just press enter and it will tell you the timetable. So it will go with like you have symptoms of weakness or incontinence for about two weeks. And then as you go through it, it'll just tell you what next to do and where to refer or who to refer. If you used to II batch this pathway I, this is something I think every everyone ed or anyone doing orthopedics should use to get a referral for that because she tells you what reflex to look out for. And if those reflex are taken, it gives you exactly what you need to do and if you follow everything in that guideline to the tee, um, no one's gonna fault you. Right. And that's exactly what I've done with this patient. Um, I've used get it right the first time. Um, actually even before I speak to orthopedics because obviously I wanna get it right the first time. Um, so the gentleman, you know that going back to the case just so everyone can see particularly for the ones that just come now. Um, so basically did to get it right. First time there is some kind of worrying symptoms because he's been having, um, you know, worsening pain, paraesthesia and weakness over the past two weeks. So that in itself kind of falls under the first category for the, or the first segment of the, get it the first time. And then asked me to do, um, you know, check his sensation, his bowel and bladder, which we've done. He actually is sensate of the bladder. So he feels when it's full. He didn't really have any incontinence. His bladder scan, pre and post was actually ok. Um, he did have good rectal tone and I couldn't really kind of, well, I didn't do the blunt needle. Um, but he did have a good rectal tone. I asked him to cough, kind of just raise intra abdominal pressure and it seemed to squeeze my finger really well. Um I wasn't actually, I was more likely, uh reassured with my findings and I didn't think this man had coquina, which is always good, but he, but I was still worried because he was still having ongoing neurology. Um, so I did the thing and just spoke with orthopedics. They didn't think it was a coquina, but our pathway because it's worsening pain with neurology. They did see him the next day and they booked an MRI and just to piece things together, he had C five C six kind of severe stenosis and then they kind of scheduled him um for the because obviously he was having ongoing neurology. Um The good thing is there was no tumors there was no my multiple myeloma, which is always good and they just attributed the atrophy, um, from just the muscle wastage from that lung. Probably it started pretty ok. And then just through time his muscles were just gradually, um, shrinking as that nerve impingement was just getting worse and worse. Yeah. Um, my question is, is that normally kind of like a pathway for you guys? That was a thing in our trust. Um But in your case, like what would have happened? Um Every so everyone's, everyone's um spinal pathways are different to one another. I think neurosurgery pays a big role for called, called the echo syndrome. And I think it's a conversation having in, in, in, I guess this is general hospitals where we do not have uh neurosurgeons, the orthopedic surgeons are babysitting these patients. Um So in my trust, the pathway is to be in touch with the neurosurgical team and then sure, whatever they say, um we will take over the care depending on what they say. But even even having a conversation with the neurosurgical team has its art, I'm not sure what to use, but um we use to refer a patient in our trust. So the same one, if you think about if you put yourself in a neurosurgical registrar's perspective and they're probably going to get thousands of query called called. So in that sense, when you write your referral to them, you want to structure it in a way that, you know, just to, just to highlight your case more to them because, you know, they have so many cases as well. For example, if you got this case at three in the morning, you could even say, you know, is this, is this called syndrome, is this something that can transfer overnight right now? So you get an MRI or can this wait locally in the morning? So you're having that advanced discussion rather than why this, you know, card eal compression. Like especially when I do this, I say or or when I make a referral, I type, this is the situation. We have no MRI these symptoms happen quite like today. This is something that we should admit overnight and wait until tomorrow morning or is it something I need to transfer over right now? So you can get something overnight. So, right, having a conversation, when you make a referral to neurosurgeons, you also need to do your sbar but also not to say press try to try to ask more like just have the options ready already. So it's quite easier to navigate. Fair enough. Um Yeah, that's actually something I learned in my experience because sometimes they'll say, well, definitely this person is not staying in the hospital. Yeah. Um and then they just kind of give, gave me the option and then as I went along, that's why what I would say, like, you know, this patient is definitely not coming in that starts in the conversation. I just want to make sure you know, there's a plan for him because obviously there's something happening. So um yeah, cool. Um so we go on to the next one. Yeah. Right. Um For those listening um we talk about, you know, cardiac get it right the first time and you know things about referring spinal patients for back pain. Um Do you guys have any questions regarding this or um things that you might want to add in terms of your experience? Um You can leave them on the chat box. Um just in the um, you know, we because uh we're short of time. If you do have any questions, just put that on the chat box and then we can go through it once we've finished the next case. And um, yeah, so um case two. So there's a 70 year old male had a fall on the stairs at 8 a.m. The patient was seen after 10 hours, which is unusual kidding. Um Yes, he was, he's in pain. He has had noted swelling on the right hip. He had apparent shortening on that right lower extremity. He was unable to move the right lower limb at present when we were reviewing him. Uh on additional kind of e examination, he was able to wiggle his toes on that right leg or right foot. Currently, he has sensation from the L1 S one dermatomes, which is fine and great. Um, obviously in these kinds of things, you know, it's not unusual just for everyone, you know, if, if you are already working on the NHS or new or they have no experience with the NHS, it's not unusual that kind of patients get seen quite late. Um because sometimes there are some issues with, you know, ambulance and queuing and all that thing. So just kind of accept that that, that happens. Um But anyways with these kinds of patients, um you know, there's a shortening of that limb in pain, right leg, 7, 70 year old, we would do an check uh x ray of that hip and femur just to check. Um we, we give them analgesia in the emergency department because obviously that is really painful. Um And yeah, we would normally speak to orthopods once the X rays have actually come, I'm not sure in your experience, Jago, do they actually call you for something? You know, if, if everyone is just staring them in the face that this is definitely enough without an x-ray. Do some people just kind of give you um kind of a preemptive. I usually get, I usually get like, oh, we got a potential enough and I sure, great. Well, make sure it's enough first before you, you know, and then do you, do you put down the phone or you, you wait for the details or did they sometimes give you the details? No, because sometimes they, some, I've been situations where it's enough. Ok. But then nothing. So I fine wait until, wait until that. Sure. Yeah. Sure. And, um, you know, I guess it always, it does make sense, you know, II showed you the picture already. Um, but it does make sense because obviously in the elderly, you know, maybe like 80 or 90 year old, even if they were, like, generally fit and well, and, you know, they're able to track and do all of those stuff, their bones are still brittle. Um So if they had a shortened leg and they do have pain, uh the likelihood that it will actually be off is pretty high. But as you've mentioned, there are times that it, it isn't like there are times that it isn't, um sometimes it's not even the femur or sometimes it isn't even that bone, it's the pubis or the pubic bone and even, or even then they may be acting enough and the X ray is absolutely normal. And if that's the case, you still need to refer to us because we need to make sure that it isn't normal or not. And that's why we think about a CT doing CT scans MRI and standard. But yeah, yeah. So, um just for everyone to kind of understand it's really, really kind of, well, I guess, important to have that first imaging already and then discuss with the orthopedics and then you can kind of discuss where this goes, is this something that we give them pain medications for and then check if they can actually walk. If not, then we rediscuss again, maybe do some further imaging as based on my experience that wouldn't, that's what normally happens in this case. This guy definitely has a femur fracture, um, on the right side and that does make sense that shortening, um, you know, the pain over there and normally what we would do in our A&E is we would give them a good amount of analgesia. Um We would normally give them a fib block or a fascia iliaca block because these fractures are really horrible. And even if you give them a good amount of painkillers, IV they would still have a lot of pain in that area. So fascial iliaca block is basically given local anesthetic around that area. And if there is no contraindication like blood thinners or anything like that, we usually just go for anatomic landmarks. Otherwise ultrasound could be done. I think fascial blocks are vital. Number one, it allows them to go to the toilet without any pain. Number two, it kind of relaxes. They don't tense much because they don't feel the pain. So in terms of me operating the next day, they're not, they're more, they're a bit more relaxed and not as tense. So, mm, I think fascial blocks are a must, right? Um Yeah. So, you know, this is a very straightforward, you know, not um Obviously I would have just called you once the x-ray have, has shown this and in my practice, um, we normally just give the fib when we're available when, when, when, when we can actually do it. Um But what, what's kind of the situation in your practice? Normally, what I would say to if you're an Ed and they have enough assume this case is happening this because there's a, there's a 36 hour window when these things need to be fixed. So from an ed perspective, assume that these patients are going to be operated tomorrow. So the least you can do or apart from the fib is making sure, you know, groups and safe are taken, coughing is taken. Sure. Um if they have any other medical issues because these patients are quite comorbid medical, those are addressed and managed as well. Um, bloods see, sure, see how they are medically as well if they've got a history of cancer. And I see the kid is getting a full length view of the fever just to see if there's any mets. Mm, anything. Sure. Otherwise, yeah, that's what I would do, right. So just to kind of help the movement in terms of these kinds of patients, obviously it's going to be busy up in the ward and I'm sure orthopedics has kind of a good list of cpod patients. Um So yeah, that's actually really helpful for our orthopedic colleagues that when you actually see a patient that even if the x-ray hasn't been done yet, but you actually see that shortening, you know, uh he's out of a risk group where this patient is elderly and they most likely, or highly likely might have a fracture. It's really helpful having those first kind of baseline workups already and particularly more if they actually have other comorbidities like, you know, diabetes or if they're on any blood thinners, it's actually really good to have all of these things. So once you get that confirmed, you know, you give the surgeon a good amount of information to prepare them for, prepare the patient. All right, cool. I mean, I guess that's pretty straightforward. Yeah, just one just I II asked John to put this in because I think just not not bread and butcher but just, just to tell you guys, I assume this case is happening tomorrow and the next day. So just make sure you're all set up for that. That's, that's essentially it cool and right. Um so it looks like no one has put any questions on the chat box. So if you do have any questions, you can still leave them here. Um while I talk about the kind of summary and the conclusion bits over here on this slide, um the question hasn't come up yet but it does, you know, sooner or maybe later in the day it does come to you, you can actually put it on the feedback. Um So we, we can kind of reflect on that. Absolutely. Yeah, and we can, we can go through that. Um But if there was things that you liked, please put that as a feedback or things that you think that might be need improvement. Um It would be rather helpful for us as well because we do like to teach a, we do want to make sure we know what we could improve on. So it would be very helpful. I put the feedback form on the chat box just in case. So you can press the link and, uh, tell us what you think. And yeah, so I think, you know, just that 30 minute, those two cases, you know, the coquina, the back pain and the n I think those are more or less majority, if not most of the referrals that go through, um, a to orthopedics. Um, and I think, you know, because those are the more common ones, it's actually really good to learn about these things just to help you master how you assess these patients and master how you actually speak with the specialist coming from, uh emergency or primary care, speaking to the specialist, the orthopedic. So I'd always like to end it this way where, you know, er, is always multifactorial in itself. Um, you're talking to loads of different individuals with different practice guideline or different baselines, knowledge, baseline, different practices and different habits. So it's always good to, you know, I wouldn't say meet up and have dinner or anything, but just get to know them in a way where you can sense what types of referrals work with them, you know, getting to know the context, you know, having a referral at 8 a.m. where everyone's had breakfast and their coffee is going to be way different to having a referral at 3 a.m. four AM in the morning. So just also understanding that context and um with experience, you definitely gain that the wisdom of what type of referrals work are you. It's going to be a headliner type of referral. This going to be the long everything type of referral and you, it would be, it would surprise you. It depends on who you're speaking, what would might, what might be appropriate or not. Uh And it's just life, you know, not everyone is the same, everyone just literally has their own preferences. You want to add something to go. No. All good, all good. Yeah. So um hopefully you learned a thing or two and um you know, hopefully your next few referrals just in your own practice become more effective and you feel like you're improving. All right. So um thank you everyone for joining us. Thanks. Um Do we plug in the 1 December 14 John? Uh I put another media at the moment so I'll pop up, but let's catch up afterwards. I'll be sure. Yeah. Thank you very much. Thanks, bye. Thank you very much. Thanks guys. Um So for everyone that's here, I just would like to plug something that's happening on the 14th of December. It is a partnership with the Royal College of Surgeons called the Grassroots Project. Um This is in, associated with the British Association of Philippis Filipino Physicians and Surgeons, but it's open you to everyone. Um IM GS locals from the UK or any medical student or doctor internationally or local that wants to join. Um It's basically going to talk about, you know, topics about the NHS. Um We're going to cover about the structure itself of the NHS, you know, cultural things, um culture shocks. Um We're also going to talk about I MG experience and we're going to explore how to maximize um portfolio specifically surgical ones. But there are other topics there that could also help um with, you know, just getting a grasp of the NHS system and the portfolio system obviously going to be a bit specific to surgery. But I think there are some things that you can take away um just in general for other things. So it's going to be a face to face um program. It's going to be on the 14th of December from the, from 12 o'clock to five o'clock. It'll be in the lovely library, which is a nice venue in the Royal College of Surgeons England in London. So the link is just on the chat box Um if you do want to join, it's going to be 10 lbs a ticket, which I think is a very reasonable pli price with lunch provided as well and a lovely venue. So um for those interested, see you there and uh thank you for joining us today. Don't forget to leave a feedback. Bye.