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Yeah, so should be live now. So, hello, everyone. Welcome to the second talk in our series Orthopedics around the World. Today. We with us today we have Mr Joe Westland. He's running ST Seven and from orthopedics in Edinburgh and he'll be talking about orthopedics in Malawi and his role as a traveling fellow for project. So Mr, you have the floor. That's great. Lovely. Well, good evening everybody. And um thanks quite a small audience tonight, but that's um it's often quite nice really. If um if you have questions as we go along, we'd like to chip in or type whatever, then that would be absolutely fine with me and I will try and answer as you go along. Otherwise plenty of questions for the end. But um, yeah, so my name's Joe ESL. I'm a, a registrar here in Edinburgh just at the back end of training now and I'm gonna be talking to you today about orthopedics around the world um in Malawi. Uh bear with me. So hopefully you can see that. So M Malawi is a small country for those of you who don't know it. I don't think I would have um really before I was involved. It's that small red thing there. I don't know if you can see my cursor but it's pretty small below the equator and off to, towards the east coast of the African continent and this is what it looks like. Slightly um oo on a, on a slightly bigger scale. So it's capital, it's called Lilongwe and that's in the central third of the, of the country in the south is the other sort of second biggest city, which is Blantyre. Interestingly, the locals really think of Blantyre as the capital. But the long way is um like the administrative capital, I'm sure there are similar sort of things like that around the, around the world. But um and then lastly in the north and where I'll be talking to you most about today is Mzuzu, which is in a more mountainous area of the country. And you can see that there's a, it's a nice map. I don't know where I got it from, but it shows that you can see it's much more mountainous up in the north than it is in the south. Now it's a landlocked country. Um Only with three borders were very small border with Tanzania, Tanzania. That's what they call it. Um In the north there, it's bordered almost entirely on the east by um by Lake Malawi in the south is Mozambique and then the Z in Zambia. Um often Malawi and Zambia, um sort of seen together and lots of diplomats. And so we look at, we will work in both countries simultaneously. So that was us learning in a long way. Um, the first time on, on our, on our first trip and this is Lake Malawi. Lake Malawi is, I think it's the third largest, um, Lake in Africa, something somewhere. Anyway, it's, it's enormous. It looks like you're on the ocean. You know, you can't see the other side of it and it's bordered by lot. It's a, it's a predominantly Christian country, lots of churches. Um, along along the coastline there, we were just staying in a, in a camp here and you could hear all the sort of gospel choirs at the weekend singing over the lake and it was an amazing experience, actually, not something I've really seen before or since. So, more specifically, just breaking the country down the north. It has six districts and, and Mzuzu Mzuzu City, er, is where we spend most of our time, but this is a geographically, very large and very rural area and that, and that's important. So it's in Zimba and Kata Bay RPI. And because the, so the, the, the transport links are very poor in Malawi, these places, although they might only go 100 and 5200 kilometers away are in real terms, an extremely long distance. Ok. And the only hospital that serves the north of the country with a doctor is in Mzuzu and, and that becomes important as, as we go through. Ok. So this is, this is Mzuzu. Um, I've got, obviously got lots and lots of pictures. It's hard to replicate it, but it is a city but not in maybe the way that, um, that you and I would imagine or, or are used to seeing cities, you know. Um, these are two streets. It's all very e exemplary streets right in the center of the city. Um, on the, on the right of your screen. That's Rosie Hackney, who I'll talk about later today. Um, when we went out on the last most recent trip, her, her bag got lost, which isn't un unfortunately all that uncommon and we had to find clothes that would fit. Cos Westerns are a bit taller than the lines. Um, and the only place we could find things was in this, um, this second hand shop. So it was a really interesting, er, endeavor to go and help her pick some clothes, um, out out there. This is the other thing of Azu. It's a mountainous area. It's in sort of a basin. So that's just taken over the top of one of the hills and, and, um, is just, just down in that, in that dip there. It's fairly big spaced out. It's quite a, quite a, um, dispersed city, I guess you would call it and some of the markets and so on. Ok. So that sounds easy now, a little bit more about Malawi. So Malawi is very poor. Um There are lots of metrics to measure how poor um a country is. There are lo loads and loads of different ways to do that. This is a good one though. So this is GDP, PPP and, and GDP Jewish resident products, how much each citizen sort of contributes economically, right? But it, the, the PPP part that what that does is it, it shows that, but relative to the expense or the cost of living to the person in that country. Ok. So what this means is Malawi over broadly is usually seven, someone's in the seventh and sort of 20th, poorest country in the world on most tables, they have very low income relative to how much it costs them in their country. So this is a good metric in my view. So it's a, it's a very poor country. Um But what's interesting about Malawi is it doesn't, everyone is poor, not without exception, obviously. But, but there's no wealth, there's little wealth inequality. So it's a very peaceful country for the most part. Right. I'm sure again, I'm sure if you were to look at government websites and so on, they probably say it's the contrary, but it's broadly seen and it definitely feels like a safe country and, and, and one of the reasons for that is that there's, there's not that much wealth inequality, everyone has nothing if, if that makes sense and, and how do they live and work well, the, the, the population is around 20 million, they predominantly live rurally. So 95% of the population live in rural communities, they still have that very traditional way of, of living out in Africa with villages and these as, and sort of smaller communities, most people don't have a four more job in the way that you and I would think about it. That is someone paying you a salary. They do exist, you know, obviously, but it's a small, it's a small percentage. It's something in the order of 10% of the country have a wage. Ok. In the way that you and I would see it, most of them um, attend to small holdings, ok? And, and they will produce, usually, usually a crop and they, they, they mainly grow maize, which is corn, ok? Uh That's the main thing and then they grind it, which you can see here in mills and that forms the, the staple of their diet and the staple of their diet is something called, er, and er, is corn flour. So maize flour and it w we in the west use maize flour and cooking, but it's mainly for thickening things. You might add it to a sauce or something to make it thicker. Or if you think back to primary school, you used to put it into water, mix it up and it becomes this funny thing with so called fix Atropic. Properties where if you hit it fast it's firm. And if you put your push finger slowly it's very soft. And, um, they eat that so they, they boil the flour, um, and it takes a lot of mixing and use these big wooden pales and it comes out in sort of blobs of, I guess, a bit similar to bread or something. It's, it, it's a dough really. And, and you use it a bit like a chapati something you, you rip, pass off of it and you, you take your food and the, um, lots of agriculture, lots of people with bikes like this stuck. These are, these are all pictures that I have to say. Uh uh with a few that I'll tell you that aren't mine are, are all just pictures we, we were taking when we were around there. So let me tell you then about you, you know, your future doctors, let me tell you a little bit about the healthcare system and, and that is what I hope you're here to talk to listen to today and, and I'll be spending a lot of time talking about these sorts of things. So the healthcare system. So it's a, it's a public healthcare system there, there, there is private exactly in the same as the UK has. It's a very similar set up. It was a British colony, um, Malawi. Um, but it's free at the point of access. There's no, there's no fee to be paid at all. Although there is a small private healthcare system and that becomes important. Bit later on today in the north of Zizi central hospital is the main hospital that serves a population of around 4 million that's widely dispersed across that enormous geographical area which is hard to get to and with poor connection, connectivity to the s federal hospital. Um and it's served by a single orthopedic surgeon. Yes, there's one surgeon. So in that entire population, I'll talk to you about how that therefore works cos clearly that can't work. They have other things to make it work. Ok. This is the hospital from above. So, and I really hope you can see my cursor but this is the main road just coming out of um um the city, there are a few cars, not many people can afford a car. Um And then there are just the, these are all single story outhouses connected by outdoor corridors. So the, the theater that there's one room that the orthopedic surgeon and his team um are in, that's in this building here and that's immediately adjacent to accidents emergency, not, not similar to what you were, you were imagining in the National Emergency Department. And then two orthopedic theaters which I'll show you in a wee bit. They have wards based, they're mixed, they're mixed wards in terms of specialty but separated by sex, male or female. And there's a pediatric ward and then there is a small private ward. Ok. And at any one point here, there's around 80 to 90 inpatients on orthopedics. And there might be one in, in the private, in the private, the district hospitals. There are, there are plenty of them, um, in those smaller areas which I, which I pointed out this here is in Carter Bay. But the reason I've, um, put this picture in is because it shows you some ambulances or, or, or, or what were ambulances? There is an ambulance service in Malawi and it serves one road and that's it. So it's a single road that connects two cities in the south to each other. Ok. A long way to Blantyre. If you were injured, anywhere else, there is not an ambulance and it's not, not a public one anyway. Ok. So these are some of the ambulances in the north uh districts that just have been left abandoned and uh pretty stuck. The wars as you would expect are very modest patients that are admitted. And, and that is a really interesting way. So, so, so patients because they live so rurally and it's very hard to get them back to the hospital. Should they need surgery? Most will have to stay in hospital? Ok. So even if they have a trivial injury that requires surgery, but in the UK, we would just send home and pick up our 10 days down the line. That's not something you can do in Malawi. Patients are admitted and they will be given a bed if there's one available and, and, and if there isn't, they will put blankets down between these beds and divide the bed numbers to ABC and so on based on the crowd. And I'll show you some pictures of that. You also don't really get bed linen. So you see if you see in the background, all these, this is a male horse. They all have different bed linen and that's cos their family is obliged to look after them. There are nursing staff and they are very good nursing staff. But the general day to day care of the patient is actually usually by a family member. So you will have a family who will bring in their food and they, they tend to sit in, in, in groups, out of the window. Uh, you, you can see someone in the background, they'll the family members of, of these men or women or whoever who they're looking after will sit in big groups and chat and cook and those sorts of things. But that is obviously a very different paradigm to, to what we're used to. And you can see the, the medics here. So none, none of those people you can see on that screen are a doctor. They are functions. I'm going to talk to you about what they are in a, in a wee bit. But, um, very traditional, the white coats very hierarchical and they go round once a week on a Monday and see the patients. Ok. It's just some other, there he goes, he's arm with a blanket on the floor. It's on the pediatric ward there. Ok. I should probably say that obviously you can't take pictures or screen grams or anything. Ok. Just I'm sure you're well aware of that. But, but please make sure you do and I've included this, this is a small child with a femoral fracture on traction again. Not, not really what we would do in the UK or we do do it between quite young Children. So the point of me putting you this here was to show you how closely you had to pack all the patients together in this hospital, particularly on the p particularly on the pediatric board and also how rudimentary some of these things are. Ok. So that traction there is, is fashioned actually from plaster casts. So they, they'll, they'll make things from plaster casts and fashion, you know, long strips of plaster, which they, um, they'll attach to maybe a weight or something that has weight to it. Very rudimentary. They still write on paper as you can see, although there are computers, a few, they still do entries. And the way, actually when I was at medical school, which wasn't that long ago, I graduated about a decade ago. But, um, you know, you can see it, it's sort of an old, old money way of doing it. And lastly, I've put this in here just to show you that this is the mechanism of trauma. Ok? And how much trauma there is per district. So Mzuzu is, is up here in the north. It's mountainous terrain and trauma is extremely common in this area. Trauma. Yeah. Falls again. Some of them are low energy falls like an elderly woman tripping and breaking a hip is extremely uncommon. Ok? Falls are falling off of things. It, it's not, it's not quite the same as, as we were. We, we imagine there, there are low energy trips and falls obviously. But the, but the burden of geriatric trauma from low energy falls is very low. That's not what this is showing road traffic collisions very common. Ok. So either being in a vehicle or more commonly being struck by a vehicle. And the, the reason for that is people walk on the roadside at night. They don't have, they might be on a bike or something that or, or not, and they don't have lights and there are no street lights or anything like that. So road traffic collisions are extremely common and actually drive light in Malawi is absolutely terrifying. They're both if you, if you're being driven or driving and I would absolutely never go out and walk on the roads at night as a pedestrian that just wouldn't happen. Sports work related a animal bites. The m the main animal that bites people is crocodiles um, and then assault on domestic violence. Unfortunately, you do, you do see out there as well? Ok. And, um, assault, assault, assault is often, um, they have a police service of sorts in Malawi but, but they tend to sort of police their own communities themselves. So somewhat, you know, unfortunately there's no sort of like innocent until proven guilty. Um, it's, if, if you're perceived to have done something wrong, there will be some sort of community discipline of you and, and, and that, and that can be quite trivial but it can be extremely, um, extremely violent actually. And a, and a common way, um, of, um, not common, but a common air way and certainly way we don't see in the UK is they'll put a tire round people and they'll set fire to tire. That's, that's not uncommon. We saw that a few times out there. Ok. So a very different, different place, very different place. But a really amazing place again, I'll speak to you more about the amazing things about Malawi, but just to paint a picture. So what I, what I've essentially said so far is it's a very poor country but uniformly so split into regions with a mountainous area in the north. The two biggest cities are in the middle and the south, which is where we don't work cos that's well served by the international community already medically. And because of that, the rural nature of it, how mountains it is, you see a high volume of trauma and that trauma tends to be high energy. Ok. That's what I've told you so far about my life. Now, doctors, there's one doctor. That's true. That's not a, like a, like I haven't gilded the Lily there. That's not smoking mirror. There was just, there is one orthopedic surgeon. That's it. Ok. And that he stood there with, with my colleague, Sam Moon, he's called Il Banda Bat. Um, is young. I dont know if you can tell that, but he's about my age. I'm 35. Um, and he is a consultant orthopedic surgeon and II have an ST seven, I'm taking a few years out for, for my doctorate. But nevertheless, the point stands right. And he has to deal with the generality of orthopedics alone. Now, you know, I think, think about yourselves, you know, if you, if you're seeing a patient, you're gonna present it to somebody or, I don't know, you know, how often would you just bang heads with somebody? You know, how often have you seen us as surgeons talking to one another or seeking the opinion of somebody else that's really common. That's a really healthy way of practicing. The can't do that. He has to just get on with it. He has to be, he has an all site operator for all injuries on those sites. Yeah. Again, think about orthopedist in the UK. What do we do? What we subspecialise I wanna do tumor surgery. And so I'll be learning about tumors and I'll forget all the stuff that I've done over the last seven or eight years as an orthopedic registrar, you know, just practice what I'm really good at and interest in. He, and he can't do that. Um, he does e essentially, it's exclusively trauma there. Orthopedist are much bigger than that. But, but that, that is all that is done in, in MZ. It's, it is orthopedic trauma, not, not limb length, discrepancy, skeletal deforms, gentle abnormalities, tumors. So that isn't done. It's just broken bone s essentially and other and infections and things like that. Ok. So Patil is a new consultant. He's, he's now in his second year when we first met him, he was in his first year. Um and he's doing an amazing job. I don't know how, I don't know how he does. It, it's unbelievable. He never gets a day off. He has to be permanently on call. Right. You know, he, he can, he can not work. He has to be working every day. He might not be resident at the weekend, but he is working and he will have to come in and he doesn't get to take any leave at all. So he does not get to take any annual leave. And one of the things we've been doing out there is sending a UK surgeon for, for between two or three weeks to relieve him. So, at least he can not work for a little bit. Cos that is, that, I mean, that's, I don't even know what the word for that is. Ok. Ok. So Patil. Patil is great. He's a really good, really good guy. He's Malawian and he was trained in East Africa. Surgical training in East Africa has only been going for about 15 years before that. People, they might have gone to medical school in Malawi. Um There is one but you would, you would have to then go um to another country place that common places would be uh Namibia, South Africa, Kenya, places like this where you don't have your surgical training. But there is now a school of surgery that includes Malawi and Gambia and places like that. And it was started by um a Dutch surgeon, Dutch. I think it might not be Dutch. Um but it hasn't been going very long. Ok. And then, then there's our healthcare professionals. Now this is what's really interesting and, and there, there isn't really an equivalent in the UK. So everybody else that you can see in that picture besides Rosie and I are orthopedic clinical officers and the clinical officers with any prefix in Malawi might be a medical or an anesthetic clinic officer. They have done a three year course with a one year internship where you're working your interns. There are two in this, uh there are two, there are two male um OC Os at the back there. Um, actually three, sorry. Sorry. And, er, the lady with the headscarf as well, they're all interns, they're all their first year having them a three year course and one year to then become fully qualified and, and they, they are amazing. So they, they learn, you know, quite a narrows of practice in terms of orthopedics, but it's all of the scope you would need in Malawi. And that's orthopedic trauma they can do with orthopedic trauma. They can, they will, they will assess, they will clar, they will reduce and they will also do emergency surgeries. And by emergency, I really mean putting on external fixators to realign bones so that then the surgeon can come at a later date to fix it when there is time debridements infections. But they don't do surgery in, in the way you're thinking they have a lot of mans, a lot of childhood mans, bent forearms, those sorts of things and they're amazing. They have great knowledge and, um, yeah, tough job. So the two that you can see there, there's, there are five or six, it varies a little bit in the ASU at any one time. There's Hilda Perry and, er, and Blackmore who are, um, they're great, they're great, great with that way. So, just moving on to, to what is done. I said it a lot, there's a lot of trauma. Yeah, a lot of trauma, a lot of trauma, a lot of trauma this was a study done. It's a long time ago now and it was done in, in Bay, which is one of the hospitals near, in the grand scheme of things. It was easy. So, these are the things that the OC Os are doing. Ok. So these are debridements. Um, e external fixation. Oh, sorry, I should have said they do amputations as well. So, mangled limbs, they'll amputate. They do all of the tono for club foot. Yeah. And they do some of the infections and those sorts of things. So they're brilliant. They do, they do a lot of work in the central areas. It's all trauma, as I've said. Ok. And it is mainly putting plates on things and nailing things. Ok. That is the, the vast majority that obviously grossly underplays the, the, the sort of skill and the judgment and actually then performing operations. But broadly, it's, or, and iron nails are what, what is mainly needed when you're out there. So it's, yeah. Ok. So, so lots of slides coming out now, just lots of cases. I'll tell you about some of them, but just to illustrate the burden of orthopedics out in Malawi. OK. I'll go through that and I'll, I'll talk to you about what we're doing and the challenges and those sorts of things. Ok. So these are just pictures that we've taken when we're out in Malawi and they're not sensation this, these are just, I could have picked any right and I have and I just shade the spectrum. So, on the left of your screen, there is a traumatic amputation of left uh left leg with degloving injury up to the mid thigh. Ok. Obviously, it's not a salvageable limb. Um That's gonna a high above knee amputation again, that was a road traffic collision. Um On the left, that's an open tibial fracture, the foot on the left and the rest of the tibia up on the right. Um On the left of your screen here, if there's an open tibial fracture in that gentleman's left leg and there's an open dislocation of the right knee. So that's the end of the femur you can see there that's the femoral combos. Um This is from a machete attacks. This is someone who's been cut all the extensors here to the fingers and thumb will be gone. It's just through the carpus here. Well, a little bit of a some carpal bones there and there's obviously something missing. So I don't know where the rest of it is. Um So that's a problem obviously, um that can be salvaged, but it won't be a good hand in, in with the resources that the Malawians have at their disposal here. You would, you would be not fined from that, but we'd be able to reconstruct everything, do repair all your tendons rehabilitate you properly. Yy, that, that obviously isn't the case there. You get, you get debridement a reapproximation and they'll deal with the consequences of that infection and that and that, and because of the time it takes people to get, it's not uncommon to, to see wo wounds in various stages of infection. You know, you just wouldn't see these things here. These are grossly infected, like all surgical wounds. This is a, someone that's degloving from a tire over a foot. Um, this is a, from, from AAA knife. Uh no, this was sorry, this is an agricultural injury, sorry, some sort of oscillating blade of some sort. It's gone through the hand here. You see between the sort of Spock, I guess. Um and open humerus, you see the, the, the arm is pointing the wrong way there. It's 100 and 80 degrees the wrong way around. Um open distal is heavier. This here is an osteosarcoma with the proximal humerus. Um They can't do anything about this. If you, if you have uh an orthopedic um tumor in Malawi, you die there, there is, there is no that, that is the only outcome irrespective of the type of tumor. How, how far along you are, there is no scope here to be able to operate in any meaningful way. Um And it's really sad, it is a really difficult part, actually, be one specialty that I want to do. And I really love, I'm going to see my fellowships in it soon. I'm off to Stanmore in London. I'm going to Sydney to do two years of just orthopedic oncology. So, something which is really important to me and they can't do anything. They would take a biopsy, a very rough biopsy. I should say not in a way that you would advise them doing, send it to the labs, it would show osteosarcoma or Ewings or whatever it might be. And the patient that's it. And the, and the patient is sent away, they, they are referred to the oncology team and they are given chemotherapy that, that is well palliative at best and, and, and the homeopathic, you know, I ju it, it's not doing anything. I mean, we might prolong life for a few months but it's no symptom control all these sorts of things. Um, I'll show you some more tunes on, on the left ear. That is a, one of the rare elderly hip fractures of someone who had a hip fracture. Now, in the UK, if you've rotated through orthopedics, we do a lot of heavy arthroplastic for hip fractures or total hip replacements. Malawians and the North cannot do joint replacements. There is no scope to do that. They don't have the right theaters, the right trained surgeon or surgeons, they do not have enough money to buy implants. So, so they do not do joint replacements in, in Azizia or in the North, they do some, you know, one of the big er, hospitals. Mzuzu is quite big and it's the third or fourth big hospital in Malawi. But in one hospital you called the Lion Center, they are putting in some joint replacements. And since the registry began in Malawi when I last checked and that was about about a decade ago, he does 700 primary joint arthroplasties. You know, that is a, that is nothing. That number is tidy. We do a, 1000 helices at the royal per year. So that should a 1000 head franches, most of them will be he. Right. A lot more. So they're treated in traction and this is the way it used to be treated in the UK. Um, like your grandparents or great grandparents, if they're still around would be able to remember this. We put you on bed rest in traction for 12 weeks and that's how it's treated and that is a big burden on the elderly. That's not, that's not, uh, a big, a big burden on us, right. Some people out our, our age, but in the elderly that's, that's akin to a, akin to a death sentence really. Um, to keep sources infections feeling strong and all of these sort of big problems. Um, if you treat with interaction for that long can be done and it was done. We weird some weird things. You see a lot of weird things and, and that, and that's because often injuries are neglected. So they'll, they'll, they'll have a problem and that they sort of won't be able to come to see a doctor or, or it'll take them a long time to get the money to, to find a way to get there. And so they'll come with weird things. So this is probably an infected non union of a distal, he, it has a temper fixation historically. Ok. But, but, but that's, that's not the case and what it's failed. So they'll come. Uh, sorry, that's a distal female. I seen this here and on and on the, on the left here. That's, that's myelomatous humerus from the pathological fracture of the, of the surgical name. Um Another myeloma here in, in the tibia and then they also get some general problems. They have a CT scanner. That's why I included this. They do have a CT scanner um and they can get CT, it's a, it's a Chinese made CT scanner and it works very well. And I, and my understanding is it, it, it wasn't as expensive as some of the ones that we would have in the UK, but right had a cocaine and fracture on, on that CT scan there. Ok. So they have an injury. Where do they go in? Malawi? Will they go to the theater? This is what theaters look like? So on the left here, um is Patil and some mou scrubbing for a case. So we use disposable gowns and, and disposable gloves out there. They don't have them for disposable gowns. So they will autoclave sterilized gowns um daily. OK. So they, they do have a unit kit, a KIN for H SDU but they, which, which is like the sterilization service of a hospital for H SDU. Um And it, but it could only autoclave things. OK? That's the only way sterilizing things is, is through an auto clay. So you get these gowns, they're extremely old. Uh Again, you probably not thought about this much folks, but surgical gowns is not just an inert thing. You don't just stick on a gown. It has to be various things or fire resistant. You can't have lymph that comes off it that might fall into a wound. It should be water, Impenetrable to water and other bodily fluids and all these sorts of things. There are, there are things in the design of a gown which are important for your protection and patient protection and so on. These are just sort of linen and cotton and they look a bit like a gown. They're all fitting, they're all one size. Um, they don't fit me, you know, they're sort of halfway up my forearm. But, um, you know, ii manage to squeeze instantly on more than one occasion. So you pop those on and then you go into an operating theater. So this is, this is the main orthopedic operating theater in there is a light on the ceiling which, which, which works. There is a bed here, a radiolucent bed, there's an image intensifier. You can't see it on here, but it is, they do have an image intensifier, which we use. So that, that sort of see arm, that taste X. We use a lot of orthopedic surgery. They have a prep room at the back there where they get kit together. They have like a, a washing down sluice type thing at the back. They have a computer screen where they can com display your X rays. This is Diathermy here and this, here is the anesthetic clinical officer. So there is no, there's no anesthetist. They, yeah, everything is done by an anesthetic clinical officer. Uh, who is amazing. He can anesthetize anything in anyone. But there's a, there's a problem, there's a problem and a really important one and that is that they run out of inhaled anesthesia a lot. Um, so you tend to restock at the start of the week on a Monday. And if you're having an operation Monday, Tuesday, Wednesday, Thursday, you might get general anesthetic if you need one. And if you don't, thereafter, unfortunately, you're gonna either not get your operation or you're gonna have a regional block, a regional block injecting the, the nerve that supply an area that is, you know, we, we do do that, that there's a big trend to that in, in surgery in general. It's called wide awake local anesthetic. No, it's or so this is a, a novelty, right? It's done in the UK. But, but it's, it's not not for the sort of things that they're having to do. You know, you're not gonna fix, we wanna fix an ankle if we had to in someone who's too, more abundant for something else. Right. Ok. But out there they're having to, they can basically give anyone the spine is the lower limb and up in the upper limb, they're having to do regional, regional blocks. Sorry, Mr Aslund. I think someone's saying that the screen share is frozen but your camera sound. All right. So have you tried reha it? Yeah, no problem. Hold on. Let me, let me just change. So is that doing anything by your service, I guess? No. Ok. Give me a second then. Um I mean, I can see on my side but I think the audience can really no problem. No problem. I'll one second, I'm gonna go to slide 10. Can you see that now? Yeah, I like it. August. Yep. Yeah. Perfect. OK, perfect. Thank you. Um So yeah, so just going back to uh this one. So, yeah, so, so there, there are problems and, and the other thing with having um regional blocks for major orthopedic surgery is the time that they last can be a problem. And also there is no sedative. So we sedate a lot of patients based on what they hear. Our pitta pater, our terrible jokes, us getting frustrated by things sores, right? They don't have that. Um And then should you get mid case and things wear out and they can start feeling things. There's no general anesthetic to convert them. And that's a problem. That is a problem. We've operated on patients who mid case, you know. So what you do, it's really tricky. You do low anesthetic infiltration, but there's a maximum dose of low, you can't just keep going and going. It's tricky. OK. It's really tricky. So that, that's what the major theater this is. This is the minors theater here. Um, where a lot of the mans are done, um, in Children, some risk K wire and so on and so forth on the right of the screen. That that's surgical tras. So again, rays, again, you will never have thought about it. You just see them appear, the surgical practitioners will scrap practitioner will, will get everything out and I'll last and I'll last a week and, and it will appear the, whilst the scrub practices out there do exactly that as I've just described, the trays are, are like this. They are wild. Are they, they all of ours have an inventory. You, if you ever watch it, if you're in the theater again, watch the scrub practitioners. They count everything before the case starts. They check everything's there. What's there? If there's anything missing, they make a note of it that will come back the next time from a sterilizer services with that thing on. This is an UN. You have no idea what's on this. Right. So, so they have, they have a few broad surgical trades which are auto place sterilized. There, there's a large fragment set. That's the, the bottom one here. Those are large plates for like Femurs tibias. And there was a small f two small fragment sets. These are these ones up here where smaller plates. Right. We don't know if you've got the right plate if it's the right length, if it, it definitely have locking plates, right? Because there are a few down here, but it's a pro it's just a problem but just not used to it. You know, you go, I mean, oh God, like I don't know what I can ask for what's coming. I just don't, I don't know, you know how we're doing these three cases today. We need these two, these two trades in this one and who knows what you're gonna find on. There's no inventory and that, and that again is something not used to. And then you operate. Now, operator, this is me with the here we're doing, he rest together and um a few, a few things, one is the sort of very questionable um light handles. I didn't notice at the time it was one of the first things my wife said when I got home, she started showing these pictures of what the fuck, what on earth are they hanging off the ceiling? Um So they're, they're the handles. Um and then the drapes again, we're used to having disposable drapes that are adhesive and they don't have those, they have reusable drapes that are non adhesive. So you have to stitch the drapes to the patient. Yeah, they probably fine. It is fine. But I was like, what the hell is? Like, what is this? Ok. And then they, the, the nurse is set up as you would expect and they're really good actually. And less are fantastic. Ok. So Tino in Malawi is uh it's, it's tricky. It's, it's mainly, it's mainly trauma. You get it. If it's often high energy or delayed patients tend to be younger than that, than, than in the UK, they will often have had a long inpatient stay to get to the theater because it, they can only get three or four major cases done a day and they've got 70 or 80 inpatients, there are long waits for this. So you might be an inpatient for seven weeks before you get your operation and then it sort of tried to heal. And now you've got, now you've gotta take down AAA M Union and that's really hard, you know. Um because all of there's a blood of callus, it involutes, all the envelops, all the neurovascular structures. It's just a much more difficult clinical paradigm. When you get there, they then go to theaters which, you know, are fine. Actually, they have all the things that you would need to do a safe operation. They're different. Yes. And there are some challenges for sure. When you get them on the table, you can make a good shot at it. Right. Um, and, er, and, and that's, that's a little bit. So, so what I wanna talk to you now about the challenges out there in Malawi or, or, or, or Northern Malawi, I can't say Malawi more generally Northern Malawi. Um, the opportunities and some of the things that I'm doing as part of project. Um Again, I'm gonna share some of that with you. So I hope II can't just, just so, you know, I can't see um comments and stuff and chat whilst I'm presenting, I can't, I don't, I don't know why. I just don't know how to jump this line and keep this on screen. OK. So I'll check in from time to time. So this is, this is a major challenge. This is a major challenge. What? And, and, and, and again, I had no concept of this at all. When I went out there, there are two things in health care right? There is being able to deliver it and then your c the care you deliver being a good quantity, ok? That there. So, so if you think about what's happening in the NHS or, or, or any Western healthcare system that you are familiar with access is not a problem where you entirely focus on incremental, sustained improvements in the quality. That is what happens in the UK. And as you go through your training and as a mandatory requirement for foundation program and for the higher training that you then go on to, you have to do annual audit and Q I, which is just incrementally improving the quality and safety of healthcare. That's what we do when you go out to a place that is low in resource, that is still a problem, right? That is still a big problem. But what you see and what everyone who's working in it sees is I can't deliver care to my patients. That's what they see. I can't have a resource to be able to deliver the care that our patients need. And that is a totally different problem. But both are equally important. You can't just increase access and it be shoddy and the quality of the care that you can deliver needs to be good. Does that make sense? But when, but when you go out to these resource poor places, Northern Malawi, the people who are you, you who you would rely upon to improve sustainably and during the quality of health care only see predominantly and I'll show you a paper on this, the, the issues with access. And we found that really, really challenging because we went out there initially to, to observe. So we went out there really just to, to watch and just, we went to theater, we went to clinics, just, just sort of we, yes, we, we partook because we were doctors and they value your opinion. Right? Most, most of the clinics. But, but what we found was when we asked and looked carefully, people said, ah, we just can't give the care and, and then when you, when you challenge them, said, well, what about the care you're giving? What about that? It's not even on their radar. Th that is not AAA challenge that they see. Understandably this is a big problem in my view, others, OK. Hierarchy and other ways of working. So w when you go out to a different healthcare system, you'll see that even if you went from here to Canada or here to the US or here or here to Brussels, right? You would see that people work differently. OK? What you find in Malawi firstly is hierarchy is still very prevalent, antiquated in that way. Hierarchy is important in many ways. OK? But, but it it is being flattened for the greater good over sort of, yeah, years at the moment, isn't it? OK? Although hierarchy's still important in many ways, but they, they're still very pointy, they're very pointy in terms of hierarchy. And, and essentially it's weird. It's like the, the, the doctor and the clinic officer are even more important than the patients. Like, like, like, like if the, if, if the clinic officers ha have a have something to get, go to, they, they'll just go, they'll just leave, leave and go and do it OK. I canceled two cases. I just, I, I've got, uh, sorry, I've got um, something I need to do and I just go and it's, it's just common, it's just culturally normal out there. And we were like, we were like, we've got like, what? But that is just how it is. OK. Hierarchy is part of that. I'm sure that other, other cultural things will contribute to it, for sure. Very, very common. OK. C and then, and then um other ways of working is, is um quite liberal with be diligent in timing, right? You know, it's, they sort of arrive about a certain time things will happen around. It's not, it's not the same, it's all very, more, much more relaxed. Um And that definitely influences their productivity in a, in a big way actually. OK. So, so all those things incrementally end up and their productivity is much lower. They, these are not Christmas, I really must make that absolutely clear. These are just different ways of working culturally relevant ways of working. Very important to understand that it took us a while to properly understand that properly here, I would say as well. Um Technology, there's this weird hybrid. It's like there's a bit of tech, right. There's a, there's a, a computer. Yeah. Right. And they might use it sometimes, but maybe not all the time and it, and it doesn't really work. And a really good example of that is um again, you won't think of these things when, when you go into hospital or your patient to the hospital, they have identifier that other than their name. So imagine a country. So, so, so, so basically everything's put under a specific identifier and everything about you is then attached to that. In, in Malawi, they have lots of regional dialects, they may speak slightly different languages to one another and they have names which to my here are similar and misspelling of someone uh uh um Carl White. So, so misspelling is super common, like crazy comments. So, so you, you might have something of a name and then you wanna find their x-rays, but it's got two letters different and that, that might not sound a big problem, but nothing is indexed in a way that makes it accessible. So they have the technology, but it's not influenced in a way that makes it really useful and reliable and, and adds it, in fact, in many ways, it detracts from, from what they're able to deliver. We found that quite stark, but it was true. The things they were trying to use didn't help. They actually slow them down with less paying attention. So, um although it's a public service and I've already mentioned to you, there is um there is some private work and so many of the surgeons will be drawn either to countries that have either a higher salary for the public concerns or, or a high portion of private patients and Mzuzu is, is, has a big problem. It's the reason they've only got one surgeon, it's because they might come for a few years and do their time and, and then they'll be poached for lack of a better term down to Blantyre or long and they'll go because they'll get better pay and they'll have access to private practice and this affects muz, er, profoundly actually. Ok. The, the reason bat is there is he was, he was born in MZ. So he, so he's from that area, he's gone back, but it's very clearly he doesn't want to stay there doesn't make it look clear, you know, day, day to day, but you can tell the way he works and so on that he, he will, he will, he will, he will definitely leave. Um I have no question about that and then the last challenge is it's really hard to maintain input when you, when you leave again. So, you know, II go twice for two weeks at a time and that you, you have 54 or five months between those visits. And it's hard because of tech and other things to maintain that relationship, that input over the time that you were away, despite wanting to and both parties I anticipate want to do. It's extremely hard um to do that. Most things are done through whatsapp. Um But developing world works through whatsapp um are here, I suppose. Um And yeah, it sounds frustrating. What are the opportunities? There are lots of them. The, the, the main one is, is sort of that. It's not that the only way is up. That is not true. Ok. There is definitely a down, but there are so many low hanging fruits that with modest changes, you can have enduring and important consequence of improvements. Right. And that actually is an amazing opportunity because if, if you go, if you know, you'll, you'll be asked something and you do an audit of thromboprophylaxis compliance and all this rubbish. There is no scope to improve, not in any meaningful way. Yeah, we might, for three months, they might do it. It might be 95%. So 92%. Right. This here, you know, there is this amazing, like Garden of Eden of Fruits, you just go and feast on, right. You have to find it, identify it and you have to learn how to try and help, um, fix things. That's not a good word, prove things. Um, oh, that's quite an exciting opportunity. Right. And then the other thing is the people. So Malawians are amazing people. I really like, have been struck and humbled by the way that they are and they're not like me, they, they, they, they, they sort of speak different, their humor is different and so on, but they're just really warm people. This is really quite quiet group. They were very, very warm, but I don't know, it's hard to explain, but the people are great and then that's what we found is that where you, where do you ask them? Like, what, what things are tricky about working them is easy. They might be able to not be able to articulate it or if they might downplay things. But when you, when you speak to them about it and sit down one on one with people and have there's so much goodwill and, and there's so much like energy to, to, to, to, to help improve. So having this group of people, this is, this is a lot of than all and this is some of the charge nurses, um all sorts of people on there, ok? Um Just a great group of people that we now work with and we do that through something called project. So project is um means we actually found it sort of embarrassing in the, in the native language. OK? In the, in the main one P MDA means to walk. But I in the regional dialect, the word from the northern districts, they, they're more like to say Quenda Kwen da. It sounds pretty similar but it's different that a slight boo boo on our part. So PROJECTA anyway, and pro project was started about two years ago um by Molex Rosie and I now sa Sam um is a consultant from an orthopedic surgeon up in um in Edinburgh. He trained up here, but he was born in Blantyre. His mother and father were Christian missionaries as well as doctors. And they spent, spent a lot of time almost all of his, his adult and early childhood in Malawi. Fortunate his father no longer is, but his mother is. And um in recognition of his late father, he was sort of incentivized to go back to Malawi and do something. So he applied for a very small amount of money. well, a small amount of money in charity terms of 5000 lbs. And with that, he appointed Rosie and I to sort of start, he'd be his fellows and to start this charity to go out there and, and understand and see where we can help in a, in an underserved area of Malawi compared to the other regions. Ok? Um And that's what we did and, and let me tell you about some of that, we weren't really sure what to do, but, you know, I've already said to you, there's access and there's quality of care and, and we said, look, we don't have money because not yet anyway. So what we want to do is try and improve with what they have the quality of care at all to, to, to improve systems within which they work to improve the access if we can. But without throw at it at least now and, and it the premise therefore probably can all, all health sense of funds has the scope to improve and you can do that and help create that in a, in a mean way. So we went out the first time and I said, we observed on the theater chatting to people and, and we, we, I, I'm, um, I'm, I'm really interested very heavily in quality improvement and I've had a lot of training in gy methodologies, you know, formally trained in these sorts of things. Uh, and, and I really love it. I really enjoy it. So we did a lot of, we did this in a very scholarly way. So we collected data, you know, it's not number zeros and ones. OK. But, but we collected a lot of data from interviews which we just, we, we appraised, which we thematically analyzed in these sorts of things and, and to summarize this is one of the things we found that the, the demand on that region out strips over the phone. And when you spoke to everybody, they were focused on increasing resource. But when you address gaps through other means, this is not something that they then spoke about. It, didn't, you couldn't generate that thought alone, it was very tricky, really, really tricky. So what we found is what we wanted to do, which was influence the way that they work and the systems of the situation they work and basically do audit and Q I with them initially, whilst we didn't have money, that wasn't even something they knew about or understood. And they definitely weren't generating de Novo. Right. That, that, that didn't come on. That's my wife making her dinner. So that made me jump. She just dropped the plate on her toe. It's not funny. It always. Um, so let me tell you about something that, uh, we, we looked at, we were fine. So what we found amongst other things was that the, the ways that they work administratively were extremely complicated and confusing and had lots of scope for error issues and it led to lots of problems actually, um an alarming amount of problems and, and, and we studied it and we watched it closely and, and this, this is a, this is a, a chart of what happens, right? So we, we've used this once, we've, we've looked at their wall and we've done things out there to help them with this. That was hard. Cos you used to incrementally to influence people, you need to get people on board working together. You can't just go and say, right, I need you to start doing the ward round on a Monday, Wednesday and Friday and you must document everything accurately that doesn't work. You have to go and watch and slowly influence just a little bit at a time that things will improve slowly. And th and this is what we're working on this. This is very hard but extremely important. If you're interested, I can talk to you about it anymore. Education. So education that's an easy one, isn't it? That's a very low hanging fruit, right. You know, we have an abundance of access to journals, guidelines, all of these things there at our fingertips and all of the practice that you're taught as a medical student and that I will have been taught and the discourse of my surgical training is based on literature and these things, they don't have that. Right? And so simple things, let's just say an open fracture. They, they will manage in quite a, a an antiquated way. Now it's a perfectly acceptable way, but by influencing, so actually to maybe just change this bit, change that bit, you can improve the quality of care that they can deliver. And we found that a a good example is, is open fractures, OK? Is open fractures. They, they don't have sterile saline to wash. We would irrigate with 69 of sterile saline, they have to use tap water, right? So uh they use tap or 5 L of tap water for the initial wash and they will use a liter of saline in theater. That's expensive. And so here we we, we held a conference er like an educational conference and this here is uh so this is a third of all the orthopedic clinic officers in the country came to our first meeting. Um And most of them were from the North. OK. So it was about 80 or 85% of the OC OS from the north and we, we, we raised money. We raised 27.5 1000 lbs at a dinner last year to at least in part fund this, you know, it goes a lot further than just funding this course, I could tell you. But, um, that helps pay for their, to get them here cos they can't afford, that pays to keep them in a simple hotel overnight for pay for the conference fees, give them all a dinner and those sorts of things. It was an amazing day. I had, had a great time and it was very well received. We formed, um, some small groups in the theater. So the theater teams are very interested in improving quality, very, very interested. So for just, for example, one you will all see is the surgical trains that start the theater case. We just say that's the way it came from. It's been going for about a decade, probably there or there about 15 years. Maybe they don't do it. But when you spoke to them, they're like, oh, yeah. No, like I see, I occasionally will ask one, oh, my goodness to go down to the long way to watch for a couple of days. And they always bring back an idea which, and they were trying to do it themselves. It was really interesting. Right. Um, it, but they didn't really know what it was. I, it's hard to explain. They didn't really know what they what it was, they were doing but they were describing Q I and audit and I was like, oh, right. OK. Well, why don't we formalized that? And, and now I sort of mentor in a whatsapp group, three of the sort of the most influential people in theater, I guess, like, we sort of realize that they are the people we, we need to influence, to influence others and, and they do projects now which we oversee and help them through and so on and so forth and, and, and this is a good one. This, this was me understanding why Qi doesn't happen. So a fish bone diagram and these are all the things we, we try to address that to, to help them start seeing. But Q I is something they can do for free and can help, even if it's smaller than frequent, it's better than doing nothing. OK. So there's a lot of time I can talk, I know this has been an hour but I could, I could talk to you a lot more. If you have questions, I would, I would of course, welcome them. But these are, these are some of my reflections just for the final few minutes. Um II anticipate that many of you are here today because there's either something you don't or, or maybe like to do, er, in your careers as doctors. Um This was novel to me. Ok. I hadn't done anything like it. I hadn't been out to a few African countries as a tourist, but I had never seen the real country for lack of a bit of time. And, and I, and what, what you may find is that adjusting to that country and the ways within that they work and, and the systems within which they work is very challenging. It's quite alienating. You'll have had this to a less extent when you just move between rotations, you. So why do they do that? That way. My last rotation was so much better or worse. This is the same is true, but it's much bigger and, and, and the consequences of everything are much bigger. You're like, oh gosh, crikey. OK. So that adjustment for me, I took at least the first trip I came back and I was like, oh Jesus, this insurmountable challenge, I didn't understand why they were doing things the way they did. And then, you know, it took a lot of time and introspection and reflection and discussion and these sorts of things to understand and, and adjust. And I go right now we start because now I understand things better and I can help them in a more meaningful way by not imposing anything on them. But understanding why they do things the way they do and making sure that we are, um you know, we are very thoughtful about that when we're out there. It's frustrating. It's very, very frustrating and, and there are so many things that frustrate you. So, again, I won't go into them, but my God, you'll be frustrated. Now, I guess everything in life is frustrating, isn't it? I'm writing about my MD at the moment, my thesis and it's so frustrating. It's just, just things in life, hard, things are frustrating. Nothing comes easy. Nothing good comes easy. So this is why, um, it's easy to provide transient improvements by throwing money than it is to produce enduring changes. Now, the analogy is that fishing and that if you know, if you give a man, if you give a man a fish, a leaf a day, give him fishing rod, right? So it's a similar, it's a similar idea. Yeah, it, it, you can, and there are still lots of charities that will go and drop in help and leave when we were out there. We, we, we, uh we linked up with a charity or British charity mainly based from traders out of London called Feet First and they go out and they do club foot surgery and they drop in bang, do loads of club feet, come home and that's cool. So that's great. And, and we need to carries that. Obviously, it goes through that. So, but this is another way of doing it. But it, and it's more enduring but it takes time to resort, uh, you know, and, and it takes buy in and all of these things. But that makes it exciting and and a real challenge and the last few days is very worthwhile, you know. Um, I'll be probably going back on my last trip, realistically, cos I, I'm going off on fellowship as well, but probably on my last trip in April or May, I haven't got a date yet and II, I'm desperate to go back and the, the thought that I won't be able to go again, at least in this capacity is, I don't, is a bit horrible really to think about because this is just such a worthwhile endeavor, you know. Um, I guess the, I gue, I guess we should really be asking the Malas if that's true. But it, but it feels to me to be a very worthwhile endeavor. Um, and one that I would encourage all of you if you're interested, uh, want to work hard, are up for the challenge to, uh, to do with your careers. I think that's everything I'd like to talk to you about today. Um, if any, any of you have any questions, um, I'd be very happy to take them. Um, hi, Miss Roslyn. I do have a question on my end. So if, let's say I were to be interested, like, as a medical student or a junior doctor, like, if I were interested to be involved in these sort of like outreach projects, how would you propose? We get started? Yeah. It's a really, I think that's quite a tricky tricky thing. It's hard for me to answer is the, is the truth because I didn't do it. And I've come in a lot more seed and with access to money. Right. Um, but I think it starts with having conversations with people that are involved and also looking for all the other charities out there that are doing it cos there are lots of them, um, there are great conferences you can go to. So there's one coming out called Gas O where you should attend as a student. Cos you'll meet all these people doing charitable things. And I therefore think probably the best way is to, you know, find some associates really. That's probably the best place to start. I think you also probably have to be prepared if you can to throw a little bit of money at it. Uh Not, not much comes for free. We've been quite lucky, I guess. Um But, but those I have spoken to students who have gone have often had to fund at least some of it um themselves. So, yeah, go, go meet people, go to conferences and potentially save a bit of money and be prepared to spend a Bob if you wanna go as a student. Thank you, Mr Aslund. And Oscar asks, um given the difference in workload in cases, et cetera, what is something that you took from your time in Malawi? Back to the UK? Yeah, that, that's a great question. Um So what I have taken back and I regularly reflect on. Actually, it's a bit better here but it's just, it's just how great the NHS is and, and, and it, it, it's made me and, and my colleagues frustrated at times about how, um, how ungrateful, so many people are with the service that they're given here, which is an amazing. So that, that, that's, that's, that's probably one of the biggest things that I've learned. I've brought back with me. I don't think that's as very good. Um starts to take, I've tried to temper that, but it does make me very grateful for the system within which I work in terms of what I've brought back. I think, I think probably it's recognizing that with good planning and execution, you can probably still use quite modest means to treat people effectively. You, there is a, there is an in an abundance these days in there, as I was saying of literature and infinitely improving, right? You know, gradually improved. There is a, there is a point where actually you say, do you know what this is? The b this is a great level of care. It's got a reasonable amount of money that has, but it's not eye watering. And why is it we're gonna have to try incrementally to improve for a tiny, tiny benefit to a few with a huge investment. So I think for me that that's it. And that's a really important skill in general sort of like almost like knowing when to stop. You know, if you've got all this stuff at your disposal, you can throw everything at everyone. But recognizing actually, you know, this is what this patient needs based on first principles, we can do it in a really good and effective way by using the cheaper plate on the. So I think that's what I've, I've brought back. Thanks for the question, Oscar. Ok. I think jail is another question as well. I'm not sure whether you wanna read down the chart. Um When I would like resources other more POSTOP complications like uh yes, yes. So yeah, definitely. Yeah. So there is so postoperative care again, is something that we, we have recoveries, recovery nurses, you would have access to high dependency or critical care if you need it and those sorts of things. So that that isn't, that isn't a thing they have, their recovery is AAA small room adjacent to the theater and it's unstaffed. So basically you just push the patient in and you should forget about them until they collected by the wall. And that really is how it runs that. It's not a oversimplification and all patients have to be stacked in there. So if, if you're, if you're one come out of the major trauma theater and then you've got three or four at a time who have had like smaller procedures like the kids who have the nips and so on, you have to lay them next to each other on these little trolleys, you know. So you look in and you see a man's head at one of the, of the table and you see a girl's head at the other end by his feet and you have to sort of stack them in. So there absolutely is. But, but what, what's interesting about the complications and I showed you an X ray is that they're sort of neglected. So, so we will follow patients up at least to see you back two weeks, check your wound, take your stitches out again and check that's all gone. So there is a important sort of denominator here. And is that yes, there probably is. But do you see them? Does it contribute to your surgical workload? Probably not like a lot of them are being managed either at home? Like they might have a like a leaky wound for forever. Just a low grade infection. It might be divided by, you won't ever see it. So, yes. And then how does the government have to support that? Um It, it doesn't really um yeah, it does not in any way. And also it has a difference in practice their influence or change the way you were practicing in the UK. And hopefully I answered that just with the, the other one, it's just being really mindful of, make sure if you can be frugal, you are frugal. Um Such a big thing. In, in healthcare now, isn't it? It's like, um, a really big thing. It's coming up with lots of conferences and I'm sure it will. Student conferences is, um, the environmental impact of surgery. Now, I'm not by any, I imagine an environmentalist. Right. I, II don't know that much about these things, but what I will say is I now look at all the stuff we're using, I think. Oh my God, like this is absolutely why just throw, put a, put one pair of gloves on to move the patient and then took them off. Oh I needed another one to put another pair on, throw them away. Everything is packaged, which is absolutely crazy like that. I definitely looked to do it differently that way. Um Patrick said, are there ways that if I would support sustainable change in these settings? Yeah. So, so this is, this is a really, really good question and it's something that um I love, right? I was really passionate, I'm really passionate about it. I love try to change systems in a scholarly way to make sure that they are sustained and good because there are two, there are two ways of creating change, right? The ones you'll be familiar with are grandiose interventions, right? So the things you'll hear, governments say, right? Or, or, or like the board at your your health board, they'll say they'll say something we're gonna do this. And the thing about grandiose invention in interventions is they're all or nothing. So if you do it and it works, you get a massive sustained change, but there's a lot of jeopardy because if it doesn't, which is not uncommon and we can all give loads of examples of that, right, then you have a huge intervention which ruffled loads of feathers, which might have cost a load of money and didn't work. So, so, so the w the, the way that you sustain change in these settings in my view is to make small incremental changes repeatedly over time and to, and to make sure that you use actual like, like I said, the word scholar a few times now, scholarly methodologies to do that. So if you wanna go and read about this, there are loads and loads and loads and loads, but there's a great resource on, I think it's on the Lothian website. So if you're talking to something like NHS Lothian quality improvement resources or something, it will start taking you through what those things look like. I've actually shown you a few that I put something on, they called a flow diagram. Very simple. OK. But it helps a lot um fishbone diagram. So there's lots of ways. But the main thing I think is to do a scholarly way, start small revisit it often and make incremental changes over time rather than grandiose interventions which may fail or are only transient CPAP. OK? I think that should be, I think we just ended there just for the sake of time. So a very big thank you, Mister Eland for taking your time every day to, to speak to share experiences with us and thank you everyone for coming as usual. Um We, I just have that feedback link. If you could fill that up, that would be great. And if you have any further questions you'd like to ask Mister Eland, you can write there and we'll forward them to him. Um So they can answer you. Uh One thing though is to include your email in the final slides in the final option as well. If you have any questions for him, because if you don't put it in, we won't know who to reply to. So yeah, I think that'll be all. Thank you, everyone. Thanks everybody. Bye now.