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Hello, everyone. I hope that you can hear me. Do let me know if you can't hear us in the chat. Um Thank you for joining us for our fifth talk in the one named participation in Plastic Series. Um We have a really exciting talk and exciting speaker today, Mr Gavel, who'll be joining us. Um He's just here, but just before we go into that, um I would like to introduce Jonathan our sponsor to give us um a quick talk, five minutes talk on mps and then I'll hand over to Nafisa to introduce Mr Gavel. Okay. Thank you, Luis. So, hello, everyone. I hope you can see my scrutiny. So my name is Jonathan and I am one of the national relationship managers here at Medical Protection mps. So we're absolutely proud and delighted to be able to sponsor and this series of sessions um as we are delighted to work with the Widening Partnership network. So just that as a way of introduction to myself and mps, you would have heard of us before. So we're one of the um leading medical defense organizations in the UK and we support our members across the world. So we were found in 18 92 and we have more than 400,000 members helping protect our members careers, reputations and finances with the world's leading medical defense organization. And what medical defense means is assisting our members with a wide range of legal and ethical problems that may arise from their professional practice such as GM see, investigations, complaints, legal and ethical dilemmas, disciplinary proceedings, etcetera. So what medical, what is medical indemnity? So you'll be aware in the UK. Um It's a legal requirement and G M C requirement to have adequate and appropriate medical indemnity in place. The good news is when you are working for the NHS, they're isn't it called NHS Indemnity, um which does cover the doctors working under the NHS excluding category to work. Um but and it's just indented is really only limited to, to the financial consequence, the patient. So even though in the legal aspect and the G M C view, you are adequately covered, you are strongly recommended to have an additional medical defense organization membership. Even when working for the NHS, as you can see on the screen, I've put a little grid there together which will give you a little summary of all the benefits that your medical defense organization can provide you if needed, such as the legal representation advice in GM see investigations, help with disciplinary proceedings, representation and advice with coroner's inquests. Big ones that I always like to point out for our members is help, let us help you respond to your patient complaints. Don't respond to patient complaints, alert alone. Um We're experts in this field and hopefully our support with patient complaints can hopefully me to get up from becoming a bigger issue and other things that the things that I like to point out. So the Sunday miser is that we're not just here to protect you and defend you when things go wrong as such. But we're also here as an organization to prevent those issues from arising. So we do a lot of support and work for our doctors on CPD courses, learning from cases which especially Pacific to prevent those risks. And you get that all involved as part of your membership just from the case files quickly. On average, we see doctors receiving across the typical career length to clinical negligence claims. This is a massive increase to 30 years ago. It was less than one and not all of these claims are obviously successful, but medical defense organizations can help you with regards to this. And we also assist with our members on nine non clinical non clinical negligence claims matters as well. Um What makes us different? We have more than 100 40,000 members in the UK. Um And there's lots of support at your fingertips. Again, the main focus is being our support to prevent the risk of a issue happening. And that's why our subscriptions and our membership fees are the most competitive in the market as we do do a lot of work with our members to prevent those issues, which therefore makes your subscriptions and indemnity cheaper. Um As you can see, fr membership is free f two memberships only 20 lb and we fix our prices between S T one and S T three at 48 lbs at 48 lb per year. There's a QR code, then there's my email address. I do reach out to me. There's any questions, but I really hope you enjoyed the session today. Thank you. Thank you very much, Jonathan. Um So we'll move on to our speaker, Mr Koval. Um So Mr Koval is very, very well known in the field of plastics. He is a plastic and reconstructive surgeon um consultant, working at King's uh Kings Guy's and ST Thomas Hospital came in college. Um and he has been a consultant since 2009. Uh He qualified from a year University College London Medical School in 1995. Um and has worked his way up to becoming a plastic consultant. Um He's got a lot of work done in complex trauma reconstruction where he's working with the orthopedics team um as well as other specialties um and has done quite a lot of charity work working with ideals and map um in Gaza to help treat um gunshot and lost victims. Um as well as being the chairman of the be first charity that helps train up plastic surgeons in developing countries as well. Um He's also known internationally and is on many international. Uh he's on quite a few international and national committees um for his plastics work over to you, Mr Kavala. Thank you very much. I'll just, I'll just share my screen and let me get this going. I'll say that we'll probably just see all of my screens at once for a second. Let me go across here. Can you see that screen guys? Is that showing? That looks great. Great. Thank you. So I'll put this up at the end for my contact details. But I mean, thanks Nafisa and thanks Louis. I'm a London plastic surgeon. I've, I've been a consultant for a bit too long, possibly now. Um And actually I feel a bit of a fraud giving this talk because I'm not really doing direct Ortho plastics work in the NHS anymore. I've kind of moved away from that and moved more into sort of the elective side, you know, as you kind of get older, you want to sort of quiet it down a bit. And Ortho plastics is, is a young person's game. Really. It's, it's hard work and it's, it's full on and there have been loads of new consultants have joined at Kings who are, who are taking that on and doing a much better job than, than I ever did or would have done, I guess. But I still do a lot of Ortho plastic stuff in with the gaza work and with the charity stuff that I do because that's mainly leg injuries and I'll come onto that. Um So I just, this is probably this slide is what I'm going to cover. Um And um you know, some of the headlines that you can see there are probably that the, the points I want to make that they're fairly simple. There's nothing particularly difficult that I'm going to tell you and for the medical students in the audience cause I gather the audience is a combination of six for medical students and junior doctors. Um So for the pre doctor people, the medical students and the six form people, actually, most of what I'm going to tell you is not going to come up in medical school finals. It's not going to come up in your interview for medical school and that kind of stuff. So don't worry too much treat this as light entertainment and just get an idea of what somebody like me gets up to really that that's probably what you want. And I think it's quite fun and I'll kind of hopefully show you why I still really enjoy doing all the stuff that I do. Um So if you look at Ortho plastics, it's in the context of major trauma. And then these are some of the things I could think of that would involve major trauma. And we now have major trauma centers around the country in the UK. Um In London, we've got four of them. So there's kings, there's Saint Mary's Imperial, there's the Royal London, which was the first one and Bart's and there's ST George's. Um and I was part of the King's major trauma center which covers South East London, Kent and Medway and it's a population of at least five million people. So, you know, getting on for 1/10 of, of the UK population, I just want to see if I can close whatsapp, which is making noise. Let's get rid of that. Otherwise, we'll just get interrupted. Um And if you, so Ortho plastics is, you know, a part of major trauma, it's actually a reasonably big part of major trauma. A lot of the major trauma workload is Ortho plastic work and I'll come onto why that is in a minute. Um And then if you look at it in terms of, you know, the context of all trauma, it's not just major trauma centers that receive trauma, every district General hospital with an emergency department will be receiving trauma, patient's neck, a fema fractures, you know, minor hand cuts and bruises and broken bones and, you know, the stuff that orthopedics would do in a district General Hospital. Um But when it comes to major trauma, um they all generally end up in the New ntc's major trauma centers. Um And actually, that's got pretty good Kings opened in 2010 and to start off with it was like, come on, guys send this to a major trauma center. Don't, don't manage it. Uh, you know, close to home because you're gonna struggle. It's going to overwhelm your D G H operating theater day after day after day. Whereas we're set up to do it. A major trauma centers were set up for that and then if you look at trauma, okay. That is in the context of all the emergencies that turn up in the E D. Okay. So, you know, this is a small part of a huge picture that we're talking about here. And you know what, when you become a sort of a super specialist, which plastic surgery is, it's a tertiary specialty. Okay. Primary GPS secondary is all the stuff you get in district general hospitals like general surgery, orthopedics, cardiology. I don't know, diabetes is their general medicine, respiratory, that kind of stuff. And then tertiary are the specialties in surgery. It's things like plastics, neurosurgery, cardiothoracic surgery, pediatric surgery, so on, so on, so on. Um but and so when you start, when you become a surgeon in one of these very niche specialties, you kind of lose track of the bigger picture. And you know, as you look at that bottom left corner, you know, I'm getting smaller and smaller and smaller in the bigger picture of the healthcare system. Okay. And look, you know, and the healthcare system is massive. Okay. This is, again, literally, I just, I just made this list up. Okay. And there's a whole load of left off, I'm sure. And healthcare involves an awful lot of stuff. And I don't know if my cursor works. It also involves, you know, the kind of forces for evil as I call them in the world. You know, politics, money, ego. Uh um and, and keep in mind, you know, this is niche stuff. So, you know, if you, if you guys are an early stage of your training, you might not want to do what I'm about to tell you, there's a whole world out there that you may want to explore in medicine. So anyway, let's go right back into Ortho plastics. So Ortho plastics as the name implies, orthopedics, plastics working together. Um And it's basically trying to manage this kind of stuff. This is from um the American Civil War, which is something like 18 65 I think. And it's someone who's had a leg injury and he's ended up having his foot amputated. I actually, I think this has been photoshopped. You know, this is early 18 65. Photoshopped this foot that's been stuck onto this picture, but he's had his leg amputated below the knee. Actually, it's very low below the knee amputation. And if you look, there's probably bone sticking out of the stump. This is probably below knee amputation that isn't going to do very well because you want to go a bit higher so that you could have enough room to fit the prosthesis on and enough room for the hinge mechanism for the ankle lower down. Um So anyway, neither him or the doctor necessarily look very happy with it, but this is kind of what we're trying to prevent. Ultimately, with Ortho plastics, it's major limb injuries and we're trying to prevent amputation, which a lot of people regard as the ultimate failure. Okay. It isn't. And I'll also come to that in a bit. Hopefully, if I haven't mentioned amputation, tell me because I can't remember if it's in this talk. Um And this is what we're trying to prevent. This is another photo from the American Civil War and there was an orthopedic surgeon from Imperial called Mick Pearce. I think his name is who would always put this photo up saying, you know, this is what we're here to prevent. Okay. And this photo is title a morning's work because this is what trauma surgeons, war surgeons used to do. And the reason why Ortho plastics, limb injuries are such a big part of major trauma if you think about it, okay. If you are subjected to a huge traumatic event, stress, like you get run over by a bus, you are in a bomb blast, you're in a an earthquake, a hurricane, you know your house collapses on top of you, you know, you fall off a tall building. Um if you are subjected to major trauma, if your injury is generally to the trunk, okay. So your chest or your abdomen, if your shot, if you're stabbed, um, if your, if your shot, if your injuries to the trunk or to the head, generally speaking, these days, you don't survive. Okay. War injuries. The stuff we see in Gaza we never see the head injuries we know ever see the thoracic injuries or actually quite a lot of the abdominal stuff, abdominal stuff is a little bit different. It depends on where the abdomen. But if it's chest or above your head, you generally don't make it to hospital. If you do, you don't survive for very long. So the patient's that survive major injuries are generally the ones with limb injuries, okay, upper limb or lower them. So, you know, if you have been in an earthquake and you are alive under the rubble, you are probably alive without ed injury without a trunk injury, but quite possibly a severe limb injury. And that's, that's where we come in. So this is my simple understanding of orthopedics. Okay. So what is orthopedics? It's fixing bones, but actually, you know the proper definition of a fracture. Okay, if you meet a proper orthopedic surgeon that they will always describe to you that a fracture is, you know, a an injury to the bone. Um sorry, I'll get it right. They will describe it. They will say a fracture is a soft tissue injury complicated by a broken bone. Okay. So always, even if you become an orthopod orthopod, don't become, you know, this focusing on the fracture orthopod, which is the stereotypical person that you might need to think about who just wants to put hammer nails and screws and plates and play with hammers and sores. Yes, there's an awful lot to do with that. But you know what, there's a whole soft tissue envelope around it. Now, orthopedics, you can divide it into internal fixation. Okay. Putting a nail down the inside of the broken bone, you can call it external fixation. Putting a Makana type of frame on the outside of the broken bone to hold it together. And then there's more complicated versions of external fixation. This is called a table spatial frame, which is actually, you know, like those flight simulators, they can move in all directions and you can orientate the fracture, you can stretch it out and lengthen it. If there's a bit of bone missing, if it's healing wonky, you can slowly corrected because they tighten the screws every day and they slowly slowly slowly move the bone. It's like a millimeter a day. And then if you look at internal fixation, yes, you can put rods down the inside of bones. But you can also put these plates on the inside as well um underneath the soft tissue. Um and they're getting more and more and more complicated. You don't need to make great big cuts anymore because you can attach this virus jig, make little holes for the screws and put the screws in via these little holes. And so you damage the soft tissue less because it's already injured. Remember, soft tissue injury, complicated by a boat, broken bone. So that's literally, that's my entire understanding of orthopedics, you now know as much as I do and then this is plastics, okay. It's managing soft tissue injury. We are, if you think of the orthopedic surgeons as being the carpenters, plastic surgeons are the upholsterers, okay. We do the padding, the cushioning the leather cover of the chair. That that's what we're trying to fix when that's been damaged and there's different ways of doing it. And we call this the reconstructive bladder. You can let a wound heal on its own with time. You can search for it directly that's primary in tension or you can wait until it's a bit cleaner and then suture it or you could skin graft it. I'll show you an example later, you can use tissue expansion by putting in inflatable bags under the skin to give you more skin. So that once it's been stretched, you can then move that skin to cover your wound. Um You can do what's called local flaps. I'll show you example an example of that and you can do what's called free flaps, free tissue transfer. And I'll come onto that in a bit and this is the simple, definitely kind of understanding of plastics, I guess. Um, you know, we don't just look after wounds, we look after skin cancer, bones, congenital hands, we do, we do cleft lip and palate. There's loads of other stuff, but this is, you know, for the purposes of this talk, this is the very simple, basic what we do in plastics. Now, if we look at, you know, trauma, the big question, when should it go to an author? Plastic Service. So the major trauma centers were set up, one of the things they did was they said, right, we need specialist, really good, you know, orthopods and we need plastic surgeons and they're going to come together and they're going to work together to look after complex lower limb injuries because that's the way it should be managed. And we learned this actually in as always, you know, lessons from war. Um, and the idea of Ortho plastics, you know, coming together in major trauma centers was mainly sort of recent wars, you know, the Gulf and Afghanistan because, you know, they were getting loads of limb injuries. The other patient's weren't surviving. Modern warfare is horribly efficient to killing people and killing lots of people. Really, really, you know, it's just stupidly effective. So, you know, the injuries that survived didn't need the general surgeon, which is typically who got sent to a war zone and an orthopedic surgeon. Every now and again, there'd be a vascular surgeon. And they found that actually the vascular surgeon and the orthopods were working together and the general surgeon was getting a bit left out because all the general surgery, patient's trunk injuries were not turning up. Um And the vascular surgeon actually was effectively trying to be a plastic surgeon, you know, revascularizing, trying to preserve soft tissue, trying to reconstruct wounds. And so it became pretty clear that when it comes to, you know, war. Um, so Ukraine now is very Ortho plastic focus, the treatment that people going to Ukraine to help. It's not necessarily neurosurgeons or general surgeons, it's orthopods and plastics. Um So the questions as a result when we came to managing major trauma in a setting like the UK, which is, you know, mainly road traffic accidents, okay. We don't have that many gunshots and blasts apart from in South London. Here we do get our fair share of gunshots. Um, but it was the major trauma centers were designed to reflect that war setting. And I actually, I think, I think they've done it really well. So, you know, if you're faced with a patient with an injury, you know, you're going right? Should I send this to a major trauma center, let's say the ambulance paramedic or you're in a D G H in the emergency department, you know, should this go to the regional Major trauma center? Now, it's really easy if the patient's got loads and loads of injuries. Okay. If they're injured top to bottom, then they're probably going to be transferred straight away to a major trauma center by helicopter, by ambulance, whatever, they'll bypass the local hospital. But if they've got an isolated limb injury, that's where it all gets a little bit confusing. And we, we've spent, we've ended up having to spend a bit more time getting this message across the country so that people don't hold onto things for too long. That's actually the problem. It's not, it's a bit like when you're on call, I'm on call this weekend coming. I would much rather be called by the team and it turned out to be a waste of time, then not be called by the team and, and actually it's something really major that gets missed. So we've been going around and the message has dissipated. It's like, look guys, if you see a major trauma, if you see an isolated major injury limit injury, please just send it straight through to the major trauma center, put them back in an ambulance and send them across. Um, uh, and they get managed much, much better because the hospitals are just set up for it better. They've got dedicated operating lists and they've got all the scanners and they've got all the kit and they've got lots of specialist surgeons. Um So when do you send a case from A D G H two, a major trauma center? It's probably when it's a complex fracture. Okay. And there's definitions of a complex fracture, you know, ones that involve joints, ones that in lots of different pieces. It's, uh, same bone fractured in two levels. Um, uh, blah, blah, blah. I'm not going to get into that because I don't know it very well. But if it's what is deemed a complex fracture and it ticks the boxes, send it to a major trauma center if it's, you know, does it need complex orthopedics? If it's a culture, yes it does. Does it need plastics? You know, that's a question to ask if you're getting yes to either of these questions or both, then just send them across from major trauma center. But this is probably only negative slide. I'm going to put a, it's also been happening is people get slowly shoulders and it's suddenly, you know, the most minor injury, you know, a paper cut, paper cut gets, gets some elevated and upgraded to being a major limb injury. And we don't want that either because the major trauma centers are busy enough as it is and simple injuries should be treated in the secondary hospitals. So just be a bit careful. Don't just go reflex sending every single fracture to a major trauma center because we can't cope with that. So, you know, not every fracture is complex, not every wound needs plastics. Okay. Plastic surgery is not a wound management service. We we are not here to just manage wounds. We get an all Forticals even now and I'll get them at the weekend saying, you know, I, I've done this operation, I've now got a patient with a wound and I'm a bit worried about it. I think I could, you know, kind of, kind of plastic surgeon come and see it and it's like, well, what's wrong with it? Whether it's a bit scabby or it's taking a bit long to heal, well, it just needs dressing for a bit longer or maybe it just needs a bit of cleaning. You know, wound management is not that difficult in most cases when it becomes complicated. That's when you call plastics. Generally speaking. And likewise, not every open fracture needs Ortho plastics, but actually most open fractures now are ending up in the major trauma centers because quite often it looks like a small open fracture, but it's tip of iceberg and they quite often are worse than you think. Um Oh yeah, if you have had a patient that been run over by a tire, okay. Think about closed degloving injuries. Now, what I mean by degloving injury is where the skin kind of gets. Let me go to the bigger picture. There you go. So you get run over the skin gets pulled under the tire. Okay. So let's see, that's bone and muscles and all the contents of the limb. This is the skin envelope. This is the deep factor before you get to muscle and other stuff, the skin gets pulled away, it gets detached from the deep fascia to all the little blood vessels that are supplying that skin get avulsed, they get ripped. And so now you potentially have a reduced blood supply to the skin. And then what happens? And this is the problem because you don't often get the full story because you don't see people being run over, you only see them in the road afterwards. And certainly the ambulance crews, they don't arrive, you know, until a bit later. So what then happens is the skin comes back again. It all pings back and it rubs against the tire here and you get this sort of grays, it might look like a bad grays or a friction burn. And so the patient turns up in hospital everything. So that's just a graze limb. But actually a lot of the skin of that limb has been detached from the underlying tissue and is now ischemic. So watch out because you're in about 48 72 hours, you might have a patient with a huge area of dead stuff with blood and fluid collected underneath. That's now trying to get infected. And we did actually learn this the hard way at King's. We had a patient with this who was a truck driver who had probably been squashed by his, his cabin because the truck turned over and he was sort of caught underneath it or is near his pelvis, he had a pelvic fracture. Everyone picked up on that, but what they missed was he had a huge degloving around his pelvis, his trunk and actually couldn't work out why he was on well and fibril and septic and they, in the end sent him for a CT scan and he died in the CT scan, er, because he had a huge degloving injury with a massive collection of infected blood pus, yuck under the skin. So think degloving injury, if you ever get a patient run over, now, what you can get is an open degloving injury where actually the skin gets ripped and then it's obvious, okay. That's not the issue closed. Degloving injuries where the skin looks okay with a few grazes. So if you end up in a major trauma center, this is what ends up happening. You're not alone, you're part of a massive team and every major trauma call um uh gets discussed in this meeting the next day. And if you look at all the different people here, there's, there's an immense amount of knowledge and experience and I just guesstimated that there's a good 300 years of experience in the room deciding what happens to this one patient. Um and that's what you want and we've got to turn the volume down, but we've got the helicopter, this is that the Kenton Sussex helicopter taking off from Kings on a nice sunny day. It's a really cool place you can get to go up to the hell a pad of a major trauma center do. So it's really nice to go up there and, and it kind of feels like proper medicines taking place. Um, and you, if you have a limb injury you've been brought in, you'll be managed according to what's called the boast four guidelines, British Orthopaedic Association, uh, standards for trauma. That's what boast is. Um, and it's been put together with the British Orthopaedic Association and back past the Plastic Surgery Association and a couple of other organizations who I can't remember. Um, and it gets rewritten every now and again and the crux of open fracture management and don't worry too much about reading all of this and knowing it, you need to know this for your final plastic surgery exam before you become a consultant, but probably not before then. But the crux of this is that actually stuff has to be managed by senior people. Okay. So experienced orthopedic surgeons experience plastic surgeons, not just people who operate on one open fracture a year, that kind of thing. These people, these are people are doing it day in day out. And secondly, it should be, shouldn't be kind of panic taken to theater in the middle of the night because things go wrong in the middle of the night. The hospital is not the same place in the middle of the night. So they don't need to go necessarily and tell unless they're really contaminated wounds and there's stuff in this list here that tells you take patient's, you can Google it okay. If you google boast four, there's loads of boasts. Okay for, for spinal trauma, pelvic trauma, head injuries, etcetera, etcetera, but the number four is the one for open fractures. Um It also gives you a protocol for give them a bit of a clean given antibiotics, then wrap it up and then take them to theater the next morning, you know, not in the middle of the night. Um And then they get managed by proper fresh teams. They haven't been up all night and so forth and outcomes are better. Okay. If you do it this way, we know that. Um um And I'll just show you a few examples. You know, here's someone this was a kid who stole a motorbike, then crashed, the motorbike, injured his leg and he left a bit of his uh femur. I think this is on the road and if you look at his leg, that's what had happened. So this is a complex fracture, an open fracture, dislocation of the knee. I think that piece of bone came from here. Um If I remember rightly it's mucky, I want to fucking zoom in. It's not the highest resolution picture, but look, you can see muck and grit that's been um ground into the bone because he's presumably scraped along the road. Um And that all needs cleaning and doing properly, but it's not a hideously contaminated wound. It's not marine or sewage contamination. So he can wait until the next day. So he gets taken through the, at the next day, the bones get put roughly in the right place. He gets this external frame and external fixator. So external fixation, internal fixation of the bones. Remember? And that wound gets a really good clean and it gets a dressing on it. And we wait for 48 hours or so like this to make sure that the wound doesn't get any worse and it does, it doesn't appear to be getting infected once we know that it is staying clean and then we take him back to theater and that external fixator gets converted to um an internal fixator. Okay. This is that big. I was telling about lots of little holes and this is a jig that gets screwed into one part of the bone and then it guides you as to where to make the other holes in the bone. And then you slide a plate underneath which I think there's an X ray off. Yeah, sort of the country, the whole thing. And look, I'm, I was amazed at this actually, I thought that bag of bones, you know, then he's going to lose that leg will never bend that knee again. But no, again, an amazing orthopod um put it together and made it look like a knee again. And that's the sideways view and it looks like a knee as well. Um, and the wound we didn't have to do anything too complicated. Okay. You don't always have to do fancy stuff. We just closed his wound. We clean, we cut the dirty edges of the skin away and we managed to get it closed and he did really, really well back to stealing bikes again, I guess. Um, and the key thing that saved this leg is that we did a really good cleaning debridement. Okay. You've got to clean your wounds, you've got to get them so that they are no longer full of contamination stuff. They've got to look, a wound can look healthy, okay. This is a healthy looking wound. This is a patient who had necrotizing fasciitis and his wound has been debrided. You had to have most of the skin of that arm removed because he had such a horrible infection. I won't go into the details of neck fash here because it's not quite the topic of the talk, but debriding the wound is what I call the perfect crime. If you're not sure, cut it away, okay. Because if you leave behind stuff that might be dirty or mucky, that will have a big consequence. And a problem to the patient, we covered it with a skin graft. This is how you take a skin graft. You use a sort of, um, uh, it's like shaving the wrong way. The blade is going sideways. Um And you basically take a thin layer of skin using this electric blade. It's like very similar to those blades. They're using kebab shops and Greece and Turkey. And you end up with a piece of skin that you feed through this thing that looks like a pasta maker. So, um where are we? The skin is just there and it's being put through this sort of mangler thing, which is putting little holes in the skin and turning it into like a string vest, like a mesh. So this is called the skin graft measure. And then you apply it to the patient and you get something like this and you have to staple it in place for a week or so. We put a vacuum dressing on to it. A week later, it looked a real mess. But you all have to be patient. You have to know that if you actually wait and treat this with a little bit of steroid cream, you can get it to look like this. You had no more surgery between those last two, but that last picture of this one and he survived and he had a limb that was functional. Um This is a footballer who had a 50 50 tackle fractured his uh tibia but had this wound with exposed tibia. This is bone, it's not periosteum, it's not muscle, it's not Fashir. So you can't just put a skin graft on it. It's a bit like trying to plant a turf grass onto a concrete floor, might look good for a short while, but it won't be able to take root. And so the grass will die. The same thing happens to a skin graft on to bone or onto metal work, for example. So you had the fracture fixed and then we planned what's called a regional flap. This is called a propeller flap. And we know that there's a little blood vessel here because we found it by a Doppler. There's the wound I showed you, we cut this great big piece of skin and we spin it like a propeller or an asymmetric propeller around. And then we design how big we need to cut our skin. We cut that out like that. We isolated on it. Vessels, there's an artery and a vein in their public to veins and then we spin it and we can get it to cover the whole that was there. And then we put a skin graft down here because this is not bone, it's muscle and the muscle will take a skin graft. It's like soil for turf. Um What else did I want to show you? Uh This is a free flap example. This is a cyclist versus a lorry nasty open fracture. The bright perfect crime clean in the wound, get it all clean. Once you're ready, put a nail down it, um then you're left with a wound like this. He needs that covered. If you go back to that, you can't pinch that closed, you can't put a skin graft on it because there's bone in it. Um And so, and there isn't an easy local flat for a hole this big. So therefore he needs something a bit more major, which is a free flat. So this is tissue on the thigh. So that's his groin just there and thigh. This is similarly a piece of skin and fascia that's been raised on a blood vessel. We actually chase that blood vessel all the way almost to the groin. Um And we um now have a piece of skin with these blood vessels hanging down on it. We plum that skin, those blood, we plum that blood, those blood vessels into his posterior tibial vessels, which are here somewhere, usually connect up an artery and two veins and that skin comes back to life and he stitch it in place and you've now got his whole covered and he's having a few reactions to some of the stitches, but that all got better pretty quickly. This was three weeks later. He was walking on it slightly short leg, but he did really well. Um And you know, as I said, I'm just, this is what I'm going to end on. You know, a lot of the simple things that we do in plastics, read a book, by the way before I forget, read a book called The Face Maker. It's just come out a few months ago by an author called Lindsey Fits Harris. And it's a, it's a biography of Harold Gillies who was sort of the grandfather of plastic surgery, a first world war surgeon. And if they're zooms in, we came up with these 10 Commandments, which I think are brilliant. They still hold true. Um, today, and if you just look up Gillies 10 Commandments, you'll find this picture on Google and you can read it. Um I stuck it on the door of our office actually, for years, it stayed there. Um And, and I think this is a code to live by and actually Gillies wrote a really cool book about plastic surgery, which is almost like a manual for how to live your life. As a plastic surgeon. There's pdfs out there somewhere, you can find them on Google if you know where to look. But the actual original book, which is from 1957 is really, really difficult to come by, but here's a Gillies operation. Okay. This is the first World War Operation. Gillies worked out that local flat thing. He was one of the first people to work out how to do local flats. He didn't detach the skin completely, he didn't propeller it. That's all a little bit more advanced. But he cut these sort of oblongs, these rectangles out and he knew that he can move them and plunked them down to a wound and leave. It's still attached to its original site. By that one side, you cut it out on three sides of the, of the rectangle. And then three weeks later, you can divide, you can separate the the original connection and this, the piece of skin will have taken root from its new home. And so this is a patient who was a gunshot to the ankle, had an open ankle that you're looking into the ankle joint. There has had a really good external fixator put on by an orthopedic colleague. The wound is clean. It's not, it might look a bit weird color. I think that's more photo, but it was a very nice clean wound and it was ready for reconstruction. So we dressed it for a short while as the very happy orthopedic surgeon Alex virus. Actually, if you like orthopedics go and visit him at the Royal London and then we've cut this. So this is the good leg. The other leg, we've got three sides of a rectangle on the opposite leg and it is connected by the skin. Here. We've left muscle exposed. So we know we can skin graph this and this has skin fat and the deep fascia, the deep fascia has a really good blood supply. So you want to try and keep that on your flaps if you can and we then connected to his other leg and his leg is now stitched together. I did this just before COVID. I think um, and, and he has to now stay like this for three weeks. It might sound horrendous, but this is actually, you know, World War One operation because in Gaza we couldn't do a free flat for him because we didn't have the equipment, we didn't have the infrastructure. And as I was saying to guys earlier before I came on live, actually plastic surgery and a lot of, lot of medicine is not just down to the doctor's, it's not just the orthopedic surgeon, the plastic surgery. And is that, is, it's the nurses in theater on the wards. It's the specialist wound nurse is, it's the physiotherapist. It's the occupational therapists. You make sure your home is adapted because limb injuries change your life. You quite often don't go back to doing your old job, you have to find a new job because if you're a roofer and you fell off your roof, you probably can't climb back up a ladder after you've had one of these injuries fixed. Um, so he stays like that for three weeks. Um, and then he has his legs tied together with a bandage. They cope surprisingly well. Actually, they mobilize. He would, he went to the bathroom on his own. They do amazingly well. And then 34 weeks later you detach that connection and if you stitch the skin back in place and you end up with something like this, I don't know if it's zooms in. Yes, it zooms in, if you very carefully, the hair is going in the wrong direction because the skin's had to be twisted round. Um You know, so that's something I'll just have to have for life and yeah, you know, just to make the point, it's a team effort. Okay. It's not just down to you. Um It is, you know, it's a, it's a, it's a gargantuan setup, Ortho plastics and major trauma and, and, you know, if you organize it properly, you can do really well. Um Those are my contact details and I just realized, and I said earlier, I was going to tell you about amputation. Um Amputation is not always a failure, okay. And just because you've had to amputate someone's leg like that very first photo from the American Civil War doesn't mean you failed because sometimes reconstructive, reconstructing majorly injured limbs that it can often be futile. You can end up leaving someone with, you know, a foot that is still attached to them, but it's insensate, it doesn't move, it maybe has pain, chronic pain because the nerves have been injured. It could have cold intolerance, which is horrible, you know, frostbite pain when you come in from the snow and you put your hands under the sink and they really hurt. Imagine having that pain all the time in your foot. Um You can end up ruining people's lives sometimes, you know, you just have to decide, you know what it's not worth saving this limb and prosthetics in this country are really, really good. We actually went to Gaza with a photojournalist who was injured in Helmand Afghanistan. Um by a blast, an IED went off, his colleague was killed. Um These were journalists from the mirror, I think and amazing guy. This, he's a proper war war photographer and he lost both his legs below, below his knees and had bilateral bologna prostheses and he came out to Gaza to cover the story for, for the mirror. Um, and, you know, he got on with it. I mean, he was in pain, he was struggling. It was his first assignment but, you know, he was back at work. Um, so you don't always, you know, it's not always a failure if you amputate. Um, anyway, I will stop there. I will try and go back to my where page and is it stop sharing there and hoping back home again. Is that right? Kind of, you know, I just had down for the helicopter. Yes. Sorry, I didn't hear any of that. You're welcome now. Yeah. But if there's any questions far away, really, if there's anything, you know, it doesn't matter how stupid it is just to get in there. Um, I'll see what I can do. Mm. Yeah. Cool. It's really difficult. I mean, everything I've shown you as functional surgery, it's not aesthetic surgery. Okay. None of these patient's will have ended up with a beautiful result again. They all have mangled limbs. Yeah. For life. So, you've got to make it really clear to patient's that. Look, you know what the alternative was, you would have lost your limb or you might have died because you had such a bad wound. It would have got septic and killed you. Um, so that's probably the first thing to say is, look, it's not about Misty's. And then, yeah, you know, in countries like the UK, there is scar therapy. That's a growing specialty amongst plastic surgeons, sort of in the private side. Really. You don't tend to get that on the NHS. It's just, it's too expensive. It's too much of a drain on resources um in the current climate especially. Um but there are in a laser and, and steroid injections and things to try and soften stuff up. Actually, physio stretching things out will often um you know, make things look a bit better and also um just time quite often wounds and scars look awful. You know, scar has not skin scar, an incision. If you just make a cut, then you stitch it back again. You will create a scar. That scar won't mature for a good 18 months. Okay. It has not fully matured for 18 months. So if you are going to do anything because the patient's don't like the scars, don't do it before 18 months. So, you know, the wise thing is, is to wait, it's to know when to not operate. Yeah. You know, we all again, this is another slide I put up quite often in my talks is every certain gets trained, we will know how to operate. The skill is knowing when to operate. I guess this wouldn't clean enough. Is the patient well enough? You know, are they going to tolerate this or is this too much of a stress? Are there other priorities that we should be concentrating on before we fix this bit? So it's knowing when to operate, that's a real skill and then what the real, real skill that, you know what I still get it wrong all the time is knowing when to not operate because I saw two patient's today in my private clinic. I wish I'd never touched. Um It's that, that's, that happens quite often. That's really easy in hindsight, but they're just going to be, you know, they're never going to be happy potentially or they don't quite get what they should have, you know, that the result, I think they've had good results and it's, it's funny. So there are yes. So knowing when to not operate as a real skill. And then also the final one I kind of added on that. That's the sort of classic saying is, you know, we all know how to operate and when to operate and when to not operate, but also be a physician who happens to operate. I think that's another really good thing to keep in mind if you can. I did I to you and I demonstrated physiology at guys and Tommy's when I was really junior. And actually those I really enjoyed it. I really, really enjoyed physiology and I really, really enjoyed the intensive care, but it wasn't what I wanted to do for life. I still wanted to work with my hands and be a surgeon. Um, but actually those jobs have helped me forever forever forever. I can go onto I T U and it helps me decide whether to operate or whether to not operate because I can tell if the patient's well enough or not, well enough. Um So anyway, I haven't really answered your question, but there is a lot of scar management stuff out there. A lot of it's woo woo, a lot of it is kind of getting there, but early days the other, I just want, I just forgot one thing, you know, when I put up my contact details at the end. Um I also mentioned there was a website mentioned called F R C S placed dot com. Um That's basically a resource. It's like a dropbox. It send an email to web masterchef, rcs place dot com. So if you can put that in the chat as well, that would be really good if you basically a dropbox folder with, if you're getting, if you, if you're going to become a trainee in plastic surgery, then this is basically everything you need for the exam for your F R C S PLAST exam. I'm not sure if the link works anymore. Actually, I've had a whole lot of issues with various domain names. Um and websites have been reject recently, but it's web Masturah at uh yeah, just web faster. Uh Plast. Yeah. And that will send an email to me or my secretary. And um and then you can, you know, you can get access to this dropbox resource. You do need quite a bit of space left on your free account. So you may want to create a free account and then tell me what email that's associated with. We've got at least 1000 people in there now from all around the world, they're using it for revising for their exams. So, yeah, I just thought I've let plaster know that. I think Prosta know it as well. I just like to let you guys know as well. Yeah. Yeah. Yeah, I think that's what plastics is really good for actually. You know, I think it's um, um, it's a really good holistic specialty. It's kind of like I would have been a general surgeon if I had been adopter maybe 20 years, maybe 15 years earlier or maybe a little bit longer than that. But once the CT scan, er, arrived, you no longer needed to do exploratory laparotomy is, you know, you could just diagnose and then you set ship it off to the specialist surgeon. Um but it was a really cool job being a general surgeon in a busy hospital because everyone came and asked you for advice and help and you could, you know, you could work with people. You don't have to, you know, you knew everyone in the hospital. Now, the closest, closest thing to that in this day and age is plastics. Yes, sir. Today I did what's called a cranioplasty. So this patient had a piece of bone removed because of a brain tumor. That bone got infected. So it had to be chucked away. So now she was left with this very wonky shaped head. So we opened her up and again, plastics and neurosurgery working together. The neurosurgeons have designed a customized plate with three D printing and everything, but they couldn't do it without plastics. And so they called me up saying, can we do this together? And we planned it takes ages to organize. Um And that's the other thing. A lot of medicine is boring. It's organization, it's admin, it's bureaucracy, it's, it's headache, but you know, get good at that stuff, get or get yourself organized and you have some really good fun working with really cool colleagues. And we put this metal plate and we use the facelift incision. Um So you can use your aesthetic training um to put this this time. She looked great at the end. Actually, she, well, hopefully, hopefully do well, it was only yesterday. So early days. I don't want to jinx it. Yeah. Yeah, we're saw sort of, uh, I would say we're not great at it. So for major trauma, know, we're really not great at it. That's the trouble is all this stuff is expensive. Healthcare is really expensive. Each of those legs I showed you. Ok. The three examples and that next batch case they would have cost probably a quarter of a million pounds. Okay to the taxpayer. That's a conservative estimate. The neck fash guy spent time on I T U. So even more expensive, his bed probably costs, you know, 10,000 lbs a night. Uh if you add up all the, all the costs. And so actually, as always, you know, psychology psychiatry as the poor cousin in medicine and plastics to a large degree is the poor cousin within the NHS. Um uh you don't get stuff funded. And so if you're trying to get, you know, new scar therapy treatments into the NHS, it all costs money. Every machine costs 100,000 lbs, you know that you want to buy, there's nothing cheap out there because the minute you put medical grade, you know, medical grade toothbrush will cost 1000 lbs. Okay. Whereas if it's, it's exactly the same thing as the toothbrush you buy in boots or, you know, electric toothbrush or whatever, which costs 50 lbs, you know, and that's the trouble. So it's an expensive business and so to try it's been a real struggle to get psychological management of major trauma patient's, there's stuff out there that's coming and charities helping and things like that. But the training, the short answer is not really, we don't really get the training. Um, and, um, it's kind of getting better so it's not just major trauma, psychological components. Okay. So I do a lot of private practice as well and most of my private practice is aesthetic surgery, cosmetic surgery. And there's a huge psychological side is like, you know, how do you tell if this patient has body dysmorphia, you know, trauma. Do you know if you've given this patient body dysmorphia because they now, you know, don't like the way they look, they don't, you know, they don't associate, they can't associate themselves with what they see in the mirror and, you know, all this kind of stuff, there's all sorts of complex stuff going on and we're basically in plastics. We get trained for some of the signs. Okay. If you spot these signs, these flags, then please get them seen by a clever doctor. That kind of that. That's probably the best it is at the moment, right? Okay. Yeah. Thank you for that answer as well. Um, Nafisa, did you have any questions? Um, so I was going to ask you, um, you've been a consultant for quite some time and you've gone through a lot of training. Um, what advice do you think give to, like new plastics. Um, so are you, I guess it's probably advice I give to any of the people in, you know, at all the levels. You know, my daughter is 1/6 form student doing her mocks at the moment, panicking in the room downstairs. Um, you know, um, it's the same thing. It's kind of, this is going to sound really patronizing. It's like if you want to do it, do it okay. And more importantly, if you don't want to do it, don't do it. So you might be, you know, I would love my kids to be a doctor because I still think it's a worthwhile thing to do and a fun thing to do if you don't hear that as much these days because of all the issues with, you know, the pay and the hours and the conditions, it'll get better and it does get better as you get senior. Okay. It definitely, definitely, it really does. Um uh So I would say, you know, if this is what you want to do then yes, get on and do it. And if you're struggling to get on to the training schemes and you really want to do it because I really struggled okay. I struggled to get into medical school. I got in at the age of just under 21 because I had rubbish a levels and even worse oh levels because I did oh levels. Um and I took it, I took a year off. Actually, I did retakes, still didn't get grades good enough, then took a year off and then just wrote to the deans of all the medical schools I could think of. And then I phoned them all on the day that the results came out and I kind of why, I don't know, I blagged my way into medical school. Okay. And so I'm not saying everyone will blagged their way in. That's not what, that's not at all what I'm saying. But it's basically, if you want it bad enough then, you know, just keep trying, keep trying, keep trying. And the same thing applied to later on as well. I did find in medical school, I passed all my exams and actually I was pretty good student. Nothing amazing. I was, I was above average. Um, and then when it came into getting into plastic surgery training, again, that's another massive bottleneck, you know, and, uh, or narrow bottlenecks, sorry. Uh, and, and again, you know, people, if, if, if you really think you're gonna be good at the job and you're gonna enjoy the job, then just keep at it, keep attic, keep at it and you'll get there. Most people I know will get there. There are very few, I don't know people who I see as being, you know, uh, worthwhile or, you know, people I think will make good plastic surgeons. There are very few of those that don't make it some some don't. Okay. There are at the system is ruthless and there are a few people who get wasted by the wayside. Um, you know, but on the whole, if you queue up for long enough you will get through eventually. You know, it's a bit like you see the crowd to get into the tube station, you think you'll never get on my train. But actually funny enough it happens. Yeah. And you get to work. Um, yeah, it is. It might seem like that. Okay. But actually it does, it does work out if you want it bad enough. Um, and actually if you don't want to decide that sooner rather than later because just don't waste your time. Okay. Don't do this for yourself. Um, that's probably my general advice. Yeah. To anyone, I guess. Um, was your question once you're on a training scheme? Is that you, you in that position if you just, you know, I think it's just for people who might be on this talk. Um, if someone was going into training for a gram for plastics with anything. Yeah, I guess the next, yeah, the next thing I think I was probably make friends. Yeah. Make lots of, you know, become that kind of person that basically is making friends with everyone, your colleagues, the other people you work alongside the other specialties. Okay. Plastics is very good at just being this blinkered specialty and we kind of get a bit caught looking down the microscope and I'm always criticizing our specialty for that and we don't see the wider picture, which is kind of why I put up that big, expanding, expanding, expanding beginning thing. Yeah, just to, you know, there is a whole world out there. We're not, this ivory towers were not the best at everything that we do, you know, we're not that special, okay. You know, we are good at what we do, but that doesn't necessarily make us really special. You know, we're not odor living because of that. Um, um, so actually go out there and make friends with neurosurgeons and orthopods and vascular surgeons and, you know, every, and the rheumatologists and the pediatricians and the I T U doctors and, you know, and if you, and it's interesting, I'm forever, uh, you know, in between, I've got a list on Friday and the NHS and I'm probably going to wander around and go and annoy someone in their theater next door who's doing a hernia repair on a general surgeon or something or someone's fixing a hand fracture. It's nothing that I'm even vaguely interested in doing. Okay. I really don't ever want to fix a hand fracture again. Okay. I've done enough of it in my training. You get beaten up with hand trauma and plastics. Um, but I'll go into that theater and I'll learn something interesting or something fun will happen and, and that, that's kind of what it's about Yeah, that's what I really like. Um, and, and so that will be possibly the best part of my day. You know, I might be doing a routine mundane operation. Okay. So you might go, oh, you know what, doing a free flap to a leg? It's the coolest thing ever. And it is okay. But once you're doing it every single day you're going to get a bit bored and it's going to get a bit mundane. And you do see surgeons that are looking a bit bitter and twisted and burnt out and they hope that life would have been a bit better than just, you know, fixing legs every single day. They can then feel like just like a factory worker. Okay. And they kind of thought, I thought I'd be more than that. Whereas all the accolades and the recognition and the respect, it's not about any of that. Actually, it's about having fun with your colleagues and go explore, go and be a nuisance. I'm kind of creeping up on colleagues all the time over their shoulder and just making annoying comments. All that. Is that how you normally hold a blade? Is that really? Oh, okay. You know, just, and it's just fun. Okay. And then you will actually every single time something I'll pick up because we don't get trade. I don't know, some certain stitch or a needle or an instrument or addressing. I don't know, whatever. There's something that you'll pick up um that you wouldn't have got within your little bubble ever. Thank you. Interesting. Yeah, I think, I hope it's been useful. Um There are any more questions in the chat. So if you don't mind, I just have one last question to round things off. You mentioned some of the work that sort of charity work and the work in Gaza um, and things like that and, um, I was just wondering if there was, if there were any opportunities for trainees to get involved in some of those things or is it? Yeah, there is because, you know, not necessarily with Gaza, that's a little bit more difficult because it's really, really difficult to get into Gaza and it's really expensive to get into Gaza. So I'm going next month sometime middle of March. Um, and actually there's a question here about how did you get involved in it? I ended up, you know, in all the orthopods at King's that made again. I have friends, okay, made friends. And they said, now, do you want to come along? We need a plastic surgeon. And I just, without thinking, said yes. And I knew nothing about Gaza. I was, I was pretty ignorant when it comes to a lot of this kind of stuff. I went and googled it and I said, God, okay. What have I done? I've just signed up to the war zone. But, you know, I just thought, you know what, actually these guys have been going, how bad can it be? And I just went and it's been really good fun. And so that's how I got started. But I was already a consultant about five years or into it. 2014. Yeah, that's right. Um, but for you guys trainees, um, I would say gaza difficult but there, there are, there's a whole lot of other stuff you can get involved with. There's the, the first charity which is the back press plastic surgery charity. Um uh And, and, and we've got a trainee's committee for Be First, which are a bunch of plastics trainees. And there's even a medical students committee, I think if I'm not. Yeah. And they just chip in and help with, you know, just, it's boring stuff. But admin, they help us interview fellows that we bring from abroad to come and observe in the UK or they help us organize, send fellows from around the world to India because there's a really good training, set up in a hospital in India where they can actually operate. Whereas if you come to the UK from abroad, you need your registration. It takes forever and you never get to actually touch your patient, but you can observe. So there's lots of stuff that trainees can get involved with. What I would do is if you go to the be first website and I think it's, I'll put it on uh keyboards, going to sleep, make you achy any second. Now. Uh, here we go. There we go. I'll, I think it's be first dot org dot UK. I'll put it in the chat. Have a look at the website. Um, there is, there is, it's a new website. There's, there is a section for the trainees, um, somewhere. I haven't had a good look through it yet but, and send a message through and that's how you can kind of just get stuck in if you're interested. Um It might not be the most glamorous work. But actually, so my be first project which I'm involved with is in Tanzania, in Darul Salam. And it's really, really early days and we've only been a few times and COVID scuppered everything. Um but we've got trainee last time we went, which was last October, September time. There were three consultants and three plastics trainees came. Um And one of them was actually F two I think. And another one with a more senior S H O level CT level. And the third one was quite a senior trainee, almost consultant training. And, you know, they were so, so useful when they came with us because they got us organized, they made sure that, you know, because us as consultants, we have rubbish, organizing our lives and keeping, you know, lists of patient's and our database updated and the photos filed and organizing the follow up that needs to happen. Because actually the local system in Tanzania is not that great either. So they're not going to do it. So we need to make sure they do it and we're really rubbish doing that. And actually the trainees were really good at organizing that. They wrote a report because we've been sponsored, given flights free flights by Emirates. Emirates wants a report. They want photos that might be putting it up on their little video that they play at the end of the flight, you know, before they come around saying any loose change. Um you know, that kind of stuff and that all happens, which means that, you know, the charity grows so it's all worthwhile stuff. So it might not seem like you get to do the glamorous stuff or the exciting stuff that will come. Okay. And that, unfortunately, that's the system in medicine. It's, it's set up that way. You know, there's a lawful lot of drops that you have to do before you get to get the glory as it were. Um But, you know, it is all fun all the way through. There's definitely fun to be had. Um And yeah, just get stuck in, in stuff, you know, look at different hats to wear. Okay. You've got your um N H S hat. So I'll talk to you about my hat, my NHS hat, my private practice had my charity hat. All these various associations that I'm involved with. Um used to be a manager at King's like a clinical director where I looked after all the surgeons. Not the most exciting job, but that taught me loads, which meant that I would then went on through, be able to build a clinic in London, you know, all that kind of stuff. Everything, you know, do put different hats and take them off, put another one on and you'll never be bored because if you're doing the same thing it does get boring. But if you've got other stuff, so gaza stuff at the moment is kind of, I'm kind of thing. Yeah, maybe it's not the most exciting thing. I'm going through that phase. My private practice I'm thinking. Yeah. Okay. The NHS had really good fun yesterday. One of the best operations I've done for ages that cranioplasty. So I'm on a high and all the other things, I don't know, but they will hopefully add up to averaging to being okay. Okay. It's never going to be the fairytale happily ever after. That's not, nothing is like that. Nothing in life is like that. But if you can kind of, you know, head above water and be having fun just, just, you know, googling around, that's pretty good, I think. Yeah, I couldn't agree more and, um, I'm just going to, um, a final message in that just for everyone to know if they want to sign up for our future talks and sign to W P U N. Um, there's also a comment by that from Victoria in the chat, which I couldn't agree with more either and what the talk was really engaging and um really great. So, thank you again, Mister Jolly. You. Thank you. Thank you. Um And just to let everyone know the next talk we have is on head and neck reconstruction in two weeks, time on the third of May. So we'll post all of those things on our social media which are post in the chat as well. So please look out for that and sign up. We love to see you there too. Thank you, Mr Kamala. Um And you go thank you, Nafisa. Thank you everyone for joining. Thank you and thanks for joining everybody. Bye bye.