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Um in amongst all of what we do as walk, we can't do our work without the aesthetic technicians who are not doctors and most of our environments, uh nurses, physiotherapists and other professionals, para medical professionals. And in the UK, obviously, we have a large number of para medical professionals, many of whom we actually try actively to involve in our teams. And I'd like to get Rocco's to come out and talk to us about what she has found as a paramedical being involved in the walk team. So uh come up and I obviously roses also our secretary. So. Hello. Oh, no. Okay. Uh Good afternoon. I'm Rose. I've been asked to talk to you today about paramedical involvement in what UK projects? Sorry, apparently I can't. Oh, okay. Um Sorry, sorry, not used computer. Uh Right. Um So I'm going to talk to you mainly today about my role as a physician associate. Um And my experience in Malawi as, as a pa, I am a physician associate and I qualified back in 2009 as one of the, one of the first physician associates um trained in the UK. I've now been working in trauma orthopedics for the last 10 years providing um acute care and as well as seeing patients in clinic and assisting in theater. Um I've also developed to the foundations and surgical skills, anatomy course for physician associates. Um I'm the current uh secretary for what UK and I was able to volunteer with feet first last year in Malawi. So uh there are many paramedical rolls. The surgical care team is um uh has many different roles in it. With paramedical involvement. They contribute to the team in many different ways. Um And there are many different title's. Some of the most common ones that you will have come across our physio extended scope, practitioners, advanced clinical practitioners and surgical care practitioners. These are healthcare practitioners, healthcare professionals who have extended their scope of practice by being educated to a master's level and um are usually trained working within a specialty um for a specific role, physician associates um uh psi ins graduates or healthcare graduates who are trained in the medical model over a two year um full time course which culminates in the P A uh national exam with Oskin's and M C Q s. After completing MSC and physician associates studies um from an accredited university were trained in general medicine and have to maintain that general medical knowledge throughout our gra freer with 50% of our C P D being general and not specialized. We're currently awaiting GM see uh regulation and uh that should be with us in 2020 for our only real restrictions at the moment are that we are unable to prescribe and we can't uh order X rays, obviously, we don't perform major surgery either. Um, but we're able to be dedicated to and we quite often take on the more traditionally medical or sort of doctor type tasks. So what's the role of a physician associate? Um as a pa working in A D G H in um trauma orthopedics. Uh I take part in the on call rotor at the S H O level. Um I also see patient's in elective and fracture clinics for my, on behalf of my consultant, who's a hand surgeon and therefore, I've developed more specialist skills treating patients' with injections when they need it as well as injecting local anesthetic for well and procedures. And I've recently uh completed a postgraduate diploma in MSK, a ultrasound um and now providing ultrasound guided uh injections. I assist in theater and I've been uh performed carpal tunnel surgery under direct supervision as well as things like the approach to the wrist. Um I'm able to assist trainees with the consultant unscrew abd, giving them the opportunity to practice independent uh surgery. Um I helped teach junior surgeons basic surgical skills and recently I helped on Dean Ary had a Berrick Hand surgery course. Um However, my colleague who's also a physician associate who works in our department feels that his skills are best utilized on the wards and he um he works five days a week. I'm on the ward, uh providing continuity of care for our trauma ward and working with the Ortho geriatric team. I think this shows how flexible the role is. Sorry, how flexible the role is it is. Um And and flex for the robbers. Indeed, I'm with uh sorry, he's doing really well. Yes, let's be one. Um And so what can I do as a physician associate in a lower middle income country? I wanted to practice medicine so I could help those most need. And it was always my ambition to um uh to carry out humanitarian um work. I found it difficult to find a place to do this and acceptance of the P A role being a very new. Um Let me roll until I found what UK um and I persistently came and attended the conferences where I was always made welcome. And they were happy to have me volunteer as a secretary. It was made clear that I'd be welcome on deployments. Uh um So I'm very happy to say that I was able to volunteer with feet first in Malawi last year. Um When we first got to Malawi, um it was important for us to register with the um uh Ministry of Health. Um And I was able to register as a clinical officer whilst I was over there. Clinical officers as you've heard are vital in Malawi providing 80 to 90% of the of orthopedic care. Uh So I was very happy to be able to do that. On the day after we got there, we went to uh the base camp of feet first where there's a lot of equipment stowed. We had to organize all this equipment. And my knowledge of surgical instruments, surgical sets and theater organization was helpful um in this and having worked with Mr Gregori and Dr o'connor. In the past, we were able to work well together. Um So the next day, we journeyed north going to more referral um places in Malawi as um most of the NGOS and doctors are focused within the large cities. We wanted to help provide care in those more neural areas that's uh less well supported. Um We, the local clinical officers had organized patient's for us to see in two neural uh villages, uh Emperor MBA and sequined. Any are facilities with basic, but we did have hand washing washing facilities and we had some furniture that we were able to move around to provide a fairly comfortable clinic space to see our patient's in during clinics. I was able to help with the assessment of patient's with history examination and most importantly, documentation. We ensured that we documented, we had our own documentation for every patient that we saw as well as writing in their health passports. So they would have their own record and ensured that patient's were referred on when we needed to have good communication with the clinical offices so that they could follow up in the future. Um Whilst out there, I saw many different conditions uh that I wouldn't usually see in the UK and was grateful to be there with uh very experienced and knowledgeable surgeon. He wasn't fazed by this huge range of conditions, as you can see. Um This is, we saw a lot of cerebral palsy. We also saw club foot that may well have been treated, but unfortunately, had been lost to follow up due to the difficulties with travel and logistics. Um We found an undiagnosed TB through simple examination of the spine and recognizing, give us uh um trained in the medical model with a problem based approach. I was able to understand and assimilate knowledge of the many conditions we saw and I look forward to building on this for subsequent visits. Um We saw many patient's in need of, of surgery, however, we ensured or were made aware of the risks and benefits of surgery and um whether surgery would be appropriate at this time in this camp or they might be better off being referred onto one of the bigger centers, particularly, they needed multiple surgeries. After seeing um patient's in clinics for a couple of days, we were ready to um operate. Uh I was able to help with the preparation of patient's and writing theater lists that we stuck up on the wall um and the theaters that were provided with, we're in a church hospital, usually used for c sections. Again, basic um equipment and it made, it was made clear early on that the nursing staff went used to the sort of strict orthopedic, um just forgotten the words sterility, strict orthopedic sterility that uh you need. And therefore, we were able to uh provide on the job training to ensure our operations were sterile. Unfortunately, also, whilst we were there, there was a pediatric um resuscitate uh pediatric patient who was arrested on the table and we had to resuscitate, I was able to help with this. And again, being trained in the medical model, having to keep up uh recess uh CPD requirements were able to apply that knowledge in whatever situation is needed during surgery. I was able to help by assisting and closing wounds, casting, um and dressing this help the surgeon um be able to prepare for the um for the next case. Um As an experienced assistant, I'm able to understand and anticipate the surgeons needs um and support the surgeon always trying to make his life easier. Essentially, after we'd performed many operations, we um conducted a postdoc ground um and we ensured communication and documentation with the clinical officers so that they were able to follow up patients' after we were gone as well as Mr Gregori um providing a virtual online um follow up clinic, which I think is really important. Obviously, in the UK, I see patient's postoperative all the time. I think with experience, this is something I can be useful I can help with. Um So team work makes the dream work. And here you can see our team of the surgeon. We've got emergency medicine consultant, we've gotten the STIs and the anesthetic assistants, clinical officers, theater nurses and theater support workers. How was I able to help this team? Well, I built a rapport with the clinic, the local staff um through good communication and I was able to adapt to um all the different situations that we faced. I was able to help with training when we felt it was necessary. Whilst always, whilst always being willing to learn, I provided surgical assistance and supported the surgeon. Um throughout uh keeping up with the hard work, I hope I've shown you that physician associates are um incredibly adaptable and flexible and therefore um ideal for work in lower and middle income countries. Thank you. Yeah. Thank you. Thank you for that. Uh Any questions doctor? Thanks Ross. That was really interesting talk. Um I just wondered whether you could talk a bit about the process of becoming registered as a clinical officer. How did you find that? Were there any barriers that you encountered during that process? So, um I was asked to provide all my documentation. So which means a science degree, biomedical science degree, my um MSC and physician associate studies, my um national exam paperwork, which for me pa is no longer have to do this, but I've had to take the national exams three times because we've, um up until now we have to prove that we maintain our general medical knowledge by taking that. So my re certification of my national exam, um and that I had, I went to a lawyer's office and got it all notarized. I sent it to Mr Gregory. He worked some magic, it went over to the Ministry of Health Health and again, the clinical offices I think works in magic. Um And the Ministry of Health decided that my qualifications were equivalent or adequate um to be classed as a clinical officer while whilst I was there. And I think that that is a barrier to someone like me working in other countries. It's very difficult to be recognized as healthcare professional when you're not a doctor essentially. So 11 more question. So in the UK, I understand that the role of a surgical care practitioner and a C P and so they might be different depending on. So if you know where they are and in terms of their training as well, do you think that you know, opportunities such as what you got exposed to, would provide more opportunity for people who are training to be a C P S and S E P s in the UK as, and we've spoken about surgical trainees going out there for electives and sort of, you know, having a more extended scope but also seeing, uh, the, the spectrum of disease and pathology that you normally would not see in the UK practice. Uh, so what are your thoughts on? I think something like that. I think any healthcare professional will benefit from, um, working in somewhere with, as you. Exactly. Exactly that with this huge burden, um, and varying conditions. Um, so yes, I'm sure, sure they would benefit, it would benefit them in some way. Definitely. Yeah. Hi there. I, I think one of your main strength there was also you have quite a bit of knowledge with social packing, um uh equipment packing and knowing how to uh sterilize equipment. Did you do any particular prep before you went on to? What, what, what, what, what kind of uh knowledge did you have about that? I think that's quite a strength you had over many others. So I, I think most of my knowledge just really comes from, from experience. Um Some people say that pas work by osmosis, well learned by osmosis and a lot of our training is kind of purely experience based. I have whilst working in the NHS, I have worked hard to try and gain surgical skills and surgical experience. And so, yeah, my knowledge of sets and surgical instruments is really just from using them day to day. I would say uh we don't have formal surgical training programs, physician associates. Um In fact, the only one in the country I've developed is the, is a two week training course in foundations and surgical skills in anatomy for PAS are credited by the rcs. So uh thank you very much. Thank you very much for having. I, I meant to say that my trip was part funded by a Bursary from what UK, for which I am incredibly grateful.