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Um continuing this concept of support. One of the unfortunate facts is that there's a lack of orthopedic surgeons in many of our lower and middle income countries we work in and in particular in Malawi, the one off peak surgeon in Mizzou is now the director at the Lion Hospital. And there was a gap in off peak service provision for about four million people. And very fortunately, the Scottish Committee for Orthopedics and Trauma came up with a medium short term, will help out the solution. And uh we put out a walk, put out an appeal and the Scottish orthopedic community came up with volunteers to help bridge the gap between the Boston mentally leaving and the new surgery being appointed and starting. And currently we actually have an orthopedic surgeon out their game doll from the borders. And the first victim who volunteered was Sam Molyneaux. And I'm glad to have Sam speaking all the way from another limit country, Edinburgh uh about his experience in uh in Malawi working there supporting the Maazouzi Central Hospital where we have long standing links. Thank you, Sam. Hi. My name is Sam Malone. You stuff Tennessee to talk a little bit about some work that I did out in the Mzuzu in Malawi and a little bit about my plans going forward. So start with her. My, I'm a orthopedic trauma consultant up in Edinburgh at the Royal Infirmary of Edinburgh. So obviously Edinburgh, a beautiful city and I've lived here for a long time, but actually I grew up out in Malawi and lived there until I was eight years old. And then when I finished school, my parents went back out there and lived there for a long time. So I have some direct links with Malawi, which is probably why I got involved with doing work out in Malawi. When I had the opportunity, some anomalies quite a small country in central southern Africa. It's actually an absolutely beautiful place. It's got a glorious lake, it's got mountains, it's got game reserves, but the trouble for Malawi is really scarcity. Malawi is incredibly poor for the last sort of 30 years. It's always been in the top 10 poorest countries in the world. And that chronic lack of money and infrastructure is extremely visible when you visit the country. So the population currently is 21 million, but skyrocketing, well understand our values these days. So by 2050 there's gonna be a population theoretically at 50 million, which is clearly unsustainable. Average income is pretty low and over 70% of the population live on less than $1.90 a day and access to the basic sanitation services is around 26%. So that's really very poor. In terms of orthopedics in Malawi, there's currently nine trained Malawian orthopedic surgeons. They're slowly coming through now. Any one time there's around 14, 15 orthopedic surgeons working in the country depending on which camps and visitors are there. And there's a whole lot of clinical officers who are trained in orthopedics for doing the basic orthopedic care such as plastering wound management, things like that all over the country. And they provide a really backbone of the basic care. But in terms of true, what we would call orthopedic open surgery. There's any really three centers that do that. Blantyre a long way and zoos e so I went to the Zoo Zoo up here in the north because I was invited to by the Scottish orthopedic Committee on Trauma and and through all the orthopedic concern because usually there's one orthopedic surgeon in them Zoo Zoo uh serving a population of around six million. But in the last little while that surgeon has left and gone down to the main center in the long way. And so Mzuzu has been left without any surgeon whatsoever. And so a few of us have gone out there taking turns to try and cover the service to at least keep it limping along until the next surgeon arrives. Unfortunately, I think that is happening very soon. A local Malawian surgeon is going to come and take over and run the service again. But for a while there was no one there with cases building up. So Mzuzu is actually really nice place. It's a nice hospital. It's well looked after. It feels a little bit like being in a sort of 1945 war environment. All very spread out. Beautiful. Um But a lot of patience is required. Yeah, it is in a slightly rundown area of them. Xhosa, I'd say quite a poor area, but there is a nice little local market within short walking distance of the hospital, which is where when I lived there, I did most of my food shopping. Um um and there's a few local little shops, but a few miles away is the main uh town of um Zoo Zoo which like most African towns are slightly overcrowded, but actually reasonably pretty where you can get access to almost western style shopping. Although as well without the average price range of a Malawian in terms of hospital facilities for orthopedics, they're about 30 mile beds, 20 female. That's a bit of a variable feast because you can just stuff in the extra mattresses on the floor. You can get hemoglobin's done. There are blood blood transfusions available. If you want electrolytes, they have to be done at private lab down the road. So there are a bit trickier. There's plenty of dressings and saline and gloves and all that kind of basic kit is well about well available. The availability of antibiotics varies dramatically. So every week, a list is put out of the exact number of tablets of each antibiotics that are available. And so when you're planning any open cases or any infected cases, you have to be thinking to yourself about what antibiotics there might be. And there's not really a viable microbiology service to help you with that. There is an X ray machine in the hospital theoretically to, there's only one while I was there, you have to go down and look at images actually on the X ray machine because the service for uploading it into the computer is broken, but at least it's there. And there is a C arm in the hospital that you can use when the power is on. It's about 50% of the time um when the power's off, there is a generator but it's not quite powerful enough to fire the electrons from the C arm for you. Weirdly, there is a CT scan er as well, which was donated donated by the Chinese iness of uh glorious large donation, which is actually really useful and once again works about half the time where there's enough power going on in terms of staff. As I say, there's usually one local consultant um links directly terms is a hospital. There's several clinical officers between four and six at any one time who would do the odd calls and overnight an emergency work um in the hospital there is general surgery, there's medicine, there's pediatrics, oncology. So it's a reasonably bustling place. Although all of these services are fairly low key and run down. That's it. Interestingly in Zuzu, there's definitely no spinal service, there's no arthroplasty service, but you can refer down to the longer and Blantyre for those services if you need. Although the arthroplasty service recently has been once again, fairly variable with, when I was there, no arthroplasty available in the country whatsoever. So what was I doing out there? Well, the bread and butter as with most Sub Saharan Africa, I guess was trauma. Roads in Malawi are pretty bad. So road traffic accidents, the main source of everything that I was doing tons of overloaded motorbikes, tons of trucks where people have paid a bribe to get through their mot. So the brakes aren't necessarily working and tons of people getting around in unsafe ways, packed into the backs of trucks or bikes mingling with the traffic so that accidents naturally happen. And actually if you look at Malawi road injuries that the fifth communist cause of death in the country as a whole for all age groups. Um and the amount of money provided for healthcare for trauma is very low. So the annual health budget from LA is around 5 lbs or less than 5 lbs per head of population for everything. And I heard out there that for every 100 lbs of HIV and AIDS money that is spent in the country. Trauma gets about 10 p and that's including all donations. So there's not really much available to help with trauma care. So this would be a typical Malawi type case. And I'm talking about there's a distinct mismatch between people who are a bit wealthier and live in the city. And the poorer community living out in the village is the average village guy might be someone like this who works selling. Would he really doesn't earn very much? He's on a bike like this. That's massively uploaded. He gets clipped by a truck. So he has a clear open fracture at the side of the road. There's no kind of ambulance service. There's no way of retrieving him. So his mates just have to carry him along a track back to his house and it's quite difficult to get there. So this would be a typical Malawi village type house, the mud huts, obviously a long gone uh small brick house. But the trouble is he's in the middle of nowhere. A long way away from anywhere that can give him any care. There's no cars that can make it to his house. So anyway, for him to get to his local hospital is on the back of a bicycle. So actually that's naturally very uncomfortable, but his wife can get a local bike taxi to get him to a local hospital. So local hospital is Chiquitita District hospital and so she Atiba is quite a long way away from them, Suzy. So there's lots of these different little district hospitals in this region. But the classic is that somebody present at their local hospital and require subsequent transfer. The real the local hospital really have very little so no really anaesthetic service beyond the one that's providing Cesarean sections, this they don't have an X ray system. So they're just clinically diagnosing fracture. So they want to transfer to um Susie. So then what happens then what's happened, Susy? There's a really nice whatsapp service between all of the clinical offices and the central Zoo Zoo Hospital. And they say, look, we've got this guy. So zoo Zoo say, well, that's great. We've got several in patient's here already waiting surgery. So we're not going to be able to do this operation until we get a slot. So you're now on to our list, wait until we get a slot of it. So there's a delay. So the patient sits in the zoo, zoo on traction, waiting, sits in your TV, on traction, awaiting transfer to Maazouzi. And in the meantime, they have to organize transfer. Obviously, there's no ambulance service. So this is actually my guy arriving uh on the back of a truck down from zoo Zoo. By the time he gets to Zoo Zoo, it's three weeks post injury. So this is by far the sort of communist situation that I saw several weeks down the line with fairly major single limb, long bone and intra articular injuries. Obviously, the multiple injured pelvic injuries that long don't tend to survive. So this was his wound at the time and this is the operating theater just to give you an idea of how much there is a, so it's a relatively clean space. It's relatively well organized equipment. It is clearly pretty basic as a main theater where we do our main operations, treatment room, things like drilling out Osteomyelitis, pulling kids forearms is done. It's really important to have those two rooms because get through 12 15, very quick minor cases in the small room, get three bigger cases done. It, patient's are recovered in the recovery area which is once again, relatively basic, not much in the way of monitoring available, but patient's seem to do reasonably well POSTOP in terms of kit. There's all the basic stuff that you would need like a sail saline and dressings and all that kind of stuff is available. They've got two large fragment sets that are sterilized each time you need them. There's a small fragment set and they've got access to the sign nail that you all know about. And so they've got the basic stuff you need. There is no locking plate system, there's no articular contoured stuff. There's definitely no arthroplasty service of any sort. And so you're really down to basic non locking or nailing, fixations of whatever comes in. So my guy end up fixing him with a combination of plates and a nail. He did quite well. I'm sure you're not real experts. So, you'll be laughing at my quality of blind locking screws for the sign nail. The previous two cases that all ended up too long. So then I made them shorter and now that it screws are too short. But anyway, did the job for a minute worked. All right. So that's the bulk of what the zoo zoo workload is about. There's also spines that come in. People have all kinds of bizarre injuries. So this guy broke his neck. Um, carrying would and you just have to organise, transfer down to a spinal service for this kind of thing. But realistically, there's very little on offer for these guys, pediatrics. Quite a lot of conservative pediatric management, quite a lot of traction management, the occasional k wiring of supracondylar elbows and things, but even those are mainly conservatively managed. The other thing I saw a fair bit of was tumor's presenting very late to the orthopedic service because there's been a crisis of some sort. Um So typically they're now fractured through a large metastasis or primary tumour. And unfortunately, obviously, there is not a huge amount to offer in that situation. I saw fairly regulating outpatients, youngsters who would ideally get an arthroplasty with pain, but there is no arthroplasty service or at least there wasn't when I was in Malawi. So they all get added to a waiting list for the main hospital down in Lilongwe for when some arthroplasty team might be available. Um Most of the ones I saw were like this secondary to a childhood disorders such as Perthes or sufi, a few 60 year olds with early onset that way, but they really weren't very common. So, what did I achieve in Malawi? I had a great time. I absolutely loved it, loved being out there. Um, I loved having a good time out there, but I really didn't change the world. I saw some good fractures uh and try to do some gentle teaching, some general teaching of how to organise the list a little bit better, things like that. But really, you can't change the world in a few weeks out in Africa. So where do we go from here? Well, I'd like to set up a whole little link. So I've chatted a little bit with a O alliance who might be able to help me with some funding and with advice for me on how to help things. I've got lots of links with Scottish orthopedic trauma to get people from all over. Um Scotland involved, Scotland is really heavily invested in Malawi and there's huge links between Scottish government and Malawi. So I think with the input of Scottish orthopedics, Renren A oh Alliance, I've got something where I can leave a potentially some more funds from the Scottish government to help directly with projects in Malawi. Obviously, I've now got some links directly with the local team in order to see what they need. What can I actually offer? Well, theoretically expertise. I'm not sure that's true. I don't think I do a better job of any of this stuff than the local guys, but I can certainly offer moral support and by going out and visiting and helping them and encouraging them with what they're doing. I think that's an important aspect. I can provide access to a network of support here in Edinburgh that's not available out there. And that's as much as anything research and academic support with a very academic unit here. And I'd like to use that to help at least define what is going on in um Zuzu because at the moment, it's a bit of an unknown and honestly, I can gather equipment together to take out there and send out there. So immediate plans, I'm hoping to set up twice early visits with my consultant colleagues and trainee colleagues. I think getting them involved early would be great. I'd like to set up a system out there for monitoring the orthopedic workload, both in um zoo, zoo and in the peripheral hospitals and then maybe developed from there to actually look at what's being done and what the outcomes are like and what further things we could aid with hoping to send out equipment and there's good links from Scotland to Malawi for sending out equipment. I'd like to set up some of my trainees doing more research to Malawi. A and certainly some of the, um there have been people doing phds out Malawi and I think that's a great way of getting extra academic input, extra interest, getting Malawi on the scene. Finally, at some point, I'd really be quite keen to go and live there. This is my family visiting when I was out. We had a great time. Obviously, I've lived out there before and I love Mulally. So hopefully at some point, maybe in the next five years or so, I'll go and live out there for a little bit long term. So, thank you very much. And uh I think there's going to be a Q and A session at some point. Thank you. Thanks Sam. Hello there. Hi. Thanks for that insight. And what hopefully Scott will achieve. Obviously, Gaiam is out there just now. Uh And some of the whatsapp supports quite interesting because it's again using technology to try and help the local surgeons. Um Have you had any questions from the floor? Mm Graham. Do, do you think that a couple of weeks, four weeks or six weeks that we can steal from our work is enough or do you think the 24 are 78 weeks old and 65 days a year support is going to be better? And how if that is better, do we achieve that from Scotland which only has just 300 something orthopedic surgeons. Um, you've got to do what you can, I guess is the truth of the matter. So going out there for a couple of weeks, a year is not something that you would do in isolations. You've got to provide long term backup, as you say, with technology these days, it's much easier to look at cases and provide advice and look at the complications that have happened and provide support in those situations. So I think that can be useful. I think that a couple of weeks, a year as a starting point that you would build on and I hope that we get more and more people going out there for slightly longer. As I say, I personally think if we can get research going in zoo Zoo Hospital itself, then that brings with it some funding for people to be out there longer term as well, which would be really good. And I think we've got to be guided a lot by what about ill? Who's the new consultant out their bills that he needs and what support he wants out there? So I think that will develop over time. Really? Thank you. And uh Debra, thanks Sam Deborah East. But here I just, what's that group high? Is that what's that group worked as a sort of virtual trauma meeting? Or is it not quite that instantaneous? You know, I they have a nasty fracture. They ask you what to do and you can provide some realistic advice or? Yeah. So at the moment, that's what we're doing with Graham who's out there. So we've got a whatsapp group he sends over images, be that photos of wounds or the X rays and says, uh geez, what should I do with this? And we'll put in our little happening as well. Actually, I do this and somebody else say, well, I'll do that or whatever and then he'll send over POSTOP X rays and you go, oh, that looks great, well done or yeah, I have run into the same trouble. So it's a little bit like a virtual trauma meeting and that works brilliantly for the group in Malawi. They have a whatsapp group for all the clinical officers trying to send stuff in terms Oozoo. So that acts in a similar way for advice issue there. Of course, is that most of the peripheral places don't have X rays. So it's much harder to give any advice on what should be done beyond. Well, we'll get them over here when we can. Yeah, thanks. Hi. And thank you so much for your talk. Just wondering, yeah, you were saying you were having Chinese coming from Scotland. Would you be open to getting Chinese from England as well or in the future? Uh No, we don't like the English. So none of them. Now, of course, we would uh definitely get whoever is interested at the moment. I've got a big list of trainees from my own hospital who are very keen to come already. So, as it is, I'm going to have to have competitive sort of applications to come on a trip out terms. Oozy. So, um, for the next couple of years I think I've already got a list of people, but I'd certainly expand that out to whoever is interested and certainly anyone who's interested in doing research, I'd love to get people out there and that's much harder to get. So loads of people are keen to go for a week, few people are keen to go for a few weeks getting any longer than that starts to get your numbers dropping. Uh There's two questions in the online audience first is from uh Souffle, I love who's asked, um Do you get a salary to allow you to go? And similarly, from Steve Manion is, could you share with us how your funded given time from the NHS Trust airfares and expenses, etcetera? Um So for the NHS Trust, I went as a sabbatical. So I was paid full time from the NHS. Luckily, uh and they gave me up to two months full salary, but they said that's just a one off um airfares and all that. I just paid for out of my own pocket. Really? We got a little bit of funding from uh local fund that Edinburgh has for international travel of all sorts and going forward. A oh, alliance are going to provide, I hope a little bit of money to help pay for things. And then I have a few contacts in Scottish government where I'm hoping, as I said earlier to try and get slightly larger amounts of funding from them in the long term to run a bit more of a mentorship program. Any other questions? I'm, of course, I was training. I just have a quick question about the banana box. You had the last slide, but the equipment that was being donated, I just ask how that works. Uh Alberto probably knows more about Bernard Box than I do, but they basically organize um creates to go out to Malawi. So it's not a very quick transfer system. But if you're not in a rush to get stuff out, they're, they're a group from Dundee who send out uh containers at a time of various equipment. So it's a very cheap way of getting quick kit out there. Uh If you want to get stuff out there very quickly, then you have to do a more expensive system. If you're interested, just speak to me afterwards. But one of the things that comes through a lot of the talks today is everybody's linking up and this is actually the future that this is hopefully what the B O A will contribute is to link up the orthopedic community. You know, I didn't know about the Banana box test until I had a problem of getting 600 oxygen concentrators to Malawi and no way of doing it. And then somebody just accidentally mentions, oh, you must speak to Alan lava rock who runs banana box test, you know, and he's got nothing to do with healthcare. It's about education and support for developing micro, uh micro businesses in Malawi. And he's been doing a few years and he gets our medical equipment out for 18 lbs for any weight of banana box, which is fantastic, but it takes three months to get there. So we send out the anesthetic equipment in Missouri Zoo is supported by NHS Lanarkshire. We send a huge amount of anesthetic equipment. Trish gets a shopping list of what they want. Again, it's, we only provide what people want and ask for. It gets sent out. Um orthopedic equipment was starting to send out orthopedic equipment that what is asked for because one of the problems, there's no point in sending out DHS screws and plates from a striker system when they've only got a Chinese copy or an Indian copy of uh the ecosystem because they don't fit as we find out on a regular basis. So it's just linkage that's really, really important. And jokes apart that we actually one of the first volunteers after Sam was high risk group is actually from Lincolnshire. So we do take Brits from anywhere and one of the other volunteers is actually an American surgeon Kieron Agarwal Harding. So we will take anybody. We're not proud Sam. Thank you very much. We look forward to Scott and the Scottish government actually standing up to the plate. Uh, but you have to start everywhere with the first step.