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Right. Hello, everyone. We're going live now. I think, um, we'll probably just wait for a few minutes as people sort of trickle in. Um, there are some poll questions that we can be doing in the meantime, if you go to the chat section on the right hand side, um, you'll see messages and feedback and polls. There's a few questions just to click through there just to give us an idea of where you're from current roles and interest in vascular surgery for the time being. Um, so you have a, have a look at them and we'll get started in about five minutes or so. Give people time to, to click on and, uh, get going. Yeah. Hello, everybody. Paul is going live on. Ok. Brilliant. Is all the poll questions released there? Uh, Jefferson, uh, just a couple of more questions. Hold on. I'm afraid I follow. Ok. I think what we can do is we make a start in, uh, a couple of minutes and then, you know, we'll get, do a bit of a blurb and then by the time we've finished doing our watering, then there might be AAA couple more people and then we'll get to Elena's proper stuff. Um, so we'll start in, in two minutes. Ok. I'm impatient. I think we'll just get kick it off a little bit and then people will come when they come. Um, so welcome everyone. This is our fifth talk. It's our day in the Life Surgery talk series. It's in association with, um, the Foundation Training Surgical Society of the West Midlands, the Royal College of Surgeons in Edinburgh and the Surgical Society of International Doctors, er, and Shrewsbury and Telford Hospitals. My name's Fraser. This is Jefferson in whichever direction he is on my screen. Um, um, we're both sho grade doctors from Shrewsbury. Um, these talks came about, uh, by talking to current trainees about their training and getting an idea of what their days entail as well as their sort of specific application process and their journeys they took to get there. Um, and we thought, well, it would be good to share these discussions that we've been having with other people and give a better idea about, you know, their specialities, about some clinical information about common presentations that they say on a day to day basis, how they got to where they are, um, anything useful that picks up along the way or things perhaps they might have done differently. Um, we're so five sessions in now. Uh, we do these sessions, er, every 2 to 3 weeks. Um, so, yeah, like, like we've been saying in previous sessions. If you attended any of those, any feedback from particular specialities that you'd like to hear from, we can arrange that. There's a few more that we've got coming up, we've got planned. Um, I, like I mentioned before, there's polls on the right to answer before the talks or during the talks, um, and just comment where you, where you're coming from, where you're studying, what position, what, where you are currently in training. Um So you've got MS Helena Smith who's an ST three in muscular sur surgery. She's working in the West Midlands currently. So, uh Helena Smith is uh uh NST three in vascular surgery. Uh She works in the reputed West Midlands deanery. Uh She's a run through trainee, which was amazing to hear and, uh, she'll tell us about what vascular surgeries all about what she does on a daily basis, what she looks forward to and what her journey has been like. So, uh, let's give it up for Helena Smith. Ok. Hi guys. Um, my name is Helena Smith. Um I'm just gonna talk to you a little bit about vascular surgery. Uh What my day to day is like the sort of things that I see. Please don't be afraid to ask any questions in the side bar. I'm happy to answer any, anything that you want to ask me. Mhm. Uh OK. You ok there. Yeah. Ok. Let's try. This is that sharing. Um, not yet. It's just on that um pri now bit if you can and then perfect. Yeah, that does that work? Yeah, it works. Yeah. Uh we just need to go to your presentation. Mm OK. OK. Is that more like it? Sorry about this? Can you see it when you go to my presentation? Um you're just on the browser at the minute. So let me see if you can get on to your your you any powerpoint now. Yes. Uh I can't see it. We 26 just hold on for a second for us guys. We'll just try and get this loaded up for you. Uh I think you need to click uh share your screen and then share entire screen instead of a window. Hi. Hello. Can you try uh looking, share entire screen and stuff? Just share a window. Um I don't actually have the speaker option at the moment. Here we go. Uh Are you sure I can uh we can see you as the speaker. Uh Do you wanna try at the moment? It just says I'm sharing the screen. So let me bring you. Can you see that? Not yet? No, give me two seconds. I'll put it. I'll put it as a PDF as a slide deck and we'll just just tell me when to change the slides. Yep. Thanks for you. Could, you could share your screen. Yeah, here we go. I've shared it. So just tell everyone to change the slides for you. Helena. OK. Could everyone see that in the chat? OK. That's better. Thanks guys. That wasn't really going anywhere. Was it? OK. So if you just change to the second slide for me. Um So just to tell you a little bit about who I am. So, um when I finished secondary school, um which in the UK is when you're 18, I went straight from secondary school to university to study medicine as an undergraduate. Um That was back in 2011 where I did uh the full six year degree with a intercalated BSC in the middle of it. Um From that I went straight into um foundation training, which was in the hospitals where I'd been an undergraduate. So that was between 2017 and 2019. At that point, I didn't really know what I wanted to do. I was thinking uh probably medicine at that point. Actually, I'd done a, an elective in New Zealand as in hematology. And I'd also got quite an interest in neurology as well. So that was sort of where I thought I was headed at that point. Um So the rotations that I picked were a little bit varied. When I did acute medicine, I did quite a bit of neurology and I wasn't very keen, but I did vascular surgery and I found it quite exciting, quite interesting. But I thought maybe I'm not a surgical person. And then as the years went on, I got a bit I've got more and more interested and that sort of led to where I am now. So by the end of my second year in foundation I was wanting to do vascular surgery. Um, I'd got, um, quite involved in some research where I was, which was at the Royal Free Hospital and I went to America to present some work on that which infused me even more. And then, um, I went to New Zealand, which, er, is what we call like an F three year. Um, I went to a place in Christchurch, a, a place called Christchurch was in the South Island and I worked as a vascular registrar for a year. Um, at which point I flew back during the COVID pandemic pretty much and interviewed and I got a number, uh, which was a run through number, which means you're essentially in vascular training from ST one, which is when you get your position, um, all the way to consultancy, which is ST eight. so the good, the benefit of that is you don't have to reinterview ast three, but I think that program was now, uh, finished. So at the moment, if people want to apply, it's, it's ast three level, which I can talk a bit about as well. Uh So if you just change the slide for me, so once you sort of start doing vascular surgery, you forget what, how you can kind of summarize it to someone who's never heard of it before. I know. I know we can't see the slides at the minute. So I, I'm going to do some jiggery poker in the background. So just keep going as you can see them and I'll just, um, have a bit of a play but continuous. No worries. So, when I speak to people and they say, what do you do? It's normally people who've not done medicine. I say, well, I'm, I'm, I'm a vascular surgery trainee and most people just look at me with a sort of a blank face. So how I like to say is we operate on any blood vessel, whether that's arteries or veins, anywhere in the body except uh generally the brain, which is the domain of the, the neurosurgeons or the heart. So we'll do just beyond the heart. So we'll do aortic, well, normally aortic root some aortic root procedures. Uh, but we won't do any cardiac or any brain, but we'll do anything elsewhere. So that means that there's a hell of a lot of variety in vascular surgery, which is one of the er, attractive points for it. Are we able to see the slides yet? So, vascular surgery, as I've said is there's a huge amount of variety. So, essentially what we're there to do is deal with any artery that's bleeding, whether that's acutely or whether that's potentially bleeding that is imminent, if it's, uh, an aneurysm of a certain size or bleeding, that we think may happen in the future. So if it's maybe uh a what we call a threshold aneurysm that has a year on year incidence of potentially rupturing and causing life threatening bleeding. So we treat things reactively when it happens, but also prophylactically in the sense that we do elective operations for these, for these people with the risk of bleeding. And we also deal with people and treat people who have blockage in their blood vessels, whether that's something that's happened chronically. So, due to lifestyle factors and age and has happened at a rate where the patient can compensate. So they're not necessarily coming in acutely but will need but can have procedures done electively to open up the blood vessels or whether that's happened suddenly and there's no ability for the body to compensate. And without the vessel being unblocked, then that patient will have either an ischemic limb or ischemic gut ischemic uh leg arm, et cetera. So I would say that's the main bulk of what we do. We also um clear out arteries anywhere in the body. So it can be limbs, um the neck and the aorta um in the vessels that supply um the bowels as well. We also deal with a lot of what's called diabetic foot disease, which is basically an epidemic at the moment with people presenting with diabetic foot sepsis. We treat things that people commonly hear about such as problems with the veins, whether that's the veins, not working properly and becoming varicose or treating people who have um post thrombotic disorder, for example, after a large iliofemoral DVT, and we also work a lot with other specialties. So, um for example, there's cross specialty working with urology. For example, if you have renal cell carcinoma invading the IVC, then that would be a joint case potentially with vascular. Uh We also work with the spinal surgeons if they need um an exposure via the abdomen to get to, to get to the spine for, for their surgery. We also operate a lot with the er, interventional cardiac surgeons who will be putting in um devices such as Tavi and pacemaker via the groin. We do groin exposures to them. So there's a huge amount of um ability to work with other specialties as well, which is attractive to somebody who wants a lot of variety, I would say, and I'll go into other things as well. Er, next slide, please. So I think when we think about vascular surgery, there is a, there is something that differentiates from other specialties in a big way and that's the um level of comorbidity in our patient population. So we treat a lot of very frail patients who have a history who have a lot of past medical, uh past medical history, they've had surgical procedure before. There's a lot of complexity. There is also a huge amount of um lifestyle factors that contribute to vascular disease it's a, it's commonly a disease of deprivation. Um, so we're treating patients who've had long smoking history. They're diabetic, they are likely to have had strokes or, um, serious cardiac events in the past. They may be on dialysis or be approaching dialysis. So a lot of the patients that we operate on will need good partnership with an anesthetist and also a lot of preoperative workup in order to make sure that they have a safe surgery and aren't having any further complications that could be a, a threat to their life and their lifestyle. Maxzide, please. So when we think about vascular surgery, a lot of our day to day work is treating patients who have chronic limb threatening ischemia. And that's patients who've had blockages building up in the arteries of the lower limbs over time due to the factors I've described previously. So we'll get a lot of patients who are on this spectrum who initially will often start with claudication. So, cramping type pain due to blockages in the arteries in their legs, and a proportion of those patients will progress to a situation where their limb is at risk due to gangrene and rest pain in the in the leg. So we use different types of techniques to try and increase um the longevity of the limb and reduce the risk of them needing an amputation or at least ensure that any amputation that they do need is delayed for as long as possible so that we can maintain, maintain their independence for them. So if you move to the next slide, please. So the thing with vascular surgery is there's a huge amount of options for patients who have this disease. This this disease is sort of bread and butter vascular surgery. And it's what a lot of the patients will be um affected by who are on the ward day to day. So it's got to be something that you can enjoy and embrace, I would say, in order to have a career in vascular surgery. So, um I've got quite a few pictures here. So vascular surgery is unique in the sense that we can do open procedures. So that would be the classic operation that you would think of where you cut the skin and use um your your scalpel, er needle holder, forceps, et cetera, or we can do endovascular surgery, which is traditionally the domain of the radiologist, but is now becoming the new frontier of vascular surgery. Essentially, it's carried out in what's called a hybrid theater, which is in the image that you can see at the top. That's a particularly fancy one with lots of um dramatic blue lighting, but it's essentially using um x rays and contrast to visualize the blood vessels. So for example, if we're doing a lower limb angiogram, the patient would be flat on the table that you can see in the center there. You'd use the ultrasound to scan the femoral artery in the groin. As you can see with the pictures up on the top left that's showing a femoral artery and cross section as you would see on an ultrasound. And then under the ultrasound guidance, you would puncture the artery with a needle. And using Seldinger technique, like you use in lots of er specialties, chest drains, et cetera. You would put a wire into the elding a needle and then over that you would put a sheath through which you can squirt contrast dye to produce these images with x-rays. Like you can see in the bottom left hand corner and in those pictures that say A and B, you can see where the narrowing is and then you use a little balloon inside the artery to essentially inflate any area of stenosis or blockage. And that helps to increase the blood flow down to the lower limb. So, angioplasty and stenting like the stent that you can see in the bottom, that's a very conformable stent that you sort of that you'd use behind the knee. We can use that to help to increase the blood flow to the foot. And we can see here is a kind of very uh futuristic graphic of what's called atherectomy, which is where you essentially can use like AAA mini drill inside the blood vessel to carve out this calcium inside, which is very hard and is restricting blood flow to the foot. There's a lot of new devices which are coming into play and I think that's one of the benefits of you can work with industry. Hi. Sorry to interrupt you. Sorry to interrupt you. I think there's no video video has disappeared briefly for all the participants. Uh I'm going to try something. I'm gonna try ending the event and restarting it and we can resume from the same slide. Really? Sorry. Is that ok? No, no, no, it's fine. Do what you've got to do. It's ok.