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move on to the S. A prize. Thanks, Ryan. So before we move on, I'd like to introduce Mr Mike Camden. Uh, Mike is currently a clinical teaching fellow at Sunderland Royal Hospital. He graduated from Newcastle Medical School during Coated 19 and started his first job with an infectious diseases at the Royal Victoria Hospital in Newcastle. He has interest with in management and surgery and has completed an M S C at master at University and health Care policy, Innovation and management. His work with Friends of Nepal Ambulance Service began during his elective in 2016 when he looked at head injuries that arrived in E. D. He then took on the position as treasurer and finally chair in 2020. He seeks to improve prehospital care with in Nepal by by proving the need for a professionalized service as well as undertaking quality improvement projects and research. So, Mike, since Wednesday Oh, yeah, got it working. Wonderful. Hello. Thank you very much for coming today. And thank you very much for this entire weekend. It's been it's been incredibly interested in my side of things. Learn a little bit about sustainability within general surgery, anesthesia and obstetrics. Um, one thing. I mean, I never thought I'd actually come here and actually talk to you guys about pre hospital care and actually about how we transport our patients. But from a surgical anesthesia and obstetric point of view, we need to work closely together in order in order to improve how our patients are actually getting to hospital. Um, so when I went to Nepal in 2016, I had the pleasure of actually attending the first ever pre hospital care conference, and they ended up showing, actually, how do you transport a patient from a road traffic accident into into an ambulance in a safe manner? And there was something like along the lines of 200 people watching, uh, this entire process go on and there's the the to emergency medical technicians working to transport the patient. And then, of course, you've got everybody taking videos of it because I've never seen anything like it before. Uh, but other than that, I'll just I'll end up moving on talking a little bit more about the nipple ambulance service in a little bit, and I want to say thank you as well to everybody from gas stock who entered the essay competition. It was an incredible way of actually gathering information and finding out if people are interested in the hospital care. But we got 39 s a submissions. Um, it was incredibly difficult to actually assess the work which we got because it was so good and actually trying to differentiate between who won. Um, it was so difficult, actually, instead of having just one prize, we ended up going towards free prizes instead. A little bit of history for pre hospital care is it really had its beginnings about 200 years ago, before the Napoleonic Wars. Um, they started off by having what they called flying chariots, which was just a horse with a car behind it. Incredibly simple. But the entire thing was is that 11 war commander or looked at the battlefield and saw that there were people in pain and there was a need to transfer them back behind, uh, back to go and find safety. Um, then pre hospital care got even bigger, Particularly during World War One, where we saw lots of patients being transported from, uh, from from from the trenches, back to back two hospitals. And Nepal first got its first professionalized prehospital care service back in 2011. And the thought process behind it was is that patients needed to be transported in safety and they needed to be protected from iatrogenic harm. The bottom right was actually one of the videos where the ambulance service tried to, uh, cell itself to Nepal to say, Actually, we need to do better for the way that we transport transporting patients. They can't just be taken in the back of taxis, and they can't be handled by family members who have got the potential to to to to to drop patients and to, uh, inadequately transfer them. So it was formed back in 2011 with some work with Stanford University. They created a three month online course which could be completed, and that gave you the position of emergency medical technician Um, the ambulance service itself is not for profit, and when it first came out, it had only charged people who could actually afford the service. But as of as of the coated pandemic, it is now free to every single patient, which is which is really, which is it's gone through big steps. It particularly sees it's time of need during times of national crisis, so that will be back in the garden or earthquake of 2015. It will also be during the coated pandemic, and I'll show you some numbers of actually how much more it's used during times of crisis. It was originally funded through volunteer donations. So through rotary clubs, um, and through through people from outside of Nepal. However, as of the coated pandemic, things have not changed. It's the government, which is now funding the organization and looking to nationalize the service province through province. It's got a long way to go, but it's starting to make really big progress, and it's now starting to be looked at as the people who will be making the standards for ambulances in the future just to give you an idea of how many patients and the ambulance service is treated. Doctor do Poly in trip even hospital ended up doing a research projects, and over seven years or so, they've seen 33,000 patients, um, since since its inception, and it's probably now along the lines of about 40,000, uh, given the data from the last two years. This is an example of the emergency medical technicians training the army during the coated pandemic on how to utilize pee pee and to keep themselves safe and to reduce spread of Corona virus from my aspect of things, um, the friends in the ambulance service was created in 2015. You were a group of mostly UK based physicians. Um, and back in 2015, we had one incredibly keen paramedic who actually attended the goalkeeper earthquakes, um, to help actually organize the service and to start creating a command of control center because the one back in 2015 was destroyed and that was part of our work with them. And during the coated 19 pandemic, we were able to provide a lot of funding to purchase reusable PPE keeping sustainability in mind. On top of that, we also have been working with paramedics and medical students, um, opportunities in pre hospital care. Back when I was a medical student, there wasn't enough work to be done within prehospital care, and I had to do my my work with the emergency department. But this is the first year where we've actually started having medical students based within the ambulances and seeing and and and collecting data straight from Nass. On top of that, we've had two very, very keen paramedics called Ana and Johnny, who ended up spending the best part of six months out in the pool with the with the emergency medical technicians and their data was published, and I'll show you a couple of slides from there. This is an example of the conditions that they deal with. No patients who got chest pain and breathlessness. Patients have strokes, people who've got diarrhea and vomiting and incredibly dehydrated. And on top of that. And I suppose, what's the key point of pre hospital care is that we deal with a lot of trauma in patients who are in car accidents and maybe over time will be starting to generate the data. To prove that, we need to, uh, we need to start making sure the helmets and mandatory and to make sure that seat belts are warning that there are certain safety features in cars. But this will. This will happen over time as we develop more and more data. Uh, this is just, uh, some more of the work just to show how long people take to get to a hospital. Um, so we are out of, say, around around about, like, 60 70 patients. Um 16 of them take between 24 72 hours to make it to an emergency department for emergency healthcare. And, I suppose something which will also notice that we see a lot of patients with a new score of zero and very few patients of a new score of 14 and maybe as emergency medical technicians or as the as the prehospital care services developed, we start seeing more and more unwell patients, and we'll start seeing that table move to the right hand side. And this is just an example of patients, the number of patients the ambulance services seen on a day to day basis, so usually it sticks around 20 patients a day. But at times of crisis, such as during the coated pandemic, they were dealing with up to 70. When you're dealing with case numbers like that, there is not a lot of time to look to yourselves and see improvement. But now is the time where there is a relaxed part of the service that you can start looking at training actually doing some quality improvement projects because there's a little room to move. But what does this actually got to do with sustainability from A from a Great, uh, it's not so much sustainability from a green source, you know, making sure that the services carbon neutral. Or that, um, it's more to do with How do you make a service sustainable in the sense of the organization itself. So you need to prove an organization needs to be there, and you need to do that through data collection. On top of that, you also need to make sure that we train our colleagues as well. So ensure that they are getting something out of their job to see that they're making improvements and actually invest in people. And people are incredibly important in an organization like this because, um, from from various different times they may. They they have not received funding and people have not been paid. And actually, when you have a situation like that, it's really incredible. It's incredibly difficult to go to work because you need to you need to you need to look after your family. And that's why hopes is incredibly important when it comes to sustainability of an organization, the individuals who actually believe in a service. Um, there's hope they there was when I was when I was at this pre hospital care conference. People never thought that it would be such a such a conference or such a need to bring people together for pre hospital care. But it's happened and they're looking forward to their second conference. In due course. It was delayed by coded, but they're doing the planning for it. Um, and we're looking forward to having more and more medical students with in Nepal working with the working with pre hospital care services. Um, from my aspect of things, you know, if if this interests you, um, and you you want to get involved the things which I can do with your time, your research knowledge and your networking opportunities. Some of your doctors in, uh within the UK and some of you guys are doctors from outside of the UK, chat to your medical students or chat with your colleagues to see if they'd like to have an experience in the pool, because people will be more than happy to have you and to learn from yourselves on. On top of that, you may come from a country where they there There is no pre hospital care service or no professionalized prehospital care service. In which case it's now time to actually have a look to see how an organization like this gets developed out of No. Where Where do you get funding from? Where do you find the staff from? How do you do the training? Now is the time to learn. Um, but other than that, that's essentially it from me. The bottom. There is just a picture from Pokhara just to show actually, how beautiful the country is. Uh, if you ever get the opportunity or the privilege to go there. Yeah, Thank you so much, Mike. That was really interesting.