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I don't want to ever seem parochial. So it's quite nice to actually have a plastic and reconstructive surgeon apart from Gorran Yelovich to come and speak to us. Um One of the important things in a lot of the work that we do overseas is the compound fracture, which often comes late and proves a huge challenge to your orthopedic skills. And part of these lessons are lessons that we can learn from. Unfortunately, the field of war and for that, I'm really grateful to, she had to come and give us some insight into some of the work that's been done in Ukraine in helping reconstruction and the deployment in Ukraine. And I believe he's just literally back hot off the plane straight into Tom a list and then somebody nagging him for slides. So without further a do, thank you very much for coming to talk to us. Thank you. Thank you very much. And again, apologies for being like, I'm actually on call and cancel the week weekend. And I've left my wife PT colleague with an open fracture on table, which I promised I'd be back in time to close in about an hour. Hopefully So I'm going to talk about this UK Med led mission, um which has been supported by B O A and back press. And um you'll see some familiar people on that slide, no doubt. So I'm gonna talk about what we've been trying to do in Ukraine because clear, it's a very different setting to some of the countries we've talked about this morning. You know, it's not a limit country. It has a really well developed healthcare system but also particularly unique challenges. I think about that Ukrainian system that really needs our help as a UK group of orthopedic and plastic surgeons. Um I'll outline what UK meds been doing. Also. Also deep has been on these missions as well. I can and feeling from her experience as well and talk about what the next steps are, which are actually Deborah about getting money as well. We're all in the same boat, I think so. I mean, Ukraine is incredibly well developed first world health care system, you know, the hospital you'd walk into and you think you're in the UK, but it's not quite the same as the UK system. It is very post Soviet, it's very inflexible, it's very much done by individual regions of blasts and then within those are blasts where are regional hospitals and other hospitals. And if you think we don't collaborate in the UK in Ukraine, they literally don't speak to each other. So it's a real problem trying to get a system wide change when you have essentially a whole lot of separate fiefdoms as part of your healthcare system. And I think because it's developed in that way, it has these kind of really weird gaps. So for example, you know, physiotherapy and occupational therapy as a kind of entity doesn't really exist widespread across Ukraine as you would expect it to do in a normal healthcare system dealing with, you know, similar civil time patience as we would do in the UK system. And from, from my perspective, you know, reconstructive surgery, plastic reconstructive search, apart from a little bit of cosmetic stuff doesn't exist as a specialty. So, you know, people doing flats to restrict limbs just does not happen. And there are weird gaps in their orthopedic repertoire, you know, obviously they're incredibly technically proficient to lose our off. I mean, it's used widespread but very few places do bone transport or managed bone defects, which is just kind of weird, you know, you know, it's amazing constructs on, but you won't do a corticosterone and move a bone to close up. You know, Tennessee sensitive gap, you sit and wait for it to kind of magically he'll somehow, which obviously doesn't. And I think really bizarrely, I think you can have both found this, you know, despite the fact this country has been a pretty full on war since 2014, that experience of war surgery has not filtered through the whole healthcare system. So it's very much an east, even their military surgeons outside the Donbas will have no military experience. It's kind of weird to think about an invasion of 24th of February clearly for the preceding. Um since 2014, their military has gone through a total redesign and has been preparing for the invasion. They, they always knew was coming and operated in a way that was incredibly agile and flexible in a way that you saw the Russian forces not operating in. So you remember these two forces start in the same place for both post Soviet, but one is operating a very different effective way compared to the other. And maybe that's because since 2014, there have been overseas UK US coalition military experts in their, teach them how to do stuff and they have adapted and adopted some of the ways we would work in the west that has not happened in the healthcare system. So I just wonder whether healthcare system is frozen in time and this is now the challenge to kind of shake it up. So what are we seeing lots of casualties by lots of casualties? I mean, tens of thousands of casualties trying to get accurate figures, as you can imagine, it's very difficult, it's a very sensitive subject. But you know, if you look at the range of where the war is, if you look at the admitted number of casualties, which is probably getting towards 100,000 kills as, you know, for, I'm sure a lot of you got experience with gallstones. You know, you can times up by five for your number of winders. And, um, we know you look at all conflicts from, you know, that's what we're up till modern day warfare. The majority of your war injured survivors will have extremity trauma. Okay. Over 80% the figure were told last week by the Deputy Health Minister was 84% of their warranted survivors have extremity trauma. So you can imagine if your system isn't really set up for doing that, you got capability gaps. That's the problem. And the other problem we have is logistical. It's a really, really big country. So to get a cashier from where they've been wounded in the east where majority of cash is being generated over to where some of the more definitive surgery is happening, which is mainly in central Ukraine. But actually initial parts of last year when deepen our first fare was very much in the West, takes days if not weeks. So you've got delayed evacuation and then you combine that with at the front end, a massive overload of of the few number of facilities that are servicing the front line. You've got very limited time for intervention and the surgeons there may not have the right skill sets because they're not been training for war. And so they don't get great to bribe, but for lots of different reasons that, you know, are beyond individuals controlled. So infection becomes a really big issue. Um And so as you can see, that creates this limited capability and capacity to deal with what is, you know, a massive healthcare burden, a burden that would overwhelm our system. If you think about a number of orthopedic surgeons and plastic surgeons who are involved in actual author, plastic limb care, it's probably about less than 100 in the UK. To be honest, probably, you know, how many people do frames? You probably know with more by name. So, you know, it would overwhelm the UK system and this was something they realized, they realized with casuals coming in, they did not know how to deal with them. They couldn't manage with bone defects, didn't know how to deal with soft tissue, they didn't know how to deprive mint. So that's what they asked UK med back in March of last year. So Steve Mannion, who was out in um without the time the initial scoping mission, Vandy Kent very are specifically, can you get people over, you can help us with this extremity trauma so deep and I found ourselves on a plane to Ukraine. So this aim has evolved, I think at the time, we were told, just get on an aircraft, get out here and work else going on, which is fine. You know, it's an entry level lot. That's kind of what you have to do is, you know, but I think that matured into a concept which is we're trying to develop an offer plastic approach to extremity trauma, which is something they do not have. And within that all the things that you know, are important. So, you know, really trying to improve our initial management bribe which which deep has been to an ipro, which is kind of first kind of what we call a role three type hospital. So it's not doing damage control is actually now beginning to think about, okay. Can we start thinking about something more definitive? So that's been a really important aim there. But also, you know, well, we've been cited for the West, more role for type hospital were doing, you know, definitive recon, you know, you've got, you've got to play the catch up of debriding, difficult fractures, open wounds which have been undertreated. So that's a skill in itself as you know, the other thing we have to do is kind of fill that gap of capability about what do you do about soft tissues? What do you do about bone defects? And so what do we have to work with? What we have some incredibly talented and engaged orthopedic trauma Atala Gee surgeons who really wanted to take it on board? You know, they really got it and, and I think in the units we interacted with, you know, that kind of really chief does it and no, not as anything else has been less. Have been loosened. And so there was some young dynamic orthopedic surgeon. And he said, actually, you know what I want to learn this stuff. I know it's really important. And I know if I can do these simple operations, I can make a big difference to my, my patient's and there was some general surgeons as well. One of the hospitals had already started doing micro surgical procedures and things like that. So, you know, we weren't starting from a total standing start, but it was pretty much a standing start. And then there was a challenge about bone defect reconstruction. And, and you know, again, there were people who are beginning to do this, you know, yeah, there's a guy in love you who does, you know, bone transport. Yes, going cute. But it wasn't widespread despite the fact that Lazaro was an established technique. So again, there was a bit of kind of, you know, education around that what to do, what not to do. And I think that the the most challenging thing which I don't think we've quite cracked yet is, you know, this idea of working as a team didn't really exist. So, you know, the trauma ologist, traumatologist to there, but general surgeons develop it microbiology as a clinical especially does not exist, they don't have clinical microbiologists. So having kind of that really essential bone infection input into the system does not exist. So that's a real capability gap. We're trying to kind of bridge by using things like clinical pharmacists who are kind of ever present and is a problem which, you know, the the creators have realized I need to deal with in our, on our gripping with it. So that was kind of on the ground aims. And then we realized, you know, our missions are intermittent. So we need to make sure that some continuity. So we had a virtual wraparound which, you know, Deborah's allude to some of the elements of. So what do we actually do what we did, you know, as you imagine. So didactic training lecture based, you know, just talking through powerpoint presentations, types of flaps trying to use as much video as possible. We, I'd say we selected for hospital, that's not really how it happened. We went to a whole lot of hospitals and four of them said, hey, will you come back or just actually, you know, can you get me operated this tomorrow? But loads cases. So you kind of go where you think you're going to be received well and supported. So we end up before um one in sort of east Central and Cipro to eat more central um in Venice and she Tamara and one in the West in the Viva, which was the kind of place where a lot of the characters were ending up at the end of the EVAC. And so that was kind of the, you know, the backstop, you know, things had to be solved there or they or they weren't going to get solved. So we set up a whatsapp group which actually incredibly useful. Um And, you know, I don't, if you can see the, the picture on whatsapp group, which is, it may not work. Um But then, you know, there's gunshot wound through distorted deal with most of the digital third of the tibia missing. It's like guys have to reconstruct that. Well, I think, I think you said, yeah, I think the restriction is probably a really well done amputation. And everyone said that's where to go. And, you know, for the Ukrainians who are faced with a soldier and they don't have to deal with this. It's crime. It's kind of really helpful for them to be able to have access and the reassurance of getting that high quality um external opinion that actually if this patient is presenting in Birmingham or London or, or Glasgow, we'd be saying the same thing to them as, as, you know, as we were to, you know, their patients'. And, you know, this is, you know, I know there's lots of stuff about tech and I've been approached twice this week about Hololens and all that kind of stuff. But this is our idea of virtual augmented reality surgery, which is um drawing on what's that picture like? That's your flatmate. Just cut around that and move. It is good. Literally, that's what we did. And, you know, that's what he did. So, you know, I think the tech is important. It's very important to, to, to um explore. But actually, you know, some of the simple stuff is the most effective. I think the lecture series that Deborah mentioned has been really well received. Um It's um it's been comprehensive. It's had a whole range of wide range of speakers from both UK and around the world. You know, military background, civilian background, people with, you know, uh war experience and people without war experience because not everyone needs to be wall surgeon to talk about this stuff. You know, once you've been shot or blown up, you've got a bone defect and you got infected wound, you know, it's something any civilian surgeon that does all the plastic surgery can deal with, to be honest. And we had these intermittent visits. So I'm not gonna take the liberty of talking to orthopedic surgeons about orthopedics. I'll stick to my my lane, which is plastics. So what do we teach? We talked about the debridement principles and how you do initially management very much about and deeper. And one of my colleagues, Evette God when we're doing in Ipro, um we also talk about simple flaps and when I say simple flats, I mean, really simple flaps, things like gastric flaps, sorry, that's gone to gastric, which we weren't doing this. Um But gastro flaps, you know, I was shown to do my first gastro flat by an orthopedic surgeon, but, you know, huge chisel down in, in friendly. So I'm like, you know, this is something that actually should totally be within the repertoire of an orthopedic surgeon. It's an absolute, within the capability, skill set, local patch change flaps as you can see there. So there's the next slide on of that. What's that picture? That's what he actually did. And it's worked, we talked about perforator flap which where you have like a blood vessel coming up to a bit of tissue and you can then elevate that island tissue on that blood vessel, then move it around. It's a really, actually, really simple technique, but it's incredibly useful that you can get you out of almost any hole. Um We brought out some dermal substitutes. So this is artificial dermal matrix. This is BTM um which actually is incredibly useful for some of these wings because you know, the thing about one of the challenges is just the number of patients they have and this stuff just goes on in like 20 seconds. You just walking on the way you make sure it's clean, stable and leave it for four weeks and we can skin graft it. And then, you know, deep in the other topic, um colleagues started talking to them about how you manage bone defects. You know, the principles of been transport, you know, use of, you know, mascular. Um they're, you know, a lot of them were, were early adopters are you using cement and spaces and being very aware of this stuff, they know about it. They read incredibly well educated um but actually just translating that kind of theoretical knowledge into practical experience was really important to get that translation over into actual clinical effect. And then finally, I said, you know, microbiological management, that is still an ongoing challenge because as your, you know, you're aware, AMR is just a curse of any war zone and it acts exists in Ukraine. But quite refreshingly, the whole problem about infection control. AMR bone infection is being gripped by their Ministry of Health. So now creating a system where they have a clinic, pharmacists are responsible for that in every hospital in Ukraine. So, you know, having said it was a very kind of rigid post Soviet system, it appears because of the pressure of warm the demand. They're having to becoming a lot more agile, a lot more reactive. So what we find, well as you imagine, you know, when you go and teach these techniques to surgeon to incredibly skilled experience anyway, they just get on with it. And so some of the stuff that was coming back and what's that group would be like? Okay. So you've been to one of our lectures, you're now doing these incredibly sophisticated limber instructions with, you know, bone transport, local flats things you look at God is that really going to work? And it does, it did fantastic, amazing so, you know, they're really proficient and I think they kind of, once we've given these very, you know, fundamental skills they're taking away and running, um, and we did select one of the units which was already doing Mark surgery and already had a microscope to develop some free flap capabilities. Like I kind of say that with a little bit of reticence because clearly, you know, we all know how resource intensive doing something like Mark surgery is. And if you've got tens of thousands of patient's, you know, you need to think about where do you put your resources? Do you put resources in doing the simple stuff like, you know, local tissue, maybe some bone transport or do you invest it in really complex surgery which will, will treat, you know, less than 1%. So I think what we're trying to do is give a balanced approach. We're trying to develop that kind of more widespread capability, which will probably deal with 80 90% of the casualties. But also let them create the capability to do it really high end sophisticated complex surgery which can deal with the residual, you know, 5 10%. Um And you know, just to show about, you know, how, how they've developed. So this is as you see, an open um wound, I think it was a, I think it's a blast injured. Um You know, that's the lateral mouth kind of blown apart. Calcaneal, blown apart pretty Manky. So it gets, it gets to bride it and it has this local fat put on it by one of the teams in Valencia and I have no idea what they've done a little. I don't, you know, I was like, wow, that's really cool. Can you get Eugene just to what's happening and tell me what he did because that looks amazing. I think I know what he did, but I've never seen this done before my life. So, you know, it's, it's incredibly, you know, we are. And I said to me in a matter of, in a year, you'll be teaching us what to do because you will unfortunately have the experience of what modern warfare does to a population and how it's best managed. You know, our experience of the UK is historic pretty much now. You were lost in common operations 10 years ago. So, you know, they are becoming, yeah, they'll become are teachers, which I think is an amazing thing. So we did focus on one unit to develop, you know, free flap capability and also do complex bone recon capability. Um As I said, it had, you know, probably the right place that had a microscope. It had some micro surgical capability. It's in LVIV. So obviously where the Cashews end up and if they can't solve in live IV, the option then is no restriction for amputation or if you're lucky, get out um to Europe somewhere main Europe and you know, thousands, probably tens of thousands of patients have now gone out to Europe. They want, want to guess how many of the UK have taken NADA. So it's all very well that we're really, we're great were leaning forward on the lethal aid. But actually we're not lifting a finger on the non lethal rate as a, as a nation. Just everyone's where. Um, so, I mean, and, you know, I think we will, we have to be really careful about because, you know, you know, surgeons like human new tool, a new technique, everyone needs to have a free flap and it's like, no, no, we're only going to do the ones cannot be restructured. So, you know, here's one where even I said, yeah, probably needs a free flap. So, you know, it's a big band defect. It was a blast injury with an open fracture. We had a long and slightly painful debate about the bone about bugs dead to me. No, no, it's fine. It's OK. It'll be, be healing. Looks dead to me. Do you think you should cut it out? And anyway, cutting story short, we lost the argument and all that bone stayed in because you got to know as I'm sure you're aware when you go to someone else is, if your guest in someone else's health care system, you can't tell what to do. So, um, so, all right, fine. OK, we'll put a free flap on it. You just see what happens and if the bone cause a problem, we can lift a flat, we go back and get whatever okay. So we, this is the first recon we did, uh we have been consequently supported them with equipment and training really nice to support them with equipment before we did this case because the instruments were not great, but we managed to get it done and we've now, you know, put some training mark skips in there. So they're learning how to market surgery and with support of them with a recurring UK mission. So, you know, this is the kind of glamour shop. So this is a free flap going on and there's the first low limb free flap on an open fracture in Ukraine. Um But, you know, that's one patient out of, you know, 10, 20 30,000. So what do we achieve? I mean, I think you always, as, you know, you always speaking, achieve more, but I think we have generated a capability. So they're now beginning to talk to each other when that whatsapp group started the conversations very much Ukrainians to Brits, Brits, Ukrainians. Now when the cases pop up, Ukrainians are talking to each other. So, you know what you could do this or you could do that. So I think, you know, it's almost watching like you like watching your kid walk. You know, I think they are at that kind of toddler stage where actually don't fall over quite as much as they might have done. So, you know, I think they are definitely beginning to, you know, walk recon with more confidence having there as well as soft tissue of developing some bone recon. And I think that's becoming, you know, we've seen cases now where they are doing bone transport. Um There's more prevalence of using spaces and mascular technique and these other kind of modalities they're beginning to tackle bone infection. Um And you know, I still think it's a work in progress and I think that'll be very enduring challenges. It's from many walls. You know, people with chronic osteomyelitis who have either not had reconstructions or had, you know, restrictions which has not worked. I think everything we've done is inject some realism about functional extraction like that extra show because, you know, because they didn't know what they could restructure what was able to be saved. They almost didn't want to amputate because well, maybe there's some magic you can do and you could save it and you're like, yeah surgeon or not a magician, you know, this, this can't be fixed. So when a leg like that comes along, you go, there is no way of fixing that too, a functional outcome. And that was the other thing to get into the head. So this is not about cool x rays or fancy flats. Is that functional recovery of that patient? If the best function recovery is prosthetic reconstruction for orthotic enhanced reconstruction. That's what she's doing. And actually, you know, that's a mindset shift for them to realize that that's not a failure. That's the success. Somebody walking, whether walking with their own leg, an orthotic or prosthetic is a success. So I think this kind of shows, you know, how much and how little we've done, to be honest. So the centers done three flaps. Yes. Done. 28 3 claps. Um The other centers we think they've done about 200 local flaps, maybe a bit more. We now have got five well established centers who are doing this work. And you know, if we stop the mission tomorrow, which actually stop the mission a few weeks, starting to run out of money, it's not a conversation, you know, they will still keep going. Um And we're trying to create this network of um reconstruct decisions. We, we kind of slight tongue in cheek gave its name Ursa Ukrainian Restrictive Surgical Association, mainly because it meant I could put Paddington Bear on it because I work at some Mary's as Paddington Bear. And do you know who voiced Paddington in the Ukrainian version or Paddington Bear? I know I know deeper nose Zelinsky. So we kind of said, hey, let's do this because like, you know, that's your presence of a maybe we'll get back to his day job. So, you know, this is, it's the beginning of that kind of, you know, linkage between them because you know, they need to communicate with, with each other almost as that's almost more important than communicating with us. But the challenge in this disruptive state as we see in many limit countries and you know, we've been working um in an imperial for five years trying to get post conflict data in various different settings in Syria, in Gaza, in northern Sri Lanka. Um to understand what is the long term healthcare burden of war, particularly extremist trauma. Um There's no data, it's very hard to get data as deep as you know, patients move around all over the place. It's difficult to track them. So we're thinking about how could we track them? How can we get that data? Because all of this is meaningless on this, we're getting good outcomes. Okay. So next steps, we need money. So uh last week is in queue. Um the idea that that meeting, it was just a meeting or conference um was to bring everyone together and basically kind of show and tell what we've been doing. Talk about all the future steps have been essentially try and butter up the donors which are mainly government. We're talking about, you know, tens of millions of pounds to support program to give us money to get it forward to this. UK government has already said no. Um which has been a disappointing because this is the cost of too um storm shadow missiles and probably I think the tracks of a challenge the tank. So, you know, it's just kind of perspectives and what's important. Um I think, you know, more focused on the improvement infection outcomes will really affect the long term increasing capacity, capability. Clearly, given the scale, you know, we've only got five centers probably need to um times up by five. And I think what we need to support our Ukrainian friends and colleagues doing is developing their own kind of specialty of. And I said, reconstructed, not plastic because, you know, these are general surgeons, plastic um operate surgeons doesn't matter what Corbyn, if they can do the start, they are reconstructive surgeons. So this is, I think for me, the most important slide, these are three surgical residents who are the first cohort are going through a program which will end up with them being reconstructive surgeons. So obviously, only three of them many times up by, by about 100 to meet the demand. But it's, you know, it's the start of something, hopefully. Thank you. And I'm sure deep and I'm happy to take questions. Any questions asked about safety, feel down to safety and wards off. Yes. No, no. Look, I'm not. I've been to okay. So I've been to quite a few war zones. It's not was then like I've ever been to. So when do you try to convince people to come out at all? What was it safe? And my class search close, you know, and if you say it's safe. I don't really believe you, but the first person came out with me on the first kind of recondition was a guy that John Scott from Glasgow. I don't know John, but John is, you know, very civilian. He's like, I don't know what this is going to be like and he, the most dangerous thing happened to him was probably overeating. So, you know, it's, it's, it's a normal society. So like IV, you know, is getting stuck in traffic junks. Go, it's totally functional now. In the east. It's very different. So where we are, I mean, did pros a UNESCO heritage site live. Eva's you, unesco heritage site now. Yes, they are rocket attacks and things like that. And you've seen stuff that's going on and things are happening but it is, it is not a country that's affected by war now, I'd be lying if I said the risk of zero, but it's as close to zero as it could be. I agree. So, I mean, you were in, in sort of love IV, which is Western Ukraine but even, even in Ipra, it's actually not that different to normal society is running, you know, a restaurants, cafes, bars, everything is open until curfew time. Um, and you don't actually, you know, you don't feel as though you're in a war zone. It's quite different in Ipra, there are air raids all the time, but because people have gotten used to it, I mean, the first time I heard the air raid siren, I looked around me because I thought people would dive for cover and actually people just carried on their normal work. Um, no one seemed unduly concerned by the siren. Um, uh, the only time that I saw people take covers when there was a drone alert because obviously with the drones, you don't know what they're looking for. And so that, that was when people took cover. But apart from that, as, as uh to say it, you genuinely don't feel that's un safety. And when, when I was in Ipra, sometimes we would finish at 9 10 o'clock and I would walk back to my accommodation from the hospital and I felt perfectly safe. Yeah, you know, in restaurants are open bars are open, you know, keep last week, you know, despite that they were worse of air attacks, people are out in cafes, you know, street musicians are live. It's, it's normal society. We have a question from a Larisa sheriff at online and he's asking, do you have a program to train surgeons from developing country war zones to manage injuries locally? Um So the short answer that is currently no, but what UK med are looking at is this is clearly a healthcare needs in lots of different places. So, you know, when I was going actually London, the rest of team, we're going on to Ethiopia there in Somalia as a team in Sudan you know, this kind of need for all plastic construction is a global meat. And so what they're thinking about doing is we can develop the model in Ukraine, we can shift and lift it to another conflict and that, you know, there's quality pressure for us to do the same kind of thing. Somalia were just saying, actually, you know, we're trying to get people to go out the door, um convince him to go to places Gene, maybe as, you know, perceived as being safe, it's really hard. So, rather than diluting our efforts, we felt like we should concentrate one country at a time. Thank you, Dave. Uh.