1 00:00:05,080 --> 00:00:07,800 Hello everyone and welcome to the Quorum podcast. 2 00:00:07,800 --> 00:00:11,480 This is where academic medicine meets remote, austere and 3 00:00:11,480 --> 00:00:18,120 resource limited areas. Welcome back to the podcast, 4 00:00:18,120 --> 00:00:21,440 This is Avacol Kelly. This week we are with Doctor 5 00:00:21,440 --> 00:00:24,200 John Quinn, who is on our teaching faculty. 6 00:00:24,480 --> 00:00:29,120 He started out as a paramedic and now he has his MD and his 7 00:00:29,120 --> 00:00:31,640 PhD. John, welcome back to the 8 00:00:31,640 --> 00:00:33,520 podcast. We could be back. 9 00:00:33,520 --> 00:00:37,440 Thank you for the opportunity. So tell us a bit about yourself 10 00:00:37,440 --> 00:00:40,240 and what's keeping you busy. Yes. 11 00:00:40,480 --> 00:00:44,080 So I've been fortunate enough to be able to be working between 12 00:00:44,080 --> 00:00:47,560 the United Kingdom and volunteering in Ukraine and 13 00:00:47,560 --> 00:00:50,800 occasionally working elsewhere throughout the the United 14 00:00:50,800 --> 00:00:53,120 Kingdom, NHS sort of trusts everywhere. 15 00:00:53,560 --> 00:00:55,520 But I've been fortunate enough to be able to do some 16 00:00:55,520 --> 00:01:00,160 volunteering training missions throughout Ukraine over the last 17 00:01:00,160 --> 00:01:02,280 few months. And I've been also been able to 18 00:01:02,280 --> 00:01:05,720 to try to push things forward on the research side for damage 19 00:01:05,720 --> 00:01:08,880 control, resuscitation and damage control procedures really 20 00:01:08,880 --> 00:01:11,960 for the last two years or so. And that's something you've done 21 00:01:11,960 --> 00:01:16,520 with the college and and Doctor Tom Allison, you've done ADCP 22 00:01:16,520 --> 00:01:19,320 course in Ukraine. So how about we start from the 23 00:01:19,320 --> 00:01:22,160 very beginning, John, tell us what is damage control 24 00:01:22,160 --> 00:01:25,560 procedures? What precisely is DCP? 25 00:01:25,720 --> 00:01:26,440 Sure. Yeah. 26 00:01:26,440 --> 00:01:30,760 So it was great to be able to engage with Doctor Tom for the 27 00:01:30,760 --> 00:01:33,360 damage control resuscitation and the damage control procedures 28 00:01:33,360 --> 00:01:36,120 workshop. Basically the long and short of 29 00:01:36,120 --> 00:01:39,400 it is this. In the remote, the remote 30 00:01:39,400 --> 00:01:42,840 medicine and really the the far forward and austere medicine 31 00:01:42,840 --> 00:01:46,120 paradigm, we need access to certain things. 32 00:01:46,120 --> 00:01:49,800 So tactical combat casualty care gives us excellent access to 33 00:01:49,800 --> 00:01:53,360 point of injury care and it really sets us up for success 34 00:01:53,920 --> 00:01:56,880 for any sort of prolonged casualty care or prolonged field 35 00:01:56,880 --> 00:01:58,480 care environment, which is great. 36 00:01:59,120 --> 00:02:02,280 However really what has to happen at some point is that 37 00:02:02,280 --> 00:02:05,720 patient may require damage control resuscitation, which is 38 00:02:05,720 --> 00:02:08,560 a really fancy way of saying they're going to have to have 39 00:02:08,560 --> 00:02:12,280 access to blood as well as all of the other aspects around it. 40 00:02:12,280 --> 00:02:14,880 However that's only part of the story. 41 00:02:14,880 --> 00:02:17,240 The other part of the story is that we need to stop the 42 00:02:17,240 --> 00:02:20,520 bleeding actually definitively. So not just determined it and 43 00:02:20,520 --> 00:02:23,560 not just sort of pressure and not just these these adjuncts 44 00:02:23,560 --> 00:02:26,920 which are very helpful and excellent for the patient, but 45 00:02:26,920 --> 00:02:29,720 really damage control procedures takes it to the the next level. 46 00:02:29,840 --> 00:02:33,920 And at the way far end of that damage control resuscitation and 47 00:02:33,920 --> 00:02:37,360 also damage control surgery paradigm that sort of that that 48 00:02:37,360 --> 00:02:40,640 trajectory for that patient, that damage control surgery is 49 00:02:40,640 --> 00:02:42,320 really only available for surgeons. 50 00:02:42,440 --> 00:02:44,160 So there's these great courses out there. 51 00:02:44,160 --> 00:02:48,600 There's the asset, the Asset plus the COTS, the COTS and the 52 00:02:48,600 --> 00:02:52,600 COTS plus course, as well as the Hess course, which is a 53 00:02:52,600 --> 00:02:55,520 humanitarian focus. All of these abbreviated courses 54 00:02:55,520 --> 00:02:59,160 for damage control surgery are brilliant for surgeons, and some 55 00:02:59,160 --> 00:03:01,880 instances they're brilliant also for anesthesiologist or 56 00:03:01,880 --> 00:03:03,880 anaesthetist. However, there's a gap. 57 00:03:04,040 --> 00:03:07,920 There's this gap between damage control, resuscitation, the 58 00:03:07,920 --> 00:03:10,920 stuff that a lot of paramedics and a lot of parkour doctors 59 00:03:10,920 --> 00:03:13,680 will be doing, and what those surgeons will be doing, and the 60 00:03:13,680 --> 00:03:17,600 gap is kind of twofold. 1 is in a paradigm, an academic paradigm 61 00:03:17,600 --> 00:03:20,280 of what you're allowed to do, so a governance thing, but it's 62 00:03:20,280 --> 00:03:24,600 also geographic what where the surgeon may actually be sitting 63 00:03:24,600 --> 00:03:27,720 and waiting for a patient to come and where you may be for 64 00:03:27,720 --> 00:03:30,080 forward with a patient. There's actually that gap. 65 00:03:30,080 --> 00:03:31,840 We say how can we close that gap? 66 00:03:32,160 --> 00:03:35,120 So the concept of damage control procedures, which has really 67 00:03:35,120 --> 00:03:38,840 been, you know, it's kicked off that significantly, not only 68 00:03:38,840 --> 00:03:41,520 with the college remote and optional medicine, but also with 69 00:03:41,520 --> 00:03:44,880 the Disaster Health Institute and kind of bringing together 70 00:03:44,880 --> 00:03:47,160 loads of partners, different universities, different 71 00:03:47,160 --> 00:03:49,800 specialist, different subject matter experts and saying, 72 00:03:49,800 --> 00:03:52,520 listen, we need to get our heads around this and we need to to 73 00:03:52,520 --> 00:03:55,520 push this forward. So the concept of damage control 74 00:03:55,520 --> 00:03:59,240 procedures is really trying to address that gap of saying we 75 00:03:59,240 --> 00:04:01,880 may have a delayed medical evacuation environment. 76 00:04:02,280 --> 00:04:04,920 We may not have access to surgeons, even though a lot of 77 00:04:04,920 --> 00:04:08,280 surgeons have a lot of guts and they're willing to to push far 78 00:04:08,280 --> 00:04:10,440 forward and they're willing to do a whole lot of stuff far 79 00:04:10,440 --> 00:04:13,120 forward. But still, even Even so, you may 80 00:04:13,120 --> 00:04:17,240 have that geographic gap and that that tyranny of distance. 81 00:04:17,519 --> 00:04:19,760 And you may also have have that gap of staying actually we need 82 00:04:19,760 --> 00:04:22,640 to do something, we don't have access to a surgeon and we need 83 00:04:22,640 --> 00:04:26,200 to be able to do some of these damage control procedures so 84 00:04:26,200 --> 00:04:28,680 that we can help reduce preventable morbidity and 85 00:04:28,680 --> 00:04:30,840 mortality. So in a nutshell, that's sort of 86 00:04:30,840 --> 00:04:34,440 what the concept of damage control procedures is and does. 87 00:04:35,360 --> 00:04:41,360 So this is about surgical skills for a nurse, a paramedic or or 88 00:04:41,360 --> 00:04:46,200 even a combat medic corpsman and having them do doctor level. 89 00:04:46,200 --> 00:04:49,760 No, not even doctor level stuff. Surgeon level skills. 90 00:04:49,880 --> 00:04:52,440 Yes, absolutely. And it's, it's absolutely. 91 00:04:52,440 --> 00:04:53,920 And it's really out of necessity. 92 00:04:54,880 --> 00:04:57,840 So yes, you're right. You know, nurses, combat medic, 93 00:04:58,040 --> 00:05:03,080 corpsman, combat medics, paramedics, EMTs, doctors and 94 00:05:03,080 --> 00:05:05,600 other other healthcare professionals that really want 95 00:05:05,600 --> 00:05:08,360 to upskill. The concept is to be able to 96 00:05:08,400 --> 00:05:11,760 give them training so that they can save a life when it's 97 00:05:11,760 --> 00:05:13,640 required. Now, having said all of that, 98 00:05:13,640 --> 00:05:15,840 there's also governance consideration. 99 00:05:16,080 --> 00:05:19,560 So a lot of countries will say no way, Jose, this is 100 00:05:19,560 --> 00:05:21,320 impossible. There's no way we're going to 101 00:05:21,320 --> 00:05:24,320 allow this to happen. There's other governance issues 102 00:05:24,320 --> 00:05:27,720 for paramedics and for doctors, for example, an emergency 103 00:05:27,720 --> 00:05:32,000 medicine doctor or a nurse or a paramedic saying actually we're 104 00:05:32,000 --> 00:05:34,160 not allowed to do that. So there's a whole lot of 105 00:05:34,160 --> 00:05:37,920 governance issues to overcome. However, we really need to just 106 00:05:38,040 --> 00:05:42,080 push far forward, do what needs to get done for the patient in 107 00:05:42,080 --> 00:05:45,080 this paradigm, this concept of damage control procedures under 108 00:05:45,080 --> 00:05:48,080 the auspices of clinical governance saying, yes, you are 109 00:05:48,080 --> 00:05:50,720 allowed to do this. But first and foremost comes the 110 00:05:50,720 --> 00:05:54,000 training comes the, the, the capability of being able to 111 00:05:54,200 --> 00:05:58,360 recognise the patients that require advance an escalation 112 00:05:58,360 --> 00:06:01,480 level of care and then being able to have the skills to 113 00:06:01,480 --> 00:06:05,400 actually competently execute those, those those 114 00:06:05,400 --> 00:06:08,000 interventions. So it's, it's quite a complex 115 00:06:08,920 --> 00:06:12,200 web of considerations. But yes, you're right, it's not 116 00:06:12,200 --> 00:06:16,120 just for surgeons anymore in in limited capacity. 117 00:06:16,280 --> 00:06:19,920 It's also the idea of being able to give these skills and give 118 00:06:19,920 --> 00:06:23,040 them into the hands of competent paramedics, nurses, other 119 00:06:23,040 --> 00:06:25,040 doctors, other healthcare professionals, as you said, 120 00:06:25,040 --> 00:06:28,600 combat medic corpsmen, combat medics, EM, TS, etcetera. 121 00:06:28,640 --> 00:06:32,520 So John, there's a lot of publications on damage control 122 00:06:32,520 --> 00:06:36,320 surgery for non surgeons on pub Med, but they're referring to 123 00:06:36,320 --> 00:06:40,960 given to giving surgical skills to non surgeons, meaning other 124 00:06:40,960 --> 00:06:46,520 doctors and not to non doctor. So how angry, how, how cross 125 00:06:46,680 --> 00:06:49,600 will the surgeons be when they hear about this programme? 126 00:06:49,800 --> 00:06:53,480 Yeah, I think it's really important to to put it in a 127 00:06:53,480 --> 00:06:57,120 framework, I think. I don't speak for surgeons. 128 00:06:57,120 --> 00:07:00,520 I know that surgeons wake up every morning and they wake up 129 00:07:00,520 --> 00:07:03,200 at 3:00 in the morning when they're on call to go in and 130 00:07:03,200 --> 00:07:05,960 save lives. That's why they are willing to 131 00:07:05,960 --> 00:07:10,480 do their residency for several years and decades, in fact, so 132 00:07:10,480 --> 00:07:13,440 that they can save lives. And they are they, as I said, 133 00:07:13,440 --> 00:07:15,240 they have guts. They're, they're willing, a lot 134 00:07:15,240 --> 00:07:19,080 of surgeons, especially in Ukraine, willing to push far 135 00:07:19,080 --> 00:07:22,600 forward and they're willing to do surgery in basements very 136 00:07:22,600 --> 00:07:26,520 close to the line of contact. However, the line is huge and 137 00:07:26,520 --> 00:07:30,080 sometimes the resource that surgeons have cannot spread 138 00:07:30,080 --> 00:07:31,920 across the line to all the areas that it needed. 139 00:07:31,920 --> 00:07:35,480 So it is possible that the concept of damage control 140 00:07:35,480 --> 00:07:39,360 procedures will really rattle a lot of cages inside the surgical 141 00:07:39,360 --> 00:07:41,560 community. However, I think it's an 142 00:07:41,560 --> 00:07:45,560 opportunity to be an adjunct, A surgical extender. 143 00:07:45,760 --> 00:07:49,920 You can extend some of these aspects under the offices, under 144 00:07:50,040 --> 00:07:52,800 the direct care and supervision by a surgeon saying, hey, 145 00:07:52,800 --> 00:07:55,080 listen, I've trained you on how to do this. 146 00:07:55,200 --> 00:07:57,440 I feel comfortable with your skill on how to do this. 147 00:07:57,840 --> 00:08:01,240 You may even have the ability to discuss the case over Starlink 148 00:08:01,240 --> 00:08:04,480 or other protected Internet by a telemedicine, maybe even 149 00:08:04,480 --> 00:08:08,120 something as simple as a WhatsApp or a Signal video call 150 00:08:08,120 --> 00:08:11,800 or sending different photos back and forth or just having 151 00:08:11,800 --> 00:08:14,960 messaging back and forth over secure communications saying, 152 00:08:15,240 --> 00:08:18,200 OK, based on all the information you said we've got, you know, 153 00:08:18,320 --> 00:08:21,560 three days for an evacuation. This patient is likely to perish 154 00:08:21,840 --> 00:08:23,960 unless we try some of these interventions. 155 00:08:24,640 --> 00:08:27,200 And I feel comfortable and confident with your with your 156 00:08:27,200 --> 00:08:29,120 approach. So let's let's continue that. 157 00:08:29,120 --> 00:08:33,600 So really an extension of that surgical, that surgical 158 00:08:33,600 --> 00:08:36,240 expertise, of course, that won't happen in all environments. 159 00:08:36,240 --> 00:08:40,400 And, and it's, it's yet to be, you know, consistently tested. 160 00:08:40,640 --> 00:08:44,000 But that's, that's really I think the the best pairing 161 00:08:44,159 --> 00:08:48,160 opportunity for surgical extension and really having 162 00:08:48,160 --> 00:08:51,320 close surgical oversight saying, listen, we can do this. 163 00:08:51,320 --> 00:08:54,320 We have the skills, we have the training, we have the equipment, 164 00:08:54,640 --> 00:08:57,360 but we need, we need, you know, the go ahead essentially. 165 00:08:57,400 --> 00:09:00,000 And I think I think surgeons, you don't need to assess that 166 00:09:00,000 --> 00:09:02,720 and they need to give their own feedback as well and say what 167 00:09:02,800 --> 00:09:06,600 whether or not they're happy with it, You know, in across all 168 00:09:06,600 --> 00:09:08,560 NATO and, and, and NATO partner nation. 169 00:09:09,040 --> 00:09:11,440 And just to go back to some of the partners that started with 170 00:09:11,440 --> 00:09:14,360 this within the College of remote officer medicine, we have 171 00:09:14,360 --> 00:09:16,760 surgeons that have that have looked at this curriculum. 172 00:09:16,760 --> 00:09:20,000 They're still reviewing a lot of discrete in the concepts with a 173 00:09:20,000 --> 00:09:23,440 really a lot of thumbs up. We also have a disaster health 174 00:09:23,440 --> 00:09:26,000 institute, a lot of surgical expertise and subject matter 175 00:09:26,000 --> 00:09:28,800 experts also reviewing and supporting the curriculum 176 00:09:28,800 --> 00:09:31,520 development. In fact, there's other partners 177 00:09:31,520 --> 00:09:34,560 such as a precisely these Medical University that have 178 00:09:34,560 --> 00:09:38,080 given massive support. And really some of the the early 179 00:09:38,520 --> 00:09:41,800 considerations of the curriculum really came out of discussions 180 00:09:41,800 --> 00:09:46,080 with with surgical expertise, trauma surgical expertise, not 181 00:09:46,080 --> 00:09:49,920 only from Europe, but also from their experience in in North 182 00:09:49,920 --> 00:09:54,320 Africa and elsewhere in Asia. So there's a lot of surgical 183 00:09:54,520 --> 00:09:58,040 roots and surgical DNA inside this curriculum and inside this 184 00:09:58,040 --> 00:10:01,840 concept, and it just needs to be explored, that needs to be 185 00:10:01,840 --> 00:10:03,760 considered and really needs to be pushed forward. 186 00:10:03,840 --> 00:10:08,280 John, you've designed this and you've run this in Ukraine. 187 00:10:08,440 --> 00:10:12,320 Walk us through how the DCP programme is. 188 00:10:12,320 --> 00:10:14,360 What does it look like? How long is it? 189 00:10:14,560 --> 00:10:16,040 What skills are you teaching what? 190 00:10:16,200 --> 00:10:19,160 What surgical skills are you giving to the medic on the 191 00:10:19,160 --> 00:10:20,560 ground? Sure, sure. 192 00:10:20,560 --> 00:10:24,000 Well, and just to go back a little bit, we, we have done a 193 00:10:24,000 --> 00:10:27,320 damage control procedures workshop, so a limited workshop 194 00:10:27,320 --> 00:10:30,480 really focusing on gathering a whole lot of information 195 00:10:31,040 --> 00:10:33,440 specifically related to damage control procedures. 196 00:10:33,600 --> 00:10:36,800 We've also done a lot of these isolated skills and you know, 197 00:10:36,880 --> 00:10:39,240 college or more than ultra medicine and the Disaster Health 198 00:10:39,600 --> 00:10:42,960 Institute are not the only groups that have that have been 199 00:10:42,960 --> 00:10:46,960 trying to explore some of this. There's also been organically 200 00:10:46,960 --> 00:10:51,360 inside Ukraine out of just sheer necessity, really trying to 201 00:10:51,360 --> 00:10:53,120 better understand some of these skills. 202 00:10:53,120 --> 00:10:57,360 Not on a mannequin, not on, not in a, in a very quiet training 203 00:10:57,360 --> 00:11:00,160 environment, but in the far in the field, in far forward 204 00:11:00,160 --> 00:11:02,400 environments with cadavers, etcetera. 205 00:11:02,600 --> 00:11:06,360 And, and you know, a lot of their qualitative and anecdotal 206 00:11:06,360 --> 00:11:11,000 feedback is also fed into these concept and systems. 207 00:11:11,000 --> 00:11:14,040 So just to go in kind of in the three phases, it's basically 3 208 00:11:14,040 --> 00:11:16,200 phases. And some instances we refer to 209 00:11:16,200 --> 00:11:18,440 them as tiers. In some instances we refer to 210 00:11:18,440 --> 00:11:22,520 them as echelons of care. But the first one is kind of a 211 00:11:22,520 --> 00:11:24,560 review. And it's really a review of the 212 00:11:24,560 --> 00:11:27,960 combat medic form. And so the idea is that if you 213 00:11:27,960 --> 00:11:30,840 are not a good competent combat medic form and within 214 00:11:30,840 --> 00:11:33,560 procedures, but you have, you know, you have the interest and 215 00:11:33,560 --> 00:11:36,160 you want to upskill yourself that idea. 216 00:11:36,160 --> 00:11:39,280 Tier 1 is really a combat medic form and skill course, a 217 00:11:39,280 --> 00:11:42,360 slightly expanded skill course. So, so there's a surgical 218 00:11:42,360 --> 00:11:46,440 airway, there's the chest drain, so a finger of thoracostomy and 219 00:11:46,440 --> 00:11:48,880 a tube thoracostomy. There's intra osseous. 220 00:11:49,000 --> 00:11:53,240 And there's also a very specific look at how to use tourniquets. 221 00:11:53,440 --> 00:11:56,680 And I know it sounds kind of basic, kind of rudimentary for a 222 00:11:56,680 --> 00:11:59,480 lot of a lot of folks out there saying a lot tourniquets. 223 00:11:59,480 --> 00:12:02,880 We've been doing that from since day one, but being able to 224 00:12:02,880 --> 00:12:05,240 really approach, Hey, let's, how do we really convert that 225 00:12:05,240 --> 00:12:07,560 tourniquet? How do we, how can we downgrade 226 00:12:07,560 --> 00:12:09,600 that tourniquet? How can we replace that 227 00:12:09,600 --> 00:12:11,240 tourniquet? How can we do it safely in a 228 00:12:11,240 --> 00:12:13,880 farm court environment where we don't entirely take something 229 00:12:13,880 --> 00:12:18,640 off, but we just sort of we, we, we try to minimise the amount of 230 00:12:18,640 --> 00:12:22,680 morbidity associated with that turn kit, but also maximise the 231 00:12:22,680 --> 00:12:25,080 medical outcome. So we look at that as well 232 00:12:25,360 --> 00:12:31,600 within tier one and then also the the idea about having access 233 00:12:31,600 --> 00:12:35,880 to really assessing a, a traumatic amputation. 234 00:12:36,200 --> 00:12:41,040 And then in Tier 2, we have a really expands quite a bit and 235 00:12:41,040 --> 00:12:45,600 we have a limited laparotomy and we have a so that's really a 236 00:12:45,600 --> 00:12:48,760 laparotomy where you open up the abdomen, you pack for quadrants 237 00:12:48,880 --> 00:12:51,560 of the abdomen, you really pack that liver in the event that 238 00:12:51,560 --> 00:12:54,560 it's bleeding, obviously with really it's indication. 239 00:12:54,800 --> 00:12:58,920 And then and then you have a damage closure as well as the 240 00:12:59,880 --> 00:13:03,080 concept of the lower limb, external fixation of the lower 241 00:13:03,080 --> 00:13:05,000 limb. And the reason it's the lower 242 00:13:05,000 --> 00:13:08,000 limb only is that, you know, you can really get some excellent 243 00:13:08,000 --> 00:13:10,960 immobilisation of the upper limb, even with partial 244 00:13:10,960 --> 00:13:16,040 traumatic amputation and being able to secure that that upper 245 00:13:16,040 --> 00:13:20,520 limb, especially for, you know, working age men and women, you 246 00:13:20,520 --> 00:13:23,160 really want to maximise the outcome. 247 00:13:23,280 --> 00:13:26,840 So when it, whether it comes to, you know, a surgical speciality 248 00:13:26,840 --> 00:13:30,160 for the upper limb, the hand, the wrist, the forearm and the 249 00:13:30,160 --> 00:13:33,520 upper limb in, in, as a whole, you really want to do that well. 250 00:13:33,960 --> 00:13:37,360 And so in the, in the lower limb, it's a little bit easier 251 00:13:37,360 --> 00:13:40,720 to train and it's a little bit easier to be able to get a lot 252 00:13:40,720 --> 00:13:44,440 of the, the, the, the, the, the tips of the trade and the tricks 253 00:13:44,440 --> 00:13:47,440 of the trade to be able to do the lower limb well with 254 00:13:47,440 --> 00:13:50,640 external fixation, which is when you actually drill screws into 255 00:13:50,640 --> 00:13:53,240 the bone and then you have an external rod to give, give 256 00:13:53,240 --> 00:13:57,040 support for, for lower limb, either parts amputation or 257 00:13:57,040 --> 00:14:00,240 significant trauma, trauma. And so that that's kind of the 258 00:14:00,240 --> 00:14:03,840 focus of up Tier 2. We also kind of expand a little 259 00:14:03,840 --> 00:14:07,000 bit and go into a little bit more detail on some of the 260 00:14:07,000 --> 00:14:11,280 aspects of of surgical amputation and then also 261 00:14:11,880 --> 00:14:14,840 expanding a little bit more about burns, exterotomy and 262 00:14:14,840 --> 00:14:17,640 fasciotomy. And really, you know, kind of 263 00:14:17,640 --> 00:14:20,840 going into a deep dive into advanced burn care. 264 00:14:20,920 --> 00:14:24,280 So that's, that's more or less. And some of these, some of these 265 00:14:24,280 --> 00:14:26,280 are interchangeable. So as we're kind of walking 266 00:14:26,280 --> 00:14:29,200 through different tiers and we deal with different groups, they 267 00:14:29,200 --> 00:14:31,480 say, well, actually, hold on, we don't want, we want it as a 268 00:14:31,480 --> 00:14:33,320 menu. We want to actually, we want 269 00:14:33,320 --> 00:14:36,720 that, that, that item from tier one, we want that put in Tier 2, 270 00:14:36,840 --> 00:14:39,320 we want that item from Tier 1 and put in tier 3, etcetera. 271 00:14:39,680 --> 00:14:45,920 Tier 3 is a bit more extreme and we look at the the use of bur 272 00:14:45,920 --> 00:14:48,400 holes. We also look at the use of 273 00:14:48,400 --> 00:14:53,480 advanced technologies and the use of partial retrograde 274 00:14:53,480 --> 00:14:57,080 endovascular balloon occlusion of the aorta or partial boa, 275 00:14:57,760 --> 00:15:02,080 which is something that is very controversial and controversial 276 00:15:02,080 --> 00:15:04,360 with surgeons, controversial with pre hospital providers, 277 00:15:04,360 --> 00:15:05,960 controversial with hospital providers. 278 00:15:06,320 --> 00:15:10,400 It's when you use a central line in the artery and you you 279 00:15:10,480 --> 00:15:14,080 actually put a catheter with a balloon all the way up to zone 1 280 00:15:14,440 --> 00:15:19,120 inside the chest for a traumatic and obtundant patient who is 281 00:15:19,120 --> 00:15:23,280 really doing poorly. And and then you can partially 282 00:15:23,280 --> 00:15:27,120 occlude the aorta and really better understand what is going 283 00:15:27,120 --> 00:15:28,640 on. What do you need to do to stop 284 00:15:28,640 --> 00:15:30,960 the bleeding? Hopefully you can get some blood 285 00:15:30,960 --> 00:15:33,720 on board as well as do a whole lot of intervention. 286 00:15:33,840 --> 00:15:36,120 And so that's sort of the, the walkthrough. 287 00:15:36,120 --> 00:15:39,280 There's also an advanced technologies, essentially the 288 00:15:39,280 --> 00:15:42,120 concept of what will become phase three likely in the next 289 00:15:42,120 --> 00:15:43,920 few years. But right now it's more or less 290 00:15:43,920 --> 00:15:46,880 a phase four, which is really quite slick stuff. 291 00:15:46,880 --> 00:15:50,480 So that's looking at brain wave activity, looking at doing HEMA 292 00:15:50,480 --> 00:15:53,960 filtration, which there's a lot of great evidence in the 293 00:15:53,960 --> 00:15:56,040 literature right now, especially with the trauma. 294 00:15:56,040 --> 00:15:59,760 And Ukraine is leading the way. They have this this excellence 295 00:15:59,760 --> 00:16:02,840 in, in medical care for the modern battle field and they're 296 00:16:02,840 --> 00:16:04,800 doing quite a bit with hemifiltration. 297 00:16:04,800 --> 00:16:07,760 So you know, you have a patient that may have waited 12 or 18 298 00:16:07,760 --> 00:16:10,920 hours with significant trauma and they may have just just 299 00:16:10,920 --> 00:16:15,040 absolute massive muscle injury, internal organ injury. 300 00:16:15,240 --> 00:16:18,480 They're really dealing with a lot of metabolic and respiratory 301 00:16:19,960 --> 00:16:23,360 acidosis and other and other really challenging issues for 302 00:16:23,360 --> 00:16:25,840 kidneys. And so the idea is that if you 303 00:16:25,840 --> 00:16:30,200 have a very cheap, very easy, relatively relatively easy tip 304 00:16:30,200 --> 00:16:33,200 to use for chemo filtration, you can actually filtrate out the 305 00:16:33,200 --> 00:16:36,640 blood and filtrate out a lot of those metabolic components that 306 00:16:36,640 --> 00:16:38,280 are that may be actually causing harm. 307 00:16:38,600 --> 00:16:41,080 And so if you can philtre those out well and still put the blood 308 00:16:41,080 --> 00:16:44,640 back and perhaps even transfuse more blood, you'll be able to 309 00:16:44,640 --> 00:16:47,520 actually have much better outcomes in the long run. 310 00:16:47,520 --> 00:16:49,320 Now, the data is still forthcoming. 311 00:16:49,680 --> 00:16:52,720 It's not readily available. It's not super cheap just yet 312 00:16:53,280 --> 00:16:55,320 and it's not terribly easy to use yet. 313 00:16:55,520 --> 00:16:58,240 However, as those technologies are coming a line, we're dealing 314 00:16:58,240 --> 00:17:02,720 with a lot of those innovative technology technology providers 315 00:17:02,720 --> 00:17:05,720 to be able to better understand, hey, how can we actually, how 316 00:17:05,720 --> 00:17:09,200 can we plug this into to the system also with the idea of 317 00:17:09,200 --> 00:17:11,240 Burr holes. So for intrapranial pressure, 318 00:17:11,440 --> 00:17:14,760 there's a few systems that actually are a little bit easier 319 00:17:14,760 --> 00:17:18,200 for the purposes of ICP measuring as well as being able 320 00:17:18,200 --> 00:17:19,480 to offload some of that pressure. 321 00:17:19,480 --> 00:17:21,200 So there's a whole lot of moving pieces. 322 00:17:21,200 --> 00:17:24,319 It's obviously not just for a specialist of an emergency 323 00:17:24,319 --> 00:17:26,319 medicine alone. This is, you know, this is 324 00:17:26,680 --> 00:17:30,600 transdisciplinary, requires neurosurgeon input, requires 325 00:17:30,600 --> 00:17:35,080 faster surgical input, traumatic surgical input and several other 326 00:17:35,080 --> 00:17:38,840 specialties to be able to really link it in and just in time 327 00:17:38,840 --> 00:17:41,240 medicine and saying, listen, this is exactly what's needed. 328 00:17:41,520 --> 00:17:44,800 We're going to wait. We have a highly contested 329 00:17:44,800 --> 00:17:46,760 environment. We need to be able to up skill a 330 00:17:46,760 --> 00:17:49,960 lot of these a lot of these providers, we need to be able to 331 00:17:49,960 --> 00:17:51,880 put these pools into their hands. 332 00:17:51,880 --> 00:17:54,920 It can't be terribly expensive. It can't be huge and burdensome 333 00:17:54,920 --> 00:17:57,880 and heavy. We need to be able to go into a 334 00:17:57,880 --> 00:18:02,040 building of opportunity or vehicle of opportunity and and 335 00:18:02,040 --> 00:18:04,920 be able to execute a lot of these very specific 336 00:18:04,920 --> 00:18:08,040 interventions exactly when they're needed to be able to 337 00:18:08,040 --> 00:18:10,000 reduce preventable morbidity, mortality. 338 00:18:10,200 --> 00:18:13,840 And I, I should also say really as like an overarching on onset 339 00:18:14,000 --> 00:18:16,440 because I know a lot of people may be saying this stuff 340 00:18:16,480 --> 00:18:20,720 absolutely crazy. We do have a, a few Seminole 341 00:18:20,720 --> 00:18:23,480 papers that I've already commented on this a little bit 342 00:18:23,480 --> 00:18:27,600 and quite a few conference presentations kind of unfolding 343 00:18:27,600 --> 00:18:31,400 it in the event that we did in, in November and keep really kind 344 00:18:31,400 --> 00:18:35,480 of set the tone for a lot of the feedback and, and, and really 345 00:18:35,480 --> 00:18:38,960 helping us Polish off the concept of the curriculum for 346 00:18:38,960 --> 00:18:41,800 damage control procedures. But what we have, you know, a 347 00:18:41,800 --> 00:18:45,200 lot of paperwork, a lot of papers coming out academically, 348 00:18:45,320 --> 00:18:48,440 trying to unpack this and put this within a framework and 349 00:18:48,440 --> 00:18:51,880 really make it a little bit easier to, to describe and, and 350 00:18:51,880 --> 00:18:54,360 under for others to understand. Hey, this is kind of where our 351 00:18:54,360 --> 00:18:56,480 thought process is. This is where we were going with 352 00:18:56,480 --> 00:18:58,480 this and this is what the curriculum is looking like. 353 00:18:58,680 --> 00:19:01,000 And so that's really the the whole concept of damage control 354 00:19:01,000 --> 00:19:02,760 procedures, more or less in a nutshell. 355 00:19:02,840 --> 00:19:06,160 Is there anything in in in motion to have a telemedicine 356 00:19:06,160 --> 00:19:09,360 requirement, requirement for like virtual oversight with a 357 00:19:09,360 --> 00:19:14,600 surgeon or having having just a WhatsApp video of you're doing a 358 00:19:14,600 --> 00:19:18,720 Burr hole? Are they going to be discussing 359 00:19:18,720 --> 00:19:20,520 this with a surgeon before they do it? 360 00:19:21,040 --> 00:19:24,120 The idea is that you should be able to work autonomous and 361 00:19:24,120 --> 00:19:26,280 offline. So the idea is that you may not 362 00:19:26,280 --> 00:19:30,720 have access to telemedicine, you may not have access to clinical 363 00:19:30,720 --> 00:19:33,120 oversight, you may not have access to medical control or 364 00:19:33,120 --> 00:19:36,000 medical direction. And so if you have excellent 365 00:19:36,000 --> 00:19:41,000 skills, if you have excellent indications for execution and 366 00:19:41,000 --> 00:19:44,800 you have clear triggers, it'll be a lot easier for the provider 367 00:19:44,800 --> 00:19:46,960 to be able to say, listen, I need to pull the trigger on 368 00:19:46,960 --> 00:19:48,040 this. We need to do this. 369 00:19:48,560 --> 00:19:52,320 Now having said that, that's a really challenging environment 370 00:19:52,320 --> 00:19:56,600 to put a paramedic or or someone who does not do these types of 371 00:19:56,600 --> 00:20:00,760 procedures to scale or to the volume that to give them 372 00:20:00,760 --> 00:20:03,360 confidence and so. Having access to that 373 00:20:03,360 --> 00:20:06,560 telemedicine online or offline medical control will be 374 00:20:06,560 --> 00:20:09,000 significantly helpful. Obviously, online medical 375 00:20:09,000 --> 00:20:12,320 control and telemedicine support is really the standard that that 376 00:20:12,320 --> 00:20:14,120 everyone is pushing for what everyone wants. 377 00:20:14,360 --> 00:20:17,280 There are a lot of units that are far forward that have access 378 00:20:17,280 --> 00:20:20,000 to telemedicine, they have access to networks and they do 379 00:20:20,000 --> 00:20:23,520 have access to medical support where you can give a picture, 380 00:20:23,640 --> 00:20:26,680 you can send vital signs, you can send mechanism of injury 381 00:20:27,000 --> 00:20:30,800 time since injury and interventions done thus far as 382 00:20:30,800 --> 00:20:32,360 well as hey, we're totally delayed. 383 00:20:32,600 --> 00:20:36,000 We are literally behind enemy lines and we do not have access 384 00:20:36,240 --> 00:20:38,560 likely for the next two to three, possibly 5 days. 385 00:20:38,560 --> 00:20:41,960 And it'll make telemedicine decision making a lot easier to 386 00:20:41,960 --> 00:20:44,440 have all of that information. You may only get part of that 387 00:20:44,440 --> 00:20:46,840 information. It may not be alive and online. 388 00:20:46,840 --> 00:20:49,920 You may have to send a packet of data and that data may may take 389 00:20:49,920 --> 00:20:52,240 several minutes or even hours for it to be actually reached 390 00:20:52,240 --> 00:20:54,680 the, the, the the surgeon. So obviously having 391 00:20:54,680 --> 00:20:58,040 contingencies with that offline medical control will be, will be 392 00:20:58,040 --> 00:21:01,360 fundamental. There's also the, the, the 393 00:21:01,360 --> 00:21:05,640 potential of just the sheer volume of patients being dealt 394 00:21:05,640 --> 00:21:07,800 with. You may not have access to a 395 00:21:07,800 --> 00:21:10,800 surgeon that is actually available to be able to sit and 396 00:21:10,800 --> 00:21:13,920 listen and comprehend and digest the clinical information being 397 00:21:13,920 --> 00:21:17,680 offered in the event of a large scale combat operation that 398 00:21:17,680 --> 00:21:20,960 involves, you know, all, all elements of power. 399 00:21:21,080 --> 00:21:24,760 So it is very, I think it's very important to, to have both that 400 00:21:24,760 --> 00:21:27,480 online telemedicine component saying, hey, listen, I really 401 00:21:27,480 --> 00:21:29,960 want to discuss this case before I start doing something. 402 00:21:30,240 --> 00:21:32,360 But at the same time appreciating and understanding 403 00:21:33,080 --> 00:21:36,320 you have to have that offline telemedicine and medical 404 00:21:36,320 --> 00:21:38,520 control, medical direction. And this is where governance 405 00:21:38,520 --> 00:21:40,200 really takes a role. You know, you have to have 406 00:21:40,200 --> 00:21:42,520 surgeons willing to say this. And I'm not willing to have this 407 00:21:42,520 --> 00:21:44,560 take place on my watch, so to speak. 408 00:21:44,680 --> 00:21:47,320 But I am willing to have this and this and this take place as 409 00:21:47,320 --> 00:21:50,120 long as I oversee and approve of the curriculum and oversee the 410 00:21:50,120 --> 00:21:53,080 training. And I, I approve, you know, 411 00:21:53,080 --> 00:21:54,680 different providers be able to do this. 412 00:21:54,920 --> 00:21:57,960 If you think back to, you know, in pre hospital days in the, in 413 00:21:57,960 --> 00:22:01,600 North America, there were, there were several instances where, 414 00:22:01,600 --> 00:22:04,240 you know, in order to be able to provide intubation in the pre 415 00:22:04,240 --> 00:22:07,320 hospital space, you had to undergo several numbers of 416 00:22:07,320 --> 00:22:10,680 intubations only in, in surgery and in theatres, surgical 417 00:22:10,680 --> 00:22:13,040 theatres, but you also had to do them in the pre hospital space. 418 00:22:13,040 --> 00:22:15,200 Then you get signed off and then the medical director would say, 419 00:22:15,200 --> 00:22:18,520 OK, you've done XM number of intubations not only in the 420 00:22:18,520 --> 00:22:21,280 hospital, but also the pre hospital space under some levels 421 00:22:21,280 --> 00:22:23,200 of revision. You now are like can do this, 422 00:22:23,320 --> 00:22:25,600 this skill, you know, autonomously. 423 00:22:25,880 --> 00:22:29,040 And so there there there's it's a it's a much larger spectrum 424 00:22:29,040 --> 00:22:30,760 when you deal with damage control procedures. 425 00:22:30,760 --> 00:22:33,720 If you think about a limited laparotomy fully cow, that's a 426 00:22:33,760 --> 00:22:36,800 that's a very involved intervention. 427 00:22:36,800 --> 00:22:38,840 If you think about any of the interventions mentioned, 428 00:22:38,840 --> 00:22:41,680 including those from tier one, which are really an expansion of 429 00:22:41,680 --> 00:22:45,720 sort of combat metformin skills, those are also those are intense 430 00:22:46,280 --> 00:22:48,280 intervention. And if you don't manage those 431 00:22:48,280 --> 00:22:51,040 properly, if you don't address those properly, if you do not 432 00:22:51,400 --> 00:22:54,280 intervene at the right time, you can definitely cause harm. 433 00:22:54,400 --> 00:23:00,360 All of these intervention 100% can cause harm, 100% can lead to 434 00:23:00,840 --> 00:23:04,600 absolute unfortunate morbidity and mortality. 435 00:23:04,880 --> 00:23:07,760 One in 100% that can happen. As with anything in medicine, 436 00:23:07,880 --> 00:23:10,960 everything that we do can definitely help and it can also 437 00:23:10,960 --> 00:23:13,600 cause harm. So being able to to give those 438 00:23:13,600 --> 00:23:16,920 these skills is going to be able to hopefully reduce preventable 439 00:23:16,920 --> 00:23:18,920 morbidity, mortality. But we have to do it smartly, 440 00:23:18,920 --> 00:23:21,360 wisely. That can't be done 9 years from 441 00:23:21,360 --> 00:23:22,840 now. I think 9 years from now will be 442 00:23:22,840 --> 00:23:25,360 too long. I think we have to be able to do 443 00:23:25,360 --> 00:23:28,440 a lot of these things now. I think we have to crawl, walk, 444 00:23:28,440 --> 00:23:30,120 run. I think we started the crawl. 445 00:23:30,120 --> 00:23:33,280 I think we're starting to walk in and at some point probably in 446 00:23:33,640 --> 00:23:37,240 Q1 and Q22027, I think we're going to be running and we 447 00:23:37,240 --> 00:23:40,160 really need to be able to get these skills into the hands of 448 00:23:40,440 --> 00:23:43,160 of these providers. And additionally with this, this 449 00:23:43,160 --> 00:23:46,480 is not just the procedures, we have to also think this doesn't 450 00:23:46,480 --> 00:23:50,240 replace anything. This only adds, so we have to 451 00:23:50,240 --> 00:23:53,360 also think about the damage control resuscitation clinical 452 00:23:53,360 --> 00:23:57,160 practise guideline from the DHA from deployed medicine and 453 00:23:57,160 --> 00:23:59,360 there's actually a few that's wonderful prolonged field care 454 00:23:59,360 --> 00:24:02,880 that the overarching damage control resuscitation document. 455 00:24:03,000 --> 00:24:05,360 Those are the same skills and concepts that have to be 456 00:24:05,360 --> 00:24:08,000 followed, right? We still have to get blood and 457 00:24:08,000 --> 00:24:09,920 blood products on board as soon as possible. 458 00:24:09,920 --> 00:24:12,960 We still have to have appropriate and responsible 459 00:24:12,960 --> 00:24:16,000 resuscitation. We still have to provide all of 460 00:24:16,000 --> 00:24:19,160 these other adjuncts with resuscitation such as TXA and 461 00:24:19,160 --> 00:24:21,360 calcium. And we, we, we have to be able 462 00:24:21,360 --> 00:24:24,200 to provide these basic interventions as, as all, you 463 00:24:24,200 --> 00:24:27,440 know, as you and I both know from all of our training, you'll 464 00:24:27,440 --> 00:24:31,240 never get to that those, those cool, sexy advanced skills 465 00:24:31,240 --> 00:24:33,960 without excellence in the basic life support. 466 00:24:33,960 --> 00:24:36,960 So we still have to remember that this is not a replacement. 467 00:24:36,960 --> 00:24:39,240 We're not saying, OK, well, this is damage control procedures. 468 00:24:39,400 --> 00:24:41,680 Now we don't have to wear, but all this other stuff, no at all 469 00:24:42,080 --> 00:24:45,200 that the basic life support still remains the mainstay 470 00:24:45,600 --> 00:24:49,200 before we jumped into these really cool advanced procedures. 471 00:24:49,200 --> 00:24:52,160 And this is, you know, something that I think all of us 472 00:24:52,160 --> 00:24:55,880 appreciate in the teaching community and in the, in the 473 00:24:55,880 --> 00:24:57,680 execution operational environment. 474 00:24:58,680 --> 00:25:01,040 You know, basic skills are really what saves lives. 475 00:25:01,320 --> 00:25:03,840 And all the advanced stuff is brilliant and excellent. 476 00:25:03,840 --> 00:25:06,200 It's it's high speed and we want to do it. 477 00:25:06,200 --> 00:25:08,840 We want to do it well, but really we'll never get there 478 00:25:08,840 --> 00:25:11,760 without having just absolute excellence in our own 479 00:25:11,760 --> 00:25:14,440 operational environment of the basic skills as well. 480 00:25:14,720 --> 00:25:16,720 You mentioned in the history of paramedics. 481 00:25:17,160 --> 00:25:22,160 I remember watching the TV show Emergency back in 1974 about the 482 00:25:22,160 --> 00:25:25,400 first paramedics and they needed to call permission. 483 00:25:25,840 --> 00:25:28,440 They had to get medical oversight for giving an IV or 484 00:25:28,440 --> 00:25:31,200 even oxygen. And then it, you know, small 485 00:25:31,200 --> 00:25:35,320 steps we built from that. So we can't, we, we had to start 486 00:25:35,320 --> 00:25:37,920 from somewhere. Are you seeing this being 487 00:25:37,920 --> 00:25:42,240 something similar to what we had to start as as paramedics until 488 00:25:42,480 --> 00:25:44,880 now we're up to doing a lot of stuff on our own. 489 00:25:46,440 --> 00:25:48,240 Absolutely. And it's a, it's an excellent 490 00:25:48,320 --> 00:25:51,880 reference point. My, my paramedic, my paramedic 491 00:25:51,880 --> 00:25:56,920 instructor, instructor Patrick, he would always talk about 492 00:25:56,920 --> 00:26:00,400 Rampart, Rampart, Rampart, the, the name of the hospital to call 493 00:26:00,560 --> 00:26:04,920 the, the, for medical direction when you have access to one of 494 00:26:04,920 --> 00:26:06,840 these fancy radio phones, etcetera. 495 00:26:07,920 --> 00:26:11,920 Yes, I do see this is the way that, that, that, that things 496 00:26:11,920 --> 00:26:14,320 are going. I, I would just, I point out two 497 00:26:14,320 --> 00:26:17,440 skills that come to mind anecdotally from my experience 498 00:26:17,440 --> 00:26:21,160 in Ukraine, intra osteus and chest tubes. 499 00:26:21,640 --> 00:26:26,560 Intra osteus access was just a challenge, as was needle 500 00:26:26,560 --> 00:26:28,320 decompression, a massive challenge. 501 00:26:28,440 --> 00:26:32,880 And as, as things expanded, as things grew forward, as a, it 502 00:26:32,880 --> 00:26:35,800 became a little bit cheaper. So cheaper to train on, cheaper 503 00:26:35,800 --> 00:26:37,800 to get your hands on, cheaper to use. 504 00:26:39,000 --> 00:26:41,880 Yes, there were, there were inappropriate intra osteus 505 00:26:42,680 --> 00:26:44,680 place. Yes, I can, I can verify that 506 00:26:44,680 --> 00:26:48,560 yes, that took place. However, as as you train it to 507 00:26:48,560 --> 00:26:52,240 scale, especially for patients that are appropriate to receive 508 00:26:52,240 --> 00:26:55,560 intra osteus, especially for damage control, resuscitation 509 00:26:55,560 --> 00:27:00,200 and transfusion medicine, it expanded massively and it wasn't 510 00:27:00,200 --> 00:27:02,600 necessarily legal. And you do have to get 511 00:27:02,880 --> 00:27:04,880 permission. And even with permission, people 512 00:27:04,880 --> 00:27:07,200 would still kind of bicker over the governance aspect. 513 00:27:07,640 --> 00:27:12,320 And now you see a large expansion of that component of 514 00:27:12,320 --> 00:27:15,880 that intervention of that modality to help patients 515 00:27:16,480 --> 00:27:18,880 massively across the line inside Ukraine. 516 00:27:19,320 --> 00:27:22,040 The same thing for finger thoracostomy and and two 517 00:27:22,040 --> 00:27:26,040 thoracostomy. I think the, I think the, the 518 00:27:26,040 --> 00:27:28,320 it's a little bit more limited certainly. 519 00:27:28,440 --> 00:27:31,600 However, you have definitely seen an expansion of the level 520 00:27:31,600 --> 00:27:34,880 of training of chess tubes. I was doing chess tube training 521 00:27:34,880 --> 00:27:43,120 in 2014 with about 6 to 8000 people in 2014 to 2015 by 20 and 522 00:27:43,400 --> 00:27:45,240 other things taking place between them. 523 00:27:45,240 --> 00:27:50,040 Obviously by 2022 we were kind of back to baseline where not a 524 00:27:50,040 --> 00:27:52,760 lot of people had access. It was not an intervention that 525 00:27:52,760 --> 00:27:55,760 was taking place in the pre hospital space in Eastern your 526 00:27:55,760 --> 00:27:59,760 brain and very rapidly, not only surgeons technically within the 527 00:27:59,760 --> 00:28:03,040 governance structure, surgeons are supposed to be doing this 528 00:28:03,240 --> 00:28:07,160 and rapidly. You had any doctor that was 529 00:28:07,160 --> 00:28:10,840 receiving patients by 2023 that had training with chest with 530 00:28:10,840 --> 00:28:13,200 finger glorcostomy and tube glorcostomy of patients that 531 00:28:13,200 --> 00:28:16,520 required that you'd have much larger access. 532 00:28:16,520 --> 00:28:19,040 Again, it's qualitative. I'm not going to tell you the 533 00:28:19,040 --> 00:28:22,440 number of of of of role ones or role twos. 534 00:28:22,440 --> 00:28:24,600 I'll cross the line that had access to this, but it was 535 00:28:24,600 --> 00:28:26,400 larger than what it was in 20/22. 536 00:28:26,720 --> 00:28:29,160 It was largely what it was in 2014 and 2015. 537 00:28:29,400 --> 00:28:35,560 So that slow expansion of being able to provide best practises a 538 00:28:35,560 --> 00:28:38,280 really life saving intervention. So we know that attention 539 00:28:38,480 --> 00:28:41,960 pneumothorax or pneumothorax will kill a patient and being 540 00:28:41,960 --> 00:28:44,320 able to get that finger to acostomy as soon as possible, 541 00:28:44,320 --> 00:28:47,440 being able to get that to acostomy as soon as possible 542 00:28:47,440 --> 00:28:49,760 will be life saving. So that has expanded. 543 00:28:49,880 --> 00:28:52,480 I don't have a number for you, but it has expanded and the 544 00:28:52,480 --> 00:28:55,560 scope has expanded. And that's just a one small 545 00:28:55,560 --> 00:29:00,040 example of what, what, what are certainly advanced skills, but 546 00:29:00,440 --> 00:29:03,480 in the grants team of, of, of of damage control, surgical 547 00:29:03,480 --> 00:29:06,800 interventions, those are only a few and then it kind of goes up 548 00:29:06,800 --> 00:29:09,040 from there, right? So I would say that those are 549 00:29:09,120 --> 00:29:13,000 those are some basic examples of, of where, where you could 550 00:29:13,000 --> 00:29:16,720 actually see that going, you know, in reference to being able 551 00:29:16,720 --> 00:29:20,040 to have medical control reaching back, Hey, I've done the 552 00:29:20,040 --> 00:29:22,720 training, can I do this now? And after you do that a few 553 00:29:22,720 --> 00:29:24,960 times, then the surgeon saying, yes, you know, you have a 554 00:29:24,960 --> 00:29:27,600 standing order, you're allowed to do a finger glorcostomy or 555 00:29:27,600 --> 00:29:29,680 you're allowed to do an intraositus access or you're 556 00:29:29,680 --> 00:29:33,280 allowed to do a needle, a needle decompression in the at the 557 00:29:33,280 --> 00:29:36,360 axilla, not no longer an anterior approach. 558 00:29:36,920 --> 00:29:40,200 And being able to do that in for nurses, for combat medics or EMT 559 00:29:40,200 --> 00:29:42,360 equivalents, 60 whiskeys, etcetera. 560 00:29:42,520 --> 00:29:45,400 So what's next for the DCP pathway? 561 00:29:45,400 --> 00:29:47,120 What? What needs to happen now? 562 00:29:47,280 --> 00:29:50,000 Yeah. So the DCP is is exploding the 563 00:29:50,000 --> 00:29:52,880 damage control procedure is course we've already executed a 564 00:29:52,880 --> 00:29:55,440 few elements of them. Right now we're really working 565 00:29:55,440 --> 00:29:59,040 hard to get governance online. Doing cadavers in Europe is a 566 00:29:59,040 --> 00:30:02,000 challenge. There's obviously a whole lot of 567 00:30:02,000 --> 00:30:05,920 technology that exists to do these types of courses and I 568 00:30:05,920 --> 00:30:09,160 think the Hess course has an excellent model and the Asset 569 00:30:09,160 --> 00:30:11,400 Plus course normally uses cadavers. 570 00:30:11,400 --> 00:30:13,760 There's actually a few that are coming up that are available in 571 00:30:13,760 --> 00:30:16,480 Europe and encourage our surgical colleagues to reach 572 00:30:16,480 --> 00:30:18,320 out. Unfortunately, if you're not a 573 00:30:18,320 --> 00:30:20,360 surgeon, you cannot do the Asset Plus course. 574 00:30:21,320 --> 00:30:27,080 But I think really what the idea of the full package and the idea 575 00:30:27,080 --> 00:30:32,120 of being able to offer it in its entirety, specifically right now 576 00:30:32,120 --> 00:30:35,200 to those who need it most, which is in Ukraine and being able to 577 00:30:35,200 --> 00:30:39,080 provide a full package to a several of a large cohort of 578 00:30:39,080 --> 00:30:42,080 trainers of learners and being able to have a training training 579 00:30:42,080 --> 00:30:46,080 system where, you know, I just to take a bit of a side a side 580 00:30:46,080 --> 00:30:49,400 detour. Ukraine and Ukrainian military 581 00:30:49,400 --> 00:30:53,920 medics are fighting in Modern Warfare and they have a lot of 582 00:30:54,320 --> 00:30:57,160 learning and a lot of observations and a lot of 583 00:30:57,160 --> 00:31:01,000 lessons that a lot of them are being shared with NATO and NATO 584 00:31:01,000 --> 00:31:01,880 partners. It's true. 585 00:31:02,040 --> 00:31:03,520 However, a lot of them are being lost. 586 00:31:03,680 --> 00:31:06,640 They're being missed because there's just the engagement that 587 00:31:06,640 --> 00:31:08,600 needs to be increased. You need to increase our 588 00:31:08,600 --> 00:31:10,760 engagement and support for our opinion colleagues. 589 00:31:11,120 --> 00:31:14,720 We have to be able to kind of shut up and listen to them and 590 00:31:14,720 --> 00:31:17,600 listen to what they have to say and listen to their experience, 591 00:31:17,600 --> 00:31:20,280 their observations and instead of necessarily teaching or 592 00:31:20,280 --> 00:31:23,120 training them, Although obviously medicine is a, is a, 593 00:31:23,440 --> 00:31:27,080 is a, a science and it's a vocation that we do exchange 594 00:31:27,160 --> 00:31:29,720 from one person to another. It's like it's a two way St of 595 00:31:29,720 --> 00:31:31,840 exchange. We need to, we need to listen, 596 00:31:32,040 --> 00:31:35,680 we need to really hear what what their experiences as well. 597 00:31:35,840 --> 00:31:39,920 So the damage control procedures will be procedures offered in 598 00:31:39,920 --> 00:31:41,440 Ukraine. Obviously there's going to be 599 00:31:41,440 --> 00:31:44,720 two echelons offered in 26. And then we want to do the full 600 00:31:44,720 --> 00:31:48,240 package start to finish in 2027. And I think it's a great 601 00:31:48,240 --> 00:31:51,280 opportunity. This is not just for the special 602 00:31:51,280 --> 00:31:55,640 operations, you know, community. This is not just for the far 603 00:31:55,640 --> 00:31:58,240 forward, high speed, low drag military medical community. 604 00:31:58,360 --> 00:32:00,840 This is really for all of those in the pre hospital space. 605 00:32:00,960 --> 00:32:03,600 So within Ukraine, obviously there's disaster response, 606 00:32:03,760 --> 00:32:06,160 there's the Ministry of Health, there's the Ministry of Internal 607 00:32:06,160 --> 00:32:08,080 Affairs and of course the Armed Forces of Ukraine. 608 00:32:08,400 --> 00:32:11,520 And we want to be able to offer this to as many people as 609 00:32:11,520 --> 00:32:13,560 possible. And I shouldn't comment as well. 610 00:32:13,560 --> 00:32:16,760 I mean, there's a lot of other softer skills such as the 611 00:32:17,480 --> 00:32:21,680 surgical, basic surgical skills. So the, the, the idea about what 612 00:32:21,680 --> 00:32:25,440 it is like to to work in theatre and then try to be as sterile as 613 00:32:25,440 --> 00:32:28,160 possible in that far forward environment. 614 00:32:28,680 --> 00:32:33,040 There's also a few more comments about resuscitation, not only 615 00:32:33,040 --> 00:32:35,560 with blood, blood products and also adjuncts. 616 00:32:36,000 --> 00:32:37,880 Unfortunately there's not enough blood, there's not enough 617 00:32:37,880 --> 00:32:40,600 universal donor blood in the country to be able to provide 618 00:32:40,600 --> 00:32:42,360 for all the patients that that we have. 619 00:32:42,560 --> 00:32:45,360 There's also not a lot of blood components necessarily. 620 00:32:45,360 --> 00:32:48,720 So being able to look at alternatives as well is also 621 00:32:48,720 --> 00:32:51,320 part of the part of the curriculum. 622 00:32:51,320 --> 00:32:54,120 John, you mentioned Disaster Health Institute. 623 00:32:54,240 --> 00:32:57,560 Tell us about DHI. Yeah, DHI. 624 00:32:57,720 --> 00:33:01,280 So I'm double hacked. I've been a faculty for college 625 00:33:01,280 --> 00:33:03,280 remote optional medicine. It's been an excellent 626 00:33:03,280 --> 00:33:06,880 experience. I also helped support the 627 00:33:06,880 --> 00:33:10,520 starting of a non for profit with the Disaster Health 628 00:33:10,520 --> 00:33:12,880 Institute. And they they are really a 629 00:33:12,880 --> 00:33:15,960 collection of subject matter experts mostly from the disaster 630 00:33:15,960 --> 00:33:20,680 health epidemiology, far forward operational medicine and 631 00:33:20,680 --> 00:33:24,640 disaster response. North America, Europe, Central 632 00:33:24,640 --> 00:33:27,480 Asia, elements from Africa and South America. 633 00:33:27,680 --> 00:33:30,400 And really trying to bring bring forward the concepts of best 634 00:33:30,400 --> 00:33:35,320 practise at a very high level. So a very operational strategic 635 00:33:35,320 --> 00:33:39,400 level and trying to bring trying to bring best practises to the 636 00:33:39,400 --> 00:33:42,400 places that need it most. There's been a whole lot of 637 00:33:42,400 --> 00:33:45,320 engagement and coordination with several different institutions, 638 00:33:45,720 --> 00:33:50,320 including the European Union and other response disaster 639 00:33:51,560 --> 00:33:53,640 institutions that do a whole lot of stuff operationally. 640 00:33:53,640 --> 00:33:56,880 But it's kind of trying to be a bit more focused on the 641 00:33:56,880 --> 00:33:59,120 strategic level. And there's been a lot of 642 00:33:59,120 --> 00:34:01,720 workshops that have been put forward trying to bring subject 643 00:34:01,720 --> 00:34:05,560 matter experts doing some red teaming and some really 644 00:34:05,560 --> 00:34:09,679 challenging exercises in, in what are we going to do if X 645 00:34:09,679 --> 00:34:13,040 happens? So disease X, obviously event X, 646 00:34:13,320 --> 00:34:17,239 not just conflict, but also disaster in, in, in general. 647 00:34:17,320 --> 00:34:21,320 And really trying to bring bring forward not only subject matter 648 00:34:21,320 --> 00:34:24,120 expertise from within the Disaster Health Institute, but 649 00:34:24,120 --> 00:34:26,840 also from around and really bring together and be a 650 00:34:26,840 --> 00:34:29,480 collaborative of saying, Hey, we need to link up all these 651 00:34:29,480 --> 00:34:31,560 things. We need to let data drive our 652 00:34:31,560 --> 00:34:33,960 decision making. And if we don't have that dad, 653 00:34:33,960 --> 00:34:37,159 that, that data, we need to run out and, and, and get that data, 654 00:34:37,159 --> 00:34:38,880 we need to run out and capture that data. 655 00:34:39,520 --> 00:34:42,159 And so that's, you know, that's one of the things, you know, 656 00:34:42,199 --> 00:34:45,960 that I think DHI really on the on the, on the front of it, 657 00:34:45,960 --> 00:34:48,840 they, they look at strategic policy stuff, but a lot of their 658 00:34:48,840 --> 00:34:52,320 subject matter experts also also engage with operational things 659 00:34:52,320 --> 00:34:54,120 as well. So trying to bridge those two 660 00:34:54,120 --> 00:34:56,560 things as, as you know from working college runoff for 661 00:34:56,560 --> 00:34:59,960 medicine, it is challenging when you engage with little big 662 00:34:59,960 --> 00:35:03,480 decision makers doing a whole lot of stuff at a high and 663 00:35:03,480 --> 00:35:05,960 strategic level. And then you're dealing with and 664 00:35:05,960 --> 00:35:09,720 really operational guys and gals that that kick indoors that put 665 00:35:09,720 --> 00:35:12,960 tourniquets on. That is being able to, to 666 00:35:13,320 --> 00:35:17,640 communicate and engage with both groups of folks is, it's a, it's 667 00:35:17,640 --> 00:35:20,760 a bit of a skill, bit of a skill set to be able to get the data 668 00:35:20,760 --> 00:35:23,360 that's needed and to be able to convert that and analyse that 669 00:35:23,360 --> 00:35:26,240 and speak to those that are, that are having, you know, the 670 00:35:26,600 --> 00:35:29,360 final decisions on a lot of things, hopefully to make 671 00:35:29,360 --> 00:35:32,280 everyone's lives better. Are you going to be speaking 672 00:35:32,280 --> 00:35:36,040 about DCP at the the Soft CMC conference in Paris? 673 00:35:37,440 --> 00:35:42,480 I, I, I think I'm missing the CMC this year, although there 674 00:35:42,480 --> 00:35:46,560 may be a late entry, but I really, those guys are doing 675 00:35:46,560 --> 00:35:49,160 great work. You know, being it went there, I 676 00:35:49,160 --> 00:35:52,920 think I was able to bring forward the concept of taking 677 00:35:53,160 --> 00:35:57,480 really advanced skills and pushing them down into echelons 678 00:35:57,480 --> 00:36:02,600 closer to to point of injury. So this was in the CMC in 679 00:36:02,600 --> 00:36:05,760 Germany. And those are just it's a great 680 00:36:05,760 --> 00:36:09,040 community of folks, the the organisers there to ABS they 681 00:36:09,040 --> 00:36:12,040 move mountains when they put these things together, that flip 682 00:36:12,040 --> 00:36:15,200 flopping between having it in Germany and having it in Paris. 683 00:36:15,400 --> 00:36:18,840 It's an excellent mixture of subject matter expertise, not 684 00:36:19,160 --> 00:36:21,680 only is in the special operations medical community, 685 00:36:21,800 --> 00:36:25,440 but also, you know, across the board in, in everyone that is 686 00:36:25,440 --> 00:36:28,440 preparing for hopefully preventing the next large 687 00:36:28,440 --> 00:36:30,920 conflict. I mean, we need to be ready for 688 00:36:30,920 --> 00:36:31,760 it. And I think they're doing a 689 00:36:31,760 --> 00:36:35,280 great job of information sharing, very ad hoc, very 690 00:36:35,280 --> 00:36:38,200 practical information sharing so that everyone understands, hey, 691 00:36:38,200 --> 00:36:41,000 what, what do we need to do? What our best practises? 692 00:36:41,080 --> 00:36:43,000 What is the data thing we need to do? 693 00:36:43,400 --> 00:36:45,720 Most of the data is true. It's coming out of Ukraine for 694 00:36:45,720 --> 00:36:49,120 the last 4 1/2 years, for last arguably to, you know, 12 years, 695 00:36:49,480 --> 00:36:51,360 it's been coming out of Ukraine. And we need to, you know, 696 00:36:51,480 --> 00:36:52,960 capture that data, analyse that data. 697 00:36:52,960 --> 00:36:54,480 And they're doing a good job of doing that. 698 00:36:54,680 --> 00:36:57,280 And there's also a lot of data coming out of the Indo Pacific 699 00:36:57,280 --> 00:36:58,760 theatre. There's a lot of events that are 700 00:36:58,760 --> 00:37:01,000 coming out of the Middle East. We need to, we need to capture 701 00:37:01,000 --> 00:37:03,720 that as well. And we really need to be able to 702 00:37:03,960 --> 00:37:07,080 put our put our heads around it so that we can better understand 703 00:37:07,480 --> 00:37:09,480 what works in one theatre may not work in another. 704 00:37:09,520 --> 00:37:12,640 It's absolutely true. What works in one military or in 705 00:37:12,640 --> 00:37:16,160 one unit may not be transferable, although elements 706 00:37:16,160 --> 00:37:18,840 of it may be. And I think the CMC is a great, 707 00:37:19,200 --> 00:37:22,160 a great venue to be able to engage with everyone in a very 708 00:37:23,520 --> 00:37:25,320 peer-to-peer Manor. And it's a, it's a great 709 00:37:25,320 --> 00:37:28,520 environment, it's a great group of folks, but I, I think I may 710 00:37:28,520 --> 00:37:32,440 be missing it this year. Unfortunately so also you and I 711 00:37:32,440 --> 00:37:35,520 are hosting another webinar for the Royal Call to Certains of 712 00:37:35,520 --> 00:37:39,600 Edinboro at the end of June and you wanted this as your topic, 713 00:37:39,600 --> 00:37:41,160 isn't it? Yes, that's right. 714 00:37:41,160 --> 00:37:44,680 Yes, damage control procedures and really unpacking it in a bit 715 00:37:44,680 --> 00:37:48,800 more academic rigour, bringing a little bit more data from some 716 00:37:48,800 --> 00:37:50,760 of the events. One event that I shouldn't 717 00:37:50,760 --> 00:37:54,920 comment on that Doctor Tom and I were able to do is a workshop of 718 00:37:54,920 --> 00:37:58,520 trying to unpack and sort of pull information out of the 719 00:37:58,520 --> 00:38:02,400 Ukrainian experience to be able to better Polish off the the 720 00:38:02,400 --> 00:38:06,320 curriculum of the DCP really specifically for Ukraine. 721 00:38:06,320 --> 00:38:11,600 So essentially it was we, we ended up in, in late November 722 00:38:12,080 --> 00:38:15,720 after doing a damage control resuscitation training, which 723 00:38:15,720 --> 00:38:18,080 was, which is absolutely brilliant with our partner 724 00:38:18,080 --> 00:38:21,080 tactical medicine N, who are just an absolute brilliant 725 00:38:21,840 --> 00:38:25,760 provider and service provider for Free Hospital care within 726 00:38:25,760 --> 00:38:28,520 the Armed Forces of Ukraine. But they also do a lot of 727 00:38:28,520 --> 00:38:32,120 training and they, they really, they, they, they pack a punch 728 00:38:32,120 --> 00:38:35,320 well above their weight class. They do, they do some, some 729 00:38:35,320 --> 00:38:37,240 great stuff. And in that, in that damage 730 00:38:37,240 --> 00:38:39,920 control procedure workshop, we, we used a nominal group 731 00:38:40,160 --> 00:38:43,120 technique, which is really a fancy way of saying we let 732 00:38:43,120 --> 00:38:47,360 everyone's voices be heard without getting any attribution. 733 00:38:47,360 --> 00:38:51,400 So we got a lot of, a lot of fields folks in the room and we 734 00:38:51,760 --> 00:38:55,120 from across the board and we, we, we had, you know, Chatham 735 00:38:55,120 --> 00:38:59,040 House rules and we were, we're, we're pulling information out or 736 00:38:59,040 --> 00:39:00,400 what's working, what's not working. 737 00:39:00,400 --> 00:39:04,080 How do you define Rule 1 and Rule 2 and what do you want and 738 00:39:04,080 --> 00:39:07,160 Rule 1 and Rule 2 and how do you define those, those skills 739 00:39:07,160 --> 00:39:10,200 specifically? And we kind of teased out a lot 740 00:39:10,200 --> 00:39:12,840 of information. It was quite combative at times. 741 00:39:12,840 --> 00:39:16,760 Academically, it was extraordinarily challenging and, 742 00:39:16,760 --> 00:39:20,440 and, and you know, by the end, we were able to clearly define 743 00:39:20,440 --> 00:39:24,360 what they wanted, what they defined as role one, which is 744 00:39:24,360 --> 00:39:27,080 actually what we one of the papers that'll be coming out. 745 00:39:27,240 --> 00:39:30,520 They really wanted to classify that as role 0, which was very 746 00:39:30,520 --> 00:39:32,040 interesting. It's been a bit of a paradigm 747 00:39:32,040 --> 00:39:36,120 shift to the military medical paradigm from NATO and the 748 00:39:36,120 --> 00:39:39,640 concept from the Department of Defence, department of War, the, 749 00:39:39,960 --> 00:39:42,400 the concept of role zero and really what they want to have 750 00:39:42,400 --> 00:39:44,720 available there, what they're willing to have available there. 751 00:39:44,720 --> 00:39:47,360 These are folks that are that are are, you know, functioning 752 00:39:47,360 --> 00:39:50,680 underground rocket fire and under drones in basements and 753 00:39:50,680 --> 00:39:53,920 they scurry from point A to point B in small groups so that 754 00:39:53,920 --> 00:39:55,960 their footprint is smaller. I mean, these are these are 755 00:39:55,960 --> 00:39:58,080 really far forward folks. I said this is what we want to 756 00:39:58,080 --> 00:39:59,720 do. This is what we consider the 757 00:39:59,720 --> 00:40:02,000 role one to beat is what we consider role zero to beat. 758 00:40:02,000 --> 00:40:03,440 That's what we consider role two to be. 759 00:40:03,480 --> 00:40:07,280 And this is what these are the exact skill sets that we would 760 00:40:07,280 --> 00:40:09,160 like in each of those actual lines of care. 761 00:40:09,520 --> 00:40:13,600 And more importantly, these are the types of medical providers 762 00:40:13,800 --> 00:40:16,240 that we just did, we described. So we defined the. 763 00:40:16,480 --> 00:40:19,680 Competency and the skill sets of the different types of of 764 00:40:20,000 --> 00:40:23,640 providers inside Ukraine and where we want them to be at rule 765 00:40:23,640 --> 00:40:27,480 zero, row one, row 2. So it was a mapping, a lexicon 766 00:40:27,480 --> 00:40:30,280 mapping exercise. It was a descriptive exercise. 767 00:40:30,480 --> 00:40:33,520 The most importantly, it was the Ukrainian voice of what they 768 00:40:33,520 --> 00:40:35,640 wanted. What they saw was the need. 769 00:40:35,720 --> 00:40:38,640 And then we were able to Polish the curriculum so we can we can 770 00:40:38,640 --> 00:40:41,920 face and we could we can meet the challenge of those need that 771 00:40:41,920 --> 00:40:44,280 each of those echelon. Now, it won't be perfect 772 00:40:44,320 --> 00:40:47,080 obviously. And I think even since November 773 00:40:48,440 --> 00:40:51,880 the threat level has changed. The number of fibre optic 774 00:40:51,880 --> 00:40:56,040 drones, the number of drones that attack medical personnel 775 00:40:56,040 --> 00:41:00,200 by, you know, the Russian forces, the number of buildings 776 00:41:00,200 --> 00:41:04,360 that are attacked with really heavy weapon systems. 777 00:41:04,800 --> 00:41:08,120 And the, the, the level of grey zone and hybrid warfare that is 778 00:41:08,120 --> 00:41:11,920 taking place across Ukraine is extreme. 779 00:41:12,120 --> 00:41:15,480 And it's, it's more extreme now than what it was in November. 780 00:41:15,720 --> 00:41:18,960 And despite the, the excellent, the positive news that we're 781 00:41:18,960 --> 00:41:22,280 hearing coming out of Ukraine about the, the, the increased 782 00:41:22,280 --> 00:41:24,880 use of land drones, air drones, and really being able to 783 00:41:24,880 --> 00:41:28,840 leverage that with the use of AI systems to capture land. 784 00:41:28,840 --> 00:41:31,040 I mean, this is all excellent and great and positive. 785 00:41:31,480 --> 00:41:34,280 There's still people dying every single day and there's still 786 00:41:34,280 --> 00:41:38,640 significant challenges in dealing with a, a huge adversary 787 00:41:39,160 --> 00:41:42,640 with a lot of people, a lot of technology. 788 00:41:42,840 --> 00:41:47,200 And the, the, you know, no qualms about completely 789 00:41:47,200 --> 00:41:50,440 obliterated the concept of genetic convention, No issue 790 00:41:50,440 --> 00:41:52,560 whatsoever about attacking civilian, civilian 791 00:41:52,560 --> 00:41:55,640 infrastructure. And also no, no, no issues 792 00:41:55,640 --> 00:41:59,200 whatsoever about going after healthcare facilities, medical 793 00:41:59,200 --> 00:42:02,640 evacuation facilities and vehicles, and doctors 794 00:42:02,640 --> 00:42:04,560 specifically and medics specifically. 795 00:42:04,560 --> 00:42:07,920 So really still a massive challenge and a massive threat. 796 00:42:09,520 --> 00:42:13,440 So when we, when we were back in, in February and March doing 797 00:42:13,440 --> 00:42:17,480 some training near some Borderlands, that was great to 798 00:42:17,480 --> 00:42:21,120 get additional data capture again, qualitative data capture 799 00:42:21,440 --> 00:42:24,600 of what we see is going on and what, what the feedback we're 800 00:42:24,600 --> 00:42:27,840 getting back from them. But overwhelmingly all of them 801 00:42:27,840 --> 00:42:30,960 said, yes, we need the DCP, we need, we need access to at a 802 00:42:30,960 --> 00:42:34,280 minimum Tier 1 and Tier 2 concepts of the damage control 803 00:42:34,280 --> 00:42:38,000 procedures because we are, we are getting patients we cannot 804 00:42:38,000 --> 00:42:40,120 deal with. We do not have the skill set to 805 00:42:40,120 --> 00:42:43,200 deal with and we're getting patients that need far more than 806 00:42:43,200 --> 00:42:45,320 what we can do. We can't get them to where they 807 00:42:45,320 --> 00:42:48,440 need to be in time. And so that's that challenge. 808 00:42:48,680 --> 00:42:51,840 Despite the threat level getting worse, despite the change in 809 00:42:51,840 --> 00:42:56,840 the, the, the battlefield, still we need, we still have this gap, 810 00:42:56,920 --> 00:42:59,680 this damage control procedures gap that we need to address. 811 00:42:59,800 --> 00:43:03,800 So hopefully we'll be able to address this gap in late June 812 00:43:03,800 --> 00:43:07,400 and and July when we go out again and and do some additional 813 00:43:07,400 --> 00:43:10,200 far forward training specifically with tier one sort 814 00:43:10,200 --> 00:43:14,440 of stuff and Tier 2 damage control procedures and also 815 00:43:14,600 --> 00:43:18,520 establish a little bit better network for cadaver training and 816 00:43:18,520 --> 00:43:20,760 a handful of other logistical things that we need to get 817 00:43:21,000 --> 00:43:24,400 online. And so that's really, that's 818 00:43:24,400 --> 00:43:27,200 really the need. So as as creative as it is that 819 00:43:27,200 --> 00:43:29,440 we're, we're getting us out there, I still feel like we're 820 00:43:29,440 --> 00:43:31,400 late. We're not too late, but I think 821 00:43:31,400 --> 00:43:34,000 we're still very late. And we need to get, we need to 822 00:43:34,000 --> 00:43:38,400 get the Ukrainian involvement much, much more get their input 823 00:43:38,400 --> 00:43:40,800 and their feedback. And I would, you know, anyone 824 00:43:40,800 --> 00:43:43,560 listening to this, I would encourage all of you to engage 825 00:43:43,560 --> 00:43:47,360 more with Ukrainian colleagues, not just trying to talk them for 826 00:43:47,360 --> 00:43:48,880 information. Obviously very busy. 827 00:43:48,880 --> 00:43:51,280 They're dealing with patients on a daily and hourly basis. 828 00:43:51,280 --> 00:43:53,840 But more importantly, what we can do for them and how we can 829 00:43:53,840 --> 00:43:56,080 support them. And I think that's something 830 00:43:56,080 --> 00:43:58,960 that is across the board, whether you're, whether you're 831 00:43:59,200 --> 00:44:01,080 doing disaster helps stuff, whether you're doing 832 00:44:01,080 --> 00:44:04,800 humanitarian health stuff that we need to be able to provide a 833 00:44:04,800 --> 00:44:08,440 lot more, a lot more support material as well as personnel if 834 00:44:08,440 --> 00:44:11,160 you are willing to go and volunteer and spend some of your 835 00:44:11,160 --> 00:44:15,600 time and expertise in countries. So I encourage everyone to to 836 00:44:15,600 --> 00:44:18,840 mobilise and provide more support, absolutely. 837 00:44:18,920 --> 00:44:21,560 For the listener who is interested in learning more 838 00:44:21,560 --> 00:44:24,960 about damage control procedures, are you planning on running a 839 00:44:24,960 --> 00:44:28,600 DCP workshop at our Medicine and Mediterranean conference at the 840 00:44:28,600 --> 00:44:31,520 end of January in Malta? Yes, absolutely. 841 00:44:31,520 --> 00:44:34,720 We were able to get elements of the damage control procedures 842 00:44:34,720 --> 00:44:37,440 really damage to resuscitation in Ukraine, which we we had 843 00:44:37,440 --> 00:44:42,400 concepts of the DCP, we had some some very specific skill sets 844 00:44:42,400 --> 00:44:45,200 there, blood warming techniques, partial verbal, etcetera. 845 00:44:45,400 --> 00:44:48,080 Yes, the answer is yes. If you have interest in damage 846 00:44:48,080 --> 00:44:51,240 control procedures, we will be running a detailed damage 847 00:44:51,240 --> 00:44:55,480 control procedures workshop with a whole lot of new information, 848 00:44:55,480 --> 00:45:00,800 new data sets and a lot of hands on stuff to do in January in 849 00:45:00,800 --> 00:45:03,720 Malta 2027. We're very much looking forward 850 00:45:03,720 --> 00:45:05,440 to that. It's going to have a completely 851 00:45:05,440 --> 00:45:08,000 revamped approach. We're going to have a whole lot 852 00:45:08,000 --> 00:45:11,480 of information from the missions in Ukraine and we're also going 853 00:45:11,480 --> 00:45:14,600 to have access to a lot more procedures themselves. 854 00:45:14,680 --> 00:45:18,600 And I would definitely encourage anyone that has interest to be 855 00:45:18,600 --> 00:45:23,160 able to take a look at that and see, see what you know, see if 856 00:45:23,160 --> 00:45:25,840 you're available, if you're available to come out in late 857 00:45:25,840 --> 00:45:29,800 January, we'd love to have you. John, my final question for you 858 00:45:29,800 --> 00:45:32,120 is this. What advice do you have for the 859 00:45:32,120 --> 00:45:35,800 remote medic, the nurse, the Doctor Who is just starting out 860 00:45:35,800 --> 00:45:38,160 in their career in austere medicine? 861 00:45:38,160 --> 00:45:45,000 See as many patients as you can. So I, I definitely, I think it 862 00:45:45,000 --> 00:45:47,600 is challenging working in the pre hospital environment, it's 863 00:45:47,600 --> 00:45:50,480 challenging working in austere environments, it's challenging 864 00:45:50,480 --> 00:45:52,120 working in this type of environment. 865 00:45:52,200 --> 00:45:56,680 And the confidence I get personally is by seeing 866 00:45:56,680 --> 00:45:58,720 patients, certainly by doing training. 867 00:45:58,720 --> 00:46:02,880 I just completed my my 9th or 7th or 8th, maybe my 9th 868 00:46:03,080 --> 00:46:06,920 advanced trauma life support training, instructor training. 869 00:46:06,960 --> 00:46:10,400 I still do my advanced burn life support, my advanced cardiac 870 00:46:10,400 --> 00:46:13,040 life support, all of these types of training that you do every 871 00:46:13,040 --> 00:46:15,960 two years, every four years. It does help with confidence. 872 00:46:15,960 --> 00:46:18,800 It helps give give you builds your confidence expensive. 873 00:46:18,800 --> 00:46:23,280 It's difficult, it's challenging to plan it, but when I see 874 00:46:23,280 --> 00:46:27,400 patients, I am encouraged and I am reinvigorated. 875 00:46:27,400 --> 00:46:29,200 So if you're out there and you're like, I really want to 876 00:46:29,200 --> 00:46:31,360 get into this, I want to learn about this more, etcetera. 877 00:46:31,760 --> 00:46:34,520 I think you need to increase your your patient volume. 878 00:46:34,760 --> 00:46:38,400 And when you do have patience, do your exam and, and document 879 00:46:38,400 --> 00:46:40,560 your exam. Do your exam well, 'cause no 880 00:46:40,560 --> 00:46:44,480 harm first, do no harm and really, really focus on these 881 00:46:44,480 --> 00:46:47,440 basic skills that they become a second nature. 882 00:46:47,760 --> 00:46:52,760 One of the opportunities I had in, in 2004 to 2006 or 7 or so, 883 00:46:53,360 --> 00:46:56,400 running a, a small clinic, multiple small clinics 884 00:46:56,400 --> 00:46:59,640 throughout Iraq, patients came in all the time and they wanted 885 00:46:59,640 --> 00:47:02,360 tablets for headaches and tablets for this and, and 886 00:47:02,360 --> 00:47:04,960 different things with their, their big toe, etcetera. 887 00:47:05,120 --> 00:47:08,120 Use it as an opportunity, use it as an opportunity to do a 888 00:47:08,120 --> 00:47:11,400 physical exam, take a clinical history, a detailed clinical 889 00:47:11,400 --> 00:47:15,680 history and, and really, really sharpen your clinical skills so 890 00:47:15,680 --> 00:47:18,520 that you have confidence, you have confidence to deal with the 891 00:47:18,600 --> 00:47:21,560 emergency and you don't become complacent and you don't say, 892 00:47:21,560 --> 00:47:23,720 oh, this is cool. I get to sit in the desk and and 893 00:47:23,720 --> 00:47:27,960 do this and that No, you know, get off to get off the desk, go 894 00:47:27,960 --> 00:47:31,040 around, see the, the, the, the area that you're at, look at the 895 00:47:31,040 --> 00:47:33,800 public health, think about the epidemiology that you can 896 00:47:33,800 --> 00:47:36,640 provide support with. You know, the far forward medic 897 00:47:36,640 --> 00:47:39,120 is not just ready for the heart attack, not just ready for the 898 00:47:39,120 --> 00:47:41,640 trauma, but you know, it's a, you're a, you're a provider of 899 00:47:41,640 --> 00:47:43,480 health. And so being able to really 900 00:47:44,200 --> 00:47:46,480 encourage and, and run out there, do a whole lot of 901 00:47:46,480 --> 00:47:49,600 different things, capture a whole lot of information, gather 902 00:47:49,600 --> 00:47:52,760 a whole lot of information, try to analyse that and try to speak 903 00:47:52,760 --> 00:47:55,600 with mentors and engage with mentors so that you can, you 904 00:47:55,600 --> 00:47:58,600 can, you know, make a, the, the healthcare of the patient in 905 00:47:58,600 --> 00:48:00,680 front of you better. But also the environment, the, 906 00:48:00,760 --> 00:48:02,800 the community that you're dealing with, whether it's four 907 00:48:02,800 --> 00:48:06,360 guys on an oil rig or whether it's, you know, 123 local 908 00:48:06,360 --> 00:48:10,640 nationals at A, at a copper mine and everything in between. 909 00:48:10,960 --> 00:48:14,600 Be able to really sit down, sit down with your patient, sit down 910 00:48:14,600 --> 00:48:17,640 with your community and capture a lot of, of information so that 911 00:48:17,640 --> 00:48:20,280 you can hopefully, you know, make the make the community 912 00:48:20,280 --> 00:48:22,080 better. You know, not to sound like a 913 00:48:22,080 --> 00:48:24,240 broken record, but reduce available morbidity and 914 00:48:24,240 --> 00:48:27,400 mortality and really and really look at what you can do to do 915 00:48:27,400 --> 00:48:31,440 that actively and practically. Doctor John Quinn, it's 916 00:48:31,480 --> 00:48:34,040 fantastic to have you on our faculty. 917 00:48:34,040 --> 00:48:36,680 You were you're making a difference in this world. 918 00:48:36,680 --> 00:48:40,160 And I think a little beam of light follows you around hitting 919 00:48:40,160 --> 00:48:42,760 England top of your head as you walk through life. 920 00:48:42,920 --> 00:48:46,000 And thank you for all that you do in the community. 921 00:48:46,200 --> 00:48:47,560 Thank you so much for the opportunity. 922 00:48:47,560 --> 00:48:49,280 I appreciate it. And that light is probably the 923 00:48:49,280 --> 00:48:55,000 police chasing me. This has been a presentation 924 00:48:55,120 --> 00:48:57,480 from the College of Remote and Offshore Medicine. 925 00:48:58,000 --> 00:49:01,880 If you would like to earn CPD credits for this podcast, you 926 00:49:01,880 --> 00:49:04,400 can join the Council of Members being.