 Good evening. With a lot of information, loads since morning and with burning questions on your mind, I request you to give a few more minutes. The idea is to stress on the relevance of research and data analysis, even in emergency settings. Again, I have to own up that this is not my original presentation. This is a presentation which was done in MSF UK office by Stefano and I am presenting on his behalf over here. But it's good to know that I was in MN three times in different parts of the country and as my predecessors explained, MN has been through a lot. The context is very complex. The activities is also dynamically changing all the time. So it's just to show how we try to figure out what was the need for the population and try to adapt to the services. And I would be taking pride in saying MSF almost like achieved to manage something in a very volatile context, which is still ongoing thanks to our colleagues there. So we are going to talk about the activities of an MSF supported hospital quite close to Thais, where interns fighting has been taking place for more than a year, a sort of siege like activity. For a year and now still we are running the facility. So this map shows where we are in MN at least focus. So the hospital which we are talking is somewhere between Yip and Thais. We do have facilities in Yip, a tertiary level referral hospital from the MOHESH. In Thais, there was OCA having a maternity iron child and trauma center as well. And then we the al-Qaeda was a secondary level MSF supported hospital. We prefer to call it as Kilo instead of al-Qaeda, which is for us a little bit not very okay. So at the beginning of 2016, we took over the hospital in the Yip governorate, the Kilo hospital. So this map shows you how the political or the military situation is there and how it is relevant to our context. Just to add a word, the green portions are the portions which are sort of with the coalition or the coalition supported government. And then the purple areas are the, I would say it is a faction of the who's fighting the coalition support. Then you have also the al-Qaeda actually areas which are dominant with them. So it's a sort of like they were having parallel governments which also impacted our activities to some extent because I remember in Ibo hospital that you have the government regional hospital and then you have a parallel hospital for the Houthis. They are one system of referrals, they are one system of taking care. So it was not very easy working in that. But it was very good for us in Kilo that every party agreed to respect MSF rules of not having weapons inside. We initially started the project with the idea that we thought because of the intense fighting happening over that in that area, we would receive and treat a lot of civilian wounded patients. But when we analyzed the data, we found that it was interesting to note that we were looking much more beyond than violence due to weapons alone. So the Kilo hospital, as you see, is a very nice hospital in a very beautiful place. We had an emergency room with almost around six beds, one OT, two ICU beds, but we did not have ventilator capacity. We had a 50 bedded IPD which included post-op, female, male and pediatric as well. And the meta anti section was being run over by MOH and supported to some extent by us. I was there when they were preparing to start the hospital and then one evening they were still installing and then they got the first patient who came in with appendicitis, interestingly, in an area where there is fighting all around. So our first patient to be operated on was an appendix patient. This is a standard data tool we use in most of our emergency projects. I will explain in a moment how it was relevant to use this tool and how much information we could get from that. The basic objective of this study was to assess the quality of data from the Kilo hospital and how the standard reporting could help us figure out the needs of the population and also to review the activities of the first 11 months, whether it was of relevance to MSF to be intervening there. The data basically comes from the ER register mainly. I will be talking only about it, but it's also linked with OT register, ICU register. The data is collected with maintaining confidentiality. So we just put the initials and then unique identifier number. But the IPD data, we just go in for the aggregate numbers. So in this, there is a column called the arrival time of the patient. And then you also have a delay to arrival, which indicates whether there was a problem in access for the population to access our health services. There is a column which is called referred by, which also indicates how the population, whether they came by themselves or whether we had other hospitals referring them and whether transportation was available. We have to take into account that moving from the idea was close to be around ties. Imagine there were so many checkpoints that the patients had to pass through to reach our service even. So it was not easy for the common people to cross the checkpoints if they belong to one faction or the other. The ambulance services even have to undergo the scrutinization, be with proper papers or something to access the services, which was also interesting in this context. And then the time of initiation of care would reflect upon our ER efficiency. The diagnosis gives an idea of what we are primarily looking at. And the procedures from, unfortunately, in this project because of the emergency context, we could have gone a little bit more in that, but we would see that in the succeeding slides. The volume of activities, this shows the resuscitation room and the ER room. We had 8,411 consultation during a 11 month period on 6,000 and odd patients, which is probably a little bit controversy. Probably the rest of them, the discrepancy is due to the follow-up consultations wrongly being entered as a first time year. The median age of the patient was around 20 years and predominantly male. The type of activities, surgical and non-surgical. So when we talk about emergency room, we are talking about like surgical and medical emergencies. Primary aim was stabilization and if it's stabilized surgical probably will be in our OT, except for complicated neuro or complicated or vascular injuries, which we had to refer. So coming to the surgical breakup, this is interesting because we expected trauma violence to be a bigger one than the trauma accidental. And we found that trauma accidental, which was mostly because of motor vehicle accidents, falling from height, children falling from height, injuries, fractures and all sorts of things. Acute abdomen to some extent and C-sections equally because we had the emoji facility. This is about triage by color. We were using the typical four level triage system of urgent immediate delayed or palliative. And interestingly we found that those people who access our services where 4000 was LO cases and the red cases were 900. The green normally is the green sometimes or red, but then it is interesting to note we had the large number of LO cases. And then coming to the outcome with the triage color, the number of patient discharged was 4000, admitted was 1000, 400, so 465, default died and then you have the referred. When I say referred patients, these are the patients who were referred to the next level of facility, next level of care with MSF referral letters. And you have a large population of discharged patients with the LO 100 cases. So, let us go to the individual breakup of this. So, in the green cases, 687 people were discharged and around 10 percent were admitted, which probably is over triaging. Coming to the LO cases, 386 people were discharged and 1200 and odd were admitted, referred or probably died, which is acceptable, you would agree because most of the discharge also means they went for further consultations, which MSF was not normally referring. It is to be understood that the orthopedic cases MSF believes in doing external fixation in emergency situations and not internal, where the population demand in Middle East was more about internal fixation and then they would go on their own to Yib hospital or to their private practitioners to get them. Or probably there were cases which were admitted in IPD stabilized after a couple of days of treatment where discharged from. The red cases seems to be fairly equally doing good for we compare with the outcome. So, it is accepted now from the American College of Surgeons that over triage rate of 50 percent and under triage of less than 5 percent is acceptable in emergency situations. Coming to the procedures, this is a breakup like we couldn't, is one of the limitation was not being able to train the staff who are entering the emergency room data to correctly capture the information into our books, even though we did a lot of procedures. The trends during the 11 months you can say that the community acceptance of our hospital was relevant, was very good because you see the case numbers going and interestingly the surgical and non-surgical at the end of month 12 is almost like equal. There was also an increase of women to access our service for cesarean section. Let me remind you in MN the repeats cesarean is almost like 15 percent and more. So, women were happy to come to our hospital in their beginning it was not easy for them to access our service. So, the conclusion is like standard reporting in emergency room, the data whatever we try to collect when waves of injuries or people are coming into the emergency room in a very complex security situation is reasonably adequate to help us identify what are the needs, what is our efficiency of care and to go in for more in-depth investigations of where we want to focus our activities. There is also an improvement needed in long term assessment of what happens to the patient outcome, how the patient was referred to our own setup or outside or where is the patient ending and what is the recovery rate or disability or whatever is happening. It is good to identify that we still continue to work because the numbers show that people are accessing our service and the need is still there and it is interesting to note that there is a shift from the original target patients of surgical and now non-surgical or almost one and equal. Of course, we still need to work on our over triage. The limitations of this study is we did not have this is a retrospective study with a approval because it was a retrospective study. We did not need the medical ethics board review, but it was okayed by our general operations control. We could not control the data when we were doing sorry when we were running the when we were collecting this. The procedures again under reported that no long term outcome data is possible with this study. So, if you have any questions for me, but before that I would like to thank all the past, present and future workers who still continue to work in killer hospital and with the caller coming in, it is still getting more busy. All right. I will take one question. Santosh has got his hands up. Yeah. On questions, just three questions, it is like two. One is that what was the situation of the, did you have any anesthetist assistance? And if there was an anesthetist assistance, why did you start internal fixation? Because like internal fixations are quite common in all ward settings now. So, it is like it is giving a final solutions to the patients and patients of the external fixation. It is like they need to go back and usually they do not come back at all. So, if you give an internal fixation, it is almost like final solution. And third question is like what about trainings? What was the quality of people you got from the community and did you have any training sessions for them? This question from an orthopedic person like why we did not go for internal fixation. I understand the MSF policy, if I am right, Dr. Vani, that in acute emergency context, MSF believes the care for the life saving, limb saving procedures and compared to the amount of people we could treat with the limb saving procedure with external fixator and the luxury of doing an internal fixation. Obviously, we need to match resources and the needs of the community. It will be ideal and especially in a country like Middle East where they are used to more sophisticated procedures. It was very difficult convincing the people like, hey look this is MSF policy we will only go in for. Second thing we did have anesthetic people, but we were there for acute limb saving and life saving surgeons and the capacity we did not have orthopedic wing as such. We were focused more on a life saving and limb saving procedures with our general surgeons at times if we are lucky with some orthopedic background for that, for one thing. It was not our criteria when we established the Kilo hospital to take on all the orthopedic cases because the bed occupancy rate would be quite high as well. We will not be able to have such a turnover of the patients. We could not afford for that. Training, believe me it was really difficult to get even the normal staff for the hospital because of the context of keeping people. We tried to do, of course there is a training all the time going on every week, every time, but then to get the people to come and work in that area was itself not very easy. Yeah. All right. Just one comment to you. A couple of times in your presentation you talked about identifying needs, analyzing hospital data. I think we have to be very careful to infer needs from analyzing hospital data. I think you only get a real sense of the needs if you do a community based sort of study because there are a lot of people who do not make it to the hospitals and we don't fully know what the needs in the community are. I can understand that you analyze patient data to provide better service in the hospital and kind of get a sense of patient profiles, but that does not equate automatically to needs in the community. I understand character doesn't give the full picture of what is exactly in the community. Yeah. But I understand that in an emergency situation may not always be easy, especially in an emergency situation to go into community based surveys. Thank you very much. Yeah. Very quick, please. We have to move. I'm sorry. I'm a pediatric cardiologist. Just one thing. In training, when you are dealing with emergency in such a dire situation, we often say is we often follow the criteria so do to see one, do one and teach one. That is the best way of training and it goes a long way. And secondly, when you are dealing with these kind of situations, ethically all the universal precautions were followed. You never mention anything about the universal precautions. I'm sorry. We take it for granted that in MSF, the quality of care would be at international standards and it's a part of the initial orientation training to any staff to adapt to universal precaution. There's no question with the infection control and universal precautions. Yeah. Thanks for reminding that. And yeah, regarding C1, we are more talking about the emergency room triaging. I would feel comfortable if we are over triaging and take a green patient in an admin rather than under triaging an ill patient who I had to lose later just because the staff were not, as such emergency triaging is not very well practiced in most of the places. It's even in India, a very new concept of like when you receive mass casualties or in a busy emergency room to make them understand that it is not that the most, most devastating looking injury is the most serious one to put them into their mind repeatedly to that, okay, you have to do a proper triage if you want to save more life within the limitations we are having. Yeah. All right. Thank you.