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Hello, good evening. Good day. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Reagan. I'm a retired cardiac surgeon in Yorkshire in the United Kingdom. The immediate past director of the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. Thank you very much for joining us this evening. We are smaller in numbers, but even so you represent the 4246 followers on Facebook, 695 on Instagram and 1016. And I always call it Twitter. We are reaching 90 countries. And what was interesting last week the Solomon Islands came online. If this is useful, please pass the word round and I look forward to seeing you all again this evening. I am wanting to talk about history and examination because it is important that we make the right decisions. We have the right information for the right reason, the right time, right consent, the right side and in theater, the right equipment, the right people, the right knowledge, everything needs to be right before you make an incision because that becomes the your indelible mark on that patient for the rest of their lives. They will look at that scar and remember everything we said and everything you did, the incision if you've been following the series also has to be right in the right place in the blade at right angles. And the incision has to be made with precision. And as we've discussed in our scalpel series, it's gotta be done with fear. And the feel is what comes in. Now, I'm particularly concerned as we help us go into the 22nd second tree that mechanistic nature of what we're doing is overtaking things. And I'm not the only one I found this book. He has mastered his emery, written by a psychiatrist, Ian Mgr who is a philosopher and psychiatrist up in Scotland and he called it the divided brain and the making of the Western world. Undoubtedly greater openness has brought its benefits and mechanistic science very clearly has two. And these should not be underestimated, but they have eroded along with much else, the power of the body in our lives by reducing it to a machine, such a tendency to see the body as an assemblage of parts or an illness as a series of discrete issues without reference to the whole, including often vitally important, emotional, psychological and spiritual issues. And it's his view, there is a tendency to discount and marginalize the importance of our embodied nature as though it was something incidental about us rather than essential to us, our very thinking, never mind our feeling is it bound up with our embodied nature and must be. And this needs to be acknowledged as part of his treatise on the dominance of the left hemisphere taking over from the right. He almost describes a psychological dystopia where the less hemisphere prefers the impersonal to the personal. And that tendency would be in any case in instantiated in fabric of technological driven and bureaucratically administered society, the impersonal would come to replace the personal, there would be a focus of material things at the expense of the living social cohesion and the bonds between person and person. And just as importantly between person and place and the context in which each person belongs will be neglected, perhaps actively disrupted as both inconvenient and incomprehensible to the left hemisphere acting on its own. And I think I'm often asked, what would the future look like in surgery without an incision? I think of the turing test of the computer. It can never match a human. And what's missing in A I is the age a human intervention. Because all ancient practitioners, she had similar ideas about the nature of healing. It was not possible to heal the body separately without reference to the mind and soul. And they recognized that the body was the only outward form of the non visible spirit being which existed in imbalance or disharmony at some level or levels of our energetic being. And that the mind's role in controlling our physical state was important. And the oldest known healers are the shamen. And the shaman priest would go into an altered state of consciousness in his journey to help the sick, patient and different civilizations have different traditions of healing built around the same principles including the Chinese as depicted here, the Indian Yogis, ancient Egypt, Greece, Polynesium Islands and the American Indians. The Zim Jewish sect studied this near the Dead Sea and Jesus of Nazareth was one of them and they lost their art with a being conquered by Rome. Their practice was picked up in the south of France, by the Ka community. But then they were destroyed by the Catholic church. And this spiritual element initially thought to be useful in the growing Christian communities was then demonized and healers were thought to be evil people in league with the devil and laws were passed to prevent these healers. It was only in the 19th century and with increased interest in spiritual organization and understanding of spiritual nature that the spiritual healing of things is coming to the fore and the New Age movement which began in America in the 20th century, popularize the ideas of healing, energy, balance, and the mind, body, and soul. But as we look at this Tao sign contemplate this. If Einstein in Tesla said the universe can be understood as waves and what we're looking at even a quantum level and visualization of the mysterious dance of quantum entanglement of photons looks in real time a bit like the terror sign. So how we missed something and our understanding and I leave you that for thought, suffice to say that we talk about how we feel and you get vibes of people and it's all about how you make people feel there's no mechanistic element to it at all. And that's how we should think about what we are doing in a very privileged health care community. We provide a service and I want you to contemplate and offer me some words that would describe the ideal service for you. Put them in the chart, please. For some reason, Gabrielle, I do not see the chat this evening. There you go. Marvelous. Got it. So do put what service means to you in the chat and reflect when you got good service. What was it about it that made good service? Um I'd also ask which company in the world depends on delivering a good service. Now, we all go past restaurants, banks, supermarkets and we got those like it scale of 1 to 5. The difference between a five out of five service and a four out of five service is a 75% reduction in footfall. And the organization that depends on good service is Disney. So as we think about the duality of the brain and the mind, body and soul. Mm As surgeons, we're intervening and every intervention carries a risk and a benefit and we need to determine what is best. Now, this is best described in Carne's prospect theory depicted here on the Y axis. The probability of outcome of doing nothing which is in the bottom or doing something at the top is in the field of a surgeon understanding the evidence base for what they're doing. And that's the risk and benefit of intervention, doing something or doing nothing. And there's a gain or loss from top to bottom. But what you've got on the X axis is the patient and the patient need to take that information and make a decision and decide. Is it worth it for me? And what happens is if you plot this out, you have the sigmoid curve which is predominantly in the bottom left hand corner of the graft of uncertainty and fear and risk and worry and concern. And I have to maintain that that is less for the surgeon, more for the patient. And in the top right hand corner is expectations and confidence which should perhaps more with the surgeon and less with the patient. But of course, this is fluctuating all the time and it is extremely temporal. It's a worrying time for patients and there's a lot to take in the fears, the benefits, the risks, the outcomes, the probabilities all need to be contextualized as summarized here and some of the risks we don't fully appreciate how we are communicating with because the risk in a Boston box can either be low dread or high dread or higher known and lower known. So if we plot this out, what we get is low grade, higher, no, I put to you would be risk of death. Low unknown, low grade would be risk of infection or bleeding, but the high grade infection would be flesh eating bug, M RSA sepsis, organ failure. But I think in what we're doing in cardiac surgery, in particular, the higher known and high dre is stroke because a lot of people, particularly the elderly people, I came across who are wanting cardiac cervix, knew people who had had a stroke and I don't want to be like that doctor. But this is actually very important because the high unknown and high dread is called a fright factor. The newspapers use this all the time because it stirs an emotional response and scares the patient. And I know that I could easily change the consent of a patient on the pause or deliberation in mentioning the word stroke. So there are subtleties about this interaction with the patient that are very important. And certainly with the elderly patients, I came across for heart surgery, we've got to recognize that some of what we do is not going to have any benefit may indeed cause harm, but certainly major operations cause a major catabolic response and starts to empty the tank. And one of the questions I posed to elderly patients coming in for heart surgery is if you drive a car and you allowed me to borrow the car and I got into it and the fuel gauge was on zero. I'd have no idea if I had to go and get it. Jerry, can to fill up the tank or could drive half a mile around the corner or if I had three or four days left because I don't own the car and haven't driven the car are not familiar with the car. The patient is familiar with their body. They're familiar with the mechanics of their systems and they will have a good feeling or what is best and you have to understand that and part of this resonance is actually connecting with a patient. And it's interesting when people are having a conversation and they're connected, there's marrowing an MRI inactivity in the brain. So you need to connect with a patient. And as you rightly say in the questions, establish a rapport build trust, but all the time noticing details, please look the part do not make any judgments, do not assume. And it is always what matters to the patient. Introduce yourself. The only way to go through your door is to use the handle and using a handle and addressing a patient by their proper title is important. One of my consultant trainees ended up in hospital and the nurses insisted on calling him Dickie. His first name was Richard, but nobody actually asked or cared to ask what he preferred. Now, although I qu quote Sherlock Holmes in this picture, he was a character based on Professor Bell Professor of Surgery at Edinburgh on infirmary. And it was his trainee Arthur Conan Doyle who used him for the character of Sherlock Holmes. Butoz previous esteemed surgeon Alza 800 BC was saying the same to use your senses to look and listen. No, not many of you answered the question of a chaperone or interpreter, whether you're male or female examining a male or female patient, you should ideally have a chaperone. You should always remember that there is a perceived power differential between you and the patient because of your knowledge. And you can reduce that by sitting on the level across the corner of a table and dressing appropriately. I had avoided t-shirts made and got rid of the t as part of my infection control. But the patients preferred it. I look more human. The rooms themselves think of a good hotel or restaurant. They must feel warm and fresh and I have to laugh that most hospitals draw curtains around the pad as if there is sound proof equipment. This is where the mechanistic tick box clocking really does irritate because what happens is and I've seen this in the hospital. It people look down with a pen and they read off a form and they tick a box at no point. Are they actually looking at the patient and a nurse colleague in our patients asked me to accompany her to neuroradiology where she was going to have coiling of an aneurysm. She was very scared and walk down to the department with the cony of noise. The people having laughter, which is and fun. But for a patient who has actually worried sick about their condition not appropriate. And then the nurse came along and went through a tick box larking only to be interrupted by the phone three times at no point. Did the focus on the patient or the need? So the important thing is to say in your own words, tell me what is troubling you. And as we approach 20 seconds, you're probably feeling a little bit awkward that we had the silence. And that is how long it takes before doctor interrupts, do not interrupt, let the person tell their story be patient. And as you sit there, be present, mimic the visual cues encourage and if they look hesitant, nothing beats the power of touch. A I computers can't reach out. Touch. Being present is the most important element. So asking about presenting complaint, listen to this story without interruption, playback when they finish and ascertain how long progression, frequency deterioration, exacerbating, relieving factors. It doesn't take long to ask those questions once they've told the story, don't sit there and write it down practice and remembering it because you have to put it together as a whole. Your job as a clinician is to take the patient's story in their own words and use medical language to put it on paper such that you can communicate with colleagues and the team, they're going to be looking after the patient. Remember, as people actually describe pain, the gestures and the facial expressions and the hands and the pointing will indicate whether it's somatic in origin or visceral in origin. Remember that pain in joints can be reflected in the joints above and below the joint affected. And there are very very few pains that would actually bring tears to the eyes, torture testicles, renal colic aortic dissections. And if you know others, please put them in the chat. Beware of the silent patient, particularly on the wards, particularly Elly and the very young and do not fall off somebody who is persistent. I remember an emergency admission of the house officer coming in with a painful blue leg and newly qualified. I really enjoying the term FGS do painful blue leg as a result of an a vein thrombosis. The symptoms were fleeting over the weekend and they were seen by seven different senior surgeons including the consultant, the woman was in distress but they perceived the chew ps hamming it up. I didn't write in the notes and of course, on Monday morning when she had the venogram, there was an a vein thrombosis. Remember in your history to think about the risks. We talked about the miasma last week of infection. But the miasma being the environment and the environment in which we live oh contributes to our health or ill health, smoking, alcohol, sun dust. And it is interesting that Sari also talked about nutrition and what you eat. Has anybody being in the hospital before for jaundice, rheumatic fever, TB epilepsy or strokes. And have you had any surgery before? So this 21 year old girl replied that she had not had surgery before and on examination had gross through our gravidarum and all the signs and symptoms of appendicitis and has a red stride. Took him to theater opened up the belly. There's no fluid in there. It looked pristine, but the most remarkable thing was I traced the tino cooler down to the cecum and there was no appendix, no appendix at all, searched the rest of the abdomen for any possible cause of peritonitis and there wasn't enclosed. Two days later, the notes arrived, she had been admitted to hospital previously and had keyhole surgery to remove the appendix. 18 months ago, she des denied surgery, denied anesthetic and said, oh, that's is what it was the important thing. Once you've got the patient's story, isn't to go through a sieve or systems inquiry. Follow these with open questions all the time, getting the patient to tell the story, you gotta listen. But also watch for the visual cues and communication and use plain language. How far can you walk? How many pills do you use? How's your breathing? Any problems eating, any problems going to the toilet with your bowels? Any problems passing urine or water, any problems with the periods, any unusual headaches, visual or hearing disturbances, any problems with mobility? All of these are followed up with the same sieve as in the presenting complaint for how long severity duration, et cetera. What tablets are you on? Look the map. It's a useful exercise in understanding the pharmacology. And it's interesting that my grandfather of 100 and four was discharged from hospital having had a heart attack, he was resuscitated four times down the corridors on 14 tablets, he couldn't even see them, he couldn't even write them, didn't know what they were for. Ask for allergies too often. We put red bands around patients wrists and say they're allergic to something I'm allergic to penicillin. Red banner on the list. So it means they don't get penicillin if they have an infection, but nobody's actually asked what type of reaction did you have. And if they reply, I was told, never, ever, ever to have penicillin don't know what happened. That's important. But if they say they get a bit of tummy ache after penicillin, that's not analogy. So do ask further the one important part of my job and what I enjoy the most is meeting different people. I've met people who have been in the Queen's trooping the color others who designed the spitfire. And when, as a junior doctor I did a locum job with geriatrics. Chatted to somebody who sat in a biplane and threw bombs by hand down on the enemy. They have wonderful stories. I enjoy the stories but taking a proper social history and understanding their dependence, who's gonna look after them at home. How are they gonna get to the hospital? How are they going to go home? All important? I love the surgical paper, the name of the dog. Because if they got a pet, what type of dog is it? What is the name of the dog? Put people in context? Because going back to their graph on the utility of the decision, you're beginning to understand the embodiment of the patient and the context in which they live. And that is important to the decisions that are made. Your examination begins to be honest, when you invited the patient into the room, you got up to the door to greet them. You watch them get up from the chair and walk into the outpatient clinic. One lady who was referred for surgery, she had difficulty getting up and when she got up, sadly, she had been incontinent, her whole demeanor and the lack of the ability to stand, screamed frailty. And this lady was re referred for open heart surgery. Greet the patient with a handshake and I'm pleased to see you all say, wash hands before any wash hands afterwards. But also before you use this, wash it as well, an alcohol gel before and after, in every case, not only just touching the patient, but at the bedside, anything and everything around the bedside too, you have to be comfortable, the patient has to be comfortable. And as you've said as well, you need to be confident. Look the part and confident in what you're doing and respect the patient. Look all the time. Look how they walk, look how they sit, look how they undress. All of those will give you some idea of the mobility and strength and group strength is one of the biggest correlations to nutritional status before you move something. Ask if it's painful and the important thing is also warm hat, have some warm hands. This is the feel and the feel is the lightness of touch. Because if you use anything more than lightness of touch, then you're using pressure and pressure is not feel that's a different sensation and goes to a different part of the brain. Remember even on the abdomen, I've seen people do this on the abdomen, massaging it, but the diaphragm is moving the organs up and down underneath. And a still hand will feel a lot more but maintain eye contact with the patient because they will be too polite to tell you if it's uncomfortable, you will see that width when I started as a junior doctor, the beds weren't electric and you had to pump them up. And there's one way we actually ascertain if the peritonism was serious or not, by the wincing if the bed bounced when taking up to a comfortable height. Percussion is a clinical ultrasound and tactile vocal parameters is clinical ultrasound as well. When you listen, listen for any noises, but for heart sounds, listen between the 1st and 2nd heart sound, there should be nothing in between and the slightest noise could be. The softest murmur. Recently saw an examination on social media where the stethoscope was placed on the chest over the heart, not recognizing any anatomical area, but the patient wasn't positioned properly and had been undressed and listening to it. They were palpating the pulse at the same time. And remember we were made in a sed plain. So you compare the right and left all the time and one of my trainees correctly picked up a coarctation of the aorta by feeding the pulses symmetrically know your anatomy when they examine the patient. And when I'm watching a trainee do an examination, I'm wanting them to know what's underneath their hands. And if you know your anatomy, particularly with CT scans, the the planes c six transpyloric plane, umbilical plane where everything happens. Lymph nodes are your first line of defense. So, examination of the lymph nodes from post occipital, post, regular, pre jugular digastric submental and submandibular internal juggler j chain an external triangle, but also the armpits as well. And everyone will go. Oh, my hand is going into the armpit. You're gonna wash your hands with soap and water afterwards. And you only need to put gloves on. If there are bodily fluids or open wounds around. Don't put gloves on to examine a patient. Please. It sends the right wrong message. Otherwise use all your senses and what you can do in your training is very simply work out what's normal and abnormal. I know the Dutch students, they all examine each other to find out what's normal or sometimes abnormal. Look at color and temperature as well. And the most important thing on your ward rounds, particularly POSTOP is to identify well or unwell and somebody is sitting in a bed with glasses on lipstick on and brushed hair, eating and drinking tea are usually very well. Is those who are quite disheveled or not? And I was called to the POSTOP patient in bed 29 four days following an aortic valve replacement. 75 and sister said c bit nauseous. Well, obviously at 75 pregnancy and does not come into the equation, but four days POSTOP and nausea having opened the chest was strange. She looked pale and went to hold her hand, but at the same time feel the pulse and she burped a fecal B I asked her sister to get an NG tube immediately. We passed an NG tube and 2 L of fecal involvement drained into the bag immediately. She has MS away for an aspiration and near death. They holding the blankets back, had drawn the curtains to examine the abdomen. Cos, hernias and adhesions are the common causes. Those are large, incarcerated, umbilical hernia. They needed attention. Guess what? Having spoken to the consultant, general surgeon and suggested that you may need urgent surgery. They wanted a CT scan. I'm told though I'm old fashioned because CT scans are the quickest and easiest way to assess people's abdomens nowadays, rather than use your clinical intuition or no, I'm not so sure myself. But that being said, you go ahead and continue your examination and your, I need to understand what normal. So what's the normal pressure you'd feel at the foot as compared to the carotid at the foot? You need a systolic pressure of 100 and 10, 100 and 20 for the carotid 40. And this is just a general way of assessing somebody in shock. It feeling all their blood pressures and you could put a systolic pressure there. The squiggle line is listening to a murmur. I joined a ay station and I forgot to take my stethoscope. But I said to the gentleman, can I have a look? And as I looked at him, I noticed the left side of the chest was constricted. There were three scars, one in the neck, one posteriorly just below uh the scapular and a left upper paramedian incision. But there are two little blue dots and he had had Hodgkin's lymphoma diagnosed with node biopsy. 20 years ago, treatment included a splenectomy. He had mental radiotherapy complicated by bronchiectasis due to the chest drain and with the scarring of bronchiectasis and repeated infractions, had a collapsed, smaller chest all done just by looking. And it's interesting to note that some of the medical students looking, looking at the chest said no scars and nobody spotted the radiotherapy dots. Remember to lie a patient flat and examining the abdomen if they can life like because one third of the abdomen is above the costal margin or one third is below the pelvic crest and lay your hand gently in the four quadrants and allow the diaphragm to move the organs up and down underneath. But it is interesting. I had a patient on the table from a cath lab emergency and the team was scrubbing and I went to calf dry as they were scrubbing. Then he had carcinoma of the penis. But nobody had ever looked when I went to the cardiology ward to see another acute patient. The following week, I looked at the clerking of the junior doctor and there was no umbilicus in the clerking and I couldn't tell from the clocking if the patient was male or female. I asked the junior doctor, what about the testicles? A junior doctor said, am I allowed to look well, a bit like breast examinations, testicular examinations are important. It's important to have a chaperone being present. But it's important because certainly I felt in college it's inappropriate to proceed with a major operation if I got questions about their general health. And to my mind, the only time a patient actually had a full M at was coming to the clinic in the hospital and consider this when we drive cars in the United Kingdom, we put them through MIT S every year. Wouldn't it be wonderful? If, if every patient who came to the hospital or saw a clinician had a full m at every time and a thorough examination doesn't take long and practiced 25 minutes in total. And that's not even rushing or hurried that being deliberate and careful in what you are doing. And it's important also because there are some cultures and some sexes and some ages that are going to be embarrassed about testicles and breast examinations. But unfortunately, in those age groups, insects, breast cancer is MS and I'm a trustee of the British Asian Cancer Association to increase awareness of examination and self examination. Remember, we have tools in our patients to actually help us look slacking inside the body. And I love the service. I get it spec savers. We check for glaucoma but look in the back of the eye. And I understand a now is actually making diagnoses of hypertension, early diabetes just by looking at scans of the eye, say a eye. He is very useful in interpretation and patent recognition. And in some radiology, it has been found to be useful but not all. But you always need the human touch. I need to be present. And I'd like you just to think when you were a child and you fell over and hurt yourself, your carer or mother or parent gave you a cuddle, they rubbed it, they kissed it better. They touched and being present and being human. And the right hemisphere is very important in what we do as commissions because this is where the art of medicine is founded on the science of what we've been learning and the joy I put to you is practicing that art and becoming that Sherlock Holmes a master condition. Some of the trainers I've come across in the years were fantastic diagnosticians. James Somerville is the emus professor at Imperial College and see a cardiologist at the Brompton Hospital at a clinical pathological meeting. Two sentences into the presentation said, why are you presenting this? This is obvious, have vast experience and knowledge able her to make the diagnosis like that. The important thing is, is that you write it in black pen, your full name, date of birth number, legible full date and on every page and at the end, you sign it with your GMC number signature, stating who you are and what you are as well. Because these are legal documents. You don't have to be right. You've just got to demonstrate that you've done it thoroughly and you are not ticking the boxes, but you're enjoying the art of practicing medicine and examining people. And I would urge you to have fun meeting new people. That's a joy in what we do. Learn what is normal and practice. Very happy to take questions from anybody. We've been rather quiet in the chat room or any observations. Somebody suggested an ectopic pregnancy as severe pain. I agree. And with abdominal pain, the accident we learned as general surgeons is of women of childbearing age with severe abdominal pain or pregnant until proved otherwise. And if you had that in your mind, you would never miss or ignore the possibility of a different differential diagnosis including ectopic pregnancy. Catch up content is available online. Please share it with your colleagues. I would also like to take the opportunity of announcing a global competition. We want you to use this link two. Put a photograph in a short description of the practice that you're doing at home. The most innovative practice as judged. But Gabriel myself and the metal crew will receive their own set of instruments and I put a set of instruments on the side here to demonstrate to enable you to practice. Yeah. And in this set you get back into scissors, forceps, mosquito ra needle holder and a scalpel blade. It would be our pleasure to send it to you. So all you need is your email, a description and a photograph. When we choose the winner, we will email you to get the best address to where we send the instruments. So I don't think the future looks bleak at all and I don't think the left hemisphere should dominate the right hemisphere in our practice far from it as an eye surgeon as it. For my first slide, the right hemisphere is the embodiment of the professional and puts in perspective what the left hemisphere should be using. Seeing. It's interesting that the observations made on the senses have we. As by im says, we have become more ce and retreated more and more from the senses, especially smell, touch and taste. You can smell a wound of fraction on a ward two or you coli mothers can taste the salty sweat for Children with cystic fibrosis. But as you said, here, we become more and more recreated from the senses as if repelled by the body and sight, the coolest of the senses and one of the most capable of detachment has come to dominate A I have to agree with that because with sight, we get system one thinking and probably the foundation of most prejudices that we see. So the competition again, Bianca is very simple. I would like you to use the link, put your email, a photograph or a model that you've been using at home to practice surgical skills. That could be with a knife, the scissors, the forceps stitching or not tying with a short description as well. Thank you very much indeed for your attention. Thank you Gabriel for the production behind the scenes and thank you for your participation this evening. I look forward to seeing you next week. We hope that that all can be online. My son comes back from boarding school from Kuala Lumpur next week and he's agreed to join me as my esteemed assistant. As we talk about the principles of assisting. We will then take a break over the Christmas period and be back with you on the eighth of January to do the cycle again. We have some interesting speakers coming up and we'll make no in due course. Thank you for attention. Thank you for this evening. Thank you, Gabrielle.