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uh huh. Good evening. Good afternoon. Good morning. Good day. Whatever you are in the world. And thank you for joining the Black about Academy of Surgical Skills. My name is David A. Regan. I'm a cardiac surgeon and Yorkshire United Kingdom. The past director of the faculty of Surgical Trainers with the War College of Sessions of Breath, I had a visiting professor at Imperial College, London. If you're retaining, thank you very much. And if this is your first time, watching the back can be a surgical skills. Welcome. I hope it makes sense. What I love working with sewer and fill the metal is the inability for this. Now to be interactive, you can put questions, name the chat room, and full will ask them. And I will answer as we go along. If you're confused or want toe, have anything particular addressed. The good news is, is that the black male Academy a surgical skills will be live face to face in Sheffield on the 27th of July. And we've just confirmed we opening in. How? With my fellow sense A Michael Grisman. Thank you very much indeed. I'm I hope to see soon. There I've also put together a very exciting project with John Riley, a very talented musicians Sheffield, and we've put on not time jingle to music. So watch this face. We'll have the video and the music to help your tie a one handed surgeons not come to that later in the Siris. If you got any questions, please put them in the truck. Please ask the questions arm website before you join, and they're just looking through your answers. Flow on rhythm on Maurine important than speed. I do not teach speed. The first instruction I had is a cardiac surgeon was just me quick. That is meaningless. My mantra is no hesitation. Deviation, interruption, repetition That is all about getting yourself set up correctly because remember, rhythm and flow is simply removing wasted movement and wasted time as you would see the rocking of the heart in the chest. It's also important that you aren't deliver it and you do it right. First time, No hesitations. The relationship with your team in theater is of paramount importance and us a surgeon, a setting the tone safety likewise, is of paramount importance. Your own physical and mental preparation is important traffic and theater, increases the airflow and increases the potential off contamination. I did a study that looked at door opening and closing in my cardiac theater, and it was opening and closing 64 times an hour, I said. That wasn't an opening and closing. It was more like an oscillation on. The most important person in theater is not the surgeon, the scrub nurse and me through just does the patient and then any leadership role in that high performance team. That leadership role is taken on by the respect of person at different stages of the operation. Your own leaders, you all equal. But the most important person is the patient. Just respect to them, respect of the tissues and respect off handling. And that's where the Black Belt Academy comes in, because I want to teach flow, rhythm and likeness of touch. But Lawson port on you. The mindset that is required. I come back to quoting from secrets and martial arts masters. And this was me, um, you to massage the undefeated summary one. We're in 16. 43 talking about this water scroll. The state of mind. Remember substituting martial arts for surgery on worry of For surgeon, the state of mind and martial art should be free off subjective bias. Your eyes are to be unfocused in a manner that maximizes the range of breath of vision You're striking, or seven should be without thought or form, just to considered the most important strike and should be refined in practice again, again and again. We don't practice until we get it right. We need to practice until we can't get it wrong in a school of entrance. There's no evil ineptness, but only good wisdom, logic and the way exists. When the mind is empty on the classic contemporary version. Off this empty mind or mushrooms, it's described by Bruce Lee be like water making its way through cracks. Do not be a setup, but adjust to the object and you shall find a way around or through. It stays rigid afterwards, disclosed themselves and to your mind, be for Ms shapeless like water. If you put water in your cap, it becomes a cup. If you put Washington bottle, it becomes a bottle, you put it in the tea part becomes a teapot. Now water can flow or can crash be water my friend the water because the records of your attitude and demeanor will ripple out through theater itself. So how does one obtain this? Well, the first one is to relax when we talked about posture and standing with your shoulders down hours by the side, and you've got a lot of major muscles of the apple and relaxed. More importantly, you have isolated intrinsic muscles of the hand where your lightness of touch is going to come in. Breathe. I know when trainings to start operating. They hold their breath on the course that you're hold your breath, the carbon dioxide goes up and your tremor gets worse, especially when operating my trainings will rush. Remember me asking them to sing a song? What hum a tube? Great. The ability to unfocused in order to become hyper where your surroundings is essential as well. This process may help you prevent eye problems later in life. The negative Americans refer to this wide angle of vision. Is our eyes Yes, the I teachers there special agents Spectravision. It is known in the military as 1000 yards staff flows achieved when a person skills are fully involved in overcoming a challenge that this now is very manageable, this process access abandoned for learning new skills and increasing challenges. The challenge is a true small. They want it gets back to flow by raising the degree of difficulty. The challenges are two great. One can return to the first eight by learning new skills, and that is what we doing in the Black Belt Academy. I am trying to offer you techniques enhance that. How to improve you operating. So the next are hard. On my list of Relax is the ratchet, and we said that we holding out needle holder, an addiction sign on were literally taking it off. Abducting. Seen a evidence? Look, I wasn't demonstrated that you can pick up your needle without putting the ratchet on and hold it gently on. Use the cuboidal shape of the shaft of the needle to Mabel the needle to flip into place. The next most important thing is rotation. Rotation is a lining. The needle properly 90 degrees, a crossword to one stitch 90 degrees into what you just want to stage on. Then you literally let the needle do well. On the years I'm curve for the needle. Have got to be used together in the same way. If you're throwing a ball, your throat let go in one through it. Movement you don't for a ball stop. Let go. It's one through it movement. So I want to just show you a novel moral that have come up with this week Week to help you with the place Point. Rotate on. I do not use plastic I'm using organic materials on I think you'll like this one. I'm taking you to the overhead cam. And what you see on the table here is I've got a boiled egg and the bone decay is there for the yolk in the middle. What I've gotta surrounding it that I've taken out and I screwed maker whites on. I'm using this model on purpose because I'm here to stitch around this junk. But the important thing is I'm going to rotate. But the rotation coney happened with a place point. So for places on that edge 90 degrees across what I want to stage, I'm going to write, take the needle. So I'm taking it into the gap between the yolk. Right. We're taking it through. Remember that the tissue holds the middle of place picked it out. I was their ready to use again. I think the first instance. Just try this yourself in one area. Now. Nobody said this was going to be easy. Uh, this is life. First time I believe ever on any surgical program. Uh, what is teaching me is the back would rotation necessary? Two point. They need a between the yolk in the white, because if I'm clumsy, it all starts scrambling. Beauty of this model, It's already I'm testing the place, but I'm testing the point. A note. When I go from the place to the point, I'm rotating back and it's in that movement on automatically unlocking my new holder neighbor may let go of the needle. Remember, as I came around the shoot, I am a circle As we went around the banana, I now need to prove my weight distribution. That's the posture and angles to my left foot in the back hand stitch. I can continue by sitting around and what I wanted to do is minimize the disturbance to the hospital. If I drop my needle holder into this, I'm getting to you Really tear Things are and if you clumsy, you can see that I've lifted the yolk itself. I'm gonna come down close of you because I love this camera, thanks to Andrew Life Sciences. And my friend came in Austin at wet lap to give you the best of you. Now I'm having to really concentrate. But this comes back to the empty mind scroll that I mentioned. Too often the models of use into teach seven do not give you feedback. Not challenging because there's not making you think about your rotation or making you think about your place Point. There you are. I've come around full circle pharmacy egg, and this has got to be a first in any surgical discipline. You can see if I'm rough. That's just what happens. So I've got here some egg whites in cubes that we're going to use this for a study to investigate the passage of needle tissue. So the idea is to come through the edge and come up to the middle, pick it out. 10 a needle over and come back this way and again. You'll see. You know, four sides on this especially could use a bit of gelatin. But what did you use a quite because of caution idea for research idea. So using creative thought here, really, it's a 400 back in for each of those we often find March atraumatic needles for stitching liver Today go to that point. It's a big needle. Can you take that all the way through on the curve? Pick it off with those scrabbling the egg, so there's a very nice model for practicing your rotation. I've shown you the banana more previously, and here we have it. Your note that I've seen I/O of this, but not you don't need sutra or you need is a needle. And the idea now is I've gone around once. That was an error that because extra hole. But you see, there's a long time where the needles come out. If I was going to criticize myself, I've got a bit of a skid there, but what I'm going to do now and see if I can get around this again and come out and exactly the same spot are you on. This is where is being consistent. I'm reliable, Mr Spot there, but look at it in a moment because with each of these. Welcome Demonstrate how accurate is stitch in years. But seeing if it comes through the same hole like that. And I'd like to see example some photographs from you. You just the same. Taking up a core to been on it. And you take your you know and I want to see this group. You see, that needle has come up now. Certainly beyond that Whole says, giving me feedback immediately on accuracy. No, my vest are being around 12 times on the maximum deviation I had one home was 2.5 millimeters. Know that I'm not speeding, but once you start doing this, you got your place Point take pick up. I was right as previously described. Then you will find you do it, develop a natural rhythm and there's a natural flow and there's no compromise at all at every stage off this process, I could be here for an hour practicing this and forget that you're there's an audience because I passed me find this is a completely impossible morning. So what does that mean when you're coming to stitch tissues now? Previously introduced this and literally I suppose you've got an English breakfast models this evening because I've offered you X. And now you've got bacon. What I like about the bacon is it too. And if you can't get back and I believe Turkey bacon is likewise very good. But I've got a girl check studio here on were gated your continuous closure. Remember, the point place retained applies. And every stage now two edges is sitting together there so I can take him in one year and put it through gently. Note my full come to forceps skills next week. But my forceps in there to help my needle location They're not there to grab the needle and rotated for you there, There to retract tissue on exposed tissue Needle is actually held on the tissue itself. You know what I like about this bacon? Moral is again. If you're very clumsy with your placement of your suitors and you need a rotation, it will tear out. Likewise, If you pull the suitor through too hard, it'll also tell so for a rotation and lightness of touch skill, I think this works very well and notice I'm doing this in two now because the two edges are not sitting together I'm not rushing, but I am being delivered and careful and all my stitches doing. So I hope you can see that this is now getting to that and really hurt because I'm going in at 90 degrees and I'm coming out of 90 degrees. Other important thing about continues teaching is that should be regular. It's another all in picked up the issues in that movie. Another are in stitch in regular. Can you make it was teaching regular. So the models have offered this evening. Oh, teaching year invitation and you see that I've just stopped myself. The ankle wasn't right on. It wasn't at the tip off the needle. Harder lost its I'm not happy with. And no matter how experienced you are, practice does how now I was in a competition on Sunday for karate Carter's I was in the Black Belt Need group, where they called out when you're out concert that you have to perform. And the interesting thing is that there have been doing martial arts for 10 years. I've been practicing it in Mid Asia. I've noticed that I could nervous in competition. Obviously, I'm not medicine theater, cause I've been doing that for 30 years. But I was nervous in competition, and I go to one part of this continent on that, honestly, had a mental blank. I've forgotten what my next move Waas and somewhat embarrassing. But it toward May and you're still messing. Is that when you practice? I've been practicing? Does your practicing facing one particular way practicing at home? I have not seen Randomizing. My house is from one to another. They called me unawares to suddenly start the Carter unannounced, not having gone through the five previous Carter's beforehand, and I thought to myself, I need to practice more until I can't get it wrong. So if I'm looking at that stitching, I would like to see. I'm not happy with that. I've started to you that, but what's happening is it's getting regular on. At least I'm not tearing this out off the vacant. As in golf, we've just had the Masters. You're only as good as your last operation. There's no room for complete Cincy at all in surgery, and you can't think, Oh, good, cause I've done hundreds. You got to go in mind like water and think you're doing your first time all the time in your practice until the concrete home. Yeah. Important thing about doing it right and first time that I think is very different to the practice of surgery. Another philosophy of mine is that we are in a privilege service industry on in the service industry. You don't get a second chance to make a first impression. Just think about that amendment and think about all the customer service encounters that you have in your everyday activities. Whether that be in a restaurant, a bank, supermarket, whatever. You know, when you have a good service encounter because you walk away feeling good now, which forgotten ization in the world Do you think this is your question to answer for next week? Which organization in the world do you think exists on the principle of making you feel good immediately in other ways? Five out of five satisfaction. I don't ask you. Do you ask your patients if they're satisfied with yourselves? And I've been doing that for 19 years and I ran it, uh, 92.6%. Five out of five patients. Obstruction Now in the service industry, the difference between the five out of five on the $4 or five is a 75% full. And football I'm sharing with you a lot of philosophy this evening on I do so because surgery is not just taking it is the whole package. As in martial arts, it is the whole package. So your relations with a team I'm important. You as mine like water are sending ripples through the team, hopefully not waves crashing in the theater door. I hope this evening that I've demonstrated a couple of extra models for you to practice on. I like for you to send me photographs of your own practice. I particularly like the perch take Okay, which was the first bolded practice that I think as ever, being bored. Cast in a surgical education program. I do have a questionnaire on this website asking you to identify two out of 10 slides that have a perfect 90 degrees. This is be interesting. I believe that you'll spot them quite easily because we're surrounded by 19. Your note for most of them operating. I did not use the forceps because the tissue is holding the forceps, the needle to allow you to pick it up and use again, and it's the passing through and pick it up. Use it again. It's a natural rhythm, a natural cycle, no Michael flow. And it's interesting. There are published studies in the American General Medicine JAMA looking at flow related to Arkham. Now this WASP with that Proscar pick surgery, where they had a laparoscopic operation score on flow by 10 professors and that diarrhea rectal correlated with out. The interesting thing is, is that the same videos were shown to lay people patients, and they spotted the same foot. There's nothing from right was mind like water. Next week we're going to continue by bringing a non dominant hand and talk about the forceps. What's interesting. Every time I've introduced forceps and stitching courses, I suddenly find, well, the principles of stitching that we've told appear to go off the window. But that's why we practice them simply before bringing them back together. I sincerely hope this has made sense. You ladies and driven. Thank you very much indeed. We're joining the Black Blob Academy and surgical skills. I'd be delighted to take questions. Film If there any questions, do ask, uh, offer anything like thank you We've got some answers, Teo. Your questions invites which slides have lines are 90 degrees. Um, it has said CNF we've got a few other comments in surgery. They say you must have a hand like a little from having, um that, um Who said that? I heard if my mom a type that in said, I want my heroes And Cedric and Phil and the other questions I've got a few more comments are ent says Wow, really nice on. But John Road has said Master class, as always. Thank you very much indeed. Drunk your number one top fan for black Belt may. So, ladies, gentlemen, thank you very much indeed. Joining us This is sweltering here in the u. K. But I appreciate it the extreme weather that many people around the world have to live in and we have just got two days of it on the system seems to be forming about but thank you very much indeed for joining the background Academy of Surgical Skills. I'll see you next Monday. Thank you to meddle. Do encourage your friends to join and follow. Do send me pictures on broken two questions and ideas. I hope you like broadcast. Good evening. Good night. Good today and be well