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Hello, good evening. Good afternoon. Good morning, good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon in Yorkshire in the United Kingdom. The immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh and a visiting professor at Imperial College, London. This is your first time to the Black Belt Academy. Thank you and welcome. And for those of you who have registered 50 from 29 countries, I am most grateful and thank you to medal for enabling us to connect across the globe and across all the time zones. We have 4245 followers on Facebook, 1114 on Twitter. I can't get used to saying the word X and 693 on Instagram. I'd like to thank Ami 1/6 year medical student in so for posting on linkedin that he follows the Black Belt Academy. Thank you and also for telling us that people have noted his skills have improved, particularly with a non do doin hand this evening, we're going to talk about gowning and gloving. Now, this is a fundamental skill that applies to anybody at any level going into theater and requiring to attend to the table and it's important to get it right. And I'll explain what I do and relate it also to current evidence. But first I want to put up a poll and the simple pole is, do you know Florence Nightingale Agnes Philip. So Weis neither or both. So it's your chance to vote, submit your answers. Now, please, do we have a, a result? He's just coming in. So it's changing at the moment. So far. A few people know Florence Nightingale both or neither. Nobody seems to both would be a as well. So II can't understand both with IG A not recognized. So if you voted just correct that, but it's interesting, isn't it? Because everybody attributes the work of Florence Nightingale in the Crimea War and the use of carbolic uh acid to sterilize the walls. But nobody knows or few know who Phillips Weiss was. Now. He was born in July 1818 and he is a Hungarian physician, a scientist of German descent, who is an obstetrician. And what he noted at the Vienna General Hospital, there were two different wards, one that was run by the midwives, another one run by the doctors. But what he noted was a difference from mortality from childbirth infection, otherwise known as postpartum pal fever or childbed fever, which in those days was often fatal. And on the doctor ward, the mortality was 18%. Whereas on the midwife ward, it was 2%. So this is another wonderful observational study made by who wondered why the difference. And the difference was so significant that the users of the public hospital, usually mothers of illegitimate Children. I actually started saying I do not want to be admitted to the doctor hospital, admit me to the midwife hospital. So Sam Weiss actually introduced hand washing with chlorinated lime solutions. And he noted the mortality fell dramatically and he tried to publish a book while he did etiology and concepts and prophylaxis of childhood fever in 1861. Now there was a problem. He could not offer a theoretical explanation for us. And his professional colleagues rejected his ideas and in fact, his ideas actually offended some doctors and he became increasingly outspoken about the significant difference in mortality with childbirth fever between the two bits and the need to wash your hands properly. It is said he had a nervous breakdown, but whether he had a nervous breakdown or not, what was interesting, he was committed to an asylum by his colleagues. Whilst in the asylum, he was actually beaten by the guards sustained an injury to his right hand that became gangrenous. And 14 days later, he died of gangrene which resulted from wound from his hand. Now, this was before Louis Pasteur who a few years later developed the germ theory ending there to the miasma theory of germs. They thought that cholera and chlamydia and black death was all in the ether and was transmitted by the environment. And it was only Louis Pasteur and his germ theory reinforced by Robert and Joseph Lister. Then the bacterial golden age came of being, I must just pause a moment because we often talk about this in the Western sense. But what is interesting in the, which is the ancient Hindu text about everyday life, which extends into about 20 volumes written 1200 to 1000 BC C described infections being caused by little creatures, Kro Rimi Kri M I. And when you think actually in the script text, they also described Dalton's theory of the atom. And all this information and knowledge came from the east to the west and was in the Great Alexander Library which burn to the ground. Maybe it's true. All our knowledge came from the east and really, we should start looking in that direction. So we are going to talk about gowning and gloving. And obviously we recognized theater scrubs that we put on. First thing to say with the scrubs is that they should be cleaned and I and after use should be laundered and one time use only and when leaving theater and going back into theater, unless you're in clean areas, you should not be wearing the same scrubs. The scrubs should cover all your undergarments. And I have my clip, my microphone on a t-shirt here. If you've got any garment visible under the scrubs that should be taken off, in theory, the scrubs should be tucked in because of the shedding and therefore this, your top should be tucked in. I don't see this reinforced at all. And I think it's down to personal preference and perhaps how people perceive they look with their bellies. I'm working on mine with the top tucked into the trousers. The next important thing as we know with any clean room, whether it be a kitchen or a laboratory in Sydney theater is actually wear a cap. Now, the cap is going through a very interesting evolution and I really enjoy the fact that people are now putting their names on the caps to identify who they are. And this reminds me this series and the Blackboard Academy is accredited by the Royal College of Surgeons of Edinburgh. The cap should cover your hair. And as you go into any public swimming bath, you are invited to wear a cap because obviously it gets caught in the filters. Those people with a beard need to put on a mask that covers the head and covers the beard as well. And I know during the COVID period, many people were asked to shave off their beards going into theater. No part of scrubbing up is a basic surgical skill and a bit like some Weiss he was determined that hand washing or lack thereof caused infection. This is an interesting thing. This is, despite what his colleagues said. In fact, you could say he was a whistleblower and he was observing the duty of candor to do what is right for his patients because of course, right is right. Even if everyone's against it and wrong is wrong, even if everyone is for it. And if you value your integrity, then you'll be prepared to take a beating from those who do not have any. There is a thought considering the current climate in the NHS and the duty of Canada. So I have set up a mock station for growing. And before I scrub, I also reflect on that tweet put out by a consultant who with righteous indignation said, why are people telling me I need to be seen to be scrubbed? I've been doing it for 20 years and there's nothing wrong with it. That is exactly wrong with it. It's the attitude and because it's always done that way, the person in theater who is actually best at assessing whether you're good to scrub is the appointed theater sister in charge of infection control. And they actually watch all the new trainee nurses and physician's assistants scrub. I sat behind the perfusion machine which gave me a direct vision of the scrub up room and I watched the junior staff scrub. I even watched some of the consultant scrub and I would pick people up if I didn't think it actually met the mark. But I invited the infection control sister to watch me scrub to pass comment. And in fact, if you're entering a theater for the first time, even after watching this evening, I invite you to do the same. It is offering also recognition of respect for the environment that you are entering. And although you've been doing it lifetime, and the problem is with many of the things that we do habitually bad habits creep in. And that is why it is useful to get somebody to observe you on a regular basis just to see if you're maintaining good habit. So the other thing is I'm wearing a ring and all jewelry. It should be taken off for an operation. Although the ring does not have any decoration on it. It does mean that bacteria can get underneath. I take it off preferentially, but provided you clean it and clean underneath, it should be alright. Obviously watches come off, jury come off. Makeup adds to the particle count in theater including eyelashes, the Jardin, the max factor, blink the eye and you get a flash of 10,000 particles in the air and nail varnish as well. And what's interesting when you go in to clean labs, even when I was in Malaysia at the b braun factory where they're making instruments, it was still a clean lab and you had to go through the gowning process when going into a valve factory. There were two stages of going in and going across the line where putting on clean boots and gowns and caps and everything and mask is mandatory. And each time you got to do it, each and every time you leave theater, it's important that you have the appropriate footwear. And we'll just mention the footwear at the present moment because that is important for posture to maintain the arch, maintain your posture. But of course, some of my colleagues preferred boots like in urology when there's lots of water about but cleanliness of hands is vitally important. And I've been looking up online if we've seen a reduction in wound infection with COVID because everybody is supposedly washing their hands and of course, extending the miasma theory on environment. We know that coins, shopping trolleys, 50 lb notes have even got traces of cocaine on them and extremely dirty. You wouldn't believe how dirty hands can be. But even in medical conferences and I read a report where people going to a conference were greeted by their host who intermittently put their hands in their pockets where they had some glitter at the end of the day, people having gone for comfort breaks in theory, washing their hands well, then scrutinize because the lights were turned off and UV was pulled on. And the number of people with glitter on their hands and glitter on their ties was huge bit worrying that, isn't it? So, good habits should be lifelong. And here I've got simulated taps and the water, two things turn the water on and ensure that it's not too cold and not too hot, too cold. It doesn't do the job, too hot. You're gonna damage the skin and make sure the temperature is right. The taps should be up at elbow level because you are going to be using these tabs at the elbow. The whole thing is during this procedure that the fingertips are going to be the cleanest and the water is always gonna drift off your elbows into the trough. The important thing is, and the technique is to do this without getting yourself wet because when you get yourself wet, your g, your g scrubs are not gonna be sterile. Now, what really got me is at one hospital I worked at these were down here and when you're doing three operations a day and you're scrubbing down there, the ergonomics of that really did cause a lot of back strain. So the dispensers are worked with your elbows, the tops are worked with your elbows and you got a nice temperature. We often use sponges on one side is a sponge on the other side. I've just used a kitchen sponge. Here is a brush. Now, I'm using a kitchen sponge this side because this is for scoring pos and you can imagine if I did this on my arm that I am actually going to do a lot of damage to the epithelium and in fact, will increase the bacterial count. So, do not use any scourer or any brush on the skin. The brush is there for the nails, but within this little packet, you'll get a nail scraper. I love the German word, the nuber. And it's a bit like CSI. And I challenge you with maybe a little knife or a pair of scissors. You used your sh or nail scraper to tend to your nails and you do that under running water and you take out the gross dirt. You can imagine there's more than just dirt as we know from CSI programs. You take that out and you get all the skin of every surface in every way you are scratched. A nut is cleaning the nails. The next important thing is then get it, use the soup, the soup with either chlorhexidine or iodine. It doesn't matter which one you use. Personally, I use the iodine because it felt better. The chlorhexidine on my hands just gave me a funny sort of funny feeling. So I preferred to use the iodine and what you need is a good lather. So, a good wash of the elbows from the hands. Good soap on the sponge and you can soap your hands and soap all the way down to the elbow, both sides and each of these washes I do for a minute. It's interesting that the NHS actually say you do it for however long it takes you to sing, Happy Birthday to yourself twice, which is an interesting concept, singing Happy Birthday to yourself twice. But part of the washing is setting up your mindset as part of that ritual. So if you've seen any expert golfer or sports person, they go through visualizing what they're going to do and they got little texts of fingers or peculiar movements that they repeat each and every time before they do this and in the same respect. And it's interesting in the World Health Organization, evidence that the ritual of this helps the surgeon focus for an operation and helps you rehearse and mentally prepare for what is ahead. When I introduced briefing and debriefing to the hospital in 2008, I had posters up around theater saying call me David, we are here to focus on the patient and if there are any issues do not hesitate to raise them. And that was theater enabling everybody to focus on why we're there. So some theaters have got thermostat control. Other theaters got a hot and cold tap, but make sure the temperature is right. So I would lather both hands a good, good lather twice from the fingertips down to the elbows and wash it off each time and let it drip into the trough and then take another three washers. And the three washers are designed to actually deal with the common areas that are not covered by washing your hands. Those are the backs of the fingers, the interosseal spaces, the palm of the hand and believe it or not around the wrist and around the thumb. So it starts with a series of movements that covers all those areas and how, which way you do it or ritual. It's useful to get into ritual in a habit of doing it. Good lather. And I'm gonna rinse that off that. A drip. My hands are always above my elbow because now you'll realize that my hands are now becoming the cleanest part of me as I scrub. So a second time good lather, good soup around the hands covering those areas, making sure that those green areas you see of my hand are thoro tender to that. You rub the back of your fingers and the palm is a good trick. Let you interdigitate your fingers. You rub around the base of your thumb and you do a thorough rub around your wrist. I didn't drop uh the drips into the trough one last time remembering that if at any stage, I inadvertently touch the taps or touch something, I will need to add a wash. And there you go. Pause for a moment. Make sure the excess water drips in to the trough. Not down your front. I must confess and apologize to all the scrub nurses who were with me in theater because I ended up with the water all over the floor because I turn around like that and drip off my elbows. It was all over the floor, at least my front was dry. And I joked with him. I said, well, yeah, I'm terribly sorry about that. Perhaps the floor needs to be cleaned as well. Ok. So you're gon pretend I'm not scrub for a moment. The gowns come in pax and these packs need to be put out on an appropriate sterile surface. A stainless steel trolley that's been wiped down with alcohol and has been properly opened with drapes. They are usually two such that the inner drape is the most thorough and the center bit is sterile as well. So when you open the pack and put it on, make sure that you peel the pack all the way back that you're not going to touch the inside and you fold it back and you place it carefully in the center of your sterile. Fly. The center as in your fingertips is the, this again has also got a number of layers that you need to undo the inside of this is tha so you take the corners out and you make sure you open it out properly across the tray. All of that is sterile. When you open it, you have got two towels and a gown, the gown is folded, such the outside is folded on the inside of the gown. So remember you can touch the inside as you pick it up, but you don't touch the outside. So back to I've got let my hands drip and dry. The important thing is is that your hands need to be thoroughly dry to be able to get on the gloves properly. And there are a couple of mistakes that I observed when scrubbing, you'll get a towel. Now, the towel is folded in half. And actually, if you open the towel out like that, I would use the top half to squeeze and dab around my fingers and around the palm to make sure my hand is clean. I then dropped that bit and use the bottom half now to dab from the rest all the way down to the elbow and off. Now I'm deliberate about that because one of the common things people do is remember the extreme bit, your fingers are clean. And if you go from clean down to your elbow and then do that, you have taken the dirt from your elbow back up your hand, so it's to the elbow and then discard. So the second thing is that don't scrunch it up and think you're doing everybody a favor by scrunching it up and folding away because you're scrunching up a dirty part of the towel and it defeats the object. Repeat the process with the other side to repeat two halves, the top half, I'm going to do with my hand again and make sure my hand is thoroughly dry. Drop that half, use the other half and now I'm going to dab, I'm not rubbing because rubbing is actually upsetting the epithelium and releasing bacteria as well. And I'm ding all the way to the elbow, catch the drips and I it off. Now your hands are your cleanest part of you. They should not leave the anterior pectoral lane. They should not go above the clavicle and they should not go above below the umbilicus. In, in essence, this is the area one in karate or your Susu, which is the xiphoid plexus. That is the level your hands should be. Should you inadvertently touch anything, do it again, another scrub and we'll come back to repeat scrubs in a moment. So the next thing before I pick up the gown, the gloves come in a folded pack and they folded with the left and right and they can be opened up on the same surface and we'll come to those in just a moment. I'll just hold it up. The glove is folded in on itself there with the collar, we cuff thumb and the fingers and we'll, it's important to know how to pick those up properly. So let's come back to the gown. Now, you need space to put a gown on because you do not want the gown billowing out or touching anything, the walls, the size, etcetera. And it's very useful to have a scrub nose there to help tie it up and also to secure your gown. But as you open the gown, you're looking at the inside and you hold it by the shoulders as you can get your hands into the sleeves as I've got there on the inside and let the gown drop away from everything. So it's dropping freely and you literally shrug your gown on. And it's at this point that you do not let your hands leave the gown. And in fact, between the white cuff and the gown, grasp that piece between your index thumb, finger and thumb, hold this position for a moment while the scrub nurse ties you up in the back according to your comfort to secure. Now, this comes to how you put your gloves on. And the best way to put your gloves on is to put them on clothes. In other words, your hands never ever leave the sleeve on the gown. You can see now as I put that on, I am standing on the inside of the gown, but the outside has not touched anything at all. And the outside of the gown is now the most thorough. So therefore, keeping my hands inside the gown is respecting the sterility on the outside. And we got to put our gloves on. So finger and thumb holding the cuff and I'm gonna put the glove on my forearm and between my finger and thumb, I'm going to grasp the cuff only of the glove. You see there, the cuff only of the glove. And I've got thumb to thumb and the fingers are pointing down my arm. I then take the cuff between the finger and thumb inside the gown, grasp the cuff and I fold it over my hand that is inside the gown. Let me just do this. I'm falling over my hand inside the gown. So you haven't seen my hand come out and I can pull it over the gown and help the gown come on by pulling on the sleeve and pull it down. You didn't see my hand come out. I folded over my hand and there you go, I'll adjust the tips in the moment. Obviously. Now, my hand is the most sterile part. It hasn't been on the outside. I can easily pick up the other glove and repeat the process, finger and the thumb inside the gown at the junction between the cuff and the gown. I am going to pick up the folded cuff of this glove, thumb to thumb fingers on top down the arm and I'm gonna fold it over and my hand opens up and I can adjust. Ok. Now, what size glove, in essence, if you have a glove too tight across your fingers, that will cause numbness in your fingertips. And you will not feel. Secondly, if it's too tight to lose, you've got lots of, ah, at the tips. So it's got to fit around your fingers carefully and snugly, we not crinkles and no, and the tips do try different sizes. In essence, the gloves should slightly flex your fingers because the hardest work actually in surgery is extension and your hands, as we have described previously and how you hold the instruments is better held in a functional position with slight flexion because that's how you're holding your fingers. Now, I can now enter the operating room. Great, the scrub and the one hand of the tie has an invitation. I'd like to call it or take it for participation. You pass this to the scrub nurse who hold this and you deliberately turn around and I'll put it on the surface. You deliberately turn around and receive the other end and tied up. You are now gowned and loved your hands a bit like the master should stay, stay close together and over your tan, they should not go above the clavicle, they should not go below the waist and they should not go beyond the petro line. And that is the space. And as you're walking around to have your hands gently clos in front of you is the best place to keep them. Once she arrived at the table by imitation, you can put your hands on the table and the surgeon and the governors can see what they are and employ them hopefully to good use and we will be discussing assisting in two weeks time. So the thing is, how long should you scrub for? Well, you're scrubbing with soap and whether it's Povidone iodine or Chlorhexidine. You're really removing the soil and dirt from your hands. So, if you're in a hobby, like mechanics or gardening, please use gloves for your mechanics and gowning because otherwise you end up with all the dirt underneath your fingernails. And of course, you wouldn't want to go to see a doctor with dirty fingernails. I recall when I was a registrar in Oxford, I had the junior staff lined up and we didn spec for haircuts and for fingernails because you needed the part, the part your fingernails are too long if you cannot properly. And if you find when trying to pers that your nail is digging into the skin, remember, they'll be talking about next week. Does the scrub nurse tie the invitation card as to not drop hands? Yes, we have a question from Grace. Does the scrub nurse tie the invitation card as do not rub hands below umbilicus or do you tie it above umbilic? The scrub nurse literally holds the card. You turn gently round, receive the card back and then you tie it appropriately depending on the size of your belly or you're tying it around the waist. Some gents will be below the belly and other people around the waist, but you're tying it comfortably around your waist and in front of you. So I'm fully gown and glove. So if you look at the World Health Organization, how long you should go for? Well, it's interesting. I would say that I'm mimicking the good recommendation in so far as that you're cleaning your nails, both sides. That's a minute. You're doing two washes of your arms from fingertips to elbow. That's in a minute each. That's three and another three washes of the hands, which is five minutes in total. What's interesting is that the more you wash, the more likely you are to actually start damaging the, the skin. So it appears that 4 to 5 minutes is a maximum wash. As I've described at the beginning of the day, if you scrub for 10 minutes and particularly if you start using hot water or a scouring brush, you're going to increase the bacterial count in your hand. This is interesting though, in fact, the best bactericidal we get is alcohol. So therefore, once you've done a good scrub at the beginning of the day to remove all the dirt and remove the dirt from underneath the fingernails. Between cases as long as there's not a long period or you haven't left theater, an alcohol rub is sufficient if however, you take a comfort break or have lunch or leave the theater and come back. I think you need to do another soap wash. And thereafter, between cases, particularly if you got a multiple cases on the list, you can describe alcohol and the advantages particularly in countries where water is a scarcity that it's effective, it can last up to six hours on a gloved hand before the bacterial counts start coming back to normal and it saves water. The other important thing is it dries quite quickly and the dry hands and particularly having dry hands is very useful for getting the gloves on. What's interesting when I first started surgery, a lot of gloves came with talc powder in it to help you get the gloves on. But actually, the talc itself caused a lot of tissue inflammation and scarring and have been discarded. Part of doing this correctly is part of the ritual and mindset. And it's quite interesting and you can observe yourself. The expert surgeon will wear the hat in particular way, ears tucked in ears, tucked out your note. They put their masks in different ways as well around the ears over the top bone, the top, they all have their little peculiarities, which is all part of setting the mindset. And it's interesting that surgeons go and scrub at a particular t and I recognize it myself. I let the junior staff scrub and I can watch them, they go and drape and prep up having, watch them do it properly in the first instance and confident they're doing it correctly. And I'd have the peace and tranquility of the scrub room and going through the ritual of washing hands, rehearsing the operation and setting the mindset. So I hope that has made sense to you. There's a lot in the literature there of good practice. Bad practice, et cetera. I think I've summarized what's nice recommendations. NHS recommendations and World Health Organization. And please pay attention to the scrubbing because it's the attention to the little things and practicing yourself and maintaining that discipline applies to every aspect of surgery, not just washing the hands. And if somebody says sorry you touched something, say thank you very much because in that moment of scrubbing up, you might not be aware that your gown has touched something or your hand is inadvertently touched an AAP. Thank them for it and do it again. It is all part of that learning process. Ok. Mr C is actually saying that in the theater orthopedic environments, the space suits and Charlie suits are there. I'm not familiar with gowning up in Charlie suits and I would actually have to default and learn from the scrub nurses and people in theater. I would not assume that I can walk into an orthopedic theater and put on a Chinese suit. So I do not know and repeat hand washing should be discussed as part of your team brief and the culture is best verbalized and discussed. So everybody understands the cultural norms. So it should be in order for people to pick other people up. If they see an inadvertent touching of a nonsterile surface in theater, there should be the inner core or the surgeon, the scrub nurse and assistant who are gown and the outer core of people who are moving around theater. I suggested in our theater that if you could not name the patient, the age or the operation, you had no business in theater. It out of respect for the patient as well. I tried to introduce that to no avail. And of course, our theater door was opening 60 times an hour and people would wander in and out at will. The other thing is the masks. One last thing about masks and we all forget about the arguments about COVID masks, etcetera. All it is doing is stopping the natural spittle and spray when you talk. So anybody looking over from the anesthetic end should have a mask on but try telling that to some anesthetists and it should cover both the nose and the mouth. The other important thing is that if you've got a cold change, your mask, obviously with every case. But if you sneeze, don't turn away from the wound, if you sneeze, sneeze directly into the mask, facing the wound, because it all blo behind you. If you turn to the side and sneeze, you're pointing the exhaust towards the wound. So if you ha do sneeze, sneeze, get your head high away from the wound, sneeze directly and the exhaust is out the back and not into the wound. I would like to invite you to do a simple observation study, watch how people wash their hands. I'm also astounded in the modern era watching people and I taking comfort breaks and using their mobile phones during comfort breaks as well. So, the last, my husband were environmental dirty thing, apart from 50 lb notes and coins our cell phones and what I loved I saw on Twitter in Japan, in the cloakroom, they have a sterilized zinc unit built in to the WC to sterilize the cell phone. But cell phones are also very dirty. So, thank you very much for joining the Black Belt Academy of Surgical Skills. I've enjoyed your company this evening. We'd love to hear your feedback and please, if you've got any questions, submit them. Now, Gabriel, do we have any questions? Would you like to add, add anything? And my fellow send a Mister Christopher ca is online as well. So any comments, no questions at the moment. But if Chris has any comments, then I'm sure everyone would love to hear that. I think one can take a certain pride in how well you scrub. I worked with a consultant Mr Lincoln who said I can tell how good a surgeon is by how well they drape. I would add to Mr Lincoln's observation and take it one step back. I can tell how good a surgeon is by their attention to detail. When they scrub. There's a thought. Remember in theater your hands around. Yeah. Xiphoid susu clasped. Never stand with un folded or under the armpits. Not good. Thank you for your attention. Wish you well and see you next week when we talk about history and examination.