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Hello. Good evening. Good day. Good afternoon, Wherever you are in the world and to the Black Belt Academy of Surgical Skills. My name is David Reagan. I'm a cardiac surgeon in Yorkshire and United Kingdom, the past director of the Faculty of Surgical Trainers for the Royal College Assistance of Edinburgh and a visiting professor at Imperial College, London and the Masters in Surgical Education Program. In the past couple of weeks, we have covered history and examination. The principle of what we do is to serve, but in being able to do that highlighted last week, it is important to look after your own physical and mental health, including your spiritual and emotional energy levels. For those of you who are observant, you will see that I am now carrying a third bar on my black belt in karate to mark my journey through the martial arts. And to date, this journey has been purely technical skills. And it's interesting to note the last physical examination for martial arts for me is in four years' time when I can do my fourth done. But that would be the last physical test, and after that your progression is measured by Pierre Endorsement On your contribution to the arts of martial arts. I also reflect that I spent many years learning basic skills, and it is true. Once you get your black belt, then you really and truly begin to examine and reflect on what you're doing and why. Which brings us to the title for this evening's presentation court. Make a stand and in the first instance of what to draw on that value proposition of serving and looking after other people but also looking after yourself and reflect on the motors text The Book of five rings in the practice of every way of life, every kind of work. There is a state of mind called that of deviant if you strive diligently on your chosen path day after day. If your heart is not in accord with it, then if you think you're on a good path from the point of view of straight and true, this is not a genuine path. If you do not pursue a genuine path to it's confirmation, then a little bit of crookedness of mind will later turn into a major war. And this is the essence, I suppose, of the GI Guy, as we discovered last week, is doing what you love doing, what you value doing what you paid for. And it's all coming together in one overlap in a van diagram. We are in a very privileged industry, a service industry, and we're here to serve. And I asked you in our previous lecture, to reflect on what it means to you as a customer and what does good service look like? And when you get good service, I'm sure you will agree with me. It made you feel unique. It made you feel special, made you feel a sentient special human being. And I think that is where my values and philosophy come from. It is to serve. I was then, reflecting on the Hippocratic oath that some of you have medical students have taken. And at Southampton. When I qualified in 1985 we didn't take such a earth. But many medical schools still do, and that Earth was to prescribe only beneficial treatments according to your own abilities and judgment, to refrain from causing harm or hurt, and to live an exemplary personal and professional life. When I read that in the way of the warrior and martial arts. It is much the same because, really, what dictates this all is your values. But it's not for you to impose your values on the patient. It's what matters to the patient and their values. They count, and you are there to serve, to realize what their needs and hopefully meet those needs within your limits without evasion, equivocation or mental reservation of any kind. And this means that daily clinical practice and surgery in particular presents sometimes some difficult conundrums. And it's not black or white. As you see behind me, there are 50 shades of grey grey, and it is quite reasonable to hold two perspectives in your mind without making judgment. If you look at it from one way, as we said before, that looks like a blog will turn and 90 degrees it's a cylinder, and it's important that you put yourself in the patient's shoes. And for those of you have been patients. It is an eye opening experience to walk in the shoes of the patient because that is when you start to understand the complexities of clinical practice and situational judgments that our time dependent and context dependent where you have this fusion or intersection of values, patient values and your values. Now, if they're in synergy, there's not a problem they're not in. Synergy is not for you to impose your values on the patient at all. And one example for that in surgery is dealing with patients who refuse to have a blood transfusion as Jehovah's Witnesses. Now, I am very happy as a cardiac surgeon to operate on patients who refuse blood transfusion because an accomplishment is patient. I am happy to describe the risks and benefits of their decision, and I respect that decision. But I'm also comforting to my abilities to deliver operation without any blood loss. And I have operated on a number of people who have refused blood transfusion. But in that consent, I have understood and met the needs of the patient. But I think that will become somewhat more difficult. If I was a pediatric cardiac surgeon and the parents refused transfusion on a child personally, I then I would have a degree of discomfort with that decision because it all depends on the individual being capable, encompass mentors in making that decision, and the third party is making that for somebody who's not in legal terms of of a mature age. The point being is that this means there is a myriad of possibilities every day in our clinical practice. And we have to, as clinicians do, what is right according to the evidence and best practice. But also we need to do the right thing. And if you don't feel valued or if you don't feel your values are synergistic with the organization which you work, the best advice is get up from the table and find a community of practice that shares your values. But that's it is the moral imperative of training surgery, and being a doctor is not teaching you the facts and figures is teaching you to be and to become the best you can be. And as we suggested last week, that starts with a reflection of yourself to understand how your own attitudes and your own values positive, negative seen unseen, and that djuhari window of the unknown dictate your behavior and therefore your conduct. Because if there is synergy between your attitude, behavior and conduct, we would all agree that is integrity. And if there's a dissonance in that I would say that somebody's decision genius So the ultimate of human studies. It's knowledge of yourself to understand your own biases and behaviors, but also to seek feedback and reflect on what you're doing in everyday practice, because that is the way you grow and you develop. It's not just reflection in this book called Anti Fragile. Learning to Thrive through Disruption, Challenge and Change. The talk by Dr Page Williams was a reflection is reflecting moment to moment. I want to put up a pool for you to answer these questions, please, on growth, reflection and whether you are courageous. And so you could you put that pole question up for us. On growth is 1 to 5 strongly agree, as five strongly disagree is one. I experiment with new ideas, a new way of doing things take on challenges that come my way. Reflective. I refried quickly take time to think about the impact of my behavior on others, and I regularly see feedback about my work courageous. The work I do is important to other people and the things I do contribute to society. So if you'd like to do that Pole, please and answer those questions and think about it yourself and what it means to you. Thanks. The normative ethical philosophy is very simple. It's the golden rule that is described in most scriptures is you treat others as you would like others to treat you, and I think as a simple philosophy and a simple value that should be our guide, Our moral compass for what we do and you've got to stand up correct. So standing up is not just the physical posture of standing correctly, but standing up straight is emblematic all of your justness and uprightness in life and actions. But let's take this further and talk about the impact of standing up and standing straight. When you were born, your spine was curved, and when you started to lift your head, it's 6 to 9 months. The cervical lordosis started to develop, and when you started to walk the lumber lordosis developed as well, giving the spine It's characteristic shape. Now. Their shape is important because it balances the stresses and strains across the ligaments and muscles of your spine and standing upright and standing properly preserves that because you're more aware than I am of all the joints and facets of the spine. And, of course, all the nerves come out of parameter. After years of surgery, I had a 95% C five C six foramen occlusion on my left hand side on my right hand side. There was giving me neurological pain in my hand, and that was from where and 10. I'm interested to note that in the questions before this, not many of you have been told about posture and how to look after your spine. And I'm extremely grateful to Vanessa Landsberg, who is a registered physiotherapy and Pilates expert who has put together a sheet of exercises that you can do to improve your spinal health. Because Joseph Pilates actually said, You are as old as you are spying, and I like that. And in essence, when you're standing up straight from the label, your ear to your shoulder through your hip to your ankle just behind your knee is the perfect stance, and it's interesting. In many sports. They preserved the back and that lumber more doses. In tennis, you hold a racket, your back is straight. You kept the band at the knee. Your shoulders are back and open, ready to take a shot. In golf, 95% of golf is standing properly that your alignment of the golf club is at 90 degrees to where you want to go, and the whole posture is aligned. Your shoulders, your hips, your knees and ankles in that direction. Such at your arms. A swing as a pendulum beneath your shoulders. Your head is steady and your shoulder comes under your chin in the backswing with your left arm straight. Carried it through and following through changing your posture from your back foot to the front foot as you carry the club through. In my passion in karate, the basic stance is likewise and then cushion, and she stands a weight distribution of 60 40 with the knee over the toes on the front foot and the back foot locked out in the angle between the two toes, about 45 degrees. This maintains the total of the pelvis, but also the ass of the spine, and the bad knee protects the groin and the locked out back leg prevent you from being pushed over. My point being that in every sport there is a posture that you need to actually adopt to preserve the spine. And the interesting thing is, in surgery, we do not attend to that at all. The table height is Barkley important? Because think about it. You wouldn't do your ironing down there and you wouldn't do your ironing up there. And kitchen counters are made for the medium height of the population to optimize the function of the upper limb or too frequently, I see trainees come into theater and do not adjust the height of the table. The first thing to note is as we're leaning forward as the chin leaves the midline for every centimetre it gains a kilogram and weight such that by 10 centimeters protruding rinse. You have effectively holding 10 kg of extra weight on your head and imagine doing that for a number of hours. A weight such as this were unconscious of it. But then wonder why we're fatigued at the end of the day. But not only that, As we lean forward, the shoulders roll forward, the pectoral muscles are lost, you lose the tilt of the pelvis and the pelvis should be the anterior to the pelvis should be at level with the posterior edge, so anterior tilt of the pelvis comes from bad posture, and in doing that, your hamstring shorten increased lumbar lordosis is rolling of the shoulders protruding of the chin, and you end up with a stooped posture. It's interesting that spinal disease is a leading contribution to sickness and sick days, costing about $225 billion a year in the states and up to 20 million lbs a year in the UK, 1/5 of the population in the UK See the GP with back problems, and this is going to get worse with age, and it's going to get worse with diabetes. But what we know in surgery that the incidence of back problems and neck problems and plastic surgeons is about 90% in cardiac surgeons similarly, but in the population as a whole reaches 27% over a lifetime. But we do not address this in our practice is surgeons, and we wonder why we are fatigued and have pain at the end of the day and during the day, you should be taking regular microbe breaks. A lot of people suggest that you should stand on a soft Matt and exercise the calves. Certainly when you're not in theater, stretching exercises, hands behind your back, walking out from the wall. Keeping your head and chin in shoulders against the wall are simple stretching exercises across the arm and back, and there are plenty of them online. And now on the website, the Black Belt Academy of Surgical Skills dot org. That's important to exercise. And I note from your replies that not many of you exercise on a regular basis because to maintain your spinal health, you need to actually have good core muscles and again on website. There are plenty of those around. Suffice to say that, should you get any pain or discomfort, you should consult a physiotherapist or sports therapist to give you advice because I'm not going to be prescribing a particular exercise for everybody. It needs to be customized. And I wish that I had actually had this lesson very early on in my career because certainly now in karate, I find that with my anterior till to my pelvis, my hamstrings are short, and I certainly can't get my kicks up as high as I would like to, and certainly not like my sons. So please very simple thing you can do is to stand properly. Stand up right now. The other thing is some people wear loops and this cardiac surgeons, we do not wear loops, and they actually add to the weight, particularly if you've got a camera or light on top of that as well on a head band. I note that designs vision have come out with some loops that have got a prism in it so you can stand straight. But be looking down. And I'm holding my hands here for a deliberate reason, because this thing comes on to the function of your upper limb. Now, between your shoulder joint and your fingers, there are 30 bones and the size of the muscles that move your shoulders and arms are balanced on front and back and on the outside and go from big from the chest wall and scapula to the upper arms upper arm. Too low arm low on to the fingers. They get smaller and less powerful. But just imagine if you're operating with your shoulders up your elbows out, fixing your scapula, your Terry's manner. Major Terry's minor, influenced by the natives supraspinatus muscles latissimus dorsi serratus anterior trapezius muscles. All of those major muscles are now employed. Just stand there for a moment and hold your arms out. How long can you do that without them getting tired? But then also think of some of the daily activities that we do with our arms. And what's beautiful about the function of the upper arm is our ability to prone eight and super Nate. This means that we can feed ourselves and attend to personal hygiene. Our ability to prone eight and super Nate put your hands together up and down like that really makes us autonomous. The hand was described in 18 33 by Charles Bell as a divine gift from God because of its unique function, and that's why it appears in the Sistine Chapel as well, because it's beautifully balanced. But as Raymond Talus, who is a philosopher, a biologist following on from Darwin's work that demonstrated that the interlocking are the carpal metacarpal joints of the thumb, is such in humans is a little bit more shallow than that in apes. Giving us this unique ability to bring our fingers together and is that ability to bring our fingers together that I think really is essential part of surgery Now when you think about it, many of our functions were due in daily life. Translate into surgery without us knowing using the screwdriver, for example. Pronation Super Nation Look at the axis of rotation between the common place, the origin and the index and middle finger, this pronation super nation. The folding of the radius of the owner through that wonderful joint at the top of the radius and the owner on the ring and the synovial joint there gives you that ability to smoothly rotate. But the beauty of the upper limb and the elbow, and the short in particular, is that you can do this at each and every angle. You can take a screwdriver anywhere. The pronation through pronated Cherries and prenatal quadratus is a kind of weak action. The super nation I've asked previously is done by the major muscle of the upper arm, the biceps. And that is why screws are made clockwise because to tighten the screw is a super nation and you're using your biceps all the time. So the function and understanding the function of the upper limb, the relationship of the muscles to the shoulder girdle, the trapezius. The more muscles you use, the more fatigued that you're going to be during the course of an operation. So to reduce that fatigue to assist your ability to use your hands to oppose your fingers posture is vitally important. They do this in every sport, and that, since your head is the heaviest part of your body. If that deviates from the midline, you increase the risk of injury. I was interested to read it this afternoon. That running is likewise dependent on keeping your head aligned with your hips and your uncles. And if you run your head out of that alignment, the more likely it is you're going to injure your hips and knees and reflect on a colleague who took up running and went to a church to learn how to run. I suppose this lesson this evening is fundamentally asking you to make a stand. We've covered the moral and ethical element, but also there is an important element for your own health and ability, but ability to get the most out of your hand because it's the opposition of the pulp of your fingers that's going to give you the feel. And, as I said, the biggest muscles, a proximal going to the very smallest muscles of your hand and the intrinsic muscles of your hand are the ones that enable you, as Lord, one hand said to feel and caress the tissues because the marker cells and the Migranal corpuscles and the palpable fingers would give you the field. So getting back to the golf club the samurai sword, the tennis racket. What is interesting with these instruments is that a grip, a tight grip on them, is not going to give you a feel for the instrument. And the tight grip of your surgical instruments as well is not going to give you a feel of the instrument and give you that necessary hectic feedback as you're operating. I sincerely heard this makes sense that we have challenged your thinking, and I hope that making a stand is going to help you become better surgeons mentally, physically, spiritually and emotionally, but also technically because that is where we need to go. And I commend this book by Della Fish kindly lent me or given to me by Linda. The car side called refocusing postgraduate medical education from the technical to the moral code of practice because we're not here just to teach you to operate. We are here to teach you to be the best you can be says you too can deliver the best service possible to your patients in the future. And remember, it is a journey. I would like my journey and martial arts. You're only as good as your last operation and there's no room for complacency. And we should seek to better ourselves every day in feedback and practice. That's why I like this energy between martial arts and surgery. Thank you very much indeed for your attention. Thank you for participating. And I look forward to seeing you next week when we deviate from this theme from a week to discuss a very important element and technical technical lifesaving skill of putting in a chest rate. And I'm joined by a fellow sensei, Michael Guzman, as we talk about that. Thank you. Good evening. Good day and goodnight. Be well