Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello Good Evening, Good afternoon, Good Morning, wherever you are in the world and welcome to the Black Belt Academy of surgical Skills, my name is david regan, I'm a retired cardiac surgeon in yorkshire, in the United Kingdom and the past director of the faculty of surgical trainers for the Royal College of surgeons of Edinburgh and a visiting professor at Imperial College London. If this is your first time to the Black Belt Academy, welcome and I hope you find it useful because we are starting with the first cause. I'd like to thank the 3293 followers on facebook and the 527 on instagram, thank you very much indeed for your interest following and I do hope you like the not time video that were put out that I believe goes some way to demystify how to tie knots. The program this year is being interspersed with speakers, and that is thanks to the fact that the medal platform allows me to invite speakers, and this can only be done because we have a producer in the background gabrielle, who were taking your questions on the chat, and you're very welcome to interrupt me as we go along next week, we're going to be talking to Professor, Roger, neighbor, who's the author of this book expert, and in two weeks time, I'm delighted to inform you that Rich deveny have retired Navy Seal commander, who's author of the book, attributes, and global speaker and leader on human factors and teams, will be joining the Black Belt for discussion. Tonight, we're going to be talking about the first cause and I go back to my start in karate and Tokyo co is the Red Bell, the first grade that you get starting karate and Tokyo co stands for first calls for the great ultimate, no even though I'm now third down each time, we go to the lesson, we do tokyo coup again and again and it advanced as we do it backwards, and although the counter, which is a collection of movements is relatively simple, it is the foundation of your development in martial arts, it goes from a simple guillain barre or block to afford punch turning around, blocking, and doing that north south east and west. When you're doing it as advanced, done, the technique has to be perfect and you practice until you can't get it wrong and that's exactly it the technique and how you stand and how you walk and how you throw a punch is of vital importance to make the movement effective but also to reduce the fatigue and risk of injury on yourself. Earlier on this year. I talked with fellow Sensei john taylor, who's fifth dan in martial arts, and he described the need to teach people how to walk properly in karate because as you walk forward, you propel the body motion off the back foot in big toe and sweep it around and throw a punch and that movement includes the court in the spine, I'm produces power that is why bruce lee was able to affect the one inch punch that was simulated by a shirlene priest in new york who demonstrated that one inch punch was akin to being hit by a car at 30 miles per hour. Now, I'm not teaching power, I'm not teaching speed with teaching technique, and what's interesting is that we seem to have lost in surgery. The emphasis on technique starting with posture and for 22 years have been running a cardio course called Power Excellence where we take the candidates at the end of the day to a driving range to have a lesson golf and what's peculiar about golf is the acronym gasp Group address, stance position, and the grip is peculiar and feel somewhat awkward, but it's a light group, The address is 90 degrees to the ball. An alignment is from the hips and shoulders aligning with the flag. The per posture is quite peculiar. You're standing with your bottom out with your chin up. These like you bent and apart at shoulder width such that the shoulders can affect the pendulum swing and your left shoulder rotates underneath the chin. The club comes through, the weight transfers onto left foot and you're facing forward with the belly button and on the club, there's a sweet spot perfect spot take the club now, it's a complicated game and if you look online, there are lots and lots of videos as experts try and explain to you what it's all about, but it all starts with posture 9.58 seconds. Do you recognize the time well that is the world record for 100 m set by usain bolt in 2009 in Berlin, At the same games, he did 19.19 seconds for 200 m what sets you saying bolt aside is not only his lightning reflexes, but his ability to launch himself out the blocks, and when people have analyzed this, the alignment of his head, he shoulders his hips as he launches out the blocks is in a perfect straight line that gives him that edge and that extra bit there are four points for starting out the blocks with your hands on the line. Your lead leg, knee can be over the line, and when you go up into set, your hips are slightly higher than your shoulders, your front leg is at 90 degrees and your back leg is at 100 and 20 degrees and you launch yourself off those angles are there to optimize the movement and the proportion even as you're talking and not a competitive sprinter running involves bending at the ankles, nodded the hips, such as your hips, ankles, and head all inclined slur before and you're running. Minimizing injury and fatigue even when riding a horse and many years ago you used to go horse riding the way you sit in the saddle is important because your seat controls the ride of the horse and you're holding the horse, not where your thighs, but with your calves, your feet are pointing forward, not unlike keep it. As you in karate stance, your heels are down, and as you're going round, showjumping you're turning your head and that simple movement of turning the head is subtly altering your shoulders, your hips, and telling the horse which direction to go because the heaviest thing you're coming around with you each, and every day whether it's full of information or not is your head, it weighs 5.4 kg just by standing properly underlined with your head tip your head to the front of the shoulders to your hips, knees, and the ankles. The perfect straight line with a cervical and lumbar lordosis is the problem is, is that as we move our head forward for every 2.5 centimeters, it gains an equivalent of 4.5 kg such that when you're standing in your chins protruding forwards, you're holding something up akin to 19 kg on your head and what happens there is you gents protruded sternocleidomastoid Czar shortened. You lose the cervical more doses. Your shoulders roll in pectoralis major, shortens you get a thoracic kyphosis and then over a period of time, an anterior pelvic tilt shortening of the hamstrings and a loss of the lumbar lordosis as well. And it's not surprising, therefore, we find that the incidents of muscular skeletal problems among surgeons approaches 27% in their lifetime and up to 92.5% amongst plastic surgeons and cardiac surgeons alike. I've got a few a screw between five and six in my neck, and I'm radiological proof, as you can see on the website that I've got my head screwed on some people might question whether that's screwed on correctly or not, but that's a different matter the problem is that we are standing at a table or day everyday operating and not attending to our posture and if you go onto our website, be be a double f dot org Vanessa, who is a trained physio therapist, has outlined some simple exercises that you can do and should do at the beginning and end of every day of operating to maintain your posture and the way you're standing because. Otherwise, you're going to end up the problem, and it's interesting that not many of you at answering your questions this evening have attended to posture or thought about it. Simple core exercises are important and simple squats in karate that in advance down the hold us in these stress positions or thibaudet, she for up to two minutes, maintaining a straight back without leaning forward and maintaining your posture. Now, you know, this is important because you do everyday things and you haven't really thought about it. Mhm, yeah, you're not gonna iron there are you because it's uncomfortable you're not gonna iron down here because it is uncomfortable. Likewise, you automatically adjust an ironing board to a height that enables the functional movement of the upper limb and that is why kitchen tables and kitchen counters are the height they are because it is the height that enables the median population to operate and function. Now what's interesting even down to daily activities like chopping and if you go on a website, there are lots and lots of videos on how to chop and what's interesting is that they point out if you got it at the wrong height. You'll end up with fatigue, but there's a nice description in what they're doing, it's holding the salary between the thumb and finger, the other fingers holding it on the board, so it doesn't slip the nail of their longest finger is adjusting the depth and your knife is a smooth, regular movement and not chopping. It's almost a rocking movement and that's why sometimes are designed with the curve, and the most expert has said person can do this very easily. What's interesting is that the knife cos talking about how to cut, see it's much easier to cut with a very sharp knife than it is with a blood knife and that is true with surgery as well, so simple activities that you do are important now. The other important thing to bear in mind is yeah up, and then and those who have you are not anatom. Ast have to recognize that the upper limb is only joined to the skeleton by the clavicle. The humerus joins the glenoid cavity on the scapula, which moves around the chest wall, and this movement allows abduction, abduction, flexion, extension, and sir conduction. It reminds me of a youtube video I saw of young men standing up against the wall with a piece of chalk trying to circumscribe a perfect circle, but that's what the upper limb can do, but I want you to try something from moment to play with me. We are unique as humans because we can oppose our fingers and there's our hands that give us our ability to explore the outside world. Apparently koala bears in australia can also oppose, but in surgery, we are wanting to use our hands and the fingertips have got more representation for sensation and are better able to appreciate the environment in which we live, Then our highs think about that we are better exploring our environment through feel, and that is what surgery is all about is feel, but that comes to how you hold it so stand there for a moment, and go through the sector size of opposing your thumb and fingers with your elbows up in the air and why are we doing that the first layer of rotator cuff muscles, the super spinatus, infraspinatus, teres minor, and subscapularis are there as the first small muscles moving the humerus, but after that you get the major muscles, petraeus major, petraeus minor down, toy aids, trapezius, latissimus dorsi, and serratus anteria, but even though we have just been opposing our fingers at this level for 30 seconds, you are starting to feel tired because you're using major muscles. Your elbows have left the side and those big muscles around the shoulder girdle are starting to fatigue. You add that to poor posture and then you wonder why you feel totally worn out at the end of the day. No really our shoulders need to be down, uh elbows need to be by their side, slightly extended and palmer flexed like that just like that like a thunderbirds puppet. What this actually does is, removes the activity of all the major muscles of the shoulder, the neck, the fore arm in the upper arm, and then allows you to do something magical and the magic comes with the fact that we can oppose our fingers and everything is at the tip because the whole of surgery is ability to bring the pulps of our fingers together to feel to feel the tissues that your instruments should be an extension on your hands. Now every instrument has a purpose and revenge Mint has a feel, take the sore, for example, a nice economic group for the hand. The position and the soaring is such that the soaring happens as you go down not back and there's a rhythm and the float in soaring. The simple hammer is not to be gripped tightly and banged using upper arm, the weight of the hammer, and the moment of that is important, and they're different sizes the claw hammer, of course, they're the pivot, axion, and the force times distance in the moment is such, this optimized the instruments that you use in surgery have been designed by people have thought about their function and the ergonomics and thanks to krista Gara, who's a sense of the Black Belt Academy and amateurs, professor in of Surgery in candida and gabrielle, we have on our website a list of all the instruments and the surgeons who have designed them, there's one little floor in this so that most of the surgeons were male and the average hand is actually formidable video than a woman and 6% of men are left handed, as opposed to 9.9% of women who are left 100 damning, lies the problem, and I'm delighted that we are welcome with b braun, who are looking at the ergonomics of instruments and how to formulate shape and size of instruments for the modern generation and different size hands. What's interesting is that the mail finger, index finger ring finger is bigger than index finger unless reverse in women, but even so no matter the size of your hand, it's the feel to the opposition of your fingers. That is important now the hand has got 27 bones, 29 joints, and to date 100 and 23 ligaments and apparently a plastic surgeons will tell you is much better to lose an index finger than the others, but my sense i chris kelly will tell me more about that, but this movement, the extension of the distal interphalangeal joint can only happen by four unique muscles in the hand, the lumbrical, they do not have any bony insertion of bony origin, and as they are important for bringing the paps together, so the simple posture of your hand and applying your fingers instrument is very important. We have plenty of instruction and hold how to hold a pencil there you go kurt, the World College of surgeons of edinburgh a pencil. We hold that by a pencil grip and we write with flexion and extension on the fingers and movement of the wrist and say grip and that pincer movement is generating 25 newtons on average, up to 30 in men, we don't want that movement in surgery. In survey your fingers have got to be applied to the instrument and that comes down to whether you're holding a pair of scissors and it's the lightness of touch that will give you the hectic feel back from the tissue so you can feel what you're cutting, if you grip it too tight, you will not be able to feel the tissues and we do not put a distance inter phalangeal joint through these rings, now admittedly, they're designed for mental fingers, but even with small fingers. If you put your fingers obliquely across the rings and hold them with the palps, you'll get better control and feeling likewise with the forceps, we said you're not gripping it like a pen, so using flexion on your fingers, you're extending your fingers and maximizing the pressure and feel minimizing the pressure and maximizing the field of the instrument by using that movement like a base for the needle holder. Now, the needle holder is two surgeons, I think but like a golf club, is to a golfer. You hold it properly and allow the anatomical movement and rotation of your forearm to do the work with minimal movement and the needle would do the work for you and that cannot happen if you put your fingers through needle holders, we would recommend that you hold the needle holder on the line of access between your index and middle finger and extending to your common flexor origin because that is pro nation and Super Nation, pro nation and Super Nation. You know this just holding a screwdriver pick up a screwdriver, put it in your hand, pro nation, super nation, pro nation, super Nation on the beauty about the function of the upper limb, is that you know and have experienced yourself working in confined spaces on a car, flat back wardrobe at home. In that organ, angle, your upper limb and shoulder girdle can orientate your forearm and hence your hand to prone, eight and super nate in each and every position on that line of access now, I demonstrate to you why that rotation is important, Consider for a moment, my fingers are through the instrument, I'm going to super prune it and just short of the horizontal, Super neat and it's just short of the vertical, but if I do that you can see that the end of the needle hoarder itself is moving around and I have limited movement and taking it on and off as clumsy. If I extend my finger down the needle holder, Pommard by holding it between my fifth and ring finger, now bit like a screwdriver, the horizontal, and the vertical. I've almost got 270 degrees of rotation with relative ease and how do we do that is simply using your opponent's policies, another intrinsic muscle of the hands to take the ratchet arm and off now it is vitally important that you understand this first cause that you're standing properly that your shoulders are down your elbows by your side, slightly extended and palmer flexed that isolates the small muscles of the hand from big muscle interference, removes the tremors, removes fatigue, maintains the posture and maintain your health for those of you. Who actually wear loops. The measurement of your loop distance and focal distance should bear that in mind is where are your hands comfortable simply doing this opposing it tips your fingers. You tried it earlier on up here and your arms got tired and you actually probably found it was rather difficult, but as soon as you relax them by your side and started opposing your fingers, it became easier and less tiring and said that distance that is your working distance. If you're wearing loops and it's not distance in this height that determines the height of the table for the height of the patient, so if the patient is that height and that's where you're working you have to adjust the table accordingly and usually I say the height of the patient for me is with anterior superior. I explain and I can stand and adjust the height. You know what the thing is is that, If you don't do that, it's amazing how difficult and how awkward the simple movements and functional anatomy of the hand becomes. And I recall when I was a trainee asking the boss to come into theater because I was in difficulty and all they did is one adjust the light two they made the incision bigger and three they adjusted the table, which of course can tilt and even that simple two degrees will give you extra movement and appreciation of where we are. Unfortunately unlike sports and unlike golf, we don't have lessons and how to stand how to hold instruments how to align nobody explains where the sweet spot is on your instrument, but that's what we're trying to do in the Black Belt Academy of Surgical Skills and I intend to the website you can read about these amazing people who designed the instruments that you and I used today. That's what surgery is about once we come to actually operating to make it easier for you to function to flow without hesitation, deviation, interruption repetition without fatigue, maintaining your own muscular skeletal health. That is important. We do that in every other sport. I do recall going to center parks and going off clay pigeon shooting and had fantastic instruction and how to hold the gun and how to point it and that was 90 degrees underneath to support an elbow up at 90 degrees. At the other side, turn, at the hips, follow a foot in front and shoot. The interesting thing was is that somebody in the same car going to declare Pridgen shoot, thought they were diaper, handed, doing it and got the gun and literally shot from the hip and didn't follow the instruction. His sixth success rate on that day must have been barely 20%. I don't shoot that often, but I followed the instruction, followed the setup, followed the position and got 100%. What we don't teach in surgery and what you do need to attend to is your set up each, and every time it's often forgotten as you walk into theater, is often forgotten as you take over and it's often forgotten under stress, but if you pause, take a deep breath and think to yourself what can I do to make it easier. It's these simple setup things and understanding your posture and the function of the upper limb, the first cause that will help you in your surgery and it's something that will emphasize as we go through exercises in this diet of the Blackbird Academy, going back to australia and the fact that koala bears can actually oppose this, which I didn't know myself prof, hannah be at the University of zurich has noted that we are evolving as human beings and actually um in particular embryonic supply of the limb upper limb bud is by the median artery and then most people at birth that disappears because it splits into the owner and radio artery. What they've noticed is an increasing evidence of persistence of the median artery and people are saying that's because the function of the upper limb itself so per amount importance we need extra blood going to the upper limb, it doesn't cause any heart, but that is the theory, is part of the evolution and our function of human beings in exploring the environment of the aca, lemon hand. Interestingly, one third of australians now have a persistent median artery as well as the owner and radio, so what were the koala bears and posed in your fingers and one third of Aussies, having a meaning. We all know that a continent been separated from the rest has accelerated the evolution of the upper limb, interesting we've had a run through on ergonomics. I hope the relevance of our everyday activity is now emphasized. I hope you think about it. Next time you go into theater that you now consider yourself an athlete look after nutritional, but your musculoskeletal fitness because to be sharp, you have to stay sharp and on that note what's interesting with my sword, yeah, the position and movement of the sword is prescribed and described down to the degrees and handed through the centuries of samurais and practicing higher. Do you don't do that in surgery, which is a shame, but I hope the Black Belt Academy addresses that have you got any questions, don't hesitate to ask, and I'm delighted next week, we'll be talking to Professor, Roger, knee, burn how to become an expert, and he is the world's most foremost thinker on the subject. I have the privilege of working with him at Imperial coverage. The week after that, we're going to take these basic principles, the first cause and talk about Aristotle and Euclid and how geometry dictates how we set out thinking on how to stitch and the following week delighted to announce their deveny retired Navy seal will be talking about team performance dr, and trust. Thank you very much Indeed for joining the black Part Academy of Surgical Skills thank you very much Gabrielle, do we have any questions not at the moment. No questions well. I hope that was all clear that and hope we assimilated, you're thinking, Thank you for your attention. Thank you very much Gabrielle. I wish you well and I'll see you next week, Good night, good day, Good morning.