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Hello. Good evening. Good day. Good morning. Good afternoon. Wherever you are in the world and a special welcome to show Santa in Nepal who has joined us this evening He is a regular follow er were breaking from our usual run of basic skills to tackle this evening. An important surgical skill which have done properly saves lives and have done badly can cause serious harm. My name is David Reagan. I'm a cardiac surgeon in Yorkshire, in the United Kingdom. I'm past Director the faculty of surgical trainers for the Royal College Assistance of Edinburgh and a visiting professor at Imperial College. I'm especially pleased that we are using the medal platform and fill the CEO joins us this evening. But I'm also joined because of his platform by fellow sensei Michael Gussman, who is a thoracic surgeon. And Hull turns out that Michael nose, fill and fill was also training as a cardiothoracic surgeon. Welcome. And thank you, both of you. Your note this evening that I'm wearing a stethoscope and fills comment was it is unusual for a surgeon to worry a stethoscope while I put it to you that wounds heal provided to get oxygen and have a good blood supply. And therefore, as a surgeon, you therefore need to be sure that your airways and breathing and your circulation are intact. And there's an A B. C. I also think that the stethoscope is often forgotten by the surgeon, and it's a very important diagnostic tool. Without further ado, I'd like to introduce you to my colleague Michael Grisman and Michael. Perhaps you'd like to say a few words about yourself before we go in to your presentation. You kindly put together, and Phil is going to join us in the discussion at the end. Thank you. Fall, Michael. Thank you very much, Mr Oregon. And thank you for the kind introduction. And, uh, I've also got to just say thank you to fill. I mean, as you said, we were trainees together and 20 s together in cardio thoracic, and it was brilliant training, and it's gone on to do brilliant things with this, uh, with this platform that we're using this evening, which is absolutely fantastic. So I mean, the topic of chest rains is is obviously a multi specialty comes across all different areas of medicine, and it's very, very important and although obviously you may not be in certain regularly or you you may be in a specialty that has a certain amount to do with it. But it is important that the considerations that you see here, the rapid response report, the national patients. So these considerations have taken into account so much in the theme of and I've tried to structure it so that it goes in in line with sort of Mr Regan's Black Belt Academy. Obviously, you sure your patient needs a chest rain And now, obviously hours Mr Reagan is registrar at the l G I. And it is very important that you know your indications so that you've you've actually examined the patient. You have taken a history. You're very clear yourself on why you're putting it in. If you've got a patient, for example, with, uh, significant bullous emphysema and they're coming in and you've you've got a pneumothorax and I'm thinking of this on the hoof. But it's it's a common, pretty common scenario. You want to be sure that you know why you're putting it in our they breathless because of that, or are they developed a pneumothorax and you don't want to be relying on sort of hearsay. It's very important that you take that, uh, in mind yourself. Obviously as well. Very critical that you examine the patient and Mr Reagan got a stethoscope around his neck and you listen to the chest. You may need to be very sure that you're confident and comfortable with the indication, and obviously you're going to check imaging, and I will say it's on the next slide. I believe that you want to check, check and check again. And if you just go back to the previous one So I don't, uh, skip anything because these are really important. Uh, do you feel comfortable enough to do it? And obviously, early on in your if you are going into a specialty where you're going to be putting lots of drains, um, you need to feel confident. And again if you're only putting them in sporadically, you need to make sure that you feel confident and make sure the senior supports available. These things seem small, but if you get into trouble, uh, these are these are very important. And I would say this any time any surgeon needs to be very familiar with what he or she is using and the tools available to them now. Obviously, it was going into any operation. You do your debrief, and it's very important that you confirmed that you've got everything on the and you checked it yourself. So next slide mystery, obviously as part of any surgical procedure, and it should be taken as such is the patient consented? Now? Personally, there's a lot of debate around this, but I think it's not unreasonable. And I would recommend getting a formal written consent that you've gone through the reason you're doing it. And it, of course, it depends what the status of the patient is. If you're putting it in an emergency in trauma, then that's not so relevant. But if you are putting it in for someone who in a more elective manner, and I would I would recommend doing that and the imaging is absolutely critical. You want to make sure you've checked it, you've checked it again. You certainly don't want to be in a situation where, whatever reason, it's going in the wrong side, and, uh, again, is there a staff nurse available to help you with this? That you would I know there's been previous talks on assistance, but that's just as important. You don't want to find yourself starting the procedure turning around, and there's nobody available when. Obviously, this is significant, and you don't want to put the patient into more trouble than they already might have been. I think it's absolutely crucial. Obviously, you want your patient to be comfortable, Uh, anyway. But it's particularly important that you position them in a way. Uh, that is a position that they can tolerate for the few moments, and it may take a while this procedure, and you don't want them to be regularly and moving. It's not fair on them, and it's just going to make your life more difficult. And I would suggest that you want to make sure the pain relief has been administered again. It's all about the condition of patients in You don't want to be, um, you don't want to be doing that, obviously, in a situation which is semi emergent, but it's it's about using remembering these things and using them in a nuance situation. Next time, Mr Reagan, So aseptic is the final point, but Mr Reagan is gonna simulated on his model very shortly in terms of the actual procedure. But it's it's very important, as I say, to have them around 45 degrees. But you may find patients are comfortable. Patients with severe COPD or major infusion can get very breathless. You need to take all of them. We're going to cover the safety triangle, I think in a moment. So I think you're going to look at flicking over to to doing the simulation. Is that right, Mr Reagan? A note on anesthesia. It's absolutely important. So I would always suggest that, uh, obviously patients, this is going to be an uncomfortable procedure. Uh, you want to make it as easy as possible Now anesthesia. You think about a small orange needle to bring up a bleb, and then you're going to look at using more down onto the pleura. It's absolutely critical that if you can, you take your time to ensure it's taken effect, because this for a patient they're going to be obviously uncomfortable. The ribs are going to be. The muscles are going to be contracting it. It can be very, very miserable for the patient and more difficult to insert if you don't take this into account. And obviously, people who use local anesthetic a lot, you need to make sure that you've calculated the amount prior to, uh, administering it. So that's where we are, Mr Reagan. We can cover that in a second. Super. Thank you very much indeed, Michael. And we'll come on on to that. I'd like to take you across to model that I'm going to use. I've been thinking about to help you understand the insertion of chest rains, and really, it is an A B C of chest rains. Now imagine that I'm This is you're looking at the side of the patient. So this is the side, and the patient should be comfortable lying down, preferably with the arm behind the head, as if reclining and for an elective procedure will be lying down. You have put the arm behind the head, obviously, and trauma patients, uh, you've got to be careful because the arm indeed might be broken or there could be injury there. But we're going for a safe triangle, which is boarded posterity by the lateral latissimus dorsi anteriorly by the pectoralis muscle. And you should draw a horizontal line across from the nipple, so below the axilla above the horizontal line in front of the Latissimus Dorsi and behind the pectoral muscle. And that is what I've tried to represent here Latissimus Dorsi petrol muscle. And I'm growing that as the line from the nipple. Now you're going to feel for the intercostal space. And sometimes, as you can see with this rib, that's how thick the chest wall can be. And palpations is sometimes very difficult. Clearly, you would have diagnosed this, hopefully clinically, with a stethoscope but tactile focal from lettuce and percussion, as I mentioned previously, of basic ultrasound skills. And, in essence, we are going to go immediately above the rib if that's a cross section of the rib. On the lower surface, there's a groove, and the neurovascular bundle of the vein artery and nerve runs in. That group of the safest thing is to always go above the rib because going below it, it you run the risk of hitting the intercostal artery. Now I palpate where that rib is, and often people market with indelible pen. But I'd like to offer you a little trick. I take a pound coin and I press the pound coin onto that surface and you'll find probably better here if I press the power cord in my arm. I've got an area. A ring marked the beauty about using this. It gives me an area that I'm going to fill with local anesthetic. But also, when I press the patient, I'm not going to rub this off. So I press the coin on the rib mainly by the rib to make a mark. Now, just using a little alcohol swap. As Michael says, they put a bleb of local anesthetic again. But then I fill the whole area marked by that coin with local anesthetic because somatic supply is the skin and you need to make sure you've got lots of local anesthetic. Now, in the middle of that, I'm going in above the rib. Just aspirating before I inject all the way in aspirate inject, and if you feel the periosteum periosteum is uncomfortable, more local anesthetic, you go all the way in and effectively. What you're trying to do is fill a large area on the skin, local anesthetic around the Periosteum and a similar large area of local anesthetic on the pleura and This is the collar study of local anesthetic. The other thing is in using a green needle for an elective case. I confirmed the diagnosis because I can either aspirated air. I take it back just a bit so I can't. And then I'm in the parietal pleur, and I put more local under set again. And having done that, I go and wash my hands because this is a sterile procedure. Proper downing and gloving is required to ensure that's an aseptic technique. But in proper downing gloving, you're also giving that necessary five minutes at least for your local anesthetic to work. Next. We are now going to make having prepped up. Remember in circular fashion, using chlorhexidine from inside out to an area of 25 centimeters around, clean and put your drapes up to cover are now going to use the 11 blade to make a stab incision, and I'm going to keep it in the Lantus lines, a stab incision, and the width of this is going to be or is the diameter of the coin that I pressed on the surface and note in using my 11 blade has previously described. I'm holding my finger against the edge. So I'm not plunging it in without controlling the depth, as you can see there. And I have made a full thickness skin incision. Yeah. Now, the secret is not to go in and use one of these things called a trocar. They should be banned. This can ask your blood, um, solid organs, and I've actually seen it put into the abdomen and the liver, so trocars should be banned. The best things this is for is in your garden shed. I'm not sure if you connect with them, but I would ban trocars altogether. We next go through the muscles remembering that the external obliques run down with a line in your fingers if you hold your hand against your chest and the internal obliques run 90 degrees the opposite way, and what we're going to do is with a blunt instrument. I'm using a mosquito, but I would recommend using a Roberts because it's a bit longer and it's got a blood and really split the tissues all the way through, splitting them the two directions until you're actually into the chest cavity. And once you're in, just make sure it's open and then I would recommend you do a finger sweep. Your finger goes in all the way through and the sweets around, and you can feel that you're in the chest. And I have previously in trauma cases put my finger in felt a liver, felt a spleen. And have you ever felt the stomach because of traumatic herniation of the diaphragm? And I put that all the way through, And I'm not sure in this case, if I am all the way through yet because it is a long way, and it does require patients and blunt that section to get all the way through. That's the thing. We're doing these live models making sure they're good, good space to put it in, and now you can see there I am all the way in, but my fingers gone in and I've swept around and I'm losing my little finger to put the drain in. Then it's very simply putting the last whole of the drain on the end of the instrument that you used an inserted drain end and push it in there and you can see it is now in the chest. A lot of people will go ahead and clamp drains here because they think they're going to be covered in fluid. And I think I'm going to let Aaron drained Clamps should again be banned in normal practice and should only be used by experts, thoracic surgeons in the POSTOP pneumonectomy patients where they want to control the mediastinal shift and blood loss. Otherwise, you leave it open and leaving it open to the air means that for the moment everything is safe. It's not contention. Indeed, you might get some blood out here, and it's useful to have a drug to catch that the drain is now in position. My fellow sensor, Who's on this evening, Mr Cody shared with me this drain stitch from Maurizio McLaughlin published in the Annals of Surgery. And essentially, it is a mattress suture. It's a single stitch through both sides, and I don't have a silk suture. I've got a polling here, but indeed, some people would say pulling is better. So I've got a mattress suture. You do not use a purse string because if you tie a posting at the end, what you end up with is necrosis and something that looks akin to a bullet wound. This is a single stitch closure and the mattress future around it. Now I'm going to I'm going to put a not halfway down this. Okay? Yeah, and that. But there is going to be used to secure the drain in the end. So what I'm going to do now is take this around the drain a few times, take the end of that suture through the mattress, pull it down tight, and now secure the drain and you secure the drain with a surgeon's not, which is to throws the same direction. One to put it down tight. So secure and secure. You're not. Yeah. So it's a single stitch, not a secured. What people have seen in the past has now put lots and lots of sleep on their now. The sleep and the adhesive of the sleep is a fantastic culture medium for staph aureus. Not only that, I have seen sufficient sleek put on chest rain slides that actually constricts the chest and constricts the breathing. So simple gauze cut as a Y put over the site like that with a simple bit of tape across the top chest written down the other side you connect to under water seal and low pressure, high volume suction from the wall. The drain itself over a number of days will actually cause a prosthesis, and the lung will inflate and stick to the chest wall. So, in summary, as Michael said, have the right equipment use lots of local anesthetic. Make a good decision. That pound coin trick. Have you seen my arm? You can still see the mark from the pound coin, and I hope you now believe that that acts as an indelible There you go and terrible, and it gives me the size and position of the local anesthetic I need to put in. There's also the director of That is the width of the incision that I'm going to make, and it's blunt dissection all the way through. I put my little finger in. Of course, if the multiple rib fractures you do need to be careful of lacerating your glove and even your finger un broken ribs and I'll leave myself open to comment from Michael. I'm from Phil, who also trained in cardio thoracic surgery. Your comments gentlemen, and we'll take comments from the audience. No, I think, uh, as I was trying to say the start. It's exactly that. It's about preparation. I think you want to make sure you know the patient. And if you're going to put the chest brain in, you know the patient yourself. I've examined taking the history and see the imaging and absolutely right, like any other sort of invasive or surgical procedure for safety is making sure that you've got all your equipment checked and you've got You've got the appropriate help with you. However skilled you are, you want to be able to turn around and have someone to be able to pass things I/O of a sterile field, etcetera. I don't know what feels thought. So I don't think there's much that I can add that you two gentlemen haven't haven't already said. But I guess the question from my side does your approach change when this is a patient who's a week versus those who are asleep? Well, the answer to that is, is that in a trauma situation, usually getting patients come in. They were unconscious and intubated in some level. One trauma centers in America in these situations, and you you've got evidence of seat belt injury evidence of perhaps a paradoxical movement of the ribs. You know there's going to be or fluid in the chest, particularly if you use this and you're listening to elementary both sides. So chest rain put in using blood dissection in the safe triangle, as described in many cases, is almost a stat as part of your ABC. Before you even start going to CT scans remembering that in some of these cases your chest brain might indeed be diagnostic. If the multiple rib French is, you'll find that a liter of blood quite quickly can collect from the intercostal vessels. But if your bleeding persists, you're starting to enter and indications for thoracotomy there and then. But what you've done is immediately stabilize the patient, improve the inflammation of the lungs, improved the oxygenation overall for the next stage, and a good chest rain in the trauma situation can be diagnostic, particularly sweeping your finger around the inside. And in my experience, I have felt about how I have felt liver. I have felt the stomach, and I have felt the spleen. Anything can herniated through the diaphragm. In elective patients, analgesia is very important. That's why I provided they're not allergic. Use at least 10 mills and think of the constant. The somatic supply to the chest wall includes the purer, and it is equally painful. There is a lot of pressing, but with deliberate splitting of the intercostal muscles, you should be able to enter the pleural space if they're goes in. Not a big problem, because once you understand under suction, the lung will come up. The other thing is, is that everybody gets hung up about the bottle being below the patient. True, and if it inadvertently comes above the patient, that's not a big deal because they're all fluid in the bottle will go into the chest. When it goes below, the patient again will come out to the chest. I have seen trauma patients transferred with chest drains clamped and the clamp changes. A situation is open to closed and attention. Pneumothorax is most more likely in that circumstance. And that's why I would not advocate the use of clamps at all, except for in the hands of experts. Thoracic surgeons like Michael, who would want to manage mediastinal shift after pneumonectomy. But how often do you do that, Michael? Well, that's a pneumonectomy, Um, post pneumonectomy question is a talk in itself, but I mean, obviously the role of a clamp. And I know this is a broad talk, and that's what I try to say at the start is when you when you're approaching drains, you may hear people going in a safe triangle. You hear people going anteriorly, but I think when you're starting, you do things as described and that that's really important in terms of cramping after a pneumonectomy, some people don't put a drain after a pneumonectomy. Some people leave it open, UH, two free drainage and obviously the one about the The reason people clamp it is because the government shit the mediastinum and have the obviously the significant consequences that can have the patient. But you unclamp it because you want to check the patient's not bleeding and obviously bleeding into a pneumonectomy space Can the patient can lose a lot of blood into that into that space. So there's, I would say, when you're putting and you're starting to put chest strains in, is making sure that you've got. As I said, I keep saying it's all about the patient you want to make sure you've got someone who can supervise you and give you advice because there's so many scenarios and so many different, uh, things described about chest strains, and I'm sure things you won't see. But if it's if, if obviously you're not sure, I think the thing is to to ask, isn't it? So So michael. The questions on the chat room as well is, is it necessary to direct the drain up or down? I think they say, if it's a rare, it's up. If it's blood is down. To be honest, as long as the drain is in the pleural cavity as the lung comes up, it will drain or fluid. It doesn't necessarily have to go up or down your thoughts, Michael. Know? I think on, uh, exactly as you say. Now you can start going into to the sort of nuance situation where you've got a complex pleural space. But for a pleural space that's unilocular, so to speak and either got blood or fluid in it. Yeah, people do say about positioning, and I think on those slides we thought about post procedure. It's very important you do your post procedure checks. I don't know when you were getting to them. But if you've got a pleural space, it's not complicated, so to speak. And you put a drain, it should drain. And that's when it comes to the other questions that we've got on those slides. Um, and and we go to those following the search. Michael. Well, it's absolutely important that you obviously, if it's some of the first strange you put in, you get a field. As with most of the things you're doing, surgery or medicine, you're going to feel triumphant. You put it in, but it's very importantly, regularly assess your patient. This is a very broad talk at the start of trying to come up with the sort of situation that patient with severe emphysema, these patients, for example, I've got very little reserve. So if something is going wrong, you want to be back and forward and have a lot of input, because you may find that you're putting them in when they're in extremists, and you want to make sure they're improving at the same time. If you put in the drain and it's obviously there's the second point, it's draining a significant amount of blood is, Mr Reagan said. You want to be making sure that you're regularly seen that, and you are active on it. So if you do need to do something about it, you get to it early. You know, if you put and and it can happen that drains go in with, however skilled, and however you know experience following all the guidelines that drains don't go in ideally. So if that's happened, you want to make sure that your patient remains clinically well. And, of course, I think it's absolutely of really importance. Even experience training searchers that you get a chest chest strain, uh, chest X ray after your chest brain to re assess the situation to make sure that what you've put it in for is resolving, For example, is the lung is inflated after a pneumothorax? Or is your effusion improving? Certainly, if you put it in for a white out, you've drained two liters of blood and it's still the same. You're going to be a bit worried about what? I'd certainly be very worried about that, and he wants to check that your drains in the right place. I don't know if you have any thoughts from from the two of you. Just when checking the chest X ray, you can see on the chest X ray the holes and the interruption of the radiolucent line on the chest X ray. And it's important to ensure that all the holes are in the pleural space. Because if they're not, that's when you get surgical emphysema. And indeed, some people will start blowing up with surgical emphysema and that usually because you have not got the drain in the right position or in putting it in, you've actually pierced a bully, and you've got a massive air leak. Your comment. My home? No, I think if you have got surgical emphysema, it's always important to check, as you say, because if the patient starts swelling up and you've got the drain secured on the skin as the surgical emphysema and you can get massive surgical emphysema, which itself is pretty much as as a sequel, is something you manage. But it's the underlying aspect that you want to sort out. So, yeah, you want to make sure that it's not pulling your drain out. I guess it would be my point there, and your brain is properly secure, and the holes the drain are sitting in the pleural cavity and not in the chest wall. So final considerations. Michael Suction know again, I wanted to make this a discussion and for questions, because it's obviously a huge topic management of strange management of the pleural space. Now my thought would be for suction. You want to make sure again, and I keep going back to it all about patient safety, and you're putting suction on an appropriate setting with the right skill makes people training. You don't want to suck it up to the hook it up to the wrong type of suction unit, I think. Obviously, high volume low pressure, Absolutely. And I think, uh, obviously you may put it on in the setting. So where you might use suction is when you've got a pneumothorax and the lungs not come up, you might do that, But beware if the patients got a significant leak or significant emphysema that obviously you don't want to suck the lung up too hard at the same time. Uh, you may make the early worse, So that's the thoughts on suction. I don't know if you all have any more thoughts on that? Yeah, So you've got clamping there and I've already said, Michael, I think the clam shoot only beyond thoracic surgical wards. You need to be very, very careful. And again, I think the thing around clamping is if you're going to clamp a drain in the communication that is all the way through, the medicine isn't a communications. That's the key. There are settings where you may find thoracic surgeons and get differences of opinion. I'm sure advocate clamping of the drain, but you want to make sure that everybody knows the drains clamped, including, I would say, the patients. It's very important that you tell them, and it's obviously a lot of drains put in in patients who are awake. It's an uncomfortable procedure, Um, and it's to be mindful that this is a process that is going to be pretty miserable often for a patient, and, uh, so regular communication with them is important, and it goes back to the to the, uh, to the basics. But it is, really, you know, for patients who are going through, which is very uncomfortable procedure. Obviously the point about local anesthetic absolutely critical. I know Mr Carries on surgeons who operate a lot with local anesthetic. It is a skill in that in itself. But it's very important that you get that right, because if you get the draining, it is uncomfortable Initially irritated the nerve it's going to be, it's going to be a miserable and you want the patient up and about. So So it's it's all about communicating with me. And if your first rain has not succeeded, you might need another. And I recall being registered at the Brunton Hospital dealt with a number of people with adult respiratory distress syndrome, and I think I counted a total of 14 drains in one patient. And in this situation, the lungs are actually liver like and solid. And the smallest of uh, uh, pneumothorax of 250 miles is enough to actually upset the ventilation. So these patients used to go to CT scan, and they marked on the chest wall exactly where the new cataracts was, and care had to be taken to put the drain and bluntly and sweep your finger around, because even the blunt roberts that are used to split the muscle would be enough to combat the lung, and it was painstaking and careful to ensure you did no injury to the underlying lung type of drain system. Michael, you've got that on the list. You know, I think it's another point on the drain. I think if you've got a drain in, that's either get back to it and it's not far enough or it's not doing. What it should be doing is the acceptance that you may need to put another drain. You don't want to go pushing a nonsterile tubing into the chest because it's not going in for an empyema. Your risk doing that? Um, and obviously, if it is something that's not resolving, then you need to address that surgical versus selling. A drain is obviously a huge debate in the only have been having that locally recently. I think the thing with the seldinger is if you've got obviously someone with a very unstable chest wall and you you put in a A, obviously you don't get the same guidance, and you don't have the benefit of what I think is crucially being able to put the finger into the pleural space to make sure that you're safe. But also the the cell doing it drains. If the smaller and the chest wall is obviously the meters and moving, then you can kink. I would say smaller. Selling it drains easily. Easier. Excuse me. Um, any thoughts, Mr Reagan? Know, I I I think the seldinger brain goes into the domain of under radiological control. The needle that comes with the seldinger is smaller and even sharper and can cause significant damage. So I think in the expert hands under radiological control. Ultrasound control. Very good indeed. I would not recommend the use on the warts because of that problem. And I've actually for draining pleural effusion on the ward, Uh, for a static thing. Used a van flown, but I wouldn't as a beginner start using the seldinger brain because of the potential of combating. If you're using it, you put it in a bit like a van flown once you in. Then you hold the seldinger part, the metal part, and then you slide the plastic over it, so I put it in and then slide it over it into the space. You don't continue pushing with a trocar. So we've talked about the drain system and under water seal and suction and pleurodesis will happen over 5 to 6 days. And when it stops bubbling, take it off suction. Wait another 24 hours. Confirm that the chest on chest X ray, that lung is up and then you can remove it. So, Michael, everybody goes removing the chest. Rain. Any points on that, please? No, I think again, it's it's a skill in itself. Um, so, um sorry, Michael. Know? I was going to say I was thinking about that, and I think you want to make sure that obviously the drains done what it's needed to do. And again, it's not just a case of thinking. Oh, it's just Let's pull it out. You've got the training stuff and that would be my thoughts on that. And again, your need. Algesia. It'll be uncomfortable. Not as uncomfortable as putting it in. I have a second pair of hands, and the other question that always ask Michael to get the patient is comfortable and relaxed. You are comfortable and relaxed with the right equipment and addressing Michael, do you breathe in and breathe out when you take the drain out? Not the surgeon, the patient I think whatever you do, it's very important that you got clear communication and you talk the patient very clearly. You talking through it very clearly. What you don't want is is a sort of bungled operation where the patient breathing halfway as you're taking the drain out and you want to basically, is hold your breath. So when you're ready to slide it down, hold your breath, then you slide it out. So if I come back over to my model here and thank you sensitive study for this one stitch insertion, I have cut that. Not I've undone this around. And now you can see I've got two lengths. That was the original, not I pointed out to length. So I asked the patient to hold their breath, slide that out in the field, and I can now tie the knot that I'm bringing together. And this with a simple dressing over the top. That mattress stitches buckling that and it's as simple as that. So there you go. Mister Goodman, Are you there? Any questions from our audience? Any targeted care for surgical emphysema? Michael, Surgical Emphysema is the key point, I would say is you want to make sure that you've got adequate pleural drainage so that your brain you've got a chest draining. UH, that is that is functioning, and that's the key. Now, obviously, there are other things about managing. You know, you can put back packs in the skin and incisions, but that would be in a situation where you've got adequate pleural drainage and your patients is obviously very distressing for a patient to have surgical emphysema to the point where their eyes are closed. And obviously that does it in itself. It's It's frightening and going to appreciate that for a patient. And it's it's obviously going to limit mobility and things, which is so crucial after after, uh, after any sort of chest issue that you're trying to resolve, you want to be able to get your lungs working, so to speak and get them up walking about sooner rather than later. It's comfortably possible. Michael. I'm extremely grateful to you for your contribution this evening. I hope that we have made the insertion of chest drains a little clearer and more simple. If you the audience have any other surgical procedures that you would like us to address, please send an email. I also like to remind you of the competition that we set where we invited you to put stitches in a banana. I'll circulate the pictures. Remember that the best three, as judged by medal and Black Belt Academy will get their own set of instruments and we'll post these to you. You need to actually take your photograph black and white high resolution and post it on Social media and Tag Medal and Black Belt Academy. We will then contact you through social Media and medal. We'll get your address and we will post you the winners Top three, your own set of instruments. Thank you very much indeed for joining the blackmailed Academy of Surgical Skills this evening. We will see you next week as we continue our philosophy on development of surgical skills. I think Phil, we're talking about diastolic learning next week, are we not? We have got a great session on diastolic learning. Have you ever been in theater? And the trainer said, Not like this, but like that and we were wondering what this actually meant. So join us next week. Eight o'clock, 17 October. Thank you very much indeed, and Michael. Thank you very much indeed. For joining us and thank you. The audience for participating this evening and for your questions. Uh, you've got a question. Is this open to people outside the UK? This competition is open globally. We will post a set of instruments to you wherever you are in the world. If you're stitching. Is that good? Thank you. Thank you.