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Yeah, hello. Good evening. Good day. Good morning, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Reagan. I am 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. Thank you very much to the 3302 followers on Facebook and the 598 on Instagram, Josten has gone to 599 and be grateful if we could top 600 by the end of the evening. If this is your first time. Thank you very much for joining us. And if you're returning, thank you. I am broadcasting from North Yorkshire on a caravan site outside because I'm between homes and my challenge to you is if I can bring this to you outside and a small part of Yorkshire, then you've got no excuse to practice the skills that we're going to demonstrate this evening. And fortunately this week, all those cloudy, there's a bit of wind. I hope you enjoy the ambient background noise of the birds and the birdsong at this time, the evening, they on full song. I've gone around the beautiful grounds here at Running Park to pick up a few props for this evening. My main prop is this, there you go. That is a dandelion with lions tooth canker wart, Irish Daisy monks head or priest crown. And for those with a religious inclination, this is supposed to symbolize grief or the passion of Christ, the folded umbrellas of each of the seeds or purpose was supposed to indicate whether it was going to rain or not. And the most remarkable thing about this is that each parachute or Kappas, as you can see, there has about 100 filaments of bristles each attached to a single point a bit like the old fashioned chimney rush. Uh huh area is a 10% but that 10% of area as to four times the drag of this parachute and was reported in nature in 2018 when they worked out for the first time ever. Why dandelion seed is one of the best fliers in nature and the seas can go up to 100 kilometers. And why I actually bring that in this evening is because we're talking about lightness of touch and the lightness of touch applies to the use of the forceps. Now for the first cause or great ultimate in Tokyo Co which is the first cancer karate they teach you position and posture. And we have been talking about position and posture. And uh and the important thing about this position, it isolates removes all the major muscles involved in supporting humerus and scapula. Because every time you move the arm out, we start using trapezius deltoids, perpetuators. And as soon as you bring in those big muscles, not only are you going to get fatigued long term musculoskeletal problems but bringing in those big you're going to bring in tremor. Now, a colleague on Twitter, Juan Barbarossa tweeted about trimmer the other day and the best thing you can do for that is stand properly and hold your hands properly. The second thing you do, yes, you are nervous when you start operating and the forceps seem to go like this as you approach something to pick it up and you hold your breath thinking that breathing would make it worse. Is interesting that the Cleveland Clinic today reported a whole lot of exercises and the power of breathing. And the very simple thing is four by four by four breathing slowly, four counts, hold it for four counts and breathe out for four counts. Again, breathing actually is part of the Madonna and is therefore connected to your parasympathetic system. And the best thing you can do to control tremor and relax is to concentrate on your breathing either. Now, the posture functional position, the hands are relaxed and that means the intrinsic muscles of the hands are now can do their bit. And the important muscles are the lumbar calls and they are unique because they don't have any burning origin or bony insertion and they extend the distal interphalangeal joint there. And with the opponents policies, it brings the palps of the fingers together. And that is exactly what surgery is all about is the feel you get more sensory input. So that helps your fingers to, you can do the brain. The thing is, is that if you start using your flex of digital and performers, which is the Popeye muscle or your forearm, one of the biggest muscles and form, you're flexing the D I P joint and it's that, that cliffhangers support themselves on the brink of destiny. And as soon as you start doing that, and I am pinching her and I can see that pinch pressure and even through gloves, notice trainees when they're putting too much pressure. So I did ask, what was the pinch pressure of the average female? And that is 25 museums in a male that can get up to 35 40 newtons. You're quite right in pointing out the surface area at the tip of your forceps is probably five times 10 to the minus 6 m grade five millimeters squared. And that does mean the pressure force over area causes damage. And I've shown this before and I'll show it again because this is important because when you're concentrating on your non dominant as your dominant hand, the non dominant hand can cause damage. So if we take that is 25 newtons over five times 10 to the minus 6 m splay, you're actually looking at the pressure of five million Newton, it's forceps I have caused um it and if you look at this carefully, the full thickness bruising of that, there's also been demonstrated on histological studies of the barrel and of the endothelium. All because the focusing on the right hand and gripping with the left. So the best thing you can do is think of lumbrical extending the D I P joint and holding it properly. And to do that, you balance the forceps on your first bossom interosseous and you fold your fingers across them like that simple folding. Even if I try hard, I am not going to be able to put 25 meetings of pinch pressure in there that folding works no matter my arm position. So and lightness of touch comes through your finger and VIP joins. I've got an important. So the forceps should be considered in. There is a surgery, a lot of exploration of the inner body is done with your fingers, but we are operating at depth and the forceps with an F as well like your fingers must be regarded as an existing dissed to explore, to pick up, to hold, to retract, never to grab, never to grasp. And it always has to be accurate, deliberate and with the finest touches, this needs to happen with both your right hand and your left hand and it doesn't come automatically and it doesn't come under stressed in theater when you asked to follow it or hold something as well. And that is why it's important to take some simple models and the practice of whom. So one of the first models I'm going to show you, we actually took as the black powder Cavaney with fellow senses, Chris Caddy and John Taylor with the support of reborn. And we set up a challenge and the challenge was to take eight grains of rice into bendy straws in the shortest time possible. The competition. Mhm And the fun was just, people came back in and again because they want to do better and the best time is 15.84 seconds. Now, I'm not going to try and replicate that this evening, not at all, but you practice it with a simple rule. You drop rice, you stopped the clock and we're going to take you over to the camera and we're going to see. Yes. What I've done here is very simply taken. These are bendy straws, okay and place them blue tack on a plate. So hold them in position. Now, the rice itself is longer than the diameter of the end of the straws. And this makes it challenging emphasize. It makes it a Chester size because now you need to pick up the rice and orientated such you can drop it in. He had of the straw. Remember when you drop it, you stopped. And the important thing as described by another colleague, Tim Terry, who will be introduced to you as our new Sensei in two weeks time, do not rush, slow and deliberant slow surgery is fast surgery and deliberate surgery. There's no point trying to rush what's in it thing about the rice itself, it skids across the pan. You can turn this into a glimpse and what we're going to have on our app. In due course, we have set this told years since Sienna has set this to music and a metronome and you can test your skills, very simple accuracy and precision. The thing is you can change not only the height and direction of the straws, you can add more as well to make it funny. I like using anything and everything I can find in the kitchen. And this collection of seeds of mustard coriander, fennel and pepper give another wonderful test of picking up solid objects. I think the most difficult one is the mustard mustard seen. It is very, very, very sordid. And if you grab it too hard, it goes flying off pharmacy a little easier to pick. Your coriander has good, which is in and the biggest, the purpose is, uh, easiest to pick up and again, simply picking these up and set the clock to it as you wish. But practicing picking the seeds up right hand and left hand. If you video it, dude, arm yourself with the force. I like it. It's very simple physically focusing it to lightness of touch. Because if I grab it too hard, these, they're flying off, you can use any sort of seeds. And if you've got some depth, we can see the seeds. This is a lovely model for taking individual seeds off and making it more difficult right hand, popping it in. And you can see it only just fits in the end of that straw, left hand as well, gently pick off the seed, put it in the end of the straw, the diameter is about the same. So therefore, it's a challenge. But to make it a bit easier for yourself, you can use a wider, it's true and reach down inside. I look at this sometimes I think my auntie colleagues will probably be thinking, oh, I've seen something like this down the throat with the nasal cavity. And I always look at this and think does it actually look like the turbinates in the nasal cavity? And again, I'm trying to pick them up, deliberately put them in his drawers. Now, the other thing about these suits there a little bit moist and they do stick to the end of the faucets. So making it a little bit more of a challenge. But the thing about models and practice, every single model should be giving you so challenge. I've just had a message from and I apologize this evening for some reason. Uh Internet connection is on and off Gabriel. Are you still there? Yes, everything is working properly. Okay. Thank you very much. I think this is a very look at that. I'll take it down. You can see I'm not checking on that. That seed is right. Mhm. The same diameter as the straw. So it is actually quite a challenge. There's quite a challenge. There you go. Put that in. But often we're dealing with soggy surfaces and blood and tissue and those were cooking this afternoon. We've got some beef tomatoes and I looked at these beef tomatoes and thought, oh, look at that in that gelatinous mass in the middle. Guess what I've spotted, I've spotted some seeds. Can we actually reach into these seeds and pick them out and doing this? I'm reminded of my affirming colleagues who perhaps are removing foreign bodies from the cornea. I need a model of lightness of touch to take out the seeds and not pick up anything. Oh, so anything you've got at home will do anything with seeds will possibly work as far as an exercise in test is concerned. So the next blackness of touch exercise is again part of the salmon fillets and uh baby new potatoes and salad and beef tomatoes and cooked this afternoon is being suggested by Surah in Baghdad and Surah. What she did was take oh potato, boiled it. And in this case, we need to actually tease the skin gently off the potato and see if you can peel it off and peel it off in. There's the forceps themselves can be used as a gentle dissection tool in itself and putting it in and opening it up. It can also be used to separate, gently separate and develop planes. What I like about this model that so uh suggested is like all organic material. It is flimsy and delicate and it represents what we would expect to see with operating in survey and not infrequently from across tissues where we need to develop planes and gently strip off. There you go, a little bit of skin. You can see that skin there is extremely thin and they didn't also think about it is to pick it up without see that mashing the potato underneath. So the control and delicacy comes in a model that is testing your right and left hand skills peeling off the skin of status. You can do this with the cooked tomato as well, cooked tomato. Again, we'll give you a thicker skin somewhat easier. Perhaps there's a starter for 10. You should try that before moving on to something as delicate as thin. Get that looking at the clouds up a few on this looking clouds. So there's a challenge I was looking at flowers. Stick with the statement, flowers. Can you take the pedals off out destroying the petals, take it off the bottom sunflowers a bit easier. Others a little more difficult. But if I grab this petal and I'll take it by itself, grab this pepper, putting a bit of pressure on it and we look at that without the pressure, you can see that it's caused it like the banana. A lot of damage. Imagine that peple as mucosa or endothelium, that is effectively the amount of damage that you're going to do. So, it's important with all these models. Can you exercise extreme cab going back to our dandelion? Let's see if we can take off each purpose, grapeseed, reach in and take one off at a time. All these exercises or testing skills. Mhm. Uh Very fragile. And that's what I like about this one. It is really. There you go. Got to in that one. I haven't got one yet. Yeah, I wonder to practice. So this also is now lightness of touch, but introducing a degree of accuracy and precision is reaching in gently, picking up a single purpose and picking it up from the head. Coming a little bit closer. You can see, uh like I love this camera supplied by educate life sciences too, Kevin Austin of wetland. And the focus is fantastic. I hope you agree. Feather. Oh, yes. Wind outside is helping me pick this off and disperse the seeds. But I hope that you get the picture. So accuracy, precision and especially lightness of touch is critical. But there's another problem that I find with the use of four steps and that happens when you've seen this model before. Haven't we will be covering it and talking about it. What I've done here is taken an apple core to the banana and I've put staples around the clock into the banana skin. Those of you have seen the black belt exercise and stitching what we require 12 perfectly radio sutures. As we go around, the forceps should not be delivering the needle, the forceps is there to hold the issue and to retract, it should never ever be used to grab the needle. And in this exercise, we're going to take the needle I/O of the tissue. As you see, the tissue holds the needle itself. But as I'm retracting, focusing on the tissue stitching, I should not be pulling the staple out of the banana like that because the private, as you're focusing on dominant hand in stitching is that your non dominant had not only grabs as we've demonstrated and causes problem, but it drifts and drifting. It'll pull away in town. It is therefore very important that okay, found on stitching courses as soon as you put the forceps in the ability of people to actually stitch seems to deteriorate. So in the beginning, I separate the two skills, but this as an advanced skill is there, Kenshoo and then you have it there. You have it. I've tried to demonstrate to you. Yes, simple exercises did. I hope like the of this podcast, I hope you like the exercises that are demonstrating and that challenge you to send me some pictures. But also for those of you who are not practicing with your right hand and your left hand on a regular basis, perhaps now you should remember the position for your forceps is that hand position because that's bringing the tips of your fingers together to enable you to feel the tissue. And with that feel you'll get feedback from the tissue and how it is working. Thank you very much indeed, for joining the Blackboard Academy of Surgical Skills. We look forward to seeing you next week. I will try and resolve the I T issues. I'm going to come to you for Malaysia next week as I'm going to be joining my son on his half term. And the week after that, we've got a special guest being uh next week, I actually a week after that, we have got a special guest and a new sense. I Tim Turi, who's going to be talking to Chris Cuddy about coaching and mentoring, both of which are needed on your journey of mastery. The week after that, I'm going to be joined by a special guest as we talk about assisting skills, I'll be putting Yeah, if it's up on medal in the next day, thank you very much for joining. Do pass the word round do fill in the feedback form. And thank you very much Gabrielle for the production.