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Hello, good evening. Good afternoon. Good morning. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is Darigan. I'm a professor in the Medical Education Research and Development Unit of the Faculty of Medicine at the University of Malaya. And I'm the immediate past director of the Faculty of Surgical Trainers of the Royal College of Surgeons of Edinburgh. They have accredited this program and you will get CPD points for joining us if this is your first time, welcome and if you are returning, thank you very much. Indeed, we are now reaching over 4700 people in 100 and 33 countries and increasing. Thank you to me who offers the service free and thank you to the production and Vanish who is 1/4 year medical student wanting to do cardiac surgery, who is here in the Faculty of Medicine at the University of Malaya. Behind the scenes, two, a fellow Mr Chris Caddy, who has just stepped off counsel for the Royal College of Sur of Edinburgh and has rewired retired plastic surgeon into coaching and mentoring. He's in the background will join the conversation later and he is my most fabulous critique of these sessions. So, thank you tonight, we are joined from Egypt, Georgia, Germany, India, Jordan, Nepal, Qatar, Romania, Singapore, United Kingdom, USA Zambia and Zimbabwe. To name a few. As Darwin observed, monkeys used their hands to pull out fawns and birds and hunt and pick for each other's parasites. Nevertheless, he noted they were clumsy in their actuals compared to mine. And we have discussed previously the uniqueness of the human hand and the green one. Nonetheless, these foreign body extractions emphasize a long evolution of tweezer like opposition of the thumb and the fingers, a posture familiar to many of you when you've taken tweezers to try and remove a th or splinter from your hand or foot, we have examined the key grips of the human hand, essentially a three finger grip, the other hand grip. But there are two other important elements. The palp to palp grip, and the fingertip to fingertip grip, depending on the function. And if you look at the anatomy of the terminal digit with the bone and the nail, you can understand the uniqueness and the ability to pick things up with a nail, pincer grip. It has suggested the original forceps we use as blacksmith's tons forging metal. The Latin being for hot Ferrum, iron and re to hold. Hence forceps. Today, forceps is actually loosely applied to any surgical instrument which fixes or grips tissues or structures So it embraces the definition of tweezers, dissecting forceps, intestinal clamps, artery forceps, dental forceps, bone cutting forceps, obstetric extraction forceps. Uh that was literally under cooking dagger back in the 17 nineties and hidden by the Chamberlain family who had this magic way of delivering babies. But we are not going to go into obstetric forceps. In general, forceps have two limbs. They're either two bendy bits of metal joined together, forged of one or two bits of metal joined together or a block in between C A hinge creating a pivot. We are going to look and focus on what's called the spring forceps of two bending muscles. Now, spring forceps or tweezers, Latin valsella, a plucking item are readily formed by taking two bits of metal bending them on itself. In the case, as you imagine of sugar tongs or other tongs that you perhaps use in the kitchen. It is likely this metallic shape preceded by organic structures, possibly. And I don't know if you eat mussels, but using the shells or the mussels themselves, the bi shells, you can pluck out the muscle meat in eating them. Interestingly enough. My son became very adapted doing this at the age of nine to the astonishment of many waiters in said restaurants, you can imagine taking a pliant bit of green wood, bending the shape like splitting a bit of bamboo and or wedging it open below a node that elasticity of the green stick or the bamboo would give you that similar spring feeling greenwood forceps are still made by British rural craftsmen to handle baked potatoes on an open fire. And in the late 19th century in Sarawak, a wooden device of spring forcep construction controlled by removable loops of cane was employed to immobilize the glands of the penis during ritual transfixion. It doesn't bear thinking about surgical forceps is a fundamental instrument in the realm of surgery and have a long and intricate history. They're used in both the right and left hand and by everybody in theater and the history is reflected in the evolution of medical practices and technology and these instruments are designed for grasping, holding manipulating objects during surgery. And I've gone through enormous number of changes. The origin of surgical forceps can be traced back to ancient civilizations and early evidence suggests that rudimentary forms of forceps were used in ancient Egypt, Greece and Rome. And these tools are often made of bronze or iron and used to extract foreign objects from wounds or dead tissue. The famous Greek physician Hippocrates is often credited with some of the earliest records of using surgical instruments resembling forceps. And he, his writings indicate a sophisticated understanding of surgical techniques and the tools required for each of these procedures. One of the best treaties on the History of Forces was by me Christiansen published in 1938 and he considered the early development of the surgical instrument based on archaeological material in European museums which has rarely has medical provenance. He believed that certain gold, silver, copper and bronze tweezers for were used for Appalachian removal of hair and found in the Middle East as early as the 3000 BC. Some of these could remove sprinters and thorns and thus were the forerunners of what we would regard today as the surgical spring forceps. His physical analysis of larger copper Egyptian forceps, perhaps his oldest 3300 BC convinced him that many were applied to extract arrowheads and penetrating missiles of battle. On the other hand, he believed that numer of forceps in the 2nd and 1st millennia, BC found in Scandinavia and Northern Europe or not for surgery, but for pulling out hair and shaving. In reality before 1897 when Vesuvius buried Pompeii, medical provenance for the use of forceps is uncertain. Even four steps undoubted for surgical procedures were described by Hippocrates. And among the 556 Pompe and other accepted surgical instruments are the fifth century 80 spring forceps. In other words, the two bits of bendy metals form the majority of the forceps, whereas P forceps only a fraction and this was reversed. In the 15th century, 60% of the Roman instruments scrutinized were made of copper or alloy or bronze and sometimes I am, but many of these actually corroded and disappeared, folding the metal on itself. It certainly the easiest form of making a tweezer next, they separate it to two limbs and put a block in between to increase the spring. And the third is made in which the two legs are welded together or riveted at one end. And all three constructions have been found amongst Roman artifacts during the medieval period, surgical practices stagnated in Europe. And it's also possible that many of the instruments did not survive because of disintegration. However, as we have previously said in the Black Belt Academy, although it was the dark ages in Europe, this was the golden age of Persia and the renowned Persian physician Zari often referred to as the father of surgery described and illustrated over 200 instruments in his medical encyclopedia. Ta each tool for each different procedure was described in detail to clarify how to use it for each treatment. And it was intended for medical students. Perhaps he was the forerunner of the Black Belt Academy, the Renaissance period as we have previously described, marked a new revival in scientific inquiry and medical advancements and it was ambrose pare 1510 to 1590. A French barber surgeon made notable contributions to surgical instruments and he is credited for designing several types of forceps for different purposes. There were a whole lot of different versions of the spring like forceps, some of them included three limbs that you took apart. And Alfonso Ferrier in 1555 used these three limbs you can imagine for pulling out bullets and This was also used by Boffin in the mid 19th century to approximate wounds. That is all things in surgery. It was the inception of aseptic survey by Lister that actually made surgical instruments desirable possible and useful for use because the cleaning of the secure angle at the top here proved extremely difficult. Many people came up with different ways of taking apart, dismounting it. That was and sh and down brothers to facilitate the cleaning of the instrument. But this did not prove popular. The next important element of the forceps are the jaws which determined its particular function from fine form extraction, broad craniotomy c shaped for ocular specular deep groove or copper filled for needle holding flattened or asymmetrical for eyelid, holding spike for tongue, holding straight curved fenestrated, hooked, initially smooth. But it was the Romans who actually introduced teeth that we now see across most of our forceps and they made them a cross ring. As you see in these, in the early 18th century, anatomists increased the use of these spring forceps because now they're being used in the left hand as the right hand became dominant in dissection. Although they are commonly used their finger and thumb as hooks for grosser dissection. And indeed as surgeons today, some of the best tweezers that you have of forceps are your fingers and grasping and holding and retracting tissue cos that provides the lips of touch. Anatomical dissection. Forceps were employed widely for post Mortem work. And in the 18 thirties, the dissecting forceps as we know them today entered the operating theater and the Spring Forcep enjoyed a considerable revival. Now, you were very good in the questions in identifying many of the different forceps. These mosquitoes or handles are pivot forceps for grasping and hoarding. But you came up with fakers and mountains. Cheeto trees, Littlewood, Babcock, Ferguson, Iris, Alice Cocker Creel. And of course mcgill Forceps used by anesthetist for putting down tubes. But it's the dissecting forceps that we are going to be looking at. And it was GGO in 1723 that described the dissecting forceps. And I love what he said, he said, and he held them in his left hand. They should be used in the left hand as one holds a pen with a thumb, one branch inferiorly and the index and middle fingers superiorly like that. It is used to elevate fine and delicate parts for dissection and which quickly promotes tidy work. This is not too dissimilar what Roy Barkley Mohan was talking about and his work, they have evolved into the modern era that changes the surgery. And of course, laparoscopic surgery has meant that they are now at the end of long instruments. But the advances of metal angy have meant that we can create all sorts of forceps of fine, thick and different shapes. And the jaws have different shapes and teeth for different functions and different capabilities. Of course, with minimally invasive surgery. Now, we are now looking at and it's interesting that research is going into pressure sensors at the end of the forceps to give you feedback on the force and pressure that has been used. And with uniport surgery, having flexible arms and snake like arms and robotic arms with four dimensional movement of forceps is possible, but it's interesting that they are now being built with sense of feedback to measure pressure. And that is essentially what the major problem is. I think with forceps today. Now I want you to do this simple exercise for me, you are going to take your finger and thumb and I want to pinch your forearm and I want you to pinch it as hard as you can. You can't, you can't apply that degree of force because when you flex the D IP joints, you got two major muscles involved, the flexor digitorum profundus and the flexor polish this longus. These are the two Popeye muscles in the third deep compartment of the forearm and they straddled with radius and, and the endo membrane. Those mass are the muscles that are used for by cliffhangers. Tom Cruise uses that in mission impossible to hang off helicopters. I do not want you to use that action at all. Coming back to the description of P to P, not tip to tip. So you put P to P by extending the D IP joints using the lumbrical. Now with that extended finger. I want you to do the same and try and pinch yourself as hard as you can try harder. You can't, there's a limit to how much force that you can put on that action. And if you remember that action, you will always negate the force. Now, the force is significant because we've got an example here two hours ago, I took these Aden's tooth forceps. You can see they've got a double tooth, one side that has a single tooth, the other side interdigitating. Now, Ason was a famous neurosurgeon. And despite the fact that is operating in the brain, he was using two forceps on the dura for a firm grip. It has a new dimension. I want to pick your brains. But you can see here on the banana, the teeth mark that are made after an hour's use on the opposite side, I've used some simple regular forceps with a cross hatching here and even that simple crosshatching. And I was just pressing like that. You can see the lines of the hatches of the jaws. It is that force that is difficult. So going back to your G CSE physics, pressure equals force of the area. And the average pinch pressure like that. And note when I'm pinching, my fingernails are blanched, that's not feel you can see my nail blanching there that is now pressure and the average pinch pressure for Maron is between 3035 MS and for women 20 to 25. So if we take the average force generated by your flexor poly longest and your flexor digital and Profundus, you have 25 newtons. Now I'm being generous in looking at the opposing end of this forcep and saying that is five millimeters squared, of course, five millimeters squared is five times 10 to the minus 6 m. So pressure equals force over area and that equates to 5 million newtons per meter squared newtons meters squared. 5 million. No, that's 200 kilopascal. So I'm gonna ask the audience for those of you who drive, what is the pressure that you put in the car tire? Cos this is also equates to 725 psi So why are you doing that? I'm just going to get out some spinach leaves any answers to that question? Car tire pressure. Some of you must drive any answers, please put them in the chat 1.3 bar. Oh Doctor Rudd, I haven't converted this to bar. Can you put that in psi for me, usually the psi I used to put in my car tires was about 35 psi you can see this is 725 psi and the important thing is when you look at it and now my sense, a Mr carry will be really pleased that I'm using a skin hook to leave, lift up this banana. And if I lift this up, I'll focus down a bit further because I think you really have to appreciate the banana skin is probably four millimeters thick. But you can see there that the damage is full thickness. It is blackened all the way through. Imagine if that was bowel versus a vessel that would be endothelial cell genocide or mucosal massacre because of indigit use of the forceps. Notwithstanding that the forceps themselves can stab and in any solid organ can easily penetrate an inflame limb, some kidney or liver and go straight through. Indeed, it could go through the bowel as well. So poking holes is quite easy to do so we should not actually grab and this is a fresh bit of spinach out of the fridge washed for the next home recipe. And if I grab the edges, it crushes, you put that under the microscope, you put that under the microscope that you can see the marks on my forceps on that spinach organic material massacred by poor force and poor skill. And that is what you have to realize is that as soon as you start seeing the blanching of your fingers, as soon as you bend the D IP joint, you will be putting excessive force through those instruments. That is not a good idea because much of what we do with forceps is peeling tissues. And what I have got here is a tomato that I've put in some boiling water. And I'm going to use this tomato as an example of wet tissue. And can I actually use my forceps to gently peel the skin off? Is tomato easy, you would say certainly. But now you are actually thinking about using your forceps as perhaps a blunt tool for dissection but gently retracting and holding the tissue. It looks like a wet inflamed surface, does it not? But sura from Baghdad offered something even better. She took some boiled potatoes and suggested that, can you peel the skin of this potato? Now, we're getting something that's even thinner. That's rough. Yeah. You see that? Yeah, so thin. I can see my forceps underneath. Can you peel the skin of rotator and develop it? And I'm using the forceps in both hands and many of these tasks because as a surgeon and as an assistant, you need to be adept at using forceps with both hands. It is awfully thin as you can see and will tear very gently. Look at that paper thin, paper sim. But what these simple exercises are teaching you is lightness of touch and because they're wet and sticky, well, funnily enough when you get inside the body and you're dissecting, you'll find that all your surfaces you're operating on are wet and sticky. I'm sorry. But synthetic materials, suture pads, et cetera cannot in any way. Mimic this again. Like many of the models that we show here on the Black Belt Academy. I find myself totally engrossed. No problem. There's a question Yes. Uh So Rinku has asked, can you use the forceps uh inside, for example, to hold the dermis and not the epidermis? Yes. But again, be be light to touch. But in fact, for stitching the skin, I would not hold. Basically, I'm reflecting, I'm not grabbing at all. And that's why our plastic surgeons use skin hooks because you should not be grabbing or holding the tissue. If you're holding tissue, it should be really fibrous relatively avascular and you're using it for retraction because I've demonstrated to you on the banana and on spinach, the damage that can be done. But I love this. I love this peeling. And again, in keeping with our philosophy with the Blackburn Academy, don't worry, all of this material, the tomato and the potatoes are going back in the fridge and they will be eating wonderful as part of the recipe. The next element of your stitching is accuracy and precision. And this is being able to pick up things and put them and place them in particular orientation. So the first up, we have Besma rice here in a dish, I'm picking it up and you can see that it is actually wider and the diameter of the straw. So I have to orientate it to drop it in. And I note that my forceps are wet and they're sticking. So I'm just gonna give them a wipe. And in fact, in theater, if that was the case, I'd give them a little wipe on a swab so it didn't stick. So they go pick it up, orientate it. And again, this is an exercise that you can use two forceps, two hands and port. One of our Forceps competitions that the association of surgeons of training have invited us to the A GM. Coming up in March, we will have a Forceps competition and the idea is to take eight grains of rice and put them into each of these straws and we are timing it. This is timing it for fun, of course, but you drop it, you are disqualified. No chaos has offered a very nice metronome and timing of this exercise that's gonna appear on our app which will be coming out this year. We can set this to music and to a timer and have fun practicing, picking up rice and dropping it in a straw, but that's rice and it's dry. The difficulty is because the length of the rice is greater than the diameter of the straw. You have to orientate properly, but you can use anything and everything. Here. I have a little bowl of different scenes. I have pepper. I have mustard which are these smaller ones and there you go. If you grab too hard, it goes flying off and he did as well again. Let's try that again. I have cumin seems to be a shortage of cumin here lasted. Pepper. C and Coriander DS side seeds around in different shapes. Some smooth, some irregular. But if you grab them hard, you, we'll send them ski skidding across the ball. Now, if you're practicing with a friend, you can challenge each other in Timeless or your friend could call out the different colors. I haven't found Bendy Straws yet and I'm trying to still find Bendy straws here. When I have found Bendy straws. You're putting that in cos bendy straws, it can make, it's even more challenging by putting a different direction. Oh, well, if I can't find those, of course, if you go to the baking aisle, you'll find all sorts of sugary colored sprinkles that you put on your cookies. Again. This is kind of fun because you've got different colors and different shapes and different sizes. Now, the thing about the sugary ones is if you grab them too hard, they do fall apart. So this you require a even lighter touch, but you could record in advance if you want orange, red, orange to green, red, to yellow, green, to red, blue, to green, blue, to green and make it a again and make it fun. All sorts of picking up is possible. Take the tomato, we have seeds, we have seeds in a wet sticky environment. Are we able to pick up these seeds carefully? This is not too dissimilar to debriding a wound in casualty. Again, all these skills are teaching accuracy, imprecision. So the lightness of touch, definitely accuracy and precision and I'm using both hands. I've got a tissue paper off to the side here so I can catch the seeds. But I'm thinking of my days doing endocrine surgery, the parathyroid glands didn't look too dissimilar to this actually. And you got, I'm sure many of you working in different specialties looking at this model will think. Ah, yes, that's not too dissimilar to what we do in theater in this circumstance. Perhaps you'd like to put that in the chat. I am thinking of debriding wounds. I've said thought of parathyroid surgery. Can anybody else suggest where this could be useful as an exercise, exploring et sticky area? All of that is not a depth and in keeping with in depth, why not use a pepper? I love the pepper as we've sh used before for dissection. But if you look down on the inside, we have at the bottom here, all these wonderful pips. Can you pick up that PIB and place it in the straw one by one deliberately picking it up? I'm putting in the straw watermelon, pumpkin, butternut squash, chilies. Many of the vegetables that I walked past in the gile supermarket today would have adequately sufficed for this exercise. But the depth cannot be beaten using a pepper. So there we have precision in picking up and putting into straws. You can make it challenging. As I said by using bendy straws or reducing the diamet of the straw. Fantastic competitions easy. You take. What about, what do we have here? Mm No, it's not. Maggots. Got another soft and delicate exercise. I have overcooked some rice here. Risotto rice. You can see if I pick it up, whoosh squished. Can I now pick this up both hands and put them in to the straws without crushing them. So with a little bit of imagination walking around a supermarket looking at all the different fruits and vegetables that are available with potential seeds, rice peppers, you can now start practicing your fidelity. So we have mastered force and recognized that we need to bring the palps of our fingers in contact with the forceps for the lightness of dutch. We have recognized that we now require fidelity and accuracy in picking up all these objects wet or dry, small or large. But the biggest problem comes when you actually set somebody to do a task. And over the years of teaching tutoring courses and Power excellence, I have started the teaching with the dominant hand only doing the stitching. And when we get do the stitching, we are practicing with our non dominant hand behind our back. What I found over the years is that as soon as I introduced the non-dominant hand, the forceps, the stitching goes awry. There's a tendency to actually take a needle and pick it up using the forceps. As we've previously demonstrated that is wrong, the tissue will hold the suture, hold the needle in position, you do not need forceps to hold the needle in this exercise, which is an extension of the stitching exercise that we have described and will revisit. I want you to stitch. But as you go round stitching, you're holding an appropriate staple in position. And the idea is as you move round in the direction that you're gently holding the staple as you would retracting tissues without pulling the staple out of the banana. Because what I've noticed with people who are focused on the right hand only and have not developed the interdependency of right hand and left hand function. The left hand, if your right hand dominant grabs, drags and drifts and you will pull out the staples from the banana. And as you become more stressed and as you become more focused, you lose all control of your left hand which will then wreak havoc and cause serious damage. So as we put forceps and stitching together and holding of tissues, you need to realize that your forceps are there to complement. Yeah, actions of your dominant hand and the forceps have really become the reserve of the non dominant hand. And although it's not dominant, your function of the forceps are critical for traction, countertraction, but also with excessive force could well cause serious damage. So that's why in the Black Belt Academy, we teach this separately and then invite you to consider them together once you have mastered the skill of each. So are there any questions from the audience or any observations, I'll ask my colleague and fellows, Mr Cady to join the conversation. He is actually in Florida at the moment for America, but here I am in Kuala Lumpur and he is in America and you are spread across the globe and that's what the modern teacher an incredible reach. No, I haven't choose like four steps to change 1 m position. Our forceps are still there retracting. So David comments, Mr C once again, absolutely brilliant. Um The, the way that you've co covered the history and development of forceps was uh it would take people many hours in the library to find all of that information and you put it into one fell swoop um particularly like the, the, the um uh potato peeling the, the skin off the outside of it. I said I have to credit in Baghdad for sharing that. I think it's a wonderful model. Well, II completely agree. It's, it's something we've noticed before, but nobody said, why don't you use it as an exercise? And so it was, it was really, really powerful. Very good. Thank you. And, and ladies and gentlemen, please do share your pictures and your experiences of fruits and vegetables or organic materials in your part of the world. I know I go through N SK supermarket and look at piles of exotic fruit, not knowing what on earth they are, but actually wondering what do they taste like? How do they cook? But also can I use them in the Black Belter category? Any questions from anybody? No interest finish any observations from your point of view? Mm. Uh This is something that I haven't tried yet. Uh Perhaps I have to try first. Well, the simple message is with a little bit of imagination with very little in expense. A walk around the supermarket will actually give you lots of ideas into practice. It is my ambition that all people wanting to do surgery will register with a black belt academy. And hopefully one day in doing so, we will get you a set of reasonable quality instruments to enable you to practice at home. Do remember I am standing here at the kitchen counter because the kitchen counter is slightly low. I've put a chopping board on it and the chopping board must be about 14 millimeters thick and that chopping board brings the counter height to the perfect height for me to operate posture and handling of the instruments are incredibly important. I am reminded of this every time I go for my yo lesson at the Japan Club here in Kuala Lumpur. The arrangement of how you hold the sword, how you draw the sword, the direction of the hilt of the sword tells you where your cut is going to start. Your cut is gonna be perfect. Your handling of the instrument is gonna be perfect. It has to be a flatness and touch the position of your feet, determine the position of your pelvis, which also determines the position of your shoulder and all of that is going to affect what you do. These are not simple things, but what is very interesting is that learning the i, the sense they can watch me go through the cars and go through the practice and I'm with you. I got a second done with any I and thought I knew it all how long completely wrong. When you've got an expert looking at the way you're doing it and giving you feedback on each and every element, you start suddenly realizing that there's a lot more to our movement like us to touch economy of movement and flow and direction that we could apply to our surgical teaching. What's interesting when we actually do cultures opposite each other, the sense would go stand opposite. And I don't know if it's because he is bold, but it's not just him. The experts in the club. When you stand opposite, you can feel the intensity of their focus as they draw the sword and as they approach towards it, it is quite remarkable. It's just palpable, but their attention to detail is absolutely incredible as well. And all we have to learn is 12 cars. When you say 12 is not much, but to be honest, people spend a lifetime mastering the technique getting it just right. And that is what surgery is about is getting it just right. And each day you practice, think to yourself. Oh, that wasn't quite right. Perhaps I do this. But the thing about these low fidelity models, it allows you to play, it allows you to practice and play is the best form of learning. So, regard all these models as elements of play and if it goes wrong you're playing, not a problem but you're learning and that is the important element. Thank you very much. Indeed, for your attention. We look forward to seeing you next week and we're going to go on to, ah, oh, there you go. I thought I wanted to try one more thing. Oh, golly. I knew I had it here. One more thing. Let's go over. I have here a plate of spaghetti. Now this is well cooked spaghetti and it is very soft and it reminds me why I was wanting to use a plate of spaghetti. Is, can I take one of these elements of spaghetti without actually crushing it or breaking it? And is it possible for me to t not right? Oopsie on the left? Ok. Because next week we are going to talk, talk about not ty, but I thought to myself as we are doing not, ah, you see, broken it. This is the first time I am doing this exercise and I thought, oh, what a wonderful opportunity to create and develop a new, ah, damn. Now that means I go back to another bit of spaghetti. But to get my drift, I am playing, I'm playing with ideas. I am playing with the complex movement now of trying to tie a knot in the spaghetti. And I'm doing it for the first time. Live on here because I thought it would be rather fun. I tried it last time, but unfortunately the air conditioning in here dried out the spaghetti. So, what I did was cook the spaghetti and I've left it on a plate. Careful, David, careful, careful, careful. It's gonna break apart. Yes. Yes. Yes. Yes. Ah, it's almost, there, isn't it? But there you go, chopping off bits as we go along and I anxiously trying to do, do this in time, etcetera. And as I am anxiously trying to do it in time, guess what? I am not actually focusing on the fidelity and I require, does that sound familiar as a trainee? You're anxiously trying to beat the clock and there you go. So, there you go. I have started the exercise. Mr Cadi is going to be laughing, but I'm gonna ask him to try it himself. I'm watching, I'm watching with all II II feel for you. I really do. No. No. Well, the thing is the important thing is, is that I'm not going to set you exercises. Damn, you see, I grabbed it too hard, almost there, almost there. Guess what I'm going to be doing next. I'm going to be coming back and practicing this exercise and I ain't gonna practice until I get it. Can't get it wrong. The thing is about well cooked spaghetti that I'm chomping it up with my forceps. So there you go. Video yourself tying reef knot, a flat knot with a cooked piece of spaghetti. Because next, I think we're going to be talking about Knots Square and Secure Knots. And the week after that I have a very special guest who's the CEO of dendrite Clinical Databases. I've known him for 30 years. Peter Walton is a doctor who went to Donville and Keys. He was the first medic to do an MBA at the London School of Economics and he established what's now a global company that looks after databases and we're gonna be talking about data because Deming said in God we trust but a anybody else requires data. So that's our forthcoming attractions for the next two weeks. Please spread the word. Thank you, Venice for supporting this evening. Thank you to you for asking the questions. Rinku and John and Chris for your observations. We will see you next week and I'm going to spend the next 20 minutes, mastering time or not and cook spaghetti. See you next week. Thank you.