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Hello, Good day. Good afternoon. Good morning, wherever you are in the world. And welcome to the first pre recording of the Black Belt Academy of Surgical Skills. I'm taking this opportunity to interview significant people in my life or significant people in surgery. And I have the pleasure this evening of introducing a friend mentor who's helped me throughout my career. This story behind this I spent 18 months doing research at the Thrombosis Research Institute in London and was purely laboratory based. Some people thought had actually gone native. I didn't do any operating during this time and focused on research alone. And, of course, not using one's hands' came back to clinical practice and finding myself rusty as a consultant, said, I don't understand this. You can open cases and babies as sweet as apple pie, but you cannot operate. But that's because I hadn't been using my hands for 18 months, and I was cycled from the Brompton Hospital to summaries, and the consultant there had delighted telling me that I has been recycled as a reject because I couldn't operate. The funny thing is, I started at Saint Mary's, where I met my friend and colleague Mr Ashok Cherien, who has the patience of job and stood opposite me for 18 months, and I did 256 cases. The funny thing is, the same consultant one day had problems with theater and came out and said, Problem is Reagan is that you avoid the difficult cases. So the funny thing is that a joke and I shared from that moment each time we did a case was was this case difficult enough for me? Now Ash walks going to introduce himself, but he's been in cardiac surgery for almost 40 years. He's met all the significant people in cardiac surgery, and I understand he's the only person has ever been slapped in the face by Mother Teresa. But he'll tell that story. But Ashok not only stood opposite me with the patience of job for 18 months and enabled my confidence. The reason to chat to him this evening is not only because of his wisdom and insight into surgery, but to address that simple problem. I went to Saint Mary's not having done any cardiac surgery or any operating at all for 18 months. My hands didn't work, and one of the things that has come out from, uh, Black Belt Academy of Surgical Skills is that people are don't quite understand the need to practice. So, Ashok, tell us who you are. Were you born where you went to medical school in a potted history of your surgical career? I'm an old 75 years old now, And I was I was born in Madras, in Chennai, was called Chennai, and, uh, my father used to be the dean of Madras Metric College and the surgeon general of the Madras presidency. But he retired the year before I was born, so I guess, for want of anything better to do, I came along, But But he was an amazing man. My father, uh, he had applied to get into medical school, and he he got some Kerala and he applied to get into medical school with the application form that his friend had got and copied in pencil, and my father got in. The poor friend didn't. And then he did his medicine and Madras Medical. He's one of the oldest, most famed institutions, and then the, uh, Cunningham son, Cunningham thought there a beautiful hospital and our teachers were absolutely amazing. But I only did my first year there because at that point my father got transferred to Bombay. So he took. My father would never let me. I was the youngest child and the ugliest. And I think I think my father's favorite, uh, he took me to Bombay, and I got put into Grant better because it was the next best medical college. But my father was a practicing anti surge until much, much later, and he was a surgeon in the British Army in the first World War. He was posted in Baghdad, and he showed me his set of instruments that all field officers had to carry in their pockets. There were two silver tubes. I still have them. One silver and one half of the silver tube was full of curved and straight needles. Sharp cutting needles and the other half of the silver tube was full of morphine tablets and and the other tube has scalpel blades and suture material. But the switch material is pure silver, and and then and then for for linen sutures, he the In those days, I think the British army was supplied with either Indian or African elephant, uh, spoofs that they want the linen around. I still got those two and he taught me how to stitch and cut initially to start with. And then I came to Bombay and I started working and we had an amazing professor in pharmacology and he wanted a lot of experimental work to be done on cats, dogs and rats and mice. So I got into that and I got to that, uh, professor of Cardiac Saturday and professor of genocide used to come there to try and get their little work done. And they saw me working there and they said, Would you like to join us as well? Perfect opportunity. And it all came back student. So they taught me how to cut the stitch as well. And then the the sergeant at that time and a cardiac surgery was a measure method. He had the most delicate, gentle hands I've seen in anyone, and he really taught me how to work and how to switch. He also taught me how to be polite and humble, and I still remember after working after I qualified, I was working with him for four or five years, and I became the restaurant surgeon to the whole hospital is 1000 800 bed hospital, and I thought it was a wonderful chap. I got a swollen head and I totally misbehaved. I wrote notes against another surgeon and looked after one of my patient's to help me out of trouble. Magic meds. Math used to call me Dick, which means son and and parse. It's amazing, man. He called me into his room and said, Deekraal locked the door. I've been slapped by two people. Actually, he called me through and said, Decrease. We close that door and he slapped me one of the face. He said he was a popular man over here. He become the most unpopular man. Look at you, What have you done and says, Remember when I got to that job and I got to the job and you're lucky because nobody else wanted this? It wasn't because you were good. So you made me bring back, you know, it's rewrite the whole thing in a polite manner. Uh, never made anybody feel smaller in public. They had to tell them something. It was always privately done, and I still remember. Imagine that after He talked to me at tears going down his cheeks, and he hugged me and said, Good to cry. You're a good boy. It was amazingly touching, basically touching. And then I worked with a man. After that, I worked with our professor of general surgery system called Cool Kids, and he he worked with C. Walton really high, and I worked with gold here in 1969 and he worked with bulk A. Uh, it wasn't really high at the same time as Christian by night. And really, I always said, there are only two really brilliant men that worked worked with him. One was calculate and the other one was Kristine Bernard. This is Christian Bernard. Brilliance came from the fact that once he started concentrating, nothing would attractive. Not even a beautiful woman, he said. I think and and And And culture came from a little village. Huge shoulder, narrow hip man looked, looked a bit like a little gorilla but amazing surgeon as well. And in his in his village, they had, uh, water canals to go to the fields, and the and those canals had swing doors to swing doors, and they never blocked She sat in front of them for hours watching them and worked out that they never blocked because they had a cleaning side of the side of the valley. Flip flap. It would wash out the dirt, so there's always meant to be a tiny leak that that that And that's what he did with Walton. Very high. But I think fortunately, I stole the idea from him, but they put into a dog. I think this was in 65 or 60 for, because when he came back, he showed me a Sydney angiogram of his bileaflet valve and the dog. Then he went on to become the dean of, uh, another medical college. He left us, and his wife's brother used to work with the case and the man who did the first heart transplant in India. So with him, I got involved in the heart transplant business, and it's all that pure luck. Pure luck. And then I came, and when we were medical students and I was working, then we didn't have Confucius in those days, and we had the old, uh, screen oxen ater that took about the day to clean and polish and get back way and he just a gallon of blood to prime. So that is my job to do that. And after about a year of doing that, I think, uh, imagine that I felt sorry for me and he said, a shock. He said. I watched you operate on rats and dogs. You're allowed to open and close The patient put the patient on bypass so I'd open and close the patient, open the patient, put him on bypass, go and run the Heartland mission and come back and then the rigs bag. But we couldn't really afford the rigs bag in India. So from the rigs bag, we made a metal reusable bubble oximeter. And it's only then that I learned that the size of the bubble going through the blood is very important. The little bubbles are the one little bubbles of oxygen. I would, which oxen itched about oxen. It the blood and the big bubbles of oxygen are the ones where carbon dioxide refuses into, and the important thing is you go to deform it afterwards. So I mean the bricks back deforming chamber could only use once. I used to use old stainless steel ball I got it with anti form agent and you got to bake it after you, uh, got it. So it sticks on and we started doing that, but I could never get a candle that produced big and small bubbles. So I used to I used to reuse the rigs back candle. And we did a lot of cases with that. And that taught me about oxen. Eight hours. And in those days, there was no, uh, cardia plasia. We used to operate with blood and, uh, so busy infused the Caroni Archie's of blood every half an hour. And it's a terrible thing we did. It's only later I learned what we were doing. You'd operate on the heart until it died, basically beat itself to its history, quickly put the scandal until the Corona, Austria, and fed it oxygenated blood and started beating again, he said, Well, let's give it 30 seconds. So after 30 seconds and go back to ischemic ischemically, damaging their poor heart, it's amazing. But we had our patient's on a ventilator for at least 23 days. Four stop and only went later we could afford was the birds rental later which I think is still the best ventilator because I used to sleep next to the patient of the birds ventilator in between. And like in the minister, the sounds of us went to go to wake up. It's an amazing thing to learn postop management as well. It is a huge experience. And then, uh, growth matter used to let me operate on my own. The first thing you gave me were close, my trolls. And he taught me how to do the closed metro. He could do a close mitral in 30 minutes, flat skin to skip. But I took 30 minutes to do the thoracotomy. And then I said, Now you got to put your finger into the, uh, actual appendix to feel them The mitral valves. I said, Yes, sir. So what? We used to take a pasturing around the mitral brass. I took this person not by the atrial appendage. So I took a pasturing, put my finger in, tightened it independent, and so you're doing a very good job. And he went out and I opened the valve I dolly to the valve, and I forgot to loosen the runs and snare around the atrial appendage and I took my finger out. Of course, the issue appendage came out as well. So as you call him, call him. Call him. Call him when he came in, There's not a problem. So you got two fingers, pinch it. So we pinched it in his stitches and patient by the grace of God lived. But he never took over a case unless he thought I couldn't handle it. And he gave me time to do it. And that gives you huge courage. And and and and and occasionally I really bugged up the case so badly nobody could save it. But it insists I do the next case, and that gives you an enormous amount of conference. Huge conference. That's when we had one of, uh, one of my senior red straws. His wife was seven months pregnant and she came with an M u boma that had burst. And I was the rest in surgeon one called. So I took her to theatre in seven months. Pregnant burst of, um, a woman, my my my friend's wife and measurement that destiny just just retired. So for no other sits Ferd's. This is your case for you. He said. What do you plan to do? Is the one thing I can think of doing is doing a colostomy and taking this ever move out, he said, You'll kill the fetus and the mother, he said, You need to do a hemicolectomy. So I said, Cyber me to Hemicolectomy on a seven month pregnant woman's uterus in the sweetest and said said, Cyber, go to comment. Decry. All right, I'll come, I'll come And he came And he scrug He took the he did a hemicolectomy primary anastomosis because he didn't want to live a colostomy with this pregnant lady she went to term. The boy is called Version, uh, still alive. Uh, this surgery he did neurosurgery, thoracic surgery, vascular surgery, cardiac surgery and we were basically a TB unit. We didn't do that much cardiac surgery. He bought the heart lung machines, Most of the pumps locally made, etcetera Polystan pump for the arterial line. And and we just used it during the they talk. So the only tubing that really tore was that, um, as a tube and the arterial pump. So we had y connection before it went into the tube. I connection coming out one tube and the pump, the other tube clamped. So the minute the tube burst, we put two clamps on the burst tube, took it out reverse, put the other tube and cleaned blood and started again. And we never lost a patient. Did that happen? And some. And it teaches you so much. And soon after that, because of the work I did in the the rival hospital, they had nobody to send. When the man in Australia, Mr Windsor needed somebody to assist and he's spoken to him and he promised to send someone he had no one to send. So, by luck, rival institution he sent me. I went there and I worked with Harry Winsor. He did the first heart transplant in Australia. Shanahan really started using Cardia Plasia in Australia. And Victor Chang was a Chinese amazing surgeon as well. Uh, and I started working with them and for fun. For the first month, Mr Windsor only talked to me in slang, in Australian slang. The end of the mother said, I'm terribly sorry. Says I can't understand what you're saying. I better go back. He said, no, I was just testing out. You're right, you can't. Just because I couldn't understand anyway. But he started speaking. He took me to his club. Great owner. I think, too. I got one of these Aussie clubs and we used to operate with him on one day and the weekend at pediatrics in another hospital. But the days we operated with him, this the operating surgeon had to prepare the cardioplegic surgeon himself because you didn't get ready made bottles, and and And if you're going to use it on your patient, my bloody sure it was right. You really made sure it was right. So you had to make your own thing. And then you put it in the fridge for it to get cold. You went to theater. You did the brief visit briefings, then 1979. We did the briefing. Then this operating started going to the sternotomy, scrubbed up and put a subclavian line, uh, proper subclavian line. And it was usually on the right, so didn't damage. The memory was to take the memory down on the left side and and the way you did it was also amazing. Classic which seldom ever, Mr. Subclavian, you have to extend the hand pull it down a little bit, extend the head and rotate it the side. You're putting the subclavian line there. So ask Mr Windsor, Why do you do This is a rash on a And he's the one who comes up with all this crazy ideas. And he said, If you turn the head of the patient to the right, you're doing the right subclavian. The angle of your brain going into your head and going into your sec becomes acute. So there's no chance of your cannula going into this into this going up. It has to go down. So you did that. Then you went and scrubbed up. You do the sternotomy. Once you did the sternotomy, you opened the right pleura widely, a little bit down into the into the pericardial. Widely, totally. So you could see if you damaged uh, the supply in when, when you put the line in, go on until you open this company and I'll come to that little bit a little later while we opened that and then you open the left, you opened the left for a widely and he took down the memory. The memory had to be taken right down to his first brunch and then you then the boss. Then, uh, initially for the first three months, the boss would come and all of us had to wear loops. I had no loops, so Mr Wincey gave me his old loops. But there were plane glasses with 2.5 magnification, and when I left, he gave it to me. Amazing man, if we ever made a mistake. We had a little black book and we wrote the mistakes down in the book on every Monday morning before we started work, we had a one hour discussion of the last week's problems, and every mistake had to be written down. And he, Shanahan and Mark would say that they had made the same mistake or not. No blame. This is how to avoid it. And you've got a small punishment. It wasn't a bad punishment or something small to make sure you never forget. And I still remember I didn't read a badly stuck creed, uh, visit on, uh, Tuesday morning and I went through the sternum and I went through the subject and transacted it when we went on bypass and I fixed it and finished the operation came out and I put in the Black Book. I think Mr when So much, You know, if something happens to theater because he had a little look at the little Black book and the next morning he came and said, Don't worry, I'm sure this happens before as well. Today I will show you how to do it. And of course you know what happened. He did it and he put you on a stating sort through the rain again. She said, Get me that black book And he wrote it down. Both of us were given the same lecture, both of us. Given the same punishment. This is absolutely great, Man. Shannon had a problem. He had a slightly I don't know. I can say the slight anyway used to bring the child and that one of the nurses would look after. But he's the one who he worked with Buck Berg for over a year and he brought back bug bug solution and completely changed. And the amount of trouble I haven't. India disappeared overnight and then but he would. He he taught me how to do snake crafts. He would have won Hlongwane that he'd wind around the heart. We have 56 anastomosis at the bottom and the same with the memory. So he usually did seven mines and projects the thin, tall man. You have big operating groups, a headlight, so I don't know how he managed it. But he sits in there. He would do 7 g the end of it. It's still there. When I was closing the Jesse, see that? I said, You can go said I'll call you having trouble He said, No, I will stay in the stay till the end. And then Victor Chang came along. He said, Little fellow. Brilliant coronavirus. He said, Brilliant. Every he got murdered could kidnapping. That went wrong. But anyway, a little Chinese Japanese was shot and severely short sighted, so he he took his glasses off. He could see everything was huge, except he did his head into the chest. But a beautiful surgeon and there's a famous artist. He could draw a perfect circle. Remember his name? David. God, I remember. I think it was Was it Michelangelo? Uh, I don't know who it was, but, uh, he said, could you send an example of his work and He drew a perfect circle. It was a visiting guard. Uh, Davinci, It was Da Vinci. Is that what it goes to? One of those two? Yes. And he But he could cut a perfect circle. Indio to with 11 blade. Never used a punch. Perfect. This is how do you do this? A Chinese magic. But they taught me a lot. And and one of the main reasons I went to Australia was my mortality in babies was very high. But I worked in a free hospital, and I did all the down syndromes and all the rest and nobody really want, want wanted to do high mortality cases and babies. So I did them and they died. So I got permission from Mr Windsor to spend one week with Tim Cartman and the Children's Hospital. And I honestly promised David he did cases 10 times worse than back and they all lived. If I had gone to him earlier, I guess he would be alive. But it will. They all live. And I really learned so much for him. And when the anesthetist was putting in the lines, especially in the neonatal take, sometimes take very long. He wouldn't even peer him through the window to see where the anesthetist was. And I went to people once and he said Children will never do that again. Never heard anyone. No, man, he got me a lot. And from there I was going to go back to India. But Mr Ross had come to India. All this time I was working and he taught me how to do homograft in India. But Majima to said I had to do 20 homograft on cadavers in the post mortem rooms. So I did the 20 and he came and was and said, I guess you're ready. And yes, the first one he gave me Mr Ross turned up in Bombay in the hospital. So he said I got and chat to him. I'll come back and I said, I must impress Mr Ross's word. So I put the first homograft in and started leaking. So I called him back nizzi. I got Mr Rossi. He'll come to see Mr Ross came back and said, It's very simple. He said, Wherever you think the apex of the commissar should go, go 3 to 4 centimeters higher and the valve never ever leak to get. Then when I came to it and I said So why didn't you write all these things? And he said People should come and watch it learn for me. And towards the end of his time, he was saying, Why don't more people do the Ross procedures? Totally awful. They didn't teach enough to train enough people. So that's an interesting element there. That there's a certain nuance to the operation. Yes, every operations. Yeah, he didn't communicate. No, that was that. That wasn't the only one When we came off bypass, he'd always put this, uh, left index finger on top of the right current osteo on top of the water and squeeze it so that I asked him for about two years. Why do you do that? Say so. I did, I tell you. And then I'll tell you one day, but because he did it, I started doing it as well. And one day that he told me. He said, If any air has left at the heart and comes out and goes out, that's the only bloody place is going to go to, Which is why you get funny changes when you come off that possibly see I said that should be written up. Does she prefer everyone to know? But he was willing to share. These are These are the elements of operations that is the black part Academy of Surgical Skills. I feel that most experts, surgeons know and it's tacit. But if you are able or sometimes willing, willing, bless it and it's making it explicit. Making the not obvious explicit is important. Ashok Ashok also told me. You said you didn't have very good hearts. Now I disagree. What did you do to practice, David? My hands were bad, and my my father used to watch. My father loved me. He'd watch me do all this stuff and he said, You know, you really need to practice. And then I went to Bombay. This is after being in Australia and they thought I was okay in Australia. I went to No, no. I went to Australia before I went to Bombay first and my father met this amazing cardiac surgeon called. They're up the student in another hospital, he said, Just go meet him and talk to him. So I went to him and he said, Uh, I like your father, he said. Uh, he said Grace, he sent you to me. I said, Sir, I'm not a very good person and my hands are not nimble enough. My note tying is not good. And then he said, Come look at my chair He said, I've had this year for 25 years and both arms were covered in knots. Thousands of notes, words, arms. This is when I sit here waiting for my patient's to come. Sometimes I have no patience, had a tie knots and I do this every day, every day. He wanted he and Maggie Metha with the two greatest surgeons. That way every day he did that. And then he told me, You got to learn how to do your instruments. He's properly, and the only way to do that is you. We didn't have milk cartons in India. We had butter shoes. So you get about a shoebox, and initially you make a hole on the on the broad side of the box. You put to tack to Wayne's down. You're allowed to take veins home from theater cannabis know Destructors. Take two veins, stick them down the tax and you stitch them. But no using, uh, six sutures. You have loops. He said, uh, you use those loops and you will only use, uh, 7080 switches. He said they will break their frustrating. But you do that and he says, Come back and see me in six months time. Six years, I promise. You said, I'll come back and he put it on his diary. So sorry, David, but but But he But I practice so hard and I got recently competent. I went back in three months. He said, This is very good, he said. But this is still not operating at the depth. You have to operate through sternotomy. And this is interesting. So you started at the top on the surface? Yeah. And then Then you cut a hole and go down and you took it in the depth. And this is something that I've noticed with many cardiac courses to date is that they put the heart on top of the box. Yes. There's no trouble. Crazy because the heart is in the boxes in the box. Yeah, and then they don't work your angle at the elbows. He taught me. He mentioned it to me. And then these two little things are so important. What about the angle? At the hour he he saw he had a few box with holes and tetanus consulting rooms. I think he told all the students This says, Come, we'll do one together is doing it is look at you he said. You're standing on a stool so you can keep your elbows straight and doing that. See how much it's trouble is causing you inside. So I said, What should I do, sir? Is you should should bend your ankle at the angle that you're holding your needle on. You thought of that? Yeah. Take the needle out. Yes. Yes, because you're working at depths because your wrist is lower than, uh, the first time I saw you. T said all I could see was there of this to face. And eventually I could do it at at quite a depth. And then one year when Mr Ross came out, he gave me his Zeiss loops and his headlight Well, that changed everything. That headlight, sir. And I try to use the head Well, we you used the headlight. All the terms grabs, right? No, I didn't. I didn't use the headlight, but use loops, of course, but it and And it's learning to operate at depth and understanding the islands very important. And and not just that. When you get it wrong, you start again and do it again. You don't put your instruments down until you get it right At least once on the night you start. So you practice until you can't get it wrong. No, initially, until you get one. Right? And then eventually, until you can't get it wrong. Yes. Yeah, That is good. Really, really excellent teaching. And then measure. How did you practice? Are shock. I could steal Wayne's. Everything from the from the pain from the theater from the cad epic room everywhere. Homograft most of mycotic says you have practice on dead bodies. Uh, and and then when I when I got of course, unable to do that at that time, you're not allowed to do it now. And, uh, and then what? Uh, prof Method used to develop me on the knuckles if I got it wrong. And it's amazing, really. If you wallop you once you try very hard not to make a mistake again, you won't develop anybody nowadays is not all of you, all of you. Well, if you twice you never forget you can't do that nowadays. So how would you encourage people to practice? And and And some people on the blackboard academy have come back and said, Why should I practice at home when I can practice on living patient who is not my friend or brother? Yes, this is I didn't seen stupidity, I think. Why should I not practice if you play going to learn to play the violin or the piano or something else in practice, you want to play football, you practice. But when you're taking somebody else's life in your hand and you want to do something with that poor man or woman you're not willing to practice and and and all these trainees and I think I disagree with this work life balance as well. But anyway, that's another point. All these trainees think they're entitled to leave the theater before the operation finish. It is five o'clock. This is how How can you do This is your patient. You operated on the patient you stayed with. At least the operation is over. I can't see the point in this this method of people, that is a different, a different conversation. But I agree with you in the sense of responsibility. But what did you do to practice? You said your hands were not very good. You got No, you did this box are working at depth. What else did you do to practice? I did this. Everything I did, I repeated for three years. Every day. There's no Saturday Sunday excuses, no question of taking a break. This happened every day, and any of my friends were at home drinking and eating. I used to live in government quarters in the hospitals, which is quite nice. I would go into my bedroom and do it. Those three hours were like my prayer time. Nobody could interfere, and eventually it's like you and your judo correct karate. Yeah, see, there's no bits. Perseverance, practice, perseverance, practice. Repeat, repeat, repeat. And if you can't get it right after all that, you give up surgery, do something else. Mhm. And the other problem is, I think senior consultants don't have the guts to tell their the juniors to take some other specialties. That's a different conversation to you. know. I know that is a different conversation, but I've got two chaps who worked with me. Yeah, they're both One is a one is a senior radiologist. Uh, he drives a Porsche. Very happy. The other one is, uh, is a breast specialist. She's very happy. She's consultant as well. And they both thanked me. I I think it's important to find people's worth. Absolutely so from an operation point of view. Then practice makes perfect, But it's perfect practice that makes perfect. Yes, of course. And understanding, as you say, all the nuances and the angles and the because you practice how to do it badly and become perfect. It's perfect. You're doing it badly. Absolutely. Yeah, absolutely. The other great people I really learned from in Britain. Uh, because Mr Ross, of course, cross. Yeah. Amazing teacher. And what do you think are the qualities I always hold you in high esteem as far as a teacher and trainer and mentor? What are the qualities of a good teacher than Ashok? Be kind. Be patient. Be gentle. Never humiliate. Ever even Mr Ross would used big English words that nobody else in very could understand. Prof. Magdy will always lean across the table and whistle. Why are you so stupid? Uh huh. Mark Dell will never, ever shouted me when I did something wrong. And you just my folly ago sheet. Mark, what are you doing? So when you look at me and smile, Yeah, but I took Mark Dealable through his first Ross procedures at Great Ormond Street. You did? Yes. And he always told everybody that I was his teacher for the Ross procedure. Very sweet of him, But his hands were far better than mine, David. So what makes good hands are shock. You've mentioned this a couple of times in a few years. The main thing that really makes a good hand is a huge intellect and knowledge. You need the knowledge, and you need to know when you're not doing it well, and you need to judge yourself and accept judgment from other people. And the other thing is that you that this is the first main thing and you need to be really humbled and accept and, uh, Waters and you need to practice and persevere and learn from everyone from the bad change. You learn how not to do something so there's no one you really can't learn from. And you got to listen to everyone I still remember. I went into Mr Ross's rooms one day, and this is You're supposed to be very bright Japanese, Japanese. This little tennis ball struck into his armpit, joined the silicon tube, the balloon, and he'd pump his armpit and this building would go up and down. And he said, Mr Rhodes, this is my new invention. You wrap this around the heart, and when the patient feels you're going to heart failure, he's got to just squeeze this balloon and the heart will be squeezed and it'll go. Go back into Charlene slow. And for some reason, I started games. Russian, Uh, would you please go and get us some coffee? Cell attack? And he came out and said, Don't ever do that again. You learn a lot from everyone. But it was so good they never had to feel jealous about anyone else. And I mean, uh, Mark D Level and yadda stock, which were chosen by Waterston. You didn't care that they didn't have any degrees from from England, he said. I want these two men see what they made of that unit. World famous, internationally famous Ashok. Then what makes a good surgeon? A good sergeant is a chap who's obviously couldn't like good eyes. He also should be able to see in three damaging. Of course. Pardon or she? Of course. Oh, she of course. My He is the, uh, royal. He she everyone even transgenders. All of them. Uh, well, no, no, not saying that. I have no objection to anyone. Where was I? So what makes a good surgeon? Uh, you should be able to three see visualize three dimensionally. That's a very, very difficult thing to do. So when you practice your operation at night, before you go into the theater in the morning, you got to go through every step of the operation every every step, and you go to see it three dimensionally, and I still remember Mark has an important meeting to go to. And we had a complex little heart, and he he repaired everything. And then he put a greasy patch on the heart, and I and I and I closed too, and school and he left for the meeting. I couldn't come off that fast. So anyway, I stayed on partial by parcel. He came back and he came back and he looked and I said, I said, This heart is not ejecting enough blood, you know? Not a problem, not a problem. Then we asked the scissors you, Rio for the bench clot to me and the and the batch. Obviously patch he had put it was too small. Soliders made a split and didn't put a diamond patch in it. And we came out like there's nothing going wrong. Three damage, your vision. And then we did a mitral valve replacement, severely calcified valve. And a severely rheumatic young girl from Egypt came off by a person. Mr. Ross left, and as I was closing, the heart went prompt and just stopped completely so quickly. Went back on bypass and said, Get Mr Ross. And so Mr Ross came and we're on bypass. The heart was the block. She let me look at the heart. So he looked at the heart, said, lift the heart up and he looked the back of the heart. He said, Take a piece away and he went and scrubbed up and came in and he he said, This, uh, there's been some either a clot or a calcium or a bit of papillary muscle that shot into the circumflex artery. So we we just graft. It's not a major problem, so and God looked after that man in so many ways. Exactly where he opened the circumflex artery was where the bit of my cardio was stuck the papillary muscle, my cousin so leader was to get out and put a patch know graft sailed off, bypassed, all diagnosed just by looking know eco back or none of the stuff. And this is therefore clinical skill, isn't it? Yes, it is, and you need to have that. And how do you get clinical skill by experience by practice, by spending available, our you can spend in your operating theater, even watching other people spend as much time as you can intensive care unit and definitely look after your patient's in the in the world. You can't have somebody else come and look at them every day and you look at them once a week. That is not and and we are talking in particular about cardiac surgery, yes, general rather than general. Sorry, Ashok. It's been a privilege and pleasure chatting to you and thank you for your insights. You talked about three dimensional skill. You talked about hands and softness of touch. Is there any other characteristic you've mentioned that you think is important? Can I mention it? Uh, I think the word you have come up with repeatedly is humility. Yes, yes. And you and you have to talk to the patient's and you have to talk to the family and you got to talk to them separately. Yes, if you're going to operate. And man, he's very, very sick. You've got to give him hope. Yes. Don't. Don't take that away from him. Uh, you know, I watch a lot of programs on animals, and I watched this program on, uh, euthanasia place for dogs. It's really it's very, very sad. Was very beautiful as well. And then over there, they got a big bottle of things. Says goodbye kisses. And it's got chocolate in it. Is it? Every dog should have some chocolate before it dies. That's true. That's only got to do. Were described. Uh, thank you very much, my friend. Thank you. Thank you for sharing your insight. And we've been talking about cardiac surgery, but the principles of salary. How many years have you been in the cardiac business? I wanted to do 50 years, David. 50 years. At the end of 47 years, my back went to not just my back. I've had good friends. You But you, You you weren't in London. Them would tell me when I when I should stop. And actually, the human resources were very kind to me. I had to sit down for a few minutes every half an hour, one hour, just 34 minutes and my back would be okay. And they came and said, You know, we'd like your work. We like what you're doing. But he said if something happened to a patient, they would sue Not just you. This through the hospital as well. So I left that day. It's right. It's the right thing to have done. Absolutely. And why was your back not very good at shock? I've got spinal stenosis. Okay, A little bit of all this bridging ethic, bad posture, bad posture. That's what I'm getting out. And 27% of surgeons in their career will have back problems, and it's sad that we do not emphasize. Yes, Posture. Uh, they say if you if you put your head down, it adds 26 kg to your brain weight. I like what Joseph Pilates says. He was old as your spine. Yes, Ash. Thank you very much. Thank you, ma'am. God bless him. Thank you very much indeed. Thank you.