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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon from Leeds Yorkshire in the United Kingdom. And I'm now a professor in the Medical Education Research and Development Unit of the Faculty of Medicine at the University of Malaya. We are coming to you live from Kuala Lumpur and our producer Gabriel, whose last evening was with us is in Lithuania. But thanks to me, we are reaching across the globe. This evening, we have 113 registrations from 34 countries and I'm delighted to see new countries have joined the list, Armenia Yemen Timor Leste to add to the numerous others from far in Afield, Tanzania, Thailand, Turkey, Morocco, Libya Jordan Syria Maldives United Kingdom knighted Emirates and many more. Thank you very much for following. Thank you for supporting the Blackboard Academy. And if this is your first time? Welcome, I was thinking what to discuss this evening because we have a cycle of syllabus until I attended Malaysian Surgical Students Society Skills Competition held in the Faculty of Medicine at the University of Malaya on Saturday. It was a fun day. 45 teams of three people from around Malaysia turned up to put their skills to the test I was running and you probably know the banana stitching competition. And I was observing how people hold instruments. I also inquired and looked at your replies to my questions that we're not very good at surgeons at teaching how to hold instruments. And this is sort of assumed and not explained and no reason was offered. And this is very strange when you think of the basic instruments that we use for eating a knife, a fork and a spoon in the brat in etiquette book that is used in the UK. How you hold a knife is important with a handle in the palm is not recommended. You hold that knife like a pen because it's unstable. Likewise, how you hold a fork with a handle in the palm and the index finger, directing the fork and directing the pressure, the spoon sometimes held as a grip. No, it doesn't actually work. It's better balanced on your middle finger, index finger and thumb. Remembering if you're eating something cold, you're scooping it towards you and something hot, scooping it away. But these things were described in the breads and have become automatic on what we eat. The interesting thing is that one of the most famous surgeons at Leeds teaching Hospital was Lloyd Bar Mohan and his bust adorns the top of the stairs in this lovely building in Great George Street. And he regarded his hands as a handsome servants on his brain. The only part of his history and didn't like he actually cast his hands in bronze. And to me that smacked a little bit of ego, but he came out with a lot of euphemisms first, he said a surgeon must have the heart of a lion, the eyes of an eagle and the hands of the lady. And we'll come back to that because there is neuroscientific proof why the lady's hands are better. But he described surgery as infinite gentleness, scrupulous care, light handling and purposeful, effective quiet movements, which are no more than a caress, all of which are necessary if an operation is gonna be the work of an artist and not merely a cure of flesh. So this brings us to the topic for this evening and how to hold the instrument is all dependent on feel and sensations. You see sensations begin as signals generated by touch receptors in your fingers and in your skin. And they travel along afferent fibers to the spinal cord, go up the spinal cord as you know to the thalamus. And the next stop is the soma cortex which translated to touch and the symmetric sent cortex as you know has got a is like headphones, it's got a humulus on there. The great representation for the tongue, the lips and the mouth at the fingers. And this area represents and is proportional to the size of the sensory input to the brain from those areas. And in fact, you are getting more sensation from your fingers to the brain, then you are from the eyes to the brain. And if you need to correct the tissues, we need to think about how we apply our hands and our fingers to the instruments because our fingers are most sensitive. And neuroscientists actually measure sensitivity by examining the minimum distance between two points on the skin that the person can identify as distinct stimuli rather than a single stimulus. And perception is greatest where the two point threshold is at its lowest. In other words, in areas where there is the most density of nerve packed fibers like your lips, mouth and your fingertips on your back, you can only discriminate things that are centimeters apart. But in the upper limb on the lateral side, it's between 36 and 38 millimeters on the medial side is somewhat less between 24 and 28 millimeters. And the sensation gets better as you go down the arm between at the lower arm is 29 laterally and medially about 28 millimeters. But this is where the fingertips come in on the dorsal antio. It's 14 millimeters for two point test. But when it comes to the fingers, the index finger, the middle finger and the baby fingers and the thumb. In men it's about 3.1 millimeters plus or minus 0.1 millimeters. And in ladies there you have it ladies, 2.7 plus or minus 0.1 not a statistical difference, but indeed, you do have the hands of a lady with your two point test being of final resolution, but there's more to touch than meets the eye. And I was interested to read this that a Dutcher professor at UC Barkeley School of Public Health said there's more to your fingertips and explains how compassion is literally at your fingertips as well. And in his lab, they took a barrier between two people, two strangers and asked one to put their arm through the barrier and waited on the other side, the other person was given a list of emotions and had to convey to the person on the other side of the barrier by touching their arm for one second, only a range of emotions. So you can think of all the different emotions there possibly are and they were given one second and the odds of getting it right by chance were about 8%. But remarkably, the participants guess compassion correctly. Nearly 60% of the time. This is interesting as doctors and the power of touch and reassurance is through your hands and gratitude, gratitude, anger, love, and fear. They got responses more than 50% of the time. And it was interesting to see that they spotted a couple of gender differences in this. When women try to communicate anger to men, men didn't get it at all. They had no idea. And interesting when men try to communicate compassion to women, she didn't know what was going on. So is this men are from Mars, women are from Venus? Mm. But it does show that touch goes beyond sensation. It's a means of communication and as doctors, we lay on hands and the power of laying on hands has been appreciated forever. What is shown by neuroscientist edmund roles that touch actually activates the orbital frontal cortex, which is linked to feelings, reward and compassion. We also know that touch builds up cooperation and relationships. You see this amongst primates who groom each other regularly. But it is actually shown to work amongst basketball players who pat themselves in the back when things have gone. Well, is is a reinforcement. Touch also signals safety and trust and we know it calms the cardiovascular system and stimulates the vagus. No, when you touch somebody, there's actual a release of Oxytocin as well. In other words, otherwise, no nice. It's a love hormone. A study by Coan Davidson, had people lying on MRI and registered the response of the brain to really disturbing white noise which would cause pain. But when people had their romantic partner present, they stroked their arm while this noise was being plagued in it touch, he effectively turned this off. It can also have economic effects apparently. So psychologist Robert Kurz had participants playing prisoners dilemma and they were more likely to be generous if the participant was gently patted on the back beforehand. And think about it, we pat people on the back almost richly in games. It is very interesting that touch therapy has also moved into medicine. And I don't think we can actually understand or underestimate the power of touch in helping patients. Like for example, Alzheimer's disease, getting them to relax and make emotion connections with others. It is also shown in Children with autism. We also know a new experience, massage therapy, reduces pain in pregnancy and reduces pain in sport injuries. It's noted in education by French psychologist, Nicholas. I think it's uh Goergen found that when teachers pat the students in a friendly way, they are more likely to speak up, class librarians did it in a study where they touched or patted somebody, then they took out a book and they were more likely to bring the book back and returned to the library. Interesting that it goes beyond the therapeutic goes beyond the neuroscientist to pin two point discrimination test. So what we're going to do this evening is that go through our generic instruments and explain how and why we hold them. And it starts by understanding the functional anatomy of the upper limb. If we are saying that the two point discrimination test is maximal at our fingertips, we want to be able to feel and just rub your fingers together like that as if you're squeezing or rubbing a little bit of salt and c food, you can feel, you can feel your face or stroke your face. You get the lightness of touch almost as if a brush is touching your face. You can get the same sensation in your fingers and to appreciate how we feel the instruments, we need to hold them with a lightness of touch, no gripping. When you bend the distal interphalangeal joint, the and the and you can try it yourself, pinch your forearm, pinched hard, really hard is actually painful. The force applied for an average person is about 25 newtons, but men can probably generate 35 newtons in that and you translate that. And when you do that, you'll also note my fingernail blanches, ok? As soon as it blanches that is pressure, that's not sensation, that's not feeling. So when I'm looking at a student holding instruments, even through gloves, I can see blanching and pressure and not sensation and feel. What is interesting. Even in my training in drawing the sword in the I, I'm told too much force, too much force lighten the pressure. I've used golf as a metaphor previously and your light in the pressure. Those of you play racket, sports, light and the pressure. But it's also interesting that sport coaches and golf and badminton and tennis teach you how to hold and how to grip and the position of your hands and standing for your shoulders, down elbows by your side and your arms slightly extended, the hands palm are flexed. You have taken out all the major muscles that support the scapula and hold the scapular to the chest wall. When you do that, 27 muscles are involved. And it's understandable that you can get fatigued and tired for a long time. The most relaxed position is standing like that. It's interesting. Even musicians know that playing a piano, that position the stool height, such the fingers can touch the keyboard. You think it's just the action of the fingers. But a professor of ent surgery in Bradford Hospital was an excellent florist and played in the local orchestra. He could not generate a note unless he sat properly. So let us come over and look specifically at some of these instruments. What is must make an apology for is that most instruments are made for left-handed right handed people. And the last discrimination in surgery is that the 7% to 10% of the population who are left handed. There are no instruments and others. Also, most instruments were designed by male surgeons and come in one size. So therefore, ladies quite likely can feel aggrieved, but that is changing and b braun is looking at it. So the scalpel, we have described how we hold a knife and we should hold a scalpel like we hold a knife first thing to say is that when passing it, pass it with a blade down and sharp it down and the blade first, OK? Because if somebody took it out of your hand, you don't want it. No PM. The blade is how in the palm of your hand? And I have my thumb and my middle finger maintaining a sagittal plane of 90 degrees to the tissues, right? And the handle is in the palm. My index finger is placed on the top and that's given me direction, pro procession and the feeling of pressure and feel to the instrument. I'm applying it at, at 45 degrees because that is the cutting belly of the instrument we don't want to see and often see people holding the knife in that respect and cutting with it. That's not an effective way of cutting. Sometimes blades that for small excisions, fusiform excisions of lesions on the skin require a different handle. And this is called a Barre blade handle and the handle is not too dissimilar to the configuration of pencil like all the instruments we can discuss this evening. The prime purpose is to apply the maximum amount of the finger pulp to the instrument in this position. Cradling the instrument, I am able to rotate the blade and feel and control the 90 degrees perpendicular cut that required for clean edges and clean cutting. No, I was doing a coronary artery bypass graft on a patient with hepatitis C and this is a young patient who required irregular artery. And I asked the registrar to take the radial artery and they proceeded to put on two gloves. And I said to the person, do you always use two gloves when operating? He said no. So I advised that it was best not to put two gloves on because you'd lose the feel in feedback but ignored me and I proceeded to open the chest. I then heard a plan and squeal David and looked up and this registrar had taken the blade directly through the skin and directly into the radial artery because he could not feel it. And I had Hepatitis C blood squirting all over et cetera. So I'm not putting it out there to say, don't wear double gloves but do be aware that double gloving if you don't do it properly. In other words, you put the big glove on first followed by the small glove. And while we're talking about gloves, the glove should sit comfortably on your finger without any tension and it should not blanch. If I'm doing that, you can see the tip of my finger blanching there. And that's now going to render my finger numb during a procedure. So your gloves should sit comfortably and they shouldn't b lounge the skin at all because you're gonna reduce the feel. The next instrument we're going to talk about. Are the para scissors? The scissors? Ah, and these are mcindoe scissors, you'll see that they have a lovely dissecting curve along them. OK? And when you use the scissors with the curve of your wrist, you should appreciate that. You can see the curve and the tip. Because if I hold it down this way, as we're dissecting, as you're looking down this instrument, I'm looking down the scissors and I'm looking down at the, this bit is a cutting point and I'm looking at the point there how I hold the scissors is really balanced in the tips of my fingers. So this time I need to be able to open and close the scissors, but I have not stuck by term or phalanx through the rings. So whether you've got big fingers or small fingers, apply your fingers to the rings of instruments obliquely. So you got maximum pulp of the finger touching. So in this situation, not only have I got stability affected by a triangle between my ring finger, thumb, index finger as a stable sort of triangle there, but I've also got my middle finger applied to the shaft and my index finger extended down. I'm not grabbing this. It's literally sitting on top of my hand. And that means that, that the the smallest of blood vessels and the smallest of nerves I can feel because I get that displacement at the tips of my fingers. I know when I'm cutting that, that feels slightly thicker. And therefore, I should consider that it's more than just a fascial layer. It's same thing applies. If we look at a very big instrument, these are fabulously long for reaching into the chest. But the position of my fingers is exactly the same. It's just come up longer shaft. But that way I hold it is exactly the same. But I guess I am getting filled. The important thing about scissors is that you never open them up any more than necessary to do the job. They are not approaching scissors wide open. I put black sack around because it might be easier. I'm not approaching anything. The scissors wide open, that's too wide. I'm approaching them with a distance of probably less than five millimeters meters. I'm never entering the operative field in that respect and your feeling the tissues, you can feel the blades actually working together because you can feel the shearing of the cat mess. Although that's blunt at the end, if pressed hard into something could perforate. That's why for taking off a cortex or pericardium, I like a thicker blade, a blunter end because you are dissecting quite solid tissue, which is often as a cortex, unsensitive tissue underneath your regular dressing. Scissors are used the same. But remember now that the points of these uh very sharp indeed and can cause significant damage. I've seen a thoracic surgeon holding the scissors upside down. So the curve is not with the curve on my wrist. The curve of my wrist is this way Yeah. And the curve is opposite. And as they dissecting, they're looking at the tip, but they cannot see the belly. And in this particular case, as a dissecting out very carefully, the belly is lower than the tip. And the belly cut the PMI artery like that, that would never happen if the tips were applied. And the belly can be seen the reverse way of holding your scissors is upside down. Similar pattern that the scissors a game are held in a triangle between the thumb, middle finger, two other fingers applied to the shaft and my baby finger extended down. Look, I've got the pulp of all fingers touching the instrument place it in. And now if I'm doing an ent operation, I can rotate my wrist around and you can see the point clearly and are working down a deep dark cavity and gently dissecting. The next comes the needle holder and I'll just take this up for a moment to explain the ergonomics of the needle holder. Again, many people holding a needle holder. And if you got any rings at all on the instruments, never ever ever put your D IP joint in. The other thing is with my thumb, it would get caught in my thumb. If somebody took it, I'd literally have a de globbing injury to hold the instrument we would recommend in the Black Belt Academy, you don't put your fingers through and I'll demonstrate why if I actually holding the straw, move my finger through, watch the movement and barely get over a 180 degree rotation of that straw. And if you're watching carefully, the tip of that is going around in circle as well. The rotation of the forearm is the radius folding over ya. And you might be able to see my finger there. And I'm pointing at the camera and you can see the axis of rotation folding is between my index finger, middle finger and the carbon flexor origin. I therefore placed the needle holder in the palm of my hand flat along that line of axis because that's the line of axis I require. And if you think about it, that's what exactly you're doing with a screwdriver. You are pronating and supernate just to add and you can put it in the chat room. What is the most powerful supernate of the lower arm? Can anybody answer that question in the chart? Gabrielle, the most powerful supernate of the arm? Well, if you're watching it, I am sating and that's the biceps and that's why your screws are actually clockwise to get a screw in. You need the extra force, you need the biceps to supernate, supernate, supernate. But what we want to do is take a needle on a circle. And if you look at my hand from there to there, from there to there is 180 degrees. And that's what pro full pronation super Nation does So if I harm my instrument now, watch the straw, I can easily get horizontal, but I can get well up to about 260 degrees with the smooth rotation. And there's that smooth rotation that is required to carry a needle on a circle through the tissues. This was illustrated very well by Samia and I helped him do an aortic valve and he did it beautifully well and he came to close in the aorta and again with a 40 proline four millimeters apart, four millimeters deep. He did the perfect over and over single layer closure of the aortotomy. It looked lovely and we were about to come off bypass as we came off bypass and the pressure increased in the order it started to that, it started to tear and pull apart and I couldn't believe it or understand it because it looked so good and he was so deliberate in his place point, rotate to the needle. I had to take over and I went to make the first ditch and I made the diagnosis cos as I took the stitch, I could not feel anything as the stitch entered the and came out there was no haptic feedback at all. Nothing. I took a little bit of the AORTA and I sent it off for histology and lo and behold, this person had severe cystic needle necrosis. I repaired it with two teflon patches a bit like making a hamburger really. And the patient was fine. But what it did emphasize to me is that although the trainee was doing beautiful stitches, I could not feel a tissue and he could not feel the tissue because he was gripping the instrument too tight. And if I'm gripping it tight and particularly if I got my fingers through it, you can see the skin blanching and my fingernails blanching because I'm gripping it too tight and you, when you grip it, you will not feel the tissue, you will not get that feedback at all. And that was the problem. And I also noticed this when teaching people how to do an aortic valve because you want to take it through the fibrous skeleton of the heart that can only be described as taking a needle to something akin to a bit like soft leather. So I can't feel the trainees stitches going through that. And I have to describe it to them and hope that they appreciate that because I did have one occasion where the suture did not hit the right layer and we had a pa prosthetic le so I do watch for blanching of the fingers and I do watch for the proper hold to give me information on is the trainee able to feel the tissues. So we come back to my favorite forceps, the forceps. And as we name these forceps and instruments, as they were mado, I would urge you to learn the names of the instruments because I think it actually as relevance and history to our specialty. But I think it also has a degree of respect to the craft and the surgeons. So I was witnessing on Saturday a number of very interesting ways over hand forceps, underhand. Burger flipping forceps from five guys, forceps that are held in that respect and they're wobbling around. Forceps held over hand. It was quite in and sort of a cross grip like that holding f you can see and none of these positions are the palps of the fingers actually applied to the instrument. So I said to you pinch like that, it was sore. It was 25 mis average 35 newtons in men. So if you look at the end of these forceps and that's about five millimeters squared and pressure equals force in the area. That's 25 newtons over five times 10 to the minus 6 m squared, which is 5 million mutants made me to describe these are serious crushing instruments. And you know that because you just pinched yourself now repeat the exercise, but keep the distal interphalangeal joint extended that one. All right, keep that extended. Now, try and pinch yourself, pinch hard and you find you can pinch and pinch and pinch, but it's not as hard as pinching like that because that involves the two biggest muscles of the forearm. Flexor, digitorum, profundus, flexor pois longus, those are the Popeye muscles there that you feel. And those are the muscles that have tom cruise hang off helicopters and cliffs. Those are gripping muscles. And actually to grip, one also has a hand slightly extended to allow those flexors to maximize the grip when you're standing and you got your hand palmar flex, you can't grip very tight. But with palmar fex, you've isolated the intrinsic muscles of the hands. So what we're trying to do when holding our instruments is use the intrinsic muscles of the hands and maximize the tip and the pulp. OK. And the muscle that does that. And if uh winning colleagues from the lumbrical team or watching, what do we say? We love the lumbricals because with the other opponents and abductive policies, you're bringing the palps of the fingers together. So if you take the principles of lightness of touch and using the intrinsic muscles of the hand, then you can start thinking, how do I pick up all sorts of instruments? These are castros, castros have got a lovely round body. OK? And when I'm holding it and I'll come over again a bit like the forceps, resting it in first dorsal into, we've already had that the, the two point sensation there is actually pretty good. And I'm bringing the palp of my index finger and my thumb and I can feel the instrument, I cannot apply an enormous amount of pressure. I'm squeezing my finger. But if I do it like that, actually, that becomes sore and I've demonstrated on the banana, a full thickness Banana massacre, but that translates to mucosal damage, endothelial damage on all other tissues. The Castro Yves is for fine tutoring. And the Castro Je, as you see has got this lovely barrel. The movement of the 70 needles for microvascular surgery are literally a feel, a roll. So it's not a pro nations super nation now. It's a finger movement and there's not much more movement than that for microvascular surgery. And I'm feeling the tissues, I'm getting the haptic feedback through the palp of my fingers, using mosquitoes or any other instrument with rings. Please don't put your fingers through them, feel it, open it up gently. You don't have to open it up wide because if you look at these rats very carefully, that's only a depth now of perhaps two millimeters at the most and to unlock it doesn't require much. No, particularly with help mosquitoes, et cetera like that to put the mosquito on and be able to take it off with the left hand. So take it off, put it on, take it off, put it on, take it off, put it on, take it off, put it on. In this occasion, I'm holding it note, palp, finger, palp, finger, palp, finger, pulp, finger or thumb. And I'm feeling the tissues just when using hemostats. You see the two curves when you're clipping a vessel to ligate it, put the two curves facing each other like that cos once you've cut it to actually take the instrument of is you hold it up. Ok. So the surgeon can get the suture around, you turn it up so you can get around the point and then you turn it such it's towards the surgeon so they can ligate it. So there's a simple movement there, hold it up around the point and you turn it so they can see the ligation going down and take it off and ease and squeeze is actually ease it off very gently without losing control and put it back on. And that allows the suture to be gathered an ease and squeeze. So the surgeon might ask for an ease and squeeze the ease and squeeze on. Hemostats cannot be done quite frankly with uh clumsy hard motion like that. So take any instrument, this is the leg. He same thing applies with the rings. Don't put your rings through it, fingers through it. Left hand can take it off in the same manner. Ease and squeeze. Remember as I pointed out for passing a suture into a field, boring it between the tip and your fingers and you've got a nice straight line to pick up to pass the future. I demonstrated that the other day passing a suture around, I could take, pick it up with my forceps, pick the suture up and take that away. All instruments, nerve hook, skin hook, nice, delicate a you don't grip them, you apply maximum fingertip pressure to your instruments. And it's only through feel that you will actually start appreciating how the tissues behave. And you will find that your operation becomes easier and more relaxed. It's interesting learning the katana that is exactly the same sort of things that the sensor is describing to me. As I'm learning the art of drawing the sword to close this evening, I just want to go through a little bit about sterilization because I think it is necessary for a surgeon to understand the process but also understand the absolute need to sterilize and maintain and look after instruments. So in ancient practices, fire in Egypt and Greece was used as a basic form of sterilization and sometimes they use sunlight to actually cleanse in instruments. It's interesting that we use ultra violet light to clean. And I notice that in some W CS, particularly in Japan, they've got a mobile phone cleaner. You put your mobile phone into an all combined light clean as well. Germ theory by Louis Pasteur and Robert Koch, totally revolutionized the field of understanding microorganisms. But it was only until Joseph Lister in the 18 sixties, he came along who utilized car carbolic acid to sterilize instruments that we saw a significant reduction and infection and cleaning of instruments and was some of us who just said, wash your hands, soap and water. But Florence Nightingale also used carboxylic acid. But the real change came in 1879 with Charles Chamberlain, a French microbiologist and a collaborative collaborator of Louis Pastel invented the Auto Cave and he used pressurized because if you pressurize demon, there's physics involved, described it IG CSC level physics, you put the pressure up, the temperature will go up as well. I think it's Charles's law and therefore you can get temperatures up to 100 and 34 and 100 and 37 degree C. And indeed, this is the most popular and safest way of sterilizing instruments to date. And it kills a broad range of microorganisms including resistant bacterial spores and is the mainstay of sterilization. Many theaters used to have these baby bell ones should an instrument drop on the floor. I remember it being put in a portable microwave type pressure sterilizing to clean the instrument. But when you walk the process, you'll see that the instruments need to be visibly checked in the sore traps cleaned. And at that stage, the function is checked as well, particularly on those instruments with hinge joints and the box joint. As you can see there, that henge is an intricate arrangement, no screws, but there's a lot of hidden soil traps and those need to be cleaned. The problem is losing water that it causes rusting. So that's why steam and high pressure steam is used rather than hot water. And through the century, sterilization methods have improved. So ethylene oxide has emerged as a valuable method. For heat sensitive instruments at low temperatures. And there are a lot of other chemical sterilis, but they're not without hazard with fumes and proper protective glasses, gloves and clothing need to be worn. The more advanced sterilizer at the moment involve water cleaves with hydrogen peroxide plasma or parasitic acid. But if you started using liquids on steel blades like this, it'll start to rust. Indeed. If you touch the Kana with your fingertips and the one thing you don't do is ever touch a fellow practitioner sword, never touch the blade. There's a ritual cleaning it because even touching it with your fingers starts the rusting process. So, Swan Morton have a Cobalt radiation source to sterilize their blades. Sterilization is still a problem and biofilms are a problem as well. Prions are also considered a problem. And that's why there was a move to disposable instruments. Is that sustainable or is that cost effective? Not. Now, the other thing is if you start putting all the instruments in the washing machine like that, you start causing mechanical damage. So it is much easier to use trays where the instruments can be packed and separated such that the steam can get around them. But also in the vigor of the process, the transportation, the instruments are not knocking against each other and not being damaged. And this is particularly important when it comes to fine instruments for micro surgery. I had was blessed with a couple of diamond tipped knives for doing arteriotomy, no matter how good the sterilization process was. Unfortunately, they were broken. It did not come back an amusing story. You also need to actually watch your instruments and there's a side biting clamp that we use to put on the aorta to enable you to put the top end of the proximal end of the bypass graft on. And on one occasion I saw that the jaws of the side biting were displaced. And I said to the sister, I'm sorry, but this instrument is broken. I don't think we should put it back on the tray. She said, no, give it to me, put it back on the tray. But having walked the sterilization process, I had observed that many instruments would go back in the tray and we recycle, but this was a potentially lethal instrument. So I clipped it on the side of my gown, did the operation and I went with the staff nurse too, say to to explain that this side biting clamp was broken. They said, yeah, yeah, give it to us. I said, well, it is actually broken and should not be recycled. And I think it needs to be destroyed to allow me to destroy it for you. So I put it on the floor and jumped on it. Hm. Did I get into trouble? It was destroyed but it was a dangerous instrument. And indeed in one Kote bypass graft that we did, we put the side biting clamp on the aorta. And I went to see the patient in recovery and suddenly, so there's no BP. The drain was on the other side. I looked over and there was 5 L of blood in the drain. So I piled into the chest because it obviously been a catastrophic hemorrhage. And what I found is that that side banking clamp that had been applied to the aorta had taken a two centimeter rent out of the aar a massive hole. We spent 07 hours standing by the bedside leaning over because the bed was that wide fixing this. And I had to do a semi root replacement, suffice to say the patient lived amazing considering we're doing massage on the heart and there was no blood in the circulation, cardiac surgeons don't give up. So I hope I've given you a flavor of the reason why we need to hold the instruments in the tips of our fingers. Because as Roy Barclay Monahan said, we need to caress the tissues and you can only caress the tissues that run your fingers down your face. As we chat, we can only caress the tissues. If we use the palp of our fingers, anything less will not giving the feedback that you should receive. And how long is she was? So, as my sense says, in karate, lighten your grip on your lighten your grip on your instruments and let you feel the natural intrinsic muscles of the hands do the work. What do we love at the Blackout Academy? We love the lumbrical and maybe in the chart you could tell me why the lumbrical are so important and so unique. So I'm looking at the chart at the moment. Perhaps somebody could put in there. I recognize some regular names. Thank you, Rinku very much and thank you, can. And if you have an answer for my question, please put it in the chart and it was a pleasure meeting you last Saturday as well. And can I had fun? I hope you had fun too. I'll probably have to wait all night if for an answer for you on why lumbrical are so good and why we love them. Nobody has actually replied. The interesting thing about the lumbrical, you have four in each hand and they are the only muscles in the body that have no bony origin and no bony insertion. So you can pinch yourself. But also we like to see men. There's a lot more to touch than meets the eye. And the laying on of hands was described as the ancient healers. And perhaps we should go back to the laying on of hands just as a reminder that your patient would like a reassuring touch, a touch on the shoulder, a touch on the back. Of course, there's inappropriate touches, but a reassuring touch on the hand, the forearm or the shoulder or the back goes a long way. You don't have to say anything, it indicates you're present. And as we have discussed this evening, it communicates empathy and compassion because above all, that's what we're in the business of doing is hoping to make our patients lives better. We are not just who of flesh. Thank you very much indeed for joining the Black Belt Academy. I do hope that you join us again next week and thinking about it and thinking of discussing the instruments this evening and looking at the talks that we've done so far, perhaps, I think I'm gonna do a dissection next week. So we're gonna dissect something out and we'll talk through the dissection and reinforce the handling of the instruments and description and how you can use the surgical tools as an extension on your fingers. Thank you and I hope to see you next week. Wish you well. And thank you for joining the Black Belt Academy. Gabrielle has been our producer to date. Unfortunately, she leaves us and I would like to thank her for all her support. I think over two years Gabrielle and she hasn't missed a single episode. She's heard it all before. I hope I kept you entertained Gabrielle. And thank you very much indeed for your support.