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Hello, good evening. Good afternoon. Good morning, 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, the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. And I'm coming live to you from Kuala Lumpur. I'm a professor in the Medical Education and Research Development Unit with the Faculty of Medicine at the University of Milan. It is 11 o'clock here this evening, Rio who is on production is in London and our special guest this m this morning or this evening is Professor Chris be having a little issue at the present moment connecting. We can see him online, but we can't hear him fastly if this is your first time joining the Black Belt Academy. Thank you very much. Indeed. And if you are returning again, many thanks, we have 1844 followers on Twitter, 842 on Instagram. Tonight, we have 111 registrations from 41 different countries, literally from A to Z. This is from Armenia Budapest, China, Egypt, Ghana Jordan Kuwait Maldives, Nepal, Sierra Leone, Somalia and a new country this evening, the Turk and is in the Caribbean Uganda UK and USA. This is only possible thanks to Metal and this is coming to free because like Metal, I believe that education should be free to. Oh, my special guest this evening and I hope will be joining us as we sort the technical issue out in the background is a professor Chris Gaa. No, I calculate between Chris and myself. We have got 76 years of surgical experience and there's little that we haven't seen or done. He started his career in 1977 as an associate professor of surgery at the University of Alberta and then went on to become a professor of surgery and Division Directive General Survey and co directive for undergraduate surgical education and direct of surgical oncology. He's been on the board of the Canadian Association of General Surgeons and Associate Dean for the University of Alberta and the Faculty of Medicine and Dentistry. He's been on the C and a Center for the University of Alberta as well on the General Faculty Council for the University of Alberta, Director of Bariatric Surgery and Revision Clinic, and the past president of the Canadian Association of General Surgeons. His interests have been general surgery, emergency, general surgery, surgical oncology and bariatric surgery. We're not quite sure while he is not able to join us at the present. And I hope we'll be able to join us with comments and take questions. This session is really your session for you to talk about and ask questions. We've asked you to answer questions before this about bleeding. And I'm very pleased to see that many of you have got the right approach. Whenever you take a knife into a body, you run the risk of bleeding. And the first bleeding I should say is helpful in that all wounds start to heal with bleeding. And I do find, and I've noticed trainees and surgeons alike really get very worried about little bleeds as they go in and tend to use the diathermy to rate the tissues. This is actually transferring energy to the tissues. An indiscriminate diathermy is going to damage the tissues. I decrease the probability of good with wound healing. It is useful to remember that arteries particularly less than one millimeter will die because of the thick medial wall. But a one millimeter vein being thinwalled will not die thin. And in those cases, one should ligate them. It is important when doing an operation to go in slow and deliberate and attend to hemostasis because this is the best time to do I sta because at the end of the operation, there'll be profuse bleeding, the patient will be cooler, the temperature will be lower. And certainly in cardiac, certainly there is more likely to be a propensity to a coagulation issue. So go in slow and come out smoothly and deliberately is important. The other thing to say is that when using swells to curtail hemostasis going in, it is very easy to lose track of the amount of blood that is being lost. And one important message that I got from doing pediatric surveys is because of the very large surface area to volume ratio in Children. It is very easy to lose blood and not be aware of it if you're dab dabbing with a swab and not attending to hemostasis. So one useful lesson that was part to me in training was to use one swab at a time. So with that in general principles of opening and closing and judicious use of the swan for routine surgery. I'm now delighted to welcome to the stage. My colleague and fellowsi, Professor Chris, welcome Chris. Thank you to the stage. Thank you David. The general principles of opening hemostasis on the way in deliberate focused diathermy of arteries, ligation pays attention to hemostasis going in and it means that coming out would be a lot easier. And I was just reminding people that it's very easy to lose blood and lose count of the amount of blood particularly in pediatric cases and therefore use one swab at a time. If not we the swabs but routine hemostasis, we will touch on. But as I said, my colleague and I have 47 years experience of operating and Chris I'm not with you. No, but I just Totted the ears out. Thank you. Thank you very much and welcome. Thank you for joining the stage and, and, and, and I just wanna thank the listeners for all the viewers, for all being here because this is important stuff and there are so many rules to follow, er, but basic principles, er, and the, the tenants of BBA are very much er, in a show in this. So it's a very important topic. Take it away. Well, uh I, you know, I think, I think there are some sort of no nos and one of them is the over reliance on quarter or diathermy as is called in the UK quarter for North America. Er, one tends to think of it as a rescue stick and the, the scorched earth policy that uh some people adopt is clearly not the right approach but judicious use of, of ca can be extremely useful. Uh, and one of the things that I always used to teach was that you don't, you don't try and cauterize where the blood has gone but where it came from. So, so using a pair of non tooth forceps to grasp the vessel and then cauterize that is likely to be a much more successful endeavor. Another topic that I think is worth always considering is that, you know, the American College of Surgeons and the Royal College of Surgeons, they're all, you know, heavily into classifying degrees of hemorrhage and how much blood loss and um, is going on. Well, these are all very nice but at the end of the day, uh, if the vena cava is bleeding, it doesn't matter what you're calling it in terms of, in terms of its, its source. I think my little adage that David laughs at the, there are only two types of bad bleeding that would you hear? And that, which is your own, uh, a good, a good edges to follow. Uh So, um for me, critical issues are around suture, ligation, er er stick tying of er vessels. I think these are, are very important and I mean, it starts even before that. Do you know how to tie a proper knot? Uh is rather important. Uh and a bunch of grammy knots are likely to slip on you and when it's a critical vessel, that's, that's not a good thing. So, think carefully about how you tie your, how you tie your knots and when to, when to sit A LG, the these are in my mind, important issue. Would you agree to indeed we, as you know, we do emphasize not time and ligation is important. And as we previously said, that veins don't necessarily follow obvious anatomical paths, particularly around exocrine glands, the head of pancreas, thyroid adrenal and all those small veins is tiresome in as many as they are. Each and every single one of them needs to be ligated properly. Yeah, I want to also make a point for those who are general surgeons that great care needs to be used when ligating in a mesentery because this may lead to lead to under perfusional death of the bowel distal to that. So one has to watch that pretty closely because it's easy to take a huge chunk of mesentery, especially in this more obese world and, and get rid of the blood supply. So I think that's a very important aspect to think about. So know your anatomy. And as you say, mindful, don't think of the reason long, many years since I did general surgery, but certainly your bowel anastomosis, you really want fresh leading edges to join together, not ischemic edges. So identifying the vessels accurately is very, very important. Indeed, I think we need David for the uh for the website, we need examples somehow, pictorial examples of what it looks like when the bleeding edges of the bowel are, you know, OK. And when they're poorly perfused, because I think, uh you know, this is something you might not recognize until it's actually staring you in the face. Indeed. But going back to the diathermy, our fellow also puts in the chatroom, charcoal doesn't bleed. But likewise attending to hemostasis, meticulous hemostasis as you go in and ligating vessels, but clean dissection, a sharp dissection. So cut with a knife, put a swab and then attend to the bleeds. In some occasions I've gone through and you probably have gone through bariatric survey 15 centimeters of fat before you actually get to the sternum. And the interesting thing is, is that you think that fat is a vascular. Indeed, it probably is. But in that you've got a big venous supply with lots of veins that all need to be ligated. Yeah. And it's best identify them as you go in because the vessels retract and certainly, although you can hold it with a forcep, even a two millimeter vein would not actually diet. And got to also that these uh large uh amounts of fat are a great source of uh infection and sepsis because they are uh they easily are culture media uh which also add to the challenges uh uh in surgery, I think uh a great deal indeed. And as we have covered before a continuous suture in those fat layers, particularly if it's poorly applied, strangulates the tissue. And you see the fat squeezing out between the sutures adding to that risk. So Chris, let's move on. You have attended to detail, you are meticulous, you tied off the veins, but sometimes pathology and tumors hide vessels and you come across a big bleed. What do you do next? Um As your text says, don't panic, apply pressure, pressure is a wonderful thing. Um And uh most certainly tumors are highly vascular. Uh and you need to carefully dissect around and please remember that when using dissecting scissors such as mcindoe that you don't use them to cut sutures because they'll get blood very quickly and make your and make your dissection around uh a large retroperitoneal tube extremely difficult. Um So I feel strongly about, about the judicious use of, of dissecting scissors. And as you say, tumors, particularly large tumors do have a are by definition very vascular. They usually have one or two veins or arteries, feeding them that they could come from any direction. So the dissection uh needs to be careful because you're not going to recognize normal anatomy and careful use of the scissors and separation of the tissues will help you find the veins. Personally, I've always found the arteries and spurs much easier to handle application of a hemostat on either side is pretty easy. Although the arteries normally retract into the tissue, but it's a large venous bleed that becomes problematic. How do you deal with that? Yeah, I think your message is important around beware of the venous bleeding because it can be really quite a challenge veins by definition, thin walled. So your judiciously applied hemostat may actually tear it and make the whole thing a whole lot worse. And even the decision around which hemostat to use. Do you use one of the, you know, a typical spencer wells with a gentle curve or a straight again. These are some of it is personal preference. But certainly I feel that the use of the, the cos is a I is a better tool because it's easier to get, uh, get the, uh, get the suture around it. Uh The other thing is, is, uh, and we're back to assisting again. The other thing is that, you know, your, your assistants need to be well schooled themselves. They need to know how to present to you the tip of the instrument. They need to allow you to get your hands behind their hands. And these, these skills unfortunately cannot really be acquired except in an operating room. Um Indeed, uh and in fact, next week, my son is on half term and he'll be helping us with the principles of assisting and we'll cover this element. But the hemostats usually come as curved and it's best to actually have the curves facing each other, particularly when doing Mery that you can get the suture around the curve. But it's a lift up to allow this negative to get around the instrument and turn it away for the surgeon such that they can see the knot going down. It's important not to pull on it and not to pull it off either. Sometimes the surgeon will ask for an ease and squeeze. Now, an squeeze is difficult as a beginner because that's letting go of the leg, clip the hemostat gently and applying it almost immediately again to allow the ligature to take up the vessel. So what would your recommendation on? When do you over serve with vessel? Thank Chris. Well, I think, I think the the vessel diameter is an important one. And certainly it's hard for me to give it to you in Frank millimeters, er, but clearly, um a good spurting er, arterial vessel er is best over son. Um uh would be my thinking around that and I'm all back to assisting because your assistant is so important and if they're ham fisted or rough with the tissues or whatever, this can make your, your life extremely difficult. Indeed, indeed. And so over saying it either be a transfixion stitch to the vessel, take the ligature around and around again and tie it or even a bigger vessel. Take a a transfixion stitch at either side of the vessel, tight and tight over. Sometimes if the vessel is actually that big and in cardiac surgery, we do see these big vessels, for example, the artery, although it's in the artery, it's still thin walled and this requires not a literature but a proper over and over stitch to close. So arterial bleeds and stitching is quite clear. What about your venous bleed? Then Chris back to don't panic um and be willing to, you know, run the suture. Um If it's a tear of a of a venous bleed, the use of that lovely clamp. Satinsky clamp is can be well used in that situation. Um I don't, we did have a picture of a Satinsky, but it's um it's very useful in that setting. It's a curved clamp like that, that you can apply again with all clamps on vessels they put on gently and you once on, remember that any inadvertent movement can mean that good tear off or make good tear even worse with venous bleeds. Sometimes there's not an obvious sight of s so packing is good to stop the immediate oozing or bleeding. But then you need to identify where the vein is below the vein is above. And this then becomes particularly problematic as you know, Chris in the retroperitoneal area because it could be taken when, when doing the packing, you know, you throw in a bunch of sponges and then you need to gently roll one edge to expose the area of interest rather than just lifting them off. And you know, there's a lot of that sort of seesawing effect that people go in for. They look and then they look again and, and that really doesn't help you at all. You have to be strategic about how you expose the bleeding and deal with it accordingly. Indeed. So having put a pack in covering a large area, the first thing to do as you've and you've recognized in the questions in preamble is if you hit a big bleed, put a pack in, put a swab on and tell the anesthetist actually got a bleed and tell them significantly because of most major surgery you would have cross matched, they will ask immediately for blood, but also they can open up the lines. And most major surgery patients have central lines and they can start administering fluid in a significant situation. And then cardiothoracic surgery we've been in that head down on the table is still a good option to restore BP and body some time. The commonest thing I've seen from major venous bleeding in a cardiac operation is the inadvertent opening of the chest, which takes out the innominate vein which runs across the sternum here. And particularly those people who have had any neck surgery, whatsoever thyroid operation, there is adhesions behind the sternum. And on one occasion, I asked as the registrar to go and do a thymectomy at the neuro hospital in Oxford. And Mr Westby sent me down there to do the operation and I called him to say that I noted that the patient had had some sort of neck or cervical surgery and I was not prepared to open the chest without a redo sore. The redo sore is an oscillating sore that enables you to gently feel through the sternum and open the sternum. And he said, don't be silly, et cetera, et cetera. I said sorry, but I'm not going to, we don't have an oscillating saw and he came down, we waited for an oscillating saw but not long enough and took a regular sternal saw through the sternum and lo and behold, we hit the innominate thing. The ominate vein is such, particularly behind the sternum is stuck, it is held open because of the adhesions. And within moments, we had 1.5 L of blood on the floor. I illustrate to the audience the size of a typical innominate thing and the size of your thumb. So the size of your, it's huge. It's huge for those people in general surgery. In the days when we used to do open high long vein ties, the dissection out of the phen fe junction, particularly if there is a, a variceal was I think one of the most challenging of all the dissections that a junior surgeon got to do. And I remember, I'm sure you remember doing a lot of uh losers uh huh vein surgery at the spem junction. And the important thing there was to make sure you identify the femoral vein above and below. And you have actually got the sp feno femoral junction because I have seen I somebody do a vein harvest for the lung subvenous vein. And we took out the femoral vein and, and a lot of femoral veins can be damaged in that respect. And II recall helping Professor Ma y with a redo operation. He wanted to open the second case as a trading register. I confess, we all preferred the professor not to open because he went straight into the heart and the attention to hemostasis was not as it would if we had done it. And you always knew that you would spend three hours extra at the end trying to stop the bleeding. And on this occasion, indeed, we hit the right ventricle as we went in. No problem. We salvaged it and stitched the ventricle did the operation and the professor turned to me and said, take out the pipes because we had gone on femal femoral bypass. So that's a large tube hose pipe into the femoral artery and one into the femoral vein that went all the way up the IVC to almost all the right, the femoral vein pipe didn't come out or there was resistance. The professor said, don't be silly and took the family pipe and pulled it out and imagine a sock coming out on your foot while the iliac vein came out as a sock on the tubing and immediately the BP dropped to 30 systolic where is a, obviously a catastrophic bleed. There's not much bleeding at the site. Fortunately, we are still in sinus rhythm and down called said, what the hell is going on and poured in blood? And the professor asked for a knife. I asked him, what is he going to do? And he wanted to open up the retroperitoneum to find this venous lead. I suggested to him from my experience in trauma surgery that if there is a large retroperitoneal bleed that is venous. The last thing one wants to open is the retroperitoneum because you will not find the source of bleeding and the patient will probably bleed out. At that time. He listened, we didn't do anything. We transfused up. The pressure, BP came up to normal. There was no bleeding from the site itself. It seemed to have tamper on it and stopped. And he asked, what do we do about the distal end around every joint? There are plenty of veins and veins in general. If you have a significant bleed, it is possible to tie them off the long and short of it is this patient made an uneventful recovery, left hospital in seven days and I saw her in clinic at three months and there are no untoward. And the one message that Professor Yakub told me, he said cardiac surgeons don't jump. And I think that's true with all surgery, you do not actually jump. Yeah. So that is my horrendous venous bleed. What about your horrendous venous bleed? Chris? I I'm trying to think back on cases of, of horrendous bleed and of course I've had them but I'm trying to put a name to somebody. Um because uh maybe one tries to scotch it from one's memory because it's, it's so unpleasant. I mean, I do remember thinking about neurosurgeons and how difficult control of bleeding within the brain is and what different techniques are used with those little paddies on strings. And I think that's a, that was an important lesson and certainly I find that terrifying to, to witness. So and I have indeed in in confined spaces trying to tampon our bleed, particularly with soft tissue around and delicate tissue. Whether in the orbit or in the cranium, you'll run the risk when packing of damaging other material. I think you've mentioned swab on string. It must be pointed out to everybody that a wet red swell, no matter what its size, small or large can easily be lost within a body cavity and having a swab on string. And some of those big packs had lengths of string on it. Even a full pack, which is like a large hand towel can get lost in a body cavity. So counting swabs in and counting swabs out is of significant importance. I recall carry on. I'm also thinking of another technique that we haven't discussed, which is a sponge on a stick can apply pressure in a more focal fashion and it's very useful in confined spaces. And people should think about that when in that situation. And but there's more go swabs wrapped on a a sponge if it comes off can also be lost. I do recall on a Sunday night being called to the ward for a lady who had arrested at the Brompton Hospital and I started cardiac massage. And as I each compression, I had blood welling out of the sternum, obviously something had happened and I had to go into the chest. I remember actually saying to the lady, don't worry, my dear, you'll be all right. Just put your hands down as it didn't hesitate to actually open the chest and had the chest open before the anesthetist arrived. There was indeed a hole following a aortic valve replacement and simply putting a finger on the hole, stop the bleeding. And in the POSTOP cardiac scenario, arterial bleeds like that are catastrophic and total blood can end up in the drains. The patient was absolutely fine, but it was interesting. This was the middle of the night and operating by the bed on a ward. And indeed, we had pat and stop the bleeding, but there was a swab left in the chest, but it turned out we had to go back in the morning just to remove clot because tamp. No, and we found that swab. We realized it only in the morning because the team helping were not regular theater staff counting swabs in counting swabs out. Chris has suggested we discuss Liger clips and where they fit in. Yeah, your feelings on li clips, sir. Well, again, judicious use is, is the right approach. They can be just perfect in the right setting. But you try liga clipping a decent size vessel vein or artery, you're going to have troubles with it. So it, it, the liga clip has to match the target that you're going for and it can be useful. And the other thing you don't want to do with LI Ecls is sort of pepper the area with these, you know, if it, if it doesn't work one or two, it's not likely to work, think of another strategy. And the other thing about the eclipse is that once you've put them in the, in an area, it makes it extremely difficult to ligate or suture, ligate a vessel around it because the clip gets in the way of, of the suture. And indeed, not only that if putting a swab in the chest or in the wound, and you have lip lips present, they find themselves in the swab. And as you take the swab out, it starts bleeding again and, and you get further further bleeding. The the important thing is also with dementia, with venous bleeds is a continuous suture in a vein is not a good idea in repairing it. If you identify the whole or rupture in the vein, a continuous suture would likely secret and marrow the vein. So interrupted sutures are the most important. A continuous suture on an artery is ok. Um But again, knowing your anatomy will enable you to decide whether you can tie that artery off or not or whether you have to repair very often, you have to repair and sometimes you need an interposition graft to repair it. And long venous vein PTF E or graft to repair vessels I needed. But by then, you would have called the cavalry and called the whole team to come out. On some occasions, the bleed might be so severe and catastrophic. I recall doing dissection on a woman who was 36 weeks pregnant and 36 weeks old. And when they called me, I said, just get her to theater and get the baby out. I arrived in theater, the baby was out, but we had the dissection to deal with. Unfortunately, with the heparinization and dealing with the dissection, the bleeding from the uterus was catastrophic and we had to do an emergency hysterectomy as well. This was one of the most horrendous cases that I've ever been involved in suffice to say, just with the team effort, we did get her out of hospital. She was in for three months, but she survived. But unfortunately, the baby suffered a toxic brain damage in the time it took to get her to theater and get the baby out. So, bleeding does matter. So, Chris, what do you do about a general ooze? Well, to me, the first thing is looking at the coagulation profile and understanding the elements of the profile and you know, your platelets are your friend and the coagulation factors are your friend and how distorted can they be? You can have a low platelet count and have a completely normal coagulation and bleeding will be controlled. Um So it's that it's that balance of the elements that's so terribly important. Um And, you know, I would always look at both sides of the equation to know what's going on. Obviously, transfused platelets are not as good as they were thing. And you know, similarly transfusion products are, are also extremely useful. So, um you know, I think caring attention needs to be paid, you know, before you start, um looking at the chart, looking at the electronic record where wherever these bits of data sit is an important part of it. The phrase we we used in cardiac surgery was general or private platelet. One has to remember that aspirin and clopidogrel and um do significantly curtail platelet function. We see this definitely in cardiac surgery and clopidogrel was definitely the worst and with and tag, particularly if they after emergency catheterization really did disrupt platelet aggregation, but aspirin likewise did the same. And what we were used to in cardiac surgery takes from the elastograms that were done real time in theater to give you some idea of where the issues lay as far as the bleeding was concerned. A simple trick to see if you've got a bleeding problem is if you use a bit of blood in a kidney dish, simply rock that side to side and that will literally give you the bleeding time. Yeah, you've heard the phrase, what's the bleeding time? It's two o'clock, sir. But a little bit of blood in a kidney dish, walking it side to side and seeing if it clots and certainly in the POSTOP count patient that was very important to assess clotting and clotting factors are extremely useful, particularly in dissection patients because the dissection, it consumes coagulation factors and platelets because people should remember as well when assessing clotting that it can take up to eight minutes. Clotting is not an instant thing. And people often are hurrying it and saying clock, clock, no, it does take time. So again, patients and surgeons aren't no. Exactly. And eight minutes with a swab in waiting for it to stop is actually a very long time. If you don't have blood be up around your swab, a constant pressure is extremely useful but taking it out before that eight minutes and putting it in, taking it out, you're not allowing the coagulation to stop. Indeed, there are a lot of topical elements you can put in the chest from essentially dry potato starch powder to sealants. All of them are encouraging cyber plotting and assisting with a clotting cascade glues are also used and sprayed on surfaces for similar reasons, particularly if there is a large oozy area, head of pancreas, taking the cortex of the lung, raw surface of the liver or spleen, they indeed can be useful to apply to those surfaces to stop bleeding. One of the most important elements is of course to remember that all enzymes actually operate at an ideal temperature and if the patient is not warm in a cold theater over hours, you will find that the cold patient will actually bleed and it is part of the tissue care bundle or surgical site infection bundle. But I think also important for hemostasis to attend to the temperature of the patient and stay warm. Very important. Absolutely. And of course, transfusion carries all the risks as well. And you've been, you know, a cancer surgeon, uh not only is the risk of transmission or less now or viral factors, but patients who have been transfused there is I understand the risk of recurrence or attenuating the immune system. And there's a correlation between a large transfusion and perhaps a poor. It's important to remember that multiple transfusions, blood is cold too because it's stored cold. So that cool more than you like. So and you can't warm the bud up because well, you can. But you know, you're not, you're not putting it under water to warm it up. So you have to be careful on that front as well. Indeed, II understand you were in did some trauma surgery as well. Chris, is that right? I tried to run away from trauma surgery. I felt that it was one of those things. Some people just, just warm to that stuff and love the crash bang wallop that exists in the trauma suite. I found there wasn't enough time to reflect on the plan of campaign. Ah, so, I mean, all general surgeons are required to be on the trauma roster, although I think even that is changing now that people are signed up to be on the trauma team and not so trauma is a topic in its own right? That requires, requires, I think proper training and going to some of the amazing centers in the US are uh are really very, you can really educate young how best to mount trauma and establish trauma teams that, that know their place and know their actions. II think as you say, and we'll probably invite our fellow John Ta to talk about trauma responses. But it's important to understand the pattern of injury. And in, in, in doing so, evaluate the treatment, understanding the mechanism, direct penetration. It's clear to follow the the knife or the wound, high velocity injuries and penetrating injuries with bullets do carry extra energy and will cause bleeding and trauma around that not only entry but also exercises but crushing injuries caused by great or extreme force applied over a period of time can also cause significant bleeding and sometimes it and don't forget renal failure because the myoglobin gets into the blood and silts up the kidneys. So and that takes some days it doesn't happen straight away. So that's to be watched for. And there's there's always a balance to be had with a large hematoma. Do you evacuate or do you leave it? And it really depends on the site, the size, the cause and the underlying effect as well. That needs separate evaluation altogether. But you also got to remember sometimes when operating, the BP might be falling and bleeding might not be apparent, you can't see it and the commonest cause for bleeding, uh, falling BP during the operation is a bleed. And certainly in the abdomen or the chest, there might be obvious signs and certainly from solid organs like the liver and spleen. They could be bleeding unnoticed in the peritoneal cavity. And you have a shattered spleen or shattered liver. Yeah. The other thing we've come across is bleeding from orifices, nose rectum, e et cetera. Those bleeds again, require specialist treatment and usually again, direct pressure, but do require endoscopic inspection. Absolutely. Mm The I suppose, what did, what did it feel like the first time you were operating, you came across a big bleeder. How did you feel it was energized, scared and energized all at the same time. This was, you know, this was my manhood on show and I needed to rise to the challenge. So, uh that's the way I saw it. What about you and very similar? And, but the first important thing is to actually have a team around you. Make sure, you know, the team and I recall doing a redo operation and we hit the right ventricle game in and had a major bleed. The niece said you want to help. I said, yes, please. And a colleague came down to help him. I said, they said, what do we need? I said we need a live patient. I attend to the bleeding if you could get fe fe lines. In the important thing is to think in these circumstances, situational awareness needs to be handed over to another surgeon in theater as you attend to the bleed itself. But keep the team, the nursing staff and the nest just informed such they can call for blood and call for help. I think we're going to ask my fellow colleague and our colleague, Chris Caddy. So we have two Christophers to join us as a sense to add his thoughts to major major bleeding. I am not sure if Mr Caddi, you've had any significant bleeds in the past. And I noted in the chat that you're talking about the reb oa as a temporizing procedure. So welcome Mr Caddy. Hi. Um very enjoying the discussion. Um But a lot of this is, is, is very high level. Yes, I've had experience lots of bleeding. Uh And every time I learn something new. So using other techniques which are sore is sort of an A&E type solution nowadays. Uh It, it's, can you describe that? Well, it, it's about using a balloon to uh to stop the bleeding. So you, you go in through the gro the groin, slide it up and occlude the aortic arch and it just stops the bleeding instantly. Uh But there are other topical agents like Celox um which once again, are incredibly aggressive in stopping bleeding. Uh and you have to know the rest of your team so that having an interventional radiologist as part of your team can be integral to getting control. So, um yeah, talk about catheters and I wasn't thinking of interventional radiology and that's extremely useful. And certainly the interventional radiologists are very good at embolize the. Using a foley catheter in a large vessel is also extremely useful. But remember when using the f catheter and inflating it to tamp on the bleeding, when you come to stitching the vessel, make sure you don't burst the balloon and otherwise you back to back to square one or the balloon into the vessel or the balloon in. Indeed. But topical agents are also extremely useful. And I'm actually thinking that maybe as surgeons we ought to actually have in the Black Belt Academy, a discussion about coagulation and hemostasis and the principles because actually bleeding is our friend. It helps healing and it is the first part of healing, but too much bleeding then becomes a problem. And we need to understand how to use it. I think, I think a session or part of a session on topical agents themselves would be useful because some of them I think are gloriously ineffective and some are quite effective. So I just be mindful about diming some product out there and getting multiple calls from the company. How dare you say this about our product? There's a lot of it is every situational awareness and then decision making and communication and teamwork. So it's about all often thinking outside of the box, you're in a situation which you haven't got any control of. You turn to your colleague and find out what would you do? So once again, you flatten the hierarchy in the theater and you use the whole team. Actually, there's, there's very seldom as, as I say, in cardiac surgery when you got a torn right ventricle, it's very seldom. There is something we cannot actually stop without a finger of pressure. A young man who had come in from an institution that committed suicide and he had stabbed himself five times in the chest with a perfect grouping over the heart. And of course, when he coughed, they were spurting but it was tampered. So we took him to theater conscious, put him asleep and opened the chest, did the stomy and indeed, there were five perfect lacerations in the heart. He didn't hit a vessel, he didn't hit a valve, he did not hit the conduction tissue and without needing to go on bypass five fingers, one on each of the ST injuries. I was able to actually control the bleeding and I over. So that that was easy. What was actually extremely difficult was the fact that he had sliced and diced his chest wall and costal cartilages and made a right mass of the costal arteries in the internal mammary artery, which took longer to control the bleeding. And over so and did five simple sutures in the ventricle which stopped the bleeding. And it, it is quite interesting that the heart, even though if you think it's going to bleed because it's uh we kept the pressure not too high, obviously, not too low, but the muscle itself was tampon the bleed. But it, the costal vessels, intercostal vessels in the internal mammary artery that proved the most difficult and to find the ends was extremely difficult. People forget that, that the intercostal vessels are live in a groove in the ribs. They're not correct. No top and so they can do it again. It can be difficult to control because and to get a suture, to and to get the su to actually bite, bite and to over and, and often in trauma situations and I've seen it in casualty as well when the heroes of the emergency surgeon have done a fantastic clamshell to go in and try and stop bleeding. But what they haven't attended to is the superior epigastric arteries and the intercostal arteries. The other arteries in that incision that continue to bleed profusely. And these are only 1.5 to 2 millimeters and they can be seriously problematic. Again, people often don't remember the location of the epigastric vessels and the superior and the inferior and what contributes the most blood to the rectus muscle is again an important piece of education to help people understand how to control. It's not just a way of up the inguinal canal. Yeah, they forget about the vessels going in, don't they? I do recall a casualty patient coming in having been stabbed in the groin. This is a 6 ft five huge bouncer and the groin laceration had lacerated the femoral vein. And despite pressure and despite everything else, he actually bled out, I suppose, I suppose that that's why it was the favorite tool or in silence of the lambs, he walked past and flicked a knife in the groin and lacerated the femoral vein very difficult to control. And unfortunately, this person bled out. We've covered all sorts of bleeding this evening from all sorts of directions. The simple message is prevention is better than cure at 10 to hemostasis going in if you've got a major bleed press on it. Call for help announce that you have some people around. You can help. Pressure is important and remember, count the swabs in, count the swabs out. Absolutely. Any final and surgical technique above everything else, accurate ligation of vessels and please dim all the tissues and cauterize it. We're not serving up charcoal does not bleed. Absolutely. It also contributes to the wound infection. Any other take home messages for our team? No, I think that's tremendous. It should be. Is it going to be written up in some way? How, how are you going to do it? I think what we should do is translate this into a piece which we'll put on the website and we'd like to thank our audience, 41 countries joined us this evening. Thank you for your attention. Thank you very much to Chris dear and thank you Chris Kelly for adding to the chat. And thank you very much indeed to Ria who has been in the production in the Black. We will see you next week at the Black Belt Academy and we will talk about the assisting skills. As I said, my son's on half term. He's been my assistant and people have noted since he started how much he's grown. I think he, I think he's 6 ft three now. So that adds to our discussion about the height of the table as well. But as we said, good assistants, make good surgeons and good surgeons, make good assistance. So we'll see you next week. Thank you. Have a good night. Thank you ciao.