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Yeah. Okay. Hi, everyone. Thanks for joining us. We'll just wait a few minutes until a few more people join. If you haven't already. I'm sorry. I say this every single night, but there is a questionnaire that we're just asking people to fill out at the start of the lecture. If you've done it once, you don't need to do it again. It's the same questionnaire each time. Um, the QR code is at the bottom, uh, in the left. Yeah, and then a few common questions that we've got every night that I thought I'd just start with. I've put them on the slide here as well. Um, but yes, we are recording the lectures. And if you fill out the feedback at the end that gets sent to you via email from medal, um, we'll be able to distribute that to you automatically. We do. It will take a little bit of time because I'll just edit them either side to get rid of my waffle. Essentially, um, so we can't send them out immediately, But the plan is to send all of them out as much as possible, I think, if yeah, and then the next thing is about certificates. So lots of people are asking about certificates. Um, so medal will automatically send you, uh, feedback at the end of this session. But it's basically just to tick boxes that say yes, I've attended the session, and yes, I filled out the post lecture feedback. Um, so if you take this, you'll then automatically get sent your certificate with your name on it and things like that, and you'll get a certificate for each lecture you attend. And then finally, the last thing is my feedback, which is really helpful to help us put on these events in the future. And no, any topics you might want us to cover. Um, so I'll put a QR code like I have every night at the end on the final slide. And I also put the feed back in, um, in the chat. It's the same feedback form every day. You just need to select which event you've come to. Um, so if you've already got the link, feel free to just do that one again and just select the miracle work workshop. Um, so let's see how we're doing. Okay. I think if we aim to start at five past. Is everyone okay with that? Um, if you haven't seen our pole in the chat, um, we've got another poll this evening. Hopefully, it's not a stupid question as yesterday because some people voted. This is a stupid question. So I didn't give that as an option today. Um, And then for those of you, I'm not sure if you've got the email, but we've managed tonight to get sorted, so we're going to do the dissection first. Um, So we'll talk that through with you all this evening and hopefully answer any questions you might have. Um, if you're squeamish, there is, um, Animal heart's in this video alongside a plastic model. But feel free to kind of look away and look back for the miracle workshop a little bit later on, if you're feeling a bit squeamish or you're eating your dinner or something like that. Um, Wendy, Who's our special guest? What's his name? This one's Mollie. Um, I've just been released, and it's like I need money. Go. If you haven't had the emails with the tick boxes, I will look into that for you. Um, apologies. Medal is not my platform. so I'm just learning, uh, learning the technology. But if you send me an email, I'll have a look. It might have gone to your junk box. So check your junk box for an email from Medal because it will have automatically been sent if you attend the lecture because I have a list of everyone. Um, yeah. Great. All right. I think we should make a start. So I will hand over to Georgia. Georgia is our cardiac registrar that joined us on Monday evening and gave a talk about the life and the day of, um and she's going to be talking us through the heart anatomy. Oh, yes. I put this update, Ray. The momentary panic. Um, yeah. So, yesterday you guys were going to get this dissection from I think, uh, well, yeah, Wendy and her colleague in Bristol. So, um, just filling in. I'm gonna do my best to do it Justice. It's an amazing video. Um, so when we talk about the heart, we always talk about the heart and the lungs that in obstructively linked together, and if we were to take the front portion of all of our chest away, this is the kind of thing that you you're gonna see. So, um, the lungs set slightly further forward than the heart, but the hearts, it's broadly speaking in the middle. So if you take your right arm, you put it onto your left shoulder approximately halfway between your elbow and your hand is where your heart is going to be underneath. So it's slightly to the left side of your body. And but generally speaking, we talked about it being in the middle. And when you actually look at a real life heart, it looks quite different from obviously your traditional emoji of a heart. Um, and it can be really quite complex. Get your head around because it doesn't sit forward in the body. It sits slightly to the side. So when we refer to the heart, we always refer to to side the left side and the right side. But quite confusingly, the right side is at the front, and the left side is at the back and around the side and then to the back as well. So actually, how it looks in your hands and how it actually sits in your body can be It takes a while to get to grips with, even if you're seeing it every day doing surgery. So, um, this is let me Hopefully this isn't gonna like we did try it. Fingers crossed. So here we have a plastic model in the middle. We have two hearts on the left and the right, So our demonstrators picking up a heart and what you're actually looking at in the middle is the same heart that you just saw in that diagram, but twisted around slightly but broadly. That's as close as it is going to be when it's in your body. So, um, we're going to start with the right side of the heart. So this is the bit that's mostly going to come around the front and what you're gonna see when you first go inside a chest. So when obviously the heart itself is just a pump, it's just muscles like you have in your lap in your legs and your bum in your arms. Um, very specialized muscles, of course. But ultimately all it's there to do is to pump blood, and to do that has to have a flow of blood in and the flow of blood out Um, And broadly speaking, when we're talking about blood going into the heart and out of the heart, we refer to the great vessels. And there are these two big tubes that you can see at the top of the heart here. So if I go back just a tiny bit to help it make a little bit of sense, those two vessels that were about to look at here are these two big vessels here. But we're looking at them from the top rather than from the side as we are here. So this one that we're pointing to hear this is one of the biggest veins in your body. Uh, it's called the superior vena cava, and that is basically going to bring all the blood back from your head. Your neck, your arms. Um, someone said they're lagging, but is it Is it lagging? Is is the sound coming out of my mouth slower than I'm actually moving my mouth? Or is it that is I'm just pausing the video. I think it's the pause. It's just the pause. Okay, Great. I'm just going to pause it so that I can talk. You talk quicker than, um than the video is going to go. So this is basically out. All the blood is going to come from your upper body back into the heart directly next to it. Uh, directly next to it. This other big vessel here, this is the aorta. So this is we'll talk about that more in a minute is where most of the blood is going to leave your heart from. So as we um So this is demonstrating the same thing again. But on the plastic model, so you can see the big one in big one out at the top. So this is the right atrium. So we have four chambers of the heart we have to at the top two at the bottom. The two at the topic called the atrium. Uh, the left and the right atrium and the two at the bottom called the ventricles. The ones at the top, The atria. Um, they do have a little bit of squeezy function, but they're mostly there to basically, um, control blood flow into the heart. So the right atrium, which is what he's just pointed to, is a big has a big floppy bit that comes around the side called the Oracle, and that's what he's holding onto here in his fingers. Um, and that's gonna sit above the ventricle. Um, and it doesn't really have a purpose, to be honest it, But what is very close to it and what is very important two things firstly, is going to be what he's pointing out here, which is your coronary arteries. So just like all the other muscles or tissues in your body, your heart, even though it's main job, is to pump blood. It needs its own blood supply. And it gets that from two coronary arteries that come just out of the very top of the hill to here, one on the right, coming this way, which is what we're looking at here, the right coronary artery and then one on the left, which comes out sort of on the other side, and it's gone. Uh, it then splits into two straight away. So we talked about two main coronary arteries left and the right, but no matter of fact, you really have three cause we have to on the left because it you have a short bit of of the start on the left and then immediately turns into two. And they're both very important. And then you have one on the right, so we have three. So what he's demonstrating here is the right coronary artery, which is going to come down, um, in between the atria and the ventricles. So in between the two chambers on the right round, the sort of the the lateral wall of the heart and then underneath and it's gonna be supplying this bottom bit of the heart underneath here. And we're just demonstrating the same thing again on this heart. And what he's going to do now is he's going to inject a little bit of fluid into the artery. This is not obviously how we would do it in real life, but this is just to demonstrate to you where the blood vessel is and how it's flowing. So as he puts a bit fluid in, that vessel is going to increase in size of it as we get some flow through it. As you can see, that's happening here. And it's just to show you really nice and clearly, and what you can't see is tens of branches coming off the side and then tens of branches coming off the side of these smaller branches. And that's how the whole muscle gets a really good blood supply. So what we is doing now is opening up the heart and basically dividing into two pretty much down the middle. So what you're going to be able to see now, I'll just wait for a good image and we'll stop it. So what you can see here is you can see this is the right atrium. So this But here is the floppy bit. We were squeezing before and we said it was the Oracle, and it doesn't really do much. Um and then this is is the right ventricle. So sort of this space here that we've opened is what would be the atrium. And that means that this sort of tenderness looking thing here is one of our heart valves. So between the top and bottom chambers between the 80 and the ventricle, we have the accurately named atrioventricular valves. You're a V valves, so you have one on each side. And then there's also going to be two of the heart valves in different positions, which we'll talk about in a minute and um, the important, the other important structure near the atrium on this side, which we haven't mentioned, um, other than the arteries is it's going to be your, um, conductive pathway in your heart. So that's basically where the electrical impulses travel that tell your heart to beat and most importantly, really something called the Sinoatrial Node, the essay node, and that's going to sit here. So on this model, what he's holding on to is this, But so it been opened up that way. This blood vessel has been cut off this model so you can't see it. So around here, which is basically around this area, but on the other side where his finger is, is where your important, um, conductive system would start. And it's not something that you can see during an operation. But it's something that we know is there, and you have to know where it is, because if you do put stitches through that or you cut it or something, you're going to leave your patient with a significant arrhythmia. They will probably need a pacemaker. So that's something you don't want to do unless you absolutely have to. And you if you do have to do it. You want to on purpose. So, um, what he's trying to demonstrate here is the difference in the wall thickness. So let me just rewind that just a couple of seconds and hide this. So I said this was the right ventricle, and you can see the walls quite thin. This on the other side, is the left ventricle. And although both sides pump and both sides squeeze, the left is the most is the strongest, Um and the more important of the two in terms of pumping blood out of your body because the right only has to pump blood into your lungs. Where was the left? Has to pump blood out of the heart into the rest of your entire body. So ever apart from your lungs, which is why it's so much thicker and stronger. So he's just demonstrating really nicely. He or she? Sorry. I keep saying here, don't you? I, um uh, the difference in the thickness of the ventricles. So the left is much, much thicker than the right cause there's a lot more muscle there cause it has to be a lot stronger. And then there's just going to show us the same thing on the model, which just makes things nice and clear, because sometimes the real heart are a bit tricky to see these things. So, as you can see here, we've got a thin wall of the right ventricle, a very thick wall of the left ventricle. This is going to be your tricuspid valve. Which is that? That valve between the right atrium and the right ventricle mentioned earlier and then really nicely. You can see here we have coronary arteries. So, um, I this is going to be your right coronary artery. So it would have come off around here and gone that way. And then this is going to be your left coronary artery, which is gonna have come from the other side of this big vessel here, which is your aorta, and comes this way. And then it comes down the sort of front and lateral part of the heart. Sorry, Lateral means side. So you can see that the right has space for lots of blood, but doesn't have very thick wall. The left has a lot less space for blood that has a much thicker wall, much stronger pump There we go. Demonstrating how the heart pumps Mhm, Georgia. I think your cursor disappears when, um when the screen is on full. Okay, so I don't know whether if you minimize it, you can still see it. Okay, let me try. Be wrong. I can see it on my screen. The white one. Like, uh, when you press when you press play in things, but then it disappears. Um, now, Yeah, I can see it now. Ok, um, let me just get back. So, um, what they're doing here is basically just opening the top bit, Batou between the 2 80 mgs and showing you how the blood is going to be leaving both ventricles. So what you can see here is hopefully you can still see this cursor. Um, is so this is your right ventricle. This is your left ventricle. This is your left atrium. This is your right atrium that's been opened up. So on the right hand side, on the right hand side, exactly where this thumb is is going to be where blood is leaving the right side of the heart to go to the lung. So it's come in from the body by those big veins that we started with. It's come through the atrium into the ventricle, and now it's going to leave through the pulmonary arteries going to the lungs. So when we talk about blood vessels, we have arteries and we have veins. What? Where they're going, what they're during doesn't really matter. They're called arteries or veins, based on whether they're going towards the heart or away from the heart. So anything that goes towards closer towards the heart is called a vein. Anything that goes away from the heart is called an artery. So even though this blood vessel is in the middle of the heart, it is technically leaving the heart because it's been coming from the right and it's going out into the lungs. So this is the pulmonary artery. Um, and that's gonna go. That's give me blood that has no oxygen in it. Uh, and it's going to go into the lungs through this route here, the cursor keeps intermittently disappearing. I'm not sure everything if we can just Yeah, just describe the way you are. I think people are still following. So that's gonna so then? Oh, that was a really good shot then. So then, as you can see by the right thumb, that's holding the forceps. Um, this triangular bit here is gonna be going out into the aorta. So the bit the big chunk that you can see in front of you, I'll try and do it in a way that if you can't see the curse you still understand is, um, the left ventricle. So this big, thick bit of purple muscle in front of you is the wall of the ventricle. And just at the tip of the left thumb, there's a dark hole so that a whole is going up into the aorta. We call this area the left ventricular outflow track because it's the outflow of blood from the left ventricle. So that's going into the aorta and out into the rest of the body. And so you can imagine the force that has to generate to get the blood out into the rest of the body is very high. And that's why you have such a thick muscle on the left compared to the right and what you can see, what they're about to grab hold of is called the mitral valve. So we had the tricuspid valve on the right hand side, which was the valve between the atrium on the right, going into the ventricle on the right. Now we have the mitral valve, which is the valve between the H one on the left going into the ventricle on the left and I think really nicely demonstrated. And what they're about to grab is basically the inside muscles of the left ventricle. So, um, as you can imagine, the pressure generated when the heart is pumping has the potential to disrupt the heart valves and the structures in the heart as well as you know, if everything isn't intact and as it should be So when the heart squeezes, we want blood to only go in one direction out the top of the heart. But just if, just like if you had, um, you know, a balloon that you could theoretically tie at two ends and you squeezed in the middle, the air or the water or whatever was in the balloon is gonna go both ways, so we don't want that to happen in the heart. We don't want blood to go back the way it came in. And that's where the valves come into play. So the bottom of the mitral valve, which is what you can see here and what they're grabbing, basically has, um, little tendons that, like they're very strong strings that attach onto the valve ends. And those strings themselves attach into the per pillory muscles, which are the tubular muscles that you can see underneath the threads that they're about to grab onto. And, um, what they do is when the heart contracts, they contract as well, so they basically squeeze onto the valve and keep it closed. If it's healthy, of course, so that the blood can't go back the way it came towards the lung, and it can only go out into the rest of the body. And and it's it's things like that. If you have a heart attack, for example, and a portion of the muscle that's responsible for holding onto the valve dies, then that valve can potentially not function as it should do anymore starts becoming leaky or narrowed. And then that's when you're gonna have problems and why patient's gonna need heart surgery. So now we're back looking at the top of the heart, and we're looking at the great vessels again. So again, on the left, what you can see is the superior vena cava, the big vein draining the head and the neck, and then on the right, in the middle of the screen is the aorta. So this is where all the blood is coming out the heart into the rest of the body, and this blood has come from the lungs. So it's got loads of auction. It's not got much carbon dioxide in anymore because we got rid of it in the lungs, which is where it just come from. So to get itself, uh, I'll just wait for them to demonstrate one second. So this is demonstrating again the mitral valve, and they were grasping hold of the cord. A tendency which are the string like tendons are going to hold onto the valve when the heart's contracting, keep it closed and make sure blood is only going one way. This is definitely not a an approved heart surgery. It doesn't quite look like this when we do operations, but it's very, very effective at showing you guys what what heart is made of. So again, that's a really nice view on the right. You've got the left on the right hand side of the screen. With the right hand, you've got the left ventricle, the left eye screen. You've got the left hand with the right ventricle. So just above the left thumb, these stringy bits here are the tricuspid valve and these stringy bits. Here are the mitral valve. So blood is coming in here and out that way, and it's coming in here and out up here. So what we're trying to demonstrate now is the Pommery veins. So I said earlier that any blood vessel that brings blood back to the heart, no matter where it's coming from or where it's going, um is called a vein. So the vessels bringing blood back from the heart are called the Pommery veins. And, uh so once blood has been to the lungs, it's then going to it's then going to come back from the top of the top and bottom of the left lung top and bottom of the right lung. So you have four primary veins because you have a superior, inferior, so superior being top inferior, being bottom on the left, and then you have a superior inferior on the right. So you have four and they come when the heart's in the body, they come into the back of the heart so you can just see one here. So this is gonna be the left inferior pulmonary vein. So that's going one comes here. One comes here, one comes here, one comes here and they're going to bring back nice, fresh blood full of oxygen into this side of the heart is then gonna be squeezed out of the heart up the aorta this way. And then this is going to continue all the way down your back and send blood to all the organs in your stomach, in your power vest and down into your legs. And then this is a really nice view of the inside of the very start of the aorta. So the aorta being that big blood vessel coming out the top going down into the rest of the body. So we have here, um, the main portion of the heart you can see on the screen is the left ventricle. And what were pointing out here is the very bottom of the aorta. We call it a or route and we're about to grasp hold of the cusp of the aortic valve. So we talked before about four major valves. We've already talked about the two that sit between the atria and the ventricles. So they're try custard on the right, the mitral on the left. Now we're talking about the ones that sit in the outflow tracts. So sit between the ventricle and either the lungs or the rest of the body. So the valve sitting between the heart and the lungs is called the pulmonary valve. Because pulmonary referring to you know, think anything to do with the lungs. Um, that's not You can't see this clearly on here, Um, or if you can, I certainly can't see it. Uh, and it's not something that you see regularly. It's certainly not something we operate on regularly in adults. It's something that's commonly operated on in Children or adults who have had surgery throughout childhood as well. Um, but the aortic valve is one of the most common things that we will operate on, as is the aorta, so you can just see if you can see my cursor. I think what we're seeing here is the very start of the left coronary artery. So as you can see, it's coming off the back. And then that's gonna come down this way and all the way down the side, and the right would have come off the front here. But we've just chopped off, and that's going to go that way and round the back. So the purpose of the aortic valve, which is what we're grasping onto here, is once the heart has squeezed and all the blood has left the heart, we don't want the blood to then fall back into the heart. We want it to continue in the rest of the body, and so it stops the blood flowing backwards again. If it is healthy, if it's not healthy and blood does stop coming backwards, we call that aortic regurgitation, or sometimes aortic insufficiency, and that can cause, you know, left untreated long term all sorts of problems, including heart failure. So that would be a common reason for us to replace the aortic valve, as would be, um, those we call them cusps, those pieces of the valve that we were grasping earlier. If I go back to it because we're nearly done and these little pockets that you can see. There we go that were grasped there they're the cusps. So if they become calcified, diseased, which infected? So all these you know the calcification occurs with age, for example, they become very stiff, as you can see at the moment, when they're healthy, they're floppy. And if they do become stiff, the valve becomes very, uh, narrowed. And it's no longer flexible. And that blockage can be, uh, can cause a lot of stress to the heart because the heart's trying to squeeze out blood through a very, very narrow hole, and again that can cause lots of problems. And so, um, narrowing, which is called aortic stenosis, is a very common reason. Probably the most common reason for us to replace the aortic valve in adults. So hopefully that has given you a good idea about what the heart looks like. Um, and why we like operating on them so much. I'm going to stop presenting and hand over to Kirstie. Um, should we do, Do you have a couple of questions? If you have any before we move on? I think everyone is mesmerized in the chat. Thanks so much Georgia. That was brilliant. And hopefully gives everyone a bit of an insight as to some of the things that can go wrong and why we might need to operate. And thank you so much to Wendy and Kim, my colleagues in Bristol who have put together this video just for you. Um, it's a brilliant video, and putting it together is a huge amount of effort, and not many people would make that effort. So definitely an amazing video. Thank you. Thank you. Thank you for doing it. Justice. I could not have done that. So that was amazing. Brilliant. Thanks. I think Let's put everyone's knowledge to the test a little bit. I got some feedback yesterday that my questions weren't hard enough, so these ones are a little bit trickier, so I'm going to start the poll now. Um, so everyone's get out, OK. Cardiomegaly is the medical term. For what? And people see it. I don't know whether I just can't see responses. Oh, yeah. There we go. Uh, maybe my questions aren't hard enough. We've still got sponsors. 84. I think we've got a few more. A few more gas is okay. So clearly My questions aren't hard enough because cardiomegaly is the word for an enlarged heart. Um, for bonus points, um, or this is does anyone know what one of the terms is for a hole in the heart? You can get holes in the heart in lots of different places. You can put your answers in the chat if you've got any suggestions. But maybe maybe I might have finally found something you all don't know. Okay, so hole in the heart is usually called. Uh oh, yeah, we've got a VSD. Does anyone know bonus points? What VSD stands for? Oh, everyone does. Okay. Septal defect. Yeah, you're right. So you can get that in pretty much anywhere in either the hr septum or the ventricular septum. Uh, anyone know what a heart with only one side is called? Anyone dextrocardia. Okay, so dextrocardia is a slightly different thing. Um, so dextrocardia is essentially dextro Meaning right. So, um, that actually means when people have their heart on the other side of their chest, which is also quite concerning when you're a doctor and you go to listen and you can't hear their heart and it's because it's on the other side, Um, which, which really excitingly, is sometimes associated with a condition called situs inversus, which basically so dextrocardia means your heart is is basically that picture you saw is completely reflected mirror image, and it's to the right situs inversus means that your entire body organs are reflected mirror image the opposite way. So, um, in theory, your left kidney will be on the right, the right community on the left or part. You know, every organ in your body is facing one way around, and every so often I'm sure Kirsty, you probably have this, um, in medical school, there would be rumor's that a certain hospital would have admitted a patient with scientists and vertigo and then all the medical schools. All the medical students in the hospital would, you know, be going to see the patient, ask permission to just examine them and listen to the heart on the right side. The left, I'm sure I'm sure some of them were got fed up with being patient, letting everyone examine them. Okay, there are a few questions, so maybe we can try and answer them. So, Georgia, do you want to talk about these? Are great questions, but I get super cardiomyopathy, sometimes called broken heart syndrome, is basically a form of, uh, inflammatory vasculopathy so effectively there's, um, extensive process. That's certainly not an area of my expertise. So Google. We'll tell you far more than I can. But basically it can. It is commonly referred to as broken heart syndrome so it can cause, um, sudden death in adults. Um, it's definitely something to Google, and someone said I had an uncle with transposition, but I don't think it's that if I presume this is transferred transposition of the great arteries and it would have been it would have affected your uncle as a baby, which is basically when, um, the great vessels, which is what we've been referring to before. Uh, they're not the right way around and they affect different. They basically attach onto different chambers. And it's one of the slightly more common reasons for babies to need. Urgent heart surgery at birth. Although you know all these heart defects in Children requiring emergency heart surgery commonly called congenital heart surgery, are incredibly rare overall. So I think I might put another question up in the pole, and we can try and answer some of the other ones as we're going, Um, so the next one so pectus current autumn is a chest wall abnormality. What's it also known as I think so your answers. Your multiple choices are tricky. There's a there's almost a trick question. Catch them out somehow. I'm still not sure I have. Yeah, which valves are the most common ones to need? The power replacement. So, um, the atrial, the aortic and mitral valves by far and the most commonly operated on the the aortic is the most common of the four, followed by the mitral, um, in terms of replacement or repair. That's a conference question, and there's debated year on year. Ultimately, um, the mitral valve is more commonly repaired than the aortic valve. Aortic valve repair is not a very wide, uh, procedure performed, at least in the UK. It's performed bit more in Europe. France, for example, Um, but mitral valve repair. We do perform quite frequently because we know that if there's just, uh, easily fixable problem with a portion of the mitral valve, and we can repair it rather than having to remove the valve and put, uh, what we call Prosthetic. So, um, you know a new valve that is not your the patient's own tissue for most patient's not all patient. So, uh, that is better. But sometimes, even if you try and repair it, it doesn't work. And then we have to replace it either during the same procedure or a couple of years later. So, um, there's a few I love that someone said that they remember one of these conditions from a Grey's Anatomy episode. I also meant to say, Alice, yes, you are right with hyperplastic left heart syndrome. Um, so clearly you're going to be a congenital heart surgeon in the future. I think that's nice the next possible step. Okay, so I didn't catch up with this one either. So pectus Karen Artem is the term for a pigeon chest, which is basically where the chest kind of balloons out like that. Um, does anyone know what the opposite of a pigeon chest is? Does anyone know what the I think it might be Latin? Term is, um the colloquial name is the funnel chest. But does anyone know what happens? What it's called when the chest goes in? Words? Yes, Seth, It's exc a bottom like excavate because it goes in words. Great knowledge. So, uh, um uh, the so a couple more What causes the heart to be on the right side? So dextrocardia when the heart is flipped around, it's just something you're born with. Uh, it's not. It's not something that would really happen over time or the heart cancelled. I wouldn't say it changes position. I would say more. The chambers can change size with certain diseases. So there's another question on the screen, Uh, for you to answer, we can come to that in a second. Um, we've got a couple of questions about the prosthetic valve. So, uh, mechanical, better than biological. Are prosthetics equally effective? So when we talk about replacing hot valves, we have two types of broad category of valves that we use. We have mechanical, which used to be made of metal, so they used to be called metallic, but they're made of like carbon composites now, so we call them mechanical. And then we have biological valves also called tissue valves, which commonly out actually come from cows now rather than pigs. But we do still have certain brands that come from pigs as well. Um, they have pros and cons to both. So what we always tell our patient's is, um, the tissue valves, the ones that come from animals are good because they don't cause blood clots as easily on the surface of the valve. Um, so they don't have such a risk of thrombosis is what we call it, but they don't tend to last as long. We don't know really now exactly how long they last. A good guess would be at least a decade. Um, but we could, you know, with the newer valves, because we've not been implanting them into patient's for long for 20 years. We don't know if they're going to last 20 years, but the best guess is that over time the tissue valves that we have from animals are going to get better and better at lasting longer and longer. The mechanical valves, The main drawback is they are very proof robotic, so they very easily form blood clots. And if that happens, that can be catastrophic. So with mechanical valves, you have to have lifelong blood thinners. Uh, and that's you almost always warfarin therapy, which you may or may not have heard, you may have some relatives taking it. Um, you know, plenty of people can get on very well taking warfarin for life. But of course, it's a big lifestyle change and something to consider. So it's not for everyone. But the positive of the mechanical valve is that they, in theory, last forever. So if you have someone who you know, for whatever reason, these heart surgery as a child or as a young adult, then they often not always but often will have mechanical valves because it reduces the chance of needing repeat operations in future. But it's very, very dependent on each specific situations. So there'll be young patient's that have tissue valves. There'll be order patient's who have mechanical valves. It's not, um, you know, uh, black and white decision? Definitely. So I think I thought I've got everyone out, but apparently not. So Pneumonectomy is Yes, you're right. The 40% of you is the removal of an entire lung. Anyone know removal of the lobe of the lung? Is it bad? Yeah. Low back to me. Um, yeah, I guess you're right. So lobectomy could be lobe of anything. So thyroid, for example, a build up of fluid outside the lung. Does anyone know this one? So typically, this is kind of between the layers of fluid outside the lung. Sorry. Layers in the chest, but outside of the lung. Okay. Yeah. Plural effusion. Oh, my goodness. Um, anyone know the time for collapsed lung? Yeah. Pneumothorax. Great. So loads more great questions. There's just one that I want to dance. Like, just because I think it's very interesting someone said about is when we were talking about one of the heart conditions, they were asking if it's different from when the heart is outside of the rib cage. So, um, I think what your phone, too is is called ectopia. Cord is another Latin name, and it's basically when babies are born with no bone covering, their hearts are often born with just a layer of skin. Or sometimes, as you've seen in dramatic photos, you know, with the heart almost outside of the chest. And that is just something again that they're born with and would be an indication to have an operation to obviously put it back inside. Because even if you could in theory, protect the heart from physical damage of being outside, which is gonna be very difficult because even, you know, small pressure on the surface of the heart can cause problems with your heart, them or the blood supply, especially in small babies. Then obviously, there's a major risk of infection there as well. So that's why it often requires surgery. And I believe again, I'm not congenital. So So certainly not my oh of expertise. But I also believe that is associated with other heart defects as well. So often there'll be other things effects at the same time as not just them, you know, putting it back inside as it were. Um, I fear that my presentation after this is the slightly more boring on of the evening. But hopefully it will be really helpful for statements, uh, interviews and all of those things. Um, so I was going to move on. We can try and answer some of your questions still, as we're going. So I know this is, um, created a lot of questions, but hopefully this is something that will be really helpful for interviews and work experience. Like I've said, Um, so a lot of the questions on Monday. We're kind of How can I get work experience? Do I have to be in a hospital? Um, does this count does that count? And I know that it's really, really difficult and something that people really stress about. Um, so I guess the whole point of this presentation is to tell you that it's not what experience you get before you're applying to uni. It's your ability to reflect on it and show how that's going to make you a better doctor or healthcare professional or essentially being able to reflect on something as a skill that will be good, whatever walk of life you go into in the future. So hopefully we'll be able to give you a few kind of key skills that will help you reflect on any any of your experiences. Um, and we'll give you something to talk about an interview or personal statement and things like that. So, um, a little bit kind of back to basics about what reflection is, um, so sorry if I'm teaching you to suck eggs here, but essentially a reflection is a way of connecting with our experiences and learning from them with you to kind of making improvements, um, on day to day actions so you can reflect on absolutely anything. It doesn't always have to be something that made you sad or angry or something you didn't. You think you didn't handle very well. Sometimes it's really nice to reflect on good things and think, Oh, I really enjoyed that. And this is how it made me feel. And, um, yeah, I really like the way that I handled that situation. And all of these are really key skills. Um, And I guess why is it important? Well, essentially, this is a career long skill. Um, no matter what area of healthcare or presumably work you go into, this is something especially in the NHS you will be asked to do. Um, it's something you have to do as a medical student all the way through to kind of consultant. You have to reflect on your clinical experiences, patient encounters, encounters with other staff, um, and talk about how you think you handled them. Um, And in the long run, I guess that the main goal is is why we do everything is to help improve patient care and the people that were looking after, um to help improve our own resilience. Because some of the things that you see, um, at work might be upsetting or distressing or make you feel sad or angry. Um, and it's really good to be able to look back and say, I would I Would I handle the situation differently, or how can I make better in the future? And in the long term, this will help you work that you were different members of the team, Um, and again come back to the thing about improving patient care. So thanks so much, Wendy. Um well, let you head off if you need to go. Thank you so much. Thank you. Bye bye. So, um, in order to teach you the skills to be able to reflect there was the basic framework that we use is Gibbs reflection cycle. Um, and it's kind of explained on the screen, but essentially, we have a description of your experience. Um, and then you think about how that experience has made you feel, and then you move on to the evaluation section, which is, you know, with the things that we're good with, the things that were bad. Um And can you analyze this situation? That's an extra step. Kind of 3.5. Can you analyze this, um, and make sense of of why it made you feel like that, or why you think it went well or why you think it went badly? Um, and then come to some conclusions as to what you can learn from that experience and how you can do it differently in the future. And then, finally, the last one is Axion. So can you come up with a bit of a plan? How would you tackle the situation in the future? And what key steps do you think you could make that you could change so that if you encounter something similar, um, you would improve it? So I've attached a few a few questions, and I've got a very short video for you to have a go. Um, I think this is the kind of thing that does work better if it's interactive, but I think probably, given that there's quite a few of us here, people wouldn't be keen to share their own situations to reflect on um so I'm going to play the next video, and if you just think about some of these questions and also the Gibbs reflective cycle. So I think in your head describe a brief summary of the experience. How not necessarily. It makes you feel, but how that doctor might have felt in that situation and how that patient might have felt in that situation. Evaluate some of the things that you think went well and some of the things that maybe didn't go quite so well. Um, and why you think they didn't go well And then finally, if you were going to have that situation, how would you tackle it again in the future? So let me just before you click. Pay. Um, this is this is the kind of structure in thinking that they're gonna be trying to pull out of you guys at interviews for, um, medical school for, you know, other university courses for job interviews. It's the kind of the ability to look at something in a in with an approach and kind of channel, your thoughts and then deliver them to, uh, in a coherent way so it can be useful to have a structure like this in your head or something similar or something that works for you that's different from this. To help you remember to say or the key points as well During your interviews. Yeah. So Allen said showing empathy. Yeah. I mean, it is not just about emotions. It might. We will often do reflections and identify physical things that we did well or could have done better. You know, I could have called at this time instead of the time I called, for example, but yeah, it is also a great way for you to try and pull out the emotions of the situation. Probably most importantly for the patient, because regularly, I have patient Say to me, You know, you do this every day, but this will be the only experience I have in my life of undergoing major heart surgery. And I'm fully, you know, I'm fully aware of that. This is, uh, the ability to not experience something, but still be able to have empathy for what they may be feeling or experiencing from what they're going through is probably the most important skill that you need to have or learn, um, to go through medical school and to be a compassionate doctor. I think so, and it's not always. It's easy. It's not always easy to put yourself in other people's shoes because we have our own biases or we have our own experiences that that frames things in certain ways for us. But this is a great way to approach situations, to try and make sure that you're having the empathy, sympathy, compassion that that we should have for all of our patient's. Really Okay, so should we try and put it into practice? Um, let's let me see if I can. No mhm Mhm. I need you to listen to me. Your COVID test came back positive. Additionally, you have ground glass opacities in your lungs. That's why you're having trouble breathing and your toes aren't read because you run without socks. You have what's being referred to as covid toe covid toe. Yes, really. It's the best you got covid toe. Guess you've been trying. This ultrasound of your leg reveals a clot that we need to treat immediately, So Okay, well, who's leg is that? I'm sorry. Well, see, I'm I'm a runner. We don't get blood clots, but it's, uh that's a That's a nice try, Mr Anderson. Please You know what I figured out? Uh, I figured out this little cold. The Ehlers are terrified of biggest moneymaker since Cryptocurrency. Speaking of how how do you get your kickbacks? I mean, is it like, a flat fee from every patient that you diagnosed? Or is it like, a percentage deal or my, uh um, be back in a moment. I need to answer a page. Yeah. Okay. What? What? Okay, Breathe, breathe. Breathe. Uh, stop. Okay, let's try this. Your blood oxygen is dangerously low. Your lungs are getting worse. And if untreated, the clot in your leg could travel to your lungs and kill. You were seeing cases like yours all of the time. Sir, this is not just a cold. It's not asthma. This won't magically go away. Sir, please let us admit you so that we can start you on steroids and and put you on blood thinners. Look, because even if you are a little bit wrong, it could be fatal. You know, I'm still waiting on that albuterol prescription, Doc. Thank you. Okay. So sorry for anyone that I've just spoiled. Great slash before. I don't think there was too many spoilers in that one. Um, let me just share my slides again. Okay? So if I briefly summarize the situation, um, we have a doctor that had to go and break a diagnosis to Asian of covid. And we have a patient who doesn't think covid is a thing. Um, and potentially, I think it's fair to say, doesn't understand potentially the risk that that diagnosis that could cause him. Um And then there's some interesting communication between Doctor Bailey and the patient. Um, so if we work through the structure of the reflective practice, there's there was a few things in the chat that already said This guy really annoyed me. So, um, the character really annoyed me. So let's start that as a discussion point. How did watching that video make you feel about that interaction so potentially some people felt a bit annoyed by the situation. Any other feelings that people were feeling as they were watching it? Uh, I don't I don't mind being the guinea pig. And yeah, my thoughts, Uh, So, um, this is a really common situation, I think. And I think when you start working as any healthcare professional, not just doctors, you have situations where you don't feel like your patient's are listening to you or you feel like you're not doing well to communicate the message. And actually, um, something I've just learned with experience is that, um, generally, it's because your patient is very scared. You haven't explained things in a way that they that resonates with them. Or perhaps you're actually missing what you know, really going on. I don't mean that in terms of a diagnosis. I mean that in terms of other aspects of a patient experience that is going to be impacting their ability to take this information on and and understand the situation and to try and basically you have not done what you need to do to meet them halfway. So, um, what did Dr Bailey do? Well, Well, she was very clear, and I think she explained things without too much medical jargon. She explained the potential complications and what she was concerned about. Some of the challenges are that for whatever reason, that we don't really know, because with the video is not really long enough. Um is why the patient doesn't agree with the doctor's diagnosis, and that's not to say that doctors are always right either. Sometimes these situations can arise because you haven't had all the information from patients' and generally speaking, patient's know best about themselves. So whenever I have a conflict between myself and a patient in a sort of a manner like this, I always think, actually, there's obviously something that I'm missing or something that I'm clearly not demonstrating that I've understood. Um, my patient is obviously not comfortable with me. And what might the doctor have been feeling? Well, I imagine she was feeling very frustrated. Um, you know, in the peak of covid, we were also scared as healthcare professionals, you know, I was not, did not have the same experience with some my colleagues. I wasn't in intensive care and I wasn't really, um, at major risk like other people were. And I felt scared. So I can't imagine how scared my colleagues that we're doing all that real frontline work were feeling What might the patient have been feeling? I'm sure the patient was scared as well, you know, even for patient's that don't necessarily agree with covid being a pandemic or whatever. I'm sure just the fact that it was such a monumental change to everybody's lifestyle and, um, new rules and not having our usual support networks and things. I'm sure they were also feeling scared, even if it wasn't because they were scared of getting a virus and becoming very sick from it and what could be learned from this situation? I think that's tricky. To be honest, I haven't made I don't know if you did. You what We all key takeaways from that, um, that encounter, Kirsty, because I'm not I've not made my mind at what I would actually learn from a situation like that yet. Yeah, I think there's been some interesting points in the chat about the fact lots of people are echoing that feeling of if they were the doctor in that situation, that they would be feel quite frustrated. And I think, you know, that comes back to the fact that, yes, it might frustrate us. But like you said, are we able to understand some of the reasons that the patient might be feeling this way? Um and then one of the other points was that they felt that the thing that Dr Bailey did really well was that she went away and composed herself and came back and tried a different approach. Uh, and a few people have said they're not sure that they would have had that approach when they were talking to the patient and that maybe they would have tried talking to him in a slightly different way, which I think is a really all of those are really valid points. And I think, like you said, if we are able to put our, um, put ourselves inpatient shoes and think about some of the reasons as to why they might be acting like that, Um, you know, that's going to help us improve their care in the picture. Yeah, Miriam said that the patient's autonomy must always be respected. Um, I think that's a really good point that will be experiences. Um, if you go into healthcare in any role where ultimately you and your patient just don't agree, you know you can you need to know that you've done everything you you are obligated to do as a professional. So for us as patient. So for me, exam day to day, that tends to be making sure that I've given my patient the full information about their operation. And although they may be low risk or unlikely, that they have all the information about what the major catastrophes can be so that nothing is a surprise and I can give them all the information. I can have brilliant communication skills. I can meet them on their level, use simple terms and they may just still disagree with me. And that is okay because, um, we are, yes, we have more knowledge. There's a power imbalance. You have to recognize that as healthcare professionals, that a lot of patient's will just take what you say because you are the doctor. And that's why it's such a privilege to have our roles, but also why we carry such a big responsibility because it is. We need to make sure that that patient's are making a decision that's right for them, and not just because we tell them it's the decision that we think they should make. I think, um, there's a really interesting point that this has raised that people are talking about, you know, the role of the doctor to inform the patient of all of the information that they can. But at the end of the day. It's the patient's decision to decide what what they choose to do with that information. And I think if we follow on from that, does anyone know what it's called when we're trying to assess the patient's ability to make a decision about their own care? Because sometimes, you know, patient's maybe given all of that information. But for whatever reason, we as healthcare professionals decide that we should make that decision. Um, in their best interest. Does anyone know what I'm alluding to here? So not quite competently. Something similar? Yeah, capacity. Um, so, uh, capacity relies on a few different things. So it's, um, correct me if I'm wrong here. Georgia. It's four different things. It's, um, the ability of a patient to listen to the information and understand it to retain it long enough that they can then communicate it back to you, um, to make sure that they understand the full like significance of their decision. So if you take way up the decision, yeah, to weigh up the options and determine which one is gonna be better for them. Yeah, and then to be able to communicate it back to you, Um, I think that's the fall. I could be wrong. Um, so with this patient here, do I think I've slightly went off on a tangent? But do we do we think he has capacity to make a decision that he doesn't want, you know, x y z treatment? Do we think he understands the information that's being given to him? So it's dividing people. It's a really drinking. Mostly, yes, there's a few nose. Yeah, so the really important thing about capacity is that it's time decision dependent. So just because, you know, someone might have capacity to say Yes, I want a cup of tea with my breakfast, but they might not have capacity to say I want to leave the hospital and I don't want that treatment that you're offering me. And so it's a big It's a pretty broad spectrum, Um, and it's also like I said, it's it's time dependent. So that means essentially, with every single decision, you should give the person the chance to make that decision every specific time points, so I might not today have capacity. Decide that I want to take my antibiotics, but tomorrow I might be feeling a little bit better. And I do have capacity. Um, so it's really important to take this into account with each different decision. So I think that probably on the fence. Um, yeah, with this sort of a mix. And the response is I am going to say that. So I think they're all like we had. This patient would have capacity to make this decision based on what we've seen. But I'm gonna agree with those of you that wrote that we don't have enough information because for me, is he Is he understanding the information? I think on a superficial level, yes. Um, is he weighing up the information? Well, yes, there's evidence that I think he said something along the lines of I you know, I don't care or don't agree with you or something like that. So perhaps he has considered the options, and he's accepted that he doesn't want treatment. Um, is he retaining it? We don't really know. Because we need a bit longer duration. Um, can he communicated? Well, yes, he can clearly communicate. So I think for me, the gray area is mostly actually, Is he truly weighing up the potential consequences? I think he's she's not given him enough information yet. I think with this patient you would need to stress that it's not uncommon for, for example, a blood clot in the leg to travel up to the heart and then into the lungs. That's called ApoE MRI embolism, as some of you correctly put in the comments and that that can be life threatening. And if we don't treat it soon, it's not always treatable later on and so on and so forth. So I'd want to see that information exchange first and then him demonstrating that he understands that and still, regardless, doesn't want treatment. Before, I actually made a decision about capacity. So I think, um, in answer to Esther's question about how would we answer the last question? I'm assuming that's how could it be approached differently in the future? I think, um, if we start by saying what could be learned from this situation, So we've had lots of points about saying, you know, they felt frustrated about the way this patient was talking to Doctor Bailey, that we didn't really feel that he fully understood the significance of what she was telling him and that perhaps Bailey was a little bit hot headed when she first with her approach to communicating with him. So what are some of the things you know, you could learn from this situation and take away? Yeah, I think there probably is always a point to being more compassionate and understanding. And Bailey probably could have done a little bit more to understand why the patient didn't think that covid was real or that he had covid toe. Yeah. Covid two remaining harm is always a really important skill to have. Um, it's not always easy, but I think that's, you know, in any situation, um, the attendance will, I think, gets sent to you at the end. So it will be one. Once the event ends, it will get sent to you. It's done automatically by the medal team. Uh, try and keep personal opinions aside. Absolutely. You know, there are plenty of patient's who will have different opinions on healthcare to you. Um, lots of polarizing topics. Blood transfusion, abortion, so on and so forth. So, um, just because it's a different opinion doesn't automatically mean that it's wrong. Um, and the same goes for keeping your personal opinions aside they They shouldn't, uh, tarnish your decision making. I think stepping out to calm down is a really good um, I did. You know, if you you will find yourself in heated discussion's, you will find yourself with patient's who are frustrated, upset, angry, you know, grieving all all these things, someone said earlier. Before you know we're only human, it's true. We're not perfect. You do have to do your best to Willy emotions in front of patient's, but it doesn't always happen. And generally therefore, if your emotions are good getting the best of you, sometimes the best thing to do is just politely say, You know, you need to leave and step out for a couple of minutes. Occasionally might even be asking a colleague to either join you or even sometimes a colleague, either the same level or more senior to actually go in, be a fresh face, fresh eyes and kind of tone down the situation, trying to fuse any tension that may have been there before. Yeah, so I think in answer to the question of if we round it off, because I'm conscious that it's five past eight, Um, the how can we approach this differently in the future. I think the point at the end about getting another doctor to confirm what you're saying, I think that probably is multifold in that. Yes. Okay, I think it's always good to involve more members of the team. Um, there might be other members of the team that, um no, the patient better. They know that. Okay, He finds it if you talk to him in this way. But why don't you try talking in this way time? Um and that's why working in the team is so good because other people can often offer other insights that you might not have thought of. I think the other thing that potentially I thought might be helpful in this situation is not always depending on what the patient wishes. Obviously, And it's important to check, but seeing if you know, he would wish a family member to be with him, uh, to explain that information more thoroughly, maybe he'll feel more calm if there's someone else around him. Because potentially, he is a little bit scared. Like we've said before for lots of different reasons and maybe having someone else there to help process the information would be helpful. Um, asking if you'd rather have that discussion at a slightly different time. Um, those kind of things are all really important. Georgia. I'm not sure what you think. Yeah, I know. I think we've raised loads of good points. Um, I think this is something just to draw everything to a close. This is basically a really good structure for you to think about whenever you see anything in a hospital in a GP practice in a dentist and pharmacy. Um, you know, try and reflect on it in your mind. Think about how you would talk about that in an interview to a panel. Um, and that would be you thought covid toe is causing a lot of discussion. I don't know if covid to Israel. It's not something I've heard about outside of Grey's Anatomy, but I think this will be a question for Google. Someone says it's when there's a blood clot in the two. Um, Kevin was associated with lots of blood clots and things, so maybe it is a real thing. I'm going to have to dip out now as well. That's fine. Georgia, Thank you so much. I'm literally just the last thing. Um, I wanted to say to everyone. So, um, the last thing I want to say. Sorry. We're running a little bit over, but we are going to run a reflection competition. Um, called the miracle work reflective competition Very originally named. So essentially what we'd really like you to do, and obviously, this is totally optional. But there would be a prize for, um, some notable entries, and we were hoping to put some of them on our website as well. So it would be a really good opportunity if this was something that you did fancy doing. Um, but what we'd really like you to do is do your own reflective piece. Um, so, ideally, what we'd like is maybe a created piece, because often people find that that's a good way of reflecting. So a piece of art, maybe a piece of music, a poem, really? It can be anything you like. I'm not particularly rt, but I right, OK, poems. Um Or if you really don't feel creatives, you could write us a short, reflective essay. Um, essentially, this is to prove that you really can reflect on anything. Um, so if if you fancy this, you would be if you could email us your submissions. The deadline is ages away, so you've got lots of time to think about it. And if you want to ask us any questions, you can drop me an email, and I'll get back to you about it. Um, but yeah, essentially, try using the Gibbs reflective framework and that I showed you earlier and pick, you know, whatever scenario you like and just practice having a bit of reflection, even if you don't want to submit it as as part of the competition, it is really good practice. Um, but I've rambled on enough about that. So finally, feedback, if you wouldn't mind, that would be really, really helpful. Um, I'll post it in the chat again, because I know some people can't access the links Emails at the bottom. Um, so if you email s c. T s in sync, uh, female, Uh um, you can ask us more questions about it, but it's also on our social media, and we're called to, uh, CTS in sync on that, you can follow it on there. Um, and it would be great to read your entries, but yeah, Anything creatives, whatever you fancy. Hope you will enjoy this evening and hopefully see you again tomorrow. I don't have anyone. Has any last questions. I'll hold on. Lots of think use. Glad you enjoyed it. I'm glad we got to do the dissection. I'm really sorry about last night for anyone that missed it. Um, sorry. Just the question. What do I mean about reflective? So if you want to do reflect a reflective created piece, for example, um, you could do a piece of art about a patient that you'd met or, uh, something you've done at school or a bit of volunteering that you've done. You could, you know, draw a piece of artwork, write a poem, something like that, and then write a short reflection using the framework that we've used tonight, Um, based on the created piece that you've done or just write an essay of. This is an experience that I've had. This is how it made me feel. Um, these are things that I would potentially do differently in the future. And this is why it's going to make me a good doctor. Um, those kind of things using the framework we had tonight. Hope that was helpful. The created peace can be literally on anything or anything. So, yeah. I don't know if you're a dancer or a pianist or anything like that. Whatever you like. Um the more creatives, the better the recordings will be available. Um, I need to edit them, and I'm away next week. So probably it's gonna be middle of February if I'm honest. Um, just because it'll take me a little while to cut out bits and bobs and edit them, and then I'll make them available as soon as I can. I know there's still a few people here trying to answer questions, so if you send the work for the reflection to our email, it's at the bottom of the screen now. It's not email. Mm. Okay. A singer is also That's absolutely fine, right? As a song. That would be great. Literally anything. I didn't want to make it to, um to structured. So whatever you want to do is absolutely fine. Um okay. I'm going to head off. Thanks. Everyone