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Hello, good evening. Good afternoon. Good day. Wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Rean. I'm a professor in the Medical Education Research and Development Unit of the Faculty of Medicine at the University of Malaya and the immediate past director, the Faculty of Surgical Trainers of the Royal College of Surgeons, who a credit this program. Welcome. If this is your first time and thank you for returning. If it's your second. Thanks to med, we now reach over 5100 people in 100 and 33 countries in tonight who is 1/4 year medical student at the Faculty of Medicine is our production engineer and he will field questions and interrupt me as we're going on and I hope that we can answer your questions tonight. We have people from around the globe, Bangladesh, China, Egypt, India, Iraq, Malaysia, Nigeria, Pakistan, Romania, Saudi, South Africa, Sri Lanka, Uganda, United Arab Emirates, UK USA and Zambia. I looked down the list, this list of letters and think we're almost there for a full alphabet. Wouldn't that be wonderful to get a full alphabet tonight. We literally at the kitchen sink and we're going to talk through scrubbing up and I'll share some of my thoughts and experiences. In essence, I regularly got the sister in theater to watch me scrub up to make sure that I was doing it correctly and maintaining the standard. I likewise would sit behind the perfusion machine and had an eye on the scrub up room and keep an eye on the junior staff scrubbing up. It was interesting. I'd certainly send people back for strobing if I didn't think it was complete. And I urge you to actually ask the senior staff in theater to watch you scrubbing up. I'm gonna give you my take and description of this. I'm sure it'll fit everywhere and I was held up as a good example of scrubbing. But before we go back, let us think of the year 1846 and I would be hero. Today is a Hungarian doctor called Ignaz Sewe. He was born in Hungary in 1880 and he graduated from Vienna Medical School in 1844 and specialized in obstetrics and worked at the Vienna General Hospital. Now in the 19th century, in Europe childbed fever or Purpur fever was an important clinical and public health problem with very high mortality. It was thought to be caused by a my asthma, the ether, the epidemicity or by will of providence. Apart from bloodletting, there was no cure and some of us cared for these women during their illnesses when they died and he did autopsies on them and he tried to correlate autopsies with clinical findings. So the first point is this is a man who was curious, who wondered about what was going on. And he tried to correlate his autopsies to clinical symptomatology through secondary data analysis of maternal death records. And as you know, last week, we talked about data, there's only through looking at the data and asking the question, why that you can determine action through analysis. So the hospital had two maternity clinics. In the first clinic, the deliveries were made by physicians and medical students. And in the second clinic, all were by midwives. The maternal mortality in the first clinic run by doctors and medical students was unexpectedly high at about 16% compared to 7% in the second clinic. Indeed, this was actually known by the ladies of the night who elected to go to the nurse led hospital rather than the doctor led hospital because they thought that the doctor led hospital was killing their friends. So in the first clinic, the doctors and the medical students believe it or not started their day by doing autopsies on women who had died the previous night. And from the autopsy room, they proceeded directly to the labor room with no cleaning of hands and delivered babies for the rest of the day. Of course, surgical gloves were not invented yet. And all clinical procedures were done with bare hands. The midwives in the second clinic, obviously never conducted autopsies. So during this time, s Weiser friend, a colleague called Klia died due to an overwhelming infection of an following an accidental laceration sustained during one of these child fever autopsies. So calls autopsy findings. Some of we noted were very similar to those of the women who died of Purpur sepsis. And he hypothesized that there were certain death particles from the body tissues of the deceased that stuck to the hands of physicians and the medical students during the autopsies and their unclean hands carried and transferred these particles to women in labor. And he thought that these particles therefore caused childbed fever deaths. He then said adequate hand washing by physicians and medical students might reduce transmission of these death particles. And he designed a an experiment and implemented handwashing for the physicians and the medical students. Before they entered the labor room, they were forced to brush underneath their nails, wash their hands and chlorine till the skin became dry and the cadaver smell was gone. And at the end of year one, the mortality rate in the first clinic dropped to 2.4% a rate similar to that seen in the second clinic. The deduction and observation is amazing. He established causality of childbed fever demonstrating a strong specific temporal association with unclean hands in 1847 without even knowing about bacteria in bugs but to some advice, seniors, this association seemed implausible and incoherent and they doubted the existence of death particles and rejected the idea of transmission through unholy hands or dirty hands. And they got very, very upset, very upset indeed. But this was compounded with his undiplomatic behavior which made more professional enemies than friends in Vienna. In fact, he was tearing his hair out because he thought the association was so obvious that something needed to be done. But nobody was listening to him sounds a bit like a whistleblower story to me. And he published a book, The Etiology, The Concept and Prevention of Purpur fever in 1860. After 13 years of his study and the book, I had an unwelcome response. It was criticized for poor language, unprofessional writing style. And with that and his frustration, he suffered bouts of depression, rage, paranoia and forgetfulness. And to be honest, his friends invited him out and colluded in taking him to a mental assignment where they left him though locked up. The irony is in trying to get out of his cage. He injured his hand and he died of sepsis. In 1865 Samuel Weiss's contribution was recognized 20 years after his death as the medical world became more receptive and wiser after germ theory described by Louis Pasteur. And of course, this is at the same time that Joseph Lister introduced antiseptic antiseptic techniques. But some of us is held as the father of had.