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Hello, good evening. Good afternoon. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David Regan. I'm a retired cardiac surgeon. I'm a professor in the Medical Education and Research Unit of the Faculty of Medicine at the University of Malaya and and the immediate past director of the Faculty of Surgical Trainers for the Royal College of Surgeons of Edinburgh. If this is your first time joining the Black Belt Academy, thank you. And if you're joining again, thank you too. We have 4245 followers in 100 and 12 countries and this would not be possible without the support of metal and the production behind the scenes. And this evening, Sue Gibson is there in Ireland and will be prompting you to ask questions and relaying observations because my computer is a little way ahead. I'm coming to you from a flat in Kuala Lumpur and it is 1130. This type, I'm bringing the kitchen sink. We have previously covered gown and gloving but not with water and this is live and the water will add a new dimension. So do bear with me. Thank you very much for answering the questions. And the first thing to comment on is yes, we do wear surgical scrubs for our protection. But also we have to remember that we are losing skin cells every day. So the dust around your house is not dust, but particularly skin s grams and we're shedding them all the time. So suppose when you're wearing scrubs, it's clean, not outside clothes. And there could be a debate of whether you tug a top in or not. That's of personal comfort and debate. But in theory, talking him means that you're desquam into your clothes. The other thing is we always wear a cap. So have to reinforce this as you know, swimming pools when you travel, invite you to wear a cap. So your hair doesn't drop into the swimming pool. But all manufacturers of food or technical equipment likewise wear covering of the hair and sometimes with a surgical mask covering the covers, the beard as well. Because then that too is a source of foreign material that could be in the wound. The other thing is it gives a sense of identity and I do applaud those who introduce the idea of putting their role and name on the heart because that is reducing power distances and enabling communication in theater. Certainly these cotton hats and this one by the College of Surgeons of Edinburgh has got a very nice sweat band on the inside. But that doesn't mean to say you take it off after theater each day, stick it in a drawer and put it back on. The important thing about scrubs and hats is that they should be laundered properly. And I often see on Twitter and social media examples of laundering or lack thereof in many theaters. And it is sad that the attention is not paid to this element of the uniform because it is a uniform. It denotes what you do. Now, scrubbing up usually happens in an area separate to theater. It is a clean room and it's a room in which you enter to scrub up before going into theater. There should be more space, but sometimes the scrub up rooms are as small as this. The other thing is is that the things should be of an ergonomic height and also the taps should be able to be turned on and turned off with your elbows because the whole idea behind this process is to keep your hands elevated and allow the water to drop off. The thing is that not many people pay attention to that element. And also when they're growing up, their blues themselves get wet. As soon as your blues and theater scrubs get wet, then you're enabling or disabling the barrier between you and the patient. So if you think the operation is gonna be wet, uner bowel surgery and urological surgery, there's a potential for being wet, particularly with lavage do wear a plastic a over the top on top of this. Also, if you're using radiology, you will need to put on a lead drape that together with a plastic apron adds to the weight and over a prolonged period of time does become uncomfortable. Jury is best taken off and if you are keeping jury on jury without patent and proper cleaning under and over is important, but I always take joy off. Likewise, when you're scrubbing up jury in the ears that should be plain, other jewelry should come out no mascara, no makeup because all that is adding to the particle count in the air in theater, scrubbing up and washing hands goes back to a gentleman called Ignace Samuel Weis and he was born in 1818. Now, before that cleanliness and hygiene was extolled by Franz Nightingale. And of course, later on we heard about Lister. But what's unusual about this man? He graduated from medical school in 1844 and specialized in obstetrics and gynecology. During that time, childbirth fever or purpureal fever was commonplace and resulted in the death of many new mothers up to 16 to 20%. Now, what I like about the story is that he made the observation that at the university hospital where the deliveries were done by surgeons and medical students who would also do autopsies and return to their daily business from an autopsy. That hospital had a mortality rate of 16%. The public hospital for those who are less fortunate were run by midwives and the infection rate at that hospital was around 4%. And he was proposed and thought that there was something going on with autopsies being carried on the hands to the woman in childbirth. And indeed a friend of his, a pathologist pricked his finger when doing one such autopsy and suffered the same symptoms as those mothers who got child and fever. And he called this death pesticides or death or death particles. It wasn't a miasma or will of providence as thought at the time. And you have to remember him calling this death particles was way before Louis Pasteur talked about bacteria. So what he did was he introduced a policy of thorough hand washing, including nail scraping and taught everybody how to do that properly over a year. And what he found was that the purpura fever rate fell from 15% to less than 2%. So he raised this with his colleagues and this was not taken very well because he was implied that the hands of the physician well Unho it and this insulted the physicians who thought they were godlike in their practice. Sound familiar. And because of that, you could say he was the first whistleblower and he was hounded. And despite all the evidence that he produced, and despite the fact, even unmarried mothers and ladies of the night were demanding to go to the public hospital because even the public realized that the infection rate was significantly lower than the university hospital where you would be attended by consultant physicians and medical students who wouldn't heed his ideas on hand washing. It is said he was actually lured to a meeting and because he is getting so frustrated at the lack of attention, they trapped him and sent him to us and asylum. The irony is in that asylum at a young age of 44 he died and he died because he said he was beaten up and he got an infection on his hand that spread to the rest of his body. It was early 20 years later that his work was recognized as of significance and he is to be regarded as the father of hand washing. Now, as a cardiac surgeon, I would sit behind the perfusion machine in line of sight of the scrub up tree and I would watch people scrub up. I actually asked the sister to watch my scrub up technique as well because I felt it was important like some of us observed to ensure that people scrubbed up properly and appropriately. And I'd like to thank one of my regular followers ring, who who's probably online at the moment for prompting me to deliver the session, the C and I'm sure she'll be watching with eager intent to highlight any discrepancies. So I look forward to your feedback, suffice to say because this is literally in the kitchen and I'm having to make do there will be lapses, but I'll draw attention to them if they are obvious. But once you started scrubbing up, it is a process and a ritual and some ritual element that will address when my fellows and say, Chris ca hopefully join us later on in the session. So I'm in the appropriate tire and I'm ready to scrub. I must make sure there's soap. Now, pausing for just a moment if you have any infection or injury on your hand that usually precludes you from scrubbing up. I know in kitchens and in theater if you've got a small cut by putting a blue bandage or elastoplast on it, having cleaned the wound just before you scrub that is appropriate. But if you have any infection or any other lesion from your hand, it's best you do not scrub it. So your hands before you go into theater should be clean. So for some of you who might indulge in hobbies that gardening or working on a car nails and hands do become grimy. And if you are going to pursue a career in surgery, I would recommend to pursue those hobbies that you don gloves to do that. Such that when you come into theater, you do not have any growth dirt on your hands and please keep your fingernails short because part of the process is cleaning your fingernails apart from coins and mobile phones, hands are some of the dirtiest things around. Inadvertently. We find ourselves doing that or scratching or other things with our hands. That is why there are rituals with eating with right hand or left hand only. But also in our house, if we've been to the supermarket or been on public transport or hand handled coins before coming back in to the house and handling food, wash your hands, soap and water is all that is required. But when you're washing up in theater, it's an extended soap and water that needs to cover all the areas of the hand, the base of the thumb, the palm of the hand, the interdigital spaces, both the ventral and the dorsal sides in the back of the fingers and the wrists below the album that is dirty. And during your scrubbing process is the tips of your fingers and your hands that are clean and all the water should drip off the elbows because the sink and the soap at the field hospital and in theater was of the wrong height. I found that three scrubs a day meant that I had a very sore back and neck and I didn't see anybody attending to the ergonomics or, and making it easier to scrub the soap you use is a personal preference. Chlorhexidine is recommended povidone iodine. But what you need is a good rather in both cases, if you have skin sensitivities, it's important that you speak to a dermatologist and get a recommendation. There are soaps available for those of you who have skin sensitive. So where to start? We have created space. The top I don't have at here that works with the elbow. We've got soap and we're going to move the camera around and open up a gown. Now, the gown should be opened onto a sterile surface in a proper way from the middle to the out. So I've cleaned the surface and it's usually stainless steel and it cleaned with alcohol having been washed down with soap and water, the gown is opened and all gowns come double packed and double wrapped. And the modern gown comes with a towel note that you can lift it open and lifting it open. You do not touch the inside. And this is important because everything on the inside is clean. So therefore, when you're dropping a gown onto a tree, beware that now everything in there is clean. Likewise, your gloves need to be placed properly, opening it up upside down and being very careful Chopin, having ensured that you got the right gown and right glove in place. You're now ready to actually start scrubbing fine water and set a flow in temperature that is comfortable for you. The first step as some we recommended is to clean your fingernails. This brush common to all theaters comes with a sponge on one side and a brush on the other. There's also a little plastic and I love the word German word er that is used to actually scrape the fingernails. Remember that with like a pan scourer. The brush is like scouring a pan and if applied to the skin that will excoriate likewise synthetic and natural sponges, if applied for a long time to the skin, it will also give a problem. So the first thing to do is to 10 to your fingernails. So wet your hands, wet your arms. And I'm going to deliberately go around each and every finger and remove what is underneath and look at this. And often think of the CSI program where in forensics, they would scrape the fingernails, it a little bit of bite on the forensic side. That if you, unfortunately you ever attacked, the best thing to do is scratch the attacker because you will leave the skin under your fingernails and proper CSI scraping of fingernails will find your attacker. So this is done under running water and all your fingernails are done deliberately right to the corners. Remember it is best that your fingernails are on the short side. Once you've done that, I apply two sets of soap to the hands and the forearm. And I've got this over here and you've gotta bear in mind that I'm at a kitchen sink. So if I touch anything, that's because I'm at a kitchen sink. But I hope to reinforce the principles and the important thing is that you work up a very good lava on both sides. So I do a very good lather around the hand and then I extend it down to the elbows on each of these rounds. Should be a minute and a full scrub is necessary every time e theater, whether it's the leave theater to go and have lunch or a cup of tea or a comfort break or to go and do something else. I would recommend that you do a full scrub. The only time you, I believe that it's acceptable not to do a full scrub. If you're literally going from one clean operation to another clean operation where you change your gown and gloves, an alcohol rub, apply two hands in the same way as we gonna dry our hands is appropriate. Otherwise, always do a follow up. So this is where it gets, you've got to keep the water running from tips of your hands down to your elbows and because my s is low because the space is low. I am actually thinking of the water dripping off either on my gown or on the floor. I was noted in my scrub procedure to have a lot of water on the floor after I scrubbed cos it all drop off to the drip off to the side. It did prove a slip hazard. And as I have got here is a mat on the floor to catch any water. So this scrub is to the elbow and it's a general scrub of the hands and the forearm and a very, very good lava. Please don't put a stopwatch on this. You might be saying it was not quite a minute or it was a minute. 100 minutes, right? As you can see, very good luck, David. Can I ask a question? Yes, of course. So no one's asked this, but I want to know you were mentioning about um, skin uh and dust and um, and I just wondered people who have really bad eczema on their hands, do they not become surgeons? Is it not a good idea for them to be surgeons? Now, that is a very good question. And I'm glad you asked it because I think it would have to be directed by a dermatologist because in theory, those people who have got severe eczema or psoriasis on their forehands, the simple process of scrubbing will may indeed exacerbate it. But also the eczema psoriasis means that the chances of desquamation or losing skin cells is higher. And therefore you could say that they are at higher risk of infection. And my answer to that it would be very simple, speak to the dermatologist and assess the severity because it might be unfortunately, so severe that s surgery perhaps is not recommended, that would be in extreme. But you're quite right. So good lather both sides on the hands. What I'm now gonna do is turn around for the brush. I've used the sponge only there and I'm now gonna leave the soap in my hands for just a moment and attend to the nails. Now, the nails are around. So you've gotta make sure that you're moving your hand over the brush. So you get into the corners and I oh and cross my fingers like that and moving it up and down the brush both sides and doing that. I do find at this moment of attention to the ritual of scrubbing up. There's an opportunity for me to reflect on what I'm going to do in the operation and visualize and rehearse in my mind, parts of the procedure. So the scrubbing up process is not just preparing your hands. That's an opportunity to prepare your mind, you know, from a sportsman. Then there about to do a high jump, take a penalty kick, the goal, they pause and you can see them going through the ritual visualization of what they're about to do. And I think describing a process is much the same. It gives you an opportunity to scrub up and think about the operation. It does become a ritual. You'll find that some people prefer a single tap. They prefer to take the middle one or the one to the right because that's my lucky t and yes, there is a psychology in that one of my colleagues always took the middle tap. If he didn't, he didn't feel comfortable and that's might seem silly. What is quite pertinent is part of your preparation for an operation ahead. So there you go and wash it. Wash this off and should at any time you touch the tab or touch anything. I would recommend that you do one more wash. It's a bit like the martial arts. You do it until you can't get it wrong. And the feet done a scrub and inadvertently touch the tap. Then I would put in another wash. So this is a soap wash of the whole arm again, followed by a I just, my hand just touched it, the sink top there and I would therefore have to throw in another scrub. So the scrubbing of the nails again, just reinforced is not just up and down. Make sure you go round. The nails, your nails are round. So it's oh getting the full semicircle, semilunar aspect of your nails and the nail brush is reserved for the nails only. Please do not use this nail brush for anything but the nails cos even though the brush is soft, it's still enough to excoriate the skin and it will increase skim loss and potential bacterial contamination. No, I've got a good lather. So once I'm happy we've done a minute on both hands. Mhm. So far I've just attended to a general wash, nail clean and then a nail spray paper like no, I'm gonna wash it right off and let it run off my elbows. You can see you're having low sing and bending down the awkward posture that I'm having to adopt to achieve that. And if you do that regularly during the day, I personally found after three cardiac operations as, as much as very uncomfortable again. Now we're gonna do the hands again. You want a very good lather. So we're gonna do the down the side of the hands and what you do on one side you do on another. We're going to do the back of the hands and on the back, then I'm going to do the individual spaces on, on the back of the hands. I then come around the thumb and make sure I go around the thumb and around the base of the thumb. And I'm going around the wrist itself as well around the thumb around the base. And now I'm coming to the ventral side again and making sure that covering each of the interdigital spaces and paying attention to the back of my fingers there. And at the same time cleaning the palm itself, once I've done that for one wash and rinse it off thoroughly, keeping my hands up, making sure the water runs off on the tips of my fingers or at least runs off directly into the sink without running from my elbows to my hands. Because as I'm doing this process, you realize that my hands are getting cleaner and my elbows are more sterile. Good mother. And there are plenty of visuals available online. But how you do it. I don't mind. As long as you cover every area and you are methodical in the process. So I do dorsum, thumbs, wrists, Troy Spaces, lack of fingers and palms. I've got another question, David. Yes. Do you find it's better to do that to do the hand washing by yourself? Very introverted or like cause cause chatting with somebody, do you forget where you've got up to or does it just become like second nature to just, you know, the sink surgical thing is usually got three or four times and you'll find that the team is scrubbing up. To be honest, as I said to you, this becomes a ritual for me and we'll discuss it further on. I usually go and catheterize and help put the patient on the table while the team are scrubbing up. I can therefore ensure the patient is in the right position. Confirm the right side if you're doing, got a narrow and the di plate and pressure areas are on. I see that a bit like a captain of an airplane going around and checking that the plane is ready for takeoff. The team are scrubbing up at that time. The other benefit of that is is that the team can then go and start prepping and the scrub up room is left for me to quietly go through my ritual of cleaning my hands and visualizing and mentally rehearsing the operation. Sometimes I would have put a prompt up on it, on the wall as a reminder because this is inverted. Commas me getting into the zone. I'm not doing too bad. I haven't got water down the front and there's not too much water on the floor. So this is my third hand wash. So I rinsed my hands at the beginning. I cleaned the nails. I did two forearm washes together with two nail scrubs. And now I've done three deliberate methodical hand washes and nails. And it's useful to be honest to get you watch, get somebody to watch you do it because over time many people get bad habits and it's the bad habits that can result and problems. So I'll ask Rinku, who's probably watching? How am I doing so far? Rinku, I've also got a question. Um He's far away. A has said about washing that much. Uh She says would not lead to contact dermatitis, but it's a question. So I'm assuming it's. Yes. Yes. And I did mention skin sensitivity at the beginning. Yeah. So if you find as a surgeon over time you get a skin sensitivity, there are different soaps available. It is worthwhile speaking to a dermatologist, but there are what hyper allergenic subs available? I personally liked Povidone iodine because it felt nice. I must say the Chlorhexidine hand wash to me felt like nails going down a blackboard and it didn't give me a nice feeling as, as long as it's thorough, it's nothing like soap and water has asked, is there any evidence? I beg your pardon? Rinko has asked. Is there any evidence for evidence? For what r you evidence for what? Yeah, I think he's gonna have to type very fast. Oh, Fatima's question about contact dermatitis. Yes, there is. There is. If I look up in the literature, there will be recommendations available in the literature. True to the, I'm trying to move the camera and there you go, I've done it with my elbows and I've turned the top off with my elbows. As I stand here, the water is dripping off my hands onto the floor. My hands are clean. They are the extreme element and clean. Now, you'll find that when you are given a towel and it's interesting that this is just one towel in here. I think of it in two halves, one half is done one hand and the other half for the other hand. And I start off. I literally dobbing around my fingers and making sure my hands are dry. Now, what is the worst thing is to have wet hands and try and put gloves on. So I'll do that on that side and I turned the towel around and to do the forearm and again, I'm diving, I'm not rubbing up and down. I'm diving all the way all the way to the. Remember the elbow is dirty, crunch that end and I drop it and leave that end. I don't touch it because that's touched my elbow and I'll repeat the process the other side. Another, another question for you, David from, uh, Fatima. How can we improve the irritation and dry skin? Good hand cream. Good hand cream. Yes. Uh, putting that overnight and reduce, uh, look after your skin between your washing. I think if you have a significant problem and it is getting worse, the best person to take advice from would be a dermatologist or try a different. So, so note that I used one side for my hand over, I'm turning it around and I'm using the other side and I'm just rotating my arm and I'm dabbing. I'm not rubbing and you're sort of padding this dry all the time, coming to the elbow. Yeah. Now, often at this stage people scrunch it up and then discard it. Remember that parts of the towel have actually touched my elbow and that will not clean in this state. You then discard the towel. Do not scrunch it up another question. Can we use two towels for each hand instead of one? Yes. Depends on the size of the towel. I had to adapt to using one towel. Usually I have two towels in a gown, not in this pack and I use one towel for one hand, but use one half of it for the hand, drop it and use the other half for the forearm and repeat the process with the other. The thing is that I'm using different parts of the towel and using the cleanest and driest part of the towel for my hands and the other part for the forearm. So at all times I'm keeping my hands clean and can towels be recycled. Sorry, I'm asking this one, can it all be recycled? Does it all go in a recycle bin or what happens to it? Well, that is a very good question as well. And some of the biggest users of refuge are theaters and the Royal College of Surgeons of Edinburgh on looking at sustainable theaters, a lot more can be done. And the corporate theaters of course, are cardiac surgeons because we've got the bypass machine, the bypass tubing, et cetera, all this could go in regular bins. However, if there's blood or contamination on your gown at the end, that is clinical waste and clinical waste costs more than 10 times even 20 times more to get rid of a bag of clinical waste. A yellow bag compared to a black bag with regular towels. So one way to save money in a hospital is look on the position of where you put the yellow bags. A student did a very good study that looked at the prevalence of regular bags to taps and found that many wards were guilty of putting clinical waste yellow bags next to regular hand washing taps. So of course, the hospital was paying an enormous amount of money. So the gown is folded and it's folded such that you are on the inside. I haven't used this particular gown before. So I'm just having to orientate myself and to orientate myself, you can see extra large. So, no, that's the right way up. And I'm going to put my hands into the pockets of the side. And when putting your gown on, this is where you need space because it's very easy for your gown to touch any of the surfaces. So if I was in theater, I'd make sure there's plenty of space around me, but also have a nurse to actually tie the gown up to stop it falling off and gather it to stop it touching as I put gloves, et cetera on. So I'm folding it stepping back and you can see it unfolds and my hands naturally go in to the gown. This is where I stand and I actually ask the scrub nurse to secure the back. The final tie is at the front and only one I've got my gloves on. Do I pass this tag? And you see there's a red bit. I pass that out to someone else to take the red bit and red bit only and gently turn to ensure I can then take the other side. But this is important because the outside of this gown is the sterile bed, my hands, the tips of my fingers on the sterile bit two. But I do commend that you put your gown on and your fingers do not come out the ends. So I am going to do we recognize that pinch, index finger and thumb and that is going to be useful now to put the gloves on. So I don't have a scrub that. So pardon me, that the gown is gonna touch the side and may drop off my shoulders. But that's why you need somebody to help. I'm careful opening up the gloves and there is a right glove and a left glove and I do not touch them with my hands when I open up the gloves with my hands in. Now, of course, I would be wearing a mask as well. And the reason we wear masks is very simply when we talk, we inadvertently, there's a little shower of spittle, ok? And some people will know it's more so when you're looking in the world, you're wearing a mask, one to protect the mucosal surfaces of your mouth. And indeed, I've got glasses on and other people wear glasses for protection, particularly if a patient is carrying a hepatitis to wear glasses is useful because that's transmitted through mucosal surfaces. And the mask is there for that purpose. The mask is actually going to get damp during the operation. And by the end of the operation of a couple of miles, it's certainly no barrier at all. If you sneeze or cough, do not look away from the wound, cough directly forwards because it'll b out the back. If you turn to the side, you'll cough out the side. So you're not doing anybody any favors by turning away just gently cough. I must say also that having a bad cold makes it problematic. Now, this is important and I hope to demonstrate it to you right hand and left hand. I am going to pick the glove up and as the glove is orientated, the fingers are that way down and the thumb is up. So I'm gonna pick it up, I'm gonna put the fingers. So they're pointing down my hand and the thumb is now to my thumb. So it's thumb to thumb, fingers down the hand and I'm holding the cuff just the cuff of this with my finger and thumb and I'm holding it down the middle and I'm holding it tightly because what I'm going to do now is take the top side of the C and fold it over my heart. And once I folded over my hand, I can therefore bring the gown and the glove down. And my hands sort of develops out into the glove. I'm kind of stuck there, but at least my hand is sterile and I've now got used to my fingers. So what I'm going to do is do it the other side. Remember, thumb to thumb and fingers down the forearm, thumb to thumb. There's the thumb, thumb to thumb there, hold the cuff and the cuff alone with a good pinch. Pick up the top surface of this cuff and you fold it over your hand. So in fact, your hand never ever leaves the inside of the gown like it. So now I know my hand is sterile. I am just going to do some fiddling and ensure that my glove comes on properly and my hand, I can pull my sleeve down. Can you see my hand has not come through? I can just gently put the fingers down. What size gloves do you need? Or you need gloves that comfortably fit your hand such that there is no space at the top that it sits over your fingers. Because as we have been teaching the Black Beard Academy, it's being able to feel. And the thing is if you have very tight gloves, you'll find that the tips of your fingers become numb and it might be the case if you're new to theater that you try different gloves. Now, some people say my simple answer to that is double gloving is appropriate, but you put the big glove on first. So I'm size eight. I put an 8.5 on first and then an eight afterwards. I've got some questions. Sorry, I hate me interrupting you. Uh I've got two questions. Actually, John asks, John says I have observed that some orthopedic surgeons wear transparent, full face shield as well as a mask. Would you recommend this for General surgery too, that is recommended for orthopedic theaters and the design of theaters. The mask and Chinese suits is because the deleterious effect of a staph infection in bone and particularly with prostheses is considerable. So the sterile environment of theaters, particularly orthopedic theaters and implant theaters with positive pressure, ventilation, uh proper hoods and exhaust mechanisms are vital to reduce staph infections. I've always marveled at their discipline and wondered why we didn't employ that in cardiac surgery because the cardiac surgeon is also an orthopedic surgeon because we cut to the standard but nobody paid attention. So I've got my gloves on and another question, sorry about gloves this time. Should you wear two gloves? I ea darker color underneath to check easily for glove tears. That was from ri think that is, that is sensible and I certainly see a lot of scrub nurses doing it and they do it for that reason. However, if you're wearing two gloves and you're not used to wearing double gloves, you're immediately changing your feel. And for a surgeon, the risk of injury, transmitting infection is less than any other environment. One because our hands are clean and often there's an alcohol in there between your glove and the skin. Two, the needles that we use in theater are usually smaller than the needles elsewhere in clinical practice and the needles in theater are not hypodermic needles. The story I have was with doing a patient with hepatitis C. Some coronary artery bypass grafts. And the registrar was going to take the red artery and he started double gloving. And I asked him, does he regularly double glove? And he said no. And I said, I prefer you not to because you're going to lose the feel. And I'm never double gloved because I lose the feel. I started the operation and I was going through the chest and I had a pint of voice say da as a guest. And I looked up and what he had done is slash through the skin and the radial artery at the same time. And I had Hepatitis C blood spraying all over theater. I don't think that would have happened if you'd was used to wearing double gloves and could feel the blade not as I'm standing here that I'm holding my hands clasped in front of the C praxis and with my hands clasped, I am sterile, but my hands should never leave the petrol line. They should never come above my shoulders and they should never go below my waist unless I'm standing at the table and I put my hands on the table. When moving around theater, I do not allow my hands out laterally. I don't raise them up and I do not drop them below the waist. And it's almost a, a song pros and part of the ritual of walking around theater gently class together. I often see people you can fold it over like that, but I don't want to see hands under the armpit. That's not good. So you always keep your hands in front of the petrol fold. Not too high, not too low, not too wide. And there, I'm ready for theater f I had touched anything at any stage, I'd have to put a new gown on and what I find between clean operations or if I have to change gloves, putting a bit of alcohol on the hands and letting it dry, removes the moisture that you get from sweaty hands below the gloves. And that's a little trick when you're changing gloves to put some alcohol on your hands. A lot of people will advocate changing gloves when it comes to occlusion. Of course, should there be a tear in the glove or a hole you need to change, step back from the table, take your glove off and in those circumstances, your hands are already outside the sleeves. And I'd asked the scrub nurse to hold the glove open so I can put my hand in my phrases. I just want to be gloved by you boo boo. Otherwise I go and go and again. Now when you take your gown off, it's important you take it off and don't just tear it off. You get somebody to undo it at the back and then you slide it off and in doing so you note that my gloves are naturally rolled up. I can therefore put my finger, thumb inside the glove, both sides, the gloves are now taken off and my hands have not touched the outside of the gloves which are now dirty because of the operation, my hands are clean. So if I'm doing a next operation, simply going to the sink, an alcohol rub is perfectly ok. Provided you go through the discipline of making sure all the spaces on your hands are properly cleaned. You do not have to do your elbows as long as the wrists and hands are done and is dry. You're ready to go again. I put it to you. If you leave theater, that's not applicable, especially if you're going to have lunch and especially if you're taking a comfort break, then you go back to the tops. It's not necessary having scraped your nails at the beginning of the day to scrape her nails again. And unless you've done something gross, you don't need to scrub your nails again, but you do need to go through the thorough hand wash and procedure and go through the drying. Now, I'm not sure if my fellow colleague and Sense Mr has been able to join us. This comes back to being a ritual. This comes back to having had a ritual and established rituals for scrubbing. And my scrub back technique has not changed in 35 years. And I find it is an excellent moment to visualize and mentally set myself for an operation. It's a moment to pause and reflect a moment to see the steps and practice the steps. But I also think as a surgeon, it's setting the tone not just for yourself, but seeing a senior surgeon scrubbing up thoroughly sets the tone not just for yourself, but sets the tone for theater. And that's why I'm confident I'm not ashamed when watching trainees scrub to say, would you mind doing another scrub, please? Because either you've touched something or you missed a bit. There's no compromise when it comes to hand washing and hand washing is the best thing we can do in all our clinical practice before you see the patient. If you touch anything at the bedside and touch anything after, if you use a stethoscope, clean the stethoscope, mobile phones are extremely dirty and I'm amazed even in hospitals to see gentlemen doing their thing, holding the mobile phone and holding themselves without the hand. And even in a hospital, I see people leaving these facilities without washing their hands. There was a very good study done where people were invited to a conference and where they were greeted with a handshake. But the people greeting them, put the hand in some glitter and she can. And at the end of the day, lunch comfort breaks. They turned the lights off and put UV lights on to highlight the fact that this glitter not only went from the hands, it went to their attire and their ties does beg the question of how thorough people were washing hands. And I might add that this was a surgical conference. So I'm very happy to, to take further skill questions. I hope Rinku, I've answered some of your questions and I commend you on sending your video and getting your scrub tech uh technique as fastidious. So, are there any other questions? Uh No, we've had a discussion about gloves. Uh Fatima would have worn two pairs, but only because the blue NHS ones broke easily. Um John said the blue ones are not sterile. Rin, you said the green ones are um, well, if, if you're wearing double gloves, if you're wearing double gloves, both gloves should be sterile. Yes. Ok. You're wearing double gloves. I'm sorry, both gloves are sterile. I accept a different color is useful because it's easy to see a tear or hole. But you know what's also a very good indicator of a hole or tear in your glove. We are in the habit of using our forceps to pick up vessels and we are somebody touch with the diathermy gosh, even though you're standing on rubber soles, if there's a hole in the glove, you'll get a burn and a shock through the hole. There's no better way of actually determining holes in gloves and, and there are studies and I can't quote them, but I know they are the people who have taken gloves after theater filled them with water and looked for the incidence of needle stick holes in gloves. It's higher than we think it is higher than we think. So. I hope this has been useful. I hope that you too will get into the ritual of scrubbing up because not just a physical process, but it's also a mental process as well as part of the Black belt academy. We want to match the skill with a mindset. Maybe. Can I ask you a question? You've got a beard. Do you have to wear something for that? I did say that in the beginning. Yes, sorry. Did I not listen, you'll find that there are surgical hoods that have an attachment that come over the beard and that is recommended too. And then do you have to wear a, a mask as well if you've got a baby in that, do you have to wear a mask as well? Yes. Yes, that is recommended. Wow. Way. Ok. Cool. Thank you. And c and certainly, as you know, during COVID, everybody who had beards, we asked to shave them off for that reason because simple thing is people with beards end up doing this and this and we do a lot of unconscious movement and things with the hands without thinking about it all the time and rubbing dirty areas and then putting it on our beards, beards actually end up as potentially very dirty and you got to be mindful of touching things and then touching your face as well, because it ends up in your face and be, and that's how germs spread. I'm reminded of that old da book called the Twits and he described one of the twits. He had a beard and the breakfast was in the beard as well. So, if you are hirsute and bearded, please remember that. Anything from your hands doing that goes to your beard. And if you are bearded, you have to consciously resist the temptation to do that as well. Perfect. That's it. That's us. Everyone said, well, we've got a few thank yous there. So that is great. Can I just, er, say just because I work with Medal? Um, if you are new to BBA, could you please give, um BBA a follow on Medal? You can, if you look, if you're on a laptop, you can look up and there will be a follow button. If you click that, then basically you'll get notified when, um, David creates a new event. When there's catch up or anything like that, you will get messaged. Ok? And also when you get the feedback form, please do fill it out cos David does read them. Well, it does help. We do read them and we do listen to what you say. The other thing is is that we are accredited by the Royal College of Centers of Edinburgh. So a feedback form means you get a certificate with that badging and therefore CPD, the catch up is always there. This is free do invite all your friends and others to participate. We are growing, we are in 100 and 12 countries. Lastly, we have a competition that closes on the first of July. And what I want to see from you is a photograph of your innovative home practice with a short explanation. The top three will receive their own set of instruments and we will endeavor to get them to you, to your hospital. Because previously, when we ran this, we had home address in the Middle East and unfortunately, local customs did not allow them through. So at this time, we'll be sending it to your hospital where you work and hopefully it will get there. So I look forward to saying that we will put the URL out again for the competition. If Sue hasn't got it, I will put it out if Sue has got it. Could you perhaps put it in the chat room? And I look forward to seeing you next week where we're going to be talking about the art of dissection and lightness of touch. I'm also very pleased to tell you that on the third of June, I will be interviewing an international expert on human factors, but particularly talking about the team because as a surgeon, you're only as good as your team and we'll be talking about team performance and how you as a surgeon can help that. Thank you very much for your attention. I wish you well, thank you Metal and thank you, Sue for the production and thank you for your attendance. Be well and I.