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Hello, good evening. Good afternoon. Good morning. Good day, wherever you are in the world and welcome to the Black Belt Academy of Surgical Skills. My name is David o'regan. I'm a retired cardiac surgeon in Yorkshire in the United Kingdom. The immediate past director of the Faculty of Surgical Trainers from the Royal College of Surgeons of Edinburgh, and a visiting professor at Imperial College London. I'm delighted to tell you that the Black Belt Academy of Surgical Skills is accredited by the Royal College of Services of Edinburgh and that will be reflected on your CPD certificates if this is your first time joining this evening. Thank you very much indeed. And I'd also like to thank the 7080 delegates registered for this evening from 27 different countries that would not be possible without the metal platform and the fantastic production behind the scenes by Gabrielle. This is going to be a conversational and presentation based on my experiences with wound infection. So please put questions in the chat and I'm happy to answer them. I'd like to thank the 4245 followers on Facebook 692 on Instagram and 1009 on X, I've been practicing cardiac surgery for 22 years. And although mt we talk about mortality and morbidity, the Cardiac Surgical Society in the UK published their results and with public seeing their results, immortality actually fell. And if I went for an operation, I'd be very happy for elective caron artery bypass grafts to have a mortality of 0.7% in the UK. That's phenomenal. But what I would not be happy about is win infection because that varies between two and 10%. And I'm going to put it out there. That would scare me more than a mortality of 0.7%. And I believe it is largely preventable and we'll discuss it as we go through. We have been focusing to date on surgical technique and we use banana because it gives you feedback. You can see the banana goes black when you squash it or squeeze it or your sutures are too tight and they tear through the banana, continuous su sutures or strangulation stitches as well as mattress sutures and vertical mattress sutures and horizontal mattress sutures. You also got to realize that within the lag zone next to any wound, whether it's the skin, the bowel or vessels, there is inflammation and edema and inflammation and edema in that L zone is going to increase the tension of the sutures, increase the tissue tension. And in doing so, is going to decrease the blood supply. So, surgical technique and your stitching technique is of absolute importance. As we discussed last week, it's sharp dissection, it's clean dissection and you go in with meticulous attention to hemostasis and respect on the tissues to bring it all together. You're probably familiar with all the local and general factors that affect wound healing and to put a smile on your face, I've summed it up as banana for local factors, foreign body or body habitus, material supply, age or ae for general factors, neurological deficit or sent loss or nutrition in especially diabetes or general factors, action, movement and stress across the roots or activity or lack thereof and frailty for general factors. The other end to massage, the metaphor, nasties that's fouling and infection, neoplasia and nicotine and accumulations of fluids and dead spaces and analeptics being another word for medicines. And we all know steroids cause problems. But I thought I'd put it there just to bring a smile to your face to keep with the banana theme. Germs are everywhere and this is a sternal wound I closed and I now like to throw out another challenge to you. I don't know why we talk about wound infection and we score wound infection. What we should be talking about is a perfect wound because anything less than a perfect wound is going to cause the patient trouble with extra dressings and time. It will cost the house system cost. And the other thing is, I have sat in morbidity mortality meetings where people have argued that's not a wound infection, it's slightly red, that's not a wound infection. It's just a serious discharge. That's not a wound infection because it's co to negative. So you could argue yourself out of whether or not it is this wound infection. But I don't believe you can argue yourself out of that is a perfect wound. And I have a whole series of tattoos and stenotomus of the same. And part of this understanding of germs are everywhere you will find on youtube, youtube and on the internet. Lovely diagram. Summarizing which bugs you'll find and which part of the body and as useful as part of your basic skills to understand which bugs you you're gonna find and which part of the body. Because quite frankly, there's more bugs in us and DNA, then we have our own cells and is that is where the infection comes from. So understanding the area of the body, you're working on the common bugs present together with a hospital protocol and appropriate antibiotic. Then you are covering a potential wound infection. And I recall doing a, an appendicectomy as a senior house officer many years ago and a very large woman and she ended up with a wound infection. She sued, she sued because it said the scar was unsly and she got a wound infection because I forgot to give the antibiotics. The wind was 10 centimeters long considering her b was 35 to 38 and four millimeters of the whites. From the right side, there were six roles of fat and from the left five. But you are successful because we haven't given antibiotics. Hospitals unknown to be bump generators. And the old Victorians knew that by the fact they put TB patients outside and opened the windows and took TB patients up into the mountains for fresh air. The old fashioned Franz Nightingale wards when I was a junior doctor were, wouldn't it? And the long wards. Now, what's interesting, the wooden floors needed oiling and the linseed oil that went on the wooden floors was a very good bactericidal agent. And for the patients to eat, they had to leave their bed if they were clinically well enough and go to the dining room to eat. Obviously, if they're unwell or had exuding fluids, food was served in their bed. What's interesting in the modern hospitals in the UK, we've got bedside entertainment systems. So the patient comes into the hospital puts on their pajamas, assumes a sick girl gets into bed and doesn't leave the bed, they eat, sleep, drink and entertained and other things in the bed, in the pajamas. And I randomized people into TV, on and TV, off and found that those people with the TV off walked five times further at day four POSTOP, then those people with TV, on and it appeared that complications were reduced. So the good book said, take up your bed and walk for good reason. Lying, still, not moving, not breathing, not getting your circulation round does add to problems in POSTOP were infections. And of course some are. And Florence Nightingale talked about the importance of scrubbing and we're going to talk about that at our next presentation. But there are a few myths about we can't keep throwing antibiotics aw infections because our hospitals have become very good breeding factories for superbugs with the antibiotics. And we're going to be entering the dark ages where we will see infections that cannot be treated and indeed in parts of the world that is happening because we're throwing out pills left, right and center white coats were banned in hospitals. It was interesting in America that white coats are used regularly by the staff and I think protect your daily clothes, but also they established who you were in the working of the team. And there's no evidence for that at all. And indeed, but doubt kept your tie out of the wound. And one of my junior staff in Oxford many years ago, ended up as the health minister for one of the political parties and was doing a local excision of it in a lumps and bumps clinic and his tie dipped in the wound. And the thing is is that when you compare industry to hospitals and clean room in the industry or pharmaceutical industry to a hospital. They are vastly different. And I invited the team who was responsible for microbiology control at the valve factory in the UK to come into theater when I was putting a valve in and do the same managements, suffice to say the theater failed dismally compared to the industry standards required to make the valve. And you would think to take the valve out of a pig and put it in a pot and out of a pot to put it in a patient that could take you out of a pot to put in, the patient would be cleaner. Not the case. The other thing is is that you'll find better filters, you know, vacuum cleaner than in many of the theaters. So it's surprising that we do not see as many wind of factions as we do anything less than a perfect word costs. And certainly in cardiac surgery, that can be enormous amount of money involved with stays, going out to a month with backpack, repeated operations, osteomyelitis and of course patient measuring. So my journey started back in 2009 when the trainee helping me with a case berated me for using bone wax on the sternum. Now, most cardiac surgeons take a bit of bone wax which is literally wax with a natural wax and rub it on the edge of the sternum to reduce the amount of bleeding off the edges. Any ch me. Why on earth are you doing? That and because we'd always done it around it that way, I did a repeat aortic valve replacement. 10 years later, honor women because the valve had failed. And when I reopened the Steny, this was the bone wax that I found in medulla of the sternum. Now, an orthopedic surgeon would not put foreign material between the bones and there with that and thinking because that's the way we always been around here. I decided we need to think differently. And Chris and I came up with a tissue care bundle. Now I counted all wound problems anything less than perfect. And you'll see over my years that it was running at a median, this is the ser chart over time. It was running at a median of about 6%. And in fact, this was the average for the unit. They introduced an antibiotic protocol and they introduced and reaffirmed hand washing and I introduced a tissue care bundle and then prep instead of iding. And for the last one, near 2000 cases had a median of 0% weird problems. A million of zero compared to my colleagues, they were 2.1. Now, regular statistics put it as p values of less than 0.0005 et cetera. And I thought, wow, and I took it to some statisticians in leeds who looked at this on a holistic point of view and because everybody had fallen and I couldn't get less than zero, no, no significant figures, but the power of the line speaks for itself and we reduced the amount of infection. So, what do we do? Well, it's important that you have a proper Prew and patients get into the bathroom and soap and water as Florence Nightingale does is very useful. You chlorhexidine wash is even better. And of course, if you go to operate on bowels, bowel prep is important. Never ever, ever use a razor. And the only serious wound infection that I got in that time was an acute case who was going to theater at nine o'clock in the morning, but went off during the night and they couldn't find the Clippers. So they took a razor to his chest and he had the most horrendous deep sternal wound infection in my post bundle record. Of course, you have to monitor glucose and diabetic patients need to be carefully treated. We'll go through scrubbing up and gowning next week. But it's amazing sitting at the pump and watching junior staff and watching consultants, etcetera scrub. I was alarmed on Twitter the other day to see a consultant actually say, how dare they pick me up on my scrub technique. I've been doing that for 20 years. Well, I'm sorry, that is the problem. And if you are not comfortable scrubbing, we'll discuss it next week. But even if you think you are get a senior n to what you're doing this. So when Chris and I talked about how we're going to reduce infection. We got rid of bone wax. We thought, what else can we do? And there was a paper in an American journal that said knife only to the sternum and he reduced his wound infection by half to date. I had been going through the skin with a knife and then cauterizing all the tissues underneath. And I have pointed out before that rates the tissues and increases the damage. Now, I was reluctant to use anything but iodine on the whole patient because I was prepping from chin to toe, one side of the table to the other side of the table and the whole legs and groin. And what's interesting is that many surgeons will put a prep on and you're supposed to let the alcohol iodine dry. But to be honest, I have never seen a surgeon stand there do nothing for five minutes to allow the iodine to dry and not infrequently to see people wipe it off. Now, this I think explains why the New England Journal of Medicine paper showed that chlorhexidine is much better because the application of it is easier, but also it tries a lot quicker and is not wiped off. Your antibiotics need to be agreed as a hospital. And as a team, we also looked at not only how we opened the chest, but also how we closed the chest and focused and picked up on poor technique as well. And on top of that, we ensured that the patient was warm in the surgical site infection bundle that is published internationally, keeping a patient warm has now become mandatory. And indeed, people have sued in America if they're not leaving theater with a warming blanket. The interesting thing is in cardiac surgery that that was excused because for many years, we have used hyperthermia as a tool to protect the organs and bypass bypass is so safe and so good. Now, you don't need to cool except in exceptional circumstances. So I kept the temperature above 32 and thoroughly rewarmed before coming off bypass. Now, I always admire my orthopedic colleagues because they have do not enter signs going into theater and, and you'll be hung, drawn and courted if you enter while we're putting in a prosthetic joint. True because staphylococcus in the bone and in joints and joint infection secondary to surgery is dreadful and the orthopedic surgeons are in lamina flow theaters and entire suits and it's super sterile. But I was putting heart valves in and also cutting through bone and during any one operation, one of the junior staff audited the door opening as more than 60 times an hour. That's not a door opening. It was an oscillation. And what I suggested is that those people coming into theater, if they could not name the patient, their age and their operation, they had no business to be in theater at all. Part of the checklist. Oh, that's what I wanted to do. But it was difficult to impose no attention to detail and closing is important and it's really wrong that at the end of the operation, everybody disappears. Leaving the most junior person who hasn't got needle skills developed yet to close. And they are under the watchful eye of an increasingly inpatient anesthetists and scrub n who are tutting and tapping their watches and saying, come on wrong. I think if the junior surgeons done the operation out of respect for the rest of the team, the consultant should close and allow the junior person to go and get a cup of tea to write the operation notes and set themselves up again. The thing is about wound infection when you start looking for it and start auditing it. And it's interesting that you put audit at the bottom of the list of things that are going to contribute to infection. But as soon as you start looking for audit and looking for an infection, everybody starts paying attention and I put this up and you can steal it really. This was a, a matrix to classify the wounds and that is on the exudate the erythema, any prevalence or separation of tissues. And this is the percentage of the wound along the y axis and green. Nothing is what we should be looking for. Mild is what everybody asks argues about is in yellow, moderate infections in the orange and severe in the red. You can document this and use this as a template in your own place of work and take it to work. And I'm offering you a quality improvement exercise for you to do to introduce to your theaters in place of work. Simply print this out and start scoring the wounds. My tissue became so reliable that even an obese bmi 40 diabetic chronic obstructive airways disease, smoker with 10 centimeters of fat between the skin and the sternum as seen here. And that is the wound, five days, POSTOP, respect the tissues. What we did as part of the audit is risk stratify the patients. So you'll see where there's red. These patients scored points because they are diabetic or chronic obstructive a disease or renal failure or peripheral vascular disease, uh cardiogenic shock anemia and we've got other renal failure, prolonged ventilation. We've got a lot of cardiac factors in here and this was an adaption of the Southern Thoracic society risk stratification score. And I was more interested to know those people who got wound infections if they had an overall score less than 10. Just because somebody leaves hospital with a perfect wound does not mean to say that they do not have a late wound infection and late wound infections following the surgery are reported up to 10%. And I put this picture up because the only leg wound infection I had have we introduced a bundle was a man who came in with quite a nasty Poland looking wound and the buggy grew, could only be found in the potting tomato potting plants. I called him back so we could do acsi scraping of his nails to send them off to microbiology to see if that bug was underneath his nails. Unfortunately, microbiology discarded it because it was a waste of time, but it would have closed the loop. And I think the reason this person got a wound infection late is because he is scratching the wound. And if you think itching is the mildest form of pain, if you're full grading the tissues and not attending to perfect deposition, you're going to get increased itching and consciously and unconsciously, you are going to scratch. And I think that is why it is important in the POSTOP period to have a dressing over the wound. You can argue what sort of dressing you put on it. But I think the dressing is a physical barrier to somebody's scratching. Of course, we all know why skin heals better if it's slightly moist and damp. And that's why you put an elastoplast over your cut, you put a dressing over the wound to improve epithelialization. Other people have introduced negative wound dressings that could increase negative pressure on the wound, that supposedly that increases the blood supply to the wound because that's what you want. You want a little bit of blood there to stimulate the healing process for thrombin to ignite the macrophages and white cells to clean the wound up. But you don't want too much because too much and scarring will result from too much bleeding and poor attention to hemostasis. The suturing technique is very important and I would keep your sutures to the layers and your clothes and layers be mindful that continuous sutures are going to strangulate tissues. If you've got a wound that is dirty or potentially dirty, I would close it with interrupted sutures because if there is a local wound infection, you can slip a suture and let it drain locally. I do not advocate for staples. The staples I think are actually strangulating the tissue and are very awkward to take out. Yes, they are used by some vascular surgeons for expediency, particularly with amputations. But I have my reservations and I would like to see interrupted sutures in a clean wound. A subcuticular stitch is fantastic. But do remember that you put a knot at one end that's gonna sit in the skin and act as a om for bacteria. So I noticed with my external wound infections at the top end of the wound, there was a bit of crusting and that was because of the knot. So what I did then is just brought the subcuticular suture through the end of the wound and put a liquor clip on there and took it through the rest of the wound and put a leg clip the other side. And of course, at 7 to 10 days you can top and tell the wound. No, this is interesting. I don't know if you know the story of positive deviance. A bit of epidemiologists were looking at the malnutrition in Children in village in Vietnam and couldn't understand why. In one village, there are some Children that thrived and other Children that did not. And they spent months and months and months looking to find out the reason why it was only when they followed one of the mothers into the rice paddy that they noticed this mother was picking up grubs to add to the harvested rice. So those Children are getting extra nutrition and protein because of the grubs. Now, my point here is that despite the systems that we work in, there are people around that have reduced wound problems to zero. And I was pleased with mine being a million of zero. And I asked the national dataset who has got the lowest or problem, you know what? They didn't have that data, no deviating slightly. The British Olympic Cycle team when they actually won the huge clutch of gold medals at the Olympics were accused of cheating because their success was so fantastic. But what the British Olympic team did is they attended to 1% of everything they attended to the bike, the positions, the nutritions, the physio, the helmets, the set up the exercise, everything they look at the whole system and found ways that could improve the whole system as well. And they found that 1% and that 1% meant the team wipe the floor with all the other nations in their success to the extent they were actually accused of cheating. So if you really want to address a wound infection is true in your system, you need to look at every single aspect and look at for that 1% because it is add more than just additive is exponential. And that is why tissue care bundles work. It's that 1% of everything. And my tissue care bundle was at seven things that reduce all wound problem to zero. And I included putting a flow seal on the sternal edges, which is a thrombin based uh hemostat. And I was challenged to say, well, that's kind of expensive. Do you want to drop that? Now, I had a predicament, I had a bundle that was working and they wanted to take one of the parts out. The costs are keeping it in was modest. The cost of one w faction would have far exceeded that. And I therefore said no, but it is interesting. Now, once you've got a successful bundle, how do you actually change it? Well, this is where a bundle only works if the whole team work together. And this is the story of the Oxford Blues, the Oxford Blues in one year of the boat race for those of you who are not in the UK, the preeminent Universities Oxford and Cambridge race down the TS usually at the end of March as the coming to spring and it holds the beginning of summer for the UK. Sometimes the weather is absolutely frightful. The Oxford team in university recruited the best world's best rowers and Olympic rowers and put them in the boat, but they wouldn't grow together. And the coach decided to sack them all much to the distress of the university in consternation because they thought he'd thrown the boat race away. But the second bas got on the boat and they pulled together and in pulling together, they won the race. What he had in the beginning were Pri Madonnas. Now what this is an important element because I sold my bundle to my colleagues. They said, yes, wonderful, et cetera. Yes. But I'm not telling them how to do an operation and putting together a series of things that I believed demonstrated would reduce through an infection. But it's like surgeons seem to actually have their own little recipe. It's my recipe and I like the way I do things and that is the problem. Quality management requires the whole team, stick together on protocols and audit the protocol and adjust it. And there's a business behind that described by Edward Demings. Now, this is rapid P DSA cycles. A protocol is not a tablet of stone. You set it up, you audit it, you see if it works, you will find it and you keep on going through this audit looking for that 1% looking for that perfect recipe because hope without a method to achieve them will remain me. Hopes and the business of health care where I think in the UK that we have failed dismally is to grow together and maintain quality improvement cycles to reduce wound infections, safe for my sternal wound infraction and for all operations, there is a preadmission process. The patient needs educated. We know fitness and weight, smoking and diabetes, anemia and drugs are important. Soap and water beforehand is wonderful and I could never understand why patients came down to theater and still had dirty feet having had a bath beforehand. What was interesting? Some people go into the bathroom, run the bath and all the steam would hide the fact that sitting in the bathroom smoking the night before a heart operation. We don't design our theaters with K Manry Dirty Exit and we're not really looking at the traffic and when I compared what industry does to our theater, you will be shocked and horrified. We do need to educate staff and the important things are as you will see in any kitchen is keep your hair up dirty fingernails, makeup mascara jury nail varnish are all banned in clean rooms that are actually making your medicines and start on goods. I cannot underestimate and understate surgical technique because what you're learning on the blackboard Academy will translate into better outcomes. And if you put more knots in there, yes or not needs to be secure as we described before for a Monory or a braided suture. But any more than that, you'll get more infection. Not only that you get the stiff little knot sticking into you when you lie on it or walk on it, there are different types of dressings and I think negative pressure wound dressings are very useful in high risk patients. But I do think we need to monitor the rooms. I do not think we should be scoring anything less than perfect rooms. And of course, the sooner the patient gets up and walks round and leaves hospital the better. So for me, we're an infection, it's not a wing and a prayer, it's meticulous attention, get everything from the beginning to the end. And the fundamental to this is surgical technique. I reflect on the beat in Oxford and the John Redcliffe had a red line policy in the hospitals. The beat anybody could walk to the theater door, the John Radcliffe, there was a red line and you couldn't go beyond the red line. It was like Star Trek Force Field. There are no different hormone infections. I recall at the Royal United Hospital in Bath, one of the theaters had lovely bay windows in this Georgian building opening up onto the cricket field and fresh air came into the theater. There weren't any increase of infections. I think we're not thinking about wound infection, the bugs come from the patient. They are encouraged to grow because you as the surgeon have not respected the tissues, but you as a surgeon also have to ensure that you look at the antibiotic policies, adhere to them, the timing and ensure the patient is in a safe environment. I'd like to share with you this video because I think that what we have got is a human factors problem. And I would like to, I'll try and share my screen present now. Share a screen and look at this. Uh I wonder entire screen. I'm trying to share Gabriel you perhaps help me here. Yeah, it's not showing at the moment but it was working before. Maybe just we tried it before. Uh entire screen. Also share assisting or I am not sure why it's not coming on. Ladies and gentlemen, we did put it up and it did work. Let me see. Um if I can maybe check. Ok, let me try this. Oh, now we can see a screen. Can you? All right, I'll reduce this and play this. Can you see the screen three? Let's try man. Right here is my great grandfather. He's the first cat. Can you hear? And you'll enjoy this. Sit back and enjoy her in our family. Herding cats. Don't let anybody tell you it's easy. Anybody can herd cattle holding together 10 bells and half while short hairs. Oh, that's another thing altogether. Being a cat herder is probably about the toughest thing I think I've ever done. I got this one this morning right here and if you look at his face it just ripped the shreds. You know, you see the movies. Yeah, you hear the stories. It's, I'm living a dream. Not everyone can do what we do. I wouldn't do nothing else. It ain't an easy job. But when you bring a herd into town and you ain't lost to one of them and a feeling like it in the world and there you have it. I think wound infection is a people probably. And you, as future surgical leaders need to encourage people to embrace the principles of quality improvement. I've given you, I hope food for thought and I hope material that you can take back to your institution and let me know how you're getting on with a quality improvement exercise. If you don't start measuring, we don't know. But I think we've got to measure the right thing and a bit like patient satisfaction. We only score the five out of five with your wound management. We going to score five out of five wounds only and look into the reasons why not. I'd be very happy to take questions from the audience, put them in the chart and answer any of your questions. Gabrielle, any observations from your side thought that was very insightful and the pictures really helped to illustrate the point. You were uh Rinku, thanks for putting up the uh nice guidance and recommendations and I think all of this should be taken as guidance and recommendations and we should all working it. Yes, is asking to comment on traumatic words, traumatic wounds, bomb blasts, bullet bars are a totally different cattle. Se there are two principles. One is the amount of debris that is taken into the wound and traumatic wounds. The second is the devascularization and injury. The first thing with a traumatic wound is stop the bleeding, but also in trying to preserve tissues and may store the blood supply to help the healing. There's a lot in the literature about compound wounds with bone fractures and of course, you're dealing with potentially not potentially seriously contaminated wounds. The youngers asked about honey and indeed honey is a fantastic thing to put on your wound because of its high osmotic uh uh potential. It is very good at cleaning bugs. And if you're in an area where you haven't got dressings, but access to honey, certainly put that on spider webs were used in the early on war as A II soak in a dressing and it improved hemostasis. Joel films and other films are being explored, particularly by the American military for rescue and survival on the battlefield and they're getting better and better, particularly with thrombin and artificial gels and expanding firms. They're very good on battlefield for extraction and salvage of patients from to a primary area, stabilization to secondary and tertiary care. Following that. This is a, a summary of different elements. When you think about weird infection, it's a whole system and you are part of that system. And I'd like you to start thinking in your own environment, how you could take this forward and invite you to try a quality improvement pathway and ensure your patients have no wound infection. Next week, we're going to continue with the principles of gowning and gloving. And then the week after I think I'm going to revisit history and examination. And just before Christmas, my son comes back from boarding school in Malaysia and is looking forward to demonstrating the principles of the assisting. We are going to take a break over Christmas uh from the 18th of December to the eighth of January Gabrielle and the med team will be also sharing a festive season, but we will come back in the new Year with fresh ideas and look forward to your participation. Just to reiterate, we are going to run a competition and the best three entries will receive their own Black Belt Academy pack. We are simply asking you to send us a picture of the most innovative practice that you are doing at home with a brief description with your email address and your work address and you will receive your own set of instruments. The closing date is the end of January. So please please do vitro pictures. Quality improvement is actually referred to as Kaiser and that's the Japanese word of continuous quality improvement. And I think that fits very well with the philosophies that we're talking about in the Blackb Academy because the improvement is not an improvement in the delivery of your service, but also improvement of your skills, your mindset and your approach to your career and surgery. It's a journey of learning and mastery is not a destination. It is a journey. Thank you very much for your attendance and thank you for your time.