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Orthopaedic Appliances for Orthopaedic Exams ( Part 2 )
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Orthopaedic Appliances for Orthopaedic Exams ( Part 2 )
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Segment:0 .
Thank you, everybody, for joining us today. Abdullah is presenting orthopedic appliances for the FARC as part two. There's a part one already on the YouTube channel. Please feel free to review that as well. This is I feel this is an important topic because one of these appliances and/or concepts does come up in the exam generally.
One of the tables one way or the other. The Abdulah has just finished operating. He's still actually. He's joining us from the hospital after he described you can actually see the markings on his face from his level two PPE. So please excuse his voice is a little dry. Thank you very much. OK, thank you, everyone.
And thank you, Sean, for your nice presentation. OK, so the title is orthopedic appliances, but in reality it is appliances and processes. I said to, although that if you look at the YouTube, you wouldn't find orthopedic appliances no. One the reason is this is a continuation of the same topic that our mentor colleague Samir started with theater design. So you will find a lot of the same, well, not same concept, the other concepts covered by Samir, and this is a continuation of the same.
So let's imagine this scenario. You are a consultant and on your list there is one patient who had one side of suspected slap technique and the other side, as you can see a metal work protruding with potential for infection, and you are planning to take that metalwork out and do the bride and wash out. Now, if you start thinking about the equipment and the things you are going to use for these two operations, it is if you are in the exam and the examiners present the scenario to you, you will start talking about I will consent the patient, make sure that the patient is marked, consented already and then I will take him to theater and I will start scrubbing.
He can interrupt you and say, OK, tell me about scrubbing, and then you will say, OK. And after finishing that, I will put him in a drape. OK tell me about the drapes. So all of these concepts and things that you do in every single day are fair game in the exam. They can interrupt you during any case or any scenario and ask what it looks to you. Like a silly question?
And then they follow it deep to find how much you know about the things you practice daily. And as you can see, this is taken from the curriculum orthopedic curriculum. You are expected to reach level four, which is, you know, specifically and broadly about these processes and instruments like Tony Kaye, sterilization in theater and theater, infection prevention and control in theater and out warming method and rational skin preparations and extension anything that you do in every day in theater.
So the previous topic, sorry, the previous lecture covered theater design patients, warming techniques, skin preparations, masks and gloves. Mechanical DVT prophylaxis, which was covered during the DVT talk and cement, which usually is covered during adult pathology or properties. Today, I will be talking about Tony Kay. I will touch on the surgical drapes again. I will talk about auto transfusion devices.
Image intensifier, diethylamide pressure. Irrigation, plaster of Paris. Imagine it. And sterilization techniques. I hope that in the future, we will recover the rest of the following topics and whatever comes that we feel is important and may come in the exam like wound dressings, vac pumps. So let's start with the tourniquet.
So what is the tourniquet? The aim of this is to give you pointers to how you phrase your answer in the exam, so they may put a picture of a tourniquet in front of you and ask you, tell me about it, or you would say, and I will use a tourniquet, and then they will stop the whole scenario. And ask, you tell me about tourniquet. So you have to have a structure in your head and always start by definition.
And then benefits, risks and complications. OK and then you describe how you use it. So for this, I'm just going to give you pointers. So what is a tourniquet? It's a pneumatic device mostly used to block or to stop the blood from the field, giving you a blood less field, allowing visualization. And it has a benefit of adding of aiding in cement into digital.
OK and then we talk about the special things you apply during the, you know, when you do the tourniquet, so you say there are different types of tourniquet, but by far the most common one is the pneumatic type, which we use in theaters and in clinics. And the principles are you apply it over the upper arm or other leg, and they apply padding, which is 2 layers of padding. And then you talk about the size of the cuff.
The principle of applying it, which for the shortest time and lowest pressure possible. You mentioned alternatives. Sorry, all different types of tourniquets, which are controlled tourniquets, which you can use for special shape of the limbs. There will be some discussion about when do you give the antibiotics and the antibiotics are given five minutes before inflation and then before inflation.
You have to accentuate the blood and you do that by using either accentuate exactly Anita. Yes, mark a bandage or simple elevation, and the pressure is 100 mercury above systolic in the upper limit and 50 in the lower limb and 50 in the upper limb. And the time limit is 120 for the lower and 90 for the upper. What happens if the operation takes longer than that and you still want to use the tourniquet?
You can say I will deflate it for 10 minutes, but the best answer is for 1 minute per 10 minutes of previous use. So if you use it for 60 minutes, you can deflate it for six minutes and so forth. OK when cannot you use a tourniquet? Any condition that is exacerbated by a stoppage of blood so vascular disease, sickle cell disease, AV fistula, diabetes sometimes which is relative contraindications because we know that we use it, the only reason we say it is because of the calcification of the vessels will make it not that effective in local anesthesia.
You can still use the tourniquet, but you have to warn the patient and you have to use it for a short period of time. We have all used it in carpal tunnel at some stage. Not not everyone agrees with that, but it is a common practice. Local sepsis is not a contraindication to using tourniquet as long as you do not use as Mark or Exaggerator.
We call it sausage. And the reason is you don't want to drain the infection, the sepsis beyond its location. Complications of Tony Kay. You've again, it is how do you phrase your answer? And one of the ways to do it is to divide it into local, distal and systemic. So the local is skin injury related to pressure necrosis. Nerve under the automaker can be injured and arteries can be either injured or thrombosis distal, which is more peripheral than the tourniquet itself.
There will be ischemic injuries, thrombosis, kostelnik syndrome, hemorrhagic or intraoperatively or postoperative and compartment syndrome, and there are systemic complications as well. But they post Tanika syndrome is related to the feeling of pins and needles and numbness and swelling and pain in the limb after the removal of the tourniquet.
The most important thing you have to, which is all usually forgotten, is documentation and communication. And it's especially important when you are using a different type of tourniquet, for example, digital tourniquet, when you are doing like a digital surgery because you are not using a inflatable, you're using usually a rubber type and usually it is well, sometimes it can be forgotten or missed under the bandage.
So it's very important to communicate with the team that it is inflated, it is deflated and document the timing of the bank itself. Now let's move to the next level. That was the asset show Mark six level for the exam. Now this is the next level up. OK, so these are some papers are some very recent evidence that I hope you will find useful, which discusses the pros and cons of using a tourniquet.
So although it is mentioned that it reduces the intraoperative blood loss. Studies have suggested that actually the overall blood loss is the same because once you release the tourniquet and you put a bandage, there will be some blood which is in the body that you cannot see. And you cannot count for. So in reality, it does not reduce the overall blood loss. The recent evidence suggests that if you want to use it, you are using it to have a blood less field so that you can operate.
It is not to reduce the blood loss and you have to weigh that carefully against the effects of it. There is another evidence here by tosupport suggests they have looked at the quality of the cement, but in the total knee replacement with or without the tourniquet, and they found that the quality of the cement is better by about one. So if the average was three without a 2 with the other way, three with the tourniquet and two without the tourniquet, suggesting that possibly it may give longevity, they followed their patients for about two years and they could not find any clinical difference.
But you know, that may turn out to be better in the very long term. Fine so let's move on to the next topic I'm going to cover is draping materials. It is partially covered by the talk by some years, so I would encourage you to go back and listen to it again. But in general, I will mention here that there are two general types of drapes that are used either for your scrubs or for draping the patient woven and non-woven.
The benefit of using a cotton fabric is that it is reusable, so in hospitals, in poorer conditions or poorer countries, or shall we call resource challenged areas? It makes more sense to use that because you can clean it again and you don't have to buy and waste. And for people who are more environmentally aware, environmentally aware again, it makes more sense to use cotton fabrics.
The benefit of the non-woven one, which is it has a smaller pores that should trap the bacteria and in theory provide more sealing and more protection against infection for both the patient and the surgeon. Having said that, WHO and NICE guidelines both say that both are effective and both are equally good in practice. So although we prefer in the UK to use the non-woven one, but it is OK to use a cotton blend because it has a very good track record and in theory they are equally the same.
So you can justify it by using that in the exam. This is the only thing I wanted to add on this topic because it was covered really nicely by Samir. The only other thing I wanted to mention is the incisional drapes. The incisional drapes is similar to what we call the IO band, which is the iodine impregnated sticky thing that we put on the patients on the field. And the theory behind it is if you stop the skin moving, you stop progressing of the bacteria from the unclean area into the clean area and then onto the wound.
That has never been proven 100% And although we continue to use it. For whatever reason. But nice actually commands that we don't use it, and if we are going to use it, we use only iota for impregnated, which is the I/O band WHO recommends against them as well against both of them. Now the reason they came up with that is no. One, there is no 100% proof that they actually work and then it will cost money for no proven benefit.
And you can think why nice would come up with that and WHO because they have responsibility for again, resource challenged areas, so they have to come up with something that would make sense to everyone in the world. So again, if the topic comes in the exam, I would mention the theoretical benefit. I would mention that WHO and nice recommends against it, but some surgeon would use a iodine impregnated, which is allowed by the nice.
So the next one is not actually a instrument, it's a process. So the question can come up in the exam. You've got a patient who is elderly, who has lost a lot of blood, and you are about to start him on a big operation that you expect them to bleed even more. So how would you think about stopping that bleeding or stopping the patient from bleeding to death? There are many ways of devising your answer or, you know, making it systematic.
One way is to say steps that you do, pre-op steps that you do enter up and steps that you do post-op. However, I found this find a nice way of devising it, which is assess, plan, communicate, and execute. So when you assess you assess the patient preoperatively, how much is their hemoglobin blood pressure? What is their cardiac function? And how much can they tolerate of blood loss?
Are they on anticoagulation? And how much do you anticipate that your operation will make them bleed? Once you've assessed all that, you plan ahead. So are you going to use adrenaline? Are you? How would you correct the hemoglobin preoperatively? Are you going to give blood transfusion or are you going to give iron, for example?
Are you going to use auto transfusion? How would you adjust your surgical technique? Are you going to do it slightly differently using of cement, for example, or not using for cement? Are you going to use a tourniquet? How would you correct the anticoagulation? And are you going to use tranexamic acid? Are you going to measure hemoglobin intraoperatively and blood pressure?
And then once you've got a plan, you communicate that plan with both the scrub team and the anesthetist. And then you execute. And when you execute the plan, you execute the plan you've mentioned and then you focus on tissue handling and the use of diaphragm. Now the reason I brought this is my next topic will be the use of control to transfusion.
So what is auto transfusion? It is a way of giving the patient their own blood. And the reason for that is you want to reduce the risk of getting transfusion from elsewhere with all the communicable diseases that you know, can affect them. In addition, there are some religious groups that do not want to get any blood transfusion. So the way to do it, it is devised into a pre donated blood or salvaged blood, and then they salvaged blood can be given intraoperatively or postoperatively.
So this is how you structure your answer. You talk about the definition, the reasons for it and the types of it. No, the tops of intraoperatively auto transfusion, which is the cell salvage in Ramachandran they gave he gave about two or three groups, but did not make a lot of sense. I found other sources. In fact, more than one source that took about only two major groups, and I think that makes it easier to remember.
So unprocessed or unwashed method or processed or washed method. And this is much easier to remember. The unprocessed or unwashed method is usually used. Post-operatively, which is types of intraoperatively or to transfusion, are divided into two in general. One is unprocessed or unwashed, which is historically the one that started first and then processed or washed method, which is the newer one.
So the older method is basically you collect the blood in the drain, you filter it and you give it back to the patient. That's pure and simple. The benefit is it's cheap, easy. The patient has lost their blood anyway, and you are just giving them back that blood. The problem with that is you cannot give it to children. You cannot leave it for long.
You have to give it immediately after collecting, and you cannot take a lot of it. And there will be other risks that I will be talking about in a second. The more advanced method, which is probably the method that the examiners would expect you to talk about. And in fact, you may bring up yourself is the worst method. Basically, it's a machine you tell the theater staff that you need and then they will bring it to you, to the theater.
And then instead of sucking, using the suction and throwing that blood away, you use the suction, which has a special filter and an anticoagulant at the tip of it. And then that sucks the blood into a special container through that filter. And then that blood goes through a washing cycle with saline to try and get rid of all the broken hemoglobin red cells, all the plasma, and then the red blood cells are concentrated, filtered again.
And given back to the patient. The benefit of that it is more robust, it gives the patient red blood cells from their own and it reduces their need to have a holographic transfusion. So the issues you need to know about is you have the patient has to lose significant amount of blood and be collected through this method because they get only 60% of it back.
And what they get only is red blood cells, so they don't get any plasma or coagulation factors. So it is not cost effective in normal operations that the patients are not expected to lose a lot of blood. It is more cost effective in revision surgery, big pelvic surgeries, stuff like that. There is another issue when you use this sucker, the suction to collect the blood just by passing through the inside of the plastic of the suction.
The red blood cells get broken down through a process here related to the activation of the coagulation and complement cascade, which means again, you don't get all the red cells, so you get only amount of it. In addition, you have to be careful during your suction because you cannot suck small amounts as soon as the blood is in contact with turbulent air during the suction. If you suck, only a drop here and a drop there.
It will be broken down. And if you again suck some clots again, it has no benefit. So the only benefit of it is if you are applying the suction under a pool of blood and collect that. Is contraindicated when you are suspecting malignancy and/or sepsis, which which is common sense when you use topical antibiotics. Again, it is contraindicated because the sample you are collecting will be concentrated even further and given back to the patient at a higher concentrations that can be toxic.
We are talking about local antibiotics. We're not talking about general antibiotics. And whenever there is a topical like wound anticoagulant. So coagulant factors, I think like surgical or cement because you don't want that to get into the bloodstream. The complications of the unwashed, which is the old method, which is just collecting a blood through the drain and giving it back to the patient, it can cause hypertension hypothermia.
It it has been reported to cause aids, DIC and even death. It can cause fibroid reaction and because the blood can be hemorrhaged, in fact, it is, some of it will be generalized. It can cause renal failure, especially if you give significant, significantly high amount of it. OK now, if the other method of giving autologous blood donation is the patient themselves, donate their own blood before the operation buys some time and that is stored for them during that time, their body is producing more blood and then that same blood is given back to the patient.
The typical method for doing so is to take one or two units. The last one about three days before the operation. You, the patient has to have a reasonably good hemoglobin before that, and they have to have reasonably good health to be able to cope with the blood loss beforehand. So people who have cardiac problems, renal problems, you are suspecting that their erythropoietin is not going to be produced in a significant amount that would compensate for the loss, then you don't give that and you don't give it when there is infection.
OK, so that's what I wanted to talk. One more scenario that can come in the exam is the Jehovah's Witness. Now, the auto transfusion is not automatically accepted by Jehovah's witness, although it is their own blood. Some of them would insist on having a full circle, which means the blood does not actually leave the cycle from their body so that the auto transfusion machine can be adjusted to accommodate that, and not all of them will even accept this.
So in the exam, don't mention it like this is the answer. You mentioned that you would suggest this and discuss it with the patient, explaining that you are happy to make this adjustment to the machine, if that would help the patient. Obviously, the discussion will go on then to discuss other methods like medical methods, erythropoietin injections and, you know, preparations beforehand and all of that, well, that's quite good.
Just the caution Jehovah's witnesses, it's their right to say no to a blood transfusion, and you need to know the steps you can perform to minimize the risk to the patient. And as Abdullah said, just to reinforce this is not the panacea or the silver bullet that helps you manage. Absolutely good. OK, moving on, the next process I'm going to talk about is image intensifier.
You will mention that you will bring that to do a manipulation under image intensifier and it's a fair game. Then to stop you and ask Tell me about image intensifier again definition. What is it? It is a fluoroscopy system for use in theater. By that, it's an X-ray machine. Components are a system where there is an X-ray tube on one side and a receiver on the other side.
This system is connected to a computer with a control panel and a monitor to show the images at least one monitor. So now you've defined it. You describe how it is done. So it is like your X-ray. There is photocathode converter on the converts that X-ray on the receiver to light, then detected by Closed circuit video system, which is shown on the monitor.
OK should be able to describe how the X-ray machine is only the X-rays are made, which is the vacuum tungsten electricity, you know, high, higher, high velocity and then hitting a Dagestan plate. You should be able to describe that. But for the image intensifier itself, this would be enough. There are factors that would affect the quality of the image. And these you need to know about what is the current, what is the voltage and the exposure time and how they affect the image you get?
So the current, which is measured by milli ampere. Is the controls, the quantity of the radiation? The number of radiation is that you are getting, the more numbers you have, the more the better quality of your image. Or the voltage, however, which is kilovolt controls the energy of each ray.
So the more voltage you have, the more penetration you get, which means then it will penetrate more of the bone, and the bone would look like the normal tissue because it doesn't stand. The less penetration you have, the more contrast you have between the bone and the soft tissue. So that's the difference between the current and the voltage, the duration of exposure is what is described as the beam on time, and that is the amount of time you are leaving your finger on the button.
So these machines, the fluoroscopy is not like a quick flash it it keeps beaming as long as the finger is on the button and this is you need to be aware of. And even this is not, you know, is not a one radiation. It's a continuous radiation. The machine nowadays controls everything for you, so you get an automated call calibration of the current and voltage, depending on what the computer in the CRM thinks is the best thing to show you the image.
And that's why you don't have to adjust it every now and then, but you still have the ability to do so should you feel that you need to. For example, if there is a metal in the way and you want to see the images better? So this is a picture of the image inside, which we have all used. There are certain techniques that you need to be aware of magnification.
When you do magnification, you are actually expanding the receiving end. So the source is the same, but the receiving is bigger. So that causes a bit of distortion, especially at the ends of it. You need to be aware of that. The opposite of that or something slightly looks like the opposite, which is called Mason or koning, which is put a physical plastic at the source, so you are reducing the source area by definition, then you are reducing the receiving end as well.
So reducing the amount of radiation that body the patient is receiving. The damaging effect of the radiation, it can be dependent on the dose, the rate and the type of tissue and the patient's ability to cope with that. So the type of tissue, the higher the what's the word, sorry, my toast is right, the more susceptible they are to damage the more active DNA production, the more susceptible to damage.
Hence, the developing embryo is highly susceptible. There is this definition, which you may be presented with and asked to answer what is stochastic and non stochastic? So stochastic means that, so the non stochastic means that there is a linear or relationship between the dose and the effect. So the more the dose, the more the effect. And there is a relationship between them.
Stochastic means there is no direct relationship, so you may have a small dose and that gives you a big effect and vice versa. And cancer is stochastic effect, especially long term because even smallest amount of radiation can lead to cancer in the long term. The non stochastic is things like burns and damage to the cornea and, you know, irritation and all of that. These are.
So the more radiation dose, the more you will feel these effects. One more thing, Qatar is highest at the X-ray site, hence you try and put that X-ray site under the table. So that all this Qatar is away from you. And the patient. Another factor that you will be expected to know is the radiation decrease according to the inverse square distance.
So and it is negligible by 2 meters, so 10 centimeter means that it reduces by 100 times, so it's squared. OK The most important thing you need to be aware of, which is the governing regulation for it, which is written there, which is short for ionizing radiation medical exposure regulations, you need to pass that course before you are allowed to use ACR.
Hence, you are expected to know about it in the exam. It is not a complex thing. It is just telling you the regulations. The law that governs how you use this and gives you. Actually, it's a useful booklet that you can, you know, you can ask to download from your local radiology radiology department because it gives you some basic physics, which you can use for the exam.
The main thing is everyone has a responsibility to reduce the exposure to radiation, either as a prescriber. Or as a obturator and in the theater, you can be both if you are having a minnesotan, for example, you can be both. And again, you are under the law. If you are black, if you don't comply with that. So the basic principle they are trying to advocate is the principle of Allen, which is as low as reasonably possible, which means you give the patient as lower total dose as reasonably possible by the end of your examination.
And in theater, that means as least so the least number of images you take for the least time possible. And by doing these steps, which I would leave you to read, you can make sure that you are reducing the radiation. And again, this is an exam question. You can be asked how would you reduce the risk of radiation in theater? I would stress on one thing that you may not find in many books, which is communication.
You need to have good communication with the radiographer. You need to establish a rapport and a clear language to this so that you don't do more x-rays than needed. No, no. I meant you go up up as an up to the sky, not up to the head of the patient. And then the, you know, the radiographer have taken three or four x-rays.
So I leave you to read that. And then we'll move to the next topic, but next topic is diet fun. The word diet. I tried to find because at some stage I was really interested to find out where it came from. It's actually Greek and it means through heat die means through passing through. And the reason is the electricity is passing and leaving the heat.
And that's the dichotomy. And the definition is the tissue heating effect when high frequency current passes through the body. The principle is if you focus a huge amount of electricity into a small area of the body, the amount of heat produced would have an effect on the tissue. And that effect can be either to cut coagulate, desecrate or damage. And then if you have control of that current, you can decide how that affects the body.
Bear in mind, the same electricity that goes into the body comes out of the body at some stage, but it does not burn on the outside because by then it is distributed over a bigger area, bigger surface and by doing so, it loses its intensity and then it loses its effect. And that's why it's very important for bipolar or unipolar to have a bigger surface of receiver and make sure that there is no objection to, you know, no nothing blocking it.
OK, now the current is alternative, cut it the current ac, and it has 0.4 to 10 megahertz. These radio frequencies do not affect the muscles or nerves, so they do not cause twitching of the muscles or the nerves. You have to have way lower frequencies than that to affect the nerves. The heat is generated through joules low, which is the amount of heat in joules is double the current density.
So the square, the current density multiplied by the body's resistance multiplied by time. So the more fluid there is in the body, the least the resistance, which means the least the heat. Hence the diaphragm doesn't work under water. The tissue temperature that can be developing at the tip of the diaphragm is about 1,000 degrees centigrade, but it reduces to 38 degrees.
Only centimeter away, and that is because it dissipates over a bigger surface. Now, there are two types of tenotomy, the most popular and the bipolar we all know them, it's how you describe them in the exam. So the monopolar you enter, the body is sort of the electricity enter the body in one side, passes through the body and gets out of the body over a receiver that is attached to a part of the body and then it goes to the machine.
Previously, it used to be earthed, but now they go to a special machine to protect patients from differences or problems with electricity. The plate has to be 70 centimeters square, and it has to have full attachment to the body with no hair or wet surfaces. OK the it has to be put away from anybody prominences, scar tissues, metallic implants and definitely away from the heart and make sure that the current does not pass anywhere near the heart, especially if there is implantable devices.
The bipolar therapy, however, does not need that plate and the current pulses through the two arms of the biceps solid biceps forceps. So it is only in that area and it has lower energy. So it's 50 units, so 50 watts compared to 400 watts for the monopolar. Now, let's talk about modes, we thought we mentioned the cutting coagulation. There are other modes and it depends on the electricity passing through and how they do.
So the cutting mode is when you have pure continuous sine wave, all of them continuous sideways. But here you have continuous and low voltage and that produces high temperature, vaporizing the tissue because the cell explosion and then a gap appears. So that's the cut. And here you don't have to have full contact with that issue because it's the heat.
It's not the electricity, the coagulation. However, you have intermittent signed sine wave, but it has more power and it goes on and then rests for a bit and then on again. Somewhere in between is figuration, which is high voltage of coagulation that causes like an explosion of the tissues, which is a mixture of vaporization and coagulation. This is when you keep it in touch, but only using so it's lower heat than cutting, so it dries only the tissue.
And then it just circulates. A blend is any mixture of the above. And just to describe it, if you look here on the left hand side is pure cut. On the right hand side is coagulation and the middle it's a blend. And if you go further on the right, you have the full duration, which is even more bigger damage around the area.
And these are the frequencies or the voltages of how they look between coagulation and cutting. You can notice that if you look at my arrow. So for the calculation, there is one wave and then and then another wave, while in the cutting it's continuous. How does what sort of things that would affect the function of the coagulation?
Number one is the mode you chose. You can choose cutting or coagulation. You can. The more time you apply it, obviously, the more heat that will generate the size of the electrode. The smaller the size, the more heat it produces. Tissue nature as we mentioned earlier, especially isca scar is like a charred, burned tissue, and it has high, very high resistance, which means it produces even more heat and more and more damage.
Tenotomy safety only thing I will mention here is there are four, three or four side effects or complications of using dynamite. We know about burns and fire, especially whenever you're using alcohol, and that's why it's very, very important to prevent any pooling of alcohol based antiseptics around the body because they can explode when you are using a diaphragm.
The smoke of diatom have been studied, and the CDC say that it contains many chemicals that can be toxic or carcinogenic, like hydrogen cyanide, cyanide and benzene. In addition, it does not kill viruses. So viruses can transmit through the vapor of these family. It can interfere with the ECG monitoring, EEG monitoring and defibrillators, especially the built in defibrillators in the patients.
So always have a clear communication with the anesthetist beforehand. And in these cases, if you can, if you can avoid using the diaphragm do. But if you have to use it, use a bi-polar instead and use it as far away from the heart as possible. That's it. That's as much as, Oh yes, NICE guidelines mention that you should not use me to cut the skin because it would increase the risk of local infection.
Remember this? Ok? I think this is as much as I wanted to talk about it. And these are some references. There is a nice booklet which comes from asset, the Association of surgical trainees. It explains it in a really nice way. This is the link for it. Penny, any remarks, you guys.
That's interesting, you found that nice guidance and saying don't use the before skin social pressure irrigation. So what is pressure? Irrigation is a method of delivering irrigation to the tissue under high pressure. So the way we irrigate the wound can be divided into low or high irrigation, high pressure irrigation, anything between 1 to 15.
Forgot the unit pound per square inch is low pressure, and anything above 15 is high pressure and there is some people devise it, you know, divide it into low, medium and high. Usually when they say high pressure, they are looking at the pulse lavarch. This is what is commonly known by but by low pressure. We are talking about using a syringe or pouring of normal saline or just giving it through a giving set with gravity assisted.
So what is the. Benefit so the difference between using the two, so the low pressure you usually use it with a brush or a scrub to try and clear the wound and reduce the amount of debris. So this is gentler to the tissues. And some studies, like the one I've mentioned here, Dreger and downers suggest that actually you move. You remove more debris through the low pressure than high debris, and it does not cause any damage to the tissues, including the healing bone.
The high pressure method the advocates say that it is more powerful and can relieve a lot more pressure. So the debris from the wound, including bacteria and advocates, suggests that they have done some studies, including beef meat. They have put some bacteria into it and try and clean it with either method and found that the bacteria removed more with the pulsed lavage you can.
You could look at the paper there. Having said that, there is a new evidence this is an international multicenter study, new, I think it's 2019 2020 from Canada. They have looked at two things. They have looked at the type of pulse so of pressure, so either high pressure or low pressure. And if you looked at using normal saline versus soap in open fractures and they looked at the amount of clinical reoperation as indication of infection rate, and they found actually that low pressure is better.
It gives low reoperation rate. And the explanation could be because by damaging the tissue, you are actually push the bacteria and the deeper, deeper, deeper into the deep tissues. And then they rebound with a bigger infection. So this is the new study, which you would be expected to quote in the FRC exam. So what is the bottom line with all the evidence, conflicting previous evidence and this big study, which only looked at open fracture, it did not look at elective cases.
It did not look at chronic infection, with which, for example, in limb reconstruction with osteomyelitis and how we wash it. They looked specifically at only open fractures. So how would you take that into practice? A pragmatic way is not to use it for open fractures or for normal cases and use it only if you're clearing an ongoing infection like a, you know, osteomyelitis.
OK concerning the additives, they found, actually that the soap gives more rebound of bacteremia compared to normal saline. So NICE guidelines suggest the following, and this is what we should be following, and this is from 2008. Do not use wound irrigation, do not in lavage and do not apply antiseptic or antibiotics to the wound before closure.
And this is what you should quote. So this is just a bit of some information to start you talking to organize your thoughts in your head. Plaster of Paris is calcium sulfate with water. It's cheap, not irritant, easily applied, malleable, so malleable and ready loosened. It is made by heating mind purified gypsum at 120 degrees.
It allows partial dehydration and then it gets it, gives it its properties recently or, you know, from the 70s when zirconium chloride is added to increase its properties. Once it's mixed with water, it produces heat and then it becomes a porous mass and porous is an important word here. The reason is it allows some breathing of the skin. So the skin underneath it is losing a bit of heat through the porosity of the.
A plaster. It needs about 36 to 72 hours to completely dry, but the patient can start walking on it if it's a full cost in about 48 hours. There are two stages like cement. The setting stage and the hardening stage, and the quality of your plaster is determined by the quality of your cast is determined by the quality of the plaster material.
The water to gypsum ratio, the age of the gypsum and the storage conditions. The more wet it becomes, the less effective. There are almost no allergic reaction to plaster of Paris. Once you've talked about it, you talk about certain techniques in how to apply it. So you always put a padding of a sufficient thickness, not thick enough, not too thick to lose reduction and not to thin to allow heat to get to the skin.
You roll the plaster bandages. You don't pull them. You allow them to dry naturally. The heat is produced depending on the speed that it dries. So the more the faster it dries, the hotter it becomes. So that's one reason for you not to draw it with, I don't know, like a, you know, a heater or something. There are some reports of Burns coming from the cockpit because of the plaster.
Fiber blast, fiber fiber glass cast is a synthetic material. It's called glass reinforced plastic. It is polymer with glass in it. OK and it comes obviously in different colors. It is stronger than plaster and lighter, but you cannot use it as the first time, you know, cast because it does not allow for swelling of the body. Complications of casting in general, you should know them DVT compartment, syndrome, swelling and subsidence leading to loss of reduction pressure sores.
We've seen it venous congestion and this symptom, which is related to stiffness of the joints, damage to the tendons, muscles and skin stabilization techniques. This is a complex topic. It's you might be expected to describe what happens if you drop something in theater and you want to clean it and then how would you clean it and what would you accept as a cleaning method?
Or what do you think happens to the instruments once they have sent to the ssd? So all these are fair because it has bearing on your work. So in general, we divide items that the patient's used into critical semi critical and non-critical items. The critical items are ones that are in contact with unprotected parts of the body, so they should have no contamination whatsoever.
The same critical are in contact normally with normal parts of the body like a mucosa, OK and intact skin, and which means they have to have protection, but it doesn't have to be the same level. And then the noncritical are anything that patients use, like clothes or medications or stuff like that. They are not in contact.
So for that, we have different levels of removal of contamination. So you have cleaning, which is just removal of the dirt, but specifically removal of bacteria. You have sterilization, high level disinfection, intermediate level disinfection and low level disinfection, and you will be expected to know the difference between them, basically. Sterilization is when you remove all bacteria, viruses, fungi and, more importantly, spores.
The high level disinfection to remove everything but spores. The low level disinfection everything, but you don't remove mycobacteria or spores. OK all of them are disinfection, cleaning doesn't remove any of these, it's just visible dirt. OK you could look at this. Summary, it's a really nice paper summarizing all of that. The WHO document has a really again nice document talking about how you sterilize how you set up a hospital with a sterilization unit.
There are some aspects that apply to us. For us, what we need to know about is the mainstream of sterilization. Our instruments is the autoclave. It should be disinfected first and cleaned before sent to SSD. The reason is we want to protect the staff there. It is left in the autoclave for 20 minutes at 121 232 degrees or for 30 minutes. If they are wrapped packed.
And there are some indicators in there put in the machine to indicate whether there is, it has done its job or not. The dry heat is not as effective as autoclave, but it is applied to 1 to two hours, 470 degrees. And again, they have to be cleaned beforehand. This is. Poor alternative, but sometimes the only alternative in some settings. Boiling itself is not good enough, antiseptics is sometimes used like a glut of aldehyde or chlorhexidine, especially they put like a small desk with the instruments.
And they leave them. This is usually used for things like the drills and machines that have multiple mobile parts. Plus, sterilization is a new technique. It's not that new, but it's new, it's a modification of the conventional steam sterilization whereby it is put in a container rigid container with its covering and then it is allowed to quickly clean.
And this is usually used when you are in need for, you know, you dropped something and you want it cleaned very, very quickly. And this is, they call it the quick cycle. So if you speak to your SSD, this is how they do it. But they don't advocate it for routine use, it is something only for emergencies, if you know, if it is needed. OK there are some chemical methods like ethylene oxide, Eto.
This is something that is commonly used, so we probably need to know about it. It's odorless, flammable and explosive, and it is. The machine is already the instruments are left with it under heat. And then once you move the machine from that, once it gets exposed to air, it loses some of its sterility. The way it works is its localization of the proteins.
Hydrogen peroxide with plasma is as effective as the other one, and it is used usually for electrical components. Um, last one is ozone or hydrogen peroxide with ozone. It breaks down into oxygen and H2O by the end of it, and the duration of the cycle is about four hours and water. It is used for many, many materials, but it is not used for brass, aluminium, liquids, textile and cellulose.
And that's it, I hope I did not send all of you to sleep, I hope some of you are still awake. Anything you would like to add goes on sterilization. Actually, I have a question to them. Do you still use flash sterilization or trust us taking that out? I did not ask our trust, I have to say, but lost trust. I know we have a rapid cycle and I assume that it is the same. Because we dropped, we dropped an instrument and we needed that, so they did that quickly.
It's the best management for Tony claw palsy. It depends on the cause. Usually it is in your apraxia, usually, which means it will come back alone on its own. Having said that, the usual practice is you check the patient, make sure that it is that not something else that you've cut during the operation and then you leave it for six weeks and then you do nerve conduction.
Absolutely so, for example, in knee replacements, a patient then gets a perineal foot. Of course, splints think a patient putting splint on. Think of the cause of this perineal foot drop. It's often not the tourniquet, so look for other reasons. Don't assume it's the tourniquet. There's a reason why the tourniquet is always put on the flesh as part of the problem. It's to avoid the nerve injury.
OK interesting about the Tony Kaye, can you apply it to the lower limb as into the lower leg or the forearm in foot and ankle. They apply to the calf? Yes, they do, but it has less efficacy because of the interosseous membrane protection of some of the vessels there, which cannot be blocked. OK is there any other questions?
OK inappropriate, and you do not have another how to deal with one important instrument fell down intraoperatively. Don't drop it. No well, you have to think outside the box. The thing is, it depends on what sort of instrument you are. If it is going to stay in the patient, it's an implant. Then you know, either you delay the operation or you are putting an implant, which has substandard and could be contaminated with long term infection problems.
So it's a judgment call, and I would personally if it's an implant. I wouldn't risk it, the patient can always come back later. But the idea is in planning why? Why are you having only one implant in the whole hospital and then you drop it? I mean, yeah, so yeah, I don't know what the other matter is. If this came up in the exam, dropped instrument or more importantly, you have one set of an instrument.
My response is always, I will ask for another set of instruments to be made available to me, either from a number of hospital or from a company before I endeavor to take on this procedure. So that I have a backup, a set of instruments in case one fails or breaks to dropped. Three the sterilization procedure is compromised. You open a packet and you find the patient is under anesthesia.
You've opened the pack and it's been compromised with a hole or something like that. So there are multiple reasons why you shouldn't have only one of any instrument. I would not say things like, I'll give it a quick rub and push it, put it back in or put it no. One thing, one thing the examiners may want to know about your knowledge of sterilization, and then he will give you the scenario and whatever answer you give him, he will block it for you.
The only thing he wants to hear is whether you send it to SSD and what they will do with it, and then it will not be something that you would leave in the body. It will be a vital instrument like, I don't know, for example, the implant holder or something that you have only one set of and it's dropped and you cannot hold it in the implant or oriented or something, but it's not staying in the body. Then what will you do?
So I think that's but that's what you are alluding to. And if that is the case, then you can say I will send it for a flash, a sterilization because we have, you know, rapid cycle in our SSD if they can't find me an alternative. Absolutely but it's yeah, I'm not that's a very reasonable thing to say, but kind of. Don't just say, oh, because it's not something that should happen, it does not make sense.
Something that should be detected if you're dropping something and flashing it, you should be reported as a potential problem. And even in terms of GMC guidance, you should be also documenting it and reporting it to the patient and explaining what you're going to do to make sure the patient doesn't have consequences managing the patient, but also what you're going to do to make sure this doesn't happen again.
So it's not. This is not an easy question, by the way. It's not a simple, put it in the flash. We are saying it like that, but it's not. The only thing is you always start by saying the best thing is in planning, I should have planned to have alternatives beforehand. And he said, yes, you plan, but all of them lost sterility in whatever, whatever and then you.
It's not. It's like giving you the tumor question. You don't immediately say, I will do this. You have to give all this the right steps beforehand. So you planned, you made sure that it's available. You asked about other alternatives. You ask in other hospitals, you brought a consultant. Next door and asked him, this is the situation. Do you do you have to have another instrument that how to use that could replace this one?
If all of them are not, then yes, and final. And the final one is. So one example where they can put a lot of pressure on you and say you've three small fragment sets you've opened, both with each one has a hole in the pack and lost. What you do? Don't say you're going to operate on the patient with the non-stop sex, either wake your patient up and come back later or get flush, and if you have to get flash for an ankle fracture, you might as well wake up the patient and do it.
Certainly the only reason for you is the patient is critical. And there is no, you know, the harms of delaying the operation are by far more than the harms of operating with a flash sterilization. And then, yeah, but then you include another consultant with you, so that's what you tell them. I will include another consultant in the decision making. Absolutely yeah, that's very true.
Thank you very much, guys. I hope it was useful. And if you later on develop any questions or have anything, just put it on the telecom group. So thank you, everybody. Abdullah, really appreciate you. First of all, just scrubbing and coming straight away to do this. I know you've missed your, first of all, tired and probably very thirsty and hungry.
And I know you have a long trip home, so we thank you so much. No problem. In fact, if that is the case, may I excused myself and just disappear and I leave it in your hands? Very upset if you don't want to generalize the mental groups. Thank you to the mentors KneeKG Evans and Hannah Darcy. And also a reminder that we have published concise notes new improved editions there.
So please reference that book if you can for your studies. We think we think it is in your best interest, and that's all we're interested in.
Segment:0 .
Thank you, everybody, for joining us today. Abdullah is presenting orthopedic appliances for the FARC as part two. There's a part one already on the YouTube channel. Please feel free to review that as well. This is I feel this is an important topic because one of these appliances and/or concepts does come up in the exam generally.
One of the tables one way or the other. The Abdulah has just finished operating. He's still actually. He's joining us from the hospital after he described you can actually see the markings on his face from his level two PPE. So please excuse his voice is a little dry. Thank you very much. OK, thank you, everyone.
And thank you, Sean, for your nice presentation. OK, so the title is orthopedic appliances, but in reality it is appliances and processes. I said to, although that if you look at the YouTube, you wouldn't find orthopedic appliances no. One the reason is this is a continuation of the same topic that our mentor colleague Samir started with theater design. So you will find a lot of the same, well, not same concept, the other concepts covered by Samir, and this is a continuation of the same.
So let's imagine this scenario. You are a consultant and on your list there is one patient who had one side of suspected slap technique and the other side, as you can see a metal work protruding with potential for infection, and you are planning to take that metalwork out and do the bride and wash out. Now, if you start thinking about the equipment and the things you are going to use for these two operations, it is if you are in the exam and the examiners present the scenario to you, you will start talking about I will consent the patient, make sure that the patient is marked, consented already and then I will take him to theater and I will start scrubbing.
He can interrupt you and say, OK, tell me about scrubbing, and then you will say, OK. And after finishing that, I will put him in a drape. OK tell me about the drapes. So all of these concepts and things that you do in every single day are fair game in the exam. They can interrupt you during any case or any scenario and ask what it looks to you. Like a silly question?
And then they follow it deep to find how much you know about the things you practice daily. And as you can see, this is taken from the curriculum orthopedic curriculum. You are expected to reach level four, which is, you know, specifically and broadly about these processes and instruments like Tony Kaye, sterilization in theater and theater, infection prevention and control in theater and out warming method and rational skin preparations and extension anything that you do in every day in theater.
So the previous topic, sorry, the previous lecture covered theater design patients, warming techniques, skin preparations, masks and gloves. Mechanical DVT prophylaxis, which was covered during the DVT talk and cement, which usually is covered during adult pathology or properties. Today, I will be talking about Tony Kay. I will touch on the surgical drapes again. I will talk about auto transfusion devices.
Image intensifier, diethylamide pressure. Irrigation, plaster of Paris. Imagine it. And sterilization techniques. I hope that in the future, we will recover the rest of the following topics and whatever comes that we feel is important and may come in the exam like wound dressings, vac pumps. So let's start with the tourniquet.
So what is the tourniquet? The aim of this is to give you pointers to how you phrase your answer in the exam, so they may put a picture of a tourniquet in front of you and ask you, tell me about it, or you would say, and I will use a tourniquet, and then they will stop the whole scenario. And ask, you tell me about tourniquet. So you have to have a structure in your head and always start by definition.
And then benefits, risks and complications. OK and then you describe how you use it. So for this, I'm just going to give you pointers. So what is a tourniquet? It's a pneumatic device mostly used to block or to stop the blood from the field, giving you a blood less field, allowing visualization. And it has a benefit of adding of aiding in cement into digital.
OK and then we talk about the special things you apply during the, you know, when you do the tourniquet, so you say there are different types of tourniquet, but by far the most common one is the pneumatic type, which we use in theaters and in clinics. And the principles are you apply it over the upper arm or other leg, and they apply padding, which is 2 layers of padding. And then you talk about the size of the cuff.
The principle of applying it, which for the shortest time and lowest pressure possible. You mentioned alternatives. Sorry, all different types of tourniquets, which are controlled tourniquets, which you can use for special shape of the limbs. There will be some discussion about when do you give the antibiotics and the antibiotics are given five minutes before inflation and then before inflation.
You have to accentuate the blood and you do that by using either accentuate exactly Anita. Yes, mark a bandage or simple elevation, and the pressure is 100 mercury above systolic in the upper limit and 50 in the lower limb and 50 in the upper limb. And the time limit is 120 for the lower and 90 for the upper. What happens if the operation takes longer than that and you still want to use the tourniquet?
You can say I will deflate it for 10 minutes, but the best answer is for 1 minute per 10 minutes of previous use. So if you use it for 60 minutes, you can deflate it for six minutes and so forth. OK when cannot you use a tourniquet? Any condition that is exacerbated by a stoppage of blood so vascular disease, sickle cell disease, AV fistula, diabetes sometimes which is relative contraindications because we know that we use it, the only reason we say it is because of the calcification of the vessels will make it not that effective in local anesthesia.
You can still use the tourniquet, but you have to warn the patient and you have to use it for a short period of time. We have all used it in carpal tunnel at some stage. Not not everyone agrees with that, but it is a common practice. Local sepsis is not a contraindication to using tourniquet as long as you do not use as Mark or Exaggerator.
We call it sausage. And the reason is you don't want to drain the infection, the sepsis beyond its location. Complications of Tony Kay. You've again, it is how do you phrase your answer? And one of the ways to do it is to divide it into local, distal and systemic. So the local is skin injury related to pressure necrosis. Nerve under the automaker can be injured and arteries can be either injured or thrombosis distal, which is more peripheral than the tourniquet itself.
There will be ischemic injuries, thrombosis, kostelnik syndrome, hemorrhagic or intraoperatively or postoperative and compartment syndrome, and there are systemic complications as well. But they post Tanika syndrome is related to the feeling of pins and needles and numbness and swelling and pain in the limb after the removal of the tourniquet.
The most important thing you have to, which is all usually forgotten, is documentation and communication. And it's especially important when you are using a different type of tourniquet, for example, digital tourniquet, when you are doing like a digital surgery because you are not using a inflatable, you're using usually a rubber type and usually it is well, sometimes it can be forgotten or missed under the bandage.
So it's very important to communicate with the team that it is inflated, it is deflated and document the timing of the bank itself. Now let's move to the next level. That was the asset show Mark six level for the exam. Now this is the next level up. OK, so these are some papers are some very recent evidence that I hope you will find useful, which discusses the pros and cons of using a tourniquet.
So although it is mentioned that it reduces the intraoperative blood loss. Studies have suggested that actually the overall blood loss is the same because once you release the tourniquet and you put a bandage, there will be some blood which is in the body that you cannot see. And you cannot count for. So in reality, it does not reduce the overall blood loss. The recent evidence suggests that if you want to use it, you are using it to have a blood less field so that you can operate.
It is not to reduce the blood loss and you have to weigh that carefully against the effects of it. There is another evidence here by tosupport suggests they have looked at the quality of the cement, but in the total knee replacement with or without the tourniquet, and they found that the quality of the cement is better by about one. So if the average was three without a 2 with the other way, three with the tourniquet and two without the tourniquet, suggesting that possibly it may give longevity, they followed their patients for about two years and they could not find any clinical difference.
But you know, that may turn out to be better in the very long term. Fine so let's move on to the next topic I'm going to cover is draping materials. It is partially covered by the talk by some years, so I would encourage you to go back and listen to it again. But in general, I will mention here that there are two general types of drapes that are used either for your scrubs or for draping the patient woven and non-woven.
The benefit of using a cotton fabric is that it is reusable, so in hospitals, in poorer conditions or poorer countries, or shall we call resource challenged areas? It makes more sense to use that because you can clean it again and you don't have to buy and waste. And for people who are more environmentally aware, environmentally aware again, it makes more sense to use cotton fabrics.
The benefit of the non-woven one, which is it has a smaller pores that should trap the bacteria and in theory provide more sealing and more protection against infection for both the patient and the surgeon. Having said that, WHO and NICE guidelines both say that both are effective and both are equally good in practice. So although we prefer in the UK to use the non-woven one, but it is OK to use a cotton blend because it has a very good track record and in theory they are equally the same.
So you can justify it by using that in the exam. This is the only thing I wanted to add on this topic because it was covered really nicely by Samir. The only other thing I wanted to mention is the incisional drapes. The incisional drapes is similar to what we call the IO band, which is the iodine impregnated sticky thing that we put on the patients on the field. And the theory behind it is if you stop the skin moving, you stop progressing of the bacteria from the unclean area into the clean area and then onto the wound.
That has never been proven 100% And although we continue to use it. For whatever reason. But nice actually commands that we don't use it, and if we are going to use it, we use only iota for impregnated, which is the I/O band WHO recommends against them as well against both of them. Now the reason they came up with that is no. One, there is no 100% proof that they actually work and then it will cost money for no proven benefit.
And you can think why nice would come up with that and WHO because they have responsibility for again, resource challenged areas, so they have to come up with something that would make sense to everyone in the world. So again, if the topic comes in the exam, I would mention the theoretical benefit. I would mention that WHO and nice recommends against it, but some surgeon would use a iodine impregnated, which is allowed by the nice.
So the next one is not actually a instrument, it's a process. So the question can come up in the exam. You've got a patient who is elderly, who has lost a lot of blood, and you are about to start him on a big operation that you expect them to bleed even more. So how would you think about stopping that bleeding or stopping the patient from bleeding to death? There are many ways of devising your answer or, you know, making it systematic.
One way is to say steps that you do, pre-op steps that you do enter up and steps that you do post-op. However, I found this find a nice way of devising it, which is assess, plan, communicate, and execute. So when you assess you assess the patient preoperatively, how much is their hemoglobin blood pressure? What is their cardiac function? And how much can they tolerate of blood loss?
Are they on anticoagulation? And how much do you anticipate that your operation will make them bleed? Once you've assessed all that, you plan ahead. So are you going to use adrenaline? Are you? How would you correct the hemoglobin preoperatively? Are you going to give blood transfusion or are you going to give iron, for example?
Are you going to use auto transfusion? How would you adjust your surgical technique? Are you going to do it slightly differently using of cement, for example, or not using for cement? Are you going to use a tourniquet? How would you correct the anticoagulation? And are you going to use tranexamic acid? Are you going to measure hemoglobin intraoperatively and blood pressure?
And then once you've got a plan, you communicate that plan with both the scrub team and the anesthetist. And then you execute. And when you execute the plan, you execute the plan you've mentioned and then you focus on tissue handling and the use of diaphragm. Now the reason I brought this is my next topic will be the use of control to transfusion.
So what is auto transfusion? It is a way of giving the patient their own blood. And the reason for that is you want to reduce the risk of getting transfusion from elsewhere with all the communicable diseases that you know, can affect them. In addition, there are some religious groups that do not want to get any blood transfusion. So the way to do it, it is devised into a pre donated blood or salvaged blood, and then they salvaged blood can be given intraoperatively or postoperatively.
So this is how you structure your answer. You talk about the definition, the reasons for it and the types of it. No, the tops of intraoperatively auto transfusion, which is the cell salvage in Ramachandran they gave he gave about two or three groups, but did not make a lot of sense. I found other sources. In fact, more than one source that took about only two major groups, and I think that makes it easier to remember.
So unprocessed or unwashed method or processed or washed method. And this is much easier to remember. The unprocessed or unwashed method is usually used. Post-operatively, which is types of intraoperatively or to transfusion, are divided into two in general. One is unprocessed or unwashed, which is historically the one that started first and then processed or washed method, which is the newer one.
So the older method is basically you collect the blood in the drain, you filter it and you give it back to the patient. That's pure and simple. The benefit is it's cheap, easy. The patient has lost their blood anyway, and you are just giving them back that blood. The problem with that is you cannot give it to children. You cannot leave it for long.
You have to give it immediately after collecting, and you cannot take a lot of it. And there will be other risks that I will be talking about in a second. The more advanced method, which is probably the method that the examiners would expect you to talk about. And in fact, you may bring up yourself is the worst method. Basically, it's a machine you tell the theater staff that you need and then they will bring it to you, to the theater.
And then instead of sucking, using the suction and throwing that blood away, you use the suction, which has a special filter and an anticoagulant at the tip of it. And then that sucks the blood into a special container through that filter. And then that blood goes through a washing cycle with saline to try and get rid of all the broken hemoglobin red cells, all the plasma, and then the red blood cells are concentrated, filtered again.
And given back to the patient. The benefit of that it is more robust, it gives the patient red blood cells from their own and it reduces their need to have a holographic transfusion. So the issues you need to know about is you have the patient has to lose significant amount of blood and be collected through this method because they get only 60% of it back.
And what they get only is red blood cells, so they don't get any plasma or coagulation factors. So it is not cost effective in normal operations that the patients are not expected to lose a lot of blood. It is more cost effective in revision surgery, big pelvic surgeries, stuff like that. There is another issue when you use this sucker, the suction to collect the blood just by passing through the inside of the plastic of the suction.
The red blood cells get broken down through a process here related to the activation of the coagulation and complement cascade, which means again, you don't get all the red cells, so you get only amount of it. In addition, you have to be careful during your suction because you cannot suck small amounts as soon as the blood is in contact with turbulent air during the suction. If you suck, only a drop here and a drop there.
It will be broken down. And if you again suck some clots again, it has no benefit. So the only benefit of it is if you are applying the suction under a pool of blood and collect that. Is contraindicated when you are suspecting malignancy and/or sepsis, which which is common sense when you use topical antibiotics. Again, it is contraindicated because the sample you are collecting will be concentrated even further and given back to the patient at a higher concentrations that can be toxic.
We are talking about local antibiotics. We're not talking about general antibiotics. And whenever there is a topical like wound anticoagulant. So coagulant factors, I think like surgical or cement because you don't want that to get into the bloodstream. The complications of the unwashed, which is the old method, which is just collecting a blood through the drain and giving it back to the patient, it can cause hypertension hypothermia.
It it has been reported to cause aids, DIC and even death. It can cause fibroid reaction and because the blood can be hemorrhaged, in fact, it is, some of it will be generalized. It can cause renal failure, especially if you give significant, significantly high amount of it. OK now, if the other method of giving autologous blood donation is the patient themselves, donate their own blood before the operation buys some time and that is stored for them during that time, their body is producing more blood and then that same blood is given back to the patient.
The typical method for doing so is to take one or two units. The last one about three days before the operation. You, the patient has to have a reasonably good hemoglobin before that, and they have to have reasonably good health to be able to cope with the blood loss beforehand. So people who have cardiac problems, renal problems, you are suspecting that their erythropoietin is not going to be produced in a significant amount that would compensate for the loss, then you don't give that and you don't give it when there is infection.
OK, so that's what I wanted to talk. One more scenario that can come in the exam is the Jehovah's Witness. Now, the auto transfusion is not automatically accepted by Jehovah's witness, although it is their own blood. Some of them would insist on having a full circle, which means the blood does not actually leave the cycle from their body so that the auto transfusion machine can be adjusted to accommodate that, and not all of them will even accept this.
So in the exam, don't mention it like this is the answer. You mentioned that you would suggest this and discuss it with the patient, explaining that you are happy to make this adjustment to the machine, if that would help the patient. Obviously, the discussion will go on then to discuss other methods like medical methods, erythropoietin injections and, you know, preparations beforehand and all of that, well, that's quite good.
Just the caution Jehovah's witnesses, it's their right to say no to a blood transfusion, and you need to know the steps you can perform to minimize the risk to the patient. And as Abdullah said, just to reinforce this is not the panacea or the silver bullet that helps you manage. Absolutely good. OK, moving on, the next process I'm going to talk about is image intensifier.
You will mention that you will bring that to do a manipulation under image intensifier and it's a fair game. Then to stop you and ask Tell me about image intensifier again definition. What is it? It is a fluoroscopy system for use in theater. By that, it's an X-ray machine. Components are a system where there is an X-ray tube on one side and a receiver on the other side.
This system is connected to a computer with a control panel and a monitor to show the images at least one monitor. So now you've defined it. You describe how it is done. So it is like your X-ray. There is photocathode converter on the converts that X-ray on the receiver to light, then detected by Closed circuit video system, which is shown on the monitor.
OK should be able to describe how the X-ray machine is only the X-rays are made, which is the vacuum tungsten electricity, you know, high, higher, high velocity and then hitting a Dagestan plate. You should be able to describe that. But for the image intensifier itself, this would be enough. There are factors that would affect the quality of the image. And these you need to know about what is the current, what is the voltage and the exposure time and how they affect the image you get?
So the current, which is measured by milli ampere. Is the controls, the quantity of the radiation? The number of radiation is that you are getting, the more numbers you have, the more the better quality of your image. Or the voltage, however, which is kilovolt controls the energy of each ray.
So the more voltage you have, the more penetration you get, which means then it will penetrate more of the bone, and the bone would look like the normal tissue because it doesn't stand. The less penetration you have, the more contrast you have between the bone and the soft tissue. So that's the difference between the current and the voltage, the duration of exposure is what is described as the beam on time, and that is the amount of time you are leaving your finger on the button.
So these machines, the fluoroscopy is not like a quick flash it it keeps beaming as long as the finger is on the button and this is you need to be aware of. And even this is not, you know, is not a one radiation. It's a continuous radiation. The machine nowadays controls everything for you, so you get an automated call calibration of the current and voltage, depending on what the computer in the CRM thinks is the best thing to show you the image.
And that's why you don't have to adjust it every now and then, but you still have the ability to do so should you feel that you need to. For example, if there is a metal in the way and you want to see the images better? So this is a picture of the image inside, which we have all used. There are certain techniques that you need to be aware of magnification.
When you do magnification, you are actually expanding the receiving end. So the source is the same, but the receiving is bigger. So that causes a bit of distortion, especially at the ends of it. You need to be aware of that. The opposite of that or something slightly looks like the opposite, which is called Mason or koning, which is put a physical plastic at the source, so you are reducing the source area by definition, then you are reducing the receiving end as well.
So reducing the amount of radiation that body the patient is receiving. The damaging effect of the radiation, it can be dependent on the dose, the rate and the type of tissue and the patient's ability to cope with that. So the type of tissue, the higher the what's the word, sorry, my toast is right, the more susceptible they are to damage the more active DNA production, the more susceptible to damage.
Hence, the developing embryo is highly susceptible. There is this definition, which you may be presented with and asked to answer what is stochastic and non stochastic? So stochastic means that, so the non stochastic means that there is a linear or relationship between the dose and the effect. So the more the dose, the more the effect. And there is a relationship between them.
Stochastic means there is no direct relationship, so you may have a small dose and that gives you a big effect and vice versa. And cancer is stochastic effect, especially long term because even smallest amount of radiation can lead to cancer in the long term. The non stochastic is things like burns and damage to the cornea and, you know, irritation and all of that. These are.
So the more radiation dose, the more you will feel these effects. One more thing, Qatar is highest at the X-ray site, hence you try and put that X-ray site under the table. So that all this Qatar is away from you. And the patient. Another factor that you will be expected to know is the radiation decrease according to the inverse square distance.
So and it is negligible by 2 meters, so 10 centimeter means that it reduces by 100 times, so it's squared. OK The most important thing you need to be aware of, which is the governing regulation for it, which is written there, which is short for ionizing radiation medical exposure regulations, you need to pass that course before you are allowed to use ACR.
Hence, you are expected to know about it in the exam. It is not a complex thing. It is just telling you the regulations. The law that governs how you use this and gives you. Actually, it's a useful booklet that you can, you know, you can ask to download from your local radiology radiology department because it gives you some basic physics, which you can use for the exam.
The main thing is everyone has a responsibility to reduce the exposure to radiation, either as a prescriber. Or as a obturator and in the theater, you can be both if you are having a minnesotan, for example, you can be both. And again, you are under the law. If you are black, if you don't comply with that. So the basic principle they are trying to advocate is the principle of Allen, which is as low as reasonably possible, which means you give the patient as lower total dose as reasonably possible by the end of your examination.
And in theater, that means as least so the least number of images you take for the least time possible. And by doing these steps, which I would leave you to read, you can make sure that you are reducing the radiation. And again, this is an exam question. You can be asked how would you reduce the risk of radiation in theater? I would stress on one thing that you may not find in many books, which is communication.
You need to have good communication with the radiographer. You need to establish a rapport and a clear language to this so that you don't do more x-rays than needed. No, no. I meant you go up up as an up to the sky, not up to the head of the patient. And then the, you know, the radiographer have taken three or four x-rays.
So I leave you to read that. And then we'll move to the next topic, but next topic is diet fun. The word diet. I tried to find because at some stage I was really interested to find out where it came from. It's actually Greek and it means through heat die means through passing through. And the reason is the electricity is passing and leaving the heat.
And that's the dichotomy. And the definition is the tissue heating effect when high frequency current passes through the body. The principle is if you focus a huge amount of electricity into a small area of the body, the amount of heat produced would have an effect on the tissue. And that effect can be either to cut coagulate, desecrate or damage. And then if you have control of that current, you can decide how that affects the body.
Bear in mind, the same electricity that goes into the body comes out of the body at some stage, but it does not burn on the outside because by then it is distributed over a bigger area, bigger surface and by doing so, it loses its intensity and then it loses its effect. And that's why it's very important for bipolar or unipolar to have a bigger surface of receiver and make sure that there is no objection to, you know, no nothing blocking it.
OK, now the current is alternative, cut it the current ac, and it has 0.4 to 10 megahertz. These radio frequencies do not affect the muscles or nerves, so they do not cause twitching of the muscles or the nerves. You have to have way lower frequencies than that to affect the nerves. The heat is generated through joules low, which is the amount of heat in joules is double the current density.
So the square, the current density multiplied by the body's resistance multiplied by time. So the more fluid there is in the body, the least the resistance, which means the least the heat. Hence the diaphragm doesn't work under water. The tissue temperature that can be developing at the tip of the diaphragm is about 1,000 degrees centigrade, but it reduces to 38 degrees.
Only centimeter away, and that is because it dissipates over a bigger surface. Now, there are two types of tenotomy, the most popular and the bipolar we all know them, it's how you describe them in the exam. So the monopolar you enter, the body is sort of the electricity enter the body in one side, passes through the body and gets out of the body over a receiver that is attached to a part of the body and then it goes to the machine.
Previously, it used to be earthed, but now they go to a special machine to protect patients from differences or problems with electricity. The plate has to be 70 centimeters square, and it has to have full attachment to the body with no hair or wet surfaces. OK the it has to be put away from anybody prominences, scar tissues, metallic implants and definitely away from the heart and make sure that the current does not pass anywhere near the heart, especially if there is implantable devices.
The bipolar therapy, however, does not need that plate and the current pulses through the two arms of the biceps solid biceps forceps. So it is only in that area and it has lower energy. So it's 50 units, so 50 watts compared to 400 watts for the monopolar. Now, let's talk about modes, we thought we mentioned the cutting coagulation. There are other modes and it depends on the electricity passing through and how they do.
So the cutting mode is when you have pure continuous sine wave, all of them continuous sideways. But here you have continuous and low voltage and that produces high temperature, vaporizing the tissue because the cell explosion and then a gap appears. So that's the cut. And here you don't have to have full contact with that issue because it's the heat.
It's not the electricity, the coagulation. However, you have intermittent signed sine wave, but it has more power and it goes on and then rests for a bit and then on again. Somewhere in between is figuration, which is high voltage of coagulation that causes like an explosion of the tissues, which is a mixture of vaporization and coagulation. This is when you keep it in touch, but only using so it's lower heat than cutting, so it dries only the tissue.
And then it just circulates. A blend is any mixture of the above. And just to describe it, if you look here on the left hand side is pure cut. On the right hand side is coagulation and the middle it's a blend. And if you go further on the right, you have the full duration, which is even more bigger damage around the area.
And these are the frequencies or the voltages of how they look between coagulation and cutting. You can notice that if you look at my arrow. So for the calculation, there is one wave and then and then another wave, while in the cutting it's continuous. How does what sort of things that would affect the function of the coagulation?
Number one is the mode you chose. You can choose cutting or coagulation. You can. The more time you apply it, obviously, the more heat that will generate the size of the electrode. The smaller the size, the more heat it produces. Tissue nature as we mentioned earlier, especially isca scar is like a charred, burned tissue, and it has high, very high resistance, which means it produces even more heat and more and more damage.
Tenotomy safety only thing I will mention here is there are four, three or four side effects or complications of using dynamite. We know about burns and fire, especially whenever you're using alcohol, and that's why it's very, very important to prevent any pooling of alcohol based antiseptics around the body because they can explode when you are using a diaphragm.
The smoke of diatom have been studied, and the CDC say that it contains many chemicals that can be toxic or carcinogenic, like hydrogen cyanide, cyanide and benzene. In addition, it does not kill viruses. So viruses can transmit through the vapor of these family. It can interfere with the ECG monitoring, EEG monitoring and defibrillators, especially the built in defibrillators in the patients.
So always have a clear communication with the anesthetist beforehand. And in these cases, if you can, if you can avoid using the diaphragm do. But if you have to use it, use a bi-polar instead and use it as far away from the heart as possible. That's it. That's as much as, Oh yes, NICE guidelines mention that you should not use me to cut the skin because it would increase the risk of local infection.
Remember this? Ok? I think this is as much as I wanted to talk about it. And these are some references. There is a nice booklet which comes from asset, the Association of surgical trainees. It explains it in a really nice way. This is the link for it. Penny, any remarks, you guys.
That's interesting, you found that nice guidance and saying don't use the before skin social pressure irrigation. So what is pressure? Irrigation is a method of delivering irrigation to the tissue under high pressure. So the way we irrigate the wound can be divided into low or high irrigation, high pressure irrigation, anything between 1 to 15.
Forgot the unit pound per square inch is low pressure, and anything above 15 is high pressure and there is some people devise it, you know, divide it into low, medium and high. Usually when they say high pressure, they are looking at the pulse lavarch. This is what is commonly known by but by low pressure. We are talking about using a syringe or pouring of normal saline or just giving it through a giving set with gravity assisted.
So what is the. Benefit so the difference between using the two, so the low pressure you usually use it with a brush or a scrub to try and clear the wound and reduce the amount of debris. So this is gentler to the tissues. And some studies, like the one I've mentioned here, Dreger and downers suggest that actually you move. You remove more debris through the low pressure than high debris, and it does not cause any damage to the tissues, including the healing bone.
The high pressure method the advocates say that it is more powerful and can relieve a lot more pressure. So the debris from the wound, including bacteria and advocates, suggests that they have done some studies, including beef meat. They have put some bacteria into it and try and clean it with either method and found that the bacteria removed more with the pulsed lavage you can.
You could look at the paper there. Having said that, there is a new evidence this is an international multicenter study, new, I think it's 2019 2020 from Canada. They have looked at two things. They have looked at the type of pulse so of pressure, so either high pressure or low pressure. And if you looked at using normal saline versus soap in open fractures and they looked at the amount of clinical reoperation as indication of infection rate, and they found actually that low pressure is better.
It gives low reoperation rate. And the explanation could be because by damaging the tissue, you are actually push the bacteria and the deeper, deeper, deeper into the deep tissues. And then they rebound with a bigger infection. So this is the new study, which you would be expected to quote in the FRC exam. So what is the bottom line with all the evidence, conflicting previous evidence and this big study, which only looked at open fracture, it did not look at elective cases.
It did not look at chronic infection, with which, for example, in limb reconstruction with osteomyelitis and how we wash it. They looked specifically at only open fractures. So how would you take that into practice? A pragmatic way is not to use it for open fractures or for normal cases and use it only if you're clearing an ongoing infection like a, you know, osteomyelitis.
OK concerning the additives, they found, actually that the soap gives more rebound of bacteremia compared to normal saline. So NICE guidelines suggest the following, and this is what we should be following, and this is from 2008. Do not use wound irrigation, do not in lavage and do not apply antiseptic or antibiotics to the wound before closure.
And this is what you should quote. So this is just a bit of some information to start you talking to organize your thoughts in your head. Plaster of Paris is calcium sulfate with water. It's cheap, not irritant, easily applied, malleable, so malleable and ready loosened. It is made by heating mind purified gypsum at 120 degrees.
It allows partial dehydration and then it gets it, gives it its properties recently or, you know, from the 70s when zirconium chloride is added to increase its properties. Once it's mixed with water, it produces heat and then it becomes a porous mass and porous is an important word here. The reason is it allows some breathing of the skin. So the skin underneath it is losing a bit of heat through the porosity of the.
A plaster. It needs about 36 to 72 hours to completely dry, but the patient can start walking on it if it's a full cost in about 48 hours. There are two stages like cement. The setting stage and the hardening stage, and the quality of your plaster is determined by the quality of your cast is determined by the quality of the plaster material.
The water to gypsum ratio, the age of the gypsum and the storage conditions. The more wet it becomes, the less effective. There are almost no allergic reaction to plaster of Paris. Once you've talked about it, you talk about certain techniques in how to apply it. So you always put a padding of a sufficient thickness, not thick enough, not too thick to lose reduction and not to thin to allow heat to get to the skin.
You roll the plaster bandages. You don't pull them. You allow them to dry naturally. The heat is produced depending on the speed that it dries. So the more the faster it dries, the hotter it becomes. So that's one reason for you not to draw it with, I don't know, like a, you know, a heater or something. There are some reports of Burns coming from the cockpit because of the plaster.
Fiber blast, fiber fiber glass cast is a synthetic material. It's called glass reinforced plastic. It is polymer with glass in it. OK and it comes obviously in different colors. It is stronger than plaster and lighter, but you cannot use it as the first time, you know, cast because it does not allow for swelling of the body. Complications of casting in general, you should know them DVT compartment, syndrome, swelling and subsidence leading to loss of reduction pressure sores.
We've seen it venous congestion and this symptom, which is related to stiffness of the joints, damage to the tendons, muscles and skin stabilization techniques. This is a complex topic. It's you might be expected to describe what happens if you drop something in theater and you want to clean it and then how would you clean it and what would you accept as a cleaning method?
Or what do you think happens to the instruments once they have sent to the ssd? So all these are fair because it has bearing on your work. So in general, we divide items that the patient's used into critical semi critical and non-critical items. The critical items are ones that are in contact with unprotected parts of the body, so they should have no contamination whatsoever.
The same critical are in contact normally with normal parts of the body like a mucosa, OK and intact skin, and which means they have to have protection, but it doesn't have to be the same level. And then the noncritical are anything that patients use, like clothes or medications or stuff like that. They are not in contact.
So for that, we have different levels of removal of contamination. So you have cleaning, which is just removal of the dirt, but specifically removal of bacteria. You have sterilization, high level disinfection, intermediate level disinfection and low level disinfection, and you will be expected to know the difference between them, basically. Sterilization is when you remove all bacteria, viruses, fungi and, more importantly, spores.
The high level disinfection to remove everything but spores. The low level disinfection everything, but you don't remove mycobacteria or spores. OK all of them are disinfection, cleaning doesn't remove any of these, it's just visible dirt. OK you could look at this. Summary, it's a really nice paper summarizing all of that. The WHO document has a really again nice document talking about how you sterilize how you set up a hospital with a sterilization unit.
There are some aspects that apply to us. For us, what we need to know about is the mainstream of sterilization. Our instruments is the autoclave. It should be disinfected first and cleaned before sent to SSD. The reason is we want to protect the staff there. It is left in the autoclave for 20 minutes at 121 232 degrees or for 30 minutes. If they are wrapped packed.
And there are some indicators in there put in the machine to indicate whether there is, it has done its job or not. The dry heat is not as effective as autoclave, but it is applied to 1 to two hours, 470 degrees. And again, they have to be cleaned beforehand. This is. Poor alternative, but sometimes the only alternative in some settings. Boiling itself is not good enough, antiseptics is sometimes used like a glut of aldehyde or chlorhexidine, especially they put like a small desk with the instruments.
And they leave them. This is usually used for things like the drills and machines that have multiple mobile parts. Plus, sterilization is a new technique. It's not that new, but it's new, it's a modification of the conventional steam sterilization whereby it is put in a container rigid container with its covering and then it is allowed to quickly clean.
And this is usually used when you are in need for, you know, you dropped something and you want it cleaned very, very quickly. And this is, they call it the quick cycle. So if you speak to your SSD, this is how they do it. But they don't advocate it for routine use, it is something only for emergencies, if you know, if it is needed. OK there are some chemical methods like ethylene oxide, Eto.
This is something that is commonly used, so we probably need to know about it. It's odorless, flammable and explosive, and it is. The machine is already the instruments are left with it under heat. And then once you move the machine from that, once it gets exposed to air, it loses some of its sterility. The way it works is its localization of the proteins.
Hydrogen peroxide with plasma is as effective as the other one, and it is used usually for electrical components. Um, last one is ozone or hydrogen peroxide with ozone. It breaks down into oxygen and H2O by the end of it, and the duration of the cycle is about four hours and water. It is used for many, many materials, but it is not used for brass, aluminium, liquids, textile and cellulose.
And that's it, I hope I did not send all of you to sleep, I hope some of you are still awake. Anything you would like to add goes on sterilization. Actually, I have a question to them. Do you still use flash sterilization or trust us taking that out? I did not ask our trust, I have to say, but lost trust. I know we have a rapid cycle and I assume that it is the same. Because we dropped, we dropped an instrument and we needed that, so they did that quickly.
It's the best management for Tony claw palsy. It depends on the cause. Usually it is in your apraxia, usually, which means it will come back alone on its own. Having said that, the usual practice is you check the patient, make sure that it is that not something else that you've cut during the operation and then you leave it for six weeks and then you do nerve conduction.
Absolutely so, for example, in knee replacements, a patient then gets a perineal foot. Of course, splints think a patient putting splint on. Think of the cause of this perineal foot drop. It's often not the tourniquet, so look for other reasons. Don't assume it's the tourniquet. There's a reason why the tourniquet is always put on the flesh as part of the problem. It's to avoid the nerve injury.
OK interesting about the Tony Kaye, can you apply it to the lower limb as into the lower leg or the forearm in foot and ankle. They apply to the calf? Yes, they do, but it has less efficacy because of the interosseous membrane protection of some of the vessels there, which cannot be blocked. OK is there any other questions?
OK inappropriate, and you do not have another how to deal with one important instrument fell down intraoperatively. Don't drop it. No well, you have to think outside the box. The thing is, it depends on what sort of instrument you are. If it is going to stay in the patient, it's an implant. Then you know, either you delay the operation or you are putting an implant, which has substandard and could be contaminated with long term infection problems.
So it's a judgment call, and I would personally if it's an implant. I wouldn't risk it, the patient can always come back later. But the idea is in planning why? Why are you having only one implant in the whole hospital and then you drop it? I mean, yeah, so yeah, I don't know what the other matter is. If this came up in the exam, dropped instrument or more importantly, you have one set of an instrument.
My response is always, I will ask for another set of instruments to be made available to me, either from a number of hospital or from a company before I endeavor to take on this procedure. So that I have a backup, a set of instruments in case one fails or breaks to dropped. Three the sterilization procedure is compromised. You open a packet and you find the patient is under anesthesia.
You've opened the pack and it's been compromised with a hole or something like that. So there are multiple reasons why you shouldn't have only one of any instrument. I would not say things like, I'll give it a quick rub and push it, put it back in or put it no. One thing, one thing the examiners may want to know about your knowledge of sterilization, and then he will give you the scenario and whatever answer you give him, he will block it for you.
The only thing he wants to hear is whether you send it to SSD and what they will do with it, and then it will not be something that you would leave in the body. It will be a vital instrument like, I don't know, for example, the implant holder or something that you have only one set of and it's dropped and you cannot hold it in the implant or oriented or something, but it's not staying in the body. Then what will you do?
So I think that's but that's what you are alluding to. And if that is the case, then you can say I will send it for a flash, a sterilization because we have, you know, rapid cycle in our SSD if they can't find me an alternative. Absolutely but it's yeah, I'm not that's a very reasonable thing to say, but kind of. Don't just say, oh, because it's not something that should happen, it does not make sense.
Something that should be detected if you're dropping something and flashing it, you should be reported as a potential problem. And even in terms of GMC guidance, you should be also documenting it and reporting it to the patient and explaining what you're going to do to make sure the patient doesn't have consequences managing the patient, but also what you're going to do to make sure this doesn't happen again.
So it's not. This is not an easy question, by the way. It's not a simple, put it in the flash. We are saying it like that, but it's not. The only thing is you always start by saying the best thing is in planning, I should have planned to have alternatives beforehand. And he said, yes, you plan, but all of them lost sterility in whatever, whatever and then you.
It's not. It's like giving you the tumor question. You don't immediately say, I will do this. You have to give all this the right steps beforehand. So you planned, you made sure that it's available. You asked about other alternatives. You ask in other hospitals, you brought a consultant. Next door and asked him, this is the situation. Do you do you have to have another instrument that how to use that could replace this one?
If all of them are not, then yes, and final. And the final one is. So one example where they can put a lot of pressure on you and say you've three small fragment sets you've opened, both with each one has a hole in the pack and lost. What you do? Don't say you're going to operate on the patient with the non-stop sex, either wake your patient up and come back later or get flush, and if you have to get flash for an ankle fracture, you might as well wake up the patient and do it.
Certainly the only reason for you is the patient is critical. And there is no, you know, the harms of delaying the operation are by far more than the harms of operating with a flash sterilization. And then, yeah, but then you include another consultant with you, so that's what you tell them. I will include another consultant in the decision making. Absolutely yeah, that's very true.
Thank you very much, guys. I hope it was useful. And if you later on develop any questions or have anything, just put it on the telecom group. So thank you, everybody. Abdullah, really appreciate you. First of all, just scrubbing and coming straight away to do this. I know you've missed your, first of all, tired and probably very thirsty and hungry.
And I know you have a long trip home, so we thank you so much. No problem. In fact, if that is the case, may I excused myself and just disappear and I leave it in your hands? Very upset if you don't want to generalize the mental groups. Thank you to the mentors KneeKG Evans and Hannah Darcy. And also a reminder that we have published concise notes new improved editions there.
So please reference that book if you can for your studies. We think we think it is in your best interest, and that's all we're interested in.
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