8 Undergoing surgery
the operating theatre experience
Introduction
In this chapter, we explain the basic principles of the operating theatre environment, the personnel who you will come across in the theatre during your placement learning experience and the broad principles of theatre practice and key health and safety considerations for both patients and theatre personnel. General principles of being a student in this environment are also explored. It is beyond the scope of this book to give full details of all aspects of caring for a patient in the operating theatre, and further reading material is provided at the end of the chapter for you to explore various aspects of what you might learn about in this placement.
Entering the operating theatre
The patient enters the theatre in the care of the anaesthetist and assistants, who will be responsible for their safety and wellbeing together with the rest of the surgical team until the end of the surgery and during the patient's time in the postoperative recovery room. We return to safety issues in the operating theatre later in the chapter; however, consider the following activity before your placement.
The World Health Organisation (WHO) has developed a number of resources to improve surgical patient safety worldwide
Take the time to explore this website:http://www.who.int/features/factfiles/safe_surgery/en/ (accessed December 2011).
Remember that when a patient has a general anaesthetic, it is important to maintain their dignity and respect and to maintain communication in some form throughout the stages of anaesthesia until they are in a sterile field, when touching them on the hand, for example, will no longer be possible. Of course, if they are having a regional anaesthetic where they will be awake during the surgery, then communication goes to the top of the list of importance in the care of the patient. Effective and caring communication is a fundamental part of nursing care and is one of the major domains in the NMC (2010) Standards and Competencies that you have to achieve to qualify as a nurse. In the new curricula, these will be found in your practice assessment documentation which you will take with you to all placements, given that your ongoing record of achievement (ORA) will be required from placement to placement (see further information on Domain 2 at http://standards.nmc-uk.org/PublishedDocuments/Standards%20for%20pre-registration%20nursing%20education%2016082010.pdf (accessed May 2011).
What does the operating theatre look like?
Television series such as Holby City and Gray's Anatomy have varying degrees of authenticity about their scenarios and context, some more dramatic than others. For most of us, that is as far as we get in terms of a visit to the operating theatre as a patient, but it is important to understand that for many of the patients in your care, this is their first experience.
Explanation of what will happen to patients when they get into the anaesthetic room and the operating theatre is an important part of reducing preoperative anxiety and if, as a student, you have this opportunity to have an ‘insider’ experience then you will be in a more informed position to help patients in your care.
The best way for you to see what the operating theatre looks like before your placement is to look at a visual presentation. You will see that it is a very ‘high tech’ area and many students experience the operating theatre, recovery ward and anaesthetic room during a critical care placement as well as a surgical placement.
Discuss with your personal tutor your learning goals with regards to communication in this placement, either on the surgical ward or in the operating theatre. When you arrive on placement, discuss with your mentor what communication competencies you have to achieve in the placement, especially important at the various progression points to the next stage of your programme and journey to become a qualified nurse.
Operating theatres in hospital are normally in a purpose-built unit set apart from the main corridors but within access of surgical wards and recovery areas. There are special safety and infection control requirements essential for an operating theatre which you will experience when you visit or have a placement there. Operating theatres usually come in groups together known as the operating theatre suite – the larger the hospital, the more of these they need to accommodate the various surgeries that need to take place. They can also be attached to day surgery units and even in the community setting, in community hospitals for example.
Consider the scenes in this video clip (which has been evaluated for its overall quality in informing you about the perioperative environment and nursing):
http://www.youtube.com/watch?v=exAQC9Ync-0 (accessed December 2011).
What does it tell you about this important and key role for nurses?
Imagine what you think it will look like and what you think you will feel in actually being in the operating theatre. When you have actually experienced it, reflect on your experience using a reflective model/framework and compare your pre-visit notes. This is an excellent reflection to write up for your learning portfolio.
Operating theatres can also be found in isolated places and war zones – the environment being a large tent rather than solid walls. Similar equipment will be found but the surgical team will have to adapt their practice accordingly.
View some of the video clips in this chapter from the viewpoint of the general operating theatre environment to gain a pre-placement idea of what to expect.
Before considering the surgical experience for the patient in the operating theatre, we can briefly consider the team members and their roles. You already met some of them in Chapter 7.
The team in the operating theatre
The operating theatre is a highly specialised, multidisciplinary work environment. Operating theatre teams consist of professionals from at least four different specialties, namely anaesthetists, nurses, operating department practitioners and surgeons.
Anaesthetists are specialist doctors who are trained in anaesthesia (refer to Ch. 7).
Surgeons are doctors who have trained in a specific field of surgery following initial qualification and mandatory experience. Examples are orthopaedics, plastic surgery, gynaecology and cardiac surgery.
Scrub nurses are nurses who work directly with one or more surgeons while they are operating on the patient. Sometimes they are called instrument nurses or practitioners (Mitchell & Finn 2008).
Another similar role is the first assistant nurse, who has gained additional qualifications as well as experience in assisting the surgeon during surgery, and undertakes a high level of technical and assistant skills but does not actually carry out the surgery.
A circulating nurse is another type of operating theatre nurse who works on the perimeter of the operating room, monitoring patient care, ensuring that the room stays sterile and keeping track of instruments and sponges. The circulating nurse is a vital team member. This role in the USA is referred to as the circulator nurse.
The AORN Journal website describes the roles of the scrub nurse and the circulator nurse: http://www.aorn.org/CareerCenter/CareerDevelopment/RoleOfThePerioperativeNurse/ (accessed June 2011). You can see where the concept of ‘scrub’ comes from in relation to being ‘scrubbed’ and sterile for working in a sterile field alongside the surgeon.
Operating department practitioners participate as part of the team in a number of roles including the scrubbed role, circulating role and, as is mostly the case in the UK, act as the ‘anaesthetic assistant’ to the anaesthetist. Watch this YouTube clip for more information: http://www.youtube.com/watch?v=buKBoyt6WQs&feature=related (accessed December 2011).
The surgery
We have mentioned a number of different types of surgery, in particular day surgery and surgery requiring a longer hospital stay which could entail minimal invasive surgery or major surgery. It is beyond the scope of this book to cover all these in any detail but further reading is recommended on all of them. When you get to your main placement in perioperative care, it is up to you to find out more about the kinds of surgery that takes place in the operating theatre in each case, and the case studies in Section 3 focus in more detail on an example of each one of these to help you understand the care of the patient in the various perioperative environments.
Day surgery
Oakley (2010:35) describes day surgery as ‘a specialist area of care where patients are admitted into a designated day surgery unit for minor and intermediate surgery, and discharged home the same day’. Examples of the types of surgical intervention you will see in a day surgery operating theatre are given in Box 8.1.
Box 8.1 Types of surgical intervention in a day surgery operating theatre
Anal fissure dilation and excision.
Varicose vein stripping and ligation.
Transurethral resection of bladder tumour.
Excision of Dupuytren's contracture.
Extraction of cataract with/without implants.
(From The Audit Commission ‘basket of 25’ (Audit Commission 2001) cited in Oakley (2010:36))
Other, more major procedures can be undertaken according to the British Association of Day Surgery (Oakley 2010) but these are considered on a strict protocol and individual basis.
Prior to your placement, identify exactly what each of the different kinds of surgery in Box 8.1 entails and make notes about each of them. After your placement is complete, check which ones you actually saw in a day surgery or other context and reflect on your experience in caring for patients in each situation.
Read the chapter by Oakley (2010) on day surgery if possible before you go to your day care surgery placement or other perioperative placements.
The articles by Mitchell (2010) and Mottram (2011) (see References) are also helpful.
Minimal invasive surgery
Certainly in the day care unit, you will see examples of minimal invasive surgery (often called keyhole surgery) using the latest technology. Surgery such as laparoscopic cholecystectomy is an example. This type of surgery obviously causes less trauma for the patient and use of the equipment requires different skills and training to ensure safe practice by members of the surgical team.
An explanation of this can be seen on this video clip which is a news item by the BBC: http://www.youtube.com/watch?v=nbdVsGS29Fk (accessed December 2011).
Major surgery (requiring longer than a day)
As noted in previous chapters, this is surgery that cannot take place in a day care unit and requires a longer stay in hospital or is an emergency. Examples classed as major surgery normally requiring a general anaesthetic (see Ch. 7) are given in Box 8.2.
Box 8.2 Examples of major surgical interventions
Hysterectomy (removal of uterus) sometimes along with a bilateral salpingo-oophorectomy (removal of both fallopian tubes and ovaries).
Abdominoperineal excision of rectum (removal of sigmoid colon and formation of an abdominal colostomy).
Upper gastrointestinal surgery
Oesophagectomy (removal of oesophagus).
Total hip replacement (arthroplasty) (replacement of both head of femur and acetabulum).
Imagine you have been allocated to observe in the orthopaedic operating theatre for the day by your mentor in the surgical ward (main placement). Identify the four most common operations likely to be performed during that period of observation.
Consider what you need to know about the areas of the body being operated on. Make a list of all the anatomy and physiology you need to read up on if you are to make a contribution to the overall care of a patient in this setting.
Each type of surgery is carried out by specialist surgeons and their teams, so patients having surgery to the ear, nose and throat will have a different surgical team and operating theatre to patients having surgery on the gastrointestinal system. Nurses who work in theatres may well specialise in the same field as the surgeon and eventually lead a team of nurses who may work only for that surgical specialty.
The nurse caring for a patient undergoing surgery for orthopaedic problems noted above will be expected to have a detailed knowledge of the anatomy and physiology of the musculoskeletal system as well as the surgery involved, including the exact instruments the orthopaedic surgeon might need to carry out the procedure.
In an orthopaedic operating theatre, the noise levels can be quite high due to the tools used, and a study by Siverdeen et al (2008) found that this could lead to potential hearing problems in staff exposed for prolonged periods and that precautions and careful monitoring of noise levels was important.
Safety in the operating theatre
There are a wide range of safety issues in the operating theatre. Given the fact that the environment has highly specialised electrical equipment, anaesthetic gases and has to be infection proof, as a student it is important that you are fully aware of the management of risk in these areas when going either to observe or to experience a full placement.
Your mentor will ensure you are made aware of local policies and procedures with regards to safety in all areas of the operating theatre and its related areas, but we now consider basic information that you can refer to either before or during the placement.
Review the NMC (2010) Essential Skills Cluster: Infection Prevention and Control.
Once you are aware of the policies, procedures and evidence base for some of the related nursing activities, undertake the following.
Linked to your forthcoming progression point (PP1 and final third year placement for those on the 2004 NMC Standards and Competencies, and PP1, PP2 or final sign off placement for those on the 2010 NMC Standards and Competencies), develop an action plan with your mentor as to the opportunities you will experience while in the operating theatre and how these can be evidenced as a record of your achieving this essential skill cluster. (See Appendix 1 at the end of this chapter for the Infection Prevention and Control Essential Skills Cluster outcomes.)
Appendix 1
Specific learning experiences in the operating theatre: checklist of possible learning outcomes
To become familiar with the layout of the operating theatre and where everything is kept, such as equipment and various intravenous fluids.
To gain experience working in a multidisciplinary team and understand the role of the theatre team as well as other health professionals who have close links to patient care in the theatre, such as radiographers or pathologists.
To gain an understanding of the importance of infection prevention and control as well as universal precautions and the sterilisation of equipment and surgical packs.
To gain an understanding of the importance of maintaining accurate documentation and recording of events in the operating theatre.
To gain experience of effective communication to ensure patient safety and to be a patient advocate at all times.
To gain experience in managing the holistic care of the patient during surgery, maintaining their dignity and also demonstrating an awareness of any special cultural needs and/or special needs such as patients with learning difficulties, loss of hearing, vision or speech.
To demonstrate understanding and practice of asepsis and aseptic technique.
To observe and/or perform surgical scrub and putting on gown and gloves.
To gain an understanding of and demonstrate implementation of all correct procedures with regards to the surgical field, including instruments, needles and swabs, types of sutures and drains used.
To demonstrate a knowledge of the various positions that patients are placed in on the operating table and the reasons why as well as for what surgical procedures.
Infection prevention in the operating theatre
Infection prevention in the operating theatre is achieved through careful use of aseptic techniques in order to prevent contamination of the open wound and isolation of the operative site from the surrounding unsterile physical environment through creating and maintaining a sterile field in which surgery can be performed safely (Weaving et al 2008).
Weaving et al's (2008) article is an Open Learning Zone article for qualified nurses but has some excellent learning tasks which you could also undertake. It has a very comprehensive reference list which is an added resource. It can be found in full at:
http://findarticles.com/p/articles/mi_m0748/is_5_18/ai_n31879368/?tag=content;col1 (accessed December 2011).
Weaving et al (2008:200) talk about a ‘back to basics’ approach as being ‘the key to optimal infection control and prevention in the operating theatre’. They note that the theatre design must first of all make sure that airborne bacteria are removed from the surrounding fields through adequate ventilation throughout the operating theatre suite as a whole (as the theatres connect with each other) as well as it being an environment that is easily cleaned and managed. Good theatre practice is second on their list of important control and prevention activities, being underpinned by a current evidence base and not just custom and practice.
They describe an evidence base regarding preparation of the patient (citing Tanner's (2006) and Tanner et al's (2007) evidence on hair removal and skin preparation) and staff preparation (special clothing and removal of jewellery, hair covering, nail care, etc.). They advocate the wearing of masks, sterile gloves and gowns by staff as a matter of course both for their own protection and that of the patient, underpinned by other evidence. Patient preparation includes the use of special sterile drapes (no touching by non-sterile personnel) and, prior to any management of sterile equipment or field, systematic hand antisepsis (hand scrubbing) with an appropriate solution. This applies to all staff involved in managing the surgical field and the actual surgical procedure. Hand hygiene applies to all personnel in the team. Many hospitals now ensure that even visitors are encouraged to use antiseptic solutions strategically placed throughout the corridors, outside wards and in other areas. Weaving et al (2008:202) also point out that even though surgical instruments arrive sterile, there may still be a risk of contamination and that ‘in order to minimise this risk, all members of the operating team need to be proficient in aseptic technique’.
Look at the following video clips of handwashing on the ward and the handwash you are expected to undertake in the operating theatre if you are going to assist as a scrub nurse.
A Complete Guide to Hand Washing (University of Leicester): http://www.youtube.com/watch?v=mWe51EKbewk (accessed May 2011).
A Comprehensive Guide to the Surgical Scrub (Whittington Hospital London): http://www.youtube.com/watch?v=L8OLnyJ3mAc&feature=related (accessed May 2011).
These are two very good examples of good handwashing practice. Your university may also have its own clinical skills video material – check this out on your virtual learning environment such as BlackBoard.
Under the supervision and direction of your mentor, practice undertaking both types of experiences and discuss what the differences are between normal day-to-day best handwashing practice and that related to the surgical scrub practice of gowning up and putting on sterile gloves for assisting during surgery. What are the challenges you experience in doing a surgical scrub handwash and gowning up/putting on gloves in the theatre environment?
Documentation before, during and after surgery
Accurate and legible record keeping in theatres is very important.
Before reading this section, review the NMC (2009) Record keeping: guidance for nurses and midwives at:
Accurate documentation at all stages of the perioperative journey is essential. Healey et al (2008), through a process of change management, updated their perioperative nursing documentation which included an evidence-based approach to perioperative practice, in particular the importance of ensuring a pre- and post-surgery count of all instruments and swabs used during the surgery.
Counting instruments, needles and swabs before surgery begins is critical to the safety of the patient, to ensure that an accurate post-surgical count balances that taken pre-surgery. It is vital that instruments, needles or swabs are not left inside the patient during operations which may involve severe bleeding and the use of many different types of large and small instruments. (See the Association for Perioperative Practice guidelines at Great Ormond Street Hospital: http://www.gosh.nhs.uk/clinical_information/clinical_guidelines/cpg_guideline_00012/#Ref_section (accessed May 2011).)
Arrange with your mentor to observe the counting and documenting of the instruments and swab both before and after surgery has taken place. If possible, do this both for a very complex surgical intervention and one that is less so.
Many operating theatres have instruments and equipment set aside for teaching purposes. It is good practice if you are in the operating theatre area for the whole of your placement to become familiar with some of these. If you are fortunate to be given an opportunity to scrub up for an operation alongside your mentor, you may also be asked to pass the surgeon specific instruments during the surgery. This may be an agreed final objective for you, and some of you may really like this special environment and wish to work there on qualifying. It is a very rewarding place to work although, as with every specialty, it is not everyone's final employment choice.
Safe positioning of the patient during surgery
Patients arriving in the operating theatre from the anaesthetic room have to placed on an operating theatre table. In order for the surgeon to be able to access the part of the body that is to be operated on, the position the patient is placed in is very important and there are different ones for different types of surgery. It is also important to note that positioning of the patient can have an effect on blood pressure, venous return and ventilation (Hughes & Mardell 2009). Again we can see how important it is that students have the knowledge about normal and disturbed physiology of the body systems as well as anatomy.
When positioning patients on the operating table, it is important that all staff involved adhere to moving and handling regulations and that (Gilmour 2010:23):
the team involved undertake a risk assessment for the moving and handling of each individual patient, and that relevant aids and methods are used to reduce patient movement and potential injury to both staff and patients. An assessment will include the physical condition of the patient, nature of the intervention and individual patient's needs.
If patients are not positioned correctly, it is possible to inflict damage to the patient, such as nerve injuries, due to their relaxed state during surgery. Gilmour (2010:23) states: ‘radial nerve injury can occur if the arm is left hanging over the edge of the operating table; ulnar nerve injury due to compression by an inappropriately placed arm support’.
Common surgical positions are highlighted in Box 8.3. (See Hughes & Mardell (2009) for images of the different positions.)
Box 8.3 Common surgical positions
Supine
Patient is positioned on their back with arms extended on arm boards or alongside their body. This position is used for general abdominal surgery such as a laparotomy, breast surgery or vascular surgery.
Lateral
Patient is placed on their side with additional support for legs (which need to be separated with a pillow), head and all pressure points. This position is used for surgery such as a total hip replacement (arthroplasty) and kidney surgery.
Prone
Patient is placed in the supine position then rolled over onto their front, with head and lower limbs supported with special supports. This position is used for surgery on the spine, neck and buttocks.
Trendelenburg
Patient is positioned as per supine but involves tilting the table head downwards at an angle of 40 degrees. This position is used for abdominal/pelvic/gynaecology procedures. (A reverse of this, where the table is tilted the other way, can also be used but the feet will need to be supported – used for certain head and neck procedures.)
Lithotomy
Patient placed on the table with buttocks at the end of the table and feet placed in fixed stirrups. This position is used for surgery on the perineum, vagina and rectum.
(Adapted from Hughes & Mardell 2009:328–333)
Universal precautions
Universal precautions were introduced in the USA in 1987 initially to manage blood-borne viruses. It was later extended to include all body fluids and matter which could carry pathogenic microorganisms, which in turn could lead to infection. This applied to any environment where this risk was a possibility.
In the operating theatre, it includes hand hygiene and protective clothing such as gloves, masks, eye protection, shoes, hats and gowns. It also covers good sharps practice (needles and syringes) and correct disposal; how to decontaminate equipment; managing used laundry and any clinical waste (such as after an amputation); and spillage of any blood or body fluids/products.
All hospitals are required to have a universal precautions policy, and the Department of Health's (DH) Health and Social Care Act 2008 (DH 2009) came into force in April 2010 for NHS providers and October 2010 for other registered providers: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_110288 (accessed May 2011).
An example of the universal precautions and operating theatre practice policy can be seen at this NHS trust document: http://www.ruh.nhs.uk/about/policies/documents/clinical_policies/local/416_Theatre_Practice_Policy.pdf (accessed May 2011).
It is essential that you discuss the universal precautions policy for your placement in the perioperative environment. Ensure that it becomes one of your learning goals, as infection prevention and control is one of the key areas of the essential skills clusters outcomes that you have to become competent in (see Box 8.3).
Read the articles by Cutter and Jordan (2004) and Gammon et al (2007) (see References) which illustrate research studies undertaken to examine compliance with standard/universal infection control policies.
Discharge of the patient from the operating theatre
Following completion of surgery, the anaesthetist will already be starting the process of lightening the anaesthesia given to the patient, who will be transferred from the operating theatre (following the counting of the instruments and swabs), ensuring the safety of the patient and any equipment attached such as intravenous fluids, catheters and drains, into the recovery area or ward where there may be other patients also in the recovery stage. This is the next part of the patient journey, discussed in Chapter 9.
Summary
This chapter has given you an insight into what you can learn in the operating theatre, either as part of your surgical ward experience or on a full placement.
Audit Commission 2001 Day Surgery; Review of National Findings, Audit Commission, London
Cutter J., Jordan S. Uptake of guidelines to avoid and report exposure to blood and body fluids. Journal of Advanced Nursing. 2004;46(4):441–452.
Department of Health. The Health and Social Care Act 2008: code of practice for health and adult social care on the prevention and control of infections and related guidance. London: DH; 2009.
Gammon J., Morgan-Samuel H., Gould D. A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. Journal of Clinical Nursing. 2007;17:157–167.
Gilmour D. Perioperative care. Pudner R., ed. Nursing the surgical patient, 3rd ed., Edinburgh: Baillière Tindall, 2010.
Healey K., Hegarty J., Keating G., et al. The change experience: how we updated our perioperative nursing documentation. Journal of Perioperative Practice. 2008;18(4):163–166.
Hughes S.J., Mardell A. Oxford handbook of perioperative practice. Oxford: Oxford University Press; 2009.
Mitchell L., Finn R. Non-technical skills of the operating theatre scrub nurses: literature review. Journal of Advanced Nursing. 2008;63(1):15–24.
Mitchell M. A patient-centred approach to day surgery nursing. Nursing Standard. 2010;24(44):40–46.
Mottram A. Like a trip to McDonald's: a grounded theory study of patient experiences of day surgery. International Journal of Nursing Studies. 2011;48(2):165–174.
Nursing and Midwifery Council. Record keeping: guidance for nurses and midwives. London: NMC; 2009.
Nursing and Midwifery Council. Standards for pre-registration nursing education. London: NMC; 2010.
Oakley M. Day surgery. Pudner R., ed. Nursing the surgical patient, 3rd ed., Edinburgh: Baillière Tindall, 2010.
Siverdeen Z., Ali A., Lakdawala A.S., McKay C. Exposure to noise in orthopaedic theatres – do we need protection? International Journal of Clinical Practice. 2008;62(11):1720–1722.
Tanner J. Surgical gloves: perforation and protection. Journal of Perioperative Practice. 2006;16(1):148–152.
Tanner J., Moncaster K., Woodings D. Perioperative hair removal: a systematic review. Journal of Perioperative Practice. 2007;17(3):118–132.
Weaving P., Cox F., Milton S. Infection prevention and control in the operating theatre: reducing the risk of surgical site infections (SSIs). Journal of Perioperative Practice. 2008;18(5):199–204.
Hughes S. Evaluating operating theatre experience. Journal of Perioperative Practice. 2006;16(6):290–298.
Hughes S., Mardell A. Oxford handbook of perioperative practice. Oxford: Oxford University Press; 2009.
Sampson H. Introducing student nurses to operating department nursing. Journal of Perioperative Practice. 2006;16(2):87–94.
Wicker P., O'Neill J. Caring for the perioperative patient, 2nd ed. Oxford: Wiley-Blackwell; 2010.
World Health Organisation – 10 facts on surgical safety: http://www.who.int/features/factfiles/safe_surgery/en/ (accessed December 2011).
Association for Perioperative Practitioners information: http://www.afpp.org.uk/about-AfPP (accessed December 2011).
The surgical count (instruments and swabs): http://www.gosh.nhs.uk/clinical_information/clinical_guidelines/cpg_guideline_00012 (accessed December 2011).
Royal College of Physicians UK latex allergy information and guidance: http://www.rcplondon.ac.uk/resources/latex-allergy-guideline (accessed May 2011).
Resuscitation Council UK guidelines on anaphylaxis: http://www.resus.org.uk/pages/reaction.pdf (accessed December 2011).
World Health Organisation safety checklist for operating theatre practice and implementation manual: http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf and http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Manual_finalJun08.pdf (accessed December 2011).
For details about this and a wide range of other excellent perioperative care resources, access the CETL website at City University London: http://www.cetl.org.uk/learning/tutorials.html and the linked online resource: http://www.cetl.org.uk/learning/perioperative-care/player.html (accessed May 2011). This site has information sheets and video/audio material on all stages of the perioperative care journey as well as quizzes and tests to check your learning.
http://www.who.int/features/factfiles/safe_surgery/en/ (accessed December 2011).
http://www.youtube.com/watch?v=U6p5LEG04mU&feature=related (accessed December 2011).
http://www.youtube.com/watch?v=CsNpfMldtyk (accessed December 2011).