Welcome to the TCAA presentation of Trauma University this morning. So none of our presenters have any disclosures, and there is a slide that allows you to get CME accreditation, and that's up there. All right, next slide. So we have a very distinguished panel of presenters today. I'm not going to take the time to introduce everybody right now, because I've asked them to give just a brief bio when they begin their section, but like I said, this presentation is interesting because it presents some challenges in the rural area. It takes it all the way through to rehab, and we've digressed a bit on various topics that are of particular interest to a number of our centers. So I want to thank everybody for participating on this. This will be case-based. We'll have a number of poll questions. We'll ask the responses and then comment on them. So next slide. With that, I'm going to introduce Thomas Resignolo. He's one of our stellar paramedic educators at TR. Let's go ahead and get started. Thank you, Dr. Maines, and thanks to all of you for tuning in in TV land out there. I'm very privileged to be part of this presentation. The objective for my portion of this presentation is to review strategies for improved EMS to ED transfer and interaction, thereby improving patient flow and care. We will be seeing a number of patients in an MCI. We will not really be discussing the care in the field. This is more tailored to me setting up the stage for the presenters as we move further down. So with that, I'm just going to start. So let's set the stage for you. I want you to understand what's available out there. It's a rural community with clear roads and weather. There are regional air services. There are three helipads in the region. One is five minutes away, one is 35 minutes away, and one is 50 minutes away. So three separate ships. There are others at 50 minutes as well. For this actual event, this is a real event that we're going to cover, the helicopter that was five minutes away is on a previous flight, so really it's 20 minutes away, and the battalion chief on scene will not know that until he calls in. The scene takes place five minutes from a rural level three trauma center. They do have ED trauma surgery, ortho, anesthesia, and 30-minute OR availability. There are a number of three level ones, 90 miles away by ground, 35 minutes by air. So as we start looking at these different patients and how we improve our patient care from the hospital standpoint dealing with EMS, these take a real big precedence in learning transport times and availability for the field providers, and that comes from the hospital system. So local EMS fire law capability, there are three ambulances staffed full-time. Each one has a paramedic and EMT basic. There are four apparatus in the fire department. Each one has an EMT, a firefighter, and a driver. There is one highway patrol officer assigned to the region, and the initial response is going to include two ambulances, one fire truck, and one highway patrol. The crash information, as called from a 911 caller, says that appears to be a 17-year-old young male driving a small truck, runs a stop sign on a side rural road. There's a minivan coming in the other direction at highway speeds. The truck plows into the minivan, and the minivan rolls, and the caller is kind of frantic saying, the minivan has rolled a number of times and is down an embankment 15 feet. So this 911 system uses CAD, computer-aided dispatch. The caller indicates that there is potential for three patients. Again, when you get initial calls, they're not always the most accurate. So it's coming in as three. Small truck, when the battalion chief gets on scene, he goes, holy cow, this is a lot worse than I thought. There's a minivan with four occupants. The rollover is as described. There's pretty good intrusion into the minivan, and the front of the truck is pretty smashed up. CAD says dispatch two ambulances and one fire truck, so seven EMS personnel. The definition of MCI is, to me, when the number of patients outweigh the number of resources. So at this point, right away, this battalion chief and paramedic are going to go, man, we're in an MCI situation. We don't have enough. And in training with the local hospital, they also realize they're going to put the hospital in a bad way. They're going to hurt the hospital with this many patients if they're all sick. So part of their pre-planned communication strategies, and I would highly encourage this, is a quick call to the hospital or to dispatch via radio or phone, however you have it pre-planned, to say, I'm on scene of an MCI. I have potentially five patients. I don't know how sick they are. More to follow, click. That lets your hospital know, before they even start triaging, that the hospital may need to implement their MCI plan and start calling in their trauma surgeons, their second trauma surgeons, all their backups. So this pre-planned communication helps in this situation because it gives them time to get an appropriate reception team. The BC also requests air transport services to be notified, and they say, stand by. They haven't done a true triage yet. They don't know where they want the helicopters. A thought process on standbys for helicopter services. So I work with Flight for Life. It's our local service, and they have three ways of being dispatched. They can do a standby request. So if this helicopter were in the pad at the hospital at this time, a standby request would mean they go to the helicopter, the crew goes to the helicopter, they're prepared to go, but they don't take off yet. They also have what's called an airborne standby. So if you're 20, 30, 40 minutes away, you can actually request the crew to fly into the area, and they will kind of circle the area, communicate by radio, and they will land if requested. It takes that 20 to 30 minute response timeout. Again, this is all part of the pre-planning. The beauty of that is with Flight for Life, and I'm sure many other services, if there's no actual landing and patient taken, there's no charge for the call. If they don't get used, they go back and nobody gets charged. So we do tend to see quite a few airborne standbys in our region. And the last would be a scene request, just fly right to the scene. The battalion chief and the paramedic discuss it briefly and say, let's not call a helicopter to the scene yet, but we do need a third ambulance. So again, all part of your pre-plan communication strategies. And now it's triage time. And I'm not here to really review triage as much as what I want you to understand is that triage has pitfalls. There are pitfalls involved. So I'm going to just go over how the battalion chief is looking at it so that you as an ED staff trauma surgeon, you kind of understand better what this group is looking at. And I would highly encourage you to recognize what triage system your people are using in the field. So for this group, they're using start triage. And the first thing they're going to say is anybody that can walk, just walk over to a green area. And we always secondary green. I know some of you out there are probably going, holy cow, they're just going to let people walk away. No, they're going to a secondary triage, but they're not the priorities. If they can walk at this time, they are not critical. Next question would be to look at spontaneous breathing. You know, I didn't always understand positioning the airway and saying, well, you position the airway and they start breathing, they become a red. And if they don't, they're black. I did review a call for a ski patrol, more recent injury, 15-year-old skier went off a jump into a tree directly in the air. When he came down, his airway and his neck were kind of occluded by the tree. He had flexed his neck pretty hard. The patroller paramedic that showed up on scene declared a pulseless anapnea patient, pulled the patient off the tree. As part of that, positioned the airway for breaths, started doing CPR and within 30 seconds, that patient started showing signs of life. It wasn't from the CPR, it was from the occluded airway. So that helped me put that in perspective a little more. So positioning the airway is the second step for them. Assuming that they're spontaneously breathing, they go down to the respiratory rate. Breathing greater than 30 for a respiratory rate is a red. If not, you move down to perfusion. I tend to work in a region that's cold most of the year. So capillary refill can be altered by that cold weather and a cold patient. I really appreciate the fact that they've added radial pulse absent or capillary refill greater than two seconds. It's an either or. I try really hard to train my folks. It's an either or. And if it is greater than two seconds or absent, it's a red. If not, you move down to mental status. If they don't obey commands, they're a red. And if they do, they're a yellow. So that's what this paramedic is facing right now. And I give these guys a lot of credit because they could have tried with three ambulances to spread out and just start taking care of patients. But the number of patients truly did outweigh the resources. So they went into a triage situation. So let's review our patients. You're going to see these a lot over the next few hours. But I'm going to just start off by saying the first one was a 17-year-old restrained male driver. The paramedic goes and does a triage and says spontaneous respirations at 16. Patient has a radio pulse. And the GCS is not okay. He's confused and he's not obeying commands appropriately. They tag him a red. And just to make matters worse, and this does play a part here, he's a local high school quarterback. He's very well known to the community. His mother is a nurse in the ED and the crew knows that his mother is most likely working today. So that's going to throw a little wrench in the works there. But this kid's going to get a red. The second patient is the 30-year-old lap belt restrained passenger. She is still in the vehicle and she's going to require some extrication. But the quick triage says respirations at 20. Poor cap refill on a thin radio pulse. I really liked that. They did both. They had a hard time with the radio pulse. And of course, at this point, the medic understands the patient's 24 weeks pregnant and his pucker factor just went through the roof. He decides poor cap refill. GCS is 15. She says, I'm 24 weeks pregnant. My belly hurts. Tender abdomen and pelvis. And he grades her a red and worries about the extrication and moves on. Five-year-old has lap belt only, restrained rear passenger, spontaneous respirations at 20, has a radio pulse, appropriate mentation for age. So for a five-year-old, we tend to use jumpstart triage. It's a little bit of a pediatric version. And he still meets all the criteria for a yellow. Appropriate mentation for age, I know most of you are probably familiar with this. But for me, appropriate mentation for age means a five-year-old is in the back of a car screaming, crying, a firefighter with all his furon leans in, kid tries to get away, tries to move away, put himself away from the man. The firefighter goes, hey, I'm here to help you. Are you okay, my friend? Hey, little buddy. And the kid stops, looks at him and says, huh, okay. And then starts crying again. Ah, that works for me. Mentation for age is appropriate. Not truly a GCS. So I put in here orange, and I'm sure some of you right now out in TV land are going, whoa, orange, there's no orange, TR, there's no orange in this. What's going on here? And some of you are not going to be okay with orange. I put this because we have to know that we all know pediatrics take a long time to, they can compensate for a long time. They don't show us their compensatory mechanisms very well. They tend to fall off the cliff and get really sick. So with this kid, I would say, is he sick or not yet sick? And I think not yet sick really works very well for this kid. So the medic really wants to put him as a red, but he goes, you know, he falls into triage as a yellow. I'm going to re-triage him. I'm going to call him an orange in my mind, but he's a yellow for now. So TR, just a comment on that. This kid has a seatbelt sign and a tender abdomen, so he almost certainly has truncal hemorrhage. And we know that the countdown for truncal hemorrhage is relatively short and absolutely agree that kids may not show that. So I'll be interested if anyone else has comments about this, but, you know, I would be tempted to put him at a red because of the risk, but strictly by the triage guidelines, he's a yellow. So I really like your orange approach. Thank you. I meant to say this earlier, and I really didn't get off to a good start with the thanks to you. So trauma is a team sport. I think Dr. Mains probably coined that phrase 20 plus years ago when I started working with him. And as far as trauma being a team sport, the first inning in the game is EMS. And I think it's really important, and Dr. Mains has pushed this for years, that we have to help our EMS providers to get what we need out of them and improve patient care. So I appreciate that comment. Thank you. We'll move on to the 32-year-old male restrained driver. He is out of the vehicle. He has rib and abdominal pain. He is lethargic, spontaneous respirations at 18, no radial pulse. His GCS is as follows. He's an easy red for them, and he's out of the vehicle. That makes life a little easier. Come on, you can do it. Last patient is a 70-year-old restrained passenger, grandma sitting in the back. She's four weeks post total hip, spontaneous respirations at 16, GCS at 15, strong radial pulse. She's a yellow based on this, and the BC and the paramedic at this point are like, thank God we have at least one true yellow. So those are your passenger, or those are all your patients, and it's time for them to make transport decisions. So they discuss helicopter. They discuss that the fact that some of these patients, they know from their quality improvement with the level three, are not going to stay at a level three. They need a level one. However, based on the proximity of the five-minute drive to the level three, the fact that the scene is very cluttered, there's not a great place to land a helicopter on scene, and the helicopter is 20 minutes out, and a good rule of thumb is you often, there's two reasons to bring a helicopter to the scene from an EMS point of view. One is to bring a skill set or things you don't have to the scene, so flight for life carries blood, say. So if you know you're going to be on scene for a while and you have a profoundly hypotensive patient, exsanguination, you can call for them to bring blood, or you can bring for a skill set such as a chest tube if that's what's needed in the field. The second reason you call a helicopter to the scene for EMS is to get somebody somewhere fast where they need to go that would take too long to drive. They know all this. They discuss it, and they say, you know what? The best thing we can do is drive all five patients to the hospital, and we're going to get the helicopters to go to the level three and wait there. So as far as EMTALA, I want to throw this out real briefly. We did deal with this a couple years ago, probably 10 years ago now. Everyone's interpretation of EMTALA rules are different. However, our corporation's interpretation of EMTALA for this is as follows. If you bring a sick patient to a hospital and then you divert to the helipad because the helicopter is there, that's a potential EMTALA violation. So what we ask our field providers to do, again, part of the preplanning is if there's no, if they're going to fly somebody and they're going to use the helicopter at the LZ of the hospital simply for ease of use, we ask them to state that and put that in their written report. They are simply coming through the hospital, entering the hospital grounds to be able to use the LZ as the most expedient LZ. And that kind of gets around any EMTALA issues. And it is hard because we've had doctors walk out and go, let me just stick my head in the ambulance and see. That's probably not a good idea. So as ED staff, out of all the five patients I've just described, which one would you want to see first? And this is a poll question and I'm not sure how to, there it is. Thank you. I'd ask you to answer this. This is the time for you to wake up and stick a finger on a button and tell me who you want to see first. In a perfect world. The majority answer, nearly half of you said the 30-year-old pregnant patient. That's certainly a potential right answer. I think there's no clear right answer here. You know, patients that need time-sensitive intervention or have uncontrolled truncal hemorrhage are the ones that you want to see absolutely first. And the 30-year-old pregnant woman is not a bad answer. You have two patients, essentially, both of them in trouble. And so I kind of like that answer. The problem is going to be extrication and management at the scene. And while it might be ideal to see patients in this order, that might not be possible based on time constraints at the scene, the need to extricate, trying to manage scarce resource. You're only five miles away. So it's a pretty quick transport and turnaround. So, T.R., what do you think? We're going to go on and talk about how these patients were managed. Yep, I'm just going to show you what you are going to get. And I want you all to think about that because there are pitfalls in triage and there are pitfalls in EMS transporting. So patient availability, as Dr. Main said, is one of the, I wouldn't say pitfalls, but it's a challenge. And sometimes there's a patient that you want to get first. And the EMS providers know who they want to get out first. But oftentimes they can't do it and they have to make hard decisions. So start triage is just a tool. I deliberately made that kid orange because it fits. And I wanted to show you that start triage doesn't always show you exactly what you need. It's made for the masses and there are always outliers. I really love the fact that field providers can think outside the box and improvise as they go. It's not cut and dry. So all of this says you may not get the sickest patient first. You may not get the one that you really want first. Be understanding when they show up. And one of the things I would say is when they do show up, please don't go, well, what about the rest of them? Tell me about this one. Tell me about that one. These guys are going to have a really rapid turnaround and they're not going to have time. So here's how you're going to get your patients. You're going to get the 17-year-old first. You're going to get the 32-year-old second. They're going to be in pretty quick proximity. The pregnant female is going to take a while to get transported. She's going to have to get extricated. It's going to take about 17 minutes to get her out and that's working hard. They do focus on getting the female out before the five-year-old because truly she's a red and they're terrified of a pregnant patient. They're terrified of pediatrics. It's a terrible call for them. They did very well. And the 70-year-old is going to be a no-brainer. Not that we don't take care of them because they could be anticoagulants, a whole bunch of other issues, but they are truly a yellow. So when they're transporting these patients, interactions with the ED staff, if you haven't heard of a 30-second or an EMS timeout report, I would highly encourage you to look at it. My personal opinion is it's becoming industry standard to have an EMS timeout when you transfer patients from the field to the ED. If you think about all the timeouts we do in a hospital setting, it makes sense that this report, the first report that you're going to get that has all the scene information goes down the pipe correctly. So an EMS timeout has to, there's a bunch of things that has to happen to make this right. The first thing is you have to have a good reporting structure. So we do ask and we train with the MIST report. So the MIST as you're seeing right here is mechanism injuries or illness signs and symptoms and treatments in 30 seconds. Now I know a lot of the nursing staff out there is going, I don't know a single paramedic that can do this in 30 seconds. With training you can. It is frustrating at times. We all get the person who comes in and goes, so this is Bill and Bill was driving his car and at that point, everyone loses what that guy's saying. That paramedic has lost control of that ED room and everyone's doing their thing and you're not helping your patient. So to get what you need out of them, encourage a MIST report. And I'm going to show how these MIST reports work. If you haven't done a timeout before for the ED staff, it does take some training. Here's a pearl for you. If you haven't done it and you're looking at starting, recruit the players you need before you even start moving down the pike. So in other words, you want your trauma doc, your trauma director, your ED director, and your ED nursing director. Those three have to be on board because it is extremely difficult to get all players into an ED room. You gotta remember that the EMS folks and the nursing staff are on opposite sides of the field. The EMS folks, they've already seen their patient. They've evaluated their patient. They've done some treatment. They're at the end stage passing off. They're not gonna see these people again. The ER staff is coming in ready to go. They know nothing about this and they need to do all their stuff. So it is hard. And here's how it usually works. And believe it or not, the EMS providers are the worst. I watch hundreds of these interactions and it always starts with a good missed report. You're 10 seconds in and somebody has an involuntary carpal spasm and their finger just hits the buckle on the transport pram. And the minute one person touches one thing, all bets are off and you lose control. It's incumbent upon everybody to say, this is an EMS timeout, go when you're ready. And I would also encourage you to have your entire team that's gonna care for that patient present for this report. It is easy to play the phone game and miss items if you're not all there. I encourage our ED and trauma physician to be on scene for a big trauma. If it can't happen, I understand, but it sure does help when it works. So I don't wanna belabor that too much. Let's go into this and see how it works. So here's your missed report. 17 year old male frontal MVC at 40 miles an hour. His chief complaint is his head hurts. We've put spinal precautions on, we've established an IV TKO. His vitals are 120 over 70, pulse at 90, respirators at 16 and an SAO2 of 95%. That's about 10 seconds. Now, I know a lot more has to go on, but for the initial report to transfer that patient in the EMS timeout for this patient, that's what's needed. Second patient, 32 year old male. I'm not gonna go over the top again. This is a mistake by the way. The van was going at highway speeds, 55, 65, but they're all focused on the truck hitting at 40. So he's gonna say 40, this is an actual call, I'm not gonna change it. Chief complaint, thoracic and abdominal pain, eight over 10, difficulty breathing, unable to assess lung sounds, which is always followed by, it was loud in the ambulance, the sirens were on. Fine. Spinal precautions, oxygen's on, IV established, starting at 250 ML normal saline bolus, nothing really in yet, vitals as seen. If you can get that much out of them in that quick of fashion, and then have the paramedic or the basic talk to the recording nurse to give the rest and the docs sometimes, you'll find this will go a lot better. So after about seven, yeah, go ahead, Dr. Manch. I just want to comment on that. You know, the bolus of 250, this patient is hypotensive and has potentially truncal hemorrhage, but the head was okay. So we've recently not been recommending doing the one liter bolus for hypotension, but rather use what you have for fluids and approach with permissive hypotension. And that was what was being done here. And that's why the 250 of saline. Thank you. I was wondering if you were going to comment on that. That's perfect. So I want to go over a couple of things with this female. I'm not going to read the report per se. I'm going to say that they, she has belly pain, nine over 10, spinal precautions, left lateral recumbent transport position, a pelvic binder was placed in the field, bilateral 16 gauge IVs, one wide open. The vitals, as you can see, BP 90 over 60, pulse 120, respirations 20. Fetal heart tones. So if you're looking for fetal heart tones in the field, please keep in mind that at the EMT basic level, fetal heart tones are not in the curriculum or scope. At the paramedic level, it is in the scope. It's not often done. The reason you don't see them often done is there's nothing the paramedic can do about anything with fetal heart tones. That being said, I want to commend these guys because in my opinion, it gives you an initial baseline for the physicians down the road to look at. That initial fetal heart tones, that rate is vital to the downstream information line. So I'm very happy they did that. It doesn't always happen. That was a good one. So let's look at this and say, come on, slide. For a pelvic binder on a pregnant patient, and I'll say anywhere in the pregnancy, for an open book, suspected open book pelvic fracture in the field, do you apply a pelvic binder? Here, A, B, C, D, I'd love to see your answers. So while they're doing that, Dr. Martin, would you like to comment on the wide open IV on that pregnant patient? Yeah. So one thing to keep in mind that we'll cover when we go over the physiologic changes in pregnancy is that pregnant patients, because of their physiologic changes, they can lose a significant amount of blood before they start to show signs and their vital signs and their hemodynamic status. And generally you want to do pretty aggressive fluid resuscitation in the pregnant patient. They're typically young and healthy without a lot of comorbidities and can tolerate a fair amount of fluid. And again, they can lose up to 20% of their total blood volume before you start to see changes in their hemodynamics. So I would, you know, bear on the side of probably more fluid is better. Thank you very much. And we're getting our results in for the polling question. And the majority of people have chosen to apply a pelvic binder. I would love for you to review that for us. Yep. So pelvic fractures in pregnancy are very rare, as you can imagine. And the literature that's out there suggests that you can use pelvic binders, external fixators. You kind of treat them like you would the non-pregnant patient. And so there's not a lot of changes there and you should, you know, place the pelvic binder as you would a non-pregnant patient. Excellent. Thank you very much. Dr. Mays, do you have anything to comment on that? Yeah, I would say this patient is serious risk for truncal hemorrhage. Like the head injury, permissive hypotension in a pregnant patient is a little bit more tricky. And I agree with the fluid resuscitation in this case. Excellent. All right, moving on. So the extrication, they did work to get the female out first. As I discussed earlier, the five-year-old finally gets out to 22-minute extrication time. I would love at that point, if they really, the whole time in the vehicle, they should be keeping track of this kid. They do try starting a couple IVs on him. He's cold, he's peripherally shunted. They've had three failed IV attempts. The question I would have for them is, do we go with an IO at this time or not? And we're not gonna go there for this talk. I'm just setting the stage. But his chief complaint is his seatbelt hurt me. 22-minute extrication time, BP 90 over 60, pulse of 130, respirators on 92% blow-by. He's sputting the nasal cannula. He's really unhappy. So that is your fourth patient at about 35 minutes post-accident. And the last one is the grandmother. Her chief complaint is hip pain 10 over 10. She's got a leg splint on, good distal neurovascular IV. Whoops, I don't know why that did that. IV is established. I'm having a hard time with my mouse. And they did give her fentanyl 100 micrograms with vitals as you see. So before I turn it over to Dr. Rubano to discuss in-hospital, I just wanna review a couple of things. Pre-planning can make your interactions way less frustrating in the ED, much more of a positive interaction. You'll get the information you need in that 30 seconds and be able to take care of your patients better. And when it's all done, a good quality improvement program means that your quality improvement works with EMS. I would encourage you to have your EMS representatives in your ED meetings and really become one because trauma is a team sport. So thanks for listening to my half. I'm one minute over. And Dr. Rubano, it is all yours. So Dr. Rubano, would you briefly introduce yourself, tell folks who you are, where you're from? And this is clearly not an ideal situation. So we'll be interested in your thoughts on how to manage this. So thank you. I'm Jerry Rubano. I'm on faculty at, through NYU Langone Health, Long Island School of Medicine. I practice out at Long Island Community Hospital, which actually is a level three trauma center. So these kinds of scenarios are honestly near and dear to my heart. And with my team, we've had to plan to be ready for these, should something like this arise. So the first place we start is that field triage is just as important to us as it is to the medics and EMTs out there. So as Tiara was saying, we really kind of pay attention to what you're telling us and what's being made, known about the patient ahead of time. So even these 10 or 15 second stories give us an idea of what's going on. The thing I throw up there is don't get lost. The reason that trauma is run the way that it's run is so that we can handle these situations when they arise. So you wanna remember to always follow your ATLS protocol. And one of the things that I like to stress is that trauma center designation is about resources, not skills. Your nurses, your surgeons may be just as skillful as those at the level two or level one, but we don't have necessarily the same resources. And we'll get into that a little bit more in detail as we go along. There are quote unquote level one surgeons at level three centers. I gave a talk actually through the TCA about a year ago, talking about the double life of a level one and level three trauma surgeon. And it was sort of my story because I was covering two different hospitals at the time. One was a level one and one was a level three. So obviously, the provider can bring a certain skillset, but again, you have to think about what resources you have at your institution. So the next question is, what patients are coming? So who are they telling us is coming in? What are each of these patients likely to need? And do we have what those patients need? The next question, obviously, that you ask yourself is what personnel and resources do I have available? If four or five patients are gonna need operations, but we only have two surgeons available or two ORs available, those are things that we wanna know and plan for before the patients start showing up. So this is just a, we'll go into all the patients in depth, but what I wanna point out is that these 10 seconds spiel that we get from the field can be very helpful. So one of the patients, and she was more of the simple one, so we'll use her just for this demonstration, was a 70-year-old restrained passenger who essentially has normal vital signs. She may be a little bit tachycardic, but otherwise pretty normal vital signs. She was four weeks post total hip, wasn't really complaining of anything else, but there was a quote-unquote obvious periprosthetic fracture. So in this, we're running things quickly in our head to see how sick do we think this patient is? She's already been tagged red, quote-unquote orange or yellow, but we're thinking to ourselves, you know what, she's pretty stable. She sounds like she's got a GCS of 14, so we're not overly concerned, and she has a periprosthetic fracture. So with her, we're really worried about hemorrhage from the hip, but otherwise we're thinking that she's gonna be pretty stable when she gets to us. And to me, in my head, I'm thinking this patient is more likely to need an orthopedic surgeon for their skillset than they're gonna need my skillset. But this is just sort of what we're thinking as we're getting involved. So triage, again, we use ATLS for this. You know, I throw up the MIST thing here with mechanism and injuries, and then one of the things that I throw in, obviously the S really stands for signs and symptoms, but it's subjective. So I do like to ask the medics after they give us their quick sign out, even if it's on the phone, do they think the patient's sick? Because a lot of times the subjective interpretation of our pre-hospital providers is really, really very useful. Myself and one of my colleagues from my former job actually are publishing a paper on this where paramedic gestalt is sometimes just as, if not more accurate than following specific criteria. So sometimes our medics would activate things that didn't meet strict trauma criteria, but when those patients were worked up, their injury severity scores and their illness was just as high, if not higher, than the patients who met true trauma criteria. So getting an idea of how sick the provider thinks the patient is is also helpful. The other thing that I start thinking about is, okay, we have five patients coming in. I have two operating rooms available. I have two surgeons and two OR teams. That's all I have available for me at my level three center. So as I'm hearing these stories, you know, I'm thinking, do I need more operating rooms in this? And if so, can I get more operating rooms running? The answer is no. When you're preparing for an MCI, you want to prepare for real, even on the practice ones. So you don't want to say, oh, I have 11 operating rooms in my hospital. I can only run 11 ORs. That's not true. You know, we have 11 operating rooms physically available, but I can only staff two operating rooms. So that's where I'm going to max out on this day. You know, so I have my two surgeons and my two OR teams. So that's sort of what we're thinking right when we're getting these phone calls. So let's get ready. You know, as one of the things was mentioned, crowd control. So there's seen safety and securement is not just for the field. We would notify, you know, security that these patients are in route. And part of the reason is, you know, one of our family members is hurt, right? So we know it's the son of one of our ER nurses. Obviously everybody's going to want to jump in and take care of them. You know, and there's going to be a lot of, you know, people kind of like swarming in, you know, to help as best as they can. But also we know that four other patients are coming in. This may be something that's, you know, quote unquote newsworthy, and people may be flocking into the ER. So we don't want to have chaos around us. The other thing that we want to have is nursing and social work availability. So we're told that a five-year-old is coming in. You know, it sounds like grandma is relatively okay, but mom and dad are pretty hurt. So who's going to be, you know, with this five-year-old while we're getting things underway? You know, so we want to see who we have available from that standpoint. And again, we need to stay focused. You know, we need to remember that we're going through ATLS protocol on each one of these patients, and we're figuring out where they best belong. So one of the things I'm planning for while this is happening is where are the patients going? So I use my institution sort of as the example to so people would have a better understanding of what I'm thinking about. I have two trauma bays. So to me, the most critical patients are the patients that are going to need emergency procedures are going to be going here. And then the other patients are going to be going to monitor beds in the ER because that's what I have to work with. So in my head, patients four and patients two, which were, you know, barely the mom and dad, the pregnant patient, as well as the 32-year-old who has belly pain and is hypotensive, those are patients that are likely going to need emergency procedures. So those are the ones who are going to go to my trauma bays and the rest are going to go to pre-planned areas in the emergency room where they can be watched closely. So what we don't want to do is get lulled into a false sense of security. So even by the way I'm talking now, it sounds like, you know, there are two sick patients and the other three are okay. That's not really the case. What we know is there are two very sick patients who are critical at this moment and three patients who may get sicker. So you don't want to get lulled into a false sense of security that the other patients are okay. So the old adage as you grow up as a trauma surgeon is that kids are stable until they're not. So as Dr. Maynes had mentioned, you know, this kid is complaining of pain from his seatbelt. You know, we're concerned about bowel injuries, we're concerned about bleeding in the belly, but he's, you know, relatively stable at the moment. So, you know, we keep in mind that he can get sicker on us very quickly. The other thing that we're thinking about is the quote-unquote grandma in the car that she has this periprosthetic hip fracture and she seems stable. We saw her blood pressure was okay. She was only a little bit tachycardic, but she can very quickly, you know, bleed pretty significantly and get hypotensive. We obviously also don't know if she's on anticoagulants or anything like that. So we have to be ready, you know, for any of these things to happen. The last is obviously the closed head injury. So the 17-year-old, the football star, you know, he's probably had his fair share of concussions before, but this, you know, obviously could be more significant because it was a high-speed car accident. He's got a mildly depressed GCS of 13, you know, so we always think about lucid intervals. You know, he sounds from the story like it's going to be a subdural or contusion, but he can easily have an epidural. And as we all know, epidurals often come in with that lucid interval where they're wide awake talking to us, and then they quickly, you know, get very sick and need to go emergently to the operating room. So even though in our head, we have these two patients that are most critical, we know that these three are sick and could get worse very quickly. So just like in the field where sometimes we put people into that re-triage category, it has to be the same in the emergency room. We don't just put them somewhere and forget about them. So these three go to monitored beds in the ER, and they're not to be forgotten about. So with that, you know, we are triaging while we're getting the phone calls. As T.R. mentioned, you're going to hear about these patients over and over again, but, you know, this is what we're trying to think about while things are coming in. So I hear that there's a 17-year-old coming in with a relatively stable set of hemodynamics, mildly depressed GCS, and that he's planned to arrive first. Again, we know that he's the local high school quarterback, and he's well-known to the community, and his mother's a nurse here. So these are the things that I'm thinking about. One, again, is that we have to keep mom calm if this is really one of her shifts. You know, we don't want to hide her from her son, but we need to, you know, treat him the way we would treat any other patient. And then based on what I've been told in the field is that, you know, this sounds like it's going to be a head injury. He's a pediatric patient, and my institution does not have neurosurgical capabilities. You know, so this patient, regardless of what we find, is somebody that we're going to have to consider for transfer because we're not a pediatric center. You know, again, you can make the argument a 17-year-old close enough to 18-year-old, but we're not a ped center, and we also don't have neurosurgical capabilities. So he's one that we're already thinking is going to have to be sent out. But the question that we have to ask ourselves while we're triaging is do we do a head CT on this patient or do we not do a head CT? We'll talk about that a bit later again. Again, just the triage before arrival, a 32-year-old father, he appears unstable, right? So his blood pressure is low. He's tachycardic. He's complaining of rib and abdominal pain. And then, you know, based on this story, you know, my kind of head is focusing in on C, right? So I'm thinking about circulation as being the biggest issue for him. So we know he's hypotensive, tachy. He's got belly pain. So I'm already thinking of intra-abdominal injury that he's going to go, you know, get a fast as soon as he gets in. You know, we'll obviously follow ATLS, but we're going to fast him, and if it's positive, we're going to the operating room. So in my head, even before the patients arrive, this is probably one of my operating room teams occupied. I'm also thinking that I'm going to need blood on this patient because he's hypotensive and tachycardic. I am a level three center, so I don't have the same size blood bank and resources as a level one trauma center. So I'm going to start to ask my blood bank to get ready even before these patients arrive. You know, we do have, you know, stat packs, which for us are two units of blood and two FFP, and, you know, a quick thing that we can get up there, and then also the massive transfusion protocol. And I know that this patient's going to tie up a bit of my nursing because we're going to have to, you know, work pretty aggressively on getting him ready. Next patient is the one that probably scares us the most, at least as a trauma surgeon at a center that doesn't have obstetrics or gynecology. So it's a 30-year-old female, as was discussed, who's, you know, a bit hypotensive, a bit tachycardic. She's 24 weeks pregnant, and she has a tender abdomen and pelvis. So the thoughts that we're thinking here is, you know, mom's unstable. In our head, we're thinking that this could be an intra-abdominal process, obviously, because she's, her belly hurts and she's got pelvic pain. But obviously what's really running through our head is, is this pregnancy related? Is there something going on with the pregnancy? Is it uterine hemorrhage? You know, so the other thing that I'm thinking to myself is this patient is likely going to the operating room as well. But she's one that I'm talking to my, you know, level one trauma center ahead of time, that they're probably gonna get two patients from me out of one. That we may be going to the operating room to deliver her, and that we're gonna be operating on her, and she's probably gonna wind up getting transferred. Again, knowing your resources is important. We heard on the first slide, and it's actually true for my institution, that we don't have obstetrics or gynecology, and there's no pediatrics here. If you have an obstetrics team and you have pediatrics available, you may not have to plan for the transfer as much as we do, but these are the things we're thinking about ahead of time. We're also thinking to ourselves that I have another nursing busy patient because there's going to be all these things going on. You know, so it's sort of the same thing as the previous patient who was really patient four from the field, but two coming in, because this patient is going to be needing lines in blood. And I'm going to be asking someone from the ER or from the team to be talking to the blood bank to see exactly what resources we have available, how much blood do we have for both of these patients and how many units of platelets and things like that. So the next is a little bit less scary, but still one that makes us nervous. So you have a five-year-old that's a seatbelt only with green passenger. His heart rate and blood pressure look reasonable, but he's got a seatbelt sign with back and abdominal tenderness and required extrication. So there's a few things that we're thinking about ahead, you know, before this patient gets in. Obviously there's the medicine side of it. We're worried like we talked about for bowel injuries and inter abdominal injuries. But we're also thinking about what workup are we going to do for him? Does he need to be scanned here or does he not need to get a scan and are we just going to work on transferring that to the hospital? With that though, there's the psychosocial elements of what we do. You know, his mom and dad are coming in. They're very unstable. Both are probably going to the operating room. He's going to be, you know, terrified when he's in the center. We're not a pediatric center. So this is one where we really rely on our social work and care management team. And you know, in my head, I'm thinking, you know, grandma sounds pretty stable. You know, can we put him at least next to grandma in the emergency department so that we have a little bit less chaos and he's a little bit more calm while we're trying to do the workup. So, so these are all the things that with these little snippets that we're hearing from the field is what we're planning for already. So again, triage before arrival, I'm thinking I have two patients that need to go to the operating room and three patients who are so far okay, but may need some resources and some resources that our institution doesn't have. So the last patient again was the seven-year-old. She's the one who is most stable to me based on the story. But I'm not going to forget that she can hemorrhage. And again, as I mentioned on the previous slide, I'm going to make use of her. You know, we don't want to forget about her as a patient, but I know that I can put her grandson next to her because she doesn't sound like she's going to need a ton of procedures. So just while me and my ER colleagues are getting ready for the, for the patients to arrive, this is what we're thinking. So two patients are going to our trauma base. We are going into the main part of the ER and two of them, the grandma and the grandson, we want together. You know, so that's, that's kind of what we're working on before the patients even get there. All right. So now we say that here we go. So now that we put our, we have this great plan ahead, we have to put the plan into action, right? So the patients start arriving and, you know, as you can tell from me kind of belaboring it on the previous slides, now is not the time to start planning. So we wanted to know our roles ahead of time. We've assigned our teams to the, to the beds they're going to be in. And we have this idea where I work, what we always say is stay a bed ahead. And what we mean by that is we want to always have a room and a resource available. So you know, we have our two patients that are going to the trauma base. You know, it sounds like one or both of them may be going to the operating room. So that means we're going to get those trauma bays ready to support the other patients. If their hemodynamics, hemodynamics change, we also want to be prepping our ICU that some of these patients may be coming up to them. You know, so ideally, we're going to get a lot of them transferred out to where they need to be. But there are some of these patients that we can keep at the level three center. So here's the first polling question from my section, based on the information provided, which patient are you most worried about? Okay, so we see the results, it looks like the most concerning is the 32 year old father. And second place is the pregnant mom. Dr. Rubano, you want to comment on that? Yeah, so I figured those are going to be the top two. In my head, I flipped them the other way to be truthful. I agree that those are the two sickest patients. The 30 year old seat belted mom makes me a little bit more nervous as a trauma surgeon because the dad, you hate to put it this bluntly, but he's probably going to be a spleen or a liver. Those as trauma surgeons, where you're kind of used to lopping out and taking care of very quickly. The idea of, you know, delivering a 24 week old baby at an institution that doesn't necessarily have pediatrics or obstetrics, and dealing with possible uterine hemorrhage makes me a bit more nervous. But those are the top two patients that I'm most worried about. I don't know if you have comments from your side, Dr. Maines, about your experience with those. No, you, I think those two clearly are the are the worst risk and your assessments correct. So the first patient that showed up was our 17 year old male. Again, I won't belabor them. He had stable vital signs and a GCS of 13. We got our appropriate missed report. You know, this is just to remind people that we do things sequentially, right? So we follow ATLS, we did our ABCDEs. And again, the only thing we really found was in disability, so to speak, his neuro exam showed a GCS of 13. His quick imaging was negative. So we did a chest x-ray, pelvic x-ray, which showed nothing of significance. And then we did a FAST, which was negative. From my standpoint, this patient does not need a total body CT. You know, we're not a pediatric center. I'm also expecting a bunch of other patients to come in. So I know I'm not going to do a total body CT, but the next polling question is, does this patient need a CT head prior to his being transferred? We've got 70% no, 30% yes. Dr. Rabano. All right. So I err on the side of no for this one, because it's not going to change terribly much. And I sort of figured that there was going to be a little bit of conversation about this. So these are my considerations when I'm thinking, am I going to get a head CT on this kid or not? By pure ATLS guidelines, the patient does not need a CT head prior to transfer, right? So we don't need to do a bunch of radiologic imaging before we transfer the patient. We're concerned about a head injury. He's going to be transferred regardless of what we find. So by strict criteria, he does not need a head CT. That being said, the real life question comes up, would I scan the patient? And I'm going to give you a great answer. It depends. So there's a lot of things we do based on the resources that we have. So my first question in my head would be, what's the anticipated time that it's going to take for EMS to get here and transport him to the level one center? If we're talking that there's horrible weather or there's other things going on, it's going to be two or three hours to get him out of the emergency room. I may scan his head to see if he has a bleed so I can kind of categorize in my head how worried am I that he's going to get worse and need emergent neurosurgical intervention. The other question is, what other scans do I need to get done? And that is a loaded question because here we're, again, picturing five patients coming in. I only have one CAT scanner, so I don't want to tie up the CAT scan with unnecessary CTs. So I'm probably going to err on the side of holding off on the CT. Until I see the other patients and determine who would need one more critically. The other thing that I do like to point out is that just because we're getting a head CT does not mean that every patient needs to be hand scanned. So if you are of the 30% or so who said, yes, this patient should get a head CT, I wouldn't say again that that's necessarily wrong based on the timing that you have to do things. But I would remind you that you don't need to do an IV contrast scan of everything else with the patient. Our chest x-ray, pelvic x-ray were fine. Our FAST was normal. So with all these other patients coming in, if you were really strongly opinionated that you have to get this head CT, you know, then I would say get a quick non-con while we're waiting to get the next patient in because that's going to be a quick CT. So again, you know, my big thing is, you know, to say that, you know, you've got to think about the resources that you have. I see a question popping up that says, so you're treating a 17-year-old as a PEDS patient even though his age is greater than 15? It's a little bit of a loaded question. I'll answer that quickly now. We have certain issues with, truthfully, with nursing competency. So even though from a trauma center standpoint, he would function as an adult and we would do a similar workup for, you know, a 17-year-old because they fall into adult category. In our hospital, we can't keep patients under 18 just by policy. So you know, if he had a completely negative workup, I would work him up in the emergency department and consider sending him home. But since he has this depressed GCS and we're concerned about an intracranial hemorrhage, for those reasons, I would be transferring him to another center. So you know, in this scenario, they elected to get a head CT which, you know, shows a small frontal parietal subdural with minimal shift in mild cerebral edema. And then the question is, you know, does this change management? And the truth is really no because he needed transfer out from our assessment regardless. So he's going to wind up, you know, at a center that has neurosurgery regardless of this. The only thing that may change is maybe he's going to get his first dose of Keppra a little bit earlier, you know, but really nothing else changed from it. So the head CT did give us a little bit more information to tell us the center we're transferring to, but you know, it didn't really change the management overall. So the next patient, 32-year-old male, hypotensive tachycardic lethargic. He's got rib and abdominal pain. We heard that he received 250 cc normal saline en route. And when he got here, he was a little bit worse than the initial story. So his blood pressure was 70 over 50, his heart rate was 150. He's desatting a little bit and his GCS is okay, but it's, you know, he lost a point. So his trauma workup, we did a fast chest x-ray, pelvic x-ray. The chest x-ray showed some rib fractures and left hemo pneumothorax. You know, and the way that I always teach people when we're doing ATLS is that you stop at each of the letters. So his airway was okay, so we didn't have to intubate him then. We got to B and there's a problem, right? So he's got a left hemo pneumothorax. So we stopped there and we placed the chest tube, you know, so that's step one. His pelvic x-ray showed no fracture, as I mentioned, and now we're at C. So as part of C, because he's hypotensive and tachycardic, we did our fast, which was grossly positive. So you know, we already had planned, you know, from our triage situation that we were going to get blood up here, you know, so we're going to start transfusing him. And like I said, we stopped at C, which means we're going to the operating room because we know we have intra-abdominal hemorrhage. So you know, polling question here, you know, is kind of related to that. And you know, so after chest tube placement, what do we think is best next? Okay, we'll see what everybody says. We introduced Roboa into the risk, into the mix. How does your level three have Roboa? So we currently do not, but we've put in sort of our applications to have it for very specific scenarios. So this patient was obviously a positive fast with intra-abdominal hemorrhage, but we don't have 24-hour interventional radiology here for angios and embolization. So for us, for pelvic fractures with those kind of bleeds that are best served by, you know, non-operative management, so to speak, we're getting it set up to become a Roboa center. All right, let's, let's see what the answers look like. So 77% say direct to the OR for damage control apparatum and then transport out by air. And then the second most frequent answer was a distant second and that's damage control apparatum and then to the level three ICU for resuscitation. Comments? Yeah. So I'm going to be the distant second group. You know, so I'm going to give also a little bit of a strange answer. It depends what we find in the operating room. But these patients can often actually be kept at the level three. And again, this is knowing what your resources are. So in theory, once we went to the operating room, we stopped the hemorrhage. You know, so if it was a splenic rupture and we took out the spleen and we took care of the bleeding, you know, the, the, the quote unquote hard part is over. So if the hemorrhage is controlled and we had definitive management in the operating room, this patient I would keep because our ICU resources and, you know, again, our center I don't want to say we're special, but the, the, the six trauma surgeons, the total of six of us are also all critical care. So we have no problem managing this patient postoperatively. So it comes back to the resource question. If you don't have the ICU capabilities for it, you would certainly transfer it out. I'm also not big on always using air for transport unless you have to. So again, if the hemorrhage was controlled in my preparation for the other patients who may need to get out of here sooner than this patient, I would reserve the helicopter for them. Okay. That's that's fair. You know, I would point out that in your situation, you had already called in your emergency call down list and you had two, two OR teams and two surgeons even prior to patient arrival. There are some instances where we're a zone one Raboa may be appropriate. If you've got to wait 30, 40, 50 minutes to actually get the operating room started, which is frequently the case with level threes. But I agree in this case, I wouldn't, wouldn't really consider that. So considerations I'm thinking at this point, again, is I only have two hours to utilize. One is now in use. We're not going to delay going to the OR. So this comes up again. Everybody can tell them kind of big on resources. We're going to go right to the operating room. You want to think about your, your, your blood bank sort of stock. So sometimes at level three hospitals, we actually have to be a little bit more decisive that we're going to the operating room now because again, we don't want to waste our resources where we say, oh, you know, obviously with the hypotensive patient, you're not going to wait. But we don't want to give people a chance to, you know, sort of get behind the eight ball and then run out of resources to treat them. So we're pretty aggressive. The second thing is, is, is the second surgeon there and based on the timeline they are. So one of the questions you have to ask yourself is if they are here, do I send them to the operating room and I continue the surgical triage in the emergency department or do I personally take the patient to the operating room? So I don't know how many people remember this, but about, I guess it's almost a decade ago now there was this horrible bus accident in the Bronx where there was a ton of patients brought into Jacobi all at once. And basically all their trauma surgeons responded. And their, their chief of trauma, you know, who honestly trained me when I was a med student, Dr. Tepperman, didn't scrub on any of the cases. You know, obviously this is just, you know, five patients, they had like 20. But part of what he wanted to do was know everything that was going on and, you know, where each person was in the stage of the operation and what resources were being utilized. You know, so for me, I would let my partner take this to the operating room and I would be seeing, you know, what else is, is going on so that we know where we are in the preparation for everything. I would also make sure and remind my ICU that there, that there have to be available because this patient's in the operating room and may be coming to them afterwards. This way everybody's on the same page and timeline. So the 30-year-old is the third patient to arrive. This is the one that made me nervous. So she's pregnant, she's hypotensive, and she has abdominal pain. In the back of our mind, patient already left trauma bay one to go to the operating room. This patient's going into trauma bay two. And again, this is just planning to stay a bed ahead. So honestly, I'm also thinking now I have another trauma bay to use if one of the other patients that comes in is sicker than we thought because we, you know, cleaned that one out when the patient went to the operating room. So she's hypotensive. She has her workup. Her FAST is negative. And then the question is, you know, do you get an ultrasound or a CAT scan on this patient? You know, it's really knowing your resources. So we do not have an ultrasound tech in the hospital 24 hours a day. So I could do a FAST, but I said that was negative, or I can get a CAT scan. So knowing my resources, I would consider getting a CAT scan on her. Remember, there are risks associated with CAT scan. They're worse during the first seven weeks. But the goal is you got to treat mom first, right? So it doesn't really matter in a patient who's this sick, you know, if you're going to use some radiation or not. The CAT scan, we're going to say for sort of, I don't want to say ease, but to move things along is that there was concern for abruption. One of the things I would like to point out, and, you know, it'll be discussed a little bit later in one of the other parts of the talk, but CT scans and ultrasounds are not really very accurate for abruption. It's, you know, more of a clinical decision. But, you know, this CT scan showed concern for abruption. Mom's hypotensive, and we got to take her to the operating room too. So this is using my second operating room. Kind of joking, I'm hoping my partner was done with the other case because I would love a second pair of hands for taking a pregnant woman to the operating room. You know, not an OBGYN surgeon, but you follow the basic tenets of hemorrhage control, and that's what all trauma surgeons are trained in. So we would get to the operating room. You know, it sounds like there was an abruption, so we would deliver the baby for this. You know, if it was viable, we would ask, honestly, our ER colleagues to be there, you know, or anesthesia because the baby's likely going to have to be intubated at 24 weeks. And this is one that we would have the whole scenario ready set up for transfer. So this is the one that I'm utilizing my helicopter for because they're going to have to get mom out of here, and really they're going to have to get the baby if he or she is surviving after this. So those are the patients that need to get out because I just don't have resources to take care of that patient population. So now what are we doing? Patients four and five are still not here yet. The two surgeons are tied up in the operating room. But this is why it's important that we had triage before arrival, right? So we're anticipating now a 70-year-old healthy, stable female with an isolated hip fracture. She shouldn't need anything truly emergent. We already told that the ABCDs are intact. But again, don't forget the basics. She's going to get a normal trauma workup, chest X-ray, pelvic X-ray. She's going to get a FAST. And she's going to be, in this scenario, she's appearing to be an isolated periprosthetic femur fracture. I would discuss with my ortho team if they handle these fractures or if this is one that needs to be transferred. But she goes into my stable for now list. And then the last patient comes in who's a five-year-old with a systolic in the 90s and heart rate of 130s and some abdominal tenderness. We're told that all the imaging studies are negative, including the FAST. But with the amount of abdominal pain that the patient's having, the fact that it's a five-year-old and I'm not a pediatric center, CAT scans and ultrasounds do miss bowel injuries. You don't always have free fluid right away. So we're still worried about this patient. So this patient is being transferred to the pediatric center without further workup because CT results really wouldn't change my management. I don't have the capabilities to keep a five-year-old here. So that's another patient that we're working on transferring out. So where are we? So this is all the stuff that we went through. So the MCI was preactivated by EMS, which is great. I'm a huge proponent of preactivations. We had two critical patients. One was OB-GYN that definitely needs transfer. The other one was a patient with massive hemoperitoneum, which may not need transfer. That's just something you're considering. And then we have three stable patients, a close head injury that needs transfer, a pediatric that needs transfer, and a periprosthetic femur fracture that needs transfer if our orthopedics doesn't handle this kind of fracture. And periprosthetic fractures are sort of their own specialty. So really, of the patients who came in, off the bat, there were three or four that we knew had to leave. Ironically enough, one of the sickest patients that came in unstable is one of the patients we can likely keep. So we did a lot for these patients. We triaged them all. We did two emergent operative interventions. We found that really only one needed a CAT scan. We were able to do this with basically two trauma surgeons, two anesthesiologists, and two operating rooms. And then three needed no emergent operative intervention. Two needed transfer to pediatric centers, sort of by criteria. And one needed a non-emergent transfer to a center with more orthopedic resources. So the summary, again, we all harp on this, is it's team sport. You had to do triage even prior to arrival. You need to know your resources. And I will comment on the one thing that says that it makes sense to transfer the dad, though, to make efforts to keep this family together. That's true. But we also have to manage the patients coming in and out. We don't want to overwhelm the other trauma center. We also don't know for sure that the pediatric center and the adult center are the same. So for instance, here in Long Island, there's one adult and PEDS trauma center, which is Stony Brook. If we were on the other part of the island, half of them would wind up at one hospital, and the PEDS would wind up at an entirely different hospital. But at that point, we would certainly try to do that. All right. Thank you. Really good summary. And the 70-year-old, at some point, we're probably going to pan scan her just based on the mechanism and other injuries in the field. But you're in a crisis situation. You're doing what you have to do for each of those patients. So I agree with your assessment of that. The other thing I would consider is doing a head and neck scan if I'm doing the CT scan brain. I generally like to see the cervical spine if we can. Other than that, I really don't have any comments. I think that was a very good summary.

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