Please welcome Luke Colburn, Alicia Brownson, Angeline Washington, and Ibrahim Pereyavi. All right. So we'll be presenting a severe pediatric crush injury with limb salvage. Let's see if this is all perfect. We have no disclosures, although I, in my future, hopefully may, but I'm Luke Colburn. I'm a fourth-year general surgery resident at the University of Arizona in Phoenix. My connection to Alaska is our program actually has had about a 20-year relationship with Alaska Native Medical Center. Some of our alumni back in the 90s moved back up to Alaska and invited the residents up there, and we've had a great relationship since then. So we go up our second, third, and fourth years as residents for about two months of the year, and it's a fantastic opportunity, as all the surgeons up in Alaska are just true bread-and-butter general surgeons, so excellent experience. Dr. Brownson, sitting in the middle there, is a fellowship-trained surgical critical care and burn surgeon. She did her fellowship at the Harborview and University of Washington, and she's now the trauma medical director at Alaska Native Medical Center. Dr. Pereyavi is a fellowship-trained hand surgeon. He did his fellowship at Curtis National in Maryland, and he's been at Alaska Native Medical Center since 2018, mostly doing upper extremity and microsurgical reconstruction. And then Angeline Washington, all the way at the end, or Captain Angeline Washington, I should say, is the trauma program manager at Alaska Native Medical Center and does a lot of the teaching statewide for a lot of providers. And our patient's family has signed consent for all the images and videos to be in this presentation. I will say there is a warning. Some of these images are a little gruesome, so if anyone's a little queasy, I'd recommend stepping out at this time. A couple objectives for the talk is to elucidate the complex trauma system of Alaska and the multidisciplinary approach used to treat patients in an effective manner. The other is to highlight and discuss the subsistence agriculture-related traumas in the state of Alaska. All right, so this is the case. We presented these two images basically right at our PM sign-out with actually no context whatsoever. We use a HIPAA-compliant texting platform, so we can get messages from all over the state. So we got this one from one of the providers in the local villages, and they just sent these two images to us. My attending, who was on at the time, responded, what's your extension? That's all she said. And immediately they were in contact with each other. So we got a little more context. It was a 3-year-old girl who was meat grinding with her mother in Elim, Alaska. I'll show you where Elim is in comparison to Anchorage in a second here. Her mom is the bicultural teacher for the village, so actually everyone in class was kind of meat grinding with her. She was cutting up the meat, and the toddler was putting the meat into the grinder. Hand went a little too far and got stuck. So immediately the meat grinder was turned off and disattached from the total grinder. She was immediately seen in the village clinic, was given pain control, ice was applied, and from there they called us to initiate transfer. That was about mid-afternoon or so on the 22nd of February last year. She was also given antibiotics and a tetanus shot. And at that time she did have sensation and capillary refill, so it was recommended that she be transferred to Anchorage rather than directly to Seattle Children's. So limb salvage in general is a complex procedure that requires some conversation and decision-making and has technical considerations and resource considerations in our case in particular. So in this case, a lot of these factors are at play. There's something called a mangled extremity severity score, which when Dr. Bronson brought it up to me, it was something that I remembered from residency but not something as a clinical orthopedic surgeon that we use commonly. I think it is useful in grading the severity of the injury. And mangled extremity is defined as a multi-component injury that includes damage to three of the four systems, including soft tissues, nerves, vascular structures, and the skeleton. And it's a very complex procedure. Soft tissues, nerves, vascular structures, and the skeleton. And the surgical decision to proceed with salvage is multifactorial. There are patient-related factors, including age, functional status, occupation, and availability of social support systems when we decide whether to offer limb salvage. In my subspecialty of upper extremity, it's more common to attempt limb salvage because generally the outcomes are better. But I also participate in lower extremity limb salvage and the soft tissue aspects of that. And so there's a lot of evidence in the trauma literature about limb salvage in the lower extremity and when is it better to do an amputation depending on severity of soft tissue injury, nerve injury, and things like that. Ischemia time is something we definitely think about. And this pertains to this case in particular. There are commonly accepted limits for ischemia time for injuries to the distal appendages. Typically you can tolerate a much longer ischemia time because there's not as much muscle tissue in the fingers. And so people have attempted replant and been successful with replants in fingers with refrigeration or keeping those appendages on ice for up to 24 hours. Above the wrist where you start having more muscle involvement with a full ischemic limb, then the warm ischemia time is considered to be the limit is around six hours. Beyond that, you really have non-viable muscle and it's not a great idea. And also something that we think about a lot, it's a multidisciplinary process. And we'll get into that more from all of the providers that are required and the surgical subspecialists that are often required to make this a successful procedure. All right. So like I said, I was going to talk about kind of where Elam is compared to Anchorage. So Anchorage is more in the southern aspect of the state, whereas Elam is kind of northwestern and very remote. So I'll show you on the next slide exactly kind of how remote this area is. But we had to figure out exactly how to airlift her from Elam to Anchorage. And fortunately during this time of year, it was the worst winter storm that Alaska was experiencing up north. This area is not accessible by roads. As you can see, there's only a flight pattern. And it's actually from Nome is where you fly from. So you have to get from Elam to Nome, which is even more west, and then fly down to Anchorage. Another challenge in this is that in certain areas of Alaska, you can't fly without lighted runways, Elam being one of those. And in the winter months when there's sometimes only four hours of daylight, it makes it exceptionally difficult to airlift patients out of this area. And then, like I said, closest thing would be for EMS to land in Elam then likely transfer to Nome and get her back down here. This is the map of all the roads in Alaska. As you can see, they're all basically clustered around the Anchorage area. There is no accessible route by road from Anchorage to Elam. So that was not an option to get her down here. And that was a big factor in the delay as well as the winter storm. Just some quick facts about Anchorage. There's about 300,000 people, which is about 40% of the population of all of Alaska. If you lump in the metropolitan area, which includes the Matanuska-Susitna borough, that's about 400,000 people. Anchorage itself is 1,900 square miles, but only about 10% of that is actually populated. And then I just double-checked to make sure no roads existed, so I did a little Google Maps search and wasn't able to find anything. This pathway from Anchorage to Nome is actually the sled dog race, the Iditarod, every year. So it is really only accessible by either snow machine or sled dog. And the Iron Dogs, which is the snow machine version of the Iditarod, is where people compete on their snow machine to do this route. And that usually takes people about 9 to 10 days to complete, so not an option here. Again, back to the challenge. There was a significant delay due to weather. There were very high winds, kind of low ceilings is how I would describe it, and a lot of turbulence in the area. So that's the biggest issue there. A normal medevac plane couldn't land in Elim, and so we had to kind of look to other routes. So thankfully we have the National Guard, the Coast Guard, and the Joint Army and Air Force Base in Anchorage. They were all contacted for this case to help assist with bringing her down to Anchorage. And so this is more of kind of how it actually happened. So the transfer center call came in around 3.30 p.m. or so. There was severe weather in the area. The military described it as kind of the worst of the winter, like I already touched on. Very high turbulence in the landing zone for Elim. So actually multiple military-grade helicopters in a HC-130 were deployed. Both had pararescue men on them in case they needed to have some sort of break in the weather. They could at least land and maybe kind of snow machine her to Nome, but that actually never happened. So they spent about 12 hours circling the area and then actually had to divert back to McGrath. The next morning a helicopter was thankfully able to land. That was deployed from Fairbanks. And then they packaged her up and went from Elim to Galena. And then from Galena put her on a HC-130 and sent her down to Anchorage to the Joint Base. And then it was transferred over to our trauma bay around 18.00 the next day. So over 30 hours later from injury time. And this is just a picture of the helicopter, the HH-60G, and then the HC-130 in the bottom right there. So, you know, in Alaska the golden hour doesn't exist. And in this case this was over 24 hours. So what happened in those 30 hours from time of injury to when the child is able to come to a trauma center? We do a lot of pre-hospital preparation by communicating with the teams, with the patient, through telemedicine. And to put it in perspective, Elim is a very small village and they do have a village clinic. The tribal health system that we work in has seven tribal health organizations, which are hospitals. We are connected to 30 hubs for care and have over 180 village clinics. Now those village clinics can be staffed by community health aides, which are trained individuals in the community. They are in Alaska on the EMT scale. And then there are sometimes providers at those clinics. And so in this particular case, there was a nurse practitioner that was at the clinic. And so we did a lot of coaching along the way on how to do extremity checks. And initially, as Dr. Pariavi said, we're trying to determine if this is a limb salvage case, because ultimately that determines location for the patient. And as the child had capillary refill initially, we actually recommended that they ice the hand through the grinder. And so over time, they kind of lost an exam on this hand. But we were able to do coaching through telemedicine. Sometimes we're actually a third party because the local clinics are communicating with their regional hub, and then we're talking with the regional hub. We rely a lot on EMS to give us, if there's limited skilled providers in the community, to actually give us that first report when they land on what the actual clinical status is of the patient. So there's a lot of communication that goes on with the providers on the ground. The other thing is that there's a lot of pre-hospital preparation at our center. The calls go to the general surgeon on call. We are a combined level two adult and pediatric trauma center. And because there's two level two pediatric trauma centers in town and only one pediatric surgery group, our hospital, the adult surgeons take the initial calls and do all the initial trauma resuscitation for the pediatric trauma patients. So this is a coordination that the trauma surgeon is having with the multiple specialties that we anticipate are going to be involved when this patient arrives. This includes anesthesia, our pediatric team, and orthopedic hand surgery. And so there is a lot of pre-preparation that's happening. In addition, we wanted to know what our plan was going to be. And again, we have the luxury of having that preparation. About two-thirds of our trauma patients that come to our center are transferred in from other rural hospitals or clinics. And so we do have kind of this luxury of being able to prepare. We actually had one of our, you know, subsistence living is a common way of life in Alaska. And so actually one of our administrators brought in a meat grinder so we could look at the parts and pre-plan how we were going to disassemble this. We also gave instructions for all pieces with the grinder to come with the child so that we could have all the tools potentially needed for this. But ultimately, we had a lot of pre-planning so that we knew what our response was going to be in the trauma bay. So in Alaska, again, we're the largest state in the U.S. and very widespread. We have, again, 23 acute care hospitals around the state and really just this vast geographic area. There's many barriers to care in Alaska, and transportation is definitely one of them. The distances that we do for our medical evacuations can sometimes be up to 1,500 miles. Again, Alaska doesn't have any level one trauma centers, and so our regional level one trauma center is Harborview Medical Center in Seattle. I like to tell people that our medevac distances comparably would be as if the President of the United States was shot in the White House and you decided to medevac him to Orlando. That's what we're talking about. And so to stabilize a patient that does not have access to a surgeon and has very limited resources is something that we do on the daily. Medevacs are also a very finite resource in Alaska, and so when we decide to medevac a trauma patient, we may be taking that medevac away from another critical emergency such as obstetrical hemorrhage, sepsis, or stroke or STEMI. And so we have had to create state guidelines to define who is priority for a medevac transport and also helping local centers with telemedicine build up capacity so that they can keep patients to reduce the burden on the medevac system and the urban trauma centers. A medevac cost is very expensive in Alaska. It ranges up to $90,000 just to Anchorage and about double that cost if you medevac someone to Seattle. We also, as Dr. Colburn shared, have a lot of weather and daylight constraints and wildlife constraints. Sometimes we can't land because there's wildlife on the runway. Specialty care is really sparse in Alaska. Again, our level two trauma centers are located in Anchorage. We have a real lack of pediatric specialists, and Anchorage is going to be the only urban center where we have a lot of surgical specialties such as hand surgery. This is also where we have most of our neurosurgeons in the state and things like pediatric orthopedic specialists. There's a lot of limited specialties, especially when we look at our surgeons, that necessitate transfer to Anchorage. This is Alaska Native Medical Center. We're located in Anchorage, as Dr. Bronson said, and we're only two miles from the other level two trauma center in the state. Some statistics about ANMC. We are a 173-bed facility that is situated right next door to the other level two facility. We serve over 160,000 Alaska Native and American Indian peoples. We have over 7,800 admissions to the hospital and greater than 18,000 surgeries per year. We were the first level two trauma center in Alaska and we got our verification by the ACS in 1999 thanks to our predecessors, Dr. Frank Sacco and Mary Lemus, who was the medical director and the trauma program manager. And they went through a lot to do this and they also worked with the state in order to get a state trauma system. We admit anywhere from 900 to 950 trauma patients per year, but in our ED, we see up to eight to 9,000 that are discharged from the emergency room. We are the referral hospital for all of the THOs in Alaska or tribal health organizations in Alaska. So trauma in Alaska, it is the leading cause of death and disability of young adults and children. About 500 to 6,000 Alaskans die, sorry, 500 to 600 Alaskans die every year. And a lot of that is due to, as we just talked about, transport time. Getting you from the rural areas to someplace, to definitive care. Over 5,000 Alaskans are admitted to hospitals throughout the state per year. And we lead the nation, and this is not something we wanna lead in, but we do lead the nation in TBI and spinal cord injuries. About 100 Alaskans will die from, will be admitted to hospital for burns, to our hospital for burns. There is no ABA verified burn center in Alaska. However, we like to say that we are the burn facility of choice, and we really do take care of most of the burns. But we have a very close relationship with Harborview Burn Center, and we are working towards advancing burn care in Alaska. And we are doing that through education, through collaborations with Harborview, and we can do another talk, totally, on burns and burn care, and thermal injuries like frostbite in Alaska. So we might come back for that. And there's a lot of unique traumas in Alaska. Moose, everybody thinks that bear injuries or bear maulings are like number one, attacks are the number one animal attack in Alaska. They're big, they're really big. And we get a lot of moose stompings, because tourists think they can pet them, and usually don't work out really well. We also have injuries from ATVs and snow machines, because that's the major mode of transportation out in the bush. And I would also say in the urban areas too, because we own all-terrain vehicles, but we know to wear helmets. So those are some of the unique ones that we have. We have unique challenges with getting patients from their point of injury to definitive care. We talked about this one. There's also incidences where a patient would have to go by boat to the region, and then take an ATV to the clinic, and then from the clinic take an airline to Anchorage. So it's very unique, and that's one of the things I really love about it, especially as I'm doing the trauma registry, and I'm looking at the charts, and I'm like, wow, this is really good, this is really good, and I get really excited about the intuition, I mean the out-of-the-box thinking of a lot of the times it's the CHAPs and EMS services in Alaska to get patients to where they need to be. There's also a lot of fishing accidents that we see because of Dutch Harbor. Everybody have seen, what's the show? Deadliest Catch. Yes. Okay, so everybody's seen Deadliest Catch, so we get a lot of fishing injuries from there. We get a lot of whaling injuries from up near the Arctic with harpoons. They whale with harpoons. So we get a lot of unique injuries, and there's nothing more that I like to do than go talk to the patients when I've heard about these injuries, because I really want to know how did this happen, what happened here? So it's really fun, it's a fun job. So trauma and mortality in Alaska. So unfortunately, we are the sixth in the nation for mortality, which is an improvement. In 2003, we were number two. And I think, and this is my personal opinion, a lot of it has to do with our growth in our trauma system as to why our death rates has gone down, and we have dropped from two to six. Actually, that's an elevation, or is it a drop? Okay, it's a drop. We have the highest rate of injuries for Alaska Natives and American Indians. There are a lot of American Indians from the lower 48 that actually live in Alaska, and we have the highest number there. And I told you about the TBI and the spinal cord injury, number one, not a good number one, but number one. And then death in Alaska, actually, it actually decreases productivity. It's like a loss of productivity of civilians in Alaska from death, unnecessarily, a lot of the times. So one of the solutions, as I said, was having a trauma system. And the foresight of our predecessors realized that it's not just an organization, but it's a state that needs to work together from, all the way from the lay person to discharge. Like, this trauma system will help all Alaskans decrease our mortality and our morbidity. So the system was created, and everybody's included, and then we actually have a trauma department within the Department of Health. I always want to say Health and Human Services, but that's not it anymore. In the Department of Health, there's a trauma system department, and Dr. Bronson actually chairs that also, that actually oversees trauma in the state. So we can also take cases that we feel like, if there was an issue with transport, we can take those cases to the state. Or if we see where there was very good transport, we can take that to the state, and we can get that out to all the personnel that was involved. So this is another state of Alaska. We like showing pictures of Alaska. And this is showing where all of the facilities are, the hospitals, the ones, and I don't know if you can see this or not, but the ones that's orange are tribal, the ones written in orange are tribal hospitals, the blue ones are military, and then the black are civilian. So we have 13 trauma centers. There's 23 facilities, 13 trauma centers, two of them are level twos, and 11 of them are level fours. And we had a little bit more than that, but COVID happened, and trauma program managers were pulled to other areas, like doing other things, and so they lost all of the criteria that you would need to meet to remain a level four, but there's interest in all of those facilities and getting back on board. It's just gonna take time. So this is a map of Alaska, and I'm pretty sure you can't read the names, but we've shown several, so you know where the central city is. Okay, so this is central Alaska. This is what we call the road system, and this area itself has, is it five, five, no, facilities in this area, 11. 13, there's 13 facilities within, 13 of our facilities are within this small road system. And then this is southeast, and there's five in this area. And to note, if you look down near Metlakatla, oh, they made it bigger. If you look down near Metlakatla and Juneau area, the distance from Juneau to Anchorage and Juneau to Seattle is close to the same, so transport from those areas may come to Anchorage or they may go to Seattle. And a lot of that has to do with Seattle having a airless system that actually goes to that area. And then there is what we call the outlying areas, and there's only five facilities within this region. So can we go back to that other slide, please? Yes, that one, not that one. Yeah, that one. Can you explain the maritime line and the statistics there? Oh, so yeah, the frontier region, those five hospitals are not on the road system, very remote. We like to pride ourselves in a lot of things. We said some maybe negative first, but Alaska has the most northern city in North America, which is Utqiagvik up in the northern tip, and they do have a level four hospital there. But we also have the most western point in the U.S. and the most eastern point in the U.S. because our Aleutian chain goes past the international date line. So we have a lot of grand things, so. All right, I knew she would do a better job with that. So our spectrum of care, it goes all the way from the, actually, injury prevention, the incident, the care, and rehab. I believe Dr. Bronson is gonna speak a little bit more about rehab later on. We do have, A&MC has an injury prevention department that we work very closely with. Also, in Alaska, there is a organization called Alaska Cares that I sit on the board of, and it's injury prevention for the state of Alaska. So there's a lot of injury prevention going on, and believe it or not, we give you all these statistics, but believe it or not, a lot of the injuries, a lot of injuries have decreased drastically in the last 20, 30, 40 years for sure. So again, we've kind of explained that we have these different hubs of care, and all of the things that go into coordinating travel and these pre-hospital arrangements. We have easy communication with all of our tribal health organizations because we all share the same HIPAA-compliant texting platform. And so as the trauma surgeon on call, I can get a text very immediately, a text page to my phone from sometimes a nurse practitioner in a remote clinic, or from a provider in one of the regional hubs. And so it allows for this ease of communication. A lot of times, right, a picture is worth a thousand words, and so getting that communication directly to the provider is really great. And then we've also highlighted that not only do we rely on our EMS MedEvac system, but sometimes we do rely on our military partners for search and rescue and medical evacuation, and that requires a lot of coordination as well. Yeah, just before going back to our case, I wanted to mention that Alaska is unique in the availability of the National Guard and the rescue paratroopers to do these field extractions, and that service is provided free of care to all residents. And so this was my first experience with direct communication with them, and they also have their own chain of command, and including an orthopedic surgeon that they communicate with directly, and so I was involved in communication with that person. And I also had an opportunity to meet these guys, the teams that did the extraction afterwards, and I would just give them a lot of credit. They certainly, I think they have to communicate with Washington, D.C. for clearance to perform this extraction because of the terrible weather on this specific case. They were saying that it was the worst winter storm in that area, which is very far north and gets very gnarly weather in general. And so, but they all felt, since this was a small child, they felt very strongly that they wanted to attempt this rescue. And I talked to the helipilot in this case, and he said they flew for 11 hours in almost no visibility conditions, and I asked him, like, how does that, what does that feel like, or how does that look? And he said, basically, they're doing low-altitude flying, looking just treetop to treetop with no other visual cues, which, so these guys are putting their own lives at risk to do this, which is really incredible. So again, our patient arrives to the trauma bay about 30 hours after time of injury on 1830, so right at that night shift change, right, when they all show up. And so this was a full trauma activation for our team. We get a call when, you know, the majority of our transports are fixed-wing because of the extreme distances, and sometimes there are even multiple fixed-wings before they get to us. So they land at a local airstrip, and then our EMS ambulanced over. So we get a tone-out when they land at the airstrip, which gives us about 20 minutes advance notice. And so with a full trauma-level activation on my trauma flow sheet, I had all of my providers in the trauma bay prior to patient arrival, yay. And so we have the whole team there. And this was a really precise, coordinated effort, and we actually have some videos from our trauma bay that you guys will get to see. I think it was said before, right, we have the sexiest job in the hospital, and you're gonna see some flames in our trauma bay. It's gonna be really exciting. So the patient arrives at 1830, and we had a pre-planned response. So primary survey was intact. Secondary survey showed just an isolated injury to the extremity as planned. By this point, the patient did not have capillary refill, as we had discussed, and so it was going to be kind of an evaluation once we got the grinder off. What we had decided to do was to intubate the patient. So the patient was intubated six minutes after arrival. She was taken off of the stretcher and placed on the floor to allow for the mechanics of us getting the grinder off. We had, again, pre-planned this. We had talked about either reversing the grinder or sawing it off, and it was determined that to use a hand saw to grind it off was going to be the proper technique. And so what happens when you put power tools in a trauma bay? With oxygen sources. So we actually isolated the patient with a sheet and removed all high-risk sources from the room, and then we proceeded to take the meat grinder off in the trauma bay. The grinder was removed at 1858, and a few x-rays were taken, a portable chest and portable extremity, and then the patient was in the OR at 1912, 42 minutes after arrival. And again, this just really is a testimony to the pre-plan and multidisciplinary response. In these videos, what you hear in the background is nothing. A quiet trauma bay run really well, right? And so it really is, I think as a trauma surgeon, what I have learned is commanding the trauma bay and having that communication with your team, even when you're really quiet, that's the sign of a team that's working really well. So we have a couple of videos. We can, and I don't know, we might need to have the back play the video. Can I add a couple things? Oh yeah, go for it. While the video loads. So when preparing for this extraction, we did an extensive search, because we had hours that we were waiting, and this is actually apparently a very common injury worldwide, and the meat grinder, the opening is kind of perfect size for a small child hand. So there's lots of videos if you look on YouTube on how to do this, and some of these are supposedly cast iron, and we had heard or learned that you could break some of them. They're brittle, so we brought an anvil, and our initial attempt was to just smash it with an anvil and see if it'll break open, and turns out this one was aluminum, and it deformed and didn't break. So we had a backup plan of having an angle grinder, which one of my partners brought from his shop, and so essentially we cut it off like a cast with a metal angle grinder, which is risky. That is risky. Oh. No real way to do that. Time. And you'll see in the next slide here, and I'll let Dr. Pariyavi talk about what initial response from looking at that, but in that hand is, that's that piece of caribou meat that that child was pushing through, and so successfully off in the trauma bay, and I'll let Dr. Pariyavi let us know what his initial thoughts were when that came off. So I'll say now that this was probably one of the most incredible cases I've been a part of. I don't know if we actually calculated the hours elapsed, but by the time we were seeing this kid in our trauma bay, about 30 hours, I think, had elapsed, which I don't think in the literature is, you know, I don't think it exists or salvage of a hand at that length of time. I think a few things contributed to this probably because she's super young and her soft tissues are very elastic, her vessels had been crimped, but not completely transected, so I think that there was some microcirculation still to the fingers the whole time, and the decision whether to ice it initially was not an immediate decision because, you know, it kind of depended on whether there is perfusion or not and what level of the hand, if it was above the wrist and you're turning a warm ischemia into cold ischemia, you're making this thing potentially worse. You're going to, you know, a lot of muscle will die, but because it was distal mid palm and fingers, and it was looking like with weather that this transport would take a really long time, we did advise the local provider to ice it inside the meat grinder to turn it into a cold ischemia of the fingers, which is well tolerated for a revascularization or replantation. And so, in general terms, you know, we talked about the factors affecting our decision to attempt salvage, and the most important thing that we think about as a hand surgeon is if this is a child, we will attempt, you know, limb salvage pretty much at any cost because their rate of recovering nerve function and functional use of the hand is much higher than an adult. And so, despite that, when I first talked to the mother, I was pretty certain that this was going to be an amputation, and I told her that, and I consented for that, and it turned out when we got into the operating room, she had capillary refill, and so the fingers were perfused once we warmed it up, and she surprisingly had no complete transfections of any of her arteries. She did have a bunch of skeletal injuries, which we addressed, and some tendon injuries, and we, yeah, we repaired a vein just to help with the congestion. So, this is what it looked like immediately post-op, probably about five hours of surgery. Surprisingly, very, very normal-looking hand. We're very happy with this, so post-operatively, we treated her as any revasc or replant. We use a warming blanket and anticoagulation. These days, generally, I think aspirin is felt to be adequate in even flap surgery, so that's what we did. So the patient actually discharged on day seven, and we have a pretty unique situation in Alaska, again, because we're a tribal health system, and we provide free care for our beneficiaries. We know that the majority of our patients are traveling from really remote villages, and so our Alaskan Indian Medical Center has created a patient housing. It's basically like an onsite hotel. It has over 200 rooms that patients and their families can stay for outpatient appointments or escorts can stay during an inpatient stay. It's connected to the hospital with a skybridge, and this is often the place that we discharge patients to prior to returning home. There is a huge lack of rehabilitation services in Alaska. This includes access to things like physical therapy, occupational therapy, speech therapy, as well as things like skilled nursing facilities and acute inpatient rehab. For children, our results are pretty good. We match the country and where we're discharging patients. But our adult TQIP data shows that 85% of our adults discharge to home, which is way too high, and it's because we have that lack of rehabilitation services, and so they stay in the hospital until they're at the level where they can return home. We have a lot of unique challenges when thinking about discharging patients. I read an article that said that there's more cell phones in the world than there are toilets, and I am sure that that is also true in Alaska. We have a lot of villages that have no running water and no sanitation systems, and so we have to talk to families. Discharge planning begins on the day of admission, and we have to really understand what kind of community our patients are returning home to to be able to match those needs. Also, we really focus on what return to community looks like for our patients. We don't have the same rate of a traditional return to work. Now, this is a child, but this applies to our adult patients as well, where we really have to talk to them about subsistence activities and what they're going to be required to do when they return home. For example, I do no elective hernia repairs in the summer because nobody wants to be on lifting restrictions when that's your short, limited months to get your subsistence for the whole entire year, which includes a lot of fishing and berry picking. These were some of the goals that we talked about with this family, and one of the important things for this child was to be able to go out and help her family with berry picking. It wasn't unusual for this child to be near the meat grinder. Having the whole family participate in subsistence activities is very normal, and we encourage to try to find how they can get back to their community living. So initially, post-op, we kept this patient in the hospital for about a month so that she could get consistent hand therapy, which is really not available outside of Anchorage and a couple other places in Southeast and in Bethel. And to have an optimal outcome with something like this, you really need good therapy attendance. And so the other thing that we have available is video assisted therapy. So when they do go back, we will often try to coordinate. The compliance is not very high with that, but it is something that we try to do. And then, you know, definitely educating the mother on what to do with the kid at home, stretching the fingers and things like that. The thing that she has going for her most is that she was three years old at the time of this injury and really a very good potential to recover. That just shows that all of her fractures did heal. And, you know, I've been very this mother has my cell phone number and they send me pictures and videos and been just very interested in seeing where she ends up with this hand. And most recently, she's actually able to grasp, has sensation, can write her name, which is pretty remarkable. And she's now five years old. Very smart kid, too, and I asked her to write her name, she wrote it backwards so that I could read it from my perspective. Yeah, backwards. Can you use your right hand to hold it, please? You go. This is funny, this is an Alaskan O.T. She's doing it as a fishing game. So, again, this has just been a remarkable case. Thank you for us. Thank you for letting us share this. You may be thinking, you know, why does this matter to me? But I think all of us know that at our trauma centers, we are faced with these really difficult challenges. We have guidelines in the gray book to identify hand surgery coverage, re-implantation capabilities of our facilities. And so that's all part of your pre-planned response at your trauma centers. We've shown that trauma patients with mangled extremities are complex and are going to require thoughtful, multidisciplinary care and that the trauma system really allows us to support the care of the severely injured trauma patient. A lot of these small clinics, they don't have a choice on if they're going to take care of the patient that comes through their door. They're the only game in town. They're the only place where families know that they can go and get health care. And so it's not if they're going to take care of trauma patients, but it's how are we going to do it? And by increasing that quality, by giving them the structural support of our trauma system, that improves outcomes. And really, I would encourage you to think about patients with return to community and having those goals for not only the patients, but the families, and that we individualize our care plans. This has been a remarkable case and we're always so happy to highlight the care that we give in Alaska. We have a great multidisciplinary team that includes, you know, the skills of having Dr. Parjavi. But I will also highlight to you all that he's also Mr. October in the Mountain Men of Alaska calendar. Check it out. So we we have a lot of fun up there, too. I'll just share the final picture of our trauma team. We're always looking for talent. We're always recruiting. If you want to come have an adventure, come and find us afterwards. Thank you guys so much. We have time for a few questions, if anybody have any questions of anybody on the panel. Great presentation, Val Samms, Air Force trauma surgeon, you know, the the military in the last couple of conflicts spent a lot of time and energy training mobile surgical teams in an area of conflict where we had total air superiority. So probably wasn't the right time. But now, obviously, we're interested in how we're going to use those small surgical teams in a peer adversary situation where we may not have air superiority and we have this prolonged field care situation, as you guys have had. So my question for you is, has the Alaskan system ever tested moving the surgical teams forward to the patient? Or if you and if you have, what what lessons learned, good and bad? Yeah, great question. We have not moved our surgical teams forward. We do work very collaboratively with the military. We have a unique advantage that we're, you know, an IHS federal system. And so we actually do, you know, a lot of our military surgeons actually come over and take call at our facility to, you know, have their readiness readiness. The although we haven't worked at moving surgical teams forward, the big push for our military system has been the access to blood products in these medical evacuations. Alaska still does not have whole blood yet. And and that's been one of the big things that our our P.J. team has requested is access to products. And again, you know, even if, you know, Alaska is so unique in that there's very few centers that provide surgical capability. And so I'm always focused on how can I have a non-surgical team stabilize a surgical patient? And I think it's those things that we can provide. Right. You know, compression, hemorrhage control, blood products and balanced resuscitation, good care for shock patients. And and so so that has been kind of our forward thinking is is trying to stabilize patients in a non-surgical manner. Thank you so much for your presentation. This is amazing. And congratulations for the hard work you did and the outcome you got. I think a lot of us probably have hand surgeons at our level one trauma centers that would not have touched that with somebody else's 10 foot pole. So thank you for what you did. And congratulations again on an amazing outcome. You mentioned education, you know, in regards to burns and whatnot. And since Alaska really truly defines rural, is there any education you wish was included in the current trauma education that we have out there? Or is there ways you really feel like we need to improve our rural trauma education? And what would you suggest? I'll let Angie talk to you, but we're like, you know, you know, the TMD TPM relationship, right? We're like the same the same continuum. So we've done a couple of things that I think can be modeled other places. Our community health aides have, you know, so our community health aides are going to see these really high severity injuries at a very low frequency. And so they have essentially a playbook. They have iPads that are kind of a choose your own adventure. Is this patient a trauma patient? Click yes. It goes to the next module. Is this a thermal injury? Click yes. It goes to the next module. And so it's our responsibility to make sure that their modules match with what we want them doing. So we work very closely as the trauma department to make sure that our care is all from the same playbook. We have done things like create videos to help them understand how to debride and dress a hand burn. We do telehealth education statewide that is highly attended by these remote villages. And we can talk through cases and give education. So I think that education is one piece of it. But I think making sure that everybody is working in the same playbook is really important. Making sure that what they're teaching at the village clinic is what I want them to be doing. And then providing that support. Again I mean the amount of calls that we get on that 30 hour that that patient's seeing in that clinic. These you know it's a lot of work for our surgeons. But we understand the importance of coaching them through a really serious trauma. So the CHAP or community health aides in small villages are family members to or know everybody else in that village. So the one thing that I would like to see and I think like trauma services could actually do this education is education on knowing when you as a CHAP person needs help. Self-help. I think that's for me that's that's one of the top things on my list to do is to be able to offer courses on identifying. Because we're talking about lay people that's gone to classes to be essentially a little bit of an EMT right. And they're out there by themselves and everybody they see they know because we're talking about villages anywhere from 100 to maybe 300 people. And so I think being able to identify that taking care of my own daughter was very stressful for me and I need to talk to somebody. And in the U.S. we are not as prone to taking care of our psychological problems or asking for psychological help. And so I think that for me is is one of the things on my to do list for education. But again you know you've got to have funding you've got to have support. I think I have the support working on funding. This question point of privilege from the voice. This is precisely what I was talking about in my earlier discussion about having a story to tell. And you have asks you need blood you need transportation mechanisms you need communication strengthened. Have you been able to share this information this type of story with your federal and state legislators like Dan Sullivan Lisa Murkowski. Yeah we should connect and talk. But it's not my it's not my strong point but I think as you've said and as we've realized advocacy is an integral part. And when we talk about the trauma system in Alaska what built that system was our advocacy at our state and federal government. And that's what built our trauma system was advocating for what we call the Alaska trauma fund that provided funding for any designated trauma centers to receive funds. And when we lost that funding that and COVID I think both of those things is why we saw a decrease in some of the level for participation at the state level. And so you're exactly right. Telling those stories are important to getting the word out that this and again it's the leading cause of death and injury for our young people ages 1 to 45. And so we it is a public health crisis and we have to work on funding so that we can have that care system. And I will say also Congresswoman Peltoli is Alaska native. Her husband actually died in a helicopter crash after she was elected to Congress. So she understands the issues that we run into as health care systems. So I think we do have some voice but we haven't lately advocated to those voices. Thank you all. Give a round of applause.

pediatric crush injury

Alaska trauma system

multidisciplinary approach

limb salvage procedure

rural trauma care

underserved areas

trauma team collaboration

geographical challenges

trauma care advocacy

specialized care access