First 24 hours of burn surge, so I'm on the ODBC for the ABA, which is the committee that's in charge of preparing for disaster preparedness. I moved here after 10 years in North Carolina, actually 15 total, but in my background, I'm a trauma surgeon who's done additional training to become a burn surgeon, and then I just came down here to start the burn center in New Orleans. What you see here, this is actually from in between us and Charlotte. This is a colonial gas pipeline. This happens in about every single city. This was 49 deaths below the age of three down in Sonora, Mexico, that a burn surgeon got a phone call about. This was actually South America. I kept everything to this, our part, and I didn't even go over to Europe. This, however, was over in Europe, and these are one of those terrifying pictures that you never really want to see, and then this is something that's well known to us here in New Orleans. We just celebrated the eighth anniversary of this Deepwater Horizon, which was on April 20th. These are all burn disasters that are also commonly trauma disasters. So this is an interesting question to ask, who is a burn patient? So first off, these are the common mechanisms. We all think about burns as being flames, so yep, flames make sense. We think about it as being scald injuries. Contact burns. It's very common in trauma, actually. You wreck the motorcycle and the muffler's on top of your leg. Chemical burns, electrical, inhalation. No cutaneous burn on the skin, but they do have an inhalation injury. And then radiation injuries. Radiations are relatively uncommon, but what's funny is that when you look at the definition of trauma according to the federal government, you know, so an injury caused by an external force, it wasn't until 2014 that burn was actually added. Prior to that, burn was actually not included in the definition of trauma, but if you really look at it, about everything you do when it comes to a burn injury is very much like trauma. We still do ABCs. We still evaluate them for other injuries when you jump out of a two-story building because your house is on fire and you can't get down the exit. So then the question becomes, is burn ever combined with trauma, and do you ever have the two of them together? Now, if you look at Steve Wolf's paper that shows 5%, you'll notice that's a little bit older, and that's like if the people do the up-to-date, but if you look at the more recent data, it's higher. It's closer to 10%. The more urban you are, the higher that percentage. If you look at the disaster situation, 25% to 30% of patients, according to our ODBC from the ABA, 25% to 30% of patients from a disaster situation, their primary injury is actually a burn injury. That's an alarmingly high number, and I'll explain why in a second. But just looking at civilian workaround, not disasters, 486,000 are presenting a year to emergency rooms across the country, so that's somewhere in the order of 24,000 to 48,000 patients. That's a small number. When we talk about what is a burn, you know, this first degree, like what you get when you go to the beach, that's not actually what we ever consider a burn. Like that stuff is going to heal with just God and nature. You don't need a burn center for that. But anything that's going to result in a blister, which is going to be some component of dermal injury, the dermis is this part right here that regenerates the epidermis. The dermis is not immortal, contrary to popular belief, and the skin is a little bit overrated. It was touted as the biggest organ. It's not. If you want to do it by mass, it's going to be muscle. If you want to do it by surface area, it's going to be your blood vessels or your lungs. So second degree is when you start to see the bulla or blister formation, and then third degree is when it goes all the way through the dermis, and fourth is when you get into fat. Fifth is when you get down to muscle, and sixth is when you get to bone. Upon coming to New Orleans, my first six patients were all burned all the way down to bone. So it was an interesting welcome to come down here, and as a matter of fact, we opened last month on April Fool's weekend, a caution note, don't do that, and then we also had our mass casualty incident last month, which was when a big hotel that was undergoing renovation with a bunch of scaffolding came in contact with a high-tension line. So this is what an inhalation injury looks like. How many minutes do you have to get out of a house once it catches on fire? This is discussion. Your retention from discussion is 50%. Your retention from PowerPoint, death by PowerPoint, is 20 at 24 hours. So how many minutes do you have to get out of a house once it catches on fire? Anywhere, two minutes, very good. Who said that? It's very good. You have two minutes to evacuate. This is five minutes. That's carina. That's the lungs. This is seven days on a ventilator. So where can they be treated? This becomes more concerning. There's over 5,500 hospitals, over 270 level one, level two trauma centers. There's only 70 verified burn centers in the United States. There's not a lot. When we start to look at it, the number of burn centers over the last 40 years has actually gone down. We've been regionalizing. The number of trauma centers has been relatively stable. When you look in the southeastern United States, I just pulled it up because you're visiting our lovely state. Prior to us opening the burn center here, if you had a trauma, a combined burn, you'd have to go to Shreveport. Mobile has a state-verified facility here, but as far as level one, ACS level one, the red one, you had to go to Houston, Galveston, or you had to go to Tampa or Shreveport. So that was a problem. We knew that we needed to be able to take care of burn traumas, potentially given a disaster being a port city in a city where people come to find trouble sometimes. Does anyone know what this is? These are all the oil and gas rigs, all 4,000 of them off the coast right now. We usually have an incident with these on a pretty regular basis, unfortunately. These are some of the things, going back to the prior presentation, that a prepared facility will have. Unfortunately, I'm in a brand-new $1.7 billion facility. These are 18 showerheads for deconning 300 people an hour with tepid water. It's not cold, not hot. This is a steam generator sled here that we put in so we can heat rooms up to 85 degrees without having to use infrared heat lamps, putting them on top, which then the fire has and causes the wounds to desiccate, increases insensible heat loss, water loss. This is a triple filtration system because sometimes the water here in New Orleans can be compromised. It undergoes carbon filtration and then undergoes light ionization filtration and then reverse osmosis. It's the most pure water you can get. Now, it doesn't go for the entire hospital. It's mainly reserved for the operating room and the labs, where we clean our supplies. These are elements of preparation. These are other elements. This is a room that will heat to 85 degrees. It doesn't look any different than any other room, but when you're cold, remember, you hit 35 degrees, 30-degree coagulation factors no longer work, and that seems to be a problem when you have heat loss because you lose 533 calories for every cc of fluid that you're losing. This is a hydrotherapy unit. This is a rate-limiting step we found with our MCIs this month, which is fine. We knew that our ER could scale for this. We'd actually done some preparations, and this is a rehabilitation center. So if they survive, you then have to take care of them and rehabilitate them, and you're all welcome to come tour. The burn availability, now, this is an interesting number. So you heard me say over 5,000 hospitals, that's over almost a million beds. For burn centers, we have 1,800 beds. We stay at 95% capacity in the United States. That's why sometimes it's hard to get a patient into a burn center. Any given day, we have 87 beds. We did Gotham Shield last year. We had 500 patients in our simulation. The United States failed. We've done 50, and we've passed. We know that in the event that someone were to launch something, that we're going to look at 50,000 survivors. It's just not going to be doable. Transportation delays are very real. Even in North Carolina last year, when we had the ice storm, we had eight-hour delays. Eight-hour delays taking care of a burn. All of a sudden, ABLS doesn't become enough. And then burn centers don't equal trauma center. I can't enforce that enough. A lot of burn centers might or burn centers are required to have an association with a trauma center, but it doesn't mean that they are a trauma center. And I was on the phone last night with someone who we were talking about the state of burn care in this region of the country, and their comment was, well, we do burns, we have orthopedic surgery. I mean, we do trauma. We have orthopedic surgery. I was like, that's so offensive to a trauma surgeon. Don't get me wrong, I appreciate my orthopedic colleagues, but trauma is so much more than just an orthopedic surgeon. I go to China about every other year to help them with some work that Dr. Meredith laid out in front. Just helping them break down their silos of culture, because to them, for many years, trauma was an orthopedic surgeon. It was like, there's so much more than that. They're now working on building trauma systems. So the first resource I would point you towards is if you go to the American Burn Association's website, it's not under public resources. For some reason, they put it under quality care. Underneath quality care is mass casualty. So you go to that link, and then you follow it, and this is probably like the take-home notes. Like when I used to teach high school, I would tell students, like, this is on your test. Like these would be some of the things that would be on your test. So for different regions of the country, they have different phone numbers for activation. In the southern region, we use BRIMS, which is a Birmingham-based emergency response network. That's basically our command center. So when there is a large burn situation, we call them, and they will begin assessing burn bed availability. These numbers change. And if you follow it further, I'm going to go into some more details. On that same page is a link to our disaster plan. So disaster plans then say, where do you need to send these patients? Who do you need to contact? Now, in truth, if there's a burn disaster, my first recommendation is to call BRIMS, activate that, and then to call your local burn center. And they will be glad. They want to know what you've got coming. They'll be calling people to come in. I'm on call back up for my trauma partners every day. So who can treat them? Now, this actually becomes the concerning part here. I have a lot of respect for my military colleagues. I just got back from San Antonio on Thursday and Friday, I was meeting with Dr. Cancio. So in the United States, looking at Lee Foshay's work, we've seen that there's been a dramatic drop in the number of people going into burns. We only produce about two to four per year. That's not a lot. Two to four burn surgeons per year is not going to be able to staff 120 places that have called themselves a burn center in the last 10. So you're probably going to see continued regionalization of burn centers. There's only about 300 practicing burn surgeons in the United States. When you compare that to trauma, we produce 240 to 260 board-eligible surgical critical care fellows per year. So that means that there's a lot more trauma surgeons than there are burn surgeons. When you look at the training paradigms for them, unfortunately, around 2008, 2009, we removed burns from the general surgeon training. In other words, prior to that, you had to have a required experience, and now you don't have that required experience. You didn't know a boy from Mississippi could talk this fast. But the problem with that was that there was 260 facilities that trained surgeons, general surgeons, and only 120 some odd places that had some form of a burn center. And so it was a hardship to be able to take all these people and then send them to these facilities. And in addition to that, there's a lot of other new stuff that's come into general surgery, like robotics and other things, mentally invasive, that have kind of taken a precedence and an interest. So general surgery had to consolidate that. And this is one of the things that we did lose. One of the exciting things about coming to New Orleans and opening a burn center is that they train over 20 general surgeons in this town per year. Between Oshkosh, Tulane, and LSU, it's over 20. So we're going to dramatically increase the exposure that trainees have from this community. And so while their rotation is not required, they have to have knowledge of it. The next thing is, well, we'll get the plastic surgeons to figure it out. Well, in truth, plastic surgeons don't actually have to do burn rotation. It's recommended, and they have to do burn recon, but they don't actually have to take care of acute burns. And then the people who probably see the most burns, more than anybody else, is emergency medicine. It's not even listed in their RRC, common program requirements. So then the next group of people would say, well, we'll get the AAST acute care surgery fellows to do it. Well, that's about 20 programs, and a former institution was one of those, and it's actually not a required rotation for the trauma fellows coming out. Meaning, if you think trauma surgeons are going to do it, don't assume that, because a lot of trauma surgeons might not have had the exposure to it. Then burn fellowships. Well, the rate-limiting step is not burn fellowships. It's actually people who want to go work in a 100-degree operating room. So while it's great hot yoga, it's not always the most desirable area to work. And so they're very variable. Meaning, like, you can do critical care, you can do non-critical care, you can do adult, you can do PEG, you can do both. You can do recon, you can do non-recon. The beautiful thing about having people who are both trauma and burn trained is that we can do the spectrum. Delays. So you know, per the work, some done by Mowry and others, that about every minute equals about 0.8 to 1% increase in mortality when that patient's sitting in the trauma bay. If you leave someone unresuscitated for two hours, there's a greater 20% burn, and mortality goes to about 20%. So one in five chance of dying is because you didn't start fluids. This is probably one of the things that's more terrifying right here. When you look at not having access to trauma, and that's why I was saying, like, it's important to have a trauma center in New Orleans, was that mortality and burns plus trauma is not 1 plus 1 equals 2. It's not 3.5% plus 45% equals 8 and a half. It's not that. It's 22 plus. 22% plus. It goes up dramatically. And that's a big concern that we have, because if there is a disaster event, and there's 25 to 30% of the patients who were injured, and it's a large scale, that have burns as a primary injury, those trauma surgeons are very quickly going to have to become burn surgeons. And so that's one of the areas that we're working on. You look at trauma, and it's beautiful. They have so much training that's available to so many different people at different levels. I spent two weeks with Roy Olson, who's one of the authors for ITLS. And it's just, I'm so amazed always, and I still consider myself privileged to get to be an instructor for some of these courses and to get to see how these have continued to develop. Unfortunately, in burns, we've only done this. We have ABLS, which is a one-size-fits-all. So we're trying to improve that. And one of the things we're doing in the ABA right now is a course that's in development. This is not a product. It's finished. It was actually sponsored by a Children's Institute grant, which is actually out of North Carolina again. And we develop simulators that have been validated for teaching escharotomy. That's a skill set that everyone should have for managing a burn disaster, which is how you release pressure in a burn, an extremity or a torso that has circumferential injury that leads to increased pressure, because basically burns dehydrate the skin, which then turns you into beef jerky. I know that sounds gross, but it turns into a giant tourniquet. This is the gentleman here who helped do that. He won the military. He was one of the ones of Lauren Blackburn and others that won the Military Innovator of the Year award. Over here on the right, that's actually Narayan Iyer. He is one who heads up BARDA for burn and blast injuries. And he's actually taking the course there with Dr. Holmes. Dr. Holmes is, again, out of North Carolina. But he's the head of the American Burn Association's Research Network. They're taking the course, auditing it to see what can we do better. And the course is designed to not be basic skills, like ABLS, which is the first 24 hours. It's designed to, which is basically stabilize and triage. It's designed to be a problem solving and procedure skills. How do we extend that from 24 hours to 96 hours? So what needs to be done first? This is a common question I get. So these are the R's that we teach. Rescue, resuscitate, remove, reconstruct, rehabilitate, reintegrate. So a lot of these things down here you're not going to be worried about with a disaster. You're going to be worried about these things up here. So the rescue component is absolutely critical. And you're used to doing ABCs in trauma. This is the twist that we put on ABCs for burns. Airway, be thinking about inhalation injury, looking for oral cutaneous, mucocutaneous injuries. I can see they have blister involvement. It's a lot easier to extubate someone who's alive than it is to explain why someone was not intubated and had a problem in transport. So I always tell people that we know that 30% of patients who have a suspected inhalation injury don't actually have one, but got intubated. It's much safer to intubate and protect someone's airway than it is to not do that and have an accident. Second thing is carbon monoxide cyanide poisoning. The half-life of carbon monoxide is 40 minutes once you put them on 100% oxygen. So it's great to get a carbon monoxide level as early as possible. It gives us a better idea if they're going to have a neurologic sequela that we need to be prepared for. Unfortunately, cyanide does not have a test that you can easily assess with. There's one that's being developed in Europe right now. It's actually a probe. It's in England. So we do recommend cyanide treatment kits. And hydroxycobalamin is one of those things that's got low-risk, high-benefit. This makes the urine a very funny color, so just note that if it's ever administered. IV access, we always say wherever you want. IO is fine. And then burn shock is different than traumatic shock. And I'm going to go through a slide on that. And then concomitant or concomitant trauma. So this is one of the things that gets left out. And we think that this is one of the reasons why that mortality is not 1 plus 1 equals 2, but is actually 4 or 5 times higher, is that when you have a trauma surgeon managing a burn or a burn surgeon managing a trauma, the two of them might not really be thinking about each other's roles. And so we think that this is one of the reasons why we don't have definition to it. We have not defined that with data yet. So that is religion and art. That is not science. And then hypothermia, I've already mentioned that. So if you notice in ATLS, the formula still uses the old Parkland 4CCs. But actually, in 2010, the ABA changed it with a consensus formula to 2 CCs per kg per percent DBSA. So they actually dropped the formula in half and modified Brooke-Army. Peds, it's 3 CCs into less than 20 kilograms. We recommend that we add a maintenance fluid with D5. And then for electrical injuries, it jumps up to 4 CCs, because remember, the burn's on the inside, not the outside. And then the key thing to take note here, that really, these are 0.5 CCs per kilogram per hour for urine output, except for electrical, which jumps up to 100. So when we had our mass schedule incident with all the electrical burns hanging off the scaffolding, they were all critical care, because they all came in with neuropathic injuries and cutaneous burns and required resuscitation. This is the mistake. This is actually Charlotte Motor Speedway, and this is New Orleans Motor Speedway. My brother is a race car driver, and so I show him this analogy. The mistake is that you calculate the fluid resuscitation, and it's just like going on the drag strip. You just get on, you put your foot on the gas, you go as fast as you can all the way down. That's not the case. Very much it's like this, where you're going to go fast sometimes and go slow other times. If they're making too much urine, you might dial the fluids down. If they're not making enough urine, you might dial the fluids up or add a colloid. This is what we think about with trauma when we have failed resuscitations. We're commonly thinking, do they still have bleeding somewhere? Do they have dead tissue? Do I have undrained pus somewhere? These are the things that keep you up at night. Reperfusion, shock sequelae. And then acute or chronic cardiac conditions. In burn, we change that just a little bit to say, do they have a compartment syndrome that I've not released? Common things being common, that's usually one of the ones that we look for first that we find. Cyanide poisoning, carbon monoxide poisoning. These are things that disrupt all the normal process in your body. Basic ATP production. So it's beautiful because in trauma, 60% of the energy in a chemical reaction for the production of ATP is actually heat and is not the formation of a bond. So when you stop the bleeding and restore the delivery of oxygen to mitochondria, the patient begins to heat back up. That is not the mechanism in burns. In burns, you've lost your cutaneous integrity. You've become a giant evaporative coil. And so as water leaves the body, you cool. So the quicker you cover the wounds, the better you do. When I used to train special forces in Winston-Salem, that was one of the things we teach was to actually use Saran Wrap because you could cover the wounds very quickly. This is after deconning, of course. And then this is a wonderful stress test, too. Your catecholamine level goes to 20 to 50 times your normal level after a burn injury. The only other time it does that in the human body is not when you're about to get audited. It's actually during labor. So it's when women experience labor. And this is actually a sustained phenomenon, which is one of the reasons why normal vasopressors or anatropic agents do not work as well in burn patients, but why vasopressing works better. Then again, looking again for trauma or inhalation injury. Inhalation injury can increase your resuscitation goals by 75% or fluids by 75%, and then congenital. In kids, for adults, we assume your heart has four chambers. In kids, you've got to remember, it's not always that way. So this is a burn. What would you guess this is? Second, third, first. African-American female, 12 years old, 62% total body surface area. You've got a 33% chance of getting it right. You didn't even have that on your board, so you get to stick that. Second degree, right? So I would agree with you. This is eight hours later. There's no camera or trick photography, no flash, nothing like that. But you can see it begins to turn pale here. That's because she's a 62% burn. So this girl was extubated following 24 hours of resuscitation, stayed on the mark, did not require any aggressive colloid or crystalloid resuscitation. She was at 3 cc's per kg. She didn't require extra fluid, but this was at 24 hours. One of the things that we see in burns is when you paint the bathroom, you're like, I thought this was white. Then the next day you walk in, it's yellow. When the paint dries or progression of disease, you're actually seeing the full severity of the injury, but you don't see it initially. And so general surgeons are right 50% of the time in assessing this wound and determining whether or not that's going to heal. Burn surgeons are only right 73% of the time. So some of the good grace in the work that we're doing right now with the ABA is trying to develop a learning algorithm and artificial intelligence for a camera that can look at a wound and beat the doctor at determining whether or not it's going to heal. So for disaster and scene, it'd be wonderful to be able to say, boop, 50% TBSA, third degree expectant. Moving on through, this is going back to the ABA website. Here are the disaster plans referred to. Here's also tracing. Some of the other things that you can have are here. It's also got our region maps. But here at the bottom is austere guidelines. These recently got published. This is what happens when the zombies attack. Or we had the 50,000. This is how you orally resuscitate somebody. It even goes into discussion about when you run out of pain medicine. And using marijuana. So this is one of those areas that you probably want to download these papers and have them available in case of something really bad, because you're not going to actually have access to the internet. But the austere guidelines were very well-written. And they cover a lot of components beyond just resuscitation and pain control. So it's one of the things that we recommend that you look at. I'm going to move on next. The ABA disaster plan right here, this is where this came from. This is for disaster. This is not for normal burn care. So please don't go home and say, Jeff Carter said that a 50% burn in a child is going to die. That's not the case. That's not what I'm saying at all. What I'm saying is that this is actually our curves. And then we have these that we've modernized in the most recently austere guidelines. Let's say, who should we black tag? Or who do we need to change our guidelines? How do we triage these patients? So that's one of the things coming out of this is knowing how you're going to triage. But having a good relationship with your local burn center is probably one of the first things to do. In fact, I just brought a poster I gave to someone here that has ABCs of burns in it. And we're dispensing them to our regional centers, hospitals here, so that they can hang it up and know, okay, this is what I need to do. And like one of the things in ABLS that we teach, school-aged children, you can run the fluids at 250 an hour if they have a 20% burn in the process of transferring them. And for adults, it's 500 CCs an hour. You don't even have to do the calculations. Part of the good things of having a relationship with the burn center is like, this is our procedure manual. You have this in North Carolina also. And then this is something we've developed down here in New Orleans. This is our resuscitation algorithm. And these are designed for the resources of a burn center. So I've had a lot of people say, can we just have yours? And so like when Joe Abraham down in Orlando asked, can I have your simulations, Jeff, before the nightclub incident? I was like, sure. But this is something that you can't transfer very well. This is something that is really designed for burn centers. But you can see here, green means good, red means stop, yellow means caution. Too much urine, we turn the fluids down, too little urine, we tinker a little bit here, we turn the fluids up by 100 CCs or 20%. Then we start to give colloid. Again, having a big blood bank and being a trauma center is one of the beauties of being able to give colloid in this situation. So this goes back to the girl that you saw earlier. The one we said, what she looked like when she arrived and how the burns got worse. This was her face and neck. And this is one of the beauties of having the relationship with the burn center. That we can bring new technology. So I'm gonna talk about, this was something that's actually being evaluated by the FDA right now and it's been heavily utilized in North Carolina. This was after removing all the dead skin from the face. I'm sorry, I have gross pictures. I should have warned you about this. Burn surgeons, we tend to do that. But this was after removing the burned skin from her face. And this is putting allograft on, which is like a biologic Band-Aid, giving it two weeks. And so you see some areas here that look like they're probably gonna heal, but a lot of stuff that's not going to heal. This is after then applying the spray skin. Seven days later, I don't have any stock in the company. They don't pay me. They don't pay any foundation I've ever worked for. Let me just make sure that that disclosure is clear. This was seven days later. Pretty hypopigmented. You know, you can see a big difference between her native skin tone here. She's about to be a teenager. This is at one month. You know, she was pretty irate with me that she had acne. I was like, you know, you have a 62% burn. Your average length of stay is 130 days at burn centers across the country. At non-burn centers, it's greater than that. You're discharged at 30 days and dressing yourself. This is at one year. So part of the beauty of working with your burn centers and being a trauma center is that you can offer the latest care to patients who otherwise might not have been able to have this outcome. The other component is that burn care has changed. It has changed dramatically in the last 20 to 30 years. It's gonna change even more in the next 10. We now have skin substitutes. So it's allergenic, meaning that it's not yours. It's from somebody else that they're building antibiotic into it as a one-year shelf life that we can cover wounds with. So we have no donor sites. The donor site for this was the size of my hand for all 62% of her body. So there are dramatic changes coming in burns and what you might have thought in the past was survivable or non-survivable is changing. And so part of the good things you can do is to have a good relationship with your burn center so that when the disaster does happen, you know what to do. And then for other things, when the patients come in, we can give them the best care they can possibly receive. I'm a strong believer in preparing for these things. The more you sweat in peace, the less you bleed in war. And so this is an example of simulation. This is similar to Charlotte's, except this is a team-based simulation here. This is using the trauma algorithm. And this gentleman in the red circle right there, those are actually survivors. One incredibly impressive way of teaching your team and getting them to have the moment of plasticity in their brain to receive information and to change your values is to trigger an emotion. And one of the ways to do that is to take survivors who have gone through counseling programs to be able to be counselors to then be conditioned such that they can participate in the simulation. So that when you have a burn survivor that says, during the debriefing following your simulation, I am so appreciative of everything you're doing. I know that you're telling me you're gonna get me chest, you're getting a chest X-ray, you're looking at my wounds. The only thing I care about right now is pain medicine. Just tell me you're gonna give me pain medicine, I can hold on another five minutes. When you have a trauma survivor who says, I've just gotten thrown out of a car 50 feet. My eyes are closed, but I can hear every word you're saying. When you turn me, just tell me what you're doing so that I know that I'm gonna be okay. That makes the team all of a sudden stop treating these human beings like meat going through a machine and recognize that these are injured people that need your love and care and support. And all of a sudden, that message that you say about hypothermia and treating them so that they're comfortable, giving them pain medicine, sticks with that person and they change their behavior. We did five sessions where we just did basic team training, looking at our trauma outcomes, and in one year, we cut our time in the trauma bay in half. We did this in the operating room with the drilling and the training, and we went to zero sentinel events. So I appreciate the military because they do this an extensive amount as far as the training goes, but in the civilian world, we also have an obligation to it, be it a disaster or even being at something like a small MCI like you have at your local institution. So I wanted to thank you and then remind everybody that injury care is truly multidisciplinary. It will find the weakest link in your chain and it will break there. If you have any questions, comments, statements, rebuttals, derogatories, or remarks, I'm happy to answer. Thank you.

burn surgeon

burn injuries

trauma

burn centers

resuscitation process

simulation training