Welcome, everyone, to TCAA's webinar today, Size Doesn't Matter, How a Single Shard of Metal Can Get You from Your Porch to the OR in One Afternoon. So we're fortunate today to have two doctors with us, Dr. Alexandra DiCaprio-Guardino and Dr. Brian Frank, who are going to present their case presentations. Let me do a quick introduction of them. Dr. Alexandra DiCaprio-Guardino is a current PGY-4 resident physician at the Geisinger-Wyoming Valley General Surgery Residency Program. She is a 2012 graduate of Fordham University, where she received her Bachelor's of Science in Biology and Anthropology. She attended the Philadelphia College of Osteopathic Medicine, graduating with her Doctor of Osteopathy in 2017. She intends to pursue a fellowship in surgical critical care, trauma, and acute care surgery after completing residency. Her academic interests include the art of the exploratory laparotomy and the changing landscape of surgical education. In her time outside of the hospital, she enjoys spending time with her husband, Eric, and two Havanese puppies, Norm and Hank. Dr. Brian Frank is a Dually Board Certified in General Surgery and Surgical Critical Care. He completed medical school at Jefferson Medical College and his surgical residency at Christiana Care Health System, where he also served as chief resident. Dr. Frank completed his surgical critical care fellowship at the University of Pennsylvania. Since completing his training, Dr. Frank has served as a trauma and critical care surgeon at Geisinger CMC in Scranton, Pennsylvania. Outside of his clinical work, he is active in the department and hospital PI committees, is the assistant director of the trauma program, and is part of the resident faculty. When not working, Dr. Frank enjoys spending time with his wife and three children. So thank you both for being with us here today. Hopefully you can hear me and we can hear you. Thank you so much for having us. We'll go ahead and get started. A little bit of background. So our center is technically a rural trauma center. We're a level two center. We see approximately 2,000 to 2,500 trauma patients a year. And we're mainly a blunt trauma center with about 90 to 95% blunt trauma. Our community is six rural counties in Northeast Pennsylvania. It's mainly a geriatric population with a mean age of our trauma patients roughly of about 63 years old. And like I said, we see mainly blunt trauma up here. We serve about 1.5 million people in that community. This is an unusual case for us because this is a case of penetrating trauma and a bit of an interesting circumstance that Dr. Gallagher is going to present for us today. All right. So first, I'd like to thank the TCA for asking us to speak here today. I'd like to thank Dr. Frank for sponsoring me in this presentation. And I'd also like to thank Deb and Christine. You've been exceedingly helpful in making this presentation happen. And I appreciate it very much. So our presentation today is Size Doesn't Matter, How a Single Shard of Metal Can Get You From Your Porch to the OR in One Afternoon. Okay. I'm pulling them out. So for disclosures, I have nothing to disclose. The objective of this presentation, I am going to discuss how one centimeter piece of metal can cause multi-system injuries in the abdomen, describe the teamwork and interdisciplinary approach required to manage complex trauma patients in the operating room, and recognize the importance of preparation and training required to handle these trauma patients. So the patient presented a 31-year-old gentleman who was a level two alert after being struck in the abdomen by an unidentified metallic object. There was a construction crew working about 15 feet away from his porch where he was standing having a drink with some friends. He experienced a sharp stabbing pain in the right abdomen and noticed blood on his shirt in addition to a laceration to the right lower abdominal wall. He complained of abdominal pain as a side of laceration. And he denied any fall after the shrapnel strike or loss of consciousness. On arrival, our primary survey showed that his airway was intact in pain, equal breath sounds bilaterally, he had a regular heart rate, palpable peripheral pulses, and a hemostatic wound to the right lower quadrant, measuring approximately two centimeters. His heart rate on arrival was 74 beats per minute. Blood pressure was 134 over 90. He was breathing at about 20 respirations per minute. He was measuring 93% on room air, and he was 36.5 degrees Celsius. His GPS was 15, alert and oriented times three. On secondary survey, there were no injuries to the head, eyes, ears, nose, and throat observed. His pelvis was stable to AP and monocompression without tenderness. He was non-tender throughout the palpation of the entire spine, cervical, thoracic, and lumbar regions without findings of bony step-off or deformity. His extremities were without long-wind deformities. Motor and sensory groves were grossly intact. Most importantly, his abdomen showed a two-centimeter hemostatic laceration to the right lower quadrant. His abdomen was soft, non-descended, diffusely tender to palpation with some involuntary guarding. These are his initial labs. On arrival, you can see his BMP. His cranial is 1.1, but there's nothing entirely remarkable about that BMP. His CBC, I wanted to point out that his hemoglobin on arrival was 13.8. His urinalysis shows some moderate blood with six to nine red blood cells, and his urinotox was negative. In addition, his ethanol was 15. He did endorse to the EMS crew that he was having some beers with friends, which coincides with this. This is his chest X-ray. It shows no acute cardiopulmonary process. You can see that both lungs are fully expanded. There's no tracheal deviation. Interestingly, no free air under the diaphragm, which with a penetrating abdominal wound we would have expected to see. From the chest X-ray, we proceeded to get a KUV, which here is the anterior view. You can see superiorly in the image, there are some distended loops of small bowel. As we look lower, you can see that there is a small object. It measures one centimeter in size, lodged right at the left hemisacrum. Recalling that his injury and his laceration was, in fact, on the right side of his abdomen, we had crossed the midline with this piece of shrapnel. Also, on the left side of this image, you can see that there's some air tracking across the abdominal wall. This is the lateral view from our KUV. You can see some street artifacts from air tracking and a blanket on top of him. Interestingly, you can also see the L5-F1 junction that our metallic object is, apparently, posteriorly in the retroperitoneal region. Our first poll for the audience, would you take this patient to the CT scanner? Okay, I'm going to close this and show the results. Can you see that? We do. Yeah. So it shows that 97% of participants in this call would take the patient to CAT scanner. So we are in agreement. We are in agreement. The interesting question came up, and we encourage participation in this conversation. So if there are any questions, please make sure to utilize the Q&A box in Zoom. And Christine or Deb will share those with us as we go. But we have a hemodynamically stable patient, but a penetrating wound that clearly traverses the abdominal cavity just based on the trajectory of the wound and the final path of the bullet or the projectile in both lateral and AP views. So there was conversation about whether or not that was warranted in a patient with peritonitis. We did opt to take the patient to CAT scanner, and we'll go through those results now. So here are some key images and cuts from our CAT scan. The axial view is an image on the left. You can see that the trajectory over the right anterior abdominal wall with an endpoint posterior to the common iliac artery and vein is associated with some interesting, and I'll point it out here, surrounding question for possible left iliac vein injury and the question of extravasational contrast around the external iliac artery and vein lumens. And in this image, when we continue on the CAT scan, it does continue down to the bifurcation of the internal and external iliac. You can also see here that there is this extended loop of jejunum with some free fluid in the abdomen and some free dots of air here. This is subcutaneous emphysema, and this image was obtained with rectal contrast in addition to IV contrast, which is why we see contrast in the ascending and descending colon. In this image, we can see some complex free fluid in the abdomen and the pelvis particularly. Furthermore, we have some loops of jejunum, and then these are our internal and external iliacs. In our coronal cut, we can see right here the psoas muscle just medially, and at the L5-S1 junction, the bullet has traversed the abdomen and is lodged there. And this would be about at the level where the aorta bifurcates into the common iliac artery. In this image, it shows here we have a small amount of free intraabdominal air, and the course is kindly pointed out for us with a positive arrow sign. We can see some subcutaneous emphysema as well. So we proceeded for our emergent operative exploration. Given that we have the imaging studies showing the question of vascular injury, we contacted our vascular surgeons prior to going to the OR, informing them that we had concern for a vascular injury based on the station of the object in addition to the read of the CAT scan. So they were kind of pre-warned that an intraoperative consultation for a question of the left iliac arteries would be shortly requested. So we proceeded to the operating room emergently after a CAT scan, and so we made a midline laparotomy from the xiphoid to pubis. It was a generous incision. Initially, we encountered some hemoperitoneum focused in the pelvis corresponding to that kind of complex hemorrhagic fluid in the pelvis. The four quadrants were passed and sequentially removed, and we began to evaluate the retroperitoneum. We evacuated the pelvic hematoma, and first we encountered multiple small bowel enterotomies with active hemorrhage noted. For this, we controlled each enterotomy. There were six with silk suture to control the hemorrhage in addition to any contamination. We then mobilized the left colon to gain access to the left retroperitoneal zone. So we have here our three retroperitoneal zones. This is zone one here. Oh. We have zone two on the right and zone two on the left and in the pelvis, zone three. So the station of our object was approximately here. I'm sorry, approximately here at the junction of zone two and three. So based on the CAT scan read, we proceeded to investigate this area first given the possibility of a vascular injury. So we were able to expose the left iliac vessels, and we did not find any surrounding hematoma. We exposed the left ureter and did not find any obvious injury there. However, based on the trajectory, again, we were concerned for a possible ureteral injury on the left. And so we administered methylene blue as a provocative test and did not find any extravasation of the methylene blue in any urine coming from the left side. So we re-evaluated at that time the small bowel enterotomies. They were all localized to a 6- to 12-centimeter segment of the bowel. We chose to resect that at that time using a GI stapler with a blue load, and then we took some medicine and carried it with an energy device. Subsequently, we inspected the trajectory of the shrapnel fragment, and in doing this, we also mobilized the right colon to expose right retroperitoneal zone. We, in doing this, encountered a large-volume rush of non-pulsatile blood, and we suspected that this was coming from a zone 1 expanding into zone 2 on the right IBC injury. And so we obtained proximal and distal control, and we're very lucky that Vascular actually walked into the operating room shortly after this occurred. So we now had this IBC injury. Luckily, we had Vascular at our side. And so we had hemostatic control. We, with the help of our Vascular Surgeon, Dr. Fong, dissected out the IBC and identified a 2-centimeter laceration along the posterolateral wall of the inferior vena cava. It was primarily repaired using a 5-0 proline suture in a running, continuous fashion while we maintained proximal and distal control. To ensure that we had a hemostasis, we also placed some thrombin gel foam over the repair, and we're very thankful that Vascular were there. We then, after moving away from the IBC, observed some clear fluid kind of pooling up in the retroperitoneal bed on the right and found a right proximal ureteral injury. In very close proximity to our IBC injury. So with this image, we can see our IBC injury was about here, and our ureteral injury was here. So if we were coming from the right, or the projectile trajectory would have gone somewhat like that. So there's about a 50% circumferential laceration to the right ureter. Urologic surgery was available to come into the operating room and assist us. We placed a 6 by 26 centimeter double J stent. So that is a thick French stent that is 26 centimeters long. And it was ensured to have adequate proximal and distal length. We did not need to statulate for the primary repair. We actually had enough length that we could make a tension-free repair. And the injury was closed primarily over the stent with interrupted monocryl sutures. So another poll for the audience. Would you leave this abdomen open for a second lift operation? Yes or no. We'll give it one more second. I think you can see our screen that shows 72% of the audience and 28% would not. Probably could have, we'll go to the next slide where we'll share a little bit more of his physiology with you, but we have the privilege of operating on one of the few younger, healthier patients that we have here at the center. So I didn't show the complex of injuries, but... So interoperatively, our physiology, we had a patient who was 33, or I'm sorry, 36 degrees Celsius. He was not on any pressure support. He was not acidotic at the time and he was not coagulopathic as evidenced just by oozing and everything during the case. He, you know, as a younger person, it was something that we discussed interoperatively and after exploring all the quadrants again, after the IVC and ureter repair, we chose to close the abdomen. So after we had this discussion, we performed a small bowel anastomosis, creating a common channel with a 75 millimeter endo-GA, or I'm sorry, GA stapler. We over-sewed the staple end of the common channel and closed our mesenteric defect. We subsequently re-explored the abdominal cavity in its entirety, irrigated the abdomen with four liters of saline, and placed blade strains. We had one blade strain by the right ureter repair, and one in the left pericardial gutter. We then closed his abdomen with two loops of EDS, and closed the midline incision with staples. We then washed out the right lower quadrant wound, and also approximated that with staples. So overall, our operative procedure was exploratory laparotomy, small bowel resection with an anastomosis, expiration of zone 1 and 2 retroperitoneal hematoma on the right, repair of a two centimeter IV elasteration with the assistance of vascular surgery, repair of a right ureteral injury with the assistance of urology, replacement of bilateral strains, and for pain control, we performed a tap block with Expro. So as far as totals, we had EBL of 400 CCs. He was given five liters of Crystalloid intraoperatively, in addition to 150 CCs of Cell Saver. He had an NG tube that was in place in the OR. We put out about 400 CCs, and the urine output was 850 CCs. We had our specimen of small bowel, and he had, as drained, an NG tube, his catheter, right blade drain in the pericardial gutter, pericardial gutter, over the ureteral and IVC repairs, and a left blade drain in the left pericardial gutter, and extending into the pelvis. So we kind of discussed again our reasons for why we closed him. He was warm, was not coagulopathic, and was not requiring any pressure support. We felt that he would appropriately be able to perfuse an anastomosis, and we did not find anything that was warranting of a second look. So overall, his injury complex was a penetrating wound to the abdomen by metallic straphenol, retained metallic foreign body over the left hemisacrum, right zone one retroperitoneal hematoma expanding into right zone two, a two centimeter laceration of the posterior lateral wall of the inferior vena cava, a right proximal ureteral injury with partial tear of the ureter, small bowel enterotomy secondary to the straphenol passage with six in total, confined to a 12 centimeter segment of bowel. And any comments before I move on to his post-op first? Okay. So he was extubated in the operating room. We did bring him to the ICU post-op for close hemodynamic monitoring given his IVC injury and repair. We wanted to make sure that his blood pressure was closely monitored. So hemoglobin trends, he was a 13.8 on admission. After off, he had a hemoglobin of 10.2 at the beginning of the case, 7.8 at the end of the case. However, his post-op day one CBC showed a hemoglobin of 11.0. So likely those ISAT values were dilutional. On post-op day one, he received a completion of 24 hours in the Boston for enterocontamination from the small bowel enterotomy. We started chemical DVT prophylaxis, VID, Lovenox for our trauma algorithm. And we transferred the patient to the third floor. On post-op day two, we got a KUV for stent evaluation, per urology's recommendations, and we removed his NG tube. We did leave him NPO overnight. So this is our KUV from post-op day two. As you can see, we have the stent here, nice curl, and here in the bladder. And then settling right here, we have the object. This is our drain coursing around the right pericardial gutter over the ureteral and IVC repairs. And then this is our left-sided drain coming down the gutter and into the pelvis. See, he does have some dilated loops of small bowel here. This is all gas in the colon and kind of coming down into the descending colon with a little bit of residual contrast from the rectal contrast administered on the trauma scan. So overall, kind of an uneventful post-op. Of course, he started passing gas and had a bowel movement on post-op day three. He was advanced to clears on that day, and he was seen taking laps around the hall, lapping our rounding group several times a day. He was advanced to a full liquid diet by day four. And post-op day five, he was advanced to a regular diet. Urology did have us get a drain creatinine from the right lace drain. It was found to be 0.8, and the drain was subsequently removed. He was discharged home with his indwelling bladder catheter and the left lace drain in place. The left lace drain we left in just for high output, likely just some ascites that we were draining out post-operatively. And then this is his follow-up course. So on post-op day 10, he was seen in our trauma clinic. His staples were removed, and the drain output had decreased and was additionally removed. He was followed up by the urology team. His Foley catheter was removed on post-op day 11, and there is plan for a cysto stent extraction and possibly uroscopy in some time. Subsequent land, post-op day 46, which is about seven weeks from his injury overall, he underwent cystoscopy, right ureteral stent catheterization with stent removal and a retrograde pyelogram. The findings from that showed no obvious extravasation, no sign of stricture, and production of proper drainage of contrast from the kidney. So another poll to the audience. Would you bring this case up at a PI meeting to discuss any opportunities for improvement? And we asked this question in the context of this is a patient who came in with a penetrating wound who was discharged within a week by what everybody would perceive as being a successful outcome for him. And he did not require any transfusion of blood products throughout the entirety of his stay, despite having an IBC injury. Okay, I'm going to close it up here. Okay, so split 39 would, 61% would not. We'll talk about the areas that we observed for improvement. Overall, we agree with the majority here that his case was successful now, granted I'm biased. As his surgeon of record, but overall, we were pleased with his outcome. But there certainly were areas that we wanted to address. Go through those. So the first area that we wanted to address was the triaging of trauma activation. This gentleman came in as a level two alert, which at our facility constitutes multiple, it may have a multiple different criteria based on anatomic injury, mechanism of injury, and certain special considerations, but also has been generally left up to the emergency physician discretion. In his case, he did have a penetrating abdominal wound. So we discussed the possibility of perhaps this being an under-triage. However, throughout his EMS transfer here, he remained stable, alert, oriented, times three, was able to communicate with the team, document it, or let the team know his needs, and only complained of some mild discomfort at that time. I think this is one of the struggles, and we can talk about more about this in the discussion part of the meeting, but this is one of the things that all trauma centers are struggling with is how do you appropriately triage this patient. He certainly had a lot of injuries, but they're all abdominal injuries, so ISS doesn't necessarily capture the complete picture of his potential illness. Now that said, by anatomic location with a penetrating wound to his torso, and that in and of itself, at most centers would qualify as a high-level activation, be it a level one or a trauma code or whatever your system calls it. Additionally, based on his post-ED destination being OR, would also warrant in most centers the criteria for an under-triage. There's certainly opportunities, and as we review these, it wouldn't necessarily be captured in the CREBARI method, which is certainly something the databases look at, but by many of the secondary criteria that many centers are using to review their cases, you would fall out as an under-triage, so we continue to work with our staff on those parameters. All the words ran out of my mouth, Dr. Frank, in a very eloquent fashion. As far as the intraoperative fluid resuscitation, on our case review, we were interested to investigate why he received five liters of Cristalloid and felt that might have been a little bit excessive as far as intraoperative resuscitation goes. I would say we were only operating him for about three and a half hours at a maximum, so that is a considerable amount of fluid. We've been performing a focused chart review for all the operative trauma patients, looking at the resuscitation that they received, and have been doing some ongoing education with balanced resuscitation efforts for the operative trauma patients. Part of what I wanted to talk about was preparation and continuing education. When we got the call about this patient for a penetrating wound to the abdomen, we prepared the trauma band arrival. We considered the potential patient needs based on the pre-hospital report, which was this gentleman who had been nearby a construction crew, felt a sharp stabbing pain in the abdomen, and was hemodynamically stable, but on his way shortly thereafter. We discussed the procedural supplies that we may need, discussed if we required a chest tube, any sort of laceration repair. We performed some task assignments as far as which team member would be doing what, who's getting the patient on the monitor, making sure that we have someone at the head of the bed for the airway, and all those sorts of things. Doing that in a very streamlined fashion is something that made this trauma in particular go very smoothly. As far as continuing education goes, skills labs, I, as a resident, have found that practicing skills is what makes us better and helps us to be as close to perfect as one can be. In the trauma setting, there are multiple skills labs. There's ATLS, which is Advanced Trauma Life Support, the concise and systemic method of initially managing the trauma patient. There's the ASCET course, which is Advanced Surgical Skills for Exposure and Trauma. This focuses on teaching surgical exposure that may threaten life or limb to the injured patient, not necessarily being something that someone would see every day and it's using cadavers. There is the ADAM course, which is the Advanced Trauma Operative Management course, focusing on penetrating trauma to the chest, abdomen, and pelvis, and appropriate operative technique and management of those. Lastly, there's the BEST course, which is the Basic Endovascular Skills for Trauma. This focuses on arterial access, endovascular techniques, and employment of the REBOA, or Resuscitative Endovascular Balloon Occlusion, of the aorta for the trauma patient. As someone who, this is my first kind of jaunt with a urologic injury, I actually sat down with our urology attendings, who helped take care of this patient, and got some pearls, some tips and tricks to kind of, if I ever need to do this in the future, what would make it easier, better, more helpful. There's some guiding principles. There's the position of the injury, whether it is proximal, mid, or distal, the length of the injury, and then the blood supply to the ureter. When you're doing these repairs, Dr. Gilbert and Dr. Kapp stress that the ureteral blood supply is very tenuous, so you want to have a well-vascularized ureter. Additionally, there are certain things like high-velocity penetrating trauma can lead to ureteral necrosis. When you do have those things, you have to be aware of how you want to create your repair. Additionally, I, as an observer, found that placing the ureteral stent was easier said than done, and in asking for some tips there, we discussed stent size in the emergent setting, selection of a six French stent is ideal. The ureter is about a seven to eight French in diameter in the normal human, and then choosing stent length. It's based on the patient's height, and then you also would need to consider body habitus, but when in doubt, one should use a longer length stent, so for individuals greater than six feet tall, a 28-centimeter stent is generally what's chosen. Between 5'6 and 5'11, a 26-centimeter stent, and then under 5'5, 5'5 and under, a 24-centimeter stent would be chosen, but truthfully, when in doubt, use a longer length stent. You know, stents will cause irritation in the bladder if they're long like this. You can see the image here. That might be uncomfortable for the patient, but I would truly rather my patient be in a bit of discomfort than have a stent that's too short and have, you know, your coil somewhere up here causing irreparable damage to the kidney. We talked about always using a stentor type or hydrophilic guide wire, and that helps to ensure that the guide wire that you're using to place the stent is not going to puncture the ureter. When you're placing the stent or the wire at first also, you can place some holding stitches, and what that does is holds open the ureter so that you can maximize your visualization and you don't have to manipulate the tissue too much or use any sort of tools and cause any crushing force on the tissue, and then after the repair, you want to minimize urinary – excuse me – minimize urinary tract pressure, so you want to make sure that you're not so you want to decompress the bladder or the folic catheter. In some cases, you might need to use nephrostomy tubes, but you want to prevent any refluxing of urine up because the stent is keeping that open. This was really eye-opening for us in the operating room. I think for all the surgeons on the call and surgical learners on the call is certainly there are other attendings who have similar experiences to our groups or experience with board examinations when you're in the hotel room and you talk about a ureteral injury and how are you going to handle it? Well, consult urology and there's a ubiquitous golf game or vacation or conference that all the urologists are at and they're not available, and so the reflex answer that we're all trained is absorbable suture, double J stent, and then the accessory maneuvers like a psoas hitch or something along those lines for tension-free anastomosis, but certainly saying those and doing those are two separate things, so it was really helpful having our urology expertise in the room and available and not golfing to help us through that. And I just wanted to close with this quote from Anita Roddick. I'm aware that success is more than a good idea. It is timing too. So in this patient's case, the stars were kind of aligned for him. He came to a center with the appropriate and available resources to coordinate and provide the necessary care and treatment. Essentially, he was in the right place at the right time. This could easily be your patient tomorrow, next week. They could be unstable. The urologist might be out of town. The oscillator might be playing golf doing a AAA down the street. You might not have available help for hours. So this patient had a fantastic outcome, which we're happy for, but there are so many other things that could have gone differently should he have gone to a different center, should he had arrived here unstable. He could have had a very different course. So had any of these variables changed, the outcome could have been exceedingly different. The scenarios are countless. I know what I just went through. And as trauma centers, there's no matter how much training and preparation we may have as a subset of facilities, we have to expect the unexpected. Thank you so much. Looks like we have a question. Sure, thank you. We have a question from Debra Clark. Was there more bleeding upon cattle brash maneuver? I don't know if I said that right. I'm wondering if you had vascular support once you identified possibility of the injury, or was it in quote unquote, oh my maneuver. Did you have cell saver available? Yeah, so if I can take them out. So we did have cell saver available. Go back to the operative procedure here. And the CAT scans first. So our initial phone call to vascular was because the shrapnel was located on the left side between the artery and vein in the Iliac region. There was this hematoma or this free fluid around it, which was our initial concern. What we, and radiology called us about the shrapnel that there was a potential for an injury there. What was underappreciated initially was on this image. This is the IVC and there's hematoma around the IVC. This is small. We didn't see this initially in our exploration. So we didn't know what was going on. We didn't see this initially in our exploration. So our approach was midline laparotomy, like Dr. Gallagher said. Pack off our quadrants, evacuate hemoperitoneum. And then by routine, except for extenuating hemorrhagic circumstances, I'll explore my retroperitoneal zone starting with zone one, bilateral zone two, and then the pelvis. So we didn't initially see any hematomas. And then Dr. Gallagher explained that we explored this left side, looking for the shrapnel, looking for the bleeding, looking for ureteral injury on this left side, which we didn't identify. And so we completed the other, or treating the other injuries, at least in a temporizing fashion, and then followed the course because with penetrating wounds, traditional teaching is you explore all zone one, two, and three hematomas. So while we didn't see an obvious hematoma, we did follow the path of the trajectory. So as we did the medial visceral rotation or the Cattell-Brash maneuver, we did encounter a large hematoma that had expanded during that time. So we would have explored this regardless. But at that point, we identified the large hematoma, the rush of blood. We had the cell saver available and utilized that blood for transfusion. And he did not require massive transfusion or anything like that. It was, we made the phone call to Vascular when we were exploring here. He needed to, based on time of day, he had some personal things he had to take care of, and then he came into the OR to help us out. At that point, we had ruled out injury on this left lower quadrant, and we're exploring the central IBC injury. And it was fortuitous that it was at that point he walked in the room. So we had obtained proximal and distal control with sponge sticks and digital pressure. And then he became available to help facilitate exposure while our hands were controlling pressure and facilitate suture control of the injury. Okay. Thank you. Another question here, I may have missed it at the beginning. I know he was hemodynamically stable, but indication for FAST, and if positive, then OR, or still transfused until stable, then CT scan, what is your practice? Do you wanna talk about that, and then I'll talk about my opinion? So there was an indication for a FAST in this patient, but we chose to forego it as he was hemodynamically stable, and proceed directly to CAT scan in the setting of his stability and the knowledge that we would be taking him immediately to the operating room. We felt that it was important, knowing that the shrapnel had crossed the midline, to be able to observe any possible injuries that we could encounter so that we could have the appropriate subspecialists and teams available with us. So we skipped the FAST to go directly to the CAT scanner and then brought him straight upstairs. So I think in the grand scheme of things, a FAST would have only just been an additional step that would show free fluid in the abdomen, but would not have shown us the very important things that the CAT scan did, which allowed us to have several other individuals relatively readily available for us. Yeah, I think Dr. Gallagher highlights that really well. It's a great tool for blunt trauma and helps screen in or screen out injuries. But in this gentleman with the, I pulled up the x-rays because of a, for the patient's right to left course, and then the anterior-posterior trajectory, there was, the disposition from the emergency department was predetermined based on this x-ray. And the utility of the CAT scan was to help us triage injuries. And if we needed additional resources in the OR, we had those available or in preparation to be available. The FAST exam wouldn't have changed that decision-making for us. Okay, I don't know if you answered this, but someone asked what precluded removal of the metallic object? We looked really hard and couldn't find it. The proximity to the iliac vessels, it was so close, it was actually palpable, but quite deeply lodged. And the iliac vessels were so very close, we felt that it would be, more likely that we would injure something than we would help our situation in removing that. Okay, and then another question. In his case and complexities, what should a newer nurse be aware of when watching him the first 24 to 48 hours after surgery? So, as far as nursing considerations, it's important to be mindful of his hemodynamic status, his urine output, his vital signs. Is he tachycardic? Is there any sudden or acute drop in urine output that would indicate he's having some decreased perfusion, any acute onset of pain in the iliac vessel? Decreased perfusion, any acute onset of pain in the abdomen indicating that perhaps there could be either additional injuries that were missed or a disruption of one of our repairs. Any changes in the color or character of the drain output? If one drain starts to become more bloody, if it was kind of a Hawaiian punch color or more serious before that, those would be things that we would look out for throughout the entire stay really, but especially in the first overnight. There's also some things that we take for granted from our nursing partners. One is attention to Foley care, making sure the Foley is adequately draining. Just because the patient has a Foley doesn't mean it's functioning all the time. And then attention to sterile maintenance or clean maintenance of that Foley catheter because he has a ureteral catheter. If that were to get infected, that's by definition a complicated urinary tract infection and could worsen his outcomes because of the need for further instrumentation with the ureteral stent that he had. So attention to the Foley catheter, maintaining a clean Foley catheter to decrease risk of urinary tract infection. He's also, because of his IVC injury that was repaired, we had maintained him on a baby aspirin after discharge, but he'd be at higher risk for thromboembolic complications because of the slight narrowing of the lumen and bureaucrastria, the injury to the endothelium of the IVC. So leg swelling certainly needs to be high on the priorities as far as physical exam findings during daily rounds. But in addition to that, attention to all the things that we do for DVT prophylaxis, STDs or sequential compression devices, the compression stockings, chemical prophylaxis based on whatever your hospital protocol is, but certainly the highest risk patient would be somebody like him. So he should be your highest priority or your highest dosing of chemical prophylaxis as well. So those things would be incredibly important and not holding those doses or skipping those doses because of trivial changes in his CBC without vital sign changes. Okay, wonderful. Does anybody have other questions? I don't see any other questions in the Q&A box, but we still have a few minutes here. So fire away if you have any burning questions, but thank you so much for this case presentation. Appreciate that. Dr. DiCapua and Guadina, who is now Dr. Gallagher since you just got married and Dr. Frank. Is there anything else you wanted to share? No, that's it. Thank you very much. Okay, thank you both. And we did post the link in the chat box to the evaluation for those of you who would like to complete that and give us some feedback. We do appreciate it so that we can continue to improve our online education and webinar offerings. And I will also send out an email to everyone who attended to have that evaluation link. So thanks everybody for attending and have a great rest of your day. Thanks, stay safe everybody. Thank you so much. Thanks, goodbye.

abdominal trauma

exploratory laparotomy

small bowel enterotomies

inferior vena cava laceration

proximal ureteral injury

teamwork in trauma care

interdisciplinary collaboration

preparation for trauma cases

continuing education in trauma care