Well, good afternoon and welcome back everybody for session two, and it is my distinct pleasure to introduce our moderator for this session, Dr. Charles Maines. Dr. Maines is a member of our Education Committee and also a member of the Board of Directors. So with that, turn it over to Dr. Maines. Hey, good afternoon, everybody. Thanks for for being here. I have a very distinguished panel that's going to help discuss this case. And I would like for you folks to introduce yourself. Maybe maybe you could start, TR. Good afternoon. My name is Thomas Resignolo. I go by TR because Resignolo is just way too long to say every time you want to talk to me. I am the EMS coordinator for Centura Health. I work heavily in Esquire. I'm in Breckenridge, Colorado. I work with five different ski areas, flight service, Flight for Life here based at my hospital. And I'm very excited to be here to help with this talk. Thank you, Marco. There are actually two of us named Marco, I've never experienced that. I guess I'll go first. I'm Marco Bonta. I'm the trauma medical director at Riverside Methodist Hospital in Columbus, Ohio. We're a 5000 admission level two trauma center. And I do a lot of consulting for hospitals to prepare for verification and that sort of thing. Thanks for having me. I'm Dr. Marco Hidalgo. I'm the trauma medical director at Lakeview Regional Medical Center. We are a level three verified ACS center and we're currently undergoing the process to become a level two. Okay. And Dr. Cunningham. I'm Kyle Cunningham. I'm a trauma critical care surgeon here at Carolinas Medical Center in Charlotte, North Carolina. And I also handle a lot of our QA and PI work here within our division and our system. So it's good to be here. All right. Well, thank you all for being here. We're going to talk about a case today that goes from the rural community through a transport. And we're going to talk about some of the differences between treatment strategies at higher and lower level trauma centers and rural facility. So the area we're in is actually a real location. It's a level three trauma center in Colorado in the mountains. It has a helicopter base and it's a very busy, robust level three trauma center. The scene is about five miles from there. The scene is also about 80 miles from a regional level one trauma center. And the helicopter base at the level three carries whole blood plasma and packed red cells. It also carries TXA on the helicopter. And the level three trauma center there also has the same whole blood and plasma. So the patient is a 38 year old male who's picking up his date for a first date at her house. He's parked in the driveway. The shooter is an ex-boyfriend who comes to the car window and shoots the driver three times. She uses the cell phone to call for help. The shooter flees the scene. Next slide. So the victim sustained three gunshot wounds, one through and through the left axilla. The left axilla has rapid blood loss. The shooter is being held by the passenger with a rolled up sweater. The victim is awake and complains of chest, abdominal, left shoulder, and right thigh pain. Next slide. She reports from the scene that the shooter was on foot with an unknown location. Two sheriff's deputies in a vehicle and one paramedic unit show up about 10 minutes after the event. She is yelling to them for help saying he's losing a lot of blood and starting to lose consciousness. Next slide. Question one. So this is a poll for the audience. We're going to ask a couple of questions. Here they are. And we're going to ask you to give us the answers. Then we're going to talk about them. We're going to present briefly a little bit of the research surrounding the issues presented by the questions. So here we go. Here's the first question. All right. So somebody says law enforcement forces approaches first. And then they give the okay. What do you think about that answer? The law enforcement approaches the scene first, TR, what do you think? What would you advise EMS to do on that? Well, I think it's important to have a pre-plan in place that you've worked out with either your normal crews or your tactical team, however your EMS crews decide to work that out. I'm a strong proponent of having all medical providers, responders trained because the tactical crew is not always available. If you, especially a rural laid out area, you may get your first responding crew that has no training whatsoever if you just stick with a tactical team. So you should look at your pre-plan in place. Everyone of course has to decide scene safety for themselves. However, I would heavily rely on law enforcement to breach the scene and determine what's safe and what's not before I approach. Okay. Do our panelists have comments? What do you advise EMS? Well, I mean, I think the long answer is we probably learned a lot from the mass shootings at places like Columbine and other high schools around the country that sitting and waiting, you know, answer D in that situation is clearly not a good answer. I think at some point, like was said previously, you want to have some sort of plan ahead of time. I think most agencies around the country are starting to get pretty good at training coordinated responses. You know, I think a lot of the answers always sort of, it depends on what's going on. Depends on the story. I think letting law enforcement sort of be the lead point on that is probably still probably the best idea for most people. Yeah. You know, I had the misfortune of being the trauma medical director at the level one trauma center for Columbine. And they learned a lot from that after action analysis. They no longer wait to secure the scene to go in with active shooters. They've changed the protocols a lot. I think it's helped. It's also cost some of our law enforcement officers their lives as well. But in terms of patients, I think everybody benefits from lessons learned. So and also on that point, I think the education sort of stop the bleed education that's been rolled out across the country. You know, when we go do stop the bleed education, I kind of say it's like the CPR was in the eighties. And I think these mass shootings have definitely highlighted the importance of having a lot of people on the scene, understanding how to save a life from limb in those situations. So the patient, here we are at the scene, the patient's lethargic, but arousable. His left chest has decreased breath sounds. There's no active bleeding from the chest. The abdomen is distended and tender. The thigh wounds are nothingness tangential. He's got no pulse in his left arm, which is where the exhalation gunshot wound is. The right radial pulse is threading. You see the vital signs there at the bottom. He's on four liters of oxygen with 89 percent. GCS is okay, no lateralizing signs. Question two, what are the first steps for EMS on the scene? And here are the poll questions. Now some of these questions get at, what about RSI at the scene? What about ABC first? What about hemorrhage control ahead of airway, or at least on par with? So there are a lot of possibilities here. Do you do tourniquet? Do you do direct pressure? What about a junctional tourniquet? And clearly these questions, there's no one good answer. And some of them, some of these questions have controversial answers. So we're going to learn as much from the audience as we learn from each other here. So the answers, it looks like number one was the first step, a blood sweep like the military would do in an austere environment. What do you folks think about that answer? I think either, I don't have it up on my screen, but I think A or D was a great, there, A or D. As far as the junctional tourniquet, not all tourniquets are created equal. If you're carrying junctional tourniquets, I do think D is a great answer as long as you're proficient and have the right equipment. Some of the newer junctional tourniquets are outstanding. Not everyone's carrying them yet. It's coming down from the military, I think within a year or two, you'll see them on the field more. There's, I think, four companies making them right now. So I absolutely agree with A or D, depending on your training and equipment. We've talked a lot about scoop and run. What's your guys' opinion on scoop and run versus play and stay and play at the scene? I'll chime in on that one and say that, to me, I think time definitive to care time and again, the literature shows that it has a direct impact on the outcomes for our patients. So I agree with T.R. A and D are good, and the point is that you're extricating, you're going. Normally, when I have this conversation at EMS, I will normally defer from scoop and run because I think that has some connotation that goes with it. I think extricate and go is probably a better way that I would phrase that, but I think the thing that we really push with our crews and our agencies and our areas, that it ultimately comes back to time. So if you can do stuff on the way, that's fantastic, but you don't want to delay the time to definitive treatment, especially when bleeding is involved. Hey, Dr. Mains, it's Marco. I got a quick question for you, sir. What do you think about all around the country in a setting like that? How often does the EMS have the authority to perform rapid sequence intubation? Is that, I mean, I'm in Ohio, it's about 50-50. Well, I agree with that. I mean, our paramedics certainly have the, it's within their scope, but there are many facilities that, or many agencies that don't have enough paramedics to do that. T.R., what you thought? I was reading the panel questions, are you discussing RSI, Dr. Bonta? Yes, sir. Yep. So, you know, again, you're talking about a very high acuity, very low frequency skills for most pre-hospital providers. I think RSI has a time and a place, I'm not sure that this is the place for it. And as an old field provider, what I would ask is, do I have a patent airway or not? Can I start moving or do I need to fix the airway before I start moving? In this case, I seem to have an airway, so I'm very happy moving. And it is very difficult to do an RSI in a moving ambulance, I understand that. So my thought on this patient would be I would not RSI this patient as long as I have a patent airway because they're not dying from airway and I need to make tracks to get them somewhere that can fix the bleeding. To you guys. So I'm going to present just very briefly a little bit of the literature surrounding the issues of these two questions. What we have on the screen here is two large national trials that look at time to hemorrhage, time to death from hemorrhage. And this is mortality per hour over time between five minutes and four hours. And what you see between these two large studies is a very consistent curve of mortality per minute over time. Next slide. This is from Howard Champion and John Holcomb's studies that took a look at the National Trauma Database, looked at the hemorrhage per minute trials. And what they've shown is over about a 15-year period in that upper left graph is the mortality for the percentage of patients that died at the scene has gradually increased while the percentage of those patients that died at the hospital has gradually decreased. And that's no reflection at all on our EMS community. They're actually really very good. Our resuscitation efforts have gotten better. Our emphasis on hemorrhage control has gotten better. And if you look at that graph on the bottom right, what we've seen is a shift in proportion between rural and urban related to percentage of patients dying at the location. And what we see is that the faster you get to hemorrhage control, the more likely they are to survive. And the differences in outcome between rural and urban really are more related to time to hemorrhage control. Next slide. And this is from one of John Holcomb's talks that looks at that consistent curve that we see in all of those studies on mortality per minute. And what you see there is stars superimposed on the curve. The green star is EMS at the scene. And that's in that 35 to 50 minute time range. The yellow star is time to the ED at the receiving facility. And that's in that golden hour period. And then the second, and then the red star is time to definitive control in the operating room. And what you see there is a mismatch. You see a delay to time to hemorrhage control in the operating room. And that should be a focus for efforts to improve outcomes. And you see the median time there of death at about 35 to 50 minutes. Our median time to hemorrhage control in the operating room at about 120 minutes. And that's why those two other graphs look the way they did. We haven't made a ton of progress with our ability to get to hemorrhage control fast enough. And what we're seeing is that one of the major determinants and outcome in major truncal hemorrhage is time to hemorrhage control. Next. And this is Dr. Numayus' group out of Miami that looked at time to hemorrhage control for penetrating trauma once it arrived at the trauma center. And what he showed was a delay of greater than 10 minutes to get to the operating room showed a threefold increase in mortality. Next slide. And if you look at the survival probability over time, the red line on top was to the operating room in less than 10 minutes. And the blue line is 11 to 60 minutes. And they proposed not talking about the golden hour anymore, but talking about maybe the golden 10 minutes. And talking about direct to the OR with major truncal hemorrhage when you're able to do it. Next slide. This was the RSI that we talked about, and this was one of the first trials. This was from San Diego, and this was almost 20 years ago. And this was one of those trials that looked at whether should we do RSI in the field in these major patients. And this had to do with head injury. The point of this study really wasn't truncal hemorrhage, but this study was terminated early. And two interesting things in this, they were at 86% success rate, meaning as TR was saying, low incidence, high risk procedure, they were really very good at that toward the end of the study. And all of the studies that we've looked at RSI show that now we're at 95, 98% success in the field getting it done. It means our paramedics are very good. The question really isn't, should we do it? The question is, should we burn our time to hemorrhage control with RSI? Next slide. Because the bad outcomes associated with this study had to do, at the bottom of the page, an average time of about six and a half minutes, adding to the scene time in the patients that's bleeding when you're on a countdown to death from truncal hemorrhage. And I haven't seen six and a half minutes hit very often. And I think that's pretty generous. Field time in our hands, most of the time is 10 to 15 minutes for RSI. And as TR pointed out, hypotension is a relative indication, not absolute. And I think we're better off if you have an airway that you can obtain with an eye gel or some other mechanism in the rig, then maybe that should be considered, or even RSI in the rig while you're moving. Because we're on a countdown to death from truncal hemorrhage, and you want to minimize time to definitive hemorrhage control. Your thoughts, folks? I'll throw in that there can be a frustration on the scene from field providers when a helicopter lands and they take the time to RSI on scene. And six minutes is, you're a rock star, it's really fast. And the reason that a helicopter will almost always RSI a flight crew is because they can't afford to have a combative patient in a moving ship. There's all kinds of bad things they could hit. In the back of an ambulance, it's more controlled. So actually, one of the things you should be thinking about when you're making your decision for air versus ground and the times that we're going to talk about is, that aircraft will probably take time to, those flight nurses and medics will take time to RSI, and it will be more like 10 minutes. So you will put more time into this patient to establish that area. Yeah, along those lines, I think, you know, when I do EMS education, discussing these topics, and as we've said, a lot of the answers to these is it depends on you and where you are. So what I, you know, generally try to teach our EMS providers in the area is that the close by people can do different things than the far away people. So if you're, you know, 45 minutes transport by ground, then you're leaning a little bit more towards securing an airway versus if you're, you know, six minutes by ground, and it's going to take you longer to get the airway than it is to get them to my hospital, then you have a completely different scenario at hand. I think it's important when we discuss these things to always say, you know, there's a lot of caveats and different ways of looking at the situation. Very well said. Yep. Next slide. So, EMS places a tourniquet at the left axilla, which partially, which relatively controls the arterial hemorrhage, but we still have continued moderate venous oozing. The left chest, there's no active hemorrhage, there are decreased breast sounds, the left thigh doesn't have evidence of hemorrhage, there are the vital signs, patient's hypotensive, no myocardic, no deficits. Next slide. Question three. Now what? So what's the destination? And these guys alluded to that a little bit. Ground versus air, ground to the closest facility, air to the scene, and then fly to the level one facility, or a rendezvous. So what would be your decision? And I think there's no clear answer here, but it really depends on knowing your system. Integrated systems of care are the next generation in saving lives and trauma, and understanding your region, the transport capabilities, the facility capabilities, really important. What would you folks do in this case? You know, you think there are level three centers, and then there are level three centers, right? I mean, I happen to know that your level three center in your region, Dr. Maines, is vastly different from many of the level three centers in Ohio, and I don't want to say anything disparaging about any of the nearby trauma centers, certainly, except there are level three trauma centers that are a level three trauma center so that they can admit and keep simple orthopedics, and that's kind of it. In other words, they don't have a general surgeon that's vigorous or often very experienced in trauma care. I'd be very interested to hear how other people, Dr. Hidalgo, how do you feel about that? I think many of us who have been to or work in level three trauma centers would save this guy's life and do the right thing, but I've been to a lot of level three trauma centers in rural states doing site surveys for the American College of Surgeons and other agencies where it would absolutely be the wrong destination. I think that's what I just said is pretty controversial, but I really wonder how everybody else feels about that. No, I think that's a good point. What does everybody else think? No, I think you're absolutely right. It's important, again, to have conversation with your EMS routing agencies on an ongoing, regular basis. Like I said at the onset, we started out as a level three, and now we're sort of rising to a level two, so we have 15-minute response times. We have in-house OR, in-house anesthesia, but we're still a level three, so you're right. There are level threes, and then there are level threes. I think it's important to have that discussion. When we started undergoing going to level two, I went around and discussed with all the EMS providers what our capabilities are, and they wanted to know what that answer is because when you get a patient like this, you really need to be able to make a decision as to what's going to be the best thing for that patient. I think it's important if you have a level three, and here it tells you what they have. They have OR and anesthesia. They can get into an OR within 20 minutes or so. The way I usually try and have the conversation with our local routing agencies is that that patient, even if we ended up transferring to a high-level care, even if we go to a level one trauma center, there's a good chance they're going to be safer stopping with us, evaluating an airway, doing a damage control resuscitation. Even if you need an airway and you're going to RSI, it was brought up earlier, it's really hard to do that in the back of the truck going 50 miles an hour, bouncing around at night with lights flickering on and off. It's not that easy. Again, those are the conversations that we try and have with all our sending agencies. Those are good points. I would point out that the majority of our level three trauma centers in rural areas in Colorado really have a general surgeon and an orthopedics and an OR within 30 minutes. The problem is that they don't do this very often. There's something to be said for muscle memory when you're trying to do complex trauma operative cases. On the other hand, there's going to be some situations where somebody is not going to survive to get out of the region. Some of our rural centers are stuck with managing a patient that's somewhat outside their scope of care and in that situation have to do the best they can. Now, this particular trauma center houses critical care trained trauma surgeons. They've got really experienced good nurses. They've got a good ICU. It's a very robust center, but that is not true of many of the trauma centers around Colorado. Next slide. Dr. Maynes, can I jump in for one second? Sure. I would like to add that a very strong QI program from your trauma system would include an MS representative or liaison that you would QI these transport decisions in a non-punitive fashion and give feedback to the agencies to prevent poor decision-making or to assist good decision-making in the field. If you don't currently have your EMS representative, it really doesn't make a lot of sense. Thank you. I will say I agree with TR again on this one. Having that mapped out ahead of time is key. Having these discussions ahead of time is key. If you're really active with your regional trauma advisory council, we have a pretty strong rack here in the Metrolina region. A lot of the agencies then become more familiar with the air medical services, know their capabilities, know the capabilities of the facilities they would be going to, and they can make a better decision for their patients about where to match that. I absolutely agree. All level threes are not created equal. We have some here that are very highly functioning. We have others that kind of hit the minimum for what you would expect for services out of a level three. It makes a big difference to me if I know I've got in-house surgery care sitting three minutes away versus a helicopter that can come that's going to have blood to resuscitate a patient that already has hemorrhage control. I think the providers on the ground have a lot more information to help make that decision. Remember that a level three trauma center need not have platelets, for example. This is such a controversial topic. I don't think there's a right or wrong answer by any means. The best point I heard is have a pre-hospital provider as part of your performance improvement team. I think that's really absolutely correct. Yeah, and I think that's the theme each of you have said is that these are not decisions to make on the fly. These are decisions that need to be made in advance and understand what you have in your region and what the needs are. Next slide. Here's a question. You're at the scene. You're getting ready to go to your destination point. Are you going to give TXA, and if so, how much? All right. Everybody says the standard answer. Well, the majority say the standard answer, which comes out of the CRASH-2 trial, and that is a gram and then start a gram drip. Let's go to the next slide. Just to refresh everybody's memory, this is the CRASH-3 trial results, 20,000 patients, 40 different countries, and it was one gram IV followed by a gram drip over eight hours, showed benefit up through three hours, and the survival disadvantage if it was given after three hours. Here is the 2020 guideline from the TCCC, partly written by our board chair, Dr. Shriver, and others. Next slide. They're recommending a two-gram push, a slow push, either IV or IO, and that's true for hemorrhage or severe TBI. That's certainly outside of the guidelines. I'm not sure I'd expect an EMS agency to do it, but what do you guys think about one or two grams at your hospitals? Next slide. We are currently revising ours. We're debating this. Our current guideline is the gram followed by the gram drip. However, we are in the process of probably updating that to the two-gram push, as you have here. I'll be honest. Most of the time we see this initiated. Pre-hospital providers in our area are really up in the literature. They're up with the protocols. We have some fantastic organizations in our area, and the initial TXAs usually initiated are in by the time the patients arrive. They really don't mess around with it. You're right about our EMS agencies being up on the literature. I was given a talk about this the other day, and somebody asked me about potentiating seizures with TXA administration. That's a complicated topic, but I think the risk versus benefit is there, but that's a really good point. Others have made the point that at eight hours, it's going to be all over. Most of our truncal hemorrhage patients have either bled to death or not in that first four hours. In the interest of time, let's move on. Next slide. Dr. Mainser, there's a really good comment in the chat that asks, does proximity to the trauma center impact the decision on TXA? I'll tell you, it sure does in Ohio a lot. How do you feel about it? Well, I'll tell you, what you're treating is hyperfibrinolysis. You'd see the benefit in that first hour, but it was a graded benefit. The sooner you give it, the better. Now, if you believe some of the literature on fibrinolytic shutdown and that smaller percentage of patients that could potentially be harmed by TXA, you could make the case to wait for your thrombolistography to see if you actually have hyperfibrinolysis prior to giving it if you're concerned about exacerbating fibrinolytic shutdown. On the other hand, the CRASH-2 trial and other studies have shown benefit unrelated to hemorrhage with TXA. So I'm not sure what the answer is. What we do in practice is if we have major vascular injury that we're worried about, we might hold on the TXA if there's no hyperfibrinolysis and we're within an hour of injury. I agree. Okay. So target blood pressure during transport from scene to the trauma center. What would be your target blood pressure for volume resuscitation? Okay, we have 110 as the first answer, followed closely by 85. Next slide. So here is the Houston study from 26 years ago on permissive hypotension. And many of the authors we all know on this paper, but they postulated that if you blow the blood pressure back up to 120 in the field prior to hemorrhage control, you're either going to pop the clot or bleed more. And they did a randomized prospective trial. They looked at almost 600 patients. And what they showed was patients did better if you rapidly transported the patient and did not resuscitate back to 120 blood pressure. And we kind of forgot about that study and didn't really put it into practice for a long time. Next slide. When you look at the outcomes on that study, mortality was higher and morbidity was higher if you resuscitated back to full resuscitation in the field. And there have been subsequent studies that have looked at this. But the thing I found most interesting about this study, we've quit using crystalloid resuscitation as our primary resuscitation fluid. And when you go back and look at the data contained in this study, the standard resuscitation group got 2,500 cc's of crystalloid in the field prior to arrival at the trauma center. If I'm looking at one of our trauma resuscitations right now and they get more than 4 or 500 cc's of crystalloid, I want to know why. And so I'd like to hear your guys' comments on this. You know, the question asked, what's the target? And I think the question begets another question. I mean, what's available? I mean, if all that's available is crystalloid, my recommended target would be way lower than that. If there's blood available, I'd start blood and, you know, with more than one obvious source of hemorrhage. This reminds me of that LA County EMS study that compared patients that arrived by private vehicle with those that arrived by EMS. In the private vehicle, patients did better. And of course, you know, I mean, it wasn't intended to be critical of pre-hospital care at all. It was just that, I mean, that study was also 25 years old, I think. And at that time, the pre-hospital was given large volumes of crystalloid. So, yeah, I mean, the EMS. So I would say if the helicopter or the transport vehicle has blood, give it. If not, you know, maybe mentation, any level of alertness, mean arterial pressure of, I don't know, you pick it, maybe 40. I don't know. Well, and that's a really good point. I mean, what the military is currently doing is putting a finger on the radio pulse, watch mentation, give tiny volumes of crystalloid or colloid until you regain radio pulse or regain mentation. Right. 20-year-old healthy military guys. And they certainly can stand that. We don't really know how low and how long for prolonged transport for permissive hypotension, but certainly permissive hypotension is in our armamentarium. There's a study out of Plano and one out of Baylor that looks at in-house application of permissive hypotension until definitive hemorrhage control. And there was some trend towards improvement survival in that study as well. So certainly it should be in our armamentarium. So this is loaded, junctional tourniquet, MASCO2. Blood pressure is 60 when they leave. Heart rate's up to 150. They vent the left chest with a rush of air. There's a little bit of blood. Blood pressure improves temporarily, then drops back to 60. Abdomen's more distended and tender. Patient arrives at the level three trauma center as a trauma team activation. OR is still not quite there, waiting for anesthesia. Next slide. So this patient arrives with a blood pressure of 60, heart rate 170. Patient's still able to phonate, gets the IVs. Breast sounds decrease in the left chest. It's right above the costal margin, posterior lateral abdominal exit wound which is distended and more tender. Next. So they do a second line, start MTP. They put a chest tube in, they get a couple of hundred cc's of blood and some air. Fast, they do a quick fast. There's no blood in the pericardium but there is blood in the abdomen. Blood pressure is still 60, heart rate's 150. They've gotten three units of blood and plasma. OR is still gonna be 10 minutes. Now you're in the ED, you've got aggressive resuscitation. You've got a persistent blood pressure less than 60 and heart rate that's still pretty high. Next slide. Next steps. After a chest tube. Next. While you're considering that, what, how do you think this patient would have done in the air from the scene? It's a good chance you're gonna code and route. I mean, I think you said it was 20 something minutes by air, I think. Yeah, it was like 27 minutes by air. 27 minutes by air. I'm assuming that's travel time. Plus the extra 10 minutes it took them to get to you. So it's never really, and then like you said, they're gonna RSI the patient. So let's say that only takes six minutes. And so, which I doubt, but it's, that's a pretty prolonged time. You know, we've had a couple of people that have been tried, have flown by air to the local level one, and we've had two where they don't quite make it. They land to us on the way. And so we kind of, you know, go back and DI that and say, you know, should I just come here directly? Which is what ended up happening. So I think this is an excellent example of a patient where the answer to depends on the distance you're gonna have to travel. A chopper is not always the best route to go further. You know, these are judgment calls. They're difficult judgment calls in remote areas. This is why rural trauma has a higher mortality than urban. And you can't make the right call all the time. And this patient, there was a real question. And the answers were pretty split. So the answer to this question, narrow lead from REBOA placement. Now, certainly not all level three trauma centers have REBOA. That's fairly controversial. Do your ER docs do it? Do your surgeons do it? What do you guys think about this? What about the, have we changed our indications for REBOA? I mean, for quite some period of time, the indication was infradiphragmatic truncal hemorrhage unresponsive to other methods. Or, you know, I'd be a little concerned about a REBOA catheter with a chest injury and with bleeding from the axilla. I absolutely agree. This is one of those unknowns. And we talked about this. You know, REBOA in this situation, in normal circumstances, you probably wouldn't want to do. But that's assuming you've got an OR that you can get to. Now, one of the indications for resuscitated thoracotomy has always been persistent blood pressure less than 70, despite aggressive resuscitation. And I wouldn't have argued with a resuscitated thoracotomy here. I agree. There's an interesting paper out of Cali, Columbia from last year. And that's where Shock Trauma sends its fellows for penetrating trauma experience. And they have a paper about chest injury REBOA, and they have a whole REBOA team that does it. So that's under consideration, but that's not what would normally be done. The question is, they didn't really think they had an aortic injury. They knew they had an axillary artery injury, which could have had increased bleeding as a result of the REBOA deployment. But they felt like that the tourniquet had relatively controlled that axillary bleeding. All they had was some venous ooze. So with that axillary tourniquet in place and apparently effective, they decided to go ahead and try the REBOA rather than the resuscitated thoracotomy. And I think had they noticed any increased bleeding, of course, they would have changed that. But I agree. We're gonna talk about opportunities to improve and that's one of them. I agree entirely. That's one of those indications that not everybody would approve of. Other comments on that? So we rarely use REBOA catheters here, but it partially it's because we're at a level one trauma center. And we have the OR immediately available where we're going for definitive control. So for zone one placements, we really don't use them that often. And I was curious of the input from the other panelists. So in this case, they're waiting for the OR. I would ask you kind of a two-part question. One, would you still use it if the OR were immediately available and not another 10 to 20 minute wait? And the second part is, do you have an upper limit of the wait that you would do? Meaning if the OR is not gonna be available for an hour yet and you're looking at transport, would you still use it? Or do you say, listen, that that's, you know, outside the limits of what I would do with that catheter? You know, that's a great question. No clear right answer, of course. I have an answer, but others have an answer before I say anything. Do you think it depends on the skillset and experience of the general surgeon that's on the way to, I mean, a lot of general surgeons in level three trauma centers don't work in the chest and might have a lot of trouble with the axillary artery too. Yeah, no, good point. So, you know, at one of our main level one trauma centers, high volume trauma center, we have a standard direct OR resuscitation. And we, the only place we've used Reboa in that setting, well, with rare exception, is major pelvic hemorrhage with hypotension. And that gets a zone three Reboa until we can get to IR. In our rural centers there, we've had a couple of instances at this rural center where they've waited for the OR and had to use Reboa. They also have transported a number of Reboa patients with zone three deployment. And so they have a fair amount of experience. And I think that's why they defaulted to it here. Whole blood resuscitation. We carry whole blood, fresh plasma, never thawed plasma, and a unit of PAC cells in all of our choppers. We've got whole blood at all of our level one, two and three centers and use it until we run out. Certainly that's our resuscitation fluid of choice. Does anyone currently think that's not a good idea? It's hard to get. We fight with blood banks sometimes. All right, next slide. And there are a number of papers out there. I put these in for folks to, just for reference. Next slide. So they go with a level, with a zone one Reboa. Blood pressure comes up to a hundred. Now this hospital does damage control laparotomies. They do it a fair amount. They service five ski areas and a lot of skiers into trees. And they decided to do a damage control laparotomy. We have a pretty standard procedure for that. So they opened the abdomen. They have a spleen and a grade four spleen. They've got a diaphragm injury, pancreatic tail injury, small bowel perforations twice, colon perforation with active spillage. They're into the resuscitation. Heart rate's 120, blood pressure's 90. Next slide. What procedures would you do at this level three trauma center for damage control? And my point here is if it were easy, anybody do it. But you're often asking rural level three surgeons to do procedures they're not entirely comfortable with. And so we've had some debate really about what's the right way to do this at a level three with limited resource. I'd also say this is a scenario that all of our rural level three centers at one time or another are gonna face and have to decide what to do with. All right, so splenectomy, ligate the mesenteric bleeding, deflate the revo as soon as possible. Go ahead and do the distal pancreatectomy with the splenectomy, resect the small bowel and colon, leave it in discontinuity, close the diaphragm, quick clot packs, do an open abdomen dressing and air transport to the level one. What are our panelists thoughts on this? I saw a thumbs up. I agree with the majority here for sure, yeah. Would everybody, I mean, closing the diaphragm I think might be a question, but if you're gonna pack bleeding, it's probably advantageous to have it closed. Some trauma surgeons don't do a lot of splenectomy or pancreatectomies. Would anyone suggest maybe closing the diaphragm or pancreatectomies? Would anyone suggest maybe just packing it and leaving it for the higher level center? A damage control apparatumy. Quick, don't get them cold and coagulopathic and get out of there. Yeah, I agree. Do what you're comfortable doing. Stop the bleeding. Next slide. All right, so key elements to damage control resuscitation. When you can't control the hemorrhage, temporizing measures like Reboa, like pelvic binders, permissive hypotension, limit crystalloid, trigger initiated blood resuscitation, damage control surgery. Next slide. And damage control surgery, primary hemorrhage control, primary contamination control, leave the abdomen open so you don't get compartment syndrome in many cases and return to the ICU to warm and resuscitate. That depends on where you are. Next slide. This is interesting. This speaks to the TCCC put on a conference back in November of 18, Dr. Butler and his group came up with all of these. They apply these advanced resuscitative care principles to preventable military deaths and applying those principles suggested that they might be able to reduce mortality by up to 40%. Now, of course, the military is a vastly different system than our rural system, but still those are the elements that they thought might be important. Next slide. So here's the operation that was actually done, which is what we all thought for. And they're gonna transfer from the operating room to a higher level center. Next slide. So they decided not to address the issue to address the axillary vascular injury. The tourniquet was working. I think it was Dr. Banta who suggested they might not wanna tackle that at a level three facility. So they put a Foley catheter into the bullet hole and blew it up to help tamponade. And that seemed to be relatively effective. The patient's four hours out from the injury, they air transport to level one with an immediately available OR team and vascular. Graboa was left in place and not inflated in case something happened and they crashed in route. They did a post-op chest X-ray that showed no hemo or pneumothorax. Next slide. At departure, here's their vital signs. You know, lactate's 2.1, INR is 1.5. Blood's running at permissive hypotension, resuscitation rates. They get about 12 minutes out from landing with this very experienced flight crew and blood pressure suddenly drops to 60. Heart rate goes up to 140. There's some increase in axillary bleeding seen. Bowel sounds are still, or breath sounds are still equal. Chest tube doesn't have an air leak and is not bleeding. Next slide. Next steps. Next slide. Hey, Dr. Mains, there's a good question in the chat. Someone wrote, Tim Murphy wrote, can re-warming continue effectively in the helicopter? I was just answering that on, I was just trying to type that out. Dr. Mains, you okay if I answer that? Oh yeah, absolutely. Go ahead, TR. So yes, most helicopter services will carry a very large hot pack that completely takes the trunk and does truncal warming. For the most part in all of my review and research, it will eliminate any further heat loss combined with the burrito wrap. It does not always provide active re-warming like we'd like. It does not allow further heat loss. That's probably the best way to answer it. So yes, re-warming continues somewhat effectively in a helicopter. And TR, you do all the education for the ski patrols, packaging, and you're flying at altitude and really cold temperatures. So you guys have been pretty effective at that. Yeah, it's still snowing today. Okay. So the answers were a narrow lead for answer D, which is B and C. So you increase whole blood administration to a blood pressure of 80 and inflate the... No, that's so... So basically B is the answer. What do you think about starting dopamine? What do you guys think? I gotta tell you, I see this all the time, varying levels of experience from our flight programs, but I can't tell you how many times I see the knee-jerk dopamine response to hypotension from hemorrhagic shock. Let's go to the next slide. So you start out normal. You begin to bleed. You introduce your neuroendocrine response with an endogenous catecholamines, and that compensates for a period of time. You shunt blood to the heart, skeletal muscle, and brain. You shut down blood flow to the gut and skin. The increased peripheral vascular resistance is a result of that. You compensate for a while. You eventually overcome the capability to compensate and you fall off the cliff into overt shock. Next slide. When we think about cardiac output and hypovolemic shock, preload is down, contractility is down for a whole bunch of reasons. Afterload has already increased because of the endogenous catecholamines, and now you add cardiac... Now you add alpha agents with basal constriction to that equation. Blood pressure goes up. Cardiac output goes down. Comments? Nope, nobody wants to treat hypovolemic shock with pressors. Certainly during the course of resuscitation, there's opportunity to use pressors for very selected reasons. If you really know your hemodynamics and you have an indication to use it, by all means use it. There was a recent paper that looked at adrenal insufficiency. And one of our reasons for persistent shock is adrenal insufficiency. Recent paper showed something like 25 or 30% of major trauma patients coming in in hypovolemic shock have a cortisol less than 25, which is lower than what you would think. And some of those centers are giving hydrocortisone on admission to hypotensive trauma patients. So there are reasons where you might have combined distributive shock. But in general, my first response to hypovolemic shock is volume. Would anyone disagree with that? It's definitely the right answer. The other one's neurogenic. You get people with mixed presentations that come in with a spinal cord injury, especially a high spinal cord injury. You do your resuscitation with the blood, follow up, your resuscitative labs, make sure. And then at that point, I usually go educate everybody that once we've achieved normal labs from a resuscitative standpoint that have persistent hypotension with a neuro injury, spinal cord injury, then you just treat it as a neurogenic shock. Yeah, I agree with that completely. So patient arrives at the level one, where should they go? Now you've got a patient who has a damage control procedure. So the abdomen's open, but presumably not actively bleeding. Although this patient has now dropped their pressure and we're not entirely sure why. And so in this circumstance, it might be different than it would be for the routine. The majority answer here is direct to OR. What do you guys think about that? I think it's really depends on your institution and how you're set up. I think, I would agree this patient's gonna wind up going to the OR. I can tell you at our institution, we're most efficient if we follow our typical patterns for presentation, just until that patient's essentially established and they're registered, we can clarify exactly what the plan is gonna be. It's a nice touch point. You don't have to stay there for very long, but it's kind of a rendezvous point that everybody knows when we go to our trauma bay and then can go from there. Similar if you come to the ICU. To me, I think, again, you hate to get back to pre-established plans, but I think it gets back to what TR was saying at the start with a pre-hospital and you need to have that plan ahead of time with law enforcement and EMS pre-hospital providers. It depends on your established relationship with your level three surgeons and physicians and ERs. What they give you is true and you have to be able to trust what they found so far that they've done a comprehensive survey of the injuries for this patient. You can triage them out and know, hey, is an injury addressed? Is it not addressed? What kind of resuscitation am I facing when this patient still arrives? Because that's really gonna sway where you go. And again, a lot of centers now have direct OR protocols that have shown a lot of success. I can just tell you that here, for any number of reasons, we tend to do best, even though we have some protocols for direct OR, unless I have a very specific set of injuries, we tend to do best and we did such based on the trauma bay first. Okay. And there's something to be said for muscle memory. And again, knowing your system and executing the plan for your system, a lot to be said for that. So direct to OR, roboa was inflated and the whole blood rate was increased. Blood pressure is up to a hundred. ETCO2 is okay. Lactates up to 3.5. TAG shows a need for platelets and cryo, but has no hyperfibrolysis. Blood resuscitation is continued and platelets and cryo are included. Next slide. Next steps. What do you do now that you've got this patient coming to the operating room? Now, some of our centers will always reopen the damage control laparotomy coming in from a receiving facility. Others, as you pointed out, may have good relationships and know the surgeons, maybe even share surgeons. And in some cases, perhaps decide not to do that. And you still have the issue of the roboa and you still have the issue of the axillary injury. So what would you do with this? Actually, I think this speaks to the need for physician to physician communication from the sending surgeon to the receiving surgeon. Because the first thing that would be in my mind is how confident was the surgeon at the index operation and the hemostasis was obtained in the abdomen? I'm not sure I'd reopen that first. It seems to me the more likely source of blood loss is probably the axilla. How do you guys feel about it? Well, they also left a drain in the pancreas. So if you were still bleeding actively, you should have a, whatever, JP bulb full of blood. Don't forget to examine the patient before you make a decision. So I think the answer depends. It's never nice to hedge. But I think if your JP was full of blood, then you might be more inclined to do it. If the JP just had some serious angryness output or not a lot of output, I think I'd be uninclined to do it at the immediate evaluation of the patient. Yeah, I was sort of torn with that too because if you're confident you don't have uncontrolled truncal hemorrhage then your next priority is the axilla. If the drop in blood pressure and the fact that they had to increase the blood rate and deployment of the reboa raises the question, did you have more truncal hemorrhages uncontrolled? So I was okay with opening the abdomen, but certainly we don't always do that for the reasons you said. So- I was gonna say being at a level one, I'd actually advocate for E at this point. And this is one of the advantages to being at a level one or a level two center is that you have other specialists available, likely on call. You potentially have a vascular team and you certainly have a partner that you're backup at this point. So whether you think this is a territory where you'd like vascular assistance or whether you feel comfortable handling or exploring this yourself, I think to me, this is the prime example of a case where you have additional help there either in-house or on their way in with this kind of lead time. This is a two-team approach in my opinion, if you're at a level one at this point. Yeah, absolutely. And that's, you know, our trauma surgeons, several of them do vascular. We have a vascular team. We have a very aggressive endovascular team. We have residents. And so our direct operating room at this facility is really a full-on OR suite. And directly across the hall is the vascular hybrid room. So 10 feet away is the vascular hybrid room. So this was a team approach. Good point. And that's really the ideal arena to treat this in. Since we never had an arteriogram, we don't really know the nature of the arterial injury in the axilla, what's the chance that a vascular surgeon could do something catheter-based? Really good point. Let's go to the next slide. Okay, oh, sorry. No, no, that's good. So there was additional oozing. So the abdomen was repacked and closed. The axilla was explored after a femoral sheath was used to put a balloon occlusion catheter into the subclavian artery to achieve proximal control on the vascular injury. And I'm a big fan of those combined approaches as you point out. Your other alternative would be a really big operation to get proximal control in the chest or try to dive into it from the axilla, which I think is also fraught with hazard. The subclavian artery can retract and lose control of that back into the chest. So I'm not a fan of diving into something like this. So in this case, we chose to go in with an endovascular occlusion catheter and gain proximal control. So the brachial, you know, I said here, I said brachial, that's not right. That's axillary artery and vein. They were both transected. There was, the median nerve was intact. There was some thrombus. Next slide. So you've got some thrombus. You've got an artery and vein combined injury transected. Next step's in the operating room. Now, in this case, you're pushing the four, the six hour warm ischemic time. This patient arrived at four hours from the time of injury. And the upper extremity has been occluded for all of this time. And you're worried about thrombus. You're worried about ischemia and reperfusion injury. So that's the question. The answer was temporary shunt of the artery and vein and fasciotomy. Well, I mean, the vein's pretty controversial, don't you think? I mean. You know, I'm a fan of fixing the vein. Here are some pictures from the operations. And I'll tell you, one of the things that people forget about is putting a Foley catheter into the bullet hole and blowing it up to use it for tamponade. And when you look at this, these are temporary shunts in the artery and vein. You see the median nerve retracted out of the way at the top of the picture on the left there. And you see the Foley catheter balloon blown up in between those vessels, having gone where it went through the bullet hole to deploy the Foley. Next slide. And there's the temporary shunts in place. So there's, you can see what happened there. The Foley catheter tamponade of the arterial hemorrhage, but it was above the vein transection, which is why they had continued using. And that Foley went in and stopped the rest of the oozing that was going on. Next. So I'm going to say a word or two about temporary shunts. I'm a fan. Not everybody is. It's certainly controversial. What are your guys' thoughts? I'm a fan too. I think it's often a board question for senior residents. Yeah. Well, so this is a paper from 2017. And the paper below that is Dave Feliciano's paper from 2008 that talks about 10 years of experience with endovascular shunts. Dr. Feliciano and I and Dr. Shackford and a number of people have had a number of discussions about this. I'm a fan of temporarily shunting both the artery and vein. You've got toxic byproducts. Reperfusion injury is primarily oxygen-free radical driven. And you need to be able to get the toxic byproducts and the edema back out of the extremity. So I like reestablishing perfusion as quickly as you can so that you minimize reperfusion injury and also minimize reperfusion injury by shunting the vein and getting it back out. And, but the evidence for this is not entirely conclusive. And most of the papers that have looked at this say it's a valuable tool. It certainly can be applied, but not mandatory. So what are the rest of you think about this? I'd say I'm a fan too, because that's what I would do. That's what you do. You think it's a good idea, right? That's just what I would do in that situation for a lot of the reasons you said, and that's just what I'm more comfortable with, which I think is also sometimes when you're doing that board answer in the wooden room is a good thing to have in your back pocket, that, you know, do the thing that you're comfortable that's safe, that's defensible. And I would definitely do that in this situation as well. If I were unable to get a vascular surgeon to come in and do it, it was just me. Well, you know, I do vascular surgery and I still did the shunts because I wanted to get reperfusion established as much as possible. And I was in the damage control situation. I had an unstable patient. I didn't want to try to harvest the vein and fix all of this. And I wanted to get him back to the ICU and get him warm and resuscitated. So I think that there's merit to it. Certainly not everybody would agree with doing these shunts. I don't want to say that it's a necessity, but like you said, it needs to be something in your back pocket. Next slide. And here's a study, another recent study from 2016 that looked at this. And there's lots of literature. These are just examples. So here's my thought on temporary shunts, particularly when you're approaching warm ischemic time and you're worried about increasing reperfusion injury and compartment syndrome. If you have a multiply injured patient that requires a lot of procedures, I like it in tibia plateau fractures with disruption because of the increased risk of compartment syndrome and the increased complexity of trying to reconstruct those injuries. Those are situations where I'll frequently try to use a shunt. They can remain in for 24 to 36 hours if necessary. And in some cases don't necessarily need anticoagulation. Your thoughts, guys? Yeah, I would agree. That's one of the things that we use. You know, we talk about heparinizing that patient, but oftentimes, especially if you're proximal with it and by and large, our experience tends to be lower extremity shunts versus upper extremity. And I think it's pretty well mirrored in the military experience as they've reported that as well. What we find on the proximal vessels, you know, if you're talking, you know, five to eight millimeter vessels, you know, your risk of that graph going down with the flow rates that you're running, that's much lower than if you start talking about distal. So people doing popatio bypasses or, you know, trying to extend some lower leg vessels. Those are much smaller, lower flow. I think they're much higher risk of going down or causing injury to the vessels upon placement of the shunt. And, you know, every time I look into this, some of the big concerns surrounding it seems to be not even necessarily that the shunt itself but the potential damage you could cause to the vessel and, you know, vessel loss and increased, you know, graph length once you do have to place that. There are some concerns surrounding that. So if you think of a smaller vessel, it's certainly more susceptible to that. Yeah, all good points. Next slide. So patient goes to the ICU, A-line, central line, blood infusion, rates modulated to resuscitation endpoints, MTP is terminated when it meets the T-clip MTP endpoint triggers. Further decisions regarding vascular repair, what to do with the open abdomen ongoing. Next slide. You're resuscitating a patient who's undergoing a prolonged damage control resuscitation. What end points for resuscitation do you use in your centers? Blood pressure, pulse, urine output? More complicated end points? A lot of discussion around that. I see this question asks, what do you do with elderly patients who have comorbidities that result in a very small sweet spot for volume on the Stirling curve? How do you establish that? And how do you manage your resuscitation? So these are the questions. On the next slide, I have the 2018 EAST guidelines for modalities for monitoring fluid status. A lot of them are recommending arterial line based flow assessments, bedside ultrasound, looking at vena cava and right ventricular volume responsiveness. Do you guys use those at your facilities? Next slide. Yeah, we do. But I think it's important to match your patient to the modality you pick. There are certain things that are gonna be different for each, again, in a scenario-based setting. Some patients are just not gonna trace well on their arterial waveform analysis. Whereas other patients have things that may limit their ability to obtain good ultrasound imaging. And so I think taking that in context and putting it with the clinical picture you're looking is most important. That's why I love the all of the above previous answer. Because I do think that the more data you have, the better. I think you have to design it to the patient in front of you, understanding the comorbidities. I mean, we see problems all the time with severe aortic stenosis, with pulmonary hypertension. You really have to take a look at the patient in front of you, is my opinion. All right, so they go to the OR, they go back to the OR, they do the interposition graphs, fasciotomy, completion arteriogram, abdominal washout, PAC removal, small bowel reanastomosis, colostomy, Hartman segment. And then back to the ICU. Next slide. Here's the discussion. You're in that situation. Would you close the abdomen within 24 hours or at a future date? And would you reanastomose the colon in this setting? I'm not sure there's a clear right answer here, but I'm interested in what everybody has to say. So yes to both is the majority opinion. So panelists, what do you think? You know, my answer is going to be, it depends, because that's always been my answer. I would look for signs of the ability to heal the anastomosis if I have them, then the answer is yes. If the patient's been in persistent shock on three pressers, then the answer is no. And I would look for other data points within there, but it's difficult to say a yes or no. I think, you know, as practices and principles, the goal would be to re-anastomose and close the abdomen as soon as those two things are safe and you would monitor whatever you think you can to ensure the increased chances that that's a safe operation. Other thoughts? I completely agree. Yeah, I absolutely agree, too. And Dr. Chrisman, I think, was on here earlier, and he will tell you that one of my pet peeves in practice is putting a time limit on when you're going to close the abdomen instead of just using, you know, the physiology of the patient, the drive, as soon as you can, but once, you know, the original insult is corrected. Yeah. You know what? I agree with that completely. I think this is entirely physiology driven and a lot of judgment involved. This is, you know, that's why this kind of stuff isn't for everybody. Next slide. So the hospital course, patient goes along, does pretty well. Heparin was continued after the shunts. Now, I'm not sure I would do that, but it was. And a couple of days later, you've got a chest CT scan now that shows a greater than 300 CC residual hemothorax with compressive atelectasis. Next slide. So residual hemothorax treatment. Here's the questions. And would you think about this differently? I mean, we see this all the time in rib fracture patients, elderly rib fracture patients. They go a couple of days, they further displace their ribs. They get three or 400 CCs of blood in their chest. So retained hemothorax is a pretty big category here. You've got a penetrating injury with a retained hemothorax. What do you think about that? So a slight majority said VATS. Second answer, also close, was interventional radiology. And the third was no intervention. So here's the EAST guidelines from 2011. And persistent retained hemothorax after placement of a tube thoracoscopy should be treated by VATS. Next. There are a number of papers that suggest weighing against that, including observation for traumatic hemothorax. Here's a paper that talks about 300 CC volume being the cutoff. Next slide. There was a paper that looked at predictors of failure. And here were those predictors for failure for non-operative management of hemothorax. Next slide. And here's the Vanderbilt protocol for management of those, which recommends generally going to VATS. What are your guys' thoughts? No clear right answer here. Sometimes the most conservative thing is the most aggressive thing. And if you have somebody that's still intubated after all this has been going on, I think for me, the safest thing would be taking back to the VATS, especially if you're looking at extubating them really quickly. I think that increases your chances of getting a successful extubation. I'd probably go to VATS in this patient. Other thoughts? I agree. I absolutely agree. Yeah, I would go to VATS. It also gives you a second look at that diaphragm repair if you want while you're there. Yeah. Good point. You know, I'm a fan of VATS in this situation. I'm pretty aggressive with it. Rib fixation is still out there controversial. We certainly see patients that benefit from rib fixation and multiple fractures. But the interesting thing was, I don't do a ton of clinical work anymore. They don't let me out of my cage that much. But I had one two-day period where I did four VATS. And three of the four, I found either lung or diaphragm injuries that needed repair. So I don't think you're wrong doing that. Sometimes it might be overly aggressive. Other thoughts? I think it's underutilized in my hospital. We used to call it our chest mess, where we started getting complications from not being aggressive about it. And now, fortunately, we don't see that so much anymore. But I think that's a consideration in these settings. Being aggressive ends up being the best course of action. All right, next. So hospital course, VATS, hemothorax evacuated, muscle flap advancement over the vascular repair, partial closure of the fasciotomies, transfers from the ICU, patient does pretty good and goes home. Next slide. So quality review, what are your opportunities to improve in this case? And there's not one right answer for this. Let's, you know, the majority say consider initial scene transport to a higher level facility by air. And consider damage control vascular procedure at the level three. So we have two extremes as the top two answers. Do it all at the level three, or put them in the air to the level one. What do our panelists think about this? I think it's back to which kind of level three do you have, and who's there that day? Yeah, exactly. I mean, I don't think I would argue with a temporary shunt at the level three if you're approaching warm ischemic time. I think in this case, this patient might not have made it if we decided to do scene transport by air. And that's certainly always the concern. And again, it depends on what's available at the level three. If it clearly exceeds the scope of care, and you don't think you can control the truncal hemorrhage at the level three, sometimes you're faced with transporting a patient who may not survive the trip. So what do you do? You repeat the ABCs, treat what you can treat and get them in the air. So I think entirely dependent on the circumstances, I agree with you guys. Other comments about this? I will say, I think this speaks, if you have these issues that you're looking at when you're reviewing the care for this patient, it speaks to a maturity of your PI program as well, you're catching all this. Because if you have a really good outcome on this, I think the typical thing we would do is sit back, and we're slapping each other on the back and say, what a great job. But to have the insight to sit and look at each of the decisions along the way is important. I also think it speaks to the way you have your PI system structured. If you're looking at a culture of safety, or a just culture set of principles, you're evaluating the decisions made independent from the outcome here. And the last thing I think is very mature about this, is this spans the spectrum of care this patient's received from the pre-hospital setting to your other facilities to your level one. And the ability to communicate backwards through the chain as well, both forwards and backwards, to have the discussion of the care of this patient, how you're going to improve that system, speaks highly, I think, of your regional authorities as well, and their ability to provide some oversight and coordination of the trauma care within your regional market. Well, I appreciate those comments. We really tried very hard to do a robust quality improvement, and we're running out of time here. Dr. Cunningham, do you have a comment about how you would approach the QI on this? Remember, the QI is what we do to protect future similar patients from whatever the problem was. I mean, you know, in the age of the pandemic, with virtual meetings, we have to, you know, if this were my case at my institution right now, I'd try to address it very comprehensively, just like Dr. Cunningham said. But I think there's some other issues we haven't talked about. You know, there's a paper that I saw a couple of days ago, it's coming out in the Green Journal, it's a non-inferiority study for unfractionated heparin instead of Lovenox. Yes. You know, I mean, I would try to approach it with contemporary literature and approach it globally. You know, of course, the controversy there with unfractionated heparin is exposure to HIV, I suppose, and, you know, balance the fiscal side with heparin-induced thrombocytopenia. I think that's a good point, you know, and heparin-induced thrombocytopenia, you know, you could get that from a flu vaccine, it appears. We have all the reversal agents, we use Praxpine for Pradaxa, but if you're going to treat heparin-induced thrombocytopenia, that's a DTI that's not reversed by Praxpine. So then you have to have other agents to reverse that. So there's a lot to talk about in all of these, absolutely. And we try to dig into them as much as we can. We try to do individual education to our physicians. We try to do, we go back through the chain to the sending hospital, to the physicians there. We have physicians do their PI program at that facility. All of the EMS agencies, we have medical direction for most of these agencies and they have individual discussion with their providers, trying to do it in a very, you know, very collaborative educational manner. But I think we try to address all of those. And then the other piece of loop closure that I think is important is, do you see this kind of circumstance occur again after the educational processes or changes in protocols or whatever has been put in place? Do you then track the results of your PI system to ensure, as you said, are you ensuring the safety of the next patient in similar circumstances? Comments? I just want to say one more thing and then I'll shut up, I promise. But, you know, Charlie, you described that relationship you have with your level three. That's a tremendous luxury. I mean, I'm sure you know that. Many of us would be hesitant to be critical of the care rendered at a hospital that chose us as the receiving definitive hospital, you know, so, and I understand that's a very sort of embryonal approach to it. And I think we have to transcend that. We have to be willing to politely have a conversation in a non-accusatory manner and stay focused on the future similar patients, but I do really think that you have, I mean, a luxurious relationship with your level three because you can interact collaboratively like that. Well, it didn't begin that way. And I have to say, you know, it's a matter of trust, it's a matter of developing relationships. We are never going to joust with a sending facility. We're just not going to do that. They know we've got their back when they're in a pinch. I mean, we've sent blood and surgeons to our sending facilities in a pinch by helicopter sometimes, and they know that we're all in this to try to do the right thing for patients. And they've come to appreciate our advice and our willingness to provide education and help them work out problems. I think that's the way a trauma system really should be organized. Absolutely. Absolutely. I'm going to say one word that the other Marco said, the word conversation, I actually use that a lot when we go out into the community and discuss things with our EMS sending facilities and sending hospitals, because like you said, most of the questions, 11 or 12 questions you had, my answer is always, it depends, kind of became a joke, right? Because the answer does always depend on something and algorithms are there to provide sort of guidelines, just like Netter is there to provide a guideline of how the body's supposed to be connected. But we know it's not always like that. But a lot of the critical thinking, it really requires a conversation to come up with sometimes the right answer. And then these patients like this, I have two favorite patients to do PIs with, great saves where everybody's like, wow, we did a really good job. Because then you can come back and kind of critique things easily, because it was like, well, the guy didn't live. We did a great job. And yeah, we could have done a little bit better here or there. And so those are great patients to do that with. And then the other flip side is somebody that's practically DOA, and everybody agrees, there's no way we could have saved their life. And then you can go in and say, well, maybe next time somebody is going to come in with a slightly different variation of this injury, and we're going to be able to tweak something here or there to save that patient's life in the future.

trauma case

gunshot wound

treatment strategies

REBOA

tranexamic acid

EMS

decision-making

blood loss

trauma centers

transport options

communication

quality improvement