Well, good morning and welcome to the best session of SCCM. It's too bad that it's on the last day. This is the case records from the Military Joint Trauma System. And you can see we have our five panelists up on the stage. Two of them are intensivists and three of them are surgical intensivists and trauma surgeons. So in terms of disclosures, these are everybody that speaks today. This is their opinions. This is not the opinions of their military service, the Department of Defense or the Defense Health Agency. And these are actual cases that we've taken care of over the last 20 years in Iraq, Afghanistan and Syria. Many of the photos are the photos of the patients, but some of them are photos of other patients just because of the situation. So the photos do not always match up with the exact patients. So why do we do this? Why are we so interested in preserving lessons learned? If you look historically over time, World War II, Vietnam, Operation Enduring Freedom, which was Afghanistan and Operation Iraqi Freedom, when the next war starts, the case fatality rate is higher than it was when it ended with the last war. And so we do things now in this interwar period to avoid losing the lessons learned so that at the start of the next conflict, our case fatality rate is lower than when it started. So lots of efforts going on in the DOD and in civilian trauma centers to preserve lessons learned from the past conflicts. And the purposes of case records of the joint trauma system is really so that these lessons learned are not forgotten. So we keep going over these cases and keep going over the lessons learned. I just wanna introduce what the joint trauma system is. The joint trauma system is the DOD's or military's trauma system. And it became a statutory requirement in 2017, but really it's existed on the battlefield since about 2004 when surgeons like Marty Shriver and his partners were downrange and recognizing that we needed to have a trauma system. When we initially went to war in Iraq and Afghanistan, we didn't go with tourniquets, we didn't go with a plan for patient movement, and we've learned a lot over the last 20 years. This is our system of care on the battlefield. Role one care is essentially tactical combat casualty care or Medicare. It's point of injury care. Tactical combat casualty care has been indoctrinated over time and it's something that we train all service members. Role two is damage control or far forward surgical care. It bridges the gap between point of wounding and definitive care on the battlefield. Role three care or combat support hospital is one of the more common names or field hospital. It's the highest level of care on the battlefield. It has a specialty support, holding capacity, and multiple surgeons and OR beds. Role four care is outside of the battle space. We have one role four right now. That's at Longstool Regional Medical Center and you'll see some cases from that today. And then role four U.S. We have large medical centers like Brook Army Medical Center, Walter Reed, where people get definitive care and undergo all of their rehab. So we're gonna be mostly focusing on the first few roles of care in the two patients that are being presented today. And this is really the joint trauma systems or the military trauma systems chain of survival and recovery. If you think about this, in the trauma center that you guys work at or any hospital that you work at, when a patient moves levels of cares, it's an elevator ride. It's an elevator ride to the operating room. It's an elevator ride to the ICU. In our system of care, that can be eight or 12,000 miles, multiple helicopter rides and multiple plane rides. So we really have some unique aspects that we have to consider when we're caring for combat casualties. And why do we do these lessons relearned? I'll tell you, we go back to the future with every war. So when you hear from the panelists today, we'll bring up lessons relearned, things we've done wrong, things we've done right. But if you read this, each stretcher bearer, each officer, each man should know how to fix a Garrett. That's a tourniquet. When Dr. Schreiber first deployed, he was not issued a tourniquet. When I first deployed, I wasn't issued a tourniquet. This was from 1918. So we continue to relearn the lessons from the past. And when you look at extremity hemorrhage control and the case fatality rate from it, you can see that over time we've gotten better because we're trying to codify lessons learned. Another example of a lesson relearned. So if you look at this, a catheter, they're looking at a catheter for balloon tamponade of intraabdominal hemorrhage. And the last line of the summary of this paper is this catheter should be further evaluated. Well, this was written in 1954. So it took about 60 years, but now we realize that there are ways to do balloon tamponade of intraabdominal hemorrhage. And really, I think the most important lesson relearned, and we're gonna talk about this in the cases today, is the use of whole blood. And whole blood was used on the battlefield of World War I and World War II. We got away from it. We didn't do evidence-based research, really looking when the red stuff changed. And so now we're back to using whole blood. Okay, so that's why we do this. Now we're gonna hear from the panelists. I just wanna introduce them. We've got Lieutenant Colonel Chris Grable. He comes from San Antonio, Texas. He works at Brooke Armory Medical Center and is a trauma surgeon. And Dr. Lieutenant Colonel Retired Chris Colombo. He's an intensivist in Tacoma, Washington. At some point he's gonna mention telehealth, I guarantee it. We've got Captain, who's gotten two promotions in rank for this panel today. Captain Amanda Wiggins, who's at the Burn Center, one of the ICU doctors at the Burn Center. Lieutenant Colonel Ramil Howe is a surgical intensivist and trauma surgeon, and she's at Baltimore Shock Trauma. And then Colonel Marty Schreiber, who at some point, I promise we'll yell at someone on the panel. He comes out of OHSU, Portland. And just won a very prestigious award last week at East. Congratulations, Dr. Schreiber. So again, the purpose of this is that so we don't forget the lessons learned. Okay, you guys are welcome to participate. It's a small group. If you guys have a question or have a comment or you think that they're talking about the wrong thing, walk up to the microphone. No one's safe in this room. I mean, who knows, we might even call on you. We can just make everybody a panelist. Okay, so let's go to our first case. Our first case is less than two years ago in Kabul, Afghanistan. For those of you who were following the news, when the Taliban started to retake Afghanistan, there were still U.S. troops and coalition troops at Abigail. This is a map of HKIA, or Hamid Karzai International Airport. This is the runway. The military side, where the hospital is like right there. Military is on this side. Civilian airport is on this side. And if you guys were watching the news, I think people realized there was this mass exodus. There was panic in Kabul. And actually, Lieutenant Colonel Howe was there during this time. We talked on the phone many times, but experienced some of this stuff firsthand. But there was panic in Kabul as, I mean, and you look at what people were doing to get out of the country, shows you how scared they were to stay there. This is a picture of Abigail. This is the gate that there was a bomb that went off on October, excuse me, August 26th. It was massively crowded, massively crowded. And there were Marines there that were trying to control the entry into the gate and to help some of the women and children and people who were allowed to come through the gate, they were helping them. And so you can get an idea of how crowded it was. On the base, this is just two comparisons. The base HKIA used to be a really quite nice base, but then when things started happening at the end of August, 2021, it was much less nice. Okay, so what happened? Around 1700, there was a large explosion at the Abbey Gate. It was a Mascow incident resulting in multiple casualties, multiple US Marine casualties and hundreds, hundreds of Afghan casualties. The patient that we're gonna talk about is a 23-year-old active duty service member who had multiple fragment injuries to all four of his extremities and abdomens. At point of injury, so point of injury care, TC3 protocols were implemented. He had a right upper extremity tourniquet, high and tight, left lower extremity tourniquet, high and tight, and a chest seal over left chest wound. So when you talk about the fate of the wounded, it's really that first level of care. So let's start with you, Dr. Grable. Go ahead and what do you think about hemorrhage control at point of injury? How much is too much? Should it be just medics that do it? Should everyone know how to put on a tourniquet? What are your thoughts on point of injury hemorrhage control? Or should we just wait till we get to the hospital? Obviously, I... Dr. Colombo, now that you're out of the military, do you think that people in the civilian world take hemorrhage control as seriously, and are they doing tourniquet training? And you guys, if you can lean into the mics when you talk. Well, having been here for four or five days and seeing emails go out frantically to find instructors for Stop the Bleed being done in the lobby of this conference, I think yes, there's been enough civilian mass-cal trauma experience, whether it's the Boston Marathon or Las Vegas shooting, that I think people recognize that this is a need, just like campaigns to learn CPR 20 years ago. Dr. Schreiber, do you teach Stop the Bleed? We do teach Stop the Bleed. We teach it to the public. We teach it to the fire department, the FBI, anyone who will take it. I think the most important revolution, the way that we've changed the way we take care of patients, is the emphasis on early hemorrhage control, and I think that is what makes the biggest difference in saving lives. It's not the resuscitation that saves lives, it's stopping bleeding. In any way you can do it as early as possible is really going to make the difference of whether or not patients live or die. And I think Stop the Bleed really is, it's an outcome of the military carrying around a first aid kit, having tourniquets on their uniforms, and now it's transitioned, like many things, to the civilian world. We've had four mass shootings, I don't know if you're all aware of that, you've been at the meeting. There's been four mass shootings, three in California, one in Washington, just since we've been here. It's going to become more and more important as this goes on. So for those of you that teach, that either tourniquet, just curious of comments from any of the panelists, do you think most people, or when you get patients with tourniquets at your trauma centers, do most people, like what do you think, it's 25%, 50%, 75% or 100% when people put on tourniquets, they get it right? Are we doing a good job teaching tourniquets? When people come in with a tourniquet, Dr. Howell, when people come into shock trauma with a tourniquet on and you go and you feel their pulse and you can feel it, how do you think we're doing with instruction on tourniquets? I think that we're doing, I would say there could still be some improvement in that. I think both when I was at BAMC and at shock trauma, I would say it's about a 60-40 in terms of having an effective tourniquet versus an ineffective tourniquet when they arrive in our trauma bay. I think further education on that and continuing our stop the bleed efforts are important. So tourniquet use has been going on for thousands of years and the pendulum swings back and forth. So back in the 90s, we were taught that tourniquets were the tool of the devil, it was never used. We learned in the wartime that they are very valuable and save lives. The pendulum is swinging now the other direction and way too many patients are coming in with tourniquets that don't need them. People with small venous injuries, almost any injury, tourniquets are being used widely. And I can see how the pendulum could swing far enough that you start doing more damage than good eventually. And this is, I think, what's happened over the millennium is that the pendulum swings too far. So one thing in the lessons learned is to stop that pendulum from swinging. And when the medics bring in a patient that doesn't need a tourniquet, I think it's important to provide education that they didn't need that tourniquet. So it's very interesting how this has gone over the thousands of years, but the pendulum is swinging too far and now too many patients are coming in with tourniquets. I'd say about 25% of the patients have a properly placed tourniquet and needed it. Which has some implications when you look at what's going on in Ukraine with long, long transport times and everybody getting tourniquets and them staying on for 13 hours and casualties not necessarily needing tourniquets. So really underscoring the emphasis of training and education when it comes to tourniquet use and the indications. And Dr. Schreiber, I agree with you. You should, you know, medic and a pre-hospital provider, nurse education on the spot is probably the best way to do it. Okay. So let me just say one thing really quick. Stop the bleed completely avoids two things, which I think is not good. Number one, they really don't talk about how long a tourniquet should be left on. And it's a topic that I think is unsettled, you know, and I think it needs to be addressed. And I think the other thing that stop the bleed fails to mention is how tight to place the tourniquet. They leave it to the teacher to do those things in the military. We believe that you should place the tourniquet to obliterate the pulse so you don't get a venous tourniquet. I think that's the right answer. But I think the topic of how long the tourniquet can be left on is really unsettled and something we need to figure out. Yeah. It's a great point. The six-hour number comes from vascular paths with collateral, you know, with collateral vasculature. It doesn't come from trauma patients who are also hypotensive and have other forms of shock. Great point by Dr. Shriver. Okay. All right. So let's go back to our case. So the patient gets to the roll one, which is very close to where this explosion happened at Abbey Gate. Sorry, it's in the 30s. He's weak and threaded carotid pulse, no measurable blood pressure. He's bleeding still from all of his extremities, so all the tourniquets are tightened to be sure they're not venous tourniquets. A pelvic binder is placed because he's got this huge left groin wound. Bilateral needle decompressions followed by bilateral finger thoracostomies and eventually chest tubes were performed and IV access, got TXA, ketamine, and one unit of cold stored low titer whole blood. So 10 minutes of point of injury, 10 minutes to roll one, so we're 20 minutes into this. Let's start with you, Dr. Wiggins. So as an intensivist, when you think about tension pneumothorax and the physiology of it, how common do you think, and we can turf this to one of the trauma surgeons, you can turf it. I mean, anybody can. You can just say, pass this to the right or left. But how common do you think tension pneumothorax is versus simple pneumothorax? So if you get a phone call and you're covering trauma and a patient's hypotensive, according to TC3 guidelines, they should all get needle decompression. Do you think that tension pneumothorax is common or a relatively uncommon phenomenon? So I think for the trauma patients, I'll probably defer to the trauma surgeons for discussing that. But as far as like, should you do a bilateral decompression and everybody in shock, I think that that is debatable because I think if you have other tools to assess, if they have a pneumothorax, like taking an ultrasound and seeing if there's lung sliding, then I would do that first before just going straight to bilateral decompression. Dr. Grable, what do you think? Do you think every patient in shock should get bilateral needle disease? I know you're very involved with the TC3 guidelines and that says it. It says it in there that in every patient in shock, if you can't figure out what it is, so should we be spending time putting needles in the chest or should we be trying to get IVs? And remember, you're one person if you're a medic. You're one person if you don't have an ultrasound. And are you going to be opening things to do a needle decompression or trying to get IV access for potential transfusion? How would you prioritize that? I would prioritize IV access and trying to get blood into the patient. I think this is something that we probably overdo and overemphasize and get a lot of unnecessary finger thoracosomies. Certainly if the person arrests, then that changes the picture completely and absolutely those patients should get bilateral finger thoracosomies. But short of that, if they have breast sounds bilaterally, you can hear their heart. Trachea is not obviously deviated. I think restoring blood volume should be the number one priority. Dr. Howe, you have anything to add to that? I agree that yes, you need to give blood and resuscitate the patient just following our March protocol as well to make sure to resuscitate them. In this particular setting when a patient, I think it's all conditional. I think in general, I agree with Dr. Graybill, but looking at this particular patient with a heart rate in the 30s and one unit of cold stored whole blood was probably the only thing available. I think ruling out all the causes of shock immediately, I think this definitely warrants a bilateral decompression right away. So I think for the rule one setting in a deployed environment, I think it's important to stop the hemorrhage and then also do the bilateral needle decompression if they're unstable and shock like this patient is. Anybody have anything to add? This is free to interrupt panel. The question is loaded of should every patient or putting it back in context for this patient, mechanism matters if somebody is in shock from a penetrating injury to an extremity. No, if somebody is a victim of a blast injury that's removed limbs, then yes. Great. Okay. I mean, to answer your question, tension pneumothorax is exceedingly uncommon cause of preventable death. After trial, I'll go years in my civilian hospital and not see a single patient who died from a tension pneumothorax and the most common cause of preventable death by far on the battlefield or in the civilian world is exsanguination. This guy's got multiple injuries, extremities, abdomen, he's known to be bleeding. It's very likely that he's exsanguinating. Having said all that, I have no problem that they did what they did. Yeah. I agree. And you give the people with the least amount of diagnostic resources the toughest decisions to make, right? And that's the pre-hospital provider. So least amount of resources and some of the hardest decisions to make. Great discussion. So now let's just, let me ask about, we've got ketamine and low titer OHO blood and TXA. You're the one guy you've got to choose what your order is going to be. Which one or what's the most life-saving? You know, when you read the records, pre-hospital, it seems like, at least the records I read, you know, ketamine is prioritized, which, you know, and I think that makes sense if the patient's not hemodynamically unstable because you want to be sure that you're monitoring their pain to prevent all the other things. But if you had to put these in order, TXA, ketamine, and cold stored low titer OHO blood, what's your order? Just go down the row. Ramil, we'll start with you. Dr. Howell, we'll start with you. We'll go down the row. How are you going to order those? You've got to put them in an order. I would give low titer OHO blood first and then TXA and then ketamine. Dr. Graybill? I would do the same. Well, then, mind you, ketamine's IM, so you can give ketamine in, like, a fraction of a second. Okay. Concur. Dr. Wiggins? Yeah. Marty? I agree, but having said that, I would give them all at once. Yeah. Well, that's what we want to do. We want to give them all at once, but we, you know, we want to give them all at once. Okay. So, this, he gets, he has all the interventions just said, and then he ends up at the roll two extended. So, they've got, and now, for this event, the hospital had, usually this team only had about one surgical team, but they had multiple surgical teams in preparation for the exodus from Kabul, Afghanistan. So, he shows up, he's unresponsive, he's got multiple planetary rooms to chest and abdomen, he has the bilateral chest tubes, severe bleeding from the groin, he's intubated with minimal sedation. So, what about timing of intubation? Like, the more they're in shock, the quicker you should intubate them? Like, we'll start with you, Dr. Schreiber, like anything, like if someone's in complete hemorrhagic shock, be sure to get that airway in, or do you, like, how do you prioritize that? So, as I just said, I like to do everything at once, because that way everything gets done faster. I like, so, when there's an opportunity to think about this, I don't want to stop in the emergency department to intubate a patient. I want to go where, so this patient's bleeding, they could be bleeding in their, we know they're probably not bleeding to death from their chest, at least you haven't told us that they've got exsanguining bleeding from their chest. They still may be bleeding to death from their abdomen or pelvis, hopefully the extremities are now controlled. I need to be in this patient's abdomen, I'm not, I don't have a CT scanner, I'm going to be operating on this patient's abdomen. I would like to take the patient wherever I'm going to operate them and have them intubated while I'm prepping, and the incision, the intubation, all of that's happening at the same time while I'm resuscitating to avoid ongoing, worsening hypotension from the intubation. I'm not doing things in order, I'm doing everything at once. Dr. Colombo, for a patient who is in hypo, severe hypovolemic or hemorrhagic shock, using positive pressure ventilation and medications needed for intubation, have you in the trauma bay or ICU ever seen anybody code from that? Obviously yes. And that, you know, they do everything at once, I'll play the mental exercise game of course all of this is going to happen at once, but there's a reason XABC or MARCH is now the primary survey, because although A comes first in the alphabet, if you don't resuscitate the hypovolemic, exsanguinating patient, you're just going to precipitate that arrest, and why ketamine is now ubiquitous on the battlefield versus all the stuff we typically use in a trauma center. This is a lesson I think we continue to relearn in civilian and military trauma centers that, you know, the patient comes in exsanguinated and they, in the ER, they're quickly trying to intubate them, and then you're doing a thoracotomy. I don't know if I'm the only person that has that experience, but, you know. I've done that. Yeah. And there was just recently a paper that came out that really said prioritizing resuscitation over intubation in a patient that doesn't have like an obvious airway obstruction or airway injury. I think for something like this to where you're resuscitating from matters, like preferably you want the shortest distance to the heart, so like a humeral IO or some sort of cortis. Yeah, that's a great point. Or the subclavian or the IJ, so that way you're not resuscitating into an IBC injury that's not getting back to the heart. Yep. Great point. Dr. Conway, you had something too? Yeah. Just quickly. Call telehealth. You also get some diagnostic information from resuscitating first. If I make this patient sedated and intubated, I don't know if he was unresponsive because he's hypoperfused. Yeah. If I'm able to resuscitate first and I get a change in mental status, then that may change my immediacy of intubating him, obviously, because he's going to the OR, he's going to need an airway control. But I lose that diagnostic piece of resuscitation if I just intubate and sedate first. Yep. Great point. Okay. So he gets a subclavian cortis. He gets more blood, more TXA. His FAST exam has fluid in the abdomen and pelvis, a huge left groin wound, which is packed and has direct pressure. His heart rate's 140. His systolic blood pressure is 80 over palp. pH is 6.9. Lactate's 12. Base deficit is negative 16. So this is a really sick guy. So you're the only person as a junior intensivist in the ER, Dr. Wiggins, you're going to call your surgeon and say, you need to do a, like, what are you going to, what do you think this guy needs, like, right now, in addition to blood products, like salt water, should he get crystalloid transfusion, roboa? He looks like he's getting close to needing an e-orthorhichotomy, would you just do it in case? What are your thoughts? You're going to call your surgeon and say, this is what I think needs to happen. Let's say this is in the ICU. This guy's in the ICU. Yeah. So I would call my friendly surgeon and say that they need to go to the operating room. Yeah. I'd give him some blood and get him over to the operating room. I would call my friendly surgeon, ask him why he isn't in the emergency department with the sick trauma patient. And also, they wouldn't be getting more TXA from me because they would get a two gram bolus up front. You want to just expand on that, Dr. Schreiber? What's that? You want to expand on that? Yes. Why do we? So I think, well, we actually did a large randomized trial in 1,000 patients that was in traumatic brain injury. We randomized patients to two grams of TXA bolus in the field versus one gram in the field, one gram in the hospital over eight hours, or placebo, placebo. And we found that in patients with intracranial hemorrhage that there was an improved survival. And based on that study and other work that's been done in the past, the TCCC has changed the TXA usage to two gram bolus as early as possible. So our medics carry TXA in Portland. And either for brain injury or for hemorrhagic shock, everybody's getting two grams. It's very, very important to give it all at once. Only the patients who got two grams had the survival benefit. The one gram, one gram group did no better than the placebo group. But the other thing that you find is that if you don't give it all at once, a significant percentage of patients don't get all of it. Some of them don't even get the second infusion started. But if you give it all at once, they get all of it, and it's the most effective given very early. Yeah, go to the microphone. Good. Audience participation, welcome. Please. Sir, is that two grams, fast push, like an anesthesiologist or 10 minutes the way I understood? So the way we did it was you solubilized the TXA in a 100 cc bag of fluid, and you just ran it in as fast as it went in. So nobody's watching it. We'd say about 10 minutes, but if it went in at 5 or 15, nobody's watching it. So no one's counting drops. Put it in a 100 cc bag, drip it in. And probably we need a TXA IM, as similar or same bioavailability as IV, and having a TXA auto-injector is something if industry would bring to this trauma community would be likely welcome, don't you think, Dr. Schreiber? Yeah, I think that has not been well studied. We do know that IM TXA will get you the same levels. It does in a delayed fashion. So we have physiologic information about how quickly the drug levels rise and fall, but we don't have efficacy information. We don't know if you get the same efficacy. It is problematic to get 2 grams of TXA into an auto-injector, but you could do really about, you'd have to do about 4 injections right now with the size of the auto-injectors. We'd like to increase the size of that, but that has not been feasible, and we don't have good data that show that you get the same efficacy in terms of outcomes. All right, very good. I see a little basic science too in case records. Okay, so now I've got this guy, goes to the operating room, he's getting resuscitated, he's got his TXA, has chest tubes, has these extremity wounds, abdominal wound, and pelvis wound. So his chest, abdomen, and left upper extremity, or sorry, left lower extremity are prepped in the field. He has a tourniquet, a second tourniquet is put on his right upper extremity because he's got a soft tissue wound there that continues to bleed. In the operating room, he's got a large hemoperitoneum, lots of small bowel aneurotomies and injuries to small bowel mesentery. He's got bleeding from pelvis and retroperitoneum. His left groin continues to bleed from this large soft tissue wound. So now you're in the operating room. So you're in the operating room, the abdomen's open. Dr. Howe, thoughts on management of junctional hemorrhage? Not just what necessarily happened with this patient, but what's your decision tool or your decision tree when you're in the operating room is junctional hemorrhage? So now- Direct pressure's not working. Yeah, so now I'm in the abdomen, and it sounds like, especially from this, you also have a lot of injuries to the small bowel mesentery. So they're also likely bleeding from that. So what I normally like to do is first get control of the aorta. So you could do that easily with a supraceliac control. You could do it using just your fingers initially. And then you could also just put in a Richardson to try to compress against that and have your assistant compress on that while you look for other sources of bleeding. And then the other thing that you can do is, if you're able to expose the infernal aorta later on and you have control of the bleeding from the small bowel mesentery, obviously you wanna move the control a little bit more distally to infernal aorta. So I would do that. That would be the steps that I would do while I'm making sure that I'm talking with anesthesia and resuscitating the patient. Cuz sometimes you get in a hole when you're trying to control bleeding and you forget the important things. So when I'm doing the supraceliac control as well, I wanna make sure I time when I did it and when I compressed on the aorta. Because time as to when my aortic occlusion stops is also very important in this case. The other option that you can also have if you have fewer hands is you could also use a reboa initially, you're already in the abdomen, so I would prefer the supraceliac aortic control. But certainly if you don't have a lot of assistance, you're by yourself, it might be easier to just put in a reboa. Again, start with zone one, and then move it down once you've controlled bleeding. Again, being mindful of your resuscitation and the time of aortic occlusion. Dr. Grable, any thoughts on that? What would be your preference for hemorrhagic control? I actually agree, or you could ask one of your intensivist colleagues to help put up a reboa while you're otherwise getting control of hemorrhage. Use all hands, all hands on deck. Dr. Schreiber, anything additional? Yeah, this is actually an interesting situation, because what I would normally do in a situation like this is not take, so I'm a maximally invasive surgeon. If there's any fellows, you can come do our maximally invasive surgery fellowship. Or photon scans to CT scan. Exactly, retinal. And so normally I would want to make a stem to stern incision, but in this situation I would like to keep it a little bit higher. Because we may have to do pelvic packing in this patient, and if you make a very long incision, then it's much more difficult to pack in the pelvis if you take your incision all the way down the syphilis pubis. So normally I'd want to keep it a little bit higher, but as you heard from all the discussion, ultimately what I would do in this patient is get control of the iliac, and you need a pretty low incision. You need to take the incision pretty low to do that. So I'd have to be in the room actually managing this patient, but I would balance between would I keep my incision a little bit higher so I can pack the pelvis versus do I want to get a control of the iliac artery in this situation. Yeah, that's a great point, and that's surgical decision making what's difficult. So they did get around the external iliac. Their incision was low from what it looked like from the notes, which were very sparse on this day, and then they were able to get external iliac control. So in the operating room, no IVC or aortic injury. Both the IMA, inferior mesenteric artery and vein, were injured and ligated. There was a fair bit of bleeding from the colonic mesentery. So after the abnormal hemostatic, the junctional wound was addressed. But before we talk about that, so Dr. Wiggins, if you're keeping up with what's going on with this patient and we're coming back to the OR and both their IM, inferior mesenteric artery and vein, IMA and IMV have been ligated. Any concerns for that post-op or? Yes. Okay. And okay, Dr. Clemo, what would you, so she calls you, so I've got concerns. I'm also concerned. Yeah. No, I mean, obviously, this is, again, having fun at the intensivist expense of asking those OR questions. But information from the OR is actually key for post-op management. And you mentioned severe bleeding from colonic mesentery. Were there any injuries, penetrating injuries to the colon or the proximal end of the alimentary canal stomach duodenum? Yeah, so that's a great question. He had multiple injuries. I just want to kind of say something. One thing about deployment, and I think we've all experienced, is that you don't have anywhere else to go, right? So it's not like you're going to do something else. Like you're kind of all in it. So the intensivists are in the OR, as you know. The neurosurgeons come in. Everybody comes in. It's an all-hands-on-deck. And so you really get to work from a multidisciplinary standpoint. I'm confused. If there's no major vascular injury, is IMA not a major vascular injury? Well, I think it's just, I'm taking this from the notes, right? So- Okay. So that's, that was, I mean, they were saying that it was IVC, aorta. But so there were so many injuries to the mesentery. It sounds like they just ligated this. It wasn't really anything that was significant. I'm concerned about everything and would ligate those vessels in a nanosecond. There's a, there's no hesitancy about ligating IMA, IMV. If there's a good collateral flow, there'll be no problems. And if there's ischemia of the, of the sigmoid or left colon, deal with it. Deal with it later. Would you start with- Stop, stop the hemorrhage. Would you start CRT like the second they get out of the OR then? Because that's a huge lactate mass and load they're going to get. Yeah, I think I would normally. But this is, at this point, there was no CRT capabilities. But yes, that was discussed. I mean, this guy's on the verge of death. You, you, you, this is not, are you going to reconstruct these vessels? Are you going to sit around putting vascular shunts in these vessels? That's, that's- Or the other option is to just take out the colon. Which wasn't, parts of it were taken out. But that was, you know, that's another thing. If you ligate the vessels and the colon starts to look dusky. And maybe you're already taking out part of the colon. Yeah, you might, right. But you're talking about, you're talking about left colon and sigmoid. Right. In a patient who's on the verge of death. This is a no brainer. Those vessels are getting ligated. So- You're still saving life. You're still stopping bleeding. You're still saving this guy's life. So in the hemorrhage control phase, yeah. So what their problem is now, from what it looks like, is the left groin wound. So they connected the abdominal incision to the femoral incision. Vascular, so the common femoral, superficial femoral, profunda were all essentially destroyed, including the vein. That's on the left side. Vascular surgeon did a shunt. The orthopedic surgeon did fasciotomies of the thigh and of the lower leg. And the general surgeons were continuing to work in the abdomen. Now, here's my question. So there's vascular surgeon, there's orthopedic surgeon, there's general surgeon. You know, so not everybody in this room is in military. But I think both military and civilian and other international militaries are saying, how do we get smaller? How do we get more nimble? How can we do this with one surgeon? Do we even need a surgeon? Maybe it could just be a medic. You know, maybe it could be a medic and two intensivists. Like, so how, what's the, how's too small? Maybe it can't. Maybe it can't. But I just, you know, no questions, just any comments from you guys as the, as kind of the international military community, certainly U.S. military community, and our commanders are saying, we want you to lighter weight and cube, we want you to not be able to, you know, we want you to be more nimble. Do you need this many surgeons for this case? Could a surgeon and a medic, a general surgeon and a medic do this case? Could you, you're, you're an experienced surgeon. Could you do this case with a medic? Could I do this case with a medic? Maybe. But would I want to do this case with a medic? No. How many, how many surgeons? I could absolutely do this with a medic and then pack up my FST and roll on to the next location with the injured patient, which is what the army wants. I can't tell if you're being sarcastic. Okay. I, I do, I would say that. Earl Grebel's sense of humor is a little confusing to me sometimes. It's not common to be deployed with a vascular surgeon, at least I've never been deployed with a vascular surgeon. So I think a well-trained trauma surgeon, I think, honestly, I think our, and this has been said many times, I don't know how many times people in the audience have heard this, but our injured war fighters deserve at least as good of care as the, as the drug addicts and drug dealers and murderers that get shot in the street. If you're a drug addict and you get shot in San Francisco, you're going to San Francisco general, you're going to get expert care from a highly resource situation. To, to, to have an injured war fighter who's potentially losing their life for their country and to be under-resourced and have, have, have a surgeon by themselves with a medic trying to save their life, that's ridiculous. That has to stop, that thinking has to stop. And it's unacceptable. You need, you need someone who can help you. This is a very complex surgery. You need exposure. There's a lot going on in this patient. The orthopedic surgeon plays a big role. But, but we need to be able to, if we're going to deploy war fighters, they need to have the ability to get top quality care from qualified surgeons. Dr. Howe, you have a comment? Yes, I completely agree with Dr. Shriver and could, could one surgeon, like a really skilled surgeon do all this potentially? They could just need to prioritize what to do next. But like he also said, things happening at the same time, I think is, is very key, especially since you could do all this and deal with the mesenteric injury and resect bowel and ligate the IMA and IMV and leave the leg basically, you know, clamp the whole entire time and then use the shunt afterwards and all these things. But you can't do it all at once. You can't do it all at once. You can't do it all at once and timing is important. So now your damage control resuscitation surgery is going to be prolonged. Your amount of blood products that you're going to need is also going to be prolonged. So I think it's really key to have them happen at the same time and have that team there to maximize this patient's survival. Yeah. That's not the only injured patient. And well, yeah, we had a bunch more, but. Yes. So there's that. And then, you know, to Dr. Shriver's comment, this is the kind of challenge that the military has to deal with is what we want is not always what we get because of some operational constraints. So, you know, the challenges of trying to do more with less, but being honest and transparent as, you know, medical providers to say what you can and can't do is I think it's important. And we learned that over and over again. Okay. So in the operating room, you had a comment. Yeah. Can you go to the microphone? Dr. Pamplin, please. Another really important aspect about this is if you don't do all this right now, it won't matter another six hours, right? Because their lactate will be out of control. That leg will be dead and the patient's going to die anyway, right? So I think that's a really important aspect when you're talking to our future planners, right? To say that we can't support this in the first place, that's possible. The war's bad, right? But if we're going to deploy the team, deploying the wrong team doesn't make it any better because six hours from now, this guy's dead if you don't do this right. That's right. And timing is everything. That's a great comment. And it's not just this guy's at risk, right? There's multiple casualties. So I've been in these scenarios and just like this, and I'm operating with a cancer surgeon, very good surgeon, doesn't know trauma, doesn't know trauma very well, but he's got, he's a skilled surgeon. We did a splenectomy, nephrectomy, and distal pancreatectomy and put a popliteal shunt in a patient in less than an hour and we're on to the next patient. If I'm doing this with a medic, all that's going to take me, I don't know how long. Too long. And you're going to be venting body heat out of your patient for a 12-hour hour course, which when you deliver your coagulopathic acidemic patient to your intensivist, then I got to put my coffee cup down and actually do something that's going to consume many, many, many more ICU and lab resources. And it's much easier to have done this expeditiously and expertly. So that's a really good argument that he's making, that we're going to, by having adequately trained people, you're going to save. Time. Time and resources. Yeah, time and resources. You're going to save your blood bank. You're going to save every other resource that's available. And I think that's a really critical element. Yep. That's a great point. Okay. So this is an operating room now, just kind of looking at this, the ischemic burden that this patient's going to have. The tourniquet on the arm, because the arm was under the drape. And I don't know if they realized it afterwards from the note, but the tourniquet had been on for a few hours for the humerus fracture. And they had to do fasciotomies of the right upper extremity. There was no pulse in the brachial artery. So forearm fasciotomies were performed in the left upper extremity. And then this casualty stayed in the operating room for resuscitation and rewarming. He was too unstable and too coagulopathic. So we talked a little bit about tourniquets in the beginning, so I don't think we have to say much more about it. But I think that the challenge is we know tourniquets save lives. But, you know, how to train and sustain, how long they stay on for, and really understanding the complications. I'll just open it up to the panelists, or if anybody in the audience has any comments or questions on that. We talked about it before, but I know we're seeing some of these realities of prolonged tourniquets and the bad outcomes from it, which is why tourniquets got a bad name previously, right? So everything, the pendulum does swing. Okay, CRT. Dr. Wiggins, you're going into the operating room, you're checking on this. CRT, yes, no for this patient. Given the degree of resuscitation that he's required and is going to be ongoing and the ischemic injury that he's had, CRT is probably going to be needed. And what if you don't have CRT? Then I get him to somewhere where I can get CRT. Okay, what if that's a plane ride to Germany? So I'm just kind of thinking about resuscitation. We can go to Dr. Colombo. What do you do when a patient has had a massive transfusion, a huge ischemic burden, potassium is seven, and your blood products are all 31 days on the shelf? What do you do? And you operated on the colon, so I'm not going to be giving a whole lot of polystyrene products. Right. I mean, obviously, the trap is if I can't have best care, then you fall into the I can't do anything, and there's a whole lot of better and minimum better best to live in, so even if we start reaching for beta agonists and bicarb and insulin just to shift and buy ourselves enough time for an evacuation to a CRT capable location. If that's the only thing that can be done, then that's what we would do. And that's what they looked at. They also called, and for multiple reasons. So the patient got a lot of calcium, and that's because of the transfusion requirement. But even though there was plenty of blood on the shelves, plenty of blood, they had been stocked up in preparation for something happening. They called for a walking blood bank. So the blood this casualty was going to get transfused was not FDA approved, cold stored, whole blood, but it was warm, fresh, not FDA approved. Not FDA approved, my gosh. Dr. Schreiber, heresy. They gave an, on FDA, they did a walking blood bank when they had a ton of blood products on the shelf. Heresy. So you know exactly how I feel about this because I was overruled at the Committee on Tactical Combat Casualty Care, because I believe that warm, fresh, whole blood should have been the first priority. Not liquid, cold stored, whole blood, because I believe that the product is vastly superior. Liquid, cold stored, whole blood is nothing compared to warm, fresh, whole blood in terms of quality as a resuscitation fluid. There's no question. Warm, fresh, whole blood is vastly superior. If I'm bleeding to death or my wife in the back who's filming this is bleeding to death, give us warm, fresh, whole blood. Don't give me that liquid, cold stored, whole blood. It's not the same quality stuff. Everybody uses their stuff. Do you, so Dr. Howell, at Shock Trauma, are they using liquid stored, cold, whole blood? Are they using component therapy? Are they doing walking blood banks in Baltimore? What's going on in Baltimore? Definitely no walking blood bank. They still use component therapy for the most part. We don't have quite as large of a store of low titer O whole blood that's cold stored. We have maybe less than 20, not quite like BMC. So we give it only to patients that we think has a good survivability. And we're a little selective on our whole blood administration. We're still trying to get a larger stock of whole blood. Dr. Wiggins, you take care of some of the sickest people in the entire DOD at the USAR Burn Center. Have you guys and patients that have massive GI bleeds or go to the OR and burn surgery, or you make them sicker before you make them better with the excisions and they have a transfusion requirement, are you guys using any whole blood in the burn center? Or is it still all component therapy? No, we use whole blood in the burn center. Where do you use it? In our massive hemorrhages. So anybody who has a GI bleed, we've had... So wait a second, for a non-trauma patient, you're using whole blood? That's correct. Oh my goodness. Okay. Call the presses. I don't know of anybody else. And what about in the operating room for tangential excisions? Are you guys using whole blood in the OR at the burn center? Dr. Wiggins? Yeah, you're still on the spot. You're not done. The answer is yes. Okay. We still use whole blood in the OR as well. Any other comments about whole blood for resuscitation of trauma and non-trauma patients? Any of the panelists? Dr. Wiggins? So I know that the... I've taken care of a patient before who's acquired hep C after he returned from a deployment where he had whole blood. And I feel like the risk benefit as far as hep C being treatable now, and then HIV is also treatable as well, the risk, I feel like it outweighs, or the benefit outweighs the risk. They are diseases of the living. If you die from hemorrhage, you don't get a chance to get your hep C. I'll be a little bit of a contrarian. So if you're in a situation where there's still ongoing combat, and this even goes against TCCC guidelines, which I'm a proponent of, and the warfighter needs to continue to be able to fight, if you're going to do something that is going to physiologically compromise them by decreasing their oxygen delivery, and you have cold stored low titer whole blood there, I think I would be reticent to just automatically trigger and make those people less fit to fight. Yeah, so our Norwegian colleagues have studied this in depth. In soft, super fit, like Norwegian medics that can pretty much run 10 miles right now and then come up here like they did nothing. But yes, they have studied it. Our US Army soldiers, I'll compare them to any of those Norwegian guys, they drink too much. But anyway, this has actually been very well studied. They take a unit of blood off those guys and they did two really good things. First of all, they studied them, they made them run, they ran just as fast, they read books, they had same memory retention. They could not document any decline in their function in either mentally or physically. Did they then shoot or blast them and see how they were as a trauma patient making, being pre-trauma anemic? Hopefully not. Have you ever given a unit of blood anemic? A hole in the literature. Have you ever given a unit of blood and then gone for a run? I have. Is it, you find it just as easy? I didn't notice a difference. I have not found that to be as easy. But the other thing they did with that. You can all do these experiments at home. When you go to your local blood center, give some blood and then go do PT. The other thing they did with the blood though is that they studied what happens to it in terms of a storage lesion, which I think is the other thing that's really important. So there are two things. They looked at the donor and then they looked at the blood. And what they found was by 14 days, there are significant deficiencies in all coagulation function. They did serial rotams over time. And by 14 days, there are significant lacks of coagulation benefit in that stored whole blood. And that's why I'm saying that the quality of the blood. And we did tags and CBCs on our liquid cold stored whole blood at 14 days. The platelet count was 75 and the MA was in the 40s. And then we put it through the Belmont, which is how we give our liquid cold stored whole blood. The platelet count drops by about 10 or 15 and the MA drops as well. This is not the same product. It's just like the two buck Chuck is not the same as a fancy bottle of wine, but they're both red and they're both wine. Is that what you're trying to say, Dr. Shriver? Exactly. Yeah, okay. And everything in between. So when you're giving whole blood, it's not a single entity. You got to think about the quality of it. Is it lucrative and how old is it? Those are having dramatic effects on the coagulation capacity of it. Don't think of all these whole bloods as equal. I think that for the point of this, when you don't have CRT, which they didn't have, they were able to give calcium and beta agonist therapy and other things. But thinking about what you're resuscitating somebody with and using a fresher product is gonna have less physiologic effects on electrolytes and other things that, and so like Dr. Shriver said, probably the best product for that. And there's a couple of research studies really looking retrospectively at the data to see what the outcomes are between fresh whole blood and low tide whole blood. Dr. Pamplin from the audience. So the question, the issue may be less about what's the right product, what's the best product to give, but more about, can you give it? So change condition, there's an active firefight going on. This is an after blast. All of your donors are out on the line. Do you call one off to give this guy a unit of fresh whole blood? These are the hard decisions. Why they don't do it at Walmart, right? It was easy, they do it at Walmart. So let me just say this. One of the three US service members that died when I was deployed, the medics who did the whole blood drive were qualifying with their weapons. And they were out in the field and the brass from one went down the back of the other and he reflexively turned and fired into the safety officer who was shot in the iliac artery and vein, and came in exsanguinated. The units of whole blood we got, the fresh whole blood were about 100 cc's because the people that were doing the blood drive weren't experienced because the medics were out in the field. So this is a tactical decision. All of these things, we're sitting here in this perfect environment, it's a beautiful sunny day in San Francisco. This is not a deployed setting where anything can be happening. You may not have the people to do the blood drive. You may have people to do a blood drive, you may not have legal cold store whole blood. Whatever the situation is, you have to be flexible and tactically ready to respond to whatever's going to happen. I think that's a great point. And from a military standpoint, and I think this could be with any skill, this walking blood bank thing has to be trained a lot. Every time a new unit comes onto the base, everybody on the base needs to know how to do this. If you're going to implement this effectively, the training commitment is significant, and it is something that definitely makes a difference in saving lives. Dr. Howell, you had something to say? Yes, I just wanted to also make a couple points, and I'm not sure if you're going to touch on this a little bit later, but this patient is also very sick. Hey, you're not supposed to know about this patient, but you do, she was there, so she's okay. I'm going to make general points to see what the other panelists think. Try to argue with Dr. Schreiber, it's always fun. No, I'm not. So this patient's very sick, potassium is seven, and he still has to also survive a Seacat flight that's about nine hours to get to Germany. And you only have a short time window because Seacat can only be there in an hour or so from whenever, it was like 4 a.m., so this is like 12 or 13 hours into the Mascow now. And they can only be there for a short time window and then rapidly leave because there's still a questionable threat in that area. And is there any thought at all, and then also the shunt that was placed also went down. So from the, I'm interested to- It's like you made my slides, Dr. Howe. What? Oh, sorry. No, no, no, no, no, keep going. So that's the question, that's the question that you guys had to make the decision is that you've got to get this guy to a higher level of care, you've got to. You've got to or he's going to die. But that higher level of care is eight hours away or nine hours away and at 30,000 feet with very limited resources. And then going back to the walking blood bank point, we were, I think there's also a positive, I think something to consider as well is do what, I mean, I don't know, I call it a limited walking blood bank where you don't have to activate like 20 people to come and give a donation. If it's just for one particular patient, asking for six units of fresh whole blood or nine units of fresh whole blood that they could potentially take with them to their flight so that they could be resuscitated would be another option so that you're not limiting your war fighters completely because one patient might be able to give two units of, I mean, one patient, one person might be able to give like two units of fresh whole blood or so. And then I think to your point as well, Dr. Gurney, I think having the people trained to do a walking blood bank especially during turnover times is also very important. Yeah, being able to adapt and train. So the decision at this time, so they did not put him on the flight to Germany. He was too unstable. Being unstable on a CCAP mission when you've got nothing else around, that's not a fun place to be for the patient or the physician. So I'm gonna, I was not there at this time, but I'm gonna caveat this. There was no resupply. I mean, the theater was closing. So I would have like raised hell and like if I couldn't get transcom to transport the patient, then I would have gone and talked to the CNN reporter or the New York Times reporter and said that the U.S. Transportation Command is refusing to transport a patient. Yes. I'm more, I'm curious about the decision to keep the patient off the flight and what was it that you guys thought was gonna get better or by keeping the patient similar to your line of thought. I'm actually a CCAP instructor at UC and anesthesia critical care is my background. We flew patients in Afghanistan based on a lack of resources at times. Picked up a guy with an open chest, hemorrhaging all over the floor. The CT surgeon said, I can't find the bleeding and I'm out of blood. Just take him back to Bagram and maybe you guys can fix it. The guy did great. But I've also called for the ECMO team to put a patient on. Right, so these are the hard decisions, right? So they, you know, from the notes and from the conversations, they felt like he was too unstable to fly, you know, just not stable enough to, and Dr. Howell, if you wanna add anything, and it seems like they were potentially. Surgery. Well, he got more surgery. Yeah. Yeah, so basically what happened was that he was still oozing from everywhere. The right upper extremity was still in question as to whether it was still oozing and actively bleeding. And then at that time, he was also still coagulopathic and so would continue to require blood products. And on top of that, he was on maximal pressers. And so for that time window, there were two C-CAT flights going. So for that first C-CAT team, we basically just wanted more time to resuscitate and warm him. And these are the hard questions, right? I mean, these are the decisions that through the retrospective scope were always easy. You know, had he gone on that flight and died during flight, the question would have been, you know, what were you guys thinking? He was coagulopathic, he was bleeding. And also keep in mind that this is just one of 32 other active duty members and many more that were also actively requiring a lot of resuscitation and critical care time. So the two C-CAT teams that came for that first round had a lot of other sick patients. So I totally agree if it was just that one patient, a C-CAT team might be able to handle all that resuscitation. But for this particular circumstance, they would be pretty overwhelmed. And you know, Dr. Howe brings up a good point. We're not really talking about the contextual part of this, that there was a lot of other stuff going on. We're just focusing on the one patient. So we're just gonna look at this patient's resuscitation, what he got. 30 units of cold stored low tide or a whole blood, five, six packs of platelets, eight units of FFP, just two of RBCs. That is an incredible transition of how we resuscitate people. Three units of warm, fresh whole blood from a walking blood bank. You know, just kind of to remind everybody of history and we really have gone back to the future. We used to give whole blood. That's all we gave until the 70s and we figured out you could separate things into component to make some money, add some preservatives. And then we use clear fluids and now we're back to whole blood. Dr. Shriver. So quick question for you. If you look at, could you go back to the resuscitation? Were you using tags to guide your resuscitation or like standard evaluation test? At this point, our tag was already packed away. And so we were not able to use the tag, but absolutely if it was available, we would have been able to use that, but it was already packed away because we were supposed to leave. So I'm curious then, how did you base how much platelets and FFP to give to this patient without? So we still had some lab capabilities. So we use CBC and saw that his platelet count was like in the 30s. So we gave some platelets, but he still acted coagulopathic and that was really the trigger to give the fresh whole blood. And that was during that time period where we had decided that he was unstable for C-cat because he was still coagulopathic. And so our thought was give him some fresh whole blood and then take some with him in flight as well. So this is a lesson that we learned actually in the Vietnam War. If you use large amounts of liquid cold sore whole blood, you will get severely thrombocytopenic. And that's why you've got to follow it just like you did. I mean, I think what, I think, let me just say what you guys did is amazing. And we haven't heard about the 31 other patients or 32 that you mentioned, but congratulations on just an incredible effort. So on that, so go ahead. Do you have access to cryoprecipitate? We only had like nine cryo, but yeah, that's another good point. We were not able to get, I think we gave one or two units, but it was not recorded. So there were a bunch of other patients during this. And, you know, this is a service member who was, you know, working at the gate to try and help some local nationals and doing his duty. So when is too much, too much? Like, you know, there's some civilian literature now that's coming out that anywhere between 17 and 27 units of blood, the case of survival is potentially really low. So should we be considering futility in this? Or what if there were, I mean, what are your thoughts on that? Like, what if you were running low on blood? What if you didn't have as many donors? Do you have a futility threshold? And should we have one? That's open to any of the panel members. That's a tough question. I'm glad I'm not a panelist. I'm glad I'm the one asking the questions. I think population percentages are great for defining policy and guidelines, but the patient in front of you is either 100% or zero, not a X percentage of survival. So I think it's dependent on the resources that you have, what's going on with the other 31 patients. And if you're packing up anyway, you might as well empty the storeroom for this gentleman. Take care of the patient in front of you. Dr. Farrar, do you have anything to say? Well, I think Dr. Gurney is recently submitting a manuscript that shows that there is no amount of blood transfusion. You're not supposed to say that. Why, are you gonna say it? No, I'm not gonna say it. So anyway, you can give up, 256 units mortality in combat casualty situations is less than 50%. So there's a series of several papers coming out from the civilians that are showing levels of about 20 units, where they're having extremely high mortalities. I don't understand the disconnect. I think it's probably maybe a statistical nightmare that they're playing with, but I don't believe in futility for this. I've personally seen people get hundreds of units and survive. But I think what you said is exactly right. It's determined by the situation. I've been in multiple casualty situation with 256 casualties and never ever made a person expectant. The challenge is not what we had. So everybody thinks about our current operating environment as austere, and it was austere at times, but what it really wasn't was truly resource constrained. Even in this, there's always concerns about resource constraints, but in a future operating environment, you just might not have this. So that's when it becomes difficult, which is why I think that one of our focuses should be on how do we figure out how to do triage for patients like this? Because this guy's gonna be clearly a survivor, right? But not if you didn't have all these resources. This is an incredibly resources of intense resuscitation. And there's another triage that's gotta go on within this patient because now you've got to think about, do we need to start doing amputations? And what are the qualities of these extremities? Are they going to be functional? We can't transport the patient because they're oozing from extremities. We're using up all of our resources. Do we need to start thinking about amputation? And then that's also another good point about the futility discussion was we gathered all the general surgeon, vascular surgeon, orthopedic surgeon, and had a discussion about where do we, and this all kind of again happened at the same time that the first CCAT team was arriving. So what are our options? Because the vascular surgeon was the proponent of re-exploring the shunt and redoing it. The orthopedic surgeons were saying the limbs or the muscles were not that viable anyway. And so we had a whole multidisciplinary discussion basically, let's just leave the shunt as it is. Likely he's gonna get amputated. We don't have to do it here right now because we have the coagulopathy under control. If we try to amputate now, coagulopathy might get worse again and then that will put him back again for the next round of CCAT flights, which is like, I think two hours away. And so we had, I think that's an important lesson as well to gather all your team and communicate with them and have them help you guide the decisions that you make and triage. And so I think that that really helped once we determined that the coagulopathy was really his main enemy for being transported. You know, and we got the fresh whole blood and things like that and resuscitated him. Those are all really good points and shows the complexity of these cases and the discussions that have to happen. Okay, so let's see what happened with this patient. So he got on the next flight, CCAT to Germany. The roll two gave them six units of the warm, fresh, whole blood to transfuse in flight if they needed to. And they did, they transfused four of it. His lactate improved from nine to five. He was treated for hyperkalemia. His potassium went up to seven. I mean, hyperkalemia en route, you know, what are your tools gonna be? You know, if you don't have CRT, it's kind of the same thing. So your same medical management tools. But now he's hyperkalemic. So Dr. Wiggins, you're the CCAT doc. He's hyperkalemic and he loses his pulse in his left lower extremity. Now it was lost about seven hours into the flight. So you have about an hour and a half or two hours before he land. But let's say it was lost one hour into the flight. So now you've got an extremity that is getting no inflow. Let's say you have an extremity that's getting no inflow. You're hyperkalemic. You've got six hours to go. So you said, what could happen? I can do anything on a CCAT flight. Well, what are you gonna do then? Let's just say your next potassium is seven and a half and your next potassium is eight. Their leg is getting more mottled. What do you do? With medical management, you're saying it's still increasing? With maximum medical management. I mean, at that point, you have to talk about turning around, I think. With this ischemic limb, just leaking potassium, you're not gonna get good control. And this patient's just gonna have a complication. What about outside the box thoughts that I don't think we've ever done, but what? Tourniquet high and tight, tourniquet high and tight. Yeah, you know, so that question comes up in some of the training things. Would you put a tourniquet on that limb? Wait a minute, wait a minute. If you're seven hours into the flight, you don't have six more hours to go. Okay, I know, but I said, now what happens? We change, we're changing it. Okay, all right. Such a pragmatist, Dr. Schreiber. You mentioned no inflow. I wanna make sure we have no outflow. Right, so that's well said. If you realize you have no inflow, potassium's going up, then you need to control the outflow. And then you've bought that patient an amputation, right, for sure. This was not the case with this, but I think that it's something that you have to think about. Okay. If you do that, if there's any way, what you really wanna do is a cool extremity. There's a medical amputation includes using liquid nitrogen with the tourniquet. You won't be able to do that. You won't have dry ice as the next best thing, but if there's any way to cool the extremity to decrease metabolism, that should also be done. You're gonna start packing dry ice in your C-cat kit now? I got a cooler. Right. Put the leg out of the way. Get it as cold as you can, because you wanna reduce metabolism. 30,000 feet. Yeah. Yeah, but you may have prevented a cardiac arrest even if the limb wasn't... Right. And that's what Dr. Schreiber was talking about is, you know, damage control and triage of the patient, triaging the limbs. Okay, so now just one day after this guy's injury, this is something that is incredible about our system of care. He's had all this done. He arrives to the launch stool. He's had his fasciotomies of his bilateral upper extremities, left lower extremity, leg and thigh. His left leg is mottled. They can't get a palpable pulse. He's oozing through all of his extremities. These are his labs on arrival to Germany. So potassium's high. Calcium's okay. Obviously, he's gotten a lot of calcium. Lactate is not the worst. And his H and H is okay and his platelets aren't that bad. So now you know this guy's going to get everything. So in terms of CRT, you know, aggressive ICU management and going to the operating room, what's your... Dr. Wiggins, you're the... Actually, let's start with Dr. Colombo. I feel like I'm picking on Dr. Wiggins. Dr. Colombo, you're the intensivist. You're going to say, this is the order I want to kind of manage this patient in, wouldn't your conversation with the surgeon? Yeah. So in conversation with the surgeon, the question really is, are we trying to preserve limb or not? If there's a chance to preserve limb, then I think OR first. If there is no reasonable chance to preserve limb, I think CRT first to make sure that the patient survives the OR, whatever the procedure is going to be. Dr. Farber, can you do CRT while you're in the OR? Do you do CRT in the OR for your ICU patients? We can do it. We usually don't do it, but we can do it. We do it in a situation... This would be a situation where you need to be operating and correcting the potassium at the same time. This patient's very much at risk for cardiac arrest with that potassium. And I'd be doing an EKG to look for peak T waves and see if they have evidence of that as well. I would probably, in this patient, not having been there, start CRT first and try to stabilize them medically before going to the operating room. Dr. Grabo, anything to add? I would start CRT immediately. Yeah. I mean, the other things that I would probably look at is his gas, see what his pH is doing and other markers as far as his renal function and dysfunction that would need to start CRT before the OR. Yeah, he's got an anion gap of eight. Actually, he's in reasonably metabolically good shape with an anion gap of eight. His potassium is very problematic and obviously his creatinine is going to continue to increase. So I think early CRT is going to be really important in this guy. And that's a fantastic X-ray with everything that happened to that guy. I know. I mean, so this is actually pretty impressive, right? So this is this patient's X-ray. You can see he's got a couple areas of metallic fragments. There's one there. That's from the injury. But his lungs so far look really good. But this is his problem list. This is directly from the note at Larmcy. So clearly this guy's got a huge physiologic burden. It's only post-injury day, like one and a half. He's had a massive resuscitation, a big ischemic burden. And so in terms of priorities, so they ran him on two CRT machines because his hyperclemia was incredibly difficult to manage. He had ICU management. And he didn't go to the OR right away. He went to the OR within 24 hours, bowel discontinuity, extremity wounds, and the vascular injuries. So then he continued to go to the operating room. We'll go through the rest of this case relatively quickly. You guys are off the hook for a minute. So he initially started with a left lower extremity through knee amputation because of distal ischemia. They tried to save his thigh. And then on post-injury day four, it was just everything was dead. So he ended up doing a hip dysartic. His right elbow, he had a disarticulation for an ischemic limb. You'll see an X-ray of that fracture and how it was fixed in a minute. And then his abdomen was re-explored. He did have one small area of ischemic bowel, which was near one of the urnastimoses that was resected. This was really a problem. And this was a problem, you know, in 2010, 11, and 12, is he continued. So even with the hip dysartic, had this progressive necrosis to both his wound on his leg and his abdominal wound. So they were debrided. And they were concerned for invasive fungal infection. So this is something that is just so incredibly potentially bad for patients. So I don't know if you guys want to make any comments on this, if you've seen this, if you have any thoughts or experience you want to share with the audience. So that was the genesis of the question much earlier. Obviously, not being a surgeon, I'm going to be the intensivist nerd. Did we have injury to the distal ends of the elementary canal and a hostile belly? There's some evidence for fungal prophylaxis in that patient immediately following or intraoperatively. But given that it's a blast wound in a very filthy place, then covering aspergillus, this would have been a, I'm sure meropenem and vanc were given by reflex. I probably would have added voriconazole to the mix right up front. He was started on ambazone and cresemba very early. And Lonstool, because Lonstool was really the place that Lonstool and Walter Reed that had this, that described this, they have a very specific blast protocol where they take biopsies of the muscle, they send it to the lab, and a blast protocol and starting early antifungals. And that's what they did, which probably ended up saving this guy's life. This is his right humerus before it got fixed. This is antibiotic beads in it after it got washed out. And this is a CT scan. You can see the metallic fragments. This is after he had his hip dysartic, so pretty profound. You can see where his hip dysartic was, which you can't get an appreciation of it. I don't have any pictures of it. This is a picture of what the wounds look like. So then they kept him at Lonstool for a couple days to stabilize him before sending him to Walter Reed. It looked like he had CRT in flight. He remained intubated. He continued to get hypothermic. He required continued, really aggressive ICU care on the flight to Walter Reed. When he did arrive there, when they did a sedation holiday, he was able to follow commands. He was able to move his limbs, and he had decent pulses of his right lower extremity, which remained fine. He continued on CRT. He had multiple trips to the operating room at Walter Reed, multiple abdominal operations and washouts, INDs with antibiotic beads, vac exchange. As you would imagine, these types of wounds require almost daily trips to the operating room. They revised his elbow. They continued antifungals. If you remember that x-ray from just two things ago, this is a pretty good result with his arm in terms of alignment of the fracture. You still see the antibiotic beads in it. He had his elbow disarticulated. He was extubated post-injury day eight. He had revision of all of his amputations. He was neurologically normal. He did, and for the interest of time, I'm not going to go through and have an extremely complicated ICU course with a massive PE, hemodynamic instability, needing to get re-intubated, aspiration pneumonia, multiple infections, but he, you know, he did not get an IVC filter. Something that we're pretty aggressive on in the military, they did targeted muscle re-intervention, TMR, of both his amputations, so he had an amputation of his upper arm on one side and the lower extremity on the other. So really kind of you can think about the challenge with that from a movement standpoint. He went through all the stuff that we do for our injured warfighters. On his fungal biopsies, he had no angioinvasive fungal infection, which is probably why he's still alive. He did have candida on it, and he underwent all the kind of war consults that we do. This is him with permission while he was in the hospital. You can see him in his electronic wheelchair. He has his hip disartic in his right extremity amputation. So he stayed at Walter Reed and did inpatient rehab. We have a great PM&R service, and military rehab, I think, is really setting standards. Discharge day 132, so lots of rehab, nutrition, and care. This is him leaving the hospital. This was actually a news feed. Again, you can see him not in a wheelchair at this time, which is pretty impressive, and that's some of the stuff that they're able to do with the targeted muscle re-intervention, and this is him 17 months after injury. So you look at this story, it's pretty impressive, all the work that's done to when you ask a question about futility, and then you see a picture like this. Okay, so any questions from the audience? The next case is shorter. Okay, first, before we go to the next case, we have just a little bit of a break. We're going to do the rapid fire round, so no long discussion, just give your answer and move on. Okay, this is your X-ray. You're downrange, and you have a, oh, go ahead. So I think there's a really important point that's really, we haven't quite hit yet. Uh-oh. I thought we hit all the points. This is this issue of standing out of the bag in theater. Yeah. Right, so I've taken, I mean, I think we've all had the experience, we've given people hundreds of units of blood, right, and they're not coagulopathic. When you resuscitate them the right way, they're not coagulopathic, so I really wonder what the thought process was in theater when he was still coagulopathic. In my mind, you know, my conversation with the surgeon at that point is, hey, what's still dying, right? Why, what have we not yet addressed? Because putting that guy on that flight with something that wasn't addressed put him at higher risk of not making it through that flight. You know, this is a, so you're right, and I'll turn it over to the panelists. These are the conversations that need to be had, but in our system of care, delaying amputation, as you know, because you've seen it for a long time, is really common because it's hard to make that decision. If somebody's actively dying, I think it's a much easier thing, but he wasn't as actively dying as some patients are, and so I'll turn it over to the panelists. I mean, I think that, you know, he brings up a good point, but the decision to do a AK or hip disartic in theater when you know they're going to a higher level, and you've got the orthopedic surgeon saying, we can do, we can save this limb, which is what, you know, usually they can. You know, he did. Yep, he did. So it's a, you know, hindsight's always 20-20. That's why we have these discussions. Comments from the panelists? Yeah, so I would say he was partly hypocoagulable because he'd been in the OR for a while, too, trying to get all those injuries, the small bowel resection, and then doing the shunt, and then the shunt, I think, a couple of times went down and had to be redone. But just being able to say, you know, we're going to do this, we're going to do this, Yeah That's great great comment. Thank you any other comments from the audience Don't be shy Okay, because the audience the panelists don't want to answer this question there They're hoping you guys ask something else don't have to answer so you have a patient that comes in they're in a blast injury dr. Wiggins you really you see this x-ray and You're like oh my goodness, and then they go to the operating room to take a look and this is what you have You have something That came from an explosion in the abdomen What do you so they get a you get a call because you know you're gonna say telehealth so dr. Grable or dr. Howard extraver someone calls you and says I have this I need to operate on and I'm afraid it's gonna explode What's the advice? What do you tell them? Don't do it put them in a helicopter that's moving a lot and vibrating and you know it's unexploded ordinance It could blow up at any time you need to take the patient to a protected setting Make sure that no other humans can be injured by this. This is a one-person Situation you don't want to risk others. Don't use bovie. Don't do anything What's that no ultrasound ultrasound can activate the devices? I didn't know that yes This is a key opportunity for everyone to learn even you dr. Chargers But This needs to come out as soon as possible in a safe protected environment with one human being at risk so I would disagree with one point I Certainly, it's a single-person Operation I would actually do this and whatever your facility is with the best lighting I mean if my anesthesia provider blows up or I blow up or Like the equipment is irrelevant. We have a thirty one point four trillion dollar deficit like funny money can go buy more So do it where the lighting's good who cares about the facility as long as there's no other people around Okay, I'll get I'll get more contrarian then okay. Well, this is good two is one and one is none So it really depends on what other facilities and equipment you have for that one person because if then that takes out the entire Facilities capability you haven't just sacrificed the one life operating you sacrifice the medical care of everybody else So I I get the balance of why you're in your best facilities risking one human as the as the balance Yeah, the funny money would have to pre buy it and get it there before it You could just you could and the point of this is that you need a plan I wish I'd put a picture of the CPG There's even a clinical practice guideline on the joint trauma system website that goes through this So not having a plan for this knowing that this is reality. There's a it can be a challenge. Go ahead. Dr. Grable Good. Just say no. Dr. Howe anything to add. Have you ever had to do this? And You need a plan for what you're gonna do with it when it's out So yeah, that's when you call Jen Gurney's husband Dan who's unexploded ordnance expert Because you're gonna do everything sharply you're just gonna cut down on it So I tell the team that once this is out of the person's body handed over to EOD to this And so that like you're gonna need to go in there and get control of whatever hemorrhage you cause from And that is the person who's in there with you is the EOD the unexploded ordnance device Officer or sergeant who is gonna take that off you? But the important thing is that this is not something that's terribly it's uncommon But it's not unheard of so having a plan Okay, it's not always trauma that we see in these Hospitals, so dr. Wiggins, you've got this girl. She comes in. She's super short of breath. She's got a little bit of JVD This is her chest x-ray her dad brought her you said, please help her We're not sure what's wrong with her. Everybody else in the family is healthy. You do an echo This is what you see on the echo thoughts on this Yeah, so that looks like a very large pericardial effusion And I'm guessing if I slow that down I can probably see RV collapse, which would be suggestive of tampon on Mm-hmm So I would be trying to figure out how to get a drain or figure out why she has a perical Cardial effusion before I put in a drink. What do you think? She has you're in Afghanistan. You're in the mountains What do you think? What's the differential diagnosis? We can just why don't we start with her meal? What do you think? So you see this and this girl comes in? What's what's the plan? This is her you want to make her better. Her dad's asking you for help Telemedicine, okay, you call dr. Pamplin Okay Okay, so you use telehealth. Okay. Good. What do you do? Dr. Grable telehealth? Yeah, I would also probably mask up because I think anthrax can cause Okay, so anthrax isn't a differential, okay, yep Put on your mask. No, dr. Pamplin was to comment on this one That point what's in your differential diagnosis? That Human is too small, so I would need telemedicine or wait until they grow up to generate a differential diagnosis Man, we need a pediatric intensivist next time. Okay, dr. Wiggins. What's in your different? I think it's something Matt Martin did His picture dr. Wiggins, what's in your differential? So what are your top three? So we heard anthrax that would not be in my top three, but that would kind of scare me but anthrax what else? Yeah, I mean some sort of an infection being the location It's got to be some sort of an infection and if she didn't have any trauma, so I would be thinking about I mean You guys already mentioned anthrax and then I think TV was in the audience as well Should mask up because that's what it was. I think it was that it was TV Okay. Now you guys get a phone call the three surgeons on this panel are in the operating room This is them operating and they're calling you saying come quick Something smells funny and this is what they're doing They're debreeding this and they are gonna hand it off to you and say what should we do next? Dr. Colombo. What is this? What should they do next? I Know it's a it's a it's a party stumper, right? Isn't it? What do you think dr. Wiggins any thoughts that's fresh This is yep. This is what you go and you go into the OR. It's smoking This guy was just in an IED blast in Iraq early in the conflicts Doctor you anyone in the audience when I think ever gets what this is. I said that grossly contaminated Stool in the wound stool in the bomb No, it's not but that would be a lot of gas being admitted from this But you know they did their stool and ball bearings was not uncommon That's why there's so many infections someone from the audience. They just have to say it louder White phosphorus, right? So it's white phosphorus so white phosphorus and wounds will cause this type of burning when the phosphorus is exposed to air It's kind of one of those things just like an unexploded ordinance You kind of have to think about it and be aware for it So most important first step is to recognize it water will initially make it worse and then make it better But say from anyone from the audience or panel know what the treatment for it is what you irrigate it with We'd all be on tele consult we'd be making phone calls right thank goodness for telehealth so dr. Pamplin if you got called you but at least you had access to the computer if you get called right so yeah copper sulfate So you you neutralize it with copper sulfate? And then I think the main thing you know in any environment or if we start seeing trends is to have Situational awareness that there can be chemical or biological things, okay? Serum Their calcium and their vitamin yeah, and they're counting they get one of the things that's a great point so these patients actually, dr. Grable go ahead and elaborate on that so white phosphorus chelates calcium it binds it very Fastidiously so these patients can become profoundly hypo calcium making a very short Yeah, so they need calcium, and they need a lot of huge doses of vitamin D as well and to be monitored, okay? This next case is a little bit faster. It's a comp it's I think it's faster We'll see you guys are gonna answer faster. We're gonna be done in 20 minutes, okay, so this is November 2017 Foot patrol clearing IED laid in Raqqa Syria City Hospital is being cleared by a USC OD team This is what Raqqa looked like in 2017 this was the actual building that this event happened in so a An 18 Delta went into when IED was a really booby trap. They'd already cleared it. They cleared the building And so explosion went off massive neck wound with hemorrhage exposed trachea multiple other fragment injuries. He's unconscious heart rates 30 Heart rates 130 respiratory story, but he does have palpable pulses. He's got a very large wound to his neck There's blood and there's bubbles blood and bubbles So that's if you get the phone call and and then fragment injuries to the rest of his body so Now we talked about C a B ABC what's the priority for this guy? He's unconscious. There's a there's blood and bubbles coming from his neck ABC or C a B Right and so what do you so how do you get an airway in this guy? Say that louder dr. Colombo follow the bubble. Yeah follow the bubbles. That's right you follow the bubbles That's where the air is going leg. This is the After quick blood sleep sweeps and taking off his kit the neck wound had completely transected his trachea and So I immediately got in my med bag got a crack tube and reached into the neck wound and Found the trachea right up under the sternum. I introduced a crack tube into The trachea and inflated the bulb and secure the airway With just bulb I did not suture or tie the tube in by any means So that's a that's the medic actually talking about his experience got it recorded and he also received a award at the State of a Union Address, so He like he said he was holding this ET tube in the patient's neck. They didn't sew it in There was the blood and bubbles so in route to the forward surgical team, which was a drive It was about a 25 minute drive this patient lost pulses CPR was initiated The wound was packed with combat gauze. They did have a unit of cold-stored low titer Oh, ho blood got TXA and ketamine. So this is where you guys are. You're on this base. It's small base. That's it That's the entire base. So you don't have very many resources. You do have a fair bit of blood It's two general surgeons one CRNA. You have an ultrasound. You have an eye stat. You've got no x-ray You've got 20 units of blood and FFP and 10 units of low titer Oh, ho blood as well as a capability for a walking blood bank. This is your ATLS area and This is your operating room fully stocked, okay, so now He gets CPR for 20 minutes. He is your only patient. He's your only patient You have those resources are holding the neck the airway in the neck. He arrives At your FST, so what is your what's kind of your thoughts for your next step he's getting CPR that's ongoing What are you gonna do make sure we have his airway, okay. Yeah, make sure so, how are you gonna do that? Well There's a couple different ways. You can actually take a look Okay, I guess you don't have a bronchoscopy to actually take a look there But I would probably you can use a bogey or something to make sure that it's actually in the trachea Or in a false lumen, so I'd probably start there and make sure that we're actually in the airway. Okay, great point So a couple other things would be look for end tidal co2 Which is a typical capability and other things just listen for breath sounds and see if the patient has equal breath sounds Okay, I'll take this one step further. I would have a medic hold the ET tube someone else put direct pressure in his chest on his neck and then I'm going in the chest and see whether or not the lungs are Expanding so you're gonna do a thoracotomy on him This is just his Just his neck or other stuff, but but yeah color change capnography could also yeah No, but but after ensuring that the airways in place I would do it. Yeah, I would do an ER thoracotomy Okay, so they did a tent thoracotomy, right? They did a tent. This was a tent. So so He simultaneously so there were two surgeons on this team and you know Because this is something that because he didn't have great access either, you know, he had a small IV in his arm He didn't have great access So two surgeons on the team one did the thoracotomy and one put a subclavian line in They were able to get cardiac activity to come back. There was no evidence of a cardiac injury Lungs were moving the abdomen was distended Probably from getting bagged at some point But the fast was they kept repeating the fast was negative the neck was bleeding a lot That was the main issue is the neck was bleeding a lot heart rate was 119 O2 sats were 86% He's on a hundred percent O2. So you are in a tent It's you the CRNA two surgeons limited resources. You do have plenty of blood but Descended abdomen fast negative looking still shocky. What's your next step? Okay, go ahead. Sorry. Sorry neck. Keep the aorta cross-clamped go control what you know is bleeding For me the negative fast is no information So we know from prompt that a third of the time and pages with exsanguinating hemorrhage The fast doesn't show anything so I wouldn't even use the term fast negative I would I would call a non-diagnostic fast and in that situation I would do one of two things either just do a laparotomy based on my suspicion looking at wounds or I would make an incision and put my finger in the in the abdomen just like with the needle fork with a Finger thoracostomy and see if it comes out with red stuff on it If it comes out with red stuff on it, then I would do a laparotomy at home I would do a I would do that with a DPL. Okay, I would do a diagnostic So you're gonna start with the abdomen. You're gonna start with the neck. Dr. How what are you gonna start with? You either or neither Yeah, and when they did the ER thoracotomy or the emergency resuscitation thoracotomy, did they also cross-clamp the aorta? They did and then they they cross-clamp the aorta. They got cardi. Actually, I can't I don't remember that from the notes I don't I'm not sure that they cross-clamped the aorta because they didn't see any blood and they had return of cardiac activity Okay, and at this point he's not neck is still bleeding a lot. His neck is still bleeding a lot. Yeah Yeah, I mean I think for me I would go with the neck first because there's a lot of bleeding there And it also depends on his injury pattern. Does he have any got fragments everywhere fragments everywhere? She's got fragments everywhere. And it depends on how reliable the FAST exam is. And so like in theater, it's never really a very clear thing. So are you going to do neck or abdomen? I'm doing neck first. You're doing neck, OK. But if I don't find any bleeding or I would, I almost want to do the two things at once as well. Well, you can't. I'm just kidding. Wait a minute, wait a minute. There's two surgeons. There's two surgeons. And the truth of the matter is I would do both at once. You can't look away from the bleeding neck. You have to address the bleeding neck. So one person can be addressing the bleeding neck. And the other one's determining whether or not there's blood in the abdomen or not, which takes 13 seconds. And I guess that's also why I asked about the cross-clamp aorta, because it matters to me that they got Rosk without stopping the bleeding. If you were to assume it was in the abdomen, he would still be massively bleeding from there with the pressure and whatever might have. And the resuscitation might have helped with that. So the fact that that's what's actively bleeding at me right now, I would likely go with the neck first. OK, that's what they did. And then with a low threshold for abdomen. And they didn't do the abdomen yet. They did the neck exploration. They saw the trachea was transected. A lot of bleeding from the vert, which was hard to be controlled. They packed it. And then there was a large amount of soft tissue bleeding. With packing, it was controlled. They secured an ET, a 6-0 ET tube, into the transected trachea. And they temporarily closed the chest. He was just hemodynamically labeled throughout the whole case. The abdomen was more distended. So are you going into the abdomen now? Is anybody not going into the abdomen now? Dr. Colombo, if you get a call and say the fastest they can. I'll happily support a trip. Now, here's the thing. I was already in there. You've already done the exploratory laparotomy. So in the next level of care, it's not just upstairs. The ORs, if you put them on the flight, it's not a sea cat. It's a helicopter. And so are you going to transport this patient or take him to the operating room? You guys take him to the operating room. Fast was negative times two. They were having a hard time. So you guys are, you said operating room for abdomen. Everyone says abdomen. Okay, that's what they did. No evidence of bleeding. He did require additional blood products and they temporarily closed both the chest and abdomen. So in terms of, so he was at this FST for about one and a half hours. Anything you're going to do to get him ready for a helicopter transport, we'll start with either one of the intensivists. So he's semi-stable. He's semi-stable. There's no bleeding in his abdomen. You've controlled it in the neck. He's coagulopathic. His airway, if you like move too fast, you're afraid it's going to come out. What are you going to do to prepare for the helicopter transport? What are you going to tell your in-flight medics? Do this, if this, or here's this for this. Or are you just going to say fly fast? Yeah, I mean, I think that airway is going to be my biggest concern in addition to having adequate blood products in transport for him. But definitely need to come up with a second, third, fourth line. What happens in case it falls out, that sort of thing. All right, so a contingency plan for the airway. Anything else? You said blood products and flight. Give him blood products and give him a contingency plan for the airway. Whatever he needs. Yeah, and general housekeeping. So if this is all just from blood loss in the neck, we haven't found any other blood loss, calcium TXA, just making sure these things are forgotten. I like that, general housekeeping, calcium TXA. Just going to start putting that in my orders, general housekeeping. All right, so I don't know why this flanged, but this is the type of helicopter that he flew in from the site that he was at in Syria. And that's what they look like when it's not stretched. Okay, so he gets to the combat support hospital in Baghdad. He arrives and they're holding his ET tube in his neck. Did the provider travel with him? I mean, this might be a rare situation where I would see. The provider did travel with him. This was a team that had a provider on it. So it wasn't a medic. I was just asking you guys the hard questions, but it was a team that had actually a surgeon that transported this patient, but the surgeon was holding the tube in the neck and could not wait to drop the patient off. And so this is the capabilities that you have at the role three, the combat support hospital. You have a CT scan as well. His hemodynamics were pretty stable. They held his airway in place. His O2 sets were low on the transport ventilator. This is his primary surveys, tachycardic. He's not on any vasopressors. His ET tube is held in, sewn into place, but not really very stably. His secondary survey from this blast injury, bilateral globe injuries, penetrating wounds to the neck, chest, and abdomen, and the left lower extremity fracture with a cool foot and minimal bleeding. So you've got this sick guy. He's stable. You are at the role three. You have some capability. What are you going to do next? Are you going to go, let me give you some more information. Okay, I thought I'm getting my own slides confused. So this is, you did get a chest x-ray because you were in a regular trauma, but you can see he still has the packing in the chest. So his platelets are a little low. His INR is 1.4. His base deficit's negative 4.2, not the worst ever. But look at his vent settings. He's on a hundred percent FiO2. He's on tidal volumes of 500 with a respiratory rate of 22. His pH is 7.1. His PaO2 is 54. And his PCO2 is 68. He is just a few hours into this injury. He's had a blast. He's had a thoracotomy, and he's already had a massive transfusion. What are you thinking? So let's start with the intensivists. I mean, like, this is no problem. Just give him a little Lasix. He's going to be fine. Are you worried about this guy's lungs? So just doing public math, you know, 0.08 change for pH for every 10. That looks almost pure respiratory, and that tube looks a little bit deep and rightward. Okay. As a Bills fan, right's not good. Okay. Again, well, and not to be cavalier, pulling that tube back when somebody was holding it in the helicopter is no small issue. So I think making sure repositioning. No, that's a great point, and that was the problem. Now, wait a minute here. They may have done that on purpose because what you have is a, you've got one good lung and one bad lung, and if you're ventilating the good lung, you're going to increase the VQ mismatch. So it would not surprise me if this was done on purpose, and there's a number of maneuvers here to consider to oxygenate this patient because, you know, it's likely they'll get worse. It's all complicated by the tenuous airway, but the first thing you think about is put the person right side down. Second thing is to ventilate the good lung, and the third thing is do a lumen ventilation if you have that capability. Which you don't have. You don't have dual lumen ventilation where you are. So this guy, I mean, this is somebody who is rapidly heading toward ECMO because that contusion on the left is going to get significantly worse, and very soon you're not going to be able to oxygenate that patient. Okay. How do you know if that lung is injured or under inflated? Collapsed. I'd pull it back first and make sure. That's a great point. So comment from the audience that that lung is injured or under inflated. The challenge with this case was that when they pulled the tube back, they were looking at the balloon in the neck. When they would move the tube forward, they were right main stemmed. So you just couldn't, there was no, you were in a pretty bad situation. So that's, so now, there's still. There were packs in the chest, weren't there? There were packs in the chest, yes. Yeah, so, I mean, one reason, so that's another aspect of it. The lung's compressed by the pack. Yeah, but you make really good points about, you know, being able to do some lung rescue ventilation strategies without kind of a robust ICU. So now he's, you saw his numbers. So now you've got to, do you want more information with the CT scan? We don't have any scans yet. Don't know all of his injuries. Just go straight to the operating room and try and secure this airway. ICU or say like, I'm gonna do what the other guys did. I'm gonna tell him to fly fast. Let's get that alarm seat team here and let's, or let's, you know, get C-CAT here and fly him fast. What are you gonna, let's start with Dr. Howe. We'll go down the line, end with Dr. Schreiber. What's your, just what's your next step? And one sentence, why? I'm going to do this and why? If you talk too long, I'll interrupt you. Yeah, so I'd like to, and he's hemodynamically normal at this point. Not on pressors. And not on pressors. If he can tolerate it, and we're in a roll three, I'd like to get a CT scan just to further evaluate if he has any other injuries. Get more information. Dr. Grebe, what do you want to do? Secure the airway, put like some steady sutures in the trachea and see if I can put like a bougie or something from above and thread that. Are you doing that in the ER or in the operating room? OR. So you're going to the OR. Anesthesia and ENT. Okay, so you're going straight to the OR. Are you getting, what are you doing, Dr. Colombo? Agree with my colleague in the back. I need that airway repositioned to know whether that lung on the left is functional or not. So you're moving the airway in the ER and getting another X-ray? That's not a choice up there, but you can do it. But if I find that, if that lung is not functional, then Dr. Schreiber is correct. We're not going to be able to oxygenate on one lung given that we're not really ventilating or oxygenating now. And it might be good to tell that LARMC flight if they're coming to us to bring toys. Okay, Dr. Wiggins? Yeah, so I'm concerned about the airway. So I'd be talking to my friendly surgeons about options for getting a more secure airway. But if that isn't an option, then I think he needs some better TLC in the ICU. Okay, so OR for airway or ICU and Dr. Schreiber. So we've got CT scan, OR for airway, airway, airway. Dr. Schreiber, what are you doing? All of them at once, but the number one priority would be the airway. This guy has a, you know, the way the guy dies in the next 10 seconds is you lose the airway and they die. So I think you've got to really focus on securing it the best you can. You're not going to do a tracheal reconstruction, but you can secure it the best you can. And then I would get the CT scan, then I'd go to the ICU. And then at the same time, I'd be calling LARMC for the lung team. Well, he had the airway. So the airway was extremely tenuous. I can actually say, because I was actually, well, this was my case. So the airway was stable enough. So the patient did get a CT scan. You can see the globe injury. This is the cross-sectional image of the neck. You can see the fractures as well as soft tissue injury. There's packing in there too. There's some combat gauze in there, which confuses it. And you can see where the vertebral artery was injured. And then this is the sagittal image as well. So now what are you thinking when you see this? Dr. Sherwood, you have the mic in your hand, like you want to say something. Well, I mean, there's a couple of really important things. I'm worried about the esophagus, which could, if that's injured, that can ultimately cause sepsis and death as well, but not this minute. But in the next 48 to 72 hours, that patient could get septic. And now I'm worried about spinal cord injury as well. And I don't know if there's been a neurologic exam or any findings. There's been no neurologic exam. So, I mean, he coded on the way to the roll two, got CPR and, you know, they never were able to do a neurologic exam on him at all. So this is potentially, it looks like it's going to be a high, like a C5 level, maybe higher level with blast injury effect, spinal cord injury, which is devastating. And also he's got bilateral globe injuries, so you can't get a good pupillary exam. So, but that's bad. So, I mean, would you stop? I would never stop in theater. Okay. Never, ever stop in theater. Medical of 85 for seven days. I feel like you're being sarcastic again. You never know with Dr. Grable. Okay, so that's a CT scan. And here's his chest X-ray or chest CT scan. So you can tell this is, and this is very early. So he's got his contusions. This is within 24 hours. So his contusions have not even really blossomed yet. So, he, on his exam, he's got, still has bleeding from his neck. His ET tube is still being held in place. The left lower extremity splinted. The left chest tubes had 600 out of the left where he had his thoracotomy and moderate bleeding from all wounds. You can see his labs. And he has not been to the operating room next. So, I think that you guys are all taken to the operating room before a CT scan. So I would imagine that you're gonna definitely take him to the operating room now. So, in the operating room, what would be your- One thing I'd wanna say on this guy is that I'm gonna do permissive hypercapnia. I'm not worried. That blood gas is just fine. Yeah. PCO-265 even higher with a pH of 7.2. If we, anything we do to ventilate this patient additionally is gonna make them worse if we increase the tidal volume. This patient has a very small lung based on all the injury. So, that tidal volume actually might be too high. And if we raise the frequency of the ventilator as well, that is all gonna cause lung injury. So, this is a patient who should get permissive hypercapnia. That's a great point. Okay, so he goes to the operating room. He's got four to five centimeter loss of trachea. Thyroid bleeding, cricothyroid, and he does have an esophageal injury like you suspected, Dr. Shriver. So, he had a tube exchange and it was marsupialized and secured. It still was ridiculously tenuous, either right main stemming or you're looking at the balloon. There was no double lumen tubes. There was no way to get two 6.0 tubes in for it to- He didn't stem it. He didn't. What's the lower limit of the trachea? How low up? We're in the mediastinum, about three centimeters from the carina, three to four centimeters from the carina. So, pretty low. He's missing a large chunk of his trachea. Yeah. And- So, you marsupialized it through the neck. He didn't stem it from above? No, he was not stented. He was not intubated from above. No, he was not. The ET2 went through the neck. So, and then vertebral artery and bony bleeding was controlled. Would you have intubated from above? Another comment here. Vertebral artery injuries are horrendous injuries to deal with. You can't fix it. It goes through the bony structures in the neck posteriorly. And, I mean, all you can do is bone wax and hemostatic agents. You're not gonna repair it. You don't have IR, which is something that could be considered otherwise. But in theater, I am terrified of having vertebral artery injuries, something that surgeons can't fix. Yeah, and in this case, he had the vertebral artery was exposed because of the injury. So it wasn't as difficult when it's totally encased by the bone. But, yeah, you're right. Those are tenuous. And then, Dr. Gribble, you mentioned stenting his trachea and intubating from above. Would you have intubated from above or tried to do that? Do you think that's an option for this? I would, based on the information I have, I would have seen if I could thread a Bougie next to it and thread an ET2 and use it like a vascular stent and put some staining sutures in it. Because I just think it's so much. Yeah, that's a great point. What you're saying is they made a stoma, right? This patient you'll see some pictures of his wounds this patient had a pretty big defect in his neck So he didn't he wasn't no there was no stoma that was made the ET tube was secured multiple places And it was still very tenuous I mean, but in some situations you can sew the skin to the trachea you can and that that is a very stable airway Yes, I mean depending on the anatomy the neck that is an option in some situations And you probably could have done that with the sternotomy would have had to go you would have had to remove the manubrium But yeah, you probably could have done that with a but that was I I do not believe that was entertained To to do a sternotomy and bring so his trachea to his skin And I I don't know it was I don't think was entertained to stent it with an ET tube either So this is some examples. This is looking at his neck from above You can see you know with the just kind of getting underneath the sternum You can see where the trachea is there and there's about a five centimeter gap Multiple attempts to keep the trachea in place. So anyway, it's oxygen challenges throughout the case He is left leg was concerned for compartment syndrome He did have fasciotomies his left chest dude continued to put stuff out. His left chest was re-explored and he had internal memory artery bleeding so that was ligated and He was hemodynamically labile in the case and a walking blood bank was called There was no low titer oho blood at this point. I don't believe but a walking blood bank was called. So now Are you gonna try and reconstruct this airway in theater or is this something that needs to have a more expertise? So he's got His abdomen is open, but there's no injuries and he's got bilateral globe injuries he has We don't know his neurologic exam and we've decided this is absolutely not futile. So do wonder we're gonna transfer him to Germany What's your prioritization? Let's start with you. Dr. Combo to intensivists and we'll go. Dr. Howe. Dr. Grable. Dr. Schreiber answer quickly What's your how what's your priorities? Transfer transfer. Okay Stabilized airway transfer. What about you? Dr. Wiggins? Yeah, so Definitely stability, I I guess I His vent setting seems like he's on pretty max settings and we're already having issues. I guess the discussion of when to Look for ECMO or call for ECMO I Would probably start thinking that about that about now and then we maybe we'll have to worry about the airway a little bit less As well, so I'd be calling tell ICO okay, and Well, you're a nice to you doctor you could be the person at the other end of the line, you're right, you know, so Prioritization dr. Howe so Definitely not airway reconstruction. I'd like to transfer the patient, but I agree with dr Wiggins that I'd like to make sure that the patient from a pulmonary status is not rapidly decompensating And if they need ECMO and if they need ECMO then is ECMO Dr. Grable is ECMO a Theater capability like should we have ECMO when we're taking care of patients in a war zone Even like where should that ECMO live? Should it live in theater should live in Germany should live in the States If it lives in the States, it's gonna take about 20 hours to get there. I mean, so is it Is is it So, what do you think is that something we should have during we should have our best role threes in any sort of A Major deployed operation with ECMO there. This is so you think this is not the opinion of the US Army So you think we should you? You think we should have ECMO capability at role threes if we're gonna have a role three if we're gonna have a combat support Hospital, you should be able to put someone on an ECMO circuit. Absolutely. Okay, anybody disagree with that? Okay, any comments from the audience? We'll give you some phone numbers to call dr. Menza, yeah We never had ECMO in theater. It came from Lawn Stool when it was being used a lot. It was the acute lung team that came from Lawn Stool. It was more of a maintenance and... And it's not just trauma patients. I mean, there's a whole host of civilians from the State Department, from the DOD, contractors with all various medical comorbidities, infectious issues, disease, non-battle injury, which is non-trauma stuff. So there's other reasons to have that capability available. Question from the audience. Did the patient get a head CT? He did. There was no evidence of a bleed on the head CT. OK, so good discussion. This is this guy's post-op chest X-ray. That's AB normal. Yeah, it's AB normal. OK, this is his labs. So move the tidal volume down, trying to oxygenate him. His PCO2 is 63, PCO2 is 57. So the airway continued to be a challenge with either right main stem or looking at the balloon through the neck wound. So hemodynamic lability improved with whole blood. So what's the next step now? I think you guys are all already calling the ECMO team, right? Not getting another CT scan. Going back to the OR ICU optimization to Germany. And then I'm going to show you a picture of what the ICU looked like. So this is your ICU. This is your ICU. And this is your ventilator. You've got this guy with that chest X-ray. And you've got that ventilator, the impact vent. But you were able to find, and this is the ICU in full swing, and you were able to go and borrow from another unit an LTV vent, which had a little bit more capability. Still continued to struggle with the ET tube. All right, so ECMO team was called. Go ahead. Can you keep them attached to the anesthesia machine? I mean, I know traditionally they don't have this. Can you keep them attached to the anesthesia machine? Are you asking? I get to ask the questions here. I would consider keeping them attached to the Traeger or whatever they use as the anesthesia machine. Yeah, that's a great point. Go ahead. So what I would say is a brand new anesthesia machine you have in the US has some capability, but it's still nothing like an ICU vent. And deployed, it's often a Teva with an impact vent or an older OR anesthesia machine, which is really not much different. I mean, I just got CPAP on my sort of upgraded OR ventilators. They're very bare bones. And so I think some of the slides you've glanced over the vent settings, there's obviously a lot more than tidal volume. So I can't help but watching this wondering if an experienced pulmonary physiologist could get more out of the vent and where they are, like more of the details. Telehealth. Honestly, bare bones is probably the most appropriate to minimize metabolic production of CO2 that I can't clear the students getting paralyzed, minimize oxygen demand. And then I just need CMV. So I need a bellows and a timer. So the lowest rent vent is probably the best one for this case. And you don't really want to optimize your PEEP or increase your PEEP at this point with this degree of tracheal injury and the tenuous. Yeah, so PEEP wasn't up there several times. But I was like, I don't know what it is, but it's probably not high, and I'm not going to push it up any higher. And also, I think it's clear that at some point, no ventilator on the planet will be adequate to oxygenate this patient. I mean, the guy's lungs are, there's no good lung left. So he's not going to survive unless he gets ECMO. OK, so we already talked about the role for ECMO in this patient. The ECMO team is about 16 to 20 hours away, but they start mobilizing relatively quickly. So he stabilized enough. Remember, I called him when the guy got there. You called him when they got there? OK, so you still had about 16 hours. Go ahead, Dr. Grabo. Who did the globe exploration? So this is at the Roll 3 in Baghdad with the ophthalmologist. Oh, I didn't realize that there was one there. Yeah, so the ophthalmologist did the globe exploration. ECMO team arrived from Santander about 36 hours after the initial call. This was actually the last ECMO cannulation that's happened in theater. And so when we talk about, do we need the capability, how do we maintain and sustain and resource these capabilities, in a very seamless ECMO cannulation, his chest was re-explored. There was a large amount of clot probably from his coagulopathy, and then he was closed up. This is a picture of his ECMO cannulation in Baghdad. He transitioned well to the machine. Man, the ECMO team, I think they bring about 1,300 or 1,400 pounds of stuff that they fly with them. I'd hate to see what their fees are for baggage, their baggage fees, because they fly civilian, and then they fly military back. Comments, Dr. Grable? Once he was on ECMO, was there any talk of doing laminectomies and decompressing his spine and put him in a halo before transport? There was not any talk about that, because he hadn't had a good neurologic exam yet and hadn't had an MRI. There was no MRI capability. But you bring up a point that there was a neurosurgeon there at the Roll 3, and that was not discussed. I just wonder if it wasn't a complete injury. So would you say that, do you know neurosurgeons that would do that in theater, that would do that operation in theater? I know we have a CPG that says that. That's not happening on this patient. The patient still has an unsecured airway. He's barely able to be oxygenated. We're not proning him. You can't do it anterior alone. You'd have to turn the guy in as prone to that. It's not happening. He's going to die from losing his airway. And the data on early spine fixation in spinal cord injury is horrible. And you can't really even clearly conclude from the available data that early fixation improves neurologic outcome. Any other comments on that? OK. Any worries about this in flight? Are you guys going to bring blood? What's your plan for flight? What's in your packing bag for flight, Dr. Howell? I would bring blood. I would make sure that somebody is monitoring. ECMO team and the CCAT team and make sure that there are contingency plans for what happens if that airway gets dislodged because that's really the main thing. And if he's an ECMO though, it's less of a major concern, but it's still, I think, a good exercise to make sure that they're familiar with unstable surgical type airways. But the blood is also important because I'm also worried about possible dislodging. I assume you did this, not you. I assume this was done off of anticoagulation or was it done? Yeah, it was done off of anticoagulation. I'd take it a step further in the airway situation, make sure that there's, you've got good headlights and good lighting and an airway tray and surgical instruments to assist with replacement of the airway if it does fall out. Everything is worst case scenario, you know, ECMO cannula fall out, airway falls out, and you need all the equipment to address the worst case. Yeah, that's a great point and that's a contingency plan. If you don't think about it before it happens, that's a great point, Dr. Sharper. Any other comments from the panel? Comments from the audience? Yeah, I would bring my ECMO goodie bag, so. What is in your ECMO goodie bag? So I'd bring another cardio help, another circuit, just in case that circuit fails in flight, so I'd have a backup circuit. And then I'd have all my pressers that I would need. I would have extra cannulas. I would have clamps to clamp the cannulas in case they were dislodged for whatever reason. I would get all that stuff together in addition to blood and pressers. Yeah, good answers. It's an interesting, you mentioned ECMO goodie bag. You trained at Emory and I remember the Emory folks coming down to Eisenhower. We had ECMO there, not for destination, but because if we were gonna transport somebody that required it in transport, it wasn't just that they required ECMO in transport, it's that they required ECMO and then we transported them to a destination. So it's an interesting thought process. This patient didn't require ECMO for flight, they required ECMO and then flight. So having the option to initiate it in theater and then the ECMO team comes and replaces supplies because they're inevitably picking the patient up for destination, I think is an alternate thought process to what we do now, which is if you need it, we have to fly it from San Antonio. It used to be from Germany, but from San Antonio. Having that resupply intrinsic to the capability is a very good point. Okay, so he undergoes multiple additional surgeries. His trachea was actually never able to be reconstructed because of the amount of loss of the trachea that was there and I think they tried printing and everything else, lots of different surgeries by ENT and ENT specialists. He did wake up. He had no evidence of hypoxic brain injury despite having a PEA arrest, which could have been from a spinal cord injury because he definitely had a spinal cord injury at C5 and then he underwent extensive rehab. This is a picture of him with his son a few months after his injury. And so what questions from the audience or any discussion? No questions, no discussion. Go ahead. There was no evidence of any stroke or anything like that? No, he had multiple MRIs, so he didn't have a stroke. He didn't have any, his neurologic injury was his spinal cord injury. Yeah, yeah. Mensah, do you have a question? Any other questions? Doctor, do you have a comment? I just want to say that I'm proud to be from a country that would put this much effort, so many people, and so many resources to save this person's life and give them the best possible life they could have. It makes me proud to wear this uniform and be part of this country. Wow, that's a nice comment, Dr. Shriver. Yep, okay, last question, this is it. So you guys already kind of talked about this stuff. This is the last question. So this is your scenario, okay? You are going somewhere, Syria, Africa, Iraq, Ukraine. You're going on a humanitarian mission. You're going to help. And you're a five-person team, these small, light teams, and we've talked about their limited capabilities. It's just you and a CRNA, some basic OR supplies, a nurse, a planner. You can have a walking blood banquet, so you've got to be the one that sets it up, and you've got a very rudimentary X-ray. So we'll start with Dr. Shriver and move to Dr. Howe. This is for all of you guys. So where you're going to be in order to get someone to the next level of care, it's four to 10 hours. So what do you pack? What do you pack? What are you going to bring? If you've got one small extra duffel to bring, Dr. Shriver, what are you packing? It's a whole duffel? Well, it's a half a duffel. A half a duffel. So I would bring shunts. Okay, vascular shunts. I would bring vascular shunts. What do I start off with in terms of instruments? I mean, I'd make sure. You have a basic OR supplies. You got what's on here, basic OR supplies, a major basic migration. You have stuff. You're a surgical team. You have the stuff that a surgical team will have. I don't know how to get the gift of stuff. How about some nice young men with large weapons? That's a good answer. Or women. Okay, that's a good answer. No, so you're going to bring force protection. Yes, I would bring force protection. Okay, what are you going to bring, Dr. Wiggins? You can go outside of the box like Dr. Shriver and say he's going to bring people with big guns. That's fair. Well, I'm not a surgeon, so I'd probably want to bring surgical instruments because that would be useless for me. But probably pressers, some airway kits, supplies, some medications, ketamine, that sort of thing, and access. Okay. Dr. Clombo? You're looking for the single thing, POCAS, in addition to what you're... Yeah, I mean, what are you thinking of? I mean, what's something you want to bring? You're going to bring airway supplies, pressers, stuff for a walking blood bank, headlights. I mean, what's important to you? What goes into your bag? Books? Point-of-care ultrasound. Point-of-care ultrasound. Telemedicine capability. Yeah. What are you going to bring, Dr. Grabo? I'm so curious to know what you're going to say. All right, well, I'll keep my cynical thing at the end. But yeah, the point-of-care ultrasound, the shunts. I assume that you have like the basic striker X-Fix kit. I would actually, if you could bring an arterial line monitor with you, I find arterial lines to be invaluable. And then my Nintendo Switch. And your Nintendo. Okay, all right. It's true, you might not be doing anything. What about you? Yeah, so I agree with the shunts. And I want to make sure, in terms of assistance, if I'm not going to have an assistance, I'm going to make sure that the basic OR supply has like a ball for something easy that I can easily do. Oh, yeah, looking at your OR sets. Because I might not have additional hands to do it. Sometimes an Alexis wound protector, although I don't use it very often, might also be helpful just to keep the abdomen open if I'm the only person operating with my CRNA. And then the A-line kit is a good idea. And probably some micropuncture kits as well. And then the ultrasound would be also very helpful. All right, very good. Anybody want to add anything? I will not bring the angry, panicky woman in the slide with me, though. I know, the gift was supposed to go away. And it's like really annoyed that it's still staying there. So I'm sorry. But the last thing is to thank you guys and give you a round of applause for a really good job answering all the questions. Any questions or comments from the audience? All right, really well done. So, you know, we continue to do this. We're trying to do it every year so we can continue to remember the lessons learned and say thank you to all the service members that have supported this country and continue to provide, and the groups that continue to provide excellent medical care for them. Thank you guys for staying for two hours. Good job to the audience.

medical professionals

trauma cases

Iraq

Afghanistan

Syria

conflicts

hemorrhage control

resuscitation

intubation

junctional hemorrhage management

blast injuries

multidisciplinary approach

skilled surgeons

prolonged resuscitation

ECMO capabilities