Thanks, it's great to be in such an august group here, and what I'm going to be mostly doing is just piling on to what everybody else has already said, from a different perspective. Oh, and I'm glad I am the last speaker of this whole thing, of the whole meeting, and so that's kind of cool, actually. So this is what, and then I've spent a lot of time in the literature, been a journal editor for 20 years, and so I see a lot of stuff that you guys don't, but I do kind of get the feel of where the literature's going sometimes, and kind of maybe hopefully share some of that here. And then we've got to talk about end-of-life stuff, and that's, I will get to that topic, but let me give you some perspective first. And so, to reiterate what everybody here has just said, you know, so what the heck is skin failure? What are we talking about? And when I look through the literature, all of it's in one journal. It's in the Advances in Skin and Wound Care, is where a lot of this stuff is, it's in other places too, but that's the, seemed to be most of the papers that I've found about this, and part of the problem is it's, this whole notion of skin failure is kind of nebulous, isn't it? It's hard to grasp as one single concept, like, okay, myocardial infarction, that one's pretty simple, right? You know, some vessel in the heart got a blood clot in it, and no blood goes past it, and the heart doesn't like that, right? But in skin failure, we're really talking about, I kind of categorize this in my own mind, take that for what it's worth, into two really categories, there's things that are the skin to begin with, there's problems with the skin, and that's where it started. A lot of us have periods of burns, that's what we do, the problem is the burn injury, the problem is the skin to start with, and TEN I think goes into that as well, but sometimes there are medical train wrecks, but that's, but a lot of it is the skin that's there, and so, a lot of my fellows, residents, students will tell you, so I have something called the golden rule in burn care, or skin care in general, is close the damn wound, okay? If the skin is the problem, if the wound is the problem, close the wound. But the skin failure topic is really not always that, is it? So when you talk about pressure ulcers, well, what's the problem? Well, it's a pressure ulcer. No, it's not. It's why are they laying in bed all the time, for whatever reason, and we see this a lot of times in the ICU as well, that they've got, you know, they're on 14 pounds per second of epinephrine or something like that, and their skin, their fingers start falling off. That's part of it. Necrotizing soft tissue infection, so it's not the skin, it's underneath the skin, the skin just has the problems with it, and there's some, you know, a lot of the other conditions that you all have already talked about, that's what, so what's the wound in that one? Well, it's not the skin. It's something else, whatever that may happen to be, so you've got to get at the source of it to begin with, and the skin, while important, is secondary in that condition, whereas in burns and TENs and the other thing, it's not. It is the primary problem. And so I think that in the notion of skin failure, we're really talking about, and I don't know how to put that into words, though, it doesn't come up with a catchy phrase, does it? It's like, well, skin failure, yes. The skin itself or something else, and it's hard to put together, but I've been thinking about that on the plane on the way up here and for the last couple of weeks. How do I really define that? Can't. Tried. But everybody gets the concept. Then, when you talk about end of life and mortality stuff, in those first kind of, when it's the skin itself, it's, burns is a good example of that. It's pretty homogenous. It is a matter of how much skin did you lose and how old are you? We've tried to put in all these other things, you know, diabetes, you know, other kind of problems, and all those get washed out from a statistical perspective by age and burn size. Oh, but what about inhalation injury? That one gets washed out too. Okay, so it's all about those two things. TEN, by the way, I don't use SJS. It's all the same thing. Just, we don't have different kinds of, oh, we're going to call this less than 20% burn. We're going to call that a, this kind of burn, and like, it's all the same biology, which you described really well, I thank you for that. And so TEN is really that kind of a thing as well, but then what about all these other ones? So the whole notion of end of life and goals of care and things like that, which are, ought to be ICU 101, by the way. You shouldn't have to have a specialist come in to talk about goals of care, which I think is maybe not such a great thing because they don't often understand, get the context of it, because they're not living with the patient every day like the nurses. You guys, whoever the nurses, y'all are the stars. You know, the doctors, we just drive by a couple times a day, right, and so that's, you really live with that, so you know what's going on with that, and you know the families and things like that, and so do the doctors, most of us. But that's really the kind of thing. So it's really about, okay, let's provide some context here. What is the problem, the real problem, the underlying problem, the primary problem, and what are the goals of care for that? And I think in those two kind of categories, in burns and in other, which we've talked about here, the goals of care and the prognosis is different, radically different between those two oftentimes. In burns, if you survive it, you're going to be fine. You're going to have some scars, and Paul and Thea and I have stuff to reconstruct, but it's not cancer, it's not going to kill you. If you make it through it, it's not going to, whereas some of these other conditions it is, you know, paraplegia, some of these other things, it's not going to go away, and so the goals of care really have to be kind of thought about for that. Okay, next one. I've got to get moving. Okay, so it's just some same things, and this is just the burn statistics that's out there. Burns per capita in the United States are going down, thankfully, but the capita keeps going up, right, so the number of burns is about the same. In fact, it's starting to go back up. If you see this one on the right side there, it's been declining, the number, total number, phenomenal number, but it's going back up now, maybe or may not be associated with some of the COVID things we're going through, but the fatalities continue to go down. Interestingly, burn mortality is linear. It's not a sigmoid shape or a second-order distribution like it's been thought for years. That's that blue line there. It's really linear, and it's based on burn size and age. That's it, and so you can really kind of nail it down to that as far as end-of-life decisions, and remember, let's see, here it goes, 50% mortality is at about, well, here it is, it's about at 60 to 70% burn. It's not 40%, okay, unless you're 80, then it is, and so that's where these things get going. You have to think about that. TEN, the score, we've already talked about that. Here it is in graphical form. Here's the other thing on there. I can tell you the literature is now demonstrating that these are way overstated, okay, and we're not real sure why. I just got a paper from Australia yesterday. They've seen a seven-fold increase in TEN since 2020. I wonder if there's vaccines or COVID itself, long COVID, who knows, that's in that, but we're seeing a lot more of it, and I know we're not using more Bactrim and Dilantin, right, so we'll see what that's going on with that, all right, so skin loss, what about the other things? Well, I was thinking about pressure ulcers, right, so okay, yeah, pressure ulcers, we see it all the time. We have this big, every hospital has them, please don't let that happen, good thing, but oftentimes you can't do anything about the real cause of it, which is their medical condition, whatever that is, and so it's, there's a lot of that, and that's where I started finding all these advances in skin and wound care papers, where there's a lot of stuff to try to say, hey, what is this skin failure thing, and I started thinking about other things. Well, what about, you know, like they're on a bunch of pressers, and they end up losing stuff, and what about necrotizing soft tissue infections, and so in reading through this, yeah, they come up a lot of these other things, and all of these are true, okay, but the cure to any disease, the best cure is prevention, right, and so what can we do to prevent these things from happening in the first place? Should, you know, over sedation of patients in the ICU, is that a good thing? No, it's not, and because they end up with pressure ulcers, things like that, but sometimes you have to do it, but I think with, you know, Propofol and Presidex and some of these newer agents that we're using now, we're starting to see less of this, I think, and because of, you know, over sedation may be the problem, and then things that has already been described here is that this other kind of skin failure that we're talking about is oftentimes related to just being critically ill, and so how do we prevent that stuff with the pressure ulcer stuff that works good, but, and this is what this journal really talks about, is trying to highlight the notion of skin failure, and what is that, and it's kind of nebulous, and so maybe that's the challenge everybody hears, well, let's get down and busy with this thing, let's call it something, and then I think skin failure for all of it probably is not the right way to go about it, but there's, you know, burns, primary skin injury, and then the other part, but we're going to have to figure out how to put all that together into one quippy phrase. I don't know how to do that yet. All right, so the skin failure thing about this is TEN up there, you can see Nikolsky sign, and then graft versus host disease, venous dorsal ulcer, we've talked about all this stuff, frostbite, trench foot, we haven't talked about that one as much, but that's a real deal. As we went through Snowmageddon in Texas, I actually had five patients with frostbite in freaking Galveston, Texas, and everybody's, well, what do you do with that? Well, I've been around the country a lot, and so this is what the guys in Minnesota do, and so that was part of the deal there. Anyway, another thing that I've been talking, and to shift back to this notion of end of life care, so there's these giant databases out around everywhere, and I've pumped out a bunch of papers with them recently. My favorite one is something called Trinetics, which has about 30 million patients in it, and it's real easy to do these searches, and so I assigned one of my fellows, hey, go look at pressure ulcers, and you'd have to figure out how to do your query right, but it found about 200,000 patients, and then, okay, who gets pressure ulcers? Well, it's always old people, right? No. That's not what it says there, and well, it's a certain patient population now. It's about the same as we all take care of in our hospitals. They have other medical conditions. Yeah, there's a lot of it, a lot of diabetes, okay, so that's the one that kind of came to my mind, so look at that, but is that from their underlying medical condition, or who knows, but interestingly, only about a quarter of them, you might suggest that anybody with a pressure ulcer is not going to do well. Well, one out of four does die within six months, but this is where I always love in audiences like this and on rounds with my students is flip it over. How many lived? Seventy-five percent. Hmm, well, we've got a big problem here, because we've got to get these things closed up, and we've got to get at the cause to begin with, and then try to get it closed up, and so remember that in these goals of care, which should be had, but remember, you're talking about probabilities, not yes or no on most of this stuff. An 80-year-old with a 70% burn is not a yes or no, but this person has a pressure ulcer, may not be as bad as you think, and so there's something to think about there. All right, so in thinking about these end-of-life considerations, the skin condition itself is very likely, highly likely to be related to the underlying condition of the patient. For instance, deconditioning, over-sedation, prolonged critical illness, cardiovascular disease, you know, their ejection fraction is negative 10, right, or local vascular issues with, you know, we've all seen this in all of our ICUs, and then these underlying dermatologic conditions. You know, in medical school, I did pretty well, but I made a C in dermatology, and now what do I do? Skin stuff all the time, but why did I make a C? Because I refused to learn their language, and still do, and said, okay, well, this is skin falling off. Call the dermatologist, come put some Latin or Greek on to this thing, right, and, but, and are very, very, very skilled, by the way, love working with dermatologists, good, smart people, and, but then, okay, but now I've got to fix this thing, so I've got to get my knives out and get going, right, and so that's the thing there, and as always, the goals of care have to be discussed, but I hope you've given your framework for that. Yes, the goals of care have to be discussed, and are absolutely important to do that with the patient and his or her family, but recognize those have to be put into context. Okay, are you going to recover or are you not? And if you're not, then maybe, you know, some other palliative issues come to the fore, but remember, but I think it's very, very important in any kind of discussion of goals of care with patients and their families is that you're there, we as the ICU providers, the surgeons, are there to provide, and the critical care nurses are there to provide context, okay, and I've gotten in fights with my European colleagues about that mostly the ICU said, well, no one, nobody would ever want to do this, and say, hey, wait a minute, wait, wait, wait, wait, wait, I'm a burn surgeon, I'm going to see this person three years from now. Once they get discharged from your ICU, you're never going to see them again, so get some context, and that's my play to the ICU nurses and the ICU doctors, God, great people, but you've got to see them later. Nothing makes you happier as a burn surgeon than to see a, you know, 45, 50-year-old man, you know, with a 50% burn who was that close to dying, you know, walk in four months later holding his grandchild, and that's what gives us the joy of what we do, and so keep that in mind is that we don't get to break the rules, but we do have to provide, but then there's the other side of that is, yeah, sometimes it's not going to go well, and we need to face that as well. So, anyways, hard to, so these guys here know I'm, it's going to be philosophy and economics at the end of the day with me, and that's the, but that's what we deal here with the goals of care, and make sure you use all your colleagues well, dermatology for skin stuff, but in general, great people and really know what they're doing. All right, so to conclude here, the emerging concepts on the concept of skin failure, I don't think you can throw it all into one bucket, and so we really got a challenge in our community to try to put some names on things. When you put a name on something, you can actually get, but the name has to ring true, or it doesn't get any traction, and so we've got a challenge there. Then the impact on outcomes of burns and TEN is pretty well defined, but the other ones are not really, I don't think yet, and so the skin is oftentimes, and these other things, the skin is really a bystander in a lot of these things, and so we got to keep in mind that, okay, we got to get at the real problem first, and then deal with the skin as a secondary thing. So, thank you very much.

skin failure

medical perspective

underlying causes

skin problems

medical conditions