BIG T Trauma Pitfalls 4

Welcome back to Behind the Knife. This is Patrick Georgoff, trauma surgeon at Duke University, and today we have another installment of the Big T Trauma series. So the Big T Trauma series offers clinically oriented material that focuses on how best to care for traumatic, injured and critically ill patients.

We've had a number of really fantastic episodes up to 20 now. Past topics include transfusion medicine for the trauma surgeon. We've covered gun violence, rib fractures, uh, specific injuries like neck trauma, a whole lot more as well. And so this series gets its name from the University of Texas in Houston at Memorial Hermann Red Duke Trauma Institute, which is one of the busiest trauma centers in the country.

And that's where I trained with my co-hosts, Dr. Teddy Puzio, uh, who's currently, uh, on faculty at UT Houston. And Dr. Jason Brill, trauma medical director for the US Indo-Pacific Command. The big man on campus and today I'm thrilled to have Dr. Tyler Simpson, who's currently one of our fellows at Duke. Tyler, welcome.

We're happy to have you. Thank you.

Alright, so Teddy, what are the big T episodes all about? So we compiled a list of scenarios that we would consider common pitfalls and trauma. And in these cases, I think pitfalls are good learning opportunities, right? One of my favorite quotes from training that I repeat very often, um, to the residents is the eyes do not see what the mind does not know.

And when you step back and you think about it, that's, that's really how we learn, right? Like, you're never gonna see something if you don't know to look for it. Uh, and this is one of the principles that's the core to all of our training And mm-hmm really the basis for these episodes, it's important to, to learn about things so you can know when to look for them and how to recognize them.

Of all of the episodes aired in the Big T trauma series, uh, the pitfalls seem to be a fan favorite. So we have compiled a list of slightly more complicated, perhaps not so obvious scenarios, uh, that we all have experienced, and we think that the wider BTK community would benefit from hearing about these.

Yeah, so this is the fourth, uh, pitfall episode. So if you haven't heard the previous ones. Take a look. You can easily search for him and find him on the website and ask. Let's get onto our first scenario. Tyler. You have a 55-year-old male who was involved in a single vehicle MVC where the driver smashed into a telephone pole while traveling approximately 55 miles per hour.

There was reportedly loss of consciousness and he arrived to the trauma bay with the G GCs of five. Heart rate is 68, blood pressure is 90 over 60. Respiratory rate is 12. Tidal. CO2 is 45 and SATs are 91%. So the, you know, complete primary and secondary survey, you do it so rapidly, uh, and efficiently with a well-oiled trauma team.

And those primary and secondary surveys are unremarkable. Uh, he's intubated in the bay given his decreased GCS and he's resuscitated with two units of whole blood, uh, without significant change in his vital signs. Get a chest x-ray, pelvic x-ray, and fast exam all unremarkable. The patient goes on to get Pan scanned.

He has

no injuries. So, Tyler, what's going on here? Well, to summarize, we've got a middle aged male and he was involved in NVC with no injuries detected on his ct. I. His mental status is altered, but he's non-responsive to blood product resuscitation. So at this point I'm concerned about potentially non-traumatic causes of his altered mental status, and I would begin by revisiting his disability in our A B, C Dees.

Yeah. So what are we looking for when we assess for disability specifically in trauma? I mentioned the GCS. Is there anything else you wanna know? Of course, in all traumas, we should perform a rapid abbreviated neuro exam, and that's to establish their level of consciousness using the GCS, and we should also assess their pupilary size and reactivity to light.

And then try to identify any gross neurological deficits. We can do this by asking the patient to follow simple commands like squeezing our hands or wiggling

their toes, and then test their response to pain if they're upended. Yeah, sure. So let's rewind the scenario. So we expand our disability exam during the primary survey and find that the pupils are three millimeters.

Bilaterally and minimally reactive and drum roll please. You can look into the future. You know that his drug drug screen ends up being positive for opioids, but we should note that EMS Yeah, did not give him any opioids. Yeah, so I think that's the key to this pitfall. The the failure to perform an adequate neurological exam and recognize non-traumatic causes of altered males status in the trauma patient.

Definitely one of those Monday morning quarterback scenarios where you are hanging your head when you're describing the scenario the next day. Very easy. A little bit of shame. Creeps in. Yep. Yeah. Easy to pick up in hindsight, but of course not readily apparent in the trauma bay when you hear, uh, this

horrible story and the paramedic shows you a photo of the car completely wrapped around this telephone pole.

And there's all this stuff going on in the background. People are really excited. 'cause man, this is gonna be a great, uh, blunt trauma. And then as it turns out, somehow, you know, this ragdoll of a person didn't have any injuries and, uh, was just intoxicated with a substance. And, and I think that's why it's so important to approach every trauma systematically.

Details matter. Mm-hmm. So, Hey Tyler. What else on exam might clue us into an opioid intoxication? Well, decreased respiratory rate, my eye pupils and altered middle status are the hallmarks of opioid intoxication. Heart rate, blood pressure, and temperature can all also be decreased. Whenever you see bradycardia in a trauma patient, you need to think about neurologic shock medication use like beta blockers, and as we see in this scenario, opioid intoxication.

Yeah, that relative bradycardia always peaks my interest, especially if they're not an older patient. So we also mentioned end-tidal CO2. So what's the role of end-tidal CO2 in trauma patients? Tyler. Well, it's an, uh, useful adjunct in the saying of trauma. Tit can be used to confirm airway placement and detect problems with ventilation like we have in this patient because they're hypoventilating from opioid overdose.

However, I would say that you most often hear about in tidal CO2 being talked about in the saying of trauma as a way to detect shock and low in tidal, CO2 levels correlate with poor perfusion. And in fact, some studies have shown that an tidal CO2 of less than 25 or so is associated with higher mortality.

Tyler, so you and I jump in a time machine. We travel back in time together. We complete the patient's trauma evaluation. Once again, no injuries are found, but this time we slip him a dose of Naloxone before we go. Wheels up to the CT scanner and he, this gentleman rises up wide

eye clears day, asks if behind the knife, still has free apps for iOS and Android.

You confirm that we actually do any fish of the bed, and so with that, let's wrap up with a quick review of Naloxone Tyler. Sure. So Naloxone is a short-acting opioid antagonist that's used as anecdotal therapy for opioid intoxication, and this is key. The goal of Naloxone administration is not to achieve a normal level of consciousness, but rather to achieve adequate ventilation.

So patients with spontaneous ventilation should receive an initial dose of 0.04 milligrams, and that dose can be titrated up every few minutes until the respiratory rate is greater than 12. Now, patients with apnea or impending respiratory arrests are gonna require initially higher doses, and typically those are on the order of 0.2 milligrams to one milligram id.

I remember as a resident, this is one of the

drugs that I. Saved in my phone as a dosage thing, right? Because this is like an emergency use drug. So when you're like a junior resident and you may be the only person that shows up to a code and you can't remember this, I would add this drug dosing and you can start adding drugs like flumazenil.

When I was a fellow, I put RSI drugs just so you have a source to, to rapidly look at them in an emergency epinephrine. Yeah. Yeah, I was, I was gonna also note, uh, and add in there, it's not just the dose. Um, you also need to know the half-life. And this is another potential pitfall. The half-life of Naloxone is often less than the opioid ingested.

Uh, so you really do need to be careful about monitoring and setting up repeat doses. Because most of the time these patients, especially if they've done something other than fentanyl, they're going to be sleepy and start decreasing their GCS here within a couple of hours. Okay, well that wraps up

another trauma pitfall.

Don't forget about opioid intoxication as a potential etiology of altered mental status and trauma. Patrick, what's our next case? I'm ready. Okay, 25-year-old male, multiple gunshot wounds who arrives to the trauma bay. Clearly in hemorrhagic shock tachycardic. Hypotensive has peritonitis. This patient's taken immediately to the operating room, and, uh, exploratory laparotomy is performed.

And on laparotomy, you're able to obtain hemorrhage control by ligating the common iliac vein. And there's a liver injury too, that's packed. There's also numerous injuries to the small bowel and a transgastric injury, and despite really balanced and appropriate. Uh, resuscitation with blood products and warming, calcium, et cetera.

He's currently on a norepinephrine infusion and the patient has a persistent lactic acidosis in. Uh, he's also hypothermic with a core body temperature of 35.2 degrees, and the gastric injuries are pretty rapidly repaired. And, and two separate small bowel, uh, resections with anastomosis are

also performed.

And at that time when we're wrapping up and performing those anastomosis, there's notice that there's oozing from the peritoneum, from the laparotomy incision, from the patient's IVs, et cetera. And. A temporary abdominal closure is done. He's taken back to the ICU where he ultimately requires MTP, but he keeps bleeding.

So he ends up going to the IR for hepatic angio embolization, goes back to the, OR 24 hours later and gets closed, and unfortunately seven days later there's a leak. So there's a lot of information there. This is a really sick patient who bled and had some physiologic arrangements in the or. Now we're dealing with this leak.

So Tyler, what's the simple answer here about the pitfall? May be quite obvious. There's a couple things, but for starters, we stayed in the operating room too long, and as trauma surgeons, we have to be able to recognize when we should bail for the sake of the patient. Mm-hmm. Exactly. This patient is sick as snot.

So Patrick, you mentioned that the patient was starting to bleed from

any manipulated tissue, and that is consistent with trauma induced coagulopathy, which is. Defined by abnormal coagulation. That's attributable to trauma, goes by a few names, but TIC is what we'll use here, typically characterized by early hypercoagulability, followed by hypercoagulability in later stages.

Tissue injury and shock synergistically provoke this endothelial immune system play platelet and clotting activation, uh, which are really accentuated by the lethal triad, which hopefully a few of our listeners have heard of, which is coagulopathy. Hypothermia and acidosis. Yeah, and I think the bottom line is.

Trauma induced coagulopathy is frightening. So the patients start oozing from everywhere. It's not just cut tissue, but also IV sites, Foley catheters, their nose, their mouth. And here's the thing, once you as a trauma surgeon, or really any surgeon for that matter, right? Other surgeons can

see this as well.

If you start to visualize this type of bleeding with your own eyes, then it's often very late in the game. Yeah. If you see it as too late, and this is why we chose this pitfall because. It takes experience to recognize which patients are at risk of developing trauma induced coagulopathy, and you have to have the wherewithal to get outta dodge quick.

You gotta finish that case as soon as possible by performing a true damage control surgery. And this patient as presented in the case very clearly, is too sick. They're physiologically deranged, cold acidotic, et cetera, and we're messing around doing bowel anastomosis, like absolutely not. That's not a good move, and there's an interest in preventing open abdomens, but this is the perfect case.

For an open abdomen, this is when you get that amp there out and temporarily dress the abdomen and live to fight another day. And as you mentioned, Teddy, if you see trauma induced coagulopathy, you, you, you've waited too long, you're too late. Yeah. No, knowing when to get out of Dodge really does take experience though.

There are a, a few things we can talk about in, in terms

of, um, predictors, but really, I. Experience is the key here. So it, it can be out of your control, right? So it could be the patient's physiology is just that poor to begin with. Um, but there are also a number of things that you could do to speed up what you are doing and really stick to damage control principles.

And I would imagine that everyone on this podcast has at some point stayed and played just a bit too long and not been watching the clock. Then lo and behold, you're watching TIC develop in, in front of your eyes. And like, like Teddy mentioned, it's not something you, for you forget. Uh, so Tyler, how can we prevent TIC generally speaking, balanced resuscitation with warm blood products, avoiding hypothermia, and most importantly obtaining control of bleeding as quickly as possible?

Yeah, that's right. And, and Tyler, for the sake of completeness, what is damage control surgery? Damage control surgery is a approach that's

designed to prioritize the immediate control of life-threatening conditions such as hemorrhage and contamination over the definitive surgical repair in the critically injured or unstable trauma patients.

So the primary goal is to stabilize the patient physiologically and prevent the lethal triad of hypothermia, acidosis, and coagulopathy, which are exacerbated by prolonged surgical procedures. Important to note here though, and here's another pitfall, that temporary abdominal closure does not equal DCS like in this patient.

Mm-hmm. So we stayed and played doing definitive repairs. That's not damage control surgery. The goal is restored physiology, not restored anatomy. So the correct approach going back in Patrick's time machine here would've been iliac ligation. Hepatic packing and whatever the minimum resection or quick whip stitching would've been

needed to prevent further contamination from the bowel injuries.

You get that done as quickly as possible, and then you do your de temporary abdominal closure and get out of there. Yeah, to, to hammer the ho, the point home. Do you have specific numbers that you might wanna follow when it comes to thinking about damage control surgery? Now these are gonna vary a little bit depending on what you read, but the most commonly cited indications for damage control surgery are a systolic blood pressure, less than 90 a pH, less than 7.2 a temperature less than 34 degrees Celsius and INR or PTT 1.5 times greater than normal.

A base deficit greater than 14, estimated blood loss greater than four liters and transfusion of 10 or more units of packed right blood cells. Essentially, it's any patients with unresolved metabolic failure after operative hemorrhage. Control and trends are important too, so patients that have increasing

lactate or falling temperature should undergo.

Damage control surgery before these classic thresholds are reached. Yeah, totally agree. Trends. Absolutely trends, right? The trends go both ways too, right? Like I think if you're trending in a better direction and you're making the, like, I've had times where I'm like, oh, we're gonna do a damage control operation, and then things turn around and you're trending in the right direction.

You don't necessarily have to. So it's good to have the data as you go along through the case. Alright, that's a good discussion. So that wraps up pitfall number two, perform a damage control operation. Get outta the or as fast as you can when dealing with a truly sick patient. So this is a nice segue into our next case in which an adult female is involved in an MVC and sustained polytrauma, including full thickness disruption of the rectus muscle from a seatbelt injury, a grade two liver lac, small bowel injury, ascending colon injury, and ecchymosis of the anterior sigmoid colon.

So the index operation. She undergoes small bowel resection,

right colectomy and hepatic packing. She gets 11 units of pack cells, 10 of FFP, and two of platelets. Now using the knowledge that you gained from our prior discussions, this patient is placed in temporary bowel closure device and she's hustled back to the ICU and discontinuity where she's resuscitated.

So. In 24 hours, she comes back for a second, look back to the or, and she's doing better overall at this point, but it's still on low dose norepinephrine and her lactate is just hanging right around three. Now at this operation, the second one, that dusky anterior colon that you saw at the initial injury is now frankly dead and you perform a sigmoid ectomy.

And there's also one of the small bowel staple lines is actually, frankly appear ischemic appearing, and that's re resected as well. So an app there goes back on and the patient returns to the ICU. It's now post-injury day number four. She's off all pressors. Lactate is completely normalized, wakes up when you turn down the sedation and she goes back to the OR and gets the followings.

There's uh, one small

bowel anastomosis, an ileocolonic anastomosis, and a colorectal anastomosis. All right, small bowel ileal to transverse colon and sigmoid to sigmoid anastomosis. Now I think you guys probably know what's coming here. It's day 12 following injury. The writing is on the wall, Patrick. No, I know.

I mean, we gotta make these obvious to some degree, but now she's got suckers. We're all sad and we, we, nothing even happened yet. I know it's, you saw it coming a mile away. So there's suck is draining now from the midline and cross-sectional imaging reveals not one, but multiple anastomotic leaks. Tyler.

Yeah, so the pitfall here is failure to perform fecal diversion at the time of a delayed colon or rectal anastomosis. I like to call this the, the surgical Shakespeare question. So to divert or not, that is the question. And so how do you decide? Yeah, yeah. This is another one of those not so straightforward

it false, how to put Humpty Dumpty back together again.

This patient was badly broken. We've gotten her through a difficult. Election of injuries and we've gotta decide what to do with her bowel. Again, you can take a look at data like temperature and heart rate and lactate and press requirements, but for this type of patient, you really gotta step back and take a look at the big picture.

This is a very sick patient recovering from a massive insult, and they're not gonna heal well. And another big hit like the one you get from intraabdominal sepsis, can really threaten this patient's recovery. I hate ostomies just as much as anyone else, and I wouldn't want one, but. We gotta think about how we fail, right, bro?

Yeah. I always plan on failing. Well, Patrick, yeah, fail. Well maybe not even fail at all, but this is where I also tend to think of difficult trauma and EGS patients really as like a flavor of patient or a brand of patient. And I know that this flavor of patient, regardless of if they're off pressors, on their third

takeback, is prone to leaks.

Another really nasty postoperative. Complications again, ask me, ask us how, you know? Right. I wanna avoid that urge and I wanna keep it simple. Keep it simple. Stupid. Make the ostomy, don't roll the dice. This patient can, ostomy reversed in the future. Yeah, I agree. One, once she's recovered, ostomy, takedowns will have a, can be frustrating sometimes.

Uh, they're not the end of the world for most patients, so let her recover and then we can put her back together again. And overall it. They very likely to be a less complicated course. Yeah. I've seen some surgeons using their emergency general surgery experience dealing with diverticulitis to inform decisions on these complex trauma patients.

And typically this is experience is used to avoid ostomy creation, but this type of thinking can be dangerous. Right, exactly. All right. That wraps up pitfall number three. Divert the super sick, blunt trauma patient and

avoid. Intraabdominal disaster whenever you can. So next up, we have a 17-year-old male who was transferred to your facility following an un Helmeted a TV accident with rollover.

He has a large scalp lack that was addressed with gauze and coband. There's some bleeding noted through the gauze. He's altered with the GCS of nine and his initial values are notable for heart rate at one 30 and blood pressure of 100 over 80. Chest x-rays. Normal pelvic x-ray shows an open book fracture and a pelvic binder is appropriately applied.

Fast is negative. He has a Foley catheter with no urine or blood in the bag. Labs are pending, but ETOH is positive. He got one liter of Crystal Lloyd en root, and he goes on to get a CT scan, which demonstrates the pelvic fracture, which is known in a moderate pelvic hematoma without active extravasation, and he returns to the trauma bay where a few minutes later he arrests.

So this is more subtle, but we've got a pitfall in mind. So Tyler. What did we miss here? What's the pitfall we're gonna get

after? Yeah, it could be a lot of thanks, but let's go ahead and share this pitfall upfront for the sake of discussion. This patient was in unrecognized hemorrhagic shock. What about his presentation suggests occult shock?

Well, Teddy for one, the patient was 17 years old and they had a high risk injury mechanism. He was initially taken to an outside hospital for evaluation and prior to the transfer, we don't really know exactly what happened there. He's tachycardic, he's got a narrow pulse pressure, and he's got relative hypotension.

His mineral status is altered, his urine output's low. All of these are consistent with at least class three hemorrhagic shock. Well, I think I have a, a question that our audience may have for the sake of discussion. What, what if he is in hemorrhagic shock, but what's the source? I thought the CT only showed a moderate size pelvic hematoma and there wasn't even any active extravasation on the ct.

So where,

where where'd the blood loss go? That's true. Now remember, the main sites for acute blood loss and trauma are the chest, the abdomen, the pelvis, and the retroperitoneum, long bones. And lastly, external or the street. Given his imaging findings, the most likely explanation is his large scalp lack or the street, especially combined with the other sites of stabilized blood loss.

Yeah, good job, Tyler. How can we clue ourselves into external bleeding as a source of his possible hemorrhagic shock? Earlier in this scenario, well begin by paying close attention to the EMS handoffs to clue into the amount of blood loss at the scene. Although even these descriptions should be taken with a grain of salt, and the patient was seen at another hospital first, so who knows how long that scalp was left to bleed before it was addressed.

Remember that hyper hypotension does not occur until class three. Hemorrhagic shock after 1.5 to two liters of

blood loss, but narrow pulse pressure, tachycardia and mental status changes can occur earlier. Or if this patient was 67 instead of 17, maybe with some baseline cardiac dysfunction and on a beta blocker, even minimal blood loss could induce shock.

Yeah. So what about objective findings? Any objective findings that can aim with detecting shock earlier? Yeah. First up is our physical exam. The patient will be cool and clamped down. Labs oftentimes show elevated lactate and uh, normal hemoglobin. Remember, trauma, patients bleed, whole blood. Also intital, CO2 can be helpful.

A low intital CO 2 25 or less suggests poor perfusion. Yeah, the, these can be tough to identify and, and it's a, a scary scenario because it would be, uh, hard to catch this before. Really a devastating collapse, especially in young patients

who will just keep compensating with heart rate and supplementing their, their cardiac output that way un until they fall off of the cliff.

And we have definitely all seen that, unfortunately. So remember to listen to your pre-hospital team, and if they told you the patient lost a lot of blood, just believe them and act like it. And even if they didn't, let's say they weren't the primary team responding, or maybe the patient was moved from their pool of blood or who knows what the circumstances are, even if EMS doesn't tell you about massive blood loss on the scene, I would still suspect it for any open wound.

Even if it's hemostatic, by the time you are looking at it and those trauma transfers, this goes back to that earlier pitfall. Watch out. Any open wound can be a source of significant bleeding. Even something that looks really minor now that just has a bandaid on it. You have no idea how much blood coming out of that wound before the patient got to you.

Yeah, not

every trauma patient bleeds out into their belly or their chest or their retro peroneum. So let's move on to our last trauma pitfall. So the case is a 70-year-old male who experienced a mechanical fall with mildly displaced left rib fractures three through nine, specifically chest x-ray shows a moderate left pneumothorax and a small left pleural fusion.

A pigtail is placed in the ED and he has admitted a step down for rib fracture protocol. Chest x-ray on hospital day number two shows a persistent small left lower lung opacity that's stable on day three, at which time the pigtail is removed and everything is kosher. You are working with case management trying to get this patient to a skilled nursing facility.

It's now day six because discharge was delayed. The patient has a pretty mean fever that's persistent. So Tyler, what's on the differential for this patient's fever? So persistent opacity on a chest x-ray in a patient with blunt chest trauma. This is concerning for atelectasis, pulmonary

contusion pneumonia, or my favorite retained hemothorax.

But if it's, uh, retained hemothorax and it's now infected, it could also be the beginning of an email. I think this is something that we see all the time. Right. And, uh, an abnormal chest x-ray. It, it really doesn't tell you much. It could be a lot of different things that you just covered. So, Tyler, what is the next step with this opacity?

Yeah. This patient needs to be imaged with the CT chest, uh, as a chest x-ray will not allow us to differentiate between a process in the lung parenchyma versus one in the plural space. Yeah. So fortunately, the CT scan demonstrates a cul related rim enhancing pleural, uh, fluid collection. The lungs actually trapped, they require vats that's ultimately converted to an open decortication, and the patient hangs out for a while longer, and they're actually discharged on hospital day 22 to an L tac where they actually, uh, have to wean from the fend.

Anything that we could have done differently

for this patient, Tyler. There's definitely a few opportunities for improvement here. For starters, a single dose of an antibiotic like ansep before or during chest tube placement may reduce some infectious complications, but more importantly, early vats within 72 hours of injury, results in decreased operative difficulty, decreased contamination or infection of the clot, and decreased hospital lengths of stay.

Yeah, so anytime a patient, traumat patient specifically has a pleural fusion in the setting of rib fractures, our suspicion for developing hemothorax should be quite high. And any patient with significant rib fracture burden should ideally get daily chest x-rays for at least the first few days of their admission, and if there's persistent or worsening or ification of the pleural space.

And they should be evaluated with the CT scan. As Tyler mentioned, if they don't have a chest tube already, this should be a time to place one. Again with a dose of antibiotics, I think that's something to easily forget. I don't, and in fact, when I started placing chest tubes, I, I never gave antibiotics.

And it's now

part of the standard protocols and, and recommendations and guidelines that a single dose, at the very least will prevent infections like an empyema or at least decrease them and if they already have a chest tube in place. Studies show that early vats in patients who are good operative candidates is, is absolutely superior.

A placement of another chest tube or a prolonged treatment with fiber Aly. Yeah, I, I agree. Some centers have even implemented plural lavage or thoracic irrigation protocols at the time of tube thoracostomy and the early. Data do look promising. I'm sure there's more to come on this in the future, but for now, the key is to look for retained hemothorax.

You have to know that it exists so that you can look for it in any remaining pleural effusion on that chest x-ray, even if you don't think that it looks very impressive. Might actually turn out to be very significant on ct, depending on your patient positioning and the quality of the x-ray. So I have a very low

threshold to get an early non-con CT on these patients to decide whether they need something further.

Yeah. Teddy, you do non-con or contrasted? Yeah, I was gonna make a comment on that. I actually changed practice and. If there's not a concentration to getting contrast, I almost get, always get a contrasted CT of the chest. 'cause I think it gives you the ability to see the, the difference between the lung parenchyma, you can have consolidated lung parenchyma and sometimes that it gives you contrast between that and the effusion to see which is which.

Yeah, that's a good point. Teddy, I use an IV contrasted scan as well if, if there's not a contraindication, it's like Teddy's. Fantastic. That wraps up our last pitfall. Don't miss a retained team at thorax and the opportunity to treat it before it becomes an empaa. So thanks to everyone for another amazing Big T Pitfalls episode.

Remember the eyes do not see with a mind does not know.

So now you know. Right? And until next time, Tyler, be sure to dominate the day. That's right.