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Hi everyone, welcome to Behind the Knife. This is Nina Clark and I'm here with John Williams, one of our other BTK Surgical Education Fellows, to talk a little bit about going back to the ABCs. We all learn them when we go through elementary school and then again when we go through ATLS. It's a beautiful system because it's simple and easy to remember.

ABC, Airway, Breathing, and Circulation. But what if we told you that those first three letters of the alphabet may need to be swapped around to CAB? We are going to be talking all about these letters, primary surveys, and how we can learn to better manage traumatically injured patients. And we are joined today by Sharmila Desanayake and Paula Ferrada, who recently authored a surgical innovation paper in JAMA surgery titled Circulation First for the Rapidly Bleeding Trauma Patient.

Is it time to reconsider the ABCs of trauma care? John, do you want to kick this off with some introductions? Absolutely. So Dr. Farada is joining us as the Division Chief of Trauma and Acute Care Surgery at

Inova Fairfax Hospital in Fairfax, Virginia. Additionally, she's the Program Director for the Surgical Critical Care Fellowship at Inova.

She's won multiple teaching awards, both as a trainee and a faculty surgeon, from organizations including the American College of Surgeons, the Eastern Association for the Surgery of Trauma, and the Association of Wound Surgeons, as well as the Pan American Trauma Society. Dr. Disinaka is a professor and the chair of surgery at Texas Tech University Sciences Center in Lubbock, Texas.

She's a trauma, burn, and acute care surgeon and has held multiple leadership positions at local, regional, and national levels, including positions within the American College of Surgeons, the American Burn Association, and the ACGME. Thank you for having us. We're really honored to spend some time together.

We're excited to be here. Well, let's get started. You both contributed to this piece in JAMA Surgery that reviews the ABCs that are currently taught kind of all over the world, really, in ATLS programs. And I'd love to start off just by diving a little bit into what's been published and what pushed you to write this

piece.

So if you don't mind, can you take us through some of the early literature that you all used to kind of form the foundation of this piece you wrote? Before talking about the literature, I was, I'm going to talk about the principle, if that's okay. We learned the ABCs from the ATLS. However, so I did my medical school in Cali, Colombia.

I had an unusual exposure to trauma when I was very little. I was scrubbing the first time in a case when I was 12 years old. So I saw how in, in Colombia, in this state hospital, where they have no resources, when they knew that a patient was in shock. They didn't stop in the E. R. They didn't put a C color in granted that most of those patients had penetrating trauma.

They didn't have blunt trauma. They basically received blood and blood transfusion and to the or to take care of them. And I saw as I was growing up in residency and when I was in Miami and as an intern second year residency at the Deaconess, Pittsburgh, the same thing, shock trauma, the same thing,

people that do trauma every day.

They don't do ABCs in that sequence for patients that are exsanguinating. They don't stop and intubate. Why? For the reasons that we put in the paper. Dr. Lisinake also can elaborate on this. Why? Because these patients are holding on for your life with their sympathetic response, trying to perfuse the brain and trying to perfuse the heart.

And we block that with the anesthesia, regardless of the medication that you put on. Then if that was not bad enough, we did positive pressure to kink the IVC, decrease further the venous return, ended up, end up with that, that patient. But when I started practicing the same thing that I was trained and seeing how some emergency medicine colleagues, which are part of our team, we're one team, emergency medicine colleagues with us.

But they looked at me like I had a third eye when I was like, please don't intubate the patient yet. Because if you intubate the patient, you're going to have, you're going to follow the ABCs exactly how the ATLS says, but you're going to have a dead patient. And it took a while. And I was like, why is it so hard to

convey these criteria?

And then the reason why it's so hard is because ATLS is the bible of trauma. So people, when they train in ATLS and they say, oh yeah, in level one trauma centers, Everything happened at the same time, and we forget that the majority of the trauma that is taken care of in the world does not necessarily happen in the shock trauma centers in the places where you have a million people show up to the trauma bay.

Sometimes you have limited resources sometimes you have one professional person taking care of them in that is when is the most important to understand the physiology and to do the best that we can to give this patient a chance of survival because seconds matter. Thank you very much. And I'd like Dr.

Nishinaki to talk. All right. So she's taken all the good points already, but no, absolutely. So I agree with everything Dr. Farada said. I think what's important to remember is this, what's going out onto the floor should be replaced by what's coming in. That's probably your fundamental principle, right?

GCS is low is not Usually, now sometimes it's because they have a concomitant head injury and that's kind of neither here nor there, but the issue is that the reason this patient is decompensating is that they're bleeding to death.

That's what needs to be corrected. We need to fix the problem. And so for me, you know, we'll talk about literature in a minute and Dr. Farad has done some great work and a lot of the early work on this. But the truth of the matter is my involvement is really coming from what we just talked about the very basic common sense.

principle that we should actually address the problem, not just do things because we were taught that this is the order things go in. I mean, quite frankly, I've never been able to find evidence for how ABC was developed beyond the fact that it's alphabetical. So that was nice. So really, I'm not sure that there ever was evidence to make that clear.

If there is, it's certainly not well documented. And so, you know, the fact that we've chosen To teach generation after generation of ER physicians, paramedics, and trauma surgeons to intubate first. I don't think that's the most sensible thing and here's why. If you

have a gunshot to the trachea, I think probably in that patient airway first is a great idea.

Well, how often does that happen, really? But the majority of our patients who are going to die are dying from either bleeding or head injury, right? And head injury is an entirely different topic, but the truth of the matter is if you're going to save a life, you're better off erring on the side of treating bleeding and trauma, because that's usually what kills people.

And if you want to treat bleeding, then causing a drop in blood pressure from giving them vasoactive agents and giving them induction agents and then putting a tube in them and then giving them positive pressure. Literally every single one of those steps that we use in an intubation is hurting. their vascular system.

That's already the reason that they're crumping. And so it just doesn't make sense to intubate a patient like that. And yet, even today, I teach ATLS as does Dr. Farhadi and a lot of people who are listening, I'm sure. There are cases there where you have a hypertensive patient after a motorcycle crash and the first thing they want you to do is intubate, even though

it's clear that that patient is likely bleeding.

And so I really think we need to have this paradigm shift. Like Dr. Farad alluded to, a lot of your listeners probably do work in busy level one trauma centers where we can do everything at once and it doesn't really matter. Because as has been shown in those centers, we are doing all of it at once.

So this is kind of an academic point. But when we teach someone who's working at a critical access hospital, that's where it matters because there's just one doctor doing everything. I'd really like that doctor to do the most important thing first. Before we did any reviews about this, it was the clinical experience and what people were already doing.

There are some papers out there, I think one is from Boquillo in Journal of Trauma saying that intubating people by EMS does not change outcome, but there was no difference in mortality. We looked at these in 2014, but we presented these in 2016 in the American Association for the Surgery of Traumas, a quick shot.

We retrospectively review

our cases in a place where I used to work before, and we showed that there was a difference in mortality. Then after that, we did a multi centric retrospective review. That was also sponsored by the WSD, but it was published in the World Journal of Surgery. I think that was published basically, I think, 2018, but we looked at the data afterwards that showed a small difference in mortality, not statistically significant.

And then we have a multicentric trial sponsored by EAST that is prospective. That is cooking right now. I cannot tell you the results until we get that published. But on the way on the journey of doing these multiple papers came out like supporting don't intubating they are intubating the or.

But what is that saying is not that the or is a magical place where people are going to survive is that you're not you're delaying the intubation to give some resuscitation. to help that patient in need to give the patient back a little bit more time. Now we start talking about agents to that, right?

The stop the bleed is

great. You don't see, you don't see people when you come with external trauma, you don't see people putting ET tubes or doing c spine immobilization. You're putting pressure, you're putting a tourniquet, you're giving back blood. Then there's pelvic packing or revoir to avoid somebody to code before you intubate them.

We all know that that's what's going to happen. If you're, if you don't have any other resource, if you're, have a patient that have a significant injury that is exsanguinating, when you're intubating, you better be sharpening the knives and then prepping the patient because you know you're going to have to do something to keep that patient alive until you have definitive, definitive bleeding control.

Yeah, I think that's really interesting. And I had seen your the retrospective multicenter trial that you published back in 2018. And I think one point is kind of interesting. And maybe you can't reveal this if it's an ongoing prospective trial. But obviously, you know, the primary outcome of mortality is probably like the first and foremost, the most important thing.

But one, I think one limitation that you might have even mentioned in the discussion pertains

to functional and neurologic outcome. And I think that Conceptually and theoretically in my mind, it makes total sense to obviously resuscitate first and intubate later, and I can't imagine that there would be a difference or there'd be like a negative difference in that strategy from a functional neurologic perspective, but what do you think about what the future might hold in terms of will the will that as a secondary outcome also be something that benefits as we see patients that do have multiple traumatic injuries?

It's not always just the bleeding limb, you know, maybe it's a you. Polytrauma where there might be some traumatic brain injury component. I think one of the difficulties of all trauma research that's done prospectively or retrospectively is that we have so many. multiply injured patients, that it is incredibly hard to tease that out.

So if we isolated a study to where we only looked at, for example, penetrating trauma, not involving the head, then I think looking at neurologic outcomes would be very reasonable. My concern is a lot of these patients in the United States at least are blunt

trauma patients from MBC, in which case it's very difficult, right, because they're also going to have rib fractures, they're also going to have head injuries, so trying to tease out those outcomes is difficult.

I think the reason mortality has been the benchmark, even though obviously with mortality being low that's very difficult because then you need large numbers, but I think it's the reason it's still been the outcome. for most studies is that when we look at resuscitation and we look at giving whole blood, when we look at giving circulation first, we're really looking at reducing the number of deaths in the first 24 hours, right?

That that's the cohort. The patients who will bleed to death in 24 hours, if you don't do something, that's who all this hard work is aimed at. The truth is the majority of trauma patients would probably do fine in most situations because they aren't that badly injured, but that's that cohort. And so I do suspect that the main benefits of switching our resuscitation approach to circulation first will continue to be mortality and specifically in those massively injured patients,

but you know, to the point that Paul and I keep trying to make that is, it's requiring a change in mindset and that's an funnily difficult change to make.

When I was training as a resident, tourniquets were verboten, right? They were the devil. You didn't use a tourniquet. What are you doing? You want to kill extremities. I mean, that, that was really how we thought of things. And now of course, everybody's got a tourniquet. I have one in my car. I'm sure all of you do too.

Tourniquets are great. They save lives. They save limbs, blah, blah, blah. So, so the problem is we're human. And we're in a human system, and however scientific we like to think we are, we're really doing about 90 percent of things every day because it's how we see people around us do them, right? And so I think that goes to the difficulty of how you change this.

Dr. Farada alluded to how difficult in the ER it is to change it, and one way I've got around that is that when I know that there's a patient coming in that I suspect may have exsanguinating hemorrhage, I'll actually, in the pre brief, in the trauma room, tell everyone, Hey, I'd like to do this with a CAB

approach because this patient is likely to have bleeding as their primary problem.

So please do not intubate until I say it's okay. We're going to focus on circulation, focus on resuscitation. And when you say that ahead of time, if you have the opportunity before the patient gets there, I've found that people are fine because now you've explained it all. It's when, you know, fighting when the ER physician has the laryngoscope poised.

That's not a great time to have this discussion. Doesn't usually go well. And so a lot of people ask me how to make this happen today, because the data I think is there. I really think the literature does strongly support this. And there is really no literature I'm aware of that supports the other way in a bleeding patient.

So given that we, I think, have literature and we're continuing to develop the literature. I think it's fine to start changing now. We just have to find ways to change it day by day without it having to be a battle while the patient's kind of rolling in the room. 100%. And I think the bridge. So I think I do the same thing that Dr.

Iznaki does. I I get the team before we come. If you have the chance and say, this is

what we're going to do. If this patient is rapidly bleeding, this is how we're going to approach it. And that changes the mindset of the people. And I think we were just talking about how wonderful it is that now the ATLS, the 11 edition is going to be X ABCs instead of ABCs.

But they're still talking just about external bleeding, which is great. It's a step in the right direction. But what about the internal bleeding? The majority of the people that it gets to our trauma base are dying of bleeding. They're not bleeding from the legs and the arms. They're bleeding in the torso.

So what do you do for those patients? I tell you that the first couple of times that I started thinking about, we need to create, we need to create momentum and change this was. You go goes down to a few patients, right? This patient that was multiple gunshot wounds came in with a GCS of four and I'm like, we need to intubate this patient by the time that we need to do something for this patient and not do intubation immediately.

By the time that I was getting my knife because the patient did not have a blood pressure was gasping for air and I know I knew she was going to lose process. I was ready to open the

chest. lost pulses the moment that I put the knife in the chest and everybody was like, Oh my God, she was not intubated.

She was like, the intubation was on six seconds before we caught in the chest and I'm like, you need to be alive to be able to remember traumatic incidents. You need to be alive to be able to feel pain. If your GCS is four or three because you're bleeding, you have a leg in the other side, rather than being alive, you have your like going towards.

towards mortality rather than being alive. So I think that that's where we need to continue to add to the literature, continue to have these conversations so we don't do things just because, like Dr. Delisnack is saying, because everybody is doing it the same way. That's how we change paradigms, by using our brains and trying to think what, how do we help the patients in need.

I think tagging on to this, so this is what happens when you get Paul and I talking together. That's great. We have all these ideas, but one thing that is tied closely to this, and I do want to mention

it we alluded to it very slightly before, is direct to OR with bleeding patients. So in our, my institution at Texas Tech, we call it the flyby.

I think it sounds cooler than direct to OR, so that's why it's a flyby. And it's because we, in our hospital, we're very fortunate. The ER, the OR and the ICU are on the same floor. And so literally the team flies by the ER on the way to the OR. And that's why it's called that. But the concept is you get your bleeding patients straight to the OR and you do your x rays, your ultrasound, whatever you need to do right there so that you have reducing the time to bleeding control.

And there is so much literature now showing, you know, Duane Duchesne's group at Tulane has done this. Many, many of us have shown that. Tying to bleeding control is probably your number one determinant of survival in that cohort, whether we keep referring to, which is those who will die in 24 hours of bleeding if you don't fix it right.

And so I think as we talk about CAB, I would also like the listeners of this group and the residents to hopefully start moving towards direct to OR in their

own hospitals. Hospitals because you know it can be done. I'll tell you how flyby started here is one night I was on trauma call and because we're here in, out in West Texas, we get patients from many, many hours away.

A huge, we're one of the most isolated level one trauma centers in the country. And a 14-year-old got shot, transabdominal gunshot wound, and I knew was coming and I knew I had a bit of time. And I said, you know what? I knew they were hypertensive, getting blood. I said, okay, we're going straight to the OR.

This was at about 2 a. m. So we literally trooped the patient through the hallway, put them in the OR, you know, and did it, and that patient's life was saved. And afterwards, of course, I did have some nursing colleagues extremely angry at me because muddy boots had tromped all the way through the OR into the room, and there were things.

And so, We had proof of concept, it saved a life, and then we worked with administration and leadership and developed a protocol and then we did simulations and we trialed it, and now we have a very pretty protocol and now everyone's cool with it. I can promise you the first time there were all sorts of things, my institution didn't write me up, I'm very grateful for that.

But, sometimes you have

to push the envelope to get things done. And then you can get the paperwork sorted out afterwards because what we're doing, my north star, my compass is if you're doing something good for the patient, for the most part, the rest will sort itself out eventually. And I think we need to advocate for our patients who definitely can't advocate for themselves at that point and work on bleeding control and circulation first, because I think we'll save the greatest number of lives that way.

Right, I think keeping the patient in the center, helping when I say we're one team, we're one team, and when we create protocols and we create change, make sure that the people that are listening and helping us make that change, the administrators, they understand that in between the clinical professionals and the administrators, the patient is in the middle, the patient is in the center of everything that we do, and knowing that everything should be targeting how do we help the patient in need.

I think you guys bring up some really good points about really some of the nuance in this decision making you preempted my question about what the data behind ABC

was really in the beginning. And I think it truly probably does come down to simplicity. Right? And it's easy to remember. It's something that we can teach an intern to do in the emergency department and really can guide a systematic resuscitation, which I do think is a huge benefit.

But as you pointed out, both of you, there is nuance to some of these decisions and there needs to be nuance to save more lives in the trauma bay. Can I just jump in on the history? So I think you have to realize that back when ABC started worth, you know, created as a thing, we actually did think that oxygenation and airway was more important than it, than we think it is now.

That actually was the mindset. And the reason I know this is if you look at what happened with ACLS, right, by far the more commonly used protocol, they thought that breaths people were giving were more important. And ACLS and the American Heart Association changed to circulation first back in 2010, guys, that they figured it out.

They looked at the data, they looked at the literature, and they

changed in 2010 to put circulation first. And yet here we are still nitpicking in 2023 as trauma surgeons. When, to me, it should be even more obvious because we have the blood actually pouring on the ground. It should be more obvious to us than to the cardiologists that circulation is first and yet we're still quibbling the point.

Yeah, it's usually pretty obvious when someone's bleeding to death, especially if it's the external bleeding. I'm curious, I guess, I think this is a hard problem to define in part because it's nuanced and it's like trauma surgeon discretion often comes into play here, right? How did you define the patient population who is ideal for this and did you use really strict terms or did you use kind of more broad generic terms of, you know, non compressible truncal hemorrhage being the main concern for low GCS or something like that.

So the way that we did it because mind you that the first. case series or retrospective study. It was only one center. It was, we use a systemic systolic blood pressure of 90. Then one of the comments was at the time, well, maybe it's the

medications that you use, maybe you use ketamine, blah, blah, blah.

So again, we did a meta analysis where we looked at all these patients, all type of drugs that develop post hypotension, post intubation hypotension. And post intubation hypotension has a clearly a correlation with mortality, you get hypotensive and then and then after that when we prove, look, it's not the drugs, it's just becoming hypotensive and if you're already like hanging on to your life to not become hypotensive, a second hit will be bad for you, which also, by the way, will be bad if you had a traumatic brain injury.

Every episode of hypotension with traumatic brain injury increases your mortality by 40%. Then we did a multi centered retrospective using also systolic blood pressure of 90 as a surrogate for bleeding. And then we discern it out afterwards. That's also the same thing that we use for the prospective trial.

But what you mentioned is key. I think that it will be almost impossible to do a randomized controlled trial with this because it is really hard to convince people to

do different things, especially when they're dealing with somebody that is in extremis. It wouldn't be easy. I'm really optimistic about the data that is coming from the EAST multicenter trial, because it not only included centers from the United States, it included centers, international centers.

So I think it will be telling once we had it published. Just to put perspective, for any trauma patient to do a prospective randomized study is difficult because of the implied consent issue, right? And that's why most of the literature, Dr. Farada's trials and others, tend toward observational. Because if you want to do interventional, which people have done, of course, with different kinds of interventions, whole blood is the one that comes to mind most easily.

You do have to spend a lot of time getting community consent and community outreach and building that I remember actually being at Harborview, just like you wouldn't know the 3 percent saline studies were being done. And oh my goodness, that was eye opening to me because it's the first time I realized how much work you have to do if you want to do a pre hospital intervention in trauma.

That they

won't just let you do it. You have to do all these tips and that takes a lot of money and that by definition limits it. I'm going to put a plug in here about trauma being incredibly underfunded, right? This is where I would love to see research funding go is helping trauma centers take the steps necessary to do true randomized trials because really that's one reason you don't see them in trauma.

Cancer studies tend to get a lot of money. Trauma does not. And this is a reason we're still. Relying on good prospective and observational data, but it's still not the gold standard yet. That's a great point. And then, you know, even once you do the RCT, you still have to get people to buy into it. One last question about the kind of definitions of who you're including in these studies and the outcomes specifically.

In one of your prior studies, Dr. Farhadi, I think you defined the CAB approach as just receipt of any resuscitative blood product prior to getting intubated. And I'm curious if you feel like that was a sufficient definition for your exposure

to CAB approach or do you feel like we need to also be able to better define if somebody responds to those blood products, is that a successful implementation of this, or if it's just truly like we're trying to go as simple as possible and say you just got blood product, that's great, you did a CAB approach.

How did you decide that and what do you think the implications of that decision were? If you're losing blood, Something as small as giving back the blood. You start giving blood early. Just that is better than nothing. It's better than just using your IV access to give your rapid sequence intubation drugs.

Right? And then maybe what we have to do in the future is define this airway as damage control airway. We want to give it an acute name. And say people that are coming hypotensive, bleeding to death. Do not intubate them as fast as you would otherwise. Give them blood before. Use other medications.

Decrease the amount of etomidate. Decrease the amount of succinylcholine. So all of those things need to be taken into consideration when the final change to the ATLS happens.

I think we're running up against the problem that we like to teach protocolized medicine and everyone thinks that's how we should do it and yet so many of these patients the nuance is where you're really going to make that difference and I think it's difficult and I think it's also important to remember For a study, you have to define it somewhere, right?

Like, you have to set a bar so you can put this set of patients here and this set of patients there. In real life, that doesn't exist. And so in real life, I would say you take the data from Dr. Farada's literature and everything else, but now you optimize it for that particular patient, which might mean you're giving whole blood, and you've got the tourniquet, and you're on your way to the OR.

And you're going to reduce the drugs you use for intubation and, I mean, there are so many things, you know, recently we've decided at our center to place the sheath, not the micropuncture sheath, not the full riboa sheath in a lot of these hypertensive patients so that if we do decide to go for riboa, it's shorter time to swap, but we're not risking quite as much the access complications.

So a lot of this is in the nuance, and I think it is important for

your listeners, especially to. Hear that, that yes, there are some guidelines, but we need to still be doctors first and think through things for the given patient in front of us. Yeah, I think it's such a great point that. You know, it's easy to get complacent with the protocolized nature of a lot of things and every patient is obviously different and unique and situations need to be taken as such.

I think one thing too that, like, I think about sometimes my, I know my institution is a whole lot different than the one down the street, which is a whole lot different than the one in Seattle or Texas. And I think, is it also worth talking about how institutional differences Kind of play a part here too.

And whether that's in terms of the resources they have, the specialists they have available at which times of day, the catchment areas of those institutions, as you mentioned, you know, you might have folks coming from miles and miles and you taking care of those patients defer in this as well.

What do you think about considering institutional factors, both when you're developing these studies? Is that something that that comes into play when you're designing a multi institution trial? And

how do you confer the results in that context? I think it's important to take that into consideration, actually, not just for studies, but for real life as well, because I'll tell you that one reason a lot of my patients, even if they are hypertensive and bleeding, are coming to me intubated is that no self respecting medic is going to get on a helicopter.

and then have to potentially wrangle a midair intubation, right? And I fully empathize with that. This, to me, that would be an exception to this. What I would say in that situation is you make sure the patient gets blood at the initial center, you intubate the best you can, and then you start pressors if you need to minimize crystalloid, get them on their Helicopter and get them to us.

So, absolutely, we need to make accommodations for institutions. So, thank you very much, John, for bringing that up because it's not a, Paul and I keep saying it's not one size fits all. It's totally not one size fits all because a middle of the air helicopter is not the place to have a crashing patient.

So, you know, we do need to help support our pre hospital folk to have blood available and also So,

to have the safest possible intubation if that's necessary. We also take it a step further. Yeah, there's a couple of studies that said patients do better intubated in the OR. Yeah, when you're in the United States and the OR is really, really fast, it's really close to the trauma bay, you just do the flyby.

I love that protocol that Dr. Isignaki has. But how about when you're in South America and the operating room is in the fourth floor and you don't have an elevator key? So it's not about the location, it's about What are you going to do to prevent that patient from coding and what are you going to do to give yourself time and give the patient time so you can make a difference between life and death, but it might be different in any in every place right you know that's, it's just encouraging for people to think outside the box for these patients are really really are sick that they need the entire team on the same page to help them survive.

You both have mentioned a lot about how you've thought through implementing these findings and

this idea at your centers and a lot of that it seems like is kind of pre team communication involving the emergency department in the decision making and management of patients where it's appropriate and flying by the AD When it's available.

So I'm curious if you have, you know, specifics that you talk through and ways that you've implemented this in the way that you approach traumatically injured patients with your emergency department physicians and with your resident trainees that you work with as well. So how have you implemented kind of the educational aspect of this and communicating some of that nuance to your trainees and colleagues?

I think it's important. So thank you. That's a great question. And I think it's important to realize that people in general, the reason protocols are all over the place, you know, I'm going to take Paula's line, protocols do not replace a brain that should be on a t shirt, I think, but, you know, we like it because it makes it easy for us.

Right. And so I think it's important for us as educators to realize that. If you want to change from the normal, it's an uphill battle. You do have to put a lot of energy into it. And so

I think just like the pre brief, it's important to talk about this at our trauma M& Ms at your local institution. And then, you know, that's why we're both here on a busy work day and behind the knife, because we know you guys do a wonderful job disseminating education to residents all over this country.

And it's all a part of it. We want to give trainees permission to challenge the paradigm, to do what's right for their patients, and not go, oh, this is how we've always done it, we have to do it this way again. I think you do that by pre briefing, by saying, okay, this isn't potentially exsanguining a patient, what can we do to get hemorrhage control quickly?

And then I think you also do it by debriefing. After the incident, having some quiet time, once whatever happens happened, to go okay, what went well, what didn't? Could we have done better? Could we have moved that patient to the OR sooner? One thing that I emphasize at MNM is the time spent in the trauma bay before they got to the OR.

And I can promise you, every single time, the team with the best of intentions says, oh, we were no more than 10 minutes in the trauma bay. And when you actually look,

it was more than 10 minutes, because the time flies so fast, we don't realize it. And it's not to point the finger or throw anyone under the bus, but it's to remind ourselves that really, we have to constantly push ourselves to stop the bleed fast, or it won't happen.

And I think you just do that again and again in a very non punitive way, but so that people get the message. That time to bleeding control is something that matters in your institution. It's something we care about. It's something we hold ourselves accountable to. And if we haven't done our very best to shorten the time to bleeding control in a given patient, we're going to use that learning for the next time.

And that's the approach that I like to take to continue to shift. I'll tell you it has shifted in the last three or four years. I looked at this recently. The time in the trauma bay for these most critically ill patients has dramatically dropped at our center. And it's just this constant month after month after month holding people accountable, discussing what we could do better.

It does move the needle. It just takes a bit of time. But you only

get better if you practice, practice, practice. And it's not only the muscle memory practice or the procedure that you do, it's your brain. Your brain tells your hands what to do. So analyzing, thinking, debriefing, insight about these difficult cases is what makes you better.

So whenever you make mistakes, you honor that patient, but not letting it happen again. Yeah, and I think, you know, there's so few opportunities for us to do that real hands on type training with the emergency department physicians, right? I mean, presumably ATLS is where that background comes together for all of us and we bring it to the trauma bay.

But I like this idea of using kind of real time feedback and using a debrief, using a pre brief, if you will, to kind of guide that learning in the context of these really sick patients that we sometimes see together and learning in the context of your own facility and your own resources, I think that's a nice way to kind of think about implementing this stuff.

I think one of the paradigm shifts that I'd love to see happen is to go from

surgeons and residents thinking of MNM as the, what did I do wrong conference to what could we do better? Because really that is what it is. It's not that you necessarily did anything wrong. But could it have been even better?

And I think when you shift the mindset to that, it becomes less blame and more, okay, we did great, but could we have done even better? And if that's your thought process to every case, it really, it makes a difference over the long term. Definitely, and I think, you know, one thing that I always think about, too, is that, especially in M& M conferences at institutions is we have those, what can we do better conversations at those conferences, but that is one small piece of the trauma care providing team pie.

And it sounds to me that, you know, we need to really increase the dialogue that already exists, but could exist in a bigger way with. The EM providers and with even ancillary staff and anesthesiologists that come down to the trauma bay and do these things just because the ATLS

primary survey framework is not a hierarchical identification of life threatening injuries.

It's just. Oh, easy way to remember them, you know, I think breaking out of that mold that I certainly had as a junior resident, which is that nothing is more important than the airway. That's not true. That just happens to be one of the list of things that is an immediate threat to the patient's life. And we need to reconsider that based off of the patient's individual presentation.

And so maybe, you know, maybe we need to send this podcast episode to the EM podcast next door. Sounds great. Actually, a lot of work that I know Dr. Farr and I both have done over the years. If you don't include your EM physicians, then I think it's not going anywhere. It totally needs to be a team approach and we need to communicate with each other.

Ditto with nursing colleagues. We haven't talked about that as much. I'll tell you, you know, a while ago, this institution, there was a nurse who wrote a complaint because they were very upset because a trauma surgeon prepped the patient's abdomen before intubating. The patient was intubated and it was like, well, actually that's That's the thing you're supposed to do,

and it just means that we need to make sure everyone understands that, that it's not the wrong thing, it's the right thing, and here's why.

And I do think trauma surgeons, you know, I mentioned earlier how we are underfunded for research. We're usually so busy doing the life saving thing, we don't spend enough time talking about why we're doing and what we're doing for life saving. We do need to become better advocates for ourselves, our profession, and our patients, because if not, even other healthcare professionals don't really understand why we do what we do.

I think we are in a good spot to maybe roll into the last little exercise we wanted to do today, which is put you both on the spot for some quick cases, and I'd really love to hear your input on how you'd manage this. And maybe we can do for each you know, talk about how you'd manage it in a really well resourced level one trauma center in the United States.

And then maybe if you were a community surgeon or a surgeon in a global setting where you maybe were the only person in the trauma bay and a, you know, maybe a nurse with you how you would manage in that case as well. John, do you want to kick it off

with that first case? So let's say that you have a patient who is a 32 year old male who is coming in from the field with a heart rate of 120 blood pressure of 80 systolic over 50 diastolic saturating 98 percent on room air, who has a gunshot wound to the left thigh with a large volume of blood loss on the field, who now arrives to the emergency department trauma bay, they have clear pulsatile bleeding from mid thigh injury concerning for a major arterial injury.

Of note, their GCS is six on arrival. All right, I'll go first. I'm taking the easy one. So if you've got to injure something, the SFA is a really fun thing to have to fix. So thank you for this case. I jumped on it. Okay. Jokes aside. So clearly this is a very salvageable patient, but we still need to do all the right things in the right order.

So yes, tourniquet is hopefully already on. This is a patient that I do not believe needs additional imaging beyond a plain x ray. I would get an x ray just off that leg very quickly on table, just to see is there an exit

wound? Is the bullet still there? I get an idea of trajectory. So, because I do think trajectory is everything, that patient would go straight to the OR with whole blood hanging in my institution and then we would start the operation.

That, that would be, I think, the most expedient way after doing a quick roll in the ER or the OR, depending on where we're at. to verify there are no other injuries. I think that's really important, right? I would imagine if I were in a setting like the critical access hospitals that send patients to me, most of them do not have surgery capability, and so I would instruct those physicians to literally just put the tourniquet and fly them with blood if they have it, and that would be it.

Paula? That's great. Is there any difference in whether you might send that patient with a secure airway if you're going to send them out of your less resourced institution? I wouldn't. I mean, I mean, I think that you start, the reason why the GCS is sick is not because they hit the head, it's because they're hypolemic.

Because they're, you're not getting, you're not getting

profuse. It's much better to use that time to get good IV accidents and start giving blood than to use that time to intubate the patient. I would not. And I will advance against, put a little bit of oxygen, jaw trust, have somebody that can back mask.

If you see eyes of six, it still means that they're breathing. Agreed. All right, we're going to make it harder for the next one. So this is a patient who is in a boating accident and they've had progressive deterioration in their mental status while en route to your hospital. They've got bruising to the extremities and the torso with a distended abdomen on arrival with a positive FAST in the right ever quadrant.

Their heart rate is 130. Blood pressure is 70 over 55. They're sat in 84 percent and they're currently on a non maroon breather, getting a new sat after that. There's no external bleeding present. However, their GCS was seven, noted by medics in route, and is now four once they've arrived in the bay. Let me ask you a question.

You told me the fast for the abdomen. What, what's going on with the lungs? Yeah, let's say that there's lung sliding bilaterally.

All right. So with IV access, you start giving blood. And if you're preparing for intubate, you better be preparing to open somebody's chest and clamp an aorta. If you have a little bit of time and somebody's back masking, putting a, an axis for it to do a revoince on one.

That also could be appropriate at this time. Just know that if you're gonna, you're gonna have to intubate this patient at some point. But when that happens, you need to have a plan in your brain because this patient is gonna code immediately after intubation. Do you think that this patient, we mentioned this earlier in the episode, but if that is somebody that the team elects to intubate in the trauma bay, is this someone that could be a good candidate for not receiving rapid sequence meds?

So it depends on if it can you or can you not put the two in the mouth, regardless of the drugs, or even if it's not a drug induced intubation, the positive pressure ventilation is still going to kink your IVC is still going to decrease the a cardiac output and result in hypertension.

So just be mindful. I'm

not saying that the patient requires intubation. And and you might not be able to delay it, but if you're not able to delay it, then you have to be prepared what's going to happen next. This one's definitely the harder case. And this is the one where, for example, you know, the flyby is great when you know the source of bleeding, the approximate location, like the previous patient gunshot to the SFA.

This patient's harder, right? Because you don't really know what's going on. But with a positive fast and unstable patient, we do know that that patient's going to the OR. But I would say in this case, I would try to delay intubation till I could get them to the OR if I, if there was you know, and bag mask or LMA.

I like the LMA in this type of situation to kind of temporize it. But, but these cases are definitely difficult. And I think this is often where people founder and struggle a little bit. Obviously, even within these vignettes, there's a lot of variability on what that person could look like and doing the right thing for that individual patient is important.

So let's see, we have another one here. There's a patient who says a 35 year old male who was working on his house earlier today and fell from a height of 20 feet off of the roof. As GCS was reported to be four in the field and is three upon arrival to the E. D. Patient. Similarly, has a sinus tachycardia to the one forties blood pressure of 70 over sixties, however, has a negative e fast on arrival, does have an unstable pelvis on examination and has obvious extensive facial trauma.

So this is not that unusual of a scenario actually. I feel like I've seen this patient. So I think it brings up a very good point about the pelvic hemorrhage, right? And that's a whole, whole nother session. But I do think that placing a binder on, I like to use the sheet actually, because that allows for access for reboa, for angiography, which a lot of these patients benefit from.

I would actually consider, assuming that you can hopefully get them to be a temporary responder, I would consider a CT scan and

actually identifying what the injuries are because they also could have a pretty bad head injury, and then deciding from there. This patient probably would end up having to be intubated.

I suspect, I don't think I'd be able to delay this patient to the OR. But I would at least have blood available. What's interesting is vasopressors. Do you start the vasopressors with the blood? Society for Critical Care Medicine actually just came out with guidelines, I think about a month ago, on this, not for trauma patients, but in general, if you expect hypotension with induction agents, do you start vasopressors?

And the data is equivocal. It's not clear whether you should or not. In this patient, I would have vasopressors handy, but I would start with the blood and hopefully he would respond to that. I think for patients with pelvic fracture fractures is there is a place where Roboa probably works the best and I don't know that this is an answer that I will give in the boards yet, maybe in 10 years, but I know many of our level one trauma centers in the United States.

I put in sheets and I put in Roboas inflating them in some three decreasing,

even if he's partial. decreasing a little bit the hypertension. If you then intubate, then bring to CT scan, then bring to the OR. And you can do while you wait for your IR colleagues to go, you can do pelvic packing as well.

All of that, what I'm telling you is completely controversial. So take it with a grain of salt, but at the end, like when people ask me, I and are you pro revolver against revolver and I'm think that that method that question is saying, are you pro Kelly clamp or against Kelly clamp, are you pro suture against suture is a tool.

that you will use that you need to learn how to use when you're a person that stops bleeding for a living. And if you know how to use a tool well, it's going to work great. And if you don't, then don't, then it's not going to work great. But it's a tool that we all need to know how to use. And sometimes you have the opportunity to do it.

Sometimes you don't. So as, as, since I'm on the Trauma Burn Critical Care Board, I'm going to defend ABS a little bit here and say we're not that far behind as long as, and I think this is important for the residents

here, as long as you can have good justification for a practice. In this case, you absolutely do.

I think partial rebar inflation, I agree with Dr. Farada, this is the perfect patient for that. If you have that and it's used in your center, it's okay to say that in the board actually. And you can say in my center, this is what I would do. And they're not going to fault you just because it isn't necessarily mainstream in that I'm, I will say over the watching over the last 10 years that I've been involved giving exams, the board is really keen to stay current.

And so if it's a practice that's well supported by physiology, basic science and the literature, and it's what you've seen done to your center. Do not feel bad about mentioning it, because even if it's not in the textbook algorithm yet, it's, as long as it's reasonable, you're not going to be dinged for it, I don't believe.

I mean, I haven't seen that happen in the last many exams that I've participated in. They've really got up to date. That's great. Well, well, thank you both for going through these kind of trickier cases with us, because I think it's something that a lot of us who train in these big well resourced centers don't necessarily

see or even have to think about all that often.

So this was a great session. Hopefully, everybody out there learned a lot. I certainly did after getting a chance to listen in. Dr. Farada and Dr. Disinake, we very much appreciate your time. Is there anything else that you want to mention as some closing remarks before we go ahead and wrap it up? I want to mention to the residents that trauma is awesome.

It's a very rewarding career. It's very intense, but then it's a place where you can really make an impact on the patient's life and the families that entrust you with their care. So we're not biased at all, of course, but yeah, absolutely. So thank you both for having us. This was wonderful. Really appreciate the chance to talk about something that clearly Doug Fred and I both care deeply about.

We love this field, as you can tell, and we like seeing it move forward. I think Watching evolution, even in our own lifetimes is incredibly rewarding. And hopefully the next generation gets to see that happen even

faster as we become more evidence based and you know, the volume of scientific literature is getting faster and faster.

But hopefully that's all helping us help our patients. So thank you both for having us. Absolutely. Well, once again, from from us and the rest of the behind the knife team, thank you both for joining us today and for all our listeners out there until next time dominate today.