Session 14 - Annual Trauma Debate

Alright, we will bring our next two debaters to the stage. Similar ground rules today, gentlemen. Uh, 12 minute opening with a one minute follow up. Resolved the stability challenge. Unstable patients should go directly to the or. Two fine contestants today taking the, uh, the Pro position Dad Puzio from University of Texas, Houston Health Science Center is gonna take the pro position and kick us off.

Welcome.

All right, another rookie. Uh, thank you Dr. Maddox and Mary. This is another David and Goliath. So I, I, my disclosure is I'm a lover, not a fighter. So have mercy on my soul. I think I'm gonna actually support both of the previous speakers as we go through this. I was realize that as I was sitting there, so, alright, got a question for everyone.

Is there anyone in this room that thinks either of these

patients should go to the emergency department? To get something done in the ED that you can't just do in the or. And I think that's an easy question, right? Everyone can say, the paramedics know this. The firefighters know this. We could probably go downstairs to the casino and ask people and they say, oh, these patients need an operation, right?

They need a surgeon. These are easy ones. Well, what about this patient? And I think this is the patient that, you know, this system really is about. So the. 23-year-old gunshot wound to the abdomen in the back heart rate of one 40 systolic of 70. This patient has hemorrhagic shock from truncal penetrating mechanism.

They should, they should not stop in the emergency department. They should go directly to the operating room. And we're gonna talk about why. The first question is, well, when do bleeding patients die? And this has been talked about. We've heard about it today. It's, this is an older study from our center, but this, you know, and people will say, this is.

That's kind of a long estimate, but the median time to

death in this study of a thousand trauma deaths was 99 minutes. So that's kind of our, our target. Right? How does this work when we think about the patient, so time zero, the accident occurs, or their injured, the average EMS response in the US somewhere around seven minutes.

So it takes seven minutes to get there and then to the trauma center, anywhere from 30 to 70 minutes. So we're looking at. Let's say 40 to 80 minutes before they hit the door, right? This is something that we can't control, but what we can control is what happens next that time from the ER to the operating room.

That's what we can kind of, we can affect. And again, let's say 99 minutes is our theoretical target. So there's some studies that I look at. As Dumas said, it takes a lot. We, we spend a lot more time in the ED than we think we do. Um, this is a study from the UK looked at 1600 patients. So you can see in the blunt trauma they had

56 minutes in the emergency department penetrating a little less, 37 maybe you argue, well, that's in the uk or maybe they didn't use video review.

Right. They should get better. That's a long time for those patients that needed a laparotomy. But this has been replicated. This was in the US so they looked at 243 hypotensive patients that needed emergency laparotomy, and what they found was median time was 55 minutes, right? That's a lot of time for these patients that are dying and they need surgery, and they also found the probability of death increases by 1% for every three minutes in the ed.

So like every minute that ticks by your risk of death for these patients increases. I like this one, right? I think maybe this is a good study that could be redone with video review and see if they can find more results. So they looked at opportunities for improvement from their medical record, actually.

So 423 deaths from hemorrhage, 150 opportunities for improvement, and over half of

them occurred in the emergency department. So this is the normal flow, right? We said 40 to 80 minutes, 50 ish minutes in the ed. To the operating room. Uh, you can see the average time there. That's a lot of time. Well, I, I think as Dr.

Joseph said, maybe if we just get rid of video review in the ED altogether, just get rid of the time in the ED and that that debate is closed. Right. We don't even have that debate anymore. Just go, take this patient who we all know needs an operation and go straight to the operating room, and that's what we're talking about today.

I think that's, that's, I'm the pro position. But this is not a, this is not a new idea, right? This is actually a really old idea. Again, I'm a rookie, so I don't know if anyone's ever talked about this at the conference, but this was actually described in the 1960s, which is surprising to me. So at University of Louisville, they talked about 10 years of doing this, and it was for cardiac stabs.

They actually operated their, or was in the ed, which was pretty cool.

But if you look at the literature, so PubMed, you know it kind of. Died out right after that. Right. There's not really much literature on this concept until really the last 10 years is when people started publishing on it. Again, the first question is why?

Like, why would you even want to do this? Right. Well, I think time is the most important thing, and we've heard a lot about pre-hospital resuscitation with whole blood, but getting them to the or for definitive hemorrhage control is important. There's a, a lot of studies in your syllabus that I outlined here are a few, and the, the theme is the same, right?

You can see the first one. Seen to, or 11 minutes surgical start, 13 minutes median time to surgical intervention. 23 minutes. That's, that is a, a very short amount of time. So if it shortens our time, people argue, well, who do you do this on? Right? We can't just take all our patients to the operating room.

We can't, you know, take patients that blunt trauma with a lot of other possible areas for bleeding. So I would say the indications vary

and you kinda have to figure out what works best for your hospital. And your EMS agencies, and we'll kind of, I'll give you some examples of that. So we look at two papers published on this.

So Dr. Martin et al, you can see on the left, that's their criteria. Pretty liberal. There's a lot of things on that list that would get you going directly to the or. And you compare that and contrast it to the criteria on the right. Much more limited. And I can tell you that in our center, our criteria is.

Much more limited because if we follow the one on the left with our volume, we just, you would overwhelm the system, right? So you have to look at your system and your resources and figure out how to make this work. We've also published on this, um, some of the criteria that we've used, uh, for this direct to operating room score.

But, you know, some of the critics would say, well, you know, as you can see, we have pre-hospital. Fast, and that's not across all spectrum. So we're trying to revise this and see if we can kind of eliminate that and figure

out how to better our criteria for these patients. So how, how does this system work?

Right? Who triggers this system? How do you initiate this? Well, I can tell you again, it varies by center. Sometimes it's the EMS agency, sometimes it's the surgeon, sometimes it's even the ED physician who takes the call. So for us, it depends on whether it's a helicopter crew or it's a ground agency. So if it's a helicopter crew, I get a phone call and I actually have the helicopter crew saved in my phone.

So when, and they have a special ringtone, so when they ring, I, I know that, oh, this is, this is gonna be something good. 'cause the helicopter crew's calling me and you pick it up and they're, they're like, this is the patient that we have the mechanism. And they, they on scene say, Hey, we should go directly to the or.

And then I say yes or no. And it sends a page out to the system and everyone kind of convenes in the operating room and we make this the res, the resuscitation starts in the operating room, but there's no I in team. Right? We've all

heard that. I love that phrase. 'cause it's not, I mean, we could all sit here and say, oh, this is great.

We should do this. But just as trauma surgeons alone, you can't really make this happen. You have to have buy-in from the system. Right. Your anesthesiologist, ours. Do A TLS and they train with us on how to resuscitate patients. The blood bank, we've heard a lot about that. You know, they are on board with this.

They bring the MTP coolers to the operating room. Patient registration. We learn the hard way. This is also a really important point 'cause the, everybody gets really flustered if they can't document on the patient, and this was a kind of a hiccup when we first started, or nursing. They need to know X-ray, even the emergency department because there's a.

What I call the fake news patients, right? So we've had patients that go to the operating room, we initiate this response, and then all of a sudden you find out they may not need an operation. I had a patient that had a carotid blowout, and the medics came in holding pressure on their carotid

blowout, and we get to the OR and we get ready to intubate 'em, and we take pressure off the carotid blowout, and it was just blood from a scalp LAC that had fallen onto their neck, and the medics were trained to just.

Hold pressure, but you know, we have an algorithm for that, right? We just aborted this or pathway and we went to the ED and we, we made it work and it was fine. This is what the system looks like. You can see here controlled chaos. But I think it, you know, when I think about this, it's, it's kind of like a NASCAR pit team, right?

Like anybody can change a tire, but in order to do that really well, you can't just show up on a Sunday on race day and just. Do this as a team, right? It, it takes a team to do this. And I can tell you that we, this is kind of like a quality improvement project. We sat down with all the stakeholders and figured out how do we, how are we gonna do this as a system?

Once we created our protocol, we practiced, right? We had a mannequin and we ran through the scenarios, and then we decided kind of what was

working and what wasn't working. And even when the system was in place and when it's working well. We still, we still do, uh, feedback. We don't do video review, but I, I mean, maybe that's a thing for, uh, direct to or, so this system is something that you can implement, um, based on your center and your resources.

And I included, uh, a QR code to our guidelines just to get an idea of how it works for us. Uh, turn it over to Dr. Debo. Thank you. Thanks.

In keeping with the, taking the lambs to the slaughter. I feel I have to say that, that, that, that was the most gentlemanly debate I've ever, I don't think I've been here one time and not see the debate or take a single, no, I don't applaud that. I don't see, I don't see, I didn't see one shot taken at Joe Dubbos and trust me, there are plenty.

Let me bring the con position debater to the stage. Dr. Joe Dubbos. Uh, incredible. Uh, history of

service to the United States in his military service. And now, uh, professor of surgery down at UT Austin, taking the composition. Please welcome Joe dubose to the stage. Oh, thank you. Yeah, he is, he speaks softly, but he carries a big stick.

So, um, and I'm gonna self deprecate a little bit to make Dr. SEO's job a little easier. I don't, my conflicts here don't matter. I mean, look at this guy. He's a rising star of trauma care and, and you, you read, dig into his history. It's always good to size up your opponent. He's a former rescue squad, fire department volunteer.

He is well trained. Practice clearly well composed. I mean, you look at health grades, he's got five stars. Patients write damn essays about how good this guy is. Incredibly safe and quite comfortable with his medical decision making. Of course, I'm, I'm, I'm, I'm a little bit daunted at this point, right? I mean, you, you put me up against the firefighter, Dr.

Maddox. Thanks Allison. Appreciate it. But he also has him a lot of experience at their center. If you've ever been to UT Houston and seen their hybrid, their hybrid trauma, or man as a, as a dual practicing vascular

trauma person, I, I had to wipe the drool, uh, off of my coat when I, uh, after they showed me this thing, and he's written quite a bit about it.

And shown us, uh, that this can work and is the way of the future in some ways. And you know, by comparison, I'm the proverbial punching bag of the Maddox faculty when it comes to debates. I have gotten that Maddox. You could see here the record and the injury reports. The dental work I needed after going up against Maddox in 2018 alone set me back for two years financially.

But I was born in the state of Texas. I know the story of the almo, so let's close the gates and let's get to fighting and swinging our things so wide, direct to the or. It makes total sense. Rapid hemorrhage control. That's what we do. Stop patients that are bleeding, definitive hemorrhage. Cool. Let's get there as quick as we can.

Quit futzing around. But my bias here is that deliver you a hybrid operating room. And I will say, if you're gonna do this, that's where you should go. Go where all the hemorrhage control interventions are capable and, and present. You bring that full tool toolkit, it might. It might, you know,

be a challenge here.

So my humble considerations are that for all the resources and effort you need to make this, how, uh, happen, how often do we really need it? Pretty expensive modality to bring into bear and are there select circumstances? We're kind of slowing from a sprint to a jog might actually prove beneficial to the patient, particularly as it applies to the use of some critical imaging.

We don't live in the world of single size scanners that take 30 minutes anymore. You can stop and get a head CT in about 30 seconds. So this is Dr. PIOs, uh, own data two year study, approximately 40 patients per year that they enrolled in this thing, right? Not a big 10% of the patients that met, uh, the criteria for inclusion here.

How there's another, there's a myriad of studies. I gave some of this in the innovations I talked about the hybrid, or this is the raptor room. And again, a very capable hybrid capability in Calgary, uh, that they introduced in 2014. 35 patients over six years were effectively used for this, right? And they had no difference in outcomes.

So what are the risks of going direct to the OR and

bypassing kind of the acute imaging that we're taught may be important in the trauma world? Well, I, I really think it's specific injury patterns we have to think about that we might miss that might have actual detriment for the patient. And that includes traumatic brain injury, spinal cord, and some tho abdominal injury.

So does a delay in TBI diagnosis and management matter in these two patients? I would contend it does, and there's some data to support that. Right. So the decompressive craniectomy literature is fascinating and a whole separate debate, but several systematic reviews have shown that when you have a delay in decompressive, craniectomy IE, taking someone to the OR for an X lab that may not be needed or just to put in a chest tube or intubate somebody, we create a situation where we may have significant detriment for the patient.

Here's another systematic review and it's fine Print down there in the bottom. Their contention here, and I agree with this, is that early decompression of the, of the cranial vault in patients who need it, saves lives with patients with TBI and we can make the same debate for spinal cord injury as well.

Uh, there's certainly

neurologic injury in general does not lend itself to being ignored for very long. We know that delays with transfers for spinal cord injuries have significant detriments, significantly higher, 30 mortality, and a host of other adverse outcomes and even intrahospital. This is an A CST Quip study conductor over six years that found a amongst spinal cord, tho cord abdominal spinal cord injury.

Patients delays were associated with significant increases in major complications. Do we miss diagnosing these by taking the patient to the operating room in a direct to or pattern? What about thoraco abdominal injuries? You get into the wrong cavity, right? Some of these can be a little tricky, and there's multiple papers that have been written about this, uh, from my own, uh, former training background.

Dr. Demetri and Dr. CIO wrote about this. Four year retrospective study, 254. Thoracoabdominal injuries. 29% needed a thoracotomy and emergent laparotomy, but most importantly, inappropriate surgical sequencing occurred in 44%. They got in the wrong cavity, and if they had just stopped to get a CT scan, they might've been able to move more

efficiently and effectively through the patient's care.

Okay. And then there are some other studies here that have talked a little bit more that I think are worth highlighting about direct to or Matt Martin sitting over here who's also my asked in, uh, debates before, uh, has written, done some nice work on this and they've looked in 2021, they reported the first of their two series and found 104 cases and direct to, or actually had a negative impact in 9% of those patients.

Is that something we could ignore? Did they miss something with CT scan that they could have a diagnosed. Expediently. Now I know what you're saying. This is the part of the talk where either people think you're crazy or they're coming after you with the torches, if we had mics in the aisles, the old gray-haired fellas and ladies would be up telling me, I'm nuts to say we need to get a CT in an unstable patient.

Right? But the practical reality here is that instability is a bell curve spectrum. Right. Just because you have showed up to the hospital, a blood pressure of 75 doesn't mean that after 500 units of blood of, of crystal or blood, that you're now not stable enough for a CT scan, which can be

done in a matter of seconds when it's really focused utilization looking at the head and other areas that you're concerned about.

So we, there are non-responders, we just have to run to the OR with, it's just a practical reality. But the responders, impartial responders, maybe we have time to get a little bit more information that can guide us and is this dangerous? Uh, to get imaging in, in, in the setting of hemodynamic instability.

Sure, there are risks, but those risks have to be outweighed and, and, and I, I think that this is a Cali study from Cali Columbia. They, they did, they took 171 hemodynamic unstable patients, about half of which went to the or half of which went to CT scan. And with the CT scan surgery was avoided entirely in 54% of patients.

And it was helpful in deciding dent, definitive specif specific surgical management in 46. Importantly, there's no difference. Between direct to or and CT patients in this particular study. So that small, very brief pause with modern CT scanners didn't have any detrimental effects. So I'll say my, my initial points on this is the direct to, or I

think have probably limited applicability relative to the resources that were thrown at it.

In terms of the capabilities. There are important subsets of patients that if we move too fast, we're gonna miss some things. And the number of patients likely to benefit from appropriate rapid imaging is probably larger. Uh, than the number that'll go to the or. Now I'm going to take a little, I'm gonna go off script here 'cause I got more time and I'm gonna do my rebuttal here as well, right?

Again, I'll come back to this guy. Look at him. I mean, he is a rising star. By comparing, I mean, he's even got the smirk down for the Brad Pitt. They have the same smile and I stand before you looking like professor Dumble dork from the Gryffindor School of Hobo. Okay? So I understand appearances and I know I'm up against it again, and my record's likely to go to oh and nine, and I'm okay with that.

And I am largely convinced by the work that Dr. Pio and them have done. But my real kind of secondary point here is if direct to the OR is good for some patients, how do we optimally identify them? Because I see a lot of struggles in that battle space. We'll go to Dr. PIOs own paper.

Here's something I love to do with papers.

A little kind of master's class that somebody taught me along the way. If you Google, you know, you can now search right within the text of these things. If you put interestingly. That is where after that word, interestingly is where everybody puts the data. They don't know what the hell to do with, so I did the same thing in this paper.

One interestingly showed up, and it is as Dr. Puzio well knows and appreciates, that's why it scratched his head of their comparator group. The patients who did not go to the or the majority of them had scores that indicated they should have. Yet those patients did pretty well with, with, uh, some of them needed a surgery in an hour.

Probably could have gotten some CT imaging in that hour. And if I do the math here correctly, about 12 of them didn't need any operation in the first 20 hours. So. Uh, you know, the, the interestingly thing played off here because I think that that highlights the, the, in our inability to accurately define who these patients go into the or with.

I'll come back to Dr. Martin's work who's done two papers on this. The 2021, only 41%

underwent an emergent lap, uh, lapa mirror emergent surgery after going the operating room, using their criteria and direct to all or in retrospect was deemed to improve care and only 63%. That's a being wrong a lot of the time.

Dr. Martin followed on with that to show us that really the only independent predictors associated with the need to go to the direct or was ISS well, that doesn't get calculated by my trauma registrar two week, two months from now. That's not helpful to me at all. So how do I even identify these patients real time?

They followed on, uh, this is fresh off the presses, February of 2025. Uh, looking at the, I assume the same 104 direct or patients, they just went back and did another project using the same data, which is a tried and true method of academia. Uh, but largely they went and the majority of patients selected for direct or deemed appropriately triaged, but only 44% had perceived benefit from the direct or so.

Even when you set up the breast criteria you can, using all the science you got, you're gonna be wrong over half the time. So even if DTY

policies are useful for some patients. I think they're very infrequently required. There's a disproportionate amount of resources relative to impact for patient care that we're giving, and you probably actually hurt some patients by bypassing imaging that can change their care for the better.

Thank you,

Dr. Dr. Puzio will give you one minute for a rebuttal. And by the way, just a debating pearl for next time you're up here. When a man's walked around with an Uncle Jesse Beard, he even put his own selfie up there. You should have had a cell phone shot of him earlier this week. Alright, doc, we're educators here, folks.

That's what we do. Dr. Puzio, I would say, uh, last week I, my wife told me I looked like a trauma patient and I needed a fresh haircut for the conference. So I appreciate your, it's very nice. It's very nice. Positive feedback. Uh, I would say this. This system of direct to, or we don't use for blunt trauma patients?

I think they're way too complex. There's too many factors. So I

would say penetrating only and penetrating hemorrhagic shock patients only. Uh, it, it, it seems to be the patient group to go after. All right. Outstanding. Well, if we could bring the house lights up, I'm gonna ask a couple of questions before we go.

Um. Um, Dr. Puzio who trains the paramedics in your system? Uh, it depends on the crews. Uh, but we have a anesthesia provider who has a, a medical, uh, OMD, and then there's ed docs, and then we the surgeons as well train them. And what about Houston Fire? Uh, emergency medicine. Okay. Joe, how does that work in Austin?

Uh, much the same. You know, central Texas is really disparate group of, it's hard to get people together around the campfire. It's very different than other locations I've been at. And I, I know Houston has a little more central control 'cause they own the AIR'S assets. Yeah. And

so the highest end of those trauma injuries that come from furthest and need the most attention, they have a little more control influence over.

We don't necessarily have that same degree with within Austin where most of our patients come by ground, we our, uh. Our main helicopter crew, the medical director is one of our partners, so trauma guides that, and we do most of the training for the medics. That's why that was the criticism to our scoring system was pre-hospital fast.

But we train them and we have like pretty good, uh, competency requirements for them. So we feel comfortable when they call us and say, Hey doc, the fast is positive and you know, we, we go off what they tell us in the field. So we have to trust them. Well, I just will end this before we vote with a story. A few years been a bit more than a few, but several years ago, Dr.

Madox and I got invited together to a emergency medicine conference. It was a room like this, thousands of ER doctors, and I gave my talk was very professional. It was Dr was gonna gonna give his talk and

we're gonna go to the airport and go home. And he said to all these ER emergency physicians, he said the.

Only role of the emergency department in the care of the hypotensive penetrating trauma patient is to wave at the guy when he goes on by up to the operating room. And we evacuated very quickly. So we didn't end up trauma patients and, and shockingly, at least I don't, he might've been, but I was not invited back, Gil by association.

Alright, let, I have to rebut. Let's, let's go. Let's vote. Let's vote all of those who believe that. Dr. Puzio carried this topic. Please raise your hand. Oh, we might be seeing Maddox's conference history with Joe Dub. Bo's first win. I'm If you believe Dr. Dub dubose carried the day today. Please raise your, oh my God, heaven.

Help us, ladies and gentlemen. His first win. Joseph dubose, my first win.

Alright,

we will take No, no, we won't. Uh, I have an executive question on this debate. Uh, I have criticism of the program committee that we asked the wrong question. The military has put the emergency room tent, the operating room tent, and the ICU tent right there together. Uh, I, um, have seen, uh, recently, uh, Japan has made a gantry.

You come into a location. Patients put on that gantry. The CT scanner is right there in a punch of a button, and that same gantry is the operating room and the ICU is right there next door. Maybe the question ought to be a redesign of our, um. Acute care surgery, trauma, surgery location in the hospital, rather than making it on the first floor, the fourth

floor, down the hall, uh, across, uh, across the parking lot.

Uh, and maybe the whole concept in the way we built hospitals, uh, even now was incorrect. Uh, you can comment on that if you wish, but I, it suddenly occurred to me maybe we asked the wrong question. Yeah, I, I will just say, uh, having seen some of that Japanese data and some of the videos that are out from there, uh, for those not familiar Japan, they don't have.

Like a trauma surgeon in house. Right? So it's an interventional radiologist in the ER doc that partnered to do this. And they have a head seat. You come off the gurney. I showed some of this in the Innovations Conference, or at least a couple of slides. They come off the gurney, they go on to bed, they get a, a seat, full CT scan, and they proceed immediately to access an interventional, uh, hemorrhage control.

And it's, it, it is, it is literally like the NASCAR paradigm, uh, with how fast it is. So I think June Mat Moore was here. For, he had a session, uh, earlier this week. If he's still around, ask him to show you some of that stuff. 'cause it's, I agree with Dr. Maddox. It is

a very impressive, um, innovation in trauma care.