Session 14 - Annual Trauma Debate

Well, good morning and welcome to T-C-C-A-C-S 2025 debates. I'm thrilled to be here with you all this morning. It's great to see so many people stick it out. This is a feature of this meeting annually, and we have some stellar combatants today to go head to head on some great topics. With that, I just wanna run the rules of the road for the debaters.

We'll have a 10 to 12 minute initial presentations. Uh, and that'll be followed by a couple of minutes of rebuttal or question and answers. Uh, either way, if there are questions from the audience, please use the system we've, uh, put together to let me know. Once we're done, we'll use a show of hands or sound of applause or some, uh, object, clearly objective measure to declare the winner.

Okay, so with that, I say we go on ahead and jump right in this first debate topic. Uh, is a good

one. It's one that I've seen both sides of resolved video review should be used to improve trauma, resuscitation and team performance. Opening our debate today. Taking the pro position will be, uh, Ryan Duma.

Ryan is from the Baylor College of Medicine, uh, associate Professor of surgery, uh, and a former trainee at my institution. So I am very much looking forward to this. Ryan, the floor's yours.

Thanks Alex. Uh, thank you Dr. Maddox. And Mary, sorry if I just record you, so, yeah. Yep. Feedback. Thank you Dr. Maddox and Mary for the invitation to speak. Um, I gotta tell you, when I got a call from Dr. Maddox that I had a chance to talk about video review. Uh, at the Maddox conference, I was beyond thrilled.

Um, I spent the last 10 years making video review my mission, uh, and I really just want to get it out there and show you guys what modern trauma performance improvement looks

like. So, uh, with that, let's get started. Uh, these are my disclosures. Um, now we're gonna hit on a lot of things pretty quickly.

All right? But I want to touch on the background. We're gonna talk about technical skills and video review. We can now assess procedures we do in the trauma bay using video review. We can watch thoracotomy, right? We can assess how long it takes. We're gonna talk about non-technical. Huge domain, right? More and more we're seeing how important tech, non-technical skills are in trauma resuscitation.

Then we'll talk about leadership, right? We're quarterbacks in the trauma bay, right? So we'll see what that looks like and how that correlates to our patients' outcomes. And then finally, we'll finish off with the TVR top 10. So, you know, first the word about my opponent, uh, Dr. Bilal Joseph certainly, uh, is one of the most accomplished trauma surgeon scientists in our field.

Um, and he is gonna try to convince you a lot of things. Alright. And honestly, I'm gonna let the trauma ponce improvement that we can get from video review, do all the work. You guys are gonna see the impact of video review, okay? But he's gonna try to convince you that TDR carries

medical legal risk. We have talked to lawyers, we've published about it.

Lawyers agree that the benefits of video review far, far outweigh the small spa, medical, legal risk of exposure. He's gonna tell you it's expensive, not true. He's gonna tell you it's without evidence. He's gonna use the words, where's the data? He's gonna tell you it's gonna be punitive. I'll tell you, we've studied nursing culture, resident culture, trainee culture.

It's absolutely very, very well perceived. And he'll also tell you it's just a trend. It's not a trend. Guys. We're here talking at it about it. One of the national largest national meetings in trauma. But remember too, guys everywhere. In modern society, everywhere you go, you're on camera. We're in a casino, right?

And so in the city of London, there's one camera for every 13 people. Right one camera for every 13 people. And interestingly, only three and a half percent are government controlled. The people want. We wanna know when our Amazon package arrives on our porch on the ring camera, right? It's part of our society.

It's part of the

fabric of society now, right? Just last year, the city of Las Vegas implemented 22 brand new cameras just to read license plates. So let's jump into trauma video review. Okay. So really. This is not a debate between Bilal and I. This is a debate between Epic, the Electronical Mecca record, and modern performance improvements.

We are high performing trauma functioning teams, right? We should be just like athletes. There's no way Peyton Manning goes into the Super Bowl and does not watch tape, sees what the team did well, what his opponents are doing, how they could be better, right? This is part of the fiber of sports culture, right?

Watching tape. That's Ray Lewis. That's Ed Reed. That's Peyton Manning. They're all watching tape. They're getting better. They're figuring out their weaknesses, how to communicate as a team, because this is the problem. What does trauma, uh, performance improvement in education currently look like? Is the status quo?

It's, it's the EMR is fairytales when it comes to trauma, right? We teach trauma in a vertical fashion, but it doesn't, it happens horizontally. Everything happening at the same time. So trying to

recreate a trauma of resuscitation from the EMR is fairytales. We've all done it. So the really, the devil's in the details, right?

That's the thing. Now, using trauma video review, we study leadership. Tone tempo ca was the chaotic, was how was the time managed? We've heard over and over this week how important it's to get to the next phase of care, right? So now we can measure it and we can study it, and we can figure out modifiable risk factors to decrease that time.

So this is a video. The, the, the patient consented to share his video. Uh, this is during me during fellowship and within the first 30 seconds, watch, watch this patient. And the, the critical mistake that my team makes, there's no audio. This is a trans cervical GSW. Right. First 30 seconds, what do I do? Oh, let's lay this patient flat.

Right? Right. It's the collective sigh. When Kenji, when Kenji Naba showed this videos of the police officers trying to help the patient, it's this collective sigh when we see what we're actually doing in a trauma bay, right? It's really dramatic to watch this play out. I'll tell you that team

never made that mistake again.

You'll never find that in electronic medical record. So because we've shown this, right, the electronic record record is woefully inadequate for this. Right. So we still, we studied procedural milestones of thoracotomy and sure enough, with uh, TVR, there's two data points we're absent that we were not able to capture With this, the chart, it's almost all absent, right?

So we're taking care of these patients, but we have no idea to tell how we're doing. Right. Okay. Same thing in P pediatric literature, right? In a subgroup, this is pediatric video review. In a subgroup of patients with an ISSA, greater than 1154 errors in 22 patients were identified and only 10 of these were identified on the electronic electronic medical record.

Again. So I hear some, I've heard people, oh, what about in-person data? Data collection? So this is the same thing. We looked at this too. We had an in-person data scientist record and watch trauma resuscitations, right? Same thing. Totally inaccurate. Right. So now we have a tool to have the most robust data collection

granular data that we can get for trauma resuscitation.

We can pause fast forward, rewind, review. And guys, it's not a trend. This is data we published over 10 years ago, uh, not quite 10 years ago, years ago. It's from east. It's level one and level two centers at the time, 30 centers, excuse me, 30% of trauma centers were already using video review. I'll tell you, I get at least one or two emails a month from centers asking for help and advice about how to start a trauma center.

OHSU, duke, Yukon, Orlando Health have all started video review centers in the last six to eight months. Right. And when video review was first described in 1998, excuse me, 1988 by Hoyt and Shafer, they were using this. This is a cathode ray tube tv. They were wheeling it in with the VCR dusting off the tapes like we can now do it with this high definition, HIPAA compliant audio visual technology that is not expensive.

You can do this for less than $10,000. You can have your team culture, your team dynamics change as you watch your resuscitations. This is

just a platform. And you'll see this particular platform, you have a complete 360 degree, degree view of the room. Right. You can see what's happening. This one is incorporated with vital signs.

So now we can, we talk about terminal bradycardia, we talk about all these things, right? But actually seeing it and seeing as the patient, as the team gets anchor bias. 'cause they're focused on an injury and they're missing the heart rate drop from 140 to 40 is dramatic. Right? I've had residents come up and tell me, like, Dr.

Aya, that was incredible to watch the heart rate that nobody, nobody saw. Right. So again, we can do this or we can do this. This is Parkland's Trauma video review, multidisciplinary conference. We sit around just like professional athletes and we watch tape over and over, and I'll tell you, we, we highlight things that we did well, right?

It's not always about finding the mistakes and it's, it's highlighting the cult. It's changing the culture. It's having a nurse come up to me and be like, Hey, Dr. Duma, you really need to watch that video from last night. The team like crushed it, right? Because really measuring, Tom, measuring quality. And team performance and trauma.

It really is two simple things. It's technical skills, and now we can

measure those, right? We can say how fast does it take to decompress the chest, right? And it's non-technical skills. We have great tools to measure this. Now, the no tech scale is widely used in trauma, and we use a lot to show how teams impact outcomes and how the performance impact outcomes.

And only then do we have a full true measurement of a trauma team's performance, right? Because, and then it's easy. Make benchmarks, get your team together, be like, Hey, we want to be outta the bay in less than 20 minutes every time. And if we're not, why? What, where did we fail? How can we improve? So technical skills, again, the data is clear.

Uh, and we've shown unfortunately guys, we're not as good as what, what we do as we think we are. 'cause what we do is really hard. We make really hard decisions with limited information. Time to chest decompression for a chest tube. And a hemodynamically abnormal patient is more than 10 minutes. That's the red bar on the right.

Right. That's too long. So now we have a benchmark that we can train to, we can simulate to. Right? Same thing time. Time to aorta, cross clamp video review. Reviewed almost 10 minutes median time to aorta cross clamp

in an exsanguinating dying patient. So I only break this, uh, if you want another great debate between Bal and I, uh, there's a fantastic podcast out there, but I only, uh, talking about IO and I know I always talked about a lot last year, but I only bring up this study because.

19 centers using video review got together to, to create a resuscitation database. Now we've grown to 41 centers using trauma video review to study the way we, we resuscitate and take care of our patients non-technical skills, increasingly important, right? So we have shown how EMS timeouts, how well we perform in es timeout correlates to patient outcomes.

Also, team performance and technical, uh, technical, uh, team performance and how we perform impacts outcomes for every point. Degradation and team performance. There was almost a two minute delay in to the next phase of care. Same thing here. Leadership team decision making right impacts the chances of a Rosc in a patient who had in patients who had ED four economies.

So how we function as teams matters, right? Same thing. This is patients

who came in alive. The chance of a cardiac arrest in person goes up, team tight, team performance is on the right. It goes up pretty predictably at the entire team performance. All studied with a camera. Now the consent process is straightforward.

The vast majority of the patient of patient centers, uh, using video review, use the general consent for treatment. It's well, well established in the medical literature we've actually published on it. This is the medical-legal review of trauma video review in the entire United States, there's only two cases.

One of 'em didn't even involve the video and the one that was involved, that didn't involve the video, the judge did not, um, allow it to be disclosed. But again, video review is so much about culture. Guys, if you, there's one takeaway. Is that the more your teams start finding ways to work better together and communicate better, the more you'll change culture.

Because ultimately that's what the lawyers said. They said that the chance, your chance of decreasing errors increases much, much more than the slight medical-legal risk of exposure. And finally, perception is universally great. We've done before and after studies of programs that have been

implemented programs, and it is well perceived by, by everybody who's under the lens.

So let's finish off with the top 10. Um, video review really offers an unparalleled way to study team dynamics during resuscitation, right? This is absolutely critical. We can study Now, the way we do technical procedures, the way we communicate the medical legal risk is overstated. TVR data is more, is much, much more accurate than electronic medical record is much, much more accurate than prospective data, right?

And guys, it's here to stay. The technology is only gonna get better, right? And we can incorporate into all our aspects performance improvement. Educational conferences, research, and, and I'll tell you, it's not going anywhere because now we've, we're moving into the operating room, right? We're studying critical events in the operating room and how the, how the teams perform, and we're identifying errors for, for opportunity, for improvement and changing the way we communicate and talk to one another.

And finally, we've heard all week about ai. Uh, these are some collaborators at Stanford. Now we're overlaying AI to help us. This is such an

incredible data source that the next challenge is how to use all that data and how to impact our patients, our patients' outcomes. Thank you.

Thank you, Dr. Duma, taking the composition as a surgeon and scientist that needs no introduction to Dear Friend. Please welcome from the University of Arizona, Dr. Bilal. Joseph, good morning. This is your first Maddox meeting, isn't it? That's right. Yeah. You mentioned, I've just changed my talk. You mentioned that it's being presented here.

I just want you to know things come here sometimes to live on and sometimes to die. History doesn't favor those being watched. It actually favors those doing the watching. So before we turn the trauma bay into Baywatch, let's talk about what we're really talking about here. I think it's important, um.

Nothing to disclose. Uh, Dr. Maddox did ask me to be nicer this year.

Um, I'm arguing the more difficult side of the position. There's no doubt about it. Um, you know, uh, you are all under surveillance, as he mentioned, without consent, which is his way of doing things. Um, history teaches us that those who record things often end up in trouble.

Oh, sorry. That was my other talk. I apologize for that. You know, Dr. Deman and I go way back. He's right. We had a great podcast on, uh, behind or, uh, behind the Knife, and this email he sent me was almost two years ago. And he always tries to manipulate you and the whole narrative. And so I just put that email up there.

But last year when I presented on iOS and we killed iOS for resuscitation at this meeting. I sent him the video when I put judgment 'cause Dr. Maddox gave his review and he's like, and then he tries to mock Dr. Maddox and says, you know, super saphenous vein cut down in 15 seconds. A think I can convince Dr.

Maddox to install IO kits in every bay. When I moved to Ben Top in September

and out of respect to you and your privacy, I didn't go down the rest of the talk there. I stopped there. Let's just be clear. So he is a, he is an expert, there's no doubt about it. He's been writing about this for over 10 years.

He's got over 19 publications. I've never written, I don't know a lot about this. I had to learn as I went on. He has podcasts and videos and so there's no doubt that we're here, uh, in his world. Um, you know, his generation is the generation of selfies and pictures, and every time you eat something, you gotta take a picture of it to make sure it tastes good.

And so I understand where you come from. It's really cool. And this is a bad trauma bay and you may wonder why it's bad. And Dr. This is a good trauma bay and this is even a better trauma bay. But the truth is, you know, um, you can watch that video a hundred times. It's not gonna stop bleeding. It's not gonna save a patient's life.

And you know, Dr. Cotton has mentioned this a couple times. Big Brother is watching you and he mentioned the

litigation risk. He said, I was gonna say it's a highly litigated area. Uh, we will talk a little bit about this with his own paper. 9% of trauma centers experienced medical-legal issues. Only 3% reported an actual medical-legal case that actually went to court.

But like everything, you know, one case is enough to kind of shut down everything. 30% of centers don't consent their patients. Around 50% of centers consent within a broad consent form. You know, he showed that first video of the cutting the patient's clothes and the patient's face was exposed. Does your consent allow that?

But if you watched his video three videos later when he had the medical professionals there, they all had white boxes over them. And that's a mistake. I'll tell you. I just picked up on that while he was presenting. But did we get consent to put the patient's face in front of all of you? I don't think so.

And so, Dr. Demas definition of HIPAA helping invading privacy on admission agreements. And then if you're gonna

consent patients to the video, do they have a right to it? Good question. Another paper here, I, I'm, I'm gonna be very objective with data here 'cause I think data is super important. Determine patient's perceptions of audio video recording not in trauma elective patients who are gonna be recorded, what they were concerned about, privacy and data breach.

Tampering of recordings. Surgeons doing things differently 'cause they're being watched. Focus on the recordings rather than the patients. And then did they have the rights to their videos? They wanna learn about their procedures. And what about medical legal things? Why don't we give them their recordings?

Why do we record and not give them their ings? So what about the impact on us as surgeons and providers? How does that work? And the truth is TBR comes with a few things that have been documented. The Hawthorne effect, anxiety, time consumption, and we'll talk a little bit more about that. What is the Hawthorne effect?

When you're on camera, you act differently.

We have eight trauma bay or seven trauma bays in Tucson. One of them has a camera in it works sometimes. Sometimes it doesn't. We don't really use it. We don't do video review at our center. I could promise you when you walk in that room. You are different than any other trauma bay, and that's a real effect.

And so that's a real question to bring forward. And are we seeing reality or just the response to being watched? I think that's important. You know, the feedback of the patient laying flat. You could have told someone to change that instead of having a video review to tell you that. And then here's another paper, 38 ED and trauma staff members in Toronto, Canada.

And how did they feel after being video recorded? Provoked anxiety, general discomfort, fear, it's real things. And then the residents. We heard a whole session on how our resident and trainees are changing the way they are. Fear of judgment. Discourages taking initiative. TVR is teaching tool may intimidate rather than empower.

This is real People, real life answers to questions. This is not my opinion. Half of what he was telling you was his

opinion. He was extrapolating that by doing these things we can change outcomes. That's not the truth. And then eroding trust and creating a culture of blame between team members. That's a real thing.

Again, that's what this, when you sit in a room with your ED colleagues and your trauma colleagues, and the video is being played, that's a real hard thing to kind of talk about. And are we fostering psychological safety or breeding fair and hesitation? And this is how he does his resident orientations.

There's a camera here, and a camera there, and a camera everywhere. The TVR process really requires a lot of time. It's not an easy process. 40% of evaluators note that the video review process is time consuming. Is it taking us away from watching the patient and doing patient care when we're watching videos?

A study found that the majority of centers review more than less than 50% of the total resuscitations. We record all these videos and more than half of 'em, and this study was done by, um oh, Dr. De. What are we doing with all these videos if

we're not watching 'em? I mean, if you, and if you, if video review's so good, why don't we watch all our videos?

I mean, this is his data. It's not my data. Really. Why are we doing this? What do we do with the unreviewed videos? Another question. I mean, it is cool. It feels great and you know, but I don't know. What about data breach? Is that a reality? We've presented at this conference multiple times. Every seven seconds, the dark web is coming in and taking our data.

You know, states are affected by healthcare data breaches, average cost 9.2 million. And Ryan, so you can understand that, that's about 6,000 cameras if you want to do the math to kind of understand what that would cost you. But it's a real thing. People are coming after our data all the time as as a terror weapon, as taking down hospital systems.

It's a real thing. We have to be careful with this and then does it really work? This is the most important question to everything. There's the hindsight. The Monday morning quarterback, hindsight bias. The tendency to see events more predictable and preventable after they occurred. So you

go in there and you're like, oh look, we should have done this.

We should have cut the glue. Should have sat 'em up. We should. Was that gonna change the actual outcome of that patient? How much do you take away from that video review? Have you ever done that study? How about unfair judgment? Decisions made in real time are judged with the advantage of knowing the outcome.

We know what happens to that patient when we're telling people, you should have done this. You should have done this. We should have gone this. Or had a, Hey, great job doing the chest tube, but are you gonna really change the chest tube insertion that went into the liver by watching a video? I don't know about overestimating predictability.

I love his, his energy, like it's so positive. I'm just trying to bring him back a little bit to re OA and iOS. Like, let's, let's be real here. You know, I'm not saying we shouldn't do it at all, but we gotta be careful and are we really seeing reality or judging the past with an unfair, clear image of what's happening?

And here's another study. 25 patients were included in the study. They did video review and then they did EMR review. Uh, so they looked at the EMR or they looked at the video. TVR

missed more variables than EMR. They were able to get 1200 variables from looking at the EMRs, 700 watching videos, and most of the medications they inability to assess came in the TVR.

So it's, there's ways to review, I, I'm not against it. I'm just saying that you gotta be careful. What, what? We're really taking another data. That's another thing. Unfortunately, Dr. Demas, he's written 19 papers and he only reads his papers. If he would read other people's papers, he would see areas he could improve.

140 participants, physicians and nurses. They did a, um, they did video assisted oral debriefing or just oral debriefing afterwards on BLS and a ED scenarios. They pretested post-test, the intervention. No difference when they used the video and not just talking about it was enough. Here's another paper.

284 patients with cardiac arrest were brought in, you know, they did video review and then put these teams back out there to change the outcome of the patients. The word outcome is the most important word here. What did they see? They did see a better improvement of

Rosc in the video review. Survival to hospital admission on discharge did not change.

So what are we really fixing by doing this? The biggest flaws really are, you know, every hospital has a different regulation. Some let you do it, some don't. Some want the tapes. Some people give it to the patients, some people don't. You know, should we review every video? Why are you recording patients if you're not gonna do it?

And if it's so good, why don't we review all of 'em? His paper said 50% of the time, they don't even look at the videos. Should we record every patient? That's the other thing. And so I, I really think, how long should we keep the videos? 30 days a year, six months will they be litigated? I promise you the lawyers can get those videos if they want them, and no study has ever measured outcomes after video review.

There's studies that have measured other things in trauma. He's written 19 papers. Why haven't you written one on an outcome difference? That you actually improve patient care? 'cause it doesn't. So

world's greatest unsolved mysteries ERA 51, the Lochness Monster and the camera and the trauma bay. I think the take home points are video review increases your risk of litigations his own data.

It's not, don't just blow that off it, it's real. Patient privacy is a real risk, and this consent is, I'm gonna use the word bullshit. 80% of patients don't know they're being recorded and they have this, our consent form of Banner Health, I think is 27 pages. In the third line is you may be able to use video to put in your chart and all this stuff, but a complete video.

I mean, people are signing this without knowing that you're gonna be bringing it to a national forum and showing their face, for example. And I just picked up on that today. I think it's important, man. You gotta be careful with this. Compromises surgeon, psychological safety, it's not that easy. It does impact us.

0, 0, 0 clinical trials or studies on the

clinical outcomes. And then my hindsight bias was I already knew I was gonna win this debate. I wanna thank Dr. Dumas for this debate. Thank you very much.

It's always a pleasure to watch the rookie debaters walk into the lion's mouth here, Ryan. Alright, we're in the interest of getting us back on time, which we will, uh, from the previous session. I'd like each debater to have no longer than a one minute rebuttal. We'll turn it to you, Ryan. I feel like I want a bit of a trap here.

I feel like I walked into a bit of a trap here. Um, no. I think Bilal makes some excellent points, but honestly I wanna hit on the consent. Um, HIPAA protects the use of VIDEOGRAPHIC data, right? It's clear we can use videos, right? That video that I showed, I have explicit consent from the patient on a signed consent form.

So videos that are used internally, we keep in for pi QI processes. The vast majority of centers delete days in delete the days in 30

days. The lawyers that we have spoken to over and over, across multiple institutions always say the same thing. It decreases your legal risk exposure by improving quality of care.

Metrics culture. When we get better and identify our weaknesses, we get better as teams. That's how that works. And then one of the things, honestly, like these videos will save lives. What we do is high impact, low frequency. Right? So that's why I don't, we don't need to watch all the videos. That's exactly, that's true.

We need to watch the ones that impact the timing is so critical. Thoracotomy, cris, airway Management, that's the ones we save and look for in the videoconference and then delete. That's the video that matters. So we're not watching all the videos. That's true, Ryan. That flashing red light, that flashing red light down there, that's the one that means your times though.

You know, there was a time we watched the patients and now he's talking about videos of thoracotomies. I mean, these are sick, dying patients. You're really gonna change anything in that moment. I mean, in sports, they always say sports, we watch videos.

Well, if you win or lose the game, you get the video. You know, why don't patients get their videos?

Then? Why are, why are we so protective? And I would just say, you know, Ryan. I want you to take this and continue to push it forward and just read other data out there to help you. I really think it's important, um, but look, there may be some uses for it, but at the end of the day, just be careful. Don't get on this train.

Just 'cause it's cool. It is one. I know he mentioned that that wasn't a real thing, but it is a real thing. I don't think. Changed anything yet. We've been doing this for a long, long time, and video review's been around for a long, long time. It's just, we got another champion for a little bit and we'll see how long this one goes.

Thank you very much. All right. Uh, if we can, it's time to cast judgment on this debate. If we could bring the house lights up. Thank you. All those who believe that Dr. Duma carried the day with the pro position. Please raise your hand. Oof.

Ooh. Alright. All those who believe Dr. Joseph carried the day today, please raise your hand.

I hate to say it, Ryan. I think the old dog's got it guys. I love you guys. The old dog's. Got it. Alright. A round of applause for the debaters. Thank you very much.

Good job boys. Good job boys. Yeah. Great job. Great job.