WEBVTT

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Welcome guys to Behind the Shield. My name is

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James Gearing and this is episode 24. And my

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guest this week is someone who kind of hits a

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little closer to home. Dr. Joseph Ibrahim is

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the Trauma Medical Director at ORMC, Orlando

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Regional Medical Center, which was my primary

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hospital in my old fire department and is my

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primary trauma center even now. Now... We are

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going to talk about the pulse shooting. That

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is not the whole focus of this interview. Dr.

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Ibrahim is an extremely interesting and intelligent

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man, and we draw all kinds of things from his

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brain. But touching on the pulse incident for

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a moment, my old station, my old first U, we

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could hit pulse with a rock. It was just within

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the city of Orlando's limits, but we were the

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next station over. And then the shooter's secondary

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target that he was trying to decide if he was

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going to hit that instead. was now my first due

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Disney Springs in the Disney area. So that incident

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hit home. Now, I was overseas. I was actually

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in Portugal with family when it happened. So

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I was really torn up to see both these areas

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that I love affected that way. So back to Dr.

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Ibrahim. He was one of the trauma team in that

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incident. And we certainly want to talk about

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that. That's an incident that... a lot of people

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want to hear about and there were some great

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lessons of things that went really really well

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and some things that they changed after through

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the first responders perspective and through

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the er perspective but i also really started

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delving into his mind about trauma in general

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i mean outside of that we get the shootings we

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get the stabbings we get you know the car car

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accidents all kinds of trauma so we talk about

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intubation in the field tourniquets needle decompression

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all these things that we're taught and How often

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they use? Are they effective? Would they be better

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used more by the first responder out in the field?

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Maybe even looking towards changing some of our

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protocols to be a little bit more aggressive

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in some of these areas. And another thing I wanted

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to put in the intro was at the end, Dr. Ibrahim

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recommended a movie, a documentary called Newtown.

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And he said, have some tissues ready. And I'm

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a bit of a kind of... cry like a three -year

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-old girl if something really plucks on the old

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heartstrings. And when the Sandy Hook shooting

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happened, which is what this movie was about,

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I had a son in kindergarten. So it tore me up

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then and it really tore me up to see it. It doesn't

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focus on the tragedy so much as the parents and

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the kids' lives before the event and then how

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they were affected after. And that really kind

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of, not that I need reminding that much, but

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even that shook me up again about how important

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it is for us to train. in all areas but obviously

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trauma is a huge one we all have schools in our

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first year whether you're a volunteer fire department

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or you're in you know manhattan we all have multiple

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schools and daycares and sadly i mean it terrifies

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me to think about this but this could happen

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in any of our elementary middle high school colleges

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um so being on top of our game you know with

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with tourniquets with our with our trauma medical

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knowledge um it's so so important because you

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could be Sitting down with your crew having dinner

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and the next thing being the middle of your worst

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call you could ever imagine. So we touched on

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that. We touched on setting the bar high and

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keeping your training high and involving your

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local ER staff to help train with the first responders.

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Getting that chain of survival as tight as possible.

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So I absolutely love this interview. You can

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probably tell I've been prepping online. I think

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this is an area that we don't delve into enough.

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where we as paramedics or EMTs can set the ER

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nurses and doctors up for success by what we

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do pre -hospital. So it was amazing to hear Dr.

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Ibrahim talk. I'm pretty sure we're probably

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going to talk to him again in the future because

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I had a million other questions when the interview

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was done. Just to preface this, we did have a

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little technical difficulties on my end. My computer

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basically had a stroke. So then I overcorrected

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some of the settings. So the first nine minutes

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sound a little rough. They're still fine, but

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they don't sound as clear as the previous podcast.

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After about nine minutes, everything settles

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down. I found where the error was. And then the

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rest of the podcast should be crystal clear,

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as I hope that most of ours are. So that being

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said, phenomenal interview. I beg, beg you guys

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again to go on iTunes. Take 60 seconds. Give

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us a good rating. The higher our rating, the

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more visible we are online through searches for

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people that haven't heard about the podcast.

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And if you haven't told everyone you know, please

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do. Find a favorite episode, share it, say you

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have to listen to this, whether it's sleep deprivation

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or PTSD or mental toughness, whatever it is,

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and let's try and spread this knowledge of these

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amazing people that we have. So without further

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ado, I introduce to you Dr. Joseph Ibrahim. Enjoy.

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Alright, so welcome Dr. Joseph Ibrahim. First,

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the very first question, am I saying your last

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name correctly? Yes, sir. Perfect. Okay, fantastic.

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Alright, so you are a trauma medical director

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at ORMC and I'm obviously going to go into the

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trauma side and some of the events that we've

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had in Orlando recently. But can you start by

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telling us about your upbringing? You were born

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in Tennessee, is that correct? Correct. I was

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born in Nashville, but grew up in the mountains

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in East Tennessee. Okay. And tell me about your

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childhood unit. What was your family like? So

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my father was a general surgeon in a very small

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town. My mother was a nurse anesthetist, had

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two sisters. Again, very, very small town, single

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traffic light town growing up. My father and

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mother divorced at a fairly young age when I

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was around 12, but I was always around medicine.

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I was fortunate enough in high school to have

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opportunities to shadow people in medical environments.

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Even to the point I got to go to the operating

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room as a senior in high school and really get

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some up -close experience since my mother worked

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in the OR. It was always around medicine from

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that point on. I did research in undergraduate

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where I got to do animal research, operating

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on hearts, doing cutting -edge stuff with satellite

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cells and things like that, where it was just

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myself and Dr. Gao, who was a research genius

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doing cutting -edge things way before satellite

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cell implantation became well -known. It was

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just a very great environment for me, very fortunate.

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all the way up and then got to work in medical

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or in college i worked in medical records in

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the hospital then worked as an ekg tech and got

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to work in various environments that made it

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just kept me around the hospital all the time

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so just very very fortunate all the way around

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when it comes to that okay and just educate me

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for a moment satellite cell what exactly is that

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so those are the cells that are not differentiated

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so they're at the basement basically basement

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membrane of our muscles before they develop into

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skeletal cells. So they've not differentiated

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yet. So what we would do is take those and basically

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cause a heart attack in these animals and then

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inject these cells before they differentiate

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with the theory that the environment that they're

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in, being surrounded by other cardiac muscle,

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they would differentiate into cardiac muscle

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and actually contract. And to the point that

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he actually did some patient trials in china

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and things like that and it was really cutting

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edge for for a 20 year old to be able to be on

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the front lines of doing those kind of things

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absolutely and is that the same kind of philosophy

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as stem cell Yeah, same thing. Okay. No, no,

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no, you're fine. Yeah, I've researched a lot

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of that, more on the musculoskeletal injury side.

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I just had a meniscus repair a while ago, and

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I'm intrigued to see if it progresses to the

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point where it might even regenerate the meniscus.

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I'd certainly get that done if that was the case.

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Sure. All right, so just touching back with your

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parents, and the reason I want to touch on this

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is I myself am a first -generation immigrant

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from the UK, and your parents were not born in

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the US as well, is that correct? My father was

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born in Cairo. I'm first generation from his

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side. My mother was from the States. She grew

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up in a very, very rural area in western Kentucky,

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so much so that they didn't have running water

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until 1985. everything was from a well so yeah

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so two different sides of life for sure yeah

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and how did an Egyptian meet a young lady in

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Kentucky they were uh she was in nursing or anesthesia

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school in Nashville where he was doing his general

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surgery residency okay so doctor nurse relationship

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correct yeah all right brilliant um so all right

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so you you were exposed to medicine what made

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you choose trauma specifically Well, you know,

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initially starting out I was torn between family

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medicine and surgery. I know that sounds like

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two different ends of the spectrum, but I wanted

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to be able to take care of whatever came through

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the door. You know, whether it be heart attack,

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whether it be an aortic rupture, whatever, whether

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it be a gunshot wound. And, you know, as I went

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through my training, you know, it became more

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and more apparent that surgery would be the better

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avenue to take for that. And then through my

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surgical training, you know, I liked basically

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all facets of that. I loved all of my surgical

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training. When I came down to Orlando to do my

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critical care, I actually did that more so thinking

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I wanted to be able to follow my patients and

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take care of them wherever they were in the hospital,

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whether it be a regular floor, whether it be

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the ICU, whatever. So I really initially did

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the ICU training and the critical care more so

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to be able to keep with my general surgical patients,

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really not thinking I would just... be as involved

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with trauma as I have become. But when I came

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and did my fellowship, I just became enthralled

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with it. I loved every aspect of it. You know,

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taking care of the total patient, you know, being

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able to operate on anything from the head and

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neck all the way down to, you know, leg injuries

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and obviously the chest and the abdomen. So,

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you know, one of the last few true general surgeons

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because everything's become so specialized these

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days. I really believe trauma surgeons and pediatric

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surgeons are the last surgeons that can really

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take care of whatever comes through the door.

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Yeah, I'm guilty of kind of holding some areas

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of medicine's feet to the coals with respect

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to chronic medicine and trying to... You've got

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to lean people back towards looking at their

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nutrition and their exercise levels as opposed

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to turning initially to long -term chronic meds.

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But trauma obviously is one of those areas of

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medicine that you cannot fix with herbs and potions.

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There's a certain point where if you snap your

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femur in half, you're obviously going to need

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to see a trauma surgeon. So I think it's definitely

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one of the purest areas of medicine still as

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well. I agree. But to your point, doing those

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things up front, Taking care of your body, taking

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care of your health and doing all those proper

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things do have a significant impact. If you are

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in a traumatic situation or traumatically injured,

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they do significantly impact your outcome, I

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believe. Yeah. No doubt. Yeah, I agree. We had

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CrossFit. CrossFit, I think he's quite a champion,

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but a high -level athlete and also a firefighter,

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Matt Chan, on the show a few weeks ago. And very,

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very muscular, very, very fit. And he had a mountain

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biking accident where the... the front part of

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his saddle went in and ruptured not the actual

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femoral artery, but one of the initial branches

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that comes right off it. And his surgeons told

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him exactly that. It was still compartmentalized.

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I don't think it broke the skin, so it kept everything

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in place. But had he not been as in shape as

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he was, he absolutely would have bled to death.

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Oh, my goodness, yeah. It's amazing. Very interesting.

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All right, well, speaking of that, so you yourself

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obviously appear to be in good shape. So what

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do you do for sports and exercise? I do a lot

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of just running and swimming. I've actually started

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swimming more and more just as I get older because

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it's easier on the joints. I used to do taekwondo

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a pretty fair amount with my family. We took

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five years of that, did jiu -jitsu for three

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or four years. Really enjoyed that, but figured

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some of these younger guys doing jiu -jitsu didn't

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care if I had my shoulder in place or not. Oh,

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really? I could have very good out of that and

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do something that could conserve my career. But

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swimming and running and a little bit of weights

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and just watching your diet, I think all those

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things come into play. I think it's a good balance

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to do all those things that you need to do. Getting

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rest is something that none of us do, right?

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in medicine i mean ems guys fire guys we're no

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better rest is probably the one area of our lives

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that we don't do very well yeah yeah that's one

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of the big pushes that i have on on this show

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and actually it's something i'm going to be pushing

00:14:00.700 --> 00:14:04.299
forward in the fire service is for some reason

00:14:04.299 --> 00:14:07.399
the standard week has been 56 hour weeks of which

00:14:07.399 --> 00:14:09.720
these men and women are up you know as you know

00:14:09.720 --> 00:14:12.740
the areas around ormc they're not exactly quiet

00:14:12.740 --> 00:14:15.169
areas so they're getting their asses kicked for

00:14:15.169 --> 00:14:18.309
24 hours and then wondering why they're sleep

00:14:18.309 --> 00:14:19.909
-deprived, wondering why we're seeing some of

00:14:19.909 --> 00:14:22.350
these mental issues manifesting, and I think

00:14:22.350 --> 00:14:25.049
that sleep is a huge part of that. Absolutely.

00:14:25.669 --> 00:14:29.070
Okay, so you touched on what brought you to Orlando,

00:14:29.149 --> 00:14:33.070
so can you elaborate on that? Sure, so I came

00:14:33.070 --> 00:14:36.490
back here for my fellowship in 2006 to 2007,

00:14:36.750 --> 00:14:39.509
and then I actually did my fellowship a little

00:14:39.509 --> 00:14:41.970
differently. I took it after my third year of

00:14:41.970 --> 00:14:44.610
general surgery training. Again, had a wonderful

00:14:44.610 --> 00:14:47.250
experience here, loved it here, but I still had

00:14:47.250 --> 00:14:49.889
commitments back in East Tennessee. So went back

00:14:49.889 --> 00:14:52.190
to East Tennessee and finished my last two years

00:14:52.190 --> 00:14:55.210
of general surgery. They asked that I stay on

00:14:55.210 --> 00:14:57.990
staff there, which I did for a couple of years

00:14:57.990 --> 00:15:00.750
at a level one trauma center as an assistant

00:15:00.750 --> 00:15:02.549
professor with East Tennessee State University.

00:15:04.490 --> 00:15:07.509
Enjoyed it very much, but again, wanted to build

00:15:07.509 --> 00:15:10.169
what I had seen here. Obviously, you can only

00:15:10.169 --> 00:15:12.610
build it to... a certain extent, you know, I

00:15:12.610 --> 00:15:14.909
can't bring the volume when it comes to trauma,

00:15:15.029 --> 00:15:18.090
you know, trauma that has its own volume. So,

00:15:18.269 --> 00:15:21.330
you know, in a sense, I kind of got bored, so

00:15:21.330 --> 00:15:24.590
to speak. And fortunately, Dr. Michael Cheatham,

00:15:24.649 --> 00:15:27.950
who's my chairman, my boss, but he's also a mentor

00:15:27.950 --> 00:15:30.389
in every part of my life, to be honest with you,

00:15:30.470 --> 00:15:33.330
he would call me pretty regularly once or twice

00:15:33.330 --> 00:15:35.690
a year. Hey, are you interested in coming back?

00:15:35.769 --> 00:15:39.220
We'd love to have you back. I kept kind of putting

00:15:39.220 --> 00:15:42.600
it off, putting it off. And in 2011, I was just

00:15:42.600 --> 00:15:45.259
at a point in my career up there that I just

00:15:45.259 --> 00:15:47.100
kind of really didn't enjoy getting up and going

00:15:47.100 --> 00:15:52.019
to work, which was unusual for me. And so my

00:15:52.019 --> 00:15:55.220
family at that time agreed to come down and check

00:15:55.220 --> 00:15:59.639
things out. And we did. And financially, it didn't

00:15:59.639 --> 00:16:03.000
really make sense, but it's where we felt led.

00:16:03.320 --> 00:16:08.659
And it has been just a great. Great experience

00:16:08.659 --> 00:16:11.139
and opportunity that I'm so blessed that we took

00:16:11.139 --> 00:16:13.440
advantage of. Yeah, it's certainly a good city

00:16:13.440 --> 00:16:16.240
to go to if you want to see trauma. I worked

00:16:16.240 --> 00:16:19.179
at Rescue 70 just down the road, so Orange and

00:16:19.179 --> 00:16:21.600
Oak Ridge. And yeah, I mean, we brought you all

00:16:21.600 --> 00:16:26.259
kinds of, you know, horrendous cases. All right.

00:16:26.279 --> 00:16:28.139
So touching on that, something I want to educate

00:16:28.139 --> 00:16:31.700
myself and my fellow EMTs and medics out there.

00:16:32.019 --> 00:16:35.440
So can you first tell me what makes RMC a level

00:16:35.440 --> 00:16:38.379
one trauma center? And then specifically after

00:16:38.379 --> 00:16:44.259
that, why and when we call a trauma alert? You

00:16:44.259 --> 00:16:46.700
know, what what kind of ball is rolling after

00:16:46.700 --> 00:16:48.000
that point? Because obviously, I know we have

00:16:48.000 --> 00:16:51.259
criteria and we initiate it. But it'd be good

00:16:51.259 --> 00:16:53.899
to hear from your side, you know, what happens

00:16:53.899 --> 00:16:58.059
and. And, you know, why that impacts the patient.

00:16:59.100 --> 00:17:02.500
Sure. So a level one center has to have certain

00:17:02.500 --> 00:17:05.460
capabilities and people ready and available 24

00:17:05.460 --> 00:17:08.539
-7. So we have an in -house trauma surgeon. We

00:17:08.539 --> 00:17:11.980
all stay here four or five nights a month. We're

00:17:11.980 --> 00:17:14.380
actually sleeping in the hospital or trying to

00:17:14.380 --> 00:17:17.200
sleep. Rarely do we sleep. But in addition, we

00:17:17.200 --> 00:17:20.019
have neurosurgical capabilities, orthopedic,

00:17:20.019 --> 00:17:22.700
interventional, radiology, which is so key to

00:17:22.700 --> 00:17:26.390
a lot of things we do. all those on the ready

00:17:26.390 --> 00:17:30.130
and available within 30 minutes. We also have

00:17:30.130 --> 00:17:33.710
ORs available at any moment, and that's proven

00:17:33.710 --> 00:17:36.869
itself over and over again to be so crucial.

00:17:37.589 --> 00:17:40.430
In addition, what people always ask, especially

00:17:40.430 --> 00:17:43.049
recently in Florida, level one versus level two.

00:17:43.210 --> 00:17:46.710
So level one and level twos are, in theory, supposed

00:17:46.710 --> 00:17:49.589
to be able to provide the same level of care.

00:17:50.349 --> 00:17:52.589
The difference is a little bit on the timing,

00:17:52.670 --> 00:17:55.289
as I just kind of alluded to. But then the other

00:17:55.289 --> 00:17:57.509
thing that sets a level one apart from a level

00:17:57.509 --> 00:18:00.029
two is the research component. So let me talk

00:18:00.029 --> 00:18:02.430
a little bit about that. So what you guys don't

00:18:02.430 --> 00:18:04.890
really see a lot of is the research side that

00:18:04.890 --> 00:18:07.509
all nine of the trauma surgeons are involved

00:18:07.509 --> 00:18:10.390
with. And what that means is we're doing constant

00:18:10.390 --> 00:18:12.849
quality assessment of what's going on with our

00:18:12.849 --> 00:18:16.369
patient outcomes. And in addition, what that

00:18:16.369 --> 00:18:18.730
allows us to do is do cutting edge techniques.

00:18:19.519 --> 00:18:21.660
For instance, we were just talking in here about

00:18:21.660 --> 00:18:25.920
my kind of pet, the REBOA catheter you may have

00:18:25.920 --> 00:18:28.299
heard about, the resuscitative endovascular balloon

00:18:28.299 --> 00:18:32.019
that we actually insert in the trauma bay. And

00:18:32.019 --> 00:18:34.420
actually, the Department of Defense is looking

00:18:34.420 --> 00:18:36.880
at using this in the field with military. But

00:18:36.880 --> 00:18:39.180
it's basically a catheter with a balloon on the

00:18:39.180 --> 00:18:42.380
end that we can insert through the femoral artery

00:18:42.380 --> 00:18:46.119
and occlude the aorta as opposed to doing the

00:18:46.119 --> 00:18:48.759
old -fashioned opening the chest. finding the

00:18:48.759 --> 00:18:50.359
aorta, putting a clamp on it, and then rushing

00:18:50.359 --> 00:18:53.160
up to the OR. We put this catheter in, and within

00:18:53.160 --> 00:18:55.720
four to five minutes, we've occluded the aorta,

00:18:55.759 --> 00:18:58.619
and the patient stabilizes almost immediately.

00:18:58.799 --> 00:19:01.619
It's just been amazing. And with that comes our

00:19:01.619 --> 00:19:03.539
ability to be involved in multi -center trials.

00:19:03.680 --> 00:19:06.359
We're currently involved with the American Association

00:19:06.359 --> 00:19:09.359
for the Surgery of Trauma, national trial with

00:19:09.359 --> 00:19:11.759
multiple centers, and we're the third biggest

00:19:11.759 --> 00:19:14.319
user in the country with that, along with Baltimore

00:19:14.319 --> 00:19:17.079
and Houston. So that, I think, sets us apart.

00:19:17.529 --> 00:19:19.490
uh, level one from a level two. And then the

00:19:19.490 --> 00:19:22.230
other part is a level one is that you're responsible

00:19:22.230 --> 00:19:25.210
for doing community outreach. Uh, what that involves

00:19:25.210 --> 00:19:28.990
is you need to take what's your biggest, biggest

00:19:28.990 --> 00:19:31.410
admission issue, which for here in central Florida,

00:19:31.450 --> 00:19:33.109
our trauma center and most trauma centers across

00:19:33.109 --> 00:19:35.849
the country, it's a ground level falls, which

00:19:35.849 --> 00:19:38.509
I know you guys get called on all the time. Yes.

00:19:38.650 --> 00:19:40.970
Uh, so whether it be a nursing home, whether

00:19:40.970 --> 00:19:42.869
it be a house, you know, had a lady fall down

00:19:42.869 --> 00:19:45.609
her stairs the other night, you know, and we're

00:19:45.609 --> 00:19:48.200
finally realizing that, that's not something

00:19:48.200 --> 00:19:49.720
to take lightly, that people can have significant

00:19:49.720 --> 00:19:54.539
injuries from that. So what we do here, our trauma

00:19:54.539 --> 00:19:57.779
program manager, Susan Ona, who is outstanding,

00:19:58.339 --> 00:20:01.920
she's done some outreach to some of our senior

00:20:01.920 --> 00:20:03.799
centers and things like that to tell them about

00:20:03.799 --> 00:20:06.660
little things like wearing the proper shoes to

00:20:06.660 --> 00:20:09.519
eliminating transitions in doorways as those

00:20:09.519 --> 00:20:12.119
that are commonplace for people to fall and things

00:20:12.119 --> 00:20:14.039
like that. And then we're also involved with

00:20:14.039 --> 00:20:16.890
the initiative of best foot forward you may have

00:20:16.890 --> 00:20:20.490
heard of it's an initiative and a program here

00:20:20.490 --> 00:20:24.549
in florida to make people aware about one of

00:20:24.549 --> 00:20:26.210
our biggest problems or one of the things we're

00:20:26.210 --> 00:20:27.750
number one in the country for and that's auto

00:20:27.750 --> 00:20:31.109
versus pedestrian and you know people commonly

00:20:31.109 --> 00:20:33.230
think well it's orlando it's the tourists and

00:20:33.230 --> 00:20:35.349
things like that well the research would show

00:20:35.349 --> 00:20:37.990
otherwise it's actually our own people oh really

00:20:37.990 --> 00:20:41.369
oh yeah it's actually not the largest percentage

00:20:41.369 --> 00:20:43.730
are people from the central florida area not

00:20:45.659 --> 00:20:49.259
So, you know, they've done things, you know,

00:20:49.259 --> 00:20:52.700
making sure people try to identify the crosswalks

00:20:52.700 --> 00:20:55.200
to making sure you're paying attention to the

00:20:55.200 --> 00:20:57.839
walking signs and things like that. So we're

00:20:57.839 --> 00:20:59.920
also heavily involved with that as well. So that,

00:20:59.960 --> 00:21:01.500
you know, those are some of the things that set

00:21:01.500 --> 00:21:03.839
us apart from the level two center that you won't

00:21:03.839 --> 00:21:07.220
see with them. Okay. Yeah, just touching on that.

00:21:07.259 --> 00:21:09.579
One thing I observed coming from England is.

00:21:10.380 --> 00:21:12.680
You know, they'll be able to turn on, make a

00:21:12.680 --> 00:21:14.799
right turn on the red. If people don't stop in

00:21:14.799 --> 00:21:16.420
the crosswalks, you think of something like OBT,

00:21:16.539 --> 00:21:18.440
which is what, eight lanes, I think, across.

00:21:19.420 --> 00:21:22.339
You know, you've got big vans, SUVs, whatever

00:21:22.339 --> 00:21:24.940
it is, and they're blocking the vision. It terrifies

00:21:24.940 --> 00:21:26.619
me because these people are flying through these

00:21:26.619 --> 00:21:28.900
reds to make a right. And all it takes is someone

00:21:28.900 --> 00:21:31.279
pushing a stroller, you know, and then the next

00:21:31.279 --> 00:21:33.279
thing you've got, you know, a dead kid. So I

00:21:33.279 --> 00:21:36.440
think educating the drivers is a huge part of

00:21:36.440 --> 00:21:40.440
trying to reduce those injuries too. Oh, absolutely.

00:21:40.779 --> 00:21:43.099
That's another key part of that initiative. It's

00:21:43.099 --> 00:21:45.940
not just the pedestrian paying attention, but

00:21:45.940 --> 00:21:47.920
you're absolutely right. It's the drivers looking

00:21:47.920 --> 00:21:50.539
for the crosswalk because it's so easy, as you

00:21:50.539 --> 00:21:52.720
pointed out on those turns like that, that people

00:21:52.720 --> 00:21:54.839
don't even look. They just, oh, no cars are coming

00:21:54.839 --> 00:21:56.980
and turning. And you're right. Somebody's in

00:21:56.980 --> 00:21:58.599
the crosswalk and there they are. It doesn't

00:21:58.599 --> 00:22:00.059
matter that they're in the crosswalk or not.

00:22:00.319 --> 00:22:03.720
The car doesn't see them. Yeah. Now, I want to

00:22:03.720 --> 00:22:06.299
touch on what you said about the balloon for

00:22:06.299 --> 00:22:08.920
the aorta. Is that for trauma anywhere in the

00:22:08.920 --> 00:22:12.420
body or specifically an aortic rupture? It's

00:22:12.420 --> 00:22:16.200
anywhere in the body. So basically, well, I should

00:22:16.200 --> 00:22:20.019
say anywhere below the diaphragm. If it's above

00:22:20.019 --> 00:22:22.759
the diaphragm, then we really probably shouldn't

00:22:22.759 --> 00:22:24.400
use it. But it's something that's used initially.

00:22:25.160 --> 00:22:27.980
In the trauma bay, the biggest benefit, I think,

00:22:27.980 --> 00:22:30.180
has been the area of pelvis fractures, which,

00:22:30.220 --> 00:22:32.180
again, we see a lot of, especially with our autoverse

00:22:32.180 --> 00:22:34.059
pedestrian community, but also with motorcycle

00:22:34.059 --> 00:22:36.740
crashes and things like that. People have open

00:22:36.740 --> 00:22:39.839
pelvis fractures, have significant bleeding.

00:22:39.940 --> 00:22:43.160
As we know, historically, that's a very difficult

00:22:43.160 --> 00:22:45.180
and treacherous area to try and control bleeding.

00:22:45.420 --> 00:22:48.799
And in most cases, we end up going to interventional

00:22:48.799 --> 00:22:52.400
radiology for embolization of those. And this

00:22:52.400 --> 00:22:54.839
has just really kind of bridged that gap between

00:22:54.839 --> 00:22:57.920
putting a binder on and they're still hypotensive

00:22:57.920 --> 00:23:01.359
to getting them to the radiology suite so they

00:23:01.359 --> 00:23:04.359
can get embolized. Because historically, that

00:23:04.359 --> 00:23:07.039
time period between putting the binder and sitting

00:23:07.039 --> 00:23:08.660
in the trauma bay and getting to interventional

00:23:08.660 --> 00:23:10.640
radiology, you're constantly giving blood products

00:23:10.640 --> 00:23:13.319
and things like that. And obviously, still the

00:23:13.319 --> 00:23:14.759
patient is at risk because they have ongoing

00:23:14.759 --> 00:23:17.559
hemorrhage. But this has significantly impacted

00:23:17.559 --> 00:23:20.589
that. And we've seen great benefits here just

00:23:20.589 --> 00:23:23.329
in the 20 some cases we've had. Wow. And you

00:23:23.329 --> 00:23:26.150
said thinking about the military using it, is

00:23:26.150 --> 00:23:28.529
this something you foresee first responders using

00:23:28.529 --> 00:23:31.890
one day as well? I do. Actually, you know, UK

00:23:31.890 --> 00:23:37.150
has used it some as have Australia first responders.

00:23:37.289 --> 00:23:39.009
But there's, you know, obviously they're set

00:23:39.009 --> 00:23:41.069
up, which, you know, is a little different. And

00:23:41.069 --> 00:23:43.430
in Australia, they actually have positions on

00:23:43.430 --> 00:23:46.150
the flights with them. But their flight teams

00:23:46.150 --> 00:23:48.849
are actually using it in a few cases that have

00:23:48.849 --> 00:23:51.569
been reported. Right. Yeah, I think that's one

00:23:51.569 --> 00:23:53.009
of the most frustrating things about being a

00:23:53.009 --> 00:23:55.049
medic is you hit that educational ceiling. And

00:23:55.049 --> 00:23:58.130
I'd love to see us, you know, create yet another

00:23:58.130 --> 00:24:00.170
level that we can progress to, we can educate

00:24:00.170 --> 00:24:03.109
to, to provide an even higher level of care before

00:24:03.109 --> 00:24:05.589
we get to the hospital. Right. And I think, you

00:24:05.589 --> 00:24:07.589
know, this catheter, they really keep streamlining

00:24:07.589 --> 00:24:10.630
it and changing it so that it's really extremely

00:24:10.630 --> 00:24:13.289
user friendly. and making it more and more of

00:24:13.289 --> 00:24:16.329
a safer profile to be used in that kind of setting.

00:24:16.490 --> 00:24:19.150
Right. Brilliant. Now, touching on trauma out

00:24:19.150 --> 00:24:23.009
in the field for a moment as well, backboarding

00:24:23.009 --> 00:24:26.230
has always been an absolute bane to a lot of

00:24:26.230 --> 00:24:29.789
first responders. We see that obviously it doesn't

00:24:29.789 --> 00:24:32.829
seem to immobilize very well. I'm told that there's

00:24:32.829 --> 00:24:35.650
no research even supporting its use. Many, many

00:24:35.650 --> 00:24:37.369
fire departments are getting away from it now.

00:24:37.750 --> 00:24:40.109
As a trauma surgeon, obviously you see this and

00:24:40.109 --> 00:24:43.470
you see... you know, the cervical and spinal

00:24:43.470 --> 00:24:46.309
damage. What's your view on backboarding and

00:24:46.309 --> 00:24:52.250
should it go away ultimately? Right. Well, first

00:24:52.250 --> 00:24:54.230
of all, I just want to say thanks to all the

00:24:54.230 --> 00:24:56.150
first responders. You know, I have to tell you

00:24:56.150 --> 00:24:58.250
one quick story if you have just a second. So

00:24:58.250 --> 00:25:01.990
my experience with first responders, when I was

00:25:01.990 --> 00:25:04.970
a resident, I was driving one Sunday afternoon

00:25:04.970 --> 00:25:08.309
and came upon a two -vehicle crash, and I was

00:25:08.309 --> 00:25:11.880
the first one there. so two people unresponsive

00:25:11.880 --> 00:25:15.380
and a cop was there and I told him who I was

00:25:15.380 --> 00:25:18.599
a surgical resident we get out and two people

00:25:18.599 --> 00:25:21.140
were basically in respiratory arrest and anyway,

00:25:21.240 --> 00:25:23.819
he didn't know what to do and Try to get in the

00:25:23.819 --> 00:25:25.660
car finally get in one of the doors. They're

00:25:25.660 --> 00:25:28.660
all kind of smashed in and get in one side I'm

00:25:28.660 --> 00:25:30.259
trying to hold the airway and hold their neck

00:25:30.259 --> 00:25:32.799
up to your point So trying to get some air any

00:25:32.799 --> 00:25:35.740
way I can into these people And I was trying

00:25:35.740 --> 00:25:36.980
to figure out how could I get him out of the

00:25:36.980 --> 00:25:39.599
car? It was just me and You know, just thinking

00:25:39.599 --> 00:25:42.099
about our first responders and how just they're

00:25:42.099 --> 00:25:43.960
quick they are. It's just amazing to me. And

00:25:43.960 --> 00:25:46.900
so I remember this very large paramedic walking

00:25:46.900 --> 00:25:49.839
up, and I said, I've got two people unresponsive,

00:25:49.839 --> 00:25:51.960
blah, blah, blah. And I said, I can't get the

00:25:51.960 --> 00:25:55.539
door open. And he, I mean, in stride, without

00:25:55.539 --> 00:25:59.740
even thinking, we're in East Tennessee, finds

00:25:59.740 --> 00:26:01.900
a big rock by the side of the road and smashes

00:26:01.900 --> 00:26:03.859
the window in the back, and we get the people

00:26:03.859 --> 00:26:06.730
out, I mean, just within seconds. And I was like,

00:26:06.750 --> 00:26:08.609
and that was brilliant. How did I not think of

00:26:08.609 --> 00:26:11.210
something like that? But anyway, my hat's off

00:26:11.210 --> 00:26:13.089
to them because they're just they're just amazing

00:26:13.089 --> 00:26:14.930
how quick thinking they are and doing the things

00:26:14.930 --> 00:26:17.410
they do. I'm spoiled that we get to do all the

00:26:17.410 --> 00:26:19.450
things in a nice setting. You know, patients

00:26:19.450 --> 00:26:21.930
on a bed, they've got great lighting. You guys

00:26:21.930 --> 00:26:25.309
are on the on the ground in the dark. So my hat's

00:26:25.309 --> 00:26:28.390
off. But back to your question about the boards.

00:26:29.509 --> 00:26:32.250
You know, I think. You're right. I think things

00:26:32.250 --> 00:26:34.730
will change over time. Right now, I think I still

00:26:34.730 --> 00:26:37.109
have to speak. The standard would be to keep

00:26:37.109 --> 00:26:39.369
them on the board. And I think it's just more

00:26:39.369 --> 00:26:42.849
honestly to protect us. If something were to

00:26:42.849 --> 00:26:46.069
happen, did you do this? The standard. And I

00:26:46.069 --> 00:26:49.750
think that's still the standard. Will that? And

00:26:49.750 --> 00:26:51.210
I agree with you. I mean, we see people all the

00:26:51.210 --> 00:26:52.809
time. In fact, I was in the yard the other night.

00:26:52.890 --> 00:26:55.089
The person was on the on a longboard laying on

00:26:55.089 --> 00:26:58.789
their side, all curled up. So in one of the rooms,

00:26:58.849 --> 00:27:00.470
I was like, well, that's probably not doing much

00:27:00.470 --> 00:27:02.609
good right now other than creating potential

00:27:02.609 --> 00:27:09.069
bed sores or pressure wounds in that area. So

00:27:09.069 --> 00:27:11.730
I think long term, we're going to come up with

00:27:11.730 --> 00:27:17.329
something different for that. What that's going

00:27:17.329 --> 00:27:21.670
to be, I wish I knew. But right now, I would

00:27:21.670 --> 00:27:23.910
still have to advocate for using boards this

00:27:23.910 --> 00:27:26.720
time just because we don't have... any way to

00:27:26.720 --> 00:27:28.880
say for sure what is the best right now yeah

00:27:28.880 --> 00:27:31.759
and i think that's the most accepted if you were

00:27:31.759 --> 00:27:34.180
if something were to happen to somebody did you

00:27:34.180 --> 00:27:36.019
do the standard and i think that's kind of what

00:27:36.019 --> 00:27:38.079
the standard is as of right now but do i think

00:27:38.079 --> 00:27:40.680
that's going to change i do yeah yeah it's it's

00:27:40.680 --> 00:27:42.660
it's like i said when when you realize there's

00:27:42.660 --> 00:27:44.519
no real research behind it and you see these

00:27:44.519 --> 00:27:46.119
people slipping around all over these boards

00:27:46.119 --> 00:27:49.700
um i think our our medical directors now have

00:27:49.700 --> 00:27:51.759
allowed us to be more intelligent with the way

00:27:51.759 --> 00:27:56.779
we uh kind of analyze the injuries and then allow

00:27:56.779 --> 00:27:59.099
us to put the patient in more of a position of

00:27:59.099 --> 00:28:00.559
comfort especially some of these elderly people

00:28:00.559 --> 00:28:02.980
with with the terrible spinal curves that you

00:28:02.980 --> 00:28:05.859
lay them on a board and they're in agony so sure

00:28:05.859 --> 00:28:08.779
yep absolutely absolutely you know you know the

00:28:08.779 --> 00:28:10.259
issues come into play when you have people with

00:28:10.259 --> 00:28:12.660
distracting injuries right they have a terrible

00:28:12.660 --> 00:28:14.960
femur fracture they have terrible you know other

00:28:14.960 --> 00:28:17.519
injuries and they can't really tell you yeah

00:28:17.519 --> 00:28:19.720
my back hurts maybe it's a little more subtle

00:28:19.720 --> 00:28:22.519
and then you miss something subtle they end up

00:28:22.519 --> 00:28:24.990
having something that was potentially dangerous

00:28:24.990 --> 00:28:27.230
that you know that's always a tough call so that

00:28:27.230 --> 00:28:29.609
those are the areas that i think we just have

00:28:29.609 --> 00:28:31.809
to get some more information on right understood

00:28:31.809 --> 00:28:36.410
okay so i guess we'll move forward now to a very

00:28:36.410 --> 00:28:40.529
uh very poignant event in in our city's history

00:28:40.529 --> 00:28:44.730
so june 12th of last year um correct me if i'm

00:28:44.730 --> 00:28:46.569
wrong this is kind of per the research i've done

00:28:46.569 --> 00:28:48.890
online you got a phone call middle of the night

00:28:48.890 --> 00:28:52.279
is that correct yes it was around 2 a .m Okay,

00:28:52.319 --> 00:28:54.240
so tell me about that day, if you wouldn't mind.

00:28:55.259 --> 00:29:00.180
Sure. So I had been on call the night before,

00:29:00.460 --> 00:29:05.279
the Friday night, and that night was relatively

00:29:05.279 --> 00:29:09.420
busy, as you know what that's like down here.

00:29:09.500 --> 00:29:15.180
We had the shooting at a local concert area where

00:29:15.180 --> 00:29:20.160
the young lady from The Voice got shot by a stalker.

00:29:21.950 --> 00:29:23.309
So we thought that was going to be our biggest

00:29:23.309 --> 00:29:27.710
thing that weekend. So 2 a .m., I was in bed.

00:29:27.869 --> 00:29:30.390
Obviously, I'm on backup call. Chad Smith was

00:29:30.390 --> 00:29:33.650
on call. And around 2 .15, he calls me and says,

00:29:33.789 --> 00:29:35.890
hey, there's a shooting in a club, and they think

00:29:35.890 --> 00:29:38.849
we're going to have 20 victims or so. I'm going

00:29:38.849 --> 00:29:40.849
to need you to come in. I'm like, I'll be right

00:29:40.849 --> 00:29:45.269
there. So I jumped up and threw on my scrubs,

00:29:45.269 --> 00:29:50.400
and I live really close. And within 10, 15 minutes.

00:29:50.660 --> 00:29:54.799
And so, you know, when I walked in, we still

00:29:54.799 --> 00:29:56.759
didn't have the significant police presence.

00:29:57.480 --> 00:29:59.900
We weren't on lockdown yet. It seemed like a

00:29:59.900 --> 00:30:03.000
typical quiet outside night to me from the side

00:30:03.000 --> 00:30:06.539
I came in, you know, all the way until I got

00:30:06.539 --> 00:30:09.920
to the trauma bay. And once I opened the double

00:30:09.920 --> 00:30:14.339
doors on the far end of the trauma bay, and it

00:30:14.339 --> 00:30:16.519
was obviously something we had never, I'd never

00:30:16.519 --> 00:30:23.769
encountered before. We had patients in every

00:30:23.769 --> 00:30:27.950
bay, patients perpendicular to the typical situation.

00:30:29.430 --> 00:30:32.289
A lot of people just kind of running around.

00:30:32.430 --> 00:30:36.109
It was just full. Patients kind of screaming

00:30:36.109 --> 00:30:40.990
and yelling. It just was obvious that this was

00:30:40.990 --> 00:30:43.150
a much different situation we'd ever experienced.

00:30:43.549 --> 00:30:47.759
I looked up and I saw Dr. Smith. at the far end

00:30:47.759 --> 00:30:49.819
of the trauma base. So I said, well, I'll start

00:30:49.819 --> 00:30:51.579
on the near end and kind of meet him in the middle.

00:30:51.619 --> 00:30:54.740
We'll just start triaging. And first one I came

00:30:54.740 --> 00:30:58.599
to, the gentleman had a very large wound to his

00:30:58.599 --> 00:31:03.440
chest and abdomen and looked to be fatal and

00:31:03.440 --> 00:31:06.619
started to evaluate him. And Dr. Smith came up

00:31:06.619 --> 00:31:09.059
to me and he said, no, no, Joey, I've already

00:31:09.059 --> 00:31:14.119
triaged him. There's nothing we can do. He's

00:31:14.119 --> 00:31:17.650
just, I told him just give him morphine. And

00:31:17.650 --> 00:31:19.769
so that's something, you know, maybe in the military

00:31:19.769 --> 00:31:21.710
setting you might have some experience with,

00:31:21.750 --> 00:31:24.849
but in the civilian setting, again, you're experienced

00:31:24.849 --> 00:31:27.910
with. We don't do that, right? We do everything

00:31:27.910 --> 00:31:31.549
for every patient. So I just kind of had this

00:31:31.549 --> 00:31:34.349
blank stare at him for a second and then realized

00:31:34.349 --> 00:31:36.869
he was exactly right. This was a true triage

00:31:36.869 --> 00:31:40.789
situation. And so then, you know, going to the

00:31:40.789 --> 00:31:43.329
next one, you know, and just remember assessing

00:31:43.329 --> 00:31:46.500
different patients. sending the next one up for

00:31:46.500 --> 00:31:48.420
surgery, sending our fourth -year resident up

00:31:48.420 --> 00:31:53.900
with him to get things started. And then it wasn't

00:31:53.900 --> 00:31:57.180
very long after that Dr. Cheatham came into the

00:31:57.180 --> 00:32:01.539
trauma bay, and Chad had called him also, and

00:32:01.539 --> 00:32:04.119
I informed him that we had sent one up to the

00:32:04.119 --> 00:32:06.160
OR, could he go cover that case, and then I would

00:32:06.160 --> 00:32:10.019
bring the next one up. So I took... After assessing

00:32:10.019 --> 00:32:11.779
three or four patients, I then took one of them

00:32:11.779 --> 00:32:14.859
upstairs and did my first exploratory laparotomy.

00:32:16.000 --> 00:32:18.740
It's just a different mindset that you quickly

00:32:18.740 --> 00:32:22.519
have to go into. I remember I had a third -year

00:32:22.519 --> 00:32:24.660
resident with me, and we took care of the abdominal

00:32:24.660 --> 00:32:28.420
wounds. We didn't close really any abdomens that

00:32:28.420 --> 00:32:30.740
night because, again, damage control. You take

00:32:30.740 --> 00:32:33.579
care of whatever's bleeding or leaking or whatever,

00:32:33.779 --> 00:32:36.599
and you put a temporary dressing on, something

00:32:36.599 --> 00:32:39.599
we call a wound back. and we get them out of

00:32:39.599 --> 00:32:43.619
the OR. And we didn't close anybody short of

00:32:43.619 --> 00:32:46.180
one surgeon closed one abdomen that night. It

00:32:46.180 --> 00:32:49.619
was a pediatric surgeon. But that's kind of the

00:32:49.619 --> 00:32:52.319
damage control mentality. You get whatever is

00:32:52.319 --> 00:32:54.079
life -threatening taken care of, and then you

00:32:54.079 --> 00:32:56.279
move on to the next one. And I remember he had

00:32:56.279 --> 00:32:59.140
several wounds going down his left arm, and the

00:32:59.140 --> 00:33:00.339
resident looked at me and said, do we need to

00:33:00.339 --> 00:33:03.960
do an arteriogram and evaluate his arm? I said,

00:33:04.000 --> 00:33:07.319
no, we're going to wrap it with a beta. Betadine

00:33:07.319 --> 00:33:09.380
soaked gauze. And if it bleeds, we'll put a tourniquet.

00:33:09.440 --> 00:33:11.920
But he's probably going to lose that arm. But

00:33:11.920 --> 00:33:13.640
we've got to move on. That's not going to kill

00:33:13.640 --> 00:33:16.660
him. And she looked up at me the same way I looked

00:33:16.660 --> 00:33:19.259
at Chad. Like, what are you talking about? And

00:33:19.259 --> 00:33:21.440
then she quickly realized, same, just like I

00:33:21.440 --> 00:33:24.460
did, you're exactly right. We've got 20, 30 more

00:33:24.460 --> 00:33:29.019
patients down there that need us. So that, again,

00:33:29.079 --> 00:33:30.740
is something that's very, very different from

00:33:30.740 --> 00:33:33.609
our training. that now we actually do incorporate

00:33:33.609 --> 00:33:35.490
into our training, but nothing that a typical

00:33:35.490 --> 00:33:40.890
civilian training incorporates. So I finished

00:33:40.890 --> 00:33:45.589
that case, went down, and saw several more, and

00:33:45.589 --> 00:33:48.670
helped some of the residents get patients to

00:33:48.670 --> 00:33:50.789
the ICU and things like that, and then took my

00:33:50.789 --> 00:33:52.750
next patient up to the OR for the next ex -lab,

00:33:52.930 --> 00:33:56.150
and took care of that patient. Again, didn't

00:33:56.150 --> 00:34:00.710
close them. I think on my third one taken up,

00:34:01.000 --> 00:34:05.319
We got a page saying code silver, which meant

00:34:05.319 --> 00:34:07.519
that there was concern that a gunman was in the

00:34:07.519 --> 00:34:13.719
ER. So I was up in the OR area at this time and

00:34:13.719 --> 00:34:15.940
turned the corner and there were two heavily

00:34:15.940 --> 00:34:18.539
armed police officers outside the OR I was going

00:34:18.539 --> 00:34:22.139
into. So you have two feelings. You're like,

00:34:22.179 --> 00:34:25.840
all right, I'm safe. But then at the same time,

00:34:25.840 --> 00:34:28.280
you're thinking my whole team is still down there

00:34:28.280 --> 00:34:30.739
in the trauma bay. Right. what's going on down

00:34:30.739 --> 00:34:34.079
there. And again, the same resident was with

00:34:34.079 --> 00:34:36.219
me and I just told her, look, let's just take

00:34:36.219 --> 00:34:37.980
care of this patient. We'll figure it out. So

00:34:37.980 --> 00:34:43.400
we took care of that patient and everything was

00:34:43.400 --> 00:34:45.420
on lockdown at that point, meaning we were basically

00:34:45.420 --> 00:34:50.159
stuck in the OR area. So I began going room to

00:34:50.159 --> 00:34:51.679
room to see, you know, if somebody needed an

00:34:51.679 --> 00:34:54.800
extra hand and went in one room where Dr. Havron

00:34:54.800 --> 00:34:58.340
was working with Dr. Patel, our vascular surgeon.

00:34:58.889 --> 00:35:00.949
The patient had a very bad subclavian artery

00:35:00.949 --> 00:35:04.869
injury and knew they were going to be busy for

00:35:04.869 --> 00:35:07.949
a while, but they said they were good. So I went

00:35:07.949 --> 00:35:09.730
to the next room, and there was one of our other

00:35:09.730 --> 00:35:11.869
fourth -year residents, Dr. Bada. He was prepping

00:35:11.869 --> 00:35:13.789
out the leg, and he said, hey, the vascular surgeon

00:35:13.789 --> 00:35:15.409
is going to come help me explore this femoral

00:35:15.409 --> 00:35:17.889
artery wound. I said, well, no, he's got his

00:35:17.889 --> 00:35:22.030
hands full two doors down. I'll just start scrubbing.

00:35:22.030 --> 00:35:23.929
I'll help you with this. We can do this. So I

00:35:23.929 --> 00:35:25.670
scrubbed in with him. We took care of that patient.

00:35:28.099 --> 00:35:30.119
You know, again, going back to that the trauma

00:35:30.119 --> 00:35:32.340
training, you know, you might, you know, even

00:35:32.340 --> 00:35:34.199
though I'm not a vascular surgeon, we are very

00:35:34.199 --> 00:35:36.179
well trained in taking care of vascular injuries.

00:35:36.320 --> 00:35:39.920
So that that's, again, one of the reasons I went

00:35:39.920 --> 00:35:44.960
into this. But, you know, it was just patient

00:35:44.960 --> 00:35:48.139
after patient. And then. Once we finished that

00:35:48.139 --> 00:35:50.380
case, the code silver had been lifted. They figured

00:35:50.380 --> 00:35:53.780
out that they were just hearing the gunfire from

00:35:53.780 --> 00:35:55.679
three blocks down because, as you know, Pulse

00:35:55.679 --> 00:35:58.139
is very close to our facility. Extremely close.

00:35:58.559 --> 00:36:01.420
Yeah, so when they breached the wall or whatever

00:36:01.420 --> 00:36:04.260
and they had to shoot out, the shooting sounded

00:36:04.260 --> 00:36:10.079
like it was in our ambulance bay. At that point,

00:36:10.159 --> 00:36:13.699
they were, again, we were not on lockdown anymore.

00:36:14.570 --> 00:36:16.909
I went back down and helped evaluate some more.

00:36:16.949 --> 00:36:19.489
I think I did one more exploratory laparotomy

00:36:19.489 --> 00:36:23.789
after that and then began, you know, seeing some

00:36:23.789 --> 00:36:26.570
of the lesser injured patients. And all that

00:36:26.570 --> 00:36:31.289
went on and on until around 730, at which time,

00:36:31.289 --> 00:36:33.989
you know, is a testament to our facility. I mean,

00:36:34.010 --> 00:36:36.969
everybody involved, you know, environmental services.

00:36:37.969 --> 00:36:40.809
We had orthopedics guys helping us take off tourniquets

00:36:40.809 --> 00:36:44.030
and evaluate people. I mean, it was. Our critical

00:36:44.030 --> 00:36:46.570
care medicine guys were running the ICUs and

00:36:46.570 --> 00:36:49.650
recovery room. And it was just, again, a total

00:36:49.650 --> 00:36:53.809
team effort. But, you know, at that point, we

00:36:53.809 --> 00:36:56.690
had one, I think, one pulse victim still in the

00:36:56.690 --> 00:36:59.630
trauma bay, which is pretty amazing. We've gotten

00:36:59.630 --> 00:37:03.110
everybody into beds and things like that. And

00:37:03.110 --> 00:37:04.869
so at that point, the day teams were kind of

00:37:04.869 --> 00:37:07.329
responding that maybe didn't hear the mass call

00:37:07.329 --> 00:37:10.300
in the night. And which that was a blessing,

00:37:10.360 --> 00:37:11.960
too. You know, if everybody would have shown

00:37:11.960 --> 00:37:13.699
up at once, we all would have been dog tired.

00:37:14.360 --> 00:37:17.400
So as it was, we had some fresh, fresh eyes,

00:37:17.460 --> 00:37:19.840
brains and legs coming in, which was good. Yeah.

00:37:20.440 --> 00:37:23.800
So we I remember we sat down in the trauma bay

00:37:23.800 --> 00:37:26.840
and laid out all the patient lists because we

00:37:26.840 --> 00:37:28.900
had we had around 60 patients that were in the

00:37:28.900 --> 00:37:32.420
hospital already on the trauma team. So we kind

00:37:32.420 --> 00:37:34.260
of divvied up, OK, who's going to round on what?

00:37:35.150 --> 00:37:37.250
And then we also needed to go back through all

00:37:37.250 --> 00:37:39.550
of these, the pulse victims and make sure all

00:37:39.550 --> 00:37:41.070
their injuries, because we took care of the most

00:37:41.070 --> 00:37:44.250
life -threatening injuries, but there may have

00:37:44.250 --> 00:37:46.929
been some lesser injuries that we missed. So

00:37:46.929 --> 00:37:49.050
we needed to go back through and reevaluate.

00:37:49.070 --> 00:37:53.489
We call our tertiary evaluation. So we did that.

00:37:55.010 --> 00:37:57.489
Just another resident, one of the senior level

00:37:57.489 --> 00:37:59.309
residents and I went and made sure we saw every

00:37:59.309 --> 00:38:05.570
single patient. And after doing that, We all

00:38:05.570 --> 00:38:09.650
met back up and just kind of continued. I started

00:38:09.650 --> 00:38:12.030
meeting with our hospital incident command. Dr.

00:38:12.170 --> 00:38:13.829
Cheatham and I would alternate, which that's

00:38:13.829 --> 00:38:17.949
a system that was put in place to have all the

00:38:17.949 --> 00:38:20.289
department heads be able to talk to each other

00:38:20.289 --> 00:38:23.789
directly to determine what things you need. For

00:38:23.789 --> 00:38:25.730
instance, for us, we were in great need of chest

00:38:25.730 --> 00:38:30.630
tubes and wound vacs, as I mentioned. That hospital

00:38:30.630 --> 00:38:32.309
incident command allowed me to look directly

00:38:32.309 --> 00:38:34.909
at the supply guy sitting next to me and say,

00:38:34.969 --> 00:38:37.510
hey, I need this and this and this. He made one

00:38:37.510 --> 00:38:41.130
phone call and we were fully stocked. Just amazing.

00:38:41.989 --> 00:38:43.670
Our hospital, again, the environment's amazing

00:38:43.670 --> 00:38:47.449
in that they do that pretty regularly. If we're

00:38:47.449 --> 00:38:50.349
full for other reasons or if the ER's backed

00:38:50.349 --> 00:38:53.190
up, things like that, our chief operating officer

00:38:53.190 --> 00:38:55.869
has gotten into a habit of calling incident command

00:38:55.869 --> 00:38:57.849
just for everybody to come together and make

00:38:57.849 --> 00:39:00.519
solutions. And so when we had to do that on that

00:39:00.519 --> 00:39:03.360
evening, it wasn't something totally new, right?

00:39:04.179 --> 00:39:06.679
Again, that's, I think, key to the success of

00:39:06.679 --> 00:39:10.579
that. But yeah, it was something, I mean, that

00:39:10.579 --> 00:39:13.179
went on, to be honest with you, you know, that

00:39:13.179 --> 00:39:15.500
was a very long day. I was actually on call that

00:39:15.500 --> 00:39:18.480
Sunday and took care of an incarcerated hernia,

00:39:18.579 --> 00:39:23.659
appendectomy, and I helped with an ovarian abscess

00:39:23.659 --> 00:39:26.800
over at Winnie Palmer. The main thing that we

00:39:26.800 --> 00:39:28.980
wanted to get out was that while we had this

00:39:28.980 --> 00:39:32.960
tragic event occur and we had to deal with a

00:39:32.960 --> 00:39:35.420
lot of the patients from that and victims from

00:39:35.420 --> 00:39:38.400
that, we were back open to the rest of our community

00:39:38.400 --> 00:39:43.949
within a few hours. again a testament to the

00:39:43.949 --> 00:39:46.269
to the system yeah i'm gonna have to say from

00:39:46.269 --> 00:39:47.849
from the outside looking in i was actually in

00:39:47.849 --> 00:39:50.349
portugal and and there's a strange irony to the

00:39:50.349 --> 00:39:52.489
whole thing my my station like i said was right

00:39:52.489 --> 00:39:54.329
down the road i mean you could hit pulse with

00:39:54.329 --> 00:39:56.030
a rock from the edge of my first shoe in orange

00:39:56.030 --> 00:39:59.289
county and then when i moved to reedy creek uh

00:39:59.289 --> 00:40:02.590
omar matin the the shooter i guess he had two

00:40:02.590 --> 00:40:04.889
targets pulse was one and disney springs with

00:40:04.889 --> 00:40:07.050
the other and that's where i protect now so it

00:40:07.050 --> 00:40:09.510
was a kind of weird twist that i wasn't physically

00:40:09.510 --> 00:40:11.530
able to be there but potentially it could have

00:40:11.530 --> 00:40:15.280
been you know me on that scene as well um but

00:40:15.280 --> 00:40:17.960
i was so impressed with with that i mean just

00:40:17.960 --> 00:40:20.059
just the overall scene i mean i'm sure it wasn't

00:40:20.059 --> 00:40:22.159
perfect in every single element with you know

00:40:22.159 --> 00:40:24.159
the first responders and some miscommunication

00:40:24.159 --> 00:40:27.559
but overall the the event itself the way they

00:40:27.559 --> 00:40:31.380
they killed him um you know when he came out

00:40:31.380 --> 00:40:34.360
you know guns blazing like in the movies versus

00:40:34.360 --> 00:40:37.280
most what incidents that are pretty uh pretty

00:40:37.280 --> 00:40:39.900
stable all the way through to you guys and how

00:40:39.900 --> 00:40:42.860
you dealt with with this incredible influx of

00:40:42.860 --> 00:40:45.199
patients from the outside looking in it looked

00:40:45.199 --> 00:40:48.059
absolutely amazing you know the whole scene went

00:40:48.059 --> 00:40:52.239
the way it did right no it's you know it went

00:40:52.239 --> 00:40:57.199
better than any any drill we've done you know

00:40:57.199 --> 00:40:58.719
you always do your drills and you know your biggest

00:40:58.719 --> 00:41:02.599
you're your own best or worst critic and I remember

00:41:02.599 --> 00:41:05.230
you know thinking oh we can do this better that

00:41:05.230 --> 00:41:08.230
better we we finished this event and we had our

00:41:08.230 --> 00:41:10.010
debriefings and such and we were like i mean

00:41:10.010 --> 00:41:11.369
obviously there were a few things here and there

00:41:11.369 --> 00:41:13.730
like you're mentioning but overall yeah from

00:41:13.730 --> 00:41:18.050
from ems and police all the way through we couldn't

00:41:18.050 --> 00:41:20.409
have been more satisfied with it honestly yeah

00:41:20.409 --> 00:41:21.989
now one thing i was going to ask you as well

00:41:21.989 --> 00:41:25.429
so did you absorb every single um patient they

00:41:25.429 --> 00:41:28.050
want any sense of chance or any of the area level

00:41:28.050 --> 00:41:32.969
one trauma centers uh no so We got all the critical

00:41:32.969 --> 00:41:36.750
ones. Eleven, I believe, did go to Florida Hospital.

00:41:36.849 --> 00:41:39.409
And while it's not a trauma center, I think they

00:41:39.409 --> 00:41:41.989
were pretty minimally wounded, so they felt like

00:41:41.989 --> 00:41:45.510
they could go to the closest center and get care.

00:41:45.829 --> 00:41:49.469
Right. Some showed up a couple days later at

00:41:49.469 --> 00:41:52.409
some of our smaller centers like Dr. Phillips

00:41:52.409 --> 00:41:54.550
and things like that with minor wounds as well.

00:41:54.650 --> 00:41:57.349
But all the major injuries were brought directly

00:41:57.349 --> 00:42:02.400
here. Okay. All right. So I guess the next question

00:42:02.400 --> 00:42:04.739
is, I mean, it sounds like everything went phenomenally

00:42:04.739 --> 00:42:06.639
well, but I mean, one of the whole points of

00:42:06.639 --> 00:42:09.900
the show and this interview is for us to learn,

00:42:10.019 --> 00:42:13.800
us to grow. So firstly, you guys specifically

00:42:13.800 --> 00:42:17.619
as trauma surgeons and in the ER, what were some

00:42:17.619 --> 00:42:19.679
of the lessons you learned from that particular

00:42:19.679 --> 00:42:22.300
incident? And if anything, what did you change

00:42:22.300 --> 00:42:25.480
after that? Sure. So some of the things that

00:42:25.480 --> 00:42:28.139
we've encompassed into our training and our...

00:42:28.889 --> 00:42:31.550
for mass casualty training is that and we actually

00:42:31.550 --> 00:42:35.090
incorporate into our regular traumas now if somebody

00:42:35.090 --> 00:42:37.769
needs to go to the operating room truly emergently

00:42:37.769 --> 00:42:40.849
you know like right that second then we can actually

00:42:40.849 --> 00:42:44.150
go up to the or you know and they will open the

00:42:44.150 --> 00:42:46.969
or around us as opposed to calling and saying

00:42:46.969 --> 00:42:50.230
hey call us when you have the room ready we get

00:42:50.230 --> 00:42:51.969
the patient to the room and then the room gets

00:42:51.969 --> 00:42:55.579
ready around us right and that That way, we bring

00:42:55.579 --> 00:42:58.380
ER staff with us until we make that transition

00:42:58.380 --> 00:43:01.079
or that pass off to the anesthesia team and the

00:43:01.079 --> 00:43:04.360
OR team. That just cuts down on some of the time

00:43:04.360 --> 00:43:06.599
needed. In a mass casualty situation, that gives

00:43:06.599 --> 00:43:09.460
you more bed availability in your trauma bay.

00:43:10.340 --> 00:43:12.619
That was something that night. We're calling

00:43:12.619 --> 00:43:15.000
up and telling our front desk person, hey, we

00:43:15.000 --> 00:43:17.219
need to come up. They said, okay, give us 10,

00:43:17.280 --> 00:43:19.460
15 minutes. I said, no, you don't understand.

00:43:20.219 --> 00:43:22.920
We're coming right now. You can open the room

00:43:22.920 --> 00:43:25.380
around us. You know, it took some talking, you

00:43:25.380 --> 00:43:28.960
know, and making them understand, hey, we need

00:43:28.960 --> 00:43:30.559
to make more beds available. We've got to do

00:43:30.559 --> 00:43:31.960
this. And they're like, OK. I mean, it didn't

00:43:31.960 --> 00:43:34.940
take very much talking, but we found that that

00:43:34.940 --> 00:43:37.199
was much more beneficial. And then the other

00:43:37.199 --> 00:43:39.679
thing, when we went on lockdown, as I mentioned,

00:43:39.739 --> 00:43:41.639
some of the surgeons that were called in, additional

00:43:41.639 --> 00:43:44.199
surgeons that were called in, they could not

00:43:44.199 --> 00:43:47.179
get to the trauma bay. So instead, they had to

00:43:47.179 --> 00:43:49.880
go directly to the operating room and we would

00:43:49.880 --> 00:43:54.760
shuttle patients up to them. As a result, we

00:43:54.760 --> 00:43:56.639
found that that is a little more efficient in

00:43:56.639 --> 00:43:59.159
a mass casualty situation. So now, and that's

00:43:59.159 --> 00:44:01.380
very much like what the military training and

00:44:01.380 --> 00:44:03.900
exercises do. They have people that are in the

00:44:03.900 --> 00:44:05.880
ORs waiting, and they have people that are triaging,

00:44:05.920 --> 00:44:08.360
and they send them their way once they evaluate

00:44:08.360 --> 00:44:10.820
them and figure out their injuries. And that,

00:44:10.840 --> 00:44:12.900
especially when you have a close unit like ours,

00:44:12.980 --> 00:44:14.519
I mean, there are nine of us, and we work together

00:44:14.519 --> 00:44:17.780
very well. We've known each other, at least seven

00:44:17.780 --> 00:44:19.619
of us have known each other for about 10 years

00:44:19.619 --> 00:44:23.110
or more. We know each other very well, trust

00:44:23.110 --> 00:44:24.789
each other to take care of patients and evaluate

00:44:24.789 --> 00:44:27.889
patients. And if they send somebody up to me

00:44:27.889 --> 00:44:30.670
in the OR saying they've got these injuries of

00:44:30.670 --> 00:44:33.409
X, Y, and Z and need surgery, then I can do the

00:44:33.409 --> 00:44:36.969
surgery. And that model has shown to be beneficial

00:44:36.969 --> 00:44:40.150
in multiple mass casualty situations and military

00:44:40.150 --> 00:44:41.929
training. And that's something that we've adopted

00:44:41.929 --> 00:44:45.090
now for our mass casualty training as well. And

00:44:45.090 --> 00:44:47.710
then lastly, as far as lessons learned with our

00:44:47.710 --> 00:44:51.940
pre -hospital care. We already do drills with

00:44:51.940 --> 00:44:55.400
them on a monthly basis. We rotate through different

00:44:55.400 --> 00:44:58.260
services, whether we go to Lakeland, Apopka,

00:44:58.440 --> 00:45:01.940
obviously Orange County, and we do drills with

00:45:01.940 --> 00:45:04.940
them. And I think communication, as you probably

00:45:04.940 --> 00:45:08.159
have seen and heard and experienced, that is

00:45:08.159 --> 00:45:13.500
99 % of the battle. And that evening, I remember

00:45:13.500 --> 00:45:15.699
some paramedics coming in and asking me, hey,

00:45:15.760 --> 00:45:17.619
I can't get back to the scene. What can I do?

00:45:18.349 --> 00:45:20.110
And I said, well, you're better at IVs than me.

00:45:20.150 --> 00:45:23.050
Put IVs in these folks. And just having that

00:45:23.050 --> 00:45:25.550
open dialogue and that ability to communicate

00:45:25.550 --> 00:45:27.170
with each other, what are the needs and where

00:45:27.170 --> 00:45:30.969
can I help? And so as a result, we just, with

00:45:30.969 --> 00:45:34.070
our EMS, we've had that for a while now, but

00:45:34.070 --> 00:45:38.409
with our OPD, the Orlando Police and Orange County

00:45:38.409 --> 00:45:40.809
Sheriff, incorporating them into the drilling

00:45:40.809 --> 00:45:43.969
even more and having their evaluations because

00:45:43.969 --> 00:45:46.550
the police department actually brought in 11

00:45:46.550 --> 00:45:48.510
patients that evening. So I think they were the

00:45:48.510 --> 00:45:52.030
second biggest transporter that night. So in

00:45:52.030 --> 00:45:53.829
a mass casualty situation, that's what you're

00:45:53.829 --> 00:45:55.190
going to see. You're going to see your police

00:45:55.190 --> 00:45:58.309
departments really stepping up and contributing

00:45:58.309 --> 00:46:00.710
to patient delivery. And I think that's important

00:46:00.710 --> 00:46:04.190
to recognize and important to involve them in

00:46:04.190 --> 00:46:06.190
the training and the drills that you do. Yeah.

00:46:06.369 --> 00:46:08.789
One of my previous guests, John Spira, he was

00:46:08.789 --> 00:46:10.550
one of the first guys on the Aurora shooting

00:46:10.550 --> 00:46:15.280
in Colorado. And he said the same thing. initially

00:46:15.280 --> 00:46:17.639
trying to do the structured triage but then it

00:46:17.639 --> 00:46:19.960
kind of went to the point where patients were

00:46:19.960 --> 00:46:21.880
getting thrown in whatever they could and transported

00:46:21.880 --> 00:46:25.619
in police cruises and I think even private vehicles

00:46:25.619 --> 00:46:29.000
so I want to touch on that a little bit because

00:46:29.000 --> 00:46:32.760
he mentioned in his how we have the start triage

00:46:32.760 --> 00:46:35.239
and obviously we need a framework he mentioned

00:46:35.239 --> 00:46:36.940
that there were some weaknesses in some areas

00:46:36.940 --> 00:46:40.400
that in real life didn't pan out the way that

00:46:40.400 --> 00:46:43.400
they would in training the the patients in in

00:46:43.400 --> 00:46:46.179
the pulse were they triaged using start triage

00:46:46.179 --> 00:46:49.260
or was it more uh just brought in you know uh

00:46:49.260 --> 00:46:52.860
as a constant flow yeah very much like you're

00:46:52.860 --> 00:46:54.880
saying initially i think they tried to triage

00:46:54.880 --> 00:46:57.460
but then as the number increased i mean we had

00:46:57.460 --> 00:47:01.460
a window there where we had i want to say 38

00:47:01.460 --> 00:47:05.579
patients in 42 minutes wow so yeah to do the

00:47:05.579 --> 00:47:07.739
typical triage with the tags and things like

00:47:07.739 --> 00:47:11.119
that it's kind of unrealistic at that point so

00:47:11.119 --> 00:47:15.000
um yeah it kind of just becomes get them here

00:47:15.000 --> 00:47:17.079
and just evaluate them you know once they get

00:47:17.079 --> 00:47:20.840
here and we did have a system where our critical

00:47:20.840 --> 00:47:24.780
care medicine and er personnel were evaluating

00:47:24.780 --> 00:47:26.820
patients when they first were brought to the

00:47:26.820 --> 00:47:28.800
emergency department in the kind of the bay there

00:47:28.800 --> 00:47:32.719
with ultrasound and vitals and if they were humanimically

00:47:32.719 --> 00:47:34.880
stable and had no free fluid in their abdomen

00:47:34.880 --> 00:47:38.000
they could do a little more structured evaluation

00:47:38.000 --> 00:47:41.630
versus if they had either unstable vital signs

00:47:41.630 --> 00:47:44.570
or had fluid in the abdomen, they were brought

00:47:44.570 --> 00:47:46.530
directly to the trauma bay for us to evaluate.

00:47:46.809 --> 00:47:51.090
Right. Okay, so I want to talk more about pre

00:47:51.090 --> 00:47:54.570
-hospital. So I know one area that is kind of

00:47:54.570 --> 00:47:57.050
introduced, but I know I've only been a fireman

00:47:57.050 --> 00:47:59.409
for 13 years, but when I first became a fireman,

00:47:59.429 --> 00:48:02.340
tourniquets were almost like... These terrifying

00:48:02.340 --> 00:48:05.300
pieces of equipment that if you put it on for

00:48:05.300 --> 00:48:07.139
more than 60 seconds, the person's leg was going

00:48:07.139 --> 00:48:10.440
to drop off. So obviously that mentality has

00:48:10.440 --> 00:48:14.400
changed now. So obviously from Pulse, but even

00:48:14.400 --> 00:48:16.920
from the other pre -hospital traumas that you

00:48:16.920 --> 00:48:20.360
have, are you seeing now in the civilian arena

00:48:20.360 --> 00:48:23.679
a good result when these crews are using tourniquets?

00:48:24.940 --> 00:48:28.219
Yes. I mean, I still don't see it. As much as

00:48:28.219 --> 00:48:31.119
we would anticipate, we have started with the

00:48:31.119 --> 00:48:32.980
Stop the Bleed campaign that you're probably

00:48:32.980 --> 00:48:37.940
familiar with to educate not just obviously pre

00:48:37.940 --> 00:48:41.400
-hospital personnel, but the true what can be

00:48:41.400 --> 00:48:43.820
considered maybe even more of a first responder

00:48:43.820 --> 00:48:46.079
or a pre -first responder, and that's civilians

00:48:46.079 --> 00:48:49.340
that are at the scenes on how to put on tourniquets,

00:48:49.360 --> 00:48:51.380
how to hold pressure, and things like that, and

00:48:51.380 --> 00:48:54.940
educate people that... The research does show

00:48:54.940 --> 00:48:58.039
that nobody's lost a limb from a tourniquet if

00:48:58.039 --> 00:49:01.679
it's only left on for two hours or less. And

00:49:01.679 --> 00:49:03.340
it's funny, in doing some of these classes that

00:49:03.340 --> 00:49:07.880
we've started, talking with civilians, I remember

00:49:07.880 --> 00:49:09.579
this one gentleman telling me, oh, I thought

00:49:09.579 --> 00:49:11.239
anybody that had a tourniquet on lost that limb.

00:49:13.099 --> 00:49:18.179
That's not exactly true. And in fact, most of

00:49:18.179 --> 00:49:21.010
them don't. The majority don't. And even further,

00:49:21.130 --> 00:49:23.309
the fact, at least if they do lose the limb,

00:49:23.369 --> 00:49:25.610
but it saves their life, we still have a live

00:49:25.610 --> 00:49:28.909
person. And, you know, people just are so fearful

00:49:28.909 --> 00:49:30.550
of, oh, gosh, are they going to lose their limb?

00:49:31.150 --> 00:49:33.369
And when you truly have somebody that's exsanguinating,

00:49:33.630 --> 00:49:35.969
I mean, that's a life -saving situation. And

00:49:35.969 --> 00:49:39.429
I think, you know, I have not seen a significant

00:49:39.429 --> 00:49:42.510
increase in our pre -hospital personnel usage

00:49:42.510 --> 00:49:44.610
of that. We did see a few that night, as I mentioned.

00:49:44.650 --> 00:49:47.170
I had some people helping me take those down.

00:49:47.849 --> 00:49:49.309
A lot of people feel uncomfortable because it

00:49:49.309 --> 00:49:51.690
does hurt, as you probably know. When people

00:49:51.690 --> 00:49:54.630
have tourniquets put on properly, if they're

00:49:54.630 --> 00:49:57.409
conscious, it's not comfortable at all. But it's

00:49:57.409 --> 00:49:59.550
not intended to be because it's intended to stop

00:49:59.550 --> 00:50:03.989
the bleeding. So, you know, it's difficult to

00:50:03.989 --> 00:50:06.769
crank that down on somebody with them wide awake.

00:50:07.670 --> 00:50:09.110
You know, and you just have to instruct them

00:50:09.110 --> 00:50:11.210
that this is stopping you from bleeding to death.

00:50:11.369 --> 00:50:15.320
And hopefully they'll understand later. Yeah,

00:50:15.380 --> 00:50:17.659
I think that that message needs to be taken out

00:50:17.659 --> 00:50:20.380
there as you're talking about. It needs to be

00:50:20.380 --> 00:50:22.199
told to people and make sure they understand

00:50:22.199 --> 00:50:24.639
that those can be a life -saving, not just in

00:50:24.639 --> 00:50:27.559
a mass casualty situation or a shooting. We talk

00:50:27.559 --> 00:50:30.619
about people falling off ladders, tree cutters.

00:50:30.699 --> 00:50:32.679
You've got sharp instruments in one hand, they

00:50:32.679 --> 00:50:34.739
fall off the ladder. Next thing you know, you've

00:50:34.739 --> 00:50:38.539
got a significant limb injury. Motorcycle crashes

00:50:38.539 --> 00:50:40.840
we see all the time with significant limb injuries.

00:50:42.960 --> 00:50:45.760
Having, you know, whether it be EMS, pre -hospital

00:50:45.760 --> 00:50:47.960
personnel or even a civilian put on a tourniquet,

00:50:47.980 --> 00:50:50.039
I think that's crucial. And as we've alluded

00:50:50.039 --> 00:50:53.039
to, I think it's lifesaving. Right. OK. And then

00:50:53.039 --> 00:50:57.320
touching on another kind of not gray area, but

00:50:57.320 --> 00:51:02.179
maybe misunderstanding the airway. So obviously.

00:51:02.829 --> 00:51:04.929
You start medic school, it's all about intubating.

00:51:05.110 --> 00:51:07.449
And then we have the king tubes. And then people

00:51:07.449 --> 00:51:09.650
say, you know, normal breather. I mean, excuse

00:51:09.650 --> 00:51:12.250
me, normal breather. Back valve mask is good

00:51:12.250 --> 00:51:15.369
as well. But the goal for me is to be the best

00:51:15.369 --> 00:51:18.449
medic I can be and prepare the patient in the

00:51:18.449 --> 00:51:20.389
best way for you guys. So think about, you know,

00:51:20.389 --> 00:51:22.590
the large bore IVs or, you know, whatever it

00:51:22.590 --> 00:51:24.070
is that's going to set you guys up for success

00:51:24.070 --> 00:51:26.570
when we walk through your door. So in an ideal

00:51:26.570 --> 00:51:28.690
world, not catering to the lowest common denominator,

00:51:28.789 --> 00:51:30.889
which a lot of the medical direction I know is

00:51:30.889 --> 00:51:35.739
kind of aimed at. Is a good intubation, is that

00:51:35.739 --> 00:51:37.739
still the ultimate thing that you're looking

00:51:37.739 --> 00:51:41.159
for a medic to bring through the doors? I mean,

00:51:41.159 --> 00:51:46.159
obviously it makes our life easier. I think in

00:51:46.159 --> 00:51:48.559
the properly trained individual, it is a life

00:51:48.559 --> 00:51:52.860
-saving event. Have I seen adverse events from

00:51:52.860 --> 00:51:55.960
attempted intubation or intubation that they

00:51:55.960 --> 00:51:58.099
thought was proper or that got dislodged somehow

00:51:58.099 --> 00:52:01.570
and now is an esophagus? Yes, and I told you

00:52:01.570 --> 00:52:04.949
I've been, I don't know, blessed or cursed, however

00:52:04.949 --> 00:52:07.449
you want to look at it, with a few experiences

00:52:07.449 --> 00:52:09.590
of being in the field, being the first person

00:52:09.590 --> 00:52:14.469
on a scene, and even helping EMS try to intubate,

00:52:14.530 --> 00:52:17.789
things like that. And again, my hat's off. I'm

00:52:17.789 --> 00:52:19.590
blessed with lighting and instruments and all

00:52:19.590 --> 00:52:21.909
those things. I don't know how you guys get proper

00:52:21.909 --> 00:52:29.280
intubation ever. It's just amazing to me. A good

00:52:29.280 --> 00:52:34.099
intubation is very beneficial. Do I think you

00:52:34.099 --> 00:52:38.059
can oxygenate somebody sufficiently with a bag

00:52:38.059 --> 00:52:42.800
valve mask? I think so. I just have seen enough

00:52:42.800 --> 00:52:46.880
where I think it depends on your comfort level

00:52:46.880 --> 00:52:50.300
and your level of training. We see some horrific

00:52:50.300 --> 00:52:52.599
injuries here. I saw horrific injuries in Tennessee

00:52:52.599 --> 00:52:56.679
where the airway is very difficult. So making

00:52:56.679 --> 00:52:59.800
an attempt is probably better just to get a mask

00:52:59.800 --> 00:53:01.440
on them, start bagging them, and get them to

00:53:01.440 --> 00:53:03.820
the closest facility to get them intubated properly.

00:53:05.239 --> 00:53:09.460
I know that's a difficult situation, and that's

00:53:09.460 --> 00:53:12.039
something that's easy for me to sit here and

00:53:12.039 --> 00:53:13.880
say in the trauma bay, seeing things that roll

00:53:13.880 --> 00:53:16.139
in, as opposed to being the guy in the field

00:53:16.139 --> 00:53:19.860
having to make that call. But I do think that

00:53:19.860 --> 00:53:21.019
that's something that we're going to have to

00:53:21.019 --> 00:53:22.599
continue to look at. The good news is they keep

00:53:22.599 --> 00:53:24.099
coming up with more and more instruments that

00:53:24.099 --> 00:53:28.260
make it easier. Things like the king tube that

00:53:28.260 --> 00:53:31.480
we seem to use a lot and see here. Different

00:53:31.480 --> 00:53:34.579
scopes now where you actually have a camera view

00:53:34.579 --> 00:53:38.760
on your laryngoscope. Right. I think those type

00:53:38.760 --> 00:53:40.940
instruments are going to make it more and more

00:53:40.940 --> 00:53:46.059
facile and better for our EMS providers to be

00:53:46.059 --> 00:53:48.679
able to do that in the field. But with the traditional

00:53:48.679 --> 00:53:51.079
laryngoscope and doing it in the field, I think

00:53:51.079 --> 00:53:55.079
if you are not very well trained, which goes

00:53:55.079 --> 00:53:56.940
to our responsibilities too as trauma centers,

00:53:57.079 --> 00:53:59.000
what are we doing to help you guys do some airway

00:53:59.000 --> 00:54:02.920
courses? We all have these simulators now where

00:54:02.920 --> 00:54:05.159
we can make difficult airways. We can do different

00:54:05.159 --> 00:54:07.619
things. How do we incorporate you guys into that

00:54:07.619 --> 00:54:09.900
education? We do it for our ER residents. We

00:54:09.900 --> 00:54:12.219
do it for our surgical critical care people.

00:54:12.519 --> 00:54:14.440
Should we not be partnering with you guys in

00:54:14.440 --> 00:54:16.320
doing that? I think the answer is yes. Yeah,

00:54:16.320 --> 00:54:19.159
absolutely. Getting you guys more engaged with

00:54:19.159 --> 00:54:20.900
that, and that way you have that same comfort

00:54:20.900 --> 00:54:23.619
level as us. But because, again, you guys are

00:54:23.619 --> 00:54:25.340
having to make the same calls we are, but you

00:54:25.340 --> 00:54:28.679
make it in the dark on a roadside. Whereas I

00:54:28.679 --> 00:54:30.539
get to make it with a patient in a bed and five

00:54:30.539 --> 00:54:35.239
to six people around me helping. So I think that's

00:54:35.239 --> 00:54:37.019
where we need to look at is how do we get you

00:54:37.019 --> 00:54:40.800
guys more training and more comfortable with

00:54:40.800 --> 00:54:42.659
that when it does happen in the middle of the

00:54:42.659 --> 00:54:45.400
night with a guy hitting a motor, running his

00:54:45.400 --> 00:54:47.800
motorcycle into a wall or a sign. He's got a

00:54:47.800 --> 00:54:50.539
bloody airway and he just has to be too. how

00:54:50.539 --> 00:54:52.860
do we create that level of comfort so there's

00:54:52.860 --> 00:54:55.119
no anxiety and you just do it just like you've

00:54:55.119 --> 00:54:57.320
done a hundred other times on a mannequin you

00:54:57.320 --> 00:55:00.099
know yeah yeah i think i'm not not defending

00:55:00.099 --> 00:55:02.699
not making excuses but a challenge that a lot

00:55:02.699 --> 00:55:04.460
of first responders have especially if they are

00:55:04.460 --> 00:55:07.019
a firefighter and medic um is that we're just

00:55:07.019 --> 00:55:09.340
jack of all trades master of none so it takes

00:55:09.340 --> 00:55:11.460
so much training to make sure that you're competent

00:55:11.460 --> 00:55:14.260
because you might be intubating you know a three

00:55:14.260 --> 00:55:16.760
-year -old and then your next call be having

00:55:16.760 --> 00:55:19.539
to rig a rope system to rescue a guy off a you

00:55:19.539 --> 00:55:22.699
know a window cleaner so so our scope of practice

00:55:22.699 --> 00:55:25.840
is so huge um it takes a lot of training which

00:55:25.840 --> 00:55:27.619
this is what this is this whole thing is about

00:55:27.619 --> 00:55:30.760
is not making excuses but reminding ourselves

00:55:30.760 --> 00:55:33.940
and myself included that if we get complacent

00:55:33.940 --> 00:55:36.590
and we stop training It's not being dramatic.

00:55:36.829 --> 00:55:38.829
Lives truly do handle, you know, hang in the

00:55:38.829 --> 00:55:40.789
balance, because if we miss these tubes consistently,

00:55:41.630 --> 00:55:42.889
I mean, that might be the difference between

00:55:42.889 --> 00:55:48.010
someone living and dying. Yes. So, OK, staying

00:55:48.010 --> 00:55:50.829
on that kind of intervention, another area that

00:55:50.829 --> 00:55:54.429
I hear people talk about is needle decompression.

00:55:55.710 --> 00:55:58.929
When you have we have certain parameters that

00:55:58.929 --> 00:56:01.489
we're supposed to have before we decompress.

00:56:01.710 --> 00:56:07.599
Is that another area that. uh, you see could

00:56:07.599 --> 00:56:09.699
be done more aggressively as well in the field.

00:56:11.239 --> 00:56:13.579
Yeah, that's funny because, you know, I was a

00:56:13.579 --> 00:56:15.659
few months ago, I was down in the trauma bay

00:56:15.659 --> 00:56:18.539
and they brought somebody in and I remember they're

00:56:18.539 --> 00:56:20.239
giving me the story and I'm looking at him like

00:56:20.239 --> 00:56:22.619
this. I said, so this guy didn't meet. And he's

00:56:22.619 --> 00:56:24.300
like, well, I really wanted to put a needle,

00:56:24.360 --> 00:56:26.659
wanted a needle decompressive, but he didn't

00:56:26.659 --> 00:56:29.179
quite meet our criteria. I was like, we need

00:56:29.179 --> 00:56:30.679
to help you guys out on that. You need to be.

00:56:30.719 --> 00:56:32.619
And then I go and look at the criteria and then.

00:56:33.099 --> 00:56:36.340
I reviewed a couple more cases where, you know,

00:56:36.340 --> 00:56:39.320
maybe it was different units or things like that,

00:56:39.340 --> 00:56:42.840
but they had needle decompression and maybe wasn't

00:56:42.840 --> 00:56:44.800
quite indicated. So, again, as you're pointing

00:56:44.800 --> 00:56:48.019
to your last point about all the things that

00:56:48.019 --> 00:56:50.380
you guys have to do, you know, it's just, again,

00:56:50.539 --> 00:56:53.960
it's amazing and can be overwhelming, I'm sure,

00:56:54.059 --> 00:56:58.079
to do all that training. But, you know, I do

00:56:58.079 --> 00:57:00.239
think we need to give you guys, and there have

00:57:00.239 --> 00:57:03.460
been multiple papers talking about. EMS and paramedic

00:57:03.460 --> 00:57:06.559
discretion to determine trauma alerts and things

00:57:06.559 --> 00:57:08.400
like that, even if they don't meet criteria and

00:57:08.400 --> 00:57:11.079
how that sometimes is better than using the criteria

00:57:11.079 --> 00:57:16.099
that we use. Yeah. So I think giving you guys

00:57:16.099 --> 00:57:18.920
a little more freedom and a little more autonomy

00:57:18.920 --> 00:57:22.179
in addition to, again, giving you the training,

00:57:22.260 --> 00:57:26.079
giving you that practice is so key because I

00:57:26.079 --> 00:57:28.219
mean, I've seen guys, I mean, seeing it used

00:57:28.219 --> 00:57:30.760
just beautifully and it was a life saving situation.

00:57:31.570 --> 00:57:34.750
and I've seen it sometimes, and the catheter

00:57:34.750 --> 00:57:38.050
didn't quite get into the thorax. You know, I

00:57:38.050 --> 00:57:40.769
do my CT scan, and it's sitting in the pec muscle.

00:57:40.889 --> 00:57:45.730
Right. Or, you know, it was put in, and there's

00:57:45.730 --> 00:57:48.210
no pneumo, but there's a pneumo on the other

00:57:48.210 --> 00:57:51.530
side. And so, again, I have the benefit of getting

00:57:51.530 --> 00:57:53.250
to play Monday morning quarterback by looking

00:57:53.250 --> 00:57:55.610
at it through the CT scanner, not being in there.

00:57:56.170 --> 00:57:57.969
In the field, trying to listen to the breath

00:57:57.969 --> 00:57:59.989
sounds in the back of an ambulance or a helicopter

00:57:59.989 --> 00:58:03.050
or things like that. So, again, I think it's

00:58:03.050 --> 00:58:04.989
just more experience, more training. But I do

00:58:04.989 --> 00:58:07.489
think based on and that's again, this is backed

00:58:07.489 --> 00:58:10.289
up by more and more research that the more training

00:58:10.289 --> 00:58:14.110
we give pre -hospital personnel, the better decisions

00:58:14.110 --> 00:58:16.610
they're able to make. And quite frankly, they

00:58:16.610 --> 00:58:18.630
do a better job at assessing what the patient

00:58:18.630 --> 00:58:22.730
needs than even our criteria can determine. Yeah.

00:58:22.769 --> 00:58:25.619
So I think that. In the long run, that is something

00:58:25.619 --> 00:58:28.219
that probably would be beneficial. Okay. And

00:58:28.219 --> 00:58:30.880
another area, I'm trying to delve in too deep

00:58:30.880 --> 00:58:32.860
because I'm not breaking any HIPAA laws, but

00:58:32.860 --> 00:58:36.599
actually my last day at Orange County, let's

00:58:36.599 --> 00:58:39.260
just say that the gods weren't happy. The third

00:58:39.260 --> 00:58:42.059
of my patients that I brought, my partner and

00:58:42.059 --> 00:58:44.440
I brought in, was a gentleman that had basically

00:58:44.440 --> 00:58:49.719
come out of a house on fire. And by this point,

00:58:49.760 --> 00:58:51.239
third -degree burns from head to toe. Everything

00:58:51.239 --> 00:58:54.030
wasn't burned but the soles of his feet. So our

00:58:54.030 --> 00:58:57.889
only option really, apart from airway and IO,

00:58:58.849 --> 00:59:04.409
was a burn sheet. So is there anything on the

00:59:04.409 --> 00:59:07.329
horizon as far as pre -hospital care for care

00:59:07.329 --> 00:59:09.190
for burns? Or is that always still going to be

00:59:09.190 --> 00:59:11.110
the kind of only thing that we're able to do

00:59:11.110 --> 00:59:13.210
apart from controlling the airway and fluids

00:59:13.210 --> 00:59:17.289
and pain medication, of course? Honestly, I don't

00:59:17.289 --> 00:59:19.789
know anything new on the horizon for them pre

00:59:19.789 --> 00:59:22.599
-hospital. There's lots of stuff. you know in

00:59:22.599 --> 00:59:24.980
the hospital for for their wounds and for things

00:59:24.980 --> 00:59:28.539
like that um but pre -hospital there's not much

00:59:28.539 --> 00:59:31.539
that i'm aware unfortunately um because there's

00:59:31.539 --> 00:59:34.320
just so much that you need to assess you know

00:59:34.320 --> 00:59:36.699
to do too much in the field and too much there

00:59:36.699 --> 00:59:38.500
you know like we just had one the other day i

00:59:38.500 --> 00:59:40.460
had to do an escharotomy on once he got here

00:59:40.460 --> 00:59:43.380
for his circumferential burn of his leg so he

00:59:43.380 --> 00:59:47.159
didn't lose pulses in the leg um you know they're

00:59:47.159 --> 00:59:48.860
just little things not little things that's a

00:59:48.860 --> 00:59:51.559
big thing but things like that that in the pre

00:59:51.559 --> 00:59:53.179
-hospital setting it's going to be very difficult

00:59:53.179 --> 00:59:56.039
to to determine and even obviously to be able

00:59:56.039 --> 00:59:57.599
to do something like that in the field would

00:59:57.599 --> 01:00:03.039
be very difficult at the most so i i think for

01:00:03.039 --> 01:00:06.280
burn stuff we're still kind of behind unfortunately

01:00:06.280 --> 01:00:09.139
on on the pre -hospital side and that there's

01:00:09.139 --> 01:00:11.280
just not a lot that we're able to offer them

01:00:11.280 --> 01:00:13.739
until we really get things evaluated and to be

01:00:13.739 --> 01:00:15.639
honest there are things that we see you know

01:00:15.639 --> 01:00:17.059
we'll think they're a certain percentage and

01:00:17.059 --> 01:00:19.909
then we Get them to breed it and cleaned up and

01:00:19.909 --> 01:00:21.210
everything and turns out they're much higher

01:00:21.210 --> 01:00:23.690
percentage than what's what we once thought right

01:00:23.690 --> 01:00:26.329
and they need you know that that increases or

01:00:26.329 --> 01:00:29.210
maybe pushes them over to requiring a resuscitation

01:00:29.210 --> 01:00:32.070
that involves a particle Parkland formula whereas

01:00:32.070 --> 01:00:34.429
prior to their debridement we thought oh they

01:00:34.429 --> 01:00:36.150
don't need Parkland formula these need fluids

01:00:36.150 --> 01:00:39.070
at 125 and then we do the Parkland formula or

01:00:39.070 --> 01:00:40.929
we do the debridement it's like oh my goodness

01:00:40.929 --> 01:00:46.300
I underestimated by 10 15 20 percent what their

01:00:46.300 --> 01:00:48.260
needs were, what their burns were, and now they

01:00:48.260 --> 01:00:51.559
need a significant more amount of fluid. And

01:00:51.559 --> 01:00:54.059
so I think that all those things are so limiting

01:00:54.059 --> 01:00:56.059
in the field because you can't really clean them

01:00:56.059 --> 01:00:58.719
off. You're trying to rush things to get them

01:00:58.719 --> 01:01:00.960
here. Your main things are still your airway

01:01:00.960 --> 01:01:04.559
and pain control and giving at least some fluids

01:01:04.559 --> 01:01:09.039
before they get here. Yeah. Okay. All right.

01:01:09.059 --> 01:01:11.179
So another area I kind of want to kind of...

01:01:11.750 --> 01:01:14.510
steer us into now I'm going to read a few names

01:01:14.510 --> 01:01:17.130
first before we delve into this because obviously

01:01:17.130 --> 01:01:20.090
Pulse is just you know one one day at ORMC and

01:01:20.090 --> 01:01:22.989
I've brought so many shooting victims and stabbing

01:01:22.989 --> 01:01:25.110
victims I know a lot of my my peers have especially

01:01:25.110 --> 01:01:28.010
from the you know OBT Pine Hills area where where

01:01:28.010 --> 01:01:30.409
there's a lot of violent crime but you guys also

01:01:30.409 --> 01:01:33.130
and I believe these people were all brought to

01:01:33.130 --> 01:01:35.909
you. Lieutenant Deborah Clayton, Deputy Norm

01:01:35.909 --> 01:01:38.849
Lewis, Deputy Brandon Coates, Deputy Jonathan

01:01:38.849 --> 01:01:42.989
Pine. So we had several of our law enforcement

01:01:42.989 --> 01:01:48.010
officers slain the last few years. And so have

01:01:48.010 --> 01:01:51.389
you, I mean, you yourself, did you notice any

01:01:51.389 --> 01:01:55.110
effects? mentally after um you know the pulse

01:01:55.110 --> 01:01:57.750
specifically but also just the collective nature

01:01:57.750 --> 01:01:59.909
of being a trauma surgeon and then also did you

01:01:59.909 --> 01:02:02.769
see the effects on on your peers in the er as

01:02:02.769 --> 01:02:07.929
well well i think you know the pulse in general

01:02:07.929 --> 01:02:09.769
obviously brought our whole community together

01:02:09.769 --> 01:02:14.090
in a much stronger way and uh i think you know

01:02:14.090 --> 01:02:16.449
the events you're you're discussing obviously

01:02:16.449 --> 01:02:18.710
i can't say say too much about each one but as

01:02:18.710 --> 01:02:21.769
far as the the impact everything's had On all

01:02:21.769 --> 01:02:24.389
of us in general, there's no doubt that there's

01:02:24.389 --> 01:02:29.110
a lot more solidarity between us and our friends

01:02:29.110 --> 01:02:32.250
and colleagues, brothers and sisters in the police,

01:02:32.510 --> 01:02:35.650
in the Orange County Sheriff's Departments, and

01:02:35.650 --> 01:02:39.230
in obviously the EMS departments around the Central

01:02:39.230 --> 01:02:42.289
Florida area. So there is no doubt that when

01:02:42.289 --> 01:02:45.909
one is injured or harmed, that it has a significant

01:02:45.909 --> 01:02:49.650
impact on all of us. And that has been very well

01:02:49.650 --> 01:02:52.670
demonstrated. On that day and on several other

01:02:52.670 --> 01:02:55.670
days, unfortunately. But, you know, there's no

01:02:55.670 --> 01:02:59.030
doubt that we're all much closer in our training,

01:02:59.190 --> 01:03:01.590
but also in our losses when things like that

01:03:01.590 --> 01:03:05.750
happen. So, again, I think Pulse is partly responsible

01:03:05.750 --> 01:03:09.090
for that, probably a major responsibility of

01:03:09.090 --> 01:03:13.730
that or a result of that. But I think those events,

01:03:13.889 --> 01:03:16.989
you know, now have much more meaning than what

01:03:16.989 --> 01:03:20.369
they did probably prior to Pulse. Again, it goes

01:03:20.369 --> 01:03:22.309
to the point that we do a lot of training we

01:03:22.309 --> 01:03:23.869
do together, a lot of different drills we do

01:03:23.869 --> 01:03:25.969
together. So we know each other on a regular

01:03:25.969 --> 01:03:28.610
basis. And as you pointed out, ORMC is a busy

01:03:28.610 --> 01:03:32.289
place. You know, Friday, Saturday night, you

01:03:32.289 --> 01:03:34.150
know, I actually I was at Chipotle the other

01:03:34.150 --> 01:03:36.289
day and I see two officers come in. I went over

01:03:36.289 --> 01:03:38.409
and just introduced myself and thank them for

01:03:38.409 --> 01:03:39.670
what they do. And they're like, oh, I thought

01:03:39.670 --> 01:03:42.110
I recognized you from the trauma bay. And so,

01:03:42.150 --> 01:03:43.789
you know, we all kind of know each other now

01:03:43.789 --> 01:03:46.559
and recognize each other. try to say hi to each

01:03:46.559 --> 01:03:48.460
other, not just at these events and these drills

01:03:48.460 --> 01:03:49.880
and these things like that, but when we're out

01:03:49.880 --> 01:03:51.360
and about in our community. And I think that

01:03:51.360 --> 01:03:55.000
speaks to the collegiality and speaks to the

01:03:55.000 --> 01:03:57.320
unified manner in which we seek to serve our

01:03:57.320 --> 01:04:00.780
community. Yeah, I agree. You hear these separations

01:04:00.780 --> 01:04:04.739
of jurisdictions or police versus fire or medics

01:04:04.739 --> 01:04:08.260
and nurses not getting on. take a step back we're

01:04:08.260 --> 01:04:11.400
all part of that same chain of survival whether

01:04:11.400 --> 01:04:14.019
it's you know on the police side or or the ems

01:04:14.019 --> 01:04:16.559
side and and for there to be any separation doesn't

01:04:16.559 --> 01:04:20.039
make any sense whatsoever no i agree totally

01:04:20.039 --> 01:04:23.380
i agree and and like i said i mean i think unfortunately

01:04:23.380 --> 01:04:25.480
you know we had that tragic event but the main

01:04:25.480 --> 01:04:27.320
one of the big things was the unified manner

01:04:27.320 --> 01:04:29.920
the whole whole city really came together and

01:04:29.920 --> 01:04:34.639
that are um ems and police and our obviously

01:04:34.639 --> 01:04:36.719
our trauma center really kind of combined and

01:04:36.719 --> 01:04:38.980
then you add on top of that we're doing things

01:04:38.980 --> 01:04:40.599
like stop the bleed you know how what do we do

01:04:40.599 --> 01:04:42.420
positive going forward from that you know we

01:04:42.420 --> 01:04:44.280
do we enhance our drilling we do things like

01:04:44.280 --> 01:04:45.780
that but then we also go out to the community

01:04:45.780 --> 01:04:48.420
and how do we educate them on stopping the bleed

01:04:48.420 --> 01:04:50.659
and being aware and all these different things

01:04:50.659 --> 01:04:54.099
to do to make our area safer yeah absolutely

01:04:54.099 --> 01:04:58.480
it was uh interesting i had uh sebastian junger

01:04:58.480 --> 01:05:02.099
who wrote tribe and and uh restepo and uh some

01:05:02.099 --> 01:05:04.840
of the other uh work that he's done and tribe

01:05:04.840 --> 01:05:07.420
was basically about how fundamentally humans

01:05:07.420 --> 01:05:10.639
are tribal and how in times of tragedy whether

01:05:10.639 --> 01:05:13.079
it was 9 -11 or the bombings in world war ii

01:05:13.079 --> 01:05:16.760
in london how they saw mental health was so much

01:05:16.760 --> 01:05:19.239
better there's a huge improvement as people banded

01:05:19.239 --> 01:05:21.179
together and felt part of something again i think

01:05:21.179 --> 01:05:25.190
that's has lost in in society and In a lot of

01:05:25.190 --> 01:05:27.449
ways, especially in this electronic generation

01:05:27.449 --> 01:05:29.750
that we're that we have. And sadly, it takes

01:05:29.750 --> 01:05:31.769
tragedies like these sometimes to bring people

01:05:31.769 --> 01:05:36.510
back together. Absolutely. You know, and that

01:05:36.510 --> 01:05:38.230
goes to, you know, you talk about I think that's

01:05:38.230 --> 01:05:40.170
another reason I like trauma is because it's

01:05:40.170 --> 01:05:42.349
definitely more of a team or try. I like the

01:05:42.349 --> 01:05:46.710
tribal link there mentality. And, you know, growing

01:05:46.710 --> 01:05:48.369
up, I played a lot of sports and things like

01:05:48.369 --> 01:05:51.500
that. So very much team sports minded. And trauma

01:05:51.500 --> 01:05:53.519
kind of leans itself in that direction. And obviously

01:05:53.519 --> 01:05:56.280
with working with EMS, working with police and

01:05:56.280 --> 01:05:58.139
you see that across the country. You know, I

01:05:58.139 --> 01:06:00.320
talk to other trauma directors and they're involved

01:06:00.320 --> 01:06:02.380
with their SWAT team and they're involved with

01:06:02.380 --> 01:06:04.019
different areas and different teams and different

01:06:04.019 --> 01:06:06.920
parts of their community. And, you know, obviously

01:06:06.920 --> 01:06:08.639
there's a big part of us that wants to serve,

01:06:08.679 --> 01:06:11.380
but there's a big part of that also that is serving

01:06:11.380 --> 01:06:13.320
us and serving something that we need inside

01:06:13.320 --> 01:06:15.059
of us. And I think you hit it on the head with

01:06:15.059 --> 01:06:18.760
the tribal. aspect of it that need for support

01:06:18.760 --> 01:06:20.900
and being able to support others at the same

01:06:20.900 --> 01:06:23.739
time you know and the one thing i talked to i

01:06:23.739 --> 01:06:25.739
talked to a group called volunteer florida just

01:06:25.739 --> 01:06:28.639
a great group of individuals who were here in

01:06:28.639 --> 01:06:31.239
florida just to uh it was from all across the

01:06:31.239 --> 01:06:33.900
south actually they're all in volunteer communities

01:06:33.900 --> 01:06:35.960
they're all none of them are very few or medically

01:06:35.960 --> 01:06:37.960
trained but they want to help see how they can

01:06:37.960 --> 01:06:39.659
help their communities better just an amazing

01:06:39.659 --> 01:06:42.400
group of people and so i got to talk with them

01:06:42.400 --> 01:06:45.159
and you know we talked about it's just When you

01:06:45.159 --> 01:06:48.360
break it down, it's just humans being human,

01:06:48.559 --> 01:06:52.400
right? I mean, doing the right thing. It shouldn't

01:06:52.400 --> 01:06:56.300
be that difficult. No. And sometimes it is, as

01:06:56.300 --> 01:06:58.780
you pointed out. But if you just break it down,

01:06:58.920 --> 01:07:01.920
it's really not that hard, I don't think. Maybe

01:07:01.920 --> 01:07:05.500
I'm simplifying it too much, but it just doesn't

01:07:05.500 --> 01:07:08.079
seem hard in my simple mind. Yeah. No, I agree.

01:07:08.199 --> 01:07:10.360
And to kind of, I guess, pull it back into pulse

01:07:10.360 --> 01:07:13.239
for a second. We're seeing the opposite, too.

01:07:13.360 --> 01:07:17.280
We're getting these people that are inhuman claiming

01:07:17.280 --> 01:07:22.340
whatever ideology they believe in, doing these

01:07:22.340 --> 01:07:24.099
horrible things. And I think to underline it,

01:07:24.139 --> 01:07:28.019
this Facebook killer that's just been on the

01:07:28.019 --> 01:07:29.420
news the last couple of days that killed that

01:07:29.420 --> 01:07:32.380
poor gentleman, Robert Goodwin, for no apparent

01:07:32.380 --> 01:07:37.480
reason. He didn't claim any affiliation, so it's

01:07:37.480 --> 01:07:39.500
just a murder. But you claim an affiliation,

01:07:39.539 --> 01:07:41.039
it becomes something else. And again, I think

01:07:41.039 --> 01:07:44.010
that... It's a crazy concept. It's a murderer

01:07:44.010 --> 01:07:46.449
who went in and killed a bunch of other fellow

01:07:46.449 --> 01:07:48.869
human beings. That's where it ends. And you can

01:07:48.869 --> 01:07:50.730
either be a human and help your community or

01:07:50.730 --> 01:07:52.789
you can be someone like that and hurt your community.

01:07:54.090 --> 01:07:59.769
Absolutely. You alluded earlier to the mental

01:07:59.769 --> 01:08:04.269
aspect for us. For trauma, especially when you

01:08:04.269 --> 01:08:07.150
look at patients and victims of violent crimes

01:08:07.150 --> 01:08:10.670
and the violent crime people that commit those

01:08:10.670 --> 01:08:12.940
things, Obviously, there's a big psychological

01:08:12.940 --> 01:08:15.820
component that we don't quite understand and

01:08:15.820 --> 01:08:18.800
they are in desperate need of understanding and

01:08:18.800 --> 01:08:21.020
help with. And unfortunately, that's a big kind

01:08:21.020 --> 01:08:23.779
of a big void in our in our country right now,

01:08:23.819 --> 01:08:27.079
I think. Yeah. Yeah, I agree. All right. Well,

01:08:27.159 --> 01:08:29.220
I have taken an hour of your time and I really,

01:08:29.319 --> 01:08:31.260
really appreciate it. We had some technical difficulties

01:08:31.260 --> 01:08:33.079
earlier, so it's probably been closer to almost

01:08:33.079 --> 01:08:35.500
an hour and a half. So I thank you so much for

01:08:35.500 --> 01:08:37.199
that. I've got a couple of short questions and

01:08:37.199 --> 01:08:40.600
then we'll let you get on your way. So firstly,

01:08:40.760 --> 01:08:42.939
I always ask my guests this. Do you have any

01:08:42.939 --> 01:08:46.279
books and or movies or documentaries that you

01:08:46.279 --> 01:08:48.600
recommend to people that you you rave about?

01:08:52.800 --> 01:08:57.659
About specifically about what? Anything at all.

01:08:58.760 --> 01:09:00.579
I don't know. These are more of the personal.

01:09:00.659 --> 01:09:03.520
But, you know, there's a writer. He's kind of

01:09:03.520 --> 01:09:07.109
Christian based. His name is John Eldridge talks.

01:09:07.430 --> 01:09:11.010
He's very much speaks about it's more to men,

01:09:11.149 --> 01:09:13.010
but it's, you know, what what men are looking

01:09:13.010 --> 01:09:14.909
for and what they need in life and what they're

01:09:14.909 --> 01:09:16.609
supposed to do with their lives. And that that

01:09:16.609 --> 01:09:19.789
one has really he's been a great person to read

01:09:19.789 --> 01:09:24.130
different things about in my personal life and

01:09:24.130 --> 01:09:27.390
how I want to live my life. OK, so he's he's

01:09:27.390 --> 01:09:34.470
a great one. You know, as far as. I think there's

01:09:34.470 --> 01:09:36.489
some other, you know, I've read a lot about the

01:09:36.489 --> 01:09:39.130
Boston bombings. I can't give you exact names

01:09:39.130 --> 01:09:43.369
right now, but different. There's a military

01:09:43.369 --> 01:09:47.329
surgeon who wrote a lot about those, their events

01:09:47.329 --> 01:09:51.369
and their situation up there. There are a lot

01:09:51.369 --> 01:09:53.789
of things that happen just by happenstance, right?

01:09:53.930 --> 01:09:55.529
And I can give you examples from our situation

01:09:55.529 --> 01:09:59.350
too, but for the Boston bombing, they... They

01:09:59.350 --> 01:10:02.590
had additional EMS personnel at the finish line.

01:10:02.729 --> 01:10:05.270
You may or may not know that. And the reason

01:10:05.270 --> 01:10:06.810
is the previous year they had an increase in

01:10:06.810 --> 01:10:10.590
their heat stroke rates. And so they had extra

01:10:10.590 --> 01:10:16.130
personnel at the finish line. Patriots Day is

01:10:16.130 --> 01:10:19.350
probably the worst day those gentlemen, those

01:10:19.350 --> 01:10:23.510
guys could have picked because the traffic is

01:10:23.510 --> 01:10:25.109
less because the whole city pretty much shuts

01:10:25.109 --> 01:10:29.489
down. That's why they had the good outcomes that

01:10:29.489 --> 01:10:32.310
they did for the injured ones that made it to

01:10:32.310 --> 01:10:35.909
the hospital because they had ease of access,

01:10:36.029 --> 01:10:38.449
they had more EMS personnel, and they could get

01:10:38.449 --> 01:10:43.390
them to the hospitals quicker. In our situation,

01:10:43.630 --> 01:10:49.090
we had three or four ER residents that were working

01:10:49.090 --> 01:10:52.529
that night. Well, they were two weeks from graduating,

01:10:52.750 --> 01:10:55.609
so they were basically attending physicians.

01:10:56.460 --> 01:10:58.560
So that increased our complement of physicians

01:10:58.560 --> 01:11:01.920
significantly. Right. You know, it happened in

01:11:01.920 --> 01:11:04.579
June and not July. And if you work in academic

01:11:04.579 --> 01:11:09.039
centers, you recognize that July is when the

01:11:09.039 --> 01:11:10.739
transition occurs and you get the new interns.

01:11:11.220 --> 01:11:13.939
Whereas we had interns that had at least 11 months

01:11:13.939 --> 01:11:16.640
of experience underneath them. So they weren't,

01:11:16.640 --> 01:11:19.300
you know, shocked by what they were seeing. I

01:11:19.300 --> 01:11:20.800
mean, they were obviously to some extent with

01:11:20.800 --> 01:11:23.659
that, but they still knew how to facilitate and

01:11:23.659 --> 01:11:27.069
triage and help out significantly. So the little

01:11:27.069 --> 01:11:29.329
things like that that just happened, that if

01:11:29.329 --> 01:11:31.369
you look at all these different mass casualties

01:11:31.369 --> 01:11:36.609
were present in these other situations too. So

01:11:36.609 --> 01:11:40.189
I think it goes to show that while it would be

01:11:40.189 --> 01:11:42.350
nice if these tragedies never happened, there's

01:11:42.350 --> 01:11:46.210
at least some hand above that's kind of watching

01:11:46.210 --> 01:11:50.810
over those. That being said, I can't give you

01:11:50.810 --> 01:11:54.329
a specific name on that. Any of those articles

01:11:54.329 --> 01:11:56.029
you read, I wish I could remember his name, but

01:11:56.029 --> 01:11:58.250
he's a military surgeon that worked in the Boston

01:11:58.250 --> 01:12:01.170
bombings. He has very good evaluations of that.

01:12:01.270 --> 01:12:03.250
But those are kind of the big ones I've read

01:12:03.250 --> 01:12:07.170
about. Did you see the Patriots Day movie they

01:12:07.170 --> 01:12:11.529
made? I have. I thought it was well done. I mean,

01:12:11.569 --> 01:12:16.369
it's a movie made for entertainment. It's got

01:12:16.369 --> 01:12:20.729
Mark Wahlberg. So it's simply entertaining. Is

01:12:20.729 --> 01:12:23.449
it something... you know i don't know i tried

01:12:23.449 --> 01:12:25.550
to see was there anything i could learn and draw

01:12:25.550 --> 01:12:28.149
from it other than you know obviously the experience

01:12:28.149 --> 01:12:30.750
that they had and how you know i didn't recognize

01:12:30.750 --> 01:12:34.189
as an outsider how they shut that city down completely

01:12:34.189 --> 01:12:37.949
to find to find those those individuals that

01:12:37.949 --> 01:12:40.750
was pretty amazing yeah extremes took into decisions

01:12:40.750 --> 01:12:43.390
they had to make so i really was impressed with

01:12:43.390 --> 01:12:47.210
that aspect of it Yeah, I know there was definitely

01:12:47.210 --> 01:12:50.189
some medical glitches, though. There's a lady

01:12:50.189 --> 01:12:52.529
there with a tube down her throat, and the guy

01:12:52.529 --> 01:12:54.350
said, yeah, she just told me whatever it was.

01:12:54.430 --> 01:12:55.729
And I'm like, how did she tell you that? She's

01:12:55.729 --> 01:12:58.529
got a tube in her throat. Oh, yeah, you can't

01:12:58.529 --> 01:13:01.810
know that. Something like that happens in a movie

01:13:01.810 --> 01:13:03.829
or video, or you're just like, well, I can't

01:13:03.829 --> 01:13:06.789
believe anything that happened. It's just part

01:13:06.789 --> 01:13:09.210
of working in medicine, and we want everything

01:13:09.210 --> 01:13:19.539
realistic. So what about any documentaries? Yes.

01:13:21.239 --> 01:13:23.380
Little Town. I don't know if you've seen that

01:13:23.380 --> 01:13:26.140
yet. It's a documentary on the Sandy Hook shooting.

01:13:26.359 --> 01:13:30.699
Oh, I haven't. No. It was on PBS. Actually, I

01:13:30.699 --> 01:13:32.899
got to see one of the first screenings of it

01:13:32.899 --> 01:13:36.680
at the Eastern Association meeting for surgery

01:13:36.680 --> 01:13:41.020
of trauma. And very well done. In fact, the director

01:13:41.020 --> 01:13:44.340
visited here. And I think she has something in

01:13:44.340 --> 01:13:46.880
the works to do something about Orlando's experience.

01:13:47.840 --> 01:13:50.859
But that's a very good documentary going into

01:13:50.859 --> 01:13:54.739
the lives of the victims' families, even. I mean,

01:13:54.760 --> 01:13:58.640
you'll need Kleenex. I mean, it's a very emotional

01:13:58.640 --> 01:14:02.300
documentary. But that was something that was

01:14:02.300 --> 01:14:05.260
very moving. And obviously, having seen it after

01:14:05.260 --> 01:14:07.659
our experience, it had even more meaning, I think.

01:14:07.779 --> 01:14:10.159
But that's something to look for. It's something

01:14:10.159 --> 01:14:12.260
I think people would appreciate, especially after

01:14:12.260 --> 01:14:15.859
our experience. It's called Littletown. You won't

01:14:15.859 --> 01:14:17.520
see it in theaters or anything like that, but

01:14:17.520 --> 01:14:21.760
it was on. They were showing it on PBS. I'm sure

01:14:21.760 --> 01:14:25.020
if you Google it, it may even be on YouTube at

01:14:25.020 --> 01:14:26.859
some point in the future. Okay, I'll have to

01:14:26.859 --> 01:14:28.819
look at that. My little boy was exactly the kindergarten

01:14:28.819 --> 01:14:31.680
age when that happened, so that was just absolutely

01:14:31.680 --> 01:14:35.539
gut -wrenching. Sure. Well, yeah, this will be

01:14:35.539 --> 01:14:37.819
a very difficult one for you to see. Having kids,

01:14:37.840 --> 01:14:41.199
it makes it even more difficult. Yeah. All right.

01:14:41.239 --> 01:14:44.399
Well, bringing it back up again, when you do

01:14:44.399 --> 01:14:45.819
need to decompress, you're done with your day,

01:14:45.920 --> 01:14:49.800
you've been saving lives, what do you do as an

01:14:49.800 --> 01:14:54.060
outlet? Well, I get to spend time with my boys.

01:14:54.199 --> 01:14:56.579
They're fantastic. They're 12. I have twin boys.

01:14:57.500 --> 01:15:02.600
They're a great outlet. enjoying life. It's fun

01:15:02.600 --> 01:15:04.939
to see them grow up. That's amazing to me that

01:15:04.939 --> 01:15:09.119
they're 12 already. Beyond that, reading and

01:15:09.119 --> 01:15:15.220
running. To be honest with you, swimming too.

01:15:15.300 --> 01:15:17.779
Swimming's been a good one. Spending time with

01:15:17.779 --> 01:15:21.979
my friends and family. I've done a lot of traveling

01:15:21.979 --> 01:15:25.720
just to do talks and meeting other people. While

01:15:25.720 --> 01:15:29.720
that may not seem... somewhat of an outlet because

01:15:29.720 --> 01:15:31.859
I'm still talking about the same things. It is,

01:15:31.880 --> 01:15:34.000
it's, I always take something away. You know,

01:15:34.039 --> 01:15:36.960
I go and teach the lesson of preparedness and

01:15:36.960 --> 01:15:39.699
stop the bleed and all those things. I've kind

01:15:39.699 --> 01:15:41.920
of, our whole facility and organization has taken

01:15:41.920 --> 01:15:46.420
that on as kind of our responsibility now is

01:15:46.420 --> 01:15:48.399
not just to tell the story, but to tell people

01:15:48.399 --> 01:15:50.859
how to be prepared and how to, how to do these

01:15:50.859 --> 01:15:54.060
things. But I always take something away. I always

01:15:54.060 --> 01:15:56.640
learn something and it's fun to meet people.

01:16:06.530 --> 01:16:08.810
Give us more credit than I think we deserve.

01:16:08.989 --> 01:16:10.770
I mean, we're just doing our job just like you

01:16:10.770 --> 01:16:12.510
do. It's like everybody, every other individual

01:16:12.510 --> 01:16:15.369
does. It just happened that we had a lot of work

01:16:15.369 --> 01:16:19.090
to do that day. But, you know, we didn't choose

01:16:19.090 --> 01:16:24.020
any of this by any stretch. But it's always fun

01:16:24.020 --> 01:16:25.939
to meet people and learn and take some of these

01:16:25.939 --> 01:16:28.739
lessons and bring it back here and make our community

01:16:28.739 --> 01:16:31.500
better. But really enjoying just that aspect

01:16:31.500 --> 01:16:33.720
of it too, just as you mentioned, the tribal,

01:16:33.819 --> 01:16:38.319
because trauma is a tribe in itself. Our trauma

01:16:38.319 --> 01:16:41.100
community as a whole is very small. I mean, I've

01:16:41.100 --> 01:16:44.260
met people even before this, but even more so

01:16:44.260 --> 01:16:47.680
now, from all the way from Seattle down to here

01:16:47.680 --> 01:16:50.899
to Boston to... southern california that you

01:16:50.899 --> 01:16:53.420
know i can call at any moment just talk to them

01:16:53.420 --> 01:16:56.699
and that's been it just brings our makes our

01:16:56.699 --> 01:16:59.399
country seem so much smaller than it is but uh

01:16:59.399 --> 01:17:02.279
that that's been really enjoyable getting to

01:17:02.279 --> 01:17:04.840
be getting to meet individuals on the national

01:17:04.840 --> 01:17:06.539
committee on trauma the chairman of the committee

01:17:06.539 --> 01:17:10.500
on trauma getting to meet him and call him and

01:17:10.500 --> 01:17:13.000
and talk to him about different aspects of things

01:17:13.000 --> 01:17:15.180
has been just amazing and he's been a great help

01:17:15.180 --> 01:17:17.670
for a lot of things but Doing all those things.

01:17:17.810 --> 01:17:19.890
But when it comes down to it, as far as just

01:17:19.890 --> 01:17:22.529
truly decompressing, I think running and swimming

01:17:22.529 --> 01:17:25.069
and exercise are still my main outlets. Right.

01:17:25.130 --> 01:17:27.050
Yeah, that's a common denominator. I've said

01:17:27.050 --> 01:17:29.029
this multiple times on the show, but exercise

01:17:29.029 --> 01:17:32.930
and family are huge ones. And then hobbies, which

01:17:32.930 --> 01:17:35.210
obviously your passion for learning and growing

01:17:35.210 --> 01:17:39.529
in the trauma field is, I guess, technically

01:17:39.529 --> 01:17:43.039
a hobby as well as a job. um all right and then

01:17:43.039 --> 01:17:45.239
so the last thing i say where can people find

01:17:45.239 --> 01:17:48.100
you but i'll expand that to to where can people

01:17:48.100 --> 01:17:50.920
contact you and find your work but also um if

01:17:50.920 --> 01:17:53.579
you want to uh talk about where they can access

01:17:53.579 --> 01:17:55.800
information for programs like stop the bleed

01:17:55.800 --> 01:18:00.939
as well sure so let's do stop the bleed first

01:18:00.939 --> 01:18:02.739
because that's way more important than me um

01:18:02.739 --> 01:18:05.899
stop the bleed is uh it's easy it's stopthebleed

01:18:05.899 --> 01:18:09.930
.org very easy okay website they have all Everything

01:18:09.930 --> 01:18:12.050
on there, material -wise, things that you need,

01:18:12.689 --> 01:18:16.949
great information. We at Orlando Health, if they're

01:18:16.949 --> 01:18:19.310
in the Central Florida area, they can go to our

01:18:19.310 --> 01:18:22.970
website and look for information as well. And

01:18:22.970 --> 01:18:25.390
we'll actually soon have, if it's not up already,

01:18:25.510 --> 01:18:30.149
have some sign -on capabilities for classes that

01:18:30.149 --> 01:18:33.949
we'll be offering. And they're free. So that's

01:18:33.949 --> 01:18:37.369
something to take advantage of. And then as far

01:18:37.369 --> 01:18:41.060
as for me, You can obviously find me on the hospital

01:18:41.060 --> 01:18:44.819
website. My email for the hospital is joseph

01:18:44.819 --> 01:18:50.739
.ibrahim at orlandohealth .com. And I'm glad

01:18:50.739 --> 01:18:53.760
to take any opportunities. I love to get involved

01:18:53.760 --> 01:18:56.300
with our community. I speak at high schools,

01:18:56.420 --> 01:19:00.340
talk to RMS agencies. I just love to be involved

01:19:00.340 --> 01:19:02.560
with these guys and get them involved with us

01:19:02.560 --> 01:19:05.850
more so because, again, Level One Center is part

01:19:05.850 --> 01:19:08.250
of the community. That's the main thing we want

01:19:08.250 --> 01:19:10.689
to get out there. Brilliant. Yeah, I'd love to

01:19:10.689 --> 01:19:14.210
try and maybe in the future get you down to my

01:19:14.210 --> 01:19:16.789
department, because even though it doesn't make

01:19:16.789 --> 01:19:20.010
the news normally, because what happens at Disney

01:19:20.010 --> 01:19:23.229
stays at Disney, but we do have an incredible

01:19:23.229 --> 01:19:26.439
amount of... of incidences that, that happened

01:19:26.439 --> 01:19:28.939
that, you know, may not be the same violent streets

01:19:28.939 --> 01:19:31.220
of, uh, some of the other areas of Orlando, but

01:19:31.220 --> 01:19:33.520
we have, we have areas that we'd certainly need

01:19:33.520 --> 01:19:36.800
to, uh, you know, stay trained on too. So. No,

01:19:36.920 --> 01:19:38.520
I would absolutely love that. No, I know you

01:19:38.520 --> 01:19:40.539
guys do a great job and a lot of training and

01:19:40.539 --> 01:19:42.399
things like that that occur behind the scenes.

01:19:42.439 --> 01:19:45.279
So yeah, I'd absolutely love to be involved with

01:19:45.279 --> 01:19:48.180
that anyway, help any way I can. I need, uh,

01:19:48.319 --> 01:19:50.039
Sabrina actually corrected me here and she's

01:19:50.039 --> 01:19:52.140
right. It's the, the documentary is new town,

01:19:52.300 --> 01:19:54.119
not little town. New town. Okay. I will change

01:19:54.119 --> 01:19:56.800
that. I'll put a link on that in the, uh, in

01:19:56.800 --> 01:20:01.739
the website as well. Okay. Brilliant. All right.

01:20:01.779 --> 01:20:03.600
So while we just pause for a second, then I'm

01:20:03.600 --> 01:20:06.699
going to, uh, I'll do the fake sign off, say

01:20:06.699 --> 01:20:08.100
goodbye to you, and then we can switch back to

01:20:08.100 --> 01:20:10.699
video and I'll just talk to you about, um, getting

01:20:10.699 --> 01:20:13.319
all this, the, the links to you so that you can,

01:20:13.340 --> 01:20:16.180
uh, you know, listen to it and share it as well.

01:20:16.220 --> 01:20:20.369
So. all right so well thank you so much for your

01:20:20.369 --> 01:20:22.850
time joe i really really appreciate it this is

01:20:22.850 --> 01:20:24.369
something that i personally wanted to do for

01:20:24.369 --> 01:20:26.390
a long time but way before this podcast but actually

01:20:26.390 --> 01:20:29.029
just sit down with with with a surgeon like yourself

01:20:29.029 --> 01:20:32.090
and and find out how i can become a better medic

01:20:32.090 --> 01:20:36.130
and and and raise the uh the possibility of saving

01:20:36.130 --> 01:20:37.909
someone's life by doing the right things before

01:20:37.909 --> 01:20:39.430
we walk through your door. So I really, really

01:20:39.430 --> 01:20:42.170
appreciate you, um, talking about that and obviously,

01:20:42.310 --> 01:20:45.090
you know, reliving that day, which I'm sure is,

01:20:45.090 --> 01:20:46.810
is not exactly the most comfortable thing to

01:20:46.810 --> 01:20:51.390
do. No, it's my pleasure. You know, it's again,

01:20:51.510 --> 01:20:54.529
we were, we were given this opportunity and it's

01:20:54.529 --> 01:20:56.350
our responsibility to share that with you guys.

01:20:56.390 --> 01:20:59.390
And again, my hat's off to all the first responders.

01:20:59.510 --> 01:21:02.029
Again, amazing job. I, we're blessed to have

01:21:02.029 --> 01:21:04.909
the comforts of, uh, all the things we have in

01:21:04.909 --> 01:21:08.170
the facility and you guys do it at extremes that

01:21:08.170 --> 01:21:10.670
we can only imagine so thank you for the for

01:21:10.670 --> 01:21:12.550
that and thank you for this opportunity okay

01:21:12.550 --> 01:21:14.189
well thank you so much you have a good day