WEBVTT 00:00:06.059 --> 00:00:09.800 Welcome to the bed. We'll go ahead and give you 00:00:09.800 --> 00:00:12.580 the story. This is all going to happen super 00:00:12.580 --> 00:00:46.570 fast. Welcome to the emergency room. Welcome 00:00:46.570 --> 00:00:49.429 back to The Deep Dive. Today we're taking on 00:00:49.429 --> 00:00:53.000 the huge field of trauma management. We're doing 00:00:53.000 --> 00:00:55.340 it with a specific lens. We're applying the Pareto 00:00:55.340 --> 00:00:57.539 principle. Exactly. We're not trying to memorize 00:00:57.539 --> 00:00:59.920 an entire textbook. No, we're after that vital 00:00:59.920 --> 00:01:02.939 20%. The high -yield knowledge and, you know, 00:01:02.939 --> 00:01:04.719 the management protocols that really deliver 00:01:04.719 --> 00:01:08.079 80 % of the life -saving capability. This is 00:01:08.079 --> 00:01:10.459 the intensive review guide. That's the mission. 00:01:10.519 --> 00:01:13.280 We've pulled from the core source material the 00:01:13.280 --> 00:01:15.480 evidence behind the advanced trauma life support 00:01:15.480 --> 00:01:18.159 methodology. So for anyone involved in that early 00:01:18.159 --> 00:01:20.659 care, we're here to solidify that systematic, 00:01:20.980 --> 00:01:23.599 concise approach. Okay, so we're hitting immediate 00:01:23.599 --> 00:01:26.719 assessment, rapid interventions, and all the 00:01:26.719 --> 00:01:28.599 critical nursing and management implications. 00:01:29.060 --> 00:01:31.299 The stuff that stabilizes a patient in that first 00:01:31.299 --> 00:01:34.099 hour. Yes, and it all starts with a core philosophy. 00:01:34.219 --> 00:01:37.500 Before we even get to ABC, there are two non 00:01:37.500 --> 00:01:39.859 -negotiables that drive every single decision. 00:01:39.879 --> 00:01:42.599 And what are they? One, you always treat the 00:01:42.599 --> 00:01:46.299 greatest threat to life first. And two, You never 00:01:46.299 --> 00:01:48.819 ever let the lack of a definitive diagnosis stop 00:01:48.819 --> 00:01:51.439 you from performing an indicated life -saving 00:01:51.439 --> 00:01:54.900 treatment. So act first, diagnose later if you 00:01:54.900 --> 00:01:57.379 have to. That's the mindset. It's what lets trauma 00:01:57.379 --> 00:01:59.840 systems all over the world work so cohesively. 00:02:00.000 --> 00:02:01.760 All right, let's unpack that using the primary 00:02:01.760 --> 00:02:05.219 survey, the famous ABCDE structure. We start 00:02:05.219 --> 00:02:08.199 with A, airway maintenance, always with C -spawn 00:02:08.199 --> 00:02:10.479 restriction. And the sources are so clear on 00:02:10.479 --> 00:02:13.580 this. Loss of an airway kills quickest, period. 00:02:13.719 --> 00:02:15.780 It's the immediate priority. But the challenge 00:02:15.780 --> 00:02:17.960 is doing it while protecting the neck. Right, 00:02:18.039 --> 00:02:21.039 it is. If you need to intervene, say, with the 00:02:21.039 --> 00:02:23.759 jaw thrust or even intubation, and you have to 00:02:23.759 --> 00:02:26.819 open that cervical. there's one key rule. OK. 00:02:27.060 --> 00:02:30.539 A team member must take over manual inline stabilization. 00:02:31.080 --> 00:02:33.139 They hold the head and neck, and they maintain 00:02:33.139 --> 00:02:35.400 that restriction through the entire procedure. 00:02:35.580 --> 00:02:37.860 So the manual hold literally replaces the collar 00:02:37.860 --> 00:02:40.080 for that moment. It's not an optional step. It's 00:02:40.080 --> 00:02:41.740 absolutely crucial. Now let's say you get that 00:02:41.740 --> 00:02:43.620 definitive airway. You place an endotracheal 00:02:43.620 --> 00:02:46.439 tube. What makes it truly definitive? I know 00:02:46.439 --> 00:02:48.580 the sources have a kind of trifecta for this. 00:02:48.830 --> 00:02:51.830 They do. First, the tube is secured in the trachea. 00:02:52.030 --> 00:02:54.050 Second, the cuff is inflated below the vocal 00:02:54.050 --> 00:02:57.229 cords. And third, it's connected to oxygen -enriched 00:02:57.229 --> 00:02:59.780 assisted ventilation. Miss any one of those, 00:02:59.860 --> 00:03:02.099 and you're not done. You are not done. You don't 00:03:02.099 --> 00:03:04.460 have a definitive airway. And what's that one 00:03:04.460 --> 00:03:07.020 small detail, that one catastrophic mistake we 00:03:07.020 --> 00:03:09.419 have to avoid if there's major facial trauma? 00:03:09.500 --> 00:03:13.199 Oh, this is a big one. You never, under any circumstances, 00:03:13.680 --> 00:03:17.340 attempt a nasopharyngeal airway if you even suspect 00:03:17.340 --> 00:03:19.879 a criperform plate fracture. Because it could 00:03:19.879 --> 00:03:22.639 go. It could go intracranially. It's a real tragic 00:03:22.639 --> 00:03:25.219 risk. You have to use the oral route. Always. 00:03:25.520 --> 00:03:29.830 Got it. OK. Moving to B for breathing and ventilation. 00:03:30.409 --> 00:03:32.810 When we're assessing, what are the early signs 00:03:32.810 --> 00:03:34.689 we're looking for? Well, you're looking for the 00:03:34.689 --> 00:03:37.490 subtle things. To Chypnea, you know, a fast respiratory 00:03:37.490 --> 00:03:40.250 rate. Or air hunger, you might see retractions. 00:03:40.330 --> 00:03:43.469 And what are we not waiting for? Cyanosis. The 00:03:43.469 --> 00:03:45.750 sources remind us that cyanosis is a late sign 00:03:45.750 --> 00:03:48.930 of hypoxia. And honestly, depending on skin pigmentation, 00:03:49.069 --> 00:03:51.629 it can be incredibly hard to even see. So if 00:03:51.629 --> 00:03:53.889 you wait until your patient looks blue, you've 00:03:53.889 --> 00:03:56.719 waited way too long. Far too long. You're already 00:03:56.719 --> 00:04:01.180 behind. Okay, so if we see that distress, the 00:04:01.180 --> 00:04:04.099 fastest life -saving intervention is for attention 00:04:04.099 --> 00:04:07.479 pneumothorax. That's a clinical diagnosis, isn't 00:04:07.479 --> 00:04:10.240 it? It is. You don't wait for an x -ray. It's 00:04:10.240 --> 00:04:13.300 a rapid decline that needs immediate decompression, 00:04:13.979 --> 00:04:16.620 needle or finger thoracostomy. And this is where 00:04:16.620 --> 00:04:18.660 some of the evidence has actually updated the 00:04:18.660 --> 00:04:21.870 procedure. Yes. This is a high yield point. The 00:04:21.870 --> 00:04:24.230 preferred site for that large over -the -needle 00:04:24.230 --> 00:04:27.310 capiter is now the fifth interspace, slightly 00:04:27.310 --> 00:04:30.209 anterior to the mid -axillary line. Right, moving 00:04:30.209 --> 00:04:32.250 away from that traditional second interspace 00:04:32.250 --> 00:04:34.790 spot. Precisely. It's a much better, safer target 00:04:34.790 --> 00:04:36.529 zone. It gives you the best chance of actually 00:04:36.529 --> 00:04:38.750 relieving the pressure. And after we've got an 00:04:38.750 --> 00:04:40.750 airway, we're using Capnography for more than 00:04:40.750 --> 00:04:43.050 just placement now. Oh, absolutely. Capnography 00:04:43.050 --> 00:04:46.589 is now a real -time monitor for everything. Ventilation, 00:04:46.829 --> 00:04:49.569 circulation, metabolism. It can even help predict 00:04:49.569 --> 00:04:52.129 the return of spontaneous circulation, ROSC, 00:04:52.189 --> 00:04:54.610 during CPR. So it's like a non -invasive report 00:04:54.610 --> 00:04:56.990 card on their whole physiological status. It 00:04:56.990 --> 00:04:59.290 is. It connects the dots between ventilation 00:04:59.290 --> 00:05:01.689 and perfusion, telling you how effective your 00:05:01.689 --> 00:05:04.129 resuscitation really is. Which brings us right 00:05:04.129 --> 00:05:07.990 to sea circulation and hemorrhage control. This 00:05:07.990 --> 00:05:10.589 feels like where the biggest paradigm shifts 00:05:10.589 --> 00:05:12.589 have happened. It really is. Hemorrhage is still 00:05:12.589 --> 00:05:14.889 the most common preventable cause of death and 00:05:14.889 --> 00:05:17.209 trauma. So the initial mantra is simple. Stop 00:05:17.209 --> 00:05:19.970 the bleeding. Direct manual pressure is always 00:05:19.970 --> 00:05:24.129 your first move. But if you have massive exsanguination 00:05:24.129 --> 00:05:27.050 from an arm or a leg, seconds count. That's a 00:05:27.050 --> 00:05:29.300 tourniquet situation. Immediately. The sources 00:05:29.300 --> 00:05:32.259 confirm it's indicated and absolutely life -saving. 00:05:32.420 --> 00:05:34.199 But there's a critical detail about applying 00:05:34.199 --> 00:05:36.279 it correctly. It's not just about slapping it 00:05:36.279 --> 00:05:38.740 on. Not at all. A poorly applied tourniquet is 00:05:38.740 --> 00:05:41.180 dangerous. It can actually make bleeding worse. 00:05:41.240 --> 00:05:43.899 How so? It might only block venous return but 00:05:43.899 --> 00:05:47.240 still allow arterial blood to pump in. So a proper 00:05:47.240 --> 00:05:50.079 one has to occlude that arterial inflow. We're 00:05:50.079 --> 00:05:53.379 talking about, um... Around 250 millimeters of 00:05:53.379 --> 00:05:56.060 mercury for an arm, maybe up to 400 for a leg. 00:05:56.300 --> 00:05:58.540 And you document the time. You must document 00:05:58.540 --> 00:06:00.800 the time of application. Okay, so bleeding is 00:06:00.800 --> 00:06:02.839 controlled. We have two large bore IVs. We've 00:06:02.839 --> 00:06:06.040 drawn bloods. Pregnancy test on females of childbearing 00:06:06.040 --> 00:06:10.339 age. Now we get to fluids. And the sources have 00:06:10.339 --> 00:06:12.920 a huge warning here. The crystalloid warning. 00:06:13.019 --> 00:06:15.779 This is probably the single biggest shift. We've 00:06:15.779 --> 00:06:17.860 learned that just dumping in crystalloid fluid 00:06:17.860 --> 00:06:20.930 is harmful. There was a specific number mentioned 00:06:20.930 --> 00:06:24.050 in one study. Yes. Resuscitation, with more than 00:06:24.050 --> 00:06:27.089 1 .5 liters of crystalloid, independently increased 00:06:27.089 --> 00:06:30.009 the odds of death. Why? I mean, for years that 00:06:30.009 --> 00:06:32.149 was the standard of care. Because it's essentially 00:06:32.149 --> 00:06:34.649 salt water. It carries no oxygen, it dilutes 00:06:34.649 --> 00:06:37.089 the clotting factors the patient has left, and 00:06:37.089 --> 00:06:39.189 it can make things like pulmonary edema worse. 00:06:39.649 --> 00:06:41.649 It contributes to what we call the lethal triad. 00:06:41.810 --> 00:06:44.149 The lethal triad. Let's quickly define that for 00:06:44.149 --> 00:06:46.629 everyone. It's a vicious cycle. Hypothermia, 00:06:46.870 --> 00:06:49.920 acidosis, and coagulopathy. Bleeding makes you 00:06:49.920 --> 00:06:52.560 cold and causes poor perfusion, which leads to 00:06:52.560 --> 00:06:55.560 acidosis. Then the cold and the acid stop your 00:06:55.560 --> 00:06:57.480 blood from clotting properly, which makes you 00:06:57.480 --> 00:07:01.079 bleed more. And around and around it goes. Exactly. 00:07:01.480 --> 00:07:04.259 Which is why we activate the massive transfusion 00:07:04.259 --> 00:07:07.980 protocol, or MTP, early. We give back what they're 00:07:07.980 --> 00:07:11.639 losing. A balanced ratio of red cells, plasma, 00:07:11.939 --> 00:07:13.779 and platelets. And there's a key medication that 00:07:13.779 --> 00:07:16.740 goes along with that. Tranexamic acid, or TXA. 00:07:16.829 --> 00:07:19.629 TXA is now standard, but it's all about timing. 00:07:20.029 --> 00:07:22.389 It only improves survival if you give it within 00:07:22.389 --> 00:07:24.790 three hours of the injury. Three hours? That's 00:07:24.790 --> 00:07:26.930 a hard deadline. It's an absolute need to know. 00:07:27.250 --> 00:07:29.810 You give a bolus dose up front, then an infusion 00:07:29.810 --> 00:07:32.310 over eight hours. Miss that three -hour window, 00:07:32.410 --> 00:07:35.120 and the benefit is essentially gone. So after 00:07:35.120 --> 00:07:37.360 all this, how are we monitoring if it's working? 00:07:37.500 --> 00:07:39.899 We can't just trust blood pressure. No, especially 00:07:39.899 --> 00:07:42.660 not in older patients. You have to trend objective 00:07:42.660 --> 00:07:45.339 seromarkers. Yeah. We look at serial base deficit 00:07:45.339 --> 00:07:47.480 and core lactate values. And what do those tell 00:07:47.480 --> 00:07:49.360 us? They tell you the severity of the shock. 00:07:49.660 --> 00:07:51.920 They reflect the metabolic acidosis from poor 00:07:51.920 --> 00:07:54.459 tissue perfusion. And crucially, they tell you 00:07:54.459 --> 00:07:56.639 if your treatment is working. And a quick management 00:07:56.639 --> 00:07:59.060 note, you don't treat that acidosis with bicarb. 00:07:59.100 --> 00:08:01.639 You do not. You treat the cause, the hemorrhage, 00:08:01.660 --> 00:08:04.660 and the poor perfusion, not the lab value. Okay, 00:08:04.699 --> 00:08:07.540 that was a huge section. Let's wrap up the primary 00:08:07.540 --> 00:08:10.519 survey with D and E disability and exposure. 00:08:10.620 --> 00:08:13.740 For D, the neuro exam, there's a vital timing 00:08:13.740 --> 00:08:16.439 rule. There is. You have to perform and document 00:08:16.439 --> 00:08:20.100 that brief exam GCS, pupil size, before you give 00:08:20.100 --> 00:08:22.720 drugs for intubation. Why is that so critical? 00:08:23.079 --> 00:08:25.579 Because if you paralyze or sedate them first, 00:08:25.740 --> 00:08:28.100 you've lost your neurological baseline, you've 00:08:28.100 --> 00:08:29.699 obscured it, and you might never get it back. 00:08:29.920 --> 00:08:32.639 It's essential for guiding care, especially in 00:08:32.639 --> 00:08:35.639 TBI. And for E? Exposure. It seems simple, cut 00:08:35.639 --> 00:08:37.639 off the clothes, but the management side connects 00:08:37.639 --> 00:08:40.279 right back to that lethal triad. It does. You 00:08:40.279 --> 00:08:42.539 expose them to final the injuries, but you immediately 00:08:42.539 --> 00:08:45.080 have to start fighting hypothermia. Anything 00:08:45.080 --> 00:08:48.320 below 36 degrees Celsius is considered mild hypothermia 00:08:48.320 --> 00:08:50.820 in trauma. But warm blankets, obviously. Yes. 00:08:51.019 --> 00:08:53.460 But the critical intervention is giving warmed 00:08:53.460 --> 00:08:56.240 intravenous fluids and blood. You're actively 00:08:56.240 --> 00:08:58.399 fighting the cold from the inside out to help 00:08:58.399 --> 00:09:01.360 break that cycle. Let's touch on adjuncts, specifically 00:09:01.360 --> 00:09:03.259 catheters. There are some serious rules here. 00:09:03.320 --> 00:09:05.759 With urinary catheters, we're monitoring volume 00:09:05.759 --> 00:09:08.700 status. The goal is about half a milliliter per 00:09:08.700 --> 00:09:11.600 kilogram per hour in adults. But there's a huge 00:09:11.600 --> 00:09:14.679 contraindication. A massive one. If you see blood 00:09:14.679 --> 00:09:17.600 at the urethral meatus or you see perineal bruising, 00:09:17.960 --> 00:09:20.940 that's a red flag for a urethral injury. Trans 00:09:20.940 --> 00:09:23.779 -rethral catheterization is strictly contraindicated. 00:09:24.080 --> 00:09:26.639 You stop. And a similar rule applies for gastric 00:09:26.639 --> 00:09:29.830 tubes if there's head trauma. Exactly. Gastric 00:09:29.830 --> 00:09:31.929 tubes were great for decompressing the stomach, 00:09:32.309 --> 00:09:34.549 but if you suspect a cribriform plate fracture, 00:09:34.929 --> 00:09:37.769 that tube must be inserted orally. To avoid that 00:09:37.769 --> 00:09:40.210 same risk of it going into the cranium. You got 00:09:40.210 --> 00:09:42.690 it. Anatomy trumps convenience every single time. 00:09:42.970 --> 00:09:45.669 Okay, that ABCDE framework is the foundation. 00:09:46.330 --> 00:09:49.049 Now let's get into some specific injuries, starting 00:09:49.049 --> 00:09:52.950 with traumatic brain injury, TBI. With TBI, the 00:09:52.950 --> 00:09:55.250 whole game shifts to preventing secondary brain 00:09:55.250 --> 00:09:58.179 insults. The number one need to know rule is 00:09:58.179 --> 00:10:00.879 you must avoid hypotension and SBP under 90, 00:10:00.960 --> 00:10:03.659 and you must avoid hypoxia at all costs. Because 00:10:03.659 --> 00:10:05.580 those two things can do more damage than the 00:10:05.580 --> 00:10:07.480 initial hit. They often do. They drastically 00:10:07.480 --> 00:10:10.379 worsen outcomes. And if that TBI patient is also 00:10:10.379 --> 00:10:12.980 hypotensive and has a high intracranial pressure, 00:10:13.480 --> 00:10:15.720 the sources point to a specific choice for osmotic 00:10:15.720 --> 00:10:18.879 agents. Yes, this is a great detail. The sources 00:10:18.879 --> 00:10:21.740 suggest that hypertonic saline is potentially 00:10:21.740 --> 00:10:24.860 better than mannitol in that specific case. And 00:10:24.860 --> 00:10:27.720 why is that? Because mannitol is a diuretic, 00:10:28.139 --> 00:10:30.440 it can make their hypovolemia or hypotension 00:10:30.440 --> 00:10:33.519 worse, which as we just said is a critical secondary 00:10:33.519 --> 00:10:36.610 insult. Hypertonic saline reduces the swelling 00:10:36.610 --> 00:10:39.870 but helps support their volume. Very smart. Okay, 00:10:40.110 --> 00:10:43.269 shifting to spine and musculoskeletal injuries. 00:10:43.330 --> 00:10:45.950 We know to restrict spinal motion, but what's 00:10:45.950 --> 00:10:47.990 the management point about the long spine boards 00:10:47.990 --> 00:10:50.769 themselves? This is so important. Long spine 00:10:50.769 --> 00:10:53.389 boards are for extrication. That's it. You have 00:10:53.389 --> 00:10:55.769 to get patients off them and onto a padded gurney 00:10:55.769 --> 00:10:58.490 as quickly as possible. To prevent pressure sores. 00:10:58.590 --> 00:11:00.629 Exactly. Especially on the sacrum and the back 00:11:00.629 --> 00:11:03.049 of the head. It's a preventable injury. And the 00:11:03.049 --> 00:11:04.840 log roll maneuver. itself to get them off the 00:11:04.840 --> 00:11:07.299 board. That's a team sport. It requires a minimum 00:11:07.299 --> 00:11:10.019 of four people, one person just on the head and 00:11:10.019 --> 00:11:12.460 c -spine maintaining alignment, three others 00:11:12.460 --> 00:11:14.679 on the body. It's not an arbitrary number, it's 00:11:14.679 --> 00:11:17.080 what you need to keep that spine perfectly straight. 00:11:17.539 --> 00:11:19.639 Lastly in this section let's hit crush syndrome, 00:11:20.159 --> 00:11:22.840 a specific renal management protocol there. Right. 00:11:23.100 --> 00:11:25.840 Severe muscle trauma releases myoglobin, which 00:11:25.840 --> 00:11:28.299 destroys the kidneys. The treatment has to be 00:11:28.299 --> 00:11:30.740 early and aggressive, which means high volume 00:11:30.740 --> 00:11:34.240 4V fluid therapy and urine alkalinization. Usually 00:11:34.240 --> 00:11:36.620 with intravenous bicarbonate, you're basically 00:11:36.620 --> 00:11:39.200 trying to flush the kidneys and keep that myoglobin 00:11:39.200 --> 00:11:41.120 from clogging everything up. All right. Let's 00:11:41.120 --> 00:11:42.980 close out with special populations, starting 00:11:42.980 --> 00:11:46.610 with kids. They can look Deceptively good. That's 00:11:46.610 --> 00:11:49.110 the trap. Their physiologic reserve is incredible. 00:11:49.450 --> 00:11:51.529 They can maintain a normal blood pressure even 00:11:51.529 --> 00:11:53.750 when they're in deep shock. So what's the absolute 00:11:53.750 --> 00:11:57.090 need to know? When they finally fail, they deteriorate 00:11:57.090 --> 00:11:59.610 precipitously and catastrophically. It's a cliff. 00:12:00.250 --> 00:12:03.269 So we start with a 20 mL alkyrigy warmed crystalloid 00:12:03.269 --> 00:12:05.929 bolus, maybe repeat it twice. If they're still 00:12:05.929 --> 00:12:08.210 unstable, you have to switch to packed red cells 00:12:08.210 --> 00:12:10.549 at 10 mL alkyrigy. And then the other end of 00:12:10.549 --> 00:12:13.009 the spectrum, the geriatric patient. They mask 00:12:13.009 --> 00:12:15.490 shock, too, but for different reasons. It's their 00:12:15.490 --> 00:12:18.149 aging physiology. They might have a fixed cardiac 00:12:18.149 --> 00:12:21.370 output or be on beta blockers. They often lack 00:12:21.370 --> 00:12:24.250 that classic tachycardic response to blood loss. 00:12:24.370 --> 00:12:25.950 So you can't trust their heart rate to tell you 00:12:25.950 --> 00:12:28.350 they're in trouble. You can't. You have to rely 00:12:28.350 --> 00:12:31.070 on those objective markers we talked about, lactate 00:12:31.070 --> 00:12:33.570 and base deficit. Their blood pressure can be 00:12:33.570 --> 00:12:36.149 misleadingly high, but the labs tell the real 00:12:36.149 --> 00:12:38.500 story. And their fragility creates other risks. 00:12:39.039 --> 00:12:40.960 Absolutely. Rib fractures are common, and in 00:12:40.960 --> 00:12:43.340 an older adult, that puts them at a huge risk 00:12:43.340 --> 00:12:45.980 for pneumonia. Pain control is key so they can 00:12:45.980 --> 00:12:48.419 breathe deeply, but you have to be so careful. 00:12:48.720 --> 00:12:51.200 Smaller doses, short -acting narcotics. Exactly. 00:12:51.899 --> 00:12:54.480 Tight -treat carefully to avoid respiratory depression 00:12:54.480 --> 00:12:57.539 or delirium. Every single intervention needs 00:12:57.539 --> 00:13:00.159 that cautious approach in the older adult. We 00:13:00.159 --> 00:13:02.500 have covered a ton of ground here. but it's such 00:13:02.500 --> 00:13:05.539 a necessary synthesis. Mastering these specific 00:13:05.539 --> 00:13:08.480 protocols, MPP activation, that three -hour TXA 00:13:08.480 --> 00:13:11.679 window, the catheter contraindications, and understanding 00:13:11.679 --> 00:13:14.120 these special populations, it really elevates 00:13:14.120 --> 00:13:16.080 your ability to deliver trauma care. I think 00:13:16.080 --> 00:13:18.019 the real strength of this whole system isn't 00:13:18.019 --> 00:13:19.879 just the list. It's that it creates a common 00:13:19.879 --> 00:13:22.200 language, you know? The wide dissemination of 00:13:22.200 --> 00:13:24.559 these principles binds everyone together, EMS, 00:13:24.820 --> 00:13:28.080 nurses, surgeons, into a single functioning unit. 00:13:28.419 --> 00:13:30.480 Everyone is speaking the same language and has 00:13:30.480 --> 00:13:32.659 the same immediate... priorities. That's it. 00:13:32.700 --> 00:13:35.019 That's the cohesive force. That shared response 00:13:35.019 --> 00:13:37.960 is what saves lives. Okay, here's a final thought 00:13:37.960 --> 00:13:40.700 for you to explore on your own. We categorize 00:13:40.700 --> 00:13:43.259 trauma prevention into primary, secondary, and 00:13:43.259 --> 00:13:46.259 tertiary. Primary prevention stops the event 00:13:46.259 --> 00:13:49.519 from happening at all think DUI laws. Secondary 00:13:49.519 --> 00:13:52.440 reduces the severity like an airbag. If you had 00:13:52.440 --> 00:13:55.159 the power to mandate one single universal primary 00:13:55.159 --> 00:13:57.000 prevention strategy based on the predictable 00:13:57.000 --> 00:13:59.440 patterns of injury, what would it be? What one 00:13:59.440 --> 00:14:01.399 thing would you change at a policy level to stop 00:14:01.399 --> 00:14:02.659 the trauma before it ever starts?