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Welcome Patrick George trauma Surgeon from Duke's University. Durham, North Carolina and director behind a knife on the Zoom Patrick Harris. Oh, we can't hear you yet. One second. Right to back. She's gonna, we can't hear you yet. Hello? Hello? Yes. Hey. All right, good morning, everyone. I'm having some uh serious FOMO over here from overseas listening to that uh the summaries from the talks today. Those sound phenomenal and uh uh doctor, thank you very much for the invitation. This will be brief. Uh It's uh great to see the folks in the audience. And hello, I'm, I'm Patrick George. I'm a trauma surgeon at Duke University. Uh as I mentioned and uh right behind the knife and uh I'm gonna share my screen. Uh I'm gonna talk to you guys a little bit today about a trauma sur called Atlas and, and how we're gonna get you all in the morning uh society connected with that. And so let me she, are you able to see her? Yeah, perfect. All right. So before we get started on the drama C was a, a small bit of shameless plug in here. Uh Behind the knife is a is the one surgery podcast in the world. We're up to over 680 episodes and we do two episodes per week. Uh, all that's for free. Uh We have a whole bunch of fantastic stuff and I'm gonna direct your attention to the Big T Trauma series. Uh We just last week had Doctor Broy on and to the U Kr trial. We do a bunch of contemporary discussions in vas in uh trauma on this series. And so that might be something that y'all are interested in. If in fact, you're here listening today, we have a lot more stuff beyond that on our website. Uh that includes lots of great videos and other resources, including a review and, and prep as well. And you know, really the biggest issue uh when it comes to trauma is, is these patients, as mentioned, you know, time is so uh so sensitive in these patients. And uh with that, though these injuries can often be quite rare and easy, even as surgeons at busy trauma centers, even some of the biggest trauma centers in the United States, you may see some of these very severe injuries only once or twice a year if that. And so then the question is, how do we educate and learn and it's through a wonderful sessions that like you guys have arranged here today and, and amazing uh and skilled lecturers uh sharing their wisdom with you. But I was always jealous of the surgical atlases that you could find for things, uh, in regards to like mis type surgery, uh, where you had these beautiful videos that were produced and edited and you could see exactly what was happening, but that's not the case for trauma surgery. And that's understandable. Certainly because when a trauma surgeon ever sees me and a patient comes in, they're definitely an extremist, they're trying to die on you. It's usually Saturday morning at 2 a.m. trying to get a video camera in that or, or even, you know, without breaking sterility is a major issue. And so we, we are trying to fix that and we're just about done with the trauma serialis. It has 24 different scenarios that covers essentially everything that was just reviewed in the summer and there except for moa intentionally. Uh but it has a lot of great resources there. And uh if you guys are ok with them, we have time. I was going to play a four minute video as an example and when the Atlas is completely finished and our app should be out, a new app should be out next week. We'll share uh the codes with you all to be able to get in and access that. So I'm gonna go ahead and play that and let me know. And if you have any issues, hearing patients with pulsatile and or expanding retro perineal hematoma should be explored regardless of the mechanism of injury So patients with a penetrating injury that violates the retro perineum. When the trajectory is unknown. In these cases, it is important to explore the entire trajectory of the injury. Before you explore retro perineal hematoma, be prepared. Ideally, you will have good access, plenty of blood, the writing instruments including multiple sections, adequate exposure and skilled help. The infrahepatic IVC is best exposed using a right to left medial visceral irritation aka the catel bras maneuver. This involves medialization of the right colon, hepatic flexure and duodenum. For more information, see scenario 10 trauma, laparotomy be prepared for massive bleeding. Both packing and digital pressure can be very effective at controlling hemorrhage. However, this limits your exposure one good way to overcome. This is to use sponge sticks to compress the IVC against the spine above and below the injury. Of note, the patient's head is now screen left. Next, you want to define the edges of the laceration. If you can identify an edge of the defect, you may be able to work your way around the entire laceration with the edges defined. You can throw a stitch or use clams to bring the edges together. Of note, this can be very challenging. Here, we happen to have excellent exposure and a conveniently located injury which is not always the case. Finally, be careful not to miss a posterior injury to the vessel. The IBC can be repaired to four or five proline suture. If bleeding is difficult to control, you can place a Satinsky clamp on the injury and suture over the clamp. Another good option is to use multiple hours clamps placed in sequence along laceration, removing clamps as you saw with the injury closed. Here, we perform a repair over a Satinsky clamp actu or not. You can also use multiple allis clamps placed in sequence. Lung laceration, removing the clamps one by one as you saw the injury closed. there are a number of other important considerations. First, avoid elaborate anti consuming maneuvers like grafts and shunts as they can get both you and the patient in trouble. Second, if the patient is an extremist, then the IVC can be ligated as a last resort while morbidity and mortality are high, this is a viable option with surprisingly good outcomes in contemporary patient series. And third, if you have concern for an injury to the IBC, avoid placing resuscitative lines in the femoral veins as fluids may extravasate from the defect, I think. So that's an example of one of the 24 scenarios. Uh And again, they, they cover the, the whole gamut and the idea is is that uh you have that access, uh you have access to that uh immediately and, and like as I mentioned, we have an app coming out so you'd be able to pull it up on your phone. Uh And um and hopefully we, we, I hope you guys find it useful and we'll engage with it. I'll work with uh uh Michael as we go forward. Uh And hopefully within the next month or so, you guys will be getting some emails and have access to this uh resource again. Thanks for inviting me this morning and for the time and uh hopefully in the future, I'll see some of y'all in person. Thank you very much. Thank you for joining us. I know it's like 5540 AM. So thank you. Dominate the day. Everyone's saying it dominate the day. All right, take care. All right guys, we now have our break. Uh and uh we look forward to getting hands on with the Atlas. So please go get your coffee. Yeah, I Yeah.