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Then. Thanks Leah. Thank you for the introduction and thank you very much for inviting me to talk. So as Leah said, I'm a clinical academic physiotherapist, I've stopped calling myself a consultant physiotherapist. This has all kicked off recently about the use of the word consultant. So I'm going back to being a clinical academic physiotherapist and I work primarily in critical care with some work in emergency care as well. I've been researching chest trauma probably for close to over 15 years now and obviously treating the patients for a lot longer. Um So I thought what I do today is, um I'll talk about we're talking about optimizing the patient to a non operative, but I do just touch on um surgical management as well, but I'm going to talk through um lots of different components of managing the patient with chest trauma. Um And we were going to try and make it interactive, but as Leah said, there's quite a few people joined. So I think we'll have to do questions at the end. I know it's really difficult to concentrate for more than 20 minutes or so, especially when the person talking has got quite dull sit tones and is a bit so hof, I do appreciate that and especially this the evening for most of us. But, um, yeah, stick with me if you can. So I'm going to start with talking. Well, I won't labor on the point about epidemiology. We all know that chest trauma is the second most common type of trauma experience. But the most important thing really to say about epidemiology is that we're experiencing a real change in our demographic over the last 10 years or so. So, whereas our young major trauma, our major trauma patients used to be the young RT C the road traffic collision. And now we're seeing our major trauma patients are much more the older patient who's sustained a low velocity fall. Um We know there's a high level of morbidity and mortality with these patients. And we also know they're really difficult to manage. Hence the reason for presentations such as this and why the chest wall injury society are really trying to push um awareness of how difficult, how difficult these patients are to manage. I always start my talks with the case study. I think it makes it relevant. So those of you have heard me talk before, bear with me for a moment. I do use the same case study because I think it really highlights what I'm going to talk about. So my case study is a paramedic who used to work for my health board and he had just retired. He was in his sort of mid sixties and he'd gone out for a walk and he'd slipped on ice and he'd fallen on his chest wall. He presented to our emergency department and he had what we saw on chest x-ray. So one or two rib fractures, he was in discomfort, obviously. So we gave him our advice, leaflets, some analgesia and we sent him home and then over the course of the next two or three days, he really sort of sort of ran into trouble really and presented back to our emergency department a few days later. And by this point, had sort of significant respiratory distress. Um we ct him this time and we actually found that he had four or five quite displaced rib fractures, um a quite a significant pneumonia and also by this point was developing an early empyema. He came up to our intensive care unit from the ed and that's where I met him. And over the course of the next month, despite sort of multiple interventions, et cetera, this patient sadly died and it really set us thinking, you know, why are we doing so badly with these patients? Um why are we not able to sort of work out which patients are going to do badly? Um So there's many difficulties that these patients face. Like I just said, one of the main difficulties is knowing which patient is going to do badly. There's many risk factors and I'll talk about those in a minute. The big problem is that the patient doesn't tend to develop complications for about 40. Um, well, up to, we'll say up to three days post injury and some is a little bit more. Um, so knowing which patients are going to do badly is really difficult. So, what I thought I'd do is go through a number of the components of management with these patients. And the first one I'm going to look at is really the first one that's relevant when the patient comes to the emergency department and that's imaging. So in terms of imaging, um I wrote the systematic review pre pandemic now, um and what we were comparing the diagnostic accuracy of lung ultrasound versus chest x-ray. Um And what we found was in that lung ultrasound um was superior in both terms of sensitivity and specificity to chest x-ray. Um There's been another study since that looked at the use of lung ultrasound by um ed clinicians. And again, they found that lung ultrasound was superior to chest x-ray, but not in terms of um CT scan. Um the CT scan is much more specific as well as sensitive compared to lung ultrasound. So at this moment in time, in terms of the evidence we've got um CT really does remain as a gold standard, definitive standard of care that we should be using with these patients. Um The the other sort of things with lung ultrasound is they can be, it can sort of be painful for the patient. Um when you're scanning over the rib fracture site, but it can be useful also for identifying costal cartilage damage and pathologies such as pneumothorax and contusions. Um The was work done by the chest wall injury society a few years back quite a few years ago now. And the reason for this work was that there was, there's no standard Amena for chest um injuries and in particular rib fractures. Um If you think of every other fracture of the body, everything's um there's all sorts of different criteria that are used. Um But nothing really was in place for rib fractures. So the work done by the Tres Wall Injury Society, as I said, um really sort of try to define each of the different fractures. So in the top, um figure you can see the in um the first picture in a, we've got an undisplaced simple rib fracture. And in picture B, we've got an undisplaced wedge fracture, rib fracture. And in C we've got an undisplaced complex rib fracture. In the figure underneath, we've got an undisplaced simple rib fracture with greater than 90% cortical contact. In B it's an offset simple rib fracture with cortical contact, but less than 90 degree. And then see, we've actually got a displaced simple rib fracture with no cortical contact. So what the chest wall injury Society have really tried to do is to give us a sort of universal language that can be used to define rib fractures and also the degree of displacement. And hopefully, that will improve our clinical care when we're talking between ourselves as clinicians. But also when we're doing our research on these patients, that we can really be definite about what we're looking at on now we're imaging and then in terms of risk stratification, I wrote a recent um systematic review which looks at all the different clinical scoring systems for patients with chest trauma. In actual fact, there are now 22 published models and what what the system review found was that they all sort of vary in terms of what um patients they use for which cohorts of chest trauma patients and where they're supposed to be used. And they all vary in terms of their, their reliability and validity, the sensitivity and specificity and so forth. So the scar score um and the thoracic trauma severity score two scores which are used for polytrauma patients who have been admitted to the critical care unit and they predict the risk of thoracic trauma related complications. The rib fracture frailty index was written by Jeff Choi the Chest wall Injury Society. And that is a risk prediction model that's used specifically for geriatric patients with um sort of focusing on the impact of frailty on patient outcomes. The PE C score we have all seen and probably many of us use within our pathways. It's not particularly sort of scientifically put well put together in terms of the methods they used. But it's a really useful, simple tool that as I said, lots of us will use and it just uses three variables which we routinely collect pain, inspiration and cough. Um And I think, you know, we all find that a sort of really useful one in our clinical practice. And then the stumble score is my score and a risk score that's used to help guide management in the ed in terms of discharge disposition. So whether the patient should be admitted to critical care or the ward or whether they can be discharged home safely, I'm just going to touch on it. I'm not going to go into a great amount of detail on this, but there's four different sort of stages to develop in a clinical prediction model and what the early stages the background work and the development study do is they'll pull together all the risk factors that could potentially be important. And then you do lots of statistical modeling to work out which risk factors should be included in the model. And then the validation study is where you actually run it on real life patients and you assess the predictive capabilities of the score and I'll show you the stumble ones, but just as an example, the stumble score, it uses age and the number of rib fractures, chronic lung disease, whether the patients anticoagulated or not and, and the oxygen saturation levels um on presentation to the ed what that gives you is a score. And as I said, then it gives you a risk of complications and that risk then equates to where the patient should be managed. Over the last few years, the scores evolved. So it is now used to predict need for higher levels of analgesia. So some of the trauma centers around the UK will say that if the patient scores a stumble score of greater than 14, for example, then the patient should be considered for regional analgesia. We also use it and we've seen it used quite widely now for if the patient scores a certain value, they should be referred for physiotherapy. Um And, and in terms of discharge disposition, it's actually got as you can see the that C index and those sensitivity and specificity values are really sort of quite good. Um in terms of how accurate the model is. Its predictive capabilities, it's been very well externally validated internationally um as well as in the UK. So it's been validated in Italy in New Zealand. It's also been validated at the moment in Australia and the Netherlands are just setting up a study on it's been validated as well for use in Scotland. So it's very well used. Um But as I showed you, there's lots of different tools out there that are, you know, equally as useful for those patients we are discharging directly home from the ED. And we really do need to think about these. I think in the past there's just been a sort of once they're home, we forget about them. But I recently did a study as part of my fellowship presented in Charlotte and the Tres Wall Injury Society Summit. Earlier in the year, it looked at what happens to those patients who we discharge home. And this has never been studied before other than in a small study in Canada and what we found over five years, over 3000 patients, we were able to look at healthcare utilization resource utilization and that included primary care, inpatient, outpatient and ed repres and mortality. And we found that in the 12 week period after injury compared to the 12 week period before injury, that there was a significant increase in healthcare utilization and that risk increased with age um COPD and preinjury anticoagulant use. So that really sort of fits quite nicely with the stumble score. We're also in my team at the moment, introducing a service where we're going to um rather than admit those patients who score 12 to 15 on the stumble score, we're actually going to discharge those home with a virtual ward. So the patient will that is normally admitted for a few days of observation, good pain relief and and physiotherapy, they will now be managed at home. So I'm hoping maybe this time next year, we'll have some results of how that new service is working. So moving on to the next thing, the next component of care for these patients. Um serial monitoring is really important. Um And really there's the why when and what? So so as, so as physiotherapists, um we really should be thinking about monitoring these patients. Um I would say as a minimum, once or twice a day from as early as possible in the patient's admission. Why? Because we know the patient is going to potentially deteriorate in that 1st 72 hours. But also we want, so we want to manage deterioration, but also we want to monitor clinical progression and what would we monitor well. It very much depends on what you've got available in your, in your health care setting. Um So if it was a lower resource setting, then you know, you really need to just think about your basic os your respiratory rate and things like that. And there's certain nobs which are often missed out. And I mentioned respiratory rate because we normally people look at heart rate, BP and temp and rate is such an important measure or variable that's often missed out. And it gives us so much information when you monitor it as a trend in chest trauma patients. And the other thing that I really want people to start assessing is rather than assessing an acute pain score is to think about getting the patient to report a dynamic pain score. So you can use something as simple as a vs a visual analog score. No to 10. What's your pain? You ask them when they first come in pre and post pain relief and all that sort of thing. But you ask the patient what their pain is on, on deep breathing exercise or cough or on moving around mobilization. OK. Moving on to the next component then. So I'm going to just touch on analgesia. So there's a recent paper that's come out to the British Journal of Analgesia which talks about um what, what's essential to reduce complications in this group is very prompt analgesia. So the promptness is very much important. But we're looking at a multimodal um sort of set up where we're looking at regional analgesia, oral and IV plus topical in some centers as well. There's increasing evidence to support the use of paravertebral blocks. Um But at this moment in time, most of the evidence is sort of retrospective case series. There's a couple of big studies going on at the moment and just being set up. So the a razor trial is looking at serratus anterior blocks. The re trial is looking at erect spiny blocks and there's a trial going on in just the feasibility work has just finished. And I'm hoping that that goes through to full trial and that's Ed Carton is looking at the use of lidocaine patches in patients aged 65 years or more. So there's a lot going on at the moment. But I think the most important thing to, to, to emphasize here is that there is until analgesia is optimized, not a huge amount we can achieve with these patients. Um So, whereas chest physio always appears as number one in the plan in the medical notes for these patients when they come in. I really believe that analgesia needs to be top of that list in the plan before we move into the next phases of each component of care. I'm going to touch on this as well. This is the work of um, of Prof Helena as in Johannesburg. Um, she's done some work with us recently and was part of our chest wall Injury Society expert panel. She's a big chest wall um injury researcher and a physiotherapist as well. She's just written a systematic review that looks at the sort of adjunctive treatments or analgesic strategies that they're there and that the physios and other members of the MDT can deliver. So K taping in the first picture, it doesn't have brilliant evidence to support it just yet, but it's certainly something I think that's going to emerge over the next few years. It's cheap. It's simple to apply and it just works on the idea that we're giving some sort of proprioceptive help with that pain. Um Obviously the next picture is acupuncture and then tens after that, and Helena's paper really sort of looked at the use of these non pharmacological interventions as being adjunctive analgesic measures for our patients. So I think these are something that they don't work for everybody. But if they do work, they do work well. And we really need to think about personalized medicine. I think with the s they're one patient group that really needs personalized medicine. I said I just mentioned surgical intervention. Um so the, so the intervention, the indications for surgical intervention or surgical fixation for our patients. Um the main ones will be if there's chest wall instability, three or more rib fractures with greater than 50% of displacement. And if there's pulmonary derangement, um or a sort of failure to wean from the ventilator, ideally, the chest wall injury society suggests that the patient should be fixed within the 1st 72 hours, but certainly in my center and, and I know very much and other centers within the UK that that is a little bit idealistic, but what I don't want and I've seen it this week with one of my patients is that the patient passed that 72 two hour period. So, so that the thoracic surgeon sort of said they're out to the optimal time period, therefore, we won't fix. So that 72 hours really should be I think a guide. But considering that some patients are not even referred in that 72 hours, maybe the surgeon only works set days. For example, I think there needs to be some flexibility in that. There's just been a really good systematic review me analysis published this week which found that surgical fixation for flail led to decreased mechanical ventilation days and intensive care length of stay but not mortality or need for tracheostomy or hospital length of stay. So there's some really good emerging evidence to show that um surgical fixation is very much the way forward. The tra Wall Injury Society are publishing hundreds of articles on this all the time. Um And we're really getting a good, strong evidence base for the need for fixation. There's two big RCTS going on at the moment and I think they will be the definitive pieces of work. There's R I which is being run out of Nottingham, I think by Ben Olivera, um I think they're close to finishing recruitment and there's the Fix Con trial in the Netherlands and I know they've finished recruitment and they're still in their follow up data collection phase. So those two trials are very much too to look out for. And I think will give us some really definitive evidence on the benefits of fixation in these patients. Um critical care. So there's lots of different components of critical care management that we could talk about. And I think what I wanted to sort of hone in on here was the benefits of um physiotherapy really. So both respiratory and rehabilitation um are important and in terms of respiratory, we're looking at maximizing form expansion and secretion removal. And traditionally, with rehabilitation, we've thought of the musculoskeletal side of things. But actually, now it's not just the musculoskeletal side of things. But with rehabilitation, we're looking to also um we're not just looking at the shoulder girdle thorax, but we're also looking at the restoration and optimization of the breathing mechanics and respiratory patterns. Um in terms of our ventilated patients, we would manage their rehabilitation the same as the non vented patients. We really emphasized the importance of early mobilization and getting the patients deed and set up and in good position as soon as possible. Just to say at this moment in time that um both respiratory and rehab overlap and they start right at the beginning of the patient's journey, but they also continue all the way through to late stages of of recovery, even sort of 12 years down the line and the two things go hand in hand together, we don't separate them anymore. It used to be that two different clinical teams would be delivering the respiratory and and the rehabilitation. But really, we should be one team and we shouldn't be considering this sort of recovery process as two separate phases. An Ed Baker from Kings in London has done an awful lot of work on this qualitative work. Looking at how we should be looking at the sort of optimal recovery path would be one that's considered as one as a whole. And not in too early and late I mentioned early mobilization and how important it is. But just to say a recent trial that's come out which it isn't just about, it isn't about the chest trauma patients. It is about all medical care patients, but we can extrapolate the data to our um trauma patients. I think so, what they found was among adults undergoing mechanical ventilation, an increase in early active mobilization did not result in significantly greater number of days alive and out of hospital than usual level of mobilization. And in actual fact, early mobilization was associated with increased adverse events. But what I would say with that, and I've listened to an awful lot of discussions about this in conferences, et cetera is that I think what team trial did was look at very early mobilization. So we participated in this trial and what we found was that they wanted us to patients out almost too early, I would say um and what and the control group, we all sort of know about early mobilization now. So the control group, the patients were all we're still doing early mobilization as that is our standard practice. So get the patients up as soon as possible. But I would say it's important to use a little bit of common sense as well. You know, when that patient is in that sort of first few hours of being admitted to the unit, they do sometimes just need a little bit of time to settle as well. Um, I've included a few bits here. You, yeah. Sorry. Um, I don't know if you can see the chat doctor just, um, put something in the chat. Do you want me to read it out or can I? Yeah, can you, can you read it out? Because if I stop sharing I'll probably never get it back on. So it was just saying how, um, the, your anecdote of the thoracic consultant, denying rib fixation after 72 hours is troubling. And as you suggested, we need to educate better, many of us as fixed patients long after the 48 to 72 hour window to very good effect and asking what were those adverse events, er, adverse events in terms of this trial? I just talked about, oh, sorry doctor. What, what do you mean in terms of that, that individual, um, that wasn't fixed in terms of it? And she said, yes, sorry, I have confused matters there. So I, I think I've even been in terms of that, that patient. Oh, ok. In terms of the patient, why wasn't the patient fixed? What was the reason the surgeon used? I assume you're asking. Um, I think it was just basically the fact that, um, he is probably not the correct thing to say here, but I think it was just used as an excuse not to fix the patient. And I think, sadly, there is often a case for almost finding a reason not to fix as opposed to finding a reason to fix. And I don't know whether that is just my center, but I would guess it probably isn't. I would, I would guess there's probably a few other people on the call who would say that that is their experience. I've had patients where the surgeon has come on to itu and has said we won't fix um because the patient is still ventilated or that sort of thing. And I've tried to say, look all the guidance out there says that, you know, fixing the patient will help us wean the patient and even anecdotally, we know that in our own center that we've had patients who have been stuck on the ventilator with a flail and we, and we've asked for them to be fixed and they've been fixed and they've weaned within a day or two without any issues at all. And the issue I've got is that our, our surgeon who used to fix everybody's moved our, we lost MC status and it's moved to another center. So he's moved with the MTC. So we're left with a thoracic surgeon who's less keen, shall we say on fixing the chest trauma? Sadly, so my service has fallen apart a little bit in that respect lately. Just fair to that. Um That was me muddy in the water. Sorry. So, yeah, that white and I know when I asking in regards to the immobilization trial, the a of that, um, I think it was things like, um, sort of need to go up on the V because these were me ventilated patients. So it was, it was an increased need for ventilation, um, beyond what was expected. And I think there were things like disconnections from, um, hemodynamic, the hemodialysis and the ventilator and things like that from memory. But I think the main one was the need for sort of quite a significant increase in ventilation. So in other words, it was just too early for these patients. And when I say very early, I mean, like within that 1st 24 hours, I mean, it's normal for us as intensive care, physios to be getting the patients up in the first of the 2nd and 3rd day. And I would very much advocate that, but there's times where we're almost, we were getting these patients up on day zero. which for some of the centers I think, like for the Australian centers where the trial was run out of, they were very much um cardiothoracic units. Whereas for us, we were running it in our general unit where the patients weren't just POSTOP, they, they were much sicker. Eli Elizabeth was just adding to that saying that a lot of them were cardiovascular and stable too. So um yeah, we were, we were expected to get patients up on quite high levels of vasopressors and we will do that in our site if we think is indicated. But for me, sometimes the patients are on high levels of vasopressors for a reason. And then primarily for us, they're very, very septic, a patient out of bed who is very septic and put a big sort of additional physiological strain on a patient in that state isn't always the right decision. I think so early rehab, I think is the message, not very early rehab. I think that's what's come out. Is that ok? Thank you very much. It's really difficult this because I'm completely blind. I'm just looking at my slides, cars going past and Phil presenting really sorry. Yeah, you um yeah, I mean, everyone could have logged off for all I could know and it could just be me and you and you, you're having a laugh, right? I'll go back to this then. So non vented patients. Um We've, there's a couple of good papers that have come out recently that have sort of looked at the benefits of noninvasive ventilation for patients with chest trauma. Um There's a few papers looking at high flow nasal oxygen and I know Jeremy Sue from Australia has looked at the delivery of high flow nasal oxygen outside of the critical care environment because in most places, we tend to only give it in critical care or high dependency and it does certainly show some favorable outcomes. So please think about your noninvasive and your high flow nasal oxygen delivery devices for the chest trauma patient. And one of the key things with them, I think is that they quite often will put off the need for mechanical ventilation. So, so think of them early as your patients going off rather than as a, we tend to use them as a last minute sort of last ditch attempt. But I think they can be used very well prophylactically early adjuncts. We've got lots and lots of adjuncts we can use. The key one is obviously the incentive spirometer. I spent a lot of time over the years saying how much I dislike incentive spirometry. But I've started to soften a little bit and mellow a bit with this over the last few years. And I've got to a point now where I think they've got place with some patients, they work well for some patients. But I don't think we need to be giving them out to every patient that comes in with chest trauma, but that's a personal thing. And I know that they've appeared in certain sort of quite high profile guidance recently within terms of um sort of suggesting that if the patient scores a certain amount on incentive spirometry, they should be considered for critical care. I'm not dead against it. I just don't think there's great research, but the answer to that then is to do the research and improve either way. Um cy or manual mechanical insu exer, there's again, not great evidence on this. And we've recently written some expert guidance for physiotherapists, managing patients with blunt chest trauma. And we've left out the koth assist for patients with rib fractures on this iteration of the guidance. Just too many people who were filling in the DL study felt that it shouldn't be used and to be fair, don't think it was the positive pressure. That was the problem. I think it was the negative pressure. Um So for me and for my practice, I think at this stage, I would probably unless the surgeon or the sort of team looking after the patients are very pro co assist and they're asking for it. I would consider just using the old fashioned birds as we used to use or the IP PB. So just in positive pressure, breathing and just give the positive pressure to decrease the work of breathing, just allow a relaxed expiration. And then after a few of these breaths, just let the patient and then try and cough and clear and all of this, you've got to have good pain relief, um rehabilitation. I'm just going to touch on. And for those of you who have heard me present, especially with the chest wall Injury Society, I've used these slides before, but I think they're really important to consider. I've talked about rehabilitation being also about your respiratory mechanics, but in terms of specific musculoskeletal rehab, the two key muscles, we need to think about is our serratus anterior and our lap dorsi. So both muscles um big, big sort of um attachments to the chest wall and they not only move the shoulder girdle but are also involved as access accessory muscles of inspiration, expiration. Um What we find with these muscles, whether the patients treated operatively or non operatively is that with sort of prolonged immobility and severe pain that we'll find that you'll get an altered line of pull. And as a result, quite often, the scapula, the line of pull of the scapula changes and you'll get what we call a secondary subacromial impingement as a result of chest trauma. And quite often it is because of these two big muscles is very susceptible to atrophy, as I said, because of prolonged pain or poor positioning. Um So we really need to sort of think about these early on. Um Oh, it worked. I've just got two more questions for you. Video on I I really I there's a bit of a delay in getting the questions. Um So Michelle asked, are you aware of many negative events using the ie would you use it just for the positive pressure element? We don't have the bed anymore. Yeah, I'd use COIS just with positive pressure. No, I'm not aware of any negative even of any sort of events or adverse events happening with using the negative pressure. Um I think it was just a general feeling amongst the sort of clinic the experienced clinicians who have been beaten chest trauma for many years. I know of centers that use it. I know Emma Swing wod in Bristol, the physio there has been using it quite often and I know of other centers where they've got very proactive um, medical teams who, who like the cough assist. And they've sort of said, well, if they get a pneumothorax, we'll stick an ICD and we'll put chest train in. So it very much depends on your, your um managing medical team. I think I would use it if I needed to. Again, it's one of those things. If the patient's going to die of a chest infection, if I don't clear their chest and I need to risk a pneumothorax, then obviously I would use it. And we have thank you. And um so Michelle said, thank you. Um and has asked at what stage would you feel niv would be indicated for patients? I know you mentioned about monitoring daily to see trends in deterioration. But would it be a case of increase in oxygen requirements and respiratory rate? Yeah, I'd go for both an increased requirement in oxygen and an increased respirator and just I would use it early. Um The later you leave it, the more uncomfortable and distressed, the patient gets, the worse their respiratory function gets, the less I find they tend to tolerate it. So if we can start it earlier with say lower pressures, then there's there's really no reason not to. And there's good evidence that using it early can reduce the need for mechanical ventilation. Um So yeah, I think it's a very under used device for not just chest trauma for any patient, if I'm honest and also extubate to niv. Um it is particularly um under utilized in, in a lot of centers and I think it's something certainly for the patients. It could work. Well, I know we've had this discussion before, haven't we? When we um we've been to Sea Wiz about um the ventilators now generally in use, I want to say thank you. So generally the ventilators in use now are really intelligent but going back to your drag and your semen before, I think just from my experience, we weaned so early onto a whisper floor high flow and then you'd find increase in failure rate and the weeding of those have been extubated. But I know we were chatting in America and saying about, you know, from a trigger perspective and had we helped these patients, you know, looking in retrospect, have we actually helped these patients by I suppose altering the trigger and the pressure support. And I don't think we had done to give them that, you know, especially if they've been ventilated for seven days. And, you know, you know, thinking about kind of the, the pathology that happens within that time. And I think we, we set ourselves to fail with these patients. Um, and so, yeah, I think they actually been on to an IV is something that maybe, you know, in hindsight, we should have done a lot more in my ICU. It is. Definitely. Yeah. And I mean, we're looking at new, there's all sorts of new modes of ventilation coming along now and we, like you said, we've got the all singing, all dancing events, but like we've started using Nava in my general, I to where we can actually assess the diaphragmatic function of, of our sort of patients and certainly the longer term vents. I think we've sort of had quite good success in that because what we often find is as soon as you get that level of critical illness, neuropathy, the diaphragmatic function drops as well. But don't ask me any more detail on that. We'll move on any more questions. No more questions. Yeah, unless there's a delay. Ok. Um Yes. So just to say that bringing it all together with regard to the muscles of the um if we're treating, whether we're treating the patient operatively or non or non operatively, the muscles take attachment to the thorax as well as the sort of shoulder girdle. You can just see in that um I don't know if I can get it to go again. No, but you could see everything just pulling on that chest wall. You can see why rib fractures are so uncomfortable just with the movement of just the upper limb. Um but it has a real impact on what the patient perceives as quality of life and sort of return to long term functional activity. And while we're talking about that, I've just finished, we're just analyzing the data from this. So I just finished this Multicenter RCT where we've looked at early exercise and blunt chest trauma, my E two trial and this was a really simple trial. So we're looking to see if um an early exercise program improves chronic pain and disability of three months post injury. And when I say simple trial, I mean, the intervention was simple. So all the patients had to do was shoulder flexion and abduction and just some simple rotations and flexion and side flexion of the thorax. So we're analyzing that data at the moment. So hopefully be able to present that soon. Um The whole sort of concept of that is this idea that we want to get patients moving after they've injured their chest. We know that and you see it with any patient, you go to see where they sat and they're fixing down and we encourage them to fix and hug a cushion or a rolled up towel, an actual fat, what we want is to try and normalize movement as much as we can and get the patient back to a good posture as early as possible where they're happy just to move their upper limbs and their thorax. Because otherwise all those joints around the thorax, just get really glued up. And the patient sort of is almost setting themselves up really for a chronic pain picture. We see it all the time. Some of my patients were coming into my, it follow up clinic in our hospital and they would have had quite significant chest trauma, they'd have sort of present with awful chronic pain problems. And we'd refer them just to for one or two sessions with one of our MS K colleagues who would just do some simple mobs encourage the patient to get moving with normal movement patterns again. And within one or two sessions with her, the patient's pain has significantly improved. So there's a general feeling that just getting the patient's moving as early as possible is really important. And I know how in South South Africa they get a lot more penetrating trauma than we do, obviously. Um But even with they're penetrating and they're blunt within six hours, they're asking the patient to be moving through full range of movement. Um And I don't know whether they get a lower incidence of chronic pain, but um just at the time, but it's certainly something that we feel is important. Um I just want to draw your attention to this after discharge. So historically, we've always told our patients 6 to 8 weeks and your pain will get better. But we know now that at least a third, maybe even up as much as two thirds of patients will have some degree of chronic pain and disability at three months, six months, one year. And there are some studies which are showing two years. It's not just chronic pain and disability, but it's also um pulmonary dysfunction as well. Ed Baker has done tons of work on this from Kings. And what he's in the process of doing is putting together a similar risk stratification tool to my stumble work. But it's a tool that we can use to, to sort of be able to predict which of these patients we need to follow up. So there's a real drive at the moment to really consider which patients we need to bring back in. We can't just keep sending these patients home with chronic pain and disability at three months and onwards. And, and what Ed's work has found is that patients really sort of develop this feeling of make and do that. They think that this is what their life is going to be like now and they accept that and, and what we really need to think more of is a sort of person centered care to approach or a personalized medicine. Now, we can't just treat all these patients, everyone will get better. Um at 6 to 8 weeks, um I mentioned breathing dysfunction. This is something that's really key for physios consider. So we've been seeing this um a lot more in our patients recently and I don't know whether it's just breathing dysfunction has become a lot more prevalent and sort of better understood since COVID. Um but as a result of factors such as the ribcage deformity, the fractures and prolonged immobility because of severe pain and also atrophy from not moving. We see that the accessory muscles are becoming very weakened and um we getting like a maladaptive spasm in some of the muscles as well. So some muscles are shortened, some are lengthened and a whole respiratory mechanics is just wrong. So the patients when they come back at three months are sort of presenting with this sort of unable to talk in a full sentence. They're gasping, they yawn and they sighing a lot. They've got very erratic tidal breaths, tidal volumes and they've got almost like an air hunger and this is something that physiotherapy can really, really help with. And we should be offering to these patients, you know, even just with sort of physio education, diaphragmatic breathing exercises, um sort of inspiratory muscle training and deactivating our muscles. You'll see these patients are very sort of um everything breathing back. A it's just teaching that sort of relaxed breathing again, just to draw your attention to this. And the QR code thing that we're encouraged to put on slides nowadays. But the reference is it or email me if you want it, this, we published this a few months ago in the journal of Trauma. So this was a chest wall injury society piece of work again. And we wrote the sort of physio guidance for patients with rib fractures and it's the respiratory and the rehabilitation and it's an international multidisciplinary. So it was written by physios, all members of the MDT nurses, surgeons, anesthetists. So it's a very multidisciplinary based piece of work. And it gives you 17, I think it was 17, 17, guideline, 18 guidelines. I think of what to do with these patients. And we look at different sort of scenarios whether patients vented, not vented surgery, not surgery and those things. But it's a really in the absence of good evidence for what we do. It's a really good start. I think in terms of helping guide what we should be doing with these patients and, and over the next few years as evidence comes in and we do more to prove what works and what doesn't, then we can update these as we go along. Um There's a reference list again. I did one of those QR Code things but not, I don't have a QR reader on my phone. Um, so if you haven't got it, um, just email me and I'll share my reference list. It's on PDF that's um, available and I can send you. There's my email address. Thank you doctor. I said as always with you, doctor Bas I'm smarter now than I was an hour ago. Much. Thanks you in a few weeks. Thanks for joining. Right. Hang on, stop. Sharing without logging you, you've stopped sharing. I'm on, it's just us three on the screen. Has everyone else gone on. So, anybody? Oh, yeah. Right. The internet has gone a little bit dodgy actually. But, um, you look a bit robotic. There we go. Has anyone got any questions so far? I've got a few. Hm. This is a surprise, Joe, here we go. Joe Sheer. So, do you have a patient info leaflet that you have developed to give to patients going straight home from D? Yeah. No. Um My fellowship at the moment is part of that, of the work is to um develop patient information leaflet, but we're going to do it. The reason it's taking so long is because we're co producing it. So we're developing it with clinicians but also with patients with lived experience. So, for us, historically, we've always thought we've known what's important to the patient, but there's a lot coming out recently that we're way off target. So there will be a leaflet coming out in the next year that will be written by both patients and clinicians. So should really hit the mark but it's not ready yet. Um So Elizabeth has said any thoughts on how you've had a few? Thank yous. Um And, and Elizabeth said, any thoughts on how early IMT may be useful and what cohort of chest trauma patients may benefit from it. Um There's absolutely zero evidence on it at the moment and it's something that I think would be a really interesting trial. We can extrapolate from some of the critical care data, I think. And, and other patient cohorts. I certainly think that the critical care population would be a good place to start because they're the ones that do tend to get most of the muscle dysfunction. Um So if I was going to do some work on it, that would be where I would start is with the critical care patients who were perhaps a little bit later down the line and are already showing a bit of dysfunction. But yeah, I think he's going to have his place where it's available. Lucy Norris has asked a question on the chat. So with a patient with chest wall trauma who was on MV in ICU, would you recommend to use manual inflation, nippy or more of an inspiration? Hold a set on the ventilator? Yeah, the um the, the del study certainly um pushed us towards recommending ventilator hyperinflation um for these patients and avoiding the cough assist. It went through numerous situations and it just kept getting pulled out every time the manual, the cough assist. So for now, I would say stick with VH unless obviously you've got a surgeon who's operated on a patient, for example, and is happy for you to have a go. But in terms of what we recommended, it was just to stick to um VH. Thank you. Um So Laura Burson has asked, just wanted to ask about the rib fracture score and the stun ball score when scoring the number of rib fractures on the wrist stratification. When you have multiple fractures per rib, I get confused to do this accurately. Can you explain it to me? Yeah. So if you've got, I would count the number of actual fractures you've got. So if you've got a flail with um with two fractures on one rib count that as two. Obviously, if you've got a complex fracture, which is in 15, you know, a commun fracture, this is in 15 different parts. You can't do it. Just count it as, you know, the two rib fractures. And the other thing to say about that is not everyone gets so a lot of the low velocity falls and certainly with us at the moment, I've seen a lot where they say no point imaging as it won't change your management. So there you can use clinical judgment and the scores been validated for clinical judgment. And I think we also to pretty much get a feel for how many fractures a patient's got just based on their bruising and where they report and their pain is. Does that help? Yeah, I mean, I must say that I have it up every single time. So when we, we I think you're better to, aren't you? It's always better to um I suppose rather. Yeah. And I think um I know we use the um Prince Henry pain score, hospital pain score in our trust. And again, would have been a dynamic um score. We moved away from the rib fracture scoring system that we had nationally a while back, didn't we? I think for us, we just as this been proven, I suppose, with the studies and the research and literature that actually didn't give you, you could ask some, you didn't ask anybody how they were feeling if they could move, if they can lift their shoulders, if they can deep breathe or cough. Whereas I suppose the ones that you've come up with now are so much more informative and allow us as you know, allow the clinic, the clinical teams to um I suppose appropriately treat now, don't they? Yeah. So I've got a few questions unless anybody else uh I'll make a stop. And if you er, where to, so in your opinion, if you were to have the alternate across the board UK recommendation, how to treat these patients preventatively, what would be your, your go to? How, how would you, what stages of approach would you, would you recommend? So I know we've kind of touched on it, but yeah, so you've got the key, the key things for me would be to pick up the patients very early, so early assessment and serial monitoring and the point of serial monitoring is that you can look at trends. So if somebody goes from having a respirator 12 to 22. You know, you know, obviously, so early early assessment, early monitoring, using a validated risk tool. I would advocate that if the patient is in pain that, you know, they're not that they're not. Um the pain is not refractory to oral analgesia. Then you get a, I'd like to see regional blocks done early in the d it's not, they're not done everywhere at the moment. But I think as early as possible, much more can be done for the patient consideration for fixation and using the chest wall injury Society guidance, I think is really important. And so many of our surgeons don't, are not even aware of it at the moment. We really need to educate and then also stratifying for later down the line. So not just being fixated on the first three days or the first sort of 6 to 8 weeks, but thinking which of these patients are going to do badly. And I'm really, really aware of so many patients at the moment that do so badly, they do fine for that acute period. They don't go off but they do badly at three and they've got such a poor quality of life as a result. So it's the whole process. I think that's really, I know um chest and society are trying to formalize a standard approach, aren't they? And that's what, you know, some of the research is doing now to see what everybody is doing in their own individual establishments. I've been, I know currently in our particular trauma network. Um, you know, we've spoken to Mr Gooseman who, um, is really try to lead trauma in our patch from a chest wall injury perspective. And, you know, we were, I was chatting with one of our local physios the other day about how, how there are discrepancies across sites and within trusts and also within networks. So obviously guidance, you know, when we receive guidance from those such as sea wis and will spread the word. But I think locally as well, I think it's really good to get some form of standard approach granted. Obviously, resources are an issue for some and I know I'm quite um I, I'm very proactive in my approach with patients with chest injuries. And so, but what I may do isn't necessarily what somebody in one of our trauma units may do. So we're trying to get together and find out what is the best approach for us locally with resources. But even if it wasn't just resource you mentioned about nasal high flow, I'm, you know, obviously coming from quick care background, I'm quite a believer of that. And although there is evidence in the trout there, I'm absolutely a believer that it prevents two and three care eventually. And I think the education aspect of it, especially when it comes down to pulmonary confusions. And normally, unless it's incredibly severe, you don't normally see them materialized until 48 72 hours. Do you? So, I think it was just about, um, having that educational aspect as well, wasn't it? And trying to get that across the board. So, we're doing the same thing. And Emma's asked a really interesting question, which I, again, this is, um, I don't know what your opinions are. I, I personally would class a sternal fracture because of the pain. Um, I would class the sternal fracture within our Prince Henry pain scar. Um I wouldn't say that all the members would agree but due to the pain and the, the issues that can be led from that. Um What are your thoughts? Um Is it part of the stumble scar? She's asked? No, I wouldn't use as part of the stumble score. The stumble score really is for patients where the management isn't dictated by something else. And with the sternal fracture quite often, we're thinking cardiac contusions, are we? And we'll monitor for um sort of cardiac injury and the patient be admitted for that. So I wouldn't include a sternal fracture within the stumble score. I would keep it a rib fractures. It's not been validated for that. Um Primarily because they'll be managed according to the potential for cardiac injury. Does that make sense to you? Lea Yeah, that makes perfect sense. And it's just interesting, isn't it? So when you, when you, you're faced with a patient who's got incredible amounts of pain and they're only apical breathing because they've got even a mildly displaced anal fracture. And I suppose that was something that I personally would have would have not with the stumble score, but with our, um, Princey pain score. Um Michelle's asked, would you start the chest wall range of movement exercise, as you mentioned from day one. Yeah, in South Africa, Helena starts within the first six hours. So their aim is within six hours. The patient is moving upper limbs and chest. They're just doing gentle exercises. So, um, so, yeah, I think that's something to work towards and they've got multiple chest drains because a lot of them have had multiple stab wounds and things and they're moving straight off. So, yeah, I would start early. But obviously, pain relief is the key thing here. So if you, if you've got a patient who's in agony, they're not going to move or do anything for you. So if you can optimize pain and you've got a block and there's no reason not to. Um, but just, it's just common sense, isn't it? You just, um, just go, I always just tell the pain the patient to move within the sort of limits of pain. So if they can lift an arm, but just a 90 then just that's fine. Just go to the point of pain. I wouldn't say they've got to push through until the pain is, is easier. But yeah, early as possible. I think the trials the results of the trial are not out yet. They could prove that it doesn't help later at all. But my gut feeling and based on what other centers do is as early as possible. Um, I think, uh, have you had enough of me yet? Can I ask any more questions? Yeah. Go on. So, and we, we, within our major trauma center, we work really, really closely within our MDT with the acute pain team and we have daily catch ups with them. And even if, even if they don't attend the physical MDT, we liaise with one another at least five days a week and um one, the so doctor a race has been instrumental in this and Clare Eastwood, who was our acute pain leader at huff itself. So, like you mentioned about the blocks, the regional blocks, so we have seen a huge improvement statistically with our patients that we've given this rate an er rectos spinal block. Um And I know in some mid trauma centers, they have rib fracture block teams that will go around 24 7, which is the ideal, isn't it? And obviously we try and work on a multimodal analgesic kind of way which um again, I'm hoping even just locally, uh we can try and uh I suppose uniform across our network, obviously, think about resources. But you've mentioned it early in your presentation and obviously you've seen massive improvements with this yourself anecdotally then. Yeah, definitely. And I think once we get some good trials there, that will be what the evidence shows there was a defi study published last week, I think. And they showed that the, the eros spinal block is now considered to be the gold standard rather than thoracic epidural because there's always a reticence with thoracic epidural there with the the elderly trauma patient who is anticoagulated. There'll be a reason not to put it in. And also that they've got to be put in on a critical care unit in a lot of centers, whereas a block can be done in D and just the final thing to say on that, there is no reason why there's got to be an anesthetist or an ed clinician putting these blocks in now. And there's an awful lot of physiotherapists who will be in, who have got themselves accredited for lung ultrasound. And if you can do your lung ultrasound, there's no reason why you can't be putting a block in. And I've already talked about this to one of my, to the, um, the anesthetist who leads our chest trauma team. She sort of said, well, you know, once you're accredited, why, why would you not put the blocks in? Um, I said that in a meeting before and I've been completely shot down. I said it where there were a lot of doctors on the call. So obviously, I would be careful when I said that. And what for them again. But why not, isn't it? Absolutely. And I think, especially with advancing roles now with physiotherapist, with advanced nurse practitioners, our A CPS. And I know we've just had a load of our local therapists that have attended the normal ultrasound course. So. Well, absolutely. Um, because, you know, and this is, this is the issue that we've got, um, even locally and maybe this has been, this may be echoed in some of the other trusts that are on, on the call is that um it, it doesn't have to be done in theater. Um, like you say, and I think, you know, if we had a clinic room bearing in mind, you know, if you think about the environment in critical care, do we take every patient that requires central line va cath to theater? We don't, we do it in the bedside. So as long as we've got a cleaner environment and we've got the person to do it surely that ups your resources tenfold. So I know that I think that is definitely something to my last question to you. I'm really sorry. Um Is with regards to um bibb somebody's chest with rib fractures clinically fail. We get this quite a lot. Um So it's a two part of the question. Really? First of all, would you give somebody with a clinical flail chest? No. OK, I have. Yeah. But on the, I've, I've done it again. It's in that situation when I've got a vented patient who is, is sedate is sedated. Um And it's one of those situations where if I don't clear the chest, the patient dies of a chest infection. So it is risk benefit. If I've got an awake patient with a flail and they're coughing and they don't need it, then no, obviously. Does that make sense? That makes sense. Absolutely. In our um guidance, it's not in the, in the, in the guidance that we published, um it would be contralateral. It would have to be ribs, not shaking and maybe percussion. But again, you've just got to think if you're shaking one side of the chest wall, you're going to be disrupting the bony anatomy on the other side. So I would only do it if I really needed to. Ok, thank you, Claire just mentioned that in our particular trust um the in hu who I prescribe and have now done training and competence can out to the blocks and this is Ray. So we need to get that published. You do cla um lovely. OK. Thank you. Any more questions. I think everyone's ready for whatever's on Netflix. So, um what we will be doing, oh, hang on, hang on. Oh Yeah, Eliza just saying, thank you. So, what we will be doing is um we'll be publishing this uh recording for those that couldn't make it. Um And then uh we can share that and also if you wouldn't mind if everyone here can actually do a feedback form for us and then you will get a certificate of attendance as well if that's ok. Um Obviously Kerry's, we've put Kerry's uh email address in the chat um as well. Um So yeah. Oh, is it gone in the chart? I I just sent the feedback form in the chart now. Oh, thank you. That's amazing. Thank you so much. Lovely. So, thank you ever so much. Um If anyone's got any questions, email that girl. Uh um um Again, it's been lovely to see everybody online. Thank you so much for attending. I really do appreciate it. Thank you. We'll see you soon. Take care everyone.