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so I'm no longer on you. So we can just You should be able to hear this. Yep, That's fine. Right, Sweetness? Sure. Or we can just do just window as well and things. Yeah. Uh, good morning, ladies and gentlemen. We're going to make a start to the Veteran's Humanitarian and conflict surgery Course. My name is Professor Man. So can I make a trauma and general surgeon who was previously in the UK military? And what I'm going to do is over the next couple of days, just take you over the fundamentals of what's required for frontline surgery. Now, everything that we do starts at some point, and what I'm going to start off today with is talking about damage control, resuscitation and, more importantly, the reality associated with damage control resuscitation, especially when talking about the humanitarian conflict or the military environment, because things are slightly different in those sorts of areas. Now, as with any talk, here's my disclosures. I have no conflicts of interest. These views are mine and mine alone and do not represent anybody of any importance. If you go all the way back to Hippocrates, he did come up with a saying, which initially did not account for diversity in the surgical work force. And the initial saying was He who wishes to be a surgeon must first go to all this was adapted somewhat by myself in a recent publication, and you know, anybody who wants to do surgery must, even in the current climates, have to have exposure to emergent or how's the word emergent work. What I am trying to do is try and find a way alongside a number of my colleagues of how we can train people for conflict for humanitarian work without them actually having gone to it. However, as you know, it's very, very difficult because certain stressors, environmental factors and also resources. Unless you've actually been there, it can be very, very different. But we will talk more about as we go through today when we talk about death, especially in terms of trauma, whether it be in the humanitarian area of the conflict in war. Whichever area is hemorrhage is the major cause of death. Now, unfortunately, in a vast number of individuals, they will never reach definitive care due to the evacuation timelines, and they will have died prior to arriving at these situations. The time is in fact the most important critical factor that we have to take into account. The quicker you get somebody to definitive care, the better it is for that individual. The longer it takes, the worse it is for that individual. So multiple timelines came into place in the 19 eighties. Are Adams Cowley from shock Trauma came up with the golden hour. He stated that patients should get to definitive care within one hour of injury. And this in a large metropolitan suburban area. You know, especially with well made roads. Helicopters was probably a pretty good place to start off with. However, in conflict zones where the mechanisms of injury also include penetrating trauma, high energy weaponry explosions. That timeline is drastically reduced because the mechanism of injury is significantly higher. Over the last two decades of the conflicts in Iraq and Afghanistan have enabled us to come up with the platinum 10 minutes. This is you getting some form of medical care within 10 minutes of being injured and time of injury. Homeostasis is the most important. The conflicts over the last two decades, I will say again, have demonstrated that you can have survivors with bilateral amputations, triple amputations, major GI sws to the chest or to the abdomen. And the reason why these patients have survived is their field medic or a person next to them, or they themselves have managed to put a tourniquet on or control hemorrhage very, very quickly. So resuscitation. What is the exact definition and the exact definition for this is basically restoration of normal physiology. However, if you imagine if you have ongoing blood loss, you cannot restore normal physiology until you have restored you know, their circulatory control. I The bleeding has stopped. Once the bleeding has stopped, then you can restore normal physiology. You can't do that if they continue to bleed. This is a great graph, nearly a decade old enough this publication, but still rings true if you have a look in the first hour, 50% of deaths are caused by exsanguination that is, individuals suffering from major blood loss. Okay, so you can save 50% of individuals from dying if you can get him a Stasis yet again similar up until the first four hours. I'll show you this graph because it explains this graph in a more visual manner. As you can see, CNS, you get death from C. N s all the way up to 30 days. Okay? And the reason why that occurs is nobody will write patients off or say this patient is non survivable based on their initial CT scan or their initial presentation. Okay, patients can take days to manifest whether they will survive from a head injury or not. The primary intervention in major head injury does remain hemorrhage control. There are many of you out there which I think you know what if somebody's bleeding, we can continue to give them blood transfusions, and that will be fine. There are two problems with this. First of all, in a conflict or a humanitarian zone, you may not have that much blood products. You may only have 10 12 units of packed red cells or, if you are in a front line, humanitarian, low resource environment. You may only have you know one or two units of threshold blood from the walking blood back. The second problem is, is blood is not that good. Blood is very good as long as you replace what is required. However, as this graph shows you for every unit of blood you transfuse. In the 1st 24 hours, you independently increase the risk of dying. So blood is remember Good. But it is also very, very bad. And I'll quote Winston Churchill here. What we need to do is be able to do what is required for that patient when they need it. Sometimes we have to be really, really quick. Other times we can take our time. It purely depends on patient physiology. Now, this is a paper God nearly 30 years ago. Now this was first came out and it brought in the term damage control. Although this was being practiced for a good number of decades before hand. And what this paper actually did show us was and I've just broken this down very, very simply. If you are seriously injured, damaged control saved your life. If you're not that seriously injured, you should go on to definitive control, okay? And definitive measures. Because nothing in life is for free. You need to do what is right by the patient dependent on the patient's physiology. If the person is hemorrhaging away in front of you, control the hemorrhage. Stop the sepsis if they're actually relatively okay, the physiology is fine. Well, do what's needed the Lethal triad. And I'm going to add two more things to this lethal triad. If you think about this, you have a patient right in front of you who is bleeding to death. If they're bleeding to death, they're losing blood volume. Blood volume is required to circulate this oxygen molecule from the atmosphere to the mitochondria. If you don't have that circulatory volume, you can't transfer that oxygen molecule down to the bottom. So instead of going undergoing aerobic respiration, you undergo an aerobic respiration. Aerobic respiration generates 38 t p. Anaerobic generates for ATP, and the key thing is, it just doesn't generate ATP. It also generates heat. So not only are you not undergoing aerobic aspiration respiration, but you're undergoing anaerobic respiration. So you're making lactic acid. You're not also generating enough heat. So you've got two problems there. You're actually becoming acidotic, and you're becoming hypothyroid because of these modalities. Also, the blood is your body's central heating fluid. It's required to circulate around, and that's what transfers the heat around your body. So if you've got volume loss, you haven't got enough central heating fluid. You haven't got enough oxygen molecules. You're not undergoing aerobic respiration. You're producing lactic acid. You're also not generating enough heat. You then, actually, you know you become acidotic and hypothermic, which subsequently leads to coagulopathy because your enzymes require you to be at the right pH, which is between 7.35 and 7.45. And the optimal temperature, which is about 36 a half 2 37 degrees. But don't forget, you're also losing blood, so you're actually losing a lot of clotting factors as you exsanguinate. Now with the acid anemia and the hypothermia. Comma metabolic disturbance is the two biggest ones, especially with acidemia, a hyper cholemia and hypocalcemia. Now, when you have somebody who comes in with a hemorrhagic component, give them calcium. The calcium will be cardio, protective against the hypochelemia, but also what it will do well, increase their in atropic effect of their heart and also increase the potency of enzymes because a lot of enzymes do require calcium. Okay, so if you get your head all the way around that the key thing to remember is it all comes down to the oxygen molecule, going down to the mitochondria and generating ATP and heat. And just as an aide memoir, uh, you can see it's they're pretty self explanatory. Now, when do I think of damage control, resuscitation and massive transfusion protocol? I'll be honest with you if you're in a humanitarian or a conflict environment. If a patient has survived to you, chances of them surviving are going to be quite good. If you think about the evacuation timelines in sub Saharan Africa in the Far East, in the jungles, it does take quite a while for a casualty. Get to you. And the fact that they've got to you shows that they've already selected themselves. Now, when they do get to you and they may be slightly acid emmick they may be, you know, hypothermic. You may think, God, I can't finish this operation now. I can't close this person. There is no harm of providing. You have the resources. And when I talk about the resources, I'm talking about ventilators, you know, to actually manage this person up until you can do a second relook or a third relook. Now what you've got to be aware of here is you may not have a ventilator. I have known field hospitals overseas to manually ventilate their patient overnight to get them better. And you can imagine how labor intensive that is with an anesthetist bagging away the person, especially if that is the only thing. Is this there? So you need to figure out amongst yourselves what is survivable, given the resources you have and what is not survivable. Now I think of damage control, resuscitation and massive transfusion protocol when I think of significant blood loss. Okay. And this can be when in a young fit individual, the systolic BP drops below 100 and 10, the heart rate goes above 100 100 and five or the hematocrit drops below 32. But as you can see with one of those modalities, it's really, really difficult to try and determine the hematocrit, especially if you do not have readily available. Labs may be easier to determine. Systolic BP by measuring their pulse is and as a rule of thumb, your carotids. If you can feel it, your BP systolic is Circle 90 for your femoral circuit. 80. Sorry, theater, radio. You can feel at 90 femoral, you can feel at 80 and carotids you can feel at 70. Okay, so your carotids is your last pulse to go because the two most important organs your body profuse, is your heart and your brain. That is the whole purpose, in fact, of doing damage control surgery is to maintain perfusion of the vital structures, as well as correcting all the metabolic disturbance is now. This is what you can look at manually. If the patient is cold to touch, you know they're going to be hypothermic. If they have puffiness of the tissues and they've got nonsurgical bleeding, you are worried about, you know, coagulopathy. So a lot of this stuff you can determine clinically dependent on how much exposure you have had. You've all heard about the grade 1234 of shock, which occurs in individuals who have had major blood loss. And they always say your heart rate goes up, your BP goes down, your urine output goes to zero. What really happens in a young fit individual is they will maintain their BP. They will maintain all of their hemodynamic parameters up until they exhaust themselves which is at this point here. Now, if you imagine this is a runaway train, it's easier to stop the train at the beginning than it is at the cliff edge. You actually have a physiological threshold of survival. Your body can only undertake or sustain a certain degree of insult before they your body cannot survive. And you may have seen this or you may see this in the future. You have a casualty brought to you who is talking to you. But they've gone past the physiological threshold of survival. And no matter what you do, the systemic inflammatory response they will not be able to survive. So this is where the damage control philosophy stems from, and it comes from the Navy, and it is saving the ship at any cost. So you're stopping the floods, which is stopping the bleeding. Okay, you're putting out the fires, which is controlling the sepsis. But if you imagine this being a warship, any time of war happens, the ship doesn't turn around to the opposition and say, You know what? I'm injured. I'm gonna limp my way across the harbor. And once I fix myself, I'll join the fight again. You also have to continue the attack. So while as you as a surgeon of putting out the fires, you know, stopping the floods. What you're also doing is you are also sustaining the attack on the enemy, which is done by your anesthetist and intensive care colleagues. And what they do is they maintain the attack and restore the physiology. That is all you got to remember. Okay, Is stop the floods, put out the fires and maintain the continuous attack. So this is what the management strategy is at the margins of physiological tolerance. It basically how when you're that badly injured that you may die, you need to do this. And what you have to do is control bleeding and contamination. And remember, in this case, physiology Trump's anatomic injury tie things off. So stop the floods, put out fires and continue with the mission, which is to restore physiology in the good old days, probably long before many of you were training. But I do remember this as a patient used to come in, and the domain of the emergency medicine doctor was the emergency department. And that's where all reign supreme then the operating room surgeons dictated what was happening alongside the anesthetist. And then finally the patient went to a critical care and the critical care and the intensity is used to determine what would happen. What we have realized. That damage control surgery is an integral component of damage control. Resuscitation. There we are, a nice Infographic there for you. So the key thing to remember is you have to stop the floods, put out the fires, okay? And just to show you that if you practice enough, it really, really does work. This paper was done by a number of my colleagues, and I actually really like this paper because of this Infographic. If you look at when hostilities began in the Iraq and Afghanistan conflicts back in 2003, a new injury severity score with a value of 75 is unsurvivable. Obviously, you may have one or 2% who defied the odds, which you can see at the beginning in 2003. However, by the time the conflict ceased or towards the latter ends in 2012, you can see there was a 13 14% survival. So you've gone from one or 2% which is within your, uh, error limit all the way up to 12 13% 40% of individuals who are surviving non survivable injuries. And the reason why that will happen wasn't because we had the kid. It wasn't because we have the resources because we had the institutional memory because we had actually the exposure. You know, the saying is, the more you sweat in peace, the less you bleed in war. The more you practice, the better you get. The more likely you are to actually, you know, make a difference when push comes to shove. So that gives you a beginning on the basis of what we are going to cover over the next couple of days, especially in terms of abdominal damage control and thoracic damage control. This morning, after our next lecture, we will go to the lab where we will undergo the damage control thoracics procedures, concentrating on a how to access the chest, the important areas within the chest and followed by you know how to get the vascular control in those specific areas. Right now, Do we have any questions from anybody? Is everybody awake or have you just logged on and just disappeared. Any questions? I've been muted. You all. You can ask any questions whenever you want to. Well, if that's not the case, I will be back in five minutes. Have a leg stretch, and we'll go on to talk about the ballistics talk. Okay, so I'll see you in five minutes. In fact, let's say we will recommence at 900. All right, ladies and gentlemen, back to do the second talk. This will be the final talk of the day before we go on to the cadaveric dissection lab, where we will demonstrate a number of maneuvers and procedures. Okay, so this is a talk about ballistics and blast injury yet again, Standard disclosure, the views of mine and mine alone and do not represent anybody of any importance. And what we're going to do during this is go through a brief overview of the history of projectiles, talk about kinetic energy and then under explain the principles of ballistics and blast. So history of projectiles. When we look at humans, we've always been a conflicted species. And initially we started off throwing punches at each other. And then we thought, Hang on. If I'm throwing a punch at somebody. It means they can throw a punch back. So how can I hit them from a distance? I'm going to throw a rock. Okay. A rock. Blunt force trauma. But it's limited by the weight of the rock and the distance. You can throw it. How can we make it a bit more lethal? Well, you know what? We can make it into a pointy spear. Spears probably have not that great a distance that you can throw them and people can see them coming so they can step aside. How can we increase the speed of a spear? Well, we'll develop arrows. As for the archers came in. You know what? How can we make it more and more deadly? Well, well developed rockets and then finally, guns. You can see the natural evolution that occurred. And in the olden days, they used to have the flint mechanism gun. Okay, flintlock mechanism. You basically pull the trigger, ignites the flint in lights, ignites the gun powder, and it blasts its way down. Now, In those days, gunpowder was made of a standard formulation, and the amount of energy transferred to the bullet was dependent on the volume of the gunpowder, the amount it combusted as well as the walking around it. Okay, that's what it was all down to. But as you know, if you want to increase the energy of a projectile and this is where kinetic, kinetic energy comes in, you have to either increase its velocity or increase its mass. If you increase its mass, you need more and more energy to propel it that same distance. Okay. And you don't really pardon the pun get as much bang for the buck. So if you look at the equation half MV squared. If you double the mass, you double the energy. If you double the velocity, you quadruple the energy. So it was a case of how do we make this bullet go faster? Because that is how we will increase the energy. So what they did was try and make it more aerodynamic, Slightly more cone shape, which allowed the bullet to go a bit further in the air and hit the target with more energy and modern day rifles. Do this by a rifling. What they do is the bullet engages the actual barrel and it starts to spin and when it spins, it stabilizes. And as it stabilizes, it oscillates less and therefore suffers from less friction and can go further. So kinetic energy. I do the apple because it all comes down to Newton. Okay, this is the equation Half MV squared. As I've said to you beforehand, if you double the mass, you double the energy. If you double the velocity, you quadruple the energy. Now, this is a Glock 19 and held weapon, and the lethal dose required is about 400. Jules, if you absorb all of that energy, you know what? You're very unlikely going to be able to walk away. And it's really easy to remember this because if you look at defibrillation when that cares, you base that around 360 jewels is the maximum amount of energy it takes to restart the heart. And you know Q e d. If it's the amount of energy that it takes to restart the heart, it is the minimum energy that it takes to actually stop the heart as well. So 400 Jules, which is what a handgun packs, is the minimum effective lethal dose. You then have assault rifles and you have a variety of these, um, derivatives of the M 16 UK variants as well as the other Kalashnikov variants. This packs about 1700. Jules, this is a Kalashnikov variant, and this packs about 2000. Jules, your average military grade assault rifle will be anywhere between 1500 to 2000 Jules of energy being transmitted. Okay, this is a breakdown of the different kinds of pistols and military rifles and the energy they deliver. So you can see to the more astute of you out there that there are some revolvers that pack more energy than a military assault rifle, especially if you look at the 44 Remington or the Magnum. And the reason why that occurs is if you look at the weight of the actual projectile. Your average nine more rounds, the weight of the round will be between 8 to 9 g. The 44 Remington packs a a gram of about nearly 16, suddenly double the weight. And then also, if you look at the muzzle velocity, that is almost 30% more than the muzzle velocity you get with a browning or the standard, you know, nine millimeter round So if you remember what I said previously, if you double the mass, you double the energy. So we've doubled the mass. But what we've also done is increase the energy by 50% as well. And that's been undertaken by increasing the muzzle velocity by 50 by 30%. So double the mass and we've increased the velocity by 30% which overall quadruples the energy. So in effect, what we've done is, you know, almost just double the velocity. Now, the more astute amongst you will recognize this, especially from the call of duty games as the Barrett. And this packs a whopping 15.5 1000 Jules of energy. Okay, these the bullets do not need to hit you for it to be lethal. It will cause the injury long, long before that. So what is ballistics if I talk to you about ballistics? What is ballistics? Well, ballistics is the study of the motion of projectiles. Okay, It's very important because not all projectiles behave the same. If you look at a precision rifle, the actual projectile will not go above the zenith of the optical scope. Whereas with a combat rifle, it will go above the point of where you're aiming. So this needs to be taken into account when aiming your rifle to actually prevent collateral damage. So with a precision rifle where you aim, the bullet will never go above that portion. Where, as with the military grade rifle, it will likely go above that. What is terminal ballistics? Well, terminal ballistics is the study of the motion of projectiles When it hits something, okay. And what happens to that projectile when it hits something and wound Ballistics is when that something is living tissue. So it is the study of the motion of projectiles when it hits living tissue. Okay, that is what terminal ballistics is. Also, a key factor here is to know about energy dump. Now, what is energy dump you may ask. Well, energy dump is very, very easily explained. Energy dump is the amount of energy which is left in the tissue. If I was shot in my chest by a bullet going at, say 500 m per second and it left my chest at 499 m per second, it is only slowed down by 1 m per second. So the relative energy dump will be quite minor. However, if I'm shot in the chest with a bullet going at 500 m per second and the bullet does not leave, my body has absorbed all of that energy. And all of that energy has been dumped into my tissues. That's where the term energy dump comes in. So it's your entry energy minus your exit energy. Okay, Now I'm going to show you a couple of rounds being shot at a barrel. The first one is being shot, and I believe it goes through a barrel which weighs about 70 kg full of water. Okay? And this round weighs about 8 to 10 g. So you can see what happens to this round. You can see the round has gone through because water is pouring out the back. So this has been a partial energy dump. But that whole 70 kg barrel was lifted clean up into the air. Okay. It shows you that it totally displaced that entire barrel. Now, this is what happens when the same round hits body armor. All of that energy has been dumped into the armour plate and that has been dumped in the term in terms of thermal energy, and it has also been dissipated over a wider surface area. This person would hopefully walk away from this bullet, but they will no doubt have sustained severe rib fractures. Okay, remember, as one of the laws goes, energy cannot be created or destroyed. Only change from one form to another. So all of this kinetic energy has been dissipated and changed into thermal energy, and that body armor populating needs to be changed. But luckily, the patient would have survived. As you can see, these are what the case things look like. So I'll give you a term explain to you the different types of ammunition there are out there. You have military bullets which are not allowed to be used in hunting, and these are the full metal jacket. The reason why you put the full metal jacket on is because lead is a soft metal and as it travels through the air, it heats up and it deforms. Okay, so that's why you put a stainless steel coat around there. You then have a hard core round, which is what we use for armor piercing rounds and then finally a trace around which you can see at night. You then have whole hunting bullets, which are your soft jackets or your soft jacket collar points which are designed to deform and mushrooms and thereby causing maximum energy dump and staying in those tissues. The ones on the left can only be used by the military. The ones on the right can only be used in hunting with the exception of firearms officers. Okay, as well as certain special military operatives. Now, I'm going to show you this video and what I want you to do is have a look at the amount of capitation it causes in the gel block. Okay, you can see the amount of defamation that occurs in this gel block. Remember, this is taken over a period of milliseconds. So I play this video a couple of times. Okay, I'll play this video again. Look at how the bullet leaves it leaves backwards. So it's tumbling. There are certain rounds which are designed which are designed to tumble. So when they hit you, they cause maximum capitation because the energy dump is also proportional to the surface area of the round exposed to living tissue. Okay, so the more area you have exposed, the more capitation occurs now you can see that capitation occurring and that wasn't there before hand. So not only do you have to deal with the bullet wound and the direct damage it causes, you also have to deal with the capitation that occurs and all of the problems associated with that. Okay, a lot of things can occur, so the actual pressure inside the cavity is below atmospheric. So not only do you have the wound to deal with the shearing forces of that cavitation, which can take up the entire thoracic and abdominal cavity, you also have a negative pressure, which sucks in all of the surrounding area. Now, as you can see, this is what a mushroom drowned looks like. And just when you thought things couldn't get worse, you have what they call a radically invasive projectile. And as you're well aware, when a bullet is fired, it rifles, it spins. So these prongs get forced together and it allows them to go through soft armour. And as soon as they hit tissue that can speculate. So one bullet one round can do that much damage, which is horrific to see. So that is a quick overview of bullets. So you understand how much damage projectiles can do, especially when it gives you a quick overview. And now we're going to go on to some things which go bang and also cause a lot of damage by the tissues that they affect. You can imagine this being a patrol and then all of a sudden, kaboom. Look at the amount of energy it takes to lift up that ground. The tarmac, everything. That is some serious energy deposition. Now, if you imagine that explosion and somebody is walking over it, that is what happens. That is what your body is subjected to. Not only are you subjected to the blast injury, you're also subjected to being hurled meters up into the air. This characteristically shows how you cannot outrun an explosion. This person in the bottom right is running up full speed and they have hardly moved. You can see the first shock wave, you know, primary blast occurring again, followed by the secondary blast which is all of these projectiles. Any second now you'll see the flame front coming through and you can see this person has hardly moved um, hum in some days, especially when it's raining. If you see a blast occurring, which is not the case in this this you can just see the thermal front. But this pick up on the floor this like missed. This is the primary blast. What it does is that shock wave causes a flash and all the do of water to be lift up. If it is drizzling, you'll see that primary blast front. Push away the drizzle wave so you can see it, whereas here what you can see is the superheated gas. Now what happens is you have an explosion. You get a sudden expansion of all of this material and it creates a relative vacuum. So you've got this huge bubble which forms. But then because air is heavier, when it's colder, it gets sucked in to replace the hot, expanding air. That's why you get the mushroom cloud. There we go. And the best way to avoid being subjected to a blast wave is to be far away from it. The further you are away from it, the less likely is to affect you. Okay. And the key thing with this is explosions are worse. in a confined space in an open space, the energy dissipates, the further you are away from it. Whereas in a confined space you actually get more and more exposure to that initial blast because it keeps bouncing off the walls. So classification, you have your primary blast injury, which is due to the shot or the overpressure. You have your secondary blast injury, which is lots of bullets coming at you. You have your tertiary blast injury, which is victim displacement. And then you have your coronary blast injury, which is due to your burns and then your quivery your PTSD at all. Okay, All of these are the different ways this can happen now. Primary blast characteristically affects your air containing organs, your bowel, your Sinuses, anywhere you have air where you get a sudden rapid expansion. And the reason why it causes problems with your gut is it doesn't cause if it doesn't cause immediate rupture, it will cause a venous infarction, which will then cause ischemia due to the Venus infarction and the inability for the arteries to supply. And then that will cause ischemia, which will manifest a few hours down the line perforated ear drums are unreliable. Sign in primary blast. Injury. Okay, you get your lung injuries, you get your bowel infarctions. The key thing is, if you suspect somebody with a primary blast injury, they need to be monitored for at least 24 to 48 hours. These are the individuals who will say to urine. Fine. Go away and they will die, Uh, asphyxiating with their own secretions. Okay. And are these kind of a picture emerges? It's very easy to treat. The big parenchymal. Injury is you just treat them with chest tubes and they will show up pretty quickly. What is more insidious is the guards ground glass kind of appearance. You then have your secondary blast injury, which are lots of bullet fragments. This is a jubilee clip from a potential, um, pipe bomb. But remember, if it's a suicide bomber, you are our exposure to biological agents. Natural fragmentation from the actual canister. But you can get premade fragments. This is a frog grenade. The reason why it's called a frog grenade is because it's designed to fragment. The explosion goes off on the inside and you can see these excoriations you end up with multiple bullets flying off in all directions. Okay, projectiles. You can see here. It may look a bit horrific, but this is relatively easy to manage with just scrubbing. You get preformed fragments. These are specifically designed, especially if you've seen the movies such as swordfish, which will teach you how to make a human claim. Or this is another kind of incendiary device which belongs to the Hellfire missiles. And this is pre made fragments which actually become molten metal and can really incapacitate your casualties. But remember all of these principles they're made in conventional weaponry. But individuals can make them themselves to mimic this tertiary blasters where an individual is thrown against a wall or another object. Okay, it is that massive displacement that occurs blast stripping itself. The best way to describe this is you have your tibia as the central part of an umbrella, and when you step on something that looks like a mine, it lifts up all the tissues. So all your tissues become the umbrella, and the middle part of it actually becomes the What's the word? I'm looking for the actual handle of the umbrella, and all of that dirt is pushed up into the tissues in the superior aspect, you can actually see the amount of damage a bomb can do. This was a van loaded up, and it destroyed the FBI building. But remember, when you have an explosion, you can have conventional weaponry, or you can have weaponized toxins and radiation, the so called dirty bomb. As I told you before hand, it's very easy to get away from bomb. The further you are away from it, the easier it is to actually limit the effects. However, with a dirty bomb, it actually is using radioactive material. So it contaminates an area which could remain inhospitable for tens of thousands of years. And if you inhale the dust well, you can be as far away from the bomb as you want. But the radiation will come with you just as the toxins well and always remember we as medical professionals we are. They're trained to deal with all eventualities should the need arise. And the only way to do that is to get exposure, know how to do the fundamental base, which is what the rest of today and tomorrow will be about. We'll teach you how to get control in the chest. We will teach you how to get a vascular access and vascular control to make it look all very, very easy. Okay, so do we have any questions? Team, I have got you all been muted, but please feel free to ask any questions. Anything at all. You can even type them in. Oh, how to? Okay, I've got a question here. How to detect primary injuries in a timely manner. Well, Nora, the best way to actually do this is undertake a proper primary survey. Now it is part of this. I was going to talk a bit about this during as the day goes on, but I'll talk about it right now. Let me stop sharing the screen so you lot aren't distracted, and I can continue to talk. So how to detect primary injuries? You do a good primary survey and a primary survey starts off with dealing with catastrophic hemorrhage. First, any evidence of compressible bleeding needs to be dealt with first. Remember what I said. The whole purpose of resuscitation is to deliver that oxygen molecule from the atmosphere to your ent issues. If you do not control primary the hemorrhage either. Catastrophic hemorrhage. There is no point in, actually, you know, securing the airway doing the breathing because the oxygen molecule will just go and sit in your alveolus. Because there's no circulation. There is no blood to take it. Anyway, As you're all well aware, you can actually not oxygenate somebody for up to 2 to 3 minutes. And they will still be able to perfuse the end organs because of the oxygen present in the Alvesco. Like so, you do deal with catastrophic hemorrhage, whether that would be with the tourniquet or packing. Then you secure the airway with C spine control. You then determine their breathing. You know, inspection palpations Percocet on auscultation. You do all of those aspects. You then check the circulation. Check their pulse, check their BP. Check the capillary refill, check the abdomen. Check all of the signs of bleeding. Remember, you can bleed into your chest, your abdomen, your pelvis, your long bones and onto the floor. Okay? Those are all important things. You then do disability and then finally exposure the disability and exposure. Uh, the exposure is to make sure you do not miss any covert injuries and the disability is to determine if there is any neurological injury now. Also, remember, a decreased GCS in the absence of head injury may be a sign of shock because your brain is an end organ and end organ hyperperfusion presents in disoriented thinking in confused speech. Think of it as low urine output. And then finally, what you then have to do is, once you've got the primary survey, remember is for life threatening injuries. Once a life threatening injuries have been addressed. You need to do a proper secondary survey, and a secondary survey is literally a meticulous examination where you feel every single bone you can imagine. Have a look inside the ears inside the nose. Have a look at the iris. Have a look inside the funders. Have a look at all my movements have been a look inside the mouth. Feel inside the mouth for any fractures. Feel for any jaw fractures feel all the way. You literally palpate the entire length and inspect the patient. That is how you actually address injuries in a timely manner, your life threatening injuries you do with the primary survey and all of your other injuries to make sure you don't miss anything which can potentially cause long term problems or in your disability. You do a secondary survey, and you're only way to get better at that is by doing them. Okay, so you go down to the emergency department and you do your resuscitation. There. Any other questions? Oh, no reason. Or Come on, you've got me as a captive faculty today, so please feel free to ask any any questions, right? I don't think you have any questions. So what I will do is I will go and prepare in the lab, and then hopefully in about 20 minutes, we can actually start maybe slightly earlier than what was scheduled on the dissection program. Okay, so if you bear with me, we will be starting this very, very shortly.