Dr. David P. Mooney - Child Injury Update

So, our very own Doctor David Mooney, who is, uh, um, kind enough today to, um, uh, share an update on child injury. As you know, he's a director of our trauma program and, um, uh, and he's been doing some exciting work within our own outcomes, uh, on trauma, um, and trauma diagnosis and, and management. And so he's gonna share, um, and get us all up to date. So, thank you very much, Doctor Mooney. Well, thanks, you guys. This is what you get when uh somebody cans their grand rounds talk. You get a filler guy. So I, what I want to do is, uh, talk for, carry on for about an hour about things and uh captive audience. So I wish there was enough commercial interest and money in pediatric injury for me to become corrupt. That'd be great. Uh, no one's suing my family over any trauma crisis, unfortunately. Um, I have no relationships with any providers of, uh, product developers. Um, Because there really aren't any. Um, and if I do not get a second laser for the Pillo Idol program within the next 3 weeks, I'm gonna shut the hospital down. And catch me outside if you hear of any money, please don't email me. Um, so, uh, child injury today. What I want to do is carry on a little bit about epidemiology. Uh, I'm a math geek. I love numbers. I, I actually enjoy sitting in front of a, a screen full of Excel spreadsheets. And, um, and talk a little bit about global stuff, a few selective issues I can carry on about and then, uh, future directions. I've been doing PD trauma care, uh, as an attending for 25 years now. And pretty much on a first name basis with anybody in the country that gives a damn about it. And so, uh, uh, I, hopefully, I can see how things are heading. Uh, trauma is as old as humans. This is either Abel killing Cain or Cain killing Abel, insisted Fri Marie would wrap my knuckles for not knowing that. Uh, but, uh, uh, again, this would be the 3rd and 4th humans that existed. Uh, one murdered the other one. And this is actually the register of the patients, uh, the first patients admitted to our hospital, uh, back when it was founded. And it's very hard to read, but if you take a lot of time going down the list, 6 of the 1st 10 patients that were admitted to this hospital were admitted for an injury. Oftentimes, poorly healing bones, fracture care, uh, a lot of actually TB and bones here when this hospital was founded, like the TB-free cows across the street to keep kids from getting uh TB in their fracture sites. Uh, so trauma has actually been a part of this facility, uh, since the day this facility started. In fact, fracture of the radius, first patient to be admitted here. But the science of trauma, you know, people often think, um, in fact, one of my, uh, people who trained me in Kansas City, felt that trauma was an act of God, that it was your time, God's will. It just, you know, was just gonna happen. And, um, there's this guy, John Snow, who was the first person to apply science to health. 1849, there was a cholera outbreak in London. And uh there were different water companies and many of them pulled water right out of the river and put it off to these pumps. And all he really did is he basically mapped out the cholera cases uh during an epidemic, and it's kind of hard to see, but there's like an X right here in the middle of this big cluster full of, uh, each dots of cholera case. And he looked at that and he mapped out the other X's of the other water pumps from the other water companies, and of the three different water companies, he found out that the, the cases were really centered around that one pump. And so he went to the pump and took the handle off. And the cholera went away from that neighborhood. And he got in a lot of trouble with the local authorities, and they put the handle back on. But he learned or he showed people that you could actually take science and apply it to diseases, and realize it's not an act of God that something happens, it's um an act of humans. And this is just some random years, injury admissions per month here. And you, this could be injuries, this could be the flu, this could be, uh, you know, appendicitis can be seasonal, and any of the conditions that we treat, especially the infectious conditions, tend to occur in a pattern and injuries do too. We, we can't predict which kid's gonna fall out of the window, but we know every year, a certain number of kids are gonna fall out of the window. Not because God ordained it, but because the way we've designed our windows. Uh, Sevra Koup, who, uh, many in the younger folks in the crowd may not know is a pediatric surgeon, uh, until his son died in an ice climbing, uh, accident, um, said if the disease were killing our children in the proportions that injuries are, people would be outraged and demand that this killer be stopped. And he said this, uh, over 45 years ago. And here's what he's talking about. Uh, the blue boxes, this is from the CDC. This is the most recent data available for causes of death, uh, in our country. The blue boxes are unintentional injury. And this could be 2004, it could be 1980. Uh, again, for the last 50 years or more, the number one cause of death for any one of us, uh, anyone below 44 in this room is unintentional injury. And if you add up the unintentional injury deaths, it's more kids die from injury each year in our country than all of the causes combined, even still. And in fact, we use that as a marker for success in the world. When a country or in the planet goes from having their children die of diarrhea and upper respiratory infections, to having their children die from injury, that's considered, they made the epidemiologic transition to becoming a, a modern westernized type country. That means they have a mature economy. Uh, very sadly, the second leading cause of death for 10 to 14 year olds is now suicide. And you can see homicide's been dropping, and it's a few rows down. That's the red ones. And you really won't be able to make this one out. But the, uh, if you look at how people die, the blue boxes or car crashes. And uh there's no such thing as a car accident. Uh, they're all a crash and they all occur by design, uh either road design or product design. Uh, and the green is actually the sad to me and um if I mentioned opioids, this probably helps us maybe a CMER for opioid training education. But the, uh, the green boxes are overdoses. And when you look at now from 25 to 64. The leading cause of death in our country is uh unintentional poisoning. And then, um, people always like to hear about, you know, the number one cause for a kid to come in the ER is a fall. And, but it turns out the #1 reason for an adult injury to come into an ER is a fall, for injury, they fall. People fall down and about half of our admissions, Johnny fell down and broke something, and the orthopedic surgeon fixes it. That's about half of any pediatric trauma center's uh admissions. Well, there's been a lot of changes over the past few years. This is from 2001 to 2007. And this is how many kids per year come into an ED for the treatment of an injury. And it gets more data from the CDC. And it's gone down from around, say, 12 kids, uh, or 12 kids per 100. So 1 out of every, say, uh, 9 kids coming into the ER per year for the treatment of an injury, down to around 1 out of every 12 kids. And that may not seem like a striking difference, but you know, it's, it's down by about a third. When you look at how many kids are being hospitalized, and again, the numbers changed to 1 out of 10,000 instead of 1 out of 100, uh, because of the kids who come into the ER only about nationally, about 2% of them have to be admitted. Most of them are treated, released from the ED, sent home. And again, down from about 22 to 16. And when you look at the death rate, so about 60% of kids who die from an injury never make it to a hospital. They're dead at the scene. And if you're in a rural area like Vermont or New Hampshire or Maine, uh, that can climb to 70 or 75% of kids die at the scene or die en route to a facility. Typically, if a kid makes it to a hospital, they don't have an overwhelming brain injury, um, they're gonna live. So, if you look, uh, the death rate was actually dropping, um, dropping per year down to around 15% and change in the 2013. And then it started to tick up again. And it may be in part because the suicide rate. Among kids has been growing every year since 2007. And um nobody really understands exactly why this is, but uh, It, it has. Injuries play such a large role in the death rates for children in our country, that uh the overall death rates parallel the injury death rates. And when you look at this, uh this is death rates, the top dotted line is the 15 to 19 year olds. And again, it sort of parallels that other line. A little uptick recently. But it doesn't, it's not even across the nation. Uh, every state is very different. Uh, we're up here in the People's Republic of Massachusetts. Um, I grew up in Missouri right there in the middle. Um, it's a great place to have a career in pediatric injury. Uh, the Saint Louis Children's Hospital presented a series of 110 children, uh, who presented to the hospital 5 years after being shot. Uh, we have typically 1, maybe 2 kids a year who get shot. Um, usually 1 or 2 by accident. And you look up at New England, uh, very low injury rates up here. But it varies even within our state. This is by uh zip code. We looked at how many, how much money was being, was the state spending on the care of injured kids per zip code in our state. And those red and black striped areas are places where over $1.5 million was spent in that one year for the care of injured kids. And if you zoom into even to zoom in Boston in the top right corner, different neighborhoods in our state have much higher injury rates than other neighborhoods. And when you look at the census data on the people who live in those areas, you find that if you, if you take a, a white person from Weston, and they are one, and then you standardize it, you make them the standard, and then you look at injury rates compared to, to that person. Um, basically, uh, poverty, um, is a 1.26 ratio, um, relative risk of injury as your income goes down. Um, 1.6 if you're African-American, 1.54 if you're Hispanic, and the injuries are cut in half if you're Asian, in our true blue state in Massachusetts. There's a huge disparity in injury rates among different ethnic groups within our state. And uh Todd Maxson, who is now, um, Todd is a, a great guy who's an idiot. Uh, he rode a motorcycle, uh, getting home from the hospital one night and basically broke his entire body. Um, he's recovered from that. Uh, but he does these very creative studies. Uh, he looked at parents who arrived at the hospital with their injured child. And fully 1/3 of them had drugs or alcohol on board. I'm not sure how in the heck he got them to consent to being tested. But, uh, 1/3 of them, uh, in the hospital when the kid arrived. He looked at kids who, that kid who was willing to jump off that fence or take that high-risk dive off that tree branch or whatever it was that got them hurt. And he found that that 1/3 of kids who presented to a hospital after getting injured to a high-risk mechanism actually had ADHD. And half of them, the parents didn't know, they're undiagnosed. Uh, and we've long known that the outcome after injury correlates directly with your income level. If you have the income to, and the wherewithal to get your child to all of their follow-up visits. And this isn't just trauma, it's for all of the conditions we treat. Like the short bow kids, if they get their PN, they make their visits, their lines are checked, if they walk all those through those things, uh, even our pilelo and idle kids, if they make their visits and they do the care, they get better. If they don't, they don't. And the outcome after injury direct correlates directly with your income level. Bullying and school violence are things that have certainly always been there, but uh seem to be at least getting more press lately. So here's what we know so far. So I've walked through a lot of data. I love data. And uh I'll try to carry on a little bit less about it. So this is a kid who came into our ED. And that's a bullet hole in the front of his neck. And it came out the back of his left shoulder. And um this actually stimulated a huge change in how we take care of trauma patients here because, uh, By the time I got down there, I was told that what had happened before I arrived was unbelievable chaos. And I caught the Boston EMS people as they were leaving, and they said they will never bring us a trauma patient again after this. Cause we don't see a lot of kids who get shot here and people like running around the room and yelling and screaming and carrying on. And when people here do the mock traumas, and it's all quiet, and it's controlled, and it's crisis resource management, this is why. Now Boston EMS says that we have the best resuscitation in the city here, that is very calm and controlled and no one's freaking out. And this is very hard to interpret, but it's the general slope that matters. This is the school shooting since 1950 in the US. So everybody likes to think about shootings cause that's what you think about if you trained in the 90s, you think about shooting, stabbings, that's what trauma is. And uh I had no idea, so that this line out here. This is the University of Texas. The guy who, um, ex-Marine, murdered his mom, murdered his wife, went to the school, climbed the tower, and shot a bunch of people. Um, that's that 10, the red is how many people died, the yellow is how many people are injured, uh, the blue is how many events. And again, it's just the general trend is what matters. I had never heard of this 1986 giant yellow spike. So a sheriff and his wife in Wyoming went to a school and took over the school. They're armed, they had bombs. Um, His, the wife supposedly um accidentally set off a bomb that injured 73 kids, none of whom died. The husband then shot the wife cause she set off the bomb earlier than expected, and then he shot himself. So there's two deaths. That was the 1986. But what you can see is, as we moved, as you move toward now. More events, more frequent, more lethal. Sandy Hook is in there, we went on standby for Sandy Hook. Um, and I called uh Danbury and I called Hartford. So, so we were, we would be ready to receive any wounded, but there were no wounded. Uh, everyone was killed because of the power of the weapon that young man had. And when you look around the country at gun laws, they're very different. Um, there's this big push to allow, uh, concealed carry, if you have a concealed carry anywhere in the country, that you could take your gun with you wherever you want. Say, and there are some states where you need no training. No, you don't even have to shoot a gun first to get a concealed carry license. You can just apply for the license and get it. Um, and we actually have the lowest gun injury rate here in the nation, in Massachusetts. And also the toughest gun laws in the nation. And I wish I could say that would prevent gun shootings. But as you can see in this little red, Connecticut also has very tough gun laws that are actually a lot tougher now. And the Sandy Hook kid, those guns were legal. His mother purchased guns legally and used them to shoot uh at a rifle range. Gun enthusiast. Sadly, because of this gun violence, instead of trying to restrict, um, keep guns out of the hands of people with mental illnesses or, you know, criminals, um, we've responded by trying to do a better job handling the injuries that occur. And, um, so, there's a stop the bleed campaign that the American College of Surgeons has rolled out. And we've probably all done our net training in how to respond to an active shooter. Seen the video of an active shooter comes into the ED, what do you do? You know, what is it, hide, fight, and something. Um, I can't remember the third thing. It's like pee your pants, poop your pants, throw up. And they give up. Um, but the, uh, but we're rolling out in schools, um, different settings, stop the bleed campaign. So again, if, if you come on someone bleeding, I don't know who, how to stop it. Teaching teachers how to do this. And one thing that we've done here, we do a lot of injury prevention. And one thing over time, I'm gonna sort of carry on about a few things, but you guys asked me to talk, so this is your fault. Um, the, um, so, Injury prevention, trying to get someone to behave doesn't work very well, as Doctor Shamberger knows. Um, it's just straight up behavior modification. You can rally the troops for a short period of time and, you know, come out with the latest thing and wear your seatbelt, don't do this, don't do that. And then for a short time, people will respond, but it fades pretty quickly. The only thing that really has been shown to work are two things, product design and laws, like childproof caps. Actually work. Um, and things like laws, like if you think you're gonna go to jail, if you don't do this, you'll probably do this. And one of the reasons why injury rates have gone down and death rates have gone down for teenagers is because car crash deaths have plummeted for teenagers because they get in a lot of trouble if they speed, if they don't have a seatbelt, they lose their license, and they actually enforce it and they lose it. I caught my son. Um, I was down by the garage. I can see my son come up the road. He stops about 5 houses down the road, 3 friends climb out, and then he drives up to the house, even though he wasn't supposed to, it wasn't legal for him to carry friends in the car yet. So totally busted him. I took his license away for the 3 months that he would have lost it for if I'd been a cop and not his father. I didn't charge him $1000 to get it back, but that would have been a good move. Um, yeah, I thought I would have given myself $1000 and routed it through him. But the, um, the other thing that we, we take a, we don't think about that much for injury prevention is, is actually environmental design. And when you look at the world that we've constructed here, uh, we constructed for our convenience and for beauty, you know, and some other things, but we don't construct it based upon the odds of a child being harmed. And we see that reflected in, in many ways. Um, one way just the product design, we give away thousands of car seats per year. Car seats should not exist. Uh, the cars should be designed to hold a child. If you're selling a car to someone who has a child, the seat should flip around and, you know, have a, so a child fits. You can get it, you know, you can get DVRs in the back of the seat. You can get to do dad known to man now in a car to entertain your child, so they don't bother you. Uh, but the, um, but you can't get a seat that actually holds a kid. And what happens from that is the seatbelt that in us sits on our largest bones in our body, our pelvis, that when the force of deceleration hits you, it distributes over that large bony surface and doesn't break it. Instead, in a child, because the backseat is too long for their stumpy legs, they have to slump forward and the seatbelt slides up to, to the belly button. And we've all seen seatbelt injuries. They were first described in 1963. And, uh, and it's been, again, well-known commodity. We see them all the time. Um, you basically get a bowel injury. We've had kids paralyzed. I mean, it's a, it's a recurring theme at every hospital in the nation, and it has been for over 50 years. Well, the latest is uh texting. Texting and distracted driving, we, we politely call it. And your phone knows if you're in the car, your phone knows if you're the driver. Your phone knows everything you've done in the past, you know, 5 years, and Apple knows, Google knows, everyone knows, and it follows you all over the place. You're this sort of data stream, data dirt, every moment of every day. And um the, uh, it can sometimes be a little creepy. My My son's wife's father is on like Fine Friends, and he's a he's a funny guy, but he will like, will be out to eat, and he will say, hey, try the, try the fish. And he's in San Francisco. But he'll say, hey, he'll, we'll find friends and say, hey, we're out at the restaurant. He gets the menu and sends us something like as a joke, reminding us that he's like, can stalk us if he wants to. So. So, a new thing comes out. This happens all the time. Like when Segways came out, a Segway goes 12 miles an hour. 12 miles an hour doesn't seem that fast. A Segway weighs around 140 pounds. And if you put it, say 150 pound person on that 140 device, you now get a 300 pound thing going 12 miles an hour. It sounds really slow, but that's a 5-minute mile. So you've got basically a New England Patriots lineman coming at you on a sidewalk, going 5 minute mile pace. And old ladies and kids are gonna be the ones who're just gonna get wiped. And it was a big fight to get them off the sidewalks and into the road. But now then you've got a vehicle in the road going 12 miles an hour with cars that are 3000 pounds going 50 miles an hour. Um anyway, so as the products come out, Consideration of the safety part of the product is usually secondary to the profit of the product, and texting is a great example. There was a lovely study done in England. I'm not sure we could do this here, given that they started with people who are 16 years of age. Uh, but they got them drunk. Well, they put them on a driving simulator and had them, you know, tested their response time to driving, you know, a kid pops out and they have to hit the brakes, or they have to steer around to something in the road. And then they, they got them, uh, legally drunk, and they showed that their reaction time, uh, was delayed by 12% with alcohol on board. Presumably, they let them sober up, and then they got them high. Uh, uh, the consent form must have been interesting for that study. Like, I don't think they had to pay them to take part in it. But the, um, and the reaction time was down 21%. And then presumably they let that wear off. Um, and they, then they had them texting and 35% delay in reaction time texting while driving. So you're probably better off being drunk. And or high, then you are texting in terms of reaction time. I'm not gonna ask anyone to raise hands, but there probably are very few people in this room that haven't texted while driving because you just can't help yourself. Everyone else on the road around you, when you're trying to get home is texting. They all are. If they're not at a light, you know, you see, you see so many people, it comes like final, you know, at least at a stoplight. So 50% of 18 to 24 year olds admit to texting while driving, which means that 50% of 18 to 24 year olds lie about texting while driving. And laws are very different from state to state. Um, so Maine passed a law. Uh, we have a law that you can't text while driving, but it's considered unenforceable, and the cops have just said they can't because you can dial your phone and you can use your GPS and do other things on your phone and have it in your hand while you're driving. And they can't tell if you're texting or, you know, looking at Facebook or GPS or whatever. So they don't even bother to enforce it. After a crash, they can ask you to look in your phone and I think they can do something to try and get your phone data from you. Uh, a law passed in Maine for no handheld device while driving, but the governor, uh, LePage vetoed it. Um, but New Hampshire, Vermont, New Hampshire, believe it or not, no handheld. The states around us, uh, and I bet Maine now that the governor's gone we'll probably bring it back around and pass it. Um, you cannot have a handheld in your hand while you're driving. Um, there's a bill right now coming up before this session of the Massachusetts legislature and Charlie Baker's supporting it, to have that ban in mass. The, the other shoe would be enforcing that law. And we'll see if that happens. Well, if you want people to ride a bike, this is what you do. Um, I'm not sure where this is, it's some town. And you can see there's a physical barrier between the bicycle and the roadway. And I tried to find a picture. I, I finagled my way into a World Health meeting, uh, in Vienna, which was pretty rough. And um there's a pedestrian part of the road, there's a bicycle part of the road. There's a bus part of the road, and the car part of the road, and then it goes the opposite. So it's pretty wide roads, but they expect you to be on a bike. They don't expect you to be in a car. We expect people to be in a car, not just in January, but all year. We think you're in a car. And we put these little bike lanes, you know, next to the lane. And it's very commonly going down Longwood Ave. I know Brookline Ave. Um, people honk at me because they want me to pull over a little bit so they can drive down the bike lane because they can just squeeze between the parked car and me to get by. And this is more what happens around here. You got some guy, you know, who's like crazy guy driving between cars to try and get, you know, somewhere on a bike. And then we're surprised that people get hurt. And I'm sorry, this is so fuzzy. Um, this is called bye-bye syndrome. So this is something that happens, um, by design, by the way we've designed our cars and our homes. This is that, this girl, a picture from our ER. This girl was run over by a car, run over by one of her parents, and um pretty good tire track, like right across her belly. Um, I don't think she had a shirt on actually, so that's why it's dirty, but he, um, we were freaking out. Luckily she was fine. But, uh, cause the weight redistributed, we thought for sure like something meaningful was hurt. She was very lucky cause it just missed her pelvis, just missed her ribs, went right across her belly with a slow roll, and nothing, nothing was hurt. We admitted her and watched her and I really, I promise nothing was hurt. But the, um, if it had gotten her chest or gotten her head, it would have been very different. About 1000 kids per year die from this mechanism in the US. And the reason is, by the way, we've designed our vehicles, and this is, this will go away. As more as you have backup lights and sensors and that stuff. Um, but it'll probably be another 5 to 10 years before fully goes away because of the older vehicles that don't have these. And the reason like a pickup truck, if you adjust the mirrors perfectly, you're sitting in your truck, the mirrors are perfect. And you're, and you, you know, you're take part in an experiment to see what you can see or not. And you, you, you're all set. You have uh somebody walk behind you. It's 35 ft back before you can see below their belly button, straight behind your vehicle. Just by the way it's designed. And again, uh, this has been known for quite some time, and people push to give, you know, cameras or sensors or something in the back of vehicles for these backup issues. And uh the car manufacturers fought it tooth and nail as they have every other safety improvement, whether it's seatbelts, lap belts, shoulder belts, airbags, they fought it every step of the way, because it's gonna add $250 to the price of a car to put these in all the cars. And they thought, you know, you do the math, you raise the price $250 someone's gonna decide not to buy that car. And a future customer. Um, so, ATVs, we have the toughest ATV laws, uh, in the state here. Uh, thanks in part to Pete Matziakos over at MGH, uh, lobbying the state House. Um, people now trailer their ATVs up to New Hampshire and, uh, ride around up there. But it's, uh, but our injury rates have dropped, uh, quite a bit from ATVs. Brains 25 cents. This was outside my medical school in St. Louis. Uh, the medical school was, was that way. You be you could actually go in there and buy a, you could buy a cow brain. Go into a store, buy a cow brain, and presumably eat the cow brain. Um, so a couple things about actually care of patients and then a little bit of caring about the future. So, um, Why do we, anyone who's like, you know, done trauma stuff with me realizes I carry on endlessly about the CT radiation. And why did you scan this? Why did you scan that? If someone scans the neck, to get a nice email. Jeez, why did you scan the kid's neck? Why'd you scan that chest, you know, etc. etc. This is, this is why. So this is uh from an adult, uh pediatric uh trauma, mixed trauma center in the Journal of Trauma. And you can see in um kids under 20 years of age, they're median. Uh, millisieverts of radiation that their patient received during their trauma evaluation was about 24 millisieverts of radiation dosing. That they just looked at all the people that came in over the last, you know, year, and how much radiation they delivered to them to determine whether they were or were not injured. And um this is from the 2008 New England Journal article. And just the thing to me is say the bottom uh right one. Abdominal CT scan, attributable risk of death from cancer. To get abdominal CT scan in 2008 was 6 to 10 millisieverts of radiation. And at that time, if you look at say a 5 year old, The black box Right. If you look over here at this 5 year old, it looks like it's about 0.09 increased risk, uh, increased lifetime attributable risk of death from cancer from the 6 to 10 millisiever dose to their abdomen. Um, And at 0.09% sounds really low, but that's 1 out of 1100 for a child that age with that kind of radiation dosing. Uh, when this stuff came out, it's now 10 years, 10+ years ago, the manufacturers of CT scanners have worked very hard to drop the dose. They've, and a lot of it interestingly is just changing the software attached to the machines. Uh, and, and modeling the images differently, not really sort of being able to get away with lower radiation dosing, just by the change in how they process the images, to process the data that comes out. And people have argued about this data. Radiologists and ER docs tend to not believe it because they like to do a lot of imaging. Um, and again, you can quibble with the numbers, but even if it's 1 in a couple 1000. In our state, there are 32,000 kids who came to EDs from trauma. Of kids who didn't have a meaningful brain injury, 3 of them died. Because it's such a low death risk from trauma in a kid who makes it to a hospital. Um, the death rate from giving them 24 millisieverts of radiation, um, starts to come to the same risk as their initial injury. And if that were it, that would be OK. But this was 150-something kids who came into our ER after having an abdominal CT scan done for trauma at an outside hospital. Heard an outside hospital, scanned them, sent them. And so we sat down with one of our radiation physicists, and it turns out it's really hard to figure out the, the dose that was delivered. You think it would just be written on the paper. But we had the, we had phantoms, we had the weight, the size, the circumference of the kid, the radiation, you know, delivered, etc. If you take up the American College of Radiology, survey CT scanners around the country, and they say, what are your settings for this study and for that study? And then what they do is they take all the numbers they received from all these different people they survey, and they draw a line at the 75th percentile of the dose delivered. So, 25% got more, 75% got less. That's, they make that 1.0. That's like the standard dose in the United States for that imaging study. And what we then did is, OK, using that bar, how many kids got more and how many kids got less. And we had, you know, a bunch of kids, of the 50% mark was right about 1.0. But we had a bunch of kids who just came in, they all lived fine, and all of the studies were readily interpretable, but about half of our kids got more than the allotted radiation that they were supposed to receive, some two or three times the dose. At the outside hospital because they didn't bother to adjust it for the kid. That's one of the reasons I get around. Uh, we also then just, uh, it's, uh, still in impressed, did a study looking at chest CT scan for injury. The only rational reason to do a chest CT in a child for injury is looking at a torn aorta, to see if they've ruptured their aorta. Pneumothorases, contusions, things you can see on a, uh, chest CT. If you cannot see them on a plain chest X-ray, they're subclinical, and we don't do anything about them. Uh, we might get another chest X-ray in a few hours to see if that CT pneumo is Grown in size or not. The, um We looked at the chance to look at all the hospitals and fis, 43 hospitals over 10 years. There were 27 kids out of all those hospitals, out of the over 200,000 injured kids who came in, they had a torn aorta, 27 children. We looked at the radiation delivered for a chest CT in the trauma situation, and we looked at the chance for having a torn aorta, and found that the chance for dying from the radiation from scanning those kids was higher than the chance for the torn aorta death. Standard management for adults, uh, Ken Maddox from Texas carries on endlessly for a torn aorta and an adult trauma patient says, get a chest X-ray. If you get a chest X-ray, and the chest X-ray is normal, you're now down to about 2 to 3% chance of the people with the torn aorta that you won't see something on the plain chest X-ray. And if that X-ray is normal in a kid, you've dramatically decreased the number of kids who need a CT. And we struggle with something, um, and this is function after injury thing. So, Our ortho people are really good at fixing bones. You see them, they fix the bone, they cast it, they pin it, they played it, they do stuff, boom, bang out the door. They're just like a machine. The kids, they even just send kids to Waltham. Kid comes in, they've got something, they have a slot in Waltham, they ship them to Waltham and, and they're done. And they just process kids through our system like nothing. Um, And you would think that the kids would then be fine. Uh, this is the thing, this is a child health questionnaire. And this is domain you ask the kids a lot of questions like it's, and then you split them up into domains like general health, physical functioning. And the general health of a child, they just ask a kid, you know, how you doing? They say, well, how are you doing? And then, um, and you just, you know, write down what they tell you. The general health of a kid, of any generic kid is they hit around 75%. They're not the general health of a kid, they don't perceive their health as being 100%. Uh, a normal kid, in other words, a kid who's not injured is the top. Uh, the blue is a mild injury. ISS less than 9, we don't really pay attention to those kids. They come and go through a lot of machine. 9 to 16, maybe ruptured spleen, greater than 16, sort of a real trauma patient. And when you look at their function after injury, as this work from uh uh Andrew up at the Milwaukee. Um, their functions down. And I'm reminded of my friend, my daughter's friend Mike. So Mike was the 8th grade football quarterback. He was the man. Nice looking kid, quarterback, you know, big dude. And he got tackled hard one time and broke his femur. Came in, got the femur fixed, femur healed great. Mike never played football again. Not through high school, no interest, nothing. Um, it changed his life. Luckily for him, he's a wealthy kid and you know, he headed off into something else that's doing fine. But if he hadn't had all the sort of support and backing and the income behind him, you know, he could end up that, that blue-haired kid on the bench, not have anything about blue hair. But the, uh, but we've wondered what keeps those kids back. Um, when I worked up at Dartmouth, Dartmouth was Happy Valley. Like nothing bad ever happens. It's, you know, you're in Hanover, you know, there's lots of trees, you know, happy Ivy League kids roaming the streets, drinking Starbucks. And, um, nothing bad goes on in Happy Valley. Well, we, I had this kid come in who got stabbed through the heart with a, a lawn toy in his backyard. And, uh, cause I had trained in Kansas City and did hearts. I took the kid to the OR, cracked his chest. It wasn't bleeding, so maybe I didn't need to crack his chest, but it went great. And he, case went fine. And, uh, unfortunately, one of the ends of it, you know, it hit his pancreas, so I had to drag it to wait for the pancreas to heal the heart was hard to find. But you know, I, I think he was an attending for about 3 months. And because when I was a new attending, everyone needed something. Um, and so, you know, I'm kind of walking tall, hey, who did the chest case without the heart surgeons kind of thing. And then the kid goes home, and he comes back in a little while later, uh, with a numb arm, like, oh shoot, I must have got some of the spreader, you know, and I'm like, oh man, big workup, everything's normal, he gets all better, goes home. Come back again later, drop spells a few weeks later, it's like falling down. I think, oh my God, maybe like dirt got in his heart with a needle with a toy or something. Some, I don't know, who knows? And huge workup. And I'm like beating myself. Like God, this, this kid is like totally stealing my mojo here. I'm like the, I'm like the man. This is my big case. I'm new attending. And so, I was actually in the elevator with a friend. I actually do have a friend who's a psychiatrist. And I was like, God, this kid's killing me, you know, he's thinking, I just, this is, this is my, I'm not a hero anymore. He goes, oh, the kid's got PTSD. Like, come on, you know, kids don't get that. And, and it goes, no, no, no, send them to me. And sure enough, to get a post-traumatic stress disorder. And so we decided to look at it in Happy Valley, where everyone's chill. How many of the kids who came in had post-traumatic stress disorder? And because no one moves up there. We had like a, we had a 100% follow-up. Everyone came back to the clinic. And we did put them through 3 hours of psych testing, them and their parents and these endless questionnaires, you know, the psych people have. And um And what we found was about a third of our kids had post-traumatic stress disorder, after their injury. Um, and it was the same in their parents. Their parents had it too. And when we looked at why people got it, um, or had acute stressor, half of which is going to have longer term issues, which I think my daughter's friend Mike had. It didn't correlate with the degree of injury. And the particularly frightening thing about that, only about 2% of kids that get hurt, get admitted. It doesn't have to be like an exploding car crash. There are some things that are higher risk, like watching your parent be harmed. Um, things that are particularly painful like long bone fractures, where you, you're in pain and you can't get people to make your pain go away. Those are higher risk for the, with those. But all those kids who come and go from our ER that we never see. have a high risk for PTSD for acute stress disorder and going on to PTSD. Um, but the biggest factor was parental stress. So even in Happy Valley, and actually sadly, the fathers didn't matter. The moms mattered. Which is says either sad things about men, but, but the um if the mom was all freaked out. They, and this, they freaked out over this, they took the kid with them. So one of the things I'm particularly careful for now cause this isn't just an injury thing. When I see that freaked out parent now, whether it's a hernia or whatever it is that's freaking them out about their kid, I try to like, you know, bring them down a little bit, that it will be fine, you know, Johnny will go home. Um, now, this will all be in the past. And when we see kids get knocked out, if they're knocked unconscious, and then they come to the next day. They have a lower rate for PTSD. Then the kids who are wide awake, come into the ER, strap them down, finger every hole, bunch of IVs, you know, do all this stuff to them without really telling them what the heck we're doing. They have a higher chance for getting it. And the folks at CHOP have been doing tremendous work on that. So here's some future directions. Thanks. So, um, more kids die. So it's primary and secondary brain injury. Primaries you hurt your brain, secondary is you lose your airway or you bleed out or you drop your pressure, you know, etc. Um, more kids die from secondary brain injury, from the sequelae of trying to manage their brain injury, then die from cancer every year in our country. And, um, it's the leading cause of death, death and long-term disability in children in our, in our nation. There's no treatment. We have no treatment right now for brain injury. There's nothing. We do a lot of things, none of them are proven to work. Um, we do things that have been proven not to harm it further, but we have nothing to make the swelling go away. We have nothing to make the neurons be preserved or recover. Uh, there's nothing, there's nothing there. Um, and the care is basic. And there's a new set of guidelines coming out in March, the latest version of the national guidelines for the care of pediatric brain injury, uh, and they're all consensus-based. It's all just what the experts got together and deemed OK to do. And there was a cool kids trial going on. Uh, Dave Edelson took his trial at the, um, Phoenix with him when he moved from Pittsburgh years ago, and the trial was canceled because they found they would never reach an endpoint. So, there's no prospective trial going on right now for the management of kids with traumatic brain injury. And looking at cancer care, I use cancer care because they've done a great job. Long slog, painful road to get to where cancer care is now for kids. Super tedious, lots of meetings, lots of, you know, sitting there with big piles of paper. The first cooperative study I could find in 1955, um, for a, a study group for cancer care for children. Right now, and this is injuries on the right. There are some cooperative groups forming up. They tend to be regional. People call their friends and say, hey, do you want to be in my windowfall study? Or you want to be in my like check the belly study. Um, there are over 100 active clinical trials, I'm sure more than that for cancer care in children. Federally funded, beautifully designed, all the rigor of an NAH study, you know, all the, all the bells and whistles. Um, I'm doing a clinical trial right now for kids, and it's been agonizing trying to get this trial going and trying to keep it going. And I've got 8 hospitals in. Every single trauma director I've, I'm working with has told me this is the first time they've ever done a prospective trial for trauma. They they've none of the Cincinnati, nationwide, CHOP, um, Salt Lake. Kansas City. Uh, Utah, and now we're gonna, we're bringing Phoenix on board. The first time they've done a prospective study for care of injuring kids. Um, about 90% of kids or greater in a COG hospital, which is great. About 30% of kids are treated injured kids are treated in PD trauma centers. Or PD centers at all. There's about 13,500 cancer patients per year and around and over 200,000 trauma kids are admitted to hospitals. These multi-center collaboratives were in everyone I can find, um, resuscitation from Shock based on a nationwide, you know, you can see the list. They're all reviews. We review, we send them our patients, you know, just some reviews of our patients or perspective reviews, we send them our data that's collected perspectively, we send it to them and they, they collate it. Lots of registries and this and that. But no intervention trials. The only one we're doing is contrast. I'll talk about in a second. I think the reason for that is because Of us Um, most PD surgeons don't focus or care that much about trauma. They take care of it and do a fine job taking care of it. You're on call, the kid comes in, you take care of the patient. Got it. Um, but there was an ad I got for an email an email for a job. The second line of first is like a major metropolitan area that's only 1 hour from good, a good place. You know, it's only 1 hour from somewhere that you would like to live instead of where you would live. But the line number 2 is limited trauma exposure. Like it's a disease. And, um, and most children don't need an operation. I mean, who wants to train, you know, for 10 years in surgery and take a profession where you're not gonna operate on anybody. You know, and, and they're teenagers, they're not babies. So you're gonna be taken by a bunch of stupid teenagers and watch them get CT'd and then talk to their moms. Um, but imagine if Wilm's tumor, if the care of Wilm's tumor was just left to the surgeons, there weren't oncologists, there weren't radiation therapists. You know, there weren't all of the other people that are involved in developing those networks of sitting down and doing the grunt work that it takes to complete a study application. I mean, you have to have time. You can't be beholden to the operating room. And oh great, I got add-on case for my giant case I need to do, and I gotta drop everything cause thank God I got overtime to do that, get that case done. But imagine if the, what the state of, of care would be like if we didn't have all those people helping us. And when you look at people, we have a lot of people now who really know how to take care of injured kids, but they're, they're geo geographically limited. So you go to the ER, our ER here is excellent. They provide excellent care for trauma kids. The patient leaves the ER, they stay behind and the patient goes on. They're geographically limited. You go up to the ICU, our ICU docs take amazing care of trauma kids while they're in the ICU. Um, and what We need somebody who just takes care of the kid wherever they are. They take care of him in the ER, they follow him up to the ICU, they take care of on the ward, they see them back. They have time to do research. They're not beholden to, you know, the OR. The OR owns us. And it's all injured kids. It's not just a kid with a spleen, it's a kid with a bone or a head or, you know, a cancer doc takes care of cancer patients. They don't take care, you know, they can specialize in a tumor. But we don't get to sit oncology, uh, like, you know, one certain thing, it's, it's a broad area. If a child falls down or they're in a car crash or something, what gets hurt just depends on what hit first. It doesn't matter, it's they still got hurt. They were still involved in an injury and so most of the other stuff that goes along with it are the same. And it might seem crazy, like you say, really, you're gonna have people in the ER that are gonna do the trauma care, not the ER docs. And it seems like it would be you know, oh no one's gonna ever go for that, you know, there, there's ED is never gonna give up that or ICU won't allow you to cleave that off. Well, the fastest email I've ever replied to, um, I didn't know who the guy was. Some guy, Kevin guy, like, I don't know, some guy from the BI sends me an email out of the blue. I've gotten funding to set up a trauma system, pediatric trauma system in Tuscany. Would you be willing to help me? Yes. I just said yes. And um details to follow. So, it turned out it wasn't, it wasn't like a credit card scam. Um, it was a, um, this guy to BI um. He's kind of a wanderer kind of guy, married uh someone from Florence, whose father was the chief trauma surgeon at the main trauma hospital there. And he got, he did set up an adult trauma system in Tuscany and I was setting up a pediatric trauma system all based out of Florence. And so, there was nothing. There was no emergency medicine in that part of Italy. There are internists and surgeons. You came into the emergency department, the nurse greeted you and sent you this way or that way to see the surgeon or the uh internist, pediatrician. And they sat at a desk. They sat at a little desk, a little chair, and then they would take your information, they would say, OK, go get some X-rays and the family would like wander down the hall to get their labs or X-rays, wherever they, they were sent to. I think that's probably how it was here, back before Gary Fleischer, and the ED was set up here in the 70s. And so, I, it was very difficult. I was forced to go to Florence for about 5, about 8 times for a week each or about 5 years. It was a struggle, but I overcame. And uh, but what we did there, and it was great cause there was a clean slate. And people didn't care there. It's very different. They didn't wanna work. So in their system, it's all socialized healthcare. It's all national healthcare. And so they're not after more patients. They're not competing, you know, and fluffing of what they could do and not, not letting you take my patients. They were happy to give up patients. And um they would come in at like 9:30 and go home at like 3:30, um, which made it a little harder to train. But, we took 6 PD surgeons, 6 critical care medicine providers, and 6 anesthesiologists, and we trained them all up to be trauma docs. We trained them to recognize when someone needed to go to the operating room, how to resuscitate them, how to, you know, problems that came up. Then they rotated. They rotated through one covered the ED, took care of the injured kids who came in, one covered the ICU and covered the ward, week, week, week, and then they were off. And they rotated so they would have actual time off to do research and studies and such. If there was someone who needed to go to the operating room, about 2% of our general surgical admissions need an operation, they call the surgeon who was on call for general surgery. And it worked very well. It's possible to do it. There are endless problems that would come with trying to do it here in the states. But it's a choice that we make, having our providers geographically arranged within the building as we do now. And it can certainly be done and it's worked well there. They get about 850 trauma admissions per year at the hospital there. There's one thing about imaging and then uh did it quit. So, the imaging studies we've been tweaking who benefits from imaging, you know, and, and really for a lot of pediatric injury care. There's some big improvements and it's just sort of tweaking. There's a lot of tweaking that goes on. They haven't been really any major jumps in care for a while. There's been a lot of like, uh, how many, who can have a kid in the hospital with ruptured spleen, the fewest number of days. People like, well, I can't keep him in for 2 days. Well, I can't keep him for 1 day. Why send him home to the ER and people, you know, carry on about like, you know, how many notes. Um, but a couple of things is contrast and ultrasound and some global stuff. So, a few years back, I was looking through a journal and almost like when Jay found the thing about the tracheal occlusion, I was flipping through some actual paper journal and I saw this article about contrast enhanced ultrasound in adults from Europe, being as good as CT scan for injury. And so I approached the head of radiology at that time and said, wow, this looks amazing, and they were way too busy. And, um, and plus he was a big CT guy. Um, and then, uh, sort of, you know, forgot about it and said about I kept, brought it back around a couple of times and then found that, um, somebody, Harriet Paltow, who's way overcommitted, but very interested. And, um, There's great European data about using this in adults and kids, and I suspect if your child got hurt in Florence, you would probably get a, they would probably get a contrast enhanced ultrasound. Um, based on the radiation numbers, not the 2008 New England Journal numbers, but based on subtracting, dividing it by 4, just presuming that's like way out of range, would probably say between 20 and 50 lives per year in the US, uh, cause around, there were over 200,000, um, abdominal CT scans done for injury in the US in kids. Um, Possibly importantly, it would save about over $140 million out of our healthcare system if this study was done instead of CT. Um, we did a pilot study with 18 kids. Uh, we found there's one kid who was a little large and not very tall, who probably was not a good ultrasound candidate in the first place. The radiologist was not very happy. Every other kid we saw their injuries. So we started a larger multi-center trial. So our pilot study 18 kids, right now we're doing our multi-center, uh, study with 8 hospitals, 146 kids. And um Accrual slow. People have not understood what it's actually like to do a study. Um, The first patient that another hospital accrued, they did not assent the child, though they said they would. Um, another study, um, they forgot to fill out half the forms. Um, and we have these people who work with us here who are just like doing constant monitoring, training these other trauma programs, how to actually do a clinical study. It's been, uh, um, a lot, a lot of work on that side of it. Huge parts of our planet don't have CT scan and we'll never have a CT scanner. And um let's do this first. Um, this is Africa. That's the thing. Um, and this is how many CT scanners the World Health Organization says there are per million people in the different countries in Africa. The white countries didn't provide data. The couple of yellow countries said 0. the, uh, Libya said they had uh 3. Per million people. The other countries are one or fewer CT scanners per million population in their nation. Um, I was in Kenya last year. They had a CT scanner in the hospital, the Kajabi up in the hills. Um, but it was, uh, $100 and something dollars. It was a private CT scanner that someone owned and stuck in this hospital. It was a few generations back. It was $100 something dollars to get a CT scanner, which was about 7 months' pay for the average patient there to get a CT scan. was very limiting, but huge chunks of Africa will never have a CT, um, or never have enough CT scanners. Um. Fascinatingly, they have ultrasound. They're portable ultrasound machines that cost like $1000 or $2000 that are pretty good. And there's now a wand, you can actually connect it into your phone. Since everybody's got a cell phone because the landlines are terrible, so they go right to cell. They've jumped the generation of the technology and you can plug it into your phone and you can see the images on your phone, uh, and transmit them and such. And this is just for people who haven't seen contrast enhanced ultrasound. This is just a CT scan of a grade 2 spleen. That's a gray scale of the same spot with maybe possibly something there, and that's the divot in the spleen seen on the contrast enhanced ultrasound. And you don't need to be a radiologist to see that there's a big unperfused part in that child's spleen. So, oh, so, I'm doing something right now with the head of radiology at CHOP. Um, he's actually over in, uh, Ethiopia right now, uh, scouting out, doing, uh, contrast enhanced ultrasound in, uh, Black Lion Children's Hospital in Ethiopia, in, in Addis Ababa. And, uh, the hope is that, well, we're doing a, gonna try and pull off a feasibility study for what's it gonna take to bring it to a third world nation like that. And, um, That has the potential to dramatically improve the care for adults and kids, uh, in, in those settings, um, cause again, they're, they're just not gonna have a CT. And then finally, the PD trauma Society. So a few years ago, we realized there was no organization in the United States dedicated to the care of injured kids. There are different organizations that consider it, but these are adult organizations that think pediatric people aren't real trauma surgeons because we don't operate and they love to operate. Or they're pediatric organizations that think the trauma is kind of like, uh, you know, not that interested in it. So, uh, we started our own group. Um, we have about 800 members now from every state, uh, nurses equal doctor. Uh, anyone who's interested in trauma is in, you care about injured kids, you're in. And, um, it's, uh, actually been taken off that we have an annual meeting, uh, that's, uh, very well attended. It's been, uh, a, a big, uh, and they're starting some now some, a lot of these reviews, these multi-center, you know, review our last kid who fell out a window or coming out of this organization. We're trying to gear it up to build some of the, the backbone structure to develop the field in the future. So, uh, despite what politicians love to tell you or Fox News or who's trying to jazz you up for some particular reason, it's actually the best time ever in the history of our planet to be a child. Uh, survival rates, the opportunities available for kids, um, again, by far the best ever. The injuries that we see in our building, uh, happen by design. It's something we've chosen to do. We've chosen to have cars instead of trains. Uh, we've chosen to have bikes in the road. We've chosen to have kids crossing the street to their school with 3000 pound vehicles going by with people that are allowed to be looking down instead of at the child. Um, and our management strategies for kids, yeah, it's a big, you know, don't operate on the spleen, but we're pretty stagnant. Um, the only way I can really see, uh, this field moving forward is if we invite in non-surgeon providers trained in trauma care, who have, who know what they're doing, provide excellent care, but at the same time have off-service time to do the work that's required to get those studies done. Thank you very much. Mm Well, David, I'd first like to thank you for presenting a very nice summary of, of the challenges of being a trauma surgeon and providing trauma care to, to kids. I, I'd also like to commend you for three of your, uh, accomplishments. I think creating that multidisciplinary, uh, organization around trauma is probably the most reasonable way to push for improved care, and I think As you mentioned, doing much of this on a national level or with uh Laws regarding ATVs and such is probably one of the few ways we can improve, uh, or, or decrease the frequency of, of trauma. Second is you're really establishing a lot of the trauma prevention programs for the Boston area, like going around to all of the, um, Centers for um Families that don't have housing and making sure that those sites are, are, uh, safe for them. And then I think the third thing is really doing the first perspective study on trauma management with the contrast enhanced ultrasound is really a very significant thing, and I would hope that that can be the genesis for future, future things of multidisciplinary studies. I know you've often expressed your frustration that the oncology programs have been able to raise much more money from the feds and the NIH because, you know, kids with cancer is a um glamorous group of patients to take care of and cure, I guess. Trauma doesn't have that. Um, impact, and yet if you look at the numbers that you showed us today, it far outnumbers the oncology. Um. Victims, if you will. So I would think that something legislatively ought to be able to be accomplished for that. Um, The, the one, The thing that you, you stressed is the um brain injury and how often that is uh The lethal event for kids, are there other targets that you could envision that would Decrease the number of kids that come in with, uh, brain injuries, it could be a focus. Well, thank you very much, and, and one thing just to speak to first, I think cancer care um has grown, uh, and the quality of cancer care and the funding for cancer research in children has grown because um the people in that field deserve it. They've done the hard work, they've set up their organizations, um, they've generated excellent data studies, you know, they're, they've really, uh, spent in, you know, countless hours creating the kind of structure that people wanna fund and then providing results that get them more funding. And, uh, one of the reasons why pediatric injury has suffered is because we haven't. Uh, it's, um, and partly, again, I would say that we haven't had the bodies to do it. We haven't had the people able to commit to that. Um, I mean, there, there are, uh, you don't wanna grow up being my child, because my world is filled with traps that children fall into. Like, uh, you know, bike helmets are, are nice, um, being out on the road is nicer. Most kids who die on a bike are hit by a car. Most adults who die on a bike are hit by a car. And, um, it's just, uh, insane to me that you ride next to traffic. I'd love to ride a bike. Uh, when I lived in New Hampshire, I rode my bike to work and ran to work and do that all the time. I, I wouldn't do it here. Because maybe, um, uh, especially because, you know, it's 10 miles, uh, because you're right next to a turning vehicle and there's been several people killed, uh, physicians in Boston by a truck turning, um, because of the design of our trucks, they can't see something right next to them. Um, and, um, there's a long list of things. Uh, one of, we currently have some money from a Spanish, uh, insurance company or Mapfree, they're here in Mass now. Um, and one of my hopes for them is to Develop a, uh, an award for someone who redesigns a product to be safer for children to use. Um, whether it's how we get on and off a school bus, um, or, um, you know, any product, that if it's safe, if it, if it enhances the safety of their product for a child without making it inconvenient for all the other people using it, that they would win the award and have some sort of annual product award. Um, but because there's a, a long, long list of, of options. Additional questions or comments for Doctor Monet, Doctor Fauza. David, uh, great talk. The response of paramedics to an injury scene is critical to outcome, but it's confusing to me how this quote unquote paramedic services industry works. How does a 911 operator, uh, choose which company to call? How does the oversight, regulatory oversight from the different states work on that, their training? How do they relate to the collaborative studies such as the ones that you're trying to establish? Would you comment a little more on those? Uh, I was on the medical control board in New Hampshire when I was up there and, there were 5 of us that did like controlled EMS in the state. And um, it's fascinating. Um, The whole EMS area is, is a completely different talk area. The average, um, so there's levels is basic, intermediate, and paramedic for provider training level in EMS. A basic provider has 110 hours of training, 4 of which have anything at all to do with pediatric. Most of the patients they transport are adults. Most of the children they transport are fine, and a kid with a fever or flu or something like that. Um, the average paramedic in the state of New Hampshire will intubate a hos a child pre-hospital once every 115 careers. So, we just said, don't even try. Just bag them and bring them in because there's no way you're gonna do it properly and there's no way we're gonna be able to continue training people for things they'll never do. Um, similarly, the average pediatric surgeon will repair a spleen, an injured spleen, every 115 careers. Most of us will never ever repair a spleen for injury. Never. It's an operation that's been going away. And if that operation needs to be done, uh, I've written a chapter about how to do it. I've never done it, and I'll probably never do it. But I'll probably write another chapter about how to do it and pull up old photos from the 70s of someone who actually did it. But EMS is a huge issue and every state is different, every area is different. We're in region four, we're in a region four for the state of Massachusetts, so we're a more developed area, we have paramedics. Um, in our area, but it's very quickly when you leave the city, the firefighters provide EMS and most of them are not paramedics, they're, they're basics. And, um, in Boston, there's an interesting political dynamic in Boston if you get sick or injured. They bring a fire truck full of firefighters. They're basics. And then Boston EMS comes, and uh they've been, there were issues about 3 years ago where a fire truck went down a hill and someone died because the brakes failed. They were coming to a guy who couldn't, was having trouble breathing. In a, in a fire truck. They brought a whole fire truck full of firefighters cause they didn't have anything else to do. And um, but anyway, so it's a whole separate issue, but it's a, it's a meaningful concern, and they train to what they do most often, and this is just such an unusual event for them that it's just hard for them to keep up the training experience. But I would love to see when someone's on the way in in the ambulance, I would love to be able to see on my phone. See the ambulance. Here's the vitals, here's the person. Here's where they are. The Mayo Clinic has this really cool screen. It's like watching your Uber arrive, they can see the ambulance is driving around Rochester on the way to the hospital. We go into like this dead zone. So the kids coming here from wherever, you get this word the kids coming, they're all standing there like, where the heck is the kid, and you have no idea what's going on. We should see their vitals, see their, see them, communicate with EMS visually on the way in. As I mentioned, it's super primitive right now. So they've just, yes, I just, it reminds this talk reminds me about 15 or 20 years ago, a former chairman of radiology here is very big in CT gave us a big thing about CT app appendicitis and how we're bumping a bunch of kids off cause they're radiating too much. So I said, why don't we just stop? Why don't we just stop doing CTs, get ultrasounds and MRIs, and then he slayed me. Now, that's what we do. So, I would say if we're killing as many kids as as we're saving by getting CTs, why we just stop. Just stop and then track the results with MRI's and ultrasounds. It doesn't seem to be that big a deal. The reason we get most CTs is not because the kid's injured, we get it to protect ourselves from liability. And that's the third arm you have to put in that calculation. You have to say, I'm not willing to get sued because I missed. You know, a tiny pneumothorax. I don't wanna get sued for that. So you have to put that in your calculation. Is Crico gonna back me? And if I have to go through a lawsuit, I never have, but it's always risky. I don't wanna have my life destroyed because I didn't get a CT. So, why don't you just say as a blanket policy, we don't get CTs at children's, we just get MRI's and ultrasounds. Well, if this contrast enhanced study hits, uh, we'll get contrast enhanced ultrasounds on, on most kids. There'll be the occasional child that still you just can't tell you need a CT. We're asked to be in a study through MGH looking at CT scan of the neck in kids under 3 years of age. And, um, they want us to read the, review the charts of these kids, and, and I told them that's over 5 years. I told them it's gonna be 1250 kids that we're gonna have to review and we had 0 CTs of the neck. We don't CT the neck. They do screening CTs of the neck and, and those young children there, like for trauma. And um with a hit rate, a positive hit rate like 0.03%. Um, and, uh, they published a study and they were, they hated me because I wouldn't be part of this study because I wasn't gonna review 1200 charts. And, um, but I think that's a reasonable option. I think um we're fine here. You know, there are times we can tune this and that and follow criteria and do less. The challenge isn't here, the challenge is another hospital, a kid who comes down from some other place. Especially an adult, adult trauma centers scan. If you crash your car on the way home, you go to an adult trauma center, they're gonna scan you from the top of your head to the bottom of your pubis. I'm gonna be turning 60, the, I'll die of something else before the radiation gets me, so I don't really care. But uh that's standard management in the adult trauma world. And um when most kids, if they go into a trauma center at all, go to an adult trauma center, not a pediatric trauma center. That's the way they're managed also, and that's really the, the burden for us. Well, David, thanks so much for your presentation today. Thank you. Your breath. No. I know. Yeah. and he left a lot of. For